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Clinica l and Community Action to Address Postpartum Hemorrhage

Prevention, Recognition,

and Management ofPostpartum Hemorrhage

TRAINER ’S GUIDE

1 Introduction

2 Causes of PPH andIntroduction to

Pathfinder’s Model for

Clinical and Community

Action to Address PPH

3 Preventing PPH through

the Active Management of

the Third Stage of Labor

(AMTSL)

4 Early Detection of PPH

5 Treating PPH and UterineAtony

6 Non-Pneumatic Anti-

Shock Garment (NASG)

7 Data Collection and

Record Keeping

8 Community Mobilization



Prevention, Recognition, and

Management of Postpartum

Hemorrhage

Pathfinder International

Watertown, MAMay, 2010

Trainer’s Guide



iPREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

© 2010 Pathfinder International. Any part of this document may bereproduced or adapted to meet local needs without prior permission fromPathfinder International, provided Pathfinder International is acknowledgedand the material is made available free of charge or at cost. Please send a copyof all adaptations from this manual to:

echnical Services Unit

Pathfinder International 9 Galen Street, Suite 217 Watertown, MA 02472



iiPREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

Acknowledgements

Te development of the training curriculum Prevention, Identification and Management ofPostpartum Hemorrhage is the result of collaboration between many individuals and organizations.Te curriculum emerged as part of a grant to Pathfinder International from the John D. andCatherine . MacArthur Foundation, and continued through a generous grant from the Pathfinder

Board of Directors. Te Board understood the importance of this training component asfundamental to advancing Pathfinder’s comprehensive model for the prevention of postpartumhemorrhage (PPH) and the reduction of morbidity and mortalities associated with PPH indeveloping countries around the world. Pathfinder is grateful for the contributions of the manyindividuals who have contributed to this curriculum and to the implementation of the projects.It is impossible to identify one author or any one person who contributed more than others tothe development of the curriculum, the research and wealth of knowledge about PPH, and thetechnology they have brought to the problems. In alphabetical order, we would like to thank:

N Rekha Masilamani: Pathfinder International,

India N Suellen Miller: Safe Motherhood Programs,

Department of Obstetrics and Gynecologyand Reproductive Sciences, University ofCalifornia, San Francisco

N Julia Monaghan: Pathfinder International

N Mydhili Moorthie: National Center ofExcellence in Women’s Health, University ofIllinois, Chicago

N

Ifeanyi Nsofor: Pathfinder International,Nigeria

N Mayra Nicola: Pathfinder International

N May Post: Extending Service Delivery/Pathfinder International

N Mizanur Rahman: Pathfinder International

N Habib Sadauki: Pathfinder International,Nigeria

N Graciela Salvador-Dávila: PathfinderInternational

N Cathy Solter: Pathfinder International

N Roli ega Umukaro: Pathfinder International,Nigeria

N Oladosu Ojengbede: University of Ibaden,Nigeria

N Jenny Wilder: Pathfinder International

N Erin Barker: Pathfinder International

N Kapila Bharucha: Pathfinder International,India

N Sandra ebben Buffington, American Collegeof Nurse-Midwives/Emory University

N Mary Burket: Pathfinder International

N Elizabeth Butrick: Safe MotherhoodPrograms, Department of Obstetrics andGynecology and Reproductive Sciences,University of California, San Francisco

N Jennifer Clark: Safe Motherhood Programs, Women’s Global Health Imperative,

University of California, San Francisco

N Susan Collins: Pathfinder International

N Amy Coughlin: Pathfinder International

N Abdelhadi Eltahir: Pathfinder International

N Susheela M. Engelbrecht: Path

N Stacie Geller: National Center of Excellencein Women’s Health, University of Illinois,

ChicagoN Patricia Gomez: Jhpiego

N Miguel Guitierrez: Pathfinder International,Peru

N Sunanda Gupta: Pathfinder International,India

N Ellen Israel: Pathfinder International

N Farouk Jega: Pathfinder International, Nigeria



iii

PREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

able of Contents

Introduction

Notes to the rainer

Clients’ Rights During Clinical raining

Demonstration echnique

Overview of raining Plan

Sample raining Agenda

Dos and Don’ts of raining

Unit 1: Introduction

Introduce trainers and participants to each other and defineterminology related to postpartum hemorrhage

Discuss expectations, purpose, and agenda of training Discuss training norms

Describe daily review exercises “Where are We?” and “Reflections”

Complete the pre-test

Unit 2: Causes of Postpartum Hemorrhage & Introduction tothe Pathfinder International Model for Clinical and CommunityAction to Address Postpartum Hemorrhage

Provide an overview of the global problem of maternal mortality

Explain the social, cultural, economic, and systemic causes of maternalmortality

Discuss the etiology of maternal death

Summarize the Pathfinder International Model for Clinical andCommunity Action to Address Postpartum Hemorrhage

Unit 3: Preventing PPH Trough the Active Management of theTird Stage of Labor (AMSL)

Discuss the causes of continued postpartum bleeding

Describe the active management of the third stage of labor (AMSL)and how it prevents PPH

Analyze the advantages and disadvantages of different uterotonicsappropriate for AMSL

Explain the uses and limitations of misoprostol for the prevention of PPH

Demonstrate AMSL with proficiency

Page

1

2

5

6

7

8

10

11

13

1618

20

23

24

27

30

33

35

40

44

51

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57

60



iv PREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

able of Contents, continued

Unit 4: Early Detection of PPH

Describe how hemorrhage causes morbidity and death

Describe methods used to improve accuracy in estimating blood lossDemonstrate the use of the blood collection drape to measure blood loss

Explain how to monitor women for signs of shock

Unit 5: reating PPH and Uterine Atony

Describe the first measures to be taken if PPH occurs

Describe the actions to be taken in each level of facility once excessiveblood loss is detected

Explain the management of hypovolemic shock

Demonstrate the treatment of PPH in a simulated emergencysituation

Unit 6: Te Non-Pneumatic Anti-Shock Garment (NASG)

Demonstrate how to apply the NASG to revive a woman in shockand remove it once she has recovered

Describe how to carry out medical and surgical procedures while the woman is in the NASG

Demonstrate how to clean, fold, and store the NASG

Explain how to develop a system for replacing the NASG after use atthe facility level

Quiz on the NASG

Unit 7: Data Collection and Record Keeping

Demonstrate the use of the logbook with real case record forms

Unit 8: Community Mobilization

Describe how to involve the community in preventing the four delays

Provide counseling on warning signs, recognizing labor, and emergencyreadiness

Develop a birth plan with a woman.

rainer’s ools

Pre-/post-test answer key

Presentation slides

Page

62

65

6871

76

79

82

86

93

97

100

103

111

113

117

119

125

127

129

131

132

138

146

147

152



2PREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

Notes to the rainer

Purpose

Tis training manual was developed to train physicians, nurses, midwives, and community-basedhealth care providers (including community health workers and skilled birth attendants). It isdesigned to actively involve the participants in the learning process. Sessions include simulation

skills practice, discussions, case studies, role plays and clinical practice, using objectiveknowledge, attitude, and skills checklists. Tis manual is meant to support the strengthening of asystem for prevention, recognition and management of PPH.

At the end of this course, the participant will be able to: describe the model for clinical andcommunity action to address postpartum hemorrhage; explain basic strategies for avoidingthe four delays leading to maternal mortality; demonstrate the active management of the thirdstage of labor (AMSL); discuss the guidelines for the administration and storage of uterotonicsto prevent and treat PPH; demonstrate the blood drape and other techniques for accurateestimation of blood loss (including visual estimation) for early diagnosis of PPH; demonstratethe application and removal of the NASG and management of hypovolemic shock patients;demonstrate proper care of the blood drape and NASG, including infection prevention, folding,and storing; review the latest guidelines for early diagnosis and management of preeclampsia andeclampsia; and compare record keeping and data collection tools appropriate for implementing acontinuum of care to address PPH.

Te manual includes a set of knowledge assessment questions, competency-based skillschecklists, trainer resources, participant materials, training evaluation tools, and a bibliography. An enclosed CD-ROM contains PowerPoint presentation slides and video clips to be presentedto participants.

Tis curriculum assumes participants already posses competency in essential newborn care andmanagement of eclampsia and preeclampsia, or can gain that capacity elsewhere. Elements ofnewborn care and eclampsia are mentioned throughout this curriculum, however they are notdiscussed comprehensively and are not included among the objectives of this training program.

Guide o SymbolsReferences to participant handouts and PowerPoint slides occur as both text and symbols in the

Methodology section. Te symbols have number designations that refer to specific objectives andthe sequence within the specific objectives. Handouts and slides are arranged in chronological

order and correspond to the numbered symbols in the Methodology section.Slide Participant Handout



3


Suggestions for Use of the raining Manual

Tis manual is designed to provide flexibility in planning, conducting, and evaluating thetraining course. Te manual is designed to allow trainers to formulate their own trainingschedule, based on results from training needs assessments and time constraints. Te manualcan be adapted for different cultures by reviewing case studies and using only the ones that are

appropriate. Additional case studies can be devised based on local statistics, cultural practices,social traditions, and local health issues.

Te curriculum can also be lengthened or shortened depending on the level of training andexpertise of the participants. Te timing of each exercise assumes that there will be no morethan 20 participants. o foster changes in behavior, learning experiences must be in the areasof knowledge, attitudes, and skills. For each session, the unit training objective and specificlearning objectives are presented in terms of achievable changes in these three areas. rainingreferences and resource materials for trainers and participants are identified.

Tis module is divided into two volumes, a rainer’s Guide and Participant’s Manual . Terainer’s Guide contains the main portion as well as a rainer’s ools section, which containsoptions for ice breakers and pre- and post-test answer keys. Te rainer’s Guide presents theinformation in two columns:

1. Content: Tis column contains the necessary technical information.

2. Learning Methodology: Tis column contains the training methodology (lecture, role play,discussion, etc.) by which the information should be conveyed and the time required tocomplete each activity.

Te Participant’s Manual contains:

N Participant handouts covering all training content

N Pre- and post-tests (participant copies)

N Participant evaluation form

Te Participant Handouts are referred to in the Methodology sections of the curriculum andinclude a number of different materials and exercises, ranging from recapitulations of thetechnical information from the content of the module, to role play descriptions, skills checklists,

and case studies.

Te Participant Handouts should be photocopied for the trainees and distributed to them atappropriate moments during the training, usually after content is covered but in advance if thehandouts are needed for an exercise. Participants should keep handouts in a folder or binder toensure that handouts remain together as a technical resource after the training course has ended.Te Participant Evaluation Form should also be copied to receive the trainees’ feedback in orderto improve future training courses. Te Methodology section is a resource for trainers for theeffective use of demonstration/return demonstration in training.



5


Client’s Rights During Clinical raining

Te rights of the client to privacy and confidentiality should be considered at all times duringa clinical training course. When a client is undergoing a physical examination it should becarried out in an environment in which her right to bodily privacy is respected. When receivingcounseling, undergoing a physical examination, or surgery, the client should be informed

about the role of each individual inside the room (e.g., service provider, individuals undergoingtraining, supervisors, instructors, researchers, etc.).

Te client’s permission must be obtained before having a clinician-in-training observe, assist with, or perform any services. Te client should understand that she has the right to refuse carefrom a clinician-in-training/participant. Furthermore, a client’s care should not be rescheduledor denied if she does not permit a clinician-in-training to be present or provide services. Insuch cases, the clinical trainer or other staff member should perform the procedure. Finally, theclinical trainer should be present during any client contact in a training situation.

Clinical trainers must be discreet in how coaching and feedback are given during training withclients. Corrective feedback in a client situation should be limited to errors that could harm orcause discomfort to the client. Excessive negative feedback can create anxiety for both the clientand clinician-in-training.

Te confidentiality of any client information obtained during history-taking, physicalexaminations or procedures must be strictly observed. Clients should be reassured of thisconfidentiality. It can be difficult to maintain strict client confidentiality in a training situation when specific cases are used in learning exercises such as case studies and clinical conferences.Such discussions always should take place in a private area, out of hearing of other staff andclients, and be conducted without reference to the client by name.

Clients should be chosen carefully to ensure that they are appropriate to participate in clinicaltraining. For example, until participants are proficient in performing the procedure, they shouldnot practice with hostile clients. Clients have the right to comfort during clinical training.Tey have the right to feel comfortable during the time they are receiving services. It is theresponsibility of clinical trainers to ensure that clinicians-in-training do not cause additionaldiscomfort.




Demonstration echnique

Te Five-Step Method of Demonstration and Return Demonstration is a training techniqueuseful in the transfer of skills. Te technique is used to ensure participants become competentin certain skills. It can be used to develop skills in cleaning soiled instruments, high-leveldisinfection, intrauterine device insertion, pill dispensation, performing a general physicalexamination, performing a breast or pelvic examination, etc. In short, it can be used for any skill

which requires a demonstration. Te following are the five steps:

1. Overall Picture: Provide participants with an overall picture of the skill you are helpingthem develop and a skills checklist. Te overall picture should include why the skill isnecessary, who needs to develop the skill, how the skill is to be performed, etc. Explainto the participants that these necessary skills are to be performed according to the stepsin the skills checklist on models in the classroom. Te skills should be practiced untilparticipants become proficient in each skill and before they perform them in a clinicalsituation.

2. rainer Demonstration: Te trainer should demonstrate the skill while giving verbalinstructions. If an anatomical model is used, a participant or co-trainer should sit atthe head of the model and play the role of the client. Te trainer should explain theprocedure and talk to the role-playing participant as she or he would to a real client.

3. rainer/Participant alk-Trough: Te trainer performs the procedure again whilethe participant verbally repeats the step-by-step procedure. Note: Te trainer does notdemonstrate the wrong procedure at any time. Te remaining participants observethe learning participant and ask questions.

4. Participant alk-Trough: Te participant performs the procedure while verbalizing

the step-by-step procedure. Te trainer observes and listens, making corrections whennecessary. Other participants in the group observe, listen, and ask questions.

5. Guided Practice: In this final step, participants are asked to form pairs. Eachparticipant practices the demonstration with her or his partner. One partner performsthe demonstration and talks through the procedure while the other partner observes andcritiques using the skills checklist. Te partners should exchange roles until both feelcompetent. When both partners feel competent, they should perform the procedure andtalk-through for the trainer, who will assess their performance using the skills checklist.



7


Participants Key training objectives

Health workersat community/village level,includingcommunitymidwives andskilled birthattendants

N Early recognition of symptoms of PPH, including knowledge and skilldevelopment of visual estimation of blood loss (including use of blooddrape where available/approved)

N Understanding use and protocols for application, removal,maintenance, and cleaning of the non-pneumatic anti-shock garment(NASG)

N Knowledge of and skill development for protocols for managingpatient care at outreach posts and transportation of patients to the

nearest equipped facility N Learning approaches to developing community response to minimize

delaysN Use of AMSL for prevention of PPH

Facility-basednursing staff

N Skills of AMSLN Skills to replace fluids and prevent shock N Understanding use and protocols for application, maintenance,

removal, and storage of the NASGN Knowledge and skill development of emergency care protocols for a

PPH patient, in general, and for a PPH patient arriving at facility inan NASG

N Knowledge for counseling family members and other care givers

Overview of raining Plan

Tis curriculum is designed for presentation at a single location with up to 20 participants.Te training is designed for easy adaptation to reach health care professionals with diversebackgrounds and responsibilities. Te curriculum can accommodate community-level health workers, including community midwives, skilled birth attendants, emergency care nursing and

medical staff, as well as higher-level facility-based providers. Ideally, participants in each trainingcourse should come from several cadres of health care professionals, to encourage teamwork inmanagement across the continuum of care.

raining Objectives

Te table below outlines training objectives pertinent to each cadre of participants. Te trainershould review the table according to the participant profile for each class and adjust the trainingplan accordingly. Only objectives appropriate to each cadre of participants should be presented.




Participants Key training objectives

Facility-basedmedical staff

N Knowledge of AMSLN Understanding use and protocols for application, maintenance, and

removal of the NASGN Knowledge and skill development of emergency care protocols for a

PPH patient, in general, and for a PPH patient arriving at facility inan NASGN Knowledge of managing surgical procedures with patient in an NASG

Anesthetist N Knowledge of AMSLN Knowledge and skill development of emergency care protocols for

utilizing anesthesia for a PPH patient, in general and for a PPHpatient arriving at facility in an NASG when NASG is removed forsurgical intervention

Facilityhousekeeping staff

N Knowledge and skills protocols to decontaminate, clean, fold and storeblood drape and NASG correctly

Ambulancedrivers

N Knowledge and skill development for protocols to transport PPHpatients in general and for PPH patients in an NASG.

N Knowledge areas to include managing shift of patient from outreachlocation onto ambulance, patient management en route, and transferof patient into facility

ime Required:

Unit opics ime1 Introduction 2 hours, 30 min.

2 Causes of PPH and Introduction to the Pathfinder InternationalModel for Clinical and Community Action to Address PPH

1 hour, 45 min.

3 Preventing PPH through the Active Management of the TirdStage of Labor (AMSL)

4 hours, 15 min.

4 Early Detection of PPH 2 hours, 45 min.

5 reating PPH and Uterine Atony 4 hours, 30 min.

6 Te Non-Pneumatic Anti-Shock Garment (NASG) 4 hours, 45 min.

7 Data Collection and Record Keeping 1 hour, 45 min.8 Community Mobilization 4 hours, 45 min.

Approximate Classroom ime Required 27 hours Teoretical training: Approximately 27 hoursClinical practicum: Varies depending upon participants’ number and experience.



9


Sample raining Agenda Te professional background of the providers participating will shape the final agenda for eachtraining, as units may need to be omitted or activities prolonged in order to meet participants’needs and objectives. Te sample training agenda below assumes all units and activities willbe taught. In addition to this schedule, the trainer will need to schedule a short practicum in AMSL at a local facility, and build in additional time for participants to debrief together after

they complete the practicum (see page 48).

Day 1Activity Time

Unit 1 9:00-10:25

Tea break 10:25-10:40

Unit 1, continued 10:40-11:45

Unit 2 11:45-12:10

Lunch break 12:10-13:10


Tea break 14:30-14:45

Unit 3 14:45-16:00

Reflections 16:00-16:15

Day 3

Activity Time

Where are we? 9:00-9:15

Unit 5 9:15-10:45

Tea break 10:45-11:00





Day 5Activity Time


Unit 7 9:15-11:00

Tea break 11-00-11:15

Unit 8 11:15-12:30



Tea break 15:00-15:15

Post-test & evaluation 15:30-16:15

Day 4

Activity Time


Unit 6 9:15-11:15

Tea break 11:15-11:30




Reflections 15 min.

Day 2Activity Time



Tea break 10:15-10:30



Unit 4 13:30-15:00

Tea break 15:00-15:15






Dos and Don’ts of raining

Te following “dos and don’ts” should ALWAYS be kept in mind by the trainer during anylearning session.

Dos

N Do maintain good eye contact.N Do prepare in advance.N Do involve participants.N Do use visual aids.N Do speak clearly.N Do speak loud enough.N Do encourage questions.N Do recap at the end of each session.N Do bridge one topic to the next.N

Do encourage participation.N Do write clearly and boldly.N Do summarize.N Do use logical sequencing of topics.N Do use good time management.N Do K.I.S. (Keep It Simple).N Do give feedback.N Do position visuals so everyone can see them.N Do avoid distracting mannerisms and distractions in the room.N Do be aware of the participants’ body language.N

Do keep the group focused on the task.N Do provide clear instructions.N Do check to see if your instructions are understood.N Do evaluate as you go.N Do be patient.

Don’ts

N Don’t talk to the flipchart.N Don’t block the visual aids.N Don’t stand in one spot—move around the room.

N Don’t ignore the participants’ comments and feedback (verbal and non-verbal).N Don’t read from curriculum.N Don’t shout at participants.



11


UNIT 1: Introduction

Introduction:Unit 1 introduces participants, trainer(s), key terms related to PPH and used in the curriculum,and establishes training norms and procedures.

Unit raining Objective:o facilitate trainer assessment of participants’ knowledge and to establish the proper setting foreffective learning.

Specific Learning Objectives:By the end of the unit, participants will be able to:

N Introduce trainers and participants to each other and define terminology related topostpartum hemorrhage;

N Discuss expectations, purpose, and agenda of training;N Establish training norms;N Introduce daily review exercises “Where are We?” and “Reflections;” andN Complete the pre-test.

raining/Learning Methodology:

N rainer presentationN DiscussionN Brainstorming

Resource Requirements:N

Computer, LCD projector, and screen or white wallN Flipchart or whiteboardN Marking pensN Name tagsN Registration formN Sign-up sheet for housekeeping teams

Evaluation Methods:N Continuous assessment of objectives being learnedN Question/answer during session

N Pre- and Post-ests



12PREVENTION, RECOGNITION, AND MANAGEMENT OF PPHPREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

ime Required:

SpecificObjective

opic ime

1 Introduce trainers and participants to each other and defineterminology related to PPH.

30 min.

2 Discuss expectations, purpose, and agenda of training. 40 min.

3 Discuss training norms. 15 min.

4 Describe daily review exercises “Where are We?” and“Reflections.”

20 min.

5 Complete the pre-test. 45 min.

otal ime Required 2 hours, 30 min.

Materials for rainers to Prepare in Advance

N raining agenda

N ranscribe terms related to PPH and their definitions onto slips of paper andplace in grab bag for introduction exercise

N Make copies of Participant Handouts, pre-test, and training agenda for all par-ticipants




CONTENT METHODOLOGY

UNIT 2


Specific Objective #1: Introduce the trainers and participants to each otherand define terminology related to postpartum hemorrhage.

Introducing rainers and Participants

erms Related to PPHTese terms and others will be clarified ingreater depth later on in the training.

Active management of third stage oflabor (AMSL): includes 3 components:a) administration of a uterotonic within 1

minute after birth of the newborn; b) afterdelayed cord clamping (once the cord stopspulsating, or within 2-3 minutes), deliveryof the placenta by controlled cord traction;c) followed by uterine massage.

Uterotonic: A drug that stimulates uterinecontractions. Drugs such as oxytocin,ergometrine, and misoprostol have stronguterotonic properties and have long been

used to prevent and treat uterine atony andreduce the amount of blood lost duringand after childbirth. Te use of a uterotonicdrug immediately after the delivery of thenewborn (i.e., in the third stage of labor)is one of the most important interventionsused to prevent PPH.

Uterotonic stability: is defined by how wellthe uterotonic maintains active ingredientpotency and other measures, like pH,

when stored over time. Because reducedpotency of uterotonic drugs may haveserious, life-threatening consequences, it iscritically important to consider the likelystorage conditions and stability of eachof the uterotonic drugs when choosing auterotonic. Tis is of a particular importancefor tropical countries (e.g., India and

Introduction (30 min.)

Te trainer should:

N Introduce him/herself to participants(Px).

N Ask Px to introduce themselves bysaying their names to the group one attime. Make sure Px have made name

tags.N Distribute the registration form and

pencils (this can also be done inadvance, as Px gather before class).

N Collect all the forms once Px have filledthem out.

N Introduction exercise: in advance,copy each key term from the list tothe left one slip of paper and copy the

corresponding definition on anotherslip of paper. Do this for all the terms.Fold the slips of paper and place themin a hat or basket.

N Ask each Px to draw a slip of paper.

N Once all Px have drawn, ask them togo around the room and identify theperson who has the term or definitioncorresponding to theirs, who will

be their introduction partner. Forexample, if one person has “uterotonic,”s/he should find the person who has thedefinition describing “uterotonic.”

N Ask Px to introduce themselves to theirpartner (e.g., say who they are, wherethey work, and what their position is).

1



METHODOLOGY: CONTINUEDCONTENT: CONTINUED


1.1

N Reconvene the large group. Ask each pairto read aloud their term and correspondingdefinition, and introduce each other withthe information they exchanged.

N Ask other Px if they agree that the match iscorrect.

N Use the content to correct/supplementanswers.

N Distribute Px Handout 1.1: erms Relatedto Postpartum Hemorrhage.

N Review the purpose of training, includingdiscussion of the different types ofproviders that will be trained and whatthey should know by the end.

Nigeria) and where refrigeration andprotection from light are not alwaysavailable and reliable. Te stability ofoxytocin is mainly affected by temperature;

the stability of ergometrine is mainlyaffected by temperature and light.

Controlled Cord raction: A two-handed delivery of the placenta, involvinggentle, firm, and steady-tension downwardcord traction with one hand and upwardsand backwards uterine counter-pressure with the other hand supporting the uterusabove the pubis, performed only on a

contracted uterus.Uterine Massage: Immediately afterthe delivery of the placenta, the skilledbirth attendant (SBA) massages theuterine fundus until the uterus is firmlycontracted.

Blood Drape (BD): Te blood drape isa funneled-shaped, plastic bag-like devicethat is placed under the woman’s buttocks

and tied around her at 2 places (at the waist and at the hips) immediately afterthe delivery of the baby (once separatedfrom the mother). Te funneled portioncollects blood, and has two markings at350 ml (warning sign) and 500ml (takeaction sign) that alert the provider to theamount of blood lost. ying the drapeproperly around the woman is importantbecause it ensures that the blood is being

collected only in the lower, funneledpart of the drape. Te blood drape willenable the attendant to assess blood lossand facilitate early diagnosis of PPHand transfer the woman for appropriatetreatment.

UNIT 1/OBJECTIVE #1





Postpartum Hemorrhage (PPH): Vaginalbleeding after delivery that exceeds 500 ml, orthat is less than 500 ml and causes symptoms.Severe PPH is vaginal bleeding greater than

1,000 ml. Bleeding immediately after delivery, within the first 24 hours, is called primaryPPH and bleeding after 24 hours is calledsecondary PPH.

Crystalloid Fluids: Ringers Lactate, NormalSaline, or Hartmann’s Solution, used for fluidreplacement for PPH.

Non-Pneumatic Anti-Shock Garment(NASG): A garment that can be placed around

the hips, lower abdomen and legs of a woman who has an obstetric hemorrhage and/or isin hypovolemic shock, which creates pressure(to her lower extremities and directly to theuterus) that will stabilize her (shunt blood toher vital organs) until she can be treated at anappropriate higher-level facility. (Note: theNASG is never to be removed unless underskilled medical supervision.)

Emergency Hysterectomy: Surgical removalof the uterus to stop intractable obstetricalhemorrhage that is often caused by an adherentplacenta. Emergency hysterectomy is a lifesaving procedure.

Hypovolemic Shock: Clinical signs ofdecompensation of the circulatory system, dueto excessive blood loss. Te blood loss maybe revealed/apparent (as in PPH from uterine

atony) or partially concealed (as in placentalabruption or ruptured uterus). Te vital signschange so the pulse is fast and weak > 110BPM, low diastolic blood pressure< 90 mmHG, and the patient may be pale,diaphoretic (excessive sweating), confused,agitated, or unconscious.

UNIT 1/OBJECTIVE #1



16

CONTENT: METHODOLOGY:

PREVENTION, RECOGNITION, AND MANAGEMENT OF PPHPREVENTION, RECOGNITION, AND MANAGEMENT OF PPH

1.2

Specific Objective #2: Discuss expectations, purpose, and agendaof training.

Participants and Venue for raining

All Px who are higher-level facility staff will be trained in AMSL (includingthe appropriate use of uterotonics), howto estimate blood loss using the blooddrape and other methods including visualestimation, and how to place the NASGand transfer a woman in the NASG.

All SBAs should be trained in preventionand management of PPH, and in use ofmisoprostol if oxytocin is not available.

Te use of the most effective uterotonicavailable should be encouraged. Forexample, if oxytocin is not available and/or not stored in appropriate conditions,misoprostol may be used for prophylaxis ofPPH.

Only staff at facilities that can providesurgery and blood transfusions will betrained to manage patients in the NASGand to remove the NASG once the womanis stable. Staff who are trained to use theseintervention techniques will be encouragedand provided techniques to transfer skillsto others within their facility with theassistance of this program.

raining venues rainings will be conducted as close aspossible to where the trainees live and work. rainers will, for the most part,continue as supervisors and, along withproject staff, will provide ongoing technicalassistance and supportive supervision to

Group Discussion and rainerPresentation (40 min.)

Te trainer should:

N Ask Px the following questions, notingresponses on flipchart:

N What do you hope to learn duringthe training?

N What are you missing at home or

at work while you are attending thetraining?

N How do you think the training willhelp you in your work?

N Using a prepared flipchart or PowerPointpresentation, review the purpose of thetraining and course objectives.

N Compare the expectations of the Px toobjectives/topics of the training in order

to determine which expectations can bemet and which cannot.

N If there are unexpected topics mentionedin Px’s expectations, discuss whether itis possible to include these in the courseor clarify that they do not fall within thescope of the training.

N Review course logistics, includinglodging, meals, hours of attendance,practicum expectations, and any othernecessary information.

N Distribute training agenda and review with Px.

N Distribute Px Handout 1.2: Participantsand Venue for raining .

N Ask if there are any questions.






ensure that trained staff retain their skills andtransfer them to others, continue to use theproject technologies, document the number of women treated, and effectively transfer women

to higher-level facilities if necessary.

UNIT 1/OBJECTIVE #2



18



1.3

Norms and Housekeeping (15 min.)

Te trainer should:

N Ask Px to brainstorm norms for the course.Tese should include times for breaksand lunch, and starting and ending times. Write a list of norms like respecting others’opinions, active participation, etc.

N Divide Px into 5 small groups. Assigneach group to be responsible for one dayof the training. Explain that on the daythey are responsible, they will be expectedto get Px back from breaks and lunchon time, collect feedback from Px andmeet with trainers at the end of the dayto review progress and make suggestionsfor improvement, prepare energizersfor after lunch, conduct the “Where are

We” exercise at the beginning of the day,conduct the “Reflections” exercise at theend of the day (explained in SpecificObjective 1.4), and other responsibilitiesthe group suggests.

N Distribute Px Handout 1.3: Some SimpleDos and Don’ts for Effective Participation.

Specific Objective #3: Discuss training norms.

Establishing Norms and Housekeeping

Some simple Dos and Don’ts for effectiveparticipation:

Do:

N Ask a question when you have one

N Feel free to share an example

N Request an example if a point is notclear

N Search for ways in which you can applya general principle or idea to your work

N ry to evaluate how well you areperforming a skill based on newtechniques you are learning

N Tink of ways you can share theknowledge gained during this training with your subordinates and co-workers

N

Be skeptical–don’t automatically accepteverything you hear

N Participate in the discussion

N Respect the ideas of other Px

Don’t:

N ry to develop an extreme problem justto prove the trainer doesn’t have all theanswers (the trainer doesn’t)

N Close your mind by saying, “Tis is allfine in theory, but...”

N Assume that all topics covered will beequally relevant to your needs

N ake extensive notes; the handouts willsatisfy most of your needs

N ry to show how much you know bymonopolizing class time






UNIT 1/OBJECTIVE #3

N Engage in side talk

N Interrupt others

N Let your mobile phone ring during class



20



1.4

Specific Objective #4: Describe daily review exercises “Where are We?”and “Reflections.”

Housekeeping Procedures

We will review what went well or didn’t go well at the end of each day in an exercisecalled “Reflections.” Also, to make sure weare “on track,” we use an exercise called“Where Are We?”

Tere is a sign-up sheet for “Housekeepingeams” for each day (2-3 Px each,

depending on the number of Px andnumber of days). aking turns, eachmorning, one Px from the Housekeepingeam will review the highlights fromthe day before. Housekeeping eamresponsibilities include: 1) conduct “Where Are We” and “Reflection” exercises, 2) helpthe group keep to time and task, and 3)be a sounding board for compliments andsuggestions which the team will bring to

daily feedback with the trainers at the endof the day.

Where Are We?

Starting each day with “Where are We?” isour opportunity to share insights, answerquestions, clarify issues, resolve problems,and review particularly important material we need to remember so that each of us (Px

and trainers alike) can get the most out ofthe course and each day’s experiences.

Starting on the second day of training,Housekeeping eam members will provideeach Px with two pieces of different coloredpaper at the beginning of each day. Onone piece of paper, Px should write which

rainer Presentation (20 min.)

Te trainer should:

N Explain that the training should be asinteractive as possible and responsive tothe needs of the group.

N Explain that the housekeeping procedureshelp ensure this.

N Explain the “Where Are We” exercise.

N Explain the “Reflections” activity.

N Explain that in addition to the“Reflections” exercise, Px should bringany problems or concerns to the attentionof the Housekeeping eam for discussion with the training team at the end of theday.

N Make a note of the Px and trainers’feedback and attempt to address those

ideas and concerns during the discussionand during the following days’ lessonplans.

N Distribute Px Handout 1.4: “Where AreWe?” and “Reflections.”






topic from the previous day’s training theyfound most useful and how they will applythat information to their work. On the otherpiece of paper, they should write a questionor concept from the previous day’s trainingthat needs clarification. Te Px conducting theexercise can help group the second pieces ofpaper by topic.

Problems identified during the “Where Are We?” session should be resolved, either by theteam or the trainers, before continuing (whenpossible), since unresolved issues may hinderthe learning process for Px.

Te exercise is not a review of the previousday, but is used to identify the highlights andmain points in each day’s experiences. Te Pxconducting the review should prepare and useit as an opportunity to share his/her insights,clarify issues, resolve problems, or reviewimportant material. Problems identifiedduring the exercise are to be resolved beforecontinuing with training.

Reflections

At the end of each day, we take time to lookover what we have done to:

N Examine what it means to us individually,and

N Explore how what we have learned can beapplied in our place of work or a broadersetting.

We close each day’s activities with a sessionof “Reflections” on the day. As in “Where Are We?” each Px will be given two differentcolored cards to complete anonymously.

On one card, Px should write what they likedabout the day and what went well. On the

UNIT 1/OBJECTIVE #4





other card, Px should write the things thatthey hope will improve. Tese commentsshould primarily address the trainingcontent, not the food or breaks.

Te Housekeeping eam and the trainingteam will review the results at the end ofthe day. Te next day, one of the trainers will announce the results and will explainhow the training team responded to thesuggestions.

At the end of each day, that day’sHousekeeping eam will meet briefly (<15min.) with the trainers to evaluate Px inputsand suggestions for improvement. Tishelps trainers evaluate the training withthe guidance of px feedback, including theperspectives of the housekeeping team.

UNIT 1/OBJECTIVE #4



PREVENTION, RECOGNITION, AND MANAGEMENT OF PPH23



1.5

Specific Objective 1.5: Complete the pre-test.

Pre-est

Te Pre-/Post-est Answer Key is found inthe rainer’s ools, page 147.

Conduct the Pre-est (45 min.)

Te trainer should:

N Explain to Px that they will be testedon course content before the coursebegins, so that we have a baseline tocompare with at the end of the course.Te tests are done to test the success ofthe training. Each test is anonymous.

N

Distribute copies of Px Handout: 1.5:Pre-est.

N Explain that the Px will have 45minutes to take the test. Tequestions are a combination of fill-in-the-blanks, multiple choice, trueand false and matching. Read theinstructions carefully.




UNI 2: Causes of Postpartum Hemorrhage and Introduction to thePathfinder International Model for Clinical and Community Action to

Address Postpartum Hemorrhage

Introduction:

Te Pathfinder International Model for Clinical and Community Action to Address PostpartumHemorrhage (PPH) integrates essential clinical interventions with equally crucial government-level advocacy and community engagement. Tis unit introduces the global problem of maternalmortality and PPH and provides an overview of the Pathfinder model to address these problems.

Unit raining Objective:

Participants will learn about the issues surrounding maternal mortality and Pathfinder’s modelfor addressing these issues.

Specific Learning Objectives:

By the end of the unit, participants will be able to:

N Provide an overview of the global problem of maternal mortality;

N Explain the social, cultural, economic, and medical causes of maternal mortality;

N Discuss the etiology of maternal death; and

N Summarize the Pathfinder International Model for Clinical and Community Action to AddressPostpartum Hemorrhage .


N Brainstorming

N rainer presentation

N Group discussion

N Group work

N Group presentations

Major References and raining Materials:N Kinzie B, Gomez P. Basic Maternal and Newborn Care: A Guide for Skilled Providers (BMNC).

Baltimore: Jhpiego, 2004. Available online: http://www.jhpiego.org/resources/pubs/mnh/BMNCrevmanEN.pdf

N International Confederation of Midwives and International Federation of Gynaecology andObstetrics. Prevention and reatment of Post-partum Haemorrhage: New Advances for LowResource Settings . 2006. Available online: http://www.pphprevention.org/files/FIGO-ICM_Statement_November2006_Final.pdf



25


N Lynch, C.B., et al., eds. Vital Statistics: An Overview. A extbook of Postpartum Hemorrhage: A Comprehensive Guide to Evaluation, Management, and Surgical Intervention. Dumfriesshire,UK: Sapiens Publishing, 2006. 17-34. Available online: http://www.sapienspublishing.com/pph_pdf/PPH.pdf

N Path. Preventing Postpartum Hemorrhage: Managing the Tird Stage of Labor. Outlook 19:3, September 2001. Available online: http://www.reproline.jhu.edu/english/2mnh/2articles/otlkpph.pdf

N Population Reference Bureau. Datafinder . Available online: http://www.prb.org/DataFinder.aspx

N WHO. Te World Health Report 2005: Make Every Mother and Child Count. Geneva: WorldHealth Organization, 2005. Available online: http://www.who.int/whr/2005/en/index.html

N WHO Department of Making Pregnancy Safer. Reducing the Global Burden: PostpartumHaemorrhage. Making Pregnancy Safer: A Newsletter of Worldwide Activity , issue 4, April 2007. Available online: http://www.who.int/making_pregnancy_safer/publications/newsletter/mps_newsletter_issue4.pdf

Resource Requirements:

N Computer, LCD projector, CD-ROM with slides, and screen or white wall

N Flipcharts and markers

Evaluation Methods:

N Verbal feedback

N Evaluation forms

ime Required:

SpecificObjective

opic ime Required

1 Provide an overview of the global problem of maternal mortality. 25 min.

2 Explain the social, cultural, economic, and systemic causes ofmaternal mortality.

35 min.

3 Discuss the etiology of maternal death. 15 min.

4 Summarize the Pathfinder International Model for Clinical andCommunity Action to Address Postpartum Hemorrhage.

30 min.

otal ime Required 1 hour, 45 min.





For the group exercises in Specific Objective 2, prepare the following written

assignments for each group:N Group 1: List and discuss the reasons why women who have home births die.

Identify measures that could save these women’s lives.

N Group 2: List and discuss the reasons why women who deliver in primary healthcare facilities die. Identify measures that could save these women’s lives.

N Group 3: List and discuss the reasons why women who deliver in tertiary carefacilities die. Identify measures that could save these women’s lives.

N Copies of Participant Handouts




CONTENT METHODOLOGY

UNIT 2


2.1

2

Definition of Maternal Mortality

Maternal mortality is defined as:

Te death of a woman while pregnantor within 42 days of termination ofpregnancy, irrespective of the durationand site of the pregnancy, from any causerelated to or aggravated by the pregnancy

or its management but not fromaccidental or incidental causes.

Maternal death is described in termsof a maternal mortality ratio (MMR).More than half of all deaths among women are due to pregnancy-relatedcauses. Worldwide, maternal deathsoccur at a rate of 400 per 100,000 livebirths. Maternal mortality is distributed

disparately among regions and amongcountries: for example, in sub-Saharan Africa, maternal death occurs in 900 ofevery 100,000 live births. Te table belowshows a selection of countries with highand low maternal mortality indicators,relative to their regions.

Group Discussion, Brainstormingand rainer Presentation (25 min.)

Te trainer should:

N Ask Px to define the term “maternalmortality.” Show Slide 2.1: TeDefinition of Maternal Mortality .

N Elicit each aspect of the defini-

tion from the Px. For instance,Px should identify “irrespectiveof site and duration of pregnancy,” aspart of the definition of maternal mor-tality.

N Ask Px the following questions:

Q: What does “irrespective of site andduration of pregnancy” mean?

Answer: Te pregnancy may be extra-uterine. Death from pregnancies endingin early miscarriage or abortion areincluded along with those ending withpremature or term births.

Q: Why does the definition contain thisclause?

Answer: So that public health responsesto high maternal mortality will include women experiencing death from allpregnancy-related causes, as well asthose who deliver at term.

Q: Why does the definition say “within 42days?”

Answer: 6 weeks is considered thepostpartum period, after which the woman’s body should have returned to

Specific Objective #1: Provide an overview of the global problem ofmaternal mortality.





2.2

2.1

Maternal Mortality in Select Countries

CountryorRegion

MaternalDeaths per100,000

live births

LifetimeRisk ofMaternal

Death(1 in __)

Sub-Saharan Africa 920 22

Angola 1400 12

Botswana 380 130

Burundi 1100 16

Ethiopia 720 27

Ghana 560 45

Guinea 910 19

Kenya 560 39Mozambique 520 45

Nigeria 1100 18

South Africa 400 110

anzania 950 24

Uganda 550 25

South Asia 500 59

Bangladesh 570 51

India 450 70

East Asia and Pacific 150 350

Papua New Guinea 470 55

Vietnam 150 280

Lat. Amr. & Carib. 130 280

Bolivia 290 89

Brazil 110 370

Ecuador 210 170

Guatemala 290 71

Peru 240 140

Mid. East & N. Afr. 210 140 Egypt 130 230

Jordan 62 450

Yemen 430 39

Indust.Countries 8 8000

United Kingdom 8 8200

USA 11 4800

World 400 92

normal.

N Show Slide 2.2: Global Map of Maternal Mortality Ratios .

N

Remind Px that the exactstatistics are not whatis important, but ratherthe fact that the MMR isunacceptably high, since in the majorityof cases, maternal mortality can beprevented

N Discuss the MMRs in various developingcountries using the content in the left-hand column.

N Show Slide 2.3: Maternal Mortality Indicators in SelectCountries .

N Ask Px what they think thecauses of maternal mortality are in theircountry or setting.

N Ask Px what barriers exist to preventingthese causes/deaths.

N Ask Px how important postpartumhemorrhage (PPH) is to the overallMMR.

N Use a PowerPoint presentation tointroduce Pathfinder’s Model for Clinicaland Community Action to AddressPostpartum Hemorrhage.

N Ask for any questions or comments.

N Distribute Px Handout 2.1: Te Definition

of Maternal Mortality .

2.3

UNIT 2/OBJECTIVE #1





Tese numbers listed may be much lower thanthe actual incidence of maternal death. If a woman gives birth at home or if she dies afterleaving the facility at which she gave birth, it is

likely that her death will not be recorded as dueto maternal causes.

While maternal mortality indicators do varydramatically within regions, 99% of all maternaldeaths occur in developing countries and aremore likely to happen where an SBA is not atthe delivery. Among deliveries with no SBA,maternal mortality is between 1,000 to 1,500per 100,000 live births. More than half of

maternal deaths occur during the postpartumperiod. Effective prevention and managementof postpartum complications can significantlyreduce overall maternal mortality.

MDG 5: Reduce Maternal Mortality

Millennium Development Goal (MDG) 5 aimsto reduce global maternal mortality by 75%by 2015. Individual countries and, in somecountries, individual districts, have MDG 5targets based on the local MMR.

UNIT 2/OBJECTIVE #1



30



Specific Objective #2: Explain the social, cultural, economic, and systemiccauses of maternal mortality.

Te 4 Delays Contributing to Mater-nal Mortality

Te importance of the community’s role inemergency obstetric care can not be un-derestimated. Programmers, providers, andcommunities need to understand, appreci-ate, and commit to avoiding the 4 delaysthat prevent women from accessing the carethey need to prevent maternal mortality.

Te role of different providers at differentlevels of health services to work with thecommunity to avoid those delays must bedefined and carried out.

Te 4 delays are:

1. Delay in recognizing that there is aproblem: When an emergency occurs,it may take the woman, her family, or atraditional birth attendant (BA) sometime to recognize that there is a problemand/or its severity. Most people who arenot clinically trained do not know howto recognize the signs of obstetric com-plications. A certain amount of bleedingis common during labor and delivery,but it is difficult for untrained people todifferentiate between a normal amountof bleeding and PPH.

2. Delay in the decision to seek care: Oncethe problem is recognized, there maybe further delay in seeking care. Mak-ing the decision to seek obstetric careis a complex process and requires manyindividuals (e.g., a woman, her husband,and key relatives) in decision-making. Women’s status and level of education,

Group Work (35 min.)

Te trainer should:

N Explain to Px that during the group workthey will be discussing the variety of causesof maternal death in their own country.

N Divide Px into 3 groups and assign eachgroup the following tasks, written on aseparate sheet or paper:

Group 1: List and discuss the reasons why women who have home births die. Identifymeasures that could save these women’slives.

Group 2: List and discuss the reasons why women who deliver in primary health carefacilities die. Identify measures that couldsave these women’s lives.

Group 3: List and discuss the reasons

why women who deliver in tertiary carefacilities die. Identify measures that couldsave these women’s lives.

N Explain that each group has 15 minutesto complete the task. Each group shouldchoose a rapporteur to record the answerson a flipchart and present the group’s workafter their discussion.

N Allow 15 minutes for the group workand then ask each group to present theirdiscussion.

N Summarize the group discussion byexplaining the 4 delays found in the left-hand column.

N Distribute Px Handout 2.2: Te Four DelaysContributing to Maternal Mortality.

2.2






the distance to a health facility, cost, per-ceived quality of care, and the perceivedbenefit of care all play major roles in reach-ing this decision. A family that is unpre-

pared wastes valuable time deciding whatto do, who to call for help, where to go, who should accompany the woman, andorganizing transportation.

3. Delay in reaching the facility that canprovide life-saving treatment: ime isoften lost going to health practitionersor facilities that are unable to managethe emergency. Tis delay depends on

the type and conditions of the road and weather, the seasons, and the availabilityand location of health care facilities. Otherfactors include distance to an appropriatefacility, access to transportation, and abilityto pay for transportation and/or care.

4. Delay at the facility, once reached, inproviding the quality emergency treatmentthe woman requires: Poorly equipped

health facilities, shortages of essential drugsand supplies, scarce human resources,and limited technical capacity of healthpersonnel contribute to a delay in theprovision of emergency obstetric treatment.Families are often unsure of where to goonce they arrive at the facility. Te familymay not agree to the treatment the medicalstaff recommend, may not agree to donateblood, or may be unable to pay for the

medical supplies needed.

Blood shortages play a critical role in the 4thdelay. Working with communities, we mustincrease awareness of the critical need foremergency blood supply and ease culturalbarriers that deter willingness to donate.Creating a base of community members

UNIT 2/OBJECTIVE 2





willing to donate at least to familymembers and, ideally, toward a sufficientsupply of blood for all who need it, is an

important aspect of addressing the 4thdelay.

Women die from maternal causes as adirect result of the low social, cultural,and economic status of women as wellas of inadequacies in existing healthsystems. Delays play a big role in maternalmortality. All these sociocultural andsystemic factors pose very great challenges

that must be dealt with if we are toovercome the problem of maternal death.

UNIT 2/OBJECTIVE #2






Specific Objective #3: Discuss the etiology of maternal death.

Etiology of Maternal Death

Severe bleeding is the largest single causeof maternal death, causing approximately25% of maternal deaths globally. PPHoccurs in approximately 10.5% of livebirths. Studies reveal that causes of maternaldeath vary dramatically from country tocountry, depending on the age of womengiving birth and access to care. In all studies

however, hemorrhage is among the topcauses, if not the greatest cause, of maternalmortality. Any attempt to reduce maternalmortality must address the major causes.

Additionally, systemic barriers to adequateblood supply also factor heavily in factormaternal death. One review concluded thatmore than 25% of deaths from PPH in

Sub-Saharan Africa can be attributed to lackof access to blood supply due to inabilityof the patient/family to pay for blood, lackof donors, unwillingness of relatives todonate blood, or inadequate blood storageor transport. Globally, less than 40% ofthe world’s blood supply is donated indeveloping countries, which account formore than 80% of the world’s population.Bates et al. conducted a literature review

finding that lack of blood supply wasreported as a significant factor in almosthalf of studies of mortality from PPH.

rainer Presentation/Discussion

(15 min.)

Te trainer should:

N Explain that during the next exercise,Px will review the medical causes(etiology) of maternal mortality.

N Distribute a copy of Px Handout 2.3: Te Five Most Common Causes

of Maternal Death to each Px. Askeach Px to spend 5 minutes fillingin the table. Each Px must list the5 most common causes of maternaldeath and write down what percentageof maternal death they think can beattributed to each of the 5 causes,starting with the most common causesof maternal death and moving to theless common, but serious, causes.

N At the end of 5 minutes, when Px havecompleted their task, show Slide 2.4:Causes of Maternal Death Worldwide.

N Review the major causes of maternaldeath and what percentage of overallmaternal death is attributed to eachcause.

N Show Slide 2.5: Percentage of MaternalDeath Due to Obstetric Hemorrhage,

by Region. Ask Px: Is this yourexperience with causes of maternaldeath? Do you find somethingdifferent in your area?

N Describe the role of poor blood supplyin mortality from PPH.

N Ask Px: what is the availability of

2.3

2.4

2.5





2.4

blood in your facility? Are storage facilitiesadequate? Can you provide blood to a woman whose relatives cannot or will notdonate blood? How can family membersin your community be encouraged todonate blood? Why is blood so expensiveand what can be done to reduce the cost ofscreening blood?

N Distribute Px Handout 2.4: Etiology of Maternal Death.

UNIT 2/OBJECTIVE #3






Specific Objective #4: Summarize the Pathfinder International Model forClinical and Community Action to Address Postpartum Hemorrhage.

Te Pathfinder International Modelfor Clinical and Community Action toAddress Postpartum Hemorrhage

Te Pathfinder model to address highmaternal mortality in developingcountries due to PPH integrates essentialclinical interventions with equally crucialgovernment-level advocacy and communityengagement. Te 6 elements of the

Pathfinder model include:

Advocacy with government officials to1.

promote enabling policies;

Prevention of PPH through the routine2.

application of AMSL;

Identification of hemorrhage through3.

accurate estimation of blood loss;

Use of key procedures and technologies

for management of PPH through:N Identification of the cause of

hemorrhage,N Fluid replacement to prevent

shock,N Use of uterotonics as appropriate,N Application of the NASG when

shock occurs for resuscitation andstabilization for transfer, and

N Blood replacement and surgery;

Community mobilization to increase4.

awareness of PPH and practical,preventative actions; and

Organization of emergency5.

transportation systems in thecommunity.

Presentation (30 min.)

Te trainer should:

N Present the model using Slide 2.6:Te Pathfinder International Model

for Clinical and Community Action to Address Postpartum Hemorrhage.

N Present the information in the left-hand column.

N Reiterate that these approaches havebeen individually tried, tested, andproven for use in the model beingimplemented.

N Explain that the project intervenes atthe community level as well as at thefacility level, addressing the 4 delays.

N Explain to Px that during this trainingthey will learn about these new

technologies and acquire the skillsneeded to use the new technologiesand approaches.

N Ask Px if they have any questionsabout the model.

Distribute Px Handouts 2.5: TePathfinder International Model forClinical and Community Action to Address

Postpartum Hemorrhage and 2.6: TePathfinder Model at Each Level.

2.6

2.5

2.6





Pathfinder’s Model for Clinical andCommunity Action to Address PPH combines multiple approaches forpreventing, recognizing, and managingPPH to prevent long-term morbidity anddeath: AMSL, accurate estimation ofblood loss, and management of shock.

Literature indicates that AMSL, usingstandard uterotonics, can prevent PPHby as much as 40% - 50%. Even thoughoxytocin is the first choice uterotonic andergometrine the second choice, misoprostolis more stable in heat than injectable

uterotonics. Tus, integrating misoprostolin AMSL where other uterotonics are notavailable or viable increases the number of women who can benefit from AMSL.

Simple technologies for more accuratevisual estimation of blood loss, such asthe blood collection drape, collectingblood from the delivery table into acalibrated jug or pail, using cholera beds

for measuring blood loss, and a standardabsorptive cloth (adapting the KangaMethod) have been devised for early andmore accurate estimation of blood loss.Using these measures means dangerousblood loss is promptly identified, reducinglife-threatening delays in treatment(including fluid replacement and uterotonicadministration to prevent shock), referral,and/or transport of women who are

bleeding to a higher-level facility for care.For those women who do develop shock,treatment with rapid replacement of lostblood volume and the use of a simplefirst aid device—the NASG—has made itpossible to revive women in shock and keepthem alive and stable for up to 56 hours, which helps mitigate delays in access to care

UNIT 2/OBJECTIVE #4





due to low transportation or service deliveryresources.

Each of these approaches have been individually

tried, tested, and proven. Trough the Model forClinical and Community Action to Address PPH ,Pathfinder is introducing these innovations intothe health system together as a continuum ofcare.

Te Pathfinder Model at Each Level

1. At the home/community level: Avoid thedelay in seeking care for obstetric emergenciesby:

N Sensitizing women and their families tothe importance of giving birth with a skilledprovider and developing birth preparednessand complication readiness plans;

N Increasing community awareness, the abilityto identify PPH, and understanding of theimportance of donating blood;

N Increasing timely decisions to seek care; and

N Organizing communication andtransportation systems with communities.

2. At the facility level:

N Incorporate 3 new technologies into existingprotocols for prevention and treatment ofPPH:

Prevent PPH by adopting enhanced1.

AMSL. Accurately estimate blood loss to detect2.

hemorrhage early, and take action, includingfluid replacement to prevent shock andadministration of uterotonics to managePPH.

Improve prevention of shock and3.

management of PPH by using the NASG to

UNIT 2/OBJECTIVE #4





stabilize women in shock until they canbe treated comprehensively.

N Use organized transport systems and

community emergency funds for timelyreferral and transportation to higher-level facilities; and

N Establish blood transfusion committeesand blood donation and screeningprocedures to ensure effective and cost-effective management of blood supply.

3. At the policy level:

N Advocate for and ensure incorporationof AMSL and the new technologies

into national policies, protocols, andPPH management guidelines;

N Engage professional societies suchas those for nurses, midwives, andobstetricians/gynecologists;

N Institutionalize the new technologiesin the pre-service curricula of

midwifery, nursing, and medicalschools and other training for SBAs;

N Update practicing providers in the newtechnologies and skills; and

N Advocate for sustainable blood supplypolicies, including provisions orfinancing schemes for families whocannot pay for blood.

Te model ensures that where ever a woman develops PPH—whether in thevillage, at a lower-level facility, or at ahigher-level facility—she can receivethe skilled, organized services she needs.It also means that every effort will bemade at each stage for prevention andearly detection of PPH, prevention of

UNIT 2/OBJECTIVE #4





shock, and management of shock from PPH.Providing a woman the best preventativecare and management possible at each stagereduces the chances her condition willdeteriorate. Te model also requires that alllevels of care and facilities are coordinatedfor smooth flow upward, as needed, and thatfeedback is returned downward, for continuousimprovement.

Development of comprehensive emergencyobstetric services is already underway in manycountries. Many countries are also improvingemergency transportation systems, for obstetric

and other health emergencies. Te model willcontribute to these efforts through sustainedadvocacy and support at the community,district, and state levels to establish communitytransportation and communication schemesfor women in need of emergency care and tostrengthen effective, comprehensive facilityservices to meet any obstetric emergency.

UNIT 2/OBJECTIVE #4




UNI 3: Preventing PPH through the Active Managementof the Tird Stage of Labor (AMSL)

Introduction:

Active management of the third stage of labor (AMSL) is a proven technique that, when

applied during childbirth, reduces the amount of blood loss and incidence of PPH. Pathfinderhas successfully introduced AMSL as an integral component of its Model for Clinical andCommunity Action to Address Postpartum Hemorrhage .


o develop the capacity of participants to actively manage the third stage of labor whenconducting deliveries.

Specific Learning Objectives:By the end of this session Px will be able to:

N Discuss the causes of continued postpartum bleeding,

N Describe AMSL and how it prevents PPH,

N Analyze the advantages and disadvantages of uterotonics appropriate for AMSL,

N Explain the uses and limitations of misoprostol for the prevention of PPH, and

N Demonstrate AMSL with proficiency.

raining/Learning Methodology:N rainer presentations

N Group discussion

N Brainstorming

N Reading of participant handouts

N Demonstration/return demonstration

N Role-play

N Case studies

N Hands-on training and practice on anatomical models for skills building

N Practicum



41


Major References and raining Materials:

N Lynch, C.B., et al., eds. Vital Statistics: An Overview. A extbook of Postpartum Hemorrhage: A Comprehensive Guide to Evaluation, Management, and Surgical Intervention. Dumfriesshire,UK: Sapiens Publishing, 2006. 17-34. Available online: http://www.sapienspublishing.com/

pph_pdf/PPH.pdfN Management Sciences for Health, World Health Organization. Uterotonics for the Active

Management of the Tird Stage of Labor. Managing Drug Supply , 2nd ed. West Hartford,C: Kumarian Press, 1997.

N Path. Preventing Postpartum Hemorrhage: Managing the Tird Stage of Labor. Outlook 19:3,September 2001. Available online: http://www.reproline.jhu.edu/english/2mnh/2articles/otlkpph.pdf

N POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of theTird Stage of Labor (AMSL): A Reference Manual for Health Care Providers . Seattle: PAH;

2007. Available online: http://www.pphprevention.org/files/AMSL_Referencemanual__English_001.pdf

N WHO. WHO Recommendations for the Prevention of Postpartum Haemorrhage. Geneva: World Health Organization, 2007. Available online: http://www.who.int/reproductive-health/publications/pph/recommendations_pph.pdf

N WHO Department of Making Pregnancy Safer. Reducing the Global Brurden: PostpartumHaemorrhage. Making Pregnancy Safer: A Newsletter of Worldwide Activity, no. 4 , April 2007. Available online: http://www.who.int/making_pregnancy_safer/publications/newsletter/mps_newsletter_issue4.pdf

N WHO Deptartment of Reproductive Health and Research. Managing Complicationsin Pregnancy and Childbirth: A Guide for Midwives and Doctors . Geneva: WHO, 2007. Available online: http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf



N Blank flipcharts

N Marking pens

N

Masking tapeClinical equipment and supplies needed: one practice station should be set up for each group of

4-5 Px. Practice stations should be set up with clinical equipment and supplies as indicatedon the following page.




AMTSL Practice Station Supplies

For each station

serving 4-5 Px

Total needed for a

class of 20-22 Px

1 5 Anatomical pelvic models

1 5 Anatomical models of baby and attached placenta

1 5 Emergency tray

3 15 Pairs sterile gloves

2 10 Clamps

1 5 Scissors

1 5 Forceps

1 5 Ambu-bag and mask

2 10 10 drip (IV) sets

1 5 5 or 10 cc syringes

2 10 IV fluids : Ringers Lactate (10 bottles; normal saline, 5% dextrose

solution, etc.)1+ 5+ Of each: oxytocin and ergometrine ampoules/misoprostol

1 5 Local anesthetic (1% plain lignocaine)

1 5 Laboratory bottles and test tubes for bedside clotting test

1 5 Pelvic examination tray

1 5 Foley catheter and urine bag

1 5 Oxygen cylinder with mask or cannula

1 5 Stethoscope

1 5 Sphygmomanometer

1+ 5+ Other emergency drugs (adrenaline, atropine, naloxone, etc.)

1 5 Episiotomy/cervical repair kit1 5 Each: blankets, baby blankets, bed sheets

varies Blocks to raise foot of bed/or table

Evaluation Methods:

N Observation and assessment of participants’ case studies

N Observation and assessment of participants during clinical practicum

N Utilization of competency-based checklists in class and in the labor ward

N Verbal feedback



N Set up clinical practicum in the hospital or clinic



43


SpecificObjective

opic ime Required

1 Discuss the causes of continued postpartum bleeding. 45 min.

2 Describe active management of the third stage of labor(AMSL) and how it prevents PPH.

30 min.

3 Analyze the advantages and disadvantages of differentuterotonics appropriate for AMSL.

30 min.

4 Explain the uses and limitations of misoprostol for theprevention of PPH.

30 min.

5 Demonstrate AMSL with proficiency. 2 hours

otal ime Required 4 hours 15 min.

plus practicum

Practicum:

If possible, arrange for all Px to experience providing AMSL in the labor ward for 2-3 hours(3 to 5 cases, if possible), 4 Px per facilitator, during the course of the training, either in theevenings or on the weekend. Using the checklist, Px should observe the facilitator perform andexplain a delivery with AMSL and then perform AMSL themselves, with feedback from otherPx using the checklist and discussion from the group. After Px have participated in the AMSLpracticum, they should have an opportunity to talk about the experience and present cases inthe classroom with the whole group. Te trainer will need to build this time into the training

agenda, based on practicum scheduling and logistics.Notes: Te practicum experience is a necessity for quality skills to be attained and retained.



CONTENT METHODOLOGY

UNIT 4


3.2

3.1

3

Specific Objective #1: Discuss the causes of continued postpartumbleeding.

How PPH causes Death andMorbidity

Te uterus is a hollow, pear-shaped,muscular organ located in the woman’spelvis. Te urinary bladder is situatedin front of the uterus and the rectum issituated behind it. Te myometrium,(the layer outside of the endometrium),is the muscle layer of the uterus thatexpands during pregnancy to hold thegrowing fetus. Te blood vessels in theuterus are intertwined with the musclefibers of the myometrium.

Causes of Continued PostpartumBleeding

Te causes of PPH can be classified into

4 categories, or “4 s:”one

N Failure of the uterus to contract afterthe delivery of the baby and placenta(uterine atony)

issue

N Retained placenta and/or products ofconception (POCs)

rauma

N Ruptured uterus

N Lacerations or tears of the cervix,vagina, or perineum

Trombin

N Bleeding disorders

Discussion, Q & A (45 min.)

Te trainer should:

N Ask Px:

Q. What does the uterus normally do afterdelivery? Answer: After delivery, if the uterus isempty, the uterus will normally contract.

Q. What if the uterus is not empty? Answer: If the uterus is not empty themuscles are prevented from contractingeffectively. If the muscles do not contractnormally (for any reason), hemorrhage will ensue.

Q. How do the contractions stop thebleeding? Answer: When the muscle fibers begin

to contract strongly, they constrict theblood vessels that lie between them, thuscontrolling the bleeding. Te musclecontractions also aid involution of theuterus.

N Show Slide 3.1: Anatomy and Physiology ofthe Uterus .

N Explain how the “cross-hatch” pattern

surrounds maternal blood vessels and what happens when the uterus contractsand relaxes.

N Show Slide 3.2: Te 4 s of PPH . Explainthat the key causes of PPH can beremembered under categories of causescalled the 4 s: tone, trauma, tissue, andthrombin.






N Write the words one, issue, rauma,and Trombin in a vertical list on aflipchart and ask Px to define and explainthe specific causes for each.

N Write responses on the flipchart.

N Ask Px if they know the predisposing/risk factors for PPH. If participants areunable to come up with the answerslisted, the trainer might want to givesome hints.

N Ask Px about the patho-physiology of thepredisposing factors.

N Ask Px if there are ways of preventing

PPH. Write responses on a flipchartand supplement as necessary. (Answers:In pregnancy, prevent or treat anemia;during delivery controlled delivery toavoid tears, AMSL to ensure early,complete delivery of the placenta,post delivery immediate breastfeeding,massage and monitoring, etc.)

N Explain that although women with pre-disposing factors should be watched forPPH, all women can develop PPH, withor without predisposing risk factors. Tismeans that providers must be equippedand alert to recognize and manage PPH. Ask Px what needs to be done to protect women from morbidity and mortalityfrom PPH.

N Ask Px whether they ever discuss with

pregnant women what they should do incase of an obstetric emergency at home.

N Ask Px to describe plans a woman andher family might make in advance that would enable them to get help during anemergency. Answers can include: choose a safe placeto give birth, choose a skilled provider,

one

Uterine atony is the most common cause ofcontinued postpartum bleeding. It often

progresses quickly and can be addressed rapidlyand effectively.

Factors contributing to uterine atony:

1. Uterine fatigue due to prolonged labor oroveruse of oxytocin for induction;

2. Precipitous labor—labor progressing veryrapidly (less than 3 hours in duration);

3. Over distension of the uterus due topolyhydramnios/excess amniotic fluid,

multiple gestation (twins, triplets),macrosomia/large fetus, as in gestationaldiabetes;

4. Retained placenta (when the placenta is notexpelled within 30 minutes following thebirth of the baby);

5. Retained placental fragments and/or clots(when pieces of the placenta are left in theuterus);

6. High parity/many children;

7. Chorioamnionitis/infection of the gestationalsac and membranes;

8. Full bladder; or

9. Need to augment labor with oxytocin.

Te contribution of uterine atony to PPH isso well known that there is a universal reflex

action: firmly massaging the uterus to stimulatecontractions. Once sure that the uterus hascontracted effectively, the practitioner shouldsearch for other causes of persistent bleedingand manage any causes found, e.g., retainedplacental fragments or clots, genital tracttrauma, and bleeding disorders.

UNIT 3/OBJECTIVE #1





3.1

3.23.3

3.4

have a emergency transport plan, preparepayment for transport, have a decision makeralways at hand, etc.

N Explain that the family and communityshould be aware of the major danger signs,including any bleeding during pregnancy.Immediately following childbirth, all womenshould be closely monitored for signs of ab-normal bleeding and caregivers must be ableto ensure access to lifesaving interventions,(either on the spot, or via rapid transfer to anappropriate facility) including the applicationof the NASG.

N Ask Px how to prevent PPH. What stepsshould be taken or considered?

N What are some of the most common harmfulpractices that contribute to PPH?

N Distribute Px Handouts 3.1: How PostpartumHemorrhage Causes Death and Morbidity, 3.2:Causes of Continued Postpartum Bleeding, 3.3:Preparing for PPH at Every Birth, and 3.4:

Preventing PPH .

N Explain that although 70% of PPH is causedby uterine atony, providers need the skillsto recognize and manage the other causes,in order of importance: trauma, tissue andthrombin.

N Ask: What types of trauma can cause PPH,

how would you assess the client for trauma,and how would you manage the differenttypes of trauma on different levels of healthfacilities?

N Ask: How would you explain “tissue” as acause of PPH, how would you assess for it,and how would you manage on differentlevels of facilities?

Preparing for PPH at Every Birth

Because two-thirds of women who developPPH have no known risk factors, providers

should assume that all women are poten-tially at risk of PPH. One of the reasons all women should be offered AMSL is becauserisk factors predict so few PPH cases.

Reliance on risk factors to classify womenat increased risk has not decreased morbid-ity and mortality associated with PPH.Moreover, relying on risk assessment canlead to unnecessary over-management of

women classified as “high risk,” which canbe detrimental both to women, (because ofadded anxiety and the cost of more frequentcare and invasive procedures) and to healthsystems (because of the higher cost of highrisk care).

Factors Predisposing Women to PPH dueto Atony Some conditions are known to increase the

likelihood of PPH. Tose conditions are:N Previous PPH

N Multiple gestation

N Preeclampsia

N Obesity

But it is important to remember thatmost PPH cases occur in women with noidentifiable risk.

70% of PPH is caused by uterine atony.Fortunately, we have the technology andstrategies to prevent and treat this life-threatening condition. But although 70% ofPPH is caused by uterine atony, recognitionand management of the other 3 causes arenecessary skills for providers. Since trauma(lacerations, uterine rupture, etc.) causes

UNIT 3/OBJECTIVE #1





PPH twice as much as tissue (retained POC’s),trauma should be investigated and managedfirst, and then tissue. Finally, if all else fails,clotting disorder should be investigated.

issue

Retained placenta, fragments or clots keep theuterus from contracting completely and bleed-ing continues. issue must be expelled orremoved by use of forceps if tissue at cervical os,or manual removal.

rauma

Lacerations of the perineum, vagina, cervix, and

rupture of the uterus must be recognized rap-idly, and either repaired or the woman trans-ported urgently to a facility where the repair canbe done (providing pressure to the lacerationas possible during transport). Providers shouldalways do a careful examination for tears, butespecially if there is bleeding even though theuterus is well contracted.

Trombin

Only 1% of women will bleed right after birthfrom clotting disorders, but women who havebled a lot may develop clotting problems calledDIC (disseminated intravascular coagulopathy) which must be treated urgently at a higher-levelfacility.

Preventing PPH

Established methods to prevent and managePPH include:

N Early detection and management of anemia;N Developing birth preparedness/complication

readiness plans;

N Preventing prolonged labor by monitoringlabor using the partogram, if available;

N Avoiding harmful traditional practices tospeed up labor (e.g. pushing on the uterus to

UNIT 3/OBJECTIVE #1

N Ask: What types of “thrombin” problemsare there, how would you assess for them,and how would you manage on differentlevels of facilities? Be sure to includeDIC as a result of severe bleeding andnot just pre-existing coagulaopathy.

N Explain that providers must have theskills to recognize and manage theseother 3 “’s” and not just “tone.”





expel the baby);

N Preventing dehydration;

N Encouraging the woman to pass urine

frequently to avoid having a full bladder;N Reducing cervical, vaginal, and perinealtrauma by avoiding routine use of forcepsand restricting use of episiotomy;

N Avoid pushing when the cervix is notcompletely dilated;

N Early detection and rapid treatment ofhemorrhage; and

N AMSL.

Anemia: For severely anemic women, a1.

blood loss of 200-250 ml can be fatal,and anemia can pre-dispose women toPPH. reatment of anemia with ironand nutrition supplementation duringpregnancy may help women survivePPH. Providers should address majorcauses of anemia such as malaria andhookworm.

All women must be encouraged to2.

develop a birth preparedness andcomplication readiness plan, and, ifpossible, to deliver with an SBA whocan provide PPH prevention and care(examples: choose a safe place of birth,a skilled provider, and have a transportaccess plan). Complication readinessincludes a realistic plan for a life-threatening complication (examples:have transport ready, have payment

for transport ready, keep a designateddecision maker at hand, identify blooddonors who would be available to donateblood immediately, etc.). Te family andcommunity should be aware of the majordanger signs of complications, includingany bleeding during pregnancy. All women should be closely monitored

UNIT 3/OBJECTIVE #1





following childbirth for signs of abnormalbleeding, and caregivers must be able toensure access to lifesaving interventions,including application of the NASG.

Prolonged labor can be the result of a baby3.

that is too large or in the wrong position tofit through the birth canal. If active laborlasts for more than 12 hours, the womanshould be moved to a facility that canprovide a Cesarean section if needed.

Harmful traditional practices such as4.

providing herbal remedies to increasecontractions, unskilled practitioners giving

oxytocin by intramuscular injection, orusing fundal pressure to assist in the deliveryof the baby can increase the likelihood ofPPH.

Dehydration may slow contractions and5.

prolong labor.

Te use of instruments (such as forceps) to6.

assist the birth is associated with increasedrisk of cervical and perineal trauma.

Delivering in a position of the mother’s7.

choosing will help avoid trauma (e.g., notflat on her back).

Maternal pushing should be avoided until8.

the cervix is completely dilated to avoidlacerations of the cervix.

Early detection and management of9.

excessive bleeding reduces the likelihood ofPPH.

AMSL consists of interventions designed10.

to:

N Shorten the third stage of labor andreduce blood loss by facilitating deliveryof the placenta, leading to effectiveuterine contractions, and

N Prevent PPH by avoiding uterine atony.

UNIT 3/OBJECTIVE #1





Literature indicates that the best predictorof PPH is a third stage of labor that lasts 18minutes or more. Tis is why early delivery ofthe placenta is important.

UNIT 3/OBJECTIVE #1






Specific Objective #2: Describe the active management of the third stageof labor (AMTSL) and how it prevents PPH.

Active Management of the TirdStage of Labor

Review of available evidence shows thatpracticing AMSL is proven to reduce theincidence of PPH, the quantity of bloodloss, and the use of blood transfusion.Remember: 40-50% of PPH can beprevented using AMSL.

Te three main components of AMSL are:

Administration of a uterotonic agent1.

within one minute after the baby isborn after ruling out the presence ofanother baby (oxytocin is the uterotonicof choice),

Controlled cord traction (CC) with2.

counter-traction to the uterus during auterine contraction, and

Uterine massage immediately after3.

delivery of the placenta to help theuterus contract as well as to assessuterine contraction.

Procedures for Each Component

Administer a uterotonic

Prepare the uterotonic during the1.

second stage of labor and have it ready

at the bedside.Deliver the baby.2.

Gently palpate the abdomen to rule out3.

presence of additional babies.

ell the woman that she will feel strong4.

cramping when the uterotonic isdelivered.

Discussion, Q&A (30 min.)

Te trainer should:

N Ask Px how they manage the thirdstage of labor when they conduct adelivery.

N Ask if anyone has practiced AMSL.

N Ask for a volunteer to describe the 3

components of AMSL. Ask other Pxto make corrections if necessary.

N Describe each of the 3 componentsusing the content in the left column.

N Ask Px the following questions:

Q: When should you give the oxytocin?

What do you do if you are attendingthe birth alone?

Answer: Te provider should inject within 1 minute.

Q: If other uterotonics contract the uterus well, why is oxytocin preferred? Answer: Oxytocin is more effective ifit has been stored properly and can beused in women with elevated bloodpressure or heart disease.

Q. Are there disadvantages/dangers of latecord clamping? Answer: Tere is no danger unless themother is HIV-infected, Rh negative,or the baby is premature or needsimmediate resuscitation. Additionally,the baby benefits from the extraperfusion of maternal blood and





Within 1 minute of delivery, give5.

oxytocin 10 IU IM. If not available,and no elevation of blood pressure(BP) or heart disease, give ergometrine,Methergine, or Syntrometrine. Givemisoprostol if an injectable is notpossible.

After delivery, immediately dry the6.

infant and assess the baby’s breathing.Ten place the reactive infant, prone,on the mother’s abdomen. Remove thecloth used to dry the baby and keep theinfant covered with a dry cloth or towel

to prevent heat loss.Before performing AMSL, gently7.

palpate the woman’s abdomen to ruleout the presence of another baby. At thispoint, do not massage the uterus.

If there is not another baby, begin8.

the procedure by giving the woman auterotonic drug. Tis should be done within one minute of childbirth.

Put the baby to the breast if this is the9.mother’s choice for infant feeding andthe baby and mother are ready.

Perform controlled cord traction

Wait for cord pulsations to cease or1.

approximately 2-3 minutes after birth ofthe baby, whichever comes first.

Clamp and cut the cord following strict2.

hygienic techniques: Clamp the cord 4cm from the baby, place second clampright next to it, and cut between theclamps with sterile razor or scissors.

Re-clamp the cord close to the mother’s3.

perineum and hold the cord in onehand.

Place the other hand just above the4.

oxygen to guard against anemia.

Q. Who can explain why immediate cordclamping is necessary for the 4 cases

mentioned? Answer: HIV infected – minimizemixing of blood between mother andbaby; Rh negative – minimize mixingto avoid antibody development thatcould affect mother’s future Rh positivebabies; premature baby – avoid additionalblood that can exacerbate jaundice;needs immediate resuscitation – need toresuscitate baby away from the mother and

near the necessary equipment.

Q. What are the dangers of exerting tractionon the cord to deliver the placenta? Answer: Te cord may tear if not done with care and make delivery of the placentamore difficult, and, if done too forcefullyand without counter pressure, tractionmay cause inversion of the uterus.

Q. Should AMSL be used even if anuterotonic is not given? Answer: No, expectant management(waiting) is indicated if there is nouterotonic available.

Q. What uterotonic should be given if neitheroxytocin nor Methergine is available? Answer: Misoprostol is effective and verystable without refrigeration.

N Summarize discussion and supplement with any missing content.

N Distribute Px Handouts 3.5: Te MainComponents of Active Management of theTird Stage of Labor (AMSL),

3.6: Administering the Uteroton-ic, 3.7: Controlled Cord raction,and 3.8: Uterine Massage.

UNIT 3/OBJECTIVE #2

3.5

3.6

3.7

3.8





woman’s pubic bone to stabilize the uterusby applying counter pressure (upward andbackward) during controlled cord traction.

Keep slight tension on the cord and await a5.

strong uterine contraction (usually within2-3 minutes after delivery).

With the first strong uterine contraction,6.

encourage the mother to push. Gently pulldownward on/apply controlled traction tothe cord to deliver the placenta. Do notpull too hard (to avoid tearing/snapping thecord, uterine prolapse, and/or inversion ofthe uterus).

Continue to apply counter-pressure to the7.

uterus. If the placenta does not descendduring 30-40 seconds of controlled cordtraction (and there is no hemorrhage andthe uterus is not filling with blood), do notcontinue to pull on the cord, instead:

N Immediately massage the fundus ofthe uterus until the uterus is contracted.Gently hold the cord and wait until the

uterus is strongly contracted. Ten, withthe next contraction, repeat controlledcord traction with counter pressure.

As the placenta delivers, hold the placenta8.

in two hands and gently turn it in onedirection, causing the membranes to twiston themselves until they slowly deliver.

Make sure mother’s bladder is empty.9.

After cutting the cord, place the infant10.

directly on the mother’s chest, prone, withthe newborn’s skin touching the mother’sskin.

If at anytime the woman begins to bleed11.

profusely, the placenta must be deliveredrapidly. It may be necessary, in anemergency only, to manually remove theplacenta.

UNIT 3/OBJECTIVE #2





Gently massage the uterus

Once the placenta is delivered,1.

immediately massage the fundus of theuterus until it contracts. Tis should

be done firmly, with enough strengthto make the uterus contract and clotsto be expelled, but not so strongly thatit causes extreme pain or damage, e.g.prolapsed uterus.

Examine the placenta carefully to be2.

sure none of it is missing. If a portion ofthe maternal surface is missing or thereare torn membranes with open vessels,

suspect retained placenta fragments andtake appropriate action.

If the membranes are not complete,3.

gently examine the upper vagina andcervix (wearing sterile or disinfectedgloves) and use a sponge forceps toremove any pieces of membrane that arevisible.

Palpate for a contracted uterus every 154.

minutes and repeat uterine massage asneeded during the first 2 hours. eachthe woman how to check to see if herown uterus is contracted and to massageit herself until it contracts, especially ifshe feels herself starting to bleed.

Gently separate the labia and inspect5.

the lower vagina and perineum forlacerations that may need to be repaired.

Ensure that the uterus does not become6.

relaxed (soft) after you stop uterinemassage by continuing to check in withthe woman.

Troughout the procedure, the providercontinues to provide support andreassurance to the woman. Remember totell her that she will feel strong cramping when the uterotonics are given.

UNIT 3/OBJECTIVE #






3.3-3.5

Specific Objective #3: Analyze the advantages and disadvantages ofuterotonics appropriate for AMTSL.

Uterotonics

Uterotonic drugs are medicines that causethe uterus to contract. Tree commonlyused uterotonics for preventing andmanaging PPH are, in order of preference:

Oxytocin: the synthetic form (Pitocin/1.

Syntocinon)

Ergot-based compounds:2.

methylergonovine maleate(Methergine), ergometrine, andSyntometrine.

Prostaglandins: misoprostol (Cytotec)3.

and carboprost tromethamine.

Te WHO recommends oxytocin as themost effective uterotonic, and that a doseof 10 IU IM for prevention be offered toall women immediately after delivery. Ifoxytocin is not available, then ergometrine,Methergine, or Syntrometrine should beoffered to women without hypertensionor heart disease. Misoprostol is a goodalternative when the others are not availableor appropriate.

Storage of uterotonics

Te stability of a uterotonic is defined ashow well it remains potent, when storedover a period of time. Ergometrine andSyntometrine are sensitive to heat andlight and oxytocin is sensitive to heat.Following the storage guidelines given bythe manufacturer is essential to keeping theuterotonic effective.

Discussion, Q&A (30 min.)

Te trainer should:

N Ask Px to explain the purpose ofuterotonics and give examples of thedifferent drugs.

N Explain that WHO stronglyrecommends that if all of thecomponents of AMSL cannot be

performed, that at least an appropriateuterotonic should be given by an SBA,trained in its use.

N Show Slides 3.3-3.5: Uterotonic Selection for Prevention of PPH .

N Review the different types ofuterotonics, the order of use based onavailability (preferably oxytocin) andviability (oxytocin, ergometrine, andlastly misoprostol), the advantages anddisadvantages of each, their dosage, andproper storage.

N Ask Px which uterotonics they use intheir own facility and how they arestored.

N Ask Px, why is oxytocin the preferreduterotonic? Answer: Oxytocin is the preferreduterotonic because it is effective 2

to 3 minutes after it is injected, hasminimal side effects, and can be usedon all women. If oxytocin is notavailable, give ergometrine 0.2 mg IM,or Syntometrine 1 ml injection, ormisoprostol 600µg orally/sublinguallyor 800-1000µg rectally.





Case Studies

Case 1: Mrs.B. is a nurse-midwife in a

clinic. Mrs. S. has come to deliver her babyat the clinic. Mrs. S has not come for anyantenatal check-ups, nor does she haveany of her medical records with her. Whatuterotonic should the nurse-midwife choosefor Mrs. S. and why?

Answer: Oxytocin, if available and properlystored; ergometrine if normal BP and noheart disease; and misoprostol if there is noacceptable storage for the others (and it isavailable).

Case 2: Mrs. L. is delivering in the clinic ina town with a peak summer temperaturesof between 40 and 45 degrees Celsius. Teelectric supply in town is erratic and thereis only one refrigerator for vaccines. Tenurse-midwife has stocks of Methergine,oxytocin, and misoprostol available in the

clinic. What should she give to mothersdelivering in the clinic during the hottestmonths?

Answer: Misoprostol, because the others would not be stable in that heat. (Pitocin ispossible with only 14% loss of potency overone year if stored at 30 degrees or less.)

Case 3: Mrs. H has come to the clinic for

her delivery. Te clinic has no oxytocinavailable and the nurse-midwife notes fromher antenatal record that she has high bloodpressure. What uterotonic should she give?

Answer: Misoprostol, because ergometrineis contraindicated.

N Distribute Px Handout 3.9: Uterotonics

N Briefly discuss storage ofuterotonics and explain

that storage of uterotonics will be explained in more detail in Unit 5.

N Distribute Px Handout 3.10: Case Studies.

N Read each of the casestudies in the left-handcolumn and ask whichuterotonic Px would use ineach case.

N Summarize all new information at the end

of the exercise. Conclude the session bytelling Px that the WHO recommendationis that oxytocin is the most effective choice,and that a dose of 10 IU IM for preventionis to be offered to all women right afterdelivery. If oxytocin is not available, thenergometrine, Methergine, or Syntometrineshould be offered to women withouthypertension or heart disease. Misoprostolis a good alternative when the others arenot available or appropriate.

N Explain that because misoprostol is newerand not as well known/used, we will goover it in more depth.

3.9

3.10

UNIT 3/OBJECTIVE #3






3.113.12

Specific Objective #4: Explain the uses and limitations of misoprostolfor prevention of PPH.

Use of Misoprostol for thePrevention of PPH

Some government guidelines andprotocols for skilled birth attendantsspecify that SBAs may independentlyprovide prophylactic misoprostol to women immediately after delivery. Sincemisoprostol is still not as commonly knownor used, this training will familiarize health

care providers participating. Te tablebelow shows the recommended doses ofmisoprostol tablets for prevention of PPH.

Route of administration and dosage ofmisoprostol for prevention of PPH

While misoprostol can be given rectally,sublingually, and orally for prevention ofPPH, the recommended route is orally.

Route ofadministration

Dosage

Oral 600µg

Sublingual 600µg

Rectal 800 – 1000µg

How does misoprostol make the uteruscontract?Misoprostol is an analogue of prostaglandinE1 that causes powerful contractions ofthe uterus. When the uterus is fatigued,misoprostol (or any uterotonic) helpsit to contract by producing the samephysiological changes as when the uteruscontracts naturally. It has been approvedfor use in the prevention and treatmentof PPH in several countries and can ofbe used to prevent PPH during the third

Discussion, role play (30 min.)

Te trainer should:

N Explain how misoprostol makes theuterus contract.

N Discus safety and side effects ofmisoprostol.

N Discuss the steps for administrationof misoprostol for the prevention of

PPH.N Ask for volunteers to play the patient

and the person accompanying thepatient.

N Te trainer will play the role of theprovider.

N Using real materials, demonstratethe provision of misoprostol forprevention of PPH, explaining each

step to Px as well as to the patient andher support person and answeringtheir questions.

N Discuss the dangers associated withmisuse of misoprostol.

N Distribute copies of Px Handouts 3.11: Te Use of Misoprostol in PPHPrevention and 3.12: Steps for Using

Misoprostol to Prevent PPH.





stage of labor when intramuscular or IVoxytocin or Methergine are unavailable orare contraindicated. Misoprostol does notrequire refrigeration and can be taken orallyfor the prevention of PPH.

What are the side effects of misoprostoland is it safe? Several studies have proven thatmisoprostol is safe and effective to preventand treat excessive postpartum bleeding. Women can take misoprostol even ifthey are also taking other medications.It is also safe and without side effects for

the newborn, so the woman who wasadministered misoprostol can feed and carefor her baby immediately.

Te side effects in the woman are transientand usually go away after 2 to 4 hours. Sideeffects include:

N Shivering (most common, should pass within first 24 hours);

N Fever (transient rise in bodytemperature), if fever continues morethan 24 hours, suspect infection;

N Headache;

N Nausea, vomiting, and diarrhea mayoccur but are rare (lasting 2-6 hours);

N Abdominal pain from uterine cramping(lasts until the uterus is well contracted);and

N Seizures and palpitations may occur,

but only when an overdose has beenadministered.

UNIT 3/OBJECTIVE #4



60



3.14

3.13

Specific Objective #5: Demonstrate AMTSL with proficiency.

Summary

AMSL reduces the incidence of PPH dueto uterine atony by 40-50% and should beoffered to all women.

Every birth attendant must have theknowledge, skills, and clinical judgment toperform AMSL and must have access tothe supplies and equipment necessary.

Where all 3 components of AMSLcannot be performed, the uterotonicshould be given prophylactically andthe uterus massaged after delivery of theplacenta. If the birth attendant has notbeen trained to apply CC or a uterotonicdrug was not given, WHO advises not toperform controlled cord traction.

Te uterotonic of choice is oxytocin,

followed by ergometrine or Methergine(not to be given if the woman has heartdisease or hypertension). Misoprostol isthe choice when an injectable uterotoniccannot be safely provided.

Early cord clamping should be doneonly if:

N Te baby is premature (less than 36 weeks),

N Te newborn is asphyxiated andimmediate resuscitation is necessary,

N Te mother is known to be HIVpositive or is Rh negative, or

N Te mother starts to bleed profuselyand the placenta must be deliveredimmediately.

Simulated Demonstration of AMSLand Simulated Practice (2 hours)

Te trainer should:

N Present the summary in the left-handcolumn. Distribute Px Handout 3.13:

AMSL.

N Assess the knowledge and Px skill levelsfrom the pretest, participation thus far,

and other means (e.g., question andanswer segments), giving weight to thecomponents that are the least understood.Note: Some Px will have no experience inperforming AMSL, others may have a lot,and some Px may have learned incorrecthabits that must be unlearned.

N Ask Px to brainstorm the steps of AMSL,including care of the newborn. Put eachstep on a separate piece of paper. Ask Px

to organize the steps in the right order andthen tape them to a flipchart.

N Clarify the components, sequence, andtiming of the components of AMSL.

N Pass out Px Handout 3.14: Competency-Based raining Skills Assessment Checklist

for Active Management of the Tird Stage ofLabor (AMSL).

N Demonstrate AMSL on a model (having

prepared all necessary supplies in advance)and explain steps as s/he goes along. Alternately, call on different participantsto tell the trainer which step is next and what should be done (the trainer shoulddemonstrate only correct procedures).

N After demonstrating AMSL on the






model, the trainer will allow each Px todo the same, while being coached by thetrainer at first and then by a fellow Px who will use the AMSL Competency-Based Checklist as a reference.Troughout the simulated practice, Pxshould practice their role as clinicianby talking to the “patient” and “familymember” while performing AMSL,explaining what is taking place, andreassuring her.

N Have Px practice in groups of 3 or 4(mixing more experienced with less

experienced Px) at different practicestations (prepared beforehand) until theyfeel confident of the steps and skills.

N Te trainer will then assess the skills thePx demonstrate in the simulated practiceand tell them if they are ready forpractice with real patients.

Never apply cord traction (pull) withoutapplying counter-pressure above the pubicbone on a well-contracted uterus

UNIT 3/OBJECTIVE #5




UNI 4: Early Detection of PPH

Introduction:

Immediate response and action are crucial for survival when PPH occurs. Accurately measuringthe amount of blood that a woman has lost is difficult to do, but important for the early

detection of PPH. Unit 4 addresses the early detection of PPH and assessment of blood lossduring childbirth.


Participants will be trained on the use of the blood collection drapes and other methods ofaccurate blood loss estimation.


By the end of this unit, Px will be able to:

N Describe how PPH causes morbidity and death,

N Describe methods used to improve accuracy in estimating blood loss,

N Demonstrate the use of the blood collection drape to measure blood loss, and

N Explain how to monitor women for signs of shock.

raining/Learning Methodology

N Brainstorming

N Group discussionN Experiential learning exercise

N Demonstration/retrun demonstration


N Role-play

N Practicum

Major References And raining Materials:

N Chua S, et al. Validation of a Laboratory Method of Measuring Postpartum Blood Loss.

Gynecological and Obstetric Investigation 46 :31-33.

N Duthie SJ, et al. Discrepancy Between Laboratory Determination and Visual Estimationof Blood Loss During Normal Delivery. European Journal of Obstetrics & Gynecology andReproductive Biology 38 :119-24.

N Lynch CB, et al., eds. A extbook of Postpartum Hemorrhage: A Comprehensive Guide toEvaluation, Management, and Surgical Intervention. Dumfriesshire, UK: Sapiens Publishing,2006. 17-34. Available online: http://www.sapienspublishing.com/pph_pdf/PPH.pdf



63



N Computer, LCD projector, CD-ROM containing slides, and screen or white wall

N Flipcharts

N Markers

N Cards

N Blood collection drape (if taught)

N Pelvic model, or use volunteer

N (Standard rag and fluids for demonstration – when ready)

N Surgical gloves - 1 pair

N Long utility gloves

N Vessels of different sizes to hold simulation blood (see Materials for rainers to Prepare in Advance, below)

N

WaterN Red dye

N Tickening agent or gelatin, if available

Evaluation Methods:

N Direct observation using monitoring checklist

N Verbal feedback

ime Required:SpecificObjective

opic ime Required

1 Describe how hemorrhage causes morbidity and death. 30 min.

2 Describe methods used to improve accuracy in estimatingblood loss.

1 hour

3 Demonstrate the use of the blood collection drape to measureblood loss.

1 hour

4 Explain how to monitor women for signs of shock. 15 min.otal ime Required 2 hours, 45 min.





N Collect common materials and/or containers used to measure blood in local

clinics or hospitals.N If there is a commonly used local fabric of a standard size, such as a kanga,

lungi, or cleaning cloth that providers can use under the patient followingdelivery to assess the amount of blood loss, include this for the demonstration.

N Prepare a solution that is similar in consistency to blood. See ParticipantHandout 4.3 for suggested formulas, or be creative and use local ingredients(water combined with red gelatin or water with a colored thickening agent) toachieve an appropriate consistency and color.

N Blood collection drapes

N Kidney dish and/or calibrated containerN Practice stations set up for blood collection drape simulation





CONTENT METHODOLOGY

UNIT 2


4.1

4

Te Urgency of the Woman’sCondition Begins as Soon asBleeding Starts

Morbidity from PPH includes potentialexposure to infected blood supply (iftransfusion is needed), anemia, and loss ofreproductive capacity if a hysterectomy isneeded to control PPH.

Immediate response and action are crucialfor survival. Tose who live in rural,remote, and hard-to-reach areas are atmuch higher risk.

Even after practicing AMSL to preventPPH, providers must be alert to andrecognize excessive postpartum bleeding. AMSL prevents only 40-50% of PPH.Te remaining cases will still need tobe diagnosed as early as possible andmanaged in a timely way.

Reasons for high mortality from PPH

N Failure to recognize excessive bloodloss and estimate amount of blood loss

N Failure to provide timely treatment forthe cause of PPH

N Failure to provide early and adequate

fluid replacement and treatment forshock

Remember, PPH can kill within 2hours if not managed aggressively andcorrectly.

Participatory Discussion (30 min.)

Te trainer should:

N Explain the difficulty in accuratelyestimating blood loss and detectingPPH using the contents in the left-hand column.

N Ask: What are the reasons for highmortality from PPH? Supplementresponses from content in the left-hand column.

N Emphasize the urgency of PPHbecause it can kill within 2 hours.

N Show Slide 4.1 HowHemorrhage Causes Shock,

Morbidity, and Death.

N Explain what shock is and why fluid

replacement is essential.N Explain how hemorrhage can lead to

shock, morbidity, and eventually todeath.

N Explain how early recognition ofshock, restoration of fluid volume,and control of hemorrhage canprevent morbidity and death.

N Distribute Px Handout 4.1: How

Hemorrhage Causes Morbidity andDeath.

Specific Objective #1: Describe how hemorrhage causes morbidity anddeath.

4.1





Te principal reason for high mortalityassociated with obstetric hemorrhage issimple: delayed recognition of excessive

bleeding and failure to provide early andadequate treatment and fluid replacement.Unless lost fluid volume is restored as soonas possible and normal tissue perfusion andoxygenation are maintained, the woman isat immediate risk of shock and death.

How hemorrhage causes shock,morbidity, and death

Understanding how hemorrhage causesshock, morbidity, and death is necessaryto understanding how to manage shockeffectively.

Severe blood loss

Decrease in circulating blood volume

Interruption in oxygen supply to tissues

endency of blood to accumulate in lowerabdomen and legs

Brain, heart, lungs deprived of oxygen

Damage to vital organs

Death

Decreases in circulating blood volumeinterrupt oxygen supply to tissues, resultingin damage to the vital organs: heart, lungs,kidneys, and brain. When the brain isdeprived of oxygen, a process of rapid

UNIT 4/OBJECTIVE #1





deterioration sets in, leading quickly tocirculatory collapse and organ failure, whichcould include cardiac arrest and death.

Shock is a highly unstable condition witha high risk of death. Immediate treatmentis needed to save the patient’s life. Shock isa reflection of inadequate tissue perfusion.Inadequate tissue perfusion means imminentcell death.

Successful outcomes depend on earlyrecognition of shock, restoration of fluidvolume, and control of hemorrhage.

UNIT 4/OBJECTIVE #1



68



4.2-4.11

Specific Objective #2: Describe methods used to improve accuracyin estimating blood loss.

Estimating Blood Loss

How can you estimate lost blood volume andPPH so that timely and adequate interventioncan be provided? What are some methods ofestimating blood loss to detect PPH?

Methods of estimating blood loss

N Visual estimation

N Use of the blood collection drapeN Use of the “Kanga Method” as in East

Africa, or adaptation with local materialsin each country

N Collection of blood in a kidney tray orin a calibrated container placed under acholera bed

N Any reliable method that can be devised - areliable method is needed!

Visual estimation can be inaccurate,unless providers are trained systematicallyto make accurate visual estimations.Published studies show that commonvisual estimation underestimates PPH by30% -50% (Chua, et al .). Tis inaccuracyincreases as blood loss increases (Duthie, etal .). Such underestimation delays diagnosisand timely action. However, much canbe done to improve visual estimation ofblood through competency-based trainingon reliable estimation of blood loss. It isalso useful to have periodic drills where atrainer arranges several examples of bloodloss at a facility, simulating real experiences,and has participants estimate and discussthe amounts. Tis improves and maintainsproviders’ ability to estimate accurately.

Experiential Learning Exercise andDemonstration (1 hour)

Te trainer should:

N Explain that this session will focus onestimation of blood loss and PPH inorder to provide timely and adequatemanagement.

N Ask: What are some methods of estimating

blood loss to detect PPH?N Discuss the different methods using the

content in the left-hand column.

N Present the visual estimation exercise, which will allow each of them to knowhow good they are at accurately estimatingblood loss.

N Give each Px a card, and say: I am nowgoing to show you some slides of blood

loss. After you see each slide (labeled a,b, c, etc.), please write down on this cardhow much blood you think has been lostin the picture on that slide. Using Slides4.2 – 4.10 , show each slide, and after eachslide ask the Px what they have noted onthe card, facilitating a lively exchange andcompetition among Px. After several Pxhave given guesses for the slide shown,show the actual amount and proceed to

the next slide. After Slide 4.10, show Slide4.11, which shows the answers for eachimage as a review.

N Ask how many Px got all answers correct, 8correct, 7 correct, etc. Give a prize to thePx who got the most correct and concludethe exercise by explaining that this clearlyshows how inaccurate visual estimation






4.2

4.3

Te “Kanga Method” of estimating bloodloss proved very effective in anzania.Standard kangas, which are large pieces ofcloth of similar size, weight, and fabric that women wear wrapped around themselves,can be used by providers in lower-levelfacilities to estimate blood loss accurately.Studies have shown that when 2 kangas aresaturated with blood, PPH can be accuratelydiagnosed for rapid, effective intervention. A cotton pad with a thin plastic lining isin use in Bangladesh, and similar testing ofstandard cloths has also been conducted in

Bangladesh.Using a cholera bed to estimate blood lossis also effective. o do so, the woman’sbuttocks would be placed over the holein the bed, rather than placing her legs instirrups at the end of the bed, and the babydelivered onto the bed, rather than off thebed. A calibrated container should be placedunder the hole in the bed so the attendantcan monitor the amount of blood collectedin the container. It is preferable for the woman not to lie flat—she may deliver inany other position she prefers (squatting,hands and knees, or lying on her side). All blood on the bed must be swept intothe hole using only a gloved hand. Watermust not be poured over the perineum oronto the bed until the postpartum bloodloss has been measured: pouring water

would artificially increase the volume ofliquid in the calibrated container, leading toinaccurate measurement.

Any reliable method that can be devised isacceptable. Other local, standard methodsof measuring bloos loss can be tested withsimulated blood to find an affordable,accessible method of estimating blood loss.

can be, unless people are trained andpracticed in more accurate visualestimation.

N Having prepared measured quantitiesof simulated blood, and with containersused in local clinics and hospitals and/or a pre-measured, standard-sized,commonly used cloths, saturate/pourinto each item different amounts of theliquid. Ask Px to estimate the quantityof liquid collected in/saturating eachitem. Reiterate that accurate visualestimation requires ongoing training and

practice.N Distribute Px Handouts 4.2: Improved

Estimation of Blood Loss and 4.3: Formu-las for Simulated Blood.

UNIT 4/OBJECTIVE #2






Specific objective #3: Demonstrate the use of the blood collection drape tomeasure blood loss.

Te Blood Collection Drapeand its Use

Te plastic blood collection drape is asimple tool that can be used to assessblood loss. As soon as excessive bloodloss is identified, corrective measures canbe taken, which will improve patientoutcomes. Skilled providers can provide allmeasures at hand to stop bleeding, begin

fluid replacement and, when necessary,transfer patients to a higher-level facility, where more extensive care can be given.Hospitals can begin emergency treatmentimmediately when excessive blood loss isrecognized. However, the blood collectiondrape is only a tool to measure blood loss.Te provider must continuously assess the woman clinically for signs of shock afterdelivery.

Te blood collection drape is a funnel-shaped plastic bag used to measure bloodloss after delivery. Te upper rectangularportion is placed under the woman’sbuttocks. Te funnel shaped/triangularportion hangs from the end of the deliverytable, or is placed flat on the table or floor(depending on the surface on which the woman is delivering). A stiff wire holdsthe pouch open to collect all blood. Tefunnel is calibrated with two lines, a yellowalert line at the 350 ml mark, which meanspreparation for transport must begin,and a red action line at the 500 ml mark, which means that the woman should betransferred immediately to a health facilitycapable of treating PPH.

rainer Presentation, Demonstra-tion, and Return Demonstration

(1 hour)

Te trainer should:

N Introduce the blood drape, explainingthat it is used for measuringpostpartum blood loss by guidingblood into the tip of the funnel, where

“warning” and “action” lines indicateserious levels of blood loss.

N Show the following slides:

N 4.12: Te Blood Collection Drape

N 4.13: Using the Blood CollectionDrape

N 4.14: Correct Placement of theBlood Collection Drape

N 4.15: Te Blood Collection

Drape in Use

N 4.16: Measuring Blood Collected inthe Funnel

N Show the actual drape and, whileholding up the drape, use Slide 4.12 toexplain the yellow alert line and the redaction line.

N Ask a Px to volunteer to play a patient

to model use of the drape. Ask thevolunteer to lie on the floor or table.Position the drape and tie it around thevolunteer, explaining each step as yougo. Demonstrate, using a gloved hand,how to push blood into the funnel andhow to lift the funnel to see clearly thelevel the blood has reached.

4.12-4.16





4.4

Te blood collection drape is made of plasticand may be hard to dispose of safely. Somecountries, like India, have anti-plastics cam-paigns and may bar this use of plastic.

Using the Blood Collection Drape

Deliver the baby

Place rectangular portion of drape underbuttocks with funnel portion hanging over

the edge of table or lying flat on bed or floor

ie blood drape around woman at 2 places(waist & hips)

Place thick, rolled towel or cloth underneaththe woman’s shoulder blades

Push all blood into the bag using a glovedhand

Assess blood loss by looking at the amountof blood collected in funnel

Hold up the end of the bag with both handsto compare the amount of blood lost inrelation to the warning and action lines

Do not remove drape to assess blood loss

How to Use the Drape

Once the baby is delivered and the amnioticfluid has passed, both gloved hands are usedto slip the blue plastic under the woman’sbuttocks. Tis will ensure that only blood

N During the second demonstration, callon different participants to tell the trainer which step to perform next and how.

N Clarify each step.

N Distribute Px Handout 4.4: Competency-Based raining Skills AssessmentChecklist for Using the BloodCollection Drape .

N After demonstrating the use of the blooddrape on the volunteer, form teams of Pxto work at prepared practice stations, soeach Px demonstrates use of the drape while fellow Px use the competency-basedchecklist as a guide.

N Circulate around the practice stations.Troughout the simulated practice, each Pxshould practice her or his role as clinicianby talking to the “patient” while applyingthe blood drape, explaining what is takingplace and reassuring the “patient.”

N Have Px practice in teams until they feel

confident of the steps and skills.

N Assess the skills of the Px.

Methodology continues on page 75.

UNIT 4/OBJECTIVE #3





and no other body fluids are collected inthe drape. Te drape should be tied aroundthe woman at both the waist and the hips.ying the drape properly is importantbecause it ensures that the blood is collected within the calibrated funnel. If the woman ispositioned at the end of the table, the pouchmay hang over the edge of the table. If the woman is lying elsewhere on the bed/tableor on the floor, the pouch may lie flat onthe bed/table/floor. Once the drape is tied,place a thick rolled towel or cloth under the woman’s shoulder blades (scapulae) and head

to lift her torso. Tis inclination will helpthe blood to flow downward into the funneland avoid the pooling of blood under herback. In any case, the birth attendant shouldperiodically use a gloved hand to manuallypush blood into the funnel if it is collectingelsewhere.

o assess the volume of blood in the funnel while the drape is still under the woman,grasp opposite edges of the top portion ofthe funnel between the fingers and thumbof each hand, lifting the funnel to a verticalposition. With the funnel vertical, the levelof the blood collected can be compared tothe yellow and red lines. Tere is no needto remove the drape from under the woman when measuring blood loss this way.

UNIT 4/OBJECTIVE #3





4.5

4.6

4.17-4.19

Cleaning and Storing the Drape

Infection prevention is critically importantand is often practiced incorrectly. Properinfection prevention, or universalprecautions, ensures that patients, providers,and staff are protected.

Tere are 3 stages in processing the bloodcollection drape for reuse: decontamination,cleaning, and storage. If the drape is not tobe reused, it must still be decontaminatedprior to disposal.

1. Decontamination is the first step.Decontamination makes everything safeto handle, killing 80-85% of all microbesand viruses. It requires 10 minutes ofimmersion in 0.05% bleach solution.Note: Over-processing (soaking toolong--more than 10 minutes) can damagethe drape; under-processing may beineffective and is unsafe.

2. If the drape is to be reused (and wateris available): Next, wash it thoroughly with detergent and water, making sureto remove all blood from the narrowest(lower) part of the funnel. Rinsethoroughly with clean water and air dryin the sun before the next step. Storage isthe final important step.

3. Storage: Because the drape is not goinginto the body of the woman, it does

not need to be sterile and sterilization would damage the material. Tus, ifthe drape is to be reused, it should bedecontaminated, cleaned, sun dried,folded, and stored until reuse.

Te trainer should:

N Explain the importance of infectionprevention when handling blood.

N Ask Px what steps they use in processingcontaminated equipment. Supplementtheir answers from the column on theleft-hand side.

N Demonstrate the cleaning of the blooddrape and the infection preventionprocedures that should be observed.

N Show Slide 4.17: Decontaminate in

0.05% Bleach Solution for 10 Minutes,Slide 4.18: Clean with Soapand Water, and Slide 4.19:Hang the Blood CollectionDrape to Dry in the Sun.

N Explain and demonstrate how to dry andfold the blood drape. (If blood drape issingle-use only in your location, discussthe proper disposal of the drape byburning or burying).

N Distribute Px Handouts 4.5: Te BloodCollection Drape and its Use and 4.6:Cleaning and Storing the Drape.

UNIT 4/OBJECTIVE #3





o Fold and Store the Drape:

N Lay the drape flat on a table.

N Fold the triangular portion of the drape

over within itself (so the point touchesthe center of the top of the funnel) andthen over the edge of the rectangularsection.

N Te opposite sides of the rectangle arefolded together, encasing the triangularportion of the drape.

N Tis is then folded along its breadth,finally looking like a square.

N Once folded, only the blue rectangular

portion is visible. Tis method of folding will occupy the least amount of space.

N Te drape should be stored in a clean,dry, and closed place.

N Remember: overexposure, and exposureover time, to bleach and other chemicalsused to disinfect may deteriorate themarkings and the plastic.

Even if the drape is not to be reused, it mustbe decontaminated before it is disposed of inaccordance with established guidelines.

UNIT 4/OBJECTIVE #3



76



4.7

Specific Objective #4: Explain how to monitor women for signs of shock.

Observing and Monitoring theWoman for Signs of Shock

Prevention All women should be examined carefullyfor tears in the vagina, cervix, or perineumas significant blood loss can occur fromsome tears. If there are tears, they shouldbe repaired, or if the provider cannot repairthem, pressure should be applied with

sterile or clean material as the woman istransferred quickly to where the repaircan be done. Ruptured uterus should besuspected if other causes cannot be found.

As soon as the placenta is delivered,examine it for torn membranes or missingpieces. If it appears that membranes aretorn, or pieces are missing, gently examinethe cervix and remove any visible tissue

with a sponge forceps. If the missing tissueis not visible, it is likely that it is retainedin the uterus and could cause excessivebleeding. Observe the woman to see if theuterus contracts normally.

Te woman should be observed andmonitored for 2 hours after delivery toassess volume of postpartum blood lossas well as vital signs and other symptoms

of shock. Use whatever method you findmost effective to monitor the amount ofpostpartum blood loss. Every 15 minutes,palpate the uterine fundus to feel whetherit is contracting or remains flabby, andmonitor vital signs. each the mother andaccompanying family members to massagethe uterus as well, especially if bleedingbegins again.

Discussion (15 min.)

Te trainer should:

N Ask Px to describe the examination of theplacenta and cervix following delivery.

N Ask Px to describe how and why to ex-amine the woman for tears.

N Ask Px to describe how to monitor a woman following delivery. Ask for sug-gestions about how to manage this whenthey are alone and busy with other pa-tients.

N Describe measures that should be takento help the uterus contract and reduceblood loss. Stress the importance ofgentle but firm uterine massage.

N Distribute Px Handout 4.7: Observing

and Monitoring the Woman for Signs ofShock.






Troughout the two-hour immediatepostpartum period, provide all measuresto help the uterus to contract and stop anybleeding:

N Keep the bladder empty;

N Remind the woman how to check andmassage her own uterus and to call you ifthe uterus stays soft or she thinks she isbleeding too much;

N Check the amount of vaginal bleedingevery 15 minutes and respond immediatelyif excessive;

N Check the woman’s BP and pulse every15 minutes and respond immediately if

abnormal;

N Every 15 minutes, check that the uterus is well contracted and massage if not;

N Put the baby to the breast; and

N Perform bimanual compression, eitherinternal or external.

Regardless of the level of the facility where the

baby is delivered, these measures should betaken (by the trained birth attendant or healthprovider).

Monitoring to detect shock: How do youknow if the woman is in shock?

Because women respond differently to the lossof similar levels of blood, based on their sizeand level of anemia (i.e., prehemorrhage blood

volume and oxygen carrying capacity), some women will exhibit signs of shock even withblood loss less than 1000 cc, or severe PPH.

Signs of the early stages of shock are increasingtachycardia, tachypnea, lowering of bloodpressure, pallor, and sweating.

UNIT 4/OBJECTIVE #4





Signs of shock include:

N Rapid heart rate/tachycardia (the first sign);

N Weak pulse;

N Rapid breathing/tachypnea;

N Fall in urine output (less than 30 ml/houris serious);

N Cold, pale, sweaty, bluish skin;

N Alteration in consciousness; and

N Falling blood pressure/hypotension (late sign).

Immediate Management

Terefore, while all efforts to manage PPHare ongoing, it is critical to be vigilant inmonitoring, observing, and recording vitalsigns and symptoms so that the onset ofshock is detected as soon as possible. Whena woman becomes restless and confused,shock is advancing rapidly and immediate,aggressive treatment is needed. If any ofthese signs are present, treat the woman forshock regardless of how much blood she haslost.

Early recognition of blood loss and timelyaction is critically important in preventingmorbidity and death from PPH, as it can belethal within as few as 2 hours. In peripheryor where higher-level care is less accessible,close monitoring and early diagnosis are evenmore critical. In regions and populations where chronic anemia and/or anemia during

pregnancy is prevalent, the recognition oflesser amounts of blood loss is clinicallyimportant. In rural areas with unskilled orminimally-trained birth attendants, wheretransportation to referral facilities takesmuch time, we need simple tools that willfacilitate early diagnosis so that we can act toavert mortality and morbidity from PPH.

UNIT 4/OBJECTIVE #4





UNI 5: reating PPH and Uterine Atony

Introduction:

With the use of AMSL to prevent PPH, early and accurate detection of PPH using the blooddrape or other methods of accurate estimation, and rapid referral and transportation, the

incidence of shock from PPH should be greatly reduced. However, about 1% to 3% of women will still suffer intractable PPH from uterine atony. Because women respond differently to theloss of similar levels of blood, there is no uniform level of blood loss at which all women willexhibit signs of shock. Terefore, vigilant observation of signs of shock while prevention effortsare ongoing is essential.


Participants will be trained in the steps and procedures necessary for treatment of PPH caused byuterine atony. Tese include management of hypovolemia and hypovolemic shock.


By the end of this unit, Px will be able to:

N Describe the first measures to be taken if PPH occurs,

N Describe the actions to be taken in each level of facility once excessive blood loss is detected,

N Explain the management of hypovolemic shock, and

N Demonstrate the treatment of PPH in a simulated emergency situation.


N Slide presentation

N Group discussion

N Case studies

N Question and answers

N Simulation exercise

Major References And raining Materials:

N Lynch CB, et al., eds. A extbook of Postpartum Hemorrhage: A Comprehensive Guide toEvaluation, Management, and Surgical Intervention. Dumfriesshire, UK: Sapiens Publishing,2006. 17-34. Available online: http://www.sapienspublishing.com/pph_pdf/PPH.pdf






N Flipchart

N Marking pens

Clinical equipment and supplies needed: one practice station should be set up for each group

of 4-5 Px. Practice stations should be set up with clinical equipment and supplies as indicatedbelow:

PPH Simulation Practice Station Supplies

For each station

serving 4-5 Px

Total needed for a

class of 20-22 Px

1 5 Emergency tray

3 15 Pairs sterile gloves

1 5 Oropharyngeal airway

1 5 Ambu-bag and mask

2 10 10 drip (IV) sets

5, 10 and 20 ml syringes/wide bore No. 16 or 18 needles

2 10 IV fluids : Ringers Lactate (10 bottles; normal saline, 5% dextrose solu-

tion, etc.)

1+ 5+ Of each: oxytocin and ergometrine ampoules/misoprostol

1 5 Local anesthetic (1% plain lignocaine)

1 5 Laboratory bottles and test tubes for bedside clotting test

1 5 Pelvic examination tray

1 5 Foley catheter and urine bag

1 5 Oxygen cylinder with mask or cannula

1 5 Stethoscope

1 5 Sphygmomanometer

1+ 5+ Other emergency drugs (adrenaline, atropine, naloxone, etc.)

1 5 Episiotomy/cervical repair kit

1 5 Blankets

Blocks to raise foot of bed/or table

Evaluation Methods:

N Simulation Exercise and Feedback



81


ime Required:

Specific

Objective

opic ime

1 Describe the first measures to be taken if PPH occurs. 45 min.

2 Describe the actions to be taken in each level of facility once

excessive blood loss is detected.

1 hour, 45 min.

3 Explain the management of hypovolemic shock. 1 hour

4 Demonstrate the treatment of PPH in a simulated emergencysituation.

1 hour

otal ime Required 4 hours, 30 min.


N Be sure that all of the clinical supplies and equipment listed under theResource Requirements are collected from the hospital in advance.


N Invite or plan for judges to provide feedback and declare the winner of thedrill competition.

N Set up practice stations before the beginning of the session.



CONTENT METHODOLOGY

UNIT 4


5.1

5.1

Specific Objective #1: Describe the first measures to be taken if PPH occurs.

5

Action for PPH

Uterine atony is the most common causeof PPH, but retained tissue, trauma andbleeding disorders are other causes thatneed investigating, and, if found, needintervention.

After performing the steps of AMSL,if you observe excessive bleeding and theuterus is contracted and the examinationsfor retained tissue or trauma are negative,a bedside clotting test can be performedto rule out coagulopathy as a possiblecause for PPH. Less than 1% of PPH isfrom previously existing coagulopathy,but uterine rupture or abruption,preeclampsia/eclampsia, or any severebleeding can lead to disseminated

intravascular coagulopathy (DIC), alife-threatening emergency, which can bedetected with this simple test. reatingDIC requires resources only found incomprehensive emergency obstetriccare facilities and immediate transfer isrequired.

Bedside Clotting est

Draw 2ml of venous blood and put it1. into a small, dry, clean, plain or red-top glass test tube (approximately 10mm x 75 mm).

Hold the tube in your closed fist to2.

keep it warm (+37°C).

After 4 minutes, tip the tube slowly3.

to see if a clot is forming. Ten tip it


Te trainer should:

N Explain that in Unit 3 we learned howto provide AMSL to all women andthat in Unit 4 we learned about the needfor early detection of PPH and aboutsimple methods for estimating blood lossmore accurately, so that timely actioncan be taken to treat it. Explain that inthis session, we are going to learn how tomonitor women after delivery to detectPPH (assess the causes of PPH (the 4 ’s)and to treat them), and how to preventshock. Finally, we are going to learn howto treat shock, if it cannot be prevented.

N Review how hemorrhage causesmorbidity and death, using

Slide 5.1: How HemorrhageCauses Shock, Morbidity, andDeath.

N Use the content in the left-handcolumn to introduce anddescribe all procedures to thePx systematically. Distribute PxHandout 5.1: Action for PPH .

N Explain that if appropriate action is

taken following the detection of excessiveblood loss, the patient is protected fromdeclining rapidly into shock, which canlead to death in a short period of time.

N Explain how to perform a bedsideclotting test to rule out coagulopathy.

N Ask Px: If the uterus does not contract when massaged, and the bleeding is






5.2

5.2-5.4

again every minute until the blood clotsand the tube can be turned upside down.

Failure of a clot to form after 7 minutes, or4.

a soft clot that breaks down easily, suggestscoagulopathy.

If the uterus does not become firm orblood loss exceeds 350 ml

In addition to continuing to keep the bladderempty, massaging the uterus every 15 minutes,and putting the baby to the breast, the SBAshould:

Administer a second dose of uterotonic to1.help the uterus to contract. Any uterotoniccan be used as per dosage below.

N Oxytocin can be given, 10-20 IU IMinitially. Oxytocin will begin to act within 2-3 minutes if given IM.

OrN Ergometrine/Methergine can be given as

an IM injection, 0.2-0.4 mg, providedthe woman does not have preeclampsia,eclampsia, high blood pressure, or heartdisease. It will act within 2-5 minutesof administration and could causenausea and vomiting. Te ergometrinerequires stringent handling and storageconditions.

Or

N Misoprostol, which can be used whererefrigeration and ideal storage conditions

are not available, can be given orally,sublingually, or rectally, as follows:

Misoprostol for treatment of PPH

Route of Administration

Dosage

Oral 600µg

Sublingual 600µg

Rectal 800 – 1000µg

heavy, what is the next step that needs tobe taken to prevent shock?

N Explain that PPH must be treated with

uterotonics first. Show Slides 5.2-5.4:Uterotonics Used for the reatment ofPPH . Explain the advantages anddisadvantages of each uterotonic andthe correct dosage of each.

N Distribute Px Handout 5.2: Steps toake if Blood Loss Exceeds 350 ml.

N Explain that keeping fluid volume highis critical to preventing shock, so, inaddition to stopping the bleeding withuterotonics and massage, adequate fluidreplacement is necessary.

N Explain the steps to be taken if the uterusdoes not become firm or the blood loss isgreater than 350ml.

N Explain steps to be taken if blood loss isgreater than 500ml.

N Before ending the session, ensure thatPx have understood the details andthe procedures given in the left hand-column.

UNIT 5/OBJECTIVE #1





N Misoprostol is effective 9-12 minutesafter administration and could causeshivering, nausea, and elevatedtemperature. It should not be given forat least 2 hours after an earlier dose.If the earlier dose caused shivering ornausea, a second dose should not begiven earlier than 8 hours after the firstdose.Recent studies show that althoughmisoprostol is not quite as effectivein treatment of PPH as otheruterotonics, it is a good alternative

when the potency of oxytocin can’tbe guaranteed because of lack ofrefrigeration or it has passed itsexpiration date. Guidelines formisoprostol may change in the nearfuture.

Initial steps to treat PPH: Start an IV2.

drip (using a 16-18 bore needle so thatthe same needle can be used if a bloodtransfusion is required) with 10-20 IU

oxytocin in 500 ml (or 20-40 IU in1000ml) crystalloid fluids (Ringer’sLactate, Normal Saline, or Hartmann’sSolution). Run at 40 drops per minuteor 150 ml/hour. (Remember that thereare different drips per ml in differentcountries, so calculate the drop perminute in order to infuse 150/ml/hour.)Subsequent IVs of crystalloid can begiven with 5-10 IU in 500 ml (10-20IU in 1000 ml), run at 150 ml/hour.Oxytocin will begin to act immediatelyif given intravenously. If high doses ofoxytocin are given with large volumesof fluid, oxytocin could have an anti-diuretic effect, causing fluid intoxication/ water toxicity. Tis is a rare side effecthowever, especially in younger women of

UNIT 5/OBJECTIVE #1





reproductive age.

If retained tissue is suspected and the SBA3.

is trained in this procedure, explore the

uterus for retained placenta and remove.If this is not successful and bleedingcontinues, request surgical assistance. If thisfacility cannot offer surgical intervention,transfer immediately to a higher facility.

If the uterus is contracted but bleeding is4.

excessive, trauma is likely. Omit uterotonictreatment, but provide fluid replacement.If the facility can provide surgical

intervention, repair the trauma. If thefacility cannot offer surgical intervention,apply pressure to the wound and transferimmediately to a higher facility.

If the bedside clotting test is positive, the5.

woman requires emergency treatment forclotting disorders either in the facility she isin if the capacity to treat exists,, or a facilityshe must be transferred to urgently to saveher life.

If bleeding from any cause exceeds500 ml:

Secure a second IV line with a 16-18 boreneedle before transfer, so that if the woman’scondition deteriorates during transfer, it willnot be difficult to start a second IV. ransferimmediately to a facility that can providehigher-level care. It is safest to refer the

woman to a facility that can provide surgicalintervention as well.

UNIT 5/OBJECTIVE #1



86



Specific Objective #2: Describe the actions to be taken in each level offacility once excessive blood loss is detected.

Observing and monitoring thewoman to detect PPH:

Te woman should be observed andmonitored for 2 hours after delivery toassess volume of postpartum blood loss,uterine firmness/tone, vital signs, andadditional symptoms.

Troughout the two-hour immediate

postpartum period, the birth attendantshould provide all measures at hand to helpreduce postpartum blood loss. Measuresshould include uterine massage, putting thebaby to the breast, and keeping the bladderempty.

Decision making and action once excessiveblood loss is detected depend on where the woman is delivering and what capacity the

facility has for providing:N Fluid replacement and oxygen, and

N Management of causes of PPH,particularly uterine atony.

Broadly speaking, action would need to beas follows on the next page.


Te trainer should:

N Remind Px that during the two-hourimmediate postpartum period, the birthattendant should provide all measures athand to help reduce postpartum bloodloss.

N Ask: What are some of these measures?

Answers include: uterine massage, puttingbaby to the breast, keeping the bladderempty.

N Explain that decisions made and actionstaken once excessive blood loss is detecteddepend on where the woman is deliveringand what capability the facility has forproviding fluid replacement and managingcauses of PPH, particularly uterine atony.

N Draw 4 columns on a flipchart labeled:

1. Extent of blood loss;

2. Where fluid replacement and PPHmanagement are not available;

3. Where only fluid replacement/PPHmanagement available; and

4. Where surgical interventions areavailable.

N Lead brainstorming to fill in the columns.

N Fill in any missing content andsummarize.

N Under the “Extent of blood loss,” column write “> than 350ml in the 1st hourafter delivery.” Ask Px to brainstorm themanagement that should go under eachcolumn. Fill in responses according to thecontent in these pages.





Extent of blood loss Response, based on resources available at place of delivery

Where fluid replacement/

PPH management not

available

Where only fluid

replacement/PPH

management available

Where surgical

interventions are

available

>350 ml after

delivery

Continuously provide

all measures at hand to

stop bleeding: additional

uterotonics, put baby tobreast, uterine massage, and

bimanual compression.

Reassess for other causes of

bleeding.

Continue to assess

symptoms and vital signs to

detect shock.

Preparations to transfer the

woman to a higher facility

if retained placental tissue,

trauma, or clotting problem

if bleeding continues

without obvious cause.

All in first column plus:

Start an IV drip with 10-20

IU oxytocin at 40 drops/minute or 150mL/hour

(depending on infusion set).

Give appropriate uterotonic

based on past history.

Prepare to transfer the

woman to a higher-level

facility if retained placental

fragments, trauma, clotting

disorder, or continued

bleeding.

All in first two columns plus:

re-examine for cause of

bleeding (atony, retained

placenta, trauma, etc.)

>500 ml in first 2 hoursafter delivery

Refer and immediatelytransport the woman to a

facility that can treat her for

PPH.

Provide details of treatment

given to referral facility.

Start above treatment,plus a second line for

fluid replacement with a

large bore needle, to be

used later if signs of shock

develop.

Refer and immediately

transport the woman to a

facility that can treat her for

PPH.

Provide details of treatment

given to referral facility.

All in first 2 columns plus:

Provide all needed

interventions, which might

include fluid and blood

replacement, surgery,

prevention and treatment

of shock, etc.

Take appropriate action in

labor room or theatre.

UNIT 5/OBJECTIVE #2





5.3

5.6

N On the flipchart, Begin again in the“Extent of blood loss” column and write“> than 500ml in the first 2 hours afterdelivery.” Again, ask Px to brainstorm themanagement that should go under eachcolumn.

N Show Slide 5.5: Decision Making and Action Depending on Place of Delivery.

N Discuss the safe transport of women,using the content in the left-hand columnsof these pages.

N Ask Px what precautions should be taken

while transporting a woman to a higherfacility for management of PPH. Noteresponses on a flipchart. Use the content inthe left-hand column to supplement the Pxanswers.

N Show Slide 5.6: Principles of Saferansfer. Ask Px to brainstorm whatis meant by each principle.

Case Studies (1 hour)

Te trainer should:

N Divide Px into 3 groups. Giveeach group a copy of 1 of the 3case studies found in Px Handout5.3: Case Studies. Ask the group tochose a Px to record their work and laterto present it. Ask each group to spend20 minutes studying the case study andanswering the questions.

N Bring Px back together and allow eachgroup 10 minutes to present their casestudies. When each group is finished, askPx to discuss the groups answers to thequestions and offer suggestions.

N Summarize the discussion and point outthat each provider, each facility, and eachreferral network must have their roles

ransporting a woman who is bleeding

N Prepare for transfer when blood lossexceeds > 350 ml in 1st hour

N ransport if blood loss > 500 ml within 2hours of delivery

N Elevate legs to improve blood supply tovital organs

N Keep the woman warm

N Send a skilled provider with the womanto ensure an open airway, to deliver firstaid if the woman goes into shock, and toexplain the care provided and the NASG

to the woman and her family.

N Continue uterine massage duringtransport

N Provide bimanual uterine compression(external if possible and internal ifnecessary)

N Ensure the referral facility knows whatuterotonics the woman has been givenand when

Principles of Safe and Effective ransfer

o achieve safe and effective transfer, thepatient has to be transferred:

N At the right time,

N By the right people,

N o the right place, and

N With the right care throughout.

At the right time: Calculate, based onaccurate estimation of blood loss and carefulobservation for signs of shock, the timeneeded to prepare for transport and totraverse the distance to the referral site.

5.5

UNIT 5/OBJECTIVE #2





and systems established, clarified, andpracticed to keep women alive.

N Distribute Px Handouts 5.4: Observ-

ing and Monitoring the Woman to DetectPPH, 5.5: Action to be aken at EachFacility Level if Excessive Blood Loss Oc-curs, and 5.6: ransporting a Woman whois Bleeding.

5.45.55.6

By the right people: All groups and individualsinvolved, including SBAs, ambulance/transportdrivers, and the patients’ families must beprepared to play the roles necessary to providetimely and safe transport.

o the right place: All individuals involvedmust know in advance which referral facilityhas the capacity to care for a woman withPPH, in shock, in an NASG, etc., so that timeis not wasted traveling to an inappropriatefacility, from which the woman will need tobe transferred again. Te referral site shouldbe informed of the patient’s situation as far in

advance as possible, so that the referral staff arefully prepared to provide emergency treatment when the woman arrives. An up-to-date recordof the patient’s history, condition, and treatmentshould be provided to the receiving facility andproviders.

With the right care throughout: Whentransferred, the patient should always beaccompanied by a skilled provider and by family

members who can donate blood if requiredand provide emotional support during transfer. Actions for the skilled provider include: ABCs(open airway, breathing, circulation), oxygenif possible, IVs for fluid replacement, placing acatheter to monitor urine output, keeping thepatient warm and in rendelenberg position,monitoring vital signs continuously, andexplaining the NASG and care provided to the woman and her family.

Case StudiesCase 1: Mrs. P. came to the primary health careunit at 16:00 hrs. A traditional birth attendant(BA) delivered Mrs. P.’s healthy baby girl athome at 04:00 hrs. Mrs. P.’s family had learnedabout danger signs to look for during deliveryfrom the community health worker. Mrs. P.’s

UNIT 5/OBJECTIVE #2





family was concerned because she seemedto be bleeding excessively. Tey decided tobring her to the clinic. When she arrived, thenurse estimated that she had lost at least 350

ml of blood. Mrs. P.’s pulse was 95 and herblood pressure was 105/60. Te facility hadno equipment or supplies for resuscitation ortreatment of PPH. Te nurse tried to massagethe uterus but it would not become firm. Shetried bimanual compression, but this wasalso not effective. Te nurse felt there wasnothing more that she could do and decidedto transfer Mrs. P. to a facility that could offermore emergency care.

Did she make the right decision? Is there1.

anything else she could have done? Was the nurse right about the amount of2.

blood Mrs. P. lost? Do you have any wayof determining how much blood Mrs. P.lost?How would the nurse know whether Mrs.3.

P. was in shock? What precautions should the nurse take4.

while transporting a woman to a higherfacility for PPH to be managed?Please state what you would do to achieve5.

the principles of safe transfer.Te patient has to be transferred:• At the right time,• By the right people,• To the right place, and• With the right care throughout.

Case 2: Mrs. H. delivered her baby in a smallprivate hospital, attended by a nurse-midwife.Te nurse-midwife gave oxytocin immediatelyafter the baby was born. Te baby girl washealthy and the nurse-midwife suggested thatMrs. H. breastfeed her baby immediately.Te midwife used controlled cord traction todeliver the placenta and immediately began

UNIT 5/OBJECTIVE #2





to gently massage the uterus. Within an hourafter the delivery, Mrs. H. began to bleed veryheavily. Te nurse midwife tried to collect asmuch of the blood as possible into a kidney

dish. Within a short time, the kidney dish wasfull. Te nurse-midwife started an IV drip with10-20 IU oxytocin in 500 ml crystalloid fluidsbefore transferring Mrs. H. to a higher-levelfacility.

Was this the right decision?1.

How much blood would you estimate that2.

Mrs. H. lost?How would the nurse-midwife know3.

whether Mrs. H. was in shock? What should she do next?4.

What precautions should she take while5.

transporting Mrs. H. to a higher facility forPPH to be managed?Please state what you would do to achieve6.

the principles of safe transfer.Te patient has to be transferred:• At the right time,• By the right people,

• To the right place, and• With the right care throughout.

Case Study 3: Mrs. B. delivered a healthybaby boy in a small district hospital with nosurgical facilities. She was attended by a studentnurse-midwife, who was supervised by a nurse-midwife on staff. Te student nurse-midwifegave oxytocin immediately after the baby was born. Te baby boy was healthy and the

student nurse-midwife suggested that Mrs. B.breastfeed her baby immediately. Te studentnurse-midwife used controlled cord tractionto deliver the placenta and immediately beganto gently massage the uterus. Within an hourafter the delivery, Mrs. B. began to bleed veryheavily. Te student nurse-midwife tried tocollect as much of the blood as possible with a

UNIT 5/OBJECTIVE #2





sanitary pad. Very quickly, the sanitary pad was completely saturated. She tried to scrapeblood into a kidney dish. Within a short time,the kidney dish was full. Te nurse-midwife

started an IV drip with 10-20 IU oxytocin in500 ml crystalloid fluids.

How much blood would you estimate that1.

Mrs. B. lost?How would the student nurse-midwife2.

know whether Mrs. B. was in shock? Was there anything else that could have3.

been done at the district hospital? What should the nurse-midwife do next?4.

What precautions should she take while5.

transporting Mrs. B. to a higher facility forPPH to be managed?Please state what you would do to achieve6.

the principles of safe transfer.Te patient has to be transferred:• At the right time,• By the right people,• To the right place, and• With the right care throughout.

UNIT 5/OBJECTIVE #2






5.1

Specific Objective #3: Explain the management of hypovolemic shock.

Reducing the Incidence of Shock

With the use of AMSL to prevent PPH,early and accurate detection of PPH with the blood drape or other methodsof accurate estimation, and rapid referraland transportation, the incidence of shockfrom PPH should be much reduced.However, about 1% to 3% of women willstill suffer intractable PPH from uterine

atony. Multiple blood transfusions are oftenneeded to resuscitate these women andregaining hemostasis may require bloodtransfusion and/or surgical intervention.

Because women respond differently to theloss of similar amounts of blood, basedon their size and level of anemia (i.e., pre-hemorrhage blood volume and oxygen

carrying capacity), there is no uniformvolume of blood loss at which a woman willexhibit signs of shock. Terefore, vigilantobservation of signs of shock while allprevention efforts are ongoing is critical.

Shock is a highly unstable condition with ahigh risk of death. Immediate treatment isneeded to save the patient’s life

Management of Hypovolemic Shock

A single individual cannot effectivelymanage this emergency situation. Helpmust be urgently requested prior to startingany treatment.


Te trainer should:

N Explain that keeping fluid volumehigh is critical to preventing shock.Tis means that preventing shockincludes not only stopping bleeding with uterotonics and massage, but alsoadequate fluid replacement.

N

Ask Px to describe the symptoms thatprecede shock and to list the vital signsfor early shock, late shock, and severeshock. Note the responses on a flipchartand supplement their answers, usingthe content in the left-hand column.

N Ask: What is the mechanism in shockthat leads to morbidity and death?Highlight the difference betweenhypoxia and hypovolemia.

N Discuss the changes that hemorrhagecauses in the body, which lead tomorbidity or death, recording theresponses on a flipchart.

N o review, show Slide 5.1: HowPostpartum Hemorrhage Causes Shock,

Morbidity, and Death.

N Review the signs of shock. Distinguishbetween the signs that indicate early

shock and later signs.

N Explain that a single service providercannot effectively manage anemergency situation. Help must beurgently requested prior to starting anytreatment.

N Describe the ABCs of managinghypovolemic shock. Remind Px that





Follow A, B, and C (airway, breathing,and circulation)

A irway and Breathing need to established

and maintained before anything else can bedone. Remember: Hypoxia kills faster thanhypovolemia.

If a woman is not responding whenspoken to, her airway may be blocked. Anindividual with the appropriate skills andtraining must see that the airway is open.

Once the airway is assured:

N Provide O2 by mask at 6-10 liters/minute

N No fluids are to be given by mouth

N Keep the patient warm

N Elevate her legs or place her inrendelenberg position.

Circulating blood volume: If the uterus isnot contracting and the woman shows signsof shock, IV fluid replacement is requiredimmediately to correct blood loss.

For effective fluid replacement:

N Ensure adequate fluid replacement

N Deliver fluid as quickly as possible for thefirst 500ml, and slowed for subsequentIV fluids, providing boluses when neededto stabilize vital signs (see below).

Start 2 IV lines with short, large-gaugecannula (16-18). Te volume that can beinfused through a cannula is proportionalto its diameter and is inversely proportionalto its length. Use only crystalloid fluids—Ringer’s Lactate, Normal Saline, orHartmann’s Solution.

hypoxia kills faster than hypovolemia.

N Explain that if an airway is blocked, anindividual with the appropriate skills and

training needs to see that the airway isopen.

N Put up 2 flipcharts side by side with“Plain IV” written on the left and “IV with uterotonic” on the right. RemindPx that when signs of shock are present,you will need to insert 2 IV lines: oneline will be a plain crystalloid fluid andthe other will be a crystalloid fluid witha uterotonic. Explain that crystalloid

fluids are Ringer’s Lactate, NormalSaline, or Hartmann’s Solution. Underthe appropriate column, write the rate at which each line must be infused.

N Explain that Px must not give more than5000 ml in the first 6 hours and 8000 mlof fluid (total of both IV lines) in the first24 hours.

N Remind Px that they must keep the woman warm throughout. Blood losscauses hypothermia and each patientmust be evaluated for blood transfusionthrough CBC, platelets, type and crossmatch, and clotting (use bedside clottingtest if possible).

N Explain that oxytocin has an anti-diuretic effect at high doses and, withlarge volumes of fluid, can cause fluid

intoxication, so the uterotonic IV mustrun much more slowly than the plain IV.

N Ask whether Px have ever seen a patient with fluid intoxication. Ask, what thesymptoms are. Is there a concern thatthe patient will experience fluid overload with several liters of the plain IV?

UNIT 5/OBJECTIVE #3





5.7

5.8

N Ask for comments and questions andclarify any remaining issues.

N Distribute Px Handout 5.7: Reducing the

Incidence of Shock and 5.8: Management ofHypovolemic Shock.


Te trainer should:

N Explain that Px will develop and presentbest practices—at different levels of thehealth system—related to treatment ofuterine atony.

N Divide Px into 3 groups and assign each1 of the following 3 cases, written onseparate sheets of paper:

Group 1: You are a group of OB/GYNsand nurses in secondary and tertiaryhospitals. Discuss and then draw a chartshowing, step-by-step, the treatment andmanagement of PPH in secondary andtertiary health facilities.

Group 2: You are a group of nursemidwives and staff nurses in a primaryhealth care center. Discuss and draw achart showing, step-by-step, the treatmentand management of PPH when it occursin primary health facilities.

Group 3: You are a group of midwivesand auxiliary nurses working in a healthpost or sub-center. Draw 2 charts

showing, step-by-step, the treatment andmanagement of PPH when it occurs (a) ina home delivery and (b) in an institutionaldelivery at sub-centers.

N Explain that Px have 15 minutes tocomplete their work and that each groupshould appoint a rapporteur who will writethe group’s chart(s), based on the group’s

IV Line #1:

Begin a PLAIN FLUID IV line, usingcrystalloid fluid, and infuse rapidly so thatthe patient receives 2000 ml in the first houras follows:

N 500 ml in the first 10 minutes

N Te next 500 ml in 10 minutes



N Subsequent PLAIN IVs should run @150 ml/hour with boluses of 250ml asnecessary to maintain the systolic BP at ≥

80 mm/Hg

IV Line # 2:

Tis is the UEROONIC IV line. TisIV should also be crystalloid fluid withuterotonic added. Continue until thepatient is stable. Give no more than 100 IUoxytocin in 24 hours, as follows:

N 500 ml fluid with oxytocin 10 – 20 IU

at 60 drops per minute (depending onthe drops per ml for the IV set-ups in aparticular country).

N 500 ml with oxytocin 20 IU at 30 dropsper minute until the patient is stable.

Tese rates will ensure that fluid intoxicationis avoided.

N Do not give more than 5000 ml total

of both IV lines in the first 6 hours and8000 ml of fluid in the first 24 hours.

N Keep the woman warm throughout:blood loss causes hypothermia.

N Evaluate the patient for blood transfusionCBC, platelets, type and cross match,and clotting (use bedside clotting test ifpossible).

UNIT 5/OBJECTIVE #3





UNIT 5/OBJECTIVE #3

Remember that oxytocin, which has anantidiuretic effect at high doses and withlarge volumes of fluid, can cause fluidintoxication, so the uterotonic IV must run

much more slowly than the plain IV.

Fluid intoxication, especially in a young woman of reproductive age, is very rareunless she has severe heart disease or otheruncommon conditions. If a maximum of5,000 ml of plain IV fluids is given duringthe first 8 hours and 8,000 ml total in 24hours, pulmonary edema and other adverseeffects are extremely unlikely. However,

only the plain IV should be used forboluses or to push fluids.

Signs of fluid intoxication are headache,vomiting, drowsiness, and convulsions.

Te danger to the patient of infusingtoo little fluid and under-correcting forhypovolemia far exceeds the danger of fluidintoxication.

If the uterus is contracted, follow thedirections for fluid replacement but omitthe use of uterotonics, find the sourceof bleeding (laceration, ruptured uterus,retained products of conception), andaddress it medically or surgically.

discussion and conclusions. Each group will get 5 minutes to present.

N Move between the groups as they work,supervising, keeping them on track, andproviding clarification as needed.

N At the end of 15 minutes, tell Px to stop work and call each group to present.

N After each group’s presentation, inviteother members of the group to add to thepresentation. Ten, invite comments anddiscussion from the rest of the class.

N Make sure that stabilization and

transport are part of action taken at thePHC and health post levels.






Simulation Exercise(1 hour, plus time for Px to prepare)

Te trainer should:

N Explain to Px that a simulation exer-cise model is often used for emergencypreparedness training. Explain what asimulation exercise entails, using thecontent in the left-hand column.

N Explain that, as with any emergency,

the clinical team must have emergencyreadiness. Tis means that eachmember of the team knows what mustbe done in an emergency and why,and that each person knows what roleshe or he will play, be it team leader(the critical role), providing fluidreplacement, providing medications, ordealing with relatives, etc. Since PPH

is not a common occurrence in mostfacilities, trained staff can lose theirskills for managing PPH. o preventthis, keeping skills sharp and ready touse, periodic drills—announced andunannounced—should be run.

N Divide Px into 3 groups and assigneach 1 of the 3 scenarios given in theleft column to perform a simulated

PPH emergency drill as realisticallyas possible within the classroom. Te3 scenarios can also be found in PxHandout 5.9: reatment of PPH:

An Emergency Situation Simula-tion Exercise. Px will not be ex-pected to explain what they aredoing, but to play their roles exactly as

5.9

Specific Objective #4: Demonstrate the treatment of PPH in a simulatedemergency situation.

reatment of PPH: An EmergencySituation Simulation Exercise

Simulation exercises model a common workplace scenario and allow Px topractice problem solving. Simulations arenot role plays in a scenario, but rather asclose to life as possible depiction, in realtime, of clinical management situations.Simulation exercises are often used for

emergency preparedness training. Anemergency is simulated and staff at alllevels—everyone from nurses, to nursemidwives, to doctors—can practiceprocedures together, to ensure that rolesand procedures are defined, they areunderstood, compatible with each other,and they are realistic for the individualfacility. Simulations are a great way toensure all roles will be performed in a real

emergency.Tere are two primary reasons forconducting a simulation exercise:

1. o verify the effectiveness of emergency plans and components thereof: Whereplans are developed for events notpreviously experienced, clinic andhospital managers and those responsiblefor caring for patients must be sure that

the plans developed will work—theeffectiveness of the planned activitiesand procedures needs to be verified.Events like eclampsia and PPH are notroutine events in many settings, butproviders and facilities must still planfor appropriate emergency responses. Where simulation exercises reveal a





they would in an emergency situation.

N Inform the Px they are expected to prepareduring the evening and set up and perform

the drill the first thing in the morning,enacting exactly what each member of thefacility team would do to deal with thesituation. During their preparation, theyshould assign a role for each team member.In the beginning of the emergencyresponse, the team leader should state thatthey will lead the response, and proceedto give assignments to each of the otherseven as they move into action. Tey should

also gather their equipment and anysupplies they might need and practice thesimulation at least once.

N Explain that the groups may invite one ormore other participants to join them, toassist with a role.

N Explain that the performance of eachgroup will be judged on:

1. Realistic, methodical, and correctapproaches to the assigned situation,

2. Appropriate responsibility taken(technical/non-technical) by teammembers, and

3. Appropriate time taken to complete theresponse correctly.

Each simulation should take approximately10 minutes.

N Offer to stay and provide support to groupsas they prepare and to arrive early in themorning to respond to questions.

N After each simulation, ask the followingquestions for discussion:

1. How did the group feel about how theirown drill went?

need for improvement, those areas canbe addressed and the exercises can berepeated, if needed, to build confidenceamong the necessary staff. Occasionally,

procedures may need to modified. Inthat case, a new simulation should beconducted to verify the effectiveness ofthe modifications.

2. o provide experience and practice to thosewho may be involved in a responding toan emergency: Simulation exercises area valuable way of putting emergencyplans into practice prior to an actual

need. Simulations allow staff identifiedin emergency plans to perform theirfunctions in a lower-stress environmentthan an actual emergency. Tis givesstaff the opportunity to explore theirroles and what is expected from them. Within the exercise format, trainers,service providers, and managershave the opportunity to identifyand correct knowledge gaps and

functional inconsistencies. Tis maylead to additional, targeted training orimprovements in the planning processafter the exercise.

Below are three scenarios for the group work. Each group will be assigned onescenario.

Scenario for Group 1:

Situation: A 28 year-old grand-multiparadelivered a healthy baby boy weighing3,000 gm at 12:30 hrs. at a sub-centre. Teplacenta delivered at 13:10 hrs. It is now13:30 hrs. She has been bleeding heavilysince delivery of the placenta. As the nurse-midwife works to stabilize her for transfer,she recognizes beginning signs of shock.

UNIT 5/OBJECTIVE #4





2. Are there things they would change?

3. o the rest of the Px and the judges: didthe team use the correct approach to theassigned situation?

4. Was the appropriate (technical/non-technical) responsibility taken by eachof the team members?

5. Was the appropriate time taken tocomplete the response correctly?

6. Ask the group performing thesimulation whether they feel theexercise was useful and how it mightbe improved/tailored for their ownfacilities.

N Repeat the same process with each group.

N Suggest that Px take these simulationsback to their facilities and perform similardrills periodically to maintain skills andprocedures.

N Suggest that Px or others in their facilitiesarrange surprize drills periodically to seehow staff would respond to an unexpectedemergency involving shock and to get allstaff on board with the role they wouldplay.

Roles: the patient, her mother-in-law, and acommunity midwife based at the sub-center


Situation: A 24 year-old woman, gravita-2,para-2, was admitted at 01:00 hrs to aprimary health center after 2 hours oflabor. On admission she was having strongcontractions 2 minutes apart, and delivereda 3500 gm baby girl precipitously at 01:20hrs. She delivered the placenta 10 minuteslater. Her BP at 01:45 hrs. was 90/70and pulse was 130. She has been bleedingheavily and showing signs of shock. She is

accompanied by her mother-in-law.Roles: the patient, her mother-in-law, onemedical officer, one community midwife, a ward aid, and an ambulance driver located ata 24/7 primary health center


Situation: A primipara at a tertiary hospitaldelivered a male baby weighing 3500 gm at

02:30 hrs. Te second stage of labor was 2hours and she was exhausted. Te placentadelivered at 03:15 hrs.

During monitoring, the student nurse foundthat the woman was bleeding heavily. Testudent nurse informed the nurse-midwife, who found the patient was showing signs ofshock. Te patient’s husband is waiting inthe corridor.

Roles: the patient, her husband, a resident,and a nurse-midwife

Additional Groups An additional scenario may be developedfor a community health center or districthospital so all participants have a role toplay.

UNIT 5/OBJECTIVE #4




UNI 6: Te Non-Pneumatic Anti-Shock Garment (NASG)

Introduction:

A key component of managing hypovolemic shock is ensuring that the available blood in thebody is redirected mostly to the upper body so that the vital organs (heart, lungs, kidneys and

brain) continue to receive oxygen and the woman is protected from vital organ damage anddeath. One way to achieve this is to place the woman in the rendelenberg position, where thehead is lower than the feet and hips. However, applying the NASG is a more effective way ofensuring the vital organs continue to receive adequate blood supply and slow bleeding at thesame time.


rainees will learn how the NASG is effective in reversing hypovolemic shock by shunting bloodfrom the veins of the abdomen and lower extremities to the vital core organs: heart, lungs,

kidneys, and brain. rainees will learn to apply, remove, decontaminate, clean, dry, and fold theNASG.


By the end of the session, Px will be able to:

N Demonstrate how to apply the NASG to revive a woman in shock, and remove it once shehas recovered;

N Describe how to carry out medical and surgical procedures while the woman is in the NASG;

N Demonstrate how to clean, fold, and store the NASG; andN Explain how to develop a system for replacing the NASG after use at the facility level.

raining/Learning Methodology

N Demonstration/return demonstration

N Discussion

N rainer Presentation

N Quiz


N Miller S, Hensleigh P. Non-Pneumatic Anti-Shock Garment. In, Lynch CB, et al., eds. Aextbook of Postpartum Hemorrhage: A Comprehensive Guide to Evaluation, Management, andSurgical Intervention. Dumfriesshire, UK: Sapiens Publishing, 2006. 136-146. Availableonline: http://www.sapienspublishing.com/pph_pdf/PPH-Chap-14.pdf



101


N Miller S, et al. A Comparative Study of the Non-Pneumatic Anti-Shock Garment for thereatment of Obstetric Hemorrhage in Egypt. International Journal of Gynecology andObstetrics 109: 1, 20-24.

N Miller S, et al. NASG raining Video. Available online: http://www.nasgexchange.org.

N Ojengbede O, et al. Management of ubal Ectopic Pregnancy with the Non-Pneumatic

Anti-Shock Garment in UCH and Adeoyo Maternity Hospital, Ibadan and Ayinke House,Lagos. Health Sector Reforms and Maternal Health. Proceedings of the 39th Annual GeneralConference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) – “OLUYOLE

2005.” Jos, Nigeria: Society of Gynaecology and Obstetrics of Nigeria, 2006. 313 – 314.

N Ojengbede OA, et al. An Analysis of Haemorrhage Reduction and Improved Recovery Among Patients with Hypovolaemic Shock Secondary to Postpartum and Post AbortionHaemorrhage: A Pilot Study of NASG in Nigeria. ropical Journal of Obstetric & Gynaecology

23: Suppl. 1, S9.

N U.S. Department of Health and Human Services Centers for Disease Control and

Prevention. Use of Bleach in Prevention of ransmission of HIV in Health Care Settings.March 9, 1995. Available online: http://www.cdc.gov/od/ohs/biosfty/bleachiv.htm.


N Flipchart

N Marker pens

N NASG

N A bowl for chits

N Prizes for quiz

Evaluation Methods:

N Each Px demonstrates application, removal, and folding of the NASG at least once

N Observation with a competency-based checklist




ime Required:

Specific

Objective

opic ime

1 Demonstrate how to apply the NASG to revive a woman inshock and remove it once she has recovered.

2 hours

2 Describe how to carry out medical and surgical procedures while the woman is in the NASG.

30 min.

3 Demonstrate how to clean, fold, and store the NASG. 45 min.

4 Explain how to develop a system for replacing the NASG afteruse at the facility level.

45 min.

Quiz Quiz on the NASG 45 min.

otal ime Required 4 hours, 45 min


N Organize 4 tables for practice, each with an NASG, BP apparatus, and copiesof the Competency-Based Checklist for Application and Removal of the NASG





CONTENT METHODOLOGY

UNIT 2


6.1-6.3

6.

6

Te Non-Pneumatic Anti-ShockGarment (NASG)

A key component of managinghypovolemic shock is ensuring that theavailable blood in the body is directedmostly to the upper body so that the vitalorgans (heart, lungs, kidneys, and brain)continue to receive oxygen and the woman

is protected from vital organ damage anddeath. One way to achieve this is to placethe woman in rendelenberg position, where the head is lower than the feet andhips. A more effective way of ensuring thisis to apply the NASG.

N Te NASG is a lightweight (1.5 kg)compression suit made of neoprene, with 6 segments that close around the

legs at the ankle, calf, thigh, pelvis, andabdomen.

N Velcro fastenings help keep the garmenton tightly.

N Te abdominal segment (#5)incorporates a small foam ball thatapplies pressure to the uterus todecrease bleeding.

N Markings on each section show how to

apply it on a woman.N When applied tightly by one person,

the garment supplies enoughcircumferential pressure from theankles to the diaphragm to reversehypovolemic shock by shunting bloodfrom the capacitance vessels of theabdomen and lower extremities to the

rainer Presentation (5 min.)

Te trainer should:

N Introduce the NASG and explain howit protects a woman from vital organdamage and death due to hypovolemicshock.

N Show Slide 6.1: A Woman in the

NASG.N Show Slide 6.2: How the NASG

Protects a Woman in HypovolemicShock.

N Show Slide 6.3: Components of theNASG .

N Show the garment to Px and explaineach part.

Demonstration (55 min.)

Te trainer should:

N Invite a volunteer to come and try onthe NASG.

N Distribute a copy of Px Handout 6.1:Flowchart for Applying the NASG toeach Px and ask them to follow thediagram as the trainer demonstratesthe application of the NASG on thevolunteer.

N Show Slide 6.4: Applying the NASG .Explain the general application ofthe NASG.

N While applying the NASG to thevolunteer, explain each step.


Specific Objective #1: Demonstrate how to apply the NASG to revive awoman in shock and remove it once she has recovered.

6.4





vital core organs- heart, lungs, kidneys,and brain.

N It is washable and reusable (at least 30times). It has received a United StatesFood and Drug Administration 510Kmedical device regulation number,K904267/A, Regulatory Class II, January 17, 1991. It can be exportedoutside the US.

N Te NASG can be easily packed into abag for storage.

A woman in shock may be unconscious and will require one-on-one nursing care to en-

sure a patent airway, prevent aspiration, etc.

Discomfort with the NASG

If the woman experiences difficultybreathing or is uncomfortable, theabdominal panel must be adjusted. If sheis hot, try a fan, cool breeze, and/or coldcompresses. If the NASG feels itchy to her,and she is stable, a provider may remove asingle leg panel briefly, apply lotion, and

quickly reapply the panel.

Application of the NASG for Any Levelof Facility or Provider

N General application

N Application for shorter women

N Application if the woman is unconscious

Steps of ApplicationGeneral Application

Step 1

N o apply the NASG, place it under the woman; the top of the NASG should beat the level of her lowest rib.

N Starting at the ankles, close segment #1

UNIT 6/OBJECTIVE #1





tightly around each ankle.

N Make sure it is tight enough so that youcan snap it and hear a sharp sound!

Step 2N Next, close segment #2 on each calf as

tightly as possible.

N ry to leave the woman’s knee free in thespace between segments so that she canbend her leg. She may be in the NASG fora long time.

Step 3

N Apply segments #3, the thigh segments, inthe same way as segments #1 and #2.

N Remember: close segments tightly enoughso that you can snap it and hear a sharpsound!

Step 4

N Segment #4, the pelvic segment, goes allthe way around the woman at the level ofthe pubic bone.

Step 5

N Place segment #5 with the pressure balldirectly over her umbilicus.

N Ten close the NASG using segment #6.

If there are two people present, they canrapidly apply the three leg segments together,each working on one leg, starting at the ankle.

However, only one person, using as muchstrength as possible, should close the pelvicand abdominal segments. If two people closethe pelvic and abdominal segments as they canapply too much pressure and compromise thepatient’s breathing.

Do not close the segment so tightly thatit restricts the woman’s breathing. One

UNIT 6/OBJECTIVE #1





UNIT 6/OBJECTIVE #1

person can sufficiently manage the wholeapplication if necessary.

When Finished

N Make sure the patient can breathenormally with the NASG segment #6in place.

N If the source of bleeding appears to beuterine atony, administer uterotonicdrugs and massage the uterus. TeNASG stretches, allowing room foryour hand to fit between the woman’sabdomen and the NASG.

Application for Short Women (if the very small garment is not available)

If a woman is shorter than those for whomthe NASGs available are designed, a simpleadjustment can be made so that the largergarment will still fit. o apply the NASGto a short woman:Step 1

N If the woman is short, fold segment #1to the inside of segment #2

N Begin with segment #2 at her ankles.

Steps 2-4

N Apply segment #3 to the thighs, asusual. Continue with the rest of thesegments as with all women.

Application if the Woman isUnconscious

You will need 2 people! Applying the garment to an unconscious woman will require 2 people to positionthe garment beneath her. Te final seg-ment, however, should still be closed usingonly the strength of one person.

Te trainer should:

N Explain application for shorter women.Note and demonstrate that the NASG isadjustable in size and that if the patient isvery short the number one segment can befolded up into the #2 segment so that the#2 segment becomes the ankle segment.

N Explain application if the woman isunconscious

N After the application is over, ask thevolunteer:

Q: Can you describe how the NASGmakes you feel?

Q: Are you experiencing any difficulty inbreathing?

Q: Are you feeling any discomfort?

Q: Are you feeling hot?

Q: Are you feeling itchy?

If the volunteer answers yes to any of thesequestions, try the methods listed in theContent section to alleviate her discomfort.Note: Do not leave the volunteer for too longin the NASG and do not apply maximum pressure.





Step 1:

N Open the NASG on a flat surface and onlyopen segments #4, #5, #6, keeping segments#1, #2, and #3, closed (but not fastened with

the Velcro).

Step 2:

N Fold segments #4 and #6 (the sides that doNO contain the ball) once towards theyellow midline dots (in toward the black sideof the NASG). Tis will prevent the Velcrofrom sticking to other parts of the NASGand to the patient or bed linen.

Step 3

N urn segments #4 and #6 once more towardthe yellow midline so that the folded edgelies along the yellow midline.

Step 4

N ake the folded segments #4 and #6 andturn them over towards the colored (maroonor blue) outside of the NASG placedapproximately where the yellow midline ison the outside. Tis will divide the upperportion of the NASG in half along thedotted line.

Step 5

N urn the woman on her side with her backfacing you and place the folded NASGon the bed with the dotted line along the

woman’s spine and the top edge of theNASG at the level of her lowest rib.

N Push the folded/rolled sections #4 and #6under her body.

Step 6

N Roll her towards you, turning her to her


UNIT 6/OBJECTIVE #1





UNIT 6/OBJECTIVE #1

other side, over the rolled portions of theNASG. She is now facing you.

N Te second person pulls the foldedsegments #4 and #6 out from under the

woman.

Step 7

N urn the woman on her back. She is nowlying in the middle of the NASG, withthe yellow dots along her spine, with thetop edge of the NASG at the level of herlowest rib on the side. Check positioningby placing, but not closing, the #5

segment with the ball over her navel.

Step 8

N Starting at the ankles, close segments #1tightly around each ankle.Remember: Make sure it is tight enoughso that you can place a finger under thesegment and snap the leg segments tohear a sharp sound!

Removal of the NASG

Te NASG should only be removed:

N Under medical supervision,

N When the woman is stable, and

N According to the time line outlinedbelow.

Rapid removal of the NASG or removal of

the segments in the wrong order can resultin death.

Step 1

Begin removing the NASG only whenthe woman’s condition has been stable fortwo hours:

N Bleeding has decreased to <50 ml/hour;

Te trainer should:

N Show Slide 6.5: Removing theNASG.

N Demonstrate how to removethe NASG.

NASG practice (45 min.)

Te trainer should:

N Divide Px into 4 teams and put each teamat one of 4 or 5 practice tables with anNASG, BP apparatus, and copies of PxHandout 6.2: Competency-Based Checklist for Applicationand Removal of the NASG.

N Go over the checklist to make sure all Px

6.2

6.5





N Hemoglobin level is >7 or thehematocrit 20% (unless the woman’susual hemoglobin is less than 7% andhematocrit is less than 20%);

N Pulse <100 and systolic BP 90 mm/Hg orgreater; and

N Te woman is conscious and aware.

Step 2

N Wait 15 minutes for redistribution ofblood to occur between removing eachsegment.

N Always wear gloves when handling a soiledgarment.

N Removal of the NASG begins with thelowest segment (typically segment #1,or segment #2 if the woman is short andsegment #2 is at her ankles) and proceedsupwards.

N 15 minutes after removing the firstsegment and before proceeding to the nextstep, take her pulse and blood pressure to

verify that she is ready for removal of thenext segment.

Step 3

N If pulse and blood pressure stable 15minutes later, remove the next section.

Steps 4 and 5

N After 15 minutes, take pulse and blood

pressure. If stable, remove the nextsegment.

N Continue following this procedure—remove a segment, wait 15 minutes, takepulse and blood pressure—until all partsof the NASG are removed.

understand how to use it.

N Have each Px practice quickly applyingand removing the NASG to short, tall,conscious, and unconscious patients

while explaining, step by step, what s/heis doing.

N Have the other Px use the checklists toobserve, see if all steps are followed andto give feedback.


UNIT 6/OBJECTIVE #1





UNIT 6/OBJECTIVE #1

CAUION: Rule of 20

If the blood pressure falls by 20 mmHg ORthe pulse increases by 20 beats/min after asegment is removed:

a) Rapidly replace ALL segments, andconsider the need for more saline orblood transfusions.

b) If there is recurrent bleeding, replace allsegments of the NASG and determine thesource of bleeding.

Avoiding Adverse Events When Usingthe NASG

N Only one person should apply the pelvicand abdominal sections of the NASG(even if the woman is unconscious andtwo people were required to begin applythe NASG).

N Monitor urine output.

N Ensure airway protection and aspirationprevention as required.

N Ensure one-on-one nursing carethroughout.

N Ensure presence of a relative/supportperson with the unconscious patient,ready to explain the purpose of thegarment when patient returns toconsciousness and call for help. Surprised,confused, or frightened patientsmay attempt to remove the garmentprematurely, resulting in death.

N Never open the abdominal panel first.


Te trainer should:

N Ask Px if they have any questions about

applying and removing the NASG.N Describe how to avoid adverse events when

using the NASG.

N Distribute Px Handouts 6.3: Photographof the NASG, 6.4: Te Non-Pneumatic

Anti-shock Garment (NASG), 6.5: How theNASG Protects a Woman in HypovolemicShock, 6.6: Te Components of the NASG,6.7: Removal of the NASG, and 6.8: Avoid-

ing Adverse Events when using the NASG.

6.3-6.6






Presentation (30 min.)

Te trainer should:

N Ask participants to list vaginalprocedures that could be performed withthe NASG on. Write responses on aflipchart and fill in missing content.

N Ask: Are there any vaginal proceduresthat cannot be performed with the

NASG on?N Ask participants to list types of surgery to

obtain hemostasis that can be performed with the lower panels of the NASG on. Write responses on a flipchart and fill inmissing content.

N Explain that vaginal procedures can beperformed with the NASG in place andthat no change needs to be made innormal procedures.

N Ask: Are there any surgical proceduresthat cannot be performed with theNASG on?

N Ask: For surgery, when should theabdominal and pelvic panels of theNASG be removed?

N Reiterate that all panels must be in placefor surgery, and the abdominal panelsshould be removed just before the firstincision.

N Encourage Px to ask questions.

N Distribute Px Handout 6.9: PerformingVaginal Procedures with the NASG On.

6.9

Specific Objective #2: Describe how to carry out medical and surgicalprocedures while the woman is in the NASG.

Vaginal Procedures with the NASGOn

Te design of the NASG permits completeperineal access. Tus, the source of mostobstetric hemorrhages can be located andtreated while the garment maintains the woman’s vital signs.

Te following vaginal procedures can be

performed on a woman in an NASG:N Repair of episiotomy or vaginal and

cervical lacerations,

N Manual removal of the placenta,

N Bimanual compression (external or in-ternal),

N Dilatation and curettage (D&C),

N Dilatation and evacuation (D&E), and

N Manual vacuum aspiration (MVA).

Abdominal Surgery with the NASG On

Surgery to obtain hemostasis can also beperformed with the NASG in place. Teabdominal and pelvic panels must beopened, but only immediately before thefirst incision. Such procedures may include:

N Cesarean section,

N Repair of ruptured uterus,

N Hysterectomy,

N Salpingectomy/salpingostomy,

N Ligation of arteries,

N Laparotomy,

N Laparoscopy,





N Removal of placenta accreta,

N Repair of broad ligament hematoma, and

N B-Lynch or other uterine compression

sutures.

Prepare the operating theatre for surgery,have all members of the surgical teamscrubbed, gowned, gloved, in place, andready to operate immediately prior to sur-gery. Te woman should be catheterized; theanesthesiologist must be prepared to admin-ister IV fluids to manage a drop in bloodpressure.

Step 1

N Remove ONLY segments #4, #5, and #6. With the abdominal portion removed,much of the benefit of the NASG is lost,and the patient may go back into shock.

Step 2

N Place the patient in steep rendelenbergposition.

N Operate as quickly as possible.

Step 3

N Replace segments #4, #5, and #6 as soonas the vaginal procedure is complete.

UNIT 6/OBJECTIVE #2






Specific Objective #3: Demonstrate how to clean, fold, and store the NASG.

Cleaning the NASG

Preparing a Bleach Solution for Soakingthe NASG

Exposure to too strong a bleach solution will cause the NASG to deteriorate. Be-cause the NASG does not go inside thebody, it can be decontaminated in a bleachsolution that one-tenth as strong as thatused in conventional instrument processing

(the NASG should be soaked in a 0.05%bleach solution; standard instrument pro-cessing uses a 0.5% bleach solution).

Dilution is necessary when using a pre-made bleach solution because bleach soldcommercially is more concentrated than0.05%. Because the concentration ofcommercially-sold bleach varies by brandand country, the amount of bleach neededto achieve a 0.05% solution will also vary.Te following chart shows how to mix0.05% solution from pre-made solutions.

Brand of Bleach (Country)% Avail.

Chlorine

Valu Check'd 3%

JIK (Africa) 3.50%

Household Bleach, Clorox (USA,

Canada, Peru), Eau de Javel (France,

Viet Nam, 15o chlorum*), ACE (Tur-key), Jif (Haiti), Red & White (Haiti),

Odex (Jordan)

5%

Blanqueador, cloro (Mexico) 6%

Lavandina (Bolivia) 8%

Chloros (UK), Leja (Peru) 10%

Extrait de Javel (France) (48o chlo-

rum*), Chloros (UK)

15%

Demonstration (15 min.)

Te trainer should:

N Ask Px: what happens if textiles areexposed to the same strong bleachsolution used on instruments?

N Explain that the NASG should becleaned in a 0.05% bleach solution, which is one-tenth as strong asthe solution used for instrumentprocessing.

N Distribute Px Handout 6.10:Recommended Dilutions ofSodium Hypochlorite (Bleach) forDecontaminating the NASG.

N Ask Px: which brand(s) of bleachare used in your facility? How muchbleach should be used to soak anNASG in 50L of water?

N Remind Px that a helpful guidelinefor decontaminating the NASG is touse one-tenth as much bleach or tentimes as much water as needed forinstrument processing.

N Show Slide 6.7 Cleaning the NASG(and also wall chart with step-by-step illustrations of the NASGcleaning process).

N Demonstrate the correct way ofdecontaminating and cleaning theNASG.

N Distribute Px Handout 6.11: Washingand Drying the NASG .

N Invite a Px to volunteer todemonstrate cleaning the NASG.

6.11

6.7

6.10





6.2

% Avail.

Chlorine

Bleach Needed to Achieve 500 Ppm

= 0.05% = 0.5 g/l Concentration for

NASG, for Every:

1 Liter of Water 50 Liters of Water

3% 0.17 ml 8.33 ml

3.50% 0.14 ml 7.14 ml

5% 0.10 ml 5.00 ml

6% 0.08 ml 4.17 ml

8% 0.06 ml 3.13 ml

10% 0.05 ml 2.50 ml

15% 0.03 ml 1.67 ml

In general, a bleach solution for soaking theNASG can be made by using one-tenth as

much bleach or ten times as much water as isnormally used for instrument processing.

In some countries, the concentrationof sodium hypochlorite is expressed inchlorometric degrees ( chlorum); 1 chlorumis approximately equivalent to 0.3% availablechlorine.

Washing and Drying the NASG

Wear heavy rubber utility gloves.

Prepare a 0.05% bleach solution in a plasticcontainer large enough to completelysubmerge the NASG.

Decontaminate the NASG by submerging itin the container for 10 minutes. You may needto put a brick, stone, or other heavy objecton the NASG to keep it under water. Do nothandle the NASG during this time.

Do not leave the NASG in the solution morethan 10 minutes. It will damage the garment.

Remove tissue or other material by scrubbing with a brush (while wearing heavy utilitygloves).

Wash the garment with detergent and cool water, by hand or in a washing machine. Donot machine dry.

Have other Px observe, using Px Handout6.2: Competency-Based raining Skills

Assessment Checklist for Application andRemoval of the NASG, and

provide feedback.N If there is time, have Px take

turns practicing until they feel they areproficient. Supervise the practice andprovide guidance as required.


UNIT 6/OBJECTIVE #3





It is best to wash the NASG alone, as otheritems, such as threads and lint, will adhere tothe Velcro.

If being hand washed, squeeze to expel excess water before drying.

Hang the NASG to dry, outside in thesunshine if possible, rotating sides for equalexposure to the sun. Keep away from plantmaterial such as grasses, burrs, sticks and othermaterial that could cling to the fabric andVelcro.

Folding and Storing the NASG

Folding the NASG correctly is key to beingable to unfold it quickly to apply on the nextpatient who is in shock. If not folded correctlythe Velcro may adhere to the wrong partsof the NASG and make it difficult to undo,causing time to be wasted when when theNASG is needed in an emergency.

If the NASG is folded correctly, the Velcro

closures will not stick as much when youunfold it, and you’ll save precious time puttingit on the next patient.

Step 1

N Start with segment #1: fold the Velcro in sothat it doesn’t stick to the outside (maroonor blue side), but is resting on the inside ofthe segment (black side).

N If you fold it correctly, the “#1” printed on

the first segment will not be visible.

Step 2

N Fold segments #2 and #3 in the same way.

Step 3

N Fold the leg segments together like a map orfan.

Demonstration and ReturnDemonstration (30 min.)

Te trainer should:

N Distribute Px Handout 6.12: Foldingand Storing the NASG and 6.13:Folding the NASG Flowchart.

N Demonstrate the correct way offolding the NASG and placing it backin its carry bag, explaining that if it is

not correctly folded it will not openeasily when it is needed for a woman who is hemorrhaging.

N Invite a Px to volunteer to demonstratefolding the NASG. Other Px observe,using the checklist, and providefeedback.

N Have Px take turns practicing untilthey feel they are proficient. Supervisethe practice and provide guidance asrequired.

6.12

6.13

UNIT 6/OBJECTIVE #3





Step 4

N Fold the leg segments, like a map, upinto the abdominal segment.

Step 5

N Fold segment #4 up across the legsegments.

N When folding segment #4, be sure totuck the Velcro located at the ends ofthe segment around to the inside. It isimportant to prevent the Velcro fromsticking to the outside of segment #6.

Step 6

N Fold segment #5 across the leg segments.

N Wrap segment #6 tightly around segment#5 and place in carry bag.

N Te NASG is now ready to be storedand, more importantly, ready to beapplied quickly to the next patient.

Storing the NASG

N Te NASG should be stored where it isvisible and easily accessible.

N Put the folded NASG into a clear plasticbag so that it is visible, but will not get wet or dusty.

N If there is more than one NASG in afacility, each NASG storage locationshould clearly indicate the others. Forexample, other NASG locations shouldbe written on a sign posted on the wallabove the storage shelf, or on the NASGstorage bag if the bag is to be left inthe storage location. Tis way, if, in anemergency, someone goes to retrieve anNASG from its usual place and does notfind it there, they will know where tolook for another one.

UNIT 6/OBJECTIVE #3






Specific Objective #4: Explain how to develop a system for replacing theNASG after use at the facility level.

Returning NASGs to lower-levelfacilities for future use

All facilities must have a clear plan in placefor getting NASGs back to their originalfacility, or back to a central distributionpoint from which NASGs are returned tothe facilities designated to use them.

NASGs will leave lower-level facilities on

women being transported to higher-levelfacilities. How will these referring facilitieshave garments to use the next time theyneed them? And how will the garments becleaned properly for safe use with minimaldamage to them?

A clear plan must be made in each facil-ity, cluster of facilities, district, etc., to getNASGs cleaned appropriately and returned

to the locations where they are needed. Tisplan could be made between each pair ofreferring and receiving facilities, or all gar-ments could go to a central place for clean-ing and redistribution to the facilities thatare supposed to have them.

Local solutions are needed because if agarment is not available when a womangoes into shock, then a critical piece of thecontinuum of care is not available.

Discussion and Group Work (45 min.)

Te trainer should:

N Point out that one operational/logisticalrequirement with the NASG is to set upa system which will ensure that a facilitythat applies an NASG on a woman inshock and refers her to a higher level getsback a replacement NASG for future use.

N

Divide the class into 3 groups, assigningeach group to discuss one facility level(primary, secondary, or tertiary). Ask thegroups to discuss and develop a systemfor:

N Deciding how many NASGs should bekept at their assigned level facility,

N Where in the facility NASGs should bekept, and

N

How NASGs should be replaced whenone is used on a woman and she isreferred to for treatment.

N Explain that one key to determining howmany NASGs are needed is to think abouthow many patients have PPH and develophypovolemic shock in a month. Tendetermine how many that would be in aday, this will help estimate adequate, butnot excessive numbers of garments.

N Allow 20 minutes for the group work.

N Reassemble the Px and ask the reporterfor each group to report back on thesystem that the group developed.

N Make sure that the plans do notinclude excessive numbers of NASGs,since cost would be prohibitive. Give





6.14

encouragement to the groups that havepractical plans for a minimum number ofNASGs needed, covering as many facilitieson all levels as possible.

N Conclude the session by synthesizing ideasof all 3 groups, seeing if a single consensusidea emerges, and informing Px that they will have to make such plans once theNASG is introduced in their facilities andreferral systems.

N Distribute Px Handout 6.14: ReturningNASGs to Lower-Level Facilities for FutureUse.

UNIT 6/OBJECTIVE #4






Questions on the NASG

1. Q: How does the NASG work?

A: Te NASG provides mild pressure,pushing blood from the lowerextremities into central circulation,making sure there is sufficient bloodgetting to the vital organs, including thebrain. Additionally, the foam ball overthe abdomen applies pressure to theblood vessels of the uterus, decreasingblood flow.

2. Q: What are the indications for usingthe NASG?

A: Te NASG could be used to manage anycondition where there is severe bleedingbelow the diaphragm. Our studieshave documented use with all forms

of obstetric hemorrhage, as long as thefetus is not viable in utero.

3. Q: What are the contraindications forNASG use?

A: In treating PPH with the NASG, thereare no absolute contraindications.For trauma patients, the NASG iscontraindicated for patients with severecongestive heart failure or preexisting

mitral stenosis. In trauma victims with injury to the chest or head,redistribution of blood to the injuredarea with NASG placement raisesthe possibility of associated increasedhemorrhage.

We have no data on uterine bloodflow and negative fetal effects of the

Quiz (45 min.)

Te trainer should:

N Explain that, by way of an interactive quiz, we will review the NASG.

N Explain that as a review of information onthe NASG, Px will participate in a quizsession.

N Divide Px into four teams. Give each Px a

copy of Px Handout 6.15 Frequently Asked Questions about the NASG .Explain that they have 15 minutes tostudy and master the answers to thequestions. At the end of 15 minutes there will be a quiz.

N At the end of 15 minutes, take back all ofthe Px study sheets.

N Pass around a bowl with chits of paper on

which the question from the FAQs are written, one question per chit. Invite eachparticipant to pick one chit. When all thequestions are distributed, ask one questionat a time from the list of NASG FAQs.Te Px who picked up that question fromthe bowl has to answer it. If s/he is unableto answer the question, invite anotherparticipant from another team to answerthe question (making sure all groups

are called on equally). Tus all Px get achance to answer one or two questions,and the whole class hears all the answersand reviews/builds new knowledge on theNASG. Te team with individuals whoanswered the most questions correctly winsa prize.

Quiz on the NASG

6.15





UNIT 6/Quiz on the NASG

NASG—it could be assumed that placingthe abdominal portion of the NASG woulddiminish uterine blood flow and could bedetrimental to fetal oxygenation.

4. Q: Does the NASG cause any discomfort?

A: Particularly in a warm environment, patientsmay complain of being hot. Fans or airconditioning should be provided if possible. After many hours, some women experienceitching. Tis can be relieved by removingone leg segment at a time and massaging with lotion. Do not open the abdominal

segment!

5. Q: Te NASG is made out of a non-breathable fabric. Won’t this make thepatient too hot, sweaty, and possiblydehydrated?

A: Women in shock are generally too cold, sothe NASG initially will cause no problem. Ifthe NASG is on for a long time, see 4 above. Additional fluids may be necessary when it is

hot and a woman is in the NASG for a longtime.

6. Q: Can the patient breathe normally withthe NASG in place?

A: Te patient should not experience difficultybreathing and if general anesthesia is needed,ventilation should not be compromised.Should the patient experience dyspnea(difficulty breathing), the NASG should beremoved and cardio-respiratory evaluationcarried out, if possible. Mitral stenosisshould be suspected and ruled out beforereplacing the NASG.

7. Q: Patients who are unconscious fromshock regain consciousness with theapplication of the garment and may

N Ask Px if they have any more questionsabout the NASG.

N Provide answers and clarification as

needed.






become frightened when they findthemselves in this garment. How do you address that?

A: Te proper care of a critically ill,unconscious patient is one-to-onenursing care. However, the reality ofsome low-resource settings is that there will not be one-to-one nursing careavailable. If this is the case, it is crucialthat a support person (family member,traditional birth attendant, or otheraccompanying person) continuouslybe involved in the patient’s care and at

her side. Te support person must beinstructed to reassure the patient that theNASG is something which has saved herlife, and to also call for assistance from anurse or doctor when needed.

8. Q: How long can/should the NASG beused on a given patient?

A: Tere is no particular time limit. Tepatient should be stable and comfortable

in the NASG for hours or days until thebleeding has been arrested (spontaneouslyor through surgery), the volume restored,and the blood replaced as needed.

9. Q: What is the longest time an NASGhas been worn?

A: o date, the longest the NASG hasbeen on a woman has been 58 hours.However, the faster the source of

bleeding is discovered and treated, andthe woman’s blood volume replaced, thebetter her chance of recovery.

10. Q: When should the NASG beremoved?

A: Te source of bleeding should have beenidentified and hemostasis attained. Ten,






remove the NASG stepwise when the clinicalimpression is that the blood volume has beenrestored with saline and blood as needed.

If equipment is available for measuring Hgband Hct, a hemoglobin (Hgb) level of about7g/dl and hematocrit (Hct/pcv) of about20% should be achieved before removing theNASG.

Note: In places where the mean pregnancyand non-pregnancy Hgb is < 7 (in India70% of pregnant women have a Hgb of < 7),it may be unrealistic to wait for an Hgb of 7

to remove the garment.

Remember: Te NASG should never beremoved unless under medical supervision!

11. Q: Why not remove the top of the NASGfirst?

A: Te largest portion of capacitance vessels arein the abdominal cavity, rather than the legs.

Removal of the abdominal segment first willcause rapid redistribution of blood and thepatient may return to a state of shock.

12. Q: How will you know if the NASG hasbeen removed prematurely?

A: If the woman is still hypovolemic, her BP will decrease and pulse will increase whena segment of the NASG is removed. If thishappens, replace the segment immediately.

13. Q: Can surgery be performed with theNASG in place?

A: Vaginal surgery and procedures, such asrepair of lacerations or D&C can and shouldbe done without complete removal of theNASG. Te upper segments (4 and 5) of theNASG must be opened for laparotomy.






14. Q: Does the NASG have to be placedand removed by a doctor?

A: After a basic training session, anyone

who is able to recognize PPH orhypovolemic shock from any sourceof obstetric hemorrhage can place theNASG. However, the decision to removethe NASG is one based on clinicaland laboratory assessment and in mostsettings would be a physician-initiateddecision with physician supervisionduring the process. Actual physicalremoval of the NASG can also be done

by a skilled health care provider. It is astepwise process which requires trainingto assess the stability of vital signs aseach segment is removed at 15-minuteintervals. Removal also requires theability to reverse shock by administeringadditional fluids or blood transfusions. When a physician is not available, well-trained midwives or clinical officers whohave been trained on NASG removal can

remove it. But, the important thing toremember is that emergency care mustalways be available when the NASG isremoved.

15. Q: How can one ensure that thegarment is free of HIV and thehepatitis virus?

A: Tere is no need to treat the NASG anydifferently than any other fabric item that

gets body fluids on it, except that the %solution needs to be lower or the fabric will wear out too quickly.

Te NASG is wrapped on the outside ofthe body; it does not go inside the body.Te NASG must be decontaminated with 0.05% bleach solution, washed,and dried in the sun. Tese are Universal






Precautions/Infection Prevention Steps.

16. Q: Why are we introducing the NASGwhen it seems it is still in the research

phase? A: Tere are different levels of evidence that

satisfy different requirements. Globally, the WHO determines what devices, medicines,and procedures can be introduced intopublic health systems. WHO holds thevery highest standards, the “gold standard”based on randomized control clinical trials(RC). Te NASG has not been tested in anRC, however, an RC, conducted by theUniversity of California, San Francisco, the World Health Organization, the Universityof Zimbabwe, and the University eachingHospital, Lusaka, Zambia and funded bythe National Institute of Health (US) andthe Bill and Melinda Gates Foundation,is underway in Zambia and Zimbabwe.Te results will not be known until 2012or 2013. In the meantime, based on the

promising results of the NASG pilot trialsin Egypt and Nigeria, the MacArthurFoundation, working closely with theNigerian Ministry of Health, decided thatthere was enough evidence for them to feelcomfortable introducing the NASG into wide spread use.





UNI 7: Data Collection and Record Keeping

Introduction:

Unit 7 addresses data collection and record keeping. Px will be trained to understand andappreciate the key roles of reliable data in health planning, projection and distribution of drugs,

and commodities. During work group exercises participants would have the opportunity tofamiliarize themselves with the different local and/or project forms and logbooks used for datacollection and record keeping.


N o build trainee’s capacity to collect and record data accurately and to train participants tounderstand the purpose of data collection, including the utilization of accurate and reliabledata to improve the quality of their services.


By the end of this session Px will be able to:

N Demonstrate the use of the logbook with real case record forms.


N Participatory discussion

N Group work with case studies

N Homework readings and exercisesN Hands-on practical exercises in filling the logbooks and data forms



N Samples of templates of patient forms and logbooks used locally or required by the project

N Participants handouts

Evaluation Methods:

N In-class observation and monitoring

N Verbal questions and answers




SpecificObjective

opic ime

1 Demonstrate the use of the logbook with real case recordforms.

1 hour, 45 min.

otal ime Required 1 hour, 45 minutes


N Participant Handouts




CONTENT METHODOLOGY

UNIT 2


Discussion and Learning Exercise(1 hour)

Te trainer should:

N Lead a discussion on the importance ofdata collection and its various uses.

N Discuss the quality issues regarding datacollection.

N Distribute Px Handouts 7.1: A Primary-Level Logbook, and 7.2: Guidance andDefinitions for Filling out FacilityLogbooks.

N Explain the headings and how tofill in the pages of the logbook. Explainthat the logbook helps systematicallydocument the condition of every patient

and the services she receives.N Explain that during the Continuum of

Care: Addressing Postpartum Hemorrhage project, the logbook was used to recorddata on each patient and then collectedby the supervisor and aggregated.

N Distribute Px Handout 7.3: PrimaryLevel Case Studies and ask Px to enterinformation from the cases into the

logbook format. Allow 10 minutes forPx to enter the data.

N Read the cases out loud, and askfor volunteers to explain what theyentered in the log.

7.1

7.2

7.3

Specific Objective #1: Demonstrate the use of the logbook withreal case record forms.

Record Keeping and DataCollectionIt is important to record basicinformation on clients who seek healthservices from providers and/or facilities.

At the provider and facility level, suchdata are necessary for diagnosis of thedisease, determining the severity of the

condition of a patient, and determiningprogression of the illness. Te providersuse these data for determining treatmentregimens and/or making referraldecisions. Also, effective monitoringand supervision for continuous qualityimprovement cannot be done withoutreliable patient data.

At the regional and national level, patientinformation is the basis for health care

planning, projection of infrastructureand supply needs, resource allocation,and an epidemiological database ofmorbidity and mortality. Withoutminimal epidemiological surveillance,no effective planning can happen toenhance the effectiveness and efficiencyof the health care system, to assess whether interventions are effective, andto improve public health.

At the intervention or project level, datacan inform if, and to what extent, anintervention or group of interventions was successful.

Numbers make sense when they arebased on quality data. Terefore, weneed good clinical record keeping in

7





7.8

7.47.5

7.6

7.7

order to produce good quality data. Te basicquality issues related to data are completeness ofinformation in terms of:N Content,N

Coverage,N imeliness, andN Accuracy.

Te reliability of data therefore depends onthe completeness and accuracy of informationcollected.

For example: Logbooks are commonly usedat facilities to note what happened to clients, what procedures were performed, and basic

information about the client. Terefore, eachand every client should be recorded in thelogbook (for completeness of coverage) andevery item in the logbook should be filled infor a client (for completeness of content). Terecord keeping for every client and every itemshould be as accurate as possible.

Data and record keeping need to be keptsimple because the primary responsibility ofproviders is to give care. However, data is alsovery important in being able to documentthe success of an intervention, which willinfluence if it is allowed to continue after theproject is over. Providers and managers on alllevels of the health system can use the data forproblem solving and quality improvement.Likewise, the data will inform decision makersif the intervention is not successful and thisinformation can be used to improve the

intervention.Summary Data and record keeping must be kept simplebecause the primary responsibility of providersis to give care. However, data is also veryimportant to document the success of anintervention.

N Ask Px:

N What they might need to change inthe forms for their specific facilities?

N Is anything missing?

N Describe any difficulties they hadusing the logbook or the definitionsduring the exercise.

N What they think is useful about usingthis logbook? For which purposes?


Te trainer should:

N Distribute Px Handouts 7.4:

Secondary-Level Facility PatientLogbook, 7.5: Secondary-LevelCase Studies, 7.6: ertiary-LevelFacility Patient Logbook, and7.7: ertiary-Level Case Studies.

N Ask Px to form 2 working groups. In-struct Group 1 to work from the second-ary-level handouts and Group 2 to workfrom the tertiary-level handouts.

N Ask each group to fill in the logbookpages, based on the instructions and thetwo case studies.

N Allow 15 minutes for the groups todiscuss and fill in the logbook. Ask areporter from each group to report backto the whole group on ease/difficulty/problems they had filling in the logbook.

N Ask for additions from the reporters’group, and then comments from the restof the class.

N Answer any questions about thelogbooks, definition guides, and use.

N Distribute copies of Px Handout 7.8:Record Keeping and Data Collection.

UNIT 7/OBJECTIVE #1





UNI 8: Community Mobilization

Introduction:

Community understanding of the four delays and support for the services that can preventand treat PPH are necessary for women to access the lifesaving emergency care described

in this curriculum. Tis unit provides an overview of ways to raise awareness of the needfor comprehensive emergency obstetric care, and to gain support among communities’ andcommunity leaders. Birth preparedness and complication readiness planning is explored in-depth because it is a service-delivery-level activity directly influenced by, and directly impacting,a woman’s life and circumstances at the household and community level.


o help participants understand the role of community-level action reducing the four delays, andproviders’ potential roles in conducting or influencing community mobilization; specifically by

helping clients make birth preparedness and complication readiness plans, which are shared withhousehold members.


By the end of this unit, participants will be able to:

N Describe how to involve the community in preventing the four delays.

N Develop a birth and complication readiness plan with a woman and provide counseling on warning signs, recognizing labor, and emergency readiness.



N Participatory discussion

N Brainstorming

N Role play


Howard-Grabman L, Snetro G. How to Mobilize Communities for Health and Social Change. Baltimore: Health Communication Partnership, 2003. Available online: http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/pdf/

Shiffman J. Generating Political Priority for Maternal Mortality Reduction in 5 DevelopingCountries. American Journal of Public Health 97 :5, 796-803.

Shiffman J, Santon C, Salazar AP. Te Emergence of Political Priority for Safe Motherhood inHonduras. Health Policy Plan 19 :6, 380-390.




Tadeous S, Maine D. oo Far to Walk: Maternal Mortality in Context. Social Science and Medicine, 38 :8, 1091-1110.

World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice . Geneva: World Health Organization, 2009. Available online: http:// whqlibdoc.who.int/publications/2006/924159084X_eng.pdf



N Blank paper

N Markers

Evaluation Methods:

N Verbal feedback

N rainer observation

N Post-test

ime Required:

Specific

Objective

opic ime

1 Describe how to involve the community in preventing thefour delays.

1 hour

2 Provide counseling on warning signs, recognizing labor, andemergency readiness.

1 hours, 15 min.

3 Develop a birth and complication readiness plan with a woman.

1 hour, 30 min.

4 Complete the post-test and course evaluation 50 min.

otal ime 4 hours, 35 min.


N Copies of role play scenarios

N Copies of Participant Handouts, the post-test, and course evaluation




CONTENT METHODOLOGY

UNIT 2


8

Te Four Delays, Community, andSkilled Providers

Refer to Unit 2, pages 34-36, as necessary.

Introduction (1 hour)

Te trainer should:

N Ask Px:

N Do you remember the four delays wediscussed in Unit 2?

N What are they?

N Record responses on a flipchart andsupplement if necessary. Ten, ask Px:

N How many of you work with thecommunity around your facility?

N What do you do with the community?

N Record responses on a flipchart. Ask Px:

N Is it important to involve thecommunity in the work of the healthfacility?

N How might you do this?

N Divide Px into four groups. Assign oneof the four delays to each group. Givegroups 30 minutes to plan how theycould involve the community in prevent-ing their assigned delay (even the fourthdelay, which is at the facility level).

N Regroup participants and ask each group

to present their ideas. Allow five minutesfor each presentation.

N Facilitate discussion of the proposedcommunity activities among the largegroup.

Specific Objective #1: Describe how to involve the community inpreventing the four delays.



132



8.1

Prevention of PPH in theCommunity

During antenatal care, providers should work with each woman to develop abirth and complication readiness plan. Ifpossible, birth planning should also involvethe decision makers in the woman’s family(husband, father, mother-in-law, etc.).Tis should ensure that the woman and

her family are aware of warning signs andhave already identified actions to take andresources to tap if warning signs presentduring pregnancy or birth. Birth andcomplication readiness plans address the firstthree delays: in recognizing the problem,in deciding to seek care, and in reachingthe facility. Community transport schemesshould be collaboratively developed byhealth authorities and facilities within each

neighborhood or village so that every familycan access those schemes quickly whenemergencies arise.

Entry points for birth planningProviders at different levels and in differentroles have varying points of entry tofacilitate birth and complication readinessplanning with pregnant women:

Community-Level Providers: Communityhealth workers, community midwives, andother skilled birth attendants working at thecommunity level, providing antenatal careand attending homebirths.

Facility-Level Providers: During routineantenatal care visits, facility-level providersshould incorporate birth and complication

Introduction (30 min.)

Te trainer should:

N Explain the roles providers can play inhelping a woman make a birth and com-plication readiness plan.

N On a flipchart, create separate columns foreach type of staff the pregnant woman andher family might encounter during preg-nancy (e.g., facility-based medical staff,community health workers, ambulancedrivers, facility support staff, etc.). Writethe name of each group at the top of eachcolumn.

N Ask Px: what entry points they have tohelp facilitate birth and complication read-iness planning. Record responses underthe appropriate columns, and supplement

responses if necessary.

N Distribute Px Handout 8.1: Prevention ofPPH in the Community .

Discussion and role play (45 min)

Te trainer should:

N Explain that a critical step in birth plan-ning, especially with women who plan to

deliver at home, is to make sure the wom-an understands the danger signs.

N Ask Px: what are the main causes of com-plications during birth for the mother?List the complications along the side of aflipchart, with room to record additionalinformation after each complication.

Specific Objective #2: Provide counseling on warning signs, recognizinglabor, and emergency readiness.






readiness planning into antenatal care

All health facility staff: All staff, whetherclinical, janitorial, or transport staff, can be

oriented to the four delays to urge their familyand community members to establish birth andcomplication readiness plans.

Counseling on Recognizing Labor,Warning Signs, and EmergencyReadiness at the Community Level At every level, providers should counsel women(and the decision makers in their families, ifpossible) on recognizing labor, warning signs,

and being prepared for obstetric emergencies, allof which address the first three delays.

Ensuring a woman understands the dangersigns A critical component of birth and complicationreadiness planning is ensuring that the womanunderstands what danger signs to look for andthat the danger signs could signify a seriouscomplication. Tis addresses the first delay.

Warning signs of obstetric complicationsProviders should counsel each woman totravel immediately to a health facility if sheexperiences any of the symptoms listed on thefollowing page.

Signs of onset of laborProviders should counsel each woman to go to afacility or contact her SBA if she notices any ofthe following three signs that signify the onset

of labor:

N Bloody, sticky vaginal discharge;

N Painful contractions five to 20 minutes apart(or closer), depending on how far she is fromthe facility if that is her choice of birth place;or

N For each complication, ask Px: how would you explain the danger signs forthis complication in a brief but complete way that the woman would understand?Record answers in the space next to eachcomplication on the flipchart.

N Ask Px:N What signs of the onset of labor

should the woman be aware of?N What known risks factors for

complications would mean a womanshould be especially encouraged todeliver at a facility?

N What danger signs should a womanknow to look for in her newbornbaby?

N Ask Px: how can we be sure the womanunderstands the information she is given?(Answer: have her repeat the information,explaining it in her own words.)

N Explain that Px will be role-playing

counseling of women on signs of laborand complications. Divide Px into pairs.Distribute role play slips to Px and allowfive minutes for the first role play. HavePx provide feedback to their role playpartner before switching roles. (If there isa group of three, be sure to allow enoughtime for all Px to play the provider role.)

N Regroup. Ask Px: Without mentioningnames,N What counseling points were

particularly important?N Was there any incorrect information

that you heard given?N What information was left out?N What did you like about the manner

with which the counselor spoke to theclient?

UNIT 8/OBJECTIVE #2




Danger Sign

(Plain Language)

Could Indicate

(Clinical Language)

At Any Time

Bag of waters breaks and labor does not begin within 24 hours• (Preterm) premature rupture of

membranesBaby stops moving for 24 hours• Fetal death

Strong abdominal pains• Infection, miscarriage, or tubal

pregnancy

Vaginal bleeding at any time:•

In an amount similar to monthly bleedingo

With paino

Placental abruption, ectopic

pregnancy, miscarriage

Vaginal bleeding without pain, in the second half of pregnancy• Placenta previa

Moderate or severe fever (above 38°C)•

Bad-smelling vaginal discharge•

Infection

Chills•

Cold sweats•

Fast breathing•

Feeling dizzy, faint, weak, or confused•

Pale skin•

Fast but weak pulse•

Shock

Strong headaches•

Blurry vision or double vision•

Pain in the upper abdomen, similar to feelings of indigestion, that•

starts suddenly and stays

Hands, feet, etc. react too much when tapped firmly with the first 2•

fingers (overactive reflexes)

Face and hands are swollen, especially when the woman first gets up•

in the morning

Sudden weight gain•

Fainting•

Fits/convulsions•

Preeclampsia

During Labor

Pain in or above the uterus between contractions• Infection

Contractions stop•

Baby feels loose in the belly•

Uterine rupture

Loss of consciousness• Shock and/or eclampsia

Strong contractions lasting longer than 12 hours (24 hours if first•

pregnancy)

Obstructed labor

Table continues on following page

UNIT 8/OBJECTIVE #2



135


UNIT 8/OBJECTIVE #2

Danger Sign

(Plain Language)

Could Indicate

(Clinical Language)

During Labor, continued

Baby comes feet, bottom, hands, or face first (before head)• Dangerous fetal position

Cord comes out before the baby• Prolapsed cord

Uterus is firm between contractions, or firm at all times•

Abdomen is sore or tender•

Baby moves less or doesn’t move at all•

Baby’s heartbeat is too fast, too slow, or undetectable•

Detached placenta

During Labor or After Delivery

More bleeding than normal:•

A “gush” or burst of blood during the second stage of laboro

Steady bleeding before the placenta has comeo

Bleeding without pain between contractionso

More blood is lost than would fit in a typical cup (providero

should explain that it is very hard to estimate blood loss

accurately, and the woman should go to a facility if there is

any worry that she has lost this much blood)

Detached placenta, PPH, or

placenta previa

Placenta does not come out• Retained placenta

Uterus feels soft, will not firm up with massage, after delivery• PPH and/or retained placenta

Fits or convulsions•

Eyes roll uncontrollably•

Hands and/or face twitch•

Skin starts to look blue around mouth•

Breathing has a loud, bubbly sound•

Eclampsia





N Water breaks.

Risk factors, when known

Several major risk factors increase thelikelihood the woman will experienceobstructed labor or other complications. Te woman should be especially encouraged todeliver in a facility if it is known that:

Te woman:

N Is carrying twins,

N Is very young,

N Was malnourished as a child,

N Has a deformed pelvis,

N Is diabetic,

N Had a previous delivery that was very dif-ficult,

N Has a history of PPH,

Or the baby:

N Is in a breech or transverse position,

N Is very large, orN Its head is still up high and can be felt

above the public bone (not in the pelvis).

Danger signs in the newborn Women should also be informed of keydanger signs for the baby before, during, orafter birth, including:

N Fever

N Diarrhea/loose stools

N Continuous crying

N Cough/breathing problems

N Irritability

N Lethargy

N Inability to feed

N Vomiting

N What didn’t you like?N How can we improve our counseling

to make sure women and their families

are well-prepared to recognize and acton danger signs? o recognize laborand be ready for emergencies?

N Distribute Px Handout 8.2: Counselingon Recognizing Labor, Warning Signs, andEmergency Readiness at the CommunityLevel and Px Handout 8.3: Danger Signsin Plain Language.

8.2

8.3

UNIT 8/OBJECTIVE #2





N Abdominal distension/pain

N Pus/pustules

Scenarios for role play

Non-provider roles can include:

N A 14-year-old primipara

N A 32-year-old grand-multipara carryingtwins

N A 24-year-old diabetic woman

N A 28 year old woman who had severebleeding with her first birth

If there is an odd number of Px, a third

person can participate in a group, playingthe woman’s husband, mother-in-law, orother family member/support person.

UNIT 8/OBJECTIVE #2



138



UNIT 8/OBJECTIVE #3

Developing a Birth andComplication Readiness Plan

Advantages of delivering at a facility Because most women who develop PPHhave no risk factors, delivering at a facilitymeans that the woman is already at aplace where she can access higher-levelcare if needed, including skilled providers,drugs, and equipment. Tis addresses the

first three delays and ensures that skilledproviders are involved and able to helpidentify problems that arise.

In addition to PPH, many othercomplications of delivery requiring higher-level care can develop unexpectedly.Delivering in a facility is especiallyimportant for young women and for womenliving with HIV, because both are more

likely to develop complications and, evenin normal deliveries, the facility can provideantiretroviral drugs for the women living with HIV for prevention of mother-to-childtransmission of HIV.

Barriers to Facility Delivery

Women may be unable to deliver in afacility because of distance, cost, providerattitudes, household decision-making, orother reasons.

Some barriers can be addressed by facilitiesthrough:

N Implementation of ambulance transporta-tion schemes, or

N Provider training that emphasizes treating women with respect, improving the qual-ity of facility services.

Brainstorming and Discussion (45 min.)

Te trainer should:

N Ask Px: do most women in your commu-nity deliver in a facility or at home?

N Write “home delivery” on one flipchart and“facility delivery” on another. Draw a linethrough the middle of each flipchart, label-

ing one side of each “advantages” and theother side “disadvantages”

N Recording responses in the appropriate sec-tions of the flipcharts, ask Px:

N What are the advantages of delivering athome?

N What are the disadvantages?

N What are the advantages of delivering ina facility?

N What are the disadvantages?

N Prepare another flipchart, labeled “barriersto facility delivery.”

Building on responses provided, ask Px:

N What are the barriers to womendelivering in a facility?

N Which barriers can the facility address,and how?

N Which barriers need to be addressed byothers (e.g., MOH)?

N Explain that birth planning can help reducebarriers to facility deliveries and ensure that

Specific Objective #3: Develop a birth plan with a woman.






women are as prepared as possible fordelivery, whether they choose to deliver ata facility or at home.

N Ask Px: has anyone ever helped a womanmake a birth plan?

N Ask the Px who respond, recording re-sponses on a flipchart:

N What are the necessary componentsof a birth and complication readinessplan?

N What questions do you ask the

woman?N What roles, in your experience, have

other decision makers played in birthplanning?

N Building on the responses provided,have Px brainstorm the information thatshould be relayed to a woman and herfamily during birth planning. Present thefollowing questions, recording answers on

flipcharts and supplementing responses asnecessary:

N What advantages of facility deliveryshould providers discuss with a womanand her family during birth planning?

N What important information aboutSBAs should the provider share withthe woman and her family?

N What specific preparations shoulda woman and her family make fordelivery in a facility?

N When should she go to the facility, and what should she bring?

N What specific preparations should a woman make if she plans to deliver

Other barriers may require involvement ofother groups, such as the MOH providingincentives for facility births, or mobilizationat the community level to generate funds for

transport and/or facility expenses.

Discussion points for birth andcomplication readiness planning When discussing birth and complicationreadiness plans with a woman and her familydecision makers, the following key messagesshould be included:

N Importance of being prepared if an emer-gency occurs;

N Advantages of delivering at a facility;

N Importance of skilled attendance in facilityor at home;

N Key preparations beforehand, depending onplace of delivery:

N For delivery at a facility: when to go, what to bring, money for transport and/or facility costs, and identifying willing

blood donors; orN For delivery at home: an SBA, clean birthspace, new blade and cord ties, plan toimmediately breastfeed, and an emphasison emergency transport plan.

Importance of skilled attendance

Whether a woman delivers in a facility or athome, skilled birth attendance is critical. Askilled birth attendant is trained in recognizingsigns of complications, including estimation of

blood lost, can provide lifesaving interventions,and can make the decision to seek higher-levelcare if needed. SBAs do not employ harmfultraditional practices, which are sometimes usedby unskilled attendants and result in seriouscomplications.

UNIT 8/OBJECTIVE #3





at home? What supplies does she need tohave ready?

N Distribute Px Handout 8.4: Developing a

Birth and ComplicationReadiness Plan and PxHandout 8.5: Birth PlanningCard .


8.4

8.5

UNIT 8/OBJECTIVE #3

Key preparations for delivery in a facility

In advance, the woman and decision makersneed to identify the following:

N Who will make the decision to go to thefacility if the decision maker is not pres-

ent?

N How will the woman travel to the facil-ity?

N Is there a cost for transportation to thefacility? If so, how will transportation bepaid for?

N How much does delivering at the facilitycost? How will that be paid for?

N How soon can the woman and her familystart saving for these expenses?

N Who will travel to the facility with the woman?

N Who is identified as a willing donor ofblood if the woman needs it?

N While the woman is away, who will lookafter her other children (if she has any)and her home?

When to go and what to bring: When a woman should go to the facility depends onhow far she lives from the facility.

A woman who lives within easy reach ofthe facility should go once labor is wellestablished (contractions regular, fiveminutes apart).

If a woman lives far from the facility, she

should begin her journey (via previouslyorganized transport) at the first signs oflabor. If she has the resources and support todo so, she should travel to the community where the facility is located two to three weeks prior to her due date. If she hasfamily or friends who live near the facilityand are able to help her, she should stay withthem until she is ready to go to the facility.





If the facility has a maternal waiting home thatthe woman is eligible to use, and she has theresources to do so, staying at the waiting homeis also recommended.

When a woman travels to the facility, she andher support person(s) should bring:

N Her birth planning card and/or maternalrecord;

N Large clean cloths, which will be used for washing, drying, and wrapping the baby and(a second set) as sanitary pads after birth;

N Clothes for both adults and the baby; and

N Food and water for the woman and her sup-port person.

Preparations for delivery at home

In advance, the woman and decision makersneed to identify the following:

N Who will make the decision to go to a facil-ity if the usual decision maker is not present?

N Who will stay with the woman during labor?

N Who will be nearby for at least 48 hours

after she gives birth?

N Who will help care for the woman’s otherchildren (if she has any) and her home whileshe is in labor and recovering?

Te provider should also reiterate to the woman(and decision makers, if possible):

N An SBA should be called at the first sign oflabor; and

N If the woman needs help, she should belinked beforehand to existing communityresources for help, such as communityemergency transport, willing blood donors,a community fund to cover costs, etc.

Some programs provide women withhome-based maternal records—simple,pictorial cards that women can use to record

UNIT 8/OBJECTIVE #3





UNIT 8/OBJECTIVE #3

information about pregnancy, labor,delivery, and complications. Home-basedmaternal records help the woman andfamily determine that complications are

developing and facilitate sharing this criticalinformation with a provider.

If a home-based maternal record is used,the provider should explain the sectionsof the card, information collected, andany signs or symbols to the woman as wellas to any decision makers with her. Teprovider should take time to verify that the woman and her companions understand the

card, especially if they cannot read. If theprovider is working with the woman alone,the woman should be instructed to explainthe card to her family members. If the woman is seen for multiple antenatal visits,the provider should review the home-basedmaternal record each time, to reinforce theimportance of the record and its accurateuse.

Preparations for delivery at homeIf a woman plans to deliver at home, sheshould identify where she will give birth.Tis should be a clean, warm room with aclean surface covered by clean cloths.

In advance of labor, the woman and herfamily should also gather the followingmaterials:

N Clean cloths of varying sizes to be used

for: the woman’s bed, drying and wrap-ping the baby, cleaning the baby’s eyes,for washing and drying the birth atten-dant’s hands, and to use as sanitary padsafter the birth;

N If there is a cloth or mat of standardsized used in the community to helpestimate blood loss (an adaptation of





the kanga method), such a cloth should beacquired if possible;

N Blankets for mother and baby;

N Clean buckets with clean water;

N A means of heating the clean water;

N Soap;

N Tree large bowls: two to be used for wash-ing and one to hold the placenta; and

N Plastic for wrapping the placenta.

Scenarios for Birth and ComplicationReadiness Planning Role Plays

Group 1 (2 Px): You are a woman pregnant with her first child and a provider counselingher on birth and complication readinessplanning. Te woman lives far from a facilityand plans to give birth at home. Te providershould discuss with her the advantages of givingbirth at a facility, the advantages of using askilled attendant for a home birth, and stepsneeded to take in either situation. Te womanshould leave the counseling session with a birth

preparedness and complication readiness plan(including transport), written or pictorial, and aplan to tell her husband, mother-in-law, and/orother decision-makers of her plans and what sheneeds.

Group 2 (2 Px): You are a pregnant woman anda provider helping her plan. Te woman livesa medium distance from the facility and this isher first pregnancy. Te woman should leavethe counseling session with a birth preparednessand complication readiness plan (includingtransport), written or pictorial, and a plan totell her husband, mother-in-law, and/or otherdecision-makers of her plans and what sheneeds.

Group 3 (3 Px): You are a woman, her husband,and a provider who live in a community with

Role Play (45 min)

Te trainer should:

N ell Px they will be role-playing birth pre-paredness counseling using Px Handout8.x and Px handout 8.x: Birth PlanningCard.

N Divide Px into groups of 2-3 Px each.Distribute Px Handout 8.6:Scenarios for Birth Planning .

N Give Px 15 minutes for the role

play, prompting them to switch roles half- way through.

N Regroup. Ask Px:

N What can providers do to help makecounseling effective?

N How should providers respond whenclients are unable to take all neededbirth preparedness measures?

N

o conclude, ask Px: what other measurescan we take in our roles as providers andcommunity members to help ensure thatall women have sound, realistic, birthpreparedness and complication readinessplans? Write suggestions on a flipchart.

8.6

UNIT 8/OBJECTIVE #3





UNIT 8/OBJECTIVE #3

a large hospital. Te woman is pregnant with her second child and she had a lot ofbleeding at her first birth, but is healthy now.Te woman and her husband favor delivery

at home because of costs. Te providershould discuss with her the advantages ofgiving birth at a facility, the advantages ofusing a skilled attendant for a home birth,and steps needed to take in either situation.Te woman and her husband shouldleave the counseling session with a birthpreparedness and complication readiness plan(including transport), written or pictorial,and plans to tell any other decision-makersof her plans and what she needs.

Group 4 (3 Px): You are a pregnant woman,her husband, and a provider. Te womanis pregnant with her first child and plans togive birth at home. Her husband’s aunt isa traditional birth attendant and the familyplans for her to help with the birth. Te woman and her husband should leave thecounseling session with a birth preparedness

and complication readiness plan and a planto tell her mother-in-law, husband’s aunt,and/or other decision-makers of her plansand what she needs.

Group 5 (2 Px): You are a pregnant womanand a provider. Tis is the woman’s sixthpregnancy and she plans to give birth athome. She gave birth to two of her childrenalone and is not concerned about having

anyone around to help her. Te providershould discuss with her the advantages ofgiving birth at facility, the advantages ofusing a skilled attendant for a home birth,and steps needed to take in either situation.Te woman should leave the counselingsession with a birth preparedness andcomplication readiness plan.






Post-est

Te Pre/Post-est Key is found in therainer’s ools, page 147.

UNIT 8/OBJECTIVE #3

Conduct the post-test and course evaluation

Conduct the Post-est and CourseEvaluation(45 min.)

Te trainer should:

N Distribute copies of Px Handout:8.7: Post-est.

N Explain that the Px will have 45minutes to take the test. Te questionsare a combination of fill-in-the-blanks,multiple choice, true and false andmatching. Read the instructions carefully.

N Distribute copies of Px Handout: 8.8:Course Evaluation.

N Ask Px to complete the evaluation beforedeparting.

8.7

8.8




rainer’s ools



147


Pre/Post-est Answer Key

Note to the rainer: Te correct answer (or answers) for each question are highlighted in bold.Tere are a total of 50 correct answers. Each correct answer is worth 2 points.

1. List at least 4 causes of uterine atony. Note to trainer: Only 4 answers are required

1. Uterine fatigue caused by prolonged labor or overuse of oxytocin for induction

2. Precipitous labor (labor that progresses very rapidly)

3. Over-distended uterus in the case of polyhydramnios (excess amniotic fluid),multiple gestation (twins, triplets), macrosomia (large fetus as in gestationaldiabetes)

4. Retained blood clots

5. High parity (many children)

6. Chorioamnionitis (infection of gestational sac and membranes)

7. Retained placenta/products of conception

2. List the 4 elements of the Pathfinder International Model for Clinical and Community Action to Address Postpartum Hemorrhage

1. Preventive active management of the third stage of labor by skilled providers at alllevels of care, including an appropriate preventive uterotonic provided within 1minute of delivery of the baby;

2. A simple plastic drape used to measure blood loss or other standard means ofaccurage estimation to alert the birth attendant of PPH;

3. A non-pneumatic anti-shock garment that reverses shock and maintains bloodaround vital organs during transport and until treatment is available; and

4. Improved communication and transportation systems to minimize the 3 delaysrelated to maternal mortality.

Multiple Choice Questions: Circle all the correct answers

3. Which of the following is a type of obstetric hemorrhage:

a. Antepartum hemorrhage

b. Postpartum hemorrhagec. A ruptured ectopic pregnancy

d. Retained placenta

e. All of the above




4. When a woman presents in hypovolemic shock, how much fluid should you infuse in the first20 minutes?

a. 250 mL

b. 500mL

c. 1000mL

d. 1500mL

5. Please mark all the steps in active management of third stage labor:

a. Administration of a uterotonic within 1 minute of delivery of the baby

b. Controlled cord traction to deliver the placenta

c. Delivery of the baby

d. Uterine massage following delivery of placenta to ensure that the uterus is contracted

e. None of the above

6. What is the oral and sublingual dose of misoprostol administered to prevent postpartumhemorrhage?

a. 200µg

b. 400µg

c. 600µg

d. 800µg

7. When is the blood drape placed underneath the woman’s buttocks and tied around her waistand hips?

a. Before delivery of the baby

b. After the delivery of the placenta

c. Immediately after the delivery of the baby

8. What does the red line on the blood drape indicate to the provider?

a. o get prepared to transfer the woman to a higher-level facilityb. o immediately transfer the woman to a higher-level facility.

c. o start observing the bleeding every 20 minutes

d. None of the above



149


9. How can you ensure that the NASG is free of the HIV virus?

a. Put it out in the sun to dry

b. Decontaminate the garment with a 0.05% chlorine solution

c. Wash the garment with soap and water or in a washing machine

d. All of the above

10. How is misoprostol commonly administered to prevent PPH?

a. Injectable

b. Oral tablets

c. Vaginally

11. Te 4 delays include:

a. Delay in recognizing that there is a problemb. Delay in the decision to seek care

c. Delay in reaching a facility that can provide life-saving treatment

d. Delay at the facility, once reached, in providing the quality emergency treatment the woman requires.

e. All of the above

rue/False Questions: Circle either (true) or F (false)

12. F A blood collection drape is a tool for measuring blood loss that can be used on all women who deliver.

13. F Obstetric hemorrhage is one of the leading causes of maternal mortality.

14. F Postpartum hemorrhage can be caused by genital tract or perineal lacerations

15. F wo-thirds of postpartum hemorrhage cases occur in women with no identifiable riskfactors

16. F When collecting data for research it is important to get the patient’s permission to usetheir information.

17. F Te most common side effect of misoprostol is shivering.




18. F Te NASG is an inflatable device that shunts blood to the brain, heart, and lungs andstabilizes hypovolemic patients

19. F Te NASG is made of neoprene and Velcro.

20. F Te NASG shunts blood from the veins of the abdomen and lower extremities to thevital core organs (heart, lungs, kidneys, and brain).

21. F If the woman experiences difficulty breathing with the NASG, the provider may adjustthe abdominal panel.

22. F Because the NASG is so effective, only 500 mL of crystalloid fluids should be given inthe first hour.

23. F Only one person, using as much strength as possible, should apply the pelvic andabdominal sections of the NASG.

24. F When removing the NASG, start at the abdominal segment

25. F When applying the NASG, start at the abdominal segment.

26. F Te NASG can be disinfected and washed 30 times.

27. F 40-50% of PPH can be prevented using AMSL.

28. F Misoprostol needs to be refrigerated.

29. F Misoprostol works by helping the uterus contract, squeezing the blood vessels closed.

30. F All women must be encouraged to develop a birth preparedness and complication-readiness plan, and to deliver (if possible) with a skilled provider.



151


Matching: Write the correct letter next to the matching definition

31. ___D__: is defined by how well it maintains active ingredientpotency and other measures like pH when stored over time.

A. Blood Drape (BD)

32. _G___ A two handed delivery of the placenta, involving

gentle downward cord traction with one hand and upwards andbackwards uterine counter-pressure with the other, performed onlyon a contracted uterus.

B. Uterotonic

33. __A__ A funnel-shaped plastic sheeting to catch blood, withmarkings at 350 ml and 500 ml, that is placed under the womanafter delivery of the baby to enable the attendant to assess bloodloss.

C. Hypovolemic Shock

34. __I__ Surgical removal of the uterus to stop intractable obstetrichemorrhage

D. Uterotonic stability

35. __B__ A drug that stimulates uterine contractions. E. Non-pneumatic Anti-ShockGarment (NASG)

36. __J__ Excessive bleeding immediately after delivery, within thefirst 24 hours

F. CrystalloidIntravenous (IV)Fluids

37. __H__Vaginal bleeding after delivery that exceeds 500 ml, or thatis less than 500 ml and causes symptoms of shock.

G. Controlled Cordraction

38. __C__Clinical signs of decompensation of the circulatory system,due to excessive blood loss.

H. PostpartumHemorrhage (PPH)

39. __E__ A garment that can be placed around the legs, pelvis, andabdomen of a woman who is in hypovolemic shock, compressingthe blood vessels in her lower extremities and the uterus, that will stabilize her (shunt blood to her vital organs) until she can betreated at an appropriate higher-level facility.

I. Emergency(Caesarean)Hysterectomy

40. __F__ Ringers Lactate, Hartmann’s Solution, Normal Saline usedfor fluid replacement for PPH.

J. Primary PostpartumHemorrhage

41. __K __ Includes 3 components a) Administration of a uterotonic within 5 minutes after the birth of a newborn b) delivery of the

placenta by controlled cord traction, (after the cord has stoppedpulsing) c) followed by uterine massage

K. Active Managementof the Tird Stage

of Labor (AMSL)




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153


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161




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•

S h i v e r i n g , n a u s e a a n d

e l e v a t e d t e m p

e r a t u r e .

R e c t a l : 8 0 0 - 1 0 0 0 µ g

t e m p e r a t u r e n a c o s e

c o n t a i n e r .



163


H o w H e m o r r h a g e C a u s e s S h o c k ,

4 . 1

o r

y , a

n

e a

S e v e r e

b l o o

d l o s s

D e c r e

a s e

i n c

i r c u

l a t i n g

b l o o

d v o

l u m e

I n t e r r u p

t i o n

i n o x y g e n s u p p

l y t o t i s s u e s

B r a

i n ,

h e a r t ,

l u n

s d e

r i v e d

o f o x

e n

a b d o m e n

& l e g s

D a m a g e

t o v

i t a l o r g a n s

D e a

t h




4 . 2

S o i l e d S a n i t a r y T o w e l

A d a p t e d f r o m : P . B o s e , F . R e g a n , S . P a t e r s o n - B r o w n , I m

p r o v i n g t h e a c c u r a c y o f e s t i m a t e d b l o o d l o s s a t o b s t e t r i c

h e m o r r h a g e u s i n g c l i n i c a l r e c o n s t r u c t i o n s . ( L o n d o n : B r i t i s h M a t e r n a l & F e t a l M e d i c i n e S

o c i e t y , n . d . ) .



165


4 . 3

S a t u r a t e d S a n

i t a r y T o w e l



h e m o r r h a g e u s i n g c l i n i c a l r e c o n s t r u c t i o n s ( L o n d o n : B r i t i s h M a t e r n a l & F e t a l M e d i c i n e S

o c i e t y n d )




4 . 4

S a t u r a t e d S w a b , 1 0 c m x 1 0 c m




o c i e t y , n . d . ) .



167


4 . 4

I n c o n t i n e n c e

P a d




o c i e t y n d )




4 . 6

S a t u r a t e d S w a b , 4 5 c m x 4 5 c m




o c i e t y , n . d . ) .



169


4 . 7

F l o o r

S p

i l l , 1 0 0 c m

D i a m e t e r

A d a p t e d

f r o m :

P .

B o s e ,

F .

R e g a n ,

S .

P a t e r s o n - B

r o w n , I m

p r o v

i n g t h e a c c u r a c y o

f e s t i m a t e d

b l o o

d l o s s a t o

b s t e t r i c

h e m o r r h a g e u s i n g c l i n

i c a l r e c o n s t r u c t i o n s

( L o n

d o n :

B r i t i s h M a t e r n a l

& F e t a l

M e d

i c i n e S

o c i e t y n d )




4 . 8

B l o o d S p i l l i n g t o F l o o r




o c i e t y , n . d . ) .



171


4 . 9

B l o o d S p i l l i n g t o F l o o r




o c i e t y n d )




4 . 1

0

F u

l l K i d n e y D

i s h

A d a p t e d

f r o m :

P .

B o s e ,

F .

R e g a n ,

S .

P a t e r s o n - B

r o w n , I m

p r o v

i n g t h e a c c u r a c y o

f e s t i m a t e d

b l o o

d l o s s a t o

b s t e t r i c

h e m o r r h a g e u s i n g c l i n

i c a l r e c o n s t r u c t i o n s .

( L o n

d o n :

B r i t i s h M a t e r n a l

& F e t a l

M e d

i c i n e S

o c i e t y , n . d . ) .



173


4 . 1 1

A

S o

i l e d S a n i t a r T o w e l

3 0 m l

B

S a t u r a t e d S a n i t a r y T o w e l

1 0 0 m l

C

S w

a b , 1 0 c m X 1 0 c m

6 0 m l

D

I n c o n t i n e n c e P a d

2 5 0 m l

E

S w

a b , 4 5 c m x 4 5 c m

3 5 0 m l

F

S p

i l l , 1 0 0 c m D i a m e t e r

5 0 0 m l

G

S p

i l l t o F l o o r ( 1 )

1 0 0 0 m l

H

S p

i l l t o F l o o r ( 2 )

2 0 0 0 m l

I

F u

l l K i d n e y D i s h

5 0 0 m l




o c i e t y n d )




4 . 1

2



175


4 . 1

3

D e l i v e r t h e b a b y ,

c l a m p a n d c u t t h e c o r d

P l a c e r e c t a n g u l a r p o r t i o n o f d r a p e

u n d e r b u t t o c k s w i t h f u n n e l p o r t i o n

h a n g

i n g o v e r t h e e d g e o f t a b l e o r l y i n g f l a t o n b e d o

r f l o o r

P l a c e t h i c k , r

o l l e d t o w e l o r c l o t h u n d e r n e a t h t h e w o m a n ’ s s h

o u l d e r b l a d e s

T i e b

l o o d d r a p e a r o u n d w o m

e n a t 2 p l a c e s ( w a i s t &

h i p s )

P u s h a l l b l o o d i n t o t h e

b a g u s i n g g l o v e d h a n d

o

o r s o a n

e p

o w n w a r

o w

o

o o

A s s e s s b l o o d l o s s b y l o o k i n g a t a

m o u n t o f b l o o d c o l l e c t e

d i n f u n n e l

H o l d u

p t h e b a g w i t h b o t h h a n

d s t o s e e a m o u n t o f b l o o d l o s t

D o n o t r e m o v e d r a p e

t o a s s e s s b l o o d l o s s




C o r r e c t P l a c e m e n t o f

t h e B l o o d

4 . 1

4

o

e c o n

r a p e



177


4 . 1

5




M

r i n

B l

l l

i n

h

F

n n

4 . 1

6



179


D e c o n t a m i n

a t e i n 0 . 0 5 %

B l e a c h

4 . 1

7

o u o n

o r

n u e s




4 . 1

8



181


4 . 1

9




H o w H e m o r r h a g e C a u s e s S h o c k ,

5 . 1

o r

y , a

n

e a

S e v e r e

b l o o

d l o s

s

D e c r

e a s e

i n c

i r c u

l a t i n g

b l o o

d v o

l u m e

I n t e r r u

p t i o n

i n o x y g e n s u p p

l y t o t i s s u e s

B r a i n

, h e a r t ,

l u n

s d e

r i v e

d o

f o x

e n

a b d o m e n

& l e g s

D a m a g e

t o v

i t a l o r g

a n s

D e a

t h



183


U t e r o t o n i c s U s e d f o r T r e a t m e n t o f P P H

5 . 2

D i s a d v a n

t a g e s

T r e a t m

e n t

R e q u i r e m e n t s

O x y t o c i n

•

E f f e c t i v e 2 - 3 m i n u t e s a f t e r

•

1 0 - 2 0 I U

I M i n i t i a l l y

•

S t o r e b e t w e e n 1 5 C &

-

( I M i n j e c t i o

n

o r I V )

.

•

C a n o n l y b e g i v e n I V o r

I M .

•

C a n b e u s e d i n

a l l w o m e n .

•

p o s s

e , s a r

w i t h 2 0 - 4

0 I U i n

1 0 0 0 m l c r y s t a l l o i d

f l u i d s ( 1 0

- 2 0 I U i n

5 0 0 m l )

.

.

•

D e l i v e r y r o

o m s t o c k m a y b e

k e p t a t r o o

m t e m p e r a t u r e —

3 0 C —

f o r u p t o o n e y e a r

w i t h a n e x p e c t e d l o s s o f

,

a n a n t i - d i u r e t i c s o c a n

c a u s e f l u i d i n t o x i c a t i o n /

w a t e r t o x i c i t y i f h i g h d o e s

g i v e n w i t h l a r g

e v o l u m e s o f

•

C a n g i v e

s u b s e q u e n t

I V s o f c r

y s t a l l o i d

w i t h 1 0 - 2

0 U i n 1 0 0 0

m l ( 5 - 1 0

I U i n 5 0 0

a b o u t 1 4 p e r c e n t .

•

L i g h t d o e s

n o t d e s t a b i l i z e

o x y t o c i n

f l u i d .

•


•

C a u s e s p h y s i o l o g i c a l

c o n t r a c t i o n s .

m •

R u n a t 1 5

0 / m l / h o u r





5 . 3

D i s a d v a n

t a g e s

T r e a t m

e n t


E r g o m e t

r i n e

•

E f f e c t i v e 2 - 5 m

i n u t e s a f t e r

0 . 2 m g - 4 m g

•

S t o r e b e t w

e e n 2 ° C –

8 ° C .

( I M I n

j e c t i o

n )

.

•

C a u s e s s u s t a i n

e d

c o n t r a c t i o n

•

E f f e c t s m a y l a s t 2 - 4

h o u r s .

•

u s e o c a s

a n a r s

r o e c r o

m

g

a n

f r e e z i n g .

•

R e q u i r e s s t r i n g e n t h a n d l i n g

a n d s t o r a g e c o n d i t i o n s .

.

•

C o n t r a i n d i c a t e

d i n w o m e n

w i t h p r e - e c l a m

p s i a ,

e c l a m p s i a , a n d

h i g h b l o o d

p r e s s u r e .

•

C a n c a u s e n a u s e a a n d

v o m i t i n g .

•

R e q u i r e s s t r i n g

e n t h a n d l i n g

a n d s t o r a g e c o

n d i t i o n s .



185



5 . 4

D i s a d v a n

t a g e s

T r e a t m

e n t


M i s o p r o s t o l

•

E f f e c t i v e 9 - 1 2 m i n u t e s

6 0 0 µ g o r a l l y o r

•

S t o r e a t r o

o m t e m p e r a t u r e

( T a b l e t )

.

•

S h i v e r i n g , n a u s e a a n d

e l e v a t e d t e m p

e r a t u r e .

8 0 0 - 1 0 0 0 µ

g r e c t a l l y

.




D e c i s i o n

M a k

i n g a n

d A c t i o n

5 . 5

e p e n

n g

o n

a c e o

e v e r y

P l a c e o f d e

l i v e r y

E x t e n t o f

b l o o d l o s s

W h e r e r e s u s c i t a t i o n / P P H

m a n a g e m e n t n o t a v a i l a b l e

W h e r e o n l y r e s u s c i t a t i o n /

P P H m a n a g e m

e n t a v a i l a b l e

W h e r e

s u r g i c a l

i n t e r v e

n t i o n s a v a i l a b l e

> 3 5 0 m

l i n

f i r s t h o u r

•

C o n t i n u o u s l y p r o v

i d e a l l m e a s u r e s

a t h a n

d t o s t o p

b l e e d i n g : p u t

b a b y

•

I n a d

d i t i o n , s

t a r t a n

I / V d r i p

w i t h 2 0 u n

i t s O x y t o c

i n i n 1 0 0 0

•

I n a d

d i t i o n ,

e x p

l o r e c a u s e

o f b l e e d i n g -

a t o n y ,

a f t e r

d e l i v e r y

t o b r e a s t , u t e r i n e m a s s a g e

,

b i m a n u a l c o m p r e s s i o n .

•

C o n t i n u e t o a s s e s s s y m p t o m s a n

d

v i t a l s i g n s .

•

m l a t

4 0 d r o p s / m

i n u t e .

•

G i v e a p p r o p r

i a t e u t e r o t o n

i c

b a s e d o n p a s t

h i s t o r y .

•

P r e p a r e t o t r a

n s f e r t h e w o m a n

r e t a i n e d p

l a c e n t a /

P O C ’ s ,

t r a u m

a , c o a g u

l o p a t h y , e t c .

a n d t a k e a p p r o p r i a t e

a c t i o

n i n l a b o r r o o m o r

w o m a n t o a

h i g h e r

f a c i l i t y

i f

r e t a i n e d p

l a c e n t a o r t r a u m

a o r

h e a v y

b l e e d i n g c o n t i n u e s .

p

l a c e n t a o r t r a u m a o r

h e a v y

b l e e d i n g c o n t

i n u e s .

.

m

n

f i r s t 2 h o u r s

a f t e r

d e l i v e r y

•

e e r a n

m m e

a t e y t r a

n s p o r t

t h e w o m a n t o a

f a c i l i t y t h a t c a n

t r e a t h e r

f o r

P P H

.

•

P r o v

i d e

d e t a i l s o

f t r e a t m e

n t g

i v e n .

•

t a r t a o v e t r e a t m e n t

•

R e f e r a n

d i m m

e d i a t e l y

t r a n s p o r t t h e w o m a n

i f s h e

r e q u

i r e s h i g h e

r l e v e

l

i n t e r v e n t i o n a

t a

f a c i l i t y t h a t

c a n t r e a t

h e r f

o r

P P H

.

•

P r o v

i d e

d e t a i l

s o

f t r e a t m e n t

g i v e n .



187


5 . 6

,

t r a n s f e r

r e d :

,

•

B y t h e r i g h t p

e o p l e ,

o

e r g p

a c e ,

•

W i t h t h e r i g h t c a r e t h r o u g h o u t .




6 . 1



189


H o w

t h e N A S G P r o t e c t s a W o m a

n i n

6 . 2

y p o

v o e m c

o c




6 . 3



191


6 . 4

P l a c e t h e N

A S G u n d e r t h e w o m a n w i t h t h e t o p e d g e a t t h e l e v e l o f h e r

o w e s r

o n

e r s

e

C l o s e s e g

m e n t 1 t i g h t l y a r o u n d e

a c h a n k l e a n d m a k e s u

r e t h a t w h e n

s n a p p e d , a s h a

r p s o u n d i s h e a r d

C l o s e

s e g m e n t 2 t i g h t l y a r o u

n d c a l f . C h e c k f o r s n a p

s o u n d .

L e a v e t h e k n e e f r e e s o t h a t t h e l e g c a n b e b e

n t

C l o s e

s e g m e n t 3 t i g h t l y a r o u n d t h i g h .

C h e c k f o r s n a

p s o u n d .

P l a c e s e g

m e n t 4 s o i t g o e s a r o u n d t h e w o m a n w i t h i t s l o w e r e d g e a t

t h e l e v e l o f h e r u b i c b o n e

P l a c e s e g m e n t 5 w i t h p r e s s u r e b a l l d i r e c t l y o v e r t h e u m b i l i c u s

M a k e s u r e t h e w o m a n c a n b r e a t h e n o r m a l l y w i t h s e g m e

n t 6 i n p l a c e




6 . 5

• W o

m a n i s s t a b l e f o r 2 h o u r s

• R e m o v e t h e l o w e s t s e m e n t – s

e m e n t 1

e g m e n t

• W a

i t f o r 1 5 m i n u t e s

• T a k e p u l s e & B P

S e g m e n t 2

• R e m o v e s e g m e n t 2

• W a i t 1 5 m i n u t e s

• T a k

e p u l s e & B P

S e g m e n t 3


• W a



S e g m e n t 4


• W a



e g m e n t s

5 & 6

• R e m o v e s e g m e n t s 5 & 6



193


A

v o i d i n g A

d v e r s e E v

e n t s W h e n

6 . 6

s n

g

e

•

O n e

e r s o n s h o u l d a

l t h e

e l v i c a n d a b d o m i n a l

s e c t i o n s o f t h e N A S

G .

•

U r i n e

o u t p u t s h o u l d

b e m o n i t o r e d

.

•

E n s u r

e a i r w a y p r o t e

c t i o n a n d a s p i r a t i o n p r e v e n t i o n a s

r e q u i r

e d .

•

n s u r

e o n e - o n - o n e

n u r s n g c a r e .

•

E n s u r

e p r e s e n c e o f a r e l a t i v e / s u p p o r t p e r s o n w i t h t h e

,

p a t i e n

t r e t u r n s t o c o

n s c i o u s n e s s .

•

N e v e r o e n t h e a b d o m i n a l a n e l f

i r s t .




6 . 7

1 .

P u t o n g l o v e s

2 .

M i x b l e a c h s o l u t i o n

3 .

( a ) I m m e r

s e N A S G

( b ) S o a k i n b l e a c h 1 0 m i n s .

4 .

S c r u b

5 .

W a s h

6 .

S q u e e z e

7 .

D r y



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Tel: 617-924-7200

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