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FHE/86.4
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ESSENTIAL OBSTETRIC FUNCTIONS
AT FIRST REFERRAL LEVEL
Report of a Technical Working Group,
Geneva, 23 27 June 1986
i
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WORLD HEALTH ORGANIZATION
DIVISION OF FAMILY HEALTH
GENEVA
1986
WORLD HEALTH ORGANIZATION
FHE/86.4
ORGANISATION MONDIALE DE LA SANTE
ENGLISH ONLY
Distr.: LIMITED
ESSENTIAL OBSTETRIC FUNCTIONS AT FIRST REFERRAL LEVEL
~~
to Reduce Maternal Mortality
Report of a Technical Working Group
Geneva, 23-27 June 1986
CONTENTS
Page
1.
INTRODUCTION
2
2.
MATERNAL HEALTH CARE IN DEVELOPING COUNTRIES
4
3.
THE ESSENTIAL OBSTETRIC FUNCTIONS
5
3.1
(
3.2
3.3
4.
5.
The essential obstetric functions related to
major causes of maternal mortality
Requirements for essential obstetric functions . .
Commentary on essential obstetric functions . . .
3.3.1 Surgical functions
3.3.2 General anaesthesia
3.3.3 Medical treatment functions
3.3.4 Blood replacement
3.3.5 Manual and/or assessment functions . . . .
3.3.6 Management of women at high risk
3.3.7 Family planning support functions
3.3.8 Neonatal special care
5
5
12
12
13
14
14
16
17
18
19
IMPLEMENTATION
19
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
19
20
21
22
22
23
23
23
General remarks
Health manpower
Physical facilities
Equipment, supplies and drugs
Supervision
Evaluation
Research
Cost and financial considerations
REFERENCES
25
ANNEX 1
ANNEX 2
ANNEX 3
ANNEX 4
ANNEX 5
ANNEX 6
Physical space
Items of furniture and equipment .
Surgical and delivery equipment
Materials for side-laboratory tests and blood transfusion
Essential drugs
....
List of participants
26
28
31
37
39
41
TABLE 1
Eight groups of essential obstetric functions
related to the major causes of maternal mortality
6
TABLE 2
• •
Requirements for essential obstetric functions
at first referral level
7
587
RT^7^e58
o7f
2n8o? «■ 888- 189
----------- --------constitute
formal publication,
It should not be reviewed,
abstracted, quoted or translated without the
agreement of the World Health Organization.
Authors alone are responsible for views expressed
in signed articles.
Ce document
ne constitue pas une publication.
II ne doit faire I'objet d'aucun compte rendu ou
r^sum^ ni d'aucune citation ou traduction tans
I'autorisation de ('Organisation mondiale de la
SanU. Les opinions exprim&s dans les articles
sign^s n'engagent que leurs auteurs.
FHE/86.4
Page 2
I
1. INTRODUCTION
Complications related to pregnancy and childbirth kill 500,000 women each year, A sharp
difference exists between the developed and developing countries, Only 1 per cent of the
maternal deaths occur in the 26 per cent of the world’s population who live in developed
countries. In contrast, the number of maternal deaths each day in India alone exceeds the
number of maternal deaths in all developed countries in one month, Maternal mortality rates
between 5 and 30 per 100,000 births are common in developed countries, In the developing
countries however, maternal mortality may reach 1,000 per 100,000 births, Anaemia,
haemorrhage, eclampsia, infections, abortions and the complications of obstructed labour
account for most of the maternal deaths in most developing countries. Deaths on this scale
may be horrendous, but they represent only a small proportion of the total morbidity
traceable to the same causes. To this must be added also the suffering which affects the
bereaved families, particularly the children who are left behind. As more data have become
available over the last decade or so, and strengthened by the common purposes and priorities
expressed in recent UN Conference on Population and at the end of the Womens’ Decade, the
World Health Organization has become increasingly concerned and active about this problem.
Supported by the United Nations Fund for Population Activity (UNFPA), WHO has initiated, in
all regions, a programme of activities which include collection, analysis and dissemination
of information on maternal mortality and coverage of maternal health care, Maternal
mortality research projects have been supported in fifteen countries so far. As part of
this programme WHO convened, in November 1985, an Interregional Meeting on Prevention of
Maternal Mortality, where information from many parts of the third world was presented on
the extent, causes and the circumstances surrounding maternal mortality and morbidity. The
meeting brought together over forty health professionals, researchers and policy-makers from
twenty-six countries and agencies. The summary report^ is contained in document
WHO/FHE/86.1 and the full proceedings will be published shortly.
After considering the extent and causes of the problem the meeting made recommendations
for actions, in four main categories: (i) policy initiatives; (ii) programmes of maternal
health care and family planning; (iii) training; and (iv) research.
Recommendations arising from a consideration of the circumstances surrounding many of
the maternal deaths in the numerous studies presented at the meeting, dealt with the role of
the health services, their availability, appropriateness and utilization. These
recommendations not only endorsed and encouraged efforts to train Traditional Birth
Attendants (TBA) and to provide within Primary Health Care (PHC) effective prenatal care,
but also addressed the first referral level, at which many of the deaths occurred. By this
first referral level is meant the district or sub-district hospital or health centre, to
which a woman identified prenatally as definitely high risk is referred, or to which a woman
is usually sent when she is in serious difficulty or emergency in pregnancy, childbirth or
immediately after. There were certain "essential obstetric functions” which can only be
performed at this level, most of them life-saving procedures in emergencies, and it is for
the lack of one or more of these that most of the maternal deaths actually happened.
Although these deficiencies were often only the proximate, not the fundamental, causes of
maternal deaths, they represented a failure on the part of the health services to seize the
last chance to save the woman. Seven essential obstetric functions at the first referral
level were identified, namely:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
to perform caesarean section
to give an anaesthetic
to give blood transfusion
to perform vacuum extraction
to carry out suction curettage for Incomplete abortion
to insert inter-uterine devices
to perform tubal ligation or vasectomy
D
FHE/86.4
Page 3
The interregional meeting recommended that WHO should convene a small working group In
order to define more completely the essential obstetric functions at the first rfeierral
level necessary for the reduction of maternal mortality and morbidity; and to describe as
specifically as possible what were the main indespensable requirements in order to carry out
these functions, in terms of staff, training and supervision, physical facilities, equipment
and supplies.
Therefore, in June 1987, WHO convened a Technical Working Group (TWG) on Essential
Obstetric Functions at the First Referral Level with these terms of reference. The TWG
re-classified these functions as follows:
1.
2.
3.
4.
5.
6.
7.
8.
(
Surgical functions
Anaesthetic functions
Medical treatment functions
Blood replacement
Manual and/or assessment functions
Family planning support functions
Management of women at high risk (e.g. maternity waiting homes in villages)
Neonatal special care
The last named was added in parenthesis, so to speak, because although it is clearly not
for the purpose of reducing maternal mortality, it is difficult to imagine a facility which
provides maternal health care at first referral level without provision of some special care
for newborns, many of whom may not be in optimal condition for much the same reasons which
put their mothers at risk, Thus the requirements for such care needed to be included for
practical planning purposes.
In order to support effectively the primary care level, these functions must be carried
out at the most peripheral level at which they can be undertaken safely and effectively.
The central focus of this report is the situation in developing countries and in particular
in their rural areas, because this is where, as the research studies considered clearly
showed, the major part of the problem is most acutely encountered. This emphasis underlies
two particular points about this report. The first is the designation of this level of care
as the ’’first referral level", rather than employing "hospital, first class health centre"
or any other such term which would prejudge the issue. The second feature is that the
functions, tasks and ski!Is needed in the management of obstetric complications are
described, and this avoids using the job titles of particular kinds of health workers, again
prejudging Issues which should be decided at the country level. Nevertheless, the general
levels of health workers considered appropriate to carry out these functions are indicated.
(
Having stated the essential functions and tasks at the first referral level of health
care, the materials and personnel needed to prevent so many unnecessary deaths from
haemorrhage, anaemia, infections, abortion, eclampsia and obstructed labour are considered.
Physical facilities, essential equipment, supplies and drugs are described and the
requirements are listed in five annexes. Implicit in the recommendations is the need for
supervision, evaluation and operational research, as well as financial considerations.
This report is directed to those decision-makers at local, national, and international
level who are concerned with the planning, financing, organization and management of
maternity care services. The guidelines provided in this report should make it possible to
determine how, and how far it may be possible to extend the functions of the first referral
level to more peripheral levels than at present exist. This may Involve the upgrading of
both staff and facilities where feasible and affordable, or may only require the extension
of the skills of certain cadres of health workers, together with a quite modest addition of
equipment and/or supplies and redeployment of space. The severe economic constraints faced
by many countries is a major background consideration in the preparation of these
guidelines. Every effort is made to include only the truly essential and indispensable
requirements.
FHE/86.4
Page 4
Not included here is any description, except by implication, of the requirements of the
primary maternal health care system. This is not omitted because the group thought it as in
any way of lesser importance, but because the terms of reference of the group concern
essential obstetric functions at the first referral level. The definition of these
functions implies that there exists also a primary level of care in the family and the
community, and that at this level such functions are carried out as prenatal examination,
screening for high risk, primary and secondary prevention of certain conditions, treating
such conditions as anaemia before they become so serious as to threaten safe childbirth,
health education, counselling, and domiciliary delivery by trained persons (whether nurse,
midwife or trained TBA) of women who desire it and are not at high risk. All these are the
very foundation on which the essential obstetric functions at first referral level should
rest: but it would have been outside the terms of reference of this group to enter into any
comprehensive description of this system of primary maternal health care. The reader can
find a description of at least the component elements in a number of other publications.
2. MATERNAL HEALTH CARE IN DEVELOPING COUNTRIES
When, as at the Interregional Meeting on Prevention of Maternal Mortality mentioned
above, the circumstances in which most maternal deaths occur are examined, one striking
feature is that a considerable majority of these came from rural areas, to an extent quite
out of proportion with the rural/urban distribution of the populations in question. As one
investigator put it succinctly
There are two notable features of the women who died in our
obstetric service: they came from far, and they arrived too late."
To substantiate this statement the reader is referred to the summary report of the above
meeting and to the Proceedings of the meeting (in press) and many of the actual study
reports therein or to fuller accounts of these studies published elsewhere e.g. that of
Kwast in Addis Ababa and that of Harrison in Zaria, Northern Nigeria3 or that of Khan
et al. in rural Bangladesh4. There will be found the general background of illiteracy,
poverty, malnutrition, Inadequate sanitation and water supply, socio-cultural problems,
often relating especially to womens’ status, and adverse traditional attitudes and practices
which will be familiar to all who have lived and worked for any length of time in the rural
areas of developing countries. Most significantly from the point of view of this report,
such studies show the high proportion (suspected, estimated or actually documented) of
maternal deaths which occur either at home, without trained assistance, or actually en route
to a district hospital. Thus, while it is quite true that the general features of poverty
and deprivation mentioned above contribute considerably to the high maternal mortality
rates, as does also the inadequate availability of preventive health services such as
prenatal care, examination of the Immediate causes of death and the circumstances in which
they occur vividly demonstrates a grave problem for most rural women of access to
life-saving procedures in emergencies during childbirth.
“
It was just such evidence which led the Interregional Meeting of
November 1985 to conclude that, although this problem was far from being the sole cause of
high maternal mortality rates in these rural areas, it was one of the most important
reasons, and yet at the same time had not so far received anything like the specific
attention which it deserved.
The TOG believes that Improvements in the quality of obstetric care at this first
referral
7““7 7level
—.a-^e--------neceS8ary> achievable and affordable, in spite of the economic
constraints faced by many nations. C
*
--China,
Chile,
Cuba, Costa Rica, Korea and Singapore, are
examples where the transformation of health services has brought about a considerable
reduction in maternal mortality.
There can be no substitute for a well organized system of maternity care with the
following characteristics:
p
FHE/86.4
Page 5
1.
2.
3.
4.
5.
6.
7.
3.
Total population coverage, which means that every pregnant woman should receive
essential prenatal care from trained personnel.
All complicated deliveries must be attended by trained health personnel in a
suitable facility.
Facilities for this purpose must be accessible and equipped to tackle pregnancy
complications most commonly associated with maternal deaths.
Family planning, as an essential part of total health care, must be provided in an
appropriate manner in all preventive and curative programmes.
Transport must be managed efficiently in order to support the primary level, for
supervision, supply and for referral in emergency.
The health facility must be made to function in such a way that the people it
serves have confidence in it as well as in the system of health care it represents.
Records of births, maternal deaths, perinatal deaths, contraceptive acceptance and
use, must be kept in a form which will permit periodic analysis of the data with
the alm of assessing performance, and planning steps for improvement.
THE ESSENTIAL OBSTETRIC FUNCTIONS
3.1 The essential obstetric functions related to major causes of maternal mortality
c
The formulation of eight groups of essential obstetric functions in relation to the
major causes of maternal mortality are shown in Table 1.
The eight groups are:
1.
2.
3.
4.
5.
6.
7.
8.
(
Surgical functions
Anaesthetic functions
Medical treatment functions
Blood replacement
Manual/assessment functions
Family planning support functions
Management of women at high risk
Neonatal special care
The order in which the eight groups are presented is not indicative of their ranking in
importance. In each group the tasks outlined have all been related to either the prevention
or management of the major causes of maternal death. In this way, the interdependence of,
or the interrelationship between, each group and its tasks become evident. Almost all
causes of death are interrelated, and priorities for implementation of interventions can be
made according to the ranking of the major causes of death prevailing in an individual
country. Health planners have an option to adopt some groups or expand others, and not
necessarily all at the same time, so as to effect a gradual build—up for improvement of
maternal health care at first referral level.
3.2 Requirements for essential obstetric functions
In planning the Improvement or expansion of obstetric services, it is necessary to be
clear about the specific skills of health staff, the facilities, the special equipment, and
the essential drugs and supplies for these essential obstetric functions. In Table 2, these
requirements have been summarized for each of the essential functions, together with
guidelines for the level or kinds of staff who are considered capable of being trained to
carry out the functions. Indications of the tasks are Included.
Important points relating to specific practice and linkage between primary, secondary
and tertiary level in the health care system have been included in the column ’Remarks* and
are therefore not necessarily repeated in the main body of the text. The same applies to
requirements of staff and facilities. More complete lists of requirements are included in
Annexes 1 to 5.
TABLE 1
FHE/86.4
Page 6
EIGHT GROUPS OF ESSENTIAL OBSTETRIC FUNCTIONS
RELATED TO THE MAJOR CAUSES OF MATERNAL MORTALITY
MAJOR CAUSES OF MATERNAL MORTALITY
ESSENTIAL OBSTETRIC FUNCTIONS
Cfcstrocted
Labour
Antepartum
Haemorrhage
Ruptured
Uterus
Postpartum
Haemorrhage
and
Abortion
Puerperal
or post
abortal
sepsis
HOP
Retained
Placenta
Ectopic
Pregnancy
Severe
Anaemia
GROUP I- SURGICAL FUNCTIONS
I7 TT7
- Caesarean section
- Surgical treatment of sepsis
- Repair of high vaginal and
cervical tear
- Laparotomy for repair of
ruptured uterus
- Removal of ectopic pregnancy
presenting as acute abdomen
- Evacuation of uterus in
uncomplicated abortion
- Oxytocin intravenous infusion
for augmentation of labour
- Amniotomy with/without I.V.
oxytocin infusion
/////// 77 7 T l
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GROUP 2 - ANAESTHESIC FUNCTIONS
General anaesthesia
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GROUP 3 - MEDICAL TREATMENT FUNCTIONS
- Treatment of shock
- Intravenous total dose
iron infusion
- Medical treatment of sepsis
- Control of hypertensive
disorders of pregnancy and
eclamptic fits
rrni /
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////// /
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GROUP 4 - BLOOD REPLACEMENT
- Blood typing, cross-matching
and transfusion
CROUP 5 -
3777 TTTT .'///// / TLTLLTL
I
MANUAL AND/OR ASSESSMENT FUNCTIO'IS
- Manual removal of placenta
- Vacuum extraction
“ Pantograph
"7 / 1 1.1
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77///// /
GROUP 6 - FAMILY PLANNING SUPPORT FUNCTION'
A.
B.
C.
D.
Surgical family planning
- tubal ligation
- vasectomy
Intrauterine device (IUD)
Norplant
Other contraceptives
PREVENTION OF UNPLANNED/UNWANTED PREGNANCIES LEADING TO
MANY OF THE MAJOR CAUSES OF MATERNAL MORTALITY
GROUP 7 - MANAGEMENT OF WOMEN AT HIGH RISK
- Maternity "Villages'or
Honea
TO PROVIDE A PLACE AT WHICH WOMEN AT HIGH RISK OF COMPLICATIONS CAN WAIT
AND RECEIVE SUPERVISION DURING LAST MONTH OF PREGNANCY
GROUP 8 - NEONATAL SPECIAL CARE
- Resuscitation
- Thernal control
- Feeding
NOTE:
FOR PREVENTION AND TREATMENT OF ASPHYXIA NEONATORUM,
I NEONATAL HYPOTHERMIA A>lND hypoglycaemia
_ I__ Z_L____ L
I
Underlined above are the seven functions Identified by the Interregional Meeting of November 1985
FHE/86.4
Psge 7
TABLE 2
REQUIREMENTS FOR ESSENTIAL OBSTETRIC FUNCTIONS
AT FIRST REFERRAL LEVEL
Function
GROUP 1
Indications
Level of akilla
required
Facilities and
additional
functions
Special
equipment
or supplies
Renarks
(see Annex)
- ESSENTIAL SURGICAL FUNCTIONS
Caesarean
section
Frequent and
life-saving;
indications
include:
(a) CPD
(b) APH
(c) Previous
difficult opera
tive vaginal
delivery
(d) Previous WF
(e) Malpresentation, especially
transverse lie.
(a) Specifically trained in
the skills required, could
be obstetrician, general
duty medical officer,
medical/clinical officer
or medical assistants or
professional midwife;
(b) The decision about when
and which health worker can
perform CS should be made
by the health authorities
and professional bodies of
each individual country;
(c) This decision should
be based on:
(1) availability of
different kinds of manpower;
(2) the number of CS
required;
(3) availability of
transport for referral;
(4) properly conducted and
evaluated health system
research acceptable to
professional bodies and
the community •
Anaesthesia
Blood trans
fusion
Blood substi
tutes
Operating
theatre
Local
anaesthesia
Doyens retractor (a) Number of CS
Green Armitage
required per year to
forceps
maintain skills and
(Annex 3 A ♦ B)
justify expense;
(b) Use of partogram
at primary level to
facilitate early
referral;
(c) transport;
(d) maternity home.
Surgical
treatment of
severe sepsis.
Severe sepsis
with complicat ions;
Peritonitis,
septic shock.
Ability to perform CS
Operative
facilities
Blood trans
fusion
Equipment for
laparotomy
(Annex 3 A ♦ B)
Repair of
high vaginal
end cervical
tears .
Prevent and
treat excessive
blood loss .
As for CS
Laparotomy
for repair
of uterine
rupture.
Uterine rupture
following
neglected obst
ructed labour,
previous CS or
other obstetric
trauma.
(») The minimum is the
skill to perform CS;
(b) It should be performed
by the most experienced
person available as
hysterectomy may be
necessary.
f
I
If tertiary level is
easily accessible,
referral of severe
sepsis may sometimes
be advisable.
If
renal failure, bowel
injury, tetanus or
gas gangrene are
present, referral to
the tertiary level is
imperative. Prophylactic
antibiotics & fluid therapy
should always be given
in cases where infection
can be anticipated, e.g.
prolonged obstructed
labour, prolonged
rupture of membranes,
haemorrhage and severe
anaemia. This applies
at all levels.
Operating
theatre
Bjoqd tram
fusion or
substitute
Operating
theatre
Anaesthesia
including local
Blood trans
fusion and
substitutes
The need for
prevention rather
than treatment must
be stressed.
FIIE/86.4
Page 8
Level of skills
required
Special
equipment
or supplies
Facilities and
additional
functions
Function
Indications
Removal of
ectopic
pregnancy
presenting
as acute
abdomen .
Presenting as
acute abdomen
and the
diagnosis is
not in doubt .
As for CS
Operative
facilities
Anaesthesia
local infil
tration
Blood transfusion
or substitute
Evacuation
of uterus in
incomplete
abortion
Incomplete
abortion
Adequately trained in
the procedures and in
the recognition of
complications and in
giving emergency
treatment.
Sterilization
Blood trans
fusion or
blood substi
tute
Anaesthesia
(Analgesia)
Paracervical
block
Use of
oxytocin by
intravenous
infusion for
augments t ion
of labour -
For inefficient
uterine action
in the absence
of CPD,
especially in
cases with APH
and eclampsia .
(a) Assessment of progress
of labour and exclusion
of CPD;
(b) Carry out a vaginal
examination to exclude the
presence of CPD, make up
solution, monitor the
i.v. drip and the progress
of 1abour .
Facilities for
CS if needed
Amniotomy
with/without
oxytocin .
Severe HDP
Eclampsia
APH, especially
abruptio
placentae ■
Someone who decides on
and performs CS
Facilities
for CS
Vacuum
aspiration is
best
Remarks
Auto-transfusion is
sometimes advantageous .
(a) Digital removal of
uterine products can
be done at primary
level as a life
saving procedure;
(b) Countries where
septic abortion is a
major cause of
maternal death should
review carefully the
circumstances under
which this occurs and
adopt the most
appropriate means to
prevent these deaths.
While the procedure
itself is relatively
simple, the dangers
from mismanagement
are serious and
include uterine
rupture.
Kocher's
forceps or
amniotomy
hooks
Augmentation of labour
by oxytocic infusion
may be required.
Staff: These surgical
...
and associated skills generally require an obstetrician or general duty medical officer
but, under certain conditions, some Qf the3e ta3kg may be carrle(j out by suitably trained medical assistants/
clinical officers or professional midwives.
General facilities required:
Operating theatre
i
FHE/86.4
Page 9
Facilities and
additional
functions
Special
equipment
or supplies
(a) Delivery
room
(b) Operating
theatre
Equipment
listed in
text and
annexes
Renatka
GENERAL OR LOCAL ANAESTHESIA
CROUP 2 -
Anaesthesia
general
Staff:
Level of skills
required
Indications
Function
Operative
deliveries
Specific training in
skills required .
Any doctor, professional nurse or medical assistant/clinical officer with appropriate training.
General facilities required;
Operating theatre .
GROUP 3 - MEDICAL TREATMENT FUNCTIONS
c
Intravenous
total dose
infusion
of iron
Severe irondef iciency
anaemia and
women who have
had major
blood loss .
Calculate correct dose; set
up i.v. infusion; detect
and manage complications.
Laboratory to
Iron dextran
test haemoglobin preparation;
or haematocrit
Promethazine
and read blood for allergic
film ;
reactions
Resusci tat ion
equipment.
Management
of severe
HDP and
eclampsia
Severe HDP
Eclampsia
Measure blood pressure
Urinalysis
Set up i.v. infusion
Emergency treatment of
convulsions
Recognize complications,
e.g. renal failure
"Eclamptic"
room
Resuscitation
equipment
Diazepam
Hydrallazine
Frusemide
Management of
uncomplicated
sepsis
Puerperal sepsis
Post-abortal
sepsis
Mild sepsis
Anyone capable of
conducting a delivery
and allowed to
give intravenous therapy
Management
of shock
due to
haemorrhage
Haemorrhage and
obstetric shock
Monitor vital functions,
including urinary output.
Blood cross
match
Management of
cause of
haemorrhage
Blood or
blood substi
tutes
c
Primary level should
be able to initiate
treatment with
diazepam .
Staff:
These functions are usually carried out by doctors, but may also be carried out by professional midwives or
medical assistants/clinical officers who have had adequate training.
General facilities required:
GROUP 4
BLOOD REPLACEMENT
Blood
transfusion
Staff:
Maternity ward, delivery suite, operating theatre.
(a) Operative
deliveries;
(b) Severe
anaemia;
(c) haemorrhage
Laboratory technicians
or physicians or health
worker, all with necessary
skills.
(a) Direct
donor/patient
cross-match;
(b) transpor
tation of donor
blood from a
regional or
national centre;
(c) maintenance
of small local
blood-bank.
Any doctor, health worker or laboratory worker with appropriate training.
General facilities required:
Laboratory .
For (a) and (b)
see list of
equipment in
annex; for (b)
refrigeration
for vehicles
and transportation; for (c;
refrigeration.
(Annex 4 A ♦ B)
This is an absolute
life-saving tool,
but it carries hazards,
the frequencies of
most of which are
not known in the
obstetric practice
of developing
countries. The type
of service required,
whether (a), (b) or
(c) will depend on the
number of transfusions
required, the
availability of skills
and requirement and
ease of transportation.
FHE/86.4
Page 12
3.3 Commentary on essential obstetric functions (see Table 2)
3.3.1
Group 1 - Surgical functions
Caesarean section: Caesarean section, together with the circumstances surrounding it, holds
the_moBt Important keys to the whole question" of maternal mortality in developing
countries. On the one hand, the maternal pregnancy complications necessitating caesarean
sections (e.g. obstructed labour, antepartum haemorrhage and severe pregnancy-induced
hypertension) are among the commonest causes of maternal mortality. On the other hand
caesarean section performed for neglected emergencies necessarily has a much higher
mortality than elective caesarean section or those performed in less dire circumstances.
Morbidity and mortality after this operation depend to a very large extent on the state
o health of the woman who is to undergo the operation and on the condition of the fetus In
uter£ just before the operation is performed. If a pregnant woman develops a compllcation~~
and yet the condition of the baby in utero is still good, this means that the complication’
is at an early stage, and that its effects are not sufficiently serious to impair either
maternal or fetal health. If the operation is performed at this stage, there will be fewer
technical problems, anaesthesia will be straightforward, blood loss will be minimal and for
its replacement, Intravenous fluids will suffice and blood transfusion will probably not be
needed. Most elective caesarean sections and about half of all emergency caeserean sections
come under this category. Caesarean section is comparatively easy to perform under these
circumstances. Even in the hands of health personnel with limited operative skill, the
operation is quite safe, and afterwards, post operative complications will be few and even
when such complications develop the chances are that they will not threaten the life of the
affected woman. However, when a pregnant woman develops a complication needing operative
delivery she may be dehydrated and acidotlc,, and
and the
the complication
complication may
may be
be advanced.
advanced, In this
case there is every likelihood that the operation will be technically difficult to perform,
and the risks fzzz.
from this source and from complications afterwards, will be high. Under these
circumstances, the most experienced health personnel available imust perform the operation,
If the operation is being performed to relieve obstructed labour, haemorrhage is likely to
be profuse, and to arrest it, hysterectomy might even be required. Afterwards, pelvic
sepsis, peritonitis and paralytic ileus may all prove fatal. ’
Injury to the bladder and
ureters are additional hazards and such injuries may result in urinary incontinence and1 even
death, There are additional dangers for women who are undergoing repeated caesarean
sections. Intra-abdominal
T ’
' ‘
adhesions resulting from a previous caesarean section may distort
the anatomical relationships
. in the area around the uterus and thus complicate the operation.
If efficient primary obstetric care with a functioning referral system exists, it will
add considerably to the safety
section.
‘ will be enhanced by the
. of caesarean -This safety
use of
ot partographs for monitoring labour, especially in
In the presence of cephalopelvic
disproportion (see notes on the partograph later in this chapter).
Instruments for caesarean section are listed in Annex 3 A under standard laparotomy set,
to which must be added the special instruments shown in
Table 2.
£ur^ical treatment of sepsis: This operation ranks among the important life-saving surgical
functions. It may involve more than drainage of pelvic abscess. When adhesions are present
in the^peritoneal cavity the risk of injury to bowel or bladder is quite high. If, however,
renal failure, bowel injury, tetanus or gas gangrene are present, referral to tertiary level
is imperative.
Repair of high vaginal and cervical tear; The
*“
operation is fairly straightforward unless
the cervical tear extends upwards to Involve the lower uterine segment in which case, a
hysterectomy may be the only means of controlling the bleeding.
Laparotomy and treatment of uterine rupture: Some comments have been made on the subject of
uterine rupture in discussing operative deliveries in relation to obstructed labour. In
places where pelvic contraction is common, and the standard of obstetric care is poor,
especially at the community level, the health services can expect to handle one case of
uterine rupture for every twenty caesarean sections. Whether the operative treatment is by
)
FHE/86.4
Page 13
repair of the rupture or by hysterectomy, the maternal mortality rate associated with this
complication can be as high as 20 per cent. As In the case of caesarean section, women who
have received full prenatal care rarely die from uterine rupture.
Removal of ectopic pregnancy presenting as acute abdomen: Delay in treatment la
particularly dangerous, and death can only be averted by arresting haemorrhage through the
removal of the ectopic pregnancy, securing haemostasis and replacing the blood loss.
Evacuation of uterus in abortion: Much of the statement made about the need for rapid
removal of the placenta or retained products of conception (see page 21) also applies to
cases of incomplete abortion, whether these are induced or spontaneous. Once evacuation is
complete, rapid recovery is usual in the majority of cases. Continuing ill health after
evacuation points to the fact that the abortion is complicated, and that there might even be
serious injuries to the genital tract, and even to the urinary bladder and gut in case of
illegal abortions. In such cases care in well-equipped hospitals is necessary if the
affected woman is to survive. The essential istruments for evacuation of uterus are listed
in Annex 3 F.
c
Intravenous oxytocin infusion for augmentation of labour: Treatment by oxytocin infusion
should only be carried out in a facility which is equipped to perform caesarean section.
The safety of this procedure depends largely on the dosage. The most dangerous complication
of the use of oxytocin infusion is uterine rupture.
Amniotomy with/wlthout intravenous oxytocin: Suitable instruments are necessary for this
relatively simple procedure to be performed efficiently. Even so the danger at this stage
is to the fetus because of cord prolapse. Maternal risk associated with this procedure is
Intrauterine infection, which is not difficult to prevent by the use of prophylactic
antibiotics.
(
Craniotomy: This obstetric operation merits discussion here as it might save a woman's life
as an alternative to caesarean section in certain areas and circumstances. Craniotomy is
performed mainly to relieve obstructed labour due to cephalopelvic disproportion in cases
where the baby is dead. However, the maternal death rate associated with craniotomy is one
of the highest in operative obstetrics and it must never be undertaken lightly. The degree
of technical skill needed to perform this operation with safety is in general greater than
that which is required for uncomplicated caesarean sections. Uterine rupture may complicate
the operation, requiring innnediate laparotomy and thus greatly increase maternal mortality.
For all these reasons and because, as obstetric services improve, need for craniotomy
decreases rapidly, it is not included as an essential obstetric function here, (Items for
this operation are listed in Annex 3 E, however, recognizing that sometimes, in a few
countries, the circumstances are so adverse, but the operative skills are sufficient and the
indications are sufficiently frequent, that the operative skills required can be maintained
through use.)
Symphysiotomy: Symphysiotomy (not included in Tables 1 and 2), is a useful alternative to
caesarean section in geographical areas where cephalopelvic disproportion is common. In
places where women may not return for future delivery after caesarean section, the advantage
of symphysiotomy is that by leaving the uterus intact, it avoids future obstetric deaths
from rupture of uterine scars. However, there are significant orthopaedic hazards, pain on
walking and abnormal gait, and the procedure should never be done unless the operator is
skilled in the technique, Eventually symphysiotomy should be completely abandoned in favour
of caesarean section.
3.3.2
Group 2 ~ General anaesthes1a
When discussing general anaesthesia, a clear distinction must be made between the
problems of anaesthesia in women in good physical condition and the problems in those who,
in spite of being in poor physical condition, still require general anaesthesia. In the
former, the essential features to be observed are the maintenance of a clear airway, the
avoidance of hypertension and the replacement of blood loss by intravenous infusions, blood
substitutes, or by whole blood.
FHE/86.4
Page 16
the attendant risk of aerloua transfusion reactions. The decision to transfuse with blood
or ita products, rather than employing plasma expanders, should be based on sound
physiologic grounds given the dangers of the former.
Solution to these problems of blood donation, storage and maintenance of adequate
supplies can be made to apply at three levels. In the case of rural hospitals, blood
grouping and direct cross-match of the recipient and donor blood, and the Immediate
transfusion of the donor blood may be all that can be possible. The equipment needed is
listed In Annex 4 B. The Immediate and especially the remote risks of transfusion are
considerable. It is under these circumstances that disease transmission Is a real risk,
especially in places where syphilis, hepatitis B viral infections and AIDS are common, In
many parts of Africa, the carrier rate for hepatitis B virus Is as high as 10 per cent
compared to only 0.1 per cent in developed countries. Most diseases transmitted through
blood transfusion are manifest several weeks or months after the transfusion, so, when
hazards such as hepatitis occur the patients seek help or die elsewhere without being seen
by the health workers who were responsible for the initial blood transfusion.
Another option is to maintain a small storage facility at the first referral level.
Domestic refrigerators are suitable for this purpose, but refrigerators which open at the
top are preferable to cabinet refrigerators.
For maximum safety, there is no doubt that the establishment of a national blood
transfusion service, with blood banks at tertiary hospitals is the best prospect. Blood
from this source can then be transported at weekly Intervals to replenish the stocks held in
domestic refrigerators in the first and second referral hospitals. The success of this
scheme relies heavily on the development of basic infrastructure, particularly
transportation, and on sophisticated technical support.
3.3.5
Group 5 - Manual and/or assessment functions
The tasks of group 5 include manual and assessment skills which, even though they are
part of surgical skills, do not need the same level of specific skills as required for group
1. Vacuum extraction and forceps delivery, even though not life-saving for the mother, play
a role in prevention of morbidity and can be life-saving for the fetus.
Manual removal of placenta: The need for this life-saving procedure can arise following any
vaginal delivery, and the IWC recommended that midwives should be trained to carry it out.
The longer the placenta is retained, the greater are the hazards, death in these cases being
due to shock from haemorrhage and infection. The best results are obtained where manual
removal of the placenta is carried out within the first hour after delivery.
There are, however, circumstances where the placenta may be retained for forty-eight
hours or longer before the woman reports for treatment. In such cases, severe anaemia and
septicaemlc shock are the dominant problems, and management is best provided at the tertiary
level of health care.
Vacuum extractor: Vacuum extraction is used to expedite vaginal delivery in certain
circumstances where, either through physical exhaustion or in the presence of ill health
(e.g. HDP), the woman in labour is unable to achieve vaginal delivery by her own efforts.
Similarly, in cases where towards the end of labour, a baby shows signs of distress while it
is still in its mother’s womb, vacuum extraction can effect rapid delivery of the baby and
so save its life. Annex 3 D lists the essential items of equipment for this procedure. In
relation to maternal mortality, the vacuum extractor has one Important advantage which none
of the other forms of operative delivery possess. Maternal hazards of extraction are rarely
fatal, whereas the same Is not true of any of the other operative deliveries. Another
reason for its safety lies in the fact that while undergoing this operative delivery,
special preparations, including Inhalation anaesthesia are not required. Adverse climatic
conditions and lack of accessories may create problems In keeping the Instrument in good
working order.
Forceps delivery: The Indications for forceps delivery are broadly speaking the same as for
vacuum extraction. Low cavity forceps delivery is a good alternative to vacuum extraction.
/
FHE/86.4
Page 17
Situations not infrequently arise where the the vacuum extractor may not be in good working
order when needed urgently, in which case a pair of Wrigley’s forceps can be used to affect
delivery of the baby. However, the degree of skill required for its use is much more than
is the case with a vacuum extractor.
c
Partograph (labour graph): The major difficulty with the prevention of prolonged and
obstructed labour Is the accurate recognition of the degree of cephalo-pelvic disproportion
(CPD), either antepartum or during labour. A partograph is meant to display the essential
features of labour against the passage of time during the first stage of labour. The three
major findings recorded on the graph are: fetal condition, labour progress, maternal
condition. These provide a visual display of the progress of labour and immediately alert
the attendant to abnormal development. In this way the labour graph acts as an "early
warning system" for the detection of CPD. It is a useful tool in the management of labour
at all levels of maternity care in many countries, and, used in peripheral clinics, has
contributed to reduction of prolonged labour and its sequelae because of earlier referral
than was previously the case. Its value in relation to the termination of labour by
caesarean section has already been mentioned. Midwives of all levels can be taught to use
and interpret partographs correctly. After implementation, continued use in the periphery
with resulting reduction of prolonged labour, maternal morbidity and perinatal mortality,
needs encouragement and regular supervision by the first referral level, which includes
discussion of cases and feed-back on referrals.
3.3.6
Group 6 - Management of women at hlgh r1sk
Results of supervision of pregnancy are optimal when prenatal clinics are supported by
hospital beds, particularly for those women needing special care during pregnancy or labour.
I
Maternity "villages" or homes: A maternity village or home close to or within the grounds
of the district or provincial hospital should form an important part of maternity care in a
rural setting where distances are far and transportation is poor. Through health promotion
and education community participation should be encouraged in building and maintaining such
a home and organizing transport for referral. The home is intended for pregnant women with
risk factors. The first group of such women should be those who have major obstetric
abnormalities and for whom operative delivery is anticipated, but whose homes are in remote
and inaccessible rural areas. Such pregnant women having received prenatal care at their
local primary health centres in the first eight months of pregnancy, are then transferred to
the maternity village to continue receiving prenatal care, and to await either elective
operative delivery or transfer to the labour ward as soon as labour starts. Pregnant women
with previous caesarean sections, previous repair of vesicovaginal fistula, and those at
risk of obstructed labour are the commonest occupants of the maternity village. Each
pregnant woman transferred from her home to the maternity village is usually accompanied by
one or two relatives. The hospital should bear the cost of providing water and also fuel
for cooking, as well as space for laundry. The accommodation should be self—catering to
allow for differences in nutritional habits and customs.
Unpublished reports indicate that matenity villages properly run and supervised, are
very effective in preventing the complications of obstructed labour, especially uterine
rupture and obstetric fistulae. Unfortunately, documented reports on the work of maternity
villages are rare. More attention should be focussed on this little known, but highly
important area of obstetric care at the first referral level in rural hospitals, and the
results should be evaluated and published.
Prenatal Care: Prenatal care is an Important obstetric function at all levels of health
care, primary,
] *
secondary, or tertiary, and everything possible must be done to promote it.
Since it is mainly a function
f
at the primary level, it is not mentioned further here, except
to say that the first referral level, like all
’’ others, must .provide it as part of its
educational and preventive work; and that at this level it can sometimes serve as an
example of the expected standards of quality of care and as a training centre for this
activity.
FHE/86.4
Page 18
3.3.7
Group 7 - Family planning support functions
Family planning has been included in essential obstetric functions because advances in
prevention and reduction of maternal mortality from all major causes are partly dependent on
progress in family planning. For example, where maternal mortality from illegal, unskilled
abortion is high, contraception is the first line of defence against unwanted pregnancy,
particularly those occurring in teenagers or multlparae. Delay of first pregnancy will
reduce mortality and resulting morbidity from obstructed labour where this is common. High
parity women often enter pregnancy at a disadvantage from repeated childbearing and are
consequently at greater risk of death, e.g. anaemia, haemorrhage, sepsis and rupture of
uterus, and control of grand-multiparity through appropriate family planning can be expected
to reduce the number of deaths among such women.
It is clear that family planning is an essential part of total health care and must be
introduced in an appropriate manner into all preventive and curative care programmes at all
levels. The aim must be to make family planning services widely available and to provide a
high standard of care, The latter is particulary important if acceptance and continued
attendance is to be encouraged and maintained, All training schools for health
professionals should ensure that their graduates have a thorough understanding of
determinants and implications of human fertility, and have a high degree of competence in
counselling, providing and supervising family planning services. Family planning
counselling should be an Integral part of prenatal and postnatal care. There are certain
family planning activities however, especially those of a surgical nature, which require
either to be performed at first referral level, or like IUD and Norplant Insertion and even
provision of oral contraceptives, should be performed at primary level but benefit from
back-up and support at first referral level also. Hence their inclusion at this level is
Indispensable.
A.
Sterilization
Sterilization is the most effective of all family planning methods. The procedures are
relatively simple and safe and any risk must be weighed against the risk of pregnancy
itself. The advantages and disadvantages must be explained very carefully in view of the
virtual irreversibility of many sterilization procedures. In assessing male and female
sterilization procedures it Is evident that there are certain differences in the context of
skills, facilities and supplies. Female sterilization requires an operating theatre, more
staff, more surgical equipment and general anaesthesia. Male sterilization can be performed
in less time, requires less equipment and can therefore be done also in remote rural areas.
Mini-laparotomy for tubal ligation is well established and the instruments needed are
listed in Annex 3. The technical aspects of these procedures are well known and documented
in a WHO publication^. Tubal ligation can, of course, be carried out in the course of a
laparotomy for other reasons, e.g. in women admitted as emergencies with uterine rupture or
women undergoing caesarean section.
Fears still exist about contraception, more so about vasectomy than in any of the other
methods. Therefore comprehensive counselling is especially important in readily
understandable terms. Essential information for couples contemplating sterilization by
vasectomy should include details and effects of the operation, post-operation fertility,
tests for sterility and post-operative contraception. Equipment for vasectomy is listed in
Appendix 3 I. WHO Guidelines for vasectomy are in press.
Clinical services for induced abortion have not been mentioned separately in Group 7.
Whether such services should be provided depends entirely on the individual country’s laws,
national health policies, priorities, needs and resources. Requirements of skills and
facilities will correspond to those listed in Group 1 under evacuation of uterus in
uncomplicated abortion. Detailed information on provision of care and services for Induced
abortion are available in a WHO publication^.
B.
Intra-uterlne contraceptive device
FHE/86.4
Page 19
C.
Norplant
D.
Other contraception (oral)
For family planning services to reach the whole community they must be widespread.
Insertion of IUDs, distribution of oral and barrier contraceptives should, of course, not be
limited to secondary care. However, they have been recommended here as an essential
function at first referral level for two reasons: firstly, to emphasize the availability of
services where appropriate facilities at primary care level do not exist; secondly, to
provide clinical back-up services for a peripheral family planning programme.
The skill of the person performing the IUD insertion, the quality of counselling,
selection, reassurance and follow-up are important determinants for the success of an IUD
programme. Studies from developed and developing countries show that nurses, midwives,
PHC-workers and rural village midwives can perform routine IUD Insertion very well. For
further details, see Table 2.
The insertion and removal of Norplant requires appropriate clinic facilities.
Information should be given on all aspects of the method, including access to removal, the
procedure itself and alternative methods of continued contraceptive protection. Health care
providers, both doctors and other health personnel can easily be trained to insert and
remove the capsules?.
Aseptic techniques must be observed for insertion of IUD or Norplant and will thus form
one of the conditions for the health care facility in relation to provision of these family
planning procedures.
Requirements for IUD insertion are listed in Appendix 3 G. Guidelines on IUD and oral
contraception have been written up extensively by WHO®*^
WHO Guidelines on the
implantation and removal of Norplant are in preparation.
3.3.8
Group 8 - Neonatal special care
Neonatal special care has been Included as maternal and newborn care are inseparable in
the discussion on requirements for essential obstetric functions. When wishing to up-grade
maternity care at this level, it would be unrealistic in practical terms if the planner did
not consider at the same time the requirements for looking after the newborn, often in
sub-optimal condition when these have survived as the products of high risk pregnancies or
complicated labours.
Some neonates - particularly those which are premature, dysmature or have been subject
to stress in obstructed labour - may suffer from severe asphyxia and are particularly
vulnerable to environmental temperatures below 20°C, which may result in hypothermia.
These conditions are mutually aggravating and can in turn result in neonatal hypoglycaemia.
Prompt and efficient resuscitation and maintenance of body temperature are essential, not
only for survival of the infant but also for the prevention of sequelae from birth trauma.
For this reason basic resuscitation equipment in good working order must be available in the
labour ward, together with an oxygen supply and a heat source. All health professionals
should be trained in newborn resuscitation methods as the quality of life of the infant
depends on proficient resuscitation<
4.
IMPLEMENTATION
4.1 General remarks
Decisions on the implementation of any or all of the recommendations in any particular
country will depend upon circumstances at national, regional and local levels. Needs vary
between and within countries both in terms of the size of the maternal mortality problem and
the relative importance of the different causes. Septic abortion is a major cause of
maternal death in many countries and requires serious consideration of the ways of
FHE/86.4
Page 20
Differing emphasis, therefore, may
individual functions.
Population density, the site and distribution of settlements, communications, and the
■ 3 and numbers of
availability of transportation vary from place to place and• the types
will all determine the ways in which the
essential obstetric services through a 1-------The most important of these considerations are discussed below.
4.2
Health manpower
based on two
“ j’s homes as possible,
by the least trained person
and second, that any health care procedure should be carried out 1,
who is competent to perform it safely and effectively.
of the essential functions according to the levels and types of skills
The grouping
requlredhs
considered very important because it allows a more tational allocation of
countries, foins
functions to different types of health personnel.. In some countries
c ,
manual
removal
of
placenta;
midwifery staff have not been permitted to do «
workers of
normal part of the practice c- ---countries, such a vital procedure s a norma p
partograph, manual removal of
comparable levels of training and experience. rThe
m
_ K which,
*..^use
-- - of the partograpn,
.
~ - c.CTnont
cv4ii
the placenta and the use of the vacuum extractor involve manual and assessment SKllls wmcn
The group felt that these functions should
are basic to the work of all trained midwives,
therefore be included in the competence of
c. all
-- trained midwives.
functions in Group 3 require more arithmetic skills and a Boater
The medical treatment
abnormal physiology and basic pharmacology. These are certainly
understanding of normal and ; , and in many countries, professional midwives and medical
normal functions for doctors; are routinely trained to carry them out. In the same way the
assistants/clinical
officers of Group 1, like caesarean section and the repair of high
«sentlai“surglcal functions
vlHnal or cervical tears are carried out by obstetricians. However, in many countries
they .eeld he con.lder.d
p.rt el eh, wort cd
“J"’
perform such functions.
of the health team is very important at the first referral level. Any
The concept
expand essential services further to the periphery may impose a strain on t e
attempt to
- - -- , especially those with higher levels of training. If a doct
supply of available manpower,
j
«- frKo firct rpfprral level, there will be many demands, not
is to 1be
— the no
-- ^nS^isO^rP"8r°tIme and energy. For the efficient running of the obstetric
just obstetric,
"therefore, it is very important that he or she be able to delegate as much of the
service,, tnererore,
-7
------ competent to accept. In such a situation,
work to the midwifery and other staff as they are
y maximize the potential of each kind of health worker by
therefore, it is imperative tocertain
u.
level of competency, they are trained to perform all
ensuring that if they have a
the relevant tasks in that group of functions.
This approach has the advantage of extending the skills of existing staff without
.. .r.T
—lU'-X:;-.1:
there will be the need for changes in basic training p 8
adequate in-service training for staff already^orklng l^the field.*^^^^^“/heaUh
advantage of this approach is that i
upon them.
effects.
first referral level, but
This will also reduce the work load at the tertiary level, wit
TBE/Bb.k
Page 21
4.3 Physical facilities
General considerations. At the first referral level, the services should be based in
centres, designated as maternity centres.
In planning the necessary physical 'facilities, knowledge of the work load envisaged is
critical. It is Intended that the facilities should cater for all the abnormal deliveries
taking place in a catchment area with a total population of 100,000 people, together with a
fair proportion of women with pregnancy complications, and others who are self-referrals.
In trying to arrive at a reasonable estimate of the number of abnormal deliveries, certain
assumptions are being made. The first is a crude birth rate of 40 per 1,000 population each
year; the second is that 5 per cent of all deliveries will be assisted or operative
deliveries; and the third is that at least half of the operative deliveries will be
caesarean sections. These estimates are based on reports from various areas in developing
countries, in particular India and Africa. Working on the above assumptions, each year we
should expect in the catchment area some 4,000 deliveries, of which 200 will be operative
deliveries and 100 caesarean sections. Some of the spontaneous deliveries, and all of the
operative deliveries will be conducted at the maternity centre, but the important point here
is that, on average, each week the maternity centre will carry out two caesarean sections.
(
(
Specla1 points about physical facl11tles . The description of the maternity centre which
follows is not intended to cover all the physical characteristics of each component of the
maternity centre(s). Rather, the aim Is to highlight the principal features. Two of the
components of the maternity centre(s) are the maternity ward and a delivery suite. The
others are a maternity home or ’’village" and an outpatient section which will include
facilities for family planning. For construction of special facilities the reader is
referred to a WHO publication^ .
Maternity ward, The only way in which the basic functions of the maternity ward differ from
those of a general ward is that it accommodates not just pregnant women and delivered
mothers but also their newborn babies. A total bed complement of 24 beds will suffice. If
25 per cent of the hypothetical number of 4,000 deliveries per annum are high- risk or
referred for delivery the ward should be capable of giving delivery care to 1,000 women, If
each patient stays on average five days in hospital, taking into account that some may stay
longer because of complications, each bed can accommodate sixty patients per year. A
maternity unit doing 1,000 deliveries per year needs 17 beds if this standard is adhered
to. A varying number of additional beds are needed for prenatal patients. Suppose that one
prenatal to three postnatal beds will suffice, an additional six beds will be needed. The
total number of obstetric beds for a unit which conducts 1,000 deliveries a year should thus
be at least 25 beds, Eight are for septic cases following delivery or abortion, while the
remainder are for prenatal and postnatal women, The proportion of beds assigned to prenatal
and postnatal women should remain flexible. Ideally, the septic and clean areas of the
maternity ward should be separate and they should not share anything in common, the aim
being to minimize the risk of the spread of infection from the septic ward to the occupants
of the clean ward, especially the newborn babies. In some countries this particular need is
rarely met. A useful compromise will be to make available extra washing facilities
throughout all sections of the maternity ward.
Because newborn babies will be nursed in cots alongside their mothers, enough room has
to be provided for this as well as for the usual medical and nursing functions. Therefore,
the distance between the centres of adjacent beds should be between 2.0 and 2.4 metres, and
the bed ends should be about 2 metres apart.
Delivery suite. From the nature of the function it serves, the delivery suite should have
easy access to both the operating theatre and the maternity ward and it should be close to
one of the main entrances to the hospital itself. Special accommodation required are a
first stage room, a delivery room, an eclamptic room, a recovery room, and space for
resuscitation of the severely asphyxiated baby.
Six beds will be sufficient for the first stage room, and one delivery bed in the
delivery or second stage room. Occasions will arise when some deliveries will have to be
conducted on beds in the first stage room. As far as possible, the necessary privacy must
COMMUNITY HEALTH CELL
326. V Main, I Block
Koramangala
Bangalore-560034
India
FHE/86.4
Page 22
be observed by the use of mobile screens. Operative vaginal deliveries not needing general
anaesthesia can all be safely conducted in the delivery room, which should also accommodate
at one of its corners, space for resuscitation of the asphyxiated newborn baby. Separate
from the delivery room, but equal in floor space is the eclamptic room with enough space to
provide intensive care for one patient and to conduct assisted vaginal delivery.
Recovery room.
room. Very
Very early
early discharge
discharge from
from hospital,
within o-ix
6-12 hours
Recovery
hospital, witnin
nuurt, after normal delivery,
To
is very popular —
with
h women
women in
in developing
developing countries.
countries. All
All that
that is
is required
required in
in such
such places,
places, is
that somewhere adjacent to the delivery room, or close to it, is set aside a room with 4-6
beds, for recovery after normal delivery, and from whence the delivered mothers and their
newborn babies can be discharged home. 1Early discharge from hospital has obvious merits.
Ideally, therefore.
but the risk of puerperal and neonatal complications will always exist,
Such
early discharge should be combined with domiciliary care by community nurses,
arrangements rarely exist because of staff shortage.
Side ward laboratory. Only
Only one
one side ward laboratory is necessary in the maternity centre,
and "thIs side ward laboratory should be in the labour ward because this is the location
where the need for the services of a side ward laboratory are greatest. The measurements
and tests to be carried out are as follows:
(a) haematocrit (or haemoglobin values);
lueairf,
and
preparation
of
smears of other body fluids such as
(b) blood counts and smears
(c)
examination
of
the
urine
for abnormal constituents such as
cerebrospinal fluid;
( ,
protein, sugar, acetone, bilirubin and urobilin;
fd'J
(d) blood grouping and blood cross
matching.
Details are provided in the annexes.
Outpatient
The
The organization
organization of this section of the maternity centre is geared
Outpatient services^.
services.
towards early prevention and detection of most of the important complications which cause
maternal mortality and morbidity, and towards health education. Another important facility
provided will be for family planning. Not all women can be seen at the same time in the
consulting and examination rooms, and for this and other reasons, a large waiting area or
hall that can accommodate up to 200 women and their relations, including husbands and young
children, is necessary. This waiting area will also be used for health education and for
Supporting facilities should include sanitary
demonstrations given by the nursing staff,
facilities, jprovision of drinking water and good ventilation, among others.
Matern1ty village or home.
Functions.
This has been is discussed under Group 6 of the Essential
o theatre
■
,, This is an essential component of the obstetric services, and although
Operating
is'shared with other areas in the hospital, it is still necessary to include in this
its use
----information about the operating theatre. The equipment that is necessary is shown in
report
the annexes.
4.4 Equipment, supplies and drugs
The recommendations made regarding equipment, supplies and drugs are listed in Annex 2
-511 and the WHO list
to 5.
For their compilation we irelied heavily on UNIPAC catalogue 1986
It needs to be stressed that the supply of consumable items should
of essential drugs
There should still be
not be allowed to run out*: before orders for fresh supplies are made,
eight months when fresh orders are placed.
enough of them to last for
1
Supervision
The functions that have been included in the list of essential obstetric functions are
It has to be recognized, however, that
there because they are essential and llfe~saving.
many of them, especially in emergency situations
i--------- or where problems have been neglected, do
carry inherent risks. The
in order to maintain and develop
The Importance
Importance of
c- supervision
-----Periodic
by the nearest obstetrician
standard of skills cannot be over-emphasized. 1------ visits
--first
referral
level
in
order
to
review cases, discuss
or midwifery supervisor to the 1--- ------’* » are adequate help
referrals and problems, and ensure that facilities, equipment and supplies
The
other
method
found
invaluable in
to maintain morale as well as technical competence.
of
skills
is
the
provision
of
written
standing
orders or
many countries for the maintenance
instructions for carrying out different procedures as agreed upon by senior professionals.
FHE/86.4
Page 23
4.6 Evaluation
It is expected that the extension of essential obstetric services will have an impact on
the health care of women. Simple reporting systems at both primary and the first referral
level will indicate the numbers of women from the local population making use of obstetric
services. Any Increase in coverage that has occurred can then be calculated. The
proportions of normal and complicated deliveries at the first referral level will give some
indication of whether or not complicated cases are reaching that level. For instance, in
many populations 5 per cent of all pregnant women are delivered by caesarean section, If
the percentage of caesarean sections at the hospital or centre is found to be significantly
less, it probably means that there are problems to be Identified and remedied. Finally, a
careful recording of the outcomes of all complicated deliveries will indicate if the
effectiveness of the service is improving or not.
4.7 Research
The consideration of this list of essential obstetric functions, and the requirements of
skills and materials for their performance has highlighted the need for further research.
Appropriate technology research is needed to produce such things as simple, inexpensive
methods for detecting and measuring anaemia, durable tubing for vacuum extractors, and
simple, effective partographs for use at primary level. Health systems research is needed
into the delegation of obstetric functions to non-physician health workers and to more
peripheral health facilities.
4.8 Cost and financial considerations
Useful information on the components of costs of building has been provided in Kenya,
thus:
352
Primary building structure
252
Secondary structure and finishes
152
Equipment and furniture
112
Electrical
82
Plumbing
42
Mechanical
22
Sewerage
Ideas on the overall cost of providing maternal health care for the whole of the third
world. based on something like the model described here, were given by Taylor and Berelson
197113
The figure they came up with was an annual per capita cost varying between US
Dollars 0.32 and 1.65 in the 1970s. The overall average cost per annum per capita was US$
0.60, or about US$14 per pregnant woman. At that time Taylor and Berelson estimated that
"the total bill for the whole of the developing world would come to just under US$ one
billion per year, including both amortized capital and operating costs”. Maintenance costs
per year could take up about a third of the capital cost, Allowing for inflation the
equivalent global cost in 1986 would be $2.6 billion. While one cannot generalize over
costs at least the following points could be borne in mind:
(i)
What is envisaged in this report does not, in most countries, entail a large
nunber of new district and sub-district hospitals. Rather it implies a mixture
of some new establishments with the up-grading of others, such as good health
centres in appropriate sites. The latter may well be the majority. Even
up-grading must cost money, but the community and local authority may well
contribute voluntarily, at least in labour and possibly also in cash or kind.
(ii)
Equipment also costs money, but in poor countries missions or other
non-government organizations often find equipment such as operating tables,
electricity generators, etc. one of the easiest things for which to raise money,
being tangible and obviously needed.
h
FHE/86.4
Page 24
(ill) On the other hand, isupplies, and all other recurring costs, whether maintanance
costs, whether maintanance
of buildings, of vehicles, or fuel or salaries, deserve
to be planned for
carefully in advance and a source of funds secured, whether central
----- 1 or provincial
or district government funds,, or fee for service,
or a mixture of any or all of
these.
(iv)
In respect of personnel, while again it is the up-grading and better use of
existing staff which is most necessary, a significant addition to total workload
of the service will entail
possibly some increase in remuneration^ ^srortla^g^n-sLvIce^ra^ing
and of supervision
--- j to be budgeted for also.
---- needs
(v)
Efficient referral being an essential element some
advisable, as well making use of community effort , budgeting for transport is
and the goodwill of other
departments.
(vi)
For maternity waiting homes or ’’’’villages
villages’’’’ r.near the hospital here community effort
should play a large part, the accommodation.1 to be provided resembling something
like a. "model
’’model*”’ home of ordinary people,
people. The clients should provide their
‘ own
food, and
only some
maintainance —
auu only
some maintainance,
water- supply and fuel, general cleaning of"the
site, <::
"!eded - —
S—ent or non-governLnt
organizations or by the community.
From these considerations c~one -may -see that the cost of providing essential obstetric
care at the first referral level
i
-x_l may—
vary - greatly even from province to province and
country to country according to the'administrative
-------- j and managerial skills deployed and the
community support enlisted.
FHE/86.4
Page 25
5.
REFERENCES
1.
Prevention of maternal mortalit
Report of a WHO Interregional Meeting,
Geneva * 11-15 November 19857 UNO document FWE/86.1
2.
Kwast B.E., Kldane-Mariam W., Saed E.M., Fowkes F.G., Epidemiology of
maternal mortality in Addis Ababa: a community-based study.
Ethiopian Medical Journal, 23(1); 7-16 (1985)
3.
Harrison K.A., Child-bearing, health and social priorities: A survey of
22,774 consecutive hospital births in Zaria, Northern Niveria.
British Journal of Obstetrics and Gynaecology, 92, supp. to No.5 (1985)
4.
Khan A.R., Jahan F.A., Begum S.F., Jalil K. , Maternal mortality In rural
Bangladesh. World Health Forum, 6(4): 325-328 (1985)
5.
Female sterilization: Guidelines for the development of services.
WHO Offset Publication, No. 26, 1980
6.
Induced abortion: Guidelines for the provision of care and services.
WHO Offset Publication, No. 49, 1979
7.
Facts about an Implantable contraceptive: Memorandum from a WHO meeting.
Bulletin of the World Health Organization, 63(3): 485-494 (1985)
8.
Oral contraceptives. Technical and safety aspects.
WHO Offset Publication, No. 64, 1982
9.
Intrauterine devices: their role in family planning care.
WHO Offset Publication, No. 75, 1983
10. Kleczkowski B.M., et al.. Approaches to planning and design of health care
facilities in developing areas. WHO Offset Publication, No. 91, 1985
11. UNIPAC, UNICEF plads - Freeport - DK-2100 Copenhagen, Denmark.
(Telephone: 01-262444/Cables: UNICEF COPENHAGEN/Telex: 19813)
12. The use of essential drugs. Second report of the WHO Expert Committee.
Technical Report Series, No. 722, WHO, Geneva, 1985
13. Taylor H.C. and Berelson B., Comprehensive family planning based on
maternal/child health services. A feasible study for a world program.
Studies in Family Planning, 2: 22-54 (1971)
FHE/86.4
Page 26
ANNEX
1
PHYSICAL SPACE
A.
MATERNITY WARD
Area in m2
Rooms
8-bed room accommodation
8-bed room accommodation
1-bed room accommodation
l“bed room accommodation
Treatment room
Equipment store
Bathrooms
Nurses’ bay and station
Shower rooms
Sluice room
Cleaners/Domestic staff room
Staff cloakroom
Pantry/ward kitchen
WCs
Corridor space
Trolley Bay
35
35
10
10
10
10
10
8
3
6
6
6
6
5
6
B. DELIVERY SUITE
Rooms
First stage
Second stage/delivery room
Eclamptic room
Sluice room
Nurses* bay
Admission/examination and
preparation room
Side laboratory
Store for consumable items
Cleaners* room
Store for non-consumable items
WCs
Shower
Waiting area for relatives
Recovery room
Area in m2
35
10
10
6
8
16
6
4
4
6
3
3
6
20
FHE/86.4
Page 27
OUTPATIENT SERVICES
Area in m2
Rooms
Waiting area 0.9m2 per woman
180
WCs:
3
Patients
3
Doctors
3
Nursing staff
4
Store
4
Cleaners’ room
6
Dispensary
4
Side laboratory
Consulting and examination
35
apartments
6
Medical records/registration counter
4
Sisters/nursing staff office
4
Height/weight measuring space
4
Blood pressure measuring area
6
Instrument preparation/packing room
10
Treatment room
D.
OPERATING SUITE
Room or compartment
Sterilizing section with store
Main operating room
Staff changing rooms (2) male and female
Trolley bay
Shower (2) - male and female
WC (2) - male and female
Scrub-up post
Anaesthetic rooms
Office
Recovery room
Area in m2
70
35
6
4
6
6
4
12
10
12
FHE/86.4
Page 28
ANNEX
2
ITEMS OF FURNITURE AND EQUIPMENT
A.
MATERNITY WARD
Room
Furniture and Equipment
8-bed room ward
Bed*(8), chair (8), bedside locker (8), overbed
table (8), hand wash-basins (2), mobile screens (3).
Spring beds, initially comfortable, sag in the middle
later. For this reason, the preference is for hoop
iron mesh rivetted to frames which ventilate well and
do not sag with age. The mattress should be about
10 cm thick, size 200 cm x 100 cm.
*Beds should be standardized, and a convenient size
for a bedstead is 200 cm x 100 cm.
1-bed room ward
Bed (1), bedside locker (1), table (1), chair (1), arm
chair (1), tray for meals (1), locker for clothes (1),
hand wash-basin (1).
Treatment room
Cupboard unit, work top, wall cupboards (3), shelves,
hooks, examination couch (1), stool (1), trolley (1),
bin (2), paper towel stand or its equivalent (1), hand
wash-basin with elbow-operated taps.
Bathroom
Freestanding bath (1), chair (1), hand-rail (1), hooks
for clothes and towels.
Shower room
Same as bathroom, except that shower replaces bath.
Sluice room
Bed-pan drier (1), bed-pan washer (1), bed-pan
sterilizer (1), ventilated cupboard for storage of
specimens (1), storage for specimen testing
equipment (1), working surface, small sink (1), hand
wash-basin.
Nurses’ station
Table (1), chairs (4), trolley for patients’
records (1), storage for stationery, wall cupboard,
refrigerator (1), notice board (1), cabinet (1), book
case (1), wash-basin.
Nurses’ bay
Office table (1), chairs (2), dwarf wall, work-top,
clock (1).
Cleaners and
domestic staff
Cleaning sink, domestic sink, draining board,
locker, storage for brushes and brooms, bins, duster
rack, cupboard for cleaning materials.
Staff cloakroom & WC
WCs (2), hand wash-basin (2), bins (2), mirrors (2),
toilet paper racks (2), clothes hooks (3), Lockers (?).
u
FHE/86.4
Page 29
Pantry or ward kitchen
Water boiler (1), boiling plate (1), refrigerator (1),
cupboard for storage of crockery and cutlery (1),
cupboard for storage of snacks and beverages (1), sink
(1), draining board (1), working surface (1), bins (2).
Equipment store
Shelves, racks, hooks.
B. .DELIVERY SUITE
Room
Furniture and Equipment
Admission room
Examination couch (1), hand wash-basin (1), scrub-up
unit with elbow taps (2), bin (1), towel/paper towels,
intravenous fluid drip stands (2), writing table (1),
chairs (2), cupboard unit with work-top (1), wall
cupboards (3), trolleys (2).
Nurses* bay
Office table (1), chairs (3), dwarf wall,
work-top (1), storage for stationery, wall
cupboard (1), notice board (1), cabinet, bookcase (1),
hand wash-basin (1), small refrigerator (?).
First stage room
As for 8-bedded room in maternity ward.
Second stage or
delivery room
Delivery bed with lithotomy rods and
stirrup (1), surgeon’s stool (1), wash-basin with
elbow taps (2), trolley (1), cupboard for storage of
sterile packs for various forms of vaginal
delivery (2), bin (1), wall clock with seconds
hand (1), thermometers and sphygmomanometer (1),
mobile operating theatre light (1). Neonatal
resuscitation trolley or shelf, cupboard for
resuscitation equipment
Eclamptic room
Same as for delivery room with these additions:
Delivery bed should have side railings; sunction
machine (1).
Shower room
)
Toilet
)
Cleaners * room )
Sluice room
)
Same as in maternity ward.
Store for consumables
Shelves, racks, cupboards
Side Laboratory
Laboratory sink (1), hand wash-basin (1), laboratory
bench with writing space (1), cupboards for reagents
(listed separately in Annex 4), hand or electricallyoperated centrifuge, refrigerator if it is to be used
for blood cross-matching, together with special
equipment.
Store for nonconsumables
Shelves, racks, hooks.
U'
FHE/86.4
Page 30
D.
OPERATING SUITE
Room
Furniture and Equipment
Main operating theatre
Operating table (1), ceiling-mounted shadowless lamp,
with 5 lamps or bulbs, pedestal-mounted shadowless
lamp, run off storage batteries in emergencies,
trolleys for instruments (3), drip stands (2), air
conditioners (2), cupboards, shelves, drums for linen,
diathermy apparatus, swab rack, containers for used
swabs and instruments, sunction apparatus, sterilizer
35 cm x 38 cm 139 L fuel (1), sterilizer drums 20 cm x
10 cm x 6 cm (1), kerosine stove (1), Cheatles forceps
26.5 cm (1), sterilizer forceps 20 cm (1).
Comments: The operating table must be sufficiently sturdy to support the
heaviest patient, and yet be moveable, easy to tilt into head down position,
easy to clean and permit a patient to be placed in the lithotomy position.
-...instruments,
. > one ma(je of stainless steel is
Regarding the trolley
for
surgical
best, with flat tops, and no guard railings. The
recommended shelves and
T
cupboards are for storage of packs of sterile, autoclaved surgical
instruments, in individual wrappings, and made into sets designed for
particular operations. One set of cupboards should be fixed to the end where
the anaesthetic team is customarily stationed.
Sterilizing room and
store
Small autoclaves, cupboards and shelves for
sterile store, large tables and sorting-out space,
drums, changing-room facilities, toilet facilities.
Comments: The instruments to be autoclaved should have first been cleaned in
their respective wards or health centres. The same with linen, which should
be laundered before being sterilized. On the whole, in a district hospital
setting small capacity autoclaves are preferable to large capacity ones.
Compared to large capacity autoclaves, small ones take a shorter time to run
and are therefore less damaging to soft goods like linen and dressing. For
this reason, it is more efficient to use a small autoclave several times a day
than to use a large machine once daily. Maintenance of autoclaves is
imperative.
Staff changing rooms
Lockers, mirror (2), hand wash-basin (2), towels,
shelves for clean scrub suits, masks and caps, rows of
hooks, mackintoshes (10), large laundry baskets for
used scrub suits.
Trolley bay
Shower
Toilet
Same as those described for maternity and labour
wards.
)
)
)
Scrub-up post
Sink units with elbow-operated taps (2), soap, bowls
containing antiseptic solution, scrub-up hand brushes.
Anaesthetic room
Sink and drainer (1), work-top (1), cupboard for
storage of drugs and instruments (2), writing table or
shelf (1), trolley (1), stool (1), anaesthetic gases,
anaesthetic machine E.M.O. (2).
Recovery ’•oom
TrolleyCs), sphygmomanometer (1), stethoscopes (2).
Office
Writing desk with cupboards under (1), chairs (3), low
table (1), notice board (1), crockery and cutlery for
light refreshments, small refrigerator (1).
1
FHE/86.4
Page 31
ANNEX
3
SURGICAL AND DELIVERY EQUIPMENT
A.
STANDARD
LAPAROTOMY SET
(Instruments)
(Quantity
Description
Stainless steel covered instrument tray 31 cm x 20 cm x 6 cm
Surgeon’s gloves - 6^/2, 7, 7^/2, 8
Towel clips, Backhaus box lock
Sponge holding forceps - 22.5 cm
Straight artery forceps - 16 cm
Hysterectomy forceps, straight - 22.5 cm
Mosquito forceps - 12.5 cm
Tissue forceps, Allis - 18.4 cm
Uterine tenaculum forceps - 28 cm
Needle holder, straight, Mayo - 17.5 cm
Surgical knife handle - No. 3
- No. 4
Surgical knife blades
Triangular point suture needles - 7.3 cm, size 6
Round-bodied needles No. 12, size 6
Deavers abdominal retractor, size 3, 2.5 x 22.5 cm
Richardson’s double-ended abdominal retractor
Curved operating scissors, Mayo - blunt pointed 17 cm
Balfour abdominal retractor 3-blade self-retaining
Straight operating scissors, blunt pointed, Mayo, 17 cm
Scissors, straight 23 cm
Suction tube - 22.5 cm 23 fr gauge
Intestinal clamps, curved, Dry - 22.5 cm
straight - 22.5 cm
Dressing forceps - 15 cm
- 25 cm
B.
1
12 pairs of each
4
6
4
4
6
6
1 pair
1
1
1
10 packets
2 packets
2 packets
1
2
1
1
1
1
1
2
2
2
1
STANDARD LAPAROTOMY SET (Dressing and Linen)
Description
Bundles of abdominal swabs with tapes
(6 in each bundle)
Vulval pads
Dressing towels
Trolley towels
Abdominal sheets
Mackintoshes - large
- small
Bundles of Ray-Tee gauze (6 in each bundle)
Operating gowns
Plain gauze and wool swabs
Lithotomy set
Mersilk in strands (each strand 0.5 m long)
Quantity
3
2
6
4
2
2
1
3
3
1
6
FHE/86.4
Page 32
c.
ITEMS FOR NORMAL DELIVERY
Description
Trolley
Sterile mackintosh
Trolley towels
Operating gown
Glove towels
Dressing towels
Anal packs
Cord ligatures
or
Cord clamp
Plain gauze and wool swabs
Kidney dish
Dressing bowl, large
Clover placental dish
Gallipots
D.
Quantity
1
2
2
1
3
3
2
3
1
2
1
1
2
VACUUM EXTRACTOR (OR FORCEPS) SET
Description
Malstrom vacuum extractor
Wrigley’s obstetric forceps
Neville Barnes obstetric forceps
Sponge-holding forceps
Spencer Wells artery forceps:
large
small
Needle holder
Stitch scissors
Episiotomy scissors
Toothed dissecting forceps
Non-toothed dissecting forceps
Quantity
4
1
1 pair
1 pair
4 pairs
2 pairs
2 pairs
1
1 pair
1 pair
1 pair
1 pair
Urethral catheter, rubber or latex 1
Foley’s urethral catheter,
gauges 12-21
1 of each
Towel clips
4
Sim’s vaginal speculum, large
1
Hamilton Bailey’s vaginalspeculum 1
E.
EMBRYOTOMY (CRANIOTOMY) SET*
Description
Neville Barnes obstetric forceps
Decapitation hook
Breech hook
Morris’s bone forceps
Simpson’s perforator
Embryotomy scissors
Episiotomy scissors
Stitch scissors
*See cautionary remarks in Chapter 3, page 14
Quantity
1 pair
1
1
4 pairs
1
1 pair
1 pair
1 pair
4
FHE/86.4
Page 33
Sponge-holding forceps
Toothed dissecting forceps
Non-toothed dissecting forceps
Spencer Wells artery forceps:
large
small
Willet’s scalp forceps
Volsellum forceps:
large
small
Urethral catheter female, latex
Needle holder
Vaginal speculum
Sim’s vaginal speculum, large
Towel clips
F.
1 pair
1 pair
1 pair
2
2
4
4
1
1
1
1
1
4
EVACUATION OF UTERUS
Description
Sponge-holding forceps
Sim’s vaginal speculum, large
Auvard self-retaining vaginal
retractor
Teale’s Volsellum forceps
Simpson’s uterine sound
Set of Hegar’s dilators,
double-ended
Uterine curettes:
blunt
sharp
Spencer Wells artery forceps,
small
Dissecting forceps
Ovum forceps
Quantity
4
1
1
2
1
2
2
2
1
1
1 pair
G. STANDARD KIT FOR INSERTION OF
INTRAUTERINE CONTRACEPTIVE DEVICE
Available with UNICEF
Description
Metal sterilization tray
with cover
Bivalve speculum: small
medium
large
Sponge holding forceps
Long straight artery forceps
Uterine sound
Torch with batteries, or other
suitable light source
Scissors
Antiseptic solution
Aqueous iodine 1 in 2500
Benzalkonium chloride 1 in 75
Quantity
1
1
1
1
1 pair
1 pair
1
1
1 pair
i
I
FHE/86.4
Page 34
IUD
IUD inserter
Sterile gloves
Sterile vulsellum
Dressing forceps
Sterile metal bowl
Vulval pads
♦
H.
MINI-LAPAROTOMY KIT
(List compiled by UNICEF in collaboration with UNFPA and WHO)
I
Description
Quantity
Allis clamp - 19 cm
1 pair
Towel clips, Backhaus
4
Control syringe 10 ml
1
Hypodermic syringe 10 ml
4
20 gauge hypodermic needles, 4 cm 12
Dressing forceps - 14 cm
1
Tissue forceps, standard - 14 cm
1
Curved mosquito forceps - 13 cm
6
Straight artery forceps - 15.5 cm
3
Babcock tissue forceps - 19.5 cm
2
Curved artery forceps - 20 cm
1
Dressing forceps - 25 cm
1
Surgical knife handle
1
Surgical blades, size 10
8
Mayo’s needle holder - 17.5 cm
1
Straight triangular point
suture needles - 5.5 cm
2
Mayo’s taper point needles,
size 6
12
Urethral catheter size 14, French
1
size 16, French
1
size 16, French
1
Tenaculum forceps
1 pair
Uterine elavator (Ramathibodi)
1
Tubal hook
(
)
1
Proctoscope
1
Stainless steel sponge bowl
1
Richardson-Eastman retractors
2
Abdominal retractor
1
Graves vaginal speculum (medium)
1
Suture scissors
1 pair
Straight operating scissors, 15 cm 1 pair
Curved scissors, 17.5 cm
2 pairs
Instrument pan with lock lid
1
u
FHE/86.4
Page 35
I.
Description
c
EQUIPMENT FOR VASECTOMY
(from UNICEF)
Quantity
Instrument tray, covered
22.5 cm x 12.5 cm x 5 cm
1
Backhaus towel clamp
4
Forceps, haemostatic:
straight 14 cm
4 pairs
curved 12.5 cm
2 pairs
Forceps, tissue - Allis 15 cm
2 pairs
Knife handle, size 3
1
Knife blades
10 packets
Hypodermic needle 22 gauge
1 box
Needle, hypodermic (Luer) 25 gauge 1 box
Needle suture - straight
2 packets
Needle, suture, catgut, Mayo
1/2 circle
2
Scissors, suture angled on
flat - 14 cm
1 pair
Syringe anaesthetic (control)
Luer - 5 ml
1
Syringe hypodermic - 5 ml
4
Sterilizer instrument
20 cm x 10 cm x 6 cm
1
Cheatle forceps - 26.5 cm
1
(All above items can be ordered as a single kit from UNIPAC Director, UNIPAC, Freeport, DK 2100 Copenhagen, Denmark)
J.
EQUIPMENT FOR NEONATAL RESUSCITATION
Descript ion
Quantity
Mucous catheter (rubber, openended 15 French-gauge-FG)
Nasal catheter (rubber, openended, 8FG
Endotracheal tubes (sterile, 12FG)
Curved stillette (for stiffening
endotracheal tube in difficult
intubations)
Suction catheters (sterile, 6FG)
Magill’s infant laryngoscope
with spare bulb and batteries
Ventillatory bag
Oxygen cylinder with flow-meter
40 cm water manometer or a simple
form of resuscitator with safety
valve and rubber bag
Laerdal infant fact mask
1 or more
1
3
1
3
1
1
1
1
2
u
FHE/86.4
Page 36
K.
EQUIPMENT FOR ANAESTHESIA
Anaesthetic facemasks
2 of each size,
Infant to large adult.
Total 14
Oropharyngeal airways
2 of each size,
00 to 5. Total 12
Laryngoscopes
2 handles + 3 pairs of blades or
2 adult + 2 paediatric plastic (Penion)
+ 2 packs of 6 spare bulbs +
30 batteries (or 8 rechargeable
batteries + charger)
Endotracheal tubes
2.5-10 mm in 0.5 mm steps, Oxford or
Magill or similar, with cuffs only on
sizes
6 mm
Urethral bougies
for use as intubating stylet
Magill’s intubating forceps
In emergency, ovum forceps can be used
Et Tube connectors
15 mm plastic (can be connected
directly to breathing valve), 3 for
each tube size
Catheter mounts (endotracheal
tube connector)
antistatic rubber, 4
Breathing hose + connectors
2 lengths of 1 metre anti-static,
4 lengths of 30 cm for connection of
vaporizers, T-piece for oxygen
enrichment
Breathing valves
Universal non-re-breathing valve,
e.g. AMBU El, Ruben, Laerdal IV,
2 of each AMBU paid! valve 2
Breathing systems
(for continuous-flow)
Ayre’s T-piece system
Magill breathing system
Self-inflating bellows
or bag (SIB)
Oxford Inflating Bellows (0IB)
AMBU, Cardiff, Vitalograph, Laerdal,
SIB, 1 adult + 1 child
Anaesthetic vaporizers
for ether, halothane & trilene
e.g. EMO, AFYA, OMV, PAC
Intravenous equipment
IV needles, cannulas including
paediatric sizes & umbilical vein
catheter IV infusion sets
Spinal needles
Range of 18- to 25-gauge
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FHE/86.4
Page 37
A N N E X
4
MATERIALS FOR SIDE LABORATORY TESTS
AND BLOOD TRANSFUSION
A.
SIDE LABORATORY
Test
Materials
Blood film preparations
Glass rods over a sink or staining tank (2),
measuring cylinder 50 ml capacity (1), wash bottle
with buffered water (1), interval timer clock (1),
rack for drying slides (1), Leishman stain,
methanol.
Blood film for
malaria parasites
Field stains A and B. Four glass containers,
microscope slides, blood lancets, cotton wool.
Total and differential
leucocyte count
Counting chamber (Newbauer), 0.05 ml pipette,
graduated 1 ml pipette, TUrk diluting solution,
tally counter (differential if possible).
Haematocri t
Microhaematocrit centrifuge (1), scale for reading
haematocrit results (2), heparinised capillary
tubes 75 mm x 1.5 mm, spirit lamp (1), blood
lancet, ethyl alcohol.
Detection of glucose in
urine
Benedict solution, pipette, pyrex test-tubes,
test-tube holder, beaker, Bunsen flame,
or
Indicator papers and tablets.
Detection of protein
in urine
Test-tubes, pipettes 5 ml,
sulphosalicylic acid 300g/litre aqueous solution
or
Indicator paper and tablets.
B.
ESSENTIAL MATERIALS FOR THE PROVISION OF
DONOR BLOOD FOR TRANSFUSION
Cross matching
Patient’s serum
Patient’s red cells
Donor red cells from pilot bottle
8.5 g/1 sodium chloride solution
20% bovine albumin
37°C water bath or incubator
Centrifuge
Pipettes
small and medium
Test-tubes
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FHE/86.4
Page 38
Collection and storage of blood
Healthy adults aged between 18 and 50 years.
A haemoglobin level above 11 g/dl.
A pregnant woman Is not to donate blood.
Blood donation by an Individual can take place at six-monthly
Intervals.
Collection of blood
Cotton wool and ethylalcohol
Sphygmomanometer cuff
Airway needle for collecting blood
Blood collecting set containing 120 ml of ACD solution
An object for donor to squeeze
Artery forceps (a pair)
Pair of scissors
Adhesive tapes
Pilot bottle containing 1 ml ACD solution attached to the
collecting bottle
Refrigerator (temperature 4°C to 6°C) for storage of donor
blood. A domestic refrigerator operated either on gas, or
electricity can also be used, but the refrigerator must not be opened
too often,
often. jA refrigerator which opens at the top is preferred to a
cabinet refrigerator.
i
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FHE/86.4
Page 39
ANNEX
5
ESSENTIAL DRUGS LIST
Essential function groups
in which a particular drug
Is used
Anaesthetics - General
Ether
Diazepam
Nitrous oxide
Oxygen
Thiopentone
Atropine
Suxamethanium
4.5
1.2.5
4.5
1.2.4.5
4.5
4.5
4.5
Anaesthetic - Local
Lignocaine
Analgesics
Paracetamol
Acetylsalicylic acid
Morphine
Pethidine
Antiallergic
Hydrocortisone
Promethazine
1.4
2.3
6
2.4
1.4
2
6
Anti-infective/antibiotics (oral and parenteral preparations)
1.2.4
Ampicillin
1.2.4
Benzylpenicillin
1.2.4
Crystalline penicillin
1.2.4
Chloramphenicol
4
Gentamycin injections
1.2
Metronidazole
1.2.4
Sulfamethoxazole-trimethoprim
1.2.4
Tetracycline
Antimalarials
Chloroquine
Pyrimethamine
Proguanll
Quinine
4
4
4
4
Antianaemia drugs
Ferrous sulphate
Folic acid
Iron dextran
4
4
2.4
Anticoagulants
Heparin
Protamine sulfate
4
4
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FHE/86.4
Page 40
Other blood products
Dried human plasma
1.2
Antihypertensive and other related drugs
Hydrallazine
Digoxin
Propranolol
2
2
2
Disinfectants
Chlorhexidlne
Iodine
Savlon
Surgical spirit
1.3.4
1.3.4
1.3.4
1.3.4
Diuretics
Frusemide
2
Oral contraceptives
Ethinylestradiol + levonorgestrel
Ethinylestradiol + norethisterone
Depot medroxy-progesterone acetate
Norethisterone
Norethisterone enantate
7
7
7
7
7
Other hormones
Insulin
Glibenclamide
2
2
Sera
Anti-D immunoglobulin (human)
Tetanus antitoxin
Tetanus toxoid
Oxytocics
Ergometrine injection
Ergometrine tablets
Oxytocin injection
4
4
4
1.4
1
1.4
Psychotherapeutic drugs
Diazepam
1.4
Intravenous solutions
Water for injections
Sodium lactate (Ringer’s)
Glucose 5Z, 50X
Glucose with sodium chloride
Potassium chloride
Sodium chloride
all groups
1.2.4
1.2.4
1.2.4
1.2.4
1.2.4
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FHE/86.4
Page 41
ANNEX 6
LIST OF PARTICIPANTS
Dr I. Al tken
Postgraduate Coordinator, Faculty of Community
Medicine, University of Papua New Guinea, Boroko,
Papua New Guinea
Dr K. Bhasker Rao
Consultant Obstetrician & Gynaecologist
Madras, India
Dr M. Fathalla
Formerly Dean, School of Medicine, Assiut University,
Assiut, Egypt; presently Responsible Officer for
Research and Development, Special Programme of
Research Development and Research Training in Human
Reproduction, World Health Organization, Geneva,
Switzerland
Dr K. A. Harrison
Professor of Obstetrics & Gynaecology, University of
Port Harcourt, Port Harcourt, Nigeria (rapporteur)
Dr Barbara E. Kwast
Formerly Lecturer in Community Obstetrics (Ethiopia)
Netherlands Technical Cooperation;
Presently Public Health Nurse & Midwife, Division of
Family Health, World Health Organization, Geneva,
Switzerland
Dr P. Severyns
Senior Technical Adviser, UNFPA, New York,
United States of America
Secretariat:
Dr R. Cook, FHE
Dr M. Belsey, MCH
Dr R. Guidotti, MCH
Dr J. Kierski, MCH
Dr Amelia Mangay Maglacas, NUR
Dr E. Wilson, HRP
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