Basic

Emergency
Obstetric
Care
A Trainers Guide

Department of Health
2004

This manual is a publication of the Department of Health, and all

rights are thus reserved by the DOH. This manual, however,
may be freely reviewed, abstracted, reproduced and translated,
in part or in its entirety, as long as it is not for sale or for use in
conjunction with commercial purposes.
Copyright 2004
The Department of Health
All Rights Reserved

Contents
Foreword
Acknowledgment
Acronyms
Introduction

The situation of maternal and newborn care in the

Philippines

The Safe Motherhood Policy

The Pregnancy, Childbirth, Postpartum and Newborn Care

(PCPNC) Manual

About the Trainers Guide

Part I

Pre-Training Activities

Technical preparation

11

Organization of the training team

11

Selection of resource persons and training of core trainers

11

Identification of partner institutions and facilities

12

Selection of participants and training needs assessment

13

Setting of schedule

13

Development of course schedule and preparation of

training materials

13

Conduct of facilitators meeting for the training

course

14

Part II

Conduct of the Training Course

Didactic phase

15
17

Module 1 Overview of BEmOC and the PCPNC

Manual

19

Module 2 Principles of Good Care

21

Module 3 Quick Check and Rapid Assessment and

Management

23

Module 4 Antenatal Care

27

Module 5 Labor, Delivery and Immediate

Postpartum

32

Module 6 Postpartum Care

39

Module 7 Newborn Care

42

Module 8 Counseling

48

Module 9 Mobilizing Community Support

51

Practicum phase

53

Module 1 Orientation on the Practicum

55

Module 2 On-Site Team Activities for Clinical

Skills in BEmOC

58

Monitoring, evaluation and action plan

61

Roles and responsibilities of the BEmOC team

63

Indicators for monitoring and evaluation

63

Monitoring and evaluation processes

65

Monitoring practicum activities

69

Daily evaluation of training activities

72

Process and output evaluation

74

Action plan
Part III Post-Training Activities

76
79

Outcome indicators

81

Continuing communication

82

Monitoring and evaluating training outcomes

83

Documentation of experiences

85

References

86

Glossary

87

Annexes

89

Trainers Notes

91

Guide to PowerPoint Presentations

177

Sample Training Schedule

179

Foreword
The past decade was marked by a slow progress in the field of maternal and child health. Of the 1.6 to 2
million babies born annually, over 3 to 4% of them die during the first month, and nearly two-thirds of
deaths occur in the critical first week after birth the perinatal period. In like manner, maternal mortality
ratio continues to be a major public health concern at 172 per 100,000 live births. Most of these deaths are
a result of poor maternal health brought about by poor nutritional status coupled with low quality care
before pregnancy, during pregnancy, childbirth and immediately after birth.
Recent improvements in medical knowledge and advances in health technology have caused a change in the
way services to pregnant women are provided. The previous paradigm utilized the risk approach where
high-risk pregnancies were first identified and referred for closer attention during the prenatal period.
Now, in contrast, every pregnant woman is considered at risk and should have access to a skilled attendant
before, during and after pregnancy.
For the strategy to succeed, the three delays of deciding to seek care, reaching appropriate care, and
receiving care at appropriate health facilities must be addressed. One critical pathway according to JICA,
WHO, UNICEF and UNFPA is to improve the accessibility, utilization, and quality of services for the
treatment of complications during pregnancy and childbirth. This is based on evidence that at least 15% of
all pregnant women will develop serious complications and require life-saving access to quality obstetric
services. Thus, the single most critical intervention is to ensure the presence of a health worker with
midwifery skills at every birth, and transportation to a more comprehensive level of 24-hour quality
obstetric care in case of emergency. The UN system has recommended the setting up of a facility with
capability to provide comprehensive obstetric care (CEmOC) in an area with at least 500,000 population
and a facility with capability to provide basic emergency obstetric care (BEmOC) in an area with at least
125,000 population.

In response to the global call of effecting substantial improvement in maternal and child health, as defined
in the Millennium Development Goals, the Department of Health has reaffirmed its commitment to invest
in women and childrens health by adopting specific goals, targets, strategies and interventions to reduce
maternal and infant mortality. It is against this background that this Trainers Guide on Basic Emergency
Obstetric Care is developed. This will serve as the national standard for training doctors, nurses and
midwives in the field of emergency obstetrics at primary level facilities. This Trainers Guide provides a full
range of concepts and strategies that enable master trainers to give high quality training to health workers
on pregnancy, childbirth, postpartum and newborn care. It is hoped that this Guide becomes a useful tool
for decision-makers, program managers and health care providers in charting out roadmaps toward
meeting the health needs of women and children.

MANUEL M. DAYRIT MD, MSc

Secretary of Health

Acknowledgment
This Trainers Guide was prepared with the help of many people and organizations. These include the
Module Writers: Dr. Ma. Lou Andal, Dr. Juanita Basilio, Dr. Ma. Elizabeth Caluag, Dr. Divina
Capuchino, Dr. Diego Danila, Elizabeth Dumaran, Dr. Josephine Hipolito, Dr. Jocelyn Ilagan, Dr. Carol
Mirano and Dr. Aurora Musngi.
Valuable support was provided by the following international donor agencies: the World Health
Organization, United Nations Childrens Fund, United Nations Population Fund and Japan International
Cooperation Agency.
The officials and staff members of the following organizations provided their valuable inputs and
comments to enhance this training guide, namely: the Technical Working Group and Secretariat of the Safe
Motherhood Program - Maternal and Child Health Division of the Department of Health, Philippine
Obstetrical and Gynecological Society, the Philippine Pediatric Society, the Philippine Board of Midwifery,
the Philippine Board of Nursing, the Integrated Midwives Association of the Philippines, the League of
Government Midwives, the Philippine Medical Association, the Philippine Academy of Family Physicians,
Center for Health Development- National Capital Region, Dr. Jose Fabella Memorial Hospital, Bureau of
International Health and Cooperation, Bureau of Health Facilities and Development, Health Policy
Development and Planning Bureau, Health Human Resource Development Bureau, Office of the
Undersecretary of the Department of Health, and World Bank. The comments of health workers who
participated in the pilot BEmOC training were also crucial in the improvement of this Training Guide.
Finally, the Department of Health acknowledges the technical assistance provided by the Center for
Reproductive Health Leadership and Development, Inc. (CRHLD) in the finalization and production of
this guide.

Acronyms
BEmOC Basic Emergency Obstetric Care

LR

Labor Room

BP

Blood Pressure

MMR

Maternal Mortality rate

CD

Compact Disc

NB

Newborn

CPR

Contraceptive Prevalence Rate

OPD

Out-patient Deployment

DR

Delivery Room

OHP

Overhead Projector

ER

Emergency Room

GP

Gravida Para

PCPNC Pregnancy, Childbirth, Postpartum

and Newborn Care

IE

Internal Examination

IM

POGS

Philippine Obstetrical and

Gynecological Society

Intramuscular Injection

PR

Pulse Rate

IV

Intravenous Injection or Infusion

RAM

Rapid Assessment and Management

LBW

__ Low Birth Weight

RR

Respiratory Rate

LCD

Liquid Crystal Display

TNA

Training Needs Assessment

LGU

Local Government Unit

TOCT

Training of Core Trainers

Introduction
A. The Situation of Maternal and
Newborn Care in the Philippines
The Philippines registered a Maternal Mortality
Rate (MMR) of 172 per 100,000 in 1998 compared to 180 per 100,000 in 1995 (National
Demographic Health Survey, 1998). Despite the
decrease in MMR, the reduction of maternal
deaths due to pregnancy related complication
remains a challenge. The 1998 NDHS indicated
that postpartum hemorrhage is the leading cause of
deaths followed by hypertensive complications,
sepsis, obstructed labor and unsafe abortion. In
the same survey, perinatal death was placed at 18
per 1000 livebirths. Compared with Malaysia and
Singapore (9.1 per 1000 livebirths & 4.1 per 1000
livebirths, respectively), the Infant Mortality Rate
(IMR) in the country is 36 per 1000 livebirths. In
the latest 2003NDHS, the percentage of LBW
babies (<2500 gms) is high at 13%, not including
those that were not weighed. This is a reflection of
the intrauterine growth retardation brought by
maternal deprivation during pregnancy. Stillbirths
or infant deaths, on the other hand, can be avoided
especially in the critical first week of life if essential
care is available during pregnancy, childbirth and

the immediate postpartum period.

As explained in the Three Delays Model, maternal
deaths occur due to delays in: (1) deciding to seek
care for perceived obstetrical complications; (2)
identifying and reaching the appropriate facility;
and (3) receiving appropriate and adequate care in
the facility.
The World Health Organization (2002) pointed
out that although most pregnancies and births are
uneventful, approximately 15% of all pregnant
women develop a potentially life-threatening
complication that calls for skilled care and some
will require a major obstetrical intervention to
survive. If Emergency Obstetric Care is available,
and women can access it in time, womens lives
can be saved.
The establishment or upgrading of strategic health
facilities on Basic Emergency Obstetric Care
(BEmOC) aims to avert death and disability
among pregnant women and newborn babies.
BEmOC refers to the functions that can be provided by a team of experienced and trained skilled
birth attendants composed of licensed doctor, nurse

and midwife who act as a team at the primary level

in providing basic emergency care to mothers and
babies to avert maternal and newborn morbidity
and mortality. The WHO recommends a ratio of
one BEmOC facility per one hundred twenty five
thousand (1:125,000) population.
The following are the six (6) basic functions of a
BEmOC facility:
1. administer parenteral antibiotics ( initial loading dose)
2. administer parenteral oxytocic drugs (for active
management of the 3rd stage of labor only)
3. administer parenteral anticonvulsants for preeclampsia and eclampsia (initial loading dose)
4. perform manual removal of placenta
5. perform removal of retained products
6. perform assisted vaginal delivery

B. The Safe Motherhood Policy

The Philippines is committed to pursuing the
principles enunciated in the Cairo and Beijing
Conferences on Population and Women respectively for the promotion of safe motherhood and
womens health, and to ensure healthy newborns.
Hence, the enactment of the Department of
Healths Administrative Order No. 79s.2000,
otherwise known as the Safe Motherhood Policy
on August 28, 2000.
It is restating its commitment to the aspiration of a
healthy nation through a more vibrant and vigorous Safe Motherhood Initiatives. The following
principles form the basis for programming the
reduction of maternal and perinatal mortality and
morbidity in the country:
2

Promotion of womens rights and gender

sensitivity;

Access to quality health and nutrition services;

Focusing on health promotion, education and
advocacy;

Establishing linkages and developing collaboration to ensure sustainability;

Mobilizing families and communities to address family planning and maternal and newborn care;

Empowering communities to recognize and
correct gender discrimination and prevent
violent and abusive behavior towards women
and girls; and

Reporting and reviewing all maternal deaths

Goal, Coverage and Scope

The Safe Motherhood Policy embraces the goal of
ensuring safe motherhood and healthy newborns,
hence, its main objective is to reduce maternal and
perinatal morbidity and mortality. Under this
policy, all women of reproductive age (15-49) and
newborns up to 28 days of life are target of interventions and services. Special attention shall be
given to indigenous women, women among highly
marginalized groups (fisher folks, farmers, urban
slums, etc.) and teenage/adolescent groups. Approaches or strategies shall be culture-based and
gender-sensitive.

Guidelines and Procedures

1. Ensuring Quality Maternal and Newborn Care
Good quality maternal and newborn health services:

Are accessible and available as close as possible
to where the women live, and at the lowest
possible facility that can provide the services

safely and effectively.

Are acceptable to potential users and responsive
to local cultural and social norms, such as
preferences for privacy, confidentiality and care
by female health workers.

Have on hand all essential supplies and equipment.

Provide comprehensive care and linkages to
other reproductive health services;

Provide for continuity of care and follow-up;

Are staffed technically competent health care
providers who rely on clear guidelines/
protocols for treatment;

Are staffed by workers who provide respectful
and non-judgmental care that is responsive to
womens needs;

Involve the client in decision-making, and see
the client as partners in health care and active
participants in protecting their own health; and

Offer economic and social support to health
care providers that enable them to do the best
job they can;

Encourage partner as well as family and community involvement in pre-natal and post-natal
services.
2. Elements of Quality Maternal and Newborn
Care

Prenatal
Pregnant Women should have at least four (4) prenatal visits for:

Health promotion: advice on nutrition (e.g

iodized salt utilization) and health care,
breastfeeding, newborn care as well as
counseling to alert women to danger signs
and help plan for birth;
Assessment: history taking, physical exami-

nation and screening test like hemoglobin/

hematocrit determination, urinalysis using
the Home Based Mothers Record (HBMR),
dental check-up and prophylaxis. (Note:
The HBMR has been updated and replaced
by the Mother and Child Book)
Prevention: Tetanus Toxoid immunization,
Micronutrient supplementation (low dose
Vitamin A, Multiple micronutrient supplementation, ferrous sulfate) and early detection and management of complications.
Treatment: Management of sexually transmitted infections, anemia, toxemia, or other
risk conditions.

Natal/ Delivery Care

All deliveries should be attended by a skilled
attendant and is within two hours from first level
referral or well-equipped hospital that can handle
emergency obstetric cases and should have the
following services:

Provide good quality care that is hygienic,

safe and sympathetic on an on-going basis;
Recognizes and manage complications,
including instituting life-saving measures
for mother and baby when called for;
Monitor progress of labor using
partograph;
Refer promptly and safely when higher-level
care is needed; and
Ensure the support/presence of husband/
partner.

Postpartum and Newborn Care

The postpartum mother together with her newborn should have at least 2 postpartum visits one
month apart for the following services:



Newborn screening for 8 congenital metabolic disorder

Apgar scoring, proper cord care
Identification and management of problems
in mothers and newborn in the 1st 24
hours
Immediate and safe referral cases needing
higher level care
Initiate exclusive breastfeeding
Counseling and health promotion on exclusive breastfeeding, follow-up immunization,
family planning, micronutrient supplementation, personal hygiene and care of newborn.
BCG immunization and compete assessment of the newborn using Growth Monitoring Chart (GMC)

C. The Pregnancy, Childbirth,

Postpartum and Newborn Care
(PCPNC) Manual
One of the strategies adopted to enable the service
providers become competent in the management
of women and their newborns was the development of the Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential Practice by
the World Health Organization. It aims to guide
health care professionals in the management of
women and newborns in said periods as well as its
application through an intensive skills training
course.

The WHO-PCPNC Manual was adopted to the

Philippine settings based on consultations with
technical groups, academe, Philippine Obstetrical
and Gynecological Society (POGS), Midwives
Association and on the results of the pilot testing of
the manual in the five areas of local government

units (LGUs) in the country. This local version

serves as the main reference book for the Skills
Training in BEmOC. This will guide service providers in their clinical decision-making through a
systematic collection, analysis, classification and use
of relevant information by suggesting key questions, essential observations and/or examinations
and recommending/applying appropriate evidenced-based interventions.

About the Trainers

Guide
Background of the Trainers Guide
The WHO document -- Pregnancy, Chilbirth,
Postpartum and Newborn Care: A Guide for
Essential Practice (PCPNC) was adopted as a
reference manual for health care providers
responsible for the care of women during
pregnancy and childbirth, and their newborns. To
facilitate the conduct of training, this training guide
was developed in collaboration with various partner
organizations that have a stake on reducing
maternal deaths in the Philippines.
A multi-sectoral PCPNC Task Force was created,
composed of representatives from the Dr. Jose
Fabella Memorial Hospital, Midwives Associations,
WHO, UNICEF, JICA and UNFPA with DOHNCDPC as chair and convenor. Several meetings
were conducted with support from UNICEF and
WHO to brainstorm on how best the training can
improve the health providers capability on
managing emergency complications of pregnancy
and childbirth.

endorsement of the Guide from other partners like

the Philippine Pediatric Society, Philippine
Obstetrics and Gynecology Society, and three
groups from the midwives associations. The last
three series of meetings to finalize the Trainers
Guide and the pre-testing was funded by the
UNFPA. A total of 23 health service providers from
lying-in or birthing facilities, Provincial Health
Offices from six UNFPA assisted provinces, and
from the Center for Health Development
participated and gave a comprehensive assessment
of the training.
With support from JICA, a two-day consultative
workshop was conducted by DOH to provide the
different stakeholders with the opportunity to
further review the draft and recommend ways to
improve it. An additional off-shoot of this
workshop was an agreement to come up with a
DOH Administrative Order entitled Implementing
Guidelines for Basic Emergency Obstetric Care
that will guide decision makers and implementers of
BEmOC in the country.

A meeting hosted by the WHO was conducted to

generate more technical inputs and solicit
5

How to Use the Trainers Guide

This Trainers Guide shall provide facilitators and
resource persons the standard technical content and
design of BEmOC training. It promotes the team
approach in the delivery of BEmOC. The overall
objective of the training is to enhance the skills of
birth attendants (doctors, nurses, midwives) in
assessing and managing conditions related to
pregnancy, childbirth, postpartum and newborn
care.
It is an 11-day training with 4-day didactic sessions
and 7-day clinical practice. The objectives of the
didactic phase are as follows:

apply the principles of good care;

enhance clinical judgment by identifying and
prioritizing patients through the application of
Quick Check and RAM;

discuss the impact of doing an immediate
general assessment of the woman upon consultation at the health facility;

perform an assessment and management of a
woman during labor, after delivery and discharge from the health facility;

recognize and respond to observed signs or
volunteered problems of mothers;

show how to care for the newborn;

demonstrate counseling skills on the essential
routine and emergency care of women and
newborn during pregnancy, childbirth, postpartum and post-abortion;

identify community support mechanisms for
maternal and newborn health.
The didactic part covers nine (9) modules, namely:
(1) Overview of BEmOC and the PCPNC Manual;
(2) Principles of Good Care; (3) Quick Check and
6

Rapid Assessment and Management; (4) Antenatal

Care; (5) Labor, Delivery and Immediate
Postpartum; (6) PostPartum Care; (7) Newborn
Care; (8) Counseling; and (9) Mobilization of
Community Support.
The practicum phase covers two (2) practicum
activities for clinical skills on BEmOC. It aims to
enhance the competencies of service providers in
applying basic emergency obstetric care to all
women and their babies. Its sessions include: (1)
Orientation for the Practicum; and (2) Practicum
Activities for Clinical Skills in BEmOC. The
practicum session shall take place in an accredited
training hospital: at the outpatient department,
emergency room, maternity ward, labor and
delivery room and wherever trainees can practice
their skills. Nearby lying-in clinics and birthing
homes, health centers and rural health units may
also serve as practicum sites provided they are
accredited as training units.
The training team shall be composed of: (1) a
training director; (2) at least five core trainers; and
(3) a finance/administrative officer. To ensure a
common understanding on the Trainers Guide and
PCPNC Manual, a two-day facilitators meeting
before the training proper will be conducted for the
team and other invited resource persons. The
resource persons or facilitators for the training will
be selected based on their experience/expertise in
the area of maternal and newborn care, orientation
on PCPNC, exposure to conduct of training
activities and willingness to be part of the team.

The Trainers Guide is organized in three

parts:
Part 1 provides checklist on pre-training preparation. It consists of the technical and administrative
requirements which need to be prepared to ensure
smooth implementation of the training, such as: (1)
organization of the training team; (2) selection of
resource; (3) persons and training-of-trainers; (4)
identification of partner institutions and facilities;
(5) selection of participants and training needs
assessment; (6) setting of schedule; (7) development of course schedule and preparation of training materials; (8) conduct of facilitators meeting;
and (9) fulfillment of administrative requirements.
Part 2 presents the nine modules of the didactic
phase and two modules of the practicum phase.
Each module and session includes presentation of
the objectives, topics, duration, methodology and
materials needed. This part also provides practical
tips on how to monitor and evaluate before, during and after the course, including the preparation
of an action plan.
Part 3 provides an overview of post-training
activities which the trainers and participants can
undertake collaboratively. This part includes discussion of outcome indicators for the training, the
need for continuing communication, how to
monitor and evaluate training outcomes and the
importance of documenting experiences.

To facilitate the use of this book, especially finding

information, the three major parts and the Annex
which includes the Trainers Notes are color
coded:
Part 1 Pre-Training Activities
Part 2 Conduct of the Training Course
A. Didactic Phase
B. Practicum Phase
C. Monitoring, Evaluation
and Action Plan
Part 3 Post-Training Activities
Annex

Yellow
Blue
Pink
Orange
Green
Violet

A Glossary is also included in page 87 to aid the

trainers and readers in understanding the meanings
of words/terms used in the guide.
The Annex Portion includes the trainers notes,
guide to the powerpoint presentation, and sample
training schedule for the didactic phase. The
trainers notes contain the various reference and
presentation materials. Sample forms and tools are
also included in this section.
Together with this Trainers Guide are the instructional materials such as the Compact Disk of
PowerPoint Presentations, a set of transparencies
of selected presentation materials and the PCPNC
Manual as main resource book.

The introductory part walks the trainer or reader

into the context of the guide which includes the
situation of maternal and newborn care in the
Philippines, the Safe Motherhood Policy and the
context of the PCPNC which serves as the main
reference book of the Trainers Guide.
7

PreTraining
Preparation
9

Prior to conducting the skills training on BEmOC, certain preparations

need to be done to ensure its smooth implementation.

10

Technical Preparation

Organization of the Training Team

A Training Team needs to be organized to lead the
following responsibilities:

Management of the training which includes
planning, organizing and running the training
sessions in an effective and collaborative
manner;

Mentoring by providing guidance and support
to individual participants;

Planning how the newly gained competencies
can be applied by the participants in their work
place;

Motivating participants by supporting them in
meeting their learning objectives; and

Conducting Training of Core Trainers (TOCT)
among resource persons/facilitators for the
different sessions in the didactic phase and area
facilitators for the practicum phase.
The composition of the team includes:

Training Director

Core Trainers

Administrative and Finance Officer

Selection of Resource Persons and

Training of Core Trainers (TOCT)
The selection of resource persons/facilitators
should take into consideration appropriate
matching of their qualifications with the training
objectives and methodology, as well as the
characteristics of the participants. The recruitment
process should be guided by selection criteria.
The TOCT aims to level-off understanding among
the Training Team, resource persons/facilitators for
the didactic phase and area facilitators for the
practicum phase about the goals, objectives and
mechanics of the BEmOC skills training. The
discussions/meetings will focus on the following:

Context of IMPAC on Safe Motherhood

Context of the PCPNC as a Reference Guide
Modules for the BEmOC Skills Training
Orientation on the Trainers Guide, particularly:


Didactic Phase - session objectives, group
activities, expected outputs and materials/
resources needed.
11

Practicum Phase


objectives


hospital departments/areas that will be
involved


hospital personnel/staff/area facilitators
who will be involved


requirements of the practicum and the
expected technical assistance from the
area facilitators


determine schedule of rotation to approximate completion of requirements
(may use as basis results of Training
Needs Assessment (TNA) to address the
gaps/skills required by the participants
on BEmOC)


forms/checklists to be filled-up by the
participants


forms/monitoring tools to be accomplished by the area facilitators to aid in
facilitating application of skills


conduct of mid-practicum assessment


how to effectively provide technical
assistance and monitoring of the participants including proper feedbacking of
observations


proper conduct and decorum during
practicum
Monitoring and Evaluation of the
Training (during and after)

Criteria for the Selection of Resource Persons:

Experience/expertise in the area of maternal
and newborn care

Orientation on PCPNC

Exposure to conduct of training activities

Willingness to be part of the team
12

Identification of Partner Institutions

and Facilities
Institutions and facilities that will be involved in the
delivery of the training course should be identified
early on. The identification process should consider
the following criteria:

Training Institution for Practicum


Accredited by Philippine Obstetrical and
Gynecological Society (POGS) or Department of Health for teaching/training


Can be government (as covered by DOH
Administrative Order) or private institutions
that will meet the criteria (covered by MOA
with Local Government Unit)

Health Facilities for Practicum


With Business Plan (according to
PhilHealth Accreditation scheme)


Accessibility of the facility


Capability of the personnel to model correct service provision and assist participants
during practice


With adequate caseload for clinical procedure (BEmOC)


Availability of essential supplies and equipment

Training Venue for the Didactic


Adequate space for the number of participants and activities that will be conducted,
including break-out groups


Availability of equipment and supplies


Availability of facilities for communication


Comfortable/well-appointed accommodation
In identifying partner institution and facilities, bear
in mind that the training scenario should be as
close as possible to the work environment of the

participants (WHO, 1997:40). In this way, there is

greater chance of putting into practice the new
skills learned in their own work sites (Mclnerney et
al., 2001; JHPIEGO, 2001).

Selection of Participants and Training

Needs Assessment
The success of the BEmOC skills training course
will also depend on a careful selection of participants. Criteria for selecting participants may
include:
LGU Participant

LGUs/provinces with high Maternal Mortality
Rate (MMR), neonatal death and low Contraceptive Prevalence Rate (CPR)

Available BEmOC facilities of LGU

Adequate support of LGU in terms of upgrading facilities, availability of supplies and allocation of budget

LGU with Investment Plan and resource management capability

Available human resources for team composition

Private institutions willing to be trained

Level of competencies of participants

designed to determine the skills which the participants would like to learn or improve during the
training, as well as their level of knowledge and
attitudes regarding BEmOC. The participants will
be asked to complete a TNA form which will be
used by the Training Team in improving the
delivery of the course.

Setting of Schedule
The schedules for TOCT among the resource
persons, dry-run for the course and actual training
should be discussed and agreed upon early enough
to prepare them accordingly. Inform them immediately as soon as the schedules are finalized.

Development of Course Schedule and

Preparation of Training Materials

Individual Participant

A schedule of all the activities that will take place

during the BEmOC skills training course should
be developed by the Training Team. This includes
information about the objectives, methodology,
time allotted to each activity and the resources/
materials needed. It is both a planning tool and a
guide for the trainers. The course schedule aims to
ensure that the flow of training is logical, the
participants are able to effectively acquire and
apply new knowledge and skills and stay focused
and interested.

Team of doctors, nurses and midwives who

serve as skilled birth attendants at the birthing
facilities that are capable of providing BEmOC

At least with experience in handling birth
deliveries

Background in basic OB-GYN and Pediatrics

Together with the course schedule, training materials such as handouts, computer-generated presentations (PowerPoint) using computer and LCD
or overhead projectors, flipchart paper,
photographs and models (e.g. dolls, chicken breast,
etc.) have to be prepared.

Once the participants have been selected, a TNA

13

List of T
raining Materials/
Resources
Training
Materials/Resources

14

Metacards
Pentel pens
Masking tape
Board
LCD and computer
Overhead projector
PCPNC Manual
Handouts on BEmOC
Manila paper
Transparencies of presentation materials
CD of PowerPoint presentations
Chalk
Prizes for games
5 drill exercises
Case study handouts
Arm model
IV butterfly/canula
Chicken breast
Drugs and supplies (magnesium sulphate,
oxytocin,
ergometrine, diazepam, IV/IM antibiotics,
arthemeter or quinine IM)
Quick Check and RAM chart
Crayola
Paste
Assorted art papers
Observation tool
Partograph and Labor chart
Examination chart for mothers (after
discharge)
Slide presentations
Undressed doll
Mannequin
Self-inflating bag

Mask size 0 & 1

Suction tube/suction device
2 towels
Clock
Skills requirement handout
Practicum forms
Patients
Hospital/birthing/lying-in facilities

Conduct Facilitators Meeting for the

Trainers Course
A two-day facilitators meeting should be conducted with core trainers to ensure that all requirements of training for the didactic and practicum
phases have been prepared. The result of the
meeting should serve as basis for doing the
necessary adjustments or improvement in the training course.

Conduct of
the Training
Course

This section consists the didactic phase, practicum phase and monitoring and evaluation
of the actual skills training on BEmOC. The objectives and topics of the three main
parts, modules and specific sessions are laid out to guide the trainers and participants
during the conduct of the training course. An appropriate mix of training methods that
were used in pre-testing this trainers guide was adopted to ensure that participants
realize the course objectives.

Didactic
Objectives

By the end of the didactic phase, participants will be able to:

apply the principles of good care;

enhance clinical judgment by identifying and prioritizing patients through the
application of Quick Check and RAM;

discuss the impact of doing an immediate general assessment of the woman
upon consultation at the health facility;

perform an assessment and management of a woman during labor, after
delivery and discharge from the health facility;

recognize and respond to observed signs or volunteered problems of mothers;

show how to care for the newborn;

demonstrate counseling skills on the essential routine and emergency care of
women and newborn during pregnancy, childbirth, postpartum and postabortion; and

identify community support mechanisms for maternal and newborn health.

Duration
The didactic phase will be conducted in four (4) days.

Methodology
Different methods and activities shall be employed to meet the objectives of the
didactic phase, particularly participatory and hands-on methods. These include:
lecture/ interactive-discussions, brainstorming/case studies, group work/
experiential sharing, demo-return demo, plenary sessions and clinical exposure.
The participants will be provided with the opportunity to describe the skill,
demonstrate the skill, practice the skill and verify whether the task is being
performed proficiently.

17

18

Module 1

Overview of BEmOC and the

PCPNC Manual
Objective

To enable participants to understand BEmOC

and the use of the PCPNC Manual.

Topics

Overview of BemOC

Use of the PCPNC Manual

Duration

1 hour and 30 minutes

Session 1

Materials needed

BEmOC and the Use of PCPNC Manual

Metacards, pentel pens, masking tape, board,

LCD/OHP, presentation materials and handouts
on BEmOC and PCPNC Manual.

Specific objective
At the end of the session, the participants will be
able to understand BEmOC and the importance of
PCPNC Manual and its use.

Methodology
Warm-up exercise
Lecture-discussion
Reinforcement
Drill

10 min
30 min
10 min
40 min

Procedure

Explain the objectives and mechanics of the

session to the participants;

Provide each participant with 2 metacards, and
ask all of them to write their ideas about
BEmOC and post their cards in the board;

Summarize the contents of the metacards by
identifying patterns of responses;

After the summary of participants ideas, proceed with the lecture-discussion on BEmOC
and rationale and design of the BEmOC skills
training course;

19


Proceed with the Drill on the PCPNC Manual

by explaining the importance of knowing how
to navigate the contents of the manual, letting
the participants go over the guide, and asking
sample topics to identify pages and clarify contents; and

Synthesize the contents of the session and link
it with Module 2.
Refer to pages 91-98 of the Trainers Notes

20

Module 2

Principles of Good Care

Objective
To provide participants with the opportunity to apply the principles of good care to
all contacts between the skilled attendant and all women and their babies.

Topics

Communication
Workplace and administrative procedures
Universal precautions and cleanliness
Organizing a visit

Duration
1 hour

Session 1

Materials needed

Principles of Good Care

4 pcs. manila papers, pentel pens, masking tape,

board, LCD/OHP, PCPNC Guide, handouts and
CD/transparencies of presentation materials on the
Principles of Good Care.

Specific objective
At the end of the session, the participants should be
able to improve skills in applying the principles of
good care.

Methodology
Lecturette 10 min
Workshop 20 min
Plenary
30 min

Principles of Good Care

The principles of good care apply to all contacts
between the skilled attendant and all women and
their babies. These principles concern:

Communication

Workplace and administrative procedures

Universal precautions and cleanliness

Organizing a visit

21

Procedure

Explain the objectives and mechanics of the

session to the participants.

Divide the participants into 4 groups. Ask each
group to list down the principles of good care
to all contacts between all women and babies
on 4 concerns:

Communication;

Workplace and administrative procedures;

Universal precautions and cleanliness; and

Organizing a visit;

Instruct the groups to write their inputs on the
manila paper and post them on the wall/board
for presentation;

Each group will be given 2 minutes to present
their outputs. While a group is presenting,
other groups will act as observers and commentators. Each group should come up with a
summary of their presentation; and

Synthesize the workshop outputs and connect
them with the next modules topics.
Refer to page 99 of the Trainers Notes

22

Module 3

Quick Check and Rapid Assessment

and Management (RAM)
Objective

To enhance the clinical judgment of a health worker by identifying and prioritizing

patients through the application of Quick Check and RAM.

Topics

Quick check
RAM
Referral system
Emergency treatment for the woman
(repair of Laceration, IV insertion,butterfly, IV cannulation, bleeding,
eclampsia and pre-eclampsia and infection)

Duration

2 hours and 30 minutes

Session 1

Materials needed

Quick Check

3 pcs manila papers with three headings namely:

SIGN, CLASSIFY and TREAT, metacards with
descriptive words, LCD, chalk, board and 1 prize.

Specific objective
At the end of the session, the participants should
be able to identify and prioritize patients from the
group.

Methodology
Lecture-discussion
Contest/reinforcement

15 min
5 min/20 min

Procedure:

Explain the objectives and mechanics of the

session to the participants;

For the Contest Activity: Divide the participants into 3 groups and distribute to them
pink, yellow and green metacards with descriptive words of patients;

Ask each group to post the cards on the corre-

23

sponding heading in the manila paper. The

fastest group with the correct answers wins a
prize. Everybody participates in checking the
answers;

For the Lecture-Discussion Activity: Discuss
things that need to be considered during the
initial contact with the woman and child seeking care. Ask the participants to share their own
experiences or what they want clarified in the
discussion; and

End the session by synthesizing the topics
covered and connect them with the next session.
Refer to page 99 of the Trainers Notes

Session 2
Rapid Assessment and Management (RAM)

Materials needed
RAM chart, LCD, 5 drill exercises, manila papers,
pentel pens, masking tape, and board.

Procedure

Explain the objectives and mechanics of the

session and link it to the previous session;

For the Lecture-Discussion: Present the RAM
chart by discussing each item and clarifying questions/queries from the learners;

For the Drill/Exercise: Check participants comprehension by posing situations, and ask them to
step by step solve a specific problem following
the RAM procedure; and

Ask the participants to summarize what they have
learned from the session; and then proceed to
the next session.
Refer to page 99 of the Trainers Notes

Specific objective:
To enable the learners to:

Perform RAM to all women of childbearing,
labor and postpartum stages;

Assess emergency and priority signs, and give
appropriate treatment; and

Refer women to hospital.

Methodology
Lecture-discussion
Drill on RAM

24

20 min
10 min/drill (5 drills)/30
min

Case Study 1
Case Study 1 Quick Check and RAM
Problem
A young woman named Fatima, who is obviously
pregnant, arrives at the health facility with an older
woman. Fatima is complaining of severe abdominal
pain. What action would you take?
Additional Data Obtained During the RAM
Fatima has the following abnormal signs:

Cold moist skin

Pulse >120/minute

Severe abdominal pain
What does this mean?
Further assessment reveals that her blood pressure is
90/50 and the temperature is 40C. How will you
manage her?

Case Study 2

Quick Check and RAM

Problem
A woman named Umi arrives at the health facility
with her mother-in-law. She is obviously in
advanced pregnancy and appears distressed with
intermittent abdominal pain, which she says occurs
about every 5 minutes. What action would you take?
Additional Data Obtained during RAM
No emergency signs are detected and her vital
signs are the following: BP 100/70, PR 85, RR 20,
temperature 36.8C. Umi is found to be in labor.
What will you do next?

Session 3

After the sharing, explain the correct process of

referring patients based on the referral system. Request a participant to describe how she/he fills
up the referral form. The discussion should lead
to the correct way of filling up of form. Highlight
important points in the referral system. Let participants discuss their management system before
referring patients. Assist in the discussion by providing additional inputs. Also, ask participants to
enumerate sample cases needing referral.

Sum-up the discussion by emphasizing important
points in the referral system. Give assignment for
the next session.

Session 4

Referral System

Emergency Treatment for the Woman

Specific objective

Specific objective

At the end of the session, the participants should

be able to refer patients correctly.

Methodology
Interactive discussion 20 min

Materials needed
Short notes of own experiences, chalk, board,
LCD/OHP

Procedure

Recapitulate the previous session and link it with

the objectives and mechanics of Session 3.

For this Interactive Discussion: Ask participants
to share their own experiences in the field regarding referral of patients;

To provide the participants with the oppoprtunity

to practice the details on emergency treatment
identified during Quick Check and RAM.

Methodology
Lecture-discussion
Demonstration/Return Demo

30 min
1 hr/1 hr & 30
min

Materials needed
Arm Model, IV Butterfly/Cannula, Chicken
Breast, drugs, and supplies

25

With eclampsia and pre-eclampsia instruct the

participants to give magnesium sulphate, diazepam (if MgSO4 is not available), appropriate
antihypertensive drug, appropriate IV/IM
antibiotics, arthemeter or quinine IM (for malaria, and glucose IV);

During the Reinforcement Activity: Supported
with actual samples, familiarize the participants
with the different drugs. To check their comprehension, ask participants to identify active
drugs;

Let the participants do the Exercise on Correct
Amputation and Regulation of Fluid; and

Synthesize the contents of the session.
Refer to pages 99-102 of the Trainers Notes

Procedure

26

Start the session by asking participants to share

their experiences in the work place. Then link
these experiences with the objectives and mechanics of the session;

For the Lecture-Discussion, discuss the following:

anatomy of female genital tract including;

degrees of laceration; and

anatomy of the arm.

In the Demonstration/Return Demonstration
Activity: With bleeding instruct the participants to demonstrate the management of emergency treatment for the woman (massage uterus
and expel clots, apply bimanual uterine compression, apply aortic compression, give oxytocin, give ergometrine, remove placenta and
fragments manually, after manual removal of the
placenta, repair the tear and empty bladder).

Module 4

Antenatal Care
Objective
To enhance the knowledge, attitudes and practices of skilled health
attendants on quality antenatal care.

Topics

Process flow of antenatal care;

Skills necessary during antenatal care;

Importance of General Assessment of a Pregnant Woman during a Visit

Duration
1 hour and 15 minutes

Session 1

Materials needed

General Assessment of a Pregnant Woman During a

Visit

Quick Check and RAM Chart, manila paper, pentel

pen, masking tape, crayola, board, LCD and
handouts.

At the end of the session, the participants should be

able to understand the importance of doing an
immediate general assessment of the pregnant
woman upon consultation at the facility.

Methodology
Drawing
Plenary
Lecturette

15 min
30 min
30 min

Procedure

Recapitulate the previous session and link the

contents to the next topics objective;

Introduce the Game Activity: Tell the participants that they will be grouped into 3-5 members where each group represents their areas or
health facility. The groups are given manila
paper where they will make a symbolic drawing
of the new lesson;
27


After 15 minutes, ask them to post their outputs

on the board. A member of each group will
explain their work in relation to the new lesson
during the plenary; and

For the lecturette: Give additional inputs that
were not discussed during the plenary presentations. Then synthesize the session emphasizing
the salient aspects of the topic.
Refer to pages 103-104 of the Trainers Notes

Session 2
Process Flow of Antenatal Care

Specific objective
At the end of the session, the participants should be
able to improve their ability in explaining the process flow of providing quality antenatal care.

Methodology
Lecturette-discussion
Reinforcement
Role Play
Workshop

20 min
25 min
20 min
15 min/1 hr 20 min

Materials needed
35 metacards (pink, yellow & green), printed
handouts, 25 pcs. manila papers, pentel pen,
masking tape/paste, board, assorted art papers, 2
scenarios, observation tool, OHP/LCD,Quick
Check and RAM Chart, case studies,

28

Procedure

Recapitulate the previous session with the use of

metacards to check on the participants comprehension of Process Flow (e.g. emergency signs
encountered during visit; assessment of a pregnant woman, pregnancy status, birth and emergency plan; screening the pregnant woman/
checking and proper management of condition;
and response to observed or volunteered problems).

Ask them to comment on the process of: a)
elaboration, and b) classification. The posted
metacards represent the phases to be followed
in the discussion of the antenatal care (e.g. B1
Quick Check and RAM; B8 Emergency
Treatment for the Woman; and C0-C1
Antenatal Care). After everything has been
explained, let a participant make a brief summary of the activity;

Proceed to the Reinforcement Activity for
Quick Check and RAM and Emergency Signs
Encounter during Antenatal Care: Review first
the conditions relevant to antenatal care. Then
divide the participants into 3 groups and assign
each to work on a specific topic:


Airway and breathing (e.g. circulation/
shock and convulsions/ unconscious;


Vaginal bleeding (bleeding in early pregnancy, severe abdominal pain, not in labor);


Dangerous fever (other danger signs).

Provide the groups with the printed information on the metacards emergency signs
(white), measure (blue), and treatment (pink).
Let participants work for 15 minutes. Instruct
them to arrange the information materials accordingly (for example: Emergency sign what
signs, what will be done to measure it, how to
manage it) and paste the outputs in the manila
paper. The assigned leader of each group will

Case Study 3 Antenatal Care

Ita is on her 6th month of pregnancy. She feels warm
and unwell. Her sister-in-law accompanies her to the
clinic. What would you do?
Additional Data during Quick Check
You elicit the information that Ita has burning urination
and is febrile. Ita also looks very ill. What will you do
next?
During RAM
Itas blood pressure is 110/70 and her temperature is
38.6C. She is ambulatory. No other signs were noted.
How will you manage her?

explain their output. Ask other groups to observe and comment on the presentation.
Congratulate the participants for their work.
Then summarize the topics discussed by highlighting the salient features. Provide the participants with reading assignments for the next
topic.
Introduce the Role Play Activity on the topic
Assessment of a Pregnant Woman, Pregnancy
Status, Birth and Emergency Plan. Tell the
participants that they will be divided into 3
groups. The 2 groups will work on a scenario
while the third group acts as observers. The
observers will give their comments on: good
points; what have been missed; and areas for
improvement.
Lead the discussion to the expected outputs of
the presentations. After the presentation, ask a
volunteer to sum up the activity. Provide a
synthesis of the topic discussed.
Proceed to the Workshop on Development of a
Birth and Emergency Plan. Instruct the participants that same groups will work together to
come up with a birth and emergency plan.
Each group will present their outputs written in

a manila paper. After the presentations, summarize the outputs and link them with the next
topic for discussion.

Facilitate the next topic, Screening the Pregnant Woman, a Lecturette-Discussion. Ask the
participants to share their own experiences, and
then answer/clarify questions. Request a participant to summarize. Provide a synthesis of the
discussions and then proceed to the next topic.

Explain that Lecture-Discussion and Reinforcement Activities will be employed in the topic,
Response to Observed Signs or Volunteered
Problems. Begin the discussion by using the
Case Study 4 Antenatal Care
Problem
Effie finds the antenatal clinic for the first time on her
seventh month of pregnancy. She looks thin and pale.
Explain the care you would give.
Additional Data during Quick Check
No emergency or priority signs are revealed so Effie is
asked to wait in line. Her blood pressure is 100/80 and
her temperature is 36.7C. What will you do next?
Data Obtained during Antenatal Care
Effie is 29 years old. She has 6 previous pregnancies,
including one miscarriage and one stillbirth. One
pregnancy was also complicated by postpartum
hemorrhage and a manual removal of the placenta.
Where will you recommend the delivery of the present
pregnancy?
On further check, Effie is noted to have
conjunctival pallor and her hemoglobin is 70 g/l. How
will you manage her?
Tactful questioning on HIV status reveals that
Effie has recently been tested positive for HIV,
following a positive test result for her husband.
What will you do next?

29

Quick Check and RAM. After this, instruct the

participants to work in pairs in doing a case
study. Let them write their outputs in the manila
paper and explain them during the plenary
presentation. Other participants will observe
and comment on the presentation. End the
discussion by providing a synthesis.

Proceed with the last topic in this session, Preventive Measures by explaining the objectives
and mechanics of the Lecture-Discussion and Reinforcement Activities. Discuss the topic focusing on how to:


give preventive measures;


advise and counsel on nutrition and self-care;


advise on labor and danger signs;
conduct routine and follow-up visits


do newborn screening; and


undergo home delivery without a skilled attendant.

In the Reinforcement Activity, divide participants
into 5 groups where each group will employ a
methodology, e.g. role-play, simulation, demonstration, lecturette, etc. Instruct them to demonstrate their understanding of the topic with
the use of a selected methodology. Each group
will be given 10 minutes for preparation and 15
minutes for presentation. Ask other groups to observe and comment on the presentation. Summarize the outputs.

End the session by synthesizing major learnings
from the different topics discussed, gaps in the
discussion and areas for improvement.
Refer to pages 103-104 of the Trainers Notes

30

Case Study 5 Antenatal Care

Problem
Yani is 15 years old. She goes to the health facility
for the first time with her mother on her 3rd month of
pregnant complaining of fresh vaginal bleeding. What
will you do next?
Additional Data during Quick Check and RAM
The only abnormality found is light vaginal bleeding
with no clots. After 6 hours, the bleeding decreases
and Yanis vital signs are stable. How will you
manage her?

Session 3
Skills Necessary during Antenatal Care

Specific objective
To enable learners to perform the procedures and skills
correctly and easily.

Methodology
Lecture-discussion
Demonstration/Return Demo

10 min
20 min/30 min

Materials needed
LCD

Procedure

Recapitulate the previous topic and link it with

the next topic. After explaining the objectives of
the session, proceed with the Lecture-Discussion on Complete PE of a Pregnant Woman,
Leopolds Maneuver & Fetal Heart Beat;

Summarize the discussion and proceed to the

Demonstration/Return Demonstration Activity.

Let the participants work in pairs wherein each
skill is performed by one learner to his/her
partner, and afterwards, exchange roles.

Once the skills have been performed, randomly
ask the participants about their experiences
while performing the skills and following the
procedure.

The session ends with a synthesis.

Case Study 6 Antenatal care

Teresa is 23 years old, G 2 P1 on her 8 month age of
gestation, with companion. She had an adequate
prenatal check up (all normal). Had a traumatic
experience during her last delivery, doesnt want to
deliver in a hospital. However, she is new in the area,
doesnt know any skilled attendant, wants a home
delivery or a birthing home. What is your advise?

Case Study 7 Antenatal Care

Martha is 38 years old G8 P7, went to visit the facility
because of dizziness and severe anemia. All her
deliveries according to her, were all normal and at
home. Upon examination: BP 160/90, with blurring of
vision, with her condition she is still insisting to have a
home delivery (all her deliveries were handled by a
Hilot). What is your advise for a birth or emergency
plan?

31

Module 5

Labor, Delivery and

Immediate PostPartum
Objective
To improve participants skills in assessing and managing a woman in labor,
during and after delivery, and until her discharge from the health facility.

Topics
Stages of labor
First stage of labor
Second stage of labor
Third stage of labor

Duration

5 hours and 20 minutes

Session 1
Stages of Labor

Specific objective
At the end of the session, the participants should be
able to:

recognize and assess the womans and fetal status at the time of admission; and

decide stage of labor after complete rapid assessment on admission.
32

Methodology
Lecture-Discussion

30 min

Materials needed
LCD/OHP, CD/transparencies of presentation
materials, white board marker, board, slides presentation and PCPNC Guide

Procedure

Present the objectives of the session and link it

with Module 4.

Proceed with the Lecture-Discussion on the
topics Examine the Woman in Labor or with
Ruptured Membranes and Decide the Stage of
Labor. This is an interactive discussion where
participants are enjoined to ask questions or
clarify gray areas, while randomly asking participants with questions to check their comprehension.

The session ends with a summary of the discussions.
Refer to pages 105-107 of the Trainers Notes

Session 2
First Stage of Labor

Specific objective
At the end of the session, the participants should be
able to:

identify abnormal findings in a woman while
assessing pregnancy and fetal status on admission;

manage identified abnormal findings in a
woman during labor;

provide supportive care for a woman in labor;

and

review and develop skills needed while attending to a woman in labor.

Methodology
Pre-Test/Game
Lecture
Case Study
Small Group Discussion
Plenary
55 min

15 min
30 min
30 min
30 min
10 min/1 hr &

Materials needed
QC and RAM Chart, 4 big cards with letters A-D,
prize, OHP/LCD, N4-N5 of PCPNC, 2 case
studies, Partograph and Labor, record acetate (4
sets), manila paper, pentel pens, masking tape and
board

Procedure

Introduce the new topic with the use of Quick

Check and RAM Chart.

In the Pre-Test/Game Activity on the topic
First Stage of Labor Respond to Obstetrical
Care and Provide Supportive Care, tell participants that they will be divided into 4 groups.
Each group is given 4 big letter cards A-D.
Once the groups have been provided their
cards, give a situation and mention 4 choices
(A-D) wherein one of these is the best course of
action to take. The groups will raise the corresponding letter they think is the correct answer.
The fastest group with the correct answer wins
a point, and the group with the most number of
points wins the game.
33

Pre-Test Game
Topics from:

1st Stage of Labor

Respond to OB problems

IE, Partograph and Labor Records
Q1.Classification of > 4 cm cervical dilatation late
active phase
a. early active phase*
b. early labor
c. not yet in labor
Q2. If a woman is not in active labor, discharge
her and advise her to return if, EXCEPT:
a. vaginal bleeding
b. discomfort*
c. membranes rupture
d. uterine contraction
Q3. Signs of obstructive labor, EXCEPT:
a. horizontal ridge across lower abdomen
b. continuous contraction
c. moderate abdominal pain*
d. labor > 24 hours
Q4.Considered as obstetrical complication,
EXCEPT:
a. abdominal pain*
b. FHT = 100x2 determinations
c. Pulsation felt during IE
d. 2 fetal heart tones
Q5.All are correct regarding supportive care
throughout labor, EXCEPT:
a. tell the woman what position to take to relieve
discomfort or pain during labor*
b. a birth companion should be around to watch the
woman in labor*
c. encourage the woman to eat and drink as she
wishes throughout the labor
e. explain all procedures to be done to the woman

34

Q6.During active labor

a. monitor the woman every 30 minutes
b. do not do vaginal exam more frequently than every
4 hours unless indicated
c. both a and b*
d. none of the above

Proceed with the topics on IE, Partograph

and Labor Record employing lecture-discussion, small group discussion and plenary presentations. In the Lecture-Discussion Activity,
introduce the procedures and forms. While
explaining the procedure on Leopolds
Maneuver, demonstrate it to one of the participants. Questions and clarification are elicited
during the demonstration, afterwards, proceed
to the discussion of a Partograph and Labor
Record.

For the Small Group Discussion, divide participants into 4 groups, where 2 groups work
separately on one case and the other 2 groups
work on the other case. Instruct the groups to
analyze the cases relating them with the topics
being discussed in 30 minutes.

In the Plenary, the leader of each group will
present the outputs, while other groups observe and give comments on the presentation.
Ask one of the learners to summarize the
discussion.

End the session by providing additional inputs
and synthesizing the different topics covered.

Lecture-Demonstration

30 min/50 min

Materials needed
OHP/LCD, AVP

Procedure

Refer to pages 108-109 of the Trainers Notes

Session 3
Second Stage of Labor

Specific objective
At the end of the session the participants should be
able to:

describe the course and conduct of normal
delivery; and

review and describe steps in the management of
breech delivery, stuck shoulder, multiple fetuses
and cord prolapse.

Explain the objectives of the session and link it

with the previous topic by recapitulating the
contents of the discussion;

For the Lecture-Discussion on Delivery of the
Baby, discuss the topic using illustrations from
audio-visual production. This is an interactive
discussion where questions and sharing of own
experiences are encouraged from participants.
Summarize the discussion and explain that
Immediate Care of Newborn will be discussed
in Module 7.

Proceed with the Lecture-Demonstration on
normal vaginal delivery, breech delivery, stuck
shoulder, dystocia, multiple births and cord
prolapse by first introducing the important
skills needed. Explain the principles while
demonstrating the procedure. This is an interactive activity where sharing of own experiences
and questions are encouraged from the participants.

The session ends with synthesis and explanation that skill enhancement will be done during
the clinical period.
Refer to pages 110-115 of the Trainers Notes

Session 4
Third Stage of Labor

Methodology
Lecture-Discussion

20 min

Specific objective

35

At the end of the session, the participants should be

able to:

describe steps in the delivery of placenta;

determine active management of the 3rd stage
of labor;

assess and manage the mother during and after
the 1st hour of complete delivery of the placenta
until discharge from the health facility;

identify and manage problems encountered in
the mother immediately postpartum; and

provide preventive measures to the mother
after delivery.

Methodology
Lecture-Discussion
Lecture-Demonstration
Case Study
Plenary
Didactic with Illustrations

30 min
30 min
30 min
20 min
15 min/2 hrs & 5 min

Materials needed:
AVP, LCD/OHP, 2 case studies, manila papers, pentel
pens, masking tape and board

Procedure:

Recapitulate the previous session, explain the

objectives of the new session and link it with
past topics;

For the Lecture-Discussion on the Delivery
of the Placenta, discuss the topic with the use
of visuals. Tell participants to share their own
experiences and ask questions to enrich the
discussion. Ask one of the participants to summarize the discussion;

Proceed to the next topics:
36


Care of the mother and newborn within first

hour of placenta delivery;

Care of the mother 1 hour after delivery of
placenta; and


Assessment of the mother after delivery and
before discharge through Lecture-Discussion.


Discuss the topic with the aid of illustrations, and sharing of experiences from the
participants.


Ask one of the participants to summarize
the discussion;
Continue with the next topic, Respond to
Problems Immediately Postpartum. Using the
case study method, the participants are divided
into 4 groups where 2 groups work separately
on 1 case study, and the other 2 groups work
separately on another case. Let the groups
work for 30 minutes and ask them to put their
outputs in the manila paper;
During the Plenary, tell the first 2 groups with
the same case to present their outputs. Ask the
other groups to observe and give comments.
After the presentations, ask the next 2 groups
to present their case study outputs. The other
groups observe and give comments. Summarize the outputs of the 4 groups;
Proceed with the last activity, Didactic Illustrations on:


management of abnormal stage of labor;
and


active management of 3rd stage of labor.
The discussion of the topic starts with an
explanation of the important skills needed by
the participants. Explain the principles while
demonstrating the procedure. This is an interactive activity where sharing of own experiences
and questions are encouraged from
participants.

Case Study 8 (Groups 2 and 4)

During the summary, mention that skill enhancement will be done during the clinical
period and the abnormal 3rd stage of labor will
be discussed in emergency measures.

The session ends with the synthesis of all the
topics covered.
Refer to pages 116-119 of the Trainers Notes

Christine M. 18 years old G2 P1 came in because of

lumbo-sacral and abdominal pain which started 1 hour
ago. No other associated signs and symptoms.
During ASK, CHECK RECORD, it was found out
that Christine is single, no prenatal check-up done
because she claimed her baby is moving throughout
the pregnancy. She expects to deliver anytime this
week.
You now perform the physical examination. Vital
signs are normal including fetal heart rate. The
abdomen is term size, uterine contraction is mild, 1-2x/
10 min. You now perform vaginal examination which
revealed: cervix 1 cm dilated, not effaced, no vaginal
bleeding nor watery discharge. So you sent her home
since she is living 5 minutes away. However, 8 hours
later, she returned to your clinic with bloody-mucoid
vaginal discharge, mild to moderate uterine
contractions 2x/10 min., IE cervix 4 cm dilated,
cephalic, station -2, (+) BOW. You monitored her every
hour.
4 hours later, IE cx 7-8 cm, BOW spontaneously
ruptured, thinly-meconiumsatained AF. She voided
urine = 120 cc, uterine contraction 2-3x/ 10 mins. modstrong.
2 hours later, IE 9 cm, st +1, vital signs still
normal.
30 minutes later, you noticed that the vulva was
gaping, you did an IE fully dilated, station +2 to +3.

37

Case Study 9 (Groups 1 and 3)

Cheska O. 32y/o G3 P2 came to the health facility at
3:00 AM, few minutes apart, she told you that uterine
contractions occurred 2x in 10 minutes, 40-60 sec.
Duration, moderate strong. On PE, vital signs were
all normal, she claimed that she has not voided urine
for 6 hours now, no urge to void till now.
IE -4 cm cervical dilatation, cephalic, BOW (-)
with clear amniotic fluid admixed with scantly bloodymucoid material. Still unable to void, you did bladder
catheterization obtaining 200 cc.
At 7:00 AM, IE cervix was 8-9 cm dilate,
station 0, clear AF, FHR 156 / min. BP 140/100,
uterine contraction now strong, 3x in 10 min. Patient
voluntarily voided amounting to 130 cc, vital signs
remains within normal limits, BP now = 130/80.
At 8:00 AM, patient complained that something
was about to come of her vagina. IE revealed that full
cervical dilatation, fully effaced, cephalic, station +2,
clear AF.
Materials to use
1) Labor Record 2) Partograph.

38

Module 6

Postpartum Care

Objective
To enhance participants capability in recognizing and responding to observed
signs or volunteered problems of mothers so they can provide preventive measures
and additional treatment.

Topics

Postpartum examination of the mother up to six weeks;

Respond to observed signs or volunteered problems; and

Preventive measure and additional treatment

Duration
1 hour and 10 minutes

Session 1
PostPartum Examination of the Mother Up to Six
Weeks

Specific objective
At the end of the session, the participants should be
able to:

assess and examine the mother after discharge
from the facility; and

conduct complete history and physical examination of a mother after discharge from a facility.

Methodology
Lecture-Discussion

15 min

Materials needed
Examination Chart for mothers after discharge and
powerpoint presentation/transparencies

Procedure

Recapitulate the previous session, link it to the

next topic by explaining the objectives of the
new session;

During the Lecture-Discussion, present the first
side of the chart (Ask, Check Record, Look,
Listen, Feel) to be used for examining the
39

mother after discharge from a facility or after a

home delivery. This is an interactive discussion
where participants share actual experiences and
relate these with the sessions topic; and

End the session by providing synthesis of the
topic discussed.
Refer to pages 120-121 of the Trainers Notes

Session 2
Respond to Observed Signs or Volunteered Problems

Specific objective
At the end of the sesssion, the participants should
be able to:

differentiate abnormal from normal signs and
manage appropriately and accordingly; and

recognize volunteered problems of a woman
after discharge from a facility and to properly
manage them accordingly.

Methodology
Lecture-Discussion
Workshop/Pyramiding
Critiquing/Plenary

10 min
30 min
30 min

Materials needed
Handouts/PCPNC Manual, OHP/LCD, Chart,
paper, pencil, manila paper, pentel pen and masking
tape

Procedure

Recapitulate the previous session, link it with

the new topic by discussing the sessions objectives;

During the Lecture-Discussion on Observed
Signs or Volunteered Problems, explain the
Ask, Check Record/Look, Listen, Feel part of
the chart. Encourage participants to ask questions or clarify gray areas in the discussion;


In the Workshop Activity, divide participants into 4 and let the groups analyze the
problems, and based on their experiences
answer the following:

what problematic signs will they observe
on postpartum mothers;

how do they classify the problematic
signs observed;

what treatment do they give and the
possible advise regarding the problematic
signs.

Provide participants with the format in preparing their responses (Chart). After 30 minutes,
let each group present outputs, while other
groups provide comments or additional inputs;

Ensure that the discussion results to the expected output from the manual for faster
Teaching-Learning process. Ask participants
about their reasons for the responses given, and
after the discussion summarize the important
points covered in the session;

For the postpartum sessions, synthesize pregnancy from antenatal to postpartum care
through simulation or role play by the participants.
Refer to page 121 of the Trainers Notes

40

Observed Signs or Volunteered Problems

If Elevated Diastolic Blood Pressure

If Pallor (Check for Anaemia)
If Signs Suggesting HIV
If Heavy Vaginal Bleeding
If Fever or Foul-Smelling Lochia
If Dribbling Urine
If Pus or Perineal Pain
If Feeling Unhappy or Crying Easily
If Vaginal Discharge 4 Weeks After Delivery
If Breast Problem
If Cough or Breathing Problem
If Taking Anti-TB Drug

Procedure

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives;

During the Lecture-Discussion, explain the
preventive measures that need to be considered
for the women. This is an interactive discussion
encouraging sharing of own experiences and
clarification of important points.

At the end of the discussion, ask one of the
participants to summarize the discussion.

End the session with a synthesis of the topic
covered in the discussion.
Refer to pages 121-122 of the Trainers Notes

Session 3
Preventive Measures and Additional Treatments

Specific objective
To enable participants to provide preventive measures and additional treatments to a woman after
discharge from a facility including immunization,
vitamin K, folic acid, ebendazole, antimalarial treatment, etc.

Methodology
Lecture-Discussion

15 min

Materials needed
OHP/LCD, handouts and PCPNC Manual

41

Module 7

Newborn Care
Objective
To enable health workers care for the newborn baby by developing the appropriate skills and needed knowledge.

Topics
Care of the newborn at the time of birth;
Newborn resuscitation;
Examination of the newborn baby; and
Care of the normal and small babies until discharge from the
health facility.

Duration
6 hours and 40 minutes

Session 1

Materials needed

Care of the Newborn at the Time of Birth

board and chalk/white board and pen, LCD and

computer/OHP, undressed doll, and bed

Specific objective
At the end of the session, the participants should be
able to describe and carry out routine care of the newborn at the time of birth.

Methodology
Interactive Discussion
Demonstration

42

50 min
10 min/1 hour

Procedure:

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives;

Lead an interactive discussion on the following
topics:


basic needs of the newborn


preparing to meet the babys needs


universal precautions


initial care of the baby at birth


keeping the baby warm


cord care

Session 2
Newborn Resuscitation

Specific objective
At the end of the session, the paticipants should be
able to:

assess and identify newborns needing resuscitation;

perform resuscitation of the newborn using
standard guidelines; and

provide after care if a baby requires help with
breathing.

Methodology
eye care


Vitamin K injection


keeping the mother and baby together after
delivery


babys first breast feed.

With the undressed doll on the table, ask participants about the basic needs of the newborn
at the time of birth. Accept all the responses
and show the appropriate card on the table as
each of the 4 main points are mentioned. Then
ask participants what they should do to prepare
for and what to do during the delivery of the
baby and why. The responses of the participants
are written on the board, after which, the
trainer compares their responses with the recommendations in the manual.

The session ends with a synthesis.

Refer to pages 123-135 of the Trainers Notes

Lecture-Discussion
Lecture-Demonstration

1 hour
1 hour/2hours

Materials needed
OHP/LCD and computer, PCPNC Manual/
Handout, Maniquin, self-inflating bag, mask size 0
& 1, suction tube/suction device, 2 towels and
clock

Procedure

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives;

During the Lecture-Discussion on Preparing
for Birth and Essential Items for Resuscitation
of the Newborn, discuss things to be considered in preparing for birth and explain the
necessity of the items needed in resuscitation of
newborn. Ask participants relevant questions to
check their comprehension of the topic and
summarize the discussion once finished;
43

Session 3
Examination of the Newborn Baby

Specific objective
At the end of the session, the participants should be
able to:

describe and carry out an examination of the baby
soon after birth, before discharge from the hospital, during the first week of life at routine, followup and sick newborn visit; and

assess, classify and treat a newborn using the
Examine the Newborn chart.

For the Lecture-Demonstration on Steps in
Resuscitation and Care After Resuscitation,
demonstrate the steps and ask learners whether
they comprehend the discussion. Summarize the
topic and link it with the next activity.

Proceed with the Workshop Activity: Tell participants that they will be divided into 4 groups.
Each group will be given the same scenario to
enhance decision-making skills on when to
start, continue or stop resuscitation. Instruct
participants to demonstrate the proper techniques in resuscitation using the appropriate
equipment to be assisted by facilitators. During
group presentation, the other groups observe,
give comments and provide additional inputs to
the presentation.

The session ends by asking participants if they
have questions, and provide synthesis to all the
topics discussed.
Refer to pages 135-155 of the Trainers Notes
44

Methodology
Lecture-Discussion
Workshop
Plenary

30 min
15 min
15 min/1 hr

Materials needed
LCD and computer, 3 case studies, manila paper,
pentel pens and masking tape and powerpoint
presentation/transparencies

Procedure

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives;

In the Lecture-Discussion on Examination of
the Newborn, discuss the chart, give ideas on
what questions to ask the mother regarding her
baby and explain how to examine the baby and
what things should be observed on the baby
until discharge. Ask participants questions
during the discussion to determine comprehension, summarize the topic and link it with the

next activity.

For the Workshop Activity, group participants
into 3 where each group is given a case to work
on. Using the chart, the groups will classify the
babys condition and give the appropriate
treatment and advise. After 15 minutes, ask the
groups to post their outputs on the board.

During the Plenary, ask the leader of each
group to present their outputs while other
groups act as observers and give comments or
additional inputs on the presentation. Ask for a
volunteer to summarize the discussions.

The session ends with a short input and synthesis of the discussion.
Refer to page 156 of the Trainers Notes
Case Study 10
Rosie is a preterm baby who was delivered an hour
ago at about 35-week gestation weighing 1800g. At
birth she started breathing spontaneously. She has
not suckled at the breast, although her mother tried to
feed her about half an hour ago.
The health worker assesses Rosie at one hour
of life. She checks the maternal record to determine if
Rosie needs any special treatment and finds that the
mother did not have any problems or illnesses during
pregnancy. Her membranes ruptured 1 hour before
delivery. She also asks the mother if she has any
concerns.
She learns that the mother is anxious because
Rosie does not want to suck. On examination, she
finds that Rosies temperature is 36C. No abnormal
findings noted.
Q: Based on these findings, how do you
classify Rosie and how will you proceed?
After 1 hour Rosies temperature is 36.8C. Her mother

was able to feed Rosie breast milk which was dripped

into her mouth as she only made a feeble attempt to
suckle the breast. After short periods of suckling at the
breast, breast milk is expressed into Rosies mouth to
ensure that she has an adequate intake of milk.
Although Rosies mother is healthy and could go
home, she arranges with her family to take care of the
other children so that she can stay with Rosie in the
hospital. Breastfeeding gradually improves during the
next 2 to 3 days and special support is given. The
mother is encouraged to breastfeed exclusively.
Rosie is fed two times hourly and by the 3rd day of life,
she no longer requires additional breast milk
expressed into her mouth. Rosie is weighed daily and
loses 10% of her birthweight (180 g) in the 1st three
days of her life. On the 4th day her weight is static and
thereafter she starts to gain weight daily.
Q: How do you know if the baby is gaining
weight?
Q: When should Rosie receive vaccinations?
What vaccinations should be given?
Rosie is ready for discharge on the 7th day after birth.
She is now breastfeeding exclusively and has gained
weight and now weighs 1700 g. Health worker carries
out pre-discharge examination again. Rosie is
examined for local infection and jaundice. There is no
jaundice nor other complications.
Q: How will you classify Rosie at this point?
What will be the criteria for discharge?
Q: How would you follow up this baby after
discharge?

45

Case Study 11
Joe was born 6 hours ago by vacuum extraction for
fetal distress. His weight is 2500 g. He required
resuscitation at birth but started to breathe
spontaneously after 4 minutes. At 1 hour of life he
made feeble attempt to suckle at the breast but has
had breast milk expressed into his mouth on two
occasions. Now the mother is calling the health
worker urgently because Joe is having convulsion.
The health worker goes to the mother immediately
but by the time she gets there Joe has stopped
convulsing but looks very pale. On examination, it
was found that Joe is not able to feed; he is cyanosed
around his mouth, looks very pale and feels stiff.

Hygiene is poor and Daisy has erythematous papular

rashes on her buttocks.
Q: What are the medical problems can you identify
using the flow chart? What should be done?

Session 4
Care of the Normal and Small Babies Until Discharge from the Health Facility

Specific objective
At the end of the session, the participants should be
able to describe and carry out the everyday care of
the baby.

Case Study 12
Daisy is brought to the health facility by her mother
and grandmother when she was 4 days old because
she will not feed and is very fretful. She had a normal
birth at term, breathed immediately and weighed
2700g. On discharge from the health facility 12 hours
after birth she was a well baby and breastfeeding well.
The mother has had 2 previous live children, but her
second baby was about 4 weeks preterm and died at
home at the age of 3 weeks. The only record for cause
of death is failure to thrive.
The health worker checks the records and finds it
unremarkable. Upon query, it was found out that Daisy
has been fretful and not feeding well for the last 2
days. Daisy was breastfeeding 6 times a day and to
try to settle her, she has been given mashed banana
and pacifier when she cries. She has lost 300g since
discharge from the health facility 3 days ago. The
umbilicus and surrounding skin are red. The mother
denies having put any substances on the umbilicus.

46

Methodology
Interactive Discussion
Lecture-Demonstration

20 min
40 min/1 hour

Materials needed
board, chalk, whiteboard pen, PCPNC Manual,
LCD and computer, and powerpoint presentation

Procedure

Recapitulate the previous session, link it with

the new topic by discussing the sessions objectives;

During the Interactive Discussion, tell participants to
write important points in the board based on the
following questions:


how long do mothers and babies stay in the
health facility;


what reasons may delay a baby from being

discharged from the health facility; and

when is the best time to teach the mother
how to take care of her baby.

Enumerate the responses, provide additional
inputs, sum up the discussion and link it with
the next activity; and

For the Lecture-demonstration, introduce the
activity by asking participants what they need to
teach the mother how to take care of her baby.
Proceed to discuss and demonstrate cord care,
hygiene, eye care, and keeping the baby warm.

End the session with a synthesis of all the topics
covered.

Refer to pages 156-159 of the Trainers Notes

47

Module 8

Counseling
Objective
To enable health workers to develop counseling skills to communicate effectively with women,
their partners and families on the essential routine and emergency care of women and newborn during pregnancy, childbirth, postpartum and post-abortion periods.

Topics

Basic facts about counseling; and

Applying the counseling skills.

Duration
2 hours and 30 minutes

Session 1

Materials needed

Basic Facts about Counseling

OHP/LCD and computer, metacards, pentel pens,

masking tape, board, powerpoint presentation/
transparencies

Specific objective
At the end of the session, the participants should be
able to:

Define counseling and interpersonal
communication; and

Discuss principles of counseling and interpersonal communication.

Methodology
48 Interactive Discussion 40 min

Procedure

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives;

During the Interactive Discussion Activity,
provide participants with metacards and ask
them to write all the things they know about
counseling based on the guide questions.
Participants will be made to work on their
responses for 10 minutes, after which they will
paste their cards on the board.


After all the participants have pasted their cards,

the trainer categorizes the responses according
to:


what they know;


why there is a need for counseling;


how to counsel mothers, partners and
families; and


characteristics of good counseling.

End the session by providing additional inputs,
synthesizing the discussion and linking it with
the next topic.
Refer to page 160 of the Trainers Notes

Session 2
Applying the Counseling Skills

Specific objective
At the end of the session, the participants should be
able to:

Demonstrate effective communication skills; and

Demonstrate appropriate counseling techniques
in the different maternal health situations.

Methodology
Lecture-Discussion
Role Play
Observation/Plenary
Group Work

1 hr and 15 min
40 min
30 min
10 min/2 hrs & 35
min

Materials needed
LCD and computer, slides, PCPNC Manual,
observation tool, board and chalk

Procedure

Recapitulate the previous session, link it with

the new topic by discussing the sessions objectives;

During the Lecture-Discussion, provide inputs
on the following issues:


HIV;


family planning;


post-abortion;


adolescent pregnancy; and


violence against women/VAW.

Participants will be encouraged to ask questions
or share own experiences with regards to the
issues being discussed. Sum up the discussion
and proceed to the next activity;

Ask for a volunteer from the participants who
will act as the mother or relative of the mother.
Demonstrate critical skills.

For the Role Play, instruct participants to group
themselves into 4 where each group portrays a
scenario or a counseling session on the following:


HIV;


woman with special needs;


family planning; and


post abortion.

Participants will be asked to prepare for their
presentation in 15 minutes and after which
present a 10 minute play; and

During the Plenary, select 4 participants to
serve as observers/critique. They will look into
the strong points and areas for improvement of
the counseling session. After all the groups have
presented, the 4 observers will present their
49

comments for 10 minutes while you write the

important points on the board, and provide
additional inputs for clarification during the
discussion. A participant will be asked to summarize the outputs.

End the session by synthesizing the discussions.
Refer to pages 161-162 of the Trainers Notes

50

Case study 14 Post Abortion and Family

Planning
A 35 year old woman had recent completion
curettage (cc) on her fifth pregnancy. She had an
incomplete abortion 5th month of gestation. She felt
guilty because her fetus happens to be a boy, for
she had a daughter. However, her recent cc
happens to be an emergency one. She had a blood
transfusion and was advised not to get pregnant in 3
years time. Her husband is very quiet.
What will be your appropriate counseling?

Case study 13

Case Study 1
5 HIV
15

Client:
I am worried what my husband will say when he finds
out I have lost the baby, and whether he will blame me
or think I did something.
Counselor:
What is the worst thing that your husband can do to
you?

A 28-year old G2 P1, 12 weeks AOG, went to your

facility for the first time with her husband, an overseas
worker who just arrived from Saudi Arabia.
Feeling guilty, the husband admitted to his wife
that he has been diagnosed to be HIV+3 years ago
while abroad.They are now very worried about the
baby being infected and are thinking of terminating
the pregnancy?
What will be your appropriate counseling?

Image from Midwives Manual on Maternal Care, Department of Health, 2000

Module 9

Mobilizing Community Support

Objective
To enable participants establish community support mechanisms for
maternal and newborn health.

Topic
Establishing Links

Duration
40 minutes

Session 1

Methodology

Establishing Links

Interactive Discussion
Lecturette

Specific objective
At the end of the session, the participants should
be able to:

Identify partners and members of the community who can become part of the support
group; and

Develop strategies/mechanisms to encourage
active community participation in supporting
maternal and newborn health.

30 min
10 min

Materials needed
LCD and computer, powerpoint presentation,
chalk and board

Procedure

Recapitulate the previous session, link it with the

new topic by discussing the sessions objectives.

51


The Interactive Discussion starts by

asking participants with the following
questions:


what groups/organizations they have
in their own areas; and


what kind of services or assistance these groups provide to
the communities.

Write the responses on the board,
and after all responses have been
noted, categorize and summarize
these for the learners. Proceed to
provide additional inputs to expound
on the discussion and clarify issues.

In the lecturette on Community
Participation/Support, begin with the
discussion by asking participants
whether it is necessary for the community to be involved in maternal and
newborn health. Responses will be
written on the board, and after
which you summarize the
outputs and provide additional inputs on the topic.

End the session with a synthesis
of the discussion.
Refer to pages 163-164 of the Trainers
Notes

Image from Midwives Manual on Maternal Care, Department of Health, 2000

52

Practicum
Objective
To enhance the competencies of participants in applying basic emergency obstetric care to all women and their babies.

Duration
The practicum activities will be conducted in seven (7) days. This
period includes on-site orientation, clinical work in the areas of assignment and mid-practicum assessment.

Methodology
A mix of methods such as observation, hands-on/experiential learning
and coaching will be employed during the practicum phase.

53

54

Module 1

Orientation on the Practicum

Objective
To familiarize participants with the overall objectives
and mechanics of the practicum phase.

Topics

Objectives and mechanics of the practicum

Expected outputs from the participants

Areas for exposure

Duration
2 hours

Materials needed

Session 1

Forms, Skills requirements handouts, board and

chalk/whiteboard pen

Pre-Practicum Orientation

Specific objective
At the end of the session, the participants will be
able to understand the objectives of the practicum,
methodology, schedule of activities and know the
hospital heads, area facilitators and preceptors.

Methodology
Lecturette
Interactive Discussion

30 min
1 hr & 30 min

Procedure

Explain the objectives of the session and link it

with the didactic phase;

Divide the participants into teams of 4 (physician, nurse, midwife and MCH Coordinator as
monitoring officer). Explain to the teams the
objectives, methodology, schedule of activities
and the personnel they will be working with at
the hospital/health facility (e.g. hospital heads,
area facilitators and preceptors); Discuss the
areas for exposure (e.g. OPD, ER, LR, DR,
55

Ward and Post-discharge) and the expected

outputs from the participants. Explain that they
have to go on duty to see and experience the
real situation, especially in handling a patient
from the emergency room;

Provide them with the forms containing the
skills requirement and explain the process of
filling-up and submission. Allow time for
comments and questions. Encourage the participants to voice out their apprehensions or
fears if there are any;

Instruct the participants to refer to the
PCPNC manual when necessary; and

End the session by synthesizing the topics
covered.

Practicum Requirements

Scrub suit
Smock gown
Cap and masks
Slippers
Colored ID picture (2x2)
Completion of requirements
Evaluation test
Full attention and cooperation

Example of Team Schedule for Area Assignments during

Practicum Phase
Area

ER
LR
DR
Ward
OPD
Postdischarge
(2nd F/OPD

Mon (Aug 2)

Tue (Aug 3)

Wed (Aug 4)

Thu (Aug 5)

AM

PM

AM

PM

AM

PM

AM

1
2
3
4
5
6

2
3
4
5
6
1

3
4
5
6
1
2

4
5
6
1
2
3

5
6
1
2
3
4

6
1
2
3
4
5

Note: Sample schedule was used during the pre-test of

this BEmOC Skills Training Guide on July 26-August 6,
2004.

56

PM

Skills Requirements per Category of Service Provider per Facility

No. of Requirements per Category of Service Provider Per Team

Skills Requirements
ER
1. IV Insertion
2. Skin testing
3. Intravenous (IV push)
to include
antibiotics
4. IM injection of Mag
sulfate loading with
monitoring of vital sign
5. Internal exam
DR
6. Normal
spontaneous
delivery
7. Perineal repair
8. Manual extraction
of placenta
9. Recognition of case
for assisted delivery
10.Removal of retained
placenta
11.Intramuscular
injection
12. Vitamin K
injection
OPD
13. TT Immunization
14. Catherer insertion
15. Uterine abdominal
compression
16. Partograph
17. Complete physical
examination to
include: Leopolds
FHT, BP, etc.
PP
18. Eye care
19. Cord care
20. Breastfeeding
latching
OPD/ER/DR/LR
21. Recognition of
danger signs

MD

PHN

RHM

3
2
2

3
2
2

3
2
3

2
3

3
1
1

1
1

1
1

3 (new); 2 (old)
3

3 (new); 2 (old)
3

3 (new); 2 (old)
3

3
3
3

3
3
3

3
3
3

1
2

Legend
Orange box = Participants are already
competent
Green box = Not provided by law

57

Module 2

On-Site Team Activities for

Clinical Skills in BEmOC
Objective
To practice BEmOC skills learned during the didactic phase

Topics

Quick Check and Rapid Assessment and Management

(RAM)

Routine Care to Mothers and Newborns

Management of Emergency during Antenatal, Labor,
Delivery and PostPartum

Accomplishment of Records and forms on PCPNC

Duration
7 days

Session 1

Materials needed

On-site Practicum Orientation

Forms, guidelines for practitioners (from the facility

where practicum will be held), rotation schedule

Specific objective
At the end of the session, the participants will be
able to execute their practicum assignments.

Methodology
58

Interactive Discussion
Tour of the hospital/facilities

1 hour
1 hour

Procedure

Tell the teams that they will proceed to the

hospital/facility and pay a courtesy call to the
head of the institution/agency;


The head of the hospital/facility or any staff

assigned to orient the participants will brief
them on relevant matters concerning the
practicum site or facility and the personnel.

After the briefing, the participants will undergo
a tour of hospital departments and facilities;

The area facilitator assigned for each group will
supervise the participants during the practice of
skills learned.

Each team will be assigned a person who will
monitor and observe the practicum activities in
the areas of assignment, as well as look into the
administrative needs of the team;

Tell the teams that with the briefing given they
can now proceed to their area rotation/assignments.

Session 2
Performance of Area Rotation/Assignments

Specific objective
At the end of the session, the participants will be
able to apply to:

Procedure

The participants will perform the skills required on rotation to the areas of assignment;

Instruct the participants to fill up the forms for
the skill requirements that they need to accomplish during the practicum and submit
these at the end of the period; Ask them to
document their personal observations, experiences and lessons learned in their practicum
journal;

Facilitators will fill in the monitoring sheet/
tool for each team assigned in their areas. They
will also report during the mid-practicum
assessment;

The team observer/monitoring person will
provide daily feedback to the facilitators and
Training Team during the entire duration of
the practicum period; and

A mid-practicum assessment meeting will be
conducted for completion of requirements,
identification of issues and problems encountered, and possible solutions or adjustments that
could still be done during the practicum period.
Refer to pages 165-166 of the Trainers Notes

Apply quick check and RAM

Perform routine care to mothers and newborns

Manage emergency during antenatal, labor,
delivery and postpartum periods

Accomplish records and forms on PCPNC

Methodology
Hands-on application of skills

Materials/resources
Patients, equipment, supplies and forms
59

Checklist for Facilitators during Mid-Practicum

Assessment
1.
a.
b.
c.
2.
a.
b.
c.
3.

60

Feedback on:
daily accomplishment
individual skills
areas for improvement
Problems identified:
area of assignment
provision of technical assistance
individual trainee
Recommendations

Monitoring,
Evaluation
and Action
Plan

Monitoring and evaluating (M & E) training is necessary to determine the effectiveness of the
course. By monitoring and evaluating the didactic and practicum activities of the participants,
trainers can measure whether they are able to describe the skill, demonstrate the skills, practice the
skills or verify whether the skills are being completed correctly. Evaluation can also gauge the
satisfaction of the participants and provide information on how to improve the BEmOC skills
training course.
Besides M & E, the preparation of an action plan is also an important component of a training
course. Training can only be considered successful if the participants are able to apply their newly
acquired skills and knowledge in their own work place, and eventually transfer the learnings to
other health workers.
This section provides practical tips on how to monitor and evaluate before, during and after the
course, including the preparation of an action plan. To contextualize the discussion, the roles
and responsibilities of the BEmOC Team and the indicators for monitoring and evaluation are
described.

62

Roles and Responsibilities

of the BEmOC Team

The BEmOC Team is composed of a physician,

nurse and midwife. Their specific duties and
responsibilities are as follows:

Physician


Team leader


Perform all six (6) BEmOC functions


Supervisory function


Networking and referral

Nurse


Assistant team leader


Does IV administration of 1-3 signal functions


Administrative function


Health education


Networking & referral for community &
institutional support

Midwife


Can do 1-3 signal functions


Assist in 4-6 signal functions


Health education


Prenatal & postnatal care


Networking & referral for community
support

Indicators for M & E

The indicators for the participants level of competency will be measured in terms of:

% of targeted service providers (participants/
trainees) who performed appropriately 6 signal
functions

63


Average score is pre and post-tests in terms of

KAS (TNA/competency and capability) which
will be administered through the following:


K written exam (case study)


A self assessment; observer checklist


S observer checklist

What Can Evaluation Measure?

Evaluation can provide trainers with information about:

Learner satisfaction: Were learners expectations
and needs met? Were learners satisfied with the
performance of the trainers, the materials and the
training process in general?

The training process: Were the training activities
conducted effectively and as planned?

The results of the training: By the end of the
training course, did learners experience the
expected changes in their attitudes, knowledge
and skills? To what extent did learners meet the
training objectives?

Transfer of the training: Are learners implementing
their new attitudes, knowledge and skills after the
training? What are some of the barriers that
learners encounter when they try to use their new
knowledge and skills? Do learners experience
problems with the retention of new knowledge and
skills over time?
Wegs, Cristina, et.al, (2003:73)

64

Monitoring and Evaluation Processes

Pre and Post-Tests

Before the course, the trainers should administer a
pre-test to assess the participants knowledge,
attitudes and skills/competency in BEmOC. After
the training, trainers should do a post-test to
determine what KAS the participants have acquired
or learned during the training. A sample of the pre
and post-tests questionnaire which has been used
during the pre-testing of this trainers guide is
shown below.

65

Skills Training On BEmOC

Pre-Test and Post-Test Questionnaire
I. True or False
Write letter T if the statement is true and F if the
statement is false. Write your answers on the space
provided.
_______ 1. Internal examination can be done on a
patient with vaginal bleeding late in pregnancy.
_______ 2. Oral Rehydration solution is given to a
patient whose blood pressure is <90/60.
_______ 3. Pregnant patient is imminent delivery
with a blood pressure of 150/100 cannot deliver
in a primary health facility.
_______ 4. Tetanus Toxoid should not be given to
a pregnant woman if she has already received 3
doses during her last pregnancy 1 year ago.
_______ 5. Oxytocin should be given after placental delivery.
_______ 6. As a health worker, you should give
antibiotics when the membranes has been ruptured for >8 hours.
_______ 7. Blurred vision, epigastric pain and
severe headache are signs of pre-eclampsia.
_______ 8. Good counseling requires an interactive process which allows for two-way exchange of
information.
_______ 9. Counseling is the same as giving advice.
_______ 10. Violence against women by their
intimate partner affects her physival, mental, including reproductive health status.
_______ 11. It is particularly important to give
adolescents whether married or unmarried, information on birth planning prevention of STI, HIV
/ AIDS and FP.
_______ 12. Bathing the newborn baby is the
66

most important task to do within the first 2 hours

of life.
_______ 13. A body temperature of 37 C is not a
danger sign in a new born baby.
_______ 14. A newborn baby does not require
resuscitation if the baby is gasping.
_______ 15. Small baby is synonymous with preterm baby.
II. Multiple Choice
Please encircle the letter of the correct answer.
1. One of the following is NOT a major cause of
maternal mortality
a. Abortion
b. Hemorrhage
c. Hypertension
d. Teenage Pregnancy
2. This skills training is intended for a health
facility based providers. One of the following is not
considered as a skilled attendant
a. Doctor
b. Hilot
c. Midwife
d. Nurse
3. The following are criteria of a good communication, except:
a. Use simple and clear language.
b. Encourage her to ask questions
c. Ask and provide information related to her
needs
d. Make the woman feel welcome

4. Which of the following is NOT a criteria of

confidentiality and privacy
a. Ensure a private place for the examination and
counseling
b. Make sure you have the womans consent before
discussing with her partner/family
c. Ensure, when discussing/transmitting necessary
messages, that you cannot be overhead.
d. Never discuss confidential information about
clients with other providers, or outside the health
facility
5. The following are emergency signs seen in a
pregnant patient requiring immediate referral,
except:
a. fever
b. vaginal bleeding
c. headache and visual disturbance
d. severe pallor
6. Which of the following is NOT an emergency
sign in a baby requiring immediate newborn care
a. just born
b. convulsions
c. any maternal concern
d. eye discharge
7. A woman in the immediate postpartum period.
The uterus few minutes ago was not soft. On her
examination, her uterus is now hard. You observed
that she has consumed 1 pad fully soaked. 4-5
minutes after, you found out that the uterus is soft
again. What is your next step?
a. observe
b. request for hemoglobin status
c. refer to hospital

d. consider it normal
8. The counseling environment should be:
a. welcoming and comfortable
b. a place with few destructions and where privacy
can be maintained
c. conducive to a counselor
d. both a and b
9.
a.
b.
c.
d.

A good counselor is:

non-judgmental
trustworthy
both a and b
none of the above

10. The characteristic of a good counselor is:

a. both the counselor and the client explore options together
b. facilitate decision-making
c. both a and b
d. none of the above
11. In counseling a pregnant adolescent, it is important for the service provider to observe the following points:
a. strict privacy and confidentiality
b. use of simple and clear language
c. not to discuss topics related to RH and sexuality
d. non-judgmental
12. The key role of health worker includes the
linking of the health services with the following.
a. community group, womens group and leaders
b. peer support group
c. TBA and other health service provider

67

13. When giving emotional support to adolescent

girls and women living with violence, it is important
to remember which of the following:
a. create a comfortable environment
b. overcome your own discomfort with her situation
c. make sure you have time and space to talk privately
d. be patient and pay attention only to things that
is relevant to present situation
14. Which of the following statements is true:
a. breastfeeding should be routinely assessed as
part of the newborn examination
b. the mothers breast should be examined if the
mother complains of nipple or breast pain
c. a mother with HIV /AIDS who chooses to
breastfeed her baby should not be allowed to do so
and must be encouraged to give milk formula
d. a and b only
15. A very small baby:
a. is a baby with birth weight <1500g and / or is a
pre-term less than 22 weeks
b. refers to twin babies
c. requires urgent referral to a hospital
d. a and b only

68

Monitoring Practicum Activities

During the practicum period, the Training Team
should carefully monitor the performance of the
participants in their areas of assignments. It is
important to assign a permanent monitor/observer per team throughout the practicum activities to ensure continuity of observations, provision
of administrative/technical assistance and immediate feedbacking on the progress of each individual
participant and the team as a whole. Tools for the
practicum activities include the Monitoring Checklist for Implementation of PCPNC Instructions to
Monitor and Observation Tool.
Refer to pages 167-176 of the Trainers Notes

69

70

71

Daily Evaluation of Training Activities

At the end of the day, trainers should conduct evaluation of training activities to identify problems and gaps
in the knowledge and skills of the participants. By
doing this on a daily basis, immediate feedback on
areas requiring improvement can be elicited, particularly on the design and implementation of the training.
Specifically, feedback should be solicited on participants satisfaction with the session activities, methods
use, resource persons, flow and pace of the training.
An evaluation tool for resource persons is shown on
the right.

72

73

Process and Output Evaluation

This is done after the training to evaluate the implementation of the course and determine whether the
objectives were achieved. In the pre-testing of this
trainers guide on BEmOC, a course evaluation
tool was used by the trainers to solicit feedback
from the participants about their overall satisfaction
and recommendations for improvements. This tool
is shown below.

Sample Evaluation Process of BEmOC

Skills Training
Participants were given metacards to write their
difficulties, helps and insights during the two-week
training period. After 15 minutes, they were asked
to post their responses on the manila paper. Their
responses were processed by asking them further
explanation or citing their reasons. The Training
Team gave their comments based on the
responses.
Afterwards, the participants were divided into
4 and tasked to compose a song whose lyrics are
the following: 1) most unforgettable experience in
the two-week activity, 2) what lessons must be
included in the course that were not included at
present, or if they feel all important lessons were
already included, which must be allotted more time,
3) the most important lessons they learned, and 4)
descriptions of the facilitators and resource
speakers. After 30 minutes, each group gave their
best performance.

74

75

Action Plan
Trainers should aid the participants in applying
their new knowledge and skills by assisting them in
developing an action plan which they could implement upon return to their work place. Two examples of matrix for an action plan are shown below
which the participants could use in planning their
future activities.

76

Effective Action Plans

Divide activities into discrete steps that are

realistic and measurable

Identify roles and responsibilities for learners, as
well as their community partners, co-workers and
supervisors

Identify the resources needed to successfully
complete all steps

Include a specific timeline for completing each
step

77

78

PostTraining
Activities
79

The Training Team should conduct post-training activities such as monitoring and
outcome evaluation based on identified indicators to assess the application of new
knowledge and skills in BEmOC by the participants in their work place. These
activities will be facilitated through sustained communication with the participants
and documentation of experiences in BEmOC.

80

Outcome Indicators

After three (3) months, the following outcomes of

the training may be measured according to the
following indicators:

Records keeping

Competency

Budget

% of deliveries in BEmOC facilities (normal

and complicated)
% of complicated deliveries managed properly (done in BEmOC facility & referred to
CEmOC from BEmOC)
Attendance of BEmOC team during delivery (methodology exit interview; postpartum counseling, observation checklist)
Patient satisfaction (exit interview; provider
client interaction, e.g. respect of privacy,
observation checklist)
Total cost of deliveries from home to
BEmOC facilities

Completeness of record

Amount of budget utilized for BEmOC

services
Source of funds
SOPs within BEmOC
MOA signed w/ CEmOC in LGUs covered
Mechanisms in place (transportation, communication)

Facilities

% of facilities experiencing stock-out supplies within the last 3 months

% of equipment in BEmOC facilities which
are functional/complete

81

Continuing Communication

Trainers should continue their communication

with the participants to follow-up their progress in
applying their new knowledge and skills in
BEmOC. The content and process of communication can be both informative and motivational.
These can be done through email exchanges,
telephone conversations, site visits and text messages. It is also important to provide the participants with user-friendly reference materials and job
aids which they can use after the course as guide in
completing BEmOC procedures or tasks.

82

How to Build Skillful Communication

Encode messages in terms that are easily
understood by the receiver;

Use specific examples rather than vague
generalizations;

Use simple and clear language;

Think about and construct the message before
sending it;

Check understanding with the receiver;

When listening, concentrate and make mental
summaries;

Avoid evaluating the message until it has been
completed;

Occasionally summarize what is being said to
check for accuracy (paraphrase); and

Ask clarifying questions to check understanding
(Felix, 1998:108-109)

Monitoring and Evaluating

Training Outcomes

After three months, the Training Team may conduct

visits to the work place of the participants to monitor
and evaluate the implementation of BEmOC services. During monitoring visits, a competency-based
skills assessment of the team and members can be
conducted to determine whether changes have
occurred in the delivery of BEmOC services in the
health facility. Also, the capability of the health facility
in terms of its equipments, record keeping and
budget allocation for BEmOC should be assessed.
The outcomes of the training can be gauged through
client exit interview, observation checklist, site visits,
interviews with participants, community partners,
supervisors and other colleagues/co-workers.

Sample Survey for BEmOC Team Members Application of

the Principles of Quality Care
Health Worker

Please do not write your name on this survey.

Please complete this survey after you have seen the health worker.
Your health team would appreciate honest feedback

Please rate each of the following areas by circling ONE number on each line:
Poor
Fair
Good
Very
Good
1. My overall satisfaction with this visit to the health
facility is
2. The reception/greeting afforded to me by the
health worker was
3. On this visit I would rate the health worker ability
to explain to me my condition as
4. The health workers patience in providing
information related to my needs
5. The extent to which I felt my privacy during
examination and counseling was observed by the
health worker
6. The extent to which I felt reassured by the health
worker that all the information I gave to them will be
treated with utmost confidentiality
7. The opportunity the health worker gave me to
express my fears or concerns and ask questions
8. My confidence in the ability of the health worker
to respond to our health care needs (mother and
new born baby)
9. The amount of time given by the health worker in
explaining to me what the treatment is and why it
should be given
10. The health workers ability to make me
understand the procedure for examination and
treatment
11. The health workers concern for me as a person
in this visit was
12. The recommendation I would give to my friends
about the health worker would be

Excell
ent

How can this health worker improve his/her service?

83

Sample Competency-Based Skills Assessment Checklist

84

Documentation of Experiences

It is important that the participants are able

Sample BEmOC Experience (s) Documentation Form
to document their experiences in handling
BEmOC cases, particularly the application of Trainee/Participant _______________________________________
knowledge and skills acquired from the train- Date/Time Frame_________________________________________
ing and mobilization of institutional and
Subject/Topic ___________________________________________
community support for maternal and newborn care. By documenting their experiences,
Documentation objective:
the participants and the trainers will be able
to identify areas for improvement which can
Outputs
Date(s)
Actions/
be inputted in redesigning the training course Activity/Case
Steps Taken
or guide in determining follow-up activities
for the participants. Below is a sample documentation form which can help the participants in systematizing their experiences with
BEmOC in their work place.

Lessons
Learned

85

References
Cunningham, Gary F., et.al. Williams Obstetrics, 21st Ed. The McGraw-Hill Companies, Inc., 2001.
Department of Health, Midwives Manual on Maternal Care, Department of Health, 2000.
Felix, Maria Leny. Leading with the People: A Handbook on Community-Based Leadership. Holy Spirit
Center of Tarlac, 1998.
Gay, Jill, et.al. What Works: A Policy and Program Guide to the Evidence on Family Planning, Safe Motherhood, and STI/HIV/AIDS Interventions - Module 1 Safe Motherhood. January 2003.
Lauver, Philip and David R. Harvey. The Practical Counselor: Elements of Effective Helping. Brooks/Cole
Publishing Company, 1997.
National Demographic Health Survey, 1998.
Wegs, Christina, et. al. Effective Training in Reproductive Health: Course Design and Delivery, 2003.
World Health Organization, Geneva. Pregnancy, Childbirth and Newborn Care A Guide for Essential
Practice. World Health Organization, 2002.
_____. Integrated Management of Pregnancy and Childbirth. Managing Conplications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors. World Health Organization, 2000.
_____. Pregnancy, Childbirth, Postpartum and Newborn Care : A Guide for Essential Practice. World
Health Organization, 2003.
86

Glossary
Anaemia low hemoglobin in the blood and is
seen as pallor of the conjunctiva, mouth, tongue
and nail beds

Lochia sloughing of decidual tissue results in a

vaginal discharge of variable quantity early in the
puerperium

Antenatal care a care for the woman and fetus

during pregnancy

Partograph a tool that helps the management of

labor

Cervix the part of the uterus that is in the

vagina

Placenta tissue within a womans uterus

(womb) that is created during pregnancy to feed
the growing fetus

Cord prolapse when umbilical cord presents

itself outside of the uterus while the fetus is still
inside
Dystocia literally means difficult labor and it is
chracterized by abnormally slow progress of labor

Pre-eclampsia hypertensive disease of pregnancy

associated with pitting edema but without convulsions

Eclampsia hypertensive disease of pregnancy

resulting in convulsions

Shock a genral body disturbance caused by

hemorrhage, trauma, dehydration and sepsis characterized by a fall in blood pressure, rapid pulse,
cold, clammy skin, vomiting and restlessness

Glucose a major nutrient of fetal growth and

energy

Uterus an organ within a womans body that

support the growth of a fetus

Labor the last few hours of human pregnancy

characterized by uterine contractions that effect
dilation of the cervix and force the fetus through
the birth canal.

87

Annexes

89

90

Trainers Notes
Didactic Phase

10 women die every 24 hours from causes related to

pregnancy and childbirth.
or 3650 maternal deaths/year, most are in the rural areas.

Module 1: Overview of BEmOC and PCPNC Manual

Session 1a: Overview of BEmOC
Infant and under Five Mortality (1990-1998)
1234
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86
12
12
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57
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1990

1991

1992

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1994

1995

1998

65

1.7
1.6

12
12

1.3
1.2
1.1
1.0

1.0
MMR

0.8

0.8
0.7

0.7
0.6
0.5

Source: UNICEF, PPAC Report 1997 & State of the Worlds

Children 1997;NSO, 1998 NDHS

1.3

0.4

0.6

0.5

0.4
0.3
0.2

Maternal Mortality Rate in the Philippines: 172/

100,000

12121212
12121212112
12121212112
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209

203

197

191

186

180

1990 1991 1992 1993 1994 1995

Source: NDHS 1998, Philippines

12
12
12
12
12
12
12
12
12

0.0
NCR CAR

II

III

IV

VI

VII

VIII

IX

X1

XII CARAGA ARMM

REGION

172

Source: FHSIS, 2000

1998

91

More than 90 percent of the total births received prenatal care from a trained birth attendant (nurses and
midwives 50%; doctors 45.5%; and trained hilots 4.4%)

Deliveries by Place
70% of births were delivered in the home

Traditional birth
attendants 4%

Hospital 27%

Doctors 46%

Others 3%
Nurse/Midwives
50%

Home 70%

Source : MCHS-PNSO, Philippines 2002

Only 60 percent of births were attended by a health care

professional (doctor or trained nurse/midwife)

Iron Supplementation and Pre-natal Visits

Nurse 1%
Doctor 33%

PERCENT OF

Midwife 26%

WOMEN

Others 1%

78.1
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99
YEARS

Traditional Birth
Attendant 39%

Source: MCHS-PNSO Philippines 2002

92

123
123
123

IRON SUPPLEMENTATION
PRENATAL VISITS (3 OR MORE)

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02

Maternal Mortality by Main Cause

NUMBER OF

RATE

603

0.4

38.19

425

0.3

26.92

3. Postpartum Hemorrhage (ICD 072)

286

0.2

18.11

4. Pregnancy with abortive outcome (ICD O000-O08)

144

0.1

9.12

5. Hemorrhage related to pregnancy (ICD o20;045;047)

121

0.1

7.66

CAUSE
CASES

AO 79 series 2000: Safe Motherhood Policy

Reproductive Health Program Framework
AO 34-A series 2000: Adolescent and Youth Policy
AO 45-B series 2000: Prevention and Management of
Abortion and Its Complications

1. Complications related to pregnancy occuring in the

course of labor, delivery and puerperium (ICD 021-099)

2. Hypertension (complicating pregnancy, childbirth and

puerperium; ICD 010-016)

Constraints/Problems in Improving Safe Motherhood

and Perinatal Health

Decreasing health budget

High cost of facility-based health services

Human resource and facilities concentrated in highly
urbanized cities/areas and limited resources in rural
areas.

Health is not main concern of Local Government Unit

Insufficient obstetric equipment and supplies

Advocacy of Safe Motherhood policy does not reach
implementors

Unavailability of skilled professional
Policy Directions-Maternal Care

RA 7322 - Increase in maternity benefits for women
workers

RA 8187 - Grant of Paternity leave

RA 7600 - Rooming-in and breastfeeding

DOH Circular 69-A - Authority for trained hilots to
attend to normal deliveries

DOH Circular 187-A - Protocol for home deliveries

On Family Planning

AO 50 series 2001: National FP Policy

AO 125 series 2002: National Natural FP Strategic Plan

AO 153 series 2000: National Strategy for VS and

Implementing Guidelines for Itinerant Teams
STD/HIV/AIDS

National STD Strategy/National Policy Guidelines for
the

Prevention and Management of STDs

AO No. series of 57-A, 1989: Policies In Abating Spread
of HIV/AIDS

AO 57-A, Expansion to National AIDS-STD Prevention
and Control Program (NASPCP)

EO No. 39: Framework for the Operations of PNAC
Policy Directions-Child Care

Policies on EPI, CDD and CARI

AO 3-A series 2000: Guidelines on Vitamin A and Iron
Supplementation

IMCI

ECCD Law

CHILD 21
Support Policies

Food Fortification Law

EO 51 - Milk Code

HSRA

Sentrong Sigla Certification

PHIC Circular #6 - Maternity Package for normal
spontaneous vaginal delivery in non-hospital facilities

93

Standards/Protocol Development - Maternal Care

DOH
Guidelines for birthing homes (draft)
MCHS quality standards embodied in SS Certification
Protocols on Home Deliveries
Midwives Manual on Maternal Care
(Partograph)
WHO
Manual on Essential Care Practice Guidelines for Pregnancy,
Childbirth and Newborn (IMPAC)
Managing Complications in Pregnancy and
Child Birth (IMPAC)
UNICEF
Maternal Death Review Guide
UNFPA
RH Service Protocols By Level of Health Facility
WHSMP
Comprehensive Emergency OB Manual (CEOBM) focusing
on effective management of emergency OB cases up to
hospital level
Referral framework for emergency OB cases and protocols
for transporting patients
Revision of DOH guidelines on pap-smear cervical screening
Strategy Development-Pregnancy Tracking and Birthing Plan
Protocol
POPCOM
Pre-Marriage Counseling Manual
Standards/Protocol Development - Child Care
DOH
AO 3-A series 2000: Guidelines on Vitamin A and Iron
Supplementation
Assessment Checklist for Essential Child Health Services
Essential Child Health Visits
Integrated Management of Childhood Illnesses Chart Booklet
Expanded Program on Immunization Manual
Manual on EPI Disease Surveillance

94

Both Child and Mother

DOH
Upang Higit Pang Makapaglingkod Manual for Public Health
Midwives
UHNP
Integrated Maternal and Child Health Manual for Health
Workers
Capability Building/Training - Maternal Care
UNFPA
Integrated Approach in Counseling and Basic RH Services
(RH Training Course)
Peer Educators Training on Counseling
UNICEF
Maternal Death Review; Midwifes Manu
JICA
Reproductive Health Training Supplementary Kit
Male Family Planning/Reproductive Health Motivator
Program
WHSMP
Training in Partography
Cyto-Screening Training of PGH MedTechs
Pap Smear Preparation Training of PHC staff
Training on Syndromic Case Management of STD
DOH
Orientation on use of Midwives Manual
Partograph Training at regional and local level
Regular post-graduate course on Suturing of Perineal
Laceration and Intravenous Fluid Insertion for Midwives
Orientation on Integrated Management of Pregnancy and
Childbirth (IMPAC) MCPC and PCPNC
Training of BHWs on Life Cycle Approach
Capability Building/Training-Child Care
UNFPA
Integrated Approach in Counseling (RH Training Course)
UNICEF and WHO
IMCI

HKI
IMCI; Training on Advocacy Skills
DOH
IMCI Training
WHSMP
Training in Partography
Cyto-Screening Training of PGH MedTechs
Pap Smear Preparation Training of PHC staff
ECCD
Community IMCI Training
IMCI Training of health workers
Basic EPI Skills Training and Cold Chain Management
Training
IEC/Advocacy
UHNP
Development of an IMCH Manual for Health Workers
DOH
Guidebook on Adolescent Health
Teen-agers Guide to a Healthy Life Style
JICA
MCH Record Book
Series of video dramas (TV 99 Program- Adolescent VTR)
ARH Promotion Program
Booklet Pangangalaga sa Kalusugan ng Ina at Sanggol A
Counseling Guide for Health Workers and Information for
Mothers
Teatro 99 Program Puppet Show
UNFPA
Video on ARH; community and facility-based IEC
interventions
HKI
Integrated MCH Basic Learning Package
Vitamin A Supplementation IEC Materials
20-minute documentary Vit. A, A Cause for Action
IMCI Behavior Change Communication Plan
National Advocacy Plan for Food Fortification and Supplementation
Comprehensive Iron Communication Plan

Nutrition Bulletin
ECCD
Mother and Child Book (draft)
USAID
Flip Charts on Integrated Counseling Cards for MCH
CBMIS to identify mothers unmet needs on FP and TT and
childrens unmet needs for immunization and Vitamin A
supplementation
Service Delivery
UNICEF
Birthing rooms for aseptic deliveries by skilled birth attendants
JICA
Established Under Five Clinic Program in Region 3
(upgrading of health facilities and provision of equipment in
Region 3)
Reproduction of mother and child book
IMaCH Package
Tosang-Making Project
Botika Binhi
ECCD
EPI - distribution of cold chain equipment
IMCI - reproduction of modules, manuals, IMCI patient
record and ECCD cards
WHSMP
ECPG being pilot-tested in NCR and Eastern Samar
Renovation/construction of delivery rooms
Distribution of disposable OB kits (colposcopes, pap smear
supplies, LEEP machines procurement, etc.)
Social hygiene clinics
Partnership among LGU, community, NGOs for referral and
services
UNICEF
Child-Friendly Integrated Childhood Care and Development
UNFPA
Teen Centers in pilot areas; RH service provision in 9 project sites
HKI
Routine distribution of Vitamin A capsules

95

MIS/Monitoring and Research

WHSMP
KAP Survey on RTI/STD
HKI
Evaluation of IMCI approach (baseline and end-line survey)
Developed monitoring system for LGUs on Vitamin A
availability and coverage
FHI
Conducted enhanced STI Control in Angeles City and a
prevalence survey of RTI/STD in the Philippines
MSH
Community-Based Management Information
System
WHSMP II
Technical studies to be conducted on FP, adolescents,
maternal mortality and STI control and HIV prevention
UNFPA
Quality Care Survey (pipeline)
Financing/Private Sector
PhilHealth
Developed maternity package by which the first two deliveries
are paid by PHIC provided these occur in accredited facilities
or are attended by accredited midwives. Only midwives
attached to an accredited institution are eligible for
accreditation.
JSI
Establishments of Well Midwife Clinics primarily for FP
services; now beginning to expand to providing child health
services
FCFI
Establishment of clinics providing maternal and child health
services, with focus on Family Planning
Issues and Concerns (Challenges)

Policy and Structure

Service Protocols and Guidelines

Service Delivery
96
Recording/Monitoring

Issues and Concerns

Policy and Management Structure

Policies and frameworks exist but on individual
programs (e.g. Safe Motherhood, Childs Health, RH
Framework, FP Policies, etc.)

Overarching framework on family health where
maternal and child health belongs not yet in place

Office structure at national level still on a programspecific assignments

Life-cycle Approach - Interface between maternal care,
family planning, and RTI/STD not yet clear

Finalization of the TBA policy

Allowing midwives to do intravenous injection
Issues and Concerns
Standards and Service Protocols

Service protocols on maternal and child health developed
and packaged by program

Core maternal and child health services to be made
available per level of facility not that clear yet (e.g. what
midwives or the BHSs should provide

Several reference materials abound - consistency of
standards across references in doubt
Service Delivery

Service provision is seldom client-oriented, but rather
programmatic; child consultation most probably include
mothers concern; but mothers consultation does not
necessarily include childs concerns, resulting to missed
opportunities for the client and other members of the
family

Lack of a single package of guidelines for health workers
to use as reference at the facility level

Manpower
MIS/Monitoring

Proliferation of different recording forms (e.g. ITRs, FP
Form 1, ECCD/GMC, HBMR, etc.)


Home-Based Maternal Record (HBMR) is not utilized to

the fullest and remains to record only prenatal care.
Often times, the care provided is not recorded or the
card is not updated. In most hospitals, HBMR is not
honored as a record of care already provided.

ECCD card/UFC is often times used to record
immunization only
Health Sector Reforms

While private-public partnership (through market
segmentation) is important in the operationalization of
ILHZs), the DOH has not been able to exert strong
influence on the private sector and the practitioners
outside DOH

Referral system community component not yet
designed

Some LGUs not convinced nor motivated to participate
in the ILHZ

Investment for public health very low
Integrated Management of Pregnancy and Childbirth
(IMPAC)
Components:

Standardization of care by setting norms and standards

Improving health system response

Improving family and community participation, practices
and response

Integrated Management of Pregnancy and Childbirth

Module 1:Overview of BEmOC and PCPNC

Manual
Session 1b: Overview of Pregnancy, Childbirth,
Postpartum and Newborn Care (PCPNC)
Pregnancy, Childbirth, Postpartum and Newborn Care:
(A guide for essential practice)
WHO recommendations for the skilled attendant providing
routine and emergency care for women and newborn during
pregnancy, delivery, postpartum and post abortion at primary
health care.
PCPNC

A manual formulated by WHO Headquarters in Geneva
and introduced by the World Health OrganizationWestern Pacific Regional Office in Manila

Endorsed by the following organization World Health
Organization (WHO) United Nations International
Childrens Educational Fund (UNICEF), United
Nations Population Fund (UNFPA) and the World Bank

It was reviewed and endorsed by the Federation
International in Gynecology and Obstetrics (FIGO)

Technical and editorial assistance was provided by the
John Hopkins Program for International Education in
Gynecology and Obstetrics (JHPIEGO)
What is PCPNC

Guides clinical decision-making.

Promotes the early detection of complications and the
initiation of early and appropriate treatment, including
timely referral.

Helps reduce high maternal and perinatal mortality and
morbidity

Used as a training and advocacy tool

Adaptable to local circumstances and settings (needs,
resources, local beliefs systems)

97

Content

Quick check, emergency management and referral

Post abortion care

Antenatal care

Labour and delivery

Postpartum care

Newborn care
Structure and Presentation

Content is presented in a framework of colored flow
charts supported by information and treatment charts

Framework is based on syndromic approach

Severity is marked in color:
- red for emergencies
- yellow for less urgent conditions
- green for normal care

MCPC

For midwives and doctors at the district hospital who are
responsible for the care of women with complications of
pregnancy and childbirth or the immediate postpartum
period, including immediate problems of a newborn.

The interventions described in these manual are based on
the latest available scientific evidence.

Format of PCPNC

Information boxes, illustrations

Disease model for assessment, classification and
management of complications

With overview for each chapter or component

Integration Approach of PCPNC and MCPC

Pregnancy, childbirth, postpartum

Pregnancy related complications and endemic conditions
/ diseases and preventive measures

Care at the facility, community and home care

Mother, newborn, partner, family, community and facility

Routine and emergency

Primary and referral care

Different vertical programs

Format of PCPNC (5 area columns)

What to ask

What to look for

What to expect to see

How to classify

What to do/ treat

Next Steps

Advertise the manuals and encourage governments,
international agencies and NGOs to use it.

Provide financial and technical support to government to
translate and adapt the manual

Provide technical support on adaptation and training

Basic EmOC: 6 functions (PCPNC)

Injectable antibiotics

Injectable oxytocics

Injectable anticonvulsants

Manual removal of placenta

Assisted vaginal delivery

Removal of retained products

98

Comprehensive EmOC (MCPC) the same as above plus

the following:

Caesarean Section

Safe Blood Transfusion

Module 2: Principles of Good Care

Principles of Good Care

Communication

Workplace and Administrative Procedures

Universal Precautions and Cleanliness

Organizing a Visit
Communication

Make the woman (and her companion) feel welcome

Uses simple and clear language

Encourage her to ask questions

Ask and provide information related to her needs

Support the woman in understanding her options and
making decisions

Seek permission from the patient when examining

Summarize the most important information, including the
information on routine laboratory tests and treatments.
Organizing a Visit

Emergency care visit

Care of woman or baby referred for special care to
secondary level facility

Routine visit for the woman and/or the baby
Workplace and Administrative Procedures

Set-up and preparation of the Workplace

Daily and occasional administrative activities

Record keeping

International conventions
Universal Precautions and Cleanliness

Wash hands

Wear gloves

Protect yourself from blood and other body fluids during
deliveries

Practice safe sharps disposal

Practice safe waste disposal

Deal with contaminated

Ensure clean laundry
Clean and steralize contaminated equipment
Clean and disinfect gloves
Sterilize gloves

Module 3: Quick Check and Rapid Assessment and

Management
Session 1: Quick Check
Please refer to Sec. B2 of PCPNC.
Module 3: Quick Check and Rapid Assessment and
Management
Session 2: Rapid Assessment and Management
Please refer to Sec. B3-B7of PCPNC.
Module 3: Quick Check and Rapid Assessment and
Management
Session 3: Emergency Treatment for the Woman
How to prepare a syringe for an injection

Wash your hands

Take the syringe and needle out of the package

Hold the syringe at the end of the plunger and hold the
needle at the base

Attach the syringe and needle

If using a vial of ready to use medicine eg. Gentamicin,
clean the vial and then carefully break the top off

Put the needle into the vial. Draw up a little more of the
medicine than required

Hold the syringe upright with needle facing up

To remove bubbles from the medicine, tap the syringe
lightly on the side. Push the plunger until the air comes
out and the medicine begins to spill from the tip of the
needle.

99


Push the plunger until you have the correct dose in the
syringe.
How to prepare a syringe for an injection
(For medicine that needs to be mixed with sterile water, e.g.
Ampicillin)

Clean the vial containing the sterile water and break the
top off

Fill the syringe with the amount of water you require
according to the instructions

Remove the bubbles if any

Clean the rubber top of the medicine vial with alcohol
swab

Inject the sterile water into the bottle with the powdered
medicine.

Shake the bottle until the medicine is well mixed with the
water

Holding the vial upside down, put the needle inside and
fill the syringe with a little more than the medicine
required

Remove the bubbles and push the medicine out until the
correct dose is obtained.

Cover the needle until you are ready to give the injection

Module 3: Quick Check and Rapid Assessment and

Management
Session 4:Emergency Treatment for the WomanAnatomy of the Female Reproductive Tract
Classification

External Organ
-copulation

Internal Organ
-ovulation
-site of fertilization
-blastocyst transport
-implantation
-development and birth of fetus
Internal Generative Organs

(visible externally from the pubis to the perinium)
Mons Pubis/Veneris

Fat-filled cushion at the anterior surface of the symphasis
pubis
Escutcheon

Female - triangular shape

Male - diamond-like
Labia Majora

two rounded folds of adipose tissues covered with skin
extending downward and backward from the mons pubis

homologue-scrotum

vary in appearance (fat content):

nullipara
-close apposition
-moist inner surface (mucus membrane)

multipara
-gape widely
-skin like inner surface

100

Labia Minora

two flat reddish folds of tissues beneath the labia majora

homologue-penile urethra and part of skin of penis

nullipara-not visible

multipara-project beyond the labia majora

two lamellae
-frenulum
-lower pair
-prepuce
-upper pair
Clitoris

short cylindrical erectile organ located near the superior
extremity of the vulva

projects between the prepuse and prenulum parts:
-glans
-body/corpus
-crura
-principal erogenous organ
Vestibule

almond shaped area enclosed by labia minora laterally extending
from the clitoris to the fourchette

functionally mature female structure of the urogenital sinus of
the embryo

perforated by six openings:
-urethra
-vagina
-ducts of bartholin gland
-ducts of paraurethral gland
Bartholin Gland

major vestibular gland located beneath the fascia at 4 and 8
oclock position

homologue -cowpers gland

ducts open on the sides of the vestibule just outside the lateral
margin of the vagina orifice

Urethral Opening/Meatus

membranous conduit for urine from the urinary
bladder to the vestibule
Skene/Parauretheral

branched tubular gland adjacent to distal urethra

ducts open on the vestibule on either side of the
urethra

homologue -prostate gland
Vestibular Tubes

almond sahped aggregations of veins

homologue -bulb of penis

liable to injury and rupture

vulvar hemotoma/hemmorhage
Hymen

thin porporated membrane at the entrance of the
vagina, hidden by labia minora

newborn
-vascular/redundant

pregnant
-thick epithelium
-rich in glycogen

menopause -thin epithelium
-with focal cornification

hymenal opening
-cresentic/circular
-cribriform
-septate/fimbriated

imperforate hymen

myrtiform caruncle
-cicatrized nodules/tissue remnants of the hymen
Vagina

tubular, musculomembranous strcuture extending
from the vulva to the uterus, interposed anteriorly
and posteriorly between the bladder and rectum

functions-excretory canal of the uterus
-organ of copulation

101

-part of the birh canal

-upper mullerian sucts
-lower urogenital sinus

nullipara
-with numerous rugae

multipara -smooth wall

vaginal inclusion cyst
-remnants of mucosal tags buried during
repair
of
vaginal
laceration
after
childbirth

portions

102

Module 4: Antenatal Care

Session 1&2: Process Flow of Antenatal Care

QUICK CHECK, RAM

DURING 1ST ANTENATAL VISIT

PREPARE A BIRTH AND
EMERGENCY PLAN

CHECK FOR PRE-ECLAMPSIA

ASK, CHECK, RECORD

CHECK FOR ANEMIA

LOOK, LISTEN, FEEL

CHECK FOR SYPHILIS

IDENTIFY SIGNS
CLASSIFY
TREAT AND RECORD

If yes, proceed to Sec. G1G8, H1-H4 of PCPNC

CHECK FOR HIV STATUS

RESPOND TO OBSERVED SIGN

OR VOLUNTEERED PROBLEMS*

GIVE PREVENTIVE MEASURES

ADVISE AND COUNSEL ON

NUTRITION AND SELF-CARE

ADVISE ON ROUTINE
FOLLOW-UP VISITS

HOME DELIVERY WITHOUT

SKILLED ATTENDANT

103

Antenatal Care

Always begin with RAM
(If the woman has no emergency or priority signs ).

Use the Pregnancy Status and Birth Plan Chart. C2;C14

Check all women for pre-eclampsia, anemia, syphilis and
HIV status C3-C6

Use chart on Respond to Observed Signs or
Volunteered Problems to classify the condition and
identify appropriate treatments
Respond to Observed Signs or Volunteered Problems

No fetal movement C7

Ruptured membranes C7

With fever or burning on urination C8

With vaginal discharge C9

With signs suggestive of HIV infection C10

Smoking, on alcohol or drug abuse or with history of
violence C10

With cough or breathing difficulty C11

On anti-tuberculosis treatment C11

Give preventive measures due C12

Develop a birth and emergency plan C14-C15

Advise on nutrition, family planning, labor signs, danger
signs, routine and follow-up visits C13 using Information
and Counselling Sheets

Record: positive findings, birth plans, treatment given,
next scheduled visit

If HIV positive, adolescent, or has special needs G1-G8;
H1-H4

104

Module 5: Labor, Delivery, Immediate Postpartum Period

Session 1: Stages of Labor-Overview
Labor

sequence of uterine contractions

cervical dilatation

bearing down

delivery of the baby
Delivery

expulsion of the baby
Immediate Postpartum Period

Equally important as labor and delivery

Most complications occur
Role of physician, nurse & midwife

To anticipate

To assess or identify problems

To treat or manage problems of the woman

Respond to problems during labour and delivery pp.

D14 D18

Observe mother and baby in the labor room one hour
after delivery. Use charts on Care of the Mther and
Newborn Within the First Hour of Delivery of the
Placenta Sec. D19 of PCPNC

For immediate postpartum management until delivery,
use Care of the Mother After the First Hour Following
Delivery of the Placenta Sec. D20 of PCPNC

To advise on danger signs, when to seek routine and
emergency care, and family planning, use Preventive
Treatment and Advise on Postpartum Care pp. D26
D28

Examination of the mother for discharge

Do not discharge the mother before 12 hours.

If mother is HIV Positive or Adolescent or has Special
Needs

If attending a delivery at the womans home, see Sec.
D29 of PCPNC.

Module 5: Labor, Delivery, Immediate Postpartum Period

Session 1: Stages of Labor-Rapid Assessment and
Management

Rapid Assessment and Management B3-B7

Examine Woman in Labor or With Ruptured Membranes
D2 D3. Then decide the stage of labor.

If and abnormal sign is identified, use the charts on Respond
to Observed Signs or Volunteered Problems D4-D5

For supportive care throughout labour and delivery, use
Supportive Care chart D6

Record findings conitnually on Labor record and partograph

105

Look, listen and feel:

Response to contractions

Check abdomen

Feel abdomen

Listen to the FHB

Measure VS

Look for pallor, dehydration
Decide the Stage of Labor
Ask, check record:

Explain to the woman that you will give her
a vaginal examination

Ask for her consent
Look, listen & feel:

Observe the vulva

Perform vaginal examination

DO NOT perform vaginal examination if
currently bleeding or at any time after 7
months of pregnancy
Module 5: Labor, Delivery, Immediate Postpartum
Period
Session 1: Stages of Labor
Contents:

Examine the woman in labor or with ruptured
membranes

Decide stage of labor
Examine the woman in labor or with ruptured
membranes
Ask, check record:

History of this labor

Check record, or if no record

If prior pregnancies

Current pregnancy

106

Signs Classify Manage

Imminent Delivery

Late active labor

Early active labor

Not yet in active labor
Review

First do RAM (B3 B7)

Assess the status of the woman and her fetus status (D2)

Decide stage of labor (D3)

107

Module 5: Labor, Delivery, Immediate Postpartum

Period
Session 2: First Stage of Labor
Contents:

First stage of labor
-not in active labor
-in active labor

Respond to obstetrical problems

Supportive care

Skills: IE, Partograph, Labor record

108

Supportive Care throughout Labor

To provide a supportive, encouraging atmosphere for
birth, be respectful of the womans wishes.

Communication

Cleanliness

Mobility

Urination

Eating, drinking

Breathing technique

Pain and discomfort relief

Birth companion
If woman is distressed or anxious, investigate the cause (D2
D3)
If pain is constant (persisting between contractions) and
very severe or sudden onset (D4)

109

Module 5: Labor, Delivery, Immediate Postpartum

Period
Session 3: Second Stage of Labor

Second Stage of Labor

Cervix dilated 10 cm

Bulging thin perineum

Head visible
Contents:

Delivery of the baby

Skills:
-Normal vaginal delivery
-Breech delivery
-Stuck shoulder
-Multiple birth
-Cord
prolapse
Second Stage of Labor
Monitor every 5 minutes:

For emergency signs using RAM (B3
B7)

Frequency, intensity and duration of
contractions

Fetal Heart Rate (D14)

Perineum thinning or bulging

Visible descent of fetal head or during
contraction

Mood and behavior: distressed, anxious
(D6)

Record findings regularly in
Labor Record and Partograph
(N4 N6)

Never leave the woman alone

110

All delivery equipment and supplies, including newborn

(NB) resuscitation equipment are available, and place of
delivery is clean and warm (25C) (L3);

Empty bladder (B12);

Assist to choose a comfortable position,
upright
as
possible;

Stay with mother and offer emotional and
physical support (D10-D11)

Allow her to push as she wishes with
contractions.
Do not urge her to push.

Wait until head visible and perineum distending

Refer urgently to hospital if 2nd stage lasts for 2hrs or
more without visible steady descent of the head.(B17)

Do not perform episiotomy routinely.

Wash hands w/ clean water and soap.

Put on gloves just before delivery.

See universal precautions during labor and delivery A4.

Ensure controlled delivery of the head

Feel gently around babys neck for the cord.

Await spontaneous rotation of shoulders and delivery
within 1-2 minutes (D17- managing STUCK
SHOULDERS).



Exclude 2nd baby.

Palpate mothers abdomen.
Give 10 IU oxytocin IM to the mother.
Watch for vaginal bleeding.
Change gloves or wash gloved hands.
Clamp and cut the cord.
Encourage initiation of breastfeeding. K2

111

Module 5: Labor, Delivery, Immediate Postpartum

Period
Session 3: Second Stage of LaborPerineal Repair
Episiotomy

Or perineotomy

Is an incision into the perineum to enlarge the space at
the outlet, thereby facilitating the birth of the child.
Maternal benefits:

A straight incision is simpler to repair and heals better
than a jagged, uncontrolled laceration;

Strength of the pelvic floor can be preserved and the
incidence of uterine prolapse, cyctocoele and rectocoele
reduced;

Structures in front and rear are protected;

Less stretching of and less damage to the anterior vaginal
wall, blader, urethra and periclitoral tissues;

Tears into the rectum can be avoided;

Second stage of labor is shortened.
Fetal benefits:

Lessens pounding of the head on the perineum so helps
prevent brain damage;

Makes birth easier.
Indications:

Prophylactic: To preserve the integrity of the pelvic floor;

Arrest of progress by resistant perineum (thick and
heavily muscled tissue, operative scars, and previous wellrepaired episiotomy);

To obviate uncontrolled tears, including extension into the
rectum;

Fetal reasons (premature babies, large babies, abnormal
positions, and fetal distress).

112

Timing of Episiotomy:

If made too late, procedure fails to prevent lacerations;

If made too early, the incision leads to loss of blood;

Is made when the perineum is bulging, when 3 to 4 cm
diameter of the fetal scalp is visible during contraction;
Lacerations of the Perineum
Maternal causes:

Precipitate, uncontrolled or unattended delivery (most
common cause);

The patients inability to stop bearing down;

Hastening the delivery by excessive fundal pressure;

Edema and friability of the perineum;

Vulvar varicosities weakening the tissue;

Narrow pubic arch with outlet contraction, forcing the
head posteriorly;

Extension of episiotomy.
Fetal causes:

Large baby;

Abnormal positions of the head (OP, face);

Breech deliveries;

Difficult forceps extractions;

Shoulder dystocia;

Congenital anomalies (hydrocephalus).
Classification of Lacerations of the Perineum
First degree laceration involves the fourchette, perineal skin
and vaginal mucosa membrane BUT NOT the underlying
fascia and muscle.
Repair aims reapproximation of the divided issue and
hemostasis. A simple interrupted suture is enough. If bleeding
is profuse, figure-8 sutures may be used.
Second degree laceration involves, in addition to the skin
and muscous membrane, the muscles of the perineal body
BUT NOT the rectal sphincter.

Repair:

Interrupted, continuous or lock stitches are used to
approximate the edges.

The deep muscles of the perineal body are sutured
together with interrupted sutures.

A running subcuticular suture or interrupted sutures,
loosely tied, bring together the skin edges.
Third degree laceration extends through the skin, mucous
membrane, perineal body AND INVOLVE the anal
sphincter.
Repair - Similar to repair of fourth degree laceration except
that the reapproximation starts with the torn ends of the anal
sphincter.
Fourth degree laceration extends through the rectal
mucosa to expose the lumen of the rectum.
Repair: (repaired in layers)

The anterior wall of the rectum is repaired with fine 000
or 0000 chromic catgut on a fused needle. Starting at the
apex, interrupted sutures are placed submucosally so that
the serosa, muscularis and submucosa of the rectum are
apposed. Others approximate edges with continuous
suture going through all layers.

The line of repair is oversewn by bringing together the
perirectal fascia and the fascia of the rectovaginal septum.
Interrupted or continuous sutures are used.

The torn ends of the rectal sphincter are identified,
grasped with allis forceps and approximated with
interrupted sutures or two figure-8 sutures.

The vaginal mucosa is then repaired as a midline
episiotomy with continuous or interrupted sutures.

The perineal muscles are sewn together with interrupted
sutures.

The skin edges are sewn together with a continuous
subcuticular suture loosely tied interrupted sutures.

Disruption of Episiotomy or Laceration Repair:

Poor healing powers (nutritional deficiencies, anemia,
exhaustion after a long and difficult labor).

Failure of technique (careless approximation of the
wound, incomplete hemostasis leading to hematoma
formation, failure to obliterate dead space).

Devitalization of tissue (use of crashing instruments,
strangulation of tissue by tying sutures too tightly,
employment of heavy catgut).

Infection
Aftercare

Maintain cleanliness

Use of antiseptic after each urination or bowel movement

No alcohol

Perilight may be used

Daily shower and washing using soap and water

Use of stool softener for those who had third or fourth
degree lacerations

Well balanced diet
Other locations of lacerations

Tissue on either urethra

Labia minora

Lateral walls of the vagina

Area of the clitoris

Cervix

Urethra

Bladder

113

Repair of median episiotomy.

A. Chromic 2-0 or 3-0 suture
is used as a continuous suture
to close the vaginal musoca
and submucosa. B. After
closing the vaginal incision and
reapproximating the cut
margins of the hymenal ring,
the suture is tied and cut.
Next, three or four interrupted
sutures of 2-0 or 3-0 chromic
are placed in the fascia and
muscle of the incised perineum. C. A continuous suture
is carried downward to unite
the superficial fascia. D.
Completion of repair. The
continuous suture is carried
upward as a subcuticular stitch.
(An alternative method of
closure of skin and subcutaneous fascia is illustrated in E.)
E. Completion of repair of
median episiotomy. A few
interrupted sutures of 3-0
chromic are placed through the
skin and subcutaneous fascia
and loosely tied. This closure
avoids burying two layers of
suture in the more superficial
layers of the perineum.

114

115

Module 5: Labor, Delivery, Immediate Postpartum

Period
Session 3: Second Stage of LaborThird Stage of Labor
Contents:

Delivery of the placenta

Care of the Mother and NB WITHIN 1st hour of
placental delivery

Care of the Mother 1hour AFTER delivery of the
placenta

Assessment of the Mother after delivery and Before
Discharge

Respond to Problems Immediately Postpartum

Skills
-Management of abnormal 3rd stage
-Antepartum Hemorrhage
-Active management of 3rd stage
Delivery of the Placenta

Monitor Mother every 5 mins:

For emergency signs using RAM (B3-B7)

Feel if uterus is well-contracted

Mood and behavior (distressed or
anxious) (D6)

Time since 3rd stage begun (time since birth)

Record findings, treatment and procedures in Labor

Record and Partograph (N4-N5)
Deliver the Placenta - Treat & Advise If Required

Ensure 10 IU oxytocin IM is given

Await strong contraction (2-3mins) and deliver by
controlled cord traction.

30mins undelivered -empty bladder, encourage
breastfeeding, repeat controlled cord traction

1hr undelivered - manual delivery (doctor), IM/IV
antibiotic
Another 1hr undelivered refer to hospital

DO NOT exert excessive traction on the cord.

DO NOT squeeze or push the uterus to deliver the
placenta.

Check the placenta and membranes if complete. If
incomplete remove fragments manually (doctor),
IM/IV antibiotic B11, B15

Check uterus if well contracted and no bleeding.
Repeat check every 5 mins.
If heavy bleeding

Massage uterus to expel clots if any, until it is hard B10

10 IU Oxytocin IM

Call for help

IV line B9, add 20 IU oxytocin x 60 drops/min

Empty bladder
If bleeding persists and uterus soft

Continue massage

Bimanual or aortic compression B10

Continue IVF with 20 IU oxytocin x 30 drops/min

Refer urgently to hospital B17

Examine perineum, lower vagina and vulva for tears. If
3rd degree refer to hospital

Collect, estimate and record blood loss throughout the 3rd
stage and immediately afterwards.

116

Care of the Mother and NB within 1st hour of delivery

of the Placenta

Monitor mother every 15 mins

Monitor baby every 15 mins
Care of the Mother and NB

Assess amount of bleeding. Less than
5mins soaked or constant trickle of
blood B10
-if bleeding from a perineal tear, repair if required B10
or Refer to hospital B17

Ask the companion to stay with the mother

Encourage the woman to pass urine

Ask, Check record:

Bleeding >250 ml

Completeness of placenta and membranes

Complications during delivery and postpartum

Needs tubal ligation or IUD

Others
Look, Listen and Feel:

Temperature

Feel the uterus

Vaginal bleeding

Perineum: tear, swelling, pus

Pallor

Care of the Mother 1HR after Delivery of the Placenta

Use chart for continuous care of the mother until
discharge.

Signs Classify Treat & Advise

Give Preventive Measures D25

Ensure that all are given before discharge.

Monitor mother at 2, 3 and 4 hrs, then every 4 hrs:

For emergency signs using RAM

Feel uterus if hard and round

Record findings, treatments and
procedures in Labor Record and
Partograph N4-N5

Never leave the woman and baby alone

DO NOT discharge before 12 hrs.

Assess, Check records Treat & Advise D25

RPR status. If none do RPR test L5

If (+) administer Benzathine Penicillin (F6)

Tetanus toxoid status -give if due (F2)

Give 500mg of Mebendazole to every woman once in 6
months (F3)

Check womans supply of iron/folate, vitamin A

Give 3 months supply of iron and counsel on compliance
(F3), give vitamin A if due (F2)

Ask whether mother and baby are sleeping under
insecticide bednet. F4

Record all treatment given using Postpartum Record
(N6)

Care of the Mother Interventions if Required

Advise on Postpartum Care and Hygiene, Nutrition D26

Advise when to seek care D28

Counsel on Birth Spacing and other Family Planning
Methods D27

Repeat examination of the mother before discharge using
Asses the mother after delivery D21. For baby J2-8.
Assess the Mother after Delivery
Use chart to examine the mother the first time after delivery
(at 1 hr after delivery or later) and for discharge.

Advise on Postpartum Care D26

Companion for the 1st 24hrs

Not to insert anything in the vagina

Rest and sleep

Importance of washing

Avoid sexual intercourse until perineal wound is healed

117

Counsel on Nutrition

Greater amount of variety of nutritious and healthy
foods

Ensure she can eat any normal foods

More nutrition counseling on thin mothers and
adolescents

No to myths and fallacies about foods

Seek help from family members about proper nutrition
of the mother
Counsel on Birth Spacing and Family Planning D27

Importance of Family Planning

Include partner of family member to be included in the
counseling

Explain non-breastfeeding can make her pregnant again

Ask desired family size

2-3 years gap is healthy to the mother and child

Give info on when to start a method after delivery will
vary on whether the woman is breastfeeding or not

Make arrangement on when to see a FP counselor, or
counsel directly

Advise correct and consistent use of condoms for dual
protection against STIs or HIV and pregnancy. Promote
their use (G2)

For HIV (+) women see G4 for FP considerations

Ask choice for Vasectomy of partner
Lactation Amenorrhea Method (LAM)

A breastfeeding woman is protected from pregnancy
only if:

Not > 6 months postpartum

Breastfeeding exclusively (8 or more times/day)

Can also choose additional FP method
Method Options for the Non-breastfeeding Woman
Can be used immediately postpartum:

Condoms

Progesterone-only pills

118

Progesterone- only injectable

Implant
Spermicide
Female sterilization (w/in 7 days or delay 6 weeks)
IUD (w/in 48 hrs of delay 4 weeks)

Delay 3 weeks:

Combined OCPs

Combined injectables

Diaphragm

Fertility
awareness

method

Delay 6 Weeks:

Progesterone-only OCPs

Progesterone-only injectables

Implants

Diaphragm
Delay 6 months:

Combined OCPs, injectables

Fertility awareness method
Advise on When to Return D28

Use chart for advising on postpartum care

Encourage woman to bring her partner or family
member to at least 1 visit
Routine Postpartum Care Visits D281st visit (D19) within

1st week, preferably within 2-3 days

2nd visit (E2) 4-6 weeks
Follow-up Visits for Problems:
If problem was:
Return in:

Fever
2 days

Lower UTI
2 days

Perineal infection or pain
2 days

Hypertention
1 week

Urinary incontinence
1 week

If problem was:

Severe anemia

Postpartum blues

HIV (+)

Moderate anemia

If treated in hospital
for complication

Return in:
2 weeks
2 weeks
2 weeks
4 weeks

Advise the women to bring her HBMR to the HC, even

for an emergency visit.

not later
than 2 weeks

Advise on danger signs

Go to hospital or HC immedaitely, anytime, urgently if:

Vaginal Bleeding 2-3 pads soaked in 20-30 mins after
delivery, increases after delivery

Convulsion

Fast or difficult breathing

Fever and too weak to get out of bed

Severe abdominal pain
Go to Health Center ASAP for the following signs:

Fever

Abdominal pain

Feels
ill

Breast swollen, red, tender, sore nipple

Urine dribbling or pain on micturition

Pain in perineum or draining pus

Foul-smelling
lochia
How to prepare for an Emergency in postpartum

Always have someone near at least 24hrs after delivery

Discuss with partner or family member about emergency
issues:
- where to go
- how to reach the hospital
- costs involved
- family and community support

Advise the woman to ask for help from the community if
needed I 1-3.

119

Module 6: Postpartum Care

Session 1: Post Partum examination of the Mother Up
to Six Weeks

Always begin with RAM pp E2-E7

For examination of the woman on postpartum follow-up
or after home delivery, use Postpartum Examination of
the Mother (P2)

Use Respond to Observed Signs of Volunteered
Problems chart if an abnormal sign is identified (E3E10)

Record all findings and treatment given then schedule
next visit.

For the first and second postpartum visits, during the fisrt
week after delivery, use the Postpartum Examination
chart (E2)

For further advise, use Advise and Counselling Section
D26

If the woman is HIV Positive, Adolescent or with Special
Needs G2-G8, H1-H4
Overview

Time between delivery of the baby 6 weeks

Complications may usually occur

Morbidity & mortality attributed to inadequate
knowledge of proper assessment and management while
the mother is in the health facility

Important role of health providers: prevent such
problems to occur
Postpartum Care Sessions:

Postpartum Examination of the Mother Up to Six
Weeks, Postpartum Care

Respond to Observed Signs and Volunteered Problems

Preventive Measures and Additional Treatments

120

Session 1: Postpartum Examination of the Mother Up to

Six Weeks (E2)

Use this chart for examining the mother after discharge
from a facility

If she delivers less than 1 week ago without a skilled

attendant, use the chart Assess the Mother After
Delivery (D21)
Ask, Check Record

When, where delivered

How are you feeling?

Pain, fever, bleeding since delivery?

Hard to void urine?

Family Planning?

Other concern?

Check records: complications, tx during delivery?

HIV Status
Look, Listen & Feel

BP, Temp

Feel uterus. Is it hard, round?

Look at vulva & perineum for: tear, swelling, pus

Look at pad for bleeding and lochia:
-does it smell?
-is it profuse?

Look for pallor
Treat and Advise

What to watch for hygiene, counsel on nutrition (D26)

Counsel on birth spacing and FP (D27)

Iron supply for 3months, compliance (F3)

Treatment or prophylaxis due: TTd (F2)

Impragnated bed for mother and babyRecord on the
mothers HBMR

Advise to return within 4-6 weeks

ASSESS AND EXAMINE THE MOTHERS

COMPLETE HISTORYAND PE

SIGNS

CLASSIFY

TREAT AND ADVISE

Module 6: Postpartum Care

Session 2: Respond to Observed Signs & Volunteered
Problems
Observed signs & Volunteered problems:

Elevated diastolic BP

Pallor

HIV status

Heavy bleeding

Fever or foul-smelling lochia

Dribbling urine

Pus or perineal pain

Feeling unhappy or crying easily

Vaginal discharge 4 weeks after delivery

Breast problem

Cough or breathing difficulty

Taking
anti-tuberculosis
drugs

Signs suggesting HIV infection
Summary

Recognize problem

Respond to volunteered problem or observed signs

Manage properly the problem

Module 6: Postpartum Care

Session 3: Preventive Measures & Additional Treatments
Contents:

Tetanus toxoid (TTd)

Vitamin A postpartum

Iron and Folic Acid

Compliance on Iron treatment

Antimalarial treatment and Paracetamol

Oral antibiotics

Signs of allergy
Tetanus toxoid

All women, 0.5 ml IM

Check TTd status: when last given, which dose
-if unknown -give TTd 1
-give TTd 2 in 4 weeks

Explasin its safe in pregnancy, ADR

Advise when is next dose

Record on mothers card
Tetanus toxoid schedule:

At 1st contact w/ woman of childbearing age or at 1st
antenatal care visist, ASAP - TTd1

At least 4 weeks after TTd1 TTd2

At least 6 months after TTd2 TTd3

At least 1 year after TTd3 TTd4

At least 1 year after TT4 TTd5
Vitamin A

200,000 IU capsule after delivery or w/in 6 weeks of
delivery

Helps recovery, good to the baby also

Nausea and headache temporary only

Do not givecapsules with high dose of vitamin A during
pregnancy

121


Mebendazole 100mg tablet = 5 tablets

Iron & Folic acid

All pregnant, postpartum and postabortion women

Give 3 months supply

1 tablet = 60mg iron, 400ug folic acid

Mottivate cmpliance
Antimalarial treatment

Give preventive intermittent treatment for
falciparum malaria

Sulfodoxine-pyrimethamine at the
beginning of 2nd and 3rd trimester to all
women according to natl policy

Check when last dose is given:
-if no dose in last month, give 3 tablets in
clinic

Advise when next dose is due

Monitor baby for jaundic eif given just
before delivery

Record in home-based record

Sulfadoxine-pyrimethamine

1 tablet= 500mg sulfadoxine + 25 mg
pyrimethamine
Second trimester = 3 tablets
Third trimester = 3 tablets

Oral anti-malarial treatment
Paracetamol

For severe pain

500 mg

1-2 tabs every 4-6 hrs
Insecticide-treated bednet

Dip in insecticide every 6 months

Provide information to help her do this
Mebendazole

Give 500 mg to every woman once in 6
months

Do not give in the first trimester

122

Summary
Complete management of a mother by:

Giving these preventive measures

Treating infectious conditions

Recognize and initially manage allergy after giving
medications

Module 6: Postpartum Care

Session 3: Preventive Measures
Additional
Treatments-RAM

&

Pregnanct women

Good communication/rights of women

Organizing a visit
Workplace and administrative procedures
Universal precautions

QUICK CHECK AND RAM

Emergency signs

A-Airway
B- Breathing
C- Circulation
D- Drugs

Priority signs

Labor pains
Classify stage of labor

Emergency treatment

Routine care

Labour and delivery

Vaginal bleeding
Convulsions
Severe abdominal pain
Dangerous fever
Labour

Non-emergency signs

Partograph and labor record

Postpartum

Newborn

Antenatal care

Term pregnancy

Module 7: Newborn Care

Session 1:Care of the Newborn Baby at the Time of
Birth D11- Immediate Newborn Care
Basic Needs of the Newborn at Birth

To breathe normally

To be warm

To be fed

To be protected
Preparing to Meet the Babys Needs

Good care of the newborn begins with good
preparation

Have clean warm towels/cloths ready for the newborn
(warmth)

Have a sterile kit to tie and cut the cord (protection)

Keep the delivery room clean and warm (warmth,
protection)

Keep the mother and baby in skin-to-skin contact from
birth to encourage breastfeeding (warmth, feeding)

Have resuscitation equipments near the delivery bed
(breathing)
Universal Precautions A4

Always remember the importance of observing
precautions to help protect the mother and baby and
ourselves from infections with bacteria, viruses including
HIV

Change the gloves. If not possible, wash gloved hands.
Give Immediate Newborn Care J10

Place baby on the mothers abdomen or arms;

Note the time of delivery;

Dry the baby . Wipe eyes. Discard wet cloth;

Assess babys breathing while drying;

Most babies cry at birth and breathe
normally.

However, a baby may behave in a number of ways after it

is born, thus we should be always be prepared for the
baby who will need help with its breathing. (Newborn
Resuscitation B11)

Clamp and cut the cord
-put ties tightly around the cord at 2 cm and 5 cm from
babys abdomen;
-cut between ties with sterile instrument.
-observe for oozing blood.

Leave baby on the mothers chest in skin-to-skin contact;

Place identification label;

Encourage initiation of breastfeeding (K2);

If HIV-positive mother-G7,G8
Care of the Newborn within the first hours of life J19
Permanent surveillance

Never leave the woman and newborn alone;

Keep the mother and baby in the delivery room;

Record findings, treatments and procedures in the labor
record;
Monitor every 15 minutes:
Baby

Breathing

warmth
Care of the mother and newborn

Wipe the eyes

Apply an eye antimicrobial within 1 hour of birth
- 1% silver nitrate drops or
- 2.5% povidone iodine drops or
- 1% tetracycline ointment.

Administer Vitamin K 0.5 -1 mg IM

If blood or meconium, wipe off with wet cloth and dry.

DO NOT remove vernix or bathe the baby.

Keep the baby warm and in skin-to-skin contact with the
mother K9

123

Keep the baby warm K9

At birth and within the first hour(s)

Warm delivery room

Dry the baby: place the baby on the mothers abdomen
or on a warm, clean and dry surface. Dry the whole
body and hair thoroughly, with a dry cloth.

Skin-to-skin contact: Leave the baby on the mothers
abdomen (before cord cut) or chest (after cord cut) after
birth for at least 2 hours. Cover the baby with a soft dry
cloth.

If unable to initiate breastfeeding, plan for alternative

feeding method K5-K8

If mother HIV+ and chooses replacement feeding, feed
accordingly (G8)

If the baby does not feed in 1 hour, examine the baby
(J2-J9). If healthy, leave the baby with the mother to try
later. Assess in 3 hours, or earlier if the baby is small (J4).

If the mother is ill and unable to breastfeed, help her to
express breast milk and feed the baby by cup (J4).

If mother cannot breastfeed at all, use one of the
following options:
- home-made or commercial formula
- donated heat-treated breast milk.
In the first two hours after birth, it is not necessary to:

Weigh or measure the baby

Bathe the baby

Dress the baby

Give the baby any other food other than breast milk

Give the baby to anyone apart from the mother

Help the mother to initiate breastfeeding within 1 hour,

when baby is ready
(K2 box 2)

Signs of readiness to breastfeed are: baby looking
around/moving, mouth open, searching.

Check position and attachment at the first feed. Offer to
help the mother at any time (K3).

Let the baby release the breast by her/himself; then offer
the second breast.
124

Review

Make sure that the delivery area is ready for the mother
and baby;

Observe universal precautions at all times (protection);

Keep the delivery room warm (warmth, protection);

Have resuscitation equipment near the delivery bed
(breathing);

Have clean warm towels/cloths ready for the baby
(warmth);

Have a sterile kit to tie/clamp and cut the cord;

Apply antimicrobial to the eyes(protection);

Keeping the mother and baby in skin-to-skin contact
encourages early breastfeeding (warmth, feeding).

Module 7: Newborn Care

Session 1: Care of the Newborn Baby at the Time of
Birth D11-Keeping the Baby Warm K9
What is hypothermia?

The Warm Chain

Warm delivery room

Immediate drying

Skin-to-skin contact

Breastfeeding

Bathing and weighing postponed

Appropriate clothing and bedding

Mother and baby together

Warm transportation

Warm resuscitation

Training and awareness
Ensure Warmth for the Newborn Baby K9

Keep the baby warm

Keep a small baby warm

Rewarm the baby skin-to-skin
Rewarm the baby skin-to-skin

Before rewarming, remove the babys cold clothing.

Place the newborn skin-to-skin on the
mothers chest dressed in a pre-warmed
shirt open at the front,a diaper, hat and socks.

125


Cover the infant on the mothers chest with her clothes

and an additional (pre-warmed) blanket.

Check the temperature every hour until normal.

Keep the baby with the mother until the babys body
temperature is in normal range.
Re-warming a cold baby

If the baby is LBW or preterm, encourage the mother
to keep the baby in skin-to-skin contact for as long as
possible, day and night.

Be sure the temperature of the room where the
rewarming takes place is at least 25C.

If the babys temperature is not 36.5C or more after 2
hours of rewarming, reassess the baby (J2-J7).

If referral needed, keep the baby in skin-to-skin position/
contact with the mother or other person accompanying
the baby.
Taking a babys temperature
If you have a thermometer:

Make sure it is clean. Shake it down so that it reads <
35C

Place the silver/red bulb end of the thermometer
under the babys arm, in the middle of the armpit

Gently hold the babys arm against his body

Keep the thermometer in place for 3-5 minutes

Remove the thermometer and read the temperature

Record the temperature in the babys notes
If you do not have a thermometer:

Feel the babys feet.

If they are cold to touch, the baby is cold and needs to
be warmed

If the babys temperature is < 36C or >37.5C, the
baby will need to be observed.

126

Does a newborn babys temperature need to be taken

routinely by a thermometer?
An accurate temperature is needed
if the baby is:

Preterm or low birthweight or sick

Admitted to the hospital

Suspected of being either hypothermic or hyperthermic

Being rewarmed during the management of
hypothermia

Being cooled down during the management of
hyperthermia

Module 7: Newborn Care

Session 1: Care of the Newborn Baby at the Time of
Birth-Breastfeeding the Newborn Baby
What to teach the mother about breastfeeding:

Correct attachment and positioning (K3box 2)

Importance of exclusive breastfeeding (K2 box 1)

How to express her milk (K5)

How to prevent or treat common problems

When to seek help
Anatomy of the Breast

127

Physiology of breastfeeding

Problems that may arise if the baby is not well attached

to the breast
The baby:

May cry a lot and be unhappy

May be slow to gain weight, or may even lose weight
The mother:

May get sore/cracked nipples

May get very full breasts which feel hard, sometimes they
may feel hot and may look red
Key points to good positioning- p.K3

The babys head and body are in a straight line

The babys face is opposite the nipple and breast

The babys upper lip or nose is opposite the mothers
nipple

The baby is held as close to the mothers body as
possible

The babys whole body is supported if the mother is in
a sitting position.
The babys first breastfeed
Help the mother to initiate breastfeeding within 1 hour, when
the baby is ready.

Key points to good attachment:

The babys mouth is widely open

The tongue is far forward in the mouth, and may be seen
over the bottom gum

The lower lip is turned outwards

The chin is touching the breast

More areola is visible above the babys
mouth than below it K3 box 2
For the mother to attach her baby, she should:

Touch her babys lips with her nipple

Wait until her babys mouth is opened widely

Move her baby quickly onto the breast, aiming the
infants lower lip well below the nipple
128

Other breastfeeding concerns K8

Give special support to the mother who is not
breastfeeding ( Mother or baby ill)

If the baby does not have a mother

Advise the mother who is not breastfeeding at all on
how to relieve engorgement ( baby died or stillborn or
mother chose replacement feeding

Module 7: Newborn Care

Session 1: Care of the Newborn Baby at the Time of
Birth-Alternative Methods of Feeding a Baby
Why a baby may not be able to breastfeed

Preterm

Low birth weight

The baby or the mother is ill

The baby or mother is referred to another hospital

Alternative feeding methods

Direct expression of breastmilk

Cup feeding

Gastric tube

Spoon

Syringe

Breastfeeding supplementer

Bottle
What are the advantages of direct expression of
breastmilk?

The mother can do it

She can do it anytime and anywhere

It does not require the baby to use a lot of energy

It encourages skin-to-skin contact between the mother
and baby

It encourages the baby to use its instinctive responses

It can be done before the baby is able to coordinate its
swallowing, sucking and breathing.
Direct expression of breastmilk into the babys mouth

Hold the baby in skin-to-skin contact, the mouth close to
the nipple.

Express the breast until some drops of breast milk
appear on the nipple.

Wait until the baby is alert and opens mouth and eyes, or
stimulate the baby lightly to awaken her/him.

Let the baby smell and lick the nipple, and attempt to
suck.

Let some breast milk fall into the babys mouth.

Wait until the baby swallows before expressing more
drops of breast milk.

After some time, when the baby has had enough, she/
he will close her/his mouth and take no more breast
milk.

Ask the mother to repeat this process every 1-2 hours if
the baby is very small (or every 2-3 hours if the baby is
not very small).

Be flexible at each feed, but make sure the intake is
adequate by checking daily weight gain.
Why cup feeding?

A cup is a simple piece of equipment

A cup is easy to clean

Simple method of feeding

The baby can take what he needs in his own time
How to Cup Feed

Ask the mother to:

Measure the quantity of milk in the cup

Hold the baby sitting semi-upright on her lap

Hold the cup of milk to the babys lips:
- rest cup lightly on lower lip
- touch edge of cup to outer part of upper lip
- tip cup so that milk just reaches the babys lips
- do not pour the milk into the babys mouth.

When the baby smells the milk, the baby becomes alert,
opens mouth and eyes, and starts to feed.

The baby will sip or suck the milk into his mouth

Preterm /Small babies take milk into their mouth with their
tongue using a lapping movement.

Preterm babies do not dribble as much as older babies.

Baby finishes feeding when mouth closes or when not
interested in taking more.
Cup Feeding
If the baby does not take the calculated amount:

Feed for a longer time or feed more often

129


Teach the mother to measure the babys intake over 24

hours, not just at each feed.

Feed the baby by cup if the mother is not available to do
so.

Baby is cup feeding well if required amount of milk is
swallowed, spilling little and weight gain is maintained.
How to hand express breastmilk

Prepare a clean containers to collect and store the milk.
A wide necked jug, jar, bowl or cup can be used.

Once expressed, the milk should be stored with a wellfitting lid or cover.

Teach the mother to express her milk by herself. DO
NOT do it for her.
How to hand express breastmilk
Teach the mother how to:
Wash her hands thoroughly.
Sit or stand comfortably and hold a clean
container underneath her breast.
Put her first finger and thumb on either side of the areola,
behind the nipple ( about 4 cm from the tip of the nipple).
Compress and release the breast between her finger and
thumb.
Compress in the same way all the way
around the breast keeping her fingers the
same distance from the nipple
How to hand express breastmilk

Express one breast until the milk just drips, then
express the other side until the milk just drips.

Continue alternating sides for at least 20-30 minutes.
If milk does not flow well:

Apply warm compresses to the breast

Gently massage the breast

130

Have someone massage her back and neck before

expressing.
How to hand express breastmilk

Feed the baby by cup immediately. If not, store
expressed milk in a cool, clean and safe place.

If necessary, repeat the procedure to express breast milk
at least 8 times in 24 hours.

Express as much as the baby would take or more, every
3 hours.

Module 7: Newborn Care

Session 1: Newborn Resuscitation-Neonatal
Resuscitation
Why learn neonatal resuscitation?

Birth asphyxia accounts for 19%of approx. 5 million
neonatal deaths that occur each year worldwide (WHO,
1995)

Outcomes of more than 1 million newborns per year
might be improved by resuscitation techniques
Which babies require resuscitation?

At least 90 percent newly born babies are vigorous

Ten percent require some kind of assistance

One percent need resuscitative measures to survive
Overview and Principles of Resuscitation

Physiologic changes at birth

Resuscitation flow diagram

Resuscitation risk factors

Equipment and personnel needed
Lungs and Circulation
In the fetus

In utero, the fetus is dependent on the placenta as the
organ of gas exchange

Air sacs are filled with fetal lung fluid

Arterioles are constricted

Pulmonary blood flow is diminished

Blood flow is diverted across ductus arteriosus
After delivery

Lungs expand with air

Fetal lung fluid leaves alveoli

Pulmonary arterioles dilate

Pulmonary blood flow increases

Blood oxygen levels rise

Ductus arteriosus constricts

Blood flows through the lungs to pick up oxygen

131

Cardiac function and compensatory mechanisms in

asphyxia

Initial response
Constriction of vascular beds in lungs, intestines, kidneys,
muscle, and skin to redistribute blood flow to heart and
brain

Late effects
Myocardial function may be impaired, cardiac output
decreases, and organ damage may occur
What Can Go Wrong During Transition

Insufficient ventilation, airway blockage, or both

Excessive blood loss or poor cardiac contractility

Sustained constriction of pulmonary arterioles

Normal Transition
These major changes take place within seconds after
birth:

Fluid in the alveoli is absorbed

Umbilical arteries and vein constrict

Blood vessels in lung tissue relax
Fetal lung fluid clearance

Improved with labor before delivery

Facilitated with effective initial breaths

Impaired by
Apnea at birth with no lung expansion
Shallow ineffective respirations
Pulmonary blood flow

Decreases with hypoxemia and acidosis due to
vasoconstriction

Increases with ventilation, oxygenation, and correction
of acidosis

132

Signs of a Compromised Newborn

Cyanosis

Bradycardia

Low blood pressure

Depressed respiratory effort

Poor muscle tone
Interruption in Normal Transition: Apnea
Primary apnea
Rapid attempts to breathe

Respirations cease

Heart rate decreases

Blood pressure is usually maintained

Responds to stimulation
Secondary Apnea

Respirations cease

Heart rate decreases

Blood pressure decreases

No response to stimulation

Provider Responses: Resuscitation Flow Diagram

Initial Steps (Block A)
Evaluation
After these initial steps, further actions are based on evaluation
of:

Respiration

Heart Rate

Color

Breathing (Block B)
If Apnea or HR <100 bpm:

Assist newborn by providing positive-pressure ventilation
with a bag and mask for 30 seconds.

Then, evaluate again

133

Important Points in the Neonatal Resuscitation Flow

Diagram

Heart rate < 60
additional steps needed

Heart rate > 60
chest compressions can be stopped

Heart rate > 100
positive-pressure ventilation can be
stopped

Asterisk (*) endotracheal intubation may be considered at
several steps

Timeline 30 seconds if no improvement, then proceed
to next step

Circulation (Block C)
If HR <60 bpm despite adequate ventilation:

Support circulation by starting chest compressions while
continuing ventilation.

Then, evaluate again. If heart rate <60, proceed to D.

Drug (Block D)
If HR <60 bpm despite adequate ventilations and chest
compressions:

Administer epinephrine as ventilation and chest
compressions continue
134

Evaluation, Decision and Action Cycle

Preparation for Resuscitation Personnel and Equipment

Trained person to initiate resuscitation at every delivery

Recruit additional personnel, if needed for complex delivery

Prepare necessary equipment
Turn on radiant warmer
Check resuscitation equipment

Module 7: Newborn Care

Session 2: Newborn Resuscitation-Initial Steps

Preparation for Resuscitation Risk Factors

Antepartum factors

Intrapartum factors

Evaluating the Newborn

Immediately after birth, the following questions must be
asked:

Why are Premature Newborns at Higher Risk?

Initial Steps

Provide Warmth

Position; clear airway (as necessary)

Dry, stimulate, reposition

Give O2 (as necessary)

Possible surfactant deficiency

Increased heat loss, poor temparature control
Possible infection
Susceptible to intracranial hemorrhage

Decide if resuscitation is needed

Open the airway

Manage if meconium is present

Provide free-flow oxygen

Prevent heat loss by

Placing newborn under radiant warmer

Drying thoroughly

Removing wet towel

135

Preventing Heat Loss

Premature newborns

Special problems

-Thin skin
-Decreased subcutaneous tissue
-Large surface area

Additional steps

Raise environment temperature

Cover with clear plastic sheeting
Open the airway by

Positioning on back or side

Slightly extending neck

Sniffing position

Aligning posterior pharynx, larynx and trachea
Opening the Airway
Meconium Present and Newborn Vigorous
If:

Respiratory effort is strong, and

Muscle tone is good, and

Heart rate is greater than 100 bpm
Then:

Use bulb syringe or large-bore suction catheter to clear
mouth and nose
Meconium Present and Newborn Not Vigorous

Tracheal suction

Administer oxygen

Insert laryngoscope, use 12F or 14F suction catheter to
clear mouth

Insert endotracheal tube

Attach endotracheal tube to suction source

Apply suction as tube is withdrawn

Repeat as necessary

136

Suctioning Meconium

Tactile Stimulation

Stimulate to Breathe, Reposition

Potentially Hazardous Forms of Stimulation

Slapping the back

Squeezing the rib cage

Forcing thighs into abdomen

Dilating anal sphincter

Hot or cold compresses or baths

Shaking
Free-flow Oxygen

137

Module 7: Newborn Care

Session
2:
Newborn
ResuscitationResuscitation Bag and Mask
Use of resuscitation bag and

When to ventilate

Types of resuscitation bags

Operation of each type of bag

Face-mask placement

Troubleshooting resuscitation bags

Evaluating ventilation
Types of Resuscitation Bags

138

mask

General Characteristics of Neonatal Resuscitation Bags

and Masks

Size of bag (200 to 750 mL)

Oxygen capability 90%-100%

Capable of avoiding excessive pressures

Appropriate-sized mask (cushioned, anatomically
shaped masks preferred)

Without reservoir: Delivers only 40% oxygen to the patient

Self-inflating Bag

Self-inflating Bag: Basic Parts

Control of Oxygen
With reservoir: 90%-100% oxygen delivered to patient
Self-inflating Bag
Control of Oxygen

139

Self-inflating Bag: Types of

Oxygen Reservoirs

Self-inflating Bag: Pressure

Amount of pressure delivered depends on the following
three factors:

How hard the bag is squeezed

Any leak between mask and newborns face

Set point of pressure-release valve
Resuscitation Bags:
Safety Features

Every bag should have at least 1 safety feature to
prevent excessive pressure.

Pressure manometer and flow-control
valve

Pressure-release
valve

Self-inflating Bags With Pressure-release Valve

Bag and Mask: Equipment
Masks
Rims

-Cushioned
-Non-cushioned
Shape

- Round
- Anatomic

shape

Size

-Small
-Large
Mask should

Tip of chin

Mouth

Nose

cover

Preparation
for
Resuscitation

Assemble equipment

Test equipment

140


Clear airway

Position newborns head

Position yourself at the side
the baby

with

head

of

Positioning Bag and Mask on Face

Do not jam the mask down on the face

Do not allow your fingers or parts of
the hands to rest on the newborns eyes

Do not put pressure on the throat
(trachea)

Testing
a
Self-inflating
Bag

Pressure against your hand?

Pressure manometer working?

Pressure-release
valve
opens?
Checklist

Before
assisting
ventilation

Select appropriate-sized mask

or

bag,

141

Face-mask Seal

Airtight seal is essential to achieve positive pressure.

Tight seal required for flow-inflating bag to inflate

Tight seal required to inflate lungs when bag squeezed
How Hard to Squeeze the Bag

Noticeable rise and fall of chest

Bilateral breath sounds

Improvement of color and heart rate

Overinflation of Lungs

If the baby appears to be taking a very deep breath,

Too much pressure is being used

Danger of producing a pneumothorax

Causes of and Solutions for Inadequate Chest Expansion

Condition
1. Inadequate

2.

Blocked

seal

airway

Frequency of Ventilation:40 to 60 breaths per minute

Chest Not Expanding Adequately

Possible causes

Seal inadequate

Airway blocked

Not enough pressure given

142

Actions
Reapply mask to
face.
Reposition
the
head.
Check for
secretions;
Suction
if
present.
Ventilate
with
newborns
mouth
slightly
open.

3. Not enough pressure Increase pressure

until there is an easy rise and fall
of the chest.Consider endotracheal
intubation.
4. Malfunctioning equipment

Check or
replace bag.


8F feeding tube

20-mL syringe

Signs of Improvement

Increasing heart rate

Improving color

Spontaneous breathing
Continued Bag-and-Mask Ventilation

Orogastric tube should be inserted
relieve
gastric
distention.

Gastric
distention
may
elevate
diaphragm, preventing full lung
expansion

Possible regurgitation and aspiration

Insertion of Orogastric Tube
Equipment

Measuring correct length

to

Insertion
of
Orogastric
Tube:
Technique

Insert through mouth, rather than
through nose (resume ventilation)

Attach 20-mL syringe and aspirate gently

Remove syringe and leave tube end open to air

Tape tube to newborns cheek
Newborn Not Improving

Check oxygen, bag, seal, and pressure

Is chest movement adequate?

Is 100% oxygen being administered?
Then

- Consider endotracheal
- Check breath sounds;

intubation
pneumothorax

is

possible
Newborn Not Improving

143

Module 7: Newborn Care

Session 2: Newborn Resuscitation-Chest Compressions
Chest Compressions

Indications for chest compressions

Performance of chest compressions

Coordination of chest compressions with positivepressure ventilation

Stopping chest compressions

Chest Compressions:

Compress heart against spine

Increase intrathoracic pressure

Circulate blood to vital organs

Chest Compressions

Temporarily increase circulation

Must be accompanied by ventilation
Chest Compressions: Indications

HR less than 60 despite 30 seconds of effective
positive-pressure ventilation
Chest Compressions:

2 People Needed

One person compresses chest

One person continues ventilation

144

Comparison of Chest Compression Techniques

Thumb Technique (Preferred)

Less tiring
Better control of compression depth
Two-Finger Technique

More convenient with only one rescuer

Better for small hands
Provides access to umbilicus for medications

Chest Compressions:

Thumb Technique

Chest Compressions
Thumb technique

Pressure must remain on sternum
Chest Compressions:

Two-finger Technique
-Tips of middle finger and index or ring finger of one hand
compress sternum-Other hand supports back

Chest Compressions: Positioning of Thumb or Fingers

Apply pressure to lower third of sternum

Avoid xyphoid process

145

Potential Complications

Laceration of liver

Broken ribs
Coordination With Ventilation

A four event cycle should take
approximately 2 seconds

Approximately 120 events per
minute (30 breaths and 90
compressions)

Chest Compressions:
Compression Pressure and Depth
-Depress sternum one third of the anterior-posterior diameter
of chest
-Duration of downward stroke shorter than
duration
of
release

146

Stopping Compressions

After 30 seconds of compressions
and ventilation, stop and check the
heart rate for 6 seconds
Newborn Not Improving
If heart rate less than 60 bpm despite adequate ventilation and
chest compressions for 30 seconds, administer epinephrine.

Module 7: Newborn Care

Session 2: Newborn Resuscitation-Endotracheal
Intubation
Indications

Equipment preparation

Laryngoscope use

Determination of tube placement

Suctioning meconium from trachea

Positive-pressure ventilation via endotracheal tube

Meconium present and baby is not vigorous

Prolonged positive-pressure ventilation required

Bag-and-mask ventilation ineffective

Chest compressions necessary

Epinephrine administration necessary

Special indications: prematurity, surfactant
administration, diaphragmatic hernia
Endotracheal Intubation: Equipment and Supplies

Equipment should be clean, protected from
contamination

Sterile disposable endotracheal tubes with uniform
diameters preferred
Characteristics of Endotracheal Tube

Sterile, disposable

Uniform diameter

Centimeter marks and vocal cord guides helpful

Uncuffed
Endotracheal Tube:

147



Appropriate Size
Select tube size based on weight and gestational age
Consider shortening tube to 13-15 cm
Stylet optional

Preparation
of
Laryngoscope:
Supplies

Select
blade
size
-No 0 for preterm newborns
-No 1 for term newborns

Check laryngoscope light

Connect suction source to 100 mm Hg

Use large suction catheter (greater than
or equal to 10F) for secretions

Small suction catheter for ET tube
Preparation
for
Intubation

Prepare resuscitation bag and mask

Turn on oxygen

Get
stethoscope

Cut tape or prepare endotracheal tube stabilizer
Endotracheal
Landmarks

148

Intubation:

Anatomic

Endotracheal Intubation:
Holding the Laryngoscope

Endotracheal Intubation
Step 1: Preparation for Insertion
Step 2: Insert Laryngoscope
Step 3: Lift Blade
Step 4: Visualize Landmarks
Step 5: Inserting Tube
Step 6: Remove Laryngoscope

Endotracheal Intubation: Checking Tube Position Signs

of correct tube position

Chest rise with each breath

Breath sounds over both lung fields

No gastric distention with ventilation

Vapor condensing on inside of tube during exhalation

Suctioning Meconium Via Endotracheal Tube

Connect endotracheal tube to meconium aspirator and
suction source

Occlude suction port to apply suction

Gradually withdraw endotracheal tube

Repeat intubation and suction as necessary

Suction for only 3 to 5 seconds as tube is withdrawn

If no meconium is recovered, proceed to resuscitation

If meconium is recovered, check heart rate

Heart rate OK: Reintubate, suction again if indicated

Heart rate decreased: Administer positive-pressure
ventilation

149


Carbon dioxide detector will change color (or reads more

than 2%-3% during exhalation)

Tip-to-lip measurement

Endotracheal Intubation: Checking Tube Position

The tube is likely not in trachea if

No chest rise

No breath sounds over lungs

Noises over the stomach

No mist in endotracheal tube

Abdomen becomes distended

Carbon dioxide detector does not
indicate exhaled Carbon dioxide

Newborn remains cyanotic or bradycardic

Tube Location in Trachea

150

Endotracheal Intubation: Radiographic Confirmation

Module 7: Newborn Care

Session
2:
Newborn
ResuscitationMedications

Indications

Epinephrine administration via

Endotracheal tube
-Umbilical vein
-Volume expansion

Sodium bicarbonate administration
Heart rate less than 60 after

30 seconds of assisted ventilation and

30 seconds of compressions and assisted ventilation
Total 60 seconds
Note: Epinephrine not indicated before adequate
ventilation established
Epinephrine:
Routes of Administration

Endotracheal tube

Umbilical vein
Epinephrine: Administration
Via Endotracheal Tube

Give directly into endotracheal tube

May use 5F feeding tube

Dilution vs flush

After instillation, give positive-pressure ventilation
Epinephrine: Administration
Via Umbilical Vein

Placing catheter in umbilical vein
-Preferred route
-3.5F or 5F end-hole catheter
-Sterile technique

Insert 2 to 4 cm

Free flow of blood when aspirated

Less depth in preterm newborns

Insertion in liver may cause damage

Epinephrine: Effects Repeated Dosing

Increase strength and rate of cardiac contractions

Peripheral vasoconstriction

May repeat dose every 3 to 5 minutes

Consider repeat dose via umbilical vein if first dose
given via endotracheal tube
Epinephrine: Poor Response (Heart Rate <60 bpm)
Recheck effectiveness of

Ventilation

Chest compressions

Endotracheal intubation

Epinephrine delivery

Consider possibility of

Hypovolemia

Severe metabolic acidosis
Poor Response to Epinephrine: Hypovolemia
Signs of Hypovolemia

Pallor after oxygenation

Weak pulses (high or low heart rate)

Poor response to resuscitation

Low blood pressure/poor perfusion
Blood Volume Expansion: Acceptable Solutions

Normal Saline

Ringers lactate

O-negative blood
Medication: Volume Expanders
Expected signs of volume expansion:

Blood pressure increases

Pulses stronger

Pallor lessens
Follow up if hypovolemia persists

Repeat volume expanders

Give sodium bicarbonate for presumed acidosis

151

Prolonged Resuscitation: Physiologic Consequences

Lactic acid buildup

Poor cardiac contractility

Decreased pulmonary blood flow
Metabolic acidosis suspected

Sodium bicarbonate administration is controversial

Use only after adequate ventilation is established

152

Medication Given: No Improvement

Recheck effectiveness of

Ventilation

Chest compressions

Endotracheal intubation

Epinephrine delivery
If heart rate is less than 60 or absent:

Consider possibility of
-Hypovolemia
-Severe metabolic acidosis

Consider conditions such as
-Pneumothorax
-Diaphragmatic hernia
-Congenital Heart Disease

Consider discontinuing resuscitation

Special Considerations

Special problems that complicate resuscitation

Management after resuscitation

Ethical consideration

Resuscitation beyond newborn period or outside
hospital delivery room
No Improvement After Resuscitation: Categories

Failure to begin spontaneous respirations

Inadequate ventilation with positive-pressure
ventilation

Baby remains cyanotic or bradycardic despite good
ventilation
Failure to Initiate Spontaneous Respirations

Brain injury (hypoxic ischemic encephalopathy)

Sedation secondary to maternal drugs
Positive-pressure Ventilation Fails to Produce Adequate
Ventilation
Mechanical blockage of airway

Meconium or mucous plug

Choanal atresia

Airway malformation

Other rare conditions

153

Positive-pressure Ventilation Fails to Produce Adequate

Ventilation

Impaired lung function

Pneumothorax

Mechanical Blockage of Airway: Choanal Atresia

Mechanical Blockage of Airway: Pharyngeal Airway
Malformation
Robin syndrome

Pleural effusion
Congenital diaphragmatic hernia
Pulmonary hypoplasia
Extreme prematurity
Congenital pneumonia

Impaired Lung Function: Pneumothorax

Impaired Lung Function: Congenital Diaphragmatic
Hernia

154

Baby Remains Cyanotic or Bradycardic

Ensure chest is moving with ventilation

Confirm 100% oxygen is being given

Consider congenital heart block or cyanotic heart disease
(rare)

Hypoglycemia

Necrotizing enterocolitis

Oxygen injury
Ethical Principles: Starting and
Stopping
Resuscitation

No different than older child or adult

No advantage to delayed, graded, or partial support

Support can be withdrawn after initiation

Base decision on data (may not be available in delivery
room)

Communicate with family prior to resuscitation if
possible
Ethical Decisions: Non-initiation of Resuscitation

Confirmed gestation < 23 weeks or birthweight < 400
grams

Anencephaly

Confirmed trisomy 13 or 18

Post-resuscitation Care
Baby requires

Close monitoring

Anticipatory care

Laboratory studies

Ethical Decision: Stopping Resuscitation

Ensure adequate resuscitation efforts

May stop after 15 minutes of asystole

Ongoing evaluation, discussion with parents and team,
if prognosis uncertain

Post-resuscitation Problems

Pulmonary hypertension

Pneumonia, aspiration, or infection

Hypotension

Fluid management

Seizure, apnea

Hypoglycemia

Feeding problems

Temperature management
Post-resuscitation Problems: Premature Infants

Temperature management

Immature lungs

Intracranial hemorrhage

155

Module 7: Newborn Care

Session 3: Examination of
Baby J2-J8

the

Newborn

When should a newborn baby be examined?

Examine routinely all babies:

within an hour of birth

for discharge

at routine and follow-up postnatal visits in the 1st week
of life, and

when the mother or provider observes danger signs.
Examination Format

Ask, Check Record

Look, Listen and Feel

SIGNS

CLASSIFY

TREAT AND ADVISE
Newborn

Care

Guidelines

CASE STUDY

Ask, Check Record

Look, Listen and Feel

SIGNS

CLASSIFY

TREAT AND ADVISE

Module 7: Newborn Care

Session 4: Care of the Newborn Until
Discharge
from
Health
Facilities
Parent
Education

Keeping the baby warm

Breastfeeding the newborn baby

Giving cord care

Ensuring
hygiene

Watching her baby and reporting her concerns

Sleeping with her baby

Attaching and positioning her baby
the
breast
J10

at

Keeping the baby warm

In cold climate keep at least an area of the room warm.

Newborns need more clothing than other children or

adults

If cold, put hat on the babys head. During cold nights

cover the baby with an extra blanket.

At night, let the baby sleep with the mother or within
easy reach to facilitate breastfeeding.

DO NOT put the baby on the cold surface

DO NOT swaddle the baby (wrap too tightly) because

swaddling makes them cold

DO NOT leave the baby in direct sun
because it may become too hot and
dehydrated
Giving cord care

Wash hands before and after cord care

Put nothing on the stump

Fold diaper below the stump

Keep stump loosely covered with clean clothes

If the stump is wet, wash with clean
water
and soap, dry with clean cloth.

156


If umbilicus is red or draining pus or

blood, see the health worker.

DO NOT bandage the stump or abdomen

DO NOT apply substances or medicines to stump

Avoid touching the stump unnecessarily
Washing the baby

Wash the face, neck and underarms daily

Wash the buttocks when soiled. Dry
thoroughly

Bathe when necessary:
-Ensure the room is warm
-Use warm water for bathing

Thoroughly dry the baby, dress and cover after bath
Monitoring the Baby

Cold feet

Breathing difficulties (grunting, fast or slow
breathing, chest in-drawing)

Any bleeding
Give prescribed treatments according to the schedule

treatments for infections

Immunizations
K12 & K13 : Treat and immunize the baby
Discharge examination

Examine every baby before planning to
discharge the mother and baby

Tell the mother when to return for
-routine postnatal visit
-if danger signs

Routine Visits
Postnatal visit
-Within the 1st week preferably within 2-3 days
Immunization visit
(if BCG, OPV-0 and HB-1 given in the 1st week of life)
-at age 6
Follow-up Visits
If the problem was
Feeding difficulty
Red umbilicus
Skin infection
Eye infection
Follow-up Visits
If the problem was
Thrush
Mother has either breast
engorgement or mastitis
Low birth weight and either
first week of life or not gaining
weight adequately
Follow-up Visits
If the problem was
Orphan baby
INH prophylaxis
Treated for possible
congenital syphilis
Mother HIV positive

Return in
2 days
2 days
2 days
2 days

Return in
2 days
2 days

7 days

Return in
7 days
14 days
14 days
14 days

Advise the mother to seek care for the baby

Return or go to the hospital immediately if the baby has:

Advise when to return with the baby K14

157



Difficulty breathing
convulsions
Fever or feels
Bleeding
Has diarrhea
not feeding at all

Go

to the health center as quickly as possible if the babyhas:

Difficulty feeding
Pus from eyes
Skin pustules
Yellow skin
A cord stump which is red and draining pus
Feed less than 5 times in 24 hours
Other concern

cold

Module 7: Newborn Care

Session 4: The Small Baby
What do we mean by a small baby?

Small baby
- born between 32-36 weeks gestation, or one to two months
early, and/or
- with a birth weight between 1500g and 2500g.

Very small baby:
- A very preterm baby born less than 32 weeks gestation or
more than 2 months early, or
-A baby with birth weight less than 1500 g
Refer baby urgently to hospital (B14)
Ensure extra warmth during referral/transport
Special needs of a small baby

To breathe normally

To be kept warm

To be fed

To be protected
Newborn examination as in N2-N9
Care of the small baby

Care of the Newborn p.N10

Additional care of a small baby (or twin) p.N11
Additional care of a Small Baby (or Twin)

Plan to keep the small baby longer before discharging.

Allow visits to the mother and baby.

158

Additional care of a Small Baby (or Twin)

Give special support for breastfeeding the
small baby (or twins) (B4)

Encourage the mother to breastfeed every
2-3 hours.

Assess breastfeeding daily: attachment, suckling, duration
and frequency of feeds, and baby satisfaction with the feed
(K3)


If alternative feeding method is used, assess the total daily

amount of milk given.

Weigh daily and assess weight gain (K7).
-Weigh and assess weight gain B7

Weigh the small baby


Every day until 3 consecutive times gaining
weight (at least 15 g/day).

Weekly until 4-6 weeks of age (reached
term).

Weigh and assess weight gain B7
If weighing daily using a precise and accurate scale
Response to abnormal finding

If
the
small
baby
is
not
suckling
effectively and does not have other danger
signs, consider alternative feeding methods

Teach the mother how to hand express breast
milk directly into the babys mouth

Teach the mother to express breast milk
and cup feed the baby


Determine appropriate amount for daily
feeds by age

If feeding difficulty persists for 3 days,
or weight loss greater than 10% of birth
weight and no other problems, refer for
breastfeeding counselling and management.
Additional care of a Small Baby (or Twin)

Ensure additional warmth for the small
baby

Ensure the room is very warm (25-28C).

Teach the mother how to keep the small baby
warm in skin-to-skin contact

Provide extra blankets for mother and baby.

Ensure hygiene

DO NOT bath the small baby. Wash as needed.

Additional care of a Small Baby (or Twin)

Assess the small baby daily

Measure temperature

Assess breathing (baby must be quiet, not
crying): listen for grunting; count breaths
per minute, repeat the count if >60
or <30; look for chest indrawing

Look for jaundice (first 10 days of life):
first 24 hours on the abdomen, then on
palms and soles.

If difficult to keep body temperature within
the normal range (36.5C to 37.5C):


Keep the baby in skin-to-skin contact
with the mother as much as possible
If body temperature below 36.5 persists
for 2 hours despite skin-to-skin contact
with mother, assess the baby

If
breathing
difficulty,
assess
the
baby

If
jaundice,
refer
the
baby
for
phototherapy.

If any maternal concern, assess the baby and respond to
the mother.
Discharging the small baby

Plan to discharge when:


Breastfeeding well


Gaining weight adequately on 3 consecutive
days

Body temperature between 36.5 and 37.5 on 3 consecutive
days


Mother able and confident in caring for
the baby


No maternal concerns.

Assess the baby for discharge.

159

Module 8: Counseling
Session 1: Basic Facts About Counseling
Overview

Health workers are expected to be counselors inmaternal
and newborn care, where the patient has to make choices
based on accurate information and in a climate where
his/her reproductive rights are respected.

It is a service which the health facility should provide.

Effective communication ensures that the client can
comprehend and act on improving his/her, as well as
his/her familys state of health.
Purpose of Counseling
In maternal and neonatal health counseling serves 3 main
purposes:

Contributes to the satisfaction of women, their families
and communities from the services she/they receive;
helps to ensure that people use services appropriately;
and, return to use them and recommend them to others

Helps to develop skills to enable women and their families
to take better care of themselves and their babies

Most importantly, it helps to empower women and teach
them new skills to help them take action on the decisions
they have to make in all aspects of their lives
Principles in Counseling

Total Honesty

Confidentiality

Non-judgemental
Counseling Skills
1. Interpersonal communication
2. Emphatic listening
3. Questioning
4. Negotiating
5. Planning
6. Evaluating

160

Knowledge on:

Maternal and newborn care

Basic Information, transmission and management of
HIV(Human Immunodeficiency Virus)

Family Planning and Modern Method Choices

Infant Feeding Choice

Adolescent Pregnancy

Violence Against Women and Children

Institutions, Health programs and projects that may be
resources to the client

National policies and laws related to the options/methods
Qualities of an Effective Counselor
Personal Qualities and Attitudes

A desire to work with people

Respect for the right & ability of people to make their
own decisions

Comfort with issues related to human sexuality & the
expression of feelings

Self-awareness (of ones own biases, expectations,
capabilities & limitations)

Unbiased attitudes toward various population groups

Tolerance for values that differ from ones own

Empathy for clients

Supportive attitude toward clients

Ability to maintain cofidentiality

Unbiased attitudes/non-judgmental

Comfort with issues related to human sexuality & the
expression of feelings.

Self-awareness (of ones own biases, expectations,
capabilities & limitations.)
Six Counselor Task of Counseling Process Model
1. Initiate counseling relationship
2. Understand counselee concerns emphatically
3. Negotiate counseling objectives
4. Identify plan to meet objectives/achieve outcomes
5. Support the plan
6. Evaluate conseling

Module 8: Counseling
Session 2: Applying Counseling Skills
HIV /AIDS

Caused by a virus called the Human Immunodeficiency Virus

This virus is spread from person to person through body
fluids such as semen, vaginal fluid or blood during
unprotected sexual intercourse;

HIV-infected blood transfusions or contaminated needles
for drug abuse or tattoos.

From an infected mother to her child during:
-pregnancy
-labour and delivery
-postpartum through breastfeeding

HIV cannot be transmitted through hugging or mosquito
bites

A special blood test is done to find out if the person is
infected with HIV
Asymptomatic Carrier
1 month after picking up HIV, flu-like symptoms develop
temporarily such as:

Fever

Sore throat

Malaise

Muscle aches

Rash

Large lymph nodes
Symptomatic HIV
(8-10 years later)

Oral and vulvovaginal candidiasis

Diarrhea

Bacterial infections (skin, upper & lower respiratory tract)

Tuberculosis

Herpes zoster/simplex

Skin infections (Fungal infections)

Opportunistic malignancies:

Kaposis sarcoma Lymphoma

HIV status in Pregnancy, WHY?

Get medical care to prevent associated illnesses

Protect sexual partner from infection

Make a choice about future pregnancies
Counseling
Why is HIV/AIDS counseling necessary?

Prevent spread of HIV/AIDS

Provide emotional support

Maximize survival

Assist beareavement process

Coordinate support resources
Who should receive HIV/AIDS counseling?

People seeking HIV test

People proven HIV positive

People diagnosed with AIDS

Significant others (family, friends, etc.)

Worried well people at high risk for HIV
Where can HIV/AIDS counseling be held?
any setting/venues which is comfortable for client to discuss
things over in privacy
Who should provide HIV/AIDS counseling?
any person can be encouraged and those willing to be trained to
provide counseling
Need to know about counselling:

Essentials of counseling

Counseling skills

Types of counseling

Ethical principles

Referral system & network for counselling
Types of counseling

Primary prevention counseling

People at risk for HIV but not known to be infected

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-Stress that infected persons should NOT donate blood or

syringes or piercing equipments
-Address perinatal transmission
-Discourage interruption of pregnancy
-Encourage prevention of future pregnancy

PERSON

COUNSELING
COMPETENCE

COUNSELING
SKILLS

KNOWLEDGE
on maternal and neonatal
care, HIV, VAWC, adolescent
pregnancy, family planning,
infant feeding choices

Highlight and discuss risk behavior of HIV and review ways

of managing individual change
Types of counseling

Counseling of HIV testing
a. Pretest counseling, aims:
-informed consent to procedure
-necessary preparation for (+) result
-provide necessary risk reduction information in acquiring
passing the infection
b. Post test counseling
- depends on the outcome of test

Secondary prevention counseling
-Person/known considered w/ HIV & ways to avoid
transmission
-Focus on the need of infected persons to recognize their
responsibility for the health & welfare of their lover/spouses
-Discuss the need of current/previous partner of possibility
of infection

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Psychosocial support counseling

-HIV infected & persons living w/ them need emotional support
-Supportive counseling to help the person react positively with
the problems
-Help live a full & productive life enabling them to resume/
assume authority over their lives & decision-making
Referral system & Network for Counseling

How to talk about HIV/AIDS

Learning to live w/ HIV/AIDS

Self Help group

Helping care-givers

Care-givers/loved ones should be taught to handle the
pressures of taking care of HIV/AIDS persons

Dealing w/ feelings of loneliness, depression and
powerlessness.

Reducing stress and avoiding conflicts.

Managing the implications of adopting &
maintain safer sex behaviors and practices
STD Prevention

Abstinence

Safe sex practices

Stick to one faithful partner

Male and female latex Condom correctly STD check up
every 6 months if you or your partner have more than one
sex partner

If STD diagnosed, have complete treatment including
partner before resuming sex

not share needles for tattooing, body piercing or injecting
drugs

If pregnant, seek prenatal care for early detection and
treatment of STD to prevent transmission to the baby.

Module 9: Mobilizing Community Support

Session 1: Establishing Links

The same messages and advise are given out rather than
conflicting information

Community Support

Ways to work together.

A good team work involves:

A common task or purpose

Understanding of different roles

Different expertise for different6 functions/tasks

Skills and personalities complement one another

Commitment to achieving functions/tasks

A leader to take responsibility & coordinate

Overview
Community support is also vital in addressing maternal and
infant morbidities & mortalities. Everyone in the community
should be informed and involved in the process of improving
the health of their locality.
Involving the community in Quality of services
Developing a comprehensive plan (to include community
involvement) in support to Maternal & newborn health
care
Community Linkages
Advantages of working together

Collaboration is a difficult challenge but brings many
benefits:

It increases the knowledge and understanding of what
different groups provide

It helps to classify roles and avoid duplication of effort
and work

It helps to clarify roles and avoid duplication of effort
and work

It leads to a more effective use of resources
Advantages..

Some groups who would not normally see themselves
as having a role in maternal and newborn health can see
how they might contribute

Health problems can be addressed more
comprehensively

A more comprehensive picture of local needs is drawn up

It helps to minimize gaps in provision and provide better
targeting of services

To help you establish linkages with other health care providers

& community groups & to establish ways of working with
them

Make a list of providers & groups that work in your
community

Organize a meeting/s where representatives from each
of these providers or groups can attend

Find out what each of these groups / providers
currently do with respect to the care of the woman &
newborn during pregnancy, delivery & the postnatal
period. Collate this information into a document to be
used as a future resource

Work out a way to coordinate & unify messages related
to the care of the woman & newborn during
pregnancy, delivery & the postnatal period. Think
about how you might be able to do this in advance:
a. You could consider generating the key messages
together
b. You could provide a list in advance that you discuss
at the meeting
To help you establish linkages with other health care providers &
community groups & to establish ways of working with them

Try to keep it simple & focused on the most important
messages & information relevant for women in your
community

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Identify the most common health problems related to

pregnancy & childbirth in your community & try to find
solutions together. Use local morbidity & mortality data
to help you.

Prepare an action plan defining responsibilities &
circulate it to all participants

Prepare an action plan defining responsibilities &
circulate it to all participants

Decide upon a person or group who will be responsible
for monitoring how the implementation of the action is
occuring
Links with traditional birth attendants and traditional
healers:

Include them in your referral system

Get them to refer women to you

Providing them with feedback on anybody they have
referred to you

Clarify together what constitutes harmful, harmless or
helpful practices

Examine what resources you could share
Links with TBAs

Share with them your knowledge and expertise

Work with them to explain the key
message of the PCPNC

Invite them to participate during meetings that you
have for community groiupos and providers

Ask for their help in identifying women who may be at
risk

Encourage them to encourage all women to deliver
with a skilled birth attendant

Encourage them to act as labour
companions for women

Tap them as a valuable source of
feedback about the services you provide

164

Practicum Phase

165

Legend:
Yellow box: Not required

166

Monitoring, Evaluation and Action Plan

Skills Training on BEmOC

Monitoring Checklist for Implementation of PCPNC
Instructions for Monitor
Part 1: Demographic Information:
This part of the monitoring checklist is self-explanatory and
should be completed at the beginning of the monitoring
visit.
Part 2: Use of the PCPNC:
(Allow approximately 1 hour to complete Part 2)
The person conducting the monitoring visit (the monitor)
should sit with the health care worker who has been trained
to use the PCPNC and ask the relevant questions in this part
of the monitoring checklist. For each NO response, the
monitor should discuss and record the reasons in the
NOTES column. It will not be necessary to ask all of the
questions in this part of the monitoring tool of all health
care workers using the PCPNC. For example, a health care
worker who provides only antenatal care should only be
asked the questions pertaining to the provision of antenatal
care. However, questions 3, 3.1, 3.2, 3.3, 4, 5, 5.1, 5.2,
6, 6.1, 6.2, 6.3, 6.4, 6.5 should be asked of all health care
workers who are using the PCPNC.
It is important to sit in a quiet room/area while asking the
questions, to ensure that the health care worker being
interviewed can concentrate on the questions being asked. It

is also important to make sure that the health care worker

understands that you are not testing her/his ability to use the
PCPNC but, instead, that you are interested in knowing how
useful it is as a guide for providing pregnancy, childbirth and
newborn care.
Part 3: Observations of Clinical Care:
(Allow approximately half a day to complete Part 3)
After completing Part 2, the monitor should observe the
health care worker while she/he provides clinical care. During
these observations, the monitor should compare the care
being provided by the health care worker with the
corresponding section(s) of the PCPNC. For example, if she
is observing care in an antenatal clinic, she should follow
the sections on quick check and RAM and antenatal care, as
well as the linkages to other relevant sections. Following
these observations, further discussion should be held with
the health care worker, focusing on any issues and/or
problems encountered with respect to using the
information in the PCPNC.
If there is more than one health care worker using the
PCPNC per facility, more time will be needed to observe
them individually. However, if they are working together on
the labour and delivery ward, it may be possible to observe
several workers at the same time. In addition, you may wish
to hold a group discussion following your observations, rather
than individual discussions.

167

Part 4: Health System Implications:

(Allow approximately 30 minutes to complete Part 4)
Part 5: Summary of Discussion:
(Allow approximately 15 minutes to complete Part 5)
The key points from the individual and group discussions
should be recorded in this part of the monitoring tool before
leaving the health facility where the monitoring activity has
taken place.

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Guide to PowerPoint Presentations

Below are the title of each Module and Session and the corresponding PowerPoint Presentation that can be
found inside the compact disk (CD).

Module and Session Title

PowerPoint Presentation

Didactic Phase
Module 1, Session 1: BEmOC and the Use of the PCPNC Manual

Module1A, Module1B

Module 2, Session 1: Principles of Good Care

Module2

Module 3, Session 1: Quick Check

Module3A

Module 3, Session 2: Rapid Assessment and Management

Module3B

Module 3, Session 4: Emergency Treatment for the Woman

Module3C, Module3D

Module 4, Session 1 and 2: Process Flow of Antenatal Care

Module4A

Module 5, Session 1: Stages of Labor

Module5A, Module5B,
Module5C

Module 5, Session 2: First Stage of Labor

Module5D

Module 5, Session 3: Second Stage of Labor

Module5E

Module 5, Session 4: Third Stage of Labor

Module5F, Module5G

Module 6, Session 1: PostPartum Examination of the Mother up to Six Weeks Module6A

Module 6, Session 2: Respond to Observed Signs and Volunteered Problems Module6B
Module 6, Session 3: Preventive Measures and Additional Treatments

Module6C, Module6D

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Module 7, Session 1: Newborn Care-Care of the New Born

at the Time of Birth

Module7A, Module7B,
Module 7C, Module7D

Module 7, Session 2: Newborn Care-Newborn Resuscitation

Module7E, Module7F,
Module7G, Module7H,
Module7I, Module7J

Module 7, Session 3: Newborn Care-Examination of the Newborn Baby

Module7K

Module 7, Session 4: Care of the Newborn-Small Babies Until

Discharge from the Health Facility

Module7L, Module7M

Module 8, Session 1: Basic Facts About Counseling

Module8A

Module 8, Session 2: Applying the Counseling Skills

Module8B

Module 9, Session 1: Establishing Links

Module9A

Monitoring, Evaluation and Action Plan

Module 1, Session 1: Monitoring, Evaluation and Action Plan

178

ModuleMEPA,
ModuleMEPB

Sample Training Schedule

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