1. family and parenting
2. motherhood
3. pregnancy

PREGNANCY & CHILDBIRTH
MANAGEMENT AT PRIMARY
HEALTH CARE LEVEL
Training Module
Second Edition - April 2012
Department of Family & Community Health
Directorate General of Health Affairs
Ministry of Health
Sultanate of Oman
(ML – 83)
PREGNANCY & CHILDBIRTH
MANAGEMENT AT PRIMARY
HEALTH CARE LEVEL
Training Module
Second Edition - April 2012
Department of Family & Community Health
Directorate General of Health Affairs
Ministry of Health
Sultanate of Oman
P reface
Improving the health of Omani families by providing comprehensive
care to all people of Oman has been an aim of MOH since its inception,
especially the women and children, women in reproductive age
together with the children below 5 years comprise around 41% of the
total population.
During the reproductive period women pass through the various
physiological events of pregnancy, parturition and post partum which
make them vulnerable to the morbidity and mortality related to this
period. Inadequate, ineffective or inefficient care during this period
not only affects their health but also puts the health of the feotus in
utero and newborn in peril. Such babies remain vulnerable to disease
and death in their early childhood too.
Lack of quality care during parturition or soon after birth can result
in poor perinatal out comes. Newborns and children below 5 years
by virtue of their poor resistance to infection are equally vulnerable
to diseases that contribute to the morbidity in this age group, hence
require special attention too.
In consideration of above aspects, MCH (Maternal &Child Health)
services have been integrated with primary health care and made
easily accessible and available to the community. A large investment
has been done in the manpower serving in the MCH area, who are
well qualified and experienced .
Several standard operative procedures manuals have been developed
to guide the health care providers on the polices, protocols and first
line management of the problems in the MCH area.
In continuation of our efforts to improve the quality of MCH care DFCH
produced two guidelines for pregnancy& childbirth management one
for primary health care providers( level-1) and the other one for the
secondary health care level (level-2). Those national guidelines were
produced and published in 2010 by a group of health care providers
1
from the area of obstetric, midwifery and primary health care. These
guidelines are meant to replace the old ANC, perinatal & postnatal
manuals. They are based on the up to date scientific and evidence
based information available.
Updating & reproducing the pregnancy &childbirth management
guidelines required the updating of the available MCH training
modules produced during 1999. Hence a new training module has
been prepared in the line with our new 2010 guidelines.
This training module is developed with the intension of enforcing the
knowledge and skills of health care providers according to the updated
internationally recommended skills and practices. It is directed at
the in-service training of health care providers at level of health care
system who are involved in provision of primary health care related to
MCH, mainly the medical officers, nurses and midwives.
We are thankful to the staff from all regions and MOH (head quarters),
master trainers and other members of regional MCH training teams, for
their great contribution in the development of this training module.
We recommend this training module be optimally utilized by all regions
of sultanate of Oman, to keep the knowledge and skills of the health
care providers in MCH area updated.
We hope that by training and retraining of health care providers, the
quality of MCH care will further improve and thus result in improvement
of the health of women and children in Oman.
Dr.Yasmin Ahmed Jaffer
Director of Family &Community Health
2
Modu le O vervie w
This module consist of ten sessions covering issues on basic antenatal care, medical & obstetric complications during pregnancy, normal
delivery and postnatal care.
It also covers other topics related to ANC&PNC area such as woman’s
rights and psychological support of women receiving antenatal and
postnatal care.
The module also includes information on quality assurance standards
of services provided during antenatal and postnatal period.
The time allocated to run the module is four days; this will be done by
conducting regional workshops arranged by MCH coordinators.
An electronic copy of the module (CD) will be provided to the trainers
to facilitate their work .The CD also contains power point presentations
of all sessions, in addition to video films.
3
A ck nowledgement
Contributors from the Department of Family & Community Health
Dr. Yasmin Ahmed Jaffer
Director of Family & Community Health
Dr. Salwa Jabber Al Shahabi
Specialist, Community Medicine
Dr. Jamila Taiseer Al Abri
Head of Women Health Section
Dr. Nahida Al Lawati
Sr. Specialist,Family &Community Medicine
Mrs. Flordeliza R. J.
Nurse Supervisor & Training coordinator
Contributor from the Department of Primary Health Care
Dr. Mariam Al Khusaibi
Sr. Specialist
Contributors from the Department of Obstetrics & Gynecology:
Dr. Hansa Dhar
Sr. Specialist,
Nizwa Hospital
Dr. Usha Varghese
Sr. Specialist,
Buraimi Hospital
Dr. Maryam Al Alawi
Jr. Specialist,
Sur Hospital
Dr. Nuha Hatem Qasim
Jr. Specialist,
Musanah Polyclinic
Contributors from the Regional Maternal & Child Health Coordinators :
Dr. Fatma Said Al Hadifi
Sr. Specialist,
North Sharqiya
Dr. Samya Salim Al Hatali
Sr. Specialist,
South Sharqiya
Dr. Fatma Ibrahim Al Hinai
Sr. Specialist,
Dhakliya
Dr. Naeema Amer Al Essai
Medical Officer,
North Batinah
Mrs. Amal Suwaid Al Yaqoobi
Sr. Senior Nurse,
Dhahira
Dr. Anbarin Al Bulushi
Sr. Specialist,
Muscat
Dr. Hanan Al Mahrooqi
Sr. Specialist,
Muscat
Dr. Tahani Khamis Al Bulushi
Medical Officer,
North Batinah
Dr. Zawan Saud Al Bulushi
Medical Officer,
South Batinah
Dr. Zuwena Ali Al Shaibani
Medical Officer,
Dhahira
Dr. Najwa Mohammed
Medical Officer
Dhofar
Other Contributors:
4
TABLE O F CO NTENTS
PREFACE.................................................................................................................................................................................................... 1
MODULE OVERVIEW.............................................................................................................................................................. 3
ACKNOWLEDGMENT............................................................................................................................................................. 4
TABLE OF CONTENTS ....................................................................................................................................................... 5
Day (1)
Session 1: Module Intorduction. .................................................................................................. 9
SESSION 2: Basic ANTENATAL CARE. ............................................................................................. 24
SESSION 2.1 : Booking a new pregnancy ......................................................................................................... 24
SESSION 2.2 : Antenatal care: First visit. ............................................................................................................ 32
SESSION 2.3 : Antenatal care: Repeat visits................................................................................................... 45
SESSION 3: General PRINCIPLES OF care..................................................................... 51
Day (2)
SESSION 4 : MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.1 : Anaemia in pregnancy..................................................................................................................... 63
SESSION 4.2 : Hypertension in pregnancy...................................................................................................... 68
SESSION 4.3 : Gestational diabetes. ........................................................................................................................ 73
SESSION 4.4 : Urinary tract infection and asyptomatic bacteriuria.................................. 80
SESSION 4.5 : Vaginal discharge during pregnancy. .......................................................................... 84
SESSION 4.6 : HIV in pregnancy. ................................................................................................................................... 91
SESSION 4.7 : Chicken pox (varicella) in pregnancy............................................................................ 96
SESSION 4.8 : Pregnancy with RhD negative blood group & ABO
incompatibility...................................................................................................................................... 100
SESSION 5 : OBSTETRIC COMPLICATIONS (Part 1)
SESSION 5.1 : Vaginal bleeding in early pregnancy.......................................................................... 105
SESSION 5.2 : Vaginal bleeding in late pregnancy & labour....................................................112
SESSION 5.3 : Fever during pregnancy and labour ...........................................................................118
5
Day (3)
SESSION 5 : OBSTETRIC COMPLICATIONS (Part 2)
SESSION 5.4 : Abdominal pain in early pregnancy ........................................................................... 128
SESSION 5.5 : Abdominal pain later pregnancy & after child birth. ............................... 133
SESSION 5.6 : Decreased fetal movement..................................................................................................... 138
SESSION 5.7 : Prelabour rupture of membranes................................................................................... 143
SESSION 6 : NORMAL LABOUR (Part 1)
SESSION 6.1 : Admitting women in labour................................................................................................... 147
SESSION 6.2 : Diagnosis & assessment of progress of labour. ......................................... 156
SESSION 6.3 : Management of the first and second stages of labour. ...................... 170
Day (4)
SESSION 6 : NORMAL LABOUR (Part 2)
SESSION 6.4 : Diagnosis & management the third stage of labour............................... 178
SESSION 6.5 : Management of malpresentation and shoulder dystocia................ 184
SESSION 7 : POSTNATAL CARE AND COMPLICATIONS
SESSION 7.1 : Routine postnatal care............................................................................................................... 193
SESSION 7.2
: Postnatal complications.......................................................................................................... 201
SESSION 8 : COMMON PROCEDURES............................................................................................211
SESSION 9 : QUALITY ASSURANCE STANDARDS AT PRIMARY
HEALTH CARE LEVEL.................................................................................................... 216
SESSION 10 : MODULE REVIEW................................................................................................................ 219
Other Contents
PROGRAM OF THE REGIONAL WORKSHOP....................................................................... 222
6
Day (1)
• Module Introduction
• Basic Antenatal Care
• General principles of Care
7
P ro g r am
Day (1)
Time
Topic
7:30 – 8:00
Registration
8:00 – 8:10
Module Introduction
8:10 – 9:40
Basic Antenatal care -Booking New Pregnancy
9:40 -10: 00
Basic Antenatal care -First visit
10:00 - 10:30
Coffee Break
10:30 - 11:55
Basic Antenatal care-First visit (Continued)
11:55 -1:10
Basic Antenatal care -Repeat visits
1:10 - 2:00
General principles of care
8
Session 1
MODULE INTRODUCTION
Session Outline
9
Program
Session 1 (Module InTRODUCTION)
Activities
Activity 1.1
MODULE OBJECTIVES
Mini lecture
Activity 1.2
SPOT CHECKS
Time
Materials and Resources
2 min
Slides 2, 3
8 min
Annex (1)
Annex (2)
10 min
10
SESSION 1: MODULE INTRODUCTION
TIME: 10 Minutes
ACTIVITY 1.1 (2 min)
MODULE OBJECTIVES
MINI LECTURE
Welcome the participants to the training.
Explain that the module provides information on pregnancy &child birth
management guidelines level-1.
Display the module’s objectives (slides 1 and 2), and then read them out, in turn.
First Display slide 2:
Module Objectives
1. Describe basic component of antenatal care
2. Identify general principles of care
3. Identify and manage specific medical complications in pregnancy
4. Identify and manage specific obstetric complication in pregnancy
Then display slide 3:
Module Objectives (Cont.)
5. State the preliminary procedure for delivery
6. Describe the steps in delivery of baby and placenta
7. Describe the care delivered to the woman after delivery
ACTIVITY 1.2 (8 min)
SPOT CHECKS
Explain that the purpose of the spot checks (Annex 1) is to help the participants
to evaluate their gain in knowledge and understanding from this module.
Inform the participants that the spot checks will not be collected, graded or
checked by any of the facilitators.
Ask the participants to individually complete the spot checks according to the
best of their
knowledge, and to keep them handy for use during the module review.
Inform the participants that their responses to the spot checks will be discussed
during the module review, and reply to any questions or comments they may
have.
Go over the instructions recorded on each spot check with the participants and
make sure that they understand how to complete them.
Allow the participants 8 minutes to complete the spot checks.
Correct answers are available in Annex (2).
11
Annex 1
Session 1 (Module Introduction)
(Spot checks)
Activity 1.2
12
Spot checks
1. Tasks of antenatal care:
Please circle the correct answer/s
A. Record personal history
B. History taking
C. Clinical examination
D. Risk grading
E. Ultrasonography
F. Lab investigation
G. Immunization
H. Health education
I. Drug prescription
J. Plan delivery
K. Referral to secondary health care
2. Danger signs and symptoms in pregnancy:
List down the signs and symptoms (at least 7)
A.
B.
C.
D.
E.
F.
G.
3. Management of patient with shock:
What type of fluid used in managing shock?
4. High risk in pregnancy:
List four of the current & previous obstetric & gynaecological risks
A.
B.
C.
D.
13
5. Anti D prophylaxis is given at:
Please provide three answers
A. Booking
B. 28-30 weeks
C. 22-24 weeks
D. 12-14 weeks
E. 34-36weeks
F. 38-40 weeks
G. Within 72 hours of delivery
6. Mention health education tips to women during pregnancy
Please provide two answers per each trimester
A. 1st trimester
1.
2.
B. 2nd trimester
1.
2.
C. 3rd trimester
1.
2.
7. Haemoglobin of 6 gms at 24 wks is classified as:
Please provide one answer
A. Mild anaemia.
B. Moderate anaemia
C. Severe anaemia
D. Very severe anaemia
8. In the management of Eclamptic convulsions, all are
correct except:
Please provide one answer
A. Give Oxygen at 4-6 liter per minute
B. Start IV line & infuse IV fluids at a rate of 130ml/hr to hydrate her
C. Magnesium sulphate to be started as protocol
D. Loading dose of diazepam if magnesium sulphate is not available
14
9. All are included in the definition of Pre-eclampsia expect:
Please provide one answer
A. Diastolic pressure ≥ 90 mmhg
B. Protienuria
C. Convulsions
D. Blood pressure is recorded higher after 20 weeks of gestation
10. Gestational Diabetes, all are correct except
Please provide one answer
A. RBS/FBS should be done at booking
B. If RBS, FSB is high at booking, OGCT should be done at 22-24
weeks
C. If RBS/FBS is high at booking, OGTT should be done immediately
D. OGTT at 22-24 weeks shows Post prandial value of ≥ 7.8 mmol
11. HIV in pregnancy, all are correct except:
Please provide one answer
A. HIV test is done for suspected cases only
B. HIV test is done for all pregnant women
C. Counseling is an important aspect of HIV management
D. Confidentiality should be ensured at all points of contact
12. Missed abortion is diagnosed by the following except:
Please provide one answer
A. Absence of fetal heart activity with crown-rump length of < 6 mm
B. Diagnosis can be confirmed by a single scan
C. Absent fetal heart before 24 wks of pregnancy
D. Cessation of pregnancy related symptoms
13. Fever during pregnancy and labour, all are correct except:
Please provide one answer
A. Encourage adequate rest
B. Restrict fluid intake
C. Paracetamol to be given every 4-6 hour
D. Use tepid sponge to help decrease temperature
15
14. Vaginal bleeding in early pregnancy can be due to all except:
Please provide one answer
A. Ectopic pregnancy
B. Molar pregnancy
C. Inevitable abortion
D. Abruptio placenta
15. The Active first stage of labour of starts from:
Please provide one answer
A. 0-3 cm
B. 3cm
C. 7cm
D. 10cm
16. The following conditions at labour need referral to
secondary care except:
Please provide one answer
A. Preterm labour
B. Prolonged labour
C. Cephalic presentation with no other risk factor
D. Rupture of membrane more than 24 hrs
17. List four tasks of postnatal care:
A.
B.
C.
D.
18. Active management of third stage of labour involves:
Please provide one answer
A. Prophylactic Oxytocin 10 units IM, early cord clamping, controlled cord
attraction, inspection of placenta and lower genital tract
B. Prophylactic Ergometrine, delayed cord clamping, controlled cord
attraction
16
Annex 2
Session 1 (Module Introduction)
(Spot checks- Correct answers)
Activity 1.2
17
Spot checks- Correct Answers
1. Tasks of antenatal care:
Please circle the correct answer/s
A. Record personal history
B. History taking
C. Clinical examination
D. Risk grading
E. Ultrasonography
F. Lab investigation
G. Immunization
H. Health education
I. Drug prescription
J. Plan delivery
K. Referral to secondary health care
Answer: all answers are correct
2. Danger signs and symptoms in pregnancy:
A.
B.
C.
D.
E.
F.
G.
List down the signs and symptoms (at least 7)
Answer: see level-1 ANC guidelines (page 7)
3. Management of patient with shock:
What type of fluid used in managing shock?
Answer: Normal saline, Ringer’s lactate
4. High risk in pregnancy:
List 4 of the current & previous obstetric & gynaecological risks
A.
B.
C.
D.
18
Answer: see level-1 ANC guidelines (page 6)
5. Anti D prophylaxis is given at:
Please provide three answers
A. Booking
B. 28-30 weeks
C. 22-24weeks
D. 12-14 weeks
E. 34-36weeks
F. 38-40weeks
G. Within 72 hours of delivery
Answer: B, E, G
6. Mention health education tips to women during pregnancy
Please provide two answers per each trimester
A. 1st trimester
1.
2.
B. 2nd trimester
1.
2.
C. 3rd trimester
1.
2.
Answer: see maternal health record (ANC green card)
7. Haemoglobin of 6 gms at 24 wks is classified as:
Please provide one answer
A. Mild anemia
B. Moderate anaemia
C. Severe anaemia
D. Very severe anaemia
Answer: C
19
8. In the management of Eclamptic convulsions, all are
correct except:
Please provide one answer
A. Give Oxygen at 4-6 liter per minute
B. Start IV line & infuse IV fluids at a rate of 130ml/hr to ehydrate her
C. Magnesium sulphate to be started as protocol
D. Loading dose of diazepam if magnesium sulphate is not available
Answer: B
9. All are included in the definition of Pre-eclampsia expect:
Please provide one answer
A. Diastolic pressure ≥ 90 mmhg
B. Protienuria
C. Convulsions
D. Blood pressure is recorded higher after 20 weeks of gestation
Answer: C
10. Gestational Diabetes, all are correct except:
Please provide one answer
A. RBS/FBS should be done at booking
B. If RBS, FSB is high at booking, OGCT should be done at 22-24 weeks
C. If RBS/FBS is high at booking, OGTT should be done immediately
D. OGTT at 22-24 weeks shows Post prandial value of ≥ 7.8 mmol
Answer: B
20
11. HIV in pregnancy, all are correct except:
Please provide one answer
A. HIV test is done for suspected cases only
B. HIV test is done for all pregnant women
C. Counseling is an important aspect of HIV management
D. Confidentiality should be ensured at all points of contact
Answer: A
12. Missed abortion is diagnosed by the following except:
Please provide one answer
A. Absence of fetal heart activity with crown-rump length of < 6 mm
B. Diagnosis can be confirmed by a single scan
C. Absent fetal heart before 24 wks of pregnancy
D. Cessation of pregnancy related symptoms
Answer: B
13.Fever during pregnancy and labour, all are correct
except:
Please provide one answer
A. Encourage adequate rest
B. Restrict fluid intake
C. Paracetamol to be given every 4-6 hour
D. Use tepid sponge to help decrease temperature
Answer: B
21
14. Vaginal bleeding in early pregnancy can be due to all
except:
Please provide one answer
A. Ectopic pregnancy
B. Molar pregnancy
C. Inevitable abortion
D. Abruptio placenta
Answer: D
15. The Active first stage of labour of starts from:
Please provide one answer
A. 0-3 cm
B. 3cm
C. 7cm
D. 10cm
Answer: B
16.The following conditions at labour need referral to
secondary care except:
Please provide one answer
A. Preterm labour
B. Prolonged labour
C. Cephalic presentation with no other risk factor
D. Rupture of membrane more than 24 hrs
Answer: C
17. List four tasks of postnatal care:
A.
B.
C.
D.
Answer: see level-1 ANC guidelines (page 85)
22
18. Active management of third stage of labour involves:
Please provide one answer
A. Prophylactic Oxytocin 10 units IM, early cord clamping, controlled
cord attraction, inspection of placenta and lower genital tract
B. Prophylactic Ergometrine, delayed cord clamping, controlled cord
attraction
Answer: A
23
Session 2
(BASIC ANTENATAL CARE)
SESSION 2.1
Booking A New Pregnancy
Session Outline
24
Program
Session 2.1 (Booking a New Pregnancy)
Activities
Time
Activity 2.1.1
SESSION INTRODUCTION
Mini lecture
5 min
Activity 2.1.2
PURPOSE AND OBJECTIVES
Mini lecture and open discussion
Activity 2.1.3
SYSTEM FOR BOOKING
Mini lecture
Activity 2.1.4
BOOKING A NEW PREGNANCY
Role play
5 min
Materials and Resources
Slide 3
Slide 4
10 min
Slides 5-8
30 min
Annex (1)
Activity 2.1.5
MANAGEING LATE BOOKING
Open discussion
15 min
Activity 2.1.6
ANC REGISTER AND MATERNAL
HEALTH RECORD
Demonstration and open discussion
20 min 1. Maternal health records,
one for each participant
Activity 2.1.7
REMINDER AND SUMMARY
5 min
2. ANC Register (RG -17),
copy of the first page
with directions, one for
each participant.
90 min
25
Slide 2
SESSION 2: BASIC ANTENATAL CARE
SESSION 2.1: Booking a NEW PREGNANCY
TIME: 90 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Explain the system for booking and the criteria for issuing a maternal
health record
2- Explain the contents of maternal health record
3- Explain the ANC Register (RG -17)
4- Explain how to manage late booking
5- Detection of factors that might increase the perinatal risks
6- Help in making pregnancy and birth a positive life experience
Display slide 2 to show the participants the learning objectives.
ACTIVITY 2.1.1 (5 min)
SESSION INTRODUCTION
MINI LECTURE
This is usually the first session in the pre-service or in-service training for health
workers in Parent Institutions. Start by telling the participants the following:
The objective of MCH is to have safe motherhood and safe childhood.
Then display slide 3:
Making motherhood safe requires action on three fronts simultaneously:
• Reducing the number of high-risk and unwanted pregnancies
• Reducing the numbers of obstetric complications
• Reducing fatality rate in women with complications
This is achieved through:
Antenatal care, Perinatal, and postnatal care.
ACTIVITY 2.1.2 (5 min)
PURPOSE AND OBJECTIVES
MINI LECTURE AND OPEN DISCUSSION
Tell the trainees the purpose of antenatal care by displaying slide 4:
Purpose of Antenatal care is:
• To promote heath of mother
• To have healthy pregnancy
• To have clean and safe delivery
• To have favorable outcome
26
Talking points on slide 4:
Pregnancy is a physiological process. However, it does carry a potential risk for
the mother, for the fetus and for the coming baby. Antenatal care is essential to
promote the health of the mother and to provide the best opportunity to have a
healthy pregnancy, clean and safe delivery and a favorable outcome, a full term
healthy baby. Each of us in his/her work-site is responsible for the health and well
being of mothers and children in the area served by the parent institution.
ACTIVITY 2.1.3 (10 min)
SYSTEM FOR BOOKING:
MINI LECTURE
Start by telling the participants: remember the golden rules of communications:
Welcome, look and smile, greet, ask, listen, explain and discuss.
Then display slide 5:
System for booking
Golden Rules
(GATHER APPROACH)
• GREET
• ASK
• TELL
• HELP
• EXPLAIN
• RETURN
Then display slide 6:
System for booking (Cont.)
Woman from the catchment area:
a. Ask her about date LMP
b. Do pregnancy Test
- 2 weeks after due date
- If negative repeat two weeks later
c. Counsel her on harm of drugs, x-ray and infection
d. Emphasize on the importance of compliance to the appointments
e. Issue the green card to her if pregnancy test is positive
Talking points on slide 6:
A woman from the catchment area is entitled for booking:
• Ask her about the date of last menstruation and if the date is overdue
by 15 days, do a pregnancy test (if the facility is available)
• If pregnancy test is negative, it should be repeated after 2 weeks
• Provide her with health education on the harm of drugs, X-ray and
infection
• Tell her about the importance of coming back as soon as her pregnancy
test is confirmed
27
Then display slide 7:
System for booking (Cont.)
Woman from outside the catchments area
If she has green maternal health record:
a. Examine and give advice according to gestational period
b. Complete her green record
c. Ask her to go to her parent institution for the next appointment
Then display slide 8:
System for booking (Cont.)
Woman from outside the catchments area
If she does not have green record:
a. Do not issue green record
b. Examine her
c. Explain that her parent institution only can issue her green record
d. Explain that her parent institution will give her the same quality care
e. Emphasize on early start of antenatal care
f. Provide her with health education
ACTIVITY 2.1.4 (30 min)
BOOKING A NEW PREGNANCY
ROLE PLAY
Ask 4 volunteers to act the scenarios in Annex (1), each pair will act one
scenario.
Ask other participants to observe and comment.
Make your own comments regarding:
• The communication skills
• Keeping the golden rules by the nurse/doctor.
• Taking correct action.
• Provision of necessary information and health education
Facilitate a debriefing session on explaining the system in each case.
ACTIVITY 2.1.5 (15 min)
MANAGING LATE BOOKING
OPEN DISCUSSION
Start by telling the participant the following:
Some women may come late for the first contact. On the other hand, After referral
to the laboratory for pregnancy test some may not show up early enough to have
an early booking and start their antenatal care.
Ask the participants if this is happening in their institutions.
Listen to their answers.
Discuss with them the causes & interventions that could be made to improve
early booking.
28
To the trainer:
Tell the participants that the following options might solve late booking
problem:
a. Health education given to mothers on different occasions e.g. with child
heath and with birth spacing
b. Involve community support group
c. Provision of clear system of women to ANC clinic once pregnancy test is
positive
ACTIVITY 2.1.6 (20 min)
ANC REGISTER AND MATERNAL HEALTH RECORD
DEMONSTRATION AND OPEN DISCUSSION
Distribute green records and copies of the first page of the ANC Register (with the
instructions) to all particpants
Go through the sections of the green maternal health record, allow for
questions.
Then go through the ANC register.
Tell the participants that they are going to work with these forms in the next
sessions.
ACTIVITY 2.1.7 (5 min)
REMINDER AND SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
29
Annex 1
Session 2.1 (Booking a New Pregnancy)
( Role Play)
Activity 2.1.4
30
Role Pay 1:
Halima is 25 years old, presented to her local health center with
missed period of more than 2 weeks. Pregnancy test was done and
showed positive results.
How would you proceed with woman?
Role Pay 2:
Amina is 25 years old, presented to a health center (outside the
catchment area)with missed period of more than 2 weeks. Pregnancy
test was done and showed positive results.
How would you proceed with woman?
31
Session 2
(BASIC ANTENATAL CARE)
Session 2.2
First Antenatal Visit
Session Outline
32
Program
Session 2.2 (fIRST ANTENATAL VISIT)
Activities
Time
Activity 2.2.1
PURPOSE AND OBJECTIVES
Mini lecture
5 min
Slide 3
Activity 2.2.2
NUMBER OF ANC VISITS
Mini lecture and open
discussion
5 min
Slide 4
ANC Guidelines level -1 (Table 6)
Activity 2.2.3
ANC TASKS AT FIRST VISIT
Brain storming and mini lecture
10 min
Flip Chart
Slide 5
Activity 2.2.4
REGISTRATION & HISTORY
TAKING
Mini lecture, exercise and
demonstration
10 min
Slides 6,7
Maternal health records
ANC register (RG-17), copies of
the first page with directions
Activity 2.2.5
FIRST EXAMINATION
Mini lecture and demonstration
12 min
Slide 8
Mannequin, tape measure,
stethoscope, BP apparatus
sonic aid, weighing scale
Activity 2.2.6
RISK GRADING
Mini lecture
2 min
Slide 9
Maternal health records
Activity 2.2.7
ULTRASONOGRAPHY IN ANC
Mini lecture
2 min
Slide 10
Activity 2.2.8
LABORATORY TESTS
Mini lecture
10 min
Slides 11,12
33
Materials and Resources
Activities
Time
Materials and Resources
Activity 2.2.9
IMMUNIZATION
Mini lecture and Open
discussion
2 min
Activity 2.2.10
HEALTH EDUCATION
Mini lecture and open
discussion
10 min
Slides 14, 15
Flip chart
ANC leaflet No. (1)
Activity 2.2.11
DRUG PRESCRIPTION
Mini lecture
2 min
Slide 16
ANC Guidelines level -1
Activity 2.2.12
REFERAL TO SECONDARY
HEALTH CARE LEVEL
Mini lecture
5 min
Slide 17
ANC Guidelines level -1
Activity y 2.2.13
PLAN OF DELIVERY
Mini lecture
5 min
Slide 18
Slide 13
Maternal health records
Activity 2.2.14
INTERPERSONAL
COMMUNICATION SKILLS
Role play
20 min
Annex (1)
ANC Guidelines level -1
Activity 2.2.15
REMINDER AND SUMMARY
5 min
Slide 2
105 min
34
SESSION 2: BASIC ANTENATAL CARE
SESSION 2.2: FIRST ANTENATAL VISIT
TIME: 105 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Enumerate the tasks of the first visit
2- Demonstrate good communication skills
3- Complete the registration activities
4- Take a full history for the first visit
5- Explain services to be provided in first visit
Display slide 2 to show the participants the learning objectives.
SESSION OUTLINE:
Activity 2.2.1 (5 min)
PURPOSE AND OBJECTIVES:
MINI LECTURE
To the Trainer:
Ask the participants the following questions:
When should the first visit (booking visit) take place?
What do we mean by pregnancy trimesters?
Listen to their answers.
Then display slide 3:
Pregnancy :Trimesters
Pregnancy is divided into three trimesters:
• The first trimester is up to 12 weeks
• The second trimester is from 13-28 weeks
• The third trimester is from 29 weeks to term Note : Antenatal care starts
as soon as the pregnancy test is confirmed. It has to be in the first trimester of
pregnancy.
Activity 2.2.2 (5 min)
NUMBER OF ANC VISITS:
MINI LECTURE AND OPEN DISCUSSION
Display slide 4:
Number of ANC visits
Recent research has shown that reduction in the number of ANC visits to fewer
structured visits in low risk cases does not affect the pregnancy outcome, (WHO
Antenatal Care Randomized Trial, 2002).
Based on this, the number of ANC visits was reduced to 6 visits for low risk
cases.
35
Talking points (on slide 4):
A schedule consisting of 6 antenatal visits is considered to be adequate for
uncomplicated pregnancy.
Each antenatal visit has a focused content. Longer time slots should be allocated
to allow comprehensive assessment and discussion. This should be possible as
the number of visits has been restricted to 6 visits in low risk cases.
To the Trainer:
Ask the participants to list the timing of antenatal visits for low risk cases and
discuss their answers.
Activity 2.2.3 (10 min)
ANC TASKS AT FIRST VISIT:
BRAIN STORMING AND MINI LECTURE
To the trainer:
Ask the participants the following question:
What are the services that are offered in the parent institution for a pregnant
mother at the first ANC visit?
Write their answers on a flip chart.
Summarize their responses to complete the list of services.
Then display slide 5:
List of ANC tasks (first ANC visit)
• Registration/ Recording personal information
• History taking
• Clinical examination
• Risk grading
• Ultrasonography
• Laboratory tests
• Immunization(TT vaccination)
• Health education
• Drug prescription (supplementation of folic acid)
• Discuss the plan of delivery
• Referral to secondary care level (if applicable)
Activity 2.2.4 (10 min)
REGISTRATION AND HISTORY TAKING:
MINI LECTURE, EXERCISE AND DEMONSTRATION
Tell the participants :In the first visit the Maternal Health Record is going to be
issued. The mother is also going to be recorded in the ANC register (RG-17) and
is going to be given a number. This number is going to be recorded in the green
record.
Then Ask the participants to look at the green record and at the first column of
the ANC register (these have already been distributed to the participants in the
previous session).
Ask them to read the instructions.
Pose the following question question:
36
What is the ANC registration number for the eleventh woman who comes
in February 2011?
Write the answers on a flip chart.
Then give 4-5 other examples and record the answers to the class.
Ensure that the system has been clearly understood. Emphasize to the
participants that the identification data should be completed and clearly filled in
the green record and the history be carefully taken.
Then display slide 6:
History Taking
•
LMP(Date of last menstruation )
•
Detailed Obstetric history in previous pregnancies
•
Specific current and previous obstetric & gynecological risks
•
Medical history; including history of chronic diseases as heart, chest,
kidney, mental disorders, epilepsy.... etc.
•
History of current danger signs and symptoms
Then display slide 7:
History Taking (Cont.)
•
Medical history of the family
•
Birth spacing history
•
Tetanus toxoid vaccination history, and verify from the vaccination card
•
History of exposure to radiation, drugs,fever and having rash in the first
trimester of current pregnancy
•
Current medication
Activity 2.2.5 (12 min)
FIRST EXAMINATION:
MINI LECTURE AND DEMONSTRATION
Display slide 8:
First Examinations
• Weight
• Height
• BMI
• Blood pressure
• Breast examination
• Systemic examination
• Obstetric examination : fundal height (from 24 weeks gestation) & fetal heart
• Ultrasonography (if available and applicable.)
37
Talking points (on slide 8):
The first examination includes:
•
Maternal weight and height
•
Body Mass Index (BMI) to be calculated (weight [kg]/height[m]².
If the BMI is < 19.8 or > 29 the nutritional status should be assessed.
•
Blood pressure (If the diastolic blood pressure is above 90 mm the
woman is at risk)
•
Systemic examination
•
Breast examination : both breasts should be inspected for any skin or
nipple changes. Both breasts should be palpated for lumps.
•
Obstetric examination. If the first visit is a late booking beyond 24 weeks,
the fundal height may also be measured (this is an activity in the repeat
visits usually).
Fetal heart sounds are checked by fetal stethoscope or by doppler .
Fetal heart recorder (sonic aid) and fetal movements are assessed at all ANC visits.
Note :if there is no female physician in the area and the woman refuses to be
examined by a male ( this may be one of the reasons for under-registration in
your area),arrange for examination at the referral center, or through a visiting
physician who may come at fixed times. In the later case, give the woman
appointment to come on that date.
• Record all findings in the green card and relevant columns of the ANC
register.
To the trainer:
It is expected that your participants have the minimum basic clinical skills; ask
three of them to demonstrate how to take the different measurements.
Activity 2.2.6 (2 min)
RISK GRADING
MINI LECTURE
Display slide 9:
Risk grading
• Risk grading should be done at every visit and plan of delivery will be
made accordingly
• Information should be updated in both the Maternal Health record and
Antenatal register.
Refer to maternal health record (risk grading section).
Activity 2.2.7 (2 min)
ULTRASONOGRAPHY IN ANC
MINI LECTURE
Display slide 10: Ultrasonography in ANC
38
•
•
•
•
Recommended for all pregnant women
To determine viability, gestational age
To determine number of foetuses..
Measurement to be used to determine gestational age:
-
Crown–rump length up to 14 weeks.
- Beyond 14 weeks: head circumference or bi-parietal diameter is
the preferable measurement
Talking points (on slide 10):
If ultrasound is available and applicable at booking, ultrasonic assessments are
recommended for all pregnant women to determine viability, gestational age
in view of last menstrual period, and to determine number of fetuses. This will
improve consistency of gestational age assessments during pregnancy.
Crown–rump length measurement is to be used to determine gestational age up
to 14 weeks. Beyond 14 weeks’, head circumference or bi-parietal diameter is the
preferable measurement.
Activity 2.2.8 (10 min)
LABORATORY TESTS
MINI LECTURE
Ask the participants to:
List the laboratory tests conducted in the first ANC visit.
Listen to their answers.
Then display slide 11:
Laboratory tests at first ANC visit
• Blood group &Rh
• Haemoglobin
• VDRL
• Sickling
• ABS(if Rh-ve)
• HIV
• Blood sugar (RBS,FBS)
• Urine for glucose,protein,ketone & microscopy
Then display slide 12:
Laboratory tests (Cont.)
• Pregnant women with RBS ≥ 7 mmol/L or FBS > 5.5mmol/L, do OGTT at
booking
• If RBS < 7 mmol/L, FBS ≤ 5.5mmol/L, do OGCT at 22-24 weeks
39
Talking points (on slide 12):
•
All women registering with ANC clinic must perform RBS or FBS as shown
in the ANC manual
−
Both RBS &FBS could be done at the first visit(depends on the woman)
−
OGTT (oral glucose tolerance test): by using 75 gm of anhydrous glucose
or 82.5 of glucose monohydrate.
−
OGCT (oral glucose challenge test): by using 50 gm of anhydrous glucose
or 55 of glucose monohydrate.
• All pregnant women must be offered urine test for albumin in each ANC visit to
detect protinuria in addition to mid -stream urine test at booking for the urine
microscopy . Asymptomatic bacteruria is common in pregnant women(usually
asymptomatic) and there is evidence that treatment of such cases will lead to
better outcomes of pregnancy.
Activity 2.2.9 (2 min)
IMMUNIZATION
MINI LECTURE AND OPEN DISCUSSION
Display slide 13:
Immunization
• Check TT status & immunize as required
• Check status of Rubella immunization, if not immunized or status not known,
immunize after delivery and give advice not to conceive for three months
Talking points (on slide 13):
Check women’s TT status and immunize as required. Each woman should be
followed up until she completes five doses of TT vaccination.
Check women’s status of Rubella immunization, if not immunized or if immunization
status is not known, immunize the woman after delivery and give advice not to
conceive for the next 3 months in order to prevent congenital Rubella syndrome
Refer to maternal health record .
To the trainer:
Discuss with participants the immunization schedule in pregnancy.
Activity 2.2.10 (10 min)
HEALTH EDUCATION:
MINI LECTURE AND OPEN DISCUSSION
Ask the participants to:
List the educational topics to be covered during the first trimester.
Listen to their answers.
40
Then display slide 14:
Health education topics during first trimester
• Danger signs and symptoms to be reported:
- Sever pallor
- Persistent headache
- Blurring of vision
- Generalized edema
- Convulsion
- Unilateral leg edema
- Calf tenderness
- Difficult breathing
- Vaginal bleeding or leaking
- Persistent or sever abdominal pain
- Unexplained persistent fever
Then display slide 15:
Health education topics during first trimester (Cont.)
• Importance of taking some nutritional elements (folic acid )
• Exercise, sleep, travel, intercourse during this period
• Managing common symptoms(nausea, constipation)
• Causes of some normal symptoms (frequency of urination, increase of vaginal
secretions)
To the Trainer:
Distribute to each participants health educational leaflet No. (1) and ask some of
them to explain it’s contents.
Activity 2.2.11 (2 min)
DRUG PRESCRIPTION
MINI LECTURE
Display slide 16:
Drug prescription
• If less than 12 weeks only folic acid daily.
• If more than 12 weeks standard dose of ferrous sulphate and folic acid daily
• All other drugs should be avoided or prescribed cautiously for clear and
specific indication.
To the Trainer:
Tell the participants about the standard dose of Iron and folic acid .
Then ask the participants to review the drugs contraindicated in pregnancy
(See guidelines level-1(table 2).
Activity 2.2.12 (5 min)
REFERAL TO SECONDARY HEALTH CARE LEVEL
MINI LECTURE
First display slide 17:
Referral to secondary health care level
• All cases should be referred for a routine ult ra sound between 22 to 24 weeks.
• According to the risk factors
41
Talking points (on slide 17):
The routine ANC care is to be at the parent institution. All cases should be referred
for a routine ultrasound between 22 to 24 weeks. In addition there are certain
Risk factors for referral at booking.
To the Trainer:
Review with the participants the need for referral at this stage and ask them to list
the risk factors for referral at booking (review ANC guidelines level-1, Table 7).
Activity 2.2.13 (5 min)
PLAN OF DELIVERY
MINI LECTURE
Display slide 18:
Plan of delivery
• Assessment for delivery should be done at each visit
• Decision depends on present, past medical & obstetrical history
Talking points (on slide 18):
Assessment for delivery should be done at each ante natal visit. The decision
depends on present, past medical & obstetrical history.
Refer to ANC guidelines level-1 pages (12 – 14).
Activity 2.2.14 (20 min)
INTERPERSONAL COMMUNICATION SKILLS
ROLE PLAY
Invite (4) volunteers to act the role plays in (Annex (1).
Explain the following to the volunteers:
-
The first pair will act the first role play (shows good interpersonal
communication skills)
-
The second pair will act the second role play (shows poor interpersonal
communication skills)
Start conducting the role plays.
Ask the participants to locate the section in the maternal health record that
would be filled by each item as you go along.
Observe, and discuss at the end with focus on the communication skills.
Activity 2.2.15 (5 min)
REMINDER AND SUMMERY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
42
Annex 1
Session 2.2 (first Antenatal visit)
(Role Play)
Activity 2.2.14
43
Role play 1:
Samera is pregnant in her first trimester, presented to the health center
for her first ANC visit.
You as a health worker perform the following tasks of the first visit
(booking):
•Registration
•History taking
•Filling the ANC record, resister
Remember (health worker) to demonstrate good communication
skills with GATHER APPROACH.
Role play 2:
Fatima is pregnant in her first trimester, presented to the health center
for her first ANC visit.
Perform the following tasks of the first visit (booking):
•Registration
•History taking
•Filling the ANC record, resister
Remember (health worker) to demonstrate poor communication
skills.
44
Session 2
(BASIC ANTENATAL CARE)
Session 2.3
Repeat Antenatal Visits
Session Outline
45
Program
Session 2.3 (Repeat antenatal visits)
Activities
Time
Activity 2.3.1
COMPONENTS OF REPEAT
VISITS
Mini lecture and open discussion
15 min
Slides 3-5
Activity 2.3.2
SPECIFIC OBSTETRIC
EXAMINATIONS
Mini lecture, demonstration and
open discussion
20 min
Slide 6
Tape measure sonic aid,
mannequin
Activity 2.3.3
LABORATORY INVESTIGATIONS
Mini lecture, exercise and open
discussion
15 min
Slide 7
Maternal health record
ANC guidelines level-1
(table 1)
Activity 2.3.4
HEALTH EDUCATION
Brainstorming, mini lecture and
open discussion
20 min
Flip Chart
Slides 8,9
Maternal health record
ANC leaflets No. 2&3.
Activity 2.3.5
REMINDER AND SUMMARY
5 min
Slide 2
75 min
46
Materials and Resources
SESSION 2: BASIC ANTENATAL CARE
SESSION 2.3: REPEAT ANTENATAL VISITS
TIME: 75 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Enumerate the tasks of repeat ANC visits
2- Complete the registration activities
3- Take a full history for the repeat visits
4- Explain the services to be provided in the repeat visits
Display slide 2 to show the participants the learning objectives.
ACTIVITY 2.3.1 (15min)
COMPONENTS OF REPEAT VISITS
MINI LECTURE AND OPEN DISCUSSION
Display slide 3:
Number and Timing of ANC visits
• Low risk pregnancy:
st
1 :at booking
2nd :at 12-14 wks
3rd :at 22-24wks (with obstetrician)
4th :at 28-30wks
5th :at 32-34 wks
6th :at 36-38 wks
40 weeks at secondary care to plan delivery
• High risk pregnancy
Frequency according to the risk
Talking points (on slide 3):
Booking visits should be done as soon as the pregnancy is confirmed.
Then list the time of each visit as shown in the slide.
If the woman is not yet delivered she should be referred to the secondary care at
40 wks to plan for the delivery .
In low risk pregnancy : 6 scheduled visits all through the pregnancy are
recommended.
In high risk pregnancy: number and frequency of visits on the condition. More
details are available in the level-2 guidelines.
To the Trainer:
Tell the participants that you will display the next two slides to show the tasks of
repeat antenatal visits in the primary health care facilities.
47
Then display slide 4:
ANC tasks at repeat visits:
• Greeting
• History (present complaints, concerns, fetal movement)
• Clinical Examination (weight,BP, fundal height, fetal heart rate)
• Risk grading
• Ultasonography examination
• Laboratory investigation
Then display slide 5:
ANC tasks at repeat visits (Cont.)
• Health education
• Supplementation : daily iron, folic acid
• Immunization: Tetanus toxoid as required
• Counseling for any worries
• Scheduling next Appointment
• Recording (ANC card and register)
• Referral to secondary level.
To the Trainer:
- While displaying slide 4&5 discuss with the participants the details for
each of these tasks. Let them express their points of view and explain the
activities in each task.
- Ask the participants to look in the maternal health record in the section for
repeat visits.
- Refer to guidelines level- 1, table (6).
ACTIVITY 2.3.2 (20 min)
SPECIFIC OBSTETRIC EXAMINATIONS
MINI LECTURE,DEMONESTRATION AND OPEN DISCUSSION
Display slide 6:
Specific obstetric examination
• Estimation of fetal size
• Check fetal heart
• Assess fetal movement
• Assess fetal presentation
Talking points on slide 6: The specific Obstetric examinations recommend at
each visit include:
1. Estimation of fetal size at each antenatal appointment to detect small- or
large-for-gestational- age ;through measuring symphsis – fundus height
2. Fetal heart sounds are checked by fetal stethoscope or by doppler
foetal heart recorder (sonic aid)
3. Fetal movements are assessed at all ANC visits
48
4. Fetal presentation should be assessed by abdominal palpation from
36 weeks onward, when presentation is likely to influence the plan of
delivery
To the Trainer:
Explain to the participants that to make fundal height measurement accurate
using a measuring tape they should:
• Identify the highest level of the fundus with light pressure, using the edge
of the hand, in case uterus is dextro-rotated, correct it. if necessary, mark
this level on the skin
• Identify the top of the symphysis by palpation through the fat of the
monspubis
• Measure with a tape from the symphysis to the level of the fundus, with
the tape face down to avoid bias. Preferably tape should be made up of
unstretchable cloth or paper
Note:
Between 20 and 34 weeks the height of the fundus in centimeters should be
approximately equal to the gestational age in weeks. (ie. at 28 weeks, the fundal
height should be 28 centimeters). If the mother is obese the measurement in
centimeters may be higher than the fundal height because of the thickness of
abdominal wall.
Note:
Fundal height higher than gestational age may indicate presence of twins or
polyhydraminios & fundal height less than gestation may indicate IUGR or
oligohydraminios.
To the Trainer:
Use the mannequin to show the participants how to measure the fundal height.
Ask the participants in turn to exercise on the mannequin.
ACTIVITY 2.3.3 (15 min)
LABORATORY INVESTIGATION
MINI LECTURE, EXERCISE AND OPEN DISCUSSION
Display slide 7:
Laboratory investigations
• Hemoglobin( to all women)
- between 28 -30 weeks of gestation
- between 36 - 38 weeks of gestation
• Urine testing for Albumin in each visit
• OGCT,OGTT at 22-24 weeks of gestation
To the Trainer:
- Distribute to the participants copy of table (1) from ANC guidelines level 1.
- Ask the participants to check the list of investigations (as per each repeat visit).
49
- Ask the participants to locate where they are going to record the results on
the green card.
- Encourage for any comments and questions
ACTIVITY 2.3.4 (20 min)
HEALTH EDUCATION
BRAIN STORMING, MINI LECTURE AND OPEN DISCUSSION
Ask the participants to:
List the health education topics to be covered in the second and third
trimester.
Ask one of the participants to write down their answers on a flip chart.
Then summarize their answers.
Then display slide 8:
Health education topics on the second trimester
• Danger signs and symptoms and when to report (see maternal
health record )
• Anaemia in pregnancy,Iron rich foods,Iron tablets
• Dental health and pregnancy clothes
• Managing of common symptoms (epigastric burning, varicosities)
• Causes of some normal symptoms (back and leg pain)
Then display slide 9:
Health education topics on the third trimester
• Danger signs and symptoms and when to report
• Effect of nutrition during pregnancy and it’s effect on breast
feeding
• Importance of fetal movement monitoring
• Signs, symptoms of labour, preparation of delivery
• Recommendation on breast feeding and birth spacing
Tell the participants ; those educational topics are mentioned in the maternal
health record.
Then emphasize on providing health education leaflets as they are designed to
provide information on many aspects related to pregnancy .leaflet No.2 at 12-14
weeks visit and No.3 at 28 weeks visit.
Distribute copies of both health education leaflet No.2&3 to each participants .
and ask few of them to explain in short the contents
ACTIVITY 2.3.5 (5 min)
REMINDER AND SUMMARY:
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
50
Session 3
GENERAL PRINCIPLES OF CARE
Session Outline
51
Program
Session 3 (general priniciple of care)
Activities
Time
Materials and Resources
Activity 3.1
RIGHTS OF THE WOMAN
Brain storming and mini lecture
5 min
Flip Chart
Slide 3
Activity 3.2
EMOTIONAL &
PSYCHOLOGICAL SUPPORT
Role play and mini lecture
15 min
Annex (1)
Slides 4-7
ACTIVITY 3.3
INFECTION PREVENTION
Mini lecture and showing video
film
10 min
Slides 8-11
CD (video film)
Activity 3.4
SHOCK
Case study
20 min
Annex (2)
50 min
52
SESSION 3: GENERAL PRINCIPLES OF CARE
TIME: 50 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Be aware of the rights of the women when receiving maternity care
2- Understand common psychological reactions during and after obstetrical
events
3- Prevent and reduce the risk of the major infections while providing
services
Display slide 2 to show the participants the learning objectives.
ACTIVITY 3.1 (5 min)
RIGHTS OF THE WOMAN
BRAIN STORMING AND MINI LECTURE
Ask the participants the following question:
What is your understanding of woman’s rights?
Ask one of the participant to volunteer to write on a flip chart the answers of
others.
Then summarize their answers.
Then display slide 3:
Woman’s
Rights
These are gained through:
• Information about her health
• Discuss her concerns
• Know in advance about any procedure
• Informed consent before any procedure
• Privacy & confidentiality
• Feeling comfortable
• Express her views
Talking points on slide 3
After listing the points in the slide tell the participant that the basic communication
technique is the key to establish honest, caring & trusting relationship with the
woman.
ACTIVITY 3.2 (15 min)
EMOTIONAL & PSYCHOLOGICAL SUPPORT
ROLE PLAY AND MINI LECTURE
Explain that this activity is a role play on emotional and psychological support.
Invite 2 participants to volunteer to play the scenario in Annex (1).
Ask the participants to evaluate the performance of the players through answering
the following questions:
53
• What did the participants like & dislike about the play?
• Did the client bring her green card?
• Did the doctor demonstrate good communication skills? Describe that.
• What is the importance of the counseling in such cases?
Then you comment on the role play .
Then display slides 4:
Emotional and psychological support
Depends on:
• Marital status and her relationship with her partner
• Social situations (religion, beliefs & expectations)
• Social support
• Nature of the problem
Then display slides 5:
Common reactions to obstetrical emergencies or death:
• Denial
• Guilt
• Anger
• Bargaining
• Depression
• Isolation
• Disorientation
Then display slides 6:
Emotional and psychological support at the time of the event:
• Greet & introduce
• Listen
• Show empathy
• Tell (provide detailed information about the situation)
• Be honest
• Ensure privacy and confidentiality
• Use clear and simple language
• Confidentiality
• Ensure supportive companionship
• Encourage companions to take an active role in care
Then display slides 7:
Emotional support after the event:
• Give practical assistant and emotional support
• Respect traditional beliefs and customs
• Provide counseling for the woman and her family
• Explain the problem to reduce anxiety and guilt
• Listen & express understanding and acceptance of woman’s feelings
• Repeat information several times & give written information
• Use non- verbal communication
ACTIVITY 3.3 (10 min)
INFECTION PREVENTION
MINI LECTURE AND SHOWING VIDEO FILM
54
First display slide 8:
Principles of infection prevention
• Every person must be considered infectious
• Hand washing is the most important practice for preventing cross
contamination
• Wear gloves
• Use barrier if splashes or spills of any body fluids are anticipated
• Follow safe work practices
Then display slide 9:
Hand washing
When?
• Before & after examining each patient
• After exposure to blood or any body fluids even if gloves were worn.
• After removing the gloves.
Then display a video film showing the steps of hand washing.
Encourage the participants to raise their comments on that film.
Then display slide 10:
Wearing gloves
• When performing the procedures
• When handling soiled instrument, gloves and other items
• When disposing contaminated waste items
Separate pairs of gloves should be used for each woman
Then display slide 11:
Wearing gown
The gown should be:
• Clean but not necessarily sterile
• Worn during all delivery procedure
ACTIVITY 3.4 (20 min)
SHOCK
CASE STUDY
Divide the participants into 3 groups.
Give each group one case study (Annex 2).
Inform them that each group should discuss and answer one question:
- Group one should answer question one
- Group two should answer question two
- Group three should answer question three
Tell them that they will have 10 min to read and discuss the case.
Then invite a member from group one to summarize the case study & the answer
to question one.
Open the discussion with other groups for comments.
Follow the same with the other groups.
To the Trainer:
Explain to the participants that all information on this session and further more
are available on section five of ANC guidelines level-1.
55
Annex 1
Session 3 (General Principles of Care)
(Role Play)
Activity 3.2.1
56
Role Play:
Hind, a 26 year old primi-gravida attended the clinic with history of
primary infertility, conceived after treatment. Her ANC period was
uneventful. She reported at 36th weeks with history of loss of fetal
movements since 3 days she was reassured by her family that this
is normal in the last month of pregnancy, ultrasonography confirmed
intrauterine fetal death. The doctor (Azza) informed the patient about
the ultrasound findings.
57
Annex 2
Session 3 (General Principles of Care)
(Case Study)
Activity 3.3
58
Case Study
Moza, 24 years old, G3P2 with unknown LMP, brought by her family
to the health center with history of vaginal bleeding of two days, in the
clinic, the patient suddenly collapsed and lost consciousness .
Question 1: How would you assess this case? What are the signs and
symptoms you should look for? What is your differential diagnosis?
Question 2: What are your immediate management steps of such a
case (shock)?
Question 3: What is the specific management of shock?
59
DAY (2)
• MEDICAL COMPLICATIONS IN
PREGNANACY
• OBSTETRIC COMPLICATIONS (Part 1)
60
P ro g r am
Day (2)
Time
Topic
7:30 – 8:00
Registration
8:00 – 8:20
Anaemia in pregnancy
8:20 – 8:50
Hypertension in pregnancy
8:50 - 9: 20
Gestational Diabetes
09:20 - 9:45
UTI and Asymptomatic bacteruria
09:45 -10:00
Vaginal discharge
10:00 -10:30
Coffee Break
10:30- 10:50
Vaginal discharge (continued)
10:50-11:25
HIV in pregnancy
11:25-11:45
Chicken Pox
11:45-12:10
RhD negative blood group and ABO incompatibility
12:10-12:40
Vaginal bleeding in early pregnancy
12:40- 1:30
Vaginal bleeding in later pregnancy and labour
1:30 - 2:00
Fever during pregnancy and labour
61
Session 4
MEDICAL COMPLICATIONS
IN PREGNANCY
62
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4 .1
Anaemia in Pregnancy
Session Outline
63
Program
Session 4.1 (ANAEMIA IN PREGNANCY)
Activities
Activity 4.1.1
Case study
Time
20 min
Materials and Resources
ANC guideline level-1
Annex (1)
20 min
64
SESSION : MEDICALCOMPLICATIONS IN PREGNANCY
SESSION 4.1: ANAEMIA IN PREGNANCY
TIME: 20 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1.Define anaemia
2.Classify anaemia according to Hb level
3.Manage anaemia
4.Give dietary advice
Welcome the participants on the second day of training, start by telling them
that this day will be discussing some of the common medical complications in
pregnancy.
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.1.1 (20 min)
CASE STUDY
Divide the participant into 3 groups; give each one case study (ِِAnnex 1).
Tell them they will have 5 minutes to read and discuss the cause as a group.
After the participants have read the case invite a member of the first group to
summarize the case No.1 and to present the answers of the questions.
Ask the participants to refer to page (23) of the ANC guidelines level-1 during
the discussion.
Repeat the process with groups 2 and 3.
65
Annex 1
Session 4.1 (Anaemia in pregnancy )
( Case Study)
Activity 4.1.1
66
Case study (1)
Muna is 29 years old, G5 P3 at 28 weeks of gestation, found to have
Hb of 9 g/dl at her regular routine check up.
Questions:
What is the diagnosis?
How would you manage her?
What dietary advice would you give?
Case study (2)
Ahlam is 25 years old, G2 P1 came for ANC booking at 6 weeks of
gestation and found to have Hb of 10.5g/dl.
Questions:
What is your diagnosis?
How would you manage her?
Case study (3)
Fatma is 30 years old, G7 P6 at 32 weeks of gestation, presented
with dyspnea, palpitation and pallor, found to have Hb of 6g/dl?
Questions:
What is your diagnosis?
How would you manage her?
67
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4 .2
Hypertension in Pregnancy
Session Outline
68
Program
Session 4.2 (HYPERTENSION IN PREGNANCY)
Activities
Time
Activity 4.2.1
CLASSIFICATION AND
MANAGEMENT OF
HYPERTENSION IN PREGNANCY
Mini lecture
25 min
Slides 3-9
5 min
Flip chart
ANC guideline level -1
Activity 4.2.2
RESPIRATORY ARREST BY
MAGNESIUM SULPHATE
Brain storming and open
discussion
30 min
69
Materials and Resources
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.2: HYPERTENSION IN PREGNANCY
TIME: 30 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1. Classify and manage hypertension in pregnancy
2. Manage convulsions in hypertension in pregnancy
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.2 (25 min)
CLASSIFICATION AND MANAGEMENT OF HYPERTENSION IN
PREGNANCY
MINI LECTURE
Tell the participant that we start talking about on hypertension in pregnancy by
clarifying the classification of this illness during pregnancy.
Then display slide 3:
Classifications of hypertension in pregnancy
Chronic hypertension:
Diastolic Bp ≥ 90 mmHg during first 20 wks of gestation.
Pregnancy induced hypertension (PIH)
Two readings of diastolic BP 90-110 mmhg 4H apart after 20wks gestations.
No proteinuria.
Then display slide 4:
Classifications of hypertension in pregnancy (cont.)
Pre-eclampsia:
Diastolic BP≥90mmhg (after 20wks gestation)
Proteinuria
No convulsion
Eclampsia:
Diastolic BP≥90mmhg (after 20wks gestation)
Proteinuria
Convulsion
Tell the participant that you will go through the management of hypertension in
pregnancy as per it’s classification.
Then display slide 5:
Management of hypertension in pregnancy
Chronic hypertension:
Refer whenever detected with routine appointment.
Pregnancy induced hypertension ( PIH):
70
Adequate rest.
Check BP twice weekly.
Refer for urgent appointment.
Then display slide 6:
Management of hypertension in pregnancy (cont.)
Pre-eclampsia:
If diastolic is >100 mmHg give labetalol 200 mg oral or hydralazine 5 mg IV over
10 min + aldomet 500 mg oral and refer as emergency
If diastolic BP is 90-100 mmHg refer by urgent appointment
Then display slide 7:
Management of hypertension in pregnancy (cont.)
Eclampsia:
Maintain airway
Manage convulsions
If in labour, expedite delivery if possible
If not in labour refer as an emergency after resuscitation
Encourage the participants to raise any questions and open the discussion
whenever needed.
Inform the participant that convulsion due to hypertension during pregnancy is an
important issue and can be faced so you will cover it in the next two slide.
First display slide 8:
Management of convulsions
• Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen
at 4-6 l/min
• Protect the women from injury but do not actively restrain her
• Start an IV line and infuse IV fluids (maintenance dose: 80 ml/hr or 1ml/kg/
hr) after the convulsion
• Give anti convulsive drugs (start a loading dose of magnesium sulphate by
preparing 4 g of 50% magnesium sulphate solution given slowly IV over 1015 minutes
Then display slide 9:
Management of convulsions (Cont.)
• If magnesium sulphate not available, loading dose of diazepam can be given
(start a loading dose of diazepam 10 mg IV slowly over 2 minutes if convulsion
recur, repeat the loading dose)
• Position the women on her left side to reduce risk of aspiration of secretions,
vomit and blood
• Aspirate the mouth and throat as necessary
• Monitor vital signs (pulse, blood pressure, and respiration), reflexes and fetal
heart rate hourly
• Refer as emergency case to secondary care institute
71
ACTIVITIES 4.2.2: ( 5 min)
RESPIRATORY ARREST BY MG SULPHATE
BRAIN STORMING AND OPEN DISCUSSION
Ask the participant the following question:
In case of respiratory arrest caused by Mg sulphate what they should do?
Write the answers of the participants on a flip chart.
Encourage the participant to discuss the answers.
Then tell the participants the correct answer.
Inform the participants the management of such case is explained in page (26) of
ANC guidelines level-1.
Note:
The correct answer is:
–
Assist ventilation with face mask and bag.
–
Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly until calcium
gluconate begins to antagonize the effects of magnesium sulfate and
respiration begins.
72
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4 .3
Gestational Diabetes
Session Outline
73
Program
Session 4.3 (Gestational Diabetes)
Activities
Activity 4.3.1
Case study
Time
Materials and Resources
30 min
Annex(1)
Annex(2)
30 min
74
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.3: GESTATIONAL DIABETES
TIME: 30 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Diagnose gestational diabetes
2- Manage gestational diabetes
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.3.1 (30min)
CASE STUDY
Provide each participant with the algorithm of screening steps of gestational
diabetes( Annex 1). Refer to ANC guidelines level-1 page (27).
Also provide each participant with case studies ( Annex 2)
Ask them to work in pairs (each two work together)
Give them around 10 minutes to discuss and answer the questions in the case
studies.
Then select some of the participants to discuss their answers (allow the chance
for more than one participant to answer the questions in each case study).
Open the discussion with others.
Encourage the participants to raise any questions or queries.
75
Annex 1
Session 4.3 (Gestational Diabetes)
(Algorithm)
Activity 4.3.1
76
Algorithm: Screening steps for Gestational Diabetes
ALL PREGNANT WOMEN
RBS/FBS at Booking
If RBS > 7 or FBS > 5.5
Do OGTT at booking
If PGBS > 7.8
Classify 38 D.M if <
22 Wks, Gestational
Diabetes > 22 Wks
– Diet advice
– Refer to the
secondary care by
easly appointment
If RBS < 7 or FBS < 5.5
Do OGTT at 22 – 24 Wks
If 2 hrs BS < 7.8
Normal
OGCT AT 22 - 24 Wks
Do OGTT
at 22 - 24 Wks
If 1 hr
BS > 7.8
Do OGTT
If PGBS
< 7.8
Gestational
Diabetes
Unlikely
OGTT at 22 - 24 Weeks
If the PGBS > 7.8 Classify as
Gestational Diabetes
If the PGBS <
7.8 Gestational
Diabetes Unlikely
– Diet advice
– Refer to the
secondary care by
easly appointment
77
Annex 2
Session 4.3 (Gestational Diabetes)
(Case study)
Activity 4.3.1
78
Case study (1)
Sumaya presented at 13 weeks of gestation for a booking visit.
Random blood sugar was 8 mmol/l, OGTT was done and the 2 hour
blood sugar test was 8.2 mmol/l.
Questions:
What is the diagnosis?
How would you manage this woman?
Is there a need for referral of this lady to secondary care level?
What dietary advice would you give her?
Case study (2)
Maha presented to the local health center at 14 weeks of gestation for
ANC booking. Fasting blood sugar was found to be 4 mmol/l.
Questions:
How would you manage this woman?
When would you plan to repeat testing for blood sugar?
What dietary advice would you give her?
79
Session 4
(MEDICAL COMPLICATIONS IN
PREGNANCY)
Session 4.4
Urinary Tract Infection and
Asymptomatic Bacteruria
Session Outline
80
Program
Session 4.4 (UINARY TRACT INFECTION AND ASYMPTOMATIC BACTERURIA)
Activities
Time
Activity 4.4.1
Brain Storming and lecture
25 min
Materials and Resources
Flip Chart
Slides 3-8
25 min
81
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.4: URINARY TRACT INFECTION AND ASYMPTOMATIC
BACTERURIA
TIME : 25 Minutes
LEARNING OBJECTIVES:
By the end of this session the participant should be able to:
1- Assess signs and symptoms of UTI in pregnancy
2- Diagnose and manage UTI in pregnancy
3- List the risk of untreated UTI in pregnancy
4- Diagnose and manage asymptomatic bacteruria
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.4.1(25 min)
BRAIN STORMING AND LECTURE
Ask the participants the following question:
What are the signs and symptoms of UTI?
Allow 5 minutes for the answers.
Write down their answers in a flip chart.
Then display slide 3&4 which show the signs and symptoms of UTI.
Fist display slide 3:
Cystitis:
Typical symptoms:
• Dysuria
• Increased frequency and urgency of urination
Other (Atypical):
• Retropubic/ suprapubic pain
• Abdominal pain
Then display slide 4:
Acute pyelonephritis:
Typical
• Dysuria
• Spiking fever /Chills
• Increased frequency and urgency of urination
• Abdominal pain
Other (Atypical):
• Retropubic/ suprapubic pain
• Loin pain /tenderness
• Tenderness in rib cage
• Anorexia
• Nausea /vomiting
82
Tell the participant that the next two slides will show the management of UTI in
pregnancy.
First display slide 5:
Management of cystitis:
• Do urine test (microscopy and culture if indicated by the microscopy).
• Encourage adequate rest.
• Encourage to increase fluid intake by mouth.
• Use paracetamol to decrease temperature
• Give Amoxicillin 500 mg orally three times per day for 5-7 days
• Repeat urine culture after 1 wk of the last dose of the antibiotics( if
the initial test was positive ).
• If the infection reoccurs for two or more times despite adequate
treatment, refer by early appointment.
Then display slide 6:
Management of Acute pyelonephritis:
• Do urine microscopy.
• Give paracetamol 1 gm
• Refer as emergency whenever detected
Then ask the participant the following question?
What are the risks of untreated UTI in pregnancy?
Allow around 3 minutes for the answers.
Write down their answers in the flip chart.
Then display slide 7:
Risk of untreated UTI
• IUGR
• preterm labour
• intrauterine fetal death
• anaemia
Then Ask the participant the following question:
What is asymptomatic bacteriuria?
Allow 3 minutes for the answers.
Write down their answers in a flip chart.
Then display slide 8:
Asymptomatic bacteriuria
• Usually diagnosed accidentally during the routine urine testing at the
booking visit as patient is asymptomatic.
• Should be treated as per the culture results, or with Amoxicillin 500
mg orally three times per day for 10 days.
• Urine culture to be repeated 1 week after the last dose of the
antibiotics.
83
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4. 5
Vaginal Discharge during
Pregnancy
Session Outline
84
Program
Session 4. 5 (VAGINAL DISCHARGE DURING PREGNANCY)
Activities
Time
Materials and Resources
Activity 4.5.1
Mini lecture
2 min
Slide 3
Activity 4.5.2
Case study
20 min
Annex (1)
Slides 4-6
Activity 4.5.3
Mini lecture
3 min
Slides 7-9
Activity 4.5.4
Mini lecture and Showing video film
5 min
Slide 10
CD (video film)
30 min
85
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4. 5: VAGINAL DISCHARGE DURING PREGNANCY
TIME: 35 Minutes
LEARNING OBJECTIVES:
By the end of this session participant should be able to:
1- Explain the effect of vaginal infection on pregnancy outcome
2- Diagnose vaginal discharge in pregnancy
3- Know the specific management of candidiasis
3- Explain how to perform speculum examination
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.5.1:( 2 min)
MINI LECTURE
Display slide 3:
Effect of vaginal infection on pregnancy outcome
Vaginal Infections in pregnancy are common and important because they can
cause :
• Spontaneous abortion
• Pre-term labour
• Chorioamnionitis
Encourage the participant for any comment/s.
ACTIVITY 4.5.2 :( 20 min)
CASE STUDY
Divide the participants into 3 groups.
Give each group one case study (Annex 1).
Tell them that they have 10 min to read and discuss the case as a group.
After the participants have read the case study, (give them 10 min).
Invite a member from the first group to summarize the case study & the answers
of the question on the same.
Open the discussion with other groups for comments.
Then display slide 4:
Diagnosis of vaginal discharge during pregnancy:
History: duration, frequency, h/o similar problem with husband, abdominal pain,
dyspareunia, dysuria and past h/o PROM and/or preterm labour.
Examination: (by speculum) inspect for:
• abnormal discharge (colour, odour),
• vulvovaginal erythema.
86
Palpate for lower abdominal pain
Follow the same with the second group .
to clarify the diagnosis and treatment of case study No (2), display slide 5:
Diagnosis and management of candidiasis
Diagnosis: candidiasis
Drug option: Miconazole or clotrimazole vaginal suppositories 200 mg inserted in
the vagina for 3 days
or - Clotrimazole 500 mg inserted in the vagina as a single dose.
Alternative: Nystatin suppositories. Each contain 100,000 unit every night for
7-14 nights.
Then invite a member from the third group to discuss case study No. (3).
Then display slide 6:
Findings suggestive of abnormal vaginal discharge:
• (Trichomoniasis):Copious, malodorous, yellow-green discharge, pruritus,
dysuria, vulvar and vaginal oedema & erythematic cervix
• (Bacterial vaginosis)Thin, off-white discharge, unpleasant “fishy” odour,
increasing after sexualintercourse, normal appearance on examination.
• Others (Gonococcal, Chlamydia).
ACTIVITY 4.5.3: (3 min)
MINI LECTURE
Tell the participant that you will discuss the management of abnormal vaginal
discharge
Then display slide 7:
Management of abnormal vaginal discharge:
• Abnormal vaginal discharge associated with lower abdominal pain suspect
chorioamnionitis or endometritis and refer as emergency.
• If no abdominal pain:
- take vaginal swab,
- Refer to the secondary care with urgent /early(one week appointment)
- Patient should be advised to check swab result and carry it with her to the
appointment in the secondary (if possible)
Then display slide 8:
Recurrent vaginal discharge:
Patient with recurrent vaginal discharge: (more than 2 times):
• Vaginal swab is mandatory to be done.
• Screen for diabetes
• Exclude oral antibiotics use
• Exclude use of antibiotic/antiseptic vaginal preparation or vaginal
douching
• Treat the partner.
87
Then display slide 9:
Remember:
• Ask the pregnant woman in every ANC visit if there is vaginal discharge.
• Vaginal swab is not mandatory if history and examination are typical for
candidiasis. However, if recurrent despite adequate treatment, vaginal
swab should be done to confirm the diagnosis or to diagnose other possible
organisms.
Activity 4.5.4: (5 min)
MINI LECTURE AND SHOWING VIDEO FILM
First Display slide 10:
How to perform speculum examination:
• In patients with vaginal discharge, a speculum examination should be
performed. It is very important to avoid hurting the patient during this
examination. This could be achieved by the following measures:
• Patient’s thighs must be widely abducted. This calls for careful draping of
the legs with covering sheet to help the patient to relax.
• The Cusco speculum should be of the correct size and should be
lubricated by smearing the blades thinly with a lubricant gel. It should be
inserted deeply.
• The blades should only be separated when the speculum has been
inserted to its full depth to avoid stretching the sensitive vaginal introitus.
Then show the video film of how to perform speculum examination.
To the Trainer
Tell the participants that water in addition to gel can be used as a lubricant.
88
Annex 1
Session 4.5 (Vaginal Discharge in Pregnancy)
(Case Study)
Activity 4.5.2
89
Case study)1(
Samia is pregnant at 20 weeks gestation presenting to ANC clinic c/o
vaginal discharge.
Question:
How would you proceed with patient?
Case study (2)
Layla is pregnant at 25 weeks gestation presenting with a vaginal
discharge, her examination shows thick cheesy white discharge that
adheres to the wall, no odor, valvular and vaginal erythema.
Questions:
What is your diagnosis?
How will you manage her?
Case study (3)
Moza is a pregnant lady presenting with vaginal discharge. History
and examination is suggestive of abnormal vaginal discharge.
Question:
What is the differential diagnosis?
90
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4.6
HIV in Pregnancy
Session Outline
91
Program
Session 4.6 (HIV IN PREGNANCY)
Activities
Time
Materials and Resources
Activity 4.6.1
Group work and open discussion
25 min
Annex (1)
Activity 4.6.2
Mini lecture
10 min
Slides 3,4
35 min
92
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.6: HIV IN PREGNANCY
TIME: 35 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Know about the steps of HIV testing in pregnancy
2- Arrange referral to secondary care
Display slide 2 to show the participants the learning objectives.
ACTIVITY 4.6.1 (25 min)
GROUP WORK AND OPEN DISCUSSION
Distribute a copy of Algorithm 3 to each of the participants (HIV testing in pregnancy)
which is available on pages (33-35) of ANC level 1 guidelines.
The participants can open the guidelines (if available) on the referred pages, otherwise
a copy of this algorithm should be prepared before starting the activity.
Give the participant 10 minutes to go through the algorithm after explaining that you
will choose from the participants to answer questions in reference to the algorithm .
Allow for brief discussion after each question.
To the Trainer:
The Questions are available in Annex (1) for the perusal of the trainer.
ACTIVITY 4.6.2 (10 min)
MINI LECTURE
First display slide 3:
Important points to be remembered:
• If HIV testing was not performed at the booking visit, for any reason, it should
be done in the subsequent visit.
• Counseling is one of the vital service to be provided following HIV screening.
It will be offered at different points of contact and by a trained health provider
using standard proper counseling materials.
Then display slide 4:
Important points to be remembered (Cont.):
•
Delivery should be arranged in a facility that matches mother’s needs, i.e.
secondary/ tertiary.
•
HIV testing should be done during the labour/post-partum for women who
have not been subjected to the test during the antenatal period (unbooked).
93
Annex 1
Session 4.6 (HIV in Pregnancy)
(Questions)
Activity 4.6.1
94
Questions on HIV testing in pregnancy:
Q1 :
Who should be tested for HIV and where?
Q2 :
How much blood is to be collected for the test?
Q3 :
Where should you send the sample?
Q4 :
What do you do if Eliza test is positive or inconclusive
(done in RPHL)?
Q5 :
What do you do if the sample could not be dispatched the
same day ?
Q6 :
How do you proceed if Eliza test is positive or inconclusive
(done in Central public health laboratory)?
Q7 :
How do you manage HIV positive cases at primary health
care including the reporting system?
Q8 :
What is the role of the HIV focal doctor at PHC?
Q9 :
What is the role of the MCH counselor?
Q10 :
What is the role of HIV counselors?
Q11 :
What is the role of the HIV focal physician?
95
SESSION 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4.7
Chicken Pox (Varicella)
in Pregnancy
Session Outline
96
Program
Session 4.7 (CHICKEN POX (VARICELLA) IN PREGNANCY)
Activities
Activity 4.7.1
Mini lecture
Time
20 min
20 min
97
Materials and Resources
slide3-7
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.7: CHICKEN POX (VARICELLA) IN PREGNANCY
TIME: 20 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Define chicken pox in pregnancy
2- Know maternal and fetal risks associated with varicella
3- Manage chicken pox in pregnancy
Display slide 2 to show the participants the learning objectives.
Activity 4.7(20 min)
MINI LECTURE
Display slide3:
Chicken Pox in pregnancy:
• Highly contagious DNA herpes virus
• Transmitted by respiratory droplets and by direct personal contact
• Incubation period is 1-3 weeks
• Disease is infectious 48 hrs before the rash appears till the vesicles crusts
over (5 days)
• It is associated with maternal and fetal risk
Then display slide 4:
Risks associated with infection by Varicella virus in pregnancy.
A) Maternal risks:
• Pneumonia: associated with high mortality rate
• Hepatitis
• Encephalitis
Then display slide 5:
Risks associated with infection by Varicella virus in pregnancy (continued)
B) Fetal risks:
-Fetal Varicella Syndrome* (very rare), if the mother developed the
disease or acquired the infection before 20 weeks (up to 28 weeks in
some cases) of pregnancy
- Varicella Infection of the Newborn: more likely if maternal infection
occurs 1-4 weeks before delivery
Then display slide 6:
Management
• Assess women’s history of chicken pox in the past.
• In all cases refer the women to the secondary care as emergency for
administration of immunoglobulin.
98
Taking points on slide (6):
It is preferable to discus the case with a specialist (from the secondary health
care hospital) before referring the case.
Then display slide 7:
Fetal Varicella Syndrome
Characterized by one or more of the following:
• Skin scarring in a dermatomal distribution
• Eye defects (microphthalmia, chorioretinitis, cataracts).
• Hypoplasia of the limbs
• Neurological abnormalities (microcephaly, cortical atrophy, mental
retardation)
• Dysfunction of bowel & bladder sphincter
At the end, allow time for a brief discussion .
99
Session 4
(MEDICAL COMPLICATIONS
IN PREGNANCY)
Session 4.8
Pregnancy with RhD Negative
Blood Group and ABO Incompatibility
Session Outline
100
Program
Session 4.8 (PREGNANCY WITH RhD NEGATIVE BLOOD GROUP
AND ABO INCOMPATIBILITY)
Activities
Activity 4.8.1
Mini lecture
Time
25 min
Materials and Resources
Slide 3-9
25 min
101
SESSION 4: MEDICAL COMPLICATIONS IN PREGNANCY
SESSION 4.8: PREGNANCY WITH RhD NEGATIVE BLOOD GROUP AND
ABO INCOMPATIBILITY
TIME : 25 Minutes
LEARNING OBJECTIVES:
By the end of this session the participants should be able to:
1- Know when to perform Coomb’s test in Rh negative women
2- Know when Anti D prophylaxis to be given
3- List risk factors of ABO incompatibility
4- List indications to perform Coomb>s test to diagnose ABO incompatibility
Display slide 2 to show the participants the learning objectives.
Activity 4.8 (25 min)
MINI LECTURE
Display slide 3:
Pregnancy with RhD negative blood group
• Husband should be tested for Rh typing
• Result should be documented in the maternal health record
• If husband is negative no further management is required
Then display slide 4:
Coomb’s test should be performed at the following intervals:
- At first visit (booking)
- At 28-30 weeks visit
- At 36-38 weeks visit
• If Coomb’s test showed to be positive, patient should be referred to the
secondary care with urgent appointment for ICT titration.
Talking points (on slide 4)
The trainer should emphasize that ICT should be done before Anti-D is given.
Then display slide 5:
Anti-D prophylaxis
Antenatal prophylaxis:
• 2 doses of 500 iu Anti D immunoglobulin is given at 28 weeks and (34-36)
weeks of gestation.
• Additional doses should be given when women are undergoing any
potential sensitizing procedures like ECV, amniocentesis or has antepartum
haemorrhage.
Postnatal prophylaxis:
• 500 iu (100 mcg) should be given within 72 hours following delivery of an
RhD positive infant.
• Blood sampling for grouping and Rh status of the infant should be performed
immediately after birth.
102
Display slide 6:
Prophylaxis following abortion:
A. Spontaneous miscarriage
• Complete or incomplete after 12 weeks of gestation
• Incomplete abortion before 12 weeks where there is dilatation and
curettage
• Spontaneous complete Abortion before 12 weeks when there is no
instrumentation, need not receive anti D immunoglobulin
Then display Slide 7:
Prophylaxis following abortion (Cont.):
B. Threatened abortion / miscarriage
• All non-sensitized RhD negative women with threatened abortion after 12
weeks of gestation
• All non-sensitized RhD negative women with threatened abortion before
12 weeks of gestation where the bleeding is heavy or repeated or where
there is associated abdominal pain and gestation is approaching 12 weeks
of gestation.
• Prophylaxis is not required if bleeding stops and fetus is viable. - If bleeding
continues intermittently after 12 weeks of gestation, anti D immunoglobulin
should be given at 6 weeks intervals.
• Dosage: 250 iu (50 mcg) before 20 weeks & 500 iu (100 mcg) after that.
Tell the participants you will display the next two slides on ABO incompatibility.
First display slide 8:
ABO incompatibility
Indications for ICT test:
A woman with history of one of the following:
• Blood transfusion
• Unexplained still birth
• Unexplained neonatal death
• Baby with severe jaundice in neonatal period
Then display slide 9:
ABO incompatibility (Cont.)
When to do ICT test
At the following intervals (make sure that ICT test is done prior to giving prophylactic
Anti-D):
• At first visit (booking).
• At 28-30 weeks visit.
• At 36-38 weeks visit.
If Coomb’s test showed to be positive, patient should be referred to the secondary
care with urgent appointment for ICT titration.
To the Trainer
Allow for comments and brief discussion while displaying the slides.
103
Session 5
OBSTETRIC COMPLICATIONS
104
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.1
Vaginal Bleeding
in Early Pregnancy
Session Outline
105
Program
Session 5.1 (VAGINAL BLEEDING IN EARLY PREGNANCY)
Activities
Activity 5.1.1
Exercise and open discussion
Time
30 min
30 min
106
Materials and Resources
Annex (1)
Annex (2)
SESSION 5: OBSTETRIC COMPLICATIONS
SESSION 5.1: VAGINAL BLEEDING IN EARLY PREGNANCY
TIME: 30 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Define vaginal bleeding in early pregnancy
2- Know differential diagnosis of vaginal bleeding in early pregnancy
3- Perform a rapid assessment of the condition and manage accordingly
Explain to the participants that this session will be discussing obstetrical
complications .
Display slide 2 to show the participants the learning objectives.
Activity 5.1.1 (30 min)
EXERCISE AND OPEN DISCUSSION
Distribute the matching exercise( Annex )1 to the participants and give them10
min to answer it.
Ask one of the participants to read the first scenarios and to give the answer.
Continue the same with the rest of the scenarios.
Allow 2-3 minutes of discussion for each scenario.
Refer to ANC guidelines page )44( for discussion.
To the Trainer:
You will discuss the answers with the participants (the correct answers are
available in Annex (2) for the perusal of the trainer only); furthermore you can
discuss the general management of those cases (shock management will be
further explained in the next session).
107
Annex 1
Session 5.1 (Vaginal Bleeding in Early Pregnancy)
(Matching Exercise)
Activity 5.1.1
108
Matching Exercise:
Read the case scenarios then put the correct number of the diagnosis in
front of the case scenario (each diagnosis could be used only once):
Case scenarios:
A- A pregnant woman with history of light vaginal bleeding and lower abdominal
pain. O/E: uterus corresponds to date, os is closed.
The diagnosis is NO. (…………)
B-
A pregnant woman with history of amenorrhea and fainting attacks .O/E:
cervix closed, with cervical motion tenderness.
The diagnosis is NO. (…………)
C- A pregnant woman with abdominal pain and history of expulsion of grape
like products .O/E: uterus larger than date.
The diagnosis is NO. (…………)
D- A pregnant woman with history of cramping abdominal pain and heavy
vaginal bleeding history of expulsion of products of conception .O/E: uterus
smaller than date.
The diagnosis is NO. (…………)
E- A pregnant woman with lower abdominal pain and heavy vaginal bleeding.
O/E: uterus smaller than date, dilated cervix.
The diagnosis is NO. (…………)
F- A pregnant woman with history of heavy vaginal bleeding associated with
abdominal pain. No history of expulsion of products of conception. O/E:
uterus corresponds to date.
The diagnosis is NO. (…………)
G- A pregnant woman with history of vaginal bleeding and cessation of
pregnancy related symptoms .Ultrasound: intrauterine gestational sac, no
cardiac activity.
The diagnosis is NO. (…………)
Diagnosis:
1.
2.
3.
4.
5.
6.
7.
Complete abortion
Ectopic pregnancy
Incomplete abortion
Inevitable abortion
Molar pregnancy
Missed abortion
Threatened abortion
109
Annex 2
Session 5.1 (Vaginal Bleeding in Early Pregnancy)
(Matching Exercise/ Correct Answers)
Activity 5.1.1
110
Matching exercise /Correct answers:
A- B-
C-
D- E- F- G- A pregnant woman with history of light vaginal bleeding and lower abdominal
pain. O/E: uterus corresponds to date, os is closed.
The diagnosis is NO. (7)
A pregnant woman with history of amenorrhea and fainting attacks .O/E:
cervix closed, with cervical motion tenderness.
The diagnosis is NO. (2)
A pregnant woman with abdominal pain and history of expulsion of grape
like products .O/E: uterus larger than date.
The diagnosis is NO. (5)
A pregnant woman with history of cramping abdominal pain and heavy
vaginal bleeding history of expulsion of products of conception .O/E: uterus
smaller than date.
The diagnosis is NO. (1)
A pregnant woman with lower abdominal pain and heavy vaginal bleeding.
O/E: uterus smaller than date, dilated cervix.
The diagnosis is NO. (4)
A pregnant woman with history of heavy vaginal bleeding associated with
abdominal pain. No history of expulsion of products of conception. O/E:
uterus corresponds to date.
The diagnosis is NO. (3)
A pregnant woman with history of vaginal bleeding and cessation of
pregnancy related symptoms .Ultrasound: intrauterine gestational sac, no
cardiac activity.
The diagnosis is NO. (6)
111
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.2
Vaginal Bleeding in Later
Pregnancy and Labour
Session Outline
112
Program
Session 5.2 (VAGINAL BLEEDING IN LATER PREGNANCY AND LABOUR)
Activities
Time
Materials and Resources
Activity 5.2.1
Case study
30 min
Annex (1)
Activity 5.2.2
Mini lecture
20 min
slides 3-7
50 min
113
SESSION 5: OBSTETRIC COMPLICATIONS
SESSION 5.2: VAGINAL BLEEDING IN LATER PREGNANCY AND LABOUR
TIME: 50 Minutes
LEARNING OBJECTIVES:
By the end of this session the participants should be able to:
1- Define vaginal bleeding in later pregnancy.
2- Know the types of vaginal bleeding in later pregnancy and labour
3- Know the differential diagnosis of vaginal bleeding in later pregnancy
4- Manage cases with vaginal bleeding in later pregnancy
5- Know how to assess and manage shock
Display slide 2 to show the participants the learning objectives.
ACTIVITY 5.2.1 (30 min)
CASE STUDY
Start by telling the participant the following:
Vaginal bleeding after 22 weeks of pregnancy and intrapartum can be life
threatening.
Ask the participants how often they encounter such situations.
Divide the participants into 3 groups, give each group a case study (ِِAnnex 1).
Tell them that they will have 5 minutes to read and discuss the case study as a
group.
After the participants have read the case invite a member of the first group to
summarize the case No.1 and to present the answers of the questions.
Ask the participants to refer to pages (45-46) of the ANC guidelines level 1 during
the discussion.
Repeat the same process with groups 2 and 3.
Activity 5.2.2 (20 min)
MINI LECTURE
Display slide 3:
Signs and Symptoms of shock:
• Fast, weak pulse (110 per minute or more)
• Low blood pressure (systolic less than 90 mm Hg)
• Pallor (especially of inner eyelid, palms or around mouth)
• Sweatiness or cold clammy skin
• Rapid breathing (rate of 30 breaths per minute or more)
• Anxiousness, confusion or unconsciousness
• Scanty urine output (less than 30 mL per hour)
114
Then display slide 4:
MANAGEMENT OF SHOCK
A. IMMEDIATE MANAGEMENT
• Call for help. Urgently mobilize all available personnel
• Monitor vital signs (pulse, blood pressure, respiration, temperature)
• If the woman is unconscious, turn her onto her side to minimize the risk of
aspiration if she vomits and to ensure that an airway is open
• Keep the woman warm but do not overheat her, as this will increase
peripheral circulation and reduce blood supply to the vital organs
• Keep the head low
Then display in sequence slides 5-7 that clarify the management of Shock.
First display slide 5 :
MANAGEMENT OF SHOCK (Cont.)
B.SPECIFIC MANAGEMENT
Start an IV infusion (two if possible) using a large-bore (16-gauge or largest
available) cannula or needle. Collect blood for estimation of haemoglobin and
cross-match just before infusion of fluids:
Rapidly infuse IV fluids (normal saline or ringer’s lactate) initially at the rate of 1
L in 15-20 minutes;
Then display slide 6:
MANAGEMENT OF SHOCK (Cont.)
B. SPECIFIC MANAGEMENT(Cont.)
Note: Avoid using plasma substitutes (e.g. dextran). There is no evidence
that plasma substitutes are superior to normal saline in the resuscitation of a
shocked woman, and dextran can be harmful in large doses
Give at least 2 L of these fluids in the first hour; then give fluid replacement for
ongoing losses.
Continue the talk by displaying slide 7:
MANAGEMENT OF SHOCK (Cont.)
B. SPECIFIC MANAGEMENT (Cont.)
• Continue to monitor vital signs (every 15 minutes) and blood loss
• Catheterize the bladder and monitor fluid intake and urine output
• Give oxygen at 6-8 L per minute by mask or nasal cannula
Allow for brief discussion on the management of shock.
115
Annex 1
Session 5.2 (Vaginal Bleeding in Later Pregnancy)
(Case Study)
Activity 5.2.1
116
Case study (1)
Fatima, G5 P6, at 26 weeks gestation. Presented to the clinic with
vaginal bleeding and abdominal pain .On examination her pulse is
120/min and blood pressure recorded as 80/60 mmhg. Fetal heart is
absent with extremely tender uterus.
Questions:
What is the diagnosis?
How would you manage this patient?
Case study (2)
Laila, G8 P4 at 40 weeks gestation with history of 2 previous caesarean
sections .Presented to the clinic with sever abdominal pain and vaginal
bleeding of 4 hours duration. On examination the pulse is 110/min
and blood pressure is 70/40 mmhg .On palpation, uterine contour was
abnormal and fetal parts can be palpated easily, in addition to that
fetal heart was absent
Questions:
What is the diagnosis?
How would you manage this patient?
Case study (2)
Maha, G4 P3 at 32 weeks gestation. Presented to the clinic with
vaginal bleeding. Examination showed rapid pulse, blood pressure
90/60 mmhg and the uterus is relaxed with normal fetal condition.
Questions:
What is the diagnosis?
How would you manage this patient?
117
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.3
Fever during Pregnancy and Labour
Session Outline
118
Program
Session 5.3 (FEVER DURING PREGNANCY AND LABOUR)
Activities
Activity 5.3.1
Exercise and group discussion
Time
30 min
30 min
119
Materials and Resources
Annex (1)
Annex (2)
SESSION 5: OBSTETRIC COMPLICATIONS
SESSION 5.3: FEVER DURING PREGNANCY AND LABOUR
TIME: 30 Minutes
Learning objectives;
By the end of this session participants should be able to:
1- Define fever in pregnancy and labour
2- Know the differential diagnosis of fever during pregnancy and labour
3- Manage fever in pregnancy
Display slide 2 to show the participants the learning objectives.
Activity 5.3.1 (30 min)
EXERCISE (MATCHING FLASH CARDS) AND GROUP DISCUSSION
Ask 10 volunteers to participate in this exercise.
Explain that five of them will have different case scenarios and the other five will
have the diagnosis for those cases (Annex 1).
Arrange for a seating in front of the main group, 5 people at each side (the group
of the case scenarios on one side and the other group on the opposite side).
Distribute the 10 flash cards among them.
Start by asking the person who is holding flash card (1) to present it and then ask
who has the diagnosis that matches the problem.
After the correct answer is given allow for comments and then discussion on the
management of such case (Allow around 3 minutes for discussion of each case.
Repeat the same with other volunteers.
At the end allow for brief discussion for the whole subject.
To the Trainer
For your reference, case scenarios with the right answers are available in Annex (2).
120
Annex 1
Session 5.3 (Fever during Pregnancy and Labour)
(Flash Cards)
Activity 5.3.1
121
Flash Card 1
Fatma is 10 weeks pregnant, presenting to ANC clinic complaining
of dysuria, increased frequency and urgency of urination. She also
complains of abdominal pain. On examination she is febrile and found
to have suprapupic tenderness.
Flash Card 2
Raya is 24 weeks pregnant presenting to ANC clinic complaining
of dysuria, increased frequency and urgency of urination. She also
complains of abdominal pain and gives a history of spiking fever
associated with chills, nausea and vomiting. On examination she is
found to have tenderness over retropubic area, loin and in rib cage.
Flash Card 3
Aysha is 19 weeks pregnant presenting to ANC clinic complaining of
fever and foul smelling vaginal discharge with abdominal pain. She also
gives a history of prolonged vaginal bleeding. On examination, she is
found to have rebound tenderness and purulent cervical discharge.
Flash Card 4
Mariam is 28 weeks pregnant presenting to ANC clinic complaining
from abdominal pain with foul smelling watery vaginal discharge with
history of loss of fluid and light vaginal bleeding. She also gives a
history of fever associated with chills. On examination, she is found to
have tender uterus and rapid fetal heart rate.
Flash Card 5
Moza is 32 weeks pregnant, presenting to the ANC clinic complaining
of difficulty in breathing and chest pain. On examination, she is found
to have fever with increased respiratory rate. Chest examination
shows rhonchi and signs of consolidation.
Flash Card 6
Cystitis
122
Flash Card 7
Acute pyelonephritis
Flash Card 8
Septic abortion
Flash Card 9
Chorioamnionitis
Flash Card 10
Pneumonia
123
Annex 2
Session 5.3 (Fever during Pregnancy and Labour)
(Flash Cards- Correct Answers)
Activity 5.3.1
124
Flash card NO. Correct Answer
Flash card 1 Cystitis
Flash card 2 Acute pyelonephritis
Flash card 3 Septic abortion
Flash card 4 Chorioaminionitis
Flash card 5 Pneumonia
125
DAY (3)
•
OBSTETRIC COMPLICATIONS IN
PREGNANCY (Part 2)
•
NORMAL LABOUR (Part 1)
126
P ro g r am
Day (3)
Time
Topic
7:30 – 8:00
Registration
8:00 – 8:30
Abdominal pain in early pregnancy
8:30 – 9:00
Abdominal pain in later pregnancy
9:00 -9:40
Decreased fetal movement
9:40 – 10:00
Prelabour rupture of membranes
10:00-10:30
Coffee Break
10:30-11:15
Admitting women with labour
11:15 -1:00
Diagnosis and assessment of progress of labour
1:00 - 2:00
Management of first and second stage of labour
127
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.4
Abdominal Pain in early Pregnancy
Session Outline
128
Program
Session 5.4 (ABDOMINAL PAIN IN EARLY PREGNANCY)
Activities
Activity 5.4.1
Brain storming and open
discussion
Activity 5.4.2
Mini lecture
Time
Materials and Resources
10 min
Flip chart
20 min
Slides 3-10
30 min
129
SESSION 5: OBSTETRIC COMPLICATIONS IN PREGNANCY
SESSION 5.4: ABDOMINAL PAIN IN EARLY PREGNANCY
TIME: 30 Minutes
LEARNING OBJECTIVES:
By the end of the session the participant should be able to:
1- Evaluate abdominal pain in early pregnancy
2- Decide on the proper diagnosis and management
Display slide 2 to show the participants the learning objectives.
ACTIVITY 5.4.1(10 min)
BRAIN STORMING AND OPEN DISCUSSION
Ask the participant the following question:
What are the causes of abdominal pain in early pregnancy?
You can invite a volunteer to write down the answers in a flip chart.
Allow 10 minutes for answers.
Then elaborate on the answers simply.
Refer to page (49) in ANC guideline level -1.
ACIVITY 5.4.2 (20 min)
MINI LECTURE
Start by displaying slide 3:
Definition (Abdominal pain in early pregnancy)
The women is experiencing pain in the first 22 weeks of pregnancy
Then display slide 4:
Differential Diagnosis(Abdominal pain in early pregnancy)
Obstetric:
• Ectopic pregnancy
• Ovarian Cyst
Medical /surgical
• Cystitis
• Acute Pyleonephritis
• Appendicitis
• Perotinitis
Then display slide 5:
Ectopic Pregnancy
Signs & Symptoms Typically Present
• Abdominal pain
• Light vaginal bleeding
130
• Closed Cervix
• Uterus slightly larger than normal
• Uterus softer than normal
Signs & Symptoms Sometimes Present
• Amenorrhea
• Tender adnexal mass
• Fainting
• Cervical motion tenderness
Refer as emergency
Then display slide 6:
Ovarian cyst
• Signs & Symptoms typically present:
– Abdominal pain
– Adnexal mass on vaginal examination
• Signs & Syptoms Sometimes present:
– Palpable, tender discrete mass in lower abdomen.
– Light vaginal bleeding
Refer as emergency
Then display slide 7:
Appendicitis
• Should be suspected in any women having abdominal pain
Signs & Symptoms typically present
• Lower abdominal pain
• Low grade fever
• Rebound tenderness
Signs & Symptoms sometimes present:
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Paralytic ileus
• Increase WBC count
• No mass in lower abdomen
• Site of pain higher than expected
Then display slide 8:
Acute Pyelonephritis
Signs & Symptoms typically present:
• Dysuria
• Fever /chills -Spiking
• Increased frequency and urgency of urination
• abdominal pain
Signs & Syptoms Sometimes present
• Retropubic/suprapubic pain/tendrness
• Loin pain/tenderness
• Tenderness in rib cage
131
• Anorexia
• Nausea/vomiting
Then display slide 9:
Peritonitis
Signs & Symptoms typically present:
• Low-grade fever/chills
• Lower abdominal pain
• Absent bowel sounds
Signs & Symptoms sometimes present
• Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Shock
Refer as emergency
Then display slide 10:
General management
• Perform a rapid evaluation of the general condition of the women,
including vital signs(pulse, blood pressure, respiration, temperature)
• Keep shock in mind as you evaluate the women further. If shock
develops, begin treatment of shock immediately
At the end allow time for a brief discussion.
132
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.5
Abdominal Pain in Later
PREGNANCY and After Childbirth
Session Outline
133
Program
Session 5.5 (ABDOMINAL PAIN IN LATER PREGNANCY AND
AFTER CHILDBIRTH)
Activities
Time
Materials and Resources
Activity 5.5.1
Brain storming and open
discussion
10 min
Flip Chart
Activity 5.5.2
20 min
Slides 3-9
Mini lecture
30 min
134
SESSION 5: OBSTETRIC COMPLICATIONS
SESSION 5.5: ABDOMINAL PAIN IN LATER PREGNANCY AND AFTER
CHILD BIRTH
TIME: 30 Minutes
LEARNING OBJECTIVES:
By the end of this session the participant should be able to:
1-Evaluate abdominal pain in later pregnancy and after child birth
2-Decide on the proper diagnosis and management
Display slide 2 to show the participants the learning objectives.
ACTIVITY 5.5.1 (10 min)
BRAIN STORMING AND OPEN DISCUSSION
Start by asking the participants this question:
What are the causes of abdominal pain in later pregnancy and after
childbirth?
You can invite a volunteer to write down the answers in a flip chart.
Allow 5 minutes for answers.
Then elaborate on the answers simply to ensure that all causes are listed.
Then ask the participants about the sign and symptoms of each cause.
ACTIVITY 5.5.2 (20 min)
MINI LECTURE
Start by displaying slide 3:
Differential Diagnosis
• Preterm labour
• Term labour
• Abruptio placenta
• Ruptured uters
• Chorioamnionitis
• Cystitis
• Acute pyelonephritis
• Appendicitis
• Twisted pedunculated fibroids
• Red generation of fibroids
• Endometritis
• Pelvic abscess
• Peritonitis
• Ovarian cyst
135
Then display slide 4:
Preterm& term labour
Symptoms & signs typically present
• Palpable contractions
• Blood stained mucus discharge(show)or watery discharge
Symptoms & signs sometimes present
• Cervical dilatation & effacement
• Light vaginal bleeding
Preterm labour : refer as emergency
Term labour : manage as in labour if facilities available
Then display slide 5:
Abruptio placenta
Symptoms & signs typically present
• Intermittent or constant abdominal pain
• Bleeding after 22wks gestation(fetus may be retained in the uterus)
Symptoms & signs sometimes present
• Shock
• Tense/tender uterus
• Decreased/absent fetal movements
• Fetal distress or absent fetal heart sounds
Refer as emergency
Then display slide 6:
Ruptured uterus
Symptoms & signs typically present
• Severe abdominal pain (may decrease after rupture)
• Bleeding (intra-abdominal and/or vaginal)
Symptoms & signs sometimes present
• Shock
• Abdominal distension/ free fluid
• Abnormal uterine contour
• Tender abdomen
• Easily palpable fetal parts
• Absent fetal movements and fetal heart sounds
• Rapid maternal pulse
Refer as emergency
Then display slide 7:
Chorioamnionitis
Symptoms & signs typically present
Foul-smelling watery vaginal discharge after 22 weeks gestation
• Fever/chills
Symptoms & signs sometimes present
• History of loss of fluid
• Tender uterus
136
• Rapid fetal heart rate
• Light vaginal bleeding
Refer as emergency
Then display slide 8:
Endometritis
Symptoms & signs typically present
• Lower abdominal pain
• Fever/chills
• Tender uterus
• Purulent, foul-smelling lochia
Symptoms & signs sometimes present
• Light vaginal bleeding
• Shock
Then display slide 9:
Pelvic abscess
Symptoms & signs typically present
• Lower abdominal pain and distension
• Persistent spiking fever/ chills
• Tender uterus
Symptoms & signs sometimes present
• Poor response to antibiotics
• Swelling in adnexa or pouch of Douglas
137
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.6
Decreased Fetal Movements
Session Outline
138
Program
Session 5.6 (DECREASED FETAL MOVEMENTS)
Activities
Activity 5.6.1
Role play
Time
40 min
Materials and Resources
Annex (1)
40 min
139
SESSION 5: OBSTETRIC COMPLICATIONS
SESSION 5.6: DECREASED FETAL MOVEMENTS
TIME: 40 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Take relevant history and do the needful assessment
2- Manage decreased fetal movements
Display slide 2 to show the participants the learning objectives.
Activity 5.6.1 (40 min)
ROLE PLAY
Invite two volunteers to perform the role play (Annex 1)
Give both of them the scenario to read.
Ask other participants to observe and give their positive and negative
comments.
Ask the volunteers to start performing the play.
Allow time for the participants to express their feelings and comments (even the
volunteers).
Then make your own comments and discuss with others the following aspects :
• The communication skills of the doctor
• The history that was taken by the doctor
• The relevance of examination that was done
• Counseling and reassurance done by the doctor
At the end greet the volunteers for their participation in the role play.
Refer to ANC guideline pages (53-54) for the management.
140
Annex 1
Session 5.6 (Decreased Fetal Movements)
(Role Play)
Activity 5.6.1
141
Role play
Moza is G3 P2 at 29 weeks gestation, presenting to the health center
with reduced fetal movements since the last night. History showed that
she had dinner at 8 pm and slept well all night. Dr.Fatima proceeded
with the management.
142
Session 5
(OBSTETRIC COMPLICATIONS)
Session 5.7
Pre-Labour Rupture of Membranes
Session Outline
143
Program
Session 5.7 (PRE-LABOUR RUPTURE OF MEMBRANES)
Activities
Activity 5.7.1
Mini lecture
Time
20 min
20 min
144
Materials and Resources
Slides 3-6
SESSION 5: OBSTETRIC COMPLICATIONS IN PREGNANCY
SESSION 5.7: PRELABOUR RUPTURE OF MEMBRANES
TIME: 20 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Evaluate a patient presenting with premature rupture of membrane
2- Decide on the proper diagnosis and management
Display slide 2 to show the participants the learning objectives.
Activity 5.7.1(20 min)
MINI LECTURE
Start by displaying slide 3:
PROM (definition)
Rupture of membranes with vaginal loss of amniotic fluid before labour has started can
be prelabour rupture of membrane (PROM) or premature prelabour rupture of membrane
before 37 weeks (PPROM).
Digital examination should be avoided where PROM is suspected.
Then display slide 4:
Diagnosis:
Maternal history:
• Gestational age
• Time of rupture of membranes
• Presence of meconium stained liquor
• Symptoms of infection: fever, faternal tachycardia, foul vaginal discharge.
Then display slide 5:
Examination:
• Sterile speculum examination:
- Presence of pool of fluid in the vagina
- Nitrazine test: amniotic fluid will turn paper blue.
- Microscopic examination of vaginal fluid show ferning due to sodium chloride
and protein
- Examination for lanugo hair.
• Abdominal examination: determine fetal lie, presentation, heart rate and presence
of contractions.
Display slide 6:
Management:
• If history and speculum examination shows evidence of leakage, refer to the
secondary care as emergency.
• If nitrazine test is positive, refer to the secondary care as emergency.
• If history, examination and nitrazine test are not suggestive of rupture of membranes,
reassure the patient and advise her to observe by applying a clean pad.
• Instruct the women to report immediately if signs of leaking liquor reoccur .
145
NORMAL LABOUR
146
Session 6
(NORMAL LABOUR)
Session 6.1
admitting a woman in labour
Session Outline
147
Program
Session 6.1 (admitting A womAn in LABOUR)
Activities
Time
Activity 6.1.1
ADMITTING A WOMAN IN
LABOUR
Brain storming and mini lecture
10 min
Flip Chart
Slides 3-6
Activity 6.1.2
SUPPORTIVE CARE DURING
LABOUR AND CHILD BIRTH
Mini lecture
10 min
Slides 7-10
Activity 6.1.3
Role play
20 min
Annex (1)
Annex (2)
Activity 6.1.4
PAIN MANGEMENT
Mini lecture
5 min
Slides 11,12
45 min
148
Materials and Resources
SESSION 6: NORMAL LABOUR
SESSION 6.1: admitting A womAn in labour
TIME: 45 Minutes
LEARNING OBJECTIVES:
By the end of this session the participants should be able to:
1- Assess women coming with labour pain
2- Know the conditions that need immediate referral to secondary care
3- Describe supportive care to be given during labour
4- Describe pain management during labour
Display slide 2 to show the participants the learning objectives.
ACTIVITY 6.1.1 (10 min)
ADMITTING A WOMAN IN LABOUR
BRAIN STORMING AND MINI LECTURE
Start by asking the participants the following question:
How you are going to assess a woman presenting with labour pain?
Listen to their answers.
Then display slide 3:
Admitting a woman in labour
• Greet the woman
• Rapid evaluation of general condition including vital signs
• Rapid evaluation of Maternal Health Record
• Physical examination including abdominal and vaginal examination
• Assess fetal condition
Then display slide 4:
Fetal Surveillance
• Listen to the fetal heart rate immediately after a contraction
• Count fetal heart rate for 1 full minute once every 15 minutes during active
phase of first stage & every 5 minutes during second stage
• Fetal heart rate abnormalities – suspect fetal distress
Then display slide 5:
Fetal Surveillance (Cont.)
• Membranes ruptured- note colour of draining liquor
• Presence of thick meconium indicates the need for close monitoring and
possible intervention
• Blood stained liquor to exclude placental separation
149
At this part of the lecture ask the participants the following question:
What are the conditions which require immediate transfer to secondary
care?
Record the answers on a flip chart.
Then display slide 6:
Conditions which require immediate transfer to secondary
• Primigravida
• Fetal malpresentation
• Fetal distress
• Ruptured membranes more than 24 hours
• Prolonged labour
• Premature labour
• Prelabour rupture of membranes
ACTIVITY 6.1.2 (10 min)
SUPPORTIVE CARE DURING LABOUR AND CHILDBIRTH
MINI LECTURE
Start by telling the participants we are going to discuss supportive care during
labour and child birth.
Display slide7:
Supportive care during labour and child birth
• Encourage the woman to have personal support from a person of her
choice – husband or mother.
• Encourage the companion to help the woman
• Ensure good communication and support by staff
• Explain all procedures, seek permission, and discuss findings with woman
• Ensure privacy and confidentiality
Then display slide 8:
Supportive care during labour and child birth (Cont.)
• Maintain cleanliness of the woman & her environment
• Clean vulval and perineal areas before each examination
• Wash your hands before and after each examination
• Ensure cleanliness of labouring area
• Clean up all spills immediately
Then Display slide 9:
Supportive care during labour and child birth (Cont.)
• Encourage the woman to move about freely
• Encourage the woman to empty bladder regularly
• Do not give enema routinely
• Encourage woman to have light frequent meals along with good hydration
• Teach breathing techniques for labour and delivery
• Help her in her pain and anxiety
150
Then Display slide10 :
Supportive care during labour and child birth (Cont.)
• Give her praise, encouragement and reassurance
• Give her information on the process and progress of labour
• Listen to the woman and be sensitive to her feelings
ACTIVITY 6.1.3 (20 min)
ROLE PLAY
Invite 2 participants to volunteer to act the scenario in Annex (1).
Ask other participants to observe and comment.
Distribute copies of the checklist to participants (Annex 2).
Ask participants to use the checklist to evaluate the performance of the nurse.
Make your own comments regarding:
• Communication skills
• Did the acting nurse explain the examination that she should perform
• Did she provide necessary supportive care to woman
Note: It is necessary to explain to the first volunteer (the nurse); it is not possible
to perform the requested examination during the role play so it will be sufficient to
explain them verbally to the second volunteer (the patient).
ACTIVITY 6.1.4 (5 min)
PAIN MANAGEMNT
MINI LECTURE
Start by telling the participant there are certain measures for managing pain in
labour which are
Then display slide 11:
Pain management
If woman is distressed by pain:
• Allow her to walk around or assume any comfortable position
• Encourage her companion to massage her back, hold her hands, and wipe
her face
• Encourage breathing techniques
• Encourage warm bath / shower
• For most women this is enough to cope with the pain of labour
• Analgesics to be given to all women who are distressed with pain
Then Display slide 12:
Pain management (Cont.)
• Pethidine 1 mg/kg body weight (but not more than 100 mg) IM every four
hours as needed or give morphine 0.1 mg/kg body weight IM
• Promethazine 25 mg IM or IV if vomiting occurs
REMINDER & SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
151
Annex 1
Session 6.1 (admitting a woman in labour)
(Role Play)
Activity 6.1.3
152
Role Play
Shamsa is G3 P2 at 38 weeks presenting to the labour room with
abdominal pain. You are a nurse (Fatima). How are you going to
proceed with this patient with regards to examination and supportive
care of labour.
153
Annex 2
Session 6.1 (admitting a woman in labour)
(Checklist handout)
Activity 6.1.3
154
Evaluation Checklist:
Evaluate the performance of the nurse by encircling Yes or No:
1. Greeting mother
Yes
No
2. Checking ANC record
Yes
No
3. Asking relevant questions about leakage, bleeding and
Yes
No
abdominal pain
4. Explaining to the woman the examination she will
perform:
A.Abdominal examination
Yes
No
B.Vaginal examination
Yes
No
C.Checking fetal heart
Yes
No
5. Provide supportive care:
A.Explain to her that she will be admitted
Yes
No
B.Explain to her that a family member can stay with her
Yes
No
C.Encourage her to move about freely
Yes
No
D.Provide reassurance with comforting words
Yes
No
E.Encourage her to empty her bladder frequently
Yes
No
F. Ask her if she has any concerns &questions
Yes
No
155
Session 6
(NORMAL LABOUR)
Session 6.2
Diagnosis and Assessment of
Progress of Labour
Session Outline
156
Program
Session 6.2 (DIAGNOSIS and assesment of progress of labour)
Activities
Time
Materials and resources
Activity 6.2.1
DIAGNOSIS AND
CONFIRMATION OF LABOUR
Mini lecture
10 min
Slides 3-5
Activity 6.2.2
DIAGNOSIS OF STAGE AND
PHASE OF LABOUR
Mini lecture and exercise(Quiz)
15 min
Slides 6-7
Annex (1)
Activity 6.2.3
ASSESSMENT OF F
DESCENT, PRESENTATION
AND POSITION OF FETAL
HEAD
Mini lecture
20 min
Slides 8-17
Activity 6.2.4
ASSESSMENT OF PROGRESS
OF LABOUR
Mini lecture
5 min
Slides 18
Activity 6.2.5
VAGINAL EXAMINATION
Mini lecture and exercise
(flash cards)
30 min
Slides 19-21
Annex (2)
Activity 6.2.6
USE OF PARTOGRAM
Mini lecture
10 min
Slides 22-28
Activity 6.2.7
USE OF PARTOGRAM
Case study
15 min
Slides 29-30
Annex (3)
105 min
157
SESSION 6: NORMAL LABOUR
SESSION 6.2: diagnosis and ASSESSMENT of PROGRESS of labour
TIME: 105 Minutes
LEARNING OBJECTIVES
By the end of this session the participants should be able to:
1- Diagnose and confirm labour
2- Explain how to perform a vaginal examination
3- Explain how to assess the fetal descent, presentation and position of the
fetal head by abdominal and vaginal examination
4- Assess the stages of labour
5- Describe, record and interpret Partogram
Display slide 2 to show the participants the learning objectives.
ACTIVITY 6.2.1 (10 min)
Diagnosis and confirmation of labour
MINI LECTURE
Start by asking participants the following question
How do you know if a woman is in labour?
Listen to the answers.
Then display slide 3:
Diagnosis and Confirmation of Labour
Suspect or anticipate labour if the woman has:
• Intermittent abdominal pain after twenty two weeks gestation
• Pain often associated with blood-stained mucus discharge (show)
• Watery vaginal discharge or a sudden gush of water
Then display slide 4:
Diagnosis and Confirmation of Labour(Cont.)
Confirm the onset of labour if there is:
• Cervical effacement; i.e. the progressive shortening and thinning of the
cervix during labour; and
• Cervical dilatation; i.e. the increase in diameter of the cervical opening
measured in centimeters
Then display slide 5:
Effacement and dilatation of the cervix
The slide shows a an illustration to what you mean by effacement and dilatation
of the cervix.
ACTIVITY 6.2.2 (15 min)
DIAGNOSIS OF STAGE AND PHASE OF LABOUR
MINI LECTURE AND EXERCISE (QUIZ)
158
Distribute the Exercise (Annex 1) to each of the participants and ask them to fill
the blank areas in the table.
Explain to them that the purposes of this quiz are to activate them and to know
what they know about stages of labour.
Discuss with them the answers.
Then display the table on slide 6:
Diagnosis of stage and phase of labour (Table)
Then display slide 7:
Duration of each stage of labour (Table)
Display first the content of the first column to brain storm the participants on the
difference in duration of each stage of labour between primi and multigravida
Then display the contents of column 2 and 3 (use the animation).
ACTIVITY 6.2.3 (20 min)
ASSESSMENT OF DESCENT, PRESENTATION AND POSITION OF FETAL
HEAD
MINI LECTURE
Display slide 8:
Descent
• By abdominal palpation: assess descent in terms of fifth of fetal head
palpation above the symphysis pubis:
 A head that is entirely above the symphysis pubis is five-fifth (5\5)
palpable.
 A head that is entirely below the symphysis pubis is zero-fifth (0\5)
palpable
Display slide 9:
Descent (Cont.)
Describe figures on this slide which is an illustration on assessment of descent by
abdominal examination.
Then display slide 10:
Descent (Cont.)
• Vaginal examination is used to assess descent by relating the level of the
fetal presenting part to the ischial spines of the maternal pelvis.
• When there is a significant degree of caput or moulding assessment
by abdominal palpation is more useful than assessment by vaginal
examination.
Then display slide 11:
Descent(Cont.)
Describe figures on this slide which is an as illustration on assessment of descent
by vaginal examination.
Tell the participants that : 0-station is at level of ischial spine
159
Then display slide 12:
Presentation and Position
• The most common presenting part is the vertex of the fetal head, if the
vertex is not the presenting part, manages as a malpresentation.
• If the vertex is the presenting part use landmark on the fetal skull to
determine the position of the fetal head in relation to the maternal pelvis.
Then display slide 13 :
Landmarks of fetal skull
Describe the landmarks.
Then display slide 14:
Determine the Position of the Fetal Head
• Fetal head normally engages in the maternal pelvis in an occipital
transverse position.
• With descent, the fetal head rotates so that the fetal occiput is anterior in
the maternal pelvis (occiput anterior position).
• Failure of an occiput transverse position to rotate to an occiput anterior
position should be managed as an occiput posterior position.
Then display slide 15 and then slide 16:
Determine the Position of the Fetal Head
illustrate what you have said in slide 14.
Then display slide 17:
Well-flexed Vertex
This slide highlights that an additional feature of a normal presentation is a wellflexed vertex with the occiput lower in the vagina than the occiput
ACTIVITY 6.2.4 (5 min)
AESSESSMENT OF PROGRESS OF LABOUR
MINI LECTURE
Ask participant the following question:
How do you assess progress of labour?
Listen and discuss their answers.
Then display slide 18:
Assessment of progress of labour
• Measuring changes in cervical effacement and dilatation
• Measuring the rate of cervical dilatation &fetal descent during the active
phase
• Assessing fetal descent during labour
Progress of first stage of labour should be plotted in a partogram in the
composite obstetric record once the woman enter the active phase of labour.
160
ACTIVITY 6.2.5 (30 min)
VAGINAL EXAMINATION
MINI LECTURE AND EXCERSIZE (FLASH CARDS)
Ask the participants the following questions:
How frequent they should perform vaginal examination?
And what they need to look for during examination?
Listen to their answers.
Then display slide 19:
Vaginal Examination
Vaginal examination should be carried out at least once every four hours during
the first stage of labour.
• Record the Followings:
1. Colour of the amniotic fluid
2. Cervical dilatation and effacement
3. Descent
• If the cervix is not dilated on first examination it may not be possible to
diagnose labour.
Then display slide 20:
Vaginal Examination (Cont.)
• If contractions persist, re-examine the woman after four hours for cervical
changes.
• At this stage, if there is effacement and dilatation, the woman is in labour;
if there is no change, the diagnosis is false labour.
• In the second stage of labour perform vaginal examination every hour.
• Plot the findings on a partogram.
Exercise to explain the right actions on doing vaginal examination for a woman coming
in labour.
Distribute flash cards (Annex 2) with correct and wrong actions during vaginal
examination.(if the participants numbers more than the cards each two can share
one card).
Divide a flip chart into two columns.
Ask participants to paste the flash cards with correct actions in the first column and
the cards with wrong actions on the second column.
Discuss the statements (actions) in the cards with participants and state your
comments.
Then display slide 21:
Vaginal Examination (Cont.)
Please note:
• Use a new sterile,vaginal pack for every vaginal examination
• Use obstetric cream as a lubricant
• Gently insert two fingers in to vagina separating the labia minora with
fingers of left hand
• Do not move the fingers when uterus contracting as this very painful
161
ACTIVITY 6.2.6 (10 min)
USE OF PARTOGRAM
MINI LECTURE
First display slide 22:
Partogram
• It is a tool to record all important information about woman & fetus during
labour. It is a tool for making decisions.
• The progress of labour is recorded as a simple graph with time on the
horizontal axis and the various important features of labour on the vertical
axis.
Then display slide 23:
Partogram. (Cont.)
Plotting the Partogram
• All observations like BP, FHR, uterine contractions are charted by plotting
on the vertical axis against the time on the horizontal axis.
• The findings of every vaginal examination are plotted on the partogram.
• The partogram is started when the cervix is 3 cm dialated
Then display slide 24:
Partogram. (Cont.)
• Every 30 minutes:
1. Count the fetal heart
2. Time the uterine contractions
3. Take the maternal pulse
• Every 2 hours: take the maternal BP
• Every 4 hours:
1. Take maternal temperature
2. Test the urine
3. Perform vaginal examination
Then display slide 25:
Partogram. (Cont.)
• What is alert line?
• What is action line?
• When should the intervention be done?
Then display slide26:
Partogram. (Cont.)
• Alert line: as soon as the cervix is 3cm or more an alert line drawn in red
obliquely upward, along the expected rate of dilatation.
• The alert line indicates the expected rate of dilatation during the active
phase of labour.
162
Then display slide27:
Partogram (Cont.)
• If the cervical dilatation is to the right of the alert line the doctor should be
informed as it gives an indication that labour is not progressing as it should
be.
• The action line is drawn parallel to the alert line, two hours to the right. This
shows when some actions should be taken.
Then display slide28:
Partogram (Cont.)
• If on any vaginal assessment the cervical dilatation is delayed two hours
or more to the right of the alert line i.e. on the action line or beyond, some
actions should be taken to ensure that labour progresses safely.
ACTIVITY 6.2.7 (15 min)
USE OF PARTOGRAM
CASE STUDY
Distribute to all participants copies of the partogram and case study in (Annex
3)
Ask them to use the information given to plot on partograms.
Give them 5-10 minutes to finish the exercise.
Ask few volunteers to present their findings.
Then display slide 29 and then slide 30.
Ask all participants to compare their partograms plotting with plotting in slide
29&30.
REMINDER AND SUMMARY
Display the session objectives (slide2) once again, and ask the participants for
any final questions or comments and address them.
163
Annex 1
Session 6.2
(diagnosis and Assessment of Progress of Labour)
(Exercise/Quiz)
Activity 6.2.2
164
EXERCISE (QUIZ)
Complete the table:
Symptoms and Signs
Stage
Phase
Cervix not dilated
------------------------------
------------------------------
Cervix dilated < 3CM
------------------------------
------------------------------
Cervix dilated 3-9cm
Rate of dilatation 1 cm per -----------------------------hour or more
------------------------------
Cervix fully dilated (10cm) -----------------------------Fetal descent continue
no urge to push
-------------------------------
Cervix fully dilated (10cm). ----------------------------urge to push
Presenting part reaches
pelvic floor.
--------------------------------
165
Annex 2
Session 6.2
(diagnosis and Assessment of Progress of labour)
(Flash Cards)
Activity 6.2.5
166
Flash Cards with correct statements (actions)
1.
Prepare antiseptic solution in a clean container
2.Use a new, sterile, vaginal pack
3.
Put on sterile disposable gloves
4.
Swab the vulva well from top to bottom using a new swab each
time
5.Use obstetric cream as lubricant
6.
Gently insert two fingers into vagina separating the labia minora
with fingers of left hand
7.
Do not move fingers when uterus is contracting
Flash Cards with wrong statements (actions)
1.
Insert three fingers during examination
2.
Move fingers when uterus is contracting (highlight that this is
painful for woman)
3.
Swab the vulva well from bottom to top
4.
Insert three fingers during vaginal examination
5.
Separate the labia minora with right hand
6.Use normal saline as a cleaning solution in procedure
167
Annex 3
Session 6.2
(diagnosis and Assessment of Progress of labour)
(Case Study)
Activity 6.2.7
168
Case Study
Mrs. Aisha is 30 years old, she is G3 P2 /39 weeks pregnant, and
has no history of any antenatal complications. She was admitted to
the labour suite on 29/05/11 at 0800 hrs with labour pain. Her Blood
presssure (BP) 125/80mmHg, pulse rate (PR) 82/min, Temperature
37C. Abdominal examination showed cephalic presentation 2/5
palpable. She is getting regular uterine contraction (3 in every 10
min) lasting for 35 seconds, Fetal heart rate (FHR)142/min.Vaginal
examination showed cervix is 4 cm dilated, fully effaced. Membrane
intact, presenting part is vertex with station at -2. Urine sugar,protein,
ketone negative.
First review at 1200 hrs Temperature 37°C, BP and PR same as
before, uterine contraction 4 in 10 min, cephalic -1 palpable,FHR136/
min regular. Vaginal examination: cervix fully effaced 7cm dilated,
membranes intact. ARM done. Clear liquor drained. Urine sugar,
protein, ketone negative.
Second review at 1500 hrs Temperature 37°C, BP130/90mmHg,PR98/
min regular,abdominal examination shows uterine contraction 2 in
every 10 min. cephalic not palpable, FHR 148/min regular. Vaginal
examination shows cervix fully effaced 10 cm dilated, membrane
absent, clear liquor draining, no caput, vertex station 0. Urine sugar,
protein negative ketone negative
She had spontaneous vaginal delivery on 29/05/2011 at 1510 hrs a
live baby boy weighing 2.950kg with APGAR 9&10 at 1&5 minutes
respectively.
169
Session 6
(NORMAL LABOUR)
Session 6.3
Management of the first and
Second stages of labour
Session Outline
170
Program
Session 6.3 (Management of THE first AND Second
stages of labour)
Activities
Time
Materials and Resources
Activity 6.3.1
MANAGEMENT OF FIRST
STAGE OF LABOUR
Mini lecture
10 min
Slides 3-4
Activity 6.3.2
MANAGEMENT OF SECOND
STAGE OF LABOUR
Mini lecture
15 min
Slides 5-7
Activity 6.3.3
INITIAL PREPARATION FOR
DELIVERY
Mini lecture
15 min
Slides 8-10
Activity 6.3.4
DELIVERY OF THE HEAD
Mini lecture
5 min
Slides 11-13
Activity 6.3.5
COMPLETION OF DELIVERY
Mini lecture
10 min
Slides 14-18
Activity 6.3.6
Showing video film
5 min
CD (video film)
60 min
171
SESSION 6: NORMAL LABOUR
SESSION 6.3: Management of first AND Second stage of labour
TIME: 60 Minutes
LEARNING OBJECTIVES:
By the end of this session participants should be able to:
1- Monitor the progress of first stage of labour
2- Monitor the progress of second stage of labour
3- Describe the initial preparation for delivery
4- Describe indications of performing episiotomy
5- Describe how to deliver the baby
Display slide 2 to show the participants the learning objectives.
ACTIVITY 6.3.1 (10 min)
MaNAGMENT OF FIRST STAGE OF laboUr
MINI LECTURE
Ask participant the following question:
What findings suggest satisfactory progress in the 1st stage of labour?
Listen to their answers.
Then display slide 3:
Progress of first stage of labour
Findings suggestive of satisfactory progress in the 1st stage of labour:
1. Regular contractions of progressively increasing frequency and duration
2. Rate of cervical dilatation at least 1cm/h during the active phase of labour
(cervical dilatation on or to the left of alert line)
3. Cervix well applied to the presenting part
Then display slide 4:
Progress of first stage of labour (Cont.)
Findings suggestive of unsatisfactory progress in the 1st stage of labour:
1. Irregular, infrequent contractions after the latent phase
2. Rate of cervical dilatation slower than 1cm/h during the active phase of
labour (cervical dilatation to the right of alert line)
3. Cervix poorly applied to the presenting part
Unsatisfactory progress can lead to prolonged labour.
ACTIVITY 6.3.2 (15 min)
MaNAGMENT OF SECOND STAGE OF laboUr
MINI LECTURE
Start by asking the participants the following question:
What findings suggestive satisfactory progress in the second stage of
labour?
172
Listen to their answers.
Then display slide 5:
Progress of Second Stage of labour
• Findings suggestive of satisfactory progress:
1. Steady descent of fetus through birth canal
2. Onset of expulsive (pushing) phase
•. Findings suggestive of unsatisfactory progress:
1. Lack of descent of fetus through birth canal
2. Failure of expulsion during the late expulsive (pushing) phase
Tell the participants that in both stages progress of fetal and maternal conditions
need to be monitored.
Then display slide 6:
Progress of Fetal Condition
• If there is fetal heart rate abnormalities (less than 110 or more than 160
b/m) suspect fetal distress and refer the patient to secondary care as
emergency.
• If malpositions or malpresentations are suspected refer the patient to
secondary care as emergency.
• If unsatisfactory progress of labour or prolonged labour is suspected refer
the patient to secondary care as emergency.
Then display slide 7:
Progress of Maternal Condition
• If the woman’s pulse is increasing she may be dehydrated or in pain, ensure
adequate hydration via oral or IV routes and provide adequate analgesia.
• If the woman’s blood pressure decreases suspect haemorrhage.
• If acetone is present in the woman’s urine suspect poor nutrition and give
oral nutritious drinks and IV fluids.
ACTIVITY 6.3.3 (15 min)
INITIAL PREPARATION FOR DELIVERY
MINI LECTURE
First display slide 8:
Normal Child Birth
Once the cervix is fully dilated and the woman is in the expulsive phase of the
second stage of labour (when she feels the urge to push), encourage the woman
to push.
Then display slides 9:
It shows a picture of illustrating fully dilated cervix.
Then ask the participants the following question:
What are the indications of episiotomy?
Listen to their answers.
173
Then display slides 10:
Episiotomy
• Episiotomy is no longer recommended as a routine procedure. There is
no evidence that routine episiotomy decreases perineal damage, future
vaginal prolapse or urinary incontinence.
• Episiotomy should be considered in the case of:
1. Complicated vaginal delivery (breech, shoulder dystocia, forceps delivery,
vacuum extraction).
2. Scarring from female genital cutting or poorly healed third or fourth degree
tears
3. Fetal distress.
Activity 6.3.4 (5 min)
DELIVERY OF The HEAD
MINI LECTURE
First display slide 11:
Delivery of the head
• Ask the mother to pant or give only small pushes with contractions as the
baby’s head delivers.
• To control birth of the head, place the fingers of one hand against the
baby’s head to keep it flexed (bent).
Then display slide12:
Delivery of the head (Cont.)
• Continue to gently support the perineum as the baby’s head is delivered.
• Once the baby’s head is delivered, ask the woman not to push.
• Feel around the baby’s neck for the umbilical cord.
Then Display slide 13:
Delivery of the head (Cont.)
• If the cord is around the neck but is loose, slip it over the baby’s head;
• If the cord is tight around the neck, doubly clamp and cut it before unwinding
it from around the neck.
Activity 6.3.5 (10 min)
COMPLETION OF DELIVERY
MINI LECTURE
Display slide 14:
Completion of delivery
• Allow the baby’s head to turn spontaneously.
• After the head turns, place a hand on each side of the baby’s head, tell the
woman to push gently with the next contraction.
• Reduce tears by delivering one shoulder at one a time.
174
Then display slide 15:
It show a picture illustrating what is mentioned in the previous slide.
Then display slide 16:
Completion of delivery (Cont.)
• If there is difficulty delivering the shoulders, suspect shoulder dystocia
• Support the rest of the baby’s body with one hand as it slides out
• Place the baby on the mother’s abdomen
• Thoroughly dry the baby, wipe the eyes and assess the baby’s breathing
Then Display slide 17:
Completion of delivery (Cont.)
• Most babies begin crying or breathing spontaneously within 30 seconds
of birth.
• If the baby is crying or breathing (chest rising at least 30 times per minute)
leave the baby with the mother.
• If the baby does not start breathing within 30 seconds, call for help and
take steps to resuscitate the baby.
• Anticipate the need for resuscitation and have a plan to get assistance for
every baby
Then display slide 18:
Completion of delivery (Cont.)
• Clamp and cut the umbilical cord immediately after delivery of the baby
• Ensure that the baby is kept warm and in skin- to –skin contact on the
mother’s chest. Wrap the baby in a soft, dry cloth, cover with a blanket and
ensure the head is covered to prevent heat loss.
• If the mother is not well, ask an assistant to care for the baby.
• Palpate the abdomen to rule out the presence of an additional baby(s) and
proceed with active management of the third stage.
Activity 6.3.6 (5 min)
SHOWING VIDEO FILM
Display a video film which shows the delivery (first and second stage of labour)
Encourage the participants to raise their comments on that film.
REMINDER AND SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
175
DAY (4)
• NORMAL LABOUR (Part 2)
• POSTNATAL CARE AND COMPLICATIONS
• QUALITY ASSURANCE STANDARDS AT
PHC LEVEL
176
P ro g r am
Day (4)
Time
Topic
7:30 – 8:00
Registration
8:00 – 8:45
Diagnosis& Management of Third Stage of labour
8:45 – 10:00
Management of Malpresentation & Shoulder Dystocia
10:00 – 10:30
Coffee Break
10:30 – 11:20
Routine Post Natal Care
11:20 – 12:30
Post Natal Complications
12:30 – 1:15
Common Procedures
1:15 – 1:35
Quality Assurance standards at PHC level
1:35 – 2:00
Module Review
177
Session 6
(NORMAL LABOUR)
Session 6.4
Diagnosis and Management of
third stage of labour
Session Outline
178
Program
Session 6.4 (Diagnosis AND Management of third stage of labour)
Activities
Time
Activity 6.4.1
DEFINITION OF THIRD STAGE
OF LABOUR
Mini lecture
5 min
Slides 3,4
Activity 6.4.2
OXYTOCIN
Mini lecture
5 min
Slides 5,6
Activity 6.4.3
CONTROLLED CORD TRACTION
Mini lecture
15 min
Slides 7-12
Activity 6.4.4
UTERINE MASSAGE &
EXAMINATION FOR PERINEAL
TEARS
Mini lecture
5 min
Slides 13,14
Activity 6.4.5
ASSESSMENT OF FOURTH
STAGE
Mini lecture
5 min
Slide 15
Activity 6.4.6
Showing video film
10 min
CD (video film)
45 min
179
Materials and Resources
SESSION 6: NORMAL LABOUR
SESSION 6.4: Diagnosis AND Management of third stage of
labour
TIME: 45 Minutes
Learning objectives
By the end of this session participants should be able to:
1- Define the third stage of labour
2- Describe the active management of third stage of labour
Display slide 2 to show the participants the learning objectives.
ACTIVITY 6.4.1 (5 min)
DEFINITION OF THIRD STAGE OF LABOUR
MINI LECTURE
Start by asking the participants the following question:
How to define the third stage of labour ?
Listen to their answers.
Then display Slide 3:
Third Stage of labour
The third stage is defined as the interval between delivery of the fetus and delivery
of the placenta.
Then display slide 4:
Active management of third stage
• Helps to prevent postpartum hemorrhage.
• Active management of the third stage include:
1. Immediate Oxytocin
2. Controlled cord traction
3. Uterine massage
Activity 6.4.2 (5 min)
OXYTOCIN
MINI LECTURE
Then display slide 5:
Oxytocin
• Within one minute of delivery of the baby, palpate the abdomen to rule out
the presence of an additional baby (s) and give Oxytocin 10 units IM.
• Oxytocin is preferred because it is effective 2-3 minutes after injection, has
minimal side effects and can be used in all women .
• If Oxytocin is not available, give Ergometrine 0.2 mg IM .
180
Then display slide 6:
Oxytocin (Cont.)
• Do not give Ergometrine to women with:
1. Pre-eclampsia
2. Eclampsia
3. High blood pressure
4. Cardiac conditions
• Because it increases the risk of convulsions and cerebro-vascular
accidents.
Activity 6.4.3 (15min)
CONTORLLED CORD TRACTION
MINI LECTURE
Display slide 7:
Controlled cord traction
1. Clamp the cord close to the perineum using sponge forceps within one
minute of delivery. Hold the clamped cord and the end of forceps with
one hand.
2. Wait for signs of placenta separation: gush of blood and lengthening of
cord.
3. Place the other hand just above the women’s pubic bone and stabilize
the uterus by applying counter traction during controlled cord traction
this helps to prevent inversion of the uterus
Then display slides 8:
Controlled cord traction (Cont.)
4. Keep slight tension on the cord and await a strong uterine contraction
(two to three minutes).
5. When the uterus becomes rounded or the cord lengthens, very gently
pull downward on the cord to deliver the placenta. Continue to apply
counter traction to the uterus with the other hand.
Then display slide 9:
Controlled cord traction (Cont.)
6. If the placenta does not descend during 30 to 40 seconds of controlled
cord traction do not continue to pull on the cord:
• Gently hold the cord and wait until the uterus is well contracted again. If
necessarily use a sponge forceps to clamp the cord closer to the perineum
as it lengthens.
• With the next contraction, repeat controlled cord traction with counter
traction.
• Never apply cord traction (pull) without applying counter traction (push)
above the pubic bone with the other hand.
181
Display slide10:
Controlled cord traction (Cont.)
7. As the placenta delivers, the thin membranes can tear off. Hold the
placenta in two hands and gently turn it until the membranes are twisted.
8. Slowly pull to complete the delivery.
9. If the membranes tear, gently examine the upper vagina and cervix and
use a sponge forceps to remove any pieces of membranes that are
present.
Then display slide 11:
Controlled cord traction (Cont.)
10.Inspect the placenta to be sure none of it is missing. If a portion of the
maternal surface is missing or there are torn membranes with vessels
suspect retained placental fragments, transfer the patient to secondary
care as emergency.
11.If uterine inversion occurs or If the cord is pulled off transfer the patient to
secondary care as emergency.
Then display slide 12:
It shows a picture illustrating controlled cord traction
Activity 6.4.4 (5 min)
UTERINE MASSAGE AND EXAMINATION FOR PERINEAL TEARS
MINI LECTURE
First Display slide 13:
Uterine massage
• Immediately massage the fundus of the uterus through the woman’s
abdomen until the uterus is contracted.
• Perform uterine palpation and inspect for excessive vaginal bleeding every
fifteen minutes for the first two hours.
• Ensure that the woman has passed urine before shifting to the ward.
Then display slide 14:
Examination for Vaginal & Cervical Tears
• Examine the woman carefully and only repair 1st and 2nd degree vaginal
tears, lacerations and episiotomy.
• transfer the patient to secondary care as emergency, in case of difficult
2nd, 3rd degree perineal tears and cervical tears
Activity 6.4.5 (5 min)
ASSESSMENT OF FOURTH STAGE
MINI LECTURE
182
First display slide 15:
Assessment of Fourth stage
• Assess estimated blood loss at delivery
• Measure vital signs
• Assess uterine tone, uterus should be firm, central and located at
the umbilicus. If uterus is deviated from central position, soft and/or
distended, check the bladder, if palpable, encourage the mother to
pass urine or insert a urinary catheter.
Activity 6.4.6 (10 min)
SHOWING VIDIO FILM
Display a video film which shows active management of third stage of labour.
Encourage the participants to raise their comments on that film.
REMINDER AND SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
183
Session 6
(NORMAL LABOUR)
Session 6.5
management of malpresentation and shoulder dystocia
Session Outline
184
Program
Session 6.5 (management of malpresentation and shoulder
dystocia)
Activities
Time
Materials and Resources
Activity 6.5.1
BREECH PRESENTATION
Mini lecture
5 min
Slides 3-5
Activity 6.5.2
DELIVERY OF BUTTOCKS AND
LEGS
Mini lecture
10 min
Slides 6-9
Activity 6.5.3
DELIVERY OF THE ARMS AND
HEAD
Mini lecture
15 min
Slides 10-18
Activity 6.5.4
DELIVERY OF BREECH
Showing video film
10 min
CD (video film)
Activity 6.5.5
SHOULDER DYSTOCIA
Mini lecture
5 min
Slides 19,20
Activity 6.5.6
MANAGEMENT OF SHOULDER
DYSTOCIA
Mini lecture
20 min
Slides 21-28
Activity 6.5.7
MANAGEMENT OF SHOULDER
DYSTOCIA
Showing video film
10 min
CD (video film)
75 min
185
SESSION 6: NORMAL LABOUR
SESSION 6.5: management of malpresentation and shoulder
DYSTOCIA
TIME: 75 Minutes
LEARNING OBJECTIVES
By the end of this session participants should be able to:
1- Describe how to deliver breech presentation
2- Describe how to manage shoulder dystocia
Display slide 2 to show the participants the learning objectives.
ACTIVITY 6.5.1 (5 min)
BREACH PRESENTATION
MINI LECTURE
First display Slide 3:
Delivery of Malpresentation
• Delivery with malpresentation should not be carried out in a primary
health care. If women presented in labour every effort should be taken
to transfer patient to the secondary care.
• Delivery can only be conducted if woman is an advanced stage of
labour and there is no time to transfer.
Then display slide 4:
Breech presentation
• Review general care principles and start an IV infusion
• Provide emotional support and encouragement
• Perform needed maneuvers gently and without undue force
Then display slide 5:
Breech presentation (Cont.)
A picture showing complete & frank breech
ACTIVITY 6.5.2 (10 min)
DELIVERY OF BUTTOCKS AND LEGS
MINI LECTURE
First display slide 6:
Delivery of the Buttocks and Legs
• Once the buttocks have entered the vagina and the cervix is fully dilated,
tell the woman she can bear down with the contractions.
• If the perineum is very tight, perform an episiotomy.
186
Then display slide 7:
Delivery of the Buttocks and Legs (Cont.)
• Let the buttocks deliver until the lower back and then the shoulder blades
are seen
• Gently hold the buttocks in one hand, but do not pull
• If the legs do not deliver spontaneously, deliver one leg at a time
• Push behind the knee to bend the leg
• Grasp the ankle and deliver the foot and leg
Then display slide 8:
Delivery of the Buttocks and Legs (Cont.)
• Repeat for the other leg
• Do not do the following:
• Never pull the baby while the legs are being delivered.
• Never hold the baby by the flanks or abdomen
Then display slide9:
Delivery of the Buttocks and Legs (Cont.)
The picture showing how to hold the baby at the hips and not to pull.
ACTIVITY 6.5.3 (15 min)
DELIVERY OF THE ARMS AND HEAD
MINI LECTURE
First display slide 10:
Delivery of the arms
Arms are felt on chest
1. Allow the arms to disengage spontaneously one by one. Only assist if
necessary.
2.After spontaneous delivery of the first arm, lift the buttocks towards the
mother’s abdomen to enable the second arm to deliver spontaneously.
3.If the arm does not spontaneously deliver, place one or two fingers in the
elbow and bend the arm, bringing the hand down over the baby’s face.
Then display slide 11:
Delivery of the arms (Cont.)
Arms are stretched above the head or folded around the neck.
• Use the Lovset’s manoeuvre:
1. Hold the baby by the hips and turn half a circle, keeping the back uppermost
and applying downward traction at the same time, so that the arm that was
posterior becomes anterior and can be delivered under the pubic arch.
Then display slide 12 :
Delivery of the arms (Cont.)
1. Assist delivery of the arm by placing one or two fingers on the upper part
of the arm. Draw the arm down over the chest as the elbow is flexed, with
the hand sweeping over the face.
187
2. To deliver the second arm, turn the baby back half a circle, keeping the
back uppermost and applying downward traction, and deliver the second
arm in the same way under the pubic arch.
Then display slide 13:
Delivery of the arms (Cont.)
A pictures illustrating Lovsets manoeuvre.
Explain the manoevure using the pictures.
Then display slide 14 :
Delivery of the arms (Cont.)
Baby’s body cannot be turned
• If the baby’s body cannot be turned to deliver the arm that is anterior first,
deliver the shoulder that is posterior:
1. Hold and lift the baby up by the ankles.
2. Move the baby’s chest towards the woman’s inner leg. The shoulder that is
posterior should deliver.
3. Deliver the arm and hand.
4. Lay the baby back down by the ankles. The shoulder that is anterior should
now deliver.
5. Deliver the arm and hand
Then display slide 15:
Delivery of the arms (Cont.)
A picture showing delivery of the shoulder that is posterior.
Then display slide 16:
Delivery of the Head
Deliver the head by the Mauriceau Smellie Veit manoeuvre as follows:
1. Lay the baby face down with the length of its body over your left hand and
forearm.
2. Place the first and second fingers of this hand on the baby’s cheekbones
beside the nose.
3. Use the other hand to grasp the baby’s shoulders with the middle finger
pushing on the occiput.
Then display slide 17:
Delivery of the Head (Cont.)
4. Apply gentle traction downward and backwards direction until delivery
of fetal chin followed by upward guidance of face and forehead over
perineum.
Note: Ask an assistant to push above the mother’s pubic bone as the head
delivers. This helps to keep the baby’s head flexed
5. Raise the baby, still astride the arm, until the mouth and nose are free
188
Then display slide 18:
A picture showing the Mauriceau Smellie Veit manoeuvre.
ACTIVITY 6.5.4 (10 min)
DELIVERY OF BREECH
SHOWING VIDEO FILM
Display a video film which shows breech delivery.
Encourage the participants to raise their comments on that film.
ACTIVITY 6.5.5 ( 5 min)
SHOURLDER DYSTOCIA
MINI LECTURE
Start by asking the participants following question:
When to suspect shoulder dystocia ?
Listen to their answers.
Then display slide 19:
Shoulder Dystocia
• The fetal head has been delivered but the shoulders are stuck and cannot
be delivered
• The fetal head is delivered but remains tightly applied to the vulva
• The chin retracts and depresses the perineum
• Traction on the head fails to deliver the shoulder, which is caught behind
the symphysis pubis
Then Display slide 20:
Shoulder Dystocia (Cont.)
• Be prepared for shoulder dystocia at all deliveries, especially if a large
baby is anticipated
• Shoulder dystocia cannot be predicted
• Patients with following risk factors should be planned for delivery in the
secondary care:
1. Previous history of shoulder dystocia & birth injuries
2. Big baby
3. Obesity
4. Diabetic mothers
ACTIVITY 6.5.6 (20 min)
MANAGEMENT OF SHOURLDER DYSTOCIA
MINI LECTURE
First display slide 21:
Management of shoulder dystocia
• H- Call for help
• E- Episiotomy, bring her to edge of table
189
•
•
•
•
•
L-Legs, Mc Roberts Manoeuvre
P-Supra pubic pressure
E-Enter pelvis
R- Delivery of posterior arm
R- Roll Over
Then display slide 22:
Management of shoulder dystocia (Cont.)
Mc Roberts Manoeuvre
1. With the woman on her back, ask her to flex both thighs, bring her knees
as far as possible towards her chest
2. Ask two assistants to push her flexed knees firmly up onto her chest
3. Wearing sterile gloves: apply firm, continues traction downwards on the
fetal head to move the shoulder that is anterior under the symphysis pubis
Then display slide 23:
Management of shoulder dystocia (Cont.)
4. Have an assistants simultaneously apply suprapubic pressure downwards
to assist the delivery of the shoulder
Note:
• Do not apply fundal pressure. This will further impact the shoulder & can
result in uterine rupture
• Avoid excessive traction on the fetal head as this may result in brachial
plexus injury
Then display slide 24:
Management of shoulder dystocia (Cont.)
A picture showing Mc Roberts Manoeuvre
Then display slide 25:
Management of shoulder dystocia (Cont.)
If the shoulder still not delivered:
1. Insert a hand into the vagina
2. Apply pressure to the shoulder that is anterior in the direction of the baby’s
sternum to rotate the shoulder and decrease the diameter of the shoulders.
If needed, apply pressure to the shoulder that is posterior in the direction
of the sternum
Then display slide 26:
Management of shoulder dystocia (Cont.)
If the shoulder still not delivered despite the above measures:
1. Insert a hand into the vagina
2. Grasp the humerus of the arm that is posterior and keeping the arm flexed
at the elbow, sweep the arm across the chest. This will provide room for
the shoulder that is anterior to move under the symphsis pubis
190
Then display slide 27:
Management of shoulder dystocia (Cont.)
A picture showing delivery of the posterior arm.
Then display slide 28:
Management of shoulder dystocia (Cont.)
If all the above measures fail to dliver the shoulder, other options included:
1. Fracture the clavicle to decrease the width of the shoulder
2. Apply traction with a hook in the axilla to extract the arm that is posterior.
ACTIVITY 6.5.7 (10 min)
MANAGEMENT OF SHOULDER DYSTOCIA
SHOWING VIDEO FILM
Display a video film which shows the management of shoulder dystocia.
Encourage the participants to raise their comments on the that film.
REMINDER AND SUMMARY
Display the session objectives (slide 2), and ask the participants for any final
questions or comments and address them.
191
POSTNATAL CARE
AND
COMPLICATIONS
192
Session 7
(POSTNATAL CARE AND
COMPLICATIONS)
Session 7.1
routine postnatal care
Session Outline
193
Program
Session 7.1 (routine postnatal care )
Activities
Time
Activity 7.1.1
ROUTINE POSTNATAL CARE
Mini lecture
5 min
Slide 3
Activity 7.1.2
TASKS OF POSTNATAL CARE
Mini lecture
20 min
Slides 4-12
Activity 7.1.3
DOCUMENTATION
Mini lecture
5 min
Slide 13
Activity 7.1.4
POSTNATAL VISITS
Mini lecture
5 min
Slide 14
Activity 7.1.5
Role play
15 min
Annex (1)
50 min
194
Materials and Resources
SESSION 7: POSTNATAL CARE AND COMPLICATIONS
SESSION 7.1: ROUTINE POSTNATAL CARE
TIME: 50 Minutes
LEARNING OBJECTIVES
By the end of this session the participants should be able to:
1. Define postnatal care at two and six weeks
2. Define tasks of postnatal care
3. Know what to document in the maternal health record and child health
record
4. Define the tasks to be done at the postnatal visits to clinic
Display slide 2 to show the participants the learning objectives.
ACTIVITY 7.1.1 (5 min)
ROUTINE POSTNATL CARE
MINI LECTURE
Start by asking the participants the following question:
What is the postnatal care?
Listen to their answers
Then display slide 3:
Postnatal care
• Care given to the woman and her baby for the first six weeks.
• Aims of postnatal care:
1. To promote the physical, mental and emotional health of the mother and
the baby.
2. To reduce the mortality &morbidity of mother & baby.
ACTIVITY 7.1.2 (20 min)
TASKS OF POSTNATAL CARE
MINI LECTURE
Start by telling the participants that you are going to discuss the tasks of postnatal
care.
Display slide 4:
Tasks of postnatal care
• Basic care of new born
• Bonding
• Breast feeding
• Birth spacing
• Education
195
Then display slide 5:
Basic care of newborn
1. Ensure warmth
At birth:
• Warm delivery room. temperature ( Should be 25-28 C)
• Dry baby
• Assess the newborn for the apgar score
• Skin-skin contact: leave the baby on the mother chest and cover with a
soft dry cloth
• Use a radiant warmer if the room not warm or the baby is pre-term.
Subsequently:
• Explain to mother that keeping the baby warm is important to the baby to
remain healthy
• Dress the baby or wrap in soft dry clean cloth
• Assess warmth every 4 hours by touching the baby’s feet
Then display slide 6:
Basic care of newborn (Cont.)
2. Hygiene
Eye care:
It is normal for a baby to have some crusting or a little discharge.
Wash the baby eyes with clean water.
Then display slide 7:
Basic care of newborn (Cont.)
Cord care
• Wash hands before and after cord care
• Do not put anything on the stump
• Fold nappy (diaper) below stump
• Keep cord stump loosely covered with clean clothes
• If stump is soiled, wash it with clean water and soap
• Dry it thoroughly with clean cloth
• If umbilicus is red or draining pus or blood, examine the baby and refer to
the paediatrician
• Explain to the mother that she should seek care if the umbilicus is red or
draining
Then display slide 8:
Basic care of newborn ( Cont.)
Remember:
• Do not bandage the stump or abdomen
• Do not apply any substances or medicine to stump
• Do not touch the stump unnecessary
196
Then display slide 9:
Basic care of newborn (Cont.)
3. Bath
At birth:
• Only remove blood or meconium
• Do not remove vernix
• Do not bath the baby before 12-18 hours
Later and at home:
• Wash the face, neck, underarms daily
• Wash buttocks when soiled. Dry thoroughly
• Bath when necessary
Then display slide 10:
Basic care of newborn.( Cont.)
4. Immunization
• Give all the required immunizations according to the national immunization
schedule
• Give vitamin A 200,000 IU to mother within 15 days after delivery, preferably
before discharge
• Give Rubella vaccine to mother if indicated
• Advice when to return for next immunization
Then display slide 11:
Basic care of newborn ( Cont.)
5. Ensure nutrition through breast feeding
• Ask the mother to help the baby attach when the baby seems to be ready
• Sings of readiness to suckle include opening the mouth, rooting, or
searching, looking around or moving
• If the mother is ill and unable to breast feed, help her to express the milk
and feed the baby by cup
• Assess attachment on the breast feeding and suckling. Help the mother
if she wishes especially if she is breast feeding for the first time or very
young mother
Then display slide 12:
Basic care of newborn ( Cont.)
6. Neonatal Screening
• Blood should be collected for routine screening from umbilical cord at birth
or by heel puncture subsequently
• Hearing test to be performed before discharge
ACTIVITY 7.1.3 (5 min)
DOCUMENTATION
MINI LECTURE
197
Display slide 13:
Documentation
Maternal health record:
• The details of labour should be entered in the maternal health record
Child health record:
• Every child must be issued a child health record & all entries should be
completed before discharge.
• The child checks done at birth should be done in the first 24 hrs & should
be entered in the child health record.
ACTIVITY 7.1.4 (5 min)
POSTNATAL VISITS
MINI LECTURE
Display slide 14
Postnatal visits
Postnatal check to clinic at 2 and 6 weeks
1. Checking:
• Blood pressure
• Pulse
• Temperature
• Hemoglobin level & urine microscopy at 6 weeks only.
2. Counseling on:
• Breast feeding,
• Birth spacing.
3. Iron supplementation to mothers for 3-6 months
ACTIVITY 7.1.5 (15 min)
ROLE PLAY
Invite 2 participants to volunteer to act the scenario in Annex (1).
Ask other participants to observe and comment.
Make your own comments regarding:
• Communication skills
• Asking the right questions
• Provision of necessary information to the woman
REMINDER AND SUMMARY
Display the session objectives (slide 2) and ask the participants for any final
questions or comments and address them.
198
Annex 1
Session 7.1 (Routine PostnataL Care)
(Role Play)
Activity 7.1.5
199
Role Play
Amna a 34 year old woman, she is Para 6 came at 6 weeks post
delivery to the postnatal clinic; postnatal care was delivered by Moza
(nurse).
200
Session 7
(POSTNATAL CARE AND
COMPLICATIONS)
Session 7.2
Postnatal Complications
Session Outline
201
Program
Session 7.2 (postnatal complications)
Activities
Time
Materials and resources
Activity 7.2.1
POSTARTUM HAEMORRHAGE
Mini lecture
5 min
Slides 3,4
Activity 7.2.2
DIAGNOSIS OF POST PARTUM
HAEMORRHAGE
Open discussion
10 min
Copies of pregnancy &
childbirth management
guidelines (level 1)
Activity 7.2.3
MANAGEMENT OF POSTPARTUM
HAEMORRHAGE
Mini lecture
7 min
Slides 5-9
Activity 7.2.4
FEVER AFTER CHILD BIRTH
Mini lecture
5 min
Slides 10,11
Activity 7.2.5
DIAGNOSIS OF FEVER AFTER
CHILDBIRTH
Open discussion
10 min
Copies of pregnancy &
childbirth management
guidelines level-1
Activity 7.2.6
BREAST ENGORGEMENT AND
MASTITIS
Mini lecture
8 min
Slides 12-15
Activity 7.2.7
POSTPARTUM DEPRESSION
Mini lecture
5 min
Slides 16,17
Activity 7.2.8
POSTPARTUM PSYCHOSIS
Mini lecture
5 min
Slides 18,19
Activity 7.2.9
Role play
15 min
Annex (1)
70 min
202
SESSION 7: postnatal CARE AND complications
SESSION 7.2: postnatal complications
TIME: 70 Minutes
LEARNING OBJECTIVES:
By the end of this session the participants should be able to:
1- Manage postpartum haemorrhage, fever after child birth
2- Deal with post partum depression and psychosis
3- Manage breast problems during postnatal period
Display slide 2 to show the participants the learning objectives.
ACTIVITY 7.2.1 (5 min)
POSTPARTUM HAEMORRHAGE
MINI LECTURE
Start by asking participant the following question:
What are the types of postpartum haemorrhage?
Listen to their answers
Then display slide 3:
Postpartum haemorrhage
Definition: blood loss sufficient to cause haemodynamic instability.
• Types:
1. Immediate: increased vaginal bleeding within the first 24 hours after
childbirth
2. Delayed: increased vaginal bleeding after the first 24 hours after
childbirth
Then display slide 4:
Postpartum haemorrhage (Cont.)
Prevention:
Active Management of third stage of labour.
1. Prophylactic Oxytocin 10u IM at delivery of anterior shoulder
2. Early Cord Clamping
3. Controlled Cord traction
4. Inspection of placenta and lower genital tract
ACTIVITY 7.2.2 (10 min)
DIAGNOSIS OF POSTPARTUM HAEMORRAGE
OPEN DISCUSSION
Ask the participants to open the pages (93- 94) in the pregnancy and childbirth
management guidelines level-1, and explain the table (diagnosis of vaginal
bleeding after child birth).
Discuss with them the signs and symptoms and probable diagnosis.
203
ACTIVITY 7.2.3 (7 min)
MANAGEMENT OF POSTPARTUM HAEMORRAGE
MINI LECTURE
Display slide 5:
Management of postapartum haemorrhage
General management
1. Call for help.
2. Quickly monitor vital signs of mother.
3. Check airway and give 100% oxygen by mask or bag.
4. Insert 2 IV lines (14G), take blood for CBC, Clotting, and cross match 4
units of blood.
5. Infuse warm crystalloids & colloids as needed
Then display slide 6:
Management of postapartum haemorrhage (Cont.)
Specific Management
1. Catheterize urinary bladder.
2. Rub the uterus +/- bimanual compression;
3. Start the medical management:
• Give syntometrine (oxytocin 5 iu/ ergometrine 0.5 mg) IM injection.
• If still bleeding, start oxytocin drip (40 iu in 0.9% NS IV) in 500 ml of
normal saline.
Then display slide 7:
Management of postapartum haemorrhage (Cont.)
Tears of Cervix, Vagina or Perineum
1. Examine the woman carefully and repair 1st degree tears of perineum &
vagina.
2. If bleeding continues transfer the patient as emergency
3. Patients with 2nd, 3rd and 4th degree perineal tear or cervical tears, should
be transferred to the secondary care as emergency after stabilization.
Then display slide 8:
Management of postapartum haemorrhage (Cont.)
Retained Placenta
1. Apply controlled cord traction to remove the placenta. Avoid forceful cord
traction & fundal pressure as they may cause uterine inversion.
2. If the placenta is not expelled, start medical management.
3. Ensure that the bladder is empty.
4. Catheterize the bladder, If necessary.
5. If the placenta is undelivered after 30 minutes of oxytocin stimulation and
controlled cord traction refer as emergency.
Then display slide 9:
Management of postapartum haemorrhage (Cont.)
Note:
Very adherent tissue may be placenta accreta. Effort to extract a placenta that
does not separate easily may result in heavy bleeding or uterine perforation which
usually requires hysterectomy. So, if bleeding continues refer as emergency
204
ACTIVITY 7.2.4 (5 min)
FEVER AFTER CHILD BIRTH
MINI LECUTRE
First display slide 10:
Fever after child birth
Problem:
Woman has fever (temperature 38°C or more) occurring more than 24 hours after
delivery. General Management:
1. Encourage bed rest. 2. Ensure adequate hydration orally or IV 3. Use a fan or tepid sponge to help decrease temperature.
Then display slide 11:
Fever after Childbirth (Cont.)
4. Paracetamol 1 gm every 4-6 hours or as needed.
5. If shock is suspected, immediately begin management.
6. Even if signs of shock are not present; keep shock in mind as you evaluate
the woman further because her status may worsen rapidly. If shock
develops, it is important to begin management immediately
ACTIVITY 7.2.5 (10 min)
DIAGNOSIS OF FEVER AFTER CHILD BIRTH
OPEN DISCUSSION
Ask the participants to open the page 96 & 97 in the pregnancy and childbirth
management guidelines (level-1) and read the tables 22 & 23 (diagnosis of fever
after child birth.
Discuss with them the signs and symptoms and probable diagnosis
ACTIVITY 7.2.6 (8 min)
BREAST ENGORGEMENT AND MASTITIS
MINI LECTURE
Display slide 12:
Breast Engorgement
• Breast engorgement is an exaggeration of the lymphatic and venous
engorgement that occurs before lactation. It is not the result of over
distension of the breast with milk.
• If the woman is breast feeding & the baby able to suckle:
1. Encourage the woman to breastfeed more frequently, using both breast at
each feeding
2. Show the woman how to hold the baby & help it attach
205
Then display slide 13:
Breast Engorgement (Cont.)
3. Relief measures before feeding may include:
• Apply warm compresses to breast/ take warm shower before
breastfeeding
• Massage the woman’s neck & back
• Express some milk before breastfeeding & wet nipple area
4. Relief measures after feeding may include:
• Support breasts with a binder or brassiere
• Apply cold compress to the breasts between feeding
• Paracetamol 1 g as needed by mouth
5. Advice the patient to report back if no response within 24 hours
Then display slide 14:
Breast Engorgement (Cont.)
• If woman is not breast feeding
1. Support breasts with a binder or brassiere
2. Apply cold compresses to the breasts
3. Avoid massaging or applying heat to the breasts
4. Avoid stimulating the nipples
5. Paracetamol 1g as needed by mouth
6. Bromocriptine 2.5 mg two times a day for 5 days
7. Follow up in three days to ensure response
Tell the participant that you are moving now to on the management of mastitis.
Then display slide15:
Mastitis
1. Treat with antibiotics
• Cloxacillin 500 mg by mouth four times per day for 10 days;
• OR erythromycin 250 mg by mouth three times per day for 10 days.
2. Encourage the woman to:
• Continue breastfeeding;
• Support breasts with a binder or brassiere;
3. Give paracetamol 1 g by mouth as needed
4. Follow up in three days to ensure response
ACTIVITY 7.2.7 (5 min)
POSTPARTUM DEPRESSION
MINI LECTURE
Start by asking the participants:
How to suspect post partum depression?
Listen to their answers
206
Then display slide 16:
Postpartum depression
• Affects up to 34% of women and typically occurs in the early postpartum
weeks or months & may persist for a year
• Depression is not necessarily one of the leading symptoms although it is
usually evident.
• Other symptoms included:
1. Irritability, exhaustion, weepiness, feelings of helplessness,
2. Low energy, loss libido and appetite
3. Sleeping disturbance
4. Headache, backache, vaginal discharge and abdominal pain
5. Obsessional thinking, fear of harming baby or herself, suicidal thoughts
and depersonalization
Then display slide 17:
Postpartum depression (Cont.)
• Prognosis good with early diagnosis and treatment.
• Prevention-support during labour & postnatal period may prevent
postpartum depression.
• Management
1. Psychological support & practical help
2. Listen to woman and provide encouragement & support.
3. Assure the woman that the experience is fairly common & many other
women experience the same thing.
4. If depression is severe, consider referral to the psychiatrist
ACTIVITY 7.2.8 (5 min)
POSTPARTUM PSYCHOSIS
MINI LECTURE
Display slide 18:
Postpartum Psychosis.
• Typically occurs around the time of delivery & affects less than 1%.
• Cause unknown, about half have history of mental illness in the past.
• How to suspect ?
- Abrupt onset of delusions or
- Hallucinations, insomnia, a preoccupation with the baby, severe depression,
anxiety,
- Despair and suicidal or infanticidal impulses.
- Care of the baby can sometimes continue as usual.
207
Then display slide 19:
Postpartum Psychosis (Cont.)
• Prognosis for recovery is excellent but about 50% of women will suffer a
relapse with subsequent deliveries.
• Management:
1. Provide psychological support and practical help.
2. Listen to the woman and provide support and encouragement. This is
important for avoiding tragic outcomes.
3. Lessen stress.
4. Avoid dealing with emotional issues when the mother is unstable.
ACTIVITY 7.2.9 (15 min)
ROLE PLAY
Invite 2 participants to volunteer to act the scenario in Annex ( 1).
Ask other participants to observe and comment.
Make your own comments regarding:
• Communication skills
• Doctor management of the patient
Then facilitate a brief discussion.
REMINDER AND SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
208
Annex 1
Session 7.2 (Postnatal Complications)
(Role Play)
Activity 7.2.9
209
Role Play
Fatima is 18 years old, para 1 (she was a primigravida) delivered
one week ago by Cesarean Section .She is brought to the doctor (Dr.
Ibtisam) in the postnatal clinic with history of crying, low mood and
not caring about her baby. Her husband is out of country. How are
you, the doctor going to deal with this woman.
210
Session 8
common procedures
Session Outline
211
Program
Session 8 (common PROCEDURES)
Activities
Activity 8.1
EPISIOTOMY
Mini lecture
Time
Materials and Resources
10 min
Slides 3-6
Activity 8.2
REPAIR OF EPISIOTOMY
Mini lecture
10 min
Slides 7-9
Activity 8.3
COMPLICATIONS OF
EPISIOTOMY
Mini lecture
5 min
Slide 10
Activity 8.4
PERINEAL TEARS
Mini lecture
5 min
Slides 11,12
Activity 8.5
REPAIR OF EPISIOTOMY
Showing video film
10 min
CD (Video film)
40 min
212
SESSION 8: COMMON PROCEDURES
TIME: 40 Minutes
LEARNING OBJECTIVES:
By the end of this session the participants should be able to:
1- Describe procedure of performing episiotomy
2- Describe procedure of repairing episiotomy
3- Describe procedure of repairing first degree vaginal and perineal tears
Display Slide 2 to show the participants the learning objectives.
ACTIVITY 8.1 (10 min)
EPISIOTOMY
MINI LECTURE
Display Slide 3:
Episiotomy
• Should not be performed routinely
Episiotomy should be considered in the case of:
1. Complicated vaginal delivery (breach, shoulder dystocia, forceps or
vacuum extraction)
2. Scarring from female genital cutting or poorly healed 3rd or 4th degree
tears
3. Fetal distress
Then display Slide 4:
Performing episiotomy
1. Apply antiseptic solution to the perineal area
2. Provide emotional support & encouragement
3. Use local infiltration with lignocaine .Make sure there are no known allergies
to lignocaine or related drugs
4. Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum &
deeply into the perineum using about 10 ml 0.5% lignocaine solution
5. Wait 2 minutes and then pinch the incision site with forceps. If the woman
feels the pinch, wait 2 minutes more then retest.
6. Wait to perform episiotomy until: the perineum is thinned out & 3-4 cm of
the baby’s head is visible during a contraction
Then display slide 5:
The picture showing the infiltration of perineal tissue with local anaesthesia
Then display slide 6:
The picture showing the procedure of making an incision while inserting two
fingers to protect baby’s head
213
ACTIVITY 8.2 (10 min)
REPAIR OF EPISIOTOMY
MINI LECUTRE
Display slide 7:
Repair of Episiotomy
1. It is important that absorbable sutures to be used for closure. Polyglycolic
sutures are preferred over chromic catgut
2. Apply antiseptic solution to the area around the episiotomy
3. Consider given another dose of lignociane.
4. Close the vaginal mucosa using continuous 2-0 suture
• Start the repair about 1 cm above the apex of the episiotomy. Continue the
suture to the level of the vaginal opening
• At the opening of the vagina, bring together the cut edges of the vaginal
opening
• Bring the needle under the vaginal opening and out through the incision
and tie
Then display slide 8:
Repair of Episiotomy (Cont.)
5. Close the perineal muscle using interrupted 2-0 suture
6. Close the skin using interrupted (or subcuticular) 2-0 suture
7. Perform rectal examination after repair of episiotomy to make sure sutures
are not felt in the rectal mucosa.
Then display slide 9:
The pictures in this slide is illustrating steps of repairing episiotomy .
ACTIVITY 8.3 (5 min)
COMPLICATIONS OF EPISIOTOMY
MINI LECTURE
Display slide 10:
Complications of episiotomy
1. If there are no signs of infection & bleeding has stopped, reclose the
episiotomy
2. If there are signs of infection, open & drain the wound. Remove infected
sutures & debride the wound
3. If infection is mild antibiotics are not required.
4. if infection is severe but does not involve deep tissues, give a combination
of antibiotics (Ampicillin 500 mg by mouth four times per day plus
metronidazole 400 mg by mouth three times per day for five days)
5. If the infection is deep, involves muscles & is causing necrosis refer the
patient to secondary care as emergency
214
ACTIVITY 8.4 (5 min)
PERINEAL TEARS
MINI LECTURE
First display slide 11:
Perineal tears
• Four degrees of tears that can occur during delivery:
1. 1st degree tear : involve the vaginal mucosa & connective tissue.
2. 2nd degree tear - involve the vaginal mucosa, connective tissue & underline
muscles.
3. 3rd degree tear - complete transaction of anal sphincter.
4. 4th degree tear –involving the rectal mucosa.
• 3rd & 4th refer to secondary care
Then display slide 12:
Repair of first degree perineal tears
1. Most first degrees tears close spontaneously without suturing.
2. Provide emotional support & encouragement
3. Use local infiltration with Lignocaine
4. Ask an assistant to check the uterus & ensure that it is contracted
5. Carefully examine the vagina,perineum and cervix.
6. If the tears is long & deep through the perineum, inspect to be sure there
is no 2nd, 3rd or 4th degree tears
7. If the underline muscles are involved refer the patient to secondary care
as emergency for repair.
ACTIVITY 8.5 (10 min)
REPAIR OF EPISIOTOMY
SHOWING VIDEO FILM
Display a video film which shows the process of repairing episiotomy.
Encourage the participants to raise their comments on that film.
REMINDER AND SUMMARY
Display the session objectives (slide 2) once again, and ask the participants for
any final questions or comments and address them.
215
Session 9
QUALITY ASSURANCE STANDARDS
IN PHC
Session Outline
216
Program
Session 9 (QUALITY ASSURANCE STANDARDS IN PHC)
Activities
Activity 9.1
Group work and open
discussion
Time
20 min
20 min
217
Materials and Resources
Quality Assurance Check lists
SESSION 9: QUALITY ASSURANCE STANDSRDS IN PHC
TIME: 20 Minutes
ACTIVITY 9.1 (20 min)
GROUP WORK AND OPEN DISCUSION
Tell the participants that the session will orient them on the quality assurance
standards of the services provided at PHC level.
Distribute a copy of quality assurance check lists (get an updated version from
the MCH coordinator).
Ask them to work in pairs to review those lists (give them 10 minutes to do that).
Then ask few of the participants to explain the contents of those lists.
Ask the participants for any comments and questions.
Tell them that many of the correct answers / information are available in pregnancy
and child birth management guidelines level -1.
218
Session 10
MODULE REVIEW
Session Outline
219
Program
Session 10 (Module REVIEW)
Activities
Time
Materials and Resources
Activity 10.1
REVIEW OF SPOT CHECKS
5 min
Activity 10.2
5 min
Slides 2, 3
10 min
Evaluation forms
5 min
Slides 1,2 (session 1)
REVIEW OF MODULE
OBJECTIVES
Activity 10.2
EVALUTION OF WORSHOP AND
SPEAKERS
Activity 10.3
REMINDERS AND CLOSURE
25 min
220
SESSION 10: MODULE REVIEW
TIME: 25 Minutes
ACTIVITY 10.1 (5 min)
REVIEW OF SPOT CHECKS
Ask the participants to pull out the spot checks completed earlier in the module
(session 1, Annex 1).
Put up the spot checks, one at a time on a flipchart (prepared earlier), and address
each one of them in turn.
Asking the participants if they would like to change their answers and give their
reasons for doing so.
Ask the participants to look at what they have put down, and to consider if they
would like to change their responses. Invite them to share their responses with
others, but assure them that they are not obliged to do so.
ACTIVITY 10.2 (5 min)
REVIEW OF MODULE OBJECTIVES
Display the module objectives (slides 1 & 2 in session 1), and ask the participants
for any final questions or comments and address them.
ACTIVITY 10.3 (10 min)
EVALUATION OF WORKSHOP AND SPEAKERS
Distribute a copy of evaluation forms of workshop and speakers (you can use
those already prepared by OMSB: Oman Medical Specialty Board).
Ask them to complete and submit to the organizer of the workshop.
The evaluation report should be submitted to OMSB as per instruction.
ACTIVITY 10.3 (5 min)
REMINDERS AND CLOSURE
Highlight the following points covered in the module:
• Health care providers at primary health facilities should be oriented on the
services provided to women during ante-natal and postnatal period.
• They should be able to identify and manage high risk pregnant women.
• Health providers at PHC level should be able to manage medical and
obstetric complications as per national guidelines (Pregnancy & childbirth
management guidelines - level 1).
• Health care providers working at PHC facilities with delivery services should
be oriented on preliminary procedures of delivery and steps in delivering
of baby and placenta.
• Psychological support of women and their rights are important issues to
take in consideration while providing the service to women during antenatal and postnatal period.
• For any clarification all providers can contact MCH coordinator.
You can cover the above points verbally or by displaying one or two slides for
this purpose.
At the end, thank the participants and wish them a good luck in their work, also
speakers and organizers of this workshop.
221
PROGRAM
OF
REGIONAL WOKSHOPS
222
Sultanate of Oman
Ministry of Health
DGHS /DHA : …………………………………… ( Region )
Training workshop in Antenatal and Postnatal care period
for Primary Health Care providers
Date
: From : ……………. to …………. ( 4 days)
Venue : ……………………………………
PROGRAM
Time
Topics for Day - 1
7:30 - 8:00
Registration
8:00 - 8:10
Module introduction
8:10 - 9:40
Basic Antenatal care -Booking new pregnancy
9:40 - 10:00
Basic Antenatal care - First visit
10:00 - 10:30
Coffee Break
10:30 - 11:55
Basic Antenatal care - First visit (continuation....)
11:55 - 1:10
Basic Antenatal care - Repeat visits
1:10 - 2:00
General principles of care
2:00 pm.
Lunch
Time
Topics for Day - 2
7:30 - 8:00
Registration
8:00 - 8:20
Anaemia in pregnancy
8:20 - 8:50
Hypertension in pregnancy
8:50 - 9:20
Gestational Diabetes
9:20 - 9:45
UTI and Asymptomatic bacteruria
9:45 - 10:00
Vaginal discharge
10:00 - 10:30
Coffee Break
10:30 - 10:50
Vaginal discharge (continuation .....)
10:50 - 11:25
HIV in pregnancy
223
Speakers
Speakers
11:25 - 11:45
Chicken pox
11:45 - 12:10
RhD negative blood group & ABO incompatibility
12:10 - 12:40 Vaginal bleeding in early pregnancy
12:40 - 1:30
Vaginal bleeding in later pregnancy & labour
1:30 - 2:00
Fever during pregnancy & labour
2:00 pm.
Lunch
Time
Topics for Day - 3
7:30 - 8:00
Registration
8:00 - 8:30
Abdominal pain in early pregnancy
8:30 - 9:00
Abdominal pain in later pregnancy
9:00 - 9:40
Decreased fetal movement
9:40 - 10:00
Prelabour rupture of membranes
10:00 - 10:30
Coffee Break
10:30 - 11:15
Admitting women with labour
11:15 - 1:00
Diagnosis & assessment of progress of labour
1:00 - 2:00
Management of the 1st & 2nd stages of labour
2:00 pm.
Lunch
Time
Topics for Day - 4
7:30 - 8:00
Registration
8:00 - 8:45
Diagnosis & management of 3rd stage of labour
8:45 - 10:00
Management of malpresentation & shoulder dystocia
10:00 - 10:30
Coffee Break
10:30 - 11:20
Routine Post natal care
11:20 - 12:30
Post natal complications
12:30 - 1:15
Common procedures
1:15 - 1:35
Quality Assurance standards at PHC level
1:35 - 2:00
Module review
2:00 pm.
Lunch
224
Speakers
Speakers