Training of Health Facility Staff
(Skilled Birth Attendant)
Clean and Safe Delivery and Management
of Postpartum Haemorrhage (PPH)
Participant Handbook
May 2013
Ministry of Health
Government of Republic of South Sudan
Published by:
Jhpiego Corporation
Brown’s Wharf
1615 Thames Street
Baltimore, Maryland 21231-3492
www.jhpiego.org
© Jhpiego Corporation, 2013. All rights reserved.
Table of Contents
FOREWORD ...................................................................................................................................... V
ACKNOWLEDGEMENTS ................................................................................................................... VI
ABBREVIATIONS AND ACRONYMS .................................................................................................. VII
BACKGROUND .................................................................................................................................. 1
COURSE OVERVIEW .......................................................................................................................... 3
Core Competencies ............................................................................................................................ 3
Course Goal......................................................................................................................................... 4
Participants’ Learning Objectives ...................................................................................................... 4
Participants’ Learning Activities......................................................................................................... 4
Training/Learning Methods ............................................................................................................... 4
Training Materials ............................................................................................................................... 4
Participant Selection Criteria ............................................................................................................. 5
Method of Evaluation ......................................................................................................................... 5
THE PPH PROGRAMME IN SOUTH SUDAN ....................................................................................... 7
CLEAN AND SAFE DELIVERY ............................................................................................................. 9
Per Guidelines for Prevention and Management PPH (GOSS 2012) .............................................. 9
Points to Remember in AMTSL ......................................................................................................10
Immediate Newborn Care ................................................................................................................10
Care in Immediate Postpartum Period ............................................................................................11
Mother..................................................................................................................................... 11
Newborn .................................................................................................................................. 11
POSTPARTUM AND NEWBORN CARE ............................................................................................. 12
Objectives of Postpartum/postnatal Care.......................................................................................12
Return of Fertility After Childbirth ....................................................................................................12
POSTPARTUM HAEMORRHAGE ...................................................................................................... 13
Primary Postpartum Haemorrhage ..................................................................................................13
Condom Tamponade for Severe PPH .................................................. Error! Bookmark not defined.
Instructions ................................................................................. Error! Bookmark not defined.
Compression of the Aorta ...................................................................................................... 14
Retained Placenta .................................................................................................................. 14
Management of Retained Placenta ...................................................................................... 15
Review Questions .............................................................................................................................16
SUPPORTIVE SUPERVISION ............................................................................................................ 18
Supervisor Skills ...............................................................................................................................18
ROLE PLAY 1: COMMUNICATING ABOUT A WOMAN’S RIGHT TO SAFE MOTHERHOOD ................. 20
Directions ..........................................................................................................................................20
Participant Roles...............................................................................................................................20
Situation ............................................................................................................................................20
Focus of the Role Play ......................................................................................................................20
Discussion Questions .......................................................................................................................21
Clean and Safe Delivery and Management of PPHParticipant Handbook
iii
ROLE PLAY 2: SUPPORTIVE SUPERVISION ..................................................................................... 22
Directions ..........................................................................................................................................22
Learners Roles ..................................................................................................................................22
Situation ............................................................................................................................................22
Focus of the Role Play ......................................................................................................................22
Discussion Questions .......................................................................................................................22
CASE STUDY 1: VAGINAL BLEEDING AFTER CHILDBIRTH ................................................................. 23
Directions ..........................................................................................................................................23
Case Study ........................................................................................................................................23
Assessment .......................................................................................................................................23
Diagnosis...........................................................................................................................................23
Care Provision ...................................................................................................................................23
Evaluation .........................................................................................................................................23
CHECKLIST 1: ASSISTING NORMAL BIRTH WITH ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOUR AND IMMEDIATE NEWBORN CARE ................................................................................... 24
CHECKLIST 2: HELPING A BABY BREATHE/NEWBORN RESUSCITATION .....................................297
CHECKLIST 3: MANAGEMENT OF SHOCK LINKED TO PPH ............................................................ 29
CHECKLIST 4: BIMANUAL COMPRESSION OF THE UTERUS .........................................................321
CHECKLIST 5: UTERINE BALLOON TAMPONADE ..........................................................................342
CHECKLIST 6: MANUAL REMOVAL OF PLACENTA .......................................................................... 34
CHECKLIST 7: EPISIOTOMY AND PERINEAL REPAIR ..................................................................... 36
APPENDICES
APPENDIX A: ACTION PLAN FOR EFFECTIVE IMPLEMENTATION OF MATERNAL AND
NEWBORN HEALTH SERVICES ...................................................................................................... A-1
Developing a Plan of Action for the Implementation of Basic Emergency Obstetric
and Newborn Care (BEmONC) Services ......................................................................................... A-1
Purposes of Knowledge and Skills Application Plan ........................................................... A-1
Characteristics of a Sound Knowledge and Skills Implementation Plan........................... A-1
Components of Knowledge and Skills Action Plan ............................................................. A-1
Format for Developing a Knowledge and Skills Application Plan ...................................... A-2
APPENDIX B: KEY INFORMATION FOR COUNSELLING ON BP/CR AND DISTRIBUTION
OF MISOPROSTOL ......................................................................................................................... B-1
APPENDIX C: MOH CIRCULAR ON STORAGE OXYTOCIN ................................................................ C-1
APPENDIX D: REFERRAL CHECKLIST............................................................................................. D-1
APPENDIX E: RECOMMENDATIONS FOR THE PREVENTION OF PPH (WHO 2012) ........................ E-1
F
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Clean and Safe Delivery and Management of PPHParticipant Handbook
Foreword
[insert MOH text here]
Clean and Safe Delivery and Management of PPHParticipant Handbook
v
Acknowledgements
This document was made possible by the generous support of the American people through
the U.S. Agency for International Development, under the terms of the Leader with
Associates Cooperative Agreement GHS-A-00-08-00002-00. The contents are the
responsibility of MCHIP and do not necessarily reflect the views of the U.S. Agency for
International Development or the United States Government.
This document was adapted from the Trainers’ Manual for the Training of CHWs developed
by the Health Services Support Project, a Jhpiego-led USAID-funded programme in
Afghanistan, as well as the basic emergency obstetric and newborn care (BEmONC) training
materials from the Jhpiego-led MAISHA Program in Tanzania. It was adapted by Sheena
Currie, Laura Fitzgerald, Isabella Ochieng and Victoria Mshiki.
About MCHIP
MCHIP is the USAID Bureau for Global Health’s flagship maternal, neonatal and child
health (MNCH) program. MCHIP supports programming in maternal, newborn and child
health, immunization, family planning, malaria, nutrition and HIV/AIDS, and strongly
encourages opportunities for integration. Cross-cutting technical areas include water,
sanitation, hygiene, urban health and health systems strengthening. Visit www.mchip.net to
learn more.
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Clean and Safe Delivery and Management of PPHParticipant Handbook
Abbreviations and Acronyms
AMTSL
Active management of third stage of labour
ANC
Antenatal care
BEmONC
Basic emergency obstetric and newborn care
BP/CR
Birth preparedness and complication readiness
CCT
Controlled cord traction
CHW
Community health worker
HHP
Home health promoter
IM
Intramuscular/intramuscularly
IU
International units
IV
Intravenous/intravenously
MCHW
Maternal and child health worker
MNCH
Maternal, newborn, and child health
MNH
Maternal and newborn health
MOH
Ministry of Health
PHCC
Primary Health Care Centre
PHCU
Primary Health Care Unit
PPH
Postpartum haemorrhage
TBA
Traditional birth attendant
UBT
Uterine balloon tamponade
WHO
World Health Organization
Clean and Safe Delivery and Management of PPHParticipant Handbook
vii
Background
Worldwide, maternal mortality remains unacceptably high despite some improvements in
recent years. South Sudan has the world’s highest maternal mortality ratio (2,054
deaths/100,000 live births). Almost 60% of all pregnant women in South Sudan receive no
antenatal care (ANC), and 80.6% of births occur at home without the attention of a skilled
birth attendant1. Only one in five (19.4%) are attended by a skilled birth attendant2 during
childbirth. Newborn mortality at 52 is also very high.
Globally, more than 13 million of the 136 million women giving birth each year suffer from
postpartum haemorrhage (PPH). PPH accounts for 34% of maternal deaths3 in Africa overall
and likely a higher percentage in South Sudan (although country-specific data are not
available). The use of uterotonic agents reduces both the amount of bleeding and the need
for additional treatments or interventions. To reduce PPH-related maternal mortality and
morbidity, all women must be protected from PPH by use of a uterotonic drug at birth,
regardless of where they deliver. To bolster these efforts, women and communities need to be
encouraged to deliver at health facilities with skilled providers, be aware of pregnancy and
delivery complications, and know how and where to seek additional care.
Provision of a clean and safe birth at a health facility that addresses respectful care, good
infection prevention practices, prevention of PPH using a uterotonic, immediate newborn
care (including those for warmth, cord care and eye care, newborn resuscitation, recognize
danger signs, and promote early and exclusive breastfeeding) will contribute significantly to
the reduction of maternal and newborn mortality in South Sudan.
The use of uterotonics for the prevention of PPH during the third stage of labour
is recommended for all births (World Health Organization [WHO] 2012). See
Appendix E.
Text Box 1. Key PPH Prevention Interventions
Facility-Based Births

Active management of third stage of labour (AMTSL):
 Oxytocin, 10 IU IM immediately after birth
 Controlled cord traction (with skilled provider only)
 Uterine massage if uterus soft or relaxed

Modified AMTSL:
 Misoprostol 600 mcg orally immediately after birth
 Uterine massage if uterus soft or relaxed
Community-Based Births

Promotion of deliveries at health care facilities

Education about PPH to women and their families

Advanced distribution and education of pregnant women on self-administration of misoprostol immediately
following delivery
Misoprostol is a uterotonic increasingly used in obstetrical and gynaecological practice,
including prevention and treatment of PPH4, particularly at the community level where no
other uterotonic option may be available. Manufactured in tablet form, it is taken orally for
The Sudan Household Health Survey, 2010.
Skilled attendant is an accredited health professional—a midwife, doctor, or nurse—who has been educated/trained
to proficiency in skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal
period, and in the identification, management and referral of complications in women and newborn (WHO, ICM and
FIGO 2004).
3 Khan et al. WHO analysis of causes of maternal death: A systematic review. The Lancet 2006; March 28.
4 Caliskan E, Dilbaz B, Meydali MM, Ozturk N, Narin MA, Haberal A. Oral Misoprostol for the third stage of labor: A
randomized trial. Obstet Gynecol 2003; 101 (5 Pt. 1): 921–928.
1
2
Clean and Safe Delivery and Management of PPHParticipant Handbook
1
PPH prevention (3 tablets or 600 mcg)5. It is also inexpensive, easy to store, stable in field
conditions, and has an excellent safety profile, when used as directed6. Various studies have
demonstrated misoprostol’s effectiveness in reducing PPH cases, reducing the need for
additional interventions, and reducing the need for referrals in a variety of communitybased settings7. Auxiliary nurse-midwives, traditional birth attendants (TBAs), and
community volunteers have feasibly and effectively dispensed and/or distributed misoprostol
at home births8,9,10.
To help address high maternal mortality, community distribution of misoprostol is being
implemented as part of a comprehensive, phased approach for the reduction of PPH in South
Sudan spearheaded by the South Sudan Ministry of Health (MOH).
Alfirevic Z, Blum J, Walraven G, Weeks A, Winikoff B. Prevention of postpartum hemorrhage with misoprostol. An
International Journal of Obstetrics and Gynaecology 2007; 99(2): S198–S201.
6 el-Refaey H, O'Brien P, Morafa W, Walder J, Rodeck C. Use of oral misoprostol in the prevention of postpartum
hemorrhage. Br J Obstet Gynaecol 1997; 104:336-39.ICM/FIGO 2006. (5 Pt. 1): 921–928.
7 McCormick ML, Sanghvi HCG, Kinzie B, McIntosh N. Averting maternal death and disability: Prevention postpartum
hemorrhage in low-resource settings. International Journal of Gynecology and Obstetrics 2002; 77(3): 267–275.
8 Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in
Tanzania. International Journal of Gynecology & Obstetrics 2005; 90: 51–55.
9 Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, Patted SS, Patel A, Edlavitch SA, Hartwell T,
Chakraborty H, Moss N. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: A
randomised controlled trial. Lancet 2006; 368(9543): 1248–1253.
10 Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, Sloan N. Misoprostol in the management of the third
stage of labour in the home delivery setting in rural Gambia: A randomised controlled trial. BJOG: An International
Journal of Obstetrics and Gynaecology 2005; 112 (9): 1277–1283.
5
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Clean and Safe Delivery and Management of PPHParticipant Handbook
Course Overview
This 5-day training is designed to prepare the skilled health care workers who are based at
health facilities and are primarily responsible for providing ANC, care in labour and
delivery, and after childbirth to women and their newborns, to prevent PPH and manage
PPH at the facilities and thereby reduce maternal deaths in South Sudan. This training
package helps provide updates on best practices for maternal and newborn care. Use of this
package assumes that basic skills, such as normal ANC and assistance at normal birth are
already being provided by the participants. More specifically, the course will prepare the
health facility staff to:

Counsel women attending ANC clinic on making birth preparedness and complication
readiness (BP/CR) plans and preventing PPH using misoprostol during home births.

Provide safe and clean birth including prevention and management PPH cases at the
health facility and refer cases to higher level as appropriate.
This training course is based on the principles of competency based training and learning.
Competency-based learning is learning by doing—learning that emphasizes how the
participant performs (i.e., a combination of knowledge, attitudes, and most important,
skills). The trainer assesses participants’ skill competency by evaluating their overall
performance.
The use of competency-based checklists to measure clinical skills or other observable
behaviours in comparison to a predetermined standard is an integral part of learning new
skills. A checklist contains the individual steps or tasks in sequence (if necessary) required
performing a skill or activity in a standard way. If opportunities allow, the participants will
also practice skills with patients.
Learning to perform a skill occurs in three stages:
1. Skill acquisition: The participant knows the steps and their sequence (if necessary) to
perform the required skill or activity but needs assistance
2. Skill competency: The participant knows the steps and their sequence (if necessary)
and can perform the required skill or activity
3. Skill proficiency: The participant knows the steps and their sequence (if necessary)
and efficiently performs the required skill or activity
CORE COMPETENCIES
The participants are expected to develop the following competencies in order to successfully
prevent and manage PPH.
1. Assist pregnant women and their family members to develop a Birth Preparedness and
Complication Readiness (BP/CR) plan using BP/CR counselling flip charts.
2. Use PPH prevention flip charts, counsel pregnant women on the use of misoprostol and
provide misoprostol for the prevention of PPH.
3. Demonstrate clean and safe childbirth, including active management of the third stage
of labour and immediate essential newborn care.
4. Provide essential newborn interventions, including those for warmth, cord care and eye
care, newborn resuscitation, recognize danger signs, and promote early and exclusive
breastfeeding.
5. Identify the presenting symptoms and signs of shock.
6. Perform adult resuscitation and management of shock.
7. Identify the presenting symptoms and signs, determine the probable diagnosis, and use
simplified management protocols for vaginal bleeding after childbirth.
Clean and Safe Delivery and Management of PPHParticipant Handbook
3
COURSE GOAL
To provide the participants with essential knowledge, skills, and attitudes in prevention of
PPH at community and health facility levels and manage cases of PPH at health facilities.
PARTICIPANTS’ LEARNING OBJECTIVES
By the end of this training, the participants will be able to:

Describe the current status of maternal and newborn health and maternal and newborn
mortality in South Sudan





Identify interventions for making pregnancy safer

Manage cases of PPH at the health facility using the PPH clinical guidelines and refer
in a timely manner when needed

Provide supportive supervision to the HHPs attached to their health facility
Define maternal death
Use interpersonal and communication skills to counsel a pregnant woman
Describe the components of BP/CR plans
Perform the steps of clean and safe delivery including active management of 3rd stage of
labour (AMTSL) and immediate essential newborn care (ENC)
PARTICIPANTS’ LEARNING ACTIVITIES
In order to achieve the learning objectives, participants will carry out following activities.


Complete the pre- and post-course theory assessment
Practice skills including clean and safe birth with AMTSL and ENC, manage shock, and
perform bimanual uterine compression, insertion of uterine balloon tamponade and
manual removal of placenta on anatomical models.
TRAINING/LEARNING METHODS






Interactive presentations
Large group discussion
Small group work
Case studies
Practice in role play setting
Clinical simulations
TRAINING MATERIALS






PPH prevention and BP/CR flip cards


Infection prevention supplies
4
Recordkeeping forms
Government of South Sudan clinical guidelines on prevention and management of PPH
Participants reference materials
Anatomical models (Mama Natalie)
Instruments and equipment for assisting normal birth, management of PPH, manual
removal of placenta, uterine balloon tamponade and newborn resuscitation
Videos
Clean and Safe Delivery and Management of PPHParticipant Handbook
PARTICIPANT SELECTION CRITERIA
Participants for this course are:


Skilled birth attendants11 who have recently been/are conducting deliveries

Interested in updating their skills and knowledge to prevent and manage PPH
Released for the training by their supervisors and have the support of their supervisors
to implement new skills
NOTE: Community Health Workers (CHWs) have a limited role in maternal,
newborn, and child health (MNCH) activities and are not currently permitted to
administer uterotonics or perform any activities related to managing PPH other
than arranging referral and, if needed, massaging the uterus if it is soft and
administering oral rehydration salts.
METHOD OF EVALUATION
Participants: A pre-test will be completed on Day 1 and a post-test on Day 4. However, the
main focus is participants’ ability to prevent and manage PPH. The evaluation includes:



Pre-course knowledge assessment
Post-course knowledge assessment
Evaluation of skills on models
Course Duration: 5 Days
Suggested Course Composition: 16 participants, four trainers
In some cases, maternal and child health workers (MCHWs) may also participate and the training will need to be
modified according to their skills level.
11
Clean and Safe Delivery and Management of PPHParticipant Handbook
5
TRAINING ON CLEAN AND SAFE BIRTH AND PREVENTING/MANAGING POSTPARTUM HAEMORRHAGE (PPH)
DAY 1
AM (4 hours)
 Welcome and opening
 Participant introductions
 Overview of the workshop: Course
expectations, training goals and
objectives, schedule, training
materials and training approach;
group norms
 Pre-test
Tea break
 Overview of maternal health
situation in South Sudan and PPH
prevention project
 Group work around 3 delays
(includes referral process)
 Review BP/CR and PPH
prevention flip cards
6
DAY 2
AM (4 hours)
 Agenda and warm-up
 Video: Assisting a normal birth
 Conducting clean and safe
delivery:
 Trainer demonstration: Clean
and safe delivery including
AMTSL and immediate routine
care of mother and newborn
Tea break
 Skill practice in clean and safe
delivery, AMTSL, immediate
routine care of mother and her
new-born
DAY 3
DAY 4
DAY 5
AM (4 hours)
 Agenda and warm-up
 Trainer demonstration:
Management of shock linked to PPH
 Skill practice in teams:
Management of shock linked to
PPH
Tea break
 Case study 1: Management of
postpartum haemorrhage.
 Trainer demonstration:
 Bimanual uterine compression
 Uterine balloon tamponade
(UBT)
- Aortic compression
 Participants practice:
 Bimanual uterine compression
 UBT
AM (4 hours)
 Agenda and warm-up
 Post-test
 Clinical simulation: Management
of postpartum haemorrhage
 Trainer demonstration: Episiotomy
and perineal repair
Tea break
 Skills practice: Episiotomy and
Perineal repair and others
 Skills practice: all skills in
classroom/clinical area and
checkout
AM (4 hours)
 Agenda and warm-up
 Introduction/orientation to record
keeping and reporting:
 Health facility admission form
 CHW register or pictorial forms
 Monthly Misoprostol & Oxytocin
Consumption Log Books
 Delivery registers
Tea break
 Skills practice in
classroom/clinical area and
checkout
LUNCH
LUNCH
LUNCH
LUNCH
LUNCH
PM (3 hours)
PM (3 hours)
PM (3 hours)
PM (3 hours)
PM (2 hours)
 Warm-up
 Pre-test results and discussion
 Role play 1: Communicating with
pregnant women
Tea break
 Update on infection prevention:
 Handwashing activity
 Personal protective equipment
 Decontamination
 Instrument processing
 Summary of the day
 Warm-up
 Overview of birth asphyxia
 Newborn resuscitation
demonstration
 Newborn resuscitation practical
session
 Practice continues
Tea break will be taken during the
practice
 Overview of postpartum and
newborn care and discussion
 Trainer presentation: Management
of postpartum haemorrhage
protocol
 Summary of the day
 Warm-up
 Misoprostol quiz
 Trainer demonstration:
 Manual removal of placenta
 Participants practice:
 Manual removal of placenta
 Ensuring supply and safe storage
of oxytocin
 Skills practice in classroom as
time allows
 Summary of the day
 Warm-up
 Groupwork: Strengthening the
referral process
 Trainer demonstration: Counselling
a woman and her family using
PPH prevention flip charts
 Participant practice: Counselling
women on prevention of PPH
 Introduction to supportive
supervision
 Role Play 2: Supportive
supervision
 Skills practice continues classroom
and checkout when able
 Summary of the day
 Warm-up
 Action plans for implementing new
skills in health facilities
Tea break
 Training evaluation
 Summary and closing
Assignments: Review
checklistassisting normal birth and
PPH guidelines
Assignments: Review PPH guidelines
and checklists
Assignments: Revise all materials,
review checklists and BP/CR and
PPH prevention flip cards
Assignments: Share blank action
plans. Ask participants to begin
completing these – to be continued
on Day 5
Clean and Safe Delivery and Management of PPHParticipant Handbook
The PPH Programme in South Sudan
Text Box 2. Maternal Death
Definition of Maternal Death: Death of a woman while she is pregnant or within 42 days after the end of pregnancy
irrespective of the cause of death.
Maternal Mortality in South Sudan:
In South Sudan 2054 women die due to complications of pregnancy and childbirth for every 100,000 births. This
means that for every 50 births, 1 woman dies. This is the highest in the world.
Direct Causes of Maternal Death:

Postpartum haemorrhage

Infection

Obstructed labour/Ruptured uterus

Eclampsia/Severe pre-eclampsia

Complications of abortion
Not being able to get timely care in case of emergency adds to the reasons why many women die. The delays include:
1. Delay in recognizing complications and making decisions about seeking care
2. Delay in arriving at the health facility
3. Delay in getting correct care once at the health facility
Figure 1. Delays That Lead to Maternal Death
There could be many reasons for each of the delays.
Birth Preparedness and Complication Readiness (BP/CR) Plans help address the
first two delays.
Components of Birth Preparedness and Complication Readiness Plans:
 Delivering with a skilled birth attendant and at a health facility
 Saving money for emergency situation including transportation
 Identifying blood donor
 Planning in advance for transportation
 Recognizing the danger signs during pregnancy and childbirth
 Identifying the decision-maker
Clean and Safe Delivery and Management of PPHParticipant Handbook
7
Text Box 3. Key Points on PPH Prevention Project










8
Many women in South Sudan die due to complications of childbirth.
Bleeding after birth is the main cause of maternal death.
The best option to reduce maternal deaths is for women to give birth with a skilled provider at a health facility
where she will be given an injection or 3 tablets of a uterotonic to reduce bleeding after the baby is born.
Research has shown that if a woman takes 3 tablets of a drug named misoprostol immediately after the birth
and before the placenta comes out she has very low risk of bleeding after birth. This also works for women who
deliver at home.
These tablets can be easily distributed by trained community health volunteers.
The eligibility criteria for women to be provided with misoprostol include:
o Has reached 32 weeks gestation or greater
o No known history of allergy to prostaglandins
o Has not had a previous Caesarean section
The set of interventions for prevention of bleeding after birth includes: counselling a woman on a Birth
Preparedness and Complication Readiness (BP/CR) plan (including delivering at a health facility with skilled
birth attendant), counselling on prevention of PPH, giving a woman misoprostol tablets, and postpartum and
newborn follow up.
Under this project, Home Health Promoters (HHPs) will be trained for 4 days and will be supported to visit
pregnant women in their areas and provide the interventions including misoprostol tablets for women who are
likely to deliver at home.
The skilled birth attendants at PHCCs/PHCUs will also be trained in interventions to prevent and manage
bleeding after birth in women who are referred to a health facility from the community.
Use the lessons learned from the learning phase to expand the programme to the whole country so that as
many women as possible are protected from PPH.
Clean and Safe Delivery and Management of PPHParticipant Handbook
Clean and Safe Delivery
Best practices in assisting childbirth (see Checklist 1):
1.
2.
3.
4.
Getting readymake sure you have all the necessary supplies
Assisting the birth and immediate newborn care
Active management of the third stage of labour
Immediate postpartum care
Text Box 4. Points to Remember for Clean and Safe Delivery
Points to Remember!

Offer active management of third stage of labour (AMTSL) to ALL women:
 Give oxytocin 10 IU (international units) intramuscularly within 1 minute of birth.
 Perform controlled cord traction (CCT) (with skilled provider only).
 Massage uterus if soft or relaxed; check uterus every 15 minutes for 2 hours; massaging it if soft.
 Perform routine examination of the placenta and membranes.
 Perform routine examination of vagina and perineum for lacerations and injury.
PER GUIDELINES FOR PREVENTION AND MANAGEMENT OF PPH
(GOSS 2012)

Oxytocin is the drug of choice for AMTSL:
 Dose for routine administration; 10 IU
intramuscularly (IM) within 1 minute, acts fast and
lasts about 2–3 minutes after childbirth
 Minimal side effects
 Affordable
 In twin pregnancy, give oxytocin after delivery of
the second baby.

Misoprostol
 A synthetic prostaglandin E1 analogue, which,
among other actions, induces uterine contraction.
When administered after delivery of the baby it
prevents postpartum haemorrhage.
 Dose and route of administration; 600 mcg orally,
within 1 minute of childbirth.
 Can also be administered through other routes;
rectal; sublingual, and vaginal.
 Onset of action is 4–9 minutes after oral
administration (7–13 minutes after rectal) and its
action may persist for about 3 hours.
 Does not need cold storage.
See Circular Storage and Use of
Oxytocin May 2013 (Appendix C).
 Should not be given to a pregnant woman as it
can cause abortion, premature labour, and even
rupture of the uterus.
 Side effects include rigours, nausea, and diarrhoea, and women should be counselled
on these before taking the tablets.

Ergometrine 0.5 mg (ergometrine maleate) by IM injection acts within 6–7 minutes
 Prolonged duration of action (2–4 hours)
 Contraindicated in patients with hypertension, pre-eclampsia, eclampsia, severe
anaemia, and valvular heart disease
 Affordable
Clean and Safe Delivery and Management of PPHParticipant Handbook
Safe Oxytocin Supply
It is important that oxytocic drugs
are stored in a cool place and kept
out of direct sun light. Keep them in
the refrigerator or cold box if you
have one. Do not use an oxytocic if
it is cloudy or has colour change.
Ensure you have sufficient supplies
for at least 1 month.

In general terms, the WHO
recommendation is that
oxytocin be stored under
refrigerated (at 2–8°C)
conditions as much as possible.

It is acceptable to keep
oxytocin injections
unrefrigerated for a short
period, for example, during
transportation, at 30°C not
exceeding 1 month or 2 weeks
at 40°C.

Storing oxytocin injections at a
maximum of 30°C may be
acceptable for quality for a
period up to 1 month.
9


Side effects include nausea and vomiting, raised blood pressure
Remember that ergometrine should not be given to women with:

Hypertensionas it increases the risk of convulsions

Severe anaemiaas it may increase the possibility of congestive cardiac failure

Heart failureas it will worsen the condition
POINTS TO REMEMBER IN AMTSL
1. Prepare the 10IU oxytocin in a syringe BEFORE second stage, so that it is ready when
you need to give it.
2. Check that there are no other babies in the uterus.
3. Give or ask assistant to give the oxytocin within 1 minute of the delivery of the baby.
4. When there is a contraction, with hand above pubic bone, apply pressure on uterus in an
upward direction; at the same time, with the other hand, pull with a firm, steady tension
on the cord in a downward direction (see Figure 2).
5. Do not massage the uterus before the placenta is delivered; do not ask the mother to
push and do not push on the fundus.
Figure 2. Supporting the Uterus while Performing Controlled Cord Traction
6. Be patient; sometimes the vaginal muscles contract and hold the placenta. It takes a few
minutes of steady pressure for the vaginal muscles to relax and release the placenta.
This firm, steady pressure is learned with practice. Do not exert too much force. At the
same time, the pressure should not be so weak that it does not work. Practice will make
you comfortable with what is the proper amount of tension.
Never apply cord traction (pull) without applying counter traction (push) above the pubic bone with
the other hand.
7. Remember that a very small amount of retained membranes can prevent the uterus from
effectively contracting. Try to avoid letting the placenta come out suddenly, because this
could cause part of the membranes to tear off and be retained. Any retained
membranes will decrease the uterine contractions AND can cause PPH.
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Clean and Safe Delivery and Management of PPHParticipant Handbook
IMMEDIATE ESSENTIAL NEWBORN CARE
The main causes of newborn death are birth asphyxia, infection, and complications of low
birth weight/prematurity. Most newborns lives can be saved through simple evidence-based
interventions immediately after birth.
1. Cleanliness – wash hands and wear gloves
2. Warmth - dry the baby well with a clean dry cloth and place ‘skin to skin’ on the
mother’s bare chest, and cover with a clean, dry cloth.
3. Breathing – if the baby does not breathe or cry immediately after birth, help the baby
to breathe by drying the baby well, and deeply rub the baby’s back to stimulate
breathing. If stimulation does not work, immediately begin basic resuscitation of the
newborn to ensure the baby breathes within one minute (see Checklist 2).
4. Breastfeeding – ensure mother starts to breastfeed the baby within the first hour after
birth
5. Cord care – clamp/tie the cord 2-3 minutes after birth with a clean tie and cut with a
sterile blade.
6. Eye care - wipe the baby’s eyes with a clean swab and apply Tetracycline ointment
See Checklist 1 for more information on the key steps of immediate newborn care.
CARE IN IMMEDIATE POSTPARTUM PERIOD
Mother

Close monitoring and surveillance during first 4 hours postpartum:
 Blood pressure, pulse, vaginal bleeding, uterine tone
 Timing:

Every 15 minutes for 1 hour

Every hour from 2–4 hours

Every 4 hours until 12 hours
Newborn

Monitor the baby’s breathing and temperature every 15 minutes for 1 hour and every 30
minutes for the second hour, by touching its upper back (if cool or hot check temperature
with thermometer); also check colour and activity.
Text Box 5. Normal Labour and Childbirth: Key Points





Support the woman’s choice for position during labour and childbirth.
Encourage her to have a support person with her.
Provide continuous emotional and physical support to the woman throughout labour.
Use active management of third stage of labour.
Put baby in skin-to-skin contact with the mother and encourage breastfeeding within the first hour.
Clean and Safe Delivery and Management of PPHParticipant Handbook
11
Postpartum and Postnatal Newborn Care
The first 48 hours after birth are the most dangerous for the mother and the baby.
It is very important that the woman be given information about danger signs in
mother and baby, and she should also have a complication readiness plan.
OBJECTIVES OF POSTPARTUM AND POSTNATAL NEWBORN CARE



Prevent or detect and manage complications arising during the postpartum period.

Counsel on continued newborn postnatal care, danger signs (newborn hot or cold, not
feeding, convulsions, breathing problems) and action to take.




Counsel on exclusive breastfeeding and support breastfeeding.
Support the mother and her family in the transition to the new family.
Promote and maintain physical, mental and social well-being of both mother and
newborn by providing education on danger signals, nutrition, rest, sleep, and personal
hygiene, and by providing micronutrients, if necessary.
Counsel and provide services for contraception and resumption of sexual activity.
Immunize the mother against tetanus.
Work with the mother, her family, and her community to prepare a plan in case of
complication.
RETURN OF FERTILITY AFTER CHILDBIRTH

There are many benefits of spacing births and there are many options available for
spacing the next pregnancy:
 Lactational amenorrhoea method (LAM)
 Condoms
 IUD
 Injectable contraceptives
 Progestin-only pills
 Combined oral contraceptive pills

Encourage the woman to go to a health facility for further counselling and supplies
Good postpartum care includes:





12
Care by a skilled provider
Focus on mother and newborn
Multiple visits including at least one to the woman’s home
Detection and management of complications in a timely fashion
Interventions and education to promote continued good health of the mother and
newborn
Clean and Safe Delivery and Management of PPHParticipant Handbook
Postpartum Haemorrhage (PPH)
PPH or bleeding after childbirth can happen quickly so it is important to monitor the
woman’s condition, the amount of vaginal bleeding and uterine tone after the birth.

PPH can be dangerous if not treated in time, and a woman can die from it. Any woman
having PPH should be referred to the nearest PHCC or hospital for treatment.

The cause of bleeding after birth in the majority of cases is failure of the womb to
contract after childbirth. Other reasons are injury to the birth canal or failure of the
placenta, or part of it, to come out.
PRIMARY POSTPARTUM HAEMORRHAGE
Primary postpartum haemorrhage is excessive genital blood loss of 500 ml or more occurring
within 24 hours after delivery. In anaemic patients, minor loss of blood may cause
deterioration of the woman’s condition. So, any situation where the bleeding causes the
woman to become weak or to faint needs attention.
Causes of postpartum
haemorrhage (4Ts)
Figure 3. Causes of Postpartum Haemorrhage (4Ts)
TONE
TRAUMA
(75%)
TISSUE
CAUSE
(16%)
(8%)
THROMBIN
(1%)
Text Box 6. General Management of Vaginal Bleeding after Childbirth

Shout for helpurgently mobilize all available personnel.

Rapidly assess the woman’s general conditionlevel of consciousness, vital signs: pulse, blood pressure,
respiration, temperature.
If shock is suspected, immediately begin treatment. Keep in mind that shock may develop in a woman who
initially appears stable, so continue assessing the woman.




Give oxytocin 10 IU IMeven if already given.
Massage the uterus to expel blood and blood clots, and to ensure that the uterus contracts firmly.
Start an IV infusion (two if the woman is in shock) using large-bore (16-gauge or largest available) cannula or
needle and infuse IV fluids (normal saline or Ringer’s lactate) at a rate appropriate for the woman’s condition.




Catheterize the bladdermonitor urine output.
Check to see if the placenta has been expelled, and examine it for completeness.
Examine for tears of the perineum, vagina, and cervix.
After bleeding is controlled (24 hours after bleeding stops), determine haemoglobin or haematocrit and give
ferrous sulphate or ferrous fumerate.*
Refer/transfer the mother to a higher level of care, if necessary.

Uterine atony is the most common cause of postpartum haemorrhage. The uterine muscles
cannot contract (squeeze) and retract (shorten) to stop bleeding. If the woman loses too much
blood, she will go into shock and die.
Clean and Safe Delivery and Management of PPHParticipant Handbook
13
Usually in the case of uterine atony, there is no time to refer the woman to the hospital. The
skilled service provider who is available is the right person to serve the woman’s. Bimanual
compression of the uterus is an emergency procedure used to help the uterus contract and
control bleeding. This is a lifesaving skill. Bimanual compression of the uterus is done to
stop postpartum haemorrhage due to uterine atony (refer to Checklist 4).
Before doing Bimanual Compression:
1. Start IV infusion drip with oxytocin 10 IU in 1/2 litre (500 ml) of normal saline or
Ringer’s lactate.
2. Catheterize the bladder.
Figure 4. Bimanual Uterine Compression and Massage
If bimanual compression does not stimulate the uterus to contract after 10 minutes and fails
to stop the bleeding, perform abdominal aortic compression.
Compression of the aorta
Figure 6. Aortic Compression

Apply downward pressure with
closed fist over abdominal aorta
through abdominal wall (just above
umbilicus, slightly to patient’s left).

With other hand, palpate femoral
pulse to check adequacy of
compression.



Pulse palpable = inadequate.
Pulse not palpable = adequate.
Maintain compression until bleeding
is controlled.
If bleeding continues, consider use of
uterine balloon tamponade (Appendix F)
and refer the woman to a facility where
operative management and more
advanced care can be obtained.
14
Clean and Safe Delivery and Management of PPHParticipant Handbook
Retained placenta
A retained placenta may cause postpartum haemorrhage, shock and death. Manual removal of a
retained placenta (MROP) is an emergency procedure to prevent the death of a mother with
retained placenta.
If the third stage of labour lasts more than 30 minutes, CCT and IV/IM oxytocin (10 IU) should
be used to manage the retained placenta.
If the placenta is retained and bleeding occurs, the manual removal of the placenta should be
expedited.
Retained placenta or placental pieces without bleeding can happen. There is no immediate
danger AS LONG AS THE MOTHER IS NOT BLEEDING. Make sure that there is no
concealed bleeding by observing the fundus for enlargement and perform MROP within 1
hour.
Whenever MROP is undertaken, a single dose of prophylactic antibiotics is recommended.
Management of Retained Placenta
The placenta may be partially or completely separated from the uterus but not expelled.
When this happens, the uterus cannot contract well and it continues to bleed.
Figure 7. Manual Removal of the Placenta (Refer to Checklist 5)
Figure 8. Placenta in Palm of Hand
Clean and Safe Delivery and Management of PPHParticipant Handbook
15
Even a small piece of membrane left in the uterus may cause postpartum haemorrhage and/or
infection.
WARNING: Rapid action in response to PPH is critical!


More than half of all maternal deaths occur within 24 hours of childbirth, mostly due to excessive bleeding.
Uterine atony is the major factor in PPH, which causes more than one-quarter of all maternal deaths worldwide.
REVIEW QUESTIONS
What Did I Learn? Find out what you know and understand in this section of the module
by answering the following questions.
1. Define postpartum haemorrhage.
2. What is uterine atony and when is it
likely to happen?
3. Describe bimanual compression.
16
Clean and Safe Delivery and Management of PPHParticipant Handbook
Clean and Safe Delivery and Management of PPHParticipant Handbook
17
Supportive Supervision
Text Box 8. Supportive Supervision
What is Supervision?

A process of guiding, helping, training, and encouraging staff to improve their performance in order to provide
high-quality health services.

Supervision is carried out by a person responsible for the performance of clinical staff and non-clinical staff.

Supervision can be conducted internally by an on-site supervisor or externally by someone who makes periodic
supervision visits.

The internal, or on-site, supervisor conducts supervisory activities as part of everyday activities. Many internal
supervisors also provide clinical services at the site.

External supervisors periodically visit health care delivery sites, where they do not work on a day-to-day basis,
to help staff improve and maintain performance and quality.
Supervisors’ responsibilities include the following:

Identify standards of good performance and communicate them to staff members.

Work with staff to periodically assess their performance compared to these standards.

Provide feedback to staff about their performance.

Work with staff and the community to identify appropriate interventions that will lead to improved worker
performance and delivery of high-quality services.

Mobilize resources from many different sources to implement interventions.

Ensure that interventions have had the intended effect.
SUPERVISOR SKILLS








18
Demonstrate technical competence
Facilitate team building
Motivate others
Facilitate meetings and discussions
Identify strengths of staff members and build on positive aspects
Provide constructive, timely and interactive feedback
Communicate effectively with staff and decision-makers
Delegate duties to staff
Clean and Safe Delivery and Management of PPHParticipant Handbook
Text Box 9. Roles and Responsibilities
Home Health Promoters

Identify pregnant women in the community.

Counsel women and their family members on:
 Birth Preparedness and Complication
Readiness
 Prevention of postpartum haemorrhage

Visit the woman after she is 8 months pregnant.

Provide misoprostol tablets and provide
instructions on use.

Keep the empty package and submit it to the
supervisor.

Provide at least 4 home visits for every pregnant
woman in the community.
 During initial months of pregnancy
 After 8 months of pregnancy
 Within 24 hours
 Within 6 days after childbirth

Maintain the list of women counselled and given
misoprostol.

Track the use of misoprostol tablets; make sure
there are always some tablets available, and store
them properly.

Collect unused tablets and return them to the
supervisor.

On a monthly basis, report to the PHCU on the
activities during the reporting month.
Health Care Providers

Provide ANC to the women who are referred by
the HHPs.

Counsel women and their family members on:
 Birth Preparedness and Complication
Readiness
 Prevention of postpartum haemorrhage

After 8 months of pregnancy, provide misoprostol
tablets and provide instruction on use, if HHP has
not yet distributed misoprostol.

Complete recordkeeping forms.

Track the use of misoprostol tablets, make sure
there are always some tablets available, and store
them properly.

Collect unused tablets and return them to the
supervisor.

If assigned the role of supervisor, collect and
compile the recordkeeping forms and misoprostol
stock reports and send report to the project office.

Provide technical support to the HHPs in case they
have problems.

Conduct normal births and carry out active
management of third stage of labour.

Manage cases of PPH referred by the HHPs as per
the clinical guidelines.
Clean and Safe Delivery and Management of PPHParticipant Handbook
19
Role Play 1: Communicating About A
Woman’s Right to Safe Motherhood
DIRECTIONS
The teacher will select three learners to perform the following roles: a skilled provider, a
woman seeking information about the services available at the health centre, and the
woman’s mother. The three learners participating in the role play should take a few minutes
to read the background information provided below and to prepare for the role play. The
observers in the group should also read the background information so that they can
participate in the small group discussion following the role play.
The purpose of the role play is to provide an opportunity for learners to appreciate the
importance of good communication when providing information to women about available
health care and their sexual and reproductive rights.
PARTICIPANT ROLES
Provider:
The provider is an experienced community midwife at the primary health
care centre who has good communication skills.
Jane:
Jane is a 28-year-old woman; she has four living children, she is now
4 months pregnant; she had one baby die shortly after birth. Her sister
died in childbirth last year.
Jane’s mother: Jane’s mother is 52 years old. She has eight living children; she had two
stillbirths, and had one child die when she was 1 month old. One of her
daughters died in childbirth last year.
SITUATION
Jane has come to the health centre with her mother. Jane’s mother and grandmother helped
her to deliver each of her babies at home. Jane has been to the health centre once before: she
brought her 5-year-old son to the health centre when he had pneumonia last year. The
women are interested in learning more about the care for women that is available at the
health centre because a relative delivered her baby at the health centre 6 months ago. Jane
is nervous about her current pregnancy because her sister died in childbirth last year.
FOCUS OF THE ROLE PLAY
The focus of the role play is the interaction between the midwife, Jane, and Jane’s mother.
The midwife should:


Be friendly and reassuring;




Describe the role of the midwife to the women;
Assess Jane’s knowledge about the role of the midwife and the services available for
women at the health centre;
Briefly explain what services are available for women at the health centre;
Encourage the women to ask questions and address the questions that are asked;
Discuss safe motherhood and a woman’s right to have safe health care.
Jane and her mother should ask questions and express concerns until the midwife has
provided them with enough information so that they understand the role of the midwife and
the care available at the health centre.
20
Clean and Safe Delivery and Management of PPHParticipant Handbook
DISCUSSION QUESTIONS
The teacher should use the following questions to facilitate discussion after the role play:
1. How did the midwife approach Jane and her mother?
2. Did the midwife give Jane and her mother enough information about the role of the
midwife? About the health centre? About her right to safe motherhood?
3. How did Jane and her mother respond to the midwife?
4. What did the midwife do to demonstrate emotional support and reassurance during her
interaction with Jane and her mother? Were the midwife’s explanations and reassurance
effective?
Clean and Safe Delivery and Management of PPHParticipant Handbook
21
Role Play 2: Supportive Supervision
DIRECTIONS
The trainer will select two learners to perform the following roles: midwife from the health
centre and a home health promoter. The two participants taking part in the role play should
take a few minutes to prepare for the activity by reading the background information
provided below. The remaining participants, who will observe the role play, should at the
same time read the background information.
The purpose of the role play is to provide an opportunity for participants to develop/practice
effective interpersonal skills with respect to providing supervision that encourages
performance improvement and improvement in the quality of services.
LEARNERS ROLES
Midwife:
Midwife Alice has been working in the health centre for 4 years. She
recently completed an in-service training course on supervision for
improving the quality of services.
HHP:
Home Health Promoter Sarla has been working in her community for 3
months, and before this as a traditional birth attendant (TBA) for 15
years.
SITUATION
Since beginning work as a HHP 3 months ago, HHP Sarla has been providing care to the
women in her community before, during, and after childbirth. She was recently trained in
distribution of misoprostol and has counselled and distributed the tablets to three women.
Alice visits Sarla’s community one day to observe her counselling a woman who is due next
month. A neighbour comes in and complains that Sarla is telling the women they must deliver
at home. The neighbour says some of the women want to go the health facility to have their
babies as they have been told by staff at the antenatal clinic this is where skilled care is
available. They cannot understand why Sarla is giving them another message. Midwife Alice
takes Sarla to sit under a tree to discuss this information and to understand what has
happened.
FOCUS OF THE ROLE PLAY
The focus of the role play is the interpersonal interaction between Midwife Alice and HHP
Sarla and the appropriateness of Midwife Alice’s supervisory skills.
DISCUSSION QUESTIONS
The trainer should use the following questions to facilitate discussion after the role play:
1. How did Midwife Alice let HHP Sarla know that there was a problem affecting her
performance as a HHP?
2. What interventions did Midwife Alice suggest to improve HHP Sarla’s performance?
3. How will MW Alice monitor improvements in HHP Sarla’s performance?
22
Clean and Safe Delivery and Management of PPHParticipant Handbook
Case Study 1: Vaginal Bleeding After Childbirth
DIRECTIONS
Read and analyse this case study individually. When the others in your group have finished
reading it, answer the case study questions. Consider the steps in clinical decision-making
as you answer the questions. The other groups in the room are working on the same or a
similar case study. When all groups have finished, we will discuss the case studies and the
answers each group has developed.
CASE STUDY
Annie is 20 years old. She gave birth to a full-term newborn 2 hours ago at home. Her birth
attendant was the local traditional birth attendant (TBA), who has brought Annie to the
health centre because she has been bleeding heavily since childbirth. The duration of labour
was 12 hours, the birth was normal, and the placenta was delivered 20 minutes after the
birth of the newborn.
ASSESSMENT
(History, Physical Examination, Screening Procedures/Laboratory Tests)
1. What will you include in your initial assessment of Annie, and why?
2. What particular aspects of Annie’s physical examination will help you make a diagnosis
immediately or identify her problems/needs, and why?
DIAGNOSIS
(Identification of Problems/Needs)
3. You have completed your rapid assessment of Annie and your main findings include the
following:
 Her pulse rate is 108 beats/minute, her blood pressure is 80/60 mm Hg, her
respiration rate is 24 breaths/minute, and her temperature is 36.8°C.
 She is pale and sweating.
 Her uterus is soft and does not contract with fundal massage. She has heavy, bright
red vaginal bleeding.
 The TBA says that she thinks the placenta and membranes were complete.
4. Based on these findings, what is Annie’s diagnosis, and why?
CARE PROVISION
(Planning and Intervention)
5. Based on your diagnosis, what is your plan of care for Annie, and why?
EVALUATION
Some placental tissue has been removed from Annie’s uterus. Fifteen minutes after the
initiation of treatment, the bleeding is less and the uterus is firm. Her pulse is 80
beats/minute and her blood pressure 100/60 mm Hg.
6. Based on these findings, what is your continuing plan of care for Annie, and why?
Clean and Safe Delivery and Management of PPHParticipant Handbook
23
Checklist 1: Assisting Normal Birth with
Active Management of Third Stage of Labour
and Immediate Newborn Care
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant_____________________________________________________________Date Observed ________________
CHECKLIST FOR ASSISTING NORMAL BIRTH WITH ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR AND
IMMEDIATE NEWBORN CARE
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
Prepare the necessary equipment and ensure the room is warm and clean.
2.
Encourage the woman to adopt the position of choice and continue
spontaneous bearing-down efforts.
3.
Tell the woman what is going to be done, listens to her, and respond attentively
to her questions and concerns.
4.
Provide continual emotional support and reassurance, as feasible.
5.
Put on personal protective barriers.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
ASSISTING THE BIRTH
1.
Wash hands and put on two pairs of high-level disinfected or sterile surgical gloves.
2.
Cleanse the woman’s perineum, and place a drape under her buttocks and one
on her abdomen; ask her to pant or give only small pushes with contractions.
3.
Control the birth of the head with the fingers of one hand to maintain flexion,
allow natural stretching of the perineal tissue, and prevent tears, and use the
other hand to support the perineum.
4.
Wipe the mucus (and membranes, if necessary) from the baby’s face
5.
Feel around the baby’s neck for the cord and respond appropriately if the cord
is present.
6.
Allow the baby’s head to turn spontaneously and, with the hands on either side
of the baby’s head, deliver the anterior shoulder.
7.
When the axillary crease is seen, guide the head upward as the posterior
shoulder is born over the perineum and lift the baby’s head anteriorly to deliver
the posterior shoulder.
8.
Support the rest of the baby’s body with one hand as it slides out and place the
baby on clean drape on the mother’s abdomen.
9.
Thoroughly dry the baby, removes wet towel and cover with a clean, dry cloth,
and assess breathing.
10. If baby does not begin breathing regularly (not crying) begin stimulation
(Checklist 2).
11. Ensure that the baby is kept warm and in skin-to-skin contact on the mother’s
chest. Tell the mother the sex of the baby
12. Palpate the mother’s abdomen to rule out the presence of additional baby(ies)
and proceed with active management of the third stage.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
24
Clean and Safe Delivery and Management of PPHParticipant Handbook
CHECKLIST FOR ASSISTING NORMAL BIRTH WITH ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR AND
IMMEDIATE NEWBORN CARE
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (SKILLED BIRTH ATTENDANTS)
1.
Give oxytocin 10 units IM Or 600 mcg misoprostol orally within 1 minute after
explaining what the drug is for and the side effects.
2.
Remove the top pair of gloves or change gloves.
3.
Clamp and cut cord approximately 3 minutes after birth.
4.
Clamp cord close to perineum and apply counter traction to stabilize the uterus.
Wait for a strong uterine contraction, then very gently pull downward on the
cord to deliver the placenta.
5.
As the placenta delivers, hold it with both hands and twist slowly so the
membranes are expelled intact.
6.
Immediately check the uterus and massage if soft.
7.
Examine the placenta, membranes, and cord for completeness.
8.
Examine the lower vagina and perineum for lacerations/tears.
9.
Cleanse perineum and apply a pad or cloth to vulva.
10. Ensure mother is warm and comfortable, and baby is with her, and encourage
breastfeeding.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (MATERNAL AND CHILD HEALTH WORKERS)
1.
Give 600 mcg misoprostol orally within 1 minute after explaining what the drug
is for and the side effects.
2.
Remove top pair of gloves or change gloves.
3.
Clamp and cuts cord approximately 3 minutes after birth.
4.
Wait until the mother expels the placenta spontaneously.
5.
Immediately check the uterus and massages if soft.
6.
Examine the placenta, membranes, and cord for completeness.
7.
Examine the lower vagina and perineum for lacerations/tears.
8.
Cleanse perineum and apply a pad or cloth to vulva.
9.
Ensure mother is warm and comfortable, and baby is with her, and encourage
breastfeeding.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-PROCEDURE TASKS
1.
Dispose of contaminated items in a plastic bag or leakproof, covered container.
2.
Decontaminate all instruments in 0.5% chlorine solution for 10 minutes.
3.
Safely dispose of needle and syringe in puncture-resistant sharps container.
4.
Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out and place them in a leakproof container or plastic bag.
5.
Wash hands thoroughly.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
IMMEDIATE POSTPARTUM AND NEWBORN CARE
1.
Monitor the woman every 15 minutes in the first hour and every 30 minutes in
the second hour checking:
 Uterine tone
 Vaginal bleeding
 Blood pressure
 Pulse
2.
Monitor baby’s temperature every 15 minutes for 1 hour; every 30 minutes for
second hour, by touching its upper back; also checks colour, breathing and
activity.
Clean and Safe Delivery and Management of PPHParticipant Handbook
25
CHECKLIST FOR ASSISTING NORMAL BIRTH WITH ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR AND
IMMEDIATE NEWBORN CARE
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
3.
Encourage and support the mother in initiating breastfeeding within the first
hour after birth. Wash the mother’s nipples only if visibly dirty.
4.
After the baby has breastfed:
 Check the cord; if there is bleeding from the cord, retie it if necessary.
 Weigh the baby.
 Examine the baby.
 Perform eye care (wipe eyes with dry swabs and apply Tetracycline
ointment).
 Ensure the baby is dressed warmly and with the mother.
 Explain to the mother the importance of delayed bathing and not to apply
anything to the skin or cord.
5.
Ask the woman if she has urinated and encourage her to do so whenever she
wishes.
6.
Encourage the woman to eat and drink.
7.
Encourage the woman to stay in the facility for next 24 hours and to attend for
further postpartum care within next 3 days.
8.
Record all information on the woman’s clinical record, including blood loss.
Record all newborn information including Apgar score and weight.
CASES
SKILL/ACTIVITY PERFORMED SATISFACTORILY
26
Clean and Safe Delivery and Management of PPHParticipant Handbook
Checklist 2: Helping a Baby Breathe/
Newborn Resuscitation
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant ______________________________________________________Date Observed _______________________
CHECKLIST FOR HELPING A BABY BREATHE/NEWBORN RESUSCITATION
(Some of the following steps/tasks should be performed simultaneously)
STEP/TASK
CASES
GETTING READY
1.
Ensure that the resuscitation area is prepared and check that equipment is
functioning (bag and mask, suction) before delivery.
2.
Thoroughly dry the baby, remove wet towel, cover with a clean, dry cloth, and
assess breathing. If baby does not begin breathing regularly (not crying),
stimulate the baby by rubbing the heel of your hand up and down along baby’s
spine. If the baby is still not breathing, clamp and cut the cord and move the
baby to a firm surface and begin resuscitation.
3.
Place the baby on his/her back on a clean, warm surface and keep covered
except for the face and chest.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
RESUSCITATION USING BAG AND MASK
1.
Position the head in a slightly extended position to open the airway.
2.
If secretions are seen, clear the airway by suctioning the mouth first and then
the nose:
 Introduce catheter or penguin sucker into the baby’s mouth no more than
5 cm beyond the lips, and suction while withdrawing catheter.
 Introduce catheter or penguin sucker into each nostril for 1–2 cm and
suction while withdrawing catheter.
 Repeat mouth and nose suction nor more than twice, if needed.
 Spend no more than 20 seconds doing this.
3.
If the baby is still not breathing, begin ventilation within 60 seconds; place the
mask on the baby’s face so that it covers the chin, mouth, and nose.
4.
Squeeze the bag with two fingers only or with the whole hand, depending on
the size of the bag.
5.
Check the seal by ventilating two or three times and observing the rise of the
chest.
6.
If the baby’s chest is rising, ventilate at a rate of 40 breaths per minute, and
observe the chest for an easy rise and fall.
7.
If the baby’s chest is not rising, determine why, rectify the problem, and
continue to ventilate.
8.
Ventilate for 1 minute, then quickly assess the baby for spontaneous
breathing and colour; if breathing is normal, stop ventilating and give to
mother and continue to monitor.
9.
If the baby is not breathing after 1 minute or is not breathing well, call for help
and improve ventilation (reposition the head, suction and open the mouth,
reapply the mask).
10. Ask assistant to check heart rate (cord pulsation or listen to heartbeat with
stethoscope).
Clean and Safe Delivery and Management of PPHParticipant Handbook
27
CHECKLIST FOR HELPING A BABY BREATHE/NEWBORN RESUSCITATION
(Some of the following steps/tasks should be performed simultaneously)
STEP/TASK
CASES
11. If the baby’s heart rate is normal but breathing is less than 30 breaths per
minute or irregular, continue to ventilate for 3–5 minutes until the baby is
breathing well; stop ventilating and monitor baby with mother.
12. If the baby is not breathing and the heart is beating, continue ventilation with
oxygen if available, organize transfer, and refer baby to a tertiary care centre,
if possible.
13. If there is no breathing after 10 minutes of ventilation or gasping type of
breathing for 20 minutes and heart rate <60: suspend resuscitation and
records the time of death.
14. Inform the mother, husband/parents/relatives of the baby’s condition and
provide emotional support to mother/parents and family members.
15. Wash hands thoroughly.
16. Complete records with details of resuscitation and condition of newborn.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-RESUSCITATION TASKS
1.
Disassemble the bag and mask and soak all resuscitator parts in 0.5%
chlorine solution for 10 minutes for decontamination.
2.
Soak suction catheters and/or penguin sucker in 0.5% chlorine solution for
10 minutes for decontamination, then wash, dry, and sterilize or high-level
disinfect.
3.
Wash all pieces thoroughly in soapy water.
4.
Rinse the parts carefully with clean water to remove all remaining detergent.
5.
Leave the items to dry before reassembling correctly (test functions).
6.
Progress to sterilize or high-level disinfect the bag and mask.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
28
Clean and Safe Delivery and Management of PPHParticipant Handbook
Checklist 3: Management of Shock Linked
to PPH
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant ______________________________________________________Date Observed _______________________
CHECKLIST FOR MANAGEMENT OF SHOCK
(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GENERAL MANAGEMENT
1.
Shout for help.
2.
Greet the woman respectfully and with kindness.
3.
If the woman is conscious and responsive, tell the woman (and her support
person) what is going to be done, listen to her, and respond attentively to her
questions and concerns.
4.
Provide continual emotional support and reassurance, as feasible.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
IMMEDIATE MANAGEMENT
1.
Check the woman’s vital signs:
 Temperature
 Pulse
 Blood pressure
 Respiration
2.
Palpate the uterus; massage if soft and expel clots.
3.
Give oxytocin 10 IU IM.
4.
Turn the woman onto her side and ensure that her airway is open. If the woman
is not breathing, begin resuscitation measures.
5.
Give oxygen at 6–8 L/minute by face mask or nasal cannula.
6.
Cover the woman with a blanket to ensure warmth.
7.
Elevate the woman’s legsif possible, by raising the foot of the bed.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
BLOOD COLLECTION, FLUID REPLACEMENT, AND BLADDER CATHETERIZATION
1.
Wash hands thoroughly and dry.
2.
Connect IV tubing to a 1 L container of normal saline or Ringer’s lactate with 20
IU oxytocin added (or 500 ml normal saline or Ringer’s lactate with 10 IU
oxytocin).
3.
Run fluid through tubing.
4.
Select a suitable site for infusion (e.g., back of hand or forearm).
5.
Place a tourniquet around the woman’s upper arm.
6.
Put on gloves.
7.
Clean skin with spirit.
8.
Insert 16- or 18-gauge needle or cannula into the vein.
9.
Draw blood for haemoglobin, cross-matching, and bedside clotting test.
10. Detach syringe from needle or cannula and connect IV tubing.
11. Secure the needle or cannula with tape.
Clean and Safe Delivery and Management of PPHParticipant Handbook
29
CHECKLIST FOR MANAGEMENT OF SHOCK
(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
12. Adjust IV tubing to run fluid at a rapid rate to infuse 1 L in 15–20 minutes.
13. Place the blood drawn into a labelled test tube for haemoglobin and cross-matching.
14. Place 2 ml of blood into a small glass test tube (approximately 10 mm x 75 mm)
to do a bedside clotting test:
 Hold the test tube in your closed fist to keep it warm.
 After 4 minutes, tip the tube slowly to see if a clot is forming.
 Tip it again every minute until the blood clots and the tube can be turned
upside down.
 If a clot fails to form or a soft clot forms that breaks down easily,
coagulopathy is possible.
15. Before removing gloves, dispose of waste materials in a leakproof container or
plastic bag.
16. Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out and place them in a leakproof container or plastic bag.
17. Use antiseptic handrub or wash hands thoroughly.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
BLADDER CATHETERIZATION
1.
Put new examination or high-level disinfected surgical gloves on both hands.
2.
Explain to the woman and clean the external genitalia.
3.
Insert catheter into the urethral orifice and allow urine to drain into a clean
receptacle, and measure and record amount.
4.
Secure catheter and attach it to urine drainage bag.
5.
Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning
them inside out and place them in a leakproof container or plastic bag.
6.
Use antiseptic handrub or wash hands thoroughly and dry.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
REASSESSMENT AND FURTHER MANAGEMENT
1.
Reassess the woman’s response to IV fluids within 15 minutes for signs of
improvement:
 Stabilizing pulse (90 beats/minute or less)
 Increasing systolic blood pressure (100 mm Hg or more)
 Improving mental status (less confusion or anxiety)
 Increasing urine output (30 ml/hour or more)
2.
If the woman’s condition improves:
 Adjust the rate of IV infusion to 1 L in 6 hours.
 Continue management for underlying cause of shock.
3.
If the woman’s condition fails to improve:
 Infuse normal saline rapidly until her condition improves.
 Continue oxygen at 6–8 L/minute.
 Continue to monitor vital signs every 15 minutes and intake and output every hour.
 Arrange for additional laboratory tests.
4.
Check vaginal bleeding. If heavy bleeding is seen, take steps to stop the
bleeding and transfuse blood, if necessary.
5.
Perform the necessary history, physical examination, and tests to determine
cause of bleeding if not already known (examine cervix, vagina, and perineum
and ask about completeness of placenta).
6.
Record all vital signs fluids and any drugs given.
7.
Make arrangements to refer the woman to higher level of care if required.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
30
Clean and Safe Delivery and Management of PPHParticipant Handbook
Checklist 4: Bimanual Compression of
the Uterus
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant ______________________________________________________Date Observed _______________________
CHECKLIST FOR BIMANUAL COMPRESSION OF THE UTERUS
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
Tell the woman what is going to be done, listen to her and respond attentively to
her questions and concerns.
2.
Provide continual emotional support and reassurance, as feasible.
3.
Ensure IV fluids with oxytocin are running.
4.
Put on personal protective barriers.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
BIMANUAL COMPRESSION
1.
Wash hands thoroughly with soap and water and dry.
2.
Put elbow-length sterile surgical gloves on both hands.
3.
Clean the vulva and perineum with antiseptic solution and place drapes under
the woman’s buttocks and over her abdomen.
4.
Insert one hand into the vagina and form a fist.
5.
Place the fist into the anterior vaginal fornix and apply pressure against the
anterior wall of the uterus.
6.
Place the other hand on the abdomen behind the uterus.
7.
Press the abdominal hand deeply into the abdomen and apply pressure against
the posterior wall of the uterus.
8.
Maintain compression until bleeding is controlled and the uterus contracts
at least 5 minutes.
9.
Gently remove hand from vagina.
10. Cleanse perineum, cover with pad, and ensure that the mother warm and
comfortable.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-PROCEDURE TASKS
1.
Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out and place them in a leakproof container or plastic bag.
2.
Wash hands thoroughly with soap and water and dry.
3.
Monitor vaginal bleeding and take the woman’s vital signs:
 Every 15 minutes for 1 hour
 Then every 30 minutes for 2 hours
4.
Make sure that the uterus is firmly contracted.
5.
Complete records.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Clean and Safe Delivery and Management of PPHParticipant Handbook
31
Checklist 6: Manual Removal of Placenta
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant_______________________________________________________Date Observed _______________________
CHECKLIST FOR MANUAL REMOVAL OF PLACENTA
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
Prepare the necessary equipment.
2.
Tell the woman what is going to be done, listen to her, and respond attentively
to her questions and concerns.
3.
Provide continual emotional support and reassurance, as feasible.
4.
Start IV of normal saline or Ringer’s lactate.
5.
Give diazepam (10 mg IV/IM) if available.
6.
Put on personal protective barriers.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
MANUAL REMOVAL OF PLACENTA
1.
Wash hands and forearms thoroughly with soap and water and dry.
2.
Put on long high-level disinfected or sterile surgical gloves on both hands.
3.
Clean vulva and perineal area and place sterile drape beneath the woman’s
buttocks.
4.
Ensure that the bladder is empty; catheterise if necessary.
5.
Hold the umbilical cord with a clamp.
6.
Pull the cord gently until it is parallel to the floor.
7.
Place the fingers of one hand into the vagina and the uterine cavity, following
the direction of the cord until the placenta is located.
8.
When the placenta has been located, let go of the cord and move that hand
onto the abdomen to support the fundus abdominally to prevent uterine
inversion.
9.
Move the fingers of the hand in the uterus laterally until the edge of the
placenta is located.
10. Keeping the fingers tightly together, ease the edge of the hand gently between
the placenta and the uterine wall, with the palm facing the placenta.
11. Gradually move the hand back and forth in a smooth lateral motion until the
whole placenta is separated from the uterine wall:
 If the placenta does not separate from the uterine wall by gentle lateral
movements, suspect placenta accreta and arrange for surgical intervention.
12. When the placenta is completely separated:
 Palpate the inside of the uterine cavity to ensure that all placental tissue has
been removed.
 Slowly withdraw the hand from the uterus bringing the placenta with it.
 Continue to provide counter-traction to the fundus by pushing it in the
opposite direction of the hand that is being withdrawn.
13. Have an assistant give oxytocin 10 IU IM and massage the fundus to encourage
uterine contraction.
14. Examine the placenta to ensure that it is complete.
32
Clean and Safe Delivery and Management of PPHParticipant Handbook
CHECKLIST FOR MANUAL REMOVAL OF PLACENTA
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
15. Examine the woman carefully and repair any tears to the cervix or vagina, or
repair episiotomy.
16. Wash perineal area and cover with a sterile sanitary napkin.
17. Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
turning them inside out and place them in a leakproof container or plastic bag.
18. Wash hands thoroughly with soap and water and dry.
19. Give a single dose of prophylactic antibiotics Ampicillin 2 g IV/IM.
20. If bleeding stops, give IV fluids slowly for at least 1 hour after removal of
placenta.
21. If there is continued heavy bleeding, give ergometrine 0.2 mg IM and oxytocin
20 units in 1 L IV fluid (normal saline or Ringer’s lactate) at 60 drops/minute
and arrange for urgent referral to higher level of care.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-PROCEDURE TASKS
1.
Monitor vaginal bleeding and take the woman’s vital signs:
 Every 15 minutes for 1 hour
 Then every 30 minutes for 2 hours
2.
Make sure that the uterus is firmly contracted.
3.
Complete patient records with details of the procedure and drugs given.
4.
Ensure woman is counselled on danger signs and self-care before discharge.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Clean and Safe Delivery and Management of PPHParticipant Handbook
33
Checklist 7: Episiotomy and Perineal Repair
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Participant_______________________________________________________Date Observed _______________________
CHECKLIST FOR EPISIOTOMY AND PERINEAL REPAIR
(Some of the following steps/tasks should be performed simultaneously)
STEP/TASK
CASES
GETTING READY
1.
Prepare the necessary equipment.
2.
Tell the woman what is going to be done and encourage her to ask questions.
3.
Listen to what the woman has to say.
4.
Make sure that the woman has no allergies to lignocaine or related drugs.
5.
Provide emotional support and reassurance, as feasible.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
MAKING THE EPISIOTOMY
1.
Clean perineum with antiseptic solution.
2.
Administer local anaesthesiaup to 10 ml 0.5% lignocaine.
3.
Wait to perform episiotomy until the perineum is thinned out and the baby’s head
is visible during a contraction. Ensure evidence-based indication to perform.
4.
Insert two fingers into the vagina between the baby’s head and the perineum.
5.
Insert the open blade of the scissors between the perineum and the fingers and
make a cut in a mediolateral direction.
6.
If birth of the head does not follow immediately, apply pressure to the episiotomy
site between contractions.
7.
Control the birth of the head to avoid extension of the episiotomy.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
REPAIRING THE EPISIOTOMY
1.
Apply antiseptic solution to area around episiotomy/tear—up to 10 ml 0.5%
lignocaine.
2.
Use a continuous suture from apex downward to repair vaginal incision.
3.
At the level of vaginal opening, bring cut edges together.
4.
Bring needle under vaginal opening and out through incision and tie.
5.
Use interrupted sutures to repair perineal muscle, working from top of perineal
incision downward.
6.
Use interrupted or subcuticular sutures to bring skin edges together.
7.
Wash perineal area and cover with a sterile sanitary napkin.
8.
Advise woman on personal hygiene (keep area clean and dry), need for good diet,
and a follow-up check within 6 days. Mild analgesics may be offered as needed.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-PROCEDURE TASKS
1.
Before removing gloves, dispose of waste materials in a leakproof container or
plastic bag.
2.
Place all instruments in 0.5% chlorine solution for decontamination.
34
Clean and Safe Delivery and Management of PPHParticipant Handbook
CHECKLIST FOR EPISIOTOMY AND PERINEAL REPAIR
(Some of the following steps/tasks should be performed simultaneously)
STEP/TASK
3.
Immerse both gloved hands in 0.5% chlorine solution and remove gloves by turning
them inside out and place them in a leakproof container or plastic bag.
4.
Wash hands thoroughly.
5.
Record procedure on woman’s record.
CASES
SKILL/ACTIVITY PERFORMED SATISFACTORILY
Clean and Safe Delivery and Management of PPHParticipant Handbook
35
36
Clean and Safe Delivery and Management of PPHParticipant Handbook
Appendix A: Action Plan for Effective
Implementation of Maternal and Newborn
Health Services
Objective: By the end of this session, participants will be able to:
1. Develop an action plan for effective implementation of maternal and newborn health (MNH) services
2. Identify the ways to collaborate with other facility staff, supervisors, County Health Department, and community
members to plan and implement MNH practices
DEVELOPING A PLAN OF ACTION FOR THE IMPLEMENTATION OF
MATERNAL AND NEWBORN HEALTH SERVICES
An action plan is a guide of how the acquired knowledge, skills, and attitudes from a
training are going to be used in contributing to strengthening the quality of MNH care.
Purposes of Knowledge and Skills Application Plan

To apply the knowledge and skills acquired during training in order to improve services
at the health facility

To help the trainer to identify areas in which trainees will require technical
assistance/coaching during follow-up supervision

As a follow-up post-training tool
Characteristics of a Sound Knowledge and Skills Implementation Plan




Meets the purpose
Is based on the actual situation and is feasible
Promotes team work
Is cost-effective and efficient
Components of Knowledge and Skills Action Plan
(refer to “Format for Developing Knowledge and Skills Application Plan” on next page)






Name of health facility
Priority changes
What shall we prepare or do to effect the change
What will we see happen in facility (expected outcome) among clients as a result of the
change
By when will we have made the changes
Anticipated limitations or comments
Clean and Safe Delivery and Management of PPHParticipant Handbook
A-1
FORMAT FOR DEVELOPING A KNOWLEDGE AND SKILLS APPLICATION PLAN
Name of Participant _________________________________________________ Health Facility ___________________________________ County ______________________ State __________________
Course Attended ________________________________________________ Dates of Training ________________________________________
WHAT WE PLAN TO DO
RESOURCES NEEDED
RESPONSIBLE
PERSONS/INSTITUTION FOR
PROVISION OF RESOURCES
BY WHEN
EXPECTED OUTCOME
LIMITATIONS OR REMARKS
Example: Ensure every
woman delivering at the
health facility receives a
uterotonic
A-2
Clean and Safe Delivery and Management of PPHParticipant Handbook
A-3
Clean and Safe Delivery and Management of PPHParticipant Handbook
Appendix B: Key Information for Counselling
on BP/CR and Distribution of Misoprostol
Text Box 10. Tips for Being an Effective Counsellor
Before Visit

Be prepared (practice the flip cards several times
before you start working in the community).

Always carry the record forms and misoprostol tablets
with you.

Ensure that the woman has time and has family
members to join the counselling session.
During Visit

Always ask for permission before entering the
compound or the house.

Be respectful, always.

Speak slowly and in the local language.

Answer questions and ask questions to ensure
learning.

Listen actively to what the woman and her family
members have to say.

Plan for the next visit if she is not ready to talk
this time for any reason.

Thank the woman and her family for their time.
After Visit

Make sure that you have completed the record and
reporting formats.
Text Box 11. Key Components of BP/CR Counselling
Following the advice and recommendations of the birth preparedness and complication readiness plan allows the
woman to deliver safely and access emergency services in case of serious illness.

Focused Antenatal Care:
 At least four visits during the pregnancy
 Receiving tetanus vaccine
 Blood pressure checks, blood, and urine
examination
 Checking the baby is growing and active
 Medicine for prevention of anaemia and
malaria
 Checking for HIV and other sexually
transmitted infections
 Health education on eating properly
 Taking frequent breaks and rest
 Advise on family planning after the baby is born





Saving money for emergency situations
 Saving a small amount money from early in
pregnancy
Knowing the woman’s blood group and identifying
potential donors
Ensuring availability of transport in case of
emergency
Identifying the health facility nearby to go in case
needed
Knowing the danger signs during pregnancy and
after childbirth

Danger Signs During Pregnancy (When to Take the Woman to a Health Facility)
 Convulsions or unconsciousness
 Vaginal bleeding
 Fever
 Severe headache and blurred vision
 Severe abdominal pain

Newborn danger signs
Baby hot or cold
Not feeding
Convulsions
Breathing problems
Text Box 12. BP/CR Key Points


Every pregnant woman, whether she is planning to deliver at home or at the facility, should have a birth
preparedness and complication readiness plan.
The plan should include:
 Determining the place where woman will deliver
 If SBA will be available to assist during the deliverydeciding which facility she may go to
 Saving money from early pregnancy for possible emergency situations like transport and buying medicines
 Making sure that transportation is available on very short notice in case there is a need to go to the
hospital
 Knowing the woman’s blood group and identifying potential blood donors to go with her in case of serious
complication during delivery
Clean and Safe Delivery and Management of PPHParticipant Handbook
B-1

B-2
Making sure that four ANC visits are made during pregnancy
Clean and Safe Delivery and Management of PPHParticipant Handbook
Text Box 13. Completing Recordkeeping Form (usually completed by Home Health Promoter)






This forms needs to be completed for all items.
If you are not able to get some information or not able to complete the task, YOU MAY MAKE ADDITIONAL
VISITS TO THE WOMAN’S HOUSE.
Visit 1:
 Enter the woman’s name and husband’s name in the space provide. If needed, seek someone’s help to
write (a teacher or a student).
 Enter if the woman is pregnant, which means if she did not have her monthly bleeding. Now enter the
information on number of months she is pregnant by colouring the moon sign—one for each month since
woman had her menstrual cycle.
 When you complete the BP/CR and PPH prevention counselling, enter that information in the next box
(item no. 10).
 If you have been given identity cards, complete the card with the woman’s name and a serial number.
 If woman is not yet 8 months pregnant, you will have to come again when she is 8 month pregnant. If the
woman is 8 month already, you may complete the tasks of giving misoprostol to the woman.
Visit 2:
 During the second visit, when woman is 8 months pregnant, enter the information in the first box when
you visit the woman’s house.
 Make sure that the woman is 8 months pregnant and enter that information in the second box.
 Also, ask the woman if a health care provider/birth attendant told her if she has one baby or more than
one baby in her womb. Enter that information in the appropriate box by looking at the picture.
 Enter in the next box when you finish repeat education on BP/CR and PPH.
 Give misoprostol to the woman and ask her to repeat instructions on how to take it and the side effects.
Visit 3:
 The third visit needs to happen within 24 hours of childbirth.
 In the first row, first box, enter a tick mark when you visit the house.
 Enter a tick mark that it is postpartum visit.
 Ask the woman where she delivered and enter that information in the next two boxes, by looking at the picture.
 Ask the woman if she had PPH, and if she had, enter a tick mark in the box showing bleeding after childbirth.
 Next, ask how many tablets of misoprostol she took and enter that information in the first box.
 Then ask if she had any side effects and enter that information on the side effects, as shown in the picture.
 Ask the woman if she has any of the danger signs, and if she has any of the following, refer her
immediately to the facility:

Convulsions or unconsciousness, excessing vaginal bleeding, fever, severe headache and blurred
vision, lower abdominal pain, or foul-smelling vaginal discharge
 Also ask questions about the danger signs in the newborn; if the baby has any of the danger signs, refer
immediately to the facility.
 Check that the baby has breastfed and is warm.
Visit 4:
 The fourth visit should happen around day six after childbirth.
 Ask the woman if she has any of the danger signs on the day of the visit; if she has one of the following,
refer immediately to the facility:

Convulsions or unconsciousness, excessive vaginal bleeding, fever, severe headache and blurred
vision, lower abdominal pain, or foul-smelling vaginal discharge.
 Enter information in the appropriate box by looking at the pictures, and refer the woman to a health
care facility.
 Also ask questions about the danger signs in the newborn; if the baby has any of the danger signs, refer
immediately to the facility.
 Enter this information in the appropriate box, by looking at the pictures, and the referral information.
 Ask if the baby is feeding well, and passing urine and stool.
 Tell the woman the benefits of family planning and encourage her to contact a health care provider at the
PHCU/PHCC.
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Appendix C: MOH Circular
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Appendix D: Referral Checklist
STEP
ACTION
1
Provide appropriate clinical care to stabilize the woman and the newborn.
2
Explain to the woman (if she is conscious) and her family what is happening and
that she or the newborn needs higher-level services.
3
Organize secure and reliable transportation for the woman.
4
Notify the referral site using phone or radio about the woman or newborn:
 Explain her condition/diagnoses.
 Describe the care already provided.
 Give the estimated time of arrival.
5
Ensure that the woman is accompanied by a family member and/or a potential
blood donor.
6
Assign a skilled care provider to attend the mother and/or the newborn during
the transfer.
7
Prepare all essential supplies and materials needed during the transfer. This
includes:
 Supplies for clean and safe delivery
 Emergency supplies (IV fluids, oxytocin, magnesium sulphate)
 Dry blankets and towels to keep the woman and the newborn warm:
 If transferring mother with newborn, practice skin to- skin contact
8
Complete referral record with:
 Name of referring and referral facility
 General patient information (name, age, address)
 Obstetric history (parity, gestational age, complications in ANC)
 Relevant post obstetric complications (e.g., previous C-section, PPH)
 The specific problem for which she is referred
 Treatment initiated and the results of treatments
 Name and signature of provider:
 Give referral record to the skilled care provider assigned to the transfer
9
Record referral in appropriate register.
10
Ensure that the assigned skilled provider obtains feedback from the referral
centre and ensures that the woman/ newborn has a follow-up management plan.
11
Ensure that in the case of maternal or newborn death during referral, the assigned
skilled provider reports mortality. (This will help us improve our services.)
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Appendix E: Recommendations for the
Prevention of PPH (WHO 2012)
1. The use of uterotonics for the prevention of PPH during the third stage of labour is
recommended for all births. (Strong recommendation, moderate-quality evidence)
2. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH.
(Strong recommendation, moderate-quality evidence)
3. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if
appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin
and ergometrine) or oral misoprostol (600 μg) is recommended. (Strong recommendation,
moderate-quality evidence)
4. In settings where skilled birth attendants are not present and oxytocin is unavailable,
the administration of misoprostol (600 μg PO) by community health care workers and lay
health workers is recommended for the prevention of PPH. (Strong recommendation,
moderate quality evidence)
5. In settings where skilled birth attendants are available, CCT is recommended for
vaginal births if the care provider and the parturient woman regard a small reduction in
blood loss and a small reduction in the duration of the third stage of labour as important
(Weak recommendation, high-quality evidence)
6. In settings where skilled birth attendants are unavailable, CCT is not recommended.
(Strong recommendation, moderate-quality evidence)
7. Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all
births while initiating simultaneous essential newborn care. (Strong recommendation,
moderate-quality evidence)
8. Early cord clamping (<1 minute after birth) is not recommended unless the neonate is
asphyxiated and needs to be moved immediately for resuscitation. (Strong
recommendation, moderate-quality evidence)
9. Sustained uterine massage is not recommended as an intervention to prevent PPH in
women who have received prophylactic oxytocin. (Weak recommendation, low-quality
evidence)
10. Postpartum abdominal uterine tonus assessment for early identification of uterine atony
is recommended for all women. (Strong recommendation, very-low-quality evidence)
11. Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in
caesarean section. (Strong recommendation, moderate-quality evidence)
12. Controlled cord traction is the recommended method for removal of the placenta in
caesarean section. (Strong recommendation, moderate-quality evidence)
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Appendix F: Uterine Balloon Tamponade
The use of intrauterine balloon tamponade (UBT) is recommended for persistent post partum
bleeding after bimanual uterine compression & external aortic compression have been used.
UBT is effective and has been approved by WHO and the MOH in South Sudan.
UTERINE BALLOON TAMPONADE FOR SEVERE PPH
Instructions
1.
2.
3.
4.
5.
6.
7.
8.
Place inner end of Foley catheter inside condom.
Using suture, securely tie condom to catheter.
Place condom inside uterine model.
Attach outer end of catheter to IV set with 500 ml fluid bag/bottle.
Infuse 250–500 ml fluid into condom until bleeding stops (or 250–500 ml with model).
Clamp catheter off with Luer lock.
Ensure that condom is held in place with vaginal packing.
When deflating condom (after 6–8 hours if patient is stable), deflate gradually by
withdrawing 50 ml fluid at a time, re-clamping to assess bleeding, etc.
During transfer, continue with IV infusion and supportive care.
Figure 5. Components of Tamponade for Severe PPH
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Checklist 5: Uterine Balloon Tamponade
Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by participant during evaluation by trainer
Participant:
Date Observed:
CHECKLIST FOR UTERINE BALLOON TAMPONADE
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
Prepare the necessary equipment.
2.
Tell the woman what is going to be done, listen to her and respond attentively
to her questions and concerns.
3.
Provide continual emotional support and reassurance, as feasible.
4.
Start IV of normal saline or Ringer’s lactate with oxytocin (20iu in 500ml).
5.
Put on personal protective barriers.
6.
Prepare UBT on a clean surface: open the condom and place inner end of Foley
catheter inside condom.
7.
Using suture or cord ties, securely tie condom to catheter.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
UTERINE BALLOON TAMPONADE
1.
Wash hands and forearms thoroughly with soap and water and dry.
2.
Put on sterile surgical gloves on both hands.
3.
Clean vulva and perineal area and place sterile drape beneath the woman’s
buttocks.
4.
Ensure that the bladder is empty; catheterise if necessary.
5.
Place the fingers of one hand into the vagina and identify the cervix. Using
clean technique, gently insert the catheter covered with the condom through
the cervix until the condom has completely passed thru the cervix.
6.
Inflate Foley catheter balloon with 20 ml water.
7.
Attach a 2-way Luer lock to the end of the catheter and then attach a large
syringe.
8.
Infuse 250 ml of fluid into the condom until bleeding stops (or 250–500 ml
with model).
9.
Twist the lock so that the fluid does not run out.
10. Decontaminate gloves in 0.5% chlorine solution and remove gloves by turning
them inside out and place them in a leakproof container or plastic bag.
11. Wash hands thoroughly with soap and water and dry.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
POST-PROCEDURE TASKS
1.
Continue to monitor vaginal bleeding and take the woman’s vital signs.
2.
Complete patient records with details of the procedure and any drugs given,
noting time when UBT inserted.
3.
Ensure arrangements for referral to higher facilities where surgical capacity is
available.
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CHECKLIST FOR UTERINE BALLOON TAMPONADE
(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
4.
CASES
The UBT can be left in utero for up to 72 hours. Check after 24 hours. When
deflating condom (if patient stable), deflate gradually by withdrawing 50 ml
fluid at a time via syringe, re-clamping to assess bleeding, etc. If the bleeding
has stopped, the UBT can be removed very slowly (over a period of a few
hours) to ensure that the bleeding does not start again.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
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