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SUKSHEMA
Facilitator's Manual
Volume: 2
Part C
Skilled Birth Attendance
during Labour, Delivery and
Postnatal Periods at 24/7 PHCs
KHPT
—1
________
WRWT PRH
Karnataka Health Promotion Trust
I
(S/9"
Volume
Section A:
Skilled Birth Attendance
during Labour, Delivery and
Postnatal Periods at 24/7 PHCs
Sukshema
Nurse Mentors Ti
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2,1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel: 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
I
IM III
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
An overview of the On-Site mentoring intervention to institutionalize quality improvement
strategy within 24/7 Primary Health Care centers in Karnataka state. The philosophy, design,
The philosophy, design, implementation process and results are detailed herein.
Copyrights
: Karnataka Health Promotion Trust and St John's National Academy of
Health Sciences
Year of Printing : 2014
Publisher
: Karnataka Health Promotion Trust
IT Park, 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 044
Karnataka, India
Phone:91-80-40400200
Fax:91-80-40400300
www.khpt.org
This process document is published with the support from the Bill & Melinda Gates Foundation under
Project Sukshema. The views expressed herein do not necessarily reflect those ofthe Foundation.
Sukshema Project Volume 2
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
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PREFACE
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Institutional deliveries in Karnataka have risen over recent years due to the efforts by the state health
directorate which were strongly complemented by various innovations and schemes implemented under
the National Rural Health Mission (NRHM) such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha
Karyakram (JSSK), ASHA support, 108 ambulance services, etc. There has been a reduction in maternal and
newborn mortality rates (MMR, NMR), but not enough to achieve the proposed state targets. With over
80% of pregnant women now delivering in facilities, it is critical that these deliveries are conducted as per
the highest standards for quality of care. To accommodate this rising demand, government had prioritized
upgradation of Primary Health Centres into 24/7 facilities to provide delivery services in rural areas and
reduce the burden on district and larger hospitals enabling them to function more appropriately as first
referral units (FRU) to provide emergency care. To achieve good quality of services provided in public
health facilities it is important that the service providers working at these facilities are proficient in skills
and practices that are appropriate particularly with reference to pregnant women, mothers and new
borns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
UF
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As a part of technical assistance to NRHM, Karnataka Health Promotion Trust and its consortium of
partners developed an innovative nurse mentor led quality improvement program after detailed situation
assessment and consultations with government. It was pilot tested in Bellary and Gulbarga during 20122013 where trained Nurse Mentors worked with 24/7 primary health centres (PHCs) staff to improve the
quality of delivery and postpartum care. The mentoring programme integrated elements of clinical
mentoring with facility-based quality improvement processes. Another critical component of the
intervention was the use of revised case sheets by the staff that helped them in multiple ways, i.e. as job aid
to adhere to standard practices, as a simple case documentation tool and as a tool to monitor and audit
quality of care. The intervention results showed marked improvements in facility readiness and provider
preparedness to deal with institutional deliveries and associated complications. Subsequently the
program was scaled up in the remaining high priority districts of northern Karnataka and further taken up
both within and outside the country.
■
As a part of this intervention, several technical products and training material were developed; they consist
of 1) process documentation of the intervention that details the process of planning, implementing and
monitoring the mentoring program, 2) Facilitator/ Trainer and Participant manuals. These materials have
as annexures within them, various tools including the case sheets that were implemented under this
initiative. We sincerely hope that these resources will be found useful by program managers in terms of
gaining an in-depth understanding of the intervention and replicating it in their respective contexts.
1-
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I
Smt. Sowjanya^ laa
Mission Director
National 1 Icalth mission
SrLES.Vastrad, i.a^s
Commissioner
Dept, of Health & Family welfare
Sri. Atul Kumar Tiwart, IAS
Principal Secretary,
Dept, of Health & family welfare
i
1
List of Contents
Acknowledgements
04
Abbreviations
05
Glossary of Terminology
08
Methods used for training
13
Organisation of training
18
Pre-test - post-test
22
Training schedule
23
Session 1
Initial Assessment at Admission - History Taking
24
Session 2
Initial Assessment at Admission - Previous Investigations
32
Session 3
Initial Assessment at Admission - General Examination
34
Session 4
Initial Assessment at Admission - Abdominal Examination
36
Session 5
Initial Assessment at Admission - Pelvic Examination
38
Session 6
Monitoring Progress of Labour, Use of Partograph,
Complications - Abnormal Labour
44
Session 7
Normal Delivery
58
Session 8
Active Management of Third Stage of Labour
60
Session 9
Fourth Stage of Labour
63
Session 10
Postnatal Care at the Facility including Counselling
65
Session 11A
Complications during labour, delivery and Postnatal Period - PPH and APH
67
Session 11B
Complications during labour, delivery and Postnatal Period -PIN
75
Sessionl 1C
Complications during labour, delivery and Postnatal Period -Infection and
Preterm Labour
83
Session 12
Preparation of Labour Room
91
Session 13
Preparation for Discharge and Referral
93
Log book
Log Book - Nurse Mentor Skill Training
131
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
Acknowledgements
The authors appreciate the support provided by numerous individuals over an extended period of time to allow
documentation of this important innovation. Special thanks to Dr B.M. Ramesh, former Project Director of Sukshema
Project, for recognizing the importance of documenting the mentoring programme so others can learn from
this activity and for the guidance provided throughout Thanks to Anna Schurmann for helping to structure the
project's knowledge management strategy and to Baneen Karachiwala who provided independent observation and
interviews of the first mentor training. The dedication of project staff—including several Bangalore-based technical
leaders, support staff, and district programme specialists who coordinated numerous field visits to several districts—
ensured high-quality observations at primary health centres and insightful interviews with those implementing the
intervention. These staff include Dr Swaroop, Dr Mahantesh, Dr Seema, Dr B. Pavan, Dr Nazia Shekhaji, and Laxshmi C.
We thank the team from St John's Research Institute that included Dr Prem Mony, Maryann Washington, Dr Annamma
Thomas, Dr Swarnarekha Bhat, Dr Suman Rao and Gayathiri Perumal other consultants for their support in the trainings
and handholding visits and for sharing their experiences that have informed the process document. We appreciate
the support of clinical consultants from University of Manitoba, Lisa Avery and Maryanne Crockett for their support
during the design of the program. We also acknowledge the efforts of Dr Sudarshan and Dr Nagaraj from Karuna Trust
for their support to the implementation of the program. Appreciation is extended to Arin Kar, Deputy Director of
Monitoring and Evaluation, for providing data support and to H.L Mohan, Director of Community Interventions and
Somshekar Hawaldhar, Deputy Director of the community intervention component for contributing to the discussion
on program coordination. Special appreciation is also due to the nurse mentors for their enthusiastic participation
in interviews and focus groups, and for facilitating the ability to observe their work in action. We thank the many
primary health centre staff and district government officials who met with us to share their candid views about the
mentoring programme. Finally, we thank Stephen Moses, Professor and Head of Community Health Sciences of Dr
James Blanchard, Director, Centre for Global Public Health, University of Manitoba for their valuable reviews and
inputs.
The funding support for development of this manual was provided by Bill and Melinda Gates Foundation.
The following institutions and individuals have contributed to development of volume 2 of the SUKSHEMA
Facilitator's Manual.
Karnataka Health Promotion Trust (KHPT)
St John's National Academy of Health Sciences (SJNAHS)
University of Manitoba (UoM)
Dr LTroy Cunningham, KHPT
Mrs Janet Bradley, UoM
Dr John Stephen SJNAHS
Ms Maryann Washington, SJNAHS
Dr Sanjiv Lewin SJNAHS
Dr K Karthikeyan, Independent Consultant
Dr Manoharan, Independent Consultant
Dr Savitha Kamalesh, SJNAHS
Ms N Gayathri, SJNAHS
Dr Reynold Washington, KHPT/UoM
Dr Lisa Avery, UoM
Dr B M Ramesh, KHPT/UoM
Mr Arin Kar, KHPT
Mohan H L, KHPT/UoM
Dr Swaroop N, KHPT
Dr Krishnamurthy, KHPT/UoM
Sukshema Project Volume 2
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Abbreviations
ABO
Blood groups A, B, 0
DDK
Disposable delivery kit
A.M.M.A -
Assessing and diagnosing,
managing, measuring and
advocating
DHO
District health officer
DMPA -
Depot medroxyprogesterone
AMTSL
Active management of the third
stage of labour
ANC
Antenatal care
ANN
acetate
DNS
Dextrose normal saline
Auxiliary nurse midwife
DPS
District programme specialist
APH
Antepartum hemorrhage
EBM
Expressed breast milk
ASHA
Accredited social health activist
ECP
Emergency contraceptive pill
ART
Antiretroviral therapy
AWW
Anganwadi worker
EDD
Expected date of delivery
AZT
Zidovudine
FEFO
First expired, first out
BCC
Behaviour change communication
FHR
Fetal heart rate
BEmONC -
Basic emergency obstetric
and neonatal care
FHS
Fetal heart sound
BM
Breast milk
FIFO
First in, first out
BMV
Bag and mask ventilation
FRU
First referral unit
BPL
Below poverty line
FS
Female sterilisation
CBO
Community-based organisation
CCT
Controlled cord traction
Gol
Government of India
CEmONC-
Comprehensive emergency
obstetric and neonatal care
H/O
History of
Hb
Haemoglobin
CHC
Community health centre
CBMWTF -
Common bio-medical waste
treatment facilities
HBV
Hepatitis B virus
HCP
Health care providers
Hg
Mercury
HBsAg -
Hepatitis B surface antigen
HCG
Human chorionic gonadotrophin
CMO
Chief medical officer
COC
Combined oral contraceptive
CPD
Cephalopelvic disproportion
CVS
Cardiovascular system
DBF
Direct breastfeeding
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Pt>stnatal Periods at \
S
HIV
Human immuno deficiency virus
MRP
Manual removal of placenta
HLD
High level disinfection
MTP
Medical termination of pregnancy
HMIS
Health management information
system
MVA
Manual vacuum aspiration
HR
Heart rate
NFHS
National Family Health Survey
h2o
Water
NGO
Non-governmental organisation
IM
Intramuscular
NRHM -
National Rural Health Mission
Inj
Injection
NS
Normal saline
IV
Intravenous
ICTC
Integrated counselling and testing
centre
Karyakram
IFA
Iron and folic acid (supplements)
NSV
No-scalpel vasectomy
IMNCI
Integrated management of
neonatal and childhood illness
PEP
Post-exposure prophylaxis
PHC
Primary health centre
IUCD
Intrauterine contraceptive device
IUD
Intrauterine deat
PIH
Pregnancy induced hypertension
IUGR
Intrauterine growth retardation
PIP
Project implementation plan
JSY
Janani Suraksha Yojana
PNC
Postnatal check-up
JHFA
Junior health female assistant
POC
Products of conception
KMC
Kangaroo mother care
PPE
Personal protective equipment
LAM
Lactational amenorrhea method
PPH
Postpartum hemorrhage
LBW
Low birth weight
Lady health visitor
PPTCT -
Prevention of parent-to-child
LHV
LMP
Last menstrual period
MgSO4
Magnesium sulfate
MM
MNCH mentor
MMR
Maternal mortality ratio
MNCH -
Maternal neonatal and child health
MO
Medical officer
P/A
Per abdomen
MoHFW-
Ministry of Health and Family
Welfare
P/S
Per speculum
P/V
Per vagi num
MoWCD-
Ministry of Women and Child
Development
Ql
Quality improvement
Multipurpose health worker
RCH
Reproductive and child health
MPHW -
Sukshema Project Volume 2
NSSK
-
Navjaat Shishu Suraksha
transmission
PPV
Positive pressure ventilation
PRI
Panchayati Raj Institution
PROM -
Premature or pre-labour rupture of
membranes
llii
RDK
Rapid diagnostic kit
STI
Sexually transmitted infection
Rh
Rhesus factor
TBA
Traditional birth attendant
RL
Ringer lactate
TT
Tetanus toxoid
RPR
Rapid plasma reagin
UTI
Urinary tract infection
RR
Respiratory rate
VDRL
RTI
Reproductive tract infection
Venereal Disease Research
Laboratory
SBA
Skilled birth attendant
VHND
Village health and nutrition day
SC
Sub-centre
WBC
White blood cell
SDM
Standard days method
WHO
World Health Organization
SN
Staff nurse
3TC
Lamivudine
Units of measurement
- At the rate of - to measure speed
Kg
- Kilogram - to measure weight
%
- Percent - to compare anything to 100
L
- Litre to measure volume
°C
- Degree Celsius - for temperature
lb
- Pound to measure pressure
mcg
- Microgram to measure weight
cc
Cubic centimetre - to measure volume
cm
- Centimetre - to measure length
mg
- Milligram to measure weight
dl
Decilitre - to measure volume
min
- Minute
ml
- Millilitre to measure volume
mm
- Millimetre to measure length
°F
- Degree Fahrenheit - for temperature
gm - Gram - to measure weight
hrs
Hours - to measure time
mmHg - Millimetre of mercury to measure BP
IU
International units - to measure dose
secs
- Seconds
U
- Units to measure dose
KCal - Kilocalories- to measure energy produced
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Pei
Glossary of Terminology
Abortion: Termination of pregnancy by the removal or expulsion of a foetus or embryo from the
uterus before 20 weeks of pregnancy
Abscess: A localized collection of pus in any part of the body, with pain and redness.
Amniotic fluid: Fluid present in the uterus during pregnancy which protects the fetal inside
Amnionitis: Infection of the protective lining around the baby (amnion or inner lining);
occurs in PROM
Anaemia: Condition caused by low hemoglobin in blood
ANC: Check up done during pregnancy to determine the condition of the woman and fetus
APGAR: The APGAR score indicates the newborn's well-being. It will be calculated at 1 minute
and at 5 minutes after birth. An APGAR score of more than 7 is considered satisfactory.
Less than 7 APGAR babies need referral to a higher centre for further management
APH: Bleeding in pregnancy (before delivery)
Asphyxia: Condition in a newborn due to severely deficient supply of oxygen to the body when
the baby is unable to breathe normally
Atonic: Lack of muscle tone; loose or soft
Assisted deliveries: Vaginal delivery when the baby's delivery has to be assisted/helped out by
using forceps or vacuum extraction applied to the baby's head
Blurred vision: Unclear or hazy vision, associated with high blood pressure, weakness
Breech presentation: When the buttocks of the fetus are in the lower area of the uterus
Chorioamnionitis: Infection of the protective lining around the fetus (amnion or inner lining and
chorion or outer lining); occurs in premature rupture of membranes (PROM)
Clammy skin: When the skin is cool, moist,and pale. Sign of emergency such as shock, dehydration
CPD: Size or space of pelvis is narrow and does not allow baby to pass through
CVS: System related to heart and circulatory system
Diastolic blood pressure: Lower reading of blood pressure
Depressed/depression: Sadness, no interest in surroundings; may be seen in postnatal period
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Sukshema Project Volume 2
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DMPA: Injectable contraceptive whose action lasts for 6 months
ECP: To be taken by a woman within 72 hours of unprotected, unplanned sexual contact to
prevent a pregnancy
Effacement: Thinning of cervix at the time of labour
Endometritis: Infection of uterus; after PROM, repeated per vaginal (PV examination, unsterile
conditions, after abortion/ MTP done in unsterile conditions
Engorgement: Filling up/ swelling
Flank pain: Pain in the side of the abdomen below the ribs
Fluctuant: Moving
Floppy: Poor muscle tone, limp
Fetal: Developing unborn baby inside the uterus
Fetal distress: Condition when the fetus is having some problem inside the uterus; detected by
abnormal heart rate (FHR more than 160/min or less than 120/min),
or irregular FHR
Fundal height: Height of the uterus which increases with pregnancy and decreases after
delivery; measuring the upper border of the uterus and comparing with the
standard in weeks of pregnancy gives the approximate duration of pregnancy
Gestation: Pregnancy / the period of development of the fetus in the uterus from conception
until birth
Gestational age: Age of an embryo or fetus; calculated in weeks
Gravidity/gravid:The number of times the woman has been pregnant
Icterus: Jaundice or yellowish discolouration of sclera (white part of eye) in adult or skin in
newborn
Infant: Baby from one month after birth to one year of age
IUGR: Inadequate/ slow growth of a fetus inside the uterus
Jerky movement: Fast movements which are not controlled and that have no purpose.
Seen in fits
KMC: Care given to small baby by placing over the chest of mother/parent to provide extra
warmth to the baby
L...
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
LAM: Used as a traditional temporary method of contraception, when a woman does not have her
monthly periods due to breast feeding
Latent: Developing or present but not visible
LBW: When the baby weight is below 2500gms (standard weight)
Lump: A localised swelling; may be hard or soft
Lochia: Discharge from the vagina from delivery up to a week
Liquor: Same as amniotic fluid
LMP: First day of last menstrual period a woman had before pregnancy, used to calculate EDD
Madilu kit: This is a postnatal kit given to mothers after delivery under a government scheme for
postnatal care of mother and baby
Mastitis: Infection of breast; seen as pain and redness
Meconium: Yellow or green coloured stools passed by the fetus inside uterus or by newborn
at birth
MRP: Done by removing the placenta by hand in condition of retained placenta
Murmur: An abnormal sound of the heart
MVA: Method of performing MTP where suction is created by a manual pump to remove
contents in uterus
Misoprostol: Drug used to cause contraction of uterus and thereby prevent or treat postpartum
hemorrhage; available as tablets of 200mcg; not given to women with asthma
Magnesium sulfate: An anti-convulsant drug used for preventing/treating eclampsia/severe
pre eclampsia without causing sedation in mother or baby
Monitoring: Observe and check the progress or quality over a period of time
Nasal flaring: An increase in nostril size due to any difficulty in breathing
Newborn: A recently born baby
Obstetric: Related to pregnancy
Obstructed: Blocked; unable to come out
Oedema: Swelling due to accumulation of water
Outcome: End result
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Sukshema Project Volume 2
Pallor: Lack of colour especially in the face; seen in anaemia and long standing diseases
Parity/Para: Total number of deliveries and abortions a woman has had till present pregnancy
Pelvis: Cavity formed by joining together of the two hip bones and sacrum; contains, protects,
and supports the intestines, bladder, and internal reproductive organs
Perineum: Area around vagina and the anus in females
PIH: Increased blood pressure (more than 140/90 mmHg) without proteinuria in a woman after
20 weeks gestation
Preterm: Pregnancy less than 37 completed weeks gestation
Pre-referral management: Activities carried out to stabilise the complicated cases before
referring to a higher centre
Presentation: That part of the fetal lying over the pelvic inlet which would be first to come out
at delivery
P/S: Using the speculum to view the vagina and cervix
P/V: Vaginal examination
Prolonged: Long duration/delayed
PROM: Rupture of membranes (bag of waters) before labour has begun; can be before
37 weeks - premature or before delivery - term or mature
Puerperal: The period immediately after delivery to 42 days
Purulent: Containing pus
Pustule: A small boil over skin filled with pus; a pimple
Retained: To hold in a particular place; not coming out
RPR: A newer blood test to screen routinely for syphilis in pregnant women
RR: Rate of breathing in one minute
Respiratory distress: Condition in which patients are not able to breathe properly and get
enough oxygen
SBA: Person (doctor, nurse, ANM) trained in pregnancy, delivery, postnatal and newborn care
SDM: Used as a traditional temporary method of contraception where a woman tracks the days of
her menstrual cycle and avoids unprotected sexual contact on fertile days of the cycle
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/"’
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Sepsis: Condition where infection from any site spreads throughout the body
Seizures: Convulsions, fits
Spontaneous: Without any effort or natural
Sterilization: A procedure to make free from live bacteria, virus or other microorganisms,
used for cleaning needles and surgical instruments
Stillbirth: Birth of a dead fetus any time after the completion of 20 weeks of gestation.
Syphilis: A sexually transmitted disease which in pregnancy may cause congenital defects
in the fetus
Systolic blood pressure: The upper level of blood pressure
Tender/tenderness: Pain felt if touched
Term: State of pregnancy which has completed 37 weeks
Transverse: Lying across
Traction: Pulling force
Tubectomy: It is a female sterilization procedure where a part of the fallopian tubes is cut.
It is a permanent method of female sterilization
Umbilicus: A scar where an umbilical cord was attached
Unconsciousness: Person not responding to calls, stimulus
Uterine massage: Gently rubbing the uterus after the delivery of placenta to help the uterus
contract and become hard
Uterine tone: Tightness of uterine muscles
Vasectomy: A surgical procedure performed on males in which the vas deferens (male tubes)
are cut. It is a permanent method of male sterilization
VDRL: Blood test done routinely for syphilis in pregnant women; similar to RPR test
Vertex: Normal presentation of the fetus in which the head lies at the opening of the uterus
Voiding: Emptying the urinary bladder
Sukshema Project Volume 2
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4siii
Methods used for Training
Several participatory methods will be used for training. This is necessary since all participants are
adults and thus following the principles of learning, it will be experiential and thus presumably
more permanent.
Method
Case Scenarios/
Case studies
What is it
Participants study
briefly a situation
that either describes
a problem and then
develop possible steps
to solve the problem
Participants discuss
related issues that arise
from the case scenario
When to use
Other important
points
To encourage
The situation presented
participants to apply
in the case scenarios
their knowledge
is comparable to
and skills to similar
one experienced by
participants. Details
problems and
situations that they may in the scenario should
encounter on the job or be just enough to
elsewhere
enable participants to
recommend solutions/
discuss related issues or
actions
Generally case scenarios
are more extensive than
hypothetical situations
and raise more issues.
Give them enough
time to exhaust the
discussion as much
as possible within
the predetermined
objectives
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Demonstration
Facilitator or another
To improve the skills or
competencies of the
volunteer participant
demonstrates or models participants
the steps of a procedure
in an artificial situation,
using mannequins or
models to familiarise
participants with it
Discussion
Facilitators and
participants or small
groups of participants
exchange ideas for the
purpose of reaching
a specified set of
objectives
This method follows
the principle - learning
by doing i$ more
permanent. A major
partofthetraining
is dependent on
demonstration of how
to do certain procedures
on the mother, new
born or how to
document information
on the case sheets. It
is important that time
is given to participants
to practice the same so
that they are confident
in doing the procedure
especially if it is a new
skill. Checklists could
be used to assist them
to monitor their own
•i
progress.
_____
This method could
be most useful if
To improve
predetermined
communication skills
objectives are made.
To test progress towards It could allow the
participants to openly
learning objectives
express their opinions
on a subject as well as
listen to the opinions of
others thus facilitating
learning through
exchange of ideas
To increase knowledge
This method is one
of the commonest
methods used in
training.
It is important to ensure
that all participants take
part in the discussion.
This is best done by
dividing the whole lot
into smallergroups.
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Sukshema Project Volume 2
Mini lecture /
presentation
Facilitator or a volunteer
participant speaks to a
group from prepared
notes or using slides
To increase knowledge
and to convey
information, facts or
concepts
Mini lectures are an
efficient way to deliver
information.
It usually Is for a short !
period of 10-15 minutes J
and thus takes note
that attention span of a "
person is limited to 20
minutes.
It also is advantageous :over the traditional
lecture method since
several volunteers can
be asked to prepare for
a session and present it. ;
The biggest
disadvantage of
this method is that
communications
is usually one way
- flowing from the
facilitator to the
participants.
Question answer
session / brainstorming
/quiz
Facilitator prepares
questions pertaining
to a topic; then asks
questions in a series to
the participants in order
to reach the predefined
objectives
To increase the
participants
introspection and
internal inquiry
To increase the
participants ability to
collect information
through analysis
<
'i
The participation of the
participants is limited.
It is used when a new
concept is introduced to
the participants.
;
This is an efficient
way to encourage
self- learning and
participation.
It helps to generate
ideas quickly and
fluidly while permitting
freedom to express any
idea or thought.
It could have a snowball
effect as one person's
thought may help
another person's
thought process and
thus increase learning.
It is important to pay
attention to every
response of participants
as this will encourage
their participation
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Role plays
This Is a simulation
technique and involves
participants to imitate
or act out a situation
It allows participants to i
practice and thus think
about situations even before they encounter j
such situations in real j
To increase one's own
awareness of one's
thought processes
• j ' ! .•
.
:
To encourage
participants to apply
life.
1
their knowledge and
•
~
It could be interesting j
skills to problems
to participants. It may 5
like those they may
: ' a:' -, encounter in the real life take time and thus clear 1
I I t
j
.
■ j
guidelines must be
To sensitise participants given to participants
to issues that they may of what is expected of J
be uncomfortable to
them (preferably a day '
address
before the role play is
to
be enacted) and how ■
To provide an
much
time Is allotted for
opportunity for
the
role
play.
participants to practice
!
how they would
It is best if feedback
communicate on the
is taken from the
job to the patients
participants who
enacted as well as from
those who observed
the role play on what
worked well and what
could be
improved.
......
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Facilitator uses videos
To sensitise participants It is an efficient way
to help participants
on issues / demonstrate to get participants to
comprehend a concept procedures that are best reflect on concepts
learnt by seeing and
that seem abstract or
/ procedure better
hearing
difficult to comprehend
or to reinforce steps of a
procedure that is vital.
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Videos
It is important to check
for sound and need for
other equipment such
as DVD player, speakers,
etc to be effective
It is also important to
be familiar with the
video for it to be used
efficiently.
1
Sukshema Project Volume 2
Reflective exercises
Facilitator prompts
reflection or internal
inquiry in participants
To facilitate participants
to perform an internal
inquiry or examine
or think of their own
perceptions, thoughts
or characteristics
To facilitate participants
to reflect and evaluate
their own practice
environment
This is efficient way
to help participants
first feel comfortable
with how they feel
about a topic and
then share their
experiences with others
in a non-threatening
environment.
Ways to perform this
is through role plays,
th ink-pair-share, idea
sheet, goals statement
etc
Discussion after the
reflective exercise
is important to help
participants consolidate
their own and others
learnings.
.—.... ....... .. or
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal
M
Organisation of Training
Resource
Topic
Time
DAY:1
WEEK1
9:00-10:30
Arrival and registration of participants___________
10:30-11:30
Introduction of participants___________________
11:30-12:00
12:30-13:30
TEA_____________________________________
Pretest: Knowledge questionnaire Participant profile
13:30-14:15
14:15-15:30
Lunch___________________________________
Inauguration
15:30-16:00
TEA
OBSTETRIC COb
PRINCIPLES ANl TOOLS
INVENTION
____ :__
KAENTATIAM I KINr fACX CM! 1-4
A KJN UblNL1 LAbt blit
DAY:1______________
WEEK 2
10:15-10:30
Session 1: History Taking including specific details of HR factors to be
considered
_________________________ TEA_________________________
10:30-11:30
Session 2: Investigations with focus on essentials and high risk factors
11:30-12:15
Session 3: General examination with focus on identification of high
risk factors______________________________________________
Session 4: Abdominal examination with focus on identification of high
risk factors
9:00-10:15
12:15-13:30
13:30-14:30
________________________ LUNCH_______________________
14:30-19:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)_____________________
WEEK 2
_________________________ DAY:2________________________
9:00-11:00
Session 5: Pelvic exam with focus on identification of high risk factors
11:00-11:15
_________________________ TEA________________________
11:15-13:30
Session 6: Monitoring progress of labour including prolonged /
obstructed labour and rupture of membranes plus use of partograph
13:30-14:30
________________________ LUNCH_______________________
14:30-19:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
DAYS
WEEK 2
9:00-10:00
~
Session 7: Preparation of labour room including emergency kits for
emergencies (PIH, PPH, Sepsis)
aa_____
Sukshema Project Volume 2
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10:00-10:45
Session 8: Conducting normal delivery with focus on prevention of
PPH
10:45-11:00
TEA
11:00-11:30
Session 9: AMTSL
11:30-12:00
Session 10: Assessment and management of 4th stage of labour
12:00-13:30
Session 11: Assessment and management of postnatal period
including counselling on danger signs and family planning
13:30-14:30
________________________ LUNCH___________________
14:30-19:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
WEEK 2
DAY:4
9:00-11:30
Session 12: Complications PPH - identification and management of
atonic uterus or retained placenta
11:30-11:45
__________________________TEA________________________
11:45-12:30
Session 12: PPH contd - identification and management of tears or
rupture of uterus and due to thrombosis
12:30-13:30
Session 13: Complication infection - identification and management
13:30-14:30
________________________ LUNCH_______________________
14:30-19:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
WEEK 2
DAYS
9:00-11:30
Session 14: Complications PIH - identification and management
11:30-11:45
__________________________TEA_____________________
11:45-12:30
Session 15: APH - identification and management
12:30-13:30
Session 16: Complication preterm labour - identification and
management
13:30-14:30
________________________ LUNCH__________________
14:30-19:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
WEEK 2
_________________________ DAY:6___________________
9:00-11:30
11:30-11:45
11:45-12:30
Session 17: Discharge counselling or preparation for referral
TEA
Session 18: Questions and Answers on all sessions
12:30-13:30
________________________ LUNCH__________________
13:30-18:30
Clinical posting in antenatal ward, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
EWBORN CONTENT AND DOCUMENTATION USIM
9:30-10:30
DAY:1
Session 1: Introduction___________________________________
Session 2: Classification of a newborn and its implications
10:30-10:45
10:45-12:30
_________________________ TEA________________________
Session 3: Routine care from birth to 1 hour including do's and don'ts
WEEK 3
9:00-9:30
______________ o
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs;
12:30-13:30
Session 4: Preparation of newborn corner including kits for emergency
13:30-14:30
___________________________ LUNCH___________________________
14:30-19:30
Clinical posting in NICU ward, postnatal ward, labour room (groups
not more than 5 with 1 facilitator)_______________________________
WEEK 3
DAY:2
9:00-9:30
Session 5: Introduction on NB resuscitation_________
9:30-10:30
Session 5 contd: Newborn resuscitation - routine care
TEA
10:30-10:45
10:45-11:30
Session 5 contd: Initial steps of resuscitation________
11:30-12:30
Session 5 contd: Bag and mask resuscitation
12:30-13:30
Session 5 contd: Chest compressions and drugs
13:30-14:30
___________________________ LUNCH____________
14:30-19:30
Clinical posting in NICU, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
DAYS
WEEK 3
9:00-10:30
Session 6: Introduction on Breastfeeding (initiation, preparation)
10:30-11:30
Session 6 contd: Breast feeding - benefits, physiology, ten steps for
successful breastfeeding, position and attachment
TEA
11:30-11:45
11:45-12:30
Session 6 contd: Breast feeding - problems and its management
12:30-13:30
Session 6: Expressed breast milk and indications for alternative
methods of giving EBM
13:30-14:30
___________________________ LUNCH____________
14:30-19:30
Clinical posting in NICU, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
WEEK 3
9:00-10:30
10:30-11:30
11:30-11:45
11:45-12:30
12:30-13:30
13:30-14:30
14:30-19:30
WEEK 3
9:00-10:30
10:30-11:30
11:30-11:45
11:45-12:30
12:30-13:30
13:30-18:30
DAY 4
Session 6: Care of a newborn 1 hr till 48 hrs of birth
Session 7: Thermal control of a newborn
TEA
Session 8: KMC
Session 9: Care of LBW baby including feeding
LUNCH
Clinical posting in NICU, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
DAYS
Session 10: Discharge counselling including problems of newborn
(danger signs)
Session 11: Referral of a sick newborn
TEA
Questions and answers on NB
LUNCH
Clinical posting in NICU, postnatal ward, labour room (5/gp)
21_______
Sukshema Project Volume 2
■
-
&
WEEKS
9:00-10:30
10:30-11:30
11:30-11:45
11:45-12:30
12:30-13:30
13:30-18:30
WEEK 4
WEEK 5
9:00-10:30
10:30-11:30
11:30-11:45
11:45-13:30
13:30-14:30
14:30-15:30
DAY 6
Session 12: IMNCI approach to care of a sick child
Session 13: IMNCI approach to care of child with diarrhea
TEA
Session 14: IMNCI approach to a child with ARI
LUNCH
Clinical posting in NICU, postnatal ward, labour room
(groups not more than 5 with 1 facilitator)
_________ ____________ Clinical Posting________ __________ _
DAYrl - DAY:6 (GROUPS OF 5 EACH IN NICU-2 DAYS/
LABOUR ROOM-2 DAYS/PN-1 DAY/AN-1DAY) IN ROTATION
___________________Systems Strengthening_________________
DAY:1
Session 1: Infection control
Session 2: Documentation
TEA
Session 2 contd: Documentation(registers to be maintained, reports,
audits, anecdotes, observations etc.)
LUNCH
Session 2 contd: Documentation(registers to be maintained, reports,
audits, anecdotes, observations etc.)
15:30-16:30
Session 2 contd: Documentation(registers to be maintained, reports,
audits, anecdotes, observations etc.)
WEEKS
9:00-10:30
10:30-11:30
11:30-11:45
11:45-13:30
13:30-14:30
14:30-15:30
15:30-16:30
WEEKS
9:00-10:30
10:30-11:30
11:30-11:45
11:45-12:45
12:45-14:00
14:30-15:30
15:30-16:30
16:30-17:30
DAY:2
Session 3:: Drugs
Session 4: Referral and transport
TEA
Session 5: Self assessment tools - use
LUNCH
Session 5 contd: Self assessment tools
Session 5: Additional roles and responsibilities of mentors
DAYS
Posttest
OSCE - Rapid assessment exercise - OB
TEA
OSCE - Rapid assessment exercise - OB
LUNCH
OSCE - Rapid assessment exercise - NB
OSCE - Rapid assessment exercise - OB
Valedictory
_____________________ 81
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Nurse Mentors Training Program
Sessions Essential Care at labour.
Delivery and Early Postnatal Period
\_____________________________________________________________ z
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INITIAL ASSESSMENT AT ADMISSION
This has five sessions as listed below
Session 1: History taking
Session 2: Previous investigations
Session 3: General examination
Session 4: Abdominal examination
Session 5: Pelvic examination.
Learning objectives
By the end of the session 1 -5 the participants will be able to
❖
Recall the importance of doing a complete initial assessment of pregnant mothers after 20
weeks of gestation, presenting at the PHC
❖
List and discuss the relevance of the components of a good initial assessment
❖
Demonstrate how to do a comprehensive assessment
❖
Demonstrate documentation in the case sheet, the details of a complete initial assessment of
the woman in labour
❖
Demonstrate mentoring skills for complete initial assessment of the pregnant mother
Refer to participants' manual chapter 1 for details and few additional case studies.
23
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
■
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Initial Assessment at
Admission - History Taking
21
I
Materials: LCD, PowerPoint slides, SBA guidelines 2010(Page 13-15), new case sheets, Antenatal
care/Thayi cards, 1 case study, 2 exercises for IMP calculation
Session time: 55minutes.
Training methods: Case studies and group activity, interactive lecture, case sheet demonstration
Session Objectives:
By the end of this session participants will be able to
J
Discuss the importance of taking complete relevant history of the pregnant women
admitted to the facility, in labour
J
Demonstrate how to take a comprehensive history of the pregnant women admitted to
the facility, in labour
J
Demonstrate the documentation of comprehensive history using the new case sheet
Duration
Teaching Steps
Discuss the objectives of the session and its relevance
Introduction
1.
General history
2. Case study and group activity: (Slide 4) ;
2 minutes
❖ Divide the team into groups of 3-4 members eachand ask
them to refer to Vblume 2 - Case study 2.1 (Part 1)for history
taking, 2 exercises to calculate EDO- Case study 2.2-2.4
(See Volume 2 - Ch 2: pg 25-26)
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❖ Ask each group to discuss what parameters they would ask
in history and write down points.
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3.
Emphasize the need for the following during history-taking ?
(Slides).
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0
15 minutes!
❖ Maintaining privacy
I
❖ Checking the antenatal card for previous history
4.
Ask participants to present their points of discussion, on Case
study 2.1 - part 1. Referto new case sheet and summarize the gaps,
re-emphasize the positives using slides (Slide 6-8)
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Sukshema Project Volume 2
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Explain the importance of collecting details to provide
identification data as well as any possibility of risk factors
such as given below
❖
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❖
Site
Age if less than 18 or more than 35 could be an
indication of possible problems for mother and baby
Present pregnancy history or presenting complaints: Ask
participants to list the symptoms a woman in labour may
come with, those that are normal and those that indicate
complications. Reinforce about the need to ask about
specific complaints during the present history
O
Normal signs: contractions, abdomen pain, watery
discharge, rupture of membranes
o
Signs that might indicate a problem: fever, swelling of
face, headache, blurred vision, vomiting, fits/seizures
, decreased foetal movement, bleeding per vagina,
foul discharge per vagina, difficulty in passing urine/
less urine, any other
1
Demonstrate documentation on case sheet mode of delivery
Obstetric history 5.
Obstetric history (Slide 9-13)
❖
Explain that it is important to ask about GPAL, calculate
gestational age of fetus and determine if she knows if it is a
single/multiple pregnancy, since these details could flag a
possible risk factor.
Review case study 2.3-2.4 on calculation of GA and ensure
they know how to calculate the GA especially when cycles
are not regular.
6.
20 minutes
Past obstetrical history
❖
Explain that it is important to ask about any complications in
the previous pregnancies and labour, and outcome of these
pregnancies since they could flag a possible risk factor in the
present pregnancy
Past medical history (Slide 14-15)
Past medical or
surgical history
7.
Summarise
8.
Check if they have any doubts. Clarify them
9.
Conclude with key points (Slide 16-17)
❖
Explain the importance of enquiring about past medical
history or surgical history
5 minutes
3 minutes
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal
iodsat2
a
Case Study 2.1- History Taking And Examination
(Facilitator's Copy)
Use this case study as a way to promote discussion around the important components that need
to be done on history and physical examination. All participants should have a copy of the case
and questions. You can then read the case out loud and ask the first question. For each question
make sure that the points listed below are mentioned. Also make sure that during the discussion
you reinforce why these questions or examinations are important to do and how it relates to good
patient care. In all cases try to avoid directly giving the answers - rather probe around the topic to
see if the participants can come up with the responses. At the end ask if there are any questions
from the participants.
PART 1: Normal Pregnancy Case Study - Part One: History and Investigations
A 24 year G2 PI presents to the PHC complaining of contractions.
What important information would you like to ask her about on history?
Use this question to have members of the groups discuss what they would want to ask the woman
and why they think this is important. The following should be mentioned. In discussion explain
why. If they do not mention all steps probe by asking, "Is there anything else you would want to
ask, why or why not?"
The following points should be discussed:
Socio-demographics
This information helps you to create rapport with the patient before asking more personal
questions. It can also help provide you with some information regarding possible risk in pregnancy
or access to care (i.e. young or old age, marginalized groups).
❖ Name
❖ Husband's name
❖ Age
❖ Contact number
❖ Caste
Obstetrical history
This information determines the gestational age of the fetus and the type of pregnancy. This is
important because it helps determine if the labour is preterm (before 37 weeks) or term, if there is
more than one baby present and if the woman has had regular access to care.
❖ IMP
❖ EDD
Sukshema Project Volume 2
I
❖ Gestational age of fetus
❖ Single or multiple
❖ ANC and number
History of presenting complaints
This information determines why the woman has come to the PHC to be seen. In this case it
would be important that in addition to asking about contractions, other possible complications of
pregnancy are ruled in or out. These include:
❖
Fever (sign of infection)
❖
Blurred vision/ swelling efface/ headache/ difficulty in passing urine/less urine (these are all
signs of preeclampsia)
❖
Fits/seizures (this is a sign of possible eclampsia if greater than 20 weeks)
❖ Watery discharge per vagina/rupture of membranes
❖
Foul discharge per vagina (sign of amnionitis/uterine infection)
❖
Pain in abdomen (sign of abruption)
❖
Foetal movement (informs us about fetal status)
❖ Contractions - frequency, strength, and onset (help us to determine if the woman is in labour)
Past obstetrical history
This information determines if the woman had any previous complications in her previous
pregnancy and labour. This may help us to assess her risk in this labour and to help plan if she should
stay to deliver at the PHC or if she needs to go to an FRU. For example, a woman with a previous
classical cesarean section should be referred as this is a contraindication to normal delivery and she
will need another cesarean section. A woman who had a previous mild postpartum hemorrhage
could still deliver at the PHC but staff should have this information at their back of their minds so
that they can be prepared to ensure that active management of the third stage of labour is done
and that she receives close attention in the immediate postpartum period.
❖ Year
❖ Mode
❖
Place
❖ Complication
❖ Outcome
Past medical and surgical history
This information determines if the woman had any pre-existing medical conditions or surgeries
that would be important to know about in pregnancy/labour.
Allergies and medications
It is important to always ask if the woman is allergic to any medications, to know which medications
you can use safely in pregnancy/labour. It is also important to know if the woman is also on any
regular medications that she actually should avoid during pregnancy or that she may need to
continue to take in pregnancy.
27
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Previous investigations/tests (will be covered in Session 2)
Certain tests should be done on all pregnant woman as these tests help diagnose certain medical
conditions that may require additional treatment in pregnancy or labour, especially related to
anemia, infections or hypertensive diseases of pregnancy.
❖
HIV
❖ Syphilis
❖
Hepatitis B
❖ Urine dipstick for protein/sugar
❖
Haemoglobin and Blood group
All patients who present for care should have these 7 components asked about as they form
the basics of good history taking and patient care and provide you with useful information to
determine diagnosis and management. With practice they become quick and easy to do.
dl_______
Sukshema Project Volume 2
Case Scenario-Calculation Of EDD
Please read out the cases and ask the participants to calculate EDD. Ask 2 participants to read out
their answers
Case study 2.2: LMP known
Laxmi, who is 18 years old, says she got her last period on January 21st, 2011. She wants to know
when she will deliver. Calculate her due date.
Answer: 9 calendar months + 7 days, i.e. October 28th, 2011
Case study 2.3: LMP not known
Seema, who is 30 years old, comes to you and says that she has not got her period for the past
three months. She last got her period on the day before Holi, i.e. March 10. Calculate her due date.
Answer: 9 calendar months + 7 days, i.e. December 16
Optional -
Case Study 2.4: Irregular cycles
Mrs. Rekha, 24 years old primigravida comes to OPD with 6 months amenorrhea (October 2013).
This is her first visit to you on 25th April 2014
How will you calculate the EDD with regular (once every 28 days) and irregular cycles
(length of cycle between 30-35 days)?
Answer Key
❖
H/o regular periods - add 9 months and 7 days to the LMP
❖ Cycles >28-30 days
❖ Add the extra number of days to arrive at EDD
❖ Cycles < 28 days
❖
Subtract the number of days from the EDD.
_____________________ ®i
\9 :
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
I"
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
■
Hand-Out 1.1: Case Study 2.1- History Taking And
Examination
(Participant's copy)
Case Study 2.1: PARTI
Normal Pregnancy: History and Investigations
A 24 year G2 PI presents to the PHC complaining of contractions. What important information
would you like to ask her about on history?
■I_____
Sukshema Project Volume 2
HAND-OUT 1.2: CASE SCENARIO-CALCULATION OF EDD
(Participant's copy)
Please read out the cases and ask the participants to calculate EDD. Ask 2 participants to read out
their answers
Case study 2.2: LMP known
Laxmi, who is 18 years old, says she got her last period on January 21st, 2011. Calculate her due
date.
Answer
Case study 2.3: LMP not known
Seema, who is 30 years old, comes to you and says that she has not got her period for the past
three months. She last got her period on the day before Holi, i.e. March 10. Calculate her due date.
Answer:
Optional -
Case Study 2.4: Regular and Irregular cycles
Mrs. Rekha, 24 years old primigravida comes to OPD with 6 months amenorrhea (October 2013).
This is her first visit to you on 25th April 2014
How will you calculate the EDD with regular (once every 28 days) and irregular cycles (length of cycle
between 30-35 days)?
Answer:
31
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Initial Assessment at
Admission - Previous investigations
Materials: PPT slides, SBA guidelines 2010(Pg 23), new case sheets, Antenatal care/Thayi cards
Session time: 40 minutes
Training methods: Interactive lecture and guided discussion
Session Objectives:
By the end of this session participants will be able to
Explain the relevance of previous laboratory investigations at the time of assessment of
a pregnant woman or woman in labour
Demonstrate documentation of previous investigations on the case sheet and assess
requirement of repeat investigations and referral
Duration
Teaching Steps
Introduction
1.
Introduce the topic and session objectives (Slide 1 -2) .
Previous
investigations
2.
Facilitate discussion on the various investigations performed in
pregnancy (Slide 3) and why it is important to check them at the
time of taking the history of a woman during pregnancy or in
labour (Slide 4)
3 minutes
❖ Common complications can be picked up
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❖ Provider can be alert about the findings
3.
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Present slides (Slide 5-12) to explain the relevance of specific blood
tests done during ANC period as recorded in ANC card; or for a
woman labour, and its documentation on the case sheet. Explain
that not all investigations are done at PHCs. However importance
of doing investigations need to be discussed as given below
:
❖
Blood haemoglobin test: low haemoglobin levels (anemia),
could be a risk for PPH and LBW. It could also compromise
the heart resulting in problems during labour. Referral of a
woman to a higher centre would be required
❖
Blood group and type: ABO incompatibility if a woman is O
group and the baby is either A or B group or if the mother is
Rh negative blood group. Health care personnel need to be
alert for jaundice in newborns presenting before 24 hours.
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❖ VDRL syphilis positive is a flag for signs of anomalies in
newborns and also infection in the newborn
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❖
HIV positive test could alert to refer a woman and newborn
later for either ART or ARV prophylaxis
❖ Urine test: positive for infection, if proteinuria is present one
must be aware of presence of pre-eclampsia or eclampsia
4.
Highlight the next steps required
❖
_____________
Demonstration
or Review of
Tests
Summarize
5.
6.
Repeat tests after assessing present situation, if required for Hb (if done before 3 months), Urine test for proteinuria
(if not checked and BP is raised)
Review with participants how to do the urine test for protein
and HIV rapid test. Inform participants that they will learn how to
perform the HIV rapid test during their clinical posting.
Brainstorm with participants (Slide 13) when a referral must be
made? Wait for responses and then explain when referral must be
done to FRU for those women with abnormal test findings:
10 minutes
5 minutes
1. Hb below /gm/dl.
2. Urine test positive for protein,
1
3. Rh negative,
4. VDRL positive,
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5. HIV positive
6. Ultrasound findings
7.
Check for and clarify any doubts. Review key points (Slide 14-15).
2 minutes
----------------------------------------------------------------------------------------------------Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
....................................................... ■
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Initial Assessment at
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Materials: PPT slides, SBA guidelines 2010(page 17-18), new case sheets, weighing scale, BP
apparatus, stethoscope
Session time: 30 minutes
Training methods: Lecture, Case sheet demonstration, Case study part 2
Session Objectives:
At the end of this session participants will be able to
J
Discuss the important of general physical examination and significance of abnormal
findings
J
Demonstrate the documentation of general examination on a case sheet
Duration
Teaching Steps
Introduction
1.
Introduce the topic, session objectives (Slide 1 -2)
2 minutes
General
examination
2.
Reinforce the relevance of examination and review of Case study
and group activity (Slide 3-4)
10 minutes
❖ Divide the team into groups and administer CASE STUDY 2.1:
PART 2 for examination of woman in pregnancy or labour
❖ Ask each group to discuss what parameters they would
check for during general examination of a woman in labour
and present theirfindings.
Reinforce that for any abnormalities detected (Slide 8-10), the
woman must be monitored and might require further tests and
referrals if the facility cannot manage the same.
3.
•
!'f:
.
•
5 minutes
Reinforce key parameters to check during a general
examination (Slide 5-7)
❖
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Raised temperature - infection
❖ Weak pulse may be shock
❖ Rapid pulse could be fever, also shock
❖ Low BP could be shock
❖
High BP could be PIH
❖ Weight - low gain could be a flag for possible malnutrition
and thus problems in fetus /newborn
w___ _
Sukshema Project Volume 2
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5 minutes
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HM
❖
Short stature (<140cms) - risk factor for obstructed labour
❖
Pallor - maybe anaemia, shock
❖
Edema - swelling of face, hands, feet - maybe anaemia, PIH,
heart or kidney or other problems
___________________ "
Summarize
oiw
i
__________________________
4.
Take participants through documentation of general examination
on case sheet and ask them to also complete Handout 5.1
(General examination)
5.
Clarify any doubts, if any on the sessionand then give them the key
messages (Slide 11-12)
7 minutes
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
Initial Assessment at
Admission - Abdominal examination
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Materials: PPT slides (11), SBA guidelines 2010(pg 19-22), new case sheets, stethoscope,
mannequin
Session time: 50 minutes
Training methods: Demonstration on mannequin followed by interactive lecture, power-point
and case sheet demo.
Session Objectives:
By the end of this session participants will be able to
J
Explain the importance of abdominal examination in a woman with labour, how to
diagnose abnormal findings
J
Demonstrate how to conduct all steps of abdominal examination
J
Demonstrate the documentation of abdominal examination on a case sheet
Teaching Steps
Introduction
1. Introduce the topic and session objectives (Slide 1-2).
Abdominal
examination
2.
Reinforce importance of abdominal examination and do's and
don'ts involved in it (Slide 3-4).
3.
Highlight the components of an abdominal examination (Slide 5).
4.
Demonstrate using mannequin and facilitate a discussion.
Reinforce information using slides (Slide 6-11):
❖ The components of abdominal exam such as estimation
of fundal height, abdominal grips 1,2,3,4, to show
lie, presentation, engagement of presenting part, FHR
monitoring
\ Hi
Abnormal
findings
5.
Duration
3 minutes
20 minutes1
4,. ■.
❖ Divide the participants into 2 groups and ask 2-3 participants
from each group to give return demonstration of abdominal
examination on the mannequin. Ask participants to observe
and comment.
20 minutes;'
Present slides to explain how to interpret few common abnormal
findings (Slide 12)
10 minutes
❖ Fundal height does not match with weeks of pregnancy:
if less - prematurity, wrong dates; if more - twins, increased
liquor
❖ Presentation - bceech, transverse
Sukshema Project Volume 2
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Engagement of presenting part - if not engaged, requires
monitoring of labour and assessment Could flag obstructed
labour
❖ FHR-less than 120/min, more than 160/min, irregular- is
fetal distress
6.
Brainstorm with participants which of these would require a
referral?
❖ Explain it is important to identify any abnormality at
admission so as to start initial management and make a
quick referral to a centre that can manage the situation
appropriately.
Summarize
7.
Show participants where abdominal exam findings must be
recorded on the new case sheet. Check if all are clear about the
use of the new case sheets for initial assessment of a woman in
labour.
8.
Clarify doubts if any and conclude with key messages of the
session (Slide 13-14).
7 minutes ?
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Initial Assessment at
Admission - Pelvic Examination
o
Materials: PPT slides (15), SBA guidelines 2010(pg: 41 -44), New case sheets, gloves, pelvic model,
video on correct /wrong steps
Session time: 55 minutes
Training methods: Demonstration with pelvis model and facilitated discussions, Interactive
lecture, Case sheet demo.
Session Objectives:
By the end of this session participants will be able to
J
Explain the importance of vaginal examination in a labour patient and assessment of
stages of labour
J
Discuss how to diagnose abnormal findings, their initial management and need for
referral
J
Demonstrate the documentation of vaginal examination on a case sheet
Teaching Steps
Introduction
1. Introduce the topic and session objectives (Slide 1 -2).
Vaginal
examination
2.
S3-
3 minutes
Using slides explain the importance of vaginal examination and
the components of vaginal examination such as dilatation of
cervix; effacement of cervix; station of presenting part; status of
membranes; status of liquor (Slide 3-4)
10 minutes!
3.
Reinforce the points on preparation of a woman for pelvic exam
and do's and don'ts when performing a pelvic exam (Slide 5-6).
32 minutes !
4.
Demonstrate using pelvic model and skull and facilitate discussion
(Slide 7-15)
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❖ How to estimate cervical dilatation, practice using bangles;
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Duration
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❖ How to estimate cervical effacement
■
❖
5.
How to estimate station of presenting part using fetal skull or
doll with fetal skull and adequacy of pelvic outlet
Invite 1-2 participants to do a return demonstration of a pelvic
exam. Ask the observers to comment. Ask participants to note
steps that were correct and wrong. Facilitate a discussion
...
Sukshema Project Volume 2
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Video on
pelvic exam
6.
Show video on pelvic exam. Inform them that more details will be
dealt with in the session "Monitoring Labour" (Slide 16)
5 minutes
❖ Descent of presenting part delayed in the context of duration
of active labour
❖ Abnormal presenting part-face, breech, limbs (transverse)
❖
Huge capput
❖
Dilatation not occurring as per the normal rate
❖ Cervical effacement delayed
Summarize
7.
Reinforce the need to do a vaginal examination at admission
to detect stage of labour and determine any abnormality for
initiation of management and referral.
8.
Ask participants to refer to the new case sheet and point out the
place they will mark the vaginal examination findings. Reinforce
the importance of these details and the need to document them
on the case sheet. Ask a participant to highlight the key messages
of the session (Slide 17-18).
9.
Review Case Study 2.1: Part 2 with participants. Clarify any doubts
of the participants.
______
5 minutes
_______________________________________________ i_____________________ -_____________________________________ __
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Case Study 2.1: Part 2
PART TWO: Physical examination (Read the following section out and then
proceeds as in the first section)
The woman is 39 weeks gestation. Her last delivery was 2 years ago. It was a normal vaginal
delivery of a live born male infant, weighing 2700 gm at term. She had no complications in her
pregnancy or labour. She has been having regular antenatal care. She is otherwise healthy, has
never had surgery, is not taking any medications and does not have any allergies. Her contractions
began 3 hours ago. They are every 5 minutes and are becoming closer together and stronger. She
has not felt her water break and she can feel good fetal movement.
What would you like to do on physical examination? i.e. what do you think you should focus on when
performing a physical examination on this woman.
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to examine, why or why not?"
General examination
A general examination provides important information about the patient's overall health as well
as possible medical conditions that may have developed due to pregnancy.
❖ Weight, Height (can indicate signs of malnourishment)
❖ Vital signs: Pulse, Blood pressure. Temperature (abnormalities can be sign of infections, high
blood pressure of pregnancy, hemorrhage)
❖
Pallor (sign of anemia)
❖ Oedema (sign of pre - eclampsia)
❖ Jaundice (sign of severe - eclampsia, haemolysis, hepatitis infection)
❖
Heart sounds, any murmurs (sign of cardiac disease or physiologic murmur)
❖
Lungs (abnormalities can be sign of fluid overload in pre-eclampsia/eclampsia, cardiac disease
or infection)
Abdominal examination
An abdominal examination is important to perform because it provides needed information about
the size, position and heart rate of the baby, heart rate of the baby, if the woman had any previous
surgeries and the tone of the uterus (contractions, abruption, or infection).
❖
Fundal height (in weeks) (abnormalities can be a sign of babies that are too large or too small
for the gestational age)
❖
Presentation (determines if baby is in a position that can be delivered vaginally- i.e. vertex,
complete or frank breech)
1...... .
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Fetal heart sounds (determines if baby is alive, or if it is in distress)
❖ Contractions present, Contraction frequency, Contractions intensity (determines if labour is
active or false)
❖
Is uterus tender (abnormalities can be a sign of infection, abruption)
❖
Previous cesarean scar (alerts you to ask about type of previous cesarean - classical and
inverted T's are contraindications to vaginal deliveries)
Vaginal examination
A vaginal examination also provides important information about the baby (presentation, if
membranes are ruptured) and helps us determine if the woman is in active labour or not.
❖ Cervical dilatation, cervical effacement (determines if in active labour and if labour is
progressing normally)
❖ Status of membranes, date and time of rupture, colour of liquor (determines if there are any
signs of infection or fetal distress)
❖
Presenting part(determines if baby is in a position that can be delivered vaginally- i.e. vertex,
complete or frank breech)
❖
Station of presenting part (determines if descent is progressing normally in labour)
Can you think of any situations when you would not want to do a vaginal exam?
Answer: The following should be mentioned. In discussion explain why. If they do not mention
both scenarios probe by asking, "Is there any other situation you can think of where you would not
want to do a vaginal exam, why or why not?"
❖
If the membranes are ruptured and the woman is not in labour. The risk for an infection in the
uterus (amnionitis) increases with the number of vaginal exams that the woman has. Therefore
you want to avoid performing an exam until she is actually showing signs of active labour.
❖
If there is vaginal bleeding after 20 weeks and the location of the placenta is not known.
Vaginal bleeding after 20 weeks in a pregnant woman (antepartum hemorrhage) can be due to
placenta previa (when the placenta covers the opening to the cervix). You want to avoid doing a
digital exam in these cases as this can make the bleeding worse.
Ask if there are any questions.
Key Points
❖ All women presenting to the PHC should have a relevant history and physical examination
performed. This provides valuable information about the woman, the pregnancy, why she is
presenting and if she can stay at the PHC or needs to be stabilized and referred.
❖
Pregnant women who present with PV bleeding after 20 weeks should not have a vaginal
examination performed if the location of the placenta is not known (documented by
Ultrasound).
❖
Pregnant women who present with prelabour rupture of membranes should not have a vaginal
examination performed if there are no signs of labour.
41
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Handout 5.1: Case Study 2.1: Part 2
PART TWO: Physical examination
(Read the following section out and then proceed as in the first section)
The woman is 39 weeks gestation. Her last delivery was 2 years ago. It was a normal vaginal
delivery of a live born male infant, weighing 2700 g at term. She had no complications in her
pregnancy or labour. She has been having regular antenatal care. She is otherwise healthy, has
never had surgery, is not taking any medications and does not have any allergies. Her contractions
began 3 hours ago. They are every 5 minutes and are becoming closer together and stronger. She
has not felt her water break and she can feel good fetal movement.
What would you like to do on physical examination? i.e. what do you think you should focus on when
performing a physical examination on this woman?
___________________
Sukshema Project Volume 2
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Labour And Delivery
This has the following sessions
Session 6: Monitoring and progress of labour, use of partograph and identification of
complication - abnormal labour
Session 7: Normal delivery
Session 8: Third stage of labour and active management of third stage of labour
Session 9: Fourth stage of labour (Upto 2hours after delivery)
Learning objectives
By the end of this session (6-9) participants will be able to
❖
Recall the stages of labour, component of and how to do labour monitoring, the significant of
using the partgraph.
❖
Demonstrate how to monitor progress of labour using the partograph in a woman admitted to
the PHC and how to manage all four stages of labour.
❖
Demonstrate the correct documentation of the partograph and case sheet for all stages of
labour for a woman admitted to the PHC.
❖
Demonstrate mentoring skills for use of partograph in first stage of labour, management of
second to fourth stages of labour, including monitoring and progress of labour in a woman
admitted to the PHC.
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postn;
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Monitoring the Progress of Labour, Use of
Partograph; Complication - Abnormal Labour
Materials: PPTslides, SBA guidelines 2010(pg 43-52), new case sheets, video, copies of Partograph,
2 exercises for partograph demonstration, 2 case scenarios for plotting of partograph, pelvic
model and a doll with a placenta,cord
Session time: 1 Hour 50 minutes
Training methods: Interactivelecture, Casestudyandgroupdiscussion, partograph demonstration
and practice sessions, Case sheet demonstration.
Session Objectives:
By the end of this session participants will be able to
J
Recall the stages of labour, components of and how to do labour monitoring, significance
of using partograph
J
Demonstrate how to use of partograph for second stage of labour, monitor labour and
estimate of progress of labour
J
Describe how partograph could help in diagnosing obstructed or prolonged labour
J
Demonstrate mentoring skills for use of partograph for first stage of labour, monitoring
labour and estimation of progress of labour
J
Demonstrate the documentation of partograph for first stage of labour, monitoring
labour general examination on a case sheet,
J
Demonstrate how to audit case sheets for partograph, monitoring labour for a patient
admitted to the facility
Teaching Steps
Duration
Introduction
1. Introduce the topic and session objectives (Slide 1 -2).
5 minutes
Monitoring of
labour
2.
Ask participants to explain about the stages of labour including
lOminutes 1
latent and active stages and duration in a primigravida and
multigravida woman
3-4),
iiiuuiyiaviua
wvinaii (Slide j
t/.
3.
Explain the significance of regular monitoring of labour sheet
(Slide 5-7). Highlight the components of labour monitoring in
latent and active stages using slides and recording the following
on the case sheet.
❖ BP, temperature (every 4 hours, more often if indicated)
❖ Pelvic examination (every 4 hours unless otherwise
indicated)
❖ Pulse, FHR and contractions (every 30min)
❖ Explain the DO5and DONTs in monitoring
Sukshema Project Volume 2
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Use of
partograph
4. Present slides (Slide 8-22)
❖
5.
JIM
20 minutes
Explain the steps to plot a partograph and how to detect
normal labour and abnormal labour (prolonged and
obstructed labour).
Slide 23:Demonstrate how to plot a partograph using 2
Partograph exercises 1-2 (See Handout 6.1-6.2). Refer participants
to additional exercises given in Mentors Manual Vol 2: Partograph
Exercise 3.1-3.2 (pg 62 - 66) that could be used by mentors for
practice or during mentoring sessions with the staff nurses.
40 minutes
❖ Divide participants into groups of 3-4 members.
❖
Distribute Partograph exercise 1 -2 (Handout 6.1 -6.2) on
normal labour, not requiring any intervention as depicted by
partograph findings to half the group.
❖ After 20 minutes review both exercises going through each
step with the participants and helping them to complete it.
❖ Ask participants to interpret partograph findings and
evaluate progress and when to refer. Discuss the findings.
❖ If time permits give them additional labour case studies
(Handout 6.3-6.4) for practice of interpreting progress of
labour using the partograph.
Prolonged and
obstructed
labour
Summarize
6.
Discuss normal delivery process and do's and don'ts during
delivery (Slide 24-27).
7.
Clarify any doubts participants might have on the use of the
partograph and how it is interpreted.
8.
Slide 28: Give the Case study - abnormal labour(Handout 6.5) on
prolonged labour to all the participants. Ask them to read it and
discuss with them the questions. Use the facilitators copy to lead
the discussion.
9.
Reinforce the meaning, causes, signs and symptoms and initial
management of prolonged and obstructed labour as given in the
slides (Slide 29-35).
10. Ask a participant volunteer to point out the partograph in the new
case sheet.
20 minutes
5 minutes
11. Check if they have any doubts on the use of partograph, and
clarify them. Reinforce the key messages. Reinforce that the case
sheet could be a tool for monitoring the progress of labour, it
could also act like a teaching aid providing opportunities for
mentors to choose one to one mentoring methods. (Slide 36-37).
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Peri*
Hand-Out 6.1: Partograph Exercise -1
Instructions:
This exercise is designed to allow you to learn while doing. Work along with the facilitator and
complete the partograph. Interpret the plotting on partograph.
One of you read aloud the Steps 1 -2, when instructed by the facilitator. Then plot on the partograph
as you read information provided in Step 3. Wait till all complete the same. Then another one of
you read Step 4. Go through the question and answers with the facilitator. Clarify any doubts.
Step 1:
o
Mrs A was admitted at 5.00 a.m. on 12.5.2010
o
Membranes ruptured 4.00 a.m.
o
Gravida 3, para 2+0
o
Hospital number 7886
o
On admission the foetal head was 4/5 palpable above the symphysis pubis and
the cervix was 2cm dilated.
Step 2:09.00 a.m.
o
The cervix is 5 cm dilated.
o
There are 3 contractions in 10 minutes, each lasting 20-40 seconds
o
Foetal heart rate (FHR) 120/min
o
Membranes ruptured, amniotic fluid clear
o
Pulse 80 per minute
o
Blood pressure 120/70 mm Hg
o
Temperature 36.8°C
Step 3
Plot the following information on the partograph:
o
09.30 a.m. FHR 120/min, Contractions 3/10 each 30 sec, Pulse 80/min
o
10.00 a.m. FHR 136/min, Contractions 3/10 each 30 sec, Pulse 80/min
o
10.30 a.m. FHR 140/min, Contractions 3/10 each 35 sec, Pulse 88/min
o
11.00 a.m. FHR 130/min, Contractions 3/10 each 40 sec, Pulse 88/min
o
11.30 a.m. FHR 136/min, Contractions 4/10 each 40 sec. Pulse 84/min
o
12.00 noon FHR 140/min, Contractions 4/10 each 40 sec, Pulse 88/min
o
12.30 p.m. FHR 130/min, Contractions 4/10 each 45 sec, Pulse 88/min
1®________
Sukshema Project Volume 2
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Step 4:1.00 p.m.
o
Cervix is fully dilated
o
Contractions 4/10 each 45 sec
o
FHR 140/min
o
Amniotic fluid clear
o
Pulse 90/min,
o
Blood pressure 100/70
o
Temp 37°C
Hand-Out 6.1: Partograph Exercise -1
Step
Question
Answer
1
What should be recorded on the
partograph?
The woman is not in active labour.
Record only the details of her history, i.e.
first 4 bullets, not the cervical dilatation.
2
What should you now record on the
partograph?
The woman is now in the active phase of
labour. Plot the given information on the
partograph._________________________
What is your diagnosis?
Normal progress of labour; good foetal
and maternal condition
3 and 4
What steps should be taken?
What do you expect to happen next?
5
Note: record on case sheet
Routine monitoring of labour; reassure
the woman; give her fluids to drink
Looking at the progress, the woman is
expected to have a normal delivery
1.20 p.m.: spontaneous delivery of a live :
female infant, Wt. 2,850g
47
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
Hand-out 6.2: Partograph Exercise 2
Instructions:
This exercise is designed to allow you to learn while doing. Work along with the facilitator and
complete the partograph. Interpret the plotting on partograph.
One of you, read aloud the Steps 1, when instructed by the facilitator. Then plot on the partograph
as you read information provided in Step 2. Wait till all complete the same. Compare your
partographs with each other. Clarify any doubts you might have. Then another one of you read
Step 3. Go through the question and answers with the facilitator. Clarify any doubts.
Step 1:
o
Mrs B was admitted at 10.00 a.m. on 2.5.2010
o
Membranes intact
o
Gravida 1, para 0+0
o
Hospital number 1443.
Record the information above on the partograph, together with the following details:
o
Cervix is 4 cm dilated
o
Contractions 2 in 10 minutes, each lasting 15sec
o
FHR 140/min
o
Membranes intact
o
Pulse 80 per minute
o
Blood pressure 100/70 mm of Hg
o
Temperature 36.2°C
Step 2:
Plot the following information on the partograph:
o
10.30 a.m. FHR 140/min, Contractions 2/10 each 15 sec, Pulse 90/min, membranes intact
o
11.00 a.m. FHR 136/min, Contractions 2/10 each 15 sec, Pulse 88/min, membranes intact
o
11.30 a.m. FHR 140/min, Contractions 2/10 each 20 sec, Pulse 84/min, membranes intact
o
12.00 noon FHR 136/min, Contractions 2/10 each 15 sec, Pulse 88/min, membranes intact
o
12.30 p.m. FHR 136/min, Contractions 1/10 each 15 sec, Pulse 90/min, membranes intact
o
1.00 p.m. FHR 140/min, Contractions 1 /10 each 15 sec, Pulse 88/min, membranes intact
o
1.30 p.m. FHR 130/min, Contractions 1 /10 each 20 sec, Pulse 88/min, membranes intact
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Step 3:
Record the information above on the partograph, together with the following details:
At 2.00 p.m.
o
Cervix is 8 cm dilated
o
Contractions 3/10 each 20 sec
o
FHR140/min
o
Membranes intact.
o
Pulse 90/min
o
BP 120/80 mmHg
o
Temperature 36.2°C
Questions
Q: What is your diagnosis? What action should be taken now?
Key for Partograph Exercise -2
Step
i
Answer
Question
What is your diagnosis
Mrs B is in active labour___________
What action will you take
Inform Mrs B of finding and what to
expect
Encourage her to move around
Encourage her to drink and eat as
de$ired____________ _____ ______
2
What is your diagnosis
Good progress
Good fetal and maternal condition
What action will you take
3
Inform Mrs B of findings and what to
expect, Reassure her; Encourage her to
move about; give her fluids to drink
What is your diagnosis
Normal labour; with good foetal and
maternal condition.
What action should be taken now?
Conduct delivery
j
Refer the patient to a facility where
augmentation or surgical intervention
can be done if she fails to progress after
10am and remains 4 cms dilated a
____________________ ffll
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Hand-Out 6.3: Labour Case Study 1
Instructions:
This exercise is designed to allow participants to learn the use and interpretation of a partograph.
Give time to participants to read through the questions and then discuss the same with them
Clarify any doubts.
Radha (wife of Gangaram), 26 years of age, third gravida, was admitted at 5:00 am on 11 June
2010 with complaints of full term pregnancy with labour pains since 2:00 am. Her membranes
ruptured at 4:00 am. She has two children of the ages of 5 and 2 years. On admission, her cervix
was dilated 2cm.
Plot the following findings on the partograph: At 9:00 am:
o
The cervix was dilated 5 cm.
o
She had 3 contractions in 10 minutes, each lasting 30 seconds.
o
The FHR was 120 beats per minute.
o
The membranes had ruptured and the amniotic fluid was clear.
o
Her pulse was 80 per minute
o
Her blood pressure was 120/70 mmHg.
o
Her temperature was 36.8° C.
Plot the following findings on the partograph.
9:30 am: FHR 120/min, contractions 3/10 each 30 seconds, pulse 80/minute, amniotic fluid clear
10:00 am: FHR 136/min, contractions 3/10 each 35 seconds, pulse 80/minute, amniotic fluid clear
10:30 am: FHR 140/min, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:00 am: FHR 130/min, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:30 am: FHR 136/min, contractions 4/10 each 45 seconds, pulse 84/minute, amniotic fluid clear
12:00 noon: FHR 140/min, contractions 4/10 each 45 seconds, pulse 88/minute, amniotic fluid
clear
12:30 pm: FHR 130/min, contractions 4/10 each 50 seconds, pulse 88/minute, amniotic fluid clear
a_____
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At 1:00 pm:
O
Cervix fully dilated
O
Contractions 4/10 each 55 seconds
o
FHR140/min
o
Amniotic fluid clear
o
Pulse 90/minute,
o
Blood pressure100/70 mmHg,
o
Temperature 37° C
Questions:
1. What is your diagnosis after plotting the partograph at 1.00pm?
2. What can you predict about the outcome for this woman?
3. Why did you predict the above?
. .. .
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at:
Hand-Out 6.4: Labour Case Study 2
Instructions:
This exercise is designed to allow participants to learn the use and interpretation of a partograph.
Give time to participants to read through the questions and then discuss the same with them
Clarify any doubts.
Rubina (wife ofZarif), age 26 years, was admitted at 11:00 am on 12 June 2009 with the complaint
of full term pregnancy with labour pains since 4:00 am. Her membranes ruptured at 9:00 am. She
has one child aged 3 years. She gave birth to a stillborn baby 5 years back.
Plot the following findings on the partograph: At 11:00 am:
o
The cervix was dilated 4 cm.
o
She had 3 contractions in 10 minutes, each lasting less than 20 seconds.
o
The FHR was 140 per minute.
o
The membranes had ruptured and the amniotic fluid was clear.
o
Her blood pressure was 100/70 mmHg.
o
Her temperature was 37° C.
o
Her pulse was 80 per minute.
Plot the following findings on the partograph
11:30 am: FHR 130/min, contractions 3/10 each 35 seconds, pulse 88/minutes, amniotic fluid clear
12:00 noon: FHR 136/min, contractions 3/10 each 40 second, pulse 90/minutes, amniotic fluid
clear
12:30 pm: FHR 140/min, contractions 3/10 each 40 seconds, pulse 88/minutes, amniotic fluid clear
1:00 pm: FHR 130/min, contractions 3/10 each 40 seconds, pulse 90/minutes, amniotic fluid clear
1:30 pm: FHR 120/min, contractions 3/10 each 45 seconds, pulse 90/minutes, amniotic fluid clear
2:00 pm: FHR 120/min, contractions 3/10 each 45 seconds, pulse 88/minutes, amniotic fluid clear
2:30 pm: FHR 118/min, contractions 3/10 each 45 seconds, pulse 90/minutes, amniotic fluid clear
Plot the following findings on the partograph
At 3:00 pm:
o
Cervix dilated 6 cm
Sukshema Project Volume 2
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o
Contractions 4/10 each 45 seconds
o
FHR 100/minute
o
Amniotic fluid meconium-stained
o
Pulse 100/minute
o
Blood pressure 120/80 mmHg
o
Temperature 37.8°C
Questions:
1. What is your diagnosis after plotting the partograph at 3.00pm? (abnormal labour)
2. What is the action you will take?
3. What initial management should be provided to the woman if she is referred?
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
9
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal
F
Case Study Abnormal Labour
(Facilitator's copy)
Facilitator instructions:
❖
Hand out the participant's case study copy.
❖
Please read out the following scenario to the participants and ask them to answer the
questions.
❖ One option on how to do this is to go around in a circle and let everyone provide an answer or
you can just let individual participants respond.
❖ The purpose of the case study is to get them to think through what steps need to be done and
why they would or would not do something. In all cases try to avoid directly giving the answers
- rather probe around the topic to see if the participants can come up with the responses.
❖ Review the key points and answer any questions at the end of the case study.
Case Study 20 yrs. old Mrs. Lakshmi, who is a primigravida is admitted with labour pains at 5 am.
On examination at 5 am: (0 hour)
o
Pulse 90/min., BP 120/80mmHg.,Temp 37.4°C,
o
P/A: 3 Contractions for 15-20 sec/10 minute, FHR 140/minute,
o
P/V: Cervix 4 cm. dilated, membranes present
What will you do?
o
Monitor for progress of labour
B) At 9.00 am (After 4 hours):
o
Pulse 98/min., BP 120/70 mmHg., Temp 38°C
o
P/A: 3 Contractions for 20-25 sec./10 min., FHR 126/min.
o
P/V: Cervix 5 cm dilated, membranes present
Is the progress normal?
o
The cervical dilatation is not as expected, i.e., 1 cm / hr., hence the progress is delayed
C) What are the signs of obstructed labour?
o
Plotted cervical dilatation line in the partograph is to the right of Line A at the four hour and
eight hour assessments
o
No cervical change (secondary arrest) with repeat PV after 4 hours in active phase of labour
o
Significant caput and moulding
Sukshema Project Volume 2
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lilil
II
o
Cervix that is not well applied to presenting part
o
Swollen, oedematous cervix
o
Ballooning lower uterine segment
o
Formation of retraction band felt over abdomen
o
Foetal or maternal distress(Mother: tachycardia, signs of dehydration & fever, baby - Foetal
distress)
o
Labour that is longer than 24 hours duration
D) How will you refer?
Do the following
o
Talk to the relatives about the condition of the patient
o
Call and determine the nearest facility where a c-section can be done if necessary
o
Arrange transport
o
Keep the woman NPO
o
Do not provide oxytocin
Give the following
❖
Insert 16-18 gauge IV and provide IV normal saline or ringer lactate @ 30 drops/min
❖ Insert Foley's catheter
❖ Start oxygen
❖ Give all the three following antibiotics
o
Ampicillin 1g either Oral or IV
o
Metronidazole either 400mg Oral or 500mg IV
o
Gentamicin 80mg either IM or IV
While in transport
❖
Keep the woman in left lateral position
❖ Continue fluid and carry extra bottles to last till she reaches the facility
❖
Provide oxygen
❖
Keep a delivery set and essential drugs handy
❖ SN accompanies the woman
Carry relevant documents
❖ Take the plotted partograph
❖ Take the filled up complication case sheet A for the patient
L55 sj
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour Delivery and Postnatal Periods at 24/7 PHCs
Hand-Out 6.5: Case Study Abnormal Labour
(Participants copy)
Case Study labour:
A. 20 yrs. old Mrs. Lakshmi, primigravida is admitted with labour pains at 5 am.
On examination at 5 am: (0 hour)
❖
Pulse 90/min., BP : 120/80 mmHg.,Temp: 37.4°C,
❖
P/A: 3 contractions for 15-20 sec./10 min., FHR: 140/min.,
❖
P/V cervix 4 cm. dilated, membranes present
What will you do?
B. At 9.00am (after 4 hours):
❖
Pulse 98/min., BP 120/70 mmHg., Temp: 38°C
❖
P/A: 3 contractions for 20-25 sec./10 min., FHR 126/min.
❖
P/V: cervix 5 cm dilated, membranes present
Is the progress normal? (Note down the reasons for your answer).
Sukshema Project Volume 2
11
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C What are the signs of obstructed labour?
D. How will you refer and what will you do before referring?
____________________QI
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal P
-7
Normal Delivery
Materials: PPT slides, SBA guidelines 2010 (pg 47-48), new case sheets, video, 5 case scenarios in
printed copies, copies of Partograph, Pelvic model and a doll with a placenta, cord, mannequin,
delivery kit, flip charts and markers
Session time: 50 minutes
Training methods: Lecture, Video, Demonstration on mannequin/pelvic model, Case sheet
demonstration.
Session Objectives:
By the end of this session participants will be able to
J
Recall the steps to conduct and manage the second stage of labour and normal delivery
J
Demonstrate how to conduct and manage the second stage of labour and normal
delivery
J
Demonstrate documentation of managing the second stage of labour and conducting
a normal delivery, in case sheets
J
Demonstrate mentoring skills for conducting and managing the second stage of labour
and normal delivery
Teaching Steps
Duration
Introduction
1. Introduce the topic and session objectives (Slide 1-2).
2 minutes
Monitoring of
labour
2.
Ask participants to explain the components of delivery. Write main
points of discussion on the flip chart.
3.
Show video of the stages of delivery of baby: head, shoulder and
body.
❖
. •’’f' . > •
Pause video at
laias
■
4.
w
■
o
Crowning
o
Delivery of head
o
Delivery of shoulder
o
Delivery of trunk
o
Putting the baby over the mother's abdomen
Present slides to explain do's and don'ts during labour; stages of
labour and indications of episiotomy (Slide 3-8); also show slides
on delivery of head, shoulders trunk; clamping cord (Slide 9-14).
3 minutes
lOrtii^tes-j
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10 minutes J
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Sukshema Project Volume 2
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Summarize
■'
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5.
Demonstrate using the mannequin/pelvic model the stages of
delivery. Divide the group in pairs and ask each to do the return
domnnctrAtinn
demonstration ncinn
using tha
the nalvir
pelvic model
model and
and fatiic
fetus.
20 minutes -
6.
Ask a volunteer to show where delivery notes and what must be
. .......................
.......................
included
recorded
in case sheets.
5 minutes
7.
ihtthekevnointc
Clarify if any doubts arise and highlight
the key points
(S^e 15-16).
________________________________________________________ I
59
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and P
____
18
Third Stage of Labour and Active Management
of Third Stage of Labour (AMTSL)
Materials: PPT slides, SBA guidelines 2010 (pg 49-50), New case sheets, video, case scenarios in
printed copies, Pelvic model and a doll with a placenta, cord, delivery kit and drug tray, PPT
Session time: 50 minutes
Training methods: Lecture, power point, demonstration -use of pelvic model or mannequin,
baby and placenta.
Session Objectives:
By the end of this session participants will be able to
J
Recall about the third stage of labour, the significance of active management of third
stage and its components, examination of placenta
J
Demonstrate how to manage third stage of labour - AMTSL, examination of placenta,
estimation of blood loss
J
Demonstrate documentation of managing the third stage of labour, in case sheets
J
Demonstrate mentoring skills for managing third stage of labour
Teaching Steps
Duration
Introduction
1. Introduce the topic and session objectives (Slide 1 -2).
2 minutes
Third stage of
labour, AMTSL
2.
Ask participants how they conduct the third stage of labour.
3.
Using slides explain the relevance of AMTSL and its importance to
reduce maternal mortality, steps of AMTSL, Dos and Don'ts
(Slide 3-11)._________ ;___________ .
Demonstrate using pelvic model or mannequin how to perform
AMTSL steps (uterotonic, controlled cord traction, uterine massage
followed by examination of placenta, estimation of blood loss)Use checklist - Handout 7.1
Demonstration 4.
of AMTSL
Summarize
gl.,,.,..
5.
Divide participants into groups and ask one or two volunteer
participants for return demonstration. Commend them for correct
steps and correct any mistakes_________ _______________ ___
6.
Ask a few participants to highlight the key learning of the session.
Wait for responses.
7.
Conclude with key messages and show the video on AMTSL
(Slide 12-13). Encourage participants to mention points that are in
line with SBA recommendations. Clarify any questions if they arise.
.
Sukshema Project Volume 2
8 minutes
30 minutes
10 minutes
:1
Bl11
Hand-Out 7.1: Evaluation Checklist
Evaluation type: model (M) or clinical practice (C)
SINo
Steps
Done
Not
done
AMTSL Step 1: Administration of a uterotonic drug
(2 points)
1.
Palpates the uterus to make sure no other baby is present
2.
If no other baby is present administers uterotonic drug
(oxytocin 10IU IM or if a woman has an IV infusion an
option of oxytocin SIU IV bolus slowly within a minute of
delivery
AMTSL Step 2: Does controlled cord traction (9 points)
3.
Clamps and cuts the cord approximately 2-3 minutes after
the birth
4.
Places the palm of the other hand on the lower abdomen
just above the woman's pubic bone________
Keeps slight tension on the cord and awaits a strong
uterine contraction
5.
6.
Applies gentle but firm downward traction to the cord
during a contraction, while at the same time applying
counter-traction abdominally______________________
7.
Waits for the next contraction and repeats the action
if manoeuvre is not successful after 30-40 seconds of
controlled cord traction
8.
As the placenta delivers, holds it in both hands______ __
9.
Uses a gentle upward and downward movement or
twisting action to deliver the membranes
10.
If membranes tear, gently examine the upper vagina and
cervix______ __________ __________________ ____
Places the placenta in the basin available
11.
AMTSL step 3: Uterine massage____________________
12.
Immediately massages the fundus of the uterus through
the woman's abdomen until the uterus is contracted (firm)
13.
Ensures the uterus does not become relaxed 9soft) after
stopping uterine massage_________________________
If the uterus becomes soft after massage, repeats uterine
massage
14.
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Teaches the woman how to massage the uterus5
___________________ _
Immediate PR care
___________ r________
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____
Examines the maternal surface of the placenta and
membranes for completeness and abnormalities
.
I
Dispo>ses
_____
the...placenta in the appropriate bin
18.
__________________________
_____ *
Removes the soiled bed linen and makes the woman
20.
comfortable_______________
17.
21.
22.
-
______
Estimates blood loss
_________________________
Assists woman to start breast feeding
I®---------------Sukshema Project Volume 2
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19
Management of Fourth Stage
(Up to 2hrs after Delivery)
Materials: PPT slides, SBA guidelines 2010 (pg 51-52), new case sheets, watch, BP apparatus,
stethoscope, gloves
Session time: 25 minutes
Training methods: Lecture, PPT, Case sheet demonstration
Session Objectives:
At the end of this session participants will be able to
Explain the importance of care provided to the mother within the first 2 hours of delivery
and steps of monitoring fourth stage of labour.
Describe the steps of monitoring fourth stage of labour.
Demonstrate documentation of fourth stage of labour in the case sheet.
Teaching Steps
Introduction
1.
Duration
Introduce the topic and objectives of the session (Slide 1-2)
2 minutes
Fourth stage of 2.
labour
Ask participants how they monitor patients soon after delivery
(4th stage). Record the same on the flip chart.
3 minutes
Assess and
Monitoring
during fourth
stage
3.
Explain using slides the importance of management of the
fourth stage, i.e. the first two hours after delivery of the placenta.
Emphasise on the need to monitor pulse, BP, uterine tone and
fundal height and bleeding PV and what any abnormality might
indicate (Slide 3-8).
15 minutes
4.
Discuss with participants any problems they face in monitoring this
stage of labour.
5.
Check with participants if they know where they would record
details of pulse, after BP uterine tone, fundal height and bleeding
PV in the new case sheet.
6.
Ask participants "how do you think you could use the case sheet as
a mentoring tool?"
7.
Clarify any doubts and conclude with key points (Slide 9-10).
Summarize
5 minutes
63
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Postpartum Or Postnatal Period
Learning objectives
By the end of the session participants will be able to
❖
Recall the importance of doing a relevant assessment for the women in the early postnatal
period.
❖
List and describe the relevance of the components of a good postnatal assessment.
❖
Demonstrate how to do a comprehensive postnatal assessment and manage postnatal period
appropriately.
❖
Demonstrate documentation of relevant early postnatal assessment and management of the
women admitted to the PHC in the case sheet.
❖
Demonstrate mentoring skills for doing a relevant early postnatal assessment and management
of the women presenting or admitted to the PHC.
Refer to Chapter 4 in the Participants manual for details of the session
s---------
Sukshema Project Volume 2
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Postnatal Care at the Facility
Materials: PPT slides, SBA guidelines 2010, new case sheets,watch, BP instrument, thermometer,
stethoscope, gloves, speculum/Cusco's speculum, flip charts, marker pens
Session time: 40 minutes
Training methods: Case studies, interactive lecture, power point presentation, Group activity,
case sheet demonstration
Session Objectives:
By the end of this session participants will be able to
Describe how postnatal care is to be provided to a recently delivered mother
at the facility
Z
Demonstrate documentation of postnatal care provided to recently delivered
mother at the facility
Teaching Steps
Duration
Introduction
1.
Introduce the topic and objectives of the session (Slide 1-2).
3 minutes
Postnatal care
at facility components
2.
Group activity: Ask participants "will you monitor a recently
delivered woman during the postnatal period" "what?"
"why?"Facilitate discussion and note down the points on a flipchart.
/minutes ■
3.
Explain and reinforce using slides (Slide 3-9):
20 minutes
❖ Significance of postpartum check up
❖ Frequency of postpartum monitoring during 48 hour stay
❖ Key components of postpartum care include
4.
o
Monitoring vital signs: BP, HR, temperature
o
Examining the breast, abdomen to check if it is contracted,
amount of bleeding PV, perineum to detect any tears
Role play: Demonstrate with another facilitator how to counsel
mothers regarding care of mother in the facility
5 minutes
❖ Preventing infection
❖ Danger signs to look for
Summarize
5.
6.
7.
❖ Diet she must take________________________ _________
Ask participants to point out where they would record the details
of postnatal check up on the new case sheet
Brainstorm with participants "how would you be able to assess
the quality of postnatal care in the facility. Wait for responses and
then tell them that it could be through audit of case sheets, exit
interview of women at discharge or direct observation.
Clarify any doubts of the participants and conclude with key points
(Slide 10-11).
5 minutes
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
"uHHHK’ I
Complications During Pregnancy, Labour, Delivery And Postnatal
Period - Identification, Initial Management And Referral
Session 11 A: Identification, initial management and referral of haemorrhage (APH and PPH)
Session 11 B: Identification, initial management and referral of PIH
Session 11 C: Identification, initial management and referral of infection and preterm labour
Session 12: Preparation of labour room
Learning objectives
By the end of the sessions participants will be able to
❖
Recall how to identify obstetric complications during pregnancy, labour and delivery and in the
postnatal period at the PHC.
❖
Explain the appropriate initial management before referral for complication identified.
❖
Demonstrate how to identify danger signs obstetric complications and provide the appropriate
initial management.
❖
Demonstrate documentation of complications and appropriate initial management at the PHC.
Refer to Chapter 5 in Mentors' manual
Sukshema Project Volume 2
fl
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Il 1A
Complications of Labour, Delivery, Postnatal PeriodIdentification, Initial Management and Referral of
Hemorrhage (PPH and APH)
Materials: PPT slides, SBA guidelines 2010(pgs 79-85), New case sheets, video, case scenarios in
printed copies,pelvic modelandadollwitha placenta, government complication management
protocols, emergency drug tray.
Session time: 60 minutes
Training methods: Case studies and group activity, interactive lecture using power point and
Video, Demonstration on pelvic model, doll and placenta, use of government labour room
protocols, Case sheet demonstration.
Session Objectives:
By the end of this session participants will be able to
Discuss how to identify danger signs/ obstetric complications at initial assessment of
labour, during labour and in postnatal period at the facility
J
Explain the initial management of obstetric complications at first assessment of labour,
during labour and in postnatal period at the facility
J
Demonstrate documentation of complications at assessment of labour, in labour and in
postnatal period at the facility on case sheets
Teaching Steps
Duration
Introduction
1.
Introduce the topic and session objectives (Slide 1 -2).
3 minutes
Identification
of danger
signs at initial
assessment,
initial
management
2.
Brainstorm with participants "what are the complications of labour,
delivery and postpartum period?" After 5 minutes ask them to
present their list and then project the list.
5 minutes
■
❖ PPH, Eclampsia, preterm labour, Infection/fever, APH.
3.
Request one or two participant volunteers to describe their
experience in handling any one of the complications
4.
Get participants to refer to the case sheet and point out what
aspect of the case sheet refers to danger signs.
❖
|S|l
1
Reinforce that complications can be detected at any time in initial assessment prior to labour, during labour, during
delivery, third stage, fourth stage, postnatal period and thus a
woman must be observed carefully during these periods.
❖ Emphasise the need to act quickly to manage the common
complications such as
67
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
:
1
Care of a
woman with
V APH
Care of a
woman with
PPH
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5,.
Ask participants: "have any of you seen a woman bleeding before
delivery?""what are some of the causes?"
6.
Explain with slides causes and presenting features of APH, initial
..I ... maha9ement ^
.....?
: □
Use case study - (Handout 10A.1) either before or after this part
7.
Brainstorm with participants: "when would you suspect PPH?" Wait
for responses and then tell them danger sign bleeding PV more
than 500 cc at delivery, passage of dots.
8.
Ask them what they would assess if a woman has bleeding.
Reinforce the need to examine the abdomen and check for
the following
❖
9.
20 minutes
Findings: uterus may or may not be not contracted, bleeding
PV heavy or very heavy, low BP, rapid pulse
10 minutes
10 minutes
5 minutes
Ask them further "what else will you look for once you know a
woman is bleeding?: (Expected response - cause of bleeding) What
investigations might be required?
❖ Causes of PPH - atonic PPH, incomplete placenta, tear, rupture
uterus, retained placenta, infection in delayed PPH
❖ Identification of cause using the PPH protocol
10 minutes
10. Then ask them, "from your experience how do you think PPHcan be
prevented and managed?"
❖ AMTSL, uterine massage, Injection Oxytocin 10IUIM, 20 IU in
500ml IV drip, removal of placenta and placental fragments,
❖
Bimanual compression,
❖
repair of 1 st and 2nd degree tears,
❖ Antibiotics (Ampicillin Igm IV, Metronidazole 500ml IV,
Gentamycin 80mg IM) in Manual removal of placenta (MRP),
and delayed PPH
❖
Referral
11. Explain the causes, identification and initial management of PPH
using slides (Slide 11-19).
12. Demonstrate how bimanual compression can be done on the
mannequin.
13. Refer them to the case sheet. Ask them to identify information that
they would need to record on the case sheet. Reinforce how the
case sheet could be used to
10 minutes
5 minutes
❖ Audit practices of staff nurses.
❖ Teach staff on a one to one basis how PPH could be identified,
assessed further and managed before referral
Summarize
14. Ask participants to point out three key learning's of the session.
Clarify if there are any doubts.
15. Conclude with key messages (Slide 20)
Sukshema Project Volume 2
2 minutes
Case Study - Early PPH
(Facilitator's Copy)
As the instructor, hand out the participants case study copy. Please read out the following scenarios
to the participants and ask them to answer the questions. One option on how to do this is to go
around in a circle and let everyone provide an answer or you can just let individual participants
respond. The purpose of the case study is to get them to think through what steps need to be
done and why they would or would not do something. In all cases try to avoid directly giving the
answers - rather probe around the topic to see if the participants can come up with the responses.
Review the key points and answer any questions at the end of the case study.
Scenario: Part A
You havejust delivered Mrs. B, a 30 year old gravida 4 para 4 at the PHC. She had a vaginal delivery for a
live born, 2.6 kg baby boy. What will you do to actively manage the third stage of labour and decrease
the risk ofpostpartum hemorrhage in this woman?
Answer: Perform active management of the third stage of labour, which involves the following
components. You do not want to give away the answers but probe to see if the participants can
provide them. For example if they do not mention giving uterotonics -ask "would you give any
medications, why or why not?"- this encourages them to actually think about the steps that need
to be taken.
❖ Administration of a uterotonic drug (5-10 mg IV or IM of oxytocin, 600 micrograms rectally of
misoprostol, or 0.2 mg IM of ergometrine). Mention that oxytocin is the preferred drug but that
the others are also acceptable to use.
❖ Clamping of the cord
❖ Gentle, controlled cord traction with one hand over the symphysis pubis to provide counter
traction and thus prevent uterine inversion
❖
Discuss that these 3 actions have been shown to decrease the risk of postpartum hemorrhage
and should be performed on all women as routine care. This is especially important to do in the
Northern Karnataka context since PPH is the leading cause of maternal deaths.
Scenario: Part B
Mrs. B. delivers the placenta. After delivery of the placenta what do you want to check for and why?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to do, why or why not?"
❖ Check that the placenta and membranes are complete, because retained placental tissue/
fragments can lead to ongoing bleeding and be a cause of PPH.
❖ You also want to check that the uterus is firm and contracted since uterine atony is the most
common cause of PPH (it is responsible for 80% of all PPH cases).
69 I
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
■H
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal
>->
❖
Examine the perineum, vagina and cervix for tears. This is because tears are the most likely
cause of PPH if the uterus is firm and well contracted and the placenta is complete.
❖
Estimate if the amount of blood loss at delivery is normal or abnormal. This helps you get a
sense of what is a normal amount of blood after delivery and what is too much bleeding after
delivery.
Scenario: Part C
On examination the uterus is well contracted and there are no perineal tears. The placenta and
membranes are intact. One hour later she begins to have heavy PV bleeding. What would you like to
do on your initial assessment of Mrs. B and why?
Answer: All of thefollowing points need to be mentioned and discussed. You want to reinforce that
there needs to be a sequential order to doing things and that in reality if 2 health care providers
are present at the same time many of these steps happen simultaneously. If they do not mention
all steps probe by asking,"Is there anything else you would want to do, why or why not?"
❖ Call for help - this allows you to have additional help for managing the patient. If help is not
available do not wait for help to come to assess the patient.
❖ An initial rapid assessment of Mrs. B should be done to look for signs of shock and if she is in
need of emergency resuscitation. These signs include: pulse >110, systolic blood pressure less
than 90 mmHg, sweatiness, cold, clammy skin, rapid breathing, altered level of consciousness,
confusion. Temperature should also be done to rule out infection.
❖ The uterus should be immediately checked to see if it is contracted. Explain that this is done
because 80% of all PPH is due to uterine atony and even though it was firm before it may have
become atonic.
❖ The perineum, vagina and cervix should be carefully re-examined for tears. While this was done
previously - now that the bleeding has started again you want to make sure that you did not
miss anything on earlierexamination.
Scenario: Part D
You have completed your initial rapid assessment of Mrs. B and your findings include the following:
Her temperature is 36.8° C, her heart rate is 100 beats per minute, her blood pressure is 116/74 and her
respirations are 18 per minute. She is alert and oriented. Her uterus is soft and boggy. There are no
perineal, vaginal or cervical tears.
Based on these findings, what is Mrs. B's diagnosis and why?
Based on these findings do you think shock is present?
Answer: Uterine atony without signs of shock. Explain that the findings of a soft, boggy,
uncontracted uterus are consistent with the diagnosis of uterine atony. Review again the signs
of shock (pulse >110, systolic blood pressure less than 90 mmHg, sweatiness, cold, clammy skin,
rapid breathing, altered level of consciousness, confusion).
How will you manage her and why?
Answer: All of thefollowing points need to be mentioned and discussed. You want to reinforce that
there needs to be a sequential order to doing things and that in reality if 2 health care providers
fli.------------
Sukshema Project Volume 2
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are present at the same time many of these steps happen simultaneously. You do not want to give
away the answers but probe to see if the participants can provide them. For example if they do
not mention starting an IV -ask"Would you start an IV, why or why not?"-This encourages them
to actually think about the steps that need to be taken.
❖ Call for help/assistance as many things need to be done simultaneously. Mrs. B should not
be left unattended nor should you delay caring for Mrs. B while help is on its way or if help is
unavailable.
❖ Begin uterine massage and continue until the uterus is firm. This helps the uterus contract. You
may also need to do a pelvic examination to remove any clot from the uterus. As long as there
is clot in the uterus the uterus will not be able to contract.
❖
Immediately give an additional dose of Oxytocin 10 Units IM x 1. If oxytocin is not available
then one of the following uterotonics can be given via an alternate route (800 micrograms
of misoprostol rectally, 0.2 mg IM of ergometrine) to help the uterus contract. Explain that
oxytocin is the preferred drug of choice, followed by misprostol, then ergometrine (ergometrine
has more adverse effects such as increasing the blood pressure). Use this point to reinforce that
the new case sheets will have information on dosages, repeat dosages and contraindications.
❖ Startan IV with a large bore needle (16 or 18guage) and run 20 Units of injectable oxytocin in
500ml of Ringers Lactate or Normal Saline at 60 drops per minute then follow with an additional
20 units of injectable oxytocin in 500ml of IV fluids at 40 drops per minute (not more than 3L).
❖
If the woman continues to bleed and the uterus does not contract after performing the above
steps then one of the following uterotonics can be given via an alternate route (800 micrograms
of misoprostol rectally, 0.2 mg IM of ergometrine) to help the uterus contract. Use this point
to reinforce that the new case sheets will have information on dosages, repeat dosages and
contraindications.
❖ Start an IV and begin fluids of either NS or RL at 40-60 drops per minute. Explain that placing an
IV ensures that you have access for more fluid administration and any additional medications if
she continues to bleed. By giving fluids, you are making sure that the woman does not become
volume depleted while you are managing the bleeding.
❖
Insert a Foley catheter will help keep the uterus contracted by making sure the bladder is
empty. It is also is a useful way to measure urine output if the woman continues to bleed.
❖ Continue to recheck her vital signs. This will let you know if the patient is remaining stable or is
beginning to deteriorate and show signs of shock.
❖ You do not need to cross-match her for blood since she is not in shock.
❖
Blood for haemoglobin does not need to be drawn immediately if she does not continue to
bleed and if she responds to your initial management.
Scenario: Part E
You correctly diagnose uterine atony. You have performed uterine massage, removed all clots from the
uterus, administered oxytocin 10 Units IM x 1, started an IV with and inserted a Foley. She has IV fluids
of500ml of NS with 20 units ofoxytocin running at 60 drops per minute. Her uterus is now firm and well
contracted. Repeat vital signs show a heart rate of 86, blood pressure of 108/72, temperature of 36.9° C
and respiratory rate of 16. Her haemoglobin is 8g/dl. There is no further PV bleeding.
Based on these findings, what is your continuing plan of care for Mrs. B and why?
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❖
Mrs. B.'s vital signs and blood loss should continue to be monitored, every 15 minutes for 1 hour,
then every 30 minutes for 2 hours, every hour for 3 hours and then every 4 hours for 24 hours.
Her uterus should be checked to make sure that it remains firm and well contracted. In addition,
she should be encouraged to breastfeed her newborn. She needs to have this additional close
monitoring because you want to make sure she does not start to bleed again. Breastfeeding
releases oxytocin and this also help to keep the uterus contracted to prevent bleeding.
❖ Twenty-four hours after the bleeding has stopped, a haemoglobin or haematocrit should be
done to check for anemia.
❖
If Mrs. B.'s hemoglobin is below 11 g/dL she should be given IFA tablets once daily for 6-9
months. This will help increase her iron stores and increase her hemoglobin.
❖ A blood transfusion is not needed if her vital signs are stable and no further bleeding occurs.
❖ She should be encouraged to express her concerns, listened to carefully, and provided
continuing emotional support and reassurance.
❖ Mrs. B. should remain at the health center for an additional 24 hours, and before discharge
counseling should be provided about danger signs in the postpartum period (bleeding,
abdominal pain, fever, headache, blurred vision), compliance with iron/folic acid treatment
and the inclusion in her diet of locally available foods rich in iron. In addition, counseling about
breastfeeding and newborn care should be provided.
❖
If recovery continues to be unremarkable, Mrs. B. and her baby should be seen by a healthcare
provider approximately 5 to 6 days after discharge.
Congratulations you have successfully managed a case of early postpartum hemorrhage.
Ask if there are any questions or points that require clarification.
Key points to review at the end of the case
❖ Active management of the third stage of labour should be performed on all women after
delivery of the baby.
❖
Inspection of the placenta and membranes, perineum, vagina and cervix and uterine tone
should be done routinely after all deliveries. Doing so routinely will help identify and/or prevent
early PPH.
❖
Early PPH is defined as bleeding greater than 500 ml in the first 24 hours after delivery. What
you really want to be able to determine is if the bleeding is much heavier than it should be (i.e.
not a normal amount).
❖ The most common cause of early PPH is uterine atony (80% of all cases). Perineal, vaginal and
cervical tears, followed by retained placenta or placental fragments are the next most common
causes.
❖ Always perform an initial rapid assessment to determine if the patient is in shock or not and
requires immediate resuscitation.
❖
®
Never leave a bleeding woman alone. Women who have had an immediate PPH need increased
monitoring for the next 24 hours to make sure no further bleeding occurs.
Sukshema Project Volume 2
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Handout 10A.1: Case Study - PPH
(Participant's copy)
Scenario: Part A
You have just delivered Mrs. B, a 30 year old gravida 4, para 4 at the PHC She had a vaginal delivery
for a live born, 2.6 kg baby boy. What will you do to actively manage the third stage of labour and
decrease the risk of postpartum hemorrhage in this woman?
Scenario: Part B
Mrs. B. delivers the placenta. After delivery of the placenta what do you want to check for and why?
Scenario: Part C
On examination the uterus is well contracted and there are no perineal tears. The placenta and
membranes are intact. One hour later she begins to have heavy PV bleeding. What would you like
to do on your initial assessment of Mrs. B and why?
Scenario: Part D
You have completed your initial rapid assessment of Mrs. Band yourfindings include thefollowing:
Her temperature is 36.8° C, her heart rate is 100 beats per minute, her blood pressure is 116/74 and
her respirations are 18 per minute. She is alert and oriented. Her uterus is soft and boggy. There
are no perineal, vaginal or cervical tears.
Based on these findings, what is Mrs. B's diagnosis and why?
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Based on these findings do you think shock is present?
How will you manage her and why?
Scenario: Part E
You correctly diagnose uterine atony. You have performed uterine massage, removed all clots
from the uterus, administered oxytocin 10 Units IM x 1, started an IV with and inserted a Foley. She
has IV fluids of 500 ml of NS with 20 units of oxytocin running at 60 drops per minute. Her uterus is
now firm and well contracted. Repeat vital signs show a heart rate of 86, blood pressure of 108/72,
temperature of 36.9° C and respiratory rate of 16. Her haemoglobin is 80. There is no further PV
bleeding.
Based on these findings, what is your continuing plan of care for Mrs. B and why?
Sukshema Project Volume 2
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Complications of Labour, Delivery and Postnatal
Period- Identification, Initial Management and
Referral of Hypertensive Disorders of Pregnancy
Materials: PPT slides, SBA guidelines 2010 (pgs 79-85), New case sheets, video, case scenarios
in printed copies,pelvic modelandadollwitha placenta, government complication management
protocols, emergency drug tray.
Session time: 1 Hour 30 minutes
Training methods: Case studies and group activity, interactive lecture using power point and
Video, Demonstration on pelvic model, doll and placenta, use of government labour room
protocols, Case sheet demonstration.
Session Objectives:
By the end of this session participants will be able to
Discuss how to identify hypertensive disorders of pregnancy initial assessment of labour,
during labour and in postnatal period at the facility
J
Explain the initial management of hypertensive disorders of pregnancy at first assessment
of labour, during labour and in postnatal period at the facility
Demonstrate documentation of hypertensive disorders of pregnancy at assessment of
labour, in labour and in postnatal period at the facility on case sheets
Teaching Steps
Reinforce
information
on
hypertensive
disorders of
pregnancy
1.
Use slides to explain classification, identification of, initial
management and referral of a woman with PIN (Slide 21-27).
2.
Encourage questions and if none if forthcoming, ask a few
questions.
Duration
10 minutes
•ant. A,
Ask
Distribute the case study (Handout 11 B.1) to each participant.
them to sit in their groups and read the case. Give them half an
hour to complete it. ?:'? ■
—
hypertensive
disorders of
pregnancy
3.
identified
throuah a case
through
scenario
4.
Discuss the questions with them
5.
Encourage any participant to share their experience of taking
of a woman with hypertensive disorders of pregnancy
10 minutes-
Request participants to go through the case sheet and check what
information must be recorded in hypertensive disorders of
pregnancy.
10 minutes
Documentation 6.
7.
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■ <1
Reinforce how reviewing documents at a PHC, could help in
identifying
❖ One to one mentoring encounters
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PI
___________________________ _
Summarize
8.
Brain storm with participants to review content
❖
How would you define hypertensive disorders of
pregnancy?
❖ How is hypertensive disorders of pregnancy classified?
❖ What is Hypertension in pregnancy?
❖ What are some danger signs that could point to a
hypertensive disorders of pregnancy?
❖ What is the drug of choice for Severe preeclampsia /
eclampsia
❖ What are some possible complications of hypertensive
disorders of pregnancy?
9.
End with the key messages (Slide 28).CIarify any doubts
Sukshema Project Volume 2
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1
Handout 10A.1: Case Study - PPH
(Participant's copy)
Facilitator's Instructions: Hand out case study participant copy. Please read out the following
scenarios to the participants and ask them to answer the questions. One option on how to do
this is to go around in a circle and let everyone provide an answer or you can just let individual
participants respond. The purpose of the case study is to get them to think through what steps
need to be done and why they would or would not do something. In all cases try to avoid directly
giving the answers - rather probe around the topic to see if the participants can come up with
the responses. When medications need to be given ask them the dose of the medication and how
they would give it. Review the key points and answer any questions at the end of the case study.
Scenario: Part A
Mrs. B is a 16 year old gravid 1 para 0 referred to your PHC from the ANM at the Sub-Centre. She
reports that at that visit she was told she had "high blood pressure" and to come to the PHC for further
assessment. A review of her records shows that she has had three antenatal visits this pregnancy and
that before this last visit all findings were within normal limits. At her last visit, it was found that her
blood pressure was 140/90 mm Hg. Her urine was negative for protein. The fetal heart sounds were
normal, the fetus was active and uterine size was consistent with dates. She is currently 37 weeks
gestational age.
What do you think about the blood pressure measurement of 140/90? Is this normal or abnormal?
Answer: It is abnormal. Discuss normal blood pressure in pregnancy. Blood pressure of greater
than or equal to 140/90 mm Hg after 20 weeks gestational age is not normal and is consistent with
the diagnosis of hypertensive disorders of pregnancy.
Why is it important to know that the urine was negative for protein?
Answer: The absence of protein in the urine indicates that the patient only has pregnancy induced
hypertension and not pre-eclampsia. If there was protein in the urine with a blood pressure of
greater than or equal to 140/90 mm Hg after 20 weeks then the patient would have pre-eclampsia.
Whenever someone presents with high blood pressure it is absolutely essential to determine if
there is protein in the urine or not as this changes your diagnosis and management.
Based on this information from her last visit of a blood pressure of 140/90 mm Hg and no proteinuria
what would your diagnosis have been then?
Answer: Mrs. B.'s signs and symptoms e.g., diastolic blood pressure 90-110 mm Hg after 20 weeks
gestation and no proteinuria are consistent with pregnancy induced hypertension.
Now, at her visit with you, what would you like to include on your initial history when talking with Mrs.
B and why?
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at
I
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to ask, why or why not?"
❖
Mrs. B. should be greeted respectfully and with kindness. This helps build rapport with the
patient.
❖ She should be told what is going to be done and listened to carefully. In addition, herquestions
should be answered in a calm and reassuring manner.This reassures the patient and also helps
build rapport.
❖ Ask specifically about the following: has she had headache, blurred vision, upper abdominal
pain or fits/seizures other problems since her last clinic visit. These are important questions
to ask because they are symptoms of hypertensive disorders of pregnancy. They area also the
danger signs that should be discussed with all pregnant women as indications to seek care
immediately.
❖ She should be asked whether fetal activity has changed since her last visit. This is important to
ask about because it provides an indication of fetal well being.
What would you like to do on physical examination and why?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking,"Is there anything else you would want to do, why or why not?
❖
Blood pressure should be measured. Blood pressure greater than or equal to 140/90 after 20
weeks gestational age is indicative of pregnancy induced hypertension. If protein is present in
the urine then it is indicative or pre-eclampsia.
❖ An abdominal examination should be done to check fetal growth and to listen for fetal heart
sounds. This is an indication of fetal wellbeing (in cases of pre-eclampsia/eclampsia reduced
placental function may lead to low birthweight; there is an increased risk of hypoxia in both the
antenatal and intrapartum periods, and an increased risk of abruptio placentae).
What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. B., and why?
Urine should be checked for protein, since the presence of protein in the urine changes the
diagnosis from pregnancy induced hypertension to pre-eclampsia.
Scenario: Part B
You have completed your assessment of Mrs. B., and your main findings include the following:
History: Mrs. B. is complaining of severe headache, and blurred vision. She denies any upper
abdominal pain, convulsions or loss ofconsciousness. She reports normal fetal movement.
Physical Examination: Mrs. B.'s blood pressure is 170/120 mm Hg, and she has 4+ proteinuria.
The fetus is active and fetal heart rate is 136 per minute. Uterine size is consistent with dates.
Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?
Answer: Mrs. B.'s signs and symptoms e.g., blood pressure greater than 160/90 mm Hg after 20
weeks gestation, 4+ proteinuria, blurred vision and severe headache are consistent with severe
pre-eclampsia.
Sukshema Project Volume 2
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Scenario: Part C
Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B., and why?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to do, why or why not?
❖
Explain to Mrs. B her condition and answer any questions she may have.
❖
She should be referred to the nearest FRU for further assessment. Prior to referral she should
receive medication to stabilize her. She will need to be delivered.
❖ Antihypertensive medications should be given to help lower her blood pressure. You do not
want to drop the systolic below 90 mm Hg as this can be too low for the fetus. Give Nifedipine
5 mg orally x 1. Providing this medication helps decrease the risk that she may have a stroke.
❖
Provide the first dose of prophylactic Magnesium sulfate prior to transfer. Women with severe
pre-eclampsia are at risk of having seizures. Giving magnesium sulfate can prevent this from
happening. Give 10 ml of Inj. Magnesium sulfate deep IM in each buttock (a total of 20 ml of
magnesium sulphate) -this is the preferred choice.
❖ Tranquilizers and sedative should NOT be given. There is no benefit to give these - they may
actually harm the woman and her baby.
❖ Call the FRU and speak with someone to let them know that Mrs. B is coming. A transfer note
should be given to Mrs. B to take with her that contains the important information for the
receiving facility (history, medications given, blood pressure, gestational age). This helps
the health care providers at the referral facility know why the woman was referred, what her
problem is and how she has been treated to date.
❖
She should not be sent alone. She has a high risk of seizure and needs to travel accompanied.
IfMrs. B had presented with convulsions what your diagnosis have been?
Answer: Eclampsia. All seizures in a pregnant woman from after 20 weeks up until 6 weeks postpartum
are eclampsia until proven otherwise.
What would your plan of care be for Mrs. B ifshe was having convulsions?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all steps
probe by asking, "Is there anything else you would want to do, why or why not?
❖
Do not leave the woman on her own. Being with her helps to prevent from fall or injury.
❖
Protect the woman from fall or injury, but do not restrain her. Restraining the patient can
actually harm her.
❖
Ensure a clear airway and breathing. If the woman is unconscious, keep her on her back with
her arms at the side; tilt her head backwards and lift her chin to open the airway.
❖ After the convulsion is over, help her turn to a left lateral position. Keep the woman in this
position throughout transportation.
❖
Keep a mouth gag between the upper and lower jaw to prevent tongue bite. (Do not attempt
this during a convulsion.)
❖ Measure the BP of the woman. Maintain a record of these. Knowing the blood pressure will let
you know if the woman will also need a dose of antihypertensive medications. If the
79 J
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 2A
ssias
systolic is greater than 160 or the diastolic greater than 110 mmHg then she will need
an antihypertensive. This prevents against the risk of her having a stroke.
❖ Give the first dose of Inj. magnesium sulphate. Give 10 ml of Inj. magnesium sulphate deep IM
in each buttock (a total of 20 ml of magnesium sulphate). It is important to ensure that this is
given deep because otherwise it can lead to the formation of an abscess at the injection site.
Magnesium sulfate is the preferred drug of choice for treating seizures in pregnancy.
❖ Start an IV infusion, and give IV fluids slowly @ 30 drops/minute and insert a Foley catheter. This
will prevent the women from becoming dehydrated, allow you to monitor urine output (which
can decrease significantly in eclamptic women) and provides IV access if you need additional
medication.
❖ Tranquilizers and sedative should NOT be given. There is no benefit to given these - they may
actually harm the woman and her baby.
❖
Immediately arrange to refer the woman to an FRU. Eclampsia is a life threatening condition
for the both the mother and baby and she needs to be transferred to a centre where they can
deliver her immediately.
❖ Ensure that the woman reaches the referral centre within 2 hours of receiving the first dose of
magnesium sulphate. This is because women with eclampsia need to be delivered within 12
hours from the onset of the seizure.
❖ She should not be sent alone. She should be transported via ambulance. This is because this is
a life threatening condition and she needs to have help with her.
If magnesium sulfate were not available in your PHC what other drug would you use for treatment of
seizures in pregnancy and how would you give it?
Answer: Diazepam 20 mg rectally in 10 ml syringe. This is second line and should be given only if
magnesium sulfate is not available. Magnesium sulfate is the preferred drug since it is better and stopping
seizures in and preventing them in cases of pre-eclampsia and eclampsia.
Congratulations you have successfully managed a case of severe- preeclampsia and eclampsia.
Ask if there are any questions or points that require clarification.
Key points to review at the end of the case
❖ Severe pre-eclampsia and eclampsia are life threatening conditions that need to be recognized
and treated immediately.
❖
Blood pressure greater than or equal to 140/90 mm Hg in pregnancy is not normal.
❖ All women with increased blood pressure in pregnancy should have their urine checked for the
presence of protein.
❖
Blood pressure greater or equal to 160 /110 requires a dose of antihypertensive before referral.
❖ Women with severe pre-eclampsia and eclampsia need to be stabilized before being referred
to the FRU.
❖ Women with severe pre-eclampsia need a prophylactic dose of magnesium sulfate prior to
transfer to the FRU. This helps prevent seizures.
❖
Magnesium sulfate is the drug of choice to treat seizures in pregnant women.
❖ Tranquilizers and /or sedatives should NOT be given to women with, pregnancy induced
hypertension, severe- pre-eclampsia or eclampsia.
❖
Never leave a seizing woman alone.
Sukshema Project Volume 2
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Hand-Out 11 B.1: Case Study: Hypertensive Disorder of Pregnancy
(Participant's Copy)
Scenario: Part A
Mrs. B is a 16 year old gravida 1 para 0 referred to your PHC from the ANM at the Sub-Centre. She
reports that at that visit she was told she had "high blood pressure" and to come to the PHC for
further assessment. A review of her records shows that she has had three antenatal visits this
pregnancy and that before this last visit all findings were within normal limits. At her last visit, it
was found that her blood pressure was 140/90 mm Hg. Her urine was negative for protein. The
fetal heart sounds were normal, the fetus was active and uterine size was consistent with dates.
She is currently 37 weeks gestational age.
What do you think about the blood pressure measurement of 140/90? Is this normal or abnormal?
Why is it important to know that the urine was negative for protein?
Based on this information from her last visit of a blood pressure of 140/90 mm Hg and no proteinuria
what would your diagnosis have been then?
Now, at her visit with you, what would you like to include on your initial history when talking with
Mrs. B and why?
What would you like to do on physical examination and why?
____________________ SV
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal P€
What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. B., and why?
Scenario: Part B
You have completed your assessment of Mrs. B., and your main findings include the following:
History: Mrs. B. is complaining of severe headache and blurred vision. She denies any upper
abdominal pain, convulsions or loss of consciousness. She reports normal fetal movement.
Physical Examination: Mrs. B.'s blood pressure is 170/120 mm Hg, and she has 4+ proteinuria.
The fetus is active and fetal heart rate is 136 per minute. Uterine size is consistent with dates.
Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?
Scenario: Part C
Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B., and
why?
If Mrs. B had presented with convulsions, what your diagnosis have been?
What would your plan of care be for Mrs. B if she was having convulsions?
..............
Sukshema Project Volume 2
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Complications of Labour, Delivery, Postnatal PeriodIdentification, Initial Management and Referral of
Infection and Preterm Labour
Materials: PPT slides, SBA guidelines 2010 (pgs 79-85), New case sheets, video, case scenarios in
printed copies, pelvic model and a dollwitha placenta, government complication management
protocols, emergency drug tray.
Session time:1 Hour
Training methods: Case studies and group activity, interactive lecture using power point and
Video, Demonstration on pelvic model, doll and placenta, use of government labour room
protocols, Case sheet demonstration.
Session Objectives:
By the end of this session participants will be able to
Discuss how to identify maternal sepsis during initial assessment of labour, during
labour and in postnatal period at the facility
J
Explain the initial management of maternal sepsis.
J
Discuss how to identify Preterm labour and the initial management.
J
Demonstrate documentation of maternal sepsis and preterm labourat assessment of
labour, in labour and in postnatal period at the facility on case sheets
Introduction
Care of a
woman with
infection
Teaching Steps
Duration
1.
introduce the topic and session objectives
5 minutes
2.
Ask participants "How many have seen women with infection
during labour or in postnatal period?" Request anyone to share
their experiences_______________________________________
3.
Ask participants to discuss in their groups "What are the common
causes of fever in a woman during labour, delivery, postnatal
period?"
4.
After 5 minutes ask participants to write their responses on the
board.
5.
Highlight the main causes of fever in mothers during delivery and
postnatal period with the help of PPTs (Slide 29-34).
6.
Ask participants to apply AMMA approach for a woman with fever
and discuss the same in the group
15 minutes
10 minutes
❖ Assess: Fever and other associated symptoms
❖ Manage: based on the cause with antibiotics and antipyretics
❖ Measure:
❖ Advocacy: 5 cleans
__________________ ei
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
7.
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Care of a
woman with
preterm labour
8.
Distribute the case scenario (Handout 10C.1) to participants.
Ask them to discuss it among the group members and then
after 5 minutes request each group to take turns and answer the
questions. Reinforce key points (Slide 35).
_______;____________________ _________________________
Present the slides on preterm labour, with or without rupture of
membranes; with or without contractions (Slide 36-38).
J
f
15 minutes
❖ Causes
9.
❖
Danger signs to watch for
❖
Initial management based on gestational age.
Discuss the significance of Dexamethasone for a woman in
imminent preterm labour
❖ Route
❖ Dosage
❖
Indications
❖ Advantages
Documentation
and audit
10. Tell participants to imagine that they were visiting the PHC. Ask
them to discuss in their groups how they would monitor the
practice of a staff in caring for a woman with infection or preterm
labour
10 minutes
11. Reinforce on how infection could be prevented with the help of
PPTs
Summarize
12. Ask participants to come out with 3 important messages
13. Project the key messages (Slide 39).
14. Clarify any doubts. Highlight the different case sheets
(complication case sheets that will be used). Reinforce the key
messages (slide 40-42).
I 84
Sukshema Project Volume 2
5 minutes
ii
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J
Case Study - Fever
(Facilitator's copy)
Facilitator's Notes: As the instructor, hand out the case study participant copy. Please read out
the following scenarios to the participants and ask them to answer the questions. One option on
how to do this is to go around in a circle and let everyone provide an answer or you can just let
individual participants respond. The purpose of the case study is to get them to think through
what steps need to be done and why they would or would not do something. In all cases try to
avoid directly giving the answers - rather probe around the topic to see if the participants can
come up with the responses. Review the key points and answer any questions at the end of the
case study.
Scenario: Part A
Mrs. B. is a 22-year-old para 1 who has come to the health centre complaining that she feel shot and
unwell. Mrs. B. reports that she gave birth vaginally to a full-term newborn 3 days ago at the health
centre. The newborn weighed 4 kg and Mrs. B. suffered a perineal laceration that required suturing. She
was counselled about danger signs before leaving the health centre, including the need to seek care
early if any danger signs occur.
Before you assess Mrs. B, what are the possible common illnesses that could be causing her fever today?
Answer: All of the following points need to be mentioned and discussed. You do not want to give
away the answers but probe to see if the participants can provide them. For example if they do
not mention one ask "Are there any other causes of fever you can think of, why or why not?"-This
encourages them to actually think about the possible illnesses that could be causing the fever.
Explain that it is important to think about what the common causes are because this helps direct
you on what questions to ask on history and what to look at on physical exam.
All of the following are common causes of fever in the postpartum woman:
❖
Uterine infection (also called endometritis or puerperal sepsis)
❖ Wound infection - this could be either an infection of a perineal wound or a caesarean section
wound
❖
Kidney infection (pyelonephritis)
❖
Breast engorgement
❖
Breast infection (this can be either a mastitis or a breast abscess)
❖ Viral infection causing diarrhoea or vomiting
What will you include in your initial assessment of Mrs. B., and why? This refers to both history and
physical examination.
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking,"Is there anything else you would want to do, why or why not?
85
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
-
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
❖
iim; *
os'"
Mrs. B. should be greeted respectfully and with kindness.This helps build rapport with
the patient.
❖
She should be told what is going to be done and listened to carefully. In addition, her questions
should be answered in a calm and reassuring manner. This helps build rapport with the patient.
❖
A rapid initial assessment should be done to determine the degree of illness: her temperature,
pulse, blood pressure and respirations should be noted. This is important to do because it
quickly lets you know how sick Mrs. B is and if she has any signs of septic shock.
❖
On history you want to inquire specifically about the presence of other signs or
symptoms, such as:
❖
o
abdominal pain or tenderness (this is a sign of uterine infection/endometritis /puerperal
sepsis),
o
bleeding, foul-smelling lochia (this also is a sign of uterine infection/endometritis /
puerperal sepsis),
o
frequent or painful urination and flank pain (this is a sign of a kidney infection/
pyelonephritis),
o
swollen or red breasts (this can be a sign of breast engorgement or breast infection/
mastitis/abscess),
o
any vomiting or diarrhoea (this is a sign of a viral infection), and
o
any loss of consciousness (this can indicate sepsis).
In addition to the initial rapid assessment on physical examination you want to perform
the following:
o
examine the breasts for signs of swelling, pain and tenderness (these are a sign of
engorgement), for any redness and swelling (this is a sign of an breast infection, mastitis),
cracked nipples, and for the presence of a lump or mass (this indicates a breast abscess)
o
examine the perineal wound for any pain, tenderness, redness, discharge, swelling,
abscess formation (these are signs of a wound infection or abscess),
o
examine the abdomen to see if there is any uterine tenderness (this is a sign of uterine
infection), and
o
examine the lochia to see if there is any purulent fouls smelling lochia (this is also a sign
of uterine infection).
What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs.
B., and why?
None at this stage - she is stable.
86
Sukshema Project Volume 2
Scenario: Part B
You have completed your assessment of Mrs. B., and your main findings include the following:
History: Mrs. B. denies abdominal pain, frequent or painful urination, abdominal tenderness, foulsmellinglochia, breast swelling or redness, vomiting or diarrhea or loss of consciousness. Physical
Examination: Mrs. B.'s temperature is 38°C, her pulse rate is 88 beats per minute, her blood pressure is
120/80 and her respiration rate is 20 breaths per minute. There is no abdominal tenderness. Her lochia
is ofnormal color and amount, and without offensive odour. Her breasts are normal with no swelling
or redness. Her perineal wound is tender with redness and swelling present extending beyond the edge
of the incision. There is no discharge or pus present.
Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?
Answer: Mrs. B.'s symptoms and signs (e.g., wound tenderness, redness and fever) are consistent with the
diagnosis of perineal wound infection.
Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B., and why?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to do, why or why not?
❖ The steps taken to manage the complication should be explained to Mrs. B. In addition, she
should be encouraged to express her concerns, listened to carefully, and provided emotional
support and reassurance.
❖ Ypu can perform one of 2 options:provide the first dose of antibiotic and refer to an FRU or if
your MO is comfortable with managing as an outpatient you can proscribe a five day course of
antibiotics and have her return for follow up.
Option one: referral.
❖ Provide the following antibiotics Cap Ampicillin 1 g,Tab Metronidazole 400 mg and Inj
Gentamicin 80 mg IM stat. This will start to treat the infection immediately.
❖ Analgesia can be provided to help with the pain and the fever. Tab Paracetamol 500 mg to take
as 3-5 times per day as needed, can be given.
❖
Make sure there is a good referral note including reason for referral, and medications given. This
provides very helpful information for the people who will see Mrs. B at the next facility.
Option two: Outpatient management and follow up.
❖ Antibiotics should be prescribed. This should consist of Cap Ampicillin 500 mg orally four times
a day for 5 days and metronidazole 400 mg orally three times a day for five days.
❖ Analgesia can be provided to help with the pain and the fever.Tab Paracetamol 500 mg to take
as 3-5 times per day as needed can be given
flat
_______________________ ■
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
0
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
■SSF’H IHE
mh
❖
Mrs. B. should be counseled about the need for good hygiene, to change her perineal pad/cloth
at least three times a day and to wear clean clothes. This will help keep the area clean.
❖
Mrs. B. should be asked to return the next day for followup and to have the perineal dressing
changed. This will let you reassess Mrs. B's wound to make sure it is getting better and not
worse.
❖
Mrs. B. should be followed up on a daily basis until the wound has healed satisfactorily. This is
necessary to make sure that MRs B is improving and not getting worse. If she does not improve
then she would require referral for further management.
Ask if there are any questions.
Key Points
❖
Uterine infection, breast engorgement and infection, wound infection and kidney infection are
all common causes of fever in a postpartum woman. Anytime a postpartum woman presents
with a fever you should be thinking about these possible causes.
❖ A careful history and physical examination focusing on these common causes will help provide
the correct diagnosis.
❖
If the woman is managed as an outpatient, whatever the diagnosis is for the cause of the fever,
follow up is always needed to make sure that the woman is getting better.
❖
If the woman is referred a good referral note should always be done and sent with the woman.
88
Sukshema Project Volume 2
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xO..
Hand-Out 11 Cl: Case Study - Fever
(Participant's copy)
Scenario: Part A
Mrs. B. is a 22-year-old para 1 who has come to the health center complaining that she feels hot
and unwell. Mrs. B. reports that she gave birth vaginally to a full-term newborn 3 days ago at the
health center. The newborn weighed 4 kg and Mrs. B. suffered a perineal laceration that required
suturing. She was counseled about danger signs before leaving the health center, including the
need to seek care early if any danger signs occur.
Before you assess Mrs. B, what are the possible common illnesses that could be causing her fever
today?
What will you include in your initial assessment of Mrs. B., and why? This refers to both history and
physical examination.
What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. B., and why?
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Scenario: Part B
You have completed your assessment of Mrs. B., and your main findings include the following:
History: Mrs. B. denies abdominal pain, frequent or painful urination, abdominal tenderness, foul
smelling lochia, breast swelling or redness, vomiting or diarrhea or loss of consciousness. Physical
Examination: Mrs. B.'s temperature is 38°C, her pulse rate is 88 beats per minute, her blood pressure
is 120/80 and her respiration rate is 20 breaths per minute.There is no abdominal tenderness. Her
lochia is of normal color and amount, and without offensive odor. Her breasts are normal with no
swelling or redness. Her perineal wound is tender with redness and swelling present extending
beyond the edge of the incision. There is no discharge or pus present.
Based on these findings, what is Mrs. B.'s diagnosis (problem/need), and why?
Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B., and
why?
M
Sukshema Project Volume 2
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IMMI
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Preparation of Labour Room
tn
Materials: SBA handbook
Session Time: 60 minutes
Training methods: Discussion, demonstration
Session Objectives:
By the end of the session the participants should be able to
Discuss the importance of preparing the labour room.
Discuss and demonstrate the articles, drugs and equipments that is required in the
labour room.
J
Discuss the problems the staff may face in keeping the labour room prepared.
Teaching Steps
Duration
Introduction
1.
Introduce the session topic and objectives
5 minutes
Reason for
being prepared
2.
Brainstorm with participants,"why should you be prepared always
in the labour room?" wait for responses
10 minutes
3.
Ask participants, "What articles, drugs and equipment must be
ready in the labour room?"Write their responses in the flip chart.
Ask them to refer to Checklist 2.4 in SBA Handbook 2010. Reinforce
requirements to conduct a delivery safely.____________ ______
Ask participants to turn to SBA handbook and refer to their
responses written on the flip chart. Request a volunteer to read
aloud how the labour room must be prepared_____________
Articles needed 4.
to be kept ready
Summarize
5.
Discuss any problems they might face in keeping the labour room
prepared always.
6.
Encourage one or two volunteers to share how they have
managed to be always ready for any woman in labour
7:
Conclude with key messages and clarify any doubts.
10 minutes
15 minutes
a
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Preparation For Discharge
Learning objectives
By the end of the session participants will be able to
❖
Demonstrate the counselling skills required before discharge including danger signs for mother
and newborn, follow up and care and FP advice.
❖
Demonstrate documentation of discharge for mother and baby.
❖
Demonstrate mentoring skills for discharge.
Refer to Chapter 6 of Mentor's manul Vol 2 manual for details of the session.
Sukshema Project Volume 2
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IZ)
in
Ol
<Z)
Preparation for Discharge or Referral
Materials: SBA guidelines 2010, new case sheets
Session time: 1 Hour
Training methods: Interactive lecture, Case sheet demonstration
Session Objectives:
By the end of the session the participants should be able to
J
Discuss the importance of counselling the mother and family before discharge.
Discuss the maternal and newborn danger signs that the mother needs to be educated
on before discharge.
Discuss the critical steps that the staff need to take to ensure timely referral of maternal
/ newborns with complications.
Teaching Steps
Introduce the
topic
Preparationfor
discharge
Duration
1.
Introduce the topic of the session and its objectives
5 minutes
2.
Group activity - counselling at discharge
15 minutes
❖ Ask participants the significance of counselling before
discharge
❖ Ask participants to describe the counselling to be given
mothers and their family about recognising danger signs in
the postnatal period
3.
Explain what advice to give families about when to seek care for
danger signs, care, follow up, FP
Bleeding in postnatal period
❖ Any kind of infection (Fever, breast pain, breathing difficulty,
foul smelling lochia, difficulty in urination, pain in abdomen,
pain in perineum) in postnatal period
❖
Regular postnatal checkups required at home/facility
30 minutes
❖ Types of contraceptive methods to be advised for recently
delivered woman
<♦ Supplementation of IFA, calcium and nutritious diet, their
significance and compliance
❖ Personal care and hygiene for a mother before discharge
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
t
<Section ArSkilled Birth Attendance during Labour, Delivery and Postnatal Periods
at 24/7 r.PHCs
4.
Transporting
a pregnant
woman with
complications
5.
*
-
■
Divide the participants into 5 groups. Ask each group to plan for
a role play (5 minutes). Request two volunteer participants from
each group to demonstrate how they would counsel a postnatal
mother just before discharge on one of the assigned topics as
given below
❖
Danger signs
❖
Follow up
❖
Family planning
❖'
Nutrition
❖
Hygiene
Brainstorm with participants “what would you do if a woman
is to be referred urgently to another center. Wait for responses,
Highlight the key points to remember for referral:
❖
Call and determine the nearest facility where labour
induction, augmentation, c-section and ICU are available if
needed
❖
Arrange transport -108, Ambulance Govt., Ambulance Pvt,
Any other form of transport
❖
In case of shock: Continue fluids and carry extra bottles to
last till she reaches the facility; provide oxygen staff nurse
to accompany the woman and monitoriTvital signs every 10
mins to adjust the IV drip
10 minutes
If the woman is pregnant, keep a delivery set and essential
drugs handy
❖
Summarize
If delivered, ensure baby is kept warm, feedings continued
6.
Ask participants to turn to the part of the new case sheet where
counselling provided for a woman at discharge could be recorded
7.
Reinforce main points
$4
Sukshema Project Volume 2
5 minutes
Sukshema Mentor's Participant Profile
1.
S.No.
Name:
2.
Place:
Mobile number:.
3.
Address:
4.
Qualification: GNM/BSc/PcBSc/MSc;
5.
Studied in an institution with attached hospital: YES / NO
6.
Years of experience/ service.
7.
Years of service in last work place.
8.
Last position held:.
-9.
Received training on MNCH (Maternal, neonatal, child health^
Type
NO
email id:.
Duration if Yes
YES
SBA
NSSK
NRHM
Any other
10. Circle your level of confidence in performing the following on a scale of 1-5 where 1 means
very low confidence and 5 means very high confidence ..
1
2
3
4
5
ii. Checking BP of a woman in labour
1
2
3
4
5
iii. Doing an abdominal exam of woman in labour
1
2
3
4
5
iv. Doing a vaginal exam of woman in labour
1
2
3
4
5
v. Monitoring labour using partograph
1
2
3
4
5
vi. Conducting normal vaginal delivery
1
2
3
4
5
vii. Giving and suturing an episiotomy
1
2
3
4
5
viii. Administering injMgSO4 to a woman
1
2
3
4
5
i.
Taking a history of a woman in labour
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
c
so
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
________________
ix. Starting an Iv for a woman
1
2
3
4
5
x. Monitoring a woman in postnatal period
1
2
3
4
5
xi. Assisting in newborn resuscitation
1
2
3
4
5
xii. Giving bag and mask resuscitation for NB
1
2
3
4
5
xiii. Giving chest compression to a NB if needed
1
2
3
4
5
xiv. Giving Inj Vitamin K to a NB
1
2
3
4
5
xv. Assisting a mother to breast feed her baby
1
2
3
4
5
xvi. Assisting a mother to give KMC
1
2
3
4
5
xvii. Checking the temperature of a NB
1
2
3
4
5
xviii. Using the radiant warmer for a NB
1
2
3
4
5
xix. Monitoring a NB from birth till discharge
1
2
3
4
5
xx. Counselling a woman on her care and NB care
1
2
3
4
5
11. In the last 1 year how many of the following you have done / performed
(approximate number)
i.
Conducted normal vaginal deliveries
ii. Given an episiotomy
iii. Given magnesium sulphate injection
iv. Done/Assisted - resuscitation for a newborn
v. Given vitamin K for a newborn
vi. Given antibiotic for a woman in labour
vii. Sutured an episiotomy
viii. Managed a woman with bleeding
ix. Managed a woman with hypertension/eclampsia
x. Managed a low birth weight baby
12. Give at least three expectations from present training
i.
ii.
iii.
Sukshema Project Volume 2
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Pre-test/Post-test (Knowledge)
Sukshema - Nurse Mentors Training Program
Pre-test
Serial Number:.
Time 1 hour
TOTAL MARK (70)
Please write the alphabet of the single best option in box provided against each question for
multiple choice questions or complete the question as indicated. Each expected answer carries
"I" mark.
1. Which of the following is NOT an adult learning principle
a.
Adults learn best when they accept responsibility for their own learning
b.
Adults learn best when learning is applied immediately
c.
Adults learn best when learning occurs in large groups
d.
Adults learn best when the learning experience is active not passive
2. Which of the following is an open endedquestion
a.
Are you feeling all right today?
b.
Is there anything else I can do for you?
What do you think brings up these feelings for you?
d.
How old is your partner
3. Feedback is most constructive when it
a.
Is delivered a long time after the learner performs a skill
b.
Is delivered using "you"statements ("you really need to.....")
c.
Is descriptive but does not pass judgment on the learners intentions or skills
d.
Does not target specific errors but rather is made up of general comments
4. After how many minutes does a learner's ability to retain and recall information
significantly decline?
a.
10 minutes
b.
30 minutes
c.
50 minutes
d.
75 minutes
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
$
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
5. A good method to spontaneously get creative list of ideas, thoughts, problems, or solutions
around a particular topic without regard to application of these ideas is called
a.
Brainstorming
b.
Role play
c.
Practicum
d.
Coaching
6. Which of the following is NOT a quality improvement principle
a.
Promotion of client and provider rights
b.
Mentoring
c.
Self-assessment
d.
Team work
7. Which of the following is a client right?
a.
Standard operating procedures
b.
Accessible, available services
C.
Opportunity to practice skills
d.
Awareness of range of services in the health care setting
8. Which of the following is a tool that could be used to ass individual staff clinical competence
a.
Case sheets
b.
Client and provider rights handout
c.
PHC operating guidelines
d.
Action plan
9. Which of the following behaviour would NOT reflect "attending" skill of a mentor
a.
Leaning forward towards the mentee
b.
Relaxed posture
c.
Crossing arms while talking to mentee
d.
Maintaining eye contact
S3
Sukshema Project Volume 2
. .. .
HI
10. Which of the following is an example of an evaluative question
a.
You do understand this, don't you?
b.
What are the main points that you have learnt?
c.
How do you think this could be managed at the PHC level?
d.
Did you have your breakfast?
11. An example of immediate response methods of clinical mentoring is
a.
Case based discussion
b.
Modelling
c.
Mini lecture
d.
Case sheet review
12. Distance mentoring makes use of the following tools EXCEPT
a.
Telephone
b.
Email
c.
Letter
d.
Face to face
13. Susheela is 24 years. She comes to the PHC in May 2012 and tells you that she is 7 months
pregnant. She says that her last period started a day before Diwali (October 18). Her due date is
a.
July 24
b.
July 28
c.
July 17
d.
July 22
14. The second stage of labour begins with and ends with
a.
onset of labour and half dilatation of the cervix
b.
onset of labour pains and full dilatation of the cervix
c.
full dilatation of the cervix and delivery of the baby
d.
Full dilatation of the cervix and delivery of the placenta
|
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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________ _______
a
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
_______________________________________________________________
15. Fetal distress is diagnosed with an FHR less than 120 beats per minute or more
than 160 beats per minute
a.
True
b.
False
c.
Not sure
16. A catheter is used to empty the bladder to manage a case of PPH
a.
True
b.
False
c.
Not sure
17. If the blood pressure for a pregnant woman is more than 140/90mmHg and there is
protein present in the urine. It is a case of
a.
Proteinuria
b.
Hypertension
c.
Eclampsia
d.
Pre-eclampsia
18. The appropriate order of steps in active management of third stage of labour include
a.
Controlled tracton, fundal massage and oxytocin
b.
Intravenous oxytocin, cord clamping and cutting and fundal massage
c.
Cord clamping and cutting, controlled cord traction, ergometrine administration and
inspection of placenta
d.
Intramuscular injection of oxytocin, controlled cord traction with counter traction to the
uterus and uterine massage
19. In the active stage of labour a vaginal examination must be done
a.
Hourly
b.
Two hourly
c.
Four hourly
d.
Not at all
Sukshema Project Volume 2
20. The dose and route of oxytocin for the initial management of PPH before you refer
the woman to the FRU are
a.
20 IU in 500ml of ringer lactate, intravenously
b.
15 IU, in 500 ml of ringer Lactate intravenously
c.
20 IU, intramuscular stat
d.
5 IU, intramuscular stat
21. Preterm labour is defined as labour before 40 weeks of gestation
a.
True
b.
False
c.
Not sure
22. Normally, 6-7 cm dilatation of the cervix is considered full dilatation
a.
True
b.
False
Don't know
23. What is the dose and route of magnesium sulfate injection for the initial management
of eclampsia
a.
5mL (2.5 g), deep IM in each buttock
b.
10mL (5 g), deep IM in each buttock
c.
15mL (7.5g), deep IM in each buttock
d.
20 mL (10 g), deep IM in each buttock
24. If a woman has good uterine contractions, but progress of labour is arrested it is called
a.
Prolonged labour
b.
Obstructed labour
Arrested labour
d.
False labour
UM
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
25. Active management of the third stage of labour must be practiced
a.
Only for women with a history of PPH
b.
Only for primipara
c.
Only for the multipara
d.
For all women
26. A woman with a ruptured uterus has which of the following signs and symptoms present
a.
Rapid maternal pulse, low BP
b.
Persistent abdominal pain and tenderness
c.
Fetal distress
d.
All of the above
27. Initial management of postpartum endometritis includes all EXCEPT
a.
Discontinuation of breast feeding
b.
Observation of colour and odour of lochia
c.
Administration of antipyretic/analgesic
d.
Administration of antibiotic
28. For a woman with 30 weeks pregnancy and sudden profuse watery discharge from
vagina you will
a.
Give antibiotics and send her home for home with follow up advice
b.
Check maternal and fetal status and send her home
c.
Give her antibiotics and refer to FRU with foot end raised
d.
Do nothing and send her home since it is too early
29. During the first two hours after birth the health care provider must
a.
Measure the woman's BP and pulse once and insert a catheter to empty her bladder
b.
Measure the woman's BP and pulse and check the uterine tone every 15 minutes
c.
Not disturb the woman if she is asleep as her rest is more important
d.
Measure the woman's BP, temperature and pulse every 15 minutes
Sukshema Project Volume 2
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30. Which of the following is a normal presentation in pregnancy
a.
Breech
b.
Vertex/cephalic
c.
Face
d.
Shoulder
31. Which of the following if detected on the partograph of a primigravida woman in labour
at a PHC indicates need for urgent referral
a.
Progressing to left of the alert line
b.
Has reached the alert line
c.
Has crossed the action line
d.
Progressing to the right of the alert line (line A)
32. A baby whose birth weight is less than
grams is a low birth weight baby
33. Breast feeding must be initiated within
minutes of normal delivery
34. What are the signs of good attachment?
35. State any four danger signs in a newborn
36. List the three major causes of mortality in newborns
I
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
6 '
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
________ '
_______________
37. Name any four benefits of KMC
38. What are the two indications for positive pressure ventilation in a neonate?
39. Expand the term STABLE in relation to transport of a sick neonate
40. Four essential needs of a newborn in the first 48 hours include
41. A baby whose weight is less than as expected for gestational age is called
Sukshema Project Volume 2
-
■I
5,1
Bl
42. A baby born term, crying well must be given
a.
Routine care
b.
Special care
c.
Resuscitation
d.
Intensive care
to
43. The eye of the baby must be cleaned from
baby
44. A baby with poorly developed breast bud, no sole creases is a
45. A baby weighing less than
grams must be referred to a higher centre
46. Breast feeding is contraindicated for a woman who is HIV positive
a.
True
b.
False
c.
Not sure
47. The dosage of Vitamin k for a newborn baby weighing 1600gms is
a.
Img
b.
0.5mg
c.
0.25mg
d.
None at all
48. What is the local treatment for sore nipple
a.
Antibiotics
b.
Good attachment
c.
Analgesics
d.
Hind milk
::::
•:
M
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
’
6
■
■
■
•
i
■
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
HH
49. Which of the following congenital anomalies is an emergency and requires
immediate transfer
a.
Diaphragmatic hernia
b. Anorectal anomaly
c.
Spina bifida
d. Congenital heart defect
50. What are any two signs that a newborn is getting enough breast feed?
BB———___
Sukshema Project Volume 2
fl.-:-’* .HWWfW’HWl'. ........... ...
Pre-testPost-test (Knowledge)
- Answer and Scoring Key
Mentoring and QI
Answer
Question No. and Content
Category
1.
Which of the following is NOT an adult learning
principle
c
1
2.
Which of the following is an open ended question
c
2
3.
Feedback is most constructive when
c
2
4.
After how many minutes does a learner's ability to
retain and recall information decline
b
i
5.
A good method to spontaneously get creative
ideas, Which of the following is NOT an adult
learning principle
a
1
6.
Which is not a quality improvement principle
7.
Which is a client right
b
b
2
2
8.
Which is a tool that could be used to assess
individual staff clinical competence
a
i
9.
Which behaviour would not reflect "attending" '*
skill of a mentor
c
1
c
b
2
d
1
10. Which is an example of an evaluative question
11. An example of immediate response methods of
clinical mentoring is
12. Distance mentoring makes use of the following
tools except
_________________________________________ TOTAL
Obstetric content
Score
i
12
13. Susheela is 24 years. She comes to the PHC in May
2012 and tells you that she is 7 months pregnant.
She says that her last period started a day before
Diwali (October 18). Her due date is
a
1
14. The second stage of labour begins with and ends
with
c
1
15. Fetal distress is diagnosed with an FHR <120 or
>160 beats per minute
a
0.5
16. A catheter is used to empty the bladder in case of
PPH__________________________________
a
0.5
17. If the BP is >140/90 in a pregnant woman and
urine protein is positive
d
1
18. The appropriate order of steps in AMTSL include
d
2
19. In active stage of labour vaginal exam must be
done
c
i
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
■
<
■■■■
-
■
•
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
■I
_________________________________________________________ .
20. The dose and route of oxytocin for initial
management of PPH before referral
a
1
21. Preterm labour is defined as labour before 40
weeks of gestation
b
0.5
22. Normally 6 -7cm dilatation of the cervix is
considered full dilatation
b
0.5
23. What is the dose and route of Magnesium
sulphate for initial management of eclampsia
b
1
24. If a woman has good uterine contractions but
progress of labour is arrested
b
1
25. AMTSL must be practices
d
1
26. A woman with ruptured uterus presents with
d
1
27. Initial management of postpartum endometritis
include all except__________________ _________
a
1
28. For a woman with 30 weeks pregnancy and
sudden profuse watery discharge from the vagina
you will__________________________
c
1
29. During the first 2 hrs after birth the HCP must
b
2
30. Which of the following is a normal presentation in
pregnancy
_________
b
1
31. Which of the following if detected on the
partograph of a primi woman in labour indicates
urgent referral
_____ _______
d
1
17
TOTAL
Qs no and Qs
Newborn content
Answer
Marks
32. Birth weight less than
......... is LBW____________
2500gm or 2.5kg
1
33. Breast feeding must be
initiated....... of birth
__
30 mins or 1/2 an hour
0.5
34. Signs of good attachment
Mouth wide open
0.5x4=2
More areola visible above than
below mouth
Chin touching breast
Lower lip everted_____
35. 4 danger signs in a
newborn (Any)
108 1
__ A
Sukshema Project Volume 2
____
Breathing difficulty
Convulsions
Discharge or redness from
umbilicus
Feeding difficulty
Vomiting or blood in stools
Hypothermia or pyrexia
Icterus
Stiff or floopy baby
Irritability or lethargy
Pustules>10 in skin
0.5x4=2
36. Three major causes of
mortality in NB
Asphyxia
Sepsis
Prematurity or LBW___
05x3=1.5
37. Four benefits of KMC
Temperature maintained
0.5x4=2
Increases milk production
Increased growth of baby
Prevents sepsis and infection
Baby more secure
Bond between mother and baby__
38. Two indication for PPV
0.5x2=1
Apnea
HR<100/min______________
39. STABLE-expand
0.25x6=1.5
Sugar
Temperature
Airway
Perfusion
Lab report
Emotional support______________
40. Four essential needs of NB
in 1st 48 hrs
0.5x4=2
Wprmth
Breast feeding
Cord care and prevention of infection
. ....
Hygiene
____
-
41. A baby whose weight is
less than as expected for
gestational age is called
Small for date or GA
0.5
42. A baby born term, crying
well must be given
a
1
43. The eye must be cleaned
Inner to outer canthus
0.2x2=0.5
44. Baby with poorly
developed breast bud, no
sole creases is
Preterm
0.5
45. A baby's whose weight is
..... must be referred to a
higher centre
1800 gm or 1.8 kgs
0.5
46. Breastfeeding is
contraindicated for a HIV
positive woman
b
0.5
47. Dosage of Vitamin K for a
NB weighing 1600gms
a
1
48. Local treatment for sore
nipple
d
1
109 I
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
49. Which congenital anomaly a
is an emergency and
requires immediate
referral_________________
50. Two signs a newborn is
getting enough breast
feed (any two)
8-10feed/day
Satisfied with feed
Passing urine 6-8 times
1
0.5x2=1
TOTAL 21
Mentoring and QI
= 12
OB content
= 17
NB content
= 21
TOTAL
= 50
-110
WWW*
Sukshema Project Volume 2
*
■
HHB
Rapid Assessment Exercise - OSCE
(Clinical)
General Instructions to Trainers
❖ Select a room large enough to accommodate ten tables with chairs arranged in a circle with
sufficient space between tables as given in the picture below.
❖ Collect all required articles / stationery / mannequins as listed.
❖
Laminate instructions for participants at each station, pictures that will be used, so that you can
use it repeatedly for all trainings.
❖ Laminate station numbers (e.g. STATION 1) in a large font size so that it is visible from a distance.
❖ Arrange each station with articles / stationery as indicated an hour before the OSCE.
❖
Paste station number in each table so that it is easily visible to all participants.
111
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
-3
. .
. . __________________ ;________ ___
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
:
'
.
0801
❖
Make arrangements for one faculty for each of the observed stations and volunteers where
indicated. Sometimes the faculty could also play the role of volunteer in an observed station.
❖
There must be an overall coordinator who will see that flow of participants goes smoothly,
answer sheets are kept in box provided for unobserved stations
❖
Brief faculty and volunteers on their role and if faculty how to use the checklist during
observation.
❖
Inform faculty/volunteers that their attention will be required completely during the OSCE.
❖
Make arrangements for tea and snacks during the OSCE.
OSCE FOR NURSE MENTORS SUKSHEMA PROJECT TRAINING PROGRAM
DATE
VENUE:
Osce Plan For Obstetrics-lntranatal and Immediate Postnatal
Station
Marks
Details
Observed /Not Observed
1.
BP________________________
2
2.
Calculation of gestational Age
2
Unobserved
3.
Abdominal Examination
2____
Observed
s4.
5.
PaftbgrSph
* - • ••».
. 4. w..s.
2-’
Observed
■
Unobserved ~
Postnatal counselling
6
Observed
_____ Preparation of Labour room
4
Unobserved
Complication - PPH , fill in the
blanks
____________ _
5
Unobserved
MgSO4____________________
5
Unobserved
9.
PV Mentoring
J_
Observed
10.
AMTSL
2
Observed
6.
7.
____
8.
Faculty
TOTAL 50
General instructions to be given by one facilitator to all the participants
❖
Each one will go through 10 stations and 2 rest stations
❖
There are 5 observed and 5 unobserved stations
❖
In the observed station you will be expected to perform some activity. Complete the task within
time given
❖
In the unobserved station you will be asked to write some information on the answer sheet.
Write your name on the answer sheet and participant number. Once you complete it fold the
answer sheet and place it in the box provided.
❖
The duration of each station will be 4 minutes. Two of the observed stations will be longer
(6 minutes). Hence the rest stations will be 2 minutes.
Sukshema Project Volume 2
w- 'Sys
- Ml |i|»
■
❖
None of the facilitators will give any comments or assistance
❖ Three stations have volunteers to help in completing the station
❖
A bell will ring, each one go to the assigned station based on participant number.
❖
Do not face the station first
❖ When the bell rings again, each participant can turn and read participant instructions.
Complete the task given.
❖
If you complete the task before time given, sit in the chair and wait
❖ When the bell rings again, you must switch to the next station.
❖ All participants will go through all the stations.
❖ The test will take approximately 50 minutes.
❖
No one will be allowed to go out of the room during the exam.
Candidates
OSCE Overall Evaluation - Stations
Unobserved
Observed
(3)
1
(8)
3
(6)
5
(8)
10
(7)
12
(32)
Total
(2)
2
(2)
4
(4)
(5)
(5)
(18)
7
8
9
Total
_L„__
2.
3.
4. ___
5. ___
6. ___
7. ___
8. ___
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Grand
Total
(50)
❖
..............
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
_______________
■
.
■
■I
Requirements For Each Station
General requirements
□ Juice for volunteers and faculty
□
□ Snacks
□ Files to place the Key for each station - 10
□ Cellotape
□ Bell, stopwatch
Station 1: Checking BP
Instructions for each station
Station 7: Preparation of labour room
□ BP Apparatus
□ Chair (1)
□ Stethoscope
□ Table(l)
□ Checklist for observer (2)
□ Answer sheet (25)
□ Chair (3)
□ Box to collect answer sheet
□ Volunteer (1)
D Instructions for volunteer
□ Table(l)
Station 2: Calculation of gestational age
Station 8: Complications PPH
□ Case scenario with answer sheet
□ Chair (1)
□ Chair (1)
□ Table(l)
□ Table(l)
□ MNCH Case sheet with all complication
case sheets
EL Box to collect answer sheet.
□ Answer sheet (25)
□ Box to collect answer sheets
114.1
Sukshema Project Volume 2
Bl
s
Station 3: Abdominal examination
Station 9: Magnesium Sulphate
Chair (1)
□
Mannequin with foetus
□
□
Bed sheet/Sheet to cover mannequin
with fetus in situ
□ Table (1)
□
Case scenario
□
Stethoscope
□
Answer sheet (25)
□
Fetoscope
□
Box-to collect answer sheets
□
Hand Sanitizer
□ Table (1)
□
Chair (2)
□
Checklistfor observer (2)
Station 4: Partograph
Station 10: PV mentoring
Chair (3)
□
Laminated partograph
□
□
MNCH Case sheet with all complication
case sheets
□ Tabled)
□
Pelvis model, Sheet, Gloves, handrub,
tray to discard gloves
□
Answer sheet (25)
□
Chair (1)
□
Volunteer to demonstrate procedure
□ Table(l)
□
Instructions for volunteer
□
□
Checklist for observer (2)
Box to collect answer sheet
Station 5: Postnatal counselling
Station 11: Rest
Station 12: AMTSL
□ Volunteer
□
Chair (3)
□
□
Instructions for volunteer
□ Table (1)
□ Table
□
Observer checklist (2)
Station 6: Rest
□
Chair (2)
□
Mannequin, Placenta
□
Gloves
□
Hand rub
□
Drug tray with - oxytocin, Methergine,
MgSO4 Misoprostol tablets, alcohol
swabs
□
Syringes with kidney tray
Chair (1)
□ Table (1) Optional
□ Tray for placenta to be placed
□
Observer checklist(2)
r
J
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
$
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
___________
Checking BP
Key for Station 1:
S.No
Observations
Marks
1.
Tells patient about the
procedure
0.25
2.
Ties cuff accurately
0.5
3.
Checks palpatory BP
0.5
4.
Deflates the cuff
fully before checking
Auscultatory BP
0.5
5.
Places the diaphragm
of the stethoscope in
the cubital fossa while
checking auscultatory
BP
________
0.5
6.
Deflates cuff at the
rate of 2mm per
second________
0.25
7.
Tells the patient
whether the BP is
normal or abnormal
0.5
Total
3
S.No
116
Sukshema Project Volume 2
it©
■
■
Calculation of Gestation Age
Key for Station 2:
S.No
S.No
Observations
Marks
i.
Correct Gestational
age (32 weeks)
i
2.
Gestation - Preterm
1
TOTAL
2
S.No
S.No
Observations
Marks
1.
Correct Gestational
age (32 weeks)
1
2.
Gestation - Preterm
1
TOTAL
2
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postni.w>. —
_______________________________________
Abdominal examination
Key for Station 3:
S.No
S. No
i
Observations
Explains about
procedure
Marks
0.5
Estimates fundal
height accurately+/~
2 weeks
1
3
Demonstrates 4
grips_____________
4
4
FHR method and site
0.5x2
5
Reports lie correctly
1
6
Thanks the lady
0.5
2
TOTAL
8
S.No
S. No
Observations
Marks
Explains about
procedure
0.5
2
Estimates fundal
height accurately +/- 2
weeks -
1
3
Demonstrates 4 grips
4
4
FHR method and site
0.5x2
5
Reports lie correctly
1
6
Thanks the lady
0.5
TOTAL
8
1
Sukshema Project Volume 2
..... ..... ..... .... .
•
■
Partograph
Key for Station 4:
S.No
■I!
Observations
Marks
i
Cervical dilatation
after 4 hours is on the
right of Line A
1
2
FHR below 120/min
1
3
Amniotic fluid
meconium stained
1
4
Complication case
sheet A
1
S.No
TOTAL
",
_____
4
S.No
-
lilfi
■
S. No
Observations
Marks
1
Cervical dilatation
after 4 hours is on the
right of Line A
1
2
FHR below 120/min
1
3
Amniotic fluid
meconium stained
1
4
Complication case
sheet A
1
TOTAL
4
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Postnatal Counselling for excessive
vaginal bleeding and Infection
Key for Station 5:
S.No
S. No
1
Observations k
Greets the lady
Marks
0.25
Content of counselling
2
Passage ofclots
0.5
3
Excessive soakage of
pads
0.5
4
Fever
0.5
5
Painful/ burning
micturition/ loin pain
0.5
6
Foul smelling-*
discharge
0.5
__
7
Painful swelling in the
breast_____
0.5
8
Tone of voice/ Body
language/ Eye contact
0.75
9
Asks if she has
understood Clarifies
doubts
0.5
10
Thanks the mother
0.5
Total marks attained
6
Sukshema Project Volume 2
....... . . .
iB!
__
Preparation of Labour room
Key for Station 6:
fc...’-' ,
..;7
Hi
1
Any 4 of these given
below are correct
Artery forceps
Scissors
Bowl with antiseptic
solution, betadine,
savlon or dettol
Episiotomy scissors
Suture material
Sterile pads
Gloves
Needle
Kidney tray
Sterile cotton balls
Sterile gauze\
2
Match the following
■ 1 -b; 2-f,3*d, 4-c
TOTAL
0.5 x4
<2.5X4
. .-.a. — ■—
4
Key for Station 6:
S.No
S.No
1
2
Observations
Marks
Any 4 of these given
below are correct
Artery forceps
Scissors
Bowl with antiseptic
solution, betadine,
savlon or dettol
Episiotomy scissors
Suture material
Sterile pads
Gloves
Needle
Kidney tray
Sterile cotton balls
Sterile gauze\_____
Match the following
1-b, 2-f, 3-d, 4-c
0.5 x4
TOTAL
4
0.5x4
■i
I
121
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
'
______ __________
Complications - PPH
Key for Station 7:
S.No
Observations
S.No
1
Case sheet F
2
No
3
Oxytocin
4
Atonic Uterus
5
True
Marks
1
1
1
TOTAL
5
Key for Station 7:
S.No
Observations
S.No
Marks
1
Case sheet F
1
2
No
1
3
Oxytocin
1
4
Atonic Uterus
1
5
True
1
TOTAL
122
Sukshema Project Volume 2
5
I
11
■
Magnesium sulfate
Key for Station 8:
S.No
S. No
Observations
Marks
1
Diagnosis - Eclampsia
1
2
Correct drug MgSO4
1
3
Correct route deep IM
1
4
Correct site Gluteal/
Both sides_ _____
1
5
10 gm of MgSO4 or
20mL of MgSO4
Total
1
5
Key for Station 8:
S.No
S. No
Observations
Marks
1
Diagnosis - Eclampsia
1
2
Correct drug MgSO4
1
3
Correct route deep IM
1
4
Correct site Gluteal/
Both sides
1
5
10 gm of MgSO4or
20mL of MgSO4
1
Total
5
____
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
...........
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
Mentoring a Staff for PV exam
Key for Station 9:
S.No
S.
No
Observations
Marks
1
Introduces self
0.25
2
Starts with telling nurse the
correct things she did
0.25
3
Identifies the mistakes (5)
0.5x5
4
♦
Does not ask for history of
♦
bleeding
♦
Does not tell the patient
♦
Not washing hands
♦
Doesn't clean perineum
♦
Washes hands with gloves
on____________________
Demonstrates correctly all the
steps (8)
♦
Asks for history of
bleeding and empty
bladder
♦
Explains procedure
♦
Washes hands
♦
Cleans perineum
♦
Inserts 2 fingers and
Finishes entire pelvic
assessment
♦
Removes gloves
♦
Washes hands
♦
Notes findings
0.5x8
5
Asks if nurse has understood
0.25
6
Asks her to demonstrate and
gives positive reinforcement
0.25
8
Is gentle, non-threatening,
non-judgmental
0.25
9
Explains why it is important to
do the procedure correctly
0.25
TOTAL
8.0
1
124.]
.....
Sukshema Project Volume 2
$
j
■HHB’
_______
AMTSL
Key for Station 10:
S.No
S. No
Observations
I
Marks
1
Checks if there is
another baby inside
by palpating the
abdomen
1
2
Gives 10 U Oxytocin IM
1
1X2
3
Controlled cord
traction correctly
(traction, counter
traction)
4
Uterine massage
1
5
Examines placenta
(cotyledons all there,
membranes complete)
1x2
. TOTA L .
7
Key for Station 10:
•.if: !• K•'!i-’T
S. No
Observations
S.No
Marks
i
Checks if there is
another baby inside
by palpating the
abdomen
1
2
Gives 10 U Oxytocin IM
1
1X2
3
Controlled cord
traction correctly
(traction, counter
traction)
4
Uterine massage
1
5
Examines placenta
(cotyledons all there,
membranes complete)
1x2
TOTAL
7
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
1
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
*
__________________________________
Instructions for Station (Laminate for eachStation)
Station 1
Check the BP for the volunteer. Assess whether the BP is normal.
Station 2
Mrs Kamala comes to the PHC with labour pains today. Her IMP is 19/4/2012.
1.
Please calculate the gestational age:
2.
Circle the correct answer
Mrs Kamala is term / preterm / post term
Station 3
Do a complete abdominal examination on the mannequin.
Tell / Report your findings to the examiner
Sukshema Project Volume 2
Station 4
Name 3 problems seen in the given partograph
1.
2.
3.
Which complication case sheet will you use?
Station 5
Mrs Vimala is getting discharged.
Counsel the woman before she goes home
Station 6
Name 4 items that you would keep in the sterile tray in the labour room
1.
2.
3.
4.
Match the condition with the drug by drawing line
Condition
Drug
1. Peurperal sepsis
a. Magsulp
2. Lady in labour at 33weeks gestation
b. Antibiotics
3. Lady in shock at 25 weeks at gestation
c. Nifedipine
4. BP=140/96, no proteinuria, no convulsion
d. IV fluids
e. Oxytocin
f. Corticosteroid
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
J-
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7
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Station 8
Ms shanty 30 years G4, P3. She gave birth to a healthy, full term baby weighing 2.6 kg. You gave
oxytocin following the birth of the baby. The placenta was delivered 5 minutes later without
complication. However, 30 minute after childbirth, Mrs Shanty complained of giddiness.
On assessment the finding are:
She looks comfortable.
Pulse 88/minute,
♦
Respiration rate 18/minute,
BP 100/80,
Temperature 37°C.
Per Abdomen:
Uterus is soft.
♦
Vagina and cervix cannot be examined as she has heavy vaginal bleeding.
Questions:
1.
Which complication case sheet would you use?.
2.
Is the lady in shock? Yes / No
37
Which is the drug you want to^give this lady immediately? Circle the answer MgSO4/Oxytocin /”*
Misoprostol/ Ampicillin /Gentamicin
4.
What is the cause of the heavy bleeding?.
5.
If her BP is 100/60 after one hour of your management, then is there worsening of her condition True / False
Station 9
A staff nurse is doing a PV examination at the PHC. You have seen her doing the procedure. Mentor
using modelling how a PV should be done
Station 10
Show how you would do AMTSL on the mannequin
Sukshema Project Volume 2
pwc - copy
PARTOGRAPH (Start at 4 cms dilatation or more; plot always on vertical lines)
Name „
663^ •
IP 5
Date and time of rupture of membranes °IAM
l-i-S- 2^IX
Graph A: Labour (Start plotting dilatation at 4 cms or more with an X on Line A corresponding to the cervical dilatation at first evaluation. Note th<
time at the top. corresponding to the first plot Measure and plot with an X ev«y four hours.» M* AUMANS; MMUg LINE)
KS.
PMC
Parity
CHlTRA
PM
5
00
[OOI
Min
a
HaH-hour intervals -—»
EOliK 11 jU ___
Hr
i
30 oolfao] ool Meo
10
9
8
7
j 6
S
i
5
4
^A
Graph B: Labour (Count contractions for 10 mlns every haff hour and record with an X; record duration In seconds)
ZE
5
4 r
■A
3
2
1
------ --------------
E3 ® BS
® SSS S
]□□□□□□□□□□
□□ E
Graph C: Maternal condition (Record pulse with an X every half hour: record BP every four hours using ’ symbol, the top arrow
denoting systolic BP and the lower arrow denoting diastolic BP; record temperature every four hours)
TT
180
160
140 i........ ...
&
aa
T
120 / \
I2 too
80
>-
> j
y
a
.x
60
T«Ptc)gh OQ DOO O O® O rhr1 II ]□[ ]OOOD[ I
][
Graph 0: Foetal condition (Record FHR with an X every half hour; record amniotic fluid (I. C, B, M) every half hour)
200
. ~~
180
-———4—
~r------------ -■■ "T"
160
a:
X
.
|' 1 :
'
1e
^41:
■
gg
___
■ -R
i—K----
—
100
1
80
- i .,.. I, J
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-------- L_------ --
540
120
—
I
t
-- --------------------
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t=]
I
1
——.
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. 1.
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129
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Log Book
Nurse Mentors Skill Training
•. . .
.. .
Introduction
This log book is designed to assist you in completing the requirements for the training program.
It will also be evidence to the experience that you will have in the obstetric or neonatal wards of
selected hospitals.
The clinical / practical experience will be in the obstetric wards of selected tertiary level hospital.
Considering that a registered nurse and mid wife is selected as a mentor although with limited
experience in the field, it is assumed that each will have basic knowledge and skills on managing
a woman during labour, at delivery and postnatal period. Given is the schedule of posting for
practical experience.
Overall Aim of the Training Programs
By the end of the training program it is anticipated that you will have had opportunity to observe
and or practice skills, develop the right attitudes, so that you become competent in providing
efficient yet empathetic care to a woman in labour, at delivery, and in the postnatal period.
I
■'■'i
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
. z Ms,;'
<
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs ■•••-Oil
HHH
Mentor Training Program tentative Schedule for Practical Experience
M/D
1
2
3
MENTORING
OBSTETRICS
Week 1
Week 2
4
5
6
1
2
3
4
5
6
7
8
7
10
11
12
13
LR
PN
AN
PH
PN
(N)
LR
LR
PN
PH
PN
LR
LR
PN
AN
PH
PN
LR
(N)
LR
PN
PN
AN
PH
PN
(N)
O
PH
PN
L
10
11
AN
(N)
AN
LR
PN
AN
(N)
AN
LR
PN
(N)
AN
PH
PN
AN
LR
PN
AN
PH
PN
LR
PN
LR
AN
9
14
9
8
LR
(N)
PN
AN
PN
AN
PN
AN
LR
(N)
LR
LR
15
16
H
D
A
7N)
- PH
PN
(N)
LR
PH
PN
LR
PH
PN
LR
PH
Y
Please note: All wil do 1 night in the OB 1 night in Neonatal (10pm to 6am) in St John's Hospital
0
B
S
T
E
T
R
I
C
M: Mentor
J 32
Sukshema Project Volume 2
D: Day
9-1 Classes
= 24 hours
2-7 Practical experience in
respective areas
= 30+8 = 38 hours
LR: Labour Room
PN: Postnatal ward
Mentor Training Program tentative Schedule for Practical Experience
NEONATAL
OBSTETRICS/NEONATAL
QIP/MENTORING
Weeks
Week 4
Week 5
17
20
19
18
21
22
23
24
PH
LR
_ _—_
Ne
PH
LR
Ne
PH
Ne
LR
H
PH
Ne
LR
LR
PH
Ne
LR
PH
Ne
PN
PH
LR
PN
PH" LR
Im ■’LR' i' ff!
PN
PN
LR
PN
.............
Ne
O
L
",
D
A
BN !
Y
■■■■
.. •
j Ns
9-11 & 2-4 Classes
24 hours
11-1 & 3-5 Practical
24+8= 32 hours
AN: Antenatal ward
25
26
27
| 28
29
30
31
32
33
34
35
V
I
S
I
T
(2
P
H
C
s)
E
V
A
L
U
A
T
I
O
N
O
B
H
O
L
D
A
Y
PH
&
PH
PN
_
Ne
PN
C
O
M
B
I
N
E
D
8-4pm
PH
N
E
Pracs
= 24 hrs
PH: Philomena's Hospital - LR
Ne: Neonatal
N: Night
r
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
133 |
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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MBHI
Objectives of the Obstetric Practical Training
By the end of the training program, you will
❖
Demonstrate how to do an initial assessment (history, previous investigations abdominal and
vaginal exam) of a woman in labour
❖ Take blood for investigations such as Hemoglobin, VDRL, group and typing, malaria, Hepatitis
and HIV
❖
Demonstrate confidence in assessing progress of labour (contractions, cervical dilatation,
cervical effacement, FHR, status of membranes, descent of presenting part)
❖
Use the partograph correctly to assess a woman beyond 20 weeks and with 4cms dilated
❖
Demonstrate confidence in assessing a woman in postnatal period
❖
Interpret and identify danger signs based on initial assessment, assessment at labour or
postnatal period
❖
Initiate initial management for a woman who presents with complications either during
intranatal or postnatal period
.
..
❖
Counsel a woman during intranatal, postnatal period on various aspects concerning their care
❖ Complete referral procedure for a woman needing it.
. 134 1
Sukshema Project Volume 2
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II
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Comments of supervisor of overall performance
Details of procedures either observed or demonstrated in OB ward
SNo
Competency
O/D
Details
of the Woman
___________________
Starting case sheet for the right person
1. Taking History (filled in case sheets)
J Calculate gestational age correctly
1.
2.
Check for presenting complaints
Check for danger signs
S Check for any problems in the past
3.
4.
5.
6.
2. Blood sampling for HB
1.
r/
3.
4,
3. Blood sampling for HIV
1.
2.
3.
4.
4. Interpret basic investigations for a woman
Hemoglobin
Blood group (?ABO incompatiability/
Rh-ve)
J
1.
2.
3. -
4.
HIV test
J VDRL test result
J Malaria result
Hepatitis result
(Arrangements will be made for
participants to visit the PPTCT center at
selected tertiary hospital to observe and
if possible perform rapid HIV test)
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs t ---
«z '
5. Demonstrate general examination of a
woman in labour
1.
2.
Check general condition
3.
Check BP accurately
£
Check pulse accurately
5.
6.
Check temperature accurately
S Check for pallor_____________
6.- Demonstrate abdominal examination of a
pregnant woman/woman in labour
1.
Z___
Check gestational age based on fundal Z___
height
Check abdominal girth
S Check if breach is near fundus
±_
5. .
6.
Check lie of fetus accurately
Check if presentation part is engaged
J Check FHR correctly
7. Demonstrate vaginal examination of a
woman in labour
1.
2.
Check if membranes intact or ruptured -3..*
J
Identify meconium stained liquor
Check cervical dilatation
4.
5.
6.
J Check if cervix is effaced
Check the presenting part
8. Monitor labour using partograph and
1.
interpret the same
2.
S Check if all details completely filled
3.
S Check if participant interprets
partograph
4.
5.
Graph A
Graph B
Graph C
Graph D
136,
Sukshema Project Volume 2
6.
9. Conduct normal delivery
Correct timing of bearing down ,
confirming full cervical dilatation
Assists in crowning
S Gives perineal support when head
bulging at perineum and delivery of
anterior shoulder
1.
2.
3.
4.
5.
6.
Z Wipes face
S Delivers shoulders
Z Delivers body
Places baby on warm clean towel
mother's abdomen
Cuts cord as specified
Cleans perineum
Places pad
Helps mother hold baby
AMTSL
J Administers uterotonic
S CCT
Z Uterine massage
10. Monitor a woman in postnatal period
Check BP accurately,
Z* Check temperature accurately,
Z Check if bleeding is normal,
Z Check if uterus contracted
1.
2.
3.
4.
5.
6.
Z Check for perineal tears
Z Repair of perineal tears
Z Check if woman is taking normal diet
S Check if woman has any danger signs
Post natal counselling
Z Danger signs
Personal Hygiene
Breastfeeding
Care of the baby
Z Family planning
137
Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
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Section A: Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
HHHRHhHmHkhmSI
■
11.
Care of a woman with bleeding
1.
J Identification of shock
Z Assessmentofquantity of bleeding
(identify excess bleeding)
J Bimanual Compression of uterus
Z Administration of appropriate IV fluid
J Administration of uterotonic
Z Transport
12.
Care of a woman with sepsis
Giving first dose of anti biotic
1.
13.
Care of a woman with prolonged
or obstructed labourer rupture of
membranes> 12hrs
1.
14.
Care of a woman with eclampsia/
pre-eclampsia/hypertension
1.
Administration of MgS04Z diazepam
Z Transport
S Referral center
138 1
......... Sukshema Project Volume 2
sukshema
Improved Maternal, Newborn & Child Health
Centre for
Global Public Health
I University
B- qf Manitoba
University of Manitoba
BECAUSEOFME
■‘i: • • n
Infra Health 4^*
INTERNATIONAL
Because Health Workers Save Lives.
St John's National Academy of
Health Sciences
apuna tru^t
20 years vl Integrated Rural Development
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