Emonc Participants Guide English

8/12/2019 Emonc Participants Guide English

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Participants Guide

5 Day Workshop:

Evidence Based Intrapartum and Newborn

Care

for PHC Center Staff

Iraq

October 2012


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Table of Contents

Workshop Schedule............................................................................................................................... 32

Homework: .........................................................................................Error! Bookmark not defined.

Topic: Newborn Resuscitation (utilizing Helping Babies Breathe methodology)Error! Bookmark not defined.

Topic: Essential Newborn Care-Immediate Newborn Care and AMTSLError! Bookmark not defined.

Topic: Infection Prevention................................... .........................Error! Bookmark not defined.

Topic: Partograph............................................................................Error! Bookmark not defined.

Topic: Postpartum Hemorrhage (PPH)......................................Error! Bookmark not defined.

Topic: Laceration Repair and Local Anesthesia ....................Error! Bookmark not defined.

Learning Guide Essential Newborn Care at Birth.....................Error! Bookmark not defined.

Learning Guide Essential Newborn Care at Birth.....................Error! Bookmark not defined.

Learning Guide: Infection Prevention .......................................Error! Bookmark not defined.

Learning guide: external and internal bimanual compression of the uterus and aortic compression Error! Bookmark not defined.

Learning guide: manual removal of placenta ..........................Error! Bookmark not defined.

Performance Checklist: LEARNING GUIDE: LACERATION REPAIR Using Continuous Suture Sparing Method Error! Bookmark notdefined.


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Workshop Schedule

Day 1:Opening/welcome/registrationExpectations & normsObjectivesClinical schedule/teams/morning reportReview of coursePre-workshop questionnaire

Evidence-based Care for intrapartum and NewbornsEssential Newborn CareDaily feedback formTeam 1: Practice in clinical area

Day 2:Warm-up/review/report from Team 1Partograph & Management of Labor Using Partograph Protoc ol

Daily feedback formTeam 2: Practice in clinical area

Day 3:Warm-up/review/report from Team 2

Infant Resuscitat ion Using Helping Babies Breathe Methodo logyDaily feedback formTeam 3: Practice in clinical area

Day 4:Objective Structured Clinical Exam for HBBWarm-up/review/report from Team 3


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Prevention and Management of PPH

Infection Prevention

Daily feedback formTeam 4: Practice in clinical area

Day 5:Warm-up/review/report from Team 4Demonstration o f Instrument Processing: 4 steps

Stabil izat ion and referral of selected obstetr ical & newborn pro blems

Post workshop questionnaireEnd of training questionnaire


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General Objectives: At the end of the workshop participants will be able to:

1. Discuss and demonstrate the elements of immediate newborn care and AMTSL.2. Use the partograph to document and manage labor.

3. Demonstrate newborn resuscitation utilizing the Helping Babies Breathe (HBB) methodology4. Use infection prevention standard precautions as described in the learning guide to protect self and clients when giving care5. Demonstrate how to prevent and manage postpartum hemorrhage.6. Describe how to identify, stabilize and refer postpartum women and newborns with selected problems.


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DAY 1

Topic: Essential Newborn Care-Immediate Newborn Care and AMTSL Time: 4 Hours 15 Min

General Objective: At the end of the session participants will be able to discuss and demonstrate the elements ofimmediate newborn care and AMTSL.

Specific Objectives:

1. Explain what Essential Newborn Care (ENC) is and what is Helping Babies Breathe (HBB)?2. Explain benefit and demonstrate Active Management of Third Stage Labor.

3. Cite the elements of Essential Newborn Care4. Explain the elements of Immediate Essential Newborn Care

a. Clean deliveryi. Clean surfaceii. Clean handsiii. Clean instrument for cord cutting

b. Thermal protectioni. Drying and stimulationii. Warmingiii. Skin-to-skin

c. Cord Carei. Timing of cord cuttingii. Do not strip before cuttingiii. Put nothing on the cordiv. Monitor for bleeding

v. Counsel mother not to put anything on the cord; wash with soap & water if soiledd. Eye care

i. Application of antibiotic eye ointmente. Vitamin K injectionf. Identification of newborng. Early initiation of breast feeding

i. Counsel regarding early initiation of breast feeding and advantages of exclusive breast feedingh. Care of the low birth weight infant


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i. Define low birth weightii. Identify special needs of low birth weight infantiii. Define Kangaroo Careiv. State advantages of Kangaroo Carev. Demonstrate positioning and wrapping for Kangaroo Carevi. Discuss referral for the LBW infant using the Kangaroo position

Homework: Read Breast Crawl Hand-out, and Care of the Newborn Reference Manual Chapter 2, pages 23-50

DAY 2

Topic: Partograph Time: 5 HoursSession Objective:At the end of the session participants will be able to: Use the partograph to document and manage labor.


1. Explain the definition, importance, and evidence to support use of the partograph2. Explain parts of the partograph including:

a. Fetal conditionb. Progress of laborc. Maternal condition

3. Record the partograph4. Interpret the partograph5. Manage labor according to the partograph protocol


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Definition of Partograph

A tool developed by the World Health Organization(WHO) to monitor, document and manage labor.

Importance of Partograph Gives a complete picture of how the mother, baby

and labor progress are doing.

Provides guidelines on when labor is no longer"normal" and on management for those situations.

Helps give continuity of care


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Partograph Game

This game can be done at the beginning of the partograph topic even before theobjectives are reviewed.

Preparation:

Prepare 2 flip charts or white boards for participants to tape their sentencesto:

1. Cut 6 pieces of cello/scotch tape for each flip chart or white board andput it on the edge of the flip chart, so participants can tape their papers

to the flip chart.2. Divide the participants into 2 groups.

3. Hand the 1 envelope to each group.4. KEY TO GAME/Unscrambled Sentences

a. The partograph / is used / to assess/ the progress / of active phase/ of labor.b. The first things / you chart / on the partograph / are the cervical

dilatation / descent / and time.

Instructions to Participants:

1. Do not open the envelope until I say, Start.2. In the envelope are 6 pieces of paper with a word or phrase written on each

piece of paper about the partograph..

3. Your job as a group will be to put the words or phrases together so theymake a complete sentence.

4. Tape the words or phrases onto the flipchart in the order decided by the

group.5. Try to do this very quickly. The first group to put their sentence together

correctly on the flip chart will win.

After Participants Have Filled the Flip Chart:

1. Ask each group if they agree with the other groups answer. If they do notagree, ask them how they would change it.

2. Announce which group is the winner.

3. Give a prize to the winning group first, then tell the other group that theyalso get a reward for participating.


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PARTOGRAPH SYMBOLS

Liquor

I =

C =M =

Intact

ClearMeconiumstained

B =A =

Blood stainedAbsent

Molding

O =

+ =

++ =

+++ =

Bones are separated and sutures can befelt easily

Bones are just touching each other

Bones are overlapping but can be

separated easily with pressure from yourfingers

Bones are overlapping but cannot beseparated easily with pressure from yourfingers

Dilatation X

Descent O

Contractions

Dots = mild contractions less than 20seconds

////////////

Diagonal lines = moderate contractions2040 seconds

Completely filled in = strong contractions

greater than 40 seconds

B P

Pulse & Fetalheart rate


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WHO Modified Partograph

Registration No._____________ Name (Last, First)__________________________________ Age_____

Date_______________Parity/Gravida_____/______LMP________EDD_________Gestation (wks)_____

ROM (Time, Date)____/________ Labour Duration (Hrs)_____ Facility/Clinic Name________________

LIQUOR

MOULDING

80

70

60

190

120

110

100

90

Alert

FETAL

HEART

RATE140

130

180

170

160

150

190180

170

160

150

140

130

120

110

100

90

80

70

60

Actio

n

1010

(CM)

Plot X

DESCENT

Plot O

HOURS HOURS

TIME

5 5

4 4

CONTRACTIONS 3 3

PER 10 MINS 2 2

Oxytocin U / L

Drops / minute

DRUGS

&

IV FLUIDS

TEMPERATURE

Amount

URINE Protein

Acetone

CERVIX Alert

200

190

0

4

Actio

n

180

10

9

8

7

6

5

3

2

1

80

70

60

130

120

110

100

90

PRESSURE

BLOOD

&

2

1

0

170

160

150

140

80

PULSE

200

190180

170

160

150

140

130

110

100

90

120

70

60

10

9

8

7

6

5

4

3


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LABOR NOTES___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please circle or write responses.

DELIVERY:DATE: TIME: METHOD: Spontaneous / Vacuum Extraction / C/S / Forceps/Destructive/Other

INDICATION FOR OPERATIVE DELIVERY__________________ANESTHESIA: None / Local /Spinal/General

PERINEUM : Intact / Episiotomy / Laceration 1st__ 2nd__ 3rd__ 4th__ Repair Yes / No

THIRD STAGE:ACTIVE MANAGEMENT: Yes / No MEDICATION______________TIME____________DOSE________IM__IV__

PLACENTA: Time: Complete / Incomplete Manual Removal Yes___ No___BLOOD LOSS AMOUNT:small (less than 250 cc)moderate (250-499 cc)large (more than 500 cc)significant for mother APGARBABY:Weight: Length__________Sex : Male / Female

Baby Presentation : Vertex / Breech / OtherStillbirth Fresh / Macerated

COMPLICATIONS OF MOTHER / BABY: None/Other_________________________________________________

Time Color Breath Heart

Tone Reflex TOTAL

1 min

5 min


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FOURTH STAGE MONITORING OF WOMAN AND BABY.WOMAN BABY

Frequency Time B/P Pulse Fundus Bleeding Bladder Breathe Suck Temp Cord

Every 15minutes forFirst 2Hours

Every 30min for 1Hour

BIRTH ATTENDANT: _________ Date: ____________


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PARTOGRAPH PROTOCOLS

Normal Latent and Active Phases

Definitions:

Normal latent phase (0-4 cm dilatation) in less than 8 hours

Normal active phase (4 10 cm dilatation) with progress at 1 cm per hour and remains on or left of the alert line.

Management

Do not augment intervene unless complications develop

Do not augment labor unless you refer to a facility where cesarean section can be done

Do not rupture membranes until baby is crowning and no progress with intact membranes (protects mother and baby frominfections; rupturing membranes before crowning not indicated with mother that is HIV positive)

Give woman and family friendly care. Explain what is happening to the woman and family after each evaluation. Teach the

woman and birth support person how to support the woman in labor:

Urinate every 2 hours

Drink fluids at least every 1 hour or more often

Eat lightly

Have a birth support person present

Tell woman what you are going to do before you do it Praise the woman for her efforts

Massage the womans legs, arms and back as needed

Help the woman feel cool when she is too hot. Encourage her to bathe. Use a cool cloth on the womans face, neck and

chest and use a hand fan to fan the woman

Talk to the woman: give emotional support and educate her about what is happening


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Teach the woman and support person breathing methods that can help the laboring woman relax and how not to pushduring crowning to allow for slow delivery of the babys head

Use comfortable positions for labor (walking, sitting, side-lying) and delivery (semi-sitting, squatting, left side, hands andknees)


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Prolonged Latent Phase

False labor

Diagnosis: No change in cervix and contractions eventually stop

Management:

Screen for urinary tract infection, uterine infection or ruptured membranes. Reassure the woman and family, give fluids and light foods, monitor contractions, BP, pulse, temperature and fetal heart

rate. Assess the womans progress every 4 hours. If woman and baby are normal after 4 to 8 hours and contractions

stop, the woman may go home.Prolonged Latent Phase

Diagnosis: Latent phase lasting longer than 8 hours with some change in cervical dilatation and effacement and contractions

are regular

Management:

Give woman and family friendly care. Refer woman and family members to a hospital where oxytocin can be used to increase contractions or cesarean section

can be done if needed. If the woman gets oxytocin for induction or stimulation of contractions for 8 hours but does not enter active phase

labor, cesarean section may be done.

Active Phase Labor Between Alert and Action Line

Diagnosis: Prolonged active phase labor: labor crosses to the right of the alert line.

This may be due to CPD or obstructed labor (passage too small or passenger too big) or poor uterine contractions (too

little power).

Management:

Do a full assessment:


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Mother: BP, pulse, temperature, hydration, bladder fullness, level of exhaustion Fetus: Fetal heart rate, presence of meconium if membranes ruptured, molding and caput Progress of labor: Contraction frequency and length, dilatation, effacement, descent

If any complications are found such as high BP, fever, fetal distress, amniotic fluid that is cloudy meconium stained or bad

smelling, fetal molding of 3+, no descent of the fetal head, refer immediately to a hospital/doctor where oxytocin can beused to increase contractions or cesarean section can be done if needed.

If all is normal, continue to give woman and family friendly care, and reevaluate in 2 4 hours. If the woman delivers before

the time for re-evaluation, remember to do active management of third stage labor and be prepared for postpartum

hemorrhage.

Active Phase Labor Crosses the Action Line

Diagnosis

Prolonged active phase labor: labor reaches or crosses to the right of the action line.

This may be due to CPD or obstructed labor (passage too small or passenger too big) or poor uterine contracti ons (toolittle power).

Management:

Do a full assessment:

Mother: BP, pulse, temperature, hydration, bladder fullness, level of exhaustion Fetus: Fetal heart rate, presence of meconium if membranes ruptured, molding and caput

Progress of labor: Contraction frequency and length, dilatation, effacement, descent Refer immediately to a hospital/doctor where oxytocin to increase contractions or cesarean section can be done if needed.

Prolonged Second Stage Labor

Diagnosis No sign of the head moving down after 30 minutes of effective pushing for a multipara or 1 hour for a primipara.


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Management: Refer after time limit has passed and all the factors mentioned in the following table have been considered.

Problem / Cause Action

Is the bladder too full? Help woman urinate

Is the cervix completely open?

Recheck the cervix. If cervix is not open, the woman

should stop pushing and continue woman and family

friendly care.

Is the woman pushing

effectively? Help the woman to push effectively.

Is the woman upset or tense?

Help the woman by talking with her and staying with

her to ease her fears or help solve the problem. Give

massage or apply a cloth to her body (cool or warm,

let the woman decide).

Does the woman need to change

position?Help the woman stand or squat to push.

Are the contractions becoming

weak or further apart? Is the

woman dehydrated or exhausted?

Give the woman oral or intravenous fluids. Encourage

her to relax between contractions. If contractions

become weaker and farther apart, refer to hospital.

Is the baby not able to fit

through the womans pelvic

bones?

Refer the woman to the hospital.

Is the baby in a difficult or

impossible birth position?

If the baby is in a posterior position, help the baby

turn by asking the woman to push in the hands and

knees position. If the baby is in an impossible birth

position, refer to the hospital.

Adapted from American College of Nurse Midwives, Life Saving Skills Manual, 4thEdition

If the baby is 37 weeks or more gestation, cephalic presentation and alive, the contractions are 3 in 10 minutes lasting 45seconds or more, the bladder is empty, the level of the head on abdominal palpation is 1/5 or 0/5, the membranes are


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ruptured, the cervix is fully dilated, and there is no evidence of CPD,,do not impose time limits. If mother and fetus arestable and progress is being made, do not intervene.

If the baby is alive but the fetal head is high refer

If the baby is not alive, refer


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How Do You Decide If a Baby Needs Resuscitation?

The baby needs resuscitation if there is no breathing or the baby is gasping

Do you use the Apgar Score to decide if resuscitation is needed Apgar Scoreis done at 1 minute after birth?

Resuscitation must be started as soon after birth as possible.

Therefore Apgar Score is NOT used to decide the need for resuscitation.

APGAR Score is used to evaluate the condition of the baby at 1 & 5 minutes of age ifbaby is breathing.

APGAR Score is not used if baby is not breathing and there is only one health

careprovider. Priority is breathing for the baby.


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IMMEDIATELY AFTER BIRTH

1. DRY & WARM

Place the baby on a clean cloth or towel on the mothersabdomen

Dry the baby from head to toe

Evaluate whether or not the baby is breathing or havingdifficulty breathing while drying the baby.

If the baby is breathing: Take away the wet towel; place the baby face down skin-to-

skin, cover with a dry cloth and put on a hat.

If the baby is NOT breathing:

Take away the wet towel, wrap the baby with a clean, drycloth, and put on a hat. Keep the baby on the mothersabdomen.

IF BABY IS NOT BREATHING OR HAVING DIFFICULTY BREATHING

1. POSITION With the baby still on the mothers abdomen, position the

babys head in the sniffing position. This is the best positionto keep the airway open.

2. SUCTION Suction with a Penguin suction device, bulb syringe, or DeLee

trap.

Suction only while pulling suction tube out, NOT while puttingit in. For bulb or Penguin, compress before inserting inmouth, release compression to suction, remove from mouthand compress bulb again to expel contents. Repeat for eachnostril. Do not insert suction tube or bulb more than 5 cm intothe mouth or 3 cm into the nose.

If meconium is present: After delivery:

If baby is vigorous: No SPECIAL suctioning is needed

If baby is NOT vigorous: Suction baby immediately after birth.Suction the mouth first. Then suction nose.

3. STIMULATE Rub your with the heel of your hand up and down the babys

spine to stimulate the baby. This can be done withoutremoving the cloth or the towel in which the baby is wrapped.

4. EVALUATE Evaluate the babys breathing. If still not breathing or gasping,give the mother 10U oxytocin, clamp and cut the cord, andmove baby to the resuscitation table.


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5. BREATHE

FOR BABY

1. Keep the baby covered except the face and chest.

2. Position the baby in sniffing position by placing a small rolledtowel under the babys shoulders.

3. If oxygen is available, give oxygen at 2 liters/min by attachingthe tubing from the tank to the ventilation bag.

4. Place mask over baby's mouth and nose and make a good

seal.

5. Compress bag 2 times to see if baby's chest rises.

6. If the chest does not rise: Reposition the baby, check the sealfor the mask, and suction the mouth and nose. Repeat step 1.

7. If the chest rises: Breathe 40 times in 1 minutefor the baby.

8. If the baby is breathing, stop ventilating and continue to supportbaby with warmth, stimulation and oxygen, if available, untilbaby is pink and active.

9. If baby is not breathing: Call for help. Check the heart rate.Continue to breathe for the baby. Check for respirations andheart rate after each 40 breaths. Does this until the baby isbreathing on her own. Then continue to support baby withwarmth, stimulation and oxygen (if available) until the baby ispink and active.


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DAY 4

Topic: Postpartum Hemorrhage (PPH) Time: 3 Hours

Session Objective: At the end of this session participants be able to to

demonstrate how to prevent and manage postpartumhemorrhage.


1. Define PPH

2. Describe the significance of PPH

3. Identify causes of PPH

4. Identify risk factors for PPH

5. Describe strategies for prevention and management of PPH6. Demonstrate external and internal bi-manual compression of the uterus

7. Demonstrate manual removal of placenta

Homework:

1. IMPAC Manual, Vaginal Bleeding After Childbirth S-27 to S-31 and P-77 toP-79 on Manual Removal of the Placenta

Postpartum Hemorrhage Defined

Immediate Postpartum Hemorrhage:

More than 500 mL of vaginal bleeding that occurs less than24 hours afterchildbirth.

Delayed postpartum hemorrhage:Excessive vaginal bleeding that occurs more than 24 hours after childbirth.

However for severely anemic women, blood loss of even 200 to 250 mL can befatal. For that reason a better definition is:

Any amount of bleeding that causes a change for the worse in the womans

cond i t ion such as low sys to l ic BP, fast pu lse, s igns o f shock.

Significance of PPH

Postpartum hemorrhage (PPH) is the leading direct cause of maternal death in developing countries

and results from problems occurring during and immediately after the third stage of labor. PPH is an

UNPREDICTABLEand RAPIDcause of maternal death worldwide. Two-thirds of women with PPH

have no risk factors. Seventy to ninety percent of immediate PPH is due to uterine atony (failure ofthe uterus to properly contract after birth).


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Postpartum HemorrhageRisk Factors

We cannot predict who will have PPH based on risk factors because:

2/3 of Women with PPH

Have No Risk Factors

This is why it is important to remember thatallwomenare considered at risk

and hemorrhage preventionmust be a part of everybir th.

During Antenatal Care

Develop a birth preparedness and complication plan

Screen routinely for, prevent and treat anemia during antenatal and

postpartum visits. Counsel on nutrition with a focus on available iron and folic

acid rich foods and provide iron/folate supplementation during pregnancy.

Help prevent anemia by addressing major causes like malaria and hookworm:

Malaria: Encourage use of insecticide-treated bed nets; give intermittent

presumptive treatment during pregnancy (IPTp) to prevent

asymptomatic infections

Hookworm: provide treatment at least once after the first trimester

Develop a complication readiness plan that includes recognition of danger

signs and what to do if they occur, where to get help and how to get there, and

saving money for transport and emergency care


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Strategies to Prevent PPH

During Labor and Second Stage

Use a partograph to monitor and manage labor and prevent prolonged labor

Encourage the woman to keep her bladder empty

Do not encourage pushing before the cervix is completely fully dilated

Do not use fundal pressure to assist the birth of the baby

Do not perform routine episiotomy

Assist the woman in the controlled delivery of the babys head and shouldersto prevent tears. Place the fingers of one hand against the babys head tokeep it flexed (bent), support the perineum and teach the woman breathingtechniques to push or to stop pushing.

Strategies to Prevent PPH

During 3rdStage and Immediately After Placental Delivery

Provide active management of the third stage of labor. This prevents upto 60% of PPH and is the single most effective way of preventingpostpartum hemorrhage

Do not use fundal pressure to assist placental delivery Do not do controlled cord traction without giving oxytocin

Use controlled cord traction only with counter traction to support the uterus Do careful inspection and repair for lacerations of the vagina, perineum, and

anus

Do careful inspection of the placenta

Massage the uterus at least every 15 minutes for first two hours after thirdstage to keep the uterus well contracted

Teach the woman to massage and check her own uterus to keep it firm and tocall for assistance if it is soft or if bleeding increases

Encourage the woman to keep her bladder empty immediately PP


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General Management for Vaginal Bleeding After Birth

Excessive bleeding is life-threatening and requires immediate action!

Remember 90% of postpartum hemorrhage is due to uterine atony!

SHOUT FOR HELP.

Massage the uterus to expel blood and blood clots. Blood clots trappedin the uterus will prevent effective uterine contractions. If bleeding doesnot stop, do external or internal bimanual compression while others aredoing the following steps.

Make a rapid evaluation of the general condition of the womanincluding vital signs (pulse, blood pressure, respiration, temperature)

Have the woman empty her bladder or ensure that the bladder isempty; catheterize the bladder only if necessary.

If shock is suspected or develops, immediately begin treatment.

Give oxytocin 10 units IM.

Start an IV infusion and infuse IV fluids. If blood is available fortransfusion, type and cross before beginning infusion of fluids andprepare blood.

Check to see if the placenta is expelled and examine the placenta tobe certain it is complete.

Examine the cervix, vagina and perineum for tears.

Provide specific treatment for the cause of postpartum hemorrhage.

24 hours after bleeding stops, check hemoglobin to evaluate if thewoman has anemia:

If hemoglobin is below 7 g/dL (severe anemia), give ferrous sulfate

or ferrous fumerate 120 mg by mouth PLUS folic acid 400 mcg by

mouth once daily for 3 months

If hemoglobin is between 711 g/dL, give ferrous sulfate or ferrous

fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once

daily for 3 months


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Internal Bimanual Compression of the Uterus


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Manual Removal of Placenta 1. Introducing One Hand into the Vagina Along Cord


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Manual Removal of Placenta 2. Supporting the Fundus While Detaching Placenta


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Manual Removal of Placenta 3. Withdrawing the Hand and Placenta From theUterus

During a Contraction


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DAY 4

Topic: Infection PreventionTime: 2 Hours 15 Minutes

General Objective: At the end of the session participants will be able to use infectionprevention standard precautions as described in the learningguide to protect self and clients when giving care.


1. Identify the components of infection prevention standard precautions2. Discuss hand hygiene practices to use to prevent infection (when to wash hands,

what can be used to wash hands, fingernail hygiene)3. Demonstrate hand washing4. Describe when to wear gloves and what kind of gloves you should wear for different

health care related activities5. Describe ways to provide personal protection when giving care (use of personal

protective equipment and preventing splashes)6. Describe ways to prevent injuries from sharps7. Demonstrate how to process patient care instruments and supplies safely8. Describe infection prevention housekeeping practices

Homework: Read: Care of the Newborn Reference Manual, Pages 185-205.

USING STANDARD PRECAUTIONS MEANS TO ALWAYS:

Consider every person potentially infectious (even the baby and medical staff).

Wash your hands.

Wear protective clothing when needed (gloves, eye protection, aprons, closedshoes).

Prevent injuries with sharps.

Process patient care instruments and equipment safely. Keep the environment clean.

Dispose of wastes safely.

WHEN TO WASH HANDS

1. When arriving / leaving work place

2. Before / after caring for or examining a mother / baby

3. Before / after using gloves


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4. After having contact with blood / body fluids from instruments, supplies orsplashes

5. Before eating, after toilet, coughing, blowing nose.

ANTISEPTIC HAND RUB

What is it?Cleaning hands with antiseptics such as alcohol (6090% ethyl or isopropyl),chlorhexidine 24%, iodine preparations 3%, betadine 7.510% or Savlon greater than1%.

Advantages:

Inhibits or kills most gram negative and gram positive bacteria, TB, viruses(HIV) and fungi. More effective than handwashing, which removes dirt, bloodand some transient germs, but not all.

If used with hand softeners like glycerin or propylene glycol, protects andsoftens skin.

How to Make:Mix 100 mL 6090% ethyl or isopropyl alcohol with 2mL skin softener (glycerin,propylene glycol, sorbitol)

How to Use:

Pour about 5 mL into hands

Rub solution into hands. Clean the palm, back of hand and especially betweenfingers and under nails, until dry.

Do not use if hands are contaminated with body fluids, but wash hands withsoap and water.

Wash hands with soap and water after every 510 uses to reduce the build-up of hand softeners.

HOW TO PREVENT SPLASHES WEAR PROTECTIVE GLASSES WHEN THERE IS A CHANCE OF GETTING SPLASHED

WITH BODY FLUIDS (RUPTURING MEMBRANES,DURING DELIVERY,DURINGSURGERY,ETC.)

WHEN RUPTURING MEMBRANES:1)STAND TO THE SIDE OF THE WOMANSVAGINA,2)TRY TO RUPTURE MEMBRANES BETWEEN CONTRACTIONS.

WHEN CUTTING UMBILICAL CORD:1)MILK CORD TOWARD THE PLACENTA BEFORETYING OR CLAMPING,2)COVER CORD WITH HAND/GAUZE WHILE CUTTING.

REMOVE CONTAMINATED GLOVES CAREFULLY

RINSE THE OUTSIDE OF GLOVES WHILE ON YOUR HAND INDECONTAMINATION SOLUTION

CAREFULLY REMOVE GLOVES BY SLOWLY PULLING THEM DOWN FROMTHE CUFF,TURNING THEM INSIDE OUT

PUT GLOVES INTO CONTAMINATED WASTE CONTAINER.

WHEN TO GLOVE


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When there is reasonable chance of contact with broken skin, mucousmembranes, blood, or other body fluids

When performing invasive procedures When handling:

Soiled instruments

Medical, or contaminated, waste When touching contaminated surfaces

GUIDELINES FOR GLOVINGWhat kind of gloves do you wear for: Procedures involving contact with broken skin or tissue under skin? Use Sterile

gloves Starting IVs, drawing blood, or handling blood or body fluid? Use clean exam

gloves Cleaning instruments, handling waste, and cleaning up blood and body fluids?

Use heavy duty gloves

Wear separate pair of gloves for each woman/newborn to preventspreading infection from client to client

Never wear gloves that are cracked, peeling or have holes.


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PERSONAL PROTECTIVE EQUIPMENT/CLOTHING

MASK ANDEYE

PROTECTION

Used for:

Sorting and cleaning instruments and linens

Attending a vaginal delivery Cutting umbilical cord

Note: Eye protection can include goggles, face shields, or plainglasses

APRON ORGOWN

Used for:

Sorting and cleaning instruments and linens

Attending a vaginal delivery

FEETPROTECTION

Closed shoe or boot made from rubber or leather. Protects thewearer from:

Injury by sharps or heavy items

Blood or other body fluids on the floor

GLOVES

Utility or Heavy Duty Gloves: To touch dirty instruments, linens andwaste, doing housekeeping and cleaning contaminated surfaces.

Single Use Examination Gloves: Use if havingcontact with intactmucous membranes and when at risk of exposure to blood or otherbody fluids.

Surgical Gloves: For all procedures having contact with tissuesunder the skin or with the blood stream.

GLOBAL STATISTICS ON OCCUPATIONAL EXPOSURE

3MILLION HEALTH CARE WORKERS (HCWS)PER YEAR REPORT NEEDLESTICK INJURIESPER YEAR

2.5%HIVINFECTIONS AMONG HCWS ARE TRANSMITTED BY NEEDLESTICK INJURIES

40%OF HEPATITIS CAND HEPATITIS BINFECTIONS AMONG HCWS ARE TRANSMITTEDBY NEEDLESTICK INJURIES


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4STEPS OF PROCESSING INSTRUMENTS AND SUPPLIES

Step 1 Decontaminate Kills viruses and many other germs

Makes items safer to handle during cleaning

Makes items easier to clean

Step 2 Clean

Removes blood, other body fluids, tissue and dirt Reduces the number of germs

Makes sterilization or high-level disinfectioneffective. If blood clot remains on instrument,germs in clot may not be completely killed bysterilization or HLD.

Step 3

High Level Disinfect(HLD)

OR

Sterilization

Kills all germs except some endospore

Use for items having contact with broken skin orintact mucous membranes

If sterilization not possible, HLD only other choice

Can be done by boiling, steaming or chemicaldisinfection (soak in 0.5% chlorine solution x 20minutes)

Kills all germs including endospores.

May not be possible to do in all settings.

Can be done by dry heat or wet heat (autoclave).

Step 4 Store or Use

Use immediately

Store in a high level disinfected or sterile coveredtray up to 1 week

If wrapped: Good for at least 30 days unless

something causes the package to becomecontaminated (tear in package or becomes wet).

Check concentration (% concentrate) of the liquid chlorine product you are using. Determine totalparts water needed using the formula below.Total Parts water = (% of liquid chlorine product / % desired strength of Chlorine solution)-1Mix 1 part liquid chlorine product with the total parts water required.Example: Make a 0.5% dilute solution from a 5% liquid chlorine product(5% / 0.5%) - 1 = 9 parts water to 1 part chlorine

Desired strength of chlorine solution 0.5% = 101 = 9

STEP 2: Use 1 part liquid chlorine product and add 9 parts water.


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INFECTIONPREVENTIONHOUSEKEEPINGPRACTICESRECOMMENDED CLEANING FOR A HEALTH FACILITY

FREQUENCY WHAT TO CLEAN

Clean with Disinfectant Cleaning Solution (mix 0.5% chlorine solution with a soap ordetergent that does not contain

an acid, ammonia or ammonium chloride)

FOLLOWINGDISCHARGE OF A

PATIENT

Mattress, bed frame, cot, incubator Any other equipment used for the patients care

IMMEDIATELY

Furniture, floors, rooms, and equipment (after a procedure orafter a delivery)

Spills

DAILY

Delivery and examination rooms Floors Furniture and equipment used daily (exam table, table tops,

counters, weighing scales)

Use separate mop, cloth, or brush to clean the sink, toilets andlatrines and waste containers

Clean with soap and water solution

WeeklyClean doors (including door handles), windows, walls, ceilings andceiling fixtures

Double Bucket Techniquehelps the disinfectant cleaning solution last longer. Use 2buckets, one with disinfectant cleaning solution and the second bucket with rinse water.Always rinse and wring out mop before dipping it into the disinfectant cleaning solution.When rinse water becomes very dirty, dispose and put in clean rinse water.


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DAY 5:

Topic: Recognition, Stabilization and Referral of Selected Maternal

and Newborn Problems

Time: 2 Hours 25 Minutes

General Objective:At the end of the session, participants will be able to identifysigns of selected problems in the mother and newborn, takeappropriate actions and refer.


1. Describe signs of convulsions in the newborn2. Take appropriate action for convulsions in the newborn at a PHC3. Explain how to determine if jaundice is severe4. Take appropriate action for a newborn identified with severe jaundice at a PHC5. Describe signs of severe pre-eclampsia and eclampsia6. Demonstrate an emergency team response for an eclamptic convulsion7. Demonstrate testing of patellar reflexes8. Describe immediate appropriate action for a woman presenting at a PHC with

symptoms of severe pre-eclampsia or eclampsia.

Homework: Read: IMPAC Manual: pages S-43 to S-46; Guidelines forManagement of Hypertensive Disorders in Pregnancy and Postpartum

Signs of convulsion in newborn: Repetitive facial movements, including sucking, chewing, or eye movements

such as repeated blinking, staring, or eye rolling

Unusual bicycling or pedaling movements

Staring Apnea (stopping breathing)

Clonic seizures, which are rhythmic jerking

movements that may involve the muscles of the face, tongue, arms, legs, or otherregions

Tonic seizures, which are stiffening or tightening or muscle groups; the head

or eyes may turn to one side, or the baby may bend or stretch one or morearms or legs

Myoclonic seizures, which are quick, single jerks involving one arm or legor the whole body

Actions to take at PHC:

Turn the baby to its side to avoid aspiration.

GivePhenobarbital 20 mg/kg single IM njection

Refer baby immediately to the hospital with a referral form describing:

what you did

what you saw


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how the baby responded

any pertinent history

How to tell visually if jaundice is severe:

In healthy babies, some jaundice almost always appears by 2 to 4days of age. It usually gets better or goes away on its own within a

week or two without causing problems. In breast-fed babies, mild jaundice sometimes lasts until 10 to 14

days after birth. In some breast-fed babies, it goes away and thencomes back. Jaundice may last throughout breast-feeding. Thisisn't usually a problem as long as the baby gets enough milk bybeing fed on demand.

The severity of the jaundice is indicated by the age of the baby andwhere the jaundice is seen on the babys body

Signs of Severe Jaundice

Day 1 Any visible jaundice

Day 2 Arms and legs Day 3 and thereafter-hands and feet

Appropriate Action if you note severe jaundice in a newborn at a PHC:

Refer as soon as possible to a hospital with a NICU.

Baby may need phototherapy and/or exchange transfusion.


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Important Research Findings on PIH

Cannot use 2nd trimester diastolic pressure topredict eclampsia.

Women who develop gestational hypertension atan earlier gestational age are more likely toprogress to pre-eclampsia.

3.4% of women with severe pre-eclampsia willhave a convulsion.

Eclampsia is abrupt in onset, without warningsigns in about 20% of women.

It is difficult to predict who will develop pre-

eclampsia.A small proportion of women with eclampsia have

normal BP.

Woman can still start PIH up to about 10 dayspostpartum.


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Problem History and Physical Examination Plan of Care

Position her on her left side to reduce the risk ofaspiration of secretions, vomit and blood

Protect her from injuries (fall), but do not attemptto restrain her

Quickly evaluate breathing, state ofconsciousness, airway, blood pressure and pulse

After the convulsion: Assess breathing:

Not breathing, use Ambu bag, with or withoutoxygen

Breathing give oxygen at 4 L per minute If she is unconscious:

Keep airway clear, aspirate the mouth andthroat as necessary.

Position her on left side Check pulse, BP and FHR half hourly and

temperature every 4 hours Check for neck rigidity Set IV line (Ringers Lactate) Pass indwelling urinary catheter (if you have one) Give magnesium sulfate. If the cause of fits has

not been determined, manage as eclampsia andcontinue to investigate other causes (e.g.,cerebral malaria, meningitis)

REFER and accompany woman.

THIS WOMAN MUST DELIVER WITHIN 12HOURS.


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Learning Guide Essential Newborn Care at Birth

Facilitators or learners can use the following learning checklist to gauge progresswhile learning to care for the newborn at birth.

This performance checklist is used with the relevant guideline to give feedback on the

health care providers performance.The checklist contains a list of items to be observed:

Rate the performance of each step or task using the following rating scale:

Scoring scale:

0= is unable to perform the step or task completely or correctly or the step/task was not

observed.

1= Performance of Step or task could be performed better (needs improvement)

2 = Performs the step or task completely and correctly.

N/A = Not Applicable (the skill should not be performed)

The finding and comments are analyzed and discussed with the providers supervised. Any

immediate corrective action(s) taken and further action(s) needed must be entered in thespaces provided.

Date:

Name of Participant

Skill Score Comment

0 1 2 N/APrepare the woman during the first stage of labor (if the woman presents in second stagelabor, go to step #4)

1. Explain to the woman and her support personwhat will be done and encourage questions

2. Review the womans chart. For example:prenatal card, partograph

3. If her medical documents are not complete,gather any information necessary to completethem.

4. Advise the woman to bathe or help her tobathe to ensure cleanliness (if possible). At

least wash her hands and wash her chest(not breasts) if not clean

5. In order to prepare the woman, explain thatthe newborn will be placed first on herabdomen and then on her chest (explain theadvantages of skin-to-skin contact) and thatbreastfeeding will be facilitated in the deliveryroom within one hour of birth, and obtain her


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Skill Score Comment

0 1 2 N/Apermission to complete these actions.

6. Provide emotional support and reassuranceand keep the woman and her family informedthroughout birth and during the immediate

postpartum period.

Preparation for childbirth

7. Check that all needed equipment,instruments, and supplies for delivery care,essential newborn care, and newbornresuscitation are available, clean,sterile/HLD. Check the newborn ventilationbag to be sure it is present in the roomand working properly.

8. Make sure that the room is warm (at least25C) and free from drafts from open

windows, doors, and fans. Make sure that allof the windows are closed.

9. NOTE:If the temperature of the room is lessthan 25, a heater should be available towarm the room or at least the newbornscorner. In hot weather, air conditioning orfans should be turned off or adjusted in thedelivery room.

10. Make sure that all surfaces the woman andbaby will come in contact with are clean anddry.

11. Make sure the room is well-lit. Have anemergency battery powered torch.

12. Arrange for a helper and make an emergencyplan.

13. Wear a clean plastic or rubber apron, closedtoed rubber shoes/sandals/slippers or shoecovers, mask, and eye protection.

14. Wash hands thoroughly with soap and waterand dry them with a clean, dry cloth (or air-dry them).

15. Wear sterile (preferable) surgical or HLD

gloves on both hands if you are doing thedelivery. Wear clean exam gloves and anapron if you are only caring for the baby.

Provide Immediate Essential Newborn Care

16. When the head is delivered, wipe the mouthand nose with gauze.

17. When the baby is fully born, place the baby


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Skill Score Comment

0 1 2 N/Aon a clean, dry towel or blanket on themothers abdomen.

18. Note the time of birth and the sex of the babyand announce them loudly enough to inform

the mother.

19. Dry the baby thoroughly except the hands.Assess the babys breathing while drying thebaby.

20. If the baby is breathing normally, take awaywet cloth, place baby skin-to-skin on mother,cover the baby and put on a hat.

21. After assessing that there is no second baby,Inject the mother with 10 U oxytocin IM for

AMTSL.

Cord Care

22. Wait for 2-3 minutes after birth or until thecord ceases to pulsate before clamping andcutting the cord.

23. Place the disposable cord clamp 2 fingers (2-3 cm) from the abdomen. Pinch the cordbelow the clamp, push the blood in the cord 2cm towards the placenta, pinch the cord andplace a second clamp. Cut the cord betweenthe two clamps using a sterile or HLD bladeor scissors.

24. Check for bleeding from the cord; if present,retie or re-clamp the cord.

Deliver the placenta

25. Deliver the placenta using controlled cordtraction.

26. Massage the uterus immediately afterplacenta is delivered.

27. Examine the placenta to be sure it iscomplete.

28. Check perineum and vagina for tears. Repairif needed.

29. Clean up the mother.

Commence exclusive breastfeeding

30. Support the mother in breastfeeding her babywithin one hour of birth and before theirtransfer out of the delivery room.

31. Verify that the babys mouth is latched onwell at the breast


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Skill Score Comment

0 1 2 N/A32. The baby is belly to belly with the mother.

33. The babys nose and chin are touching thebreast.

34. The mouth is open wide.35. All or most of the areola is inside the mouth,

especially the lower part, so that the upperpart of the areola is more visible than thelower part.

36. The babys lips are everted.

Administer vitamin K1

37. After the baby has breast fed, explain to themother that an injection will be required toprevent a bleeding problem in the baby.

38. Collect all the necessary supplies: disposable

syringe (preferably 1 ml) with needle, vitaminK, alcohol, pieces of gauze/cotton, preferablysterile.

39. Wipe the injection site with alcohol soakedcotton or gauze.

40. Inject the drug intramuscularly in the antero-lateral part of the thigh: 1 mg for a normalweight baby (0.5 for a baby weighing lessthan 1500 grams although babies this smallshould NOT deliver at a PHC Center)

41. Press injection site with a piece of clean

gauze. Do not massage.

42. Dispose of the needle and syringe in anappropriate and safe manner (in a containerfor sharp instruments).

Care of the eyes

43. Instill eye drops (tetracycline orerythromycin), one drop in each eye. Whenusing an ointment, depress the lower eyelidand place a small amount of the ointmentinside the lower lid. Do the same for the othereye.

44. Make sure that the tip of the bottle or the tubedoes not touch the eye of the baby or otherobjects.

Identification of the baby

45. Place an identification band, preferably twoone on the wrist and the other on the ankle ofthe babynoting the name of the mother and


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Skill Score Comment

0 1 2 N/Athat of the father (where available), the sex ofthe baby, and date and time of the delivery.

Weigh the baby

46. Delay taking the weight of the baby untilhe/she is stable and warm and after firstbreast feeding.

47. Place a clean cloth/paper on the pan of theweighing scale.

48. Make the necessary adjustments to bring theneedle/pointer back to zero.

49. Place the baby on the cloth/paper. If the clothis large enough, fold the sides to cover thebaby.

50. Note the weight of the baby when the pan is

not moving.51. Record the weight of the baby in the relevant

records/registers and inform the mother.

52. Do not leave the baby unattended on thescale.

Maintain the babys bodytemperature/thermal protection

53. Keep the baby warm, ideally by keepinghim/her in skin-to-skin contact on themothers chest, with the body and headcovered by a cloth or hat. If the baby cannot

be placed in skin-to-skin contact in case of aCesarean section or if the mother is ill, wrapthe baby well and cover the head.

54. Check the babys axillary temperature with athermometer.

Briefly Counsel the Mother

55. On the importance of early, exclusivebreastfeeding and of colostrum in protectingthe baby against infections.

56. To feed frequently on demand, day and night.

57. Not to give any liquids (including water) orsolids, other than breast milk.

58. Not to apply anything harmful to the cord,such as ash, mud, clay, or herbalpreparations.

59. To keep the baby warm, if necessary by skin-to-skin contact, and check the temperatureby touching the hands, feet, and abdomen to


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Skill Score Comment

0 1 2 N/Aensure that they are all warm but not too hot.

60. To call the care provider if there is anyproblem.

61. That the baby should not be bathed for atleast 6 hours after birth.

Decontamination, cleaning, andsterilization

62. Ensure the proper disposal of waste anddecontamination of the equipment andsupplies that can be reused.

63. Remove the gloves after having dipped themin the decontamination solution.

64. Wash hands and air-dry them or wipe themwith a clean cloth.

65. Replace all items after cleaning/sterilizationand replenish the disposable/consumableitems to be ready for the next delivery.

Record all the key data/information

66. Noteall the key data/information inpartograph/cards/records of the mother andbaby/registers, based on therecommendations of the facility authorities.

Ensure follow-up of mother and the baby

67. Monitor mother (B/P, pulse, fundus, bleeding,bladder) and baby (breathing, suck, temp,cord) every 15 minutes for 2 hours, every 30minutes for 1 hour, and then every 1 hour for3 hours. Record findings.


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LEARNING GUIDE: Infection Prevention

Training facilitators or learners can use the following learning checklist to gaugeprogress while learning to care for the newborn at birth.

This performance checklist is used with the relevant guideline to give feedback on the health

care providers performance. The checklist contains a list of items to be observed:

Rate the performance each step or task using the following rating scale:

Scoring scale:

0= is unable to perform the step or task completely or correctly or the step/task was not

observed.

1= Performance of Step or task could be performed better (needs improvement)

2 = Performs the step or task completely and correctly.

N/A = Not Applicable (the skill should not be performed)

The finding and comments are analyzed and discussed with the providers supervised. Anyimmediate corrective action(s) taken and further action(s) needed must be entered in the

spaces provided.

Date:

Name of Participant

Steps/Tasks Score Comments

0 1 2 NA

Handwashing

When to Wash Hands

1. When arriving/leaving work place

2. Before/after caring for or examining a mother /

baby

3. Before / after using gloves

4. When splashed with blood / body fluids

5. Before eating, after toilet, coughing, blowing

nose.

How to Wash Hands

6. Wet hands with running water and apply soap.


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0 1 2 NA

7. If using a soap bar, rinse off bar before placing

in soap holder

8. Rub together all surfaces of the hands, includingwrists, between fingers, palm and back of thehands and under fingernails.

9. Wash for 15 seconds

10. Rinse under a stream of running water

11. Dry hands. Air dry, or use clean cloth or paper

towel.

Prevent Splashing of Body Fluids

12. Wear protective glasses when there is a chance

of getting splashed with body fluids (rupturingmembranes, during delivery, during surgery,

etc.)

13. When rupturing membranes: 1) stand to the sideof the womans vagina, 2) rupture membranes

between contractions.

14. When cutting umbilical cord: 1) milk cord toward

the placenta before tying or clamping, 2) cover

cord with hand/gauze while cutting.

Remove contaminated gloves carefullya. Rinse the outside of gloves while on your

hand in decontamination solution

b. Carefully remove gloves by slowly pulling

them down from the cuff, turning them

inside out

c. Put gloves into decontamination solution

Safe Handling of Sharps

15. Use each needle and syringe only once, if

possible16. Do not take needle and syringe apart after use

17. Do not recap, bend or break needles before

disposal


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0 1 2 NA

18. After use and before disposing, decontaminate

syringes and needles by flushing 3 times with

chlorine solution (this step may not be needed ifdisposal site is secure)

19. Dispose of needles and syringes in a puncture-

proof container and dispose of the puncture-

proof container when 2/3 full.

20. Never pass sharp instruments from one hand

directly to another persons hand. Lay

instrument on surface and have other person

pick it up from that surface.

21. Always use needle holder AND tissue forceps

when suturing22. Never hold or guide needle with fingers

Infection Prevention 4 Step Process for Instruments / Supplies

Step 1: Decontamination

23. Purpose:

Kills viruses and many other germs

Makes items safer to handle during cleaning

Makes items easier to clean

24. Prepare decontamination solution based on

strength of available chlorine or jik. Chlorineshould be mixed with enough water to make a0.5% chlorine solution.

25. Open instruments before putting into pail

26. Put all instruments and supplies into the pail of

decontamination solution

27. Flush tubing (such as a DeLee trap, vacuum

extractor tubing, foley catheter) with solution

using syringe. Flush and fill bulb syringe.

28. Wipe apron with decontamination solution

29. Soak instruments and supplies for 10 minutes

Step 2: Cleaning


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0 1 2 NA

43. Make sure instruments are open

44.If disinfecting instrument tray, put tray on topof all instruments

45. Put cheatle forceps that has a string attached,

on top of everything (to pick up instrumentsafter boiling/steaming)

46. If boiling: Fills boiler with enough water so all

instruments and supplies will be covered

If steaming: Fills steamer with water up tolevel of steamer tray.

47. Cover pot

48. Bring to a boil

49. When boiling starts, time the boiling / steaming

for 20 minutes

50. After 20 minutes, use disinfected cheatle

forceps to remove instrument tray and fill traywith disinfected instruments, tubing, etc.

51. Air dry instruments and supplies

52. Covers instrument tray after instruments dried53. Put cheatle forcep in a cheatle forcep stand

that is high level disinfected (do not fill

container with disinfectant)

Sterilizing by Autoclaving

54. Purpose: Kills all germs including endospores

55. Prepare items for autoclaving (instruments open

and can put in autoclave either unwrapped or

wrapped)

56. Operate autoclave at 121o C at a pressure of

016 kPA for 20 minutes (if wrapped for 30

minutes)

57. Lets all instruments and supplies dry before

removing


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0 1 2 NA

Step 4: Storage

58. Do not store equipment or gloves in solutions.

Germs can live and grow in both antiseptic anddisinfectant solutions.

59. Keep storage area clean, dry and dust-free.

60. Packs and containers should be stored off the

floor.

61. Do not use cardboard boxes as they collect dust

and insects like to live in them and eat the

boxes.

62. Date and rotate the items (first in / first out).

63. Length of storage: Wrapped items. With proper storage and

little handling, items can be consideredsterile for 30 days. Holes in the wrappers,

damp or wet wrapped items let germs inside

of the wrapper. When in doubt about the

sterility of a wrapped item, consider itcontaminated and sterilize again.

Unwrapped items. Use unwrapped items

immediately or keep them in a covered, HLD

or sterile container for up to one week.


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Learning Guide: External & Internal Bimanual Compression ofUterus

Name:

Date:

After observing or performing, write a rating/score of performance:2= Satisfactory OR1= Needs improvement OR0 = Not done or not done correctly.

Add any other comments in the comments section below.

STEP/TASK Score Comment

0 1 2 N/A

Getting Ready

1. Tell the woman (and her support person) what is going to bedone, listen to her and respond attentively to her questionsand concerns.

2. Provide continual emotional support and reassurance, asfeasible.

EXTERNAL BIMANUAL COMPRESSION

1. Place one hand on the abdomen at the top and behind theuterus and the other hand just above the pubic bone.

1. Press hand together firmly, making sure the uterus isdirectly between your 2 hands

3. After 5 minutes, look to see if bleeding has slowed orstopped. If not stopped, proceed to internal bimanualcompression

4. Instruct assistant (or family member) to continuecompressing the uterus

5. Instruct mother to put baby to breast or, if not possible, tostimulate her nipples.

6. If bleeding continues, proceed to internal bimanual

compression.

INTERNAL BIMANUAL COMPRESSION

1. Insert one hand into the vagina and form a fist.


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Step/Task Score Comment

0 1 2 N/A

2. With your fist, apply pressure against the anterior wall ofthe uterus above the cervix.

3. Place the other hand on the abdomen behind the uterus.

4. Press the abdominal hand deeply into the abdomen andapply pressure against the posterior wall of the uterus.

5. Maintain compression until bleeding is controlled and theuterus contracts.

6. If bleeding continues, proceed to compression of aorta

POSTPROCEDURE TASKS

1. Immerse both gloved hands in 0.5% chlorine solution.

Remove gloves by turning them inside out. If disposing of gloves, place them in a leak-proof

container or plastic bag. If reusing surgical gloves, submerge them in 0.5%

chlorine solution for 10 minutes for decontamination.

2. Wash hands thoroughly with soap and water and dry witha clean cloth or air dry.

3. Monitor vaginal bleeding and take the womans vitalsigns: Every 15 minutes for 2 hours Then every 30 minutes for 1 hour.

4. Make sure that the uterus is firmly contracted.

POST-PROCEDURE TASKS

1. Monitor vaginal bleeding, palpate the uterus to ensurethat is remains contracted, and take and record thewomans vital signs: Every 15 minutes for 2 hours until stable Then every 30 minutes for 1 hour.


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Learning Guide: Manual Removal of Placenta

NAME:

Directions

Rate the performance of each step or task using the following rating scale:

1= Performs the step or task completely and correctly.

0= Is unable to perform the step or task completely or correctly or the step/task was notobserved.

N/A(not applicable) = Step was not needed.

STEP/TASK Score

GETTING READY1.Prepare the necessary equipment.

2.Tell the woman (and her support person) what is going to be

done, listen to her and respond attentively to her questionsand concerns.

3.Provide continual emotional support and reassurance, as feasible.

4.Have the woman empty her bladder or insert a catheter, ifnecessary.

5.Give anesthesia (IV pethidine and diazepam, or ketamine).

6.Give a single dose of prophylactic antibiotics: Ampicillin 2 g IV PLUS metronidazole 500 mg IV, OR Cefazolin 1 g IV PLUS metronidazole 500 mg IV

7.Put on personal protective equipment.

MANUAL REMOVAL OF PLACENTA1.Use antiseptic handrub or wash hands and forearms thoroughly

with soap and water and dry with a sterile cloth or air dry.

2.Put high-level disinfected or sterile surgical gloves on bothhands. (Note: elbow-length gloves should be used, if

available.)

3.Hold the umbilical cord with a clamp.

4.Pull the cord gently until it is parallel to the floor.

5.Place the fingers of one hand into the vagina and into the uterinecavity, following the direction of the cord until the placentais located.

6.When the placenta has been located, let go of the cord and movethat hand onto the abdomen to support the fundus

abdominally and to provide counter-traction to prevent

uterine inversion.

7.Move the fingers of the hand in the uterus laterally until the edgeof the placenta is located.

8.Keeping the fingers tightly together, ease the edge of the handgently between the placenta and the uterine wall, with the


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palm facing the placenta.

9.Gradually move the hand back and forth in a smooth lateralmotion until the whole placenta is separated from the uterine

wall: If the placenta does not separate from the uterine wall by gentle

lateral movement of the fingers at the line of cleavage,suspect placenta accreta and arrange for surgical

intervention.

10. When the placenta is completely separated: Palpate the inside of the uterine cavity to ensure that all placental

tissue has been removed.

Slowly withdraw the hand from the uterus bringing the placentawith it.

Continue to provide counter-traction to the fundus by pushing itin the opposite direction of the hand that is being

withdrawn.11. Give oxytocin 20 units in 1 L IV fluid (normal saline or

Ringers lactate) at 60 drops/minute.

12. Have an assistant massage the fundus to encourage atonicuterine contraction.

13. If there is continued heavy bleeding, give ergometrine 0.2mg IM or give prostaglandins.

14. Examine the uterine surface of the placenta to ensure that itis complete.

15. Examine the woman carefully and repair any tears to the

cervix or vagina, or repair episiotomy.

POST PROCEDURE TASKS1.Immerse both gloved hands in 0.5% chlorine solution. Remove

gloves by turning them inside out.

If disposing of gloves, place them in a leakproof container orplastic bag.

If reusing surgical gloves, submerge them in 0.5% chlorinesolution for 10 minutes for decontamination.

2.Use antiseptic handrub or wash hands thoroughly with soap and

water and dry with a clean, dry cloth or air dry.3.Monitor vaginal bleeding and take the womans vital signs: Every 15 minutes for 1 hour Then every 30 minutes for 2 hours

4.Make sure that the uterus is firmly contracted.

5.Record procedure and findings on womans record.


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Documents

Emonc Participants Guide English