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 defined. Error! Bookmark not

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Workshop Schedule Day 1: Opening/welcome/registration Expectations & norms Objectives Clinical schedule/teams/morning report Review of course Pre-workshop questionnaire Evidence-based Care for intrapartum and Newborns Essential Newborn Care Daily feedback form Team 1: Practice in clinical area Day 2: Warm-up/review/report from Team 1 Partograph & Management of Labor Using Partograph Protocol Daily feedback form Team 2: Practice in clinical area Day 3: Warm-up/review/report from Team 2 Infant Resuscitation Using Helping Babies Breathe Methodology Daily feedback form Team 3: Practice in clinical area Day 4: Objective Structured Clinical Exam for HBB Warm-up/review/report from Team 3
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Prevention and Management of PPH Infection Prevention Daily feedback form Team 4: Practice in clinical area Day 5: Warm-up/review/report from Team 4 Demonstration of Instrument Processing: 4 steps Stabilization and referral of selected obstetrical & newborn problems Post workshop questionnaire End of training questionnaire

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General Objectives: At the end of the workshop participants will be able to:
1. 2. 3. 4. 5. 6. Discuss and demonstrate the elements of immediate newborn care and AMTSL. Use the partograph to document and manage labor. Demonstrate newborn resuscitation utilizing the Helping Babies Breathe (HBB) methodology Use infection prevention standard precautions as described in the learning guide to protect self and clients when giving care Demonstrate how to prevent and manage postpartum hemorrhage. 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

General Objective: Specific Objectives:
1. 2. 3. 4.

Time: 4 Hours 15 Min

At the end of the session participants will be able to discuss and demonstrate the elements of immediate newborn care and AMTSL.

Explain what Essential Newborn Care (ENC) is and what is Helping Babies Breathe (HBB)? Explain benefit and demonstrate Active Management of Third Stage Labor. Cite the elements of Essential Newborn Care Explain the elements of Immediate Essential Newborn Care a. Clean delivery i. Clean surface ii. Clean hands iii. Clean instrument for cord cutting b. Thermal protection i. Drying and stimulation ii. Warming iii. Skin-to-skin c. Cord Care i. Timing of cord cutting ii. Do not strip before cutting iii. Put nothing on the cord iv. Monitor for bleeding v. Counsel mother not to put anything on the cord; wash with soap & water if soiled d. Eye care i. Application of antibiotic eye ointment e. Vitamin K injection f. Identification of newborn g. Early initiation of breast feeding i. Counsel regarding early initiation of breast feeding and advantages of exclusive breast feeding h. Care of the low birth weight infant
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i. ii. iii. iv. v. vi.

Define low birth weight Identify special needs of low birth weight infant Define Kangaroo Care State advantages of Kangaroo Care Demonstrate positioning and wrapping for Kangaroo Care 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 Hours

Session Objective: At the end of the session participants will be able to: Use the partograph to document and manage labor.
Specific Objectives:
1. Explain the definition, importance, and evidence to support use of the partograph 2. Explain parts of the partograph including:

a. Fetal condition b. Progress of labor c. Maternal condition 3. Record the partograph 4. Interpret the partograph 5. 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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WHO Partograph Study

Objectives:
To evaluate what effect the WHO partograph has on labor management and outcome To develop and test a protocol for labor management with partograph

Design: Study done in hospitals in Indonesia, Malaysia

and Thailand

Study Guidelines Used for Laboring Women:

Latent Phase: No intervention until after 8 hours At Action Line Decide: Oxytocin augmentation, cesarean section, or observation AND supportive treatment

WHO 1994.

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Partograph Game
This game can be done at the beginning of the partograph topic even before the objectives are reviewed. Preparation: Prepare 2 flip charts or white boards for participants to tape their sentences to: 1. Cut 6 pieces of cello/scotch tape for each flip chart or white board and put 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 they make 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 not agree, 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 they
also get a reward for participating.

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PARTOGRAPH SYMBOLS
I = C= M= Intact Clear Meconium stained

Liquor

B= A=

Blood stained Absent

O= += ++ = Molding +++ =

Bones are separated and sutures can be felt easily Bones are just touching each other Bones are overlapping but can be separated easily with pressure from your fingers Bones are overlapping but cannot be separated easily with pressure from your fingers

Dilatation Descent

X O ////// //////

Dots = mild contractions less than 20 seconds Diagonal lines = moderate contractions 20 40 seconds Completely filled in = strong contractions greater than 40 seconds

Contractions

BP Pulse & Fetal heart 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________________
190 180 170 160 150 140 130 120 110 100 90 80 70 60 LIQUOR MOULDING 10
le r A A

190 180 170 160 150 140 130 120 110 100 90 80 70 60

FETAL HEART RATE

10
io n ct

9 CERVIX (CM) 8 7 Plot X 6 5 4 DESCENT Plot O 3 2 1 0 HOURS

9 8 7 6 5 4 3 2 1 0 HOURS

TIME 5 4 3 2 1 5 4 3 2 1

CONTRACTIONS PER 10 MINS Oxytocin U / L Drops / minute

DRUGS & IV FLUIDS

BLOOD PRESSURE & PULSE

200 190 180 170 160 150 140 130 120 110 100 90 80 70 60

200 190 180 170 160 150 140 130 120 110 100 90 80 70 60

TEMPERATURE Amount Protein Acetone

URINE

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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: BLOOD LOSS AMOUNT: small (less than 250 cc) moderate (250-499 cc) large (more than 500 cc) significant for mother BABY: Weight: Sex : Male / Female Complete / Incomplete Manual Removal Yes___ No___

APGAR
Time Color Breath Hear t Tone Reflex TOTAL

Length__________

1 min

Baby Presentation : Vertex / Breech / Stillbirth Fresh / Macerated

5 min

Other

COMPLICATIONS OF MOTHER / BABY: None/Other_________________________________________________

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FOURTH STAGE MONITORING OF WOMAN AND BABY.

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

Every 15 minutes for First 2 Hours

Every 30 min for 1 Hour

BIRTH ATTENDANT:

_________

Date: ____________

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How Often to Check Using Partograph Guidelines

WHAT IF NORMAL AND IN STAGE I LABOR 4 Hours OR When you expect her to be fully dilated At each vaginal examination IF NOT NORMAL OR IN STAGE II LABOR

Dilatation

Variable

Descent

At each vaginal examination

Fetal Heart Rate Contractions: Latent Phase Active Phase Pulse

30 Minutes

15 Minutes (or more often if needed) Abnormal: 30 minutes Abnormal: Continuously 30 Minutes

1 hour 30 Minutes 30 Minutes

Blood Pressure

4 Hours

30 Minutes

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Temperature

2 Hours (may do 4 Hours if normal) 1 Hour

1 Hour

Fluid

1 Hour (more often if needed)

Urination

2 Hours

2 Hours (more often if needed)

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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. 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 from infections; 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 Page 46

Management

Teach the woman and support person breathing methods that can help the laboring woman relax and how not to push during 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 and knees)

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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). Do a full assessment: Page 48

Management:

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 be used 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 (too little power). 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

Management:

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. Page 49

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

Problem / Cause
Is the bladder too full? Is the cervix completely open? Is the woman pushing effectively? Is the woman upset or tense? Does the woman need to change position? Are the contractions becoming weak or further apart? Is the woman dehydrated or exhausted? Is the baby not able to fit through the womans pelvic bones? Is the baby in a difficult or impossible birth position? Help woman urinate

Action
Recheck the cervix. If cervix is not open, the woman should stop pushing and continue woman and family friendly care. Help the woman to push effectively. 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). Help the woman stand or squat to push. Give the woman oral or intravenous fluids. Encourage her to relax between contractions. If contractions become weaker and farther apart, refer to hospital. Refer the woman to the hospital. 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, 4th Edition

If the baby is 37 weeks or more gestation, cephalic presentation and alive, the contractions are 3 in 10 minutes lasting 45 seconds 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 are stable 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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DAY 3

Topic: Newborn Resuscitation (utilizing Helping Babies Breathe methodology)

Time: 4 Hours 20 Minutes Session Objective: At the end of the session participants will be able to demonstrate newborn resuscitation utilizing the Helping Babies Breathe (HBB) methodology. Specific Objectives: 1. Define asphyxia and hypoxia 2. Describe possible causes of hypoxia in the newborn. 3. Describe symptoms of a newborn needing resuscitation. 4. Discuss materials and equipment needed to perform newborn resuscitation 5. Explain the importance of the Golden Minute. 6. Explain the Helping Babies Breathe initiative and learning materials 7. Demonstrate newborn resuscitation using a newborn ventilation bag and mask. 8. Describe care for a baby after resuscitation. 9. Demonstrate infection prevention, cleaning and testing of newborn resuscitation equipment Homework: Read HBB Learner Workbook

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CAUSES OF HYPOXIA POOR OXYGEN CIRCULATION IN THE UTERUS: Not enough oxygen in maternal blood, e.g., mother with heart disease, asthma. Low blood pressure in the mother, e.g. compression of vena cava or aorta by the uterus, maternal bleeding. Not enough uterine relaxation due to oxytocin administration PLACENTAL FACTORS: Premature placental separation, causing maternal hemorrhage reduced maternal BP reduced placental circulation less oxygen to baby. Placental insufficiency, e.g., PIH, postmaturity, maternal high BP or infection UMBILICAL CORD COMPRESSION: Poor blood circulation through the cord due to compression or knotting TRAUMA DUE TO INSTRUMENTAL DELIVERY

Asphyxia and Hypoxia Defined Asphyxia: When a baby does not begin or sustain adequate breathing at birth. Hypoxia: Not enough oxygen in the body tissues

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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 Score is 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 if baby 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 mothers abdomen Dry the baby from head to toe Evaluate whether or not the baby is breathing or having difficulty breathing while drying the baby. If the baby is breathing: Take away the wet towel; place the baby face down skin-toskin, 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, dry cloth, and put on a hat. Keep the baby on the mothers abdomen.

1. 2.

IF BABY IS NOT BREATHING OR HAVING DIFFICULTY BREATHING With the baby still on the mothers abdomen, position the POSITION babys head in the sniffing position. This is the best position to keep the airway open. Suction with a Penguin suction device, bulb syringe, or DeLee SUCTION trap. Suction only while pulling suction tube out, NOT while putting it in. For bulb or Penguin, compress before inserting in mouth, release compression to suction, remove from mouth and compress bulb again to expel contents. Repeat for each nostril. Do not insert suction tube or bulb more than 5 cm into the 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. Rub your with the heel of your hand up and down the babys spine to stimulate the baby. This can be done without removing the cloth or the towel in which the baby is wrapped. Evaluate the babys breathing. If still not breathing or gasping, give the mother 10U oxytocin, clamp and cut the cord, and move baby to the resuscitation table.

3. STIMULATE 4. EVALUATE

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5. BREATHE
FOR BABY

1. 2. 3. 4. 5. 6. 7. 8.

Keep the baby covered except the face and chest. Position the baby in sniffing position by placing a small rolled towel under the babys shoulders. If oxygen is available, give oxygen at 2 liters/min by attaching the tubing from the tank to the ventilation bag. Place mask over baby's mouth and nose and make a good seal. Compress bag 2 times to see if baby's chest rises. If the chest does not rise: Reposition the baby, check the seal for the mask, and suction the mouth and nose. Repeat step 1. If the chest rises: Breathe 40 times in 1 minute for the baby. If the baby is breathing, stop ventilating and continue to support baby with warmth, stimulation and oxygen, if available, until baby is pink and active. If baby is not breathing: Call for help. Check the heart rate. Continue to breathe for the baby. Check for respirations and heart rate after each 40 breaths. Does this until the baby is breathing on her own. Then continue to support baby with warmth, stimulation and oxygen (if available) until the baby is pink and active.

9.

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DAY 4

Topic: Postpartum Hemorrhage (PPH)

Session Objective:

Time: 3 Hours

At the end of this session participants be able to to demonstrate how to prevent and manage postpartum hemorrhage.

Specific Objectives:
1. 2. 3. 4. 5. 6. 7.

Define PPH Describe the significance of PPH Identify causes of PPH Identify risk factors for PPH Describe strategies for prevention and management of PPH Demonstrate external and internal bi-manual compression of the uterus Demonstrate manual removal of placenta

Homework: 1. IMPAC Manual, Vaginal Bleeding After Childbirth S-27 to S-31 and P-77 to P-79 on Manual Removal of the Placenta Postpartum Hemorrhage Defined Immediate Postpartum Hemorrhage: More than 500 mL of vaginal bleeding that occurs less than 24 hours after childbirth. 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 be fatal. For that reason a better definition is: Any amount of bleeding that causes a change for the worse in the womans condition such as low systolic BP, fast pulse, signs of 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 UNPREDICTABLE and RAPID cause 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 of the uterus to properly contract after birth).
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Causes of PPH: The 3 Ts: Tone, Trauma and Thrombin Tone Bleeding due to lack of uterine muscle tone or any condition interfering with contractions of the uterus. This includes: Retained placenta, placental tissue or membranes Incomplete separation of the placenta A full bladder Over distention of the uterus due to multiple gestation, excess amniotic fluid, very large baby or multiparity Prolonged or augmented labor Trauma Uterine inversion Lacerations of the perineum, vagina or cervix Ruptured uterus Too early episiotomy Thrombin Coagulation failure interfering with blood clotting mechanism

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Postpartum Hemorrhage Risk 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 that all women are considered at risk and hemorrhage prevention must be a part of every birth.

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 he ad and shoulders to prevent tears. Place the fingers of one hand against the babys head to keep it flexed (bent), support the perineum and teach the woman breathing techniques to push or to stop pushing.

Strategies to Prevent PPH

During 3rd Stage and Immediately After Placental Delivery

Provide active management of the third stage of labor. This prevents up to 60% of PPH and is the single most effective way of preventing postpartum 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 third stage to keep the uterus well contracted Teach the woman to massage and check her own uterus to keep it firm and to call 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 trapped in the uterus will prevent effective uterine contractions. If bleeding does not stop, do external or internal bimanual compression while others are doing the following steps. Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature) Have the woman empty her bladder or ensure that the bladder is empty; 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 for transfusion, type and cross before beginning infusion of fluids and prepare blood. Check to see if the placenta is expelled and examine the placenta to be 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 the woman 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 the Uterus During a Contraction

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DAY 4

Topic: Infection Prevention

Time: 2 Hours 15 Minutes
General Objective: At the end of the session participants will be able to use infection prevention standard precautions as described in the learning guide to protect self and clients when giving care.

Specific Objectives: 1. Identify the components of infection prevention standard precautions 2. 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 washing 4. Describe when to wear gloves and what kind of gloves you should wear for different health care related activities 5. Describe ways to provide personal protection when giving care (use of personal protective equipment and preventing splashes) 6. Describe ways to prevent injuries from sharps 7. Demonstrate how to process patient care instruments and supplies safely 8. 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, closed shoes). Prevent injuries with sharps. Process patient care instruments and equipment safely. Keep the environment clean. Dispose of wastes safely.

WHEN TO WASH HANDS

1. 2. 3.

When arriving / leaving work place Before / after caring for or examining a mother / baby Before / after using gloves

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4. 5.

After having contact with blood / body fluids from instruments, supplies or splashes 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 than 1%. Advantages: Inhibits or kills most gram negative and gram positive bacteria, TB, viruses (HIV) and fungi. More effective than handwashing, which removes dirt, blood and some transient germs, but not all. If used with hand softeners like glycerin or propylene glycol, protects and softens 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 between fingers and under nails, until dry. Do not use if hands are contaminated with body fluids, but wash hands with soap and water. Wash hands with soap and water after every 5 10 uses to reduce the buildup 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, DURING SURGERY, ETC.) WHEN RUPTURING MEMBRANES: 1) STAND TO THE SIDE OF THE WOMANS VAGINA, 2) TRY TO RUPTURE MEMBRANES BETWEEN CONTRACTIONS. 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 CAREFULLY

RINSE THE OUTSIDE OF GLOVES WHILE ON YOUR HAND IN

DECONTAMINATION SOLUTION

CAREFULLY REMOVE GLOVES BY SLOWLY PULLING THEM DOWN FROM THE 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, mucous membranes, blood, or other body fluids When performing invasive procedures When handling: Soiled instruments Medical, or contaminated, waste When touching contaminated surfaces

GUIDELINES FOR GLOVING What 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 prevent spreading infection from client to client Never wear gloves that are cracked, peeling or have holes.

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PERSONAL PROTECTIVE EQUIPMENT/CLOTHING Used for: Sorting and cleaning instruments and linens Attending a vaginal delivery Cutting umbilical cord Note: Eye protection can include goggles, face shields, or plain glasses Used for: Sorting and cleaning instruments and linens Attending a vaginal delivery Closed shoe or boot made from rubber or leather. Protects the wearer from: Injury by sharps or heavy items Blood or other body fluids on the floor Utility or Heavy Duty Gloves: To touch dirty instruments, linens and waste, doing housekeeping and cleaning contaminated surfaces. GLOVES Single Use Examination Gloves: Use if having contact with intact mucous membranes and when at risk of exposure to blood or other body fluids. Surgical Gloves: For all procedures having contact with tissues under the skin or with the blood stream.

MASK AND EYE PROTECTION

APRON OR GOWN

FEET PROTECTION

GLOBAL STATISTICS ON OCCUPATIONAL EXPOSURE 3 MILLION HEALTH CARE WORKERS (HCWS) PER YEAR REPORT NEEDLESTICK INJURIES
PER YEAR

2.5% HIV INFECTIONS AMONG HCWS ARE TRANSMITTED BY NEEDLESTICK INJURIES 40% OF HEPATITIS C AND HEPATITIS B INFECTIONS AMONG HCWS ARE TRANSMITTED
BY NEEDLESTICK INJURIES

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4 STEPS OF PROCESSING INSTRUMENTS AND SUPPLIES Kills viruses and many other germs Makes items safer to handle during cleaning Makes items easier to clean Removes blood, other body fluids, tissue and dirt Reduces the number of germs Makes sterilization or high-level disinfection effective. If blood clot remains on instrument, germs in clot may not be completely killed by sterilization or HLD. Kills all germs except some endospore Use for items having contact with broken skin or intact mucous membranes If sterilization not possible, HLD only other choice Can be done by boiling, steaming or chemical disinfection (soak in 0.5% chlorine solution x 20 minutes) Kills all germs including endospores. May not be possible to do in all settings. Can be done by dry heat or wet heat (autoclave). Use immediately Store in a high level disinfected or sterile covered tray up to 1 week If wrapped: Good for at least 30 days unless something causes the package to become contaminated (tear in package or becomes wet).

Step 1

Decontaminate

Step 2

Clean

High Level Disinfect (HLD) Step 3 OR Sterilization

Step 4

Store or Use

Check concentration (% concentrate) of the liquid chlorine product you are using. Determine total parts water needed using the formula below. Total Parts water = (% of liquid chlorine product / % desired strength of Chlorine solution)-1 Mix 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% = 10 1 = 9 STEP 2: Use 1 part liquid chlorine product and add 9 parts water.

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INFECTION PREVENTION HOUSEKEEPING PRACTICES RECOMMENDED CLEANING FOR A HEALTH FACILITY FREQUENCY WHAT TO CLEAN

Clean with Disinfectant Cleaning Solution (mix 0.5% chlorine solution with a soap or detergent that does not contain an acid, ammonia or ammonium chloride) FOLLOWING Mattress, bed frame, cot, incubator DISCHARGE OF A Any other equipment used for the patients care PATIENT

IMMEDIATELY

Furniture, floors, rooms, and equipment (after a procedure or after a delivery) Spills Delivery and examination rooms Floors Furniture and equipment used daily (exam table, table tops, counters, weighing scales)

DAILY

Weekly

Use separate mop, cloth, or brush to clean the sink, toilets and latrines and waste containers Clean with soap and water solution Clean doors (including door handles), windows, walls, ceilings and ceiling fixtures

Double Bucket Technique helps the disinfectant cleaning solution last longer. Use 2 buckets, 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 identify
signs of selected problems in the mother and newborn, take appropriate actions and refer.

Specific Objectives:
1. Describe signs of convulsions in the newborn

2. 3. 4. 5. 6. 7. 8.

Take appropriate action for convulsions in the newborn at a PHC Explain how to determine if jaundice is severe Take appropriate action for a newborn identified with severe jaundice at a PHC Describe signs of severe pre-eclampsia and eclampsia Demonstrate an emergency team response for an eclamptic convulsion Demonstrate testing of patellar reflexes 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 for

Management 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 other regions 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 more arms or legs Myoclonic seizures, which are quick, single jerks involving one arm or leg or the whole body Actions to take at PHC: Turn the baby to its side to avoid aspiration. Give Phenobarbital 20 mg/kg single IM njection Refer baby immediately to the hospital with a referral form describing: what you did what you saw Page 72

 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 4 days 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 then comes back. Jaundice may last throughout breast-feeding. This isn't usually a problem as long as the baby gets enough milk by being fed on demand. The severity of the jaundice is indicated by the age of the baby and where 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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DIAGNOSIS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

Problem Look At Gestation Severe PreEclampsia BP Protein Convulsions Gestation

Criteria for Problem More than 20 weeks Diastolic 110mm Hg or more 3+ or more None More than 20 weeks Diastolic 90mm Hg or more: A few women with eclampsia have normal BP 2+ or more Present

BP Eclampsia Protein

Convulsions

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Important Research Findings on PIH

Cannot use 2nd trimester diastolic pressure to predict eclampsia. Women who develop gestational hypertension at an earlier gestational age are more likely to progress to pre-eclampsia. 3.4% of women with severe pre-eclampsia will have a convulsion. Eclampsia is abrupt in onset, without warning signs in about 20% of women. It is difficult to predict who will develop preeclampsia. A small proportion of women with eclampsia have normal BP. Woman can still start PIH up to about 10 days postpartum.

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Guidelines for Management of Severe Pre-Eclampsia and Eclampsia

Problem History and Physical Examination History Length of gestation Present or past illnesses Danger signs: Headache not relieved by Paracetemol Visual changes Upper abdominal pain Bleeding Fever Baby moving normally Physical Examination BP, pulse, temperature Increasing drowsiness or coma Reflexes Fetus: movement, fetal heart rate, fetal growth Full labor status: Contractions, vaginal examination for fetal presentation and position and descent, cervical effacement and dilation, status of membranes. OR Full postpartum status Laboratory Examination Urine: protein Bedside clotting test and/or Hb if it can be done quickly Plan of Care

Severe Preeclampsia

REFER IMMEDIATELY. Before transfer: Begin anticonvulsant drugs Give Magnesium Sulfate 5 grams with 1 mL of 2% lidocaine in the same syringe into each buttock (total 10 grams); if Magnesium Sulfate unavailable, give Diazepam 10 mgm IM. Never leave the woman alone. A convulsion with aspiration of vomit may cause the woman or fetus to die. Call ambulance and transfer to hospital. THIS WOMAN MUST DELIVER WITHIN 24 HOURS.

his

Same as for Severe Pre-eclampsia

With convulsion: Shout for help - mobilize personnel Gather equipment (airway, suction, mask and bag, oxygen) DO NOT leave the woman alone Remove sharp or dangerous objects
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Problem

History and Physical Examination

Plan of Care Position her on her left side to reduce the risk of aspiration of secretions, vomit and blood Protect her from injuries (fall), but do not attempt to restrain her Quickly evaluate breathing, state of consciousness, airway, blood pressure and pulse After the convulsion: Assess breathing: Not breathing, use Ambu bag, with or without oxygen Breathing give oxygen at 4 L per minute If she is unconscious: Keep airway clear, aspirate the mouth and throat 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 and continue to investigate other causes (e.g., cerebral malaria, meningitis) REFER and accompany woman. THIS WOMAN MUST DELIVER WITHIN 12 HOURS.

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Learning Guide Essential Newborn Care at Birth

Facilitators or learners can use the following learning checklist to gauge progress 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 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 the spaces provided. Date: Name of Participant

Skill 0

Score 1 2 N/A

Comment

Prepare the woman during the first stage of labor (if the woman presents in second stage labor, go to step #4) 1. Explain to the woman and her support person what 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 complete them. 4. Advise the woman to bathe or help her to bathe 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 that the newborn will be placed first on her abdomen and then on her chest (explain the advantages of skin-to-skin contact) and that breastfeeding will be facilitated in the delivery room within one hour of birth, and obtain her Page 78

Skill 0
permission to complete these actions. 6. Provide emotional support and reassurance and keep the woman and her family informed throughout 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 newborn resuscitation are available, clean, sterile/HLD. Check the newborn ventilation bag to be sure it is present in the room and working properly. 8. Make sure that the room is warm (at least 25C) and free from drafts from open windows, doors, and fans. Make sure that all of the windows are closed. 9. NOTE: If the temperature of the room is less than 25, a heater should be available to warm the room or at least the newborns corner. In hot weather, air conditioning or fans should be turned off or adjusted in the delivery room. 10. Make sure that all surfaces the woman and baby will come in contact with are clean and dry. 11. Make sure the room is well-lit. Have an emergency battery powered torch. 12. Arrange for a helper and make an emergency plan. 13. Wear a clean plastic or rubber apron, closed toed rubber shoes/sandals/slippers or shoe covers, mask, and eye protection. 14. Wash hands thoroughly with soap and water and dry them with a clean, dry cloth (or airdry them). 15. Wear sterile (preferable) surgical or HLD gloves on both hands if you are doing the delivery. Wear clean exam gloves and an apron if you are only caring for the baby. Provide Immediate Essential Newborn Care 16. When the head is delivered, wipe the mouth and nose with gauze. 17. When the baby is fully born, place the baby

Score 1 2 N/A

Comment

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Skill 0
on a clean, dry towel or blanket on the mothers abdomen. 18. Note the time of birth and the sex of the baby and announce them loudly enough to inform the mother. 19. Dry the baby thoroughly except the hands. Assess the babys breathing while drying the baby. 20. If the baby is breathing normally, take away wet 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 the cord ceases to pulsate before clamping and cutting the cord. 23. Place the disposable cord clamp 2 fingers (23 cm) from the abdomen. Pinch the cord below the clamp, push the blood in the cord 2 cm towards the placenta, pinch the cord and place a second clamp. Cut the cord between the two clamps using a sterile or HLD blade or 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 cord traction. 26. Massage the uterus immediately after placenta is delivered. 27. Examine the placenta to be sure it is complete. 28. Check perineum and vagina for tears. Repair if needed. 29. Clean up the mother. Commence exclusive breastfeeding 30. Support the mother in breastfeeding her baby within one hour of birth and before their transfer out of the delivery room. 31. Verify that the babys mouth is latched on well at the breast

Score 1 2 N/A

Comment

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Skill 0
32. The baby is belly to belly with the mother. 33. The babys nose and chin are touching the breast. 34. The mouth is open wide. 35. All or most of the areola is inside the mouth, especially the lower part, so that the upper part of the areola is more visible than the lower part. 36. The babys lips are everted. Administer vitamin K1 37. After the baby has breast fed, explain to the mother that an injection will be required to prevent a bleeding problem in the baby. 38. Collect all the necessary supplies: disposable syringe (preferably 1 ml) with needle, vitamin K, alcohol, pieces of gauze/cotton, preferably sterile. 39. Wipe the injection site with alcohol soaked cotton or gauze. 40. Inject the drug intramuscularly in the anterolateral part of the thigh: 1 mg for a normal weight baby (0.5 for a baby weighing less than 1500 grams although babies this small should 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 an appropriate and safe manner (in a container for sharp instruments). Care of the eyes 43. Instill eye drops (tetracycline or erythromycin), one drop in each eye. When using an ointment, depress the lower eyelid and place a small amount of the ointment inside the lower lid. Do the same for the other eye. 44. Make sure that the tip of the bottle or the tube does not touch the eye of the baby or other objects. Identification of the baby 45. Place an identification band, preferably two one on the wrist and the other on the ankle of the babynoting the name of the mother and

Score 1 2 N/A

Comment

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Skill 0
that of the father (where available), the sex of the baby, and date and time of the delivery. Weigh the baby 46. Delay taking the weight of the baby until he/she is stable and warm and after first breast feeding. 47. Place a clean cloth/paper on the pan of the weighing scale. 48. Make the necessary adjustments to bring the needle/pointer back to zero. 49. Place the baby on the cloth/paper. If the cloth is large enough, fold the sides to cover the baby. 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 the scale. Maintain the babys body temperature/thermal protection 53. Keep the baby warm, ideally by keeping him/her in skin-to-skin contact on the mothers chest, with the body and head covered by a cloth or hat. If the baby cannot be placed in skin-to-skin contact in case of a Cesarean section or if the mother is ill, wrap the baby well and cover the head. 54. Check the babys axillary temperature with a thermometer. Briefly Counsel the Mother 55. On the importance of early, exclusive breastfeeding and of colostrum in protecting the baby against infections. 56. To feed frequently on demand, day and night. 57. Not to give any liquids (including water) or solids, other than breast milk. 58. Not to apply anything harmful to the cord, such as ash, mud, clay, or herbal preparations. 59. To keep the baby warm, if necessary by skinto-skin contact, and check the temperature by touching the hands, feet, and abdomen to

Score 1 2 N/A

Comment

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Skill 0
ensure that they are all warm but not too hot. 60. To call the care provider if there is any problem. 61. That the baby should not be bathed for at least 6 hours after birth. Decontamination, cleaning, and sterilization 62. Ensure the proper disposal of waste and decontamination of the equipment and supplies that can be reused. 63. Remove the gloves after having dipped them in the decontamination solution. 64. Wash hands and air-dry them or wipe them with a clean cloth. 65. Replace all items after cleaning/sterilization and replenish the disposable/consumable items to be ready for the next delivery. Record all the key data/information 66. Note all the key data/information in partograph/cards/records of the mother and baby/registers, based on the recommendations 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 30 minutes for 1 hour, and then every 1 hour for 3 hours. Record findings.

Score 1 2 N/A

Comment

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LEARNING GUIDE: Infection Prevention

Training facilitators or learners can use the following learning checklist to gauge progress 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. Any immediate corrective action(s) taken and further action(s) needed must be entered in the spaces provided. Date: Name of Participant

Steps/Tasks 0 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.

Score 1 2 NA

Comments

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Steps/Tasks 0 7. If using a soap bar, rinse off bar before placing in soap holder 8. Rub together all surfaces of the hands, including wrists, between fingers, palm and back of the hands 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 (rupturing membranes, during delivery, during surgery, etc.) 13. When rupturing membranes: 1) stand to the side of 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 carefully a. 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 possible 16. Do not take needle and syringe apart after use 17. Do not recap, bend or break needles before disposal

Score 1 2 NA

Comments

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Steps/Tasks 0 18. After use and before disposing, decontaminate syringes and needles by flushing 3 times with chlorine solution (this step may not be needed if disposal site is secure) 19. Dispose of needles and syringes in a punctureproof container and dispose of the punctureproof 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 suturing 22. Never hold or guide needle with fingers

Score 1 2 NA

Comments

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. Chlorine should be mixed with enough water to make a 0.5% 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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Steps/Tasks 0 30. Purpose: Removes blood, other body fluids, tissue and dirt Reduces the number of germs Makes sterilization or high-level disinfection effective. If blood clot remains on instrument, germs in clot may not be completely killed by sterilization or HLD 31. Discard any disposable supplies 32. Use soapy water for cleaning process 33. Put on heavy cleaning gloves 34. Move all items from decontamination solution and put in soapy water. Make sure all instruments are still open. 35. Flush tubing, using syringe, 3 times with soapy water, if reusing. 36. Use cleaning brush or toothbrush to clean all joints on instruments 37. Wash gloves on both outside and inside, if reusing 38. Put all items into pail with clean water 39. Flush tubing, using syringe, 3 times with clean water, if reusing. Flush bulb syringe 3 times with clean water. 40. Clean apron with soapy water, then clean water, then hang to dry

Score 1 2 NA

Comments

Step 3: High Level Disinfection or Sterilizing High Level Disinfection by boiling or steaming: 41. Purpose: Kills all germs except some endospores 42. Put items into boiler/steamer (Note: it is not necessary to sterilize or HLD bulb syringes. Suction catheters and other tubing should be steamed or boiled)

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Steps/Tasks 0 43. Make sure instruments are open 44. If disinfecting instrument tray, put tray on top of all instruments 45. Put cheatle forceps that has a string attached, on top of everything (to pick up instruments after 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 to level 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 tray with disinfected instruments, tubing, etc. 51. Air dry instruments and supplies 52. Covers instrument tray after instruments dried 53. 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

Score 1 2 NA

Comments

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Steps/Tasks 0 Step 4: Storage 58. Do not store equipment or gloves in solutions. Germs can live and grow in both antiseptic and disinfectant 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 considered sterile 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 it contaminated and sterilize again. Unwrapped items. Use unwrapped items immediately or keep them in a covered, HLD or sterile container for up to one week.

Score 1 2 NA

Comments

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Learning Guide: External & Internal Bimanual Compression of Uterus

Name: Date: After observing or performing, write a rating/score of performance: 2 = Satisfactory OR 1 = Needs improvement OR 0 = Not done or not done correctly. Add any other comments in the comments section below. STEP/TASK 0 Getting Ready 1. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns. 2. Provide continual emotional support and reassurance, as feasible. EXTERNAL BIMANUAL COMPRESSION 1.
1.

Score 1 2 N/A

Comment

Place one hand on the abdomen at the top and behind the uterus and the other hand just above the pubic bone. Press hand together firmly, making sure the uterus is directly between your 2 hands

3. After 5 minutes, look to see if bleeding has slowed or stopped. If not stopped, proceed to internal bimanual compression 4. Instruct assistant (or compressing the uterus family member) to continue

5. Instruct mother to put baby to breast or, if not possible, to stimulate her nipples. 6. If bleeding continues, compression. proceed to internal bimanual

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

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Step/Task

Score 0 1 2 N/A

Comment

2. With your fist, apply pressure against the anterior wall of the uterus above the cervix. 3. Place the other hand on the abdomen behind the uterus. 4. Press the abdominal hand deeply into the abdomen and apply pressure against the posterior wall of the uterus. 5. Maintain compression until bleeding is controlled and the uterus 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. 3.

Wash hands thoroughly with soap and water and dry with a clean cloth or air dry. Monitor vaginal bleeding and take the womans vital signs: Every 15 minutes for 2 hours Then every 30 minutes for 1 hour. Make sure that the uterus is firmly contracted.

4.

POST-PROCEDURE TASKS 1. Monitor vaginal bleeding, palpate the uterus to ensure that is remains contracted, and take and record the womans 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 not observed. N/A (not applicable) = Step was not needed.

STEP/TASK GETTING READY

1. 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 questions and concerns. 3. Provide continual emotional support and reassurance, as feasible. 4. Have the woman empty her bladder or insert a catheter, if necessary. 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.

Score

MANUAL REMOVAL OF PLACENTA

1. 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 both hands. (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 uterine cavity, following the direction of the cord until the placenta is located. 6. When the placenta has been located, let go of the cord and move that 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 edge of the placenta is located. 8. Keeping the fingers tightly together, ease the edge of the hand gently 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 lateral motion 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 placenta with it. Continue to provide counter-traction to the fundus by pushing it in 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 atonic uterine contraction. 13. If there is continued heavy bleeding, give ergometrine 0.2 mg IM or give prostaglandins. 14. Examine the uterine surface of the placenta to ensure that it is complete. 15. Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy.

POST PROCEDURE 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 leakproof container or plastic bag. If reusing surgical gloves, submerge them in 0.5% chlorine solution 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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