Approach to Training

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ By the end of the session, the participant will be able to describe: ƒ Mastery learning: − Acquisition − Competency − Proficiency ƒ Adult learning ƒ Competency-based training ƒ Humanistic training

2 How did you learn to make bread?

ƒ Discuss in pairs of two ƒ Following two-by-two discussion, have several people describe to the larger group how they learned to bake bread ƒ Label as types of learning/teaching and use as reference examples throughout rest of session

3 Mastery Learning

ƒ Assumes that all learners can master (learn) the required knowledge, attitudes or skills provided sufficient time is allowed and appropriate learning methods are used ƒ Goal: 100 percent of the learners will “master” the knowledge and skills on which the learning is based

4 Mastery Learning (cont.)

Takes differences into account: ƒ Some learners are able to acquire new knowledge or new skills immediately ƒ Others require additional time or alternative learning methods ƒ Individuals learn best in different ways—through written, spoken or visual means ƒ Use a variety of teaching methods

5 Mastery Learning (cont.)

ƒ Based on principles of adult learning: ƒ Learning is participatory, relevant and practical ƒ Builds on what the learner already knows or has experienced ƒ Provides opportunities for practicing skills ƒ Uses behavior modeling ƒ Is competency-based ƒ Incorporates humanistic learning techniques

6 Stages of Learning

ƒ Skills learning usually takes place in three stages: ƒ Skill acquisition. The learner sees others perform the skill and acquires a mental picture of the required steps. The learner then attempts to perform the procedure, usually with supervision. ƒ Skill competency. Next, the learner practices until skill competency is achieved, and s/he feels confident performing the procedure. ƒ Skill proficiency occurs with repeated practice over time.

7 Skill Acquisition Knows the steps and their sequence (if necessary) to perform the required skill or activity but needs assistance

Skill Competency Knows the steps and their sequence (if necessary) and can perform the required skill

Skill Proficiency Knows the steps and their sequence (if necessary) and effectively performs the required skill or activity

8 Skill Acquisition Bread-baking example: The learner can bake bread as long as s/he has a recipe that outlines all of the ingredients as well as a colleague to guide the learner in the steps. Learner needs assistance. Skill Competency The learner can bake bread and needs to refer to the recipe only occasionally, and needs minimal coaching from a colleague. Learner can perform the required skill, although hesitantly. Skill Proficiency The learner can bake bread without referring to the recipe and does not need coaching. Learner effectively performs the skill of baking bread.

9 What is meant by “Behavior Modeling”?

ƒ And how does it help learning?

ƒ Have you ever used it? ƒ If so, how/when?

10 Behavior Modeling

ƒ When conditions are ideal, a person learns most rapidly and effectively from watching someone perform (model) a skill or activity ƒ Trainer must clearly demonstrate the skill or activity so that learners have a clear picture of the performance expected of them

11 Question ??

ƒ How is competency-based training different from any other training? ƒ Which type of training do you most commonly see used?

12 Competency-Based Training

ƒ Learning by doing ƒ Focuses on the specific knowledge, attitudes and skills needed to carry out the procedure or activity ƒ How the learner performs (i.e., a combination of knowledge, attitudes and, most important, skills) is emphasized rather than just the information learned ƒ Competency in the new skill or activity is assessed objectively by evaluating overall performance

13 Competency-Based Training (cont.)

ƒ Break down the skill or activity into essential steps ƒ Analyze each step to determine the most efficient and safe way to perform and learn it (standardization) ƒ Once a procedure has been standardized, develop competency-based learning guides and evaluation checklists to make learning the necessary steps or tasks easier and evaluating the learner’s performance more objective

14 Coaching

ƒ An essential component of CBT ƒ First explain a skill or activity, then demonstrate it using an anatomic model or other training aid, such as a video ƒ Once the procedure has been demonstrated and discussed, observe the learners and guide them in learning the skill or activity, monitoring their progress and helping them overcome problems

15 Coaching (cont.)

Coaching ensures that the learner receives feedback regarding performance: ƒ Before practice —Teacher and learners meet briefly before each practice session to review the skill, activity, and/or tasks ƒ During practice—Teacher observes, coaches and provides feedback to the learner as s/he performs the steps/tasks outlined in the learning guide ƒ After practice—Immediately after practice, the learning guide is used to discuss the learner’s performance, including strengths and specific suggestions for improvement

16 What is “Humanistic Training”?

17 Humanistic Training Techniques

ƒ Use of anatomic models (and other learning aids) which closely simulate the human body ƒ Initially working with models rather than with patients allows learners to learn and practice new skills in a simulated setting: ƒ Reduces stress for the learner ƒ Reduces risk of injury and discomfort to the patient ƒ Always treat patient/client with utmost respect: ƒ Put the patient’s/client’s well-being first ƒ Respect dignity, modesty, socio-cultural background

18 Preparation for Clinical Performance

Before performing a clinical procedure with a patient: ƒ The clinical teacher should demonstrate the skills and patient interactions several times using an anatomic model, role plays or other simulations ƒ Under the guidance of the teacher, the learner should practice the required skills and patient interactions using the model, role plays or other simulations and actual instruments in a setting that is as similar as possible to the real situation

19 How do you decide when a student is ready to begin working in a clinical situation (Clinical Practicum)?

20 Skill Competency

ƒ Only when skill competency has been demonstrated should learners have their first contact with a patient ƒ May be challenging in a pre-service education setting due to large numbers of learners ƒ Before any learner provides services to a patient, however, it is important that the learner demonstrate skill competency using models, role plays or simulations, especially for core skills

21 Summary

ƒ When mastery learning, based on adult learning principles and behavior modeling, is integrated with CBT, the result is a powerful and extremely effective method for providing clinical training ƒ When humanistic training techniques are incorporated, training time and costs can be significantly reduced

22 References

Sullivan R et al. 1998. Clinical Training Skills for Reproductive Health Professionals, 2nd ed. Jhpiego: Baltimore, MD. Schaefer L et al. 2000. Advanced Training Skills for Reproductive Health Professionals. Jhpiego: Baltimore, MD. Sullivan RL. 1995. The Competency-Based Approach to Training. Jhpiego: Baltimore, MD.

23 “Every Pregnancy is at Risk”: Current Approach to Reduction of Maternal and Neonatal Mortality Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To review: ƒ Magnitude of maternal and neonatal mortality ƒ Causes of maternal and neonatal mortality ƒ Interventions to reduce maternal and neonatal mortality: − Traditional birth attendant − Antenatal care − Risk screening − Skilled attendant at childbirth − Postnatal care

2 What is Safe Motherhood?

“A woman’s ability to have a SAFE and healthy pregnancy and childbirth.”

3 Maternal Mortality: A Global Tragedy

ƒ Annually, 529,000 women die of pregnancy related complications: ƒ 99% in developing world ƒ ~ 1% in developed countries

4 Maternal Health: Scope of Problem

ƒ 180–200 million pregnancies per year ƒ 75 million unwanted pregnancies ƒ 50 million induced abortions: ƒ 20 million unsafe abortions ƒ 30 million spontaneous abortions ƒ Approximately 600,000 maternal deaths (1 per minute) ƒ 1 maternal death = 30 maternal morbidities

5 Ask the group: What are the major causes of maternal mortality?

6 Causes of Maternal Mortality

Anemia Sepsis 8% 11% Hypertensive Obstructed Disorder Labor 10% 7%

Indirect 14%

Hemorrhage HIV 31% 3% Other direct causes Unsafe 5% Abortion Unclassified 5% 6%

Other direct causes include embolism, ectopic pregnancy, anesthesia-related. Indirect causes include: malaria, heart disease. Adapted from: WHO analysis of causes of maternal deaths: A systematic review. The Lancet, vol 367, April 1, 2006.

7 Neonatal Health: Scope of Problem

Every year: ƒ 4 million neonatal deaths (first month of life): ƒ Of those who die in the first month, 2/3 die in the 1st week ƒ Of those who die in the first week, 2/3 die in the first 24 hours ƒ Eight neonatal deaths every minute ƒ 4 million stillbirths

8 Ask the group: What are major causes of neonatal mortality?

9 Causes of Newborn Death

Other 3% Congenital Sepsis/ 14% pneumonia 27% Asphyxia 7% Infection 36% Sepsis Tetanus 11% 7%

Diarrhoea Preterm 3% 28%

10 But why do these women and newborns die?

Modified Pathway to Survival

P Recognize Get First Decide Seek Get Quality S Aid Care EOC Care R Problem to Seek Care U O Care R B V L → →→→ → I Referral E Home & Community V M Site A L

11 Maternal and Newborn Health Services

ƒ Good quality maternal and newborn health services are not universally available and accessible: > 35% receive no antenatal care ~ 50% of deliveries not attended by skilled provider ~ 70% receive no postpartum care during the first 6 weeks after delivery

12 Ask the group: What are some interventions that have not proved successful in reducing mortality?

13 Interventions to Reduce Maternal and Newborn Mortality

Historical review:

ƒ Traditional birth attendants

ƒ Antenatal care

ƒ Risk screening

Current approach:

ƒ Skilled attendant at delivery

14 Historical Review of Interventions

The flawed assumption:

Most life-threatening obstetric and newborn complications can be predicted or prevented.

15 The Crucial Facts

ƒ EVERY woman and newborn faces risk ƒ Providers and the facility must be prepared to address emergencies at all times ƒ When problems are managed in a timely manner, many lives are saved

16 Interventions: Traditional Birth Attendants

Advantages: Disadvantages: ƒ Community-based ƒ Limited access to ƒ Sought out by women emergency drugs and other resources ƒ Low-tech ƒ Distance from referral ƒ Teaches clean delivery facility may delay ƒ Can provide obstetric first emergency treatment aid at home ƒ Knowledge, skills and ƒ Can provide and teach training not standardized families preventive care and obstetric first aid

17 Interventions: Traditional Birth Attendants (cont.)

Conclusion TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services alone. There needs to be a household-to-hospital continuum of care to have the greatest impact.

18 Interventions: Antenatal Care

ƒ Antenatal care clinics started in US, Australia, Scotland between 1910–1915 ƒ New concept: screening healthy women for signs of disease ƒ By 1930s, large number (1,200) of ANC clinics opened in UK ƒ No reduction in maternal mortality

19 Interventions in ANC (cont.)

ƒ However, ANC was widely used as a maternal mortality reduction strategy in 1980’s and early 1990s ƒ Is ANC important? YES!! ƒ Focused, individualized care leads to early detection of problems and birth preparation

20 Interventions: Risk Screening

Disadvantages: ƒ Very poorly predictive ƒ Wastes valuable client-provider time ƒ If risk-negative, gives false security ƒ Conclusion: Cannot identify those at risk of maternal mortality Every Pregnancy Is at Risk

21 Interventions: Skilled Attendant at Childbirth

ƒ Proper training, range of skills ƒ Anticipate possible problems ƒ Recognize onset of complications ƒ Observe woman, monitor fetus/infant ƒ Perform essential basic interventions ƒ Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence

WHO 1999. 22 Maternal Mortality Reduction Sri Lanka 1940–1985

Health system improvements: ƒ Introduction of system of health facilities ƒ Expansion of midwifery skills ƒ Decreased use of home delivery and delivery by untrained birth attendants ƒ Spread of family planning

23 Maternal Mortality Reduction Sri Lanka 1940–1985

1800 1600 1400 1200 85% births attended by trained personnel 1000 800 600 400 200 0

Maternal Deaths per 100 000 livebirths per Deaths Maternal 1940–45 1950–55 1960–65 1970–75 1980–85

24 The Higher the Proportion of Deliveries Attended by Skilled Provider, the Lower the Country’s Maternal Mortality Ratio

2000

1800 R2 = 0.74 1600 Y Log. (Y)

1400

1200

1000

800

600

400

200

0

Maternal Deaths per 100,000 Live Births Maternal Deaths 0 102030405060708090100 % Skilled Attendant at Delivery

25 Summary

ƒ Skilled attendant at childbirth is an effective intervention ƒ The household-to- hospital continuum of care has been shown to be more effective than facility-based care alone.

Source: WHO 1999.

26 References

ACCESS Program. 2006. Home and Community-Based Health Care for Mothers and Newborns. (Technical guide.) ACCESS Program: Baltimore, MD. ACCESS Program. 2005. Household-to-Hospital Continuum of Care. (Technical guide.) ACCESS Program: Baltimore, MD. Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al. (eds). Blackwell Science Limited: London. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.

27 Evidence-Based Medicine in Maternal and Newborn Health

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Objectives of EBM Session

ƒ Provide a definition of evidence-based medicine ƒ Provide introduction of levels of evidence based on research methods and study design ƒ Present examples of EBM in RH practice

2 What is evidence-based medicine?

3 What is evidence-based medicine?

ƒ Definition: Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

Source: Oxford Centre for Evidence-Based Medicine.

4 Where do we obtain evidence to be used in our midwifery education and practice?

5 Where do we obtain our evidence?

ƒ Ideally, all clinicians would know the best methods for the care of each medical condition or situation ƒ In reality, this is not the case, so we must rely on evidence gathered by the scientific community to guide our clinical decision- making ƒ All evidence is not equally reliable so we must be able to tell the difference

6 Where do we find tools for translating research into practice?

ƒ WHO – Examples: ƒ IMPAC series – MCPC, MNP, ECPG ƒ Medical Eligibility Criteria for Contraceptive Use ƒ Standards, e.g., PMTCT of syphilis ƒ Other UN agencies ƒ National guidelines and protocols

7 All evidence is not created equal.

8 Levels of Evidence

A 1a Systematic review of randomized controlled trials

1b Individual randomized controlled trials

B 2a Systematic review of cohort studies

2b Individual cohort studies

3a Systematic review of case-control studies

3b Individual case-control studies

C 4 Case studies

D 5 Expert opinion without explicit critical appraisal

9 Relative Risk/Odds Ratio Protective Effect Deleterious Effect

0 1 5 10

10 4 studies 1579 patients

RelativeRelative Risk Risk (95%CI) (95%CI)

.05.05 .2.2 11 55 2020

11 Routine Intrapartum Fetal Monitoring 4 studies 1579 patients

RelativeRelative Risk Risk (95%CI) (95%CI) CS rates Detection of fetal cardiac abnormalities Apgar Signs of neurological abnormalities Perinatal interventions Perinatal Mortality

.05.05 .2.2 11 55 2020

12 Small Group Exercise

ƒ Each group is assigned one of the following EBM practices for discussion: 1. Use of the partograph for the management of labor 2. Labor support and position in labor 3. Routine vs. restricted use of episiotomy 4. Active management of the 3rd stage of labor ƒ Questions for Discussion: 1. What is the current practice in your country/institution? 2. What is the rationale for current practice 3. Do you think current practice is evidence-based? 4. Are all practitioners trained and competent in these skills?

13 Partograph and Criteria for Active Labor

ƒ Label with patient identifying information ƒ Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given ƒ Plot cervical dilation ƒ Alert line starts at 4 cm; from here, expect to dilate at rate of 1 cm/hour ƒ Action line: If patient does not progress as above, action is required

14 WHO Partograph Trial

ƒ Objectives: ƒ To evaluate impact of WHO partograph on labor management and outcome ƒ To devise and test protocol for labor management with partograph ƒ Design: Multicenter trial randomizing hospitals in Indonesia, Malaysia and Thailand ƒ No intervention in latent phase until after 8 hours ƒ At active phase action line consider: Oxytocin augmentation, cesarean section, or observation AND supportive treatment

WHO 1994.

15 WHO Partograph: Results of Study

All Women Before After p Implementation Implementation

Total deliveries 18254 17230

Labor > 18 hours 6.4% 3.4% 0.002

Labor augmented 20.7% 9.1% 0.023

Postpartum sepsis 0.70% 0.21% 0.028

Normal Women

Mode of delivery Spontaneous cephalic 8428 (83.9%) 7869 (86.3%) < 0.001 Forceps

341 (3.4%) 227 (2.5%) 0.005

Source: WHO 1994. 16 Position in Labor and Childbirth

ƒ Allow freedom in position and movement throughout labor and childbirth ƒ Encourage any non-supine position: ƒ Side lying ƒ Squatting ƒ Hands and knees ƒ Semi-sitting ƒ Sitting

17 Position in Labor and Childbirth (cont.)

Use of upright or lateral position compared with supine or lithotomy position is associated with: ƒ Shorter second stage of labor (5.4 minutes, 95% CI 3.9–6.9) ƒ Fewer assisted deliveries (OR 0.82, CI 0.69–0.98) ƒ Fewer episiotomies (OR 0.73, CI 0.64–0.84) ƒ Fewer reports of severe pain (OR 0.59, CI 0.41–0.83) ƒ Less abnormal heart rate patterns for fetus (OR 0.31, CI 0.11– 0.91) ƒ More perineal tears (OR 1.30, CI 1.09–1.54) ƒ Blood loss > 500 mL (OR 1.76, CI 1.34–3.32)

Source: Gupta and Nikodem 2000.

18 Support of the Woman

ƒ Give woman as much information and explanation as she desires ƒ Provide care in labor and childbirth at a level where woman feels safe and confident ƒ Provide empathetic support during labor and childbirth ƒ Facilitate good communication among caregivers, the woman and her companions ƒ Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia, and fewer operative deliveries

Source: WHO 1999.

19 Presence of Female Relative during Labor: Results

Randomized controlled trial in Botswana: 53 women with relative; 56 without

Experimental Control Group Labor Outcome p Group (%) (%) Spontaneous vaginal delivery 91 71 0.03

Vacuum delivery 4 16 0.03 Cesarean section 6 13 0.03 Analgesia 53 73 0.03 Amniotomy 30 54 0.01 Oxytocin 13 30 0.03

Madi et al. 1999.

20 Presence of Female Relative during Labor: Conclusion

Support from female relative improves labor outcomes

Madi et al. 1999.

21 Restricted Use of Episiotomy: Objectives and Design

ƒ Objective: To evaluate possible benefits, risks and costs of restricted use of episiotomy vs. routine episiotomy ƒ Design: Meta-analysis of six randomized control trials

Carroli and Belizan 2000.

22 Restricted Use of Episiotomy: Maternal Outcomes Assessed

ƒ Severe vaginal/perineal trauma ƒ Need for suturing ƒ Posterior/anterior perineal trauma ƒ Perineal pain ƒ Dyspareunia ƒ Urinary incontinence ƒ Healing complications ƒ Perineal infection

Source: Carroli and Belizan 2000.

23 Restricted Use of Episiotomy: Results of Cochrane Review

Clinically Relevant Morbidities Relative Risk 95% CI

Posterior perineal trauma 0.88 0.84–0.92

Need for suturing 0.74 0.71–0.77 Healing complications at 7 days 0.69 0.56–0.85

Anterior perineal trauma 1.79 1.55–2.07

ƒ No increase in incidence of major outcomes (e.g., severe vaginal or perineal trauma nor in pain, dyspareunia or urinary incontinence) ƒ Incidence of 3rd degree tear reduced (1.2% with episiotomy, 0.4% without) ƒ No controlled trials on controlled delivery or guarding the perineum to prevent trauma

Sources: Carroli and Belizan 2000; Eason et al. 2000; WHO 1999.

24 Outcome of Routine Episiotomy vs. Restricted Use: A Systematic Review

ƒ No benefit in terms of perineal lacerations, pain or pain medication use ƒ No benefit in preventing urinary or fecal incontinence ƒ No benefit in preventing pelvic relaxation ƒ Painful intercourse more common in women who have had an episiotomy

Source: Hartman et al. 2005.

25 Indicated Use of Episiotomy: Reviewer’s Conclusions

ƒ Implications for practice: Clear evidence to restrict use of episiotomy in normal labor ƒ Implications for research: Further trials needed to assess use of episiotomy at: ƒ Assisted delivery (forceps or vacuum) ƒ Preterm delivery ƒ Breech delivery ƒ Predicted macrosomia ƒ Presumed imminent tears (threatened 3rd degree tear or history of 3rd degree tear with previous delivery)

Sources: Carroli and Belizan 1999; WHO 2000.

26 Best Practices: Third Stage of Labor

ƒ Active management of third stage for ALL women: ƒ Oxytocin administration ƒ Controlled cord traction ƒ Uterine massage after delivery of the placenta to keep the uterus contracted ƒ Routine examination of the placenta and membranes ƒ 22% of maternal deaths caused by retained placenta ƒ Routine examination of vagina and perineum for lacerations and injury

WHO 2000.

27 Risk of Postpartum Hemorrhage

Management of Blood Loss Third Stage of Labor >500ml

Physiologic* 18.0% Active (oxytocin)** 2.7% Misoprostol** 3.6%

Sources: *Prendiville et al. 2000. **Villar et al. 2000.

28 Evidence for Active Management of the 3rd Stage of Labor

Active Physiologic OR and 95% CI Management Management

Duration 3rd Bristol 5 minutes 15 minutes Not done stage (median) Hinchingbrooke 8 minutes 15 minutes Not done Third stage > Bristol 25 (2.9%) 221 (26%) 6.42 (4.9-8.41) 30 minutes Hinchingbrooke 25 (3.3%) 125 (16.4%) 4.9 (3.22-7.43) Blood Bristol 18 (2.1%) 48 (5.6%) 2.56 (1.57-4.19) transfusion Hinchingbrooke 4 (0.5%) 20 (2.6%) 4.9 (1.68-14.25) Therapeutic Bristol 54 (6.4%) 252 (29.7%) 4.83 (3.77-6.18) oxytocics Hinchingbrooke 24 (3.2%) 161 (21.1%) 6.25 (4.33-9.96)

29 Challenges in Providing Evidence- Based Reproductive Health Care

ƒ Keeping abreast with the evidence ƒ Setting and implementing standard protocols ƒ Audit and peer review ƒ Evaluating outcomes

30 Accessing WHO

ƒ http://www.who.int ƒ Health topics ƒ Publications ƒ Search

31 References

Carroli G and Belizan J. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081. Eason E et al. Preventing perineal trauma during childbirth: A systematic review. Obstet Gynecol 2000 Mar;95(3): 464-471. Gupta and Nikodem. Maternal posture in labour. Eur J Obstet Gynecol Reprod Biol 2000 Oct;92(2): 273-277. Hartmann K et al. 2005. Outcomes of routine episiotomy: a systematic review. JAMA. May 4;293(17): 2141-2148. Maadi et al. Effects of female relative support in labor: A randomized controlled trial. Birth. 1999 Mar;26(1): 4-8. Erratum in: Birth 1999 Jun; 26(2): 137. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net.

32 References (cont.)

Prendiville WJ, Elbourne D and McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD000007. DOI: 10.1002/14651858.CD000007. Signorello LB et al. 2000. Midline episiotomy and anal incontinence: Retrospective cohort study. Br Med J 320(7227): 86–90. Villar J et al. 2002. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol Dec;100(6): 1301-1312. World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2000. WHO: Geneva. WHO Web site. http://www.who.int.

33 Women-Friendly Care: A Discussion

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Divide into Groups of 3–5 Participants

Discuss the following questions: ƒ How would you define “women-friendly care”? ƒ Why is women-friendly care important? ƒ Give some examples of care you have seen that is not women-friendly. ƒ Give some examples of care that is women- friendly. ƒ How can you help ensure that your students will value and learn to provide women-friendly care?

2 After Small Group Discussion . . .

. . . Reconvene as a large group to share your thoughts, conclusions and recommendations . . .

3 Discussion Guide for Facilitator

ƒ The next slides will have some points you will want to bring out during the discussion.

ƒ Be sure to allow, and build on, participant contributions as much as possible in summarizing the discussions.

4 How would you define “women-friendly care”?

ƒ Provides services that are acceptable to the woman: ƒ Respects beliefs, traditions, and culture ƒ Includes family, partner, or other support person in care ƒ Provides relevant and feasible advice ƒ Empowers woman and her family to become active participants in care ƒ Considers the rights of the woman: ƒ Right to information about her health ƒ Right to be informed about what to expect during visit ƒ Obtains permission/consent prior to exams and procedures ƒ Ensures that all health care staff use good interpersonal skills ƒ Considers the emotional, psychological and social well- being of the woman

5 Why is women-friendly care important?

Women-friendly care is life-saving, as studies have shown that women may refuse to seek care from a provider who “abuses” them or does not treat them well, even if the provider is skilled in preventing and managing of complications.

6 Give some examples of care that is not women-friendly

ƒ Does not respect woman or her culture or background ƒ Rude, offensive, demeaning language by health personnel ƒ Physically restrains, pushes or hits the woman ƒ Insists on routine procedures that are convenient for the health care provider but may be shameful or disgusting to the woman, e.g., lithotomy position only, routine episiotomy, frequent vaginal exams, assembly-line fashion of care ƒ Excludes partner or companion from care ƒ Separates mother and baby

7 Give some examples of care that is women-friendly

ƒ Individualizes care to woman’s needs ƒ Recognizes the richness and spiritual significance of community and culture: ƒ Is aware of traditional beliefs regarding pregnancy and childbirth ƒ Cooperates and liaises with traditional health care system when possible ƒ Provides culturally sensitive care ƒ Respects and supports the mother-baby dyad: ƒ Encourages bonding ƒ Keeps baby with mother ƒ Places baby on mother’s abdomen (at breast) immediately after birth

8 Give some examples of care that is women-friendly (cont.)

ƒ Speaks to the woman in her own language ƒ Observes rules and norms of her culture as appropriate ƒ Is aware of who makes decisions in her life and involves that person in discussions and decisions ƒ Works with traditional birth attendants when possible ƒ Learns about traditional practices: ƒ Promotes/builds on positive traditional practices ƒ Offers alternatives to those that are harmful

9 How can you help ensure that your students will value and learn to provide women-friendly care?

ƒ Consistent role modeling of women-friendly care ƒ Use of women-friendly approaches in simulated settings, e.g., with anatomic models ƒ Emphasis of women-friendly care during teaching of all procedures and types of care

10 Clinical Decision-Making

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

By end of session, participants will be able to:

ƒ Describe steps in clinical decision-making

ƒ Apply clinical decision-making steps to real life clinical situations

2 Let’s look at a case study from everyday life

ƒ Divide participants into groups of 2 to 5 participants to discuss CDM Case Study 1 ƒ Following small group work, reassemble to discuss case study

3 What Is clinical decision-making?

ƒ A purposeful, organized thinking process that links assessment with care provision and evaluation of care through series of logical steps ƒ Also known as: ƒ Problem-solving approach ƒ SOAP or SOAPIER ƒ Decision-making approach ƒ Leads to purposeful, safe and effective care

4 Ongoing Process

ƒ The clinical decision-making process is ongoing and occurs throughout the continuum of care: ƒ The provider implements the process repeatedly as the clinical situation changes and different needs or problems emerge

5 Clinical Decision-Making: Advantages

ƒ Clinical decision-making helps the provider: ƒ Collect info in an organized way, saving time and resources ƒ Breaks process into clear steps to avoid “jumping the gun” ƒ Use information so a problem or need can be correctly identified ƒ Give focused care, avoiding unnecessary, inappropriate or excessive treatments or care ƒ Evaluate the effectiveness of the care provided

6 Pass out copies of CDM Case Study 2

ƒ Read the case study together ƒ Walk participants through each step, illustrating which step of decision-making process is involved ƒ Summarize with next slides

7 Steps in Clinical Decision-Making

1) Gather information/Make an observation: ƒ History ƒ Physical examination ƒ Testing (labs, investigations) ƒ Includes both what the provider observes and what the woman reports ƒ The information gathered in this step is considered in the context of the other steps

8 Steps in Clinical Decision-Making (cont.)

2) Interpret information/Identify problems: ƒ Consider each sign/symptom in context of other findings ƒ Compare signs/symptoms to accepted descriptions/definitions of health and disease ƒ Consult reliable sources of up-to-date information ƒ Predict what may happen out of inaction and out of alternative actions

9 Steps in Clinical Decision-Making (cont.)

3) Develop care plan: ƒ Based on assessment/findings ƒ Individualized ƒ Collaborative – responsibility shared by care provider, woman and family

4) Implement care plan—also collaborative

10 Steps in Clinical Decision-Making (cont.)

5) Evaluate care plan: ƒ An ongoing process – monitor continuously ƒ Deem effective when: − Improves or maintains woman’s health − Restores abnormal findings to normal − Addresses woman’s needs − Is acknowledged as valuable by woman and her family 6) Change or continue action

11 Group Work

ƒ Participants return to small groups. ƒ Each group is to take one situation in clinic or ward from their own experience while caring for a woman. Then divide the decision-making process into steps. ƒ Record steps on flip chart. ƒ Reassemble and select 2 groups to report to larger group.

12 Medico-Legal Issues

ƒ While clinical decision-making is essential to sound care provision, documentation of: ƒ Information gathered ƒ Plan of care ƒ Implementation of care ƒ Evaluation and follow-up is essential to prevent litigation. ƒ If an intervention was not documented, it was not done.

13 Medico-Legal Case Study

ƒ Mother who is G3P2 at 29 weeks gestation arrives in admission area, complaining of indigestion. ƒ Midwife examines woman, cervix is closed, no palpable contractions. ƒ Midwife teaches woman danger signs and when to return to hospital, including return if waters break or contractions begin or no improvement by next day. ƒ Midwife did not document teaching. ƒ Woman did not return when waters broke and bleeding started and baby died. ƒ Midwife/hospital sued and found guilty because if teaching was not documented, legally it is not considered to have happened.

14 References

Ganges F. 2006. Clinical Decision-Making, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April) Schaefer L. et al. 2000. Clinical Decision-Making, in Advanced Training Skills for Reproductive Health Professionals. (Chapter 4). Jhpiego: Baltimore, MD. Schaefer L et al. 2000. Problem-Solving Skills, in Advanced Training Skills for Reproductive Health Professionals. (Chapter 3). Jhpiego: Baltimore, MD.

15 Best Practices in Infection Prevention

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

By end of session, participants will be able to: ƒ Describe disease transmission cycle ƒ Outline key IP principles ƒ Discuss appropriate handwashing and antisepsis ƒ Discuss appropriate gloving and personal protective equipment ƒ Outline safe handling of sharps ƒ Discuss proper instrument processing and waste disposal

2 The Six Components of the Disease Transmission Cycle

1. Agent: Disease-producing microorganisms 2. Reservoir: Place where agent lives, such as in or on humans, animals, plants, soil, air, or water 3. Place of exit: Where agent leaves host 4. Mode of transmission: How agent travels from place to place (or person to person) 5. Place of entry: Where agent enters next host 6. Susceptible host: Person who can become infected

3 Question ??

ƒ How can we prevent the spread of infection?

4 How can we prevent the spread of infection?

ƒ Break disease-transmission cycle ƒ Inhibit or kill infectious agent (applying antiseptic to skin prior to surgery) ƒ Block agent’s means of getting from infected person to susceptible person (handwashing or using alcohol-based hand rub) ƒ Ensuring that people, especially healthcare workers, are immune or vaccinated

5 How can we prevent the spread of infection? (cont.)

ƒ Providing health care workers with proper protective equipment to prevent contact with infectious agents ƒ Give some examples of ways to break transmission cycle (see notes)

6 Why is infection prevention important?

ƒ Protects patients/clients—helps provide quality care that is also safe ƒ Lowers health care costs—prevention is less expensive than treatment ƒ Prevents infection among health care staff and community ƒ Limits number and spread of infectious agents that can become antibiotic-resistant

7 Question ??

ƒ What is the most important infection prevention practice?

8 Handwashing

The single most practical procedure for preventing infection: Handwashing ƒ When to wash hands: ƒ Before and after examining client ƒ After contact with blood, body fluids or soiled instruments, even if gloves are worn ƒ Before and after removing gloves ƒ Upon arriving at and before leaving workplace

9 Handwashing: How to Wash Hands

ƒ Steps: ƒ Use a plain or antiseptic soap. ƒ Vigorously rub lathered hands ƒ together for 10–15 seconds. ƒ Rinse with clean running water from a tap or bucket. ƒ Dry hands with a clean towel or air dry them.

Source: Larsen 1995.

10 Alcohol-Based Handrub

ƒ More effective than handwashing unless hands are visibly soiled ƒ 2 mL emollient (e.g., glycerin) + 100 mL ethyl or isopropyl alcohol 60–90% ƒ Use 3 to 5 ml for each application and continue rubbing the solution over the hands until dry.

11 Antisepsis

ƒ Antisepsis for mucous membranes: ƒ Ask about allergic reactions ƒ Use water-based product (e.g., iodophor or chlorhexidine), as alcohols may burn or irritate mucous membranes ƒ Skin preparation for injections: ƒ If skin is clean, antisepsis is not necessary ƒ If skin appears dirty, wash with soap and water ƒ Before giving injection, dry with clean towel

12 When to Glove

ƒ When there is reasonable chance of contact with broken skin, mucous membranes, blood, or other body fluids ƒ When performing invasive procedure ƒ When handling: ƒ Soiled instruments ƒ Medical, or contaminated, waste ƒ When touching contaminated surfaces

13 Guidelines for Gloving

ƒ Wear separate pair of gloves for each woman/ newborn to prevent spreading infection from client to client ƒ What kind of gloves do you wear for: ƒ Procedures involving contact with broken skin or tissue under skin? ƒ Starting IV, drawing blood, or handling blood or body fluid? ƒ Cleaning instruments, handling waste and cleaning up blood and body fluids? ƒ Never wear gloves that are cracked, peeling or have holes.

14 Personal Protective Equipment

ƒ Gloves: utility, examination, HLD/sterile ƒ Eyewear: face shields, goggles, glasses ƒ Aprons ƒ Should be fluid-resistant ƒ Should be decontaminated after use ƒ Protective footwear

15 What’s wrong with this picture?

16 Global Statistics on Occupational Exposure

ƒ 3 million health care workers (HCWs) per year report needlestick injuries per year ƒ 2.5% HIV infections among HCWs are transmitted by needlestick injuries ƒ 40% of Hepatitis C and Hepatitis B infections among HCWs are transmitted by needlestick injuries (WHO, 2002)

17 Safe Handling of Sharps

ƒ Never pass sharp instrument from one hand directly to another person’s hand ƒ After use, decontaminate syringes and needles by flushing three times with chlorine solution ƒ Immediately dispose of sharps in puncture-proof container ƒ Which is greatest, the risk of acquiring Hepatitis B or HIV from a needlestick injury?

18 Safe Handling of Sharps (cont.)

ƒ Do not recap, bend, break, or disassemble needles before disposal ƒ Always use needle holder when suturing ƒ Never hold or guide needle with fingers

19 Instrument Processing

ƒ Decontamination: ƒ Should be done immediately after use ƒ Makes objects safer to handle ƒ How do you make a 0.5% chlorine solution for decontamination? ƒ Cleaning: ƒ Most effective way to reduce number of organisms ƒ Removes visible dirt and debris

20 Instrument Processing (cont.)

ƒ Sterilization: ƒ Destroys all microorganisms ƒ Includes autoclave, dry heat, chemicals ƒ High-level disinfection (HLD): ƒ Destroys all microorganisms except bacterial endospores ƒ Includes boiling, steaming, soaking ƒ Storage: ƒ After processing, must remain dry and clean

21 DECONTAMINATION Soak in 0.5% Chlorine solution for 10 minutes

THOROUGHLY WASH AND RINSE Wear glove and other protective barriers (glasses, visors or goggles)

Preferred Method Acceptable Methods HIGH-LEVEL STERILIZATION DISINFECTION (HLD) Chemical Autoclave Dry Heat Boil or Steam Chemical Soak 106 k Pa pressure 1700C Lid on Soak 10-24 hours (15 lbs./in2) 60 minutes 20 minutes 20 minutes 0 1210C (250 F) 20 min. unwrapped 30 min. wrapped

COOL (Use immediately or store) What’s wrong with this picture?

23 Housekeeping

ƒ Each site should follow housekeeping schedule ƒ Always wear utility gloves when cleaning ƒ Clean from top to bottom ƒ Ensure that fresh bucket of disinfectant solution is available at all times

24 Housekeeping (cont.)

ƒ Immediately clean up spills of blood or body fluids ƒ After each use, wipe off beds, tables and procedure trolleys using disinfectant solution ƒ Decontaminate cleaning equipment with chlorine solution

25 Waste Disposal

Contaminated waste includes blood and other body fluids, and items that come into contact with them, such as dressings.

ƒ Separate contaminated waste from noncontaminated waste ƒ Use puncture-proof container for sharps and destroy when two-thirds full

26 Waste Disposal (cont.)

ƒ Follow these steps to destroy contaminated waste and sharps: ƒ Add small amount of kerosene to burn ƒ Burn contaminated waste in open area downwind from care site ƒ Dispose of waste at least 50 meters away from water sources

27 Infection Prevention Grab Bag Game

ƒ Pick a question and answer!

28 Summary

ƒ Everyone (staff and patients) is at risk for infection ƒ This risk can be reduced through rigorous adherence to IP practices: ƒ Handwashing or using alcohol-based handrub ƒ Antisepsis ƒ Personal protective equipment, including gloving ƒ Safe handling of sharps and needles ƒ Instrument processing ƒ Housekeeping and waste disposal

29 References

Clark A. Grab bag of questions adapted from grab bag developed by A. Clark/ACNM. Ganges F. 2006. Infection Prevention, a presentation in Accra, Ghana in Maternal and Newborn Care Technical Update. (April) Tietjen L, Bossemeyer D and McIntosh N. 2003. Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Jhpiego: Baltimore, MD. Accessed at: http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ip manual.htm.

30 Best Practices in Focused Antenatal Care: Rationale, Components and Tools Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Describe focused antenatal care (FANC) ƒ Describe basic elements of FANC assessment and care ƒ Describe the elements of Birth Preparedness and Complication Readiness ƒ Demonstrate the provision of focused antenatal care

2 Objective of ANC

ƒ A healthy pregnancy ƒ A healthy outcome for mother and newborn ƒ Promotion of physical, mental and social health

3 Benefits of FANC

ƒ ANC visits are a unique opportunity for early diagnosis and treatment of problems: ƒ Maternal problems: anemia, vaginal bleeding, pre- eclampsia/eclampsia, infection, abnormal fetal position after 36 weeks ƒ Fetal/newborn problems: abnormal fetal growth or movement, HIV, syphilis, malaria, malnutrition

4 Benefits to Newborn May Be Even Greater than Benefits to Mother

5 Question ??

ƒ What problems have you seen with antenatal care? ƒ Why are there problems with antenatal care?

6 ANC: Why is there a problem?

ƒ Quality of care is poor: ƒ We gather information but do not use it to manage patient e.g., anemia ƒ Poor clinical management of problems – eclampsia, bleeding in pregnancy ƒ Failure to record relevant information ƒ Not women-friendly: ƒ Factory assembly-line ANC system ƒ Not client-specific ƒ Women treated poorly so do not return ƒ Poor communication: ƒ Poor counseling skills ƒ Information and education are not relevant to the woman

7 A Midwife Says:

“What I dislike about the assembly line system was that I alone had to palpate about 150 pregnant women a day. There was no privacy during history taking and the women did not give us correct information . . . It was tedious work….” – A care provider

8 What FOCUSED ANC Means !

An approach to ANC that emphasizes: ƒ Individualized care ƒ Client-centered ƒ Fewer but comprehensive visits ƒ Disease detection, not risk ƒ Classification ƒ Care by a skilled provider

9 Four Goals of Focused ANC

ƒ Early detection and treatment of problems and complications ƒ Prevention of complications and disease ƒ Birth preparedness and complication readiness ƒ Health promotion

10 The Focused ANC System

ƒ Privacy/confidentiality are assured ƒ Continuous care provided by same provider ƒ Promotes partner/support person involvement ƒ Adheres to national protocols ƒ Referral facilitated ƒ ANC, PNC and family planning services are linked and housed within the same location if possible

11 “High Risk” Women and “Low Risk” Women

ƒ What are the benefits of assigning women to “risk” categories? ƒ What are the problems with assigning women to “risk” categories?

12 Why Risk Approach Is Not Effective!

ƒ Complications cannot be predicted: All pregnant women are at risk ƒ Risk factors are not usually the direct cause of complications ƒ Many low-risk women develop complications ƒ Most high-risk women give birth without complications

13 Focused ANC Visit Schedule for the Healthy Client

ƒ Four visits: ƒ First <16 Weeks ƒ Second 20–24 ƒ Third 28–30 ƒ Fourth 36 ƒ It means good clinical decisions must be made at each visit

14 Making Good Clinical Decisions at ANC

ƒ The steps: ƒ Gathering information (history, exam, labs, etc.) ƒ Interpreting information gathered ƒ Developing a care plan ƒ Implementing care plan ƒ Evaluating care plan

15 Gathering Information: History

1234 Personal Hx * Present Preg Hx **** LMP, Complaints Past preg Hx * Medical Hx * Family/Social Hx *

16 Gathering Information: Examination

1234 General **** Pulse, Resp, BP Breast * Chest * Abdomen/Preg **** Genital * Pelvic Assess PRN only

17 18 Gathering Information: Lab/Other Investigations, e.g., US

1234 Blood * Hgb, RPR, HIV Urine - according to local protocols Albumin, Sugar Ultrasound (PRN, NOT routine in FANC)

19 Care Plan: Appropriate Counseling and LEC

ƒ Relevant to client needs ƒ Relevant to gestation ƒ Address discomforts of pregnancy

20 Basic Care Plan

ƒ Minimum of four visits for the healthy client ƒ Anemia prevention ƒ Malaria prevention ƒ Prevention of HIV transmission ƒ Treatment/prevention other STIs ƒ Tetanus immunization ƒ Preparing birth and complication preparedness plan ƒ Education and counsel – nutrition, family planning, infant feeding, hygiene

21 Care Plan: Anemia Prevention

ƒ Iron supplementation ƒ Folate supplementation ƒ Treat any factors that can cause anemia: worms, malaria, schisto, etc. ƒ Nutrition – foods rich in iron, folate and vitamin C

22 Question ??

Why bother with a birth preparedness and complication readiness plan?

23 Why Bother?

ƒ Time of labor or time of emergency is not the time to decide what to do ƒ Increase the likelihood of using a skilled attendant as arrangements have been made ƒ Frequently women/families do not seek help because they do not know they have a problem – don’t know danger signs ƒ Some complications, e.g., hemorrhage, take only 2 hours until death – all plans must be in place

24 Question ??

ƒ What are the elements of a birth preparedness and complication readiness plan?

25 The Birth Preparedness and Complication (BP/CR) Readiness Plan

ƒ Facility or place of birth ƒ Skilled provider ƒ Transportation ƒ Funds ƒ Support person ƒ Decision-maker ƒ Blood donor ƒ Danger signs in labor

26 Birth Preparedness and Complication Readiness Plan (cont.)

ƒ Where does she plan to deliver her baby? ƒ Who will accompany her in labor to her chosen center? ƒ How will she get to the health center? ƒ Does she have money and other needed items ready and accessible?

27 Birth Preparedness and Complication Readiness Plan (cont.)

ƒ If she develops a complication before or during labor, how will she reach the nearest health facility? ƒ Where will she find money for any additional cost e.g., CS? ƒ If she needs blood, who will donate?

28 THANK YOU FOR YOUR ATTENTION

29 References

Beck D et al. 2004. Care of the Newborn Reference Manual. Save the Children: Washington, D.C. Deganus S. 2004. Improving quality of antenatal care at a district hospital in Ghana, a presentation in Accra, Ghana. (29 July) Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, Maryland.

30 Optional Slides

ƒ Ghana: The Tema General Hospital Experience

31 Change at Tema General Hospital

ƒ Antenatal Care: ƒ Increased attendance ƒ Booking earlier in pregnancy ƒ Average client waiting time reduced by 1hr 40 mins ƒ Individualized care: Education and counseling more tuned to client needs ƒ All care components by the same provider ƒ Improved client-provider interaction ƒ Same provider provides continuing care to the client at all visits

32 Antenatal Attendance: 1999–2003

25,000

20,000

15,000

10,000

5,000

0 1997 1998 1999 2000 2001 2002 2003

Total Attendance New

33 The Impacts of Change (2)

ƒ Labor and delivery: ƒ Increased use of hospital delivery facilities (skilled attendant) ƒ Decreased stillbirth rate ƒ Postnatal care: ƒ Enhanced use of postnatal care services

34 Antenatal Booking and Skilled Attendance at Delivery: 1997–2003

6,000 5,000 4,000 3,000 2,000 1,000 0 1997 1998 1999 2000 2001 2002 2003 ANC Booking Deliveries

35 Stillbirths and MMR: 1997–2003

80 70 60 50 40 30 20 10 0 1997 1998 1999 2000 2001 2002 2003

MMR/1000 SBR/1000

36 Antenatal Care Bookings and Six-Week Postnatal Care Attendance: 1997–2003

6000 5000 4000 3000 2000 1000 0 1997 1998 1999 2000 2001 2002 2003

PN Attend AN Booking

37 Other Benefits of This Change

ƒ Improved staff morale ƒ Improved provider skill levels ƒ More client-friendly facilities ƒ Better use of staff skills ƒ Improved status of hospital as ƒ Clinic is recognized as center of excellence ƒ Center serves as a site for introducing new ANC country programs e.g., PMTCT ƒ Commitment by care providers to continued quality improvement

38 “Since I started practicing individualized AN care, work has become very interesting. I know my clients better, they share their problems with me because of the privacy provided. Clients feel relaxed and at ease with me. I feel more concerned and also more obliged to address their health needs. My clients seem to appreciate more the care I give to them and sometimes shower me with thank-you cards and gifts. This makes me feel great….” —ANC Care Provider

39 “There is still more room for improvement. There is still a lot to be learnt. We have a vision and we are working towards it.” —“Matron in Charge”

40 Best Practices in Prevention and Management of Malaria and Other Causes of Fever in Pregnancy

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Describe the effect of malaria on pregnant women and their newborns ƒ Discuss considerations in the transmission of malaria ƒ Describe the four main strategies to address malaria in pregnancy ƒ Define the main health education points for pregnant women living in malarious areas ƒ Describe general assessment of a woman with fever during pregnancy

2 Malaria Facts

ƒ 300 million malaria cases each year worldwide ƒ 9 of 10 cases occur in Africa ƒ An African dies of malaria every 10 seconds ƒ Affects 5 times as many as TB, AIDS, measles and leprosy combined

3 Significance of Malaria in Pregnancy

ƒ 30 million African women are pregnant yearly ƒ Malaria more frequent and severe during pregnancy: ƒ Women in 1st or 2nd pregnancy more at risk

4 Question ??

ƒ What are the effects of malaria on the mother and unborn baby?

5 Why is malaria important for pregnant women?

ƒ In malaria-endemic areas, malaria during pregnancy may account for: ƒ Up to 15% of maternal anemia ƒ 5–14% of low birth weight (LBW) ƒ 30% of “preventable” low birth weight

6 Malaria Transmission

ƒ Caused by Plasmodium Falciparum parasites ƒ Spread through female Anopheles mosquitoes, which bite mainly at night ƒ Infected mosquito bites a human ƒ Malaria parasites reproduce in human bloodstream ƒ Mosquito bites an infected person, and then goes on to bite and infect another person

7 Effect of Malaria

The effect of malaria on the pregnant woman can range from mild to severe, depending on her immunity. Level of immunity depends on: ƒ Intensity of malaria transmission – stable to unstable areas ƒ Number of previous pregnancies (women with first pregnancy has less immunity than woman having more than two pregnancies) ƒ Presence of other conditions, such as HIV, which can lower immune response

8 Effect of Malaria on Pregnancy: Stable Transmission Areas

Plasmodium Falciparum malaria

Asymptomatic Infection

Altered Placental Integrity

Placenta Attacked by Parasites

Reduced Nutrient & Oxygen Transport

Anemia Low Birth Weight (IUGR)

Source: CDC 2001. RISK OF NEWBORN MORTALITY

9 Effect of Malaria on Pregnancy: Unstable Transmission Areas Acquired immunity - low

Clinical illness

Severe disease

Risk to mother Risk to fetus

Source: WHO 2002.

10 HIV/AIDS and Malaria in Pregnancy

ƒ Being HIV+ reduces woman’s resistance to malaria: ƒ Higher risk of malaria ƒ Malaria treatment less effective ƒ Increased maternal anemia ƒ Increased risk of pre-term birth and LBW ƒ Malaria increases risk of an HIV+ woman transmitting HIV to her baby

11 Malaria Control during Pregnancy

1. Focused antenatal care and health education 2. Intermittent preventive treatment (IPT) 3. Insecticide-treated nets (ITNs) 4. Case management of malaria disease

12 1. FANC and Health Education

ƒ In Africa, at least 70% of women have at least one antenatal visit, a unique opportunity for: ƒ Health education/counseling about malaria in pregnancy ƒ Provision of iron and folate ƒ IPT ƒ Prompt diagnosis and treatment of malaria

13 Question ??

ƒ What are some points you want to remember when counseling a pregnant woman in a malarious area?

14 Health Education Points

ƒ Malaria transmitted by mosquito bites ƒ Pregnant women and children most at risk ƒ Pregnant women infected with malaria may have no symptoms ƒ Women with HIV/AIDS are at higher risk ƒ Can lead to severe anemia, abortion, LBW ƒ Malaria is preventable ƒ Malaria can be easily treated if recognized early

15 Health Education Points (cont.)

ƒ Control mosquito breeding ƒ Prevent mosquitoes from biting (and kill mosquitoes before they bite) – Insecticide- treated nets: where to find them, how to use them, how they work ƒ Kill malaria parasites in the blood – Intermittent preventive treatment: how it works, the importance of returning to receive all recommended doses

16 2. Intermittent Preventive Treatment

ƒ Based on the assumption that every woman in a malaria-endemic area is infected with malaria ƒ Recommends that every pregnant woman receives at least 2 treatment doses of an effective malaria drug ƒ Sulfadoxine-pyrimethamine (SP or Fansidar) currently considered most effective IPT drug

17 IPT

ƒ IPT with sulfadoxine-pyrimethamine: ƒ Single dose: 3 tablets taken at once, preferably under direct observation ƒ Fansidar is the most common brand name; Others include Falcidin, Laradox, Maladox ƒ SP generally more effective than chloroquine because of increasing prevalence of chloroquine resistance

18 IPT Timing of Doses

ƒ SP should be avoided during first 16 weeks of pregnancy: ƒ Initial development of fetus and organ formation ƒ Period of slow rate of growth ƒ Give first dose after quickening: ƒ Clear parasites during period of maximum fetal growth

19 IPT Timing of Doses (cont.)

ƒ WHO Recommendation: ƒ IPT should be given to all pregnant women at regularly scheduled ANC visits after quickening (after 16 weeks gestation). ƒ Ideal ANC visit schedule of four visits, three after quickening: IPT should be given at these ANC visits after quickening

20 Steps for Providing IPT

ƒ Follow local protocol ƒ Determine quickening has occurred ƒ Inquire about allergies to sulfa drugs (history of severe skin rash) ƒ Inquire about use of SP in the last month ƒ Provide 3 tablets of SP with clean water in a clean cup ƒ Observe the patient swallowing all 3 tablets (DOT)

21 Steps for Providing IPT (cont.)

ƒ Record SP on the antenatal card and on clinic record ƒ Instruct patient to return at next schedule visit or sooner if there are danger signs or she is feeling ill ƒ Ask about side effects about previous dose before giving the next dose, which should not be less than 4 weeks from the last dose

22 IPT – Instructions for SP

ƒ Contraindications to using SP: ƒ Do NOT give to women taking Septrin, Cotrimoxazole or other sulfa-containing drugs, plus ask about the use of these medicines before giving SP ƒ Do not give SP more frequently than monthly, plus be sure at least 1 month has passed since the last dose of SP

23 IPT Precautions

ƒ HIV+ women taking cotrimoxazole prophylaxis do not need IPT; they should sleep under an ITN ƒ Women taking iron and folate may continue to take it every day after receiving IPT as long as the dose of folate is not more than 0.4 mg (400 micrograms); Normally women receive 0.4 mg/day

24 3. Insecticide-Treated Nets

ƒ Reduce transmission by physically preventing mosquitoes from landing on sleeping persons ƒ Repel and kill mosquitoes that come in contact with the net ƒ Kill other insects like cockroaches, lice, bedbugs and ticks ƒ Should be used by pregnant women as early during the pregnancy as possible and throughout pregnancy and postpartum

25 ITNs: How to Use Them

ƒ Hang above bed or sleeping mat ƒ Tuck under mattress or mat ƒ Use every night, all year long ƒ Use for everybody, but if not enough ITNs for everyone, give priority to pregnant women, infants and children ƒ Remember to use a variety of methods to prevent bites

26 Summary of Health Education Points

ƒ Administer intermittent preventive treatment (IPT) with SP at least twice during pregnancy (according to country policy) at regularly scheduled ANC visits after quickening, but not more often than monthly ƒ Sleep under ITNs every night ƒ Use a variety of methods to prevent bites

27 4. Case Management

ƒ Drug efficacy ƒ Effective drugs are needed for P. falciparum ƒ Drug of choice depends on geographic drug resistance profile ƒ ACTs preferred treatment for uncomplicated malaria in 2nd or 3rd trimester ƒ Quinine drug of choice for complicated first trimester malaria

28 SP Resistance

ƒ Resistance of P. falciparum to SP has been increasing across Africa ƒ WHO recommends that where resistance has not reached high levels, countries continue to use SP for IPT as it is still effective for prevention of malaria in pregnancy ƒ No new drugs available to take the place of SP for IPT ƒ ITN use remains one of the best prevention measures available to women and families

29 Case Management

ƒ First decide whether malaria is uncomplicated or severe ƒ If uncomplicated—manage according to national protocol ƒ If severe—refer immediately to higher level of care; consider giving first dose of anti- malarial if available and the provider is familiar with its use

30 Question ??

How do you differentiate simple malaria from severe malaria in a pregnant woman?

31 Recognizing Malaria in Pregnant Women

Uncomplicated malaria Severe ƒ Fever ƒ Signs of uncomplicated ƒ Shivering/chills malaria, plus: ƒ Dizziness ƒ Headaches ƒ Breathlessness ƒ Muscle/joint pains ƒ Sleepy/drowsy ƒ Confusion/coma ƒ Nausea/vomiting ƒ Sometimes fits, jaundice, severe ƒ False labor pains dehydration

32 Managing Simple Malaria

ƒ Provide first line anti-malarial drugs: ƒ Follow country guidelines: − In first trimester, usually quinine − In second and third trimesters, some countries now use artemisinin-combined therapy (ACT) ƒ Manage fever: ƒ Analgesics, tepid sponging ƒ Diagnose and treat anemia ƒ Provide fluids

33 Fever during Pregnancy

ƒ Temperature of 38 C° or higher ƒ Malaria is NOT the only cause of fever: ƒ Bladder or kidney infection ƒ Typhoid ƒ Pneumonia ƒ Uterine infection ƒ Careful history and physical (including labs as needed) to rule out other causes

34 Fever during Pregnancy (cont.)

ƒ Ask about or examine for: ƒ Type, duration, degree of fever ƒ Signs of other infections: − Chest pain/difficulty breathing − Pain when urinating/foul smelling urine − Foul-smelling watery vaginal discharge − Tender/painful uterus or abdomen ƒ Signs of severe malaria or other danger signs

35 Fever during Pregnancy (cont.)

Refer the woman

immediately

if you suspect anything

other than

simple malaria

36 Treatment Follow-Up

ƒ Arrange follow-up within 48 hours ƒ Advise to return if condition worsens ƒ Review danger signs ƒ Reinforce use of ITNs

37 Referral

ƒ Refer immediately if: ƒ Condition does not improve within 48 hours of starting treatment ƒ Condition worsens and/or other symptoms appear ƒ Signs/symptoms suggestive of severe malaria ƒ Recurrence of malaria symptoms within 14 days of starting treatment

38 Treating Severe Malaria

ƒ Rule out other causes of convulsions/comas, such as eclampsia ƒ Refer severe complicated malaria: ƒ If referral delayed or arrival time prolonged, treatment pre-referral with aretesunate or artemisinin by rectum or IM or quinine IM (WHO 2006) ƒ Manage fever ƒ Correct dehydration and hypoglycemia as needed ƒ Control convulsions (fits) ƒ Monitor/treat for complications such as severe anemia and kidney failure

39 Summary of Case Management

ƒ Successful management of simple malaria requires prompt, complete treatment ƒ Know the signs of simple and severe malaria ƒ Fever is not caused only by malaria ƒ Malaria that recurs within 2 weeks is possibly resistant: Treat with second line drug ƒ Early referral for severe malaria avoids complications

40 References

Garner P and Gülmezoglu AM. 2000. Prevention versus Treatment for Malaria in Pregnant Women (Cochrane Review), in The Cochrane Library, Issue 4. Update Software: Oxford. Kayentao K et al. 2005. Comparison of intermittent preventive treatment with chemoprophylaxis for the prevention of malaria during pregnancy in Mali. J Infectious Diseases 191: 109–116. Menendez C et al. 2000. The impact of placental malaria on gestational age and birth weight. Journal of Infectious Diseases 181(5): 1740–1745. Njagi JK et al 2003. Prevention of anaemia in pregnancy using insecticide- treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: A randomized controlled trial. Transactions of the Royal Society of Tropical Medicine and Hygiene 97: 277–282. Ouma P et al. 2005. Does folic acid supplementation affect the efficacy of sulfadoxine-pyrimethamine in clearance of maternal P. falciparum parasitemia? Results of a randomized placebo-controlled trial. Presentation to the American Society of Tropical Medicine and Hygiene. (December)

41 References (cont.)

Parise ME et al. 1998. Efficacy of sulfadoxine-pyrimethamine for prevention of placental malaria in an area of Kenya with a high prevalence of malaria and human immunodeficiency virus infection. American Journal of Tropical Medicine and Hygiene 59(5): 813–822. Shulman CE et al. 1999. Intermittent sulphadoxine-pyrimethamine to prevent severe anaemia secondary to malaria in pregnancy: A randomized placebo- controlled trial. Lancet 353(9153): 632–636. Steketee RW et al. 2001. The burden of malaria in pregnancy in malaria-endemic areas. American Journal of Tropical Medicine and Hygiene 64 (Supple 1–2): 28– 35. Ter Kuile et al. 2003. Permethrin-treated bednets reduce malaria in pregnancy in an area of intense perennial malaria transmission in western Kenya. American Journal of Tropical Medicine and Hygiene 68(April): 100–107.

42 References (cont.)

Verhoeff F et al. 1999. Increased prevalence of malaria in HIV-infected pregnant women and its implications for malaria control. Tropical Medicine and International Health 4(1): 5–12. World Health Organization (WHO). 2004a. A Strategic Framework for Malaria Prevention and Control During Pregnancy in the African Region. WHO Regional Office for Africa: Brazzaville. World Health Organization (WHO). 2006. Guidelines for the Treatment of Malaria. WHO: Geneva World Health Organization (WHO). 2003a. Malaria in Africa. http://rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm World Health Organization (WHO)/UNICEF. 2005. World Malaria Report 2005. WHO: Geneva. World Health Organization (WHO)/UNICEF. 2003b. Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels and Differentials, 1990-2001. WHO: Geneva.

43 Best Practices in Care during Labor and Childbirth

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To identify best practices for managing labor and childbirth: ƒ Birth preparedness/complication readiness ƒ Partograph ƒ Active management of the third stage of labor ƒ Restricted episiotomy ƒ To identify harmful practices with the goal of eliminating them from practice

2 Objectives of Care during Labor and Childbirth

ƒ Protect the life of the mother and newborn ƒ Support the normal labor and detect and treat complications in timely fashion ƒ Support and respond to needs of the woman, her partner and family during labor and childbirth

3 Question ??

ƒ At what time during pregnancy and childbirth do most deaths occur?

4 When is the mother most vulnerable? (Evidence from Matlab, Bangladesh)

160 140 120 100 80 60 40 20

Deaths per 1000 person year person 1000 per Deaths 0

0 1 2 0 5 r 2 y -9 a 8-4 -36 Da Day 2 y Ye Day 3-7 a 81 D y 91-18 1 Day 43 a y D a D

During pregnancy

5 Why do we need to be prepared for birth and complications?

ƒ Acting quickly is important because a woman could die in a short period of time: ƒ In antepartum hemorrhage, she can die In just 12 hours. ƒ In postpartum hemorrhage, she can die In just 2 hours. ƒ With complications of eclampsia, in as few as 12 hours, and ƒ With sepsis, in about 3 days!

6 Why do we need to be prepared for birth and complications? (cont.)

ƒ Delay is a significant factor in many maternal and newborn deaths and disabilities: ƒ Recognizing the problem ƒ Deciding to seek care ƒ Reaching and receiving care ƒ Birth preparedness and complication readiness to reduce delays

7 Question ??

ƒ What are the elements that should be included in birth preparedness and complication readiness?

8 Birth Preparedness and Complication Readiness for the Woman and Family

ƒ Plan place for delivery ƒ Choose provider ƒ Recognize danger signs ƒ Plan for managing complications ƒ Save money or access funds ƒ Arrange transportation ƒ Identify potential blood donors

9 Birth Preparedness and Complication Readiness for the Provider

ƒ Diagnose and manage problems and complications appropriately and in a timely manner ƒ Arrange referral to higher level of care if needed ƒ Provide women-centered counseling about birth preparedness and complication readiness ƒ Educate community about birth preparedness and complication readiness

10 Complication Readiness for the Provider

ƒ Recognize and respond to danger signs ƒ Be knowledgeable and skilled in managing complications ƒ Have emergency equipment, drugs and supplies in working order and ready to use

11 Partograph and Criteria for Active Labor

ƒ Label with identifying info ƒ Note FHR, color of amniotic fluid, moulding, contraction pattern, medications given ƒ Plot cervical dilation ƒ Alert line starts at 4 cm-- then, expect dilatation at rate of 1 cm/hour ƒ Action line: If labor does not progress as above, action is required

12 WHO Partograph Trial

ƒ Objectives: ƒ To evaluate impact of WHO partograph on labor management and outcome ƒ To devise and test protocol for labor management with partograph ƒ Design: Multicenter trial randomizing hospitals in Indonesia, Malaysia and Thailand ƒ No intervention in latent phase until after 8 hours ƒ At active phase action line, consider: oxytocin augmentation, cesarean section, or observation AND supportive treatment Source: WHO 1994.

13 WHO Partograph: Results of Study

All Women Before After p Implementation Implementation Total deliveries 18254 17230 Labor > 18 hours 6.4% 3.4% 0.002 Labor augmented 20.7% 9.1% 0.023 Postpartum sepsis 0.70% 0.21% 0.028 Normal Women Mode of delivery Spontaneous 8428 (83.9%) 7869 (86.3%) < 0.001 cephalic Forceps 341 (3.4%) 227 (2.5%) 0.005

Source: WHO 1994. 14 Individual Work

ƒ Complete partograph exercise(s) ƒ Review with reassembled group

15 What actions might you take in the event of obstructed labor?

ƒ Cesarean section ƒ Episiotomy ƒ Assisted vaginal birth: ƒ Using vacuum extractor ƒ Using forceps

16 Restricted Use of Episiotomy: Objectives and Design

ƒ Objective: To evaluate possible benefits, risks and costs of restricted use of episiotomy vs. routine episiotomy ƒ Design: Meta-analysis of six randomized control trials

Carroli and Belizan 2000.

17 Restricted Use of Episiotomy: Maternal Outcomes Assessed

ƒ Severe vaginal/perineal trauma ƒ Need for suturing ƒ Posterior/anterior perineal trauma ƒ Perineal pain ƒ Dyspareunia ƒ Urinary incontinence ƒ Healing complications ƒ Perineal infection

Source: Carroli and Belizan 2000.

18 Restricted Use of Episiotomy: Results of Cochrane Review

Clinically Relevant Relative Risk 95% CI Morbidities Posterior perineal trauma 0.88 0.84–0.92 Need for suturing 0.74 0.71–0.77 Healing complications at 0.69 0.56–0.85 7 days Anterior perineal trauma 1.79 1.55–2.07

ƒ No increase in incidence of major outcomes (e.g., severe vaginal or perineal trauma nor in pain, dyspareunia or urinary incontinence) ƒ Incidence of 3rd degree tear reduced (1.2% with episiotomy, 0.4% without) ƒ No controlled trials on controlled delivery or guarding the perineum to prevent trauma Sources: Carroli and Belizan 2000. Eason et al. 2000; WHO 1999. 19 Indicated Use of Episiotomy: Reviewers’ Conclusions

ƒ Implications for practice: Clear evidence to restrict use of episiotomy in normal labor ƒ Implications for research: Further trials needed to assess use of episiotomy at: ƒ Assisted delivery (forceps or vacuum) ƒ Preterm delivery ƒ Breech delivery ƒ Predicted macrosomia ƒ Presumed imminent tears (threatened 3rd degree tear or history of 3rd degree tear with previous delivery)

Sources: Carroli and Belizan 2000. WHO 1999.

20 Clean Delivery

ƒ Infection accounts for 11% of all maternal deaths ƒ Infection/pneumonia accounts for 26% of newborn deaths ƒ Tetanus accounts for 7% of newborn deaths ƒ These deaths can be largely avoided with infection prevention practices

21 Infection Prevention Practices

ƒ Use disposable materials once and decontaminate reusable materials throughout labor and childbirth ƒ Wear gloves during vaginal examination, during birth of newborn and when handling placenta ƒ Wear protective clothing (shoes, apron, glasses) ƒ Wash hands ƒ Wash perineum with soap and water and keep it clean ƒ Ensure that surface on which newborn is delivered is kept clean ƒ High-level disinfect instruments, gauze and ties for cutting cord

22 Third Stage

ƒ Time of greatest/most rapid physiologic change and highest risk of hemorrhage ƒ Uterus as a muscle, must contract to stop bleeding ƒ Placenta must separate from wall of uterus and be delivered

23 Best Practices: Third Stage of Labor

ƒ Offer active management of third stage for ALL women: ƒ Oxytocin administration ƒ Controlled cord traction ƒ Uterine massage after delivery of the placenta to keep the uterus contracted ƒ Routine examination of the placenta and membranes ƒ Routine examination of vagina and perineum for lacerations and injury

Source: WHO 1999.

24 Question ??

How effective is active management of the third stage of labor at preventing postpartum hemorrhage?

25 ACTIVEACTIVE vs.vs. EXPECTANTEXPECTANT MANAGEMENTMANAGEMENT OFOF THIRDTHIRD STAGESTAGE 66 studiesstudies 48504850 womenwomen 95%95% CICI PostpartumPostpartum hemorrhage hemorrhage ≥≥500500 mlml 0.380.38 (0.32-0.46)(0.32-0.46) LossLoss ofof bloodblood≥≥10001000 mlml 0.330.33 (0.21-0.51)(0.21-0.51) MaternalMaternal hemoglobinhemoglobin 2424 –– 48 48 hh postpartumpostpartum <9 <9 g/lg/l 0.400.40 (0.29-0.55)(0.29-0.55) NeedNeed for for transfusion transfusion 0.340.34 (0.22-0.53)(0.22-0.53) ThirdThird stage stage >40 >40 minmin 0.180.18 (0.14-0.24)(0.14-0.24) ManualManual removalremoval of of placenta placenta 1.211.21 (0.82-1.78)(0.82-1.78) PostpartumPostpartum curettage curettage 0.740.74 (0.43-1.28)(0.43-1.28) VomitingVomiting 2.192.19 (1.68-2.86)(1.68-2.86) NauseaNausea 1.831.83 (1.51-2.23)(1.51-2.23) ApgarApgar <7 <7 atat 5º5º min.min. 1.001.00 (0.38-2.66)(0.38-2.66) NewbornNewborn admissionadmission toto ICUICU 0.820.82 (0.60-1.11)(0.60-1.11) NoNo breastfeedingbreastfeeding atat dischargedischarge 0.920.92 (0.82-1.04)(0.82-1.04)

26 .1.1 .2.2 11 55 1010 ICM/FIGO Joint Statement on Active Management of the Third Stage of Labor (AMTSL)

ƒ AMSTL has been proven to reduce the incidence of postpartum hemorrhage, reduce the quantity of blood loss and reduce the use of transfusion ƒ AMSTL should be offered to all women who are giving birth ƒ Every attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out AMSTL

27 Best Practices: Labor and Childbirth

ƒ Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc.): ƒ Less use of analgesia OR 0.68 (CI 0.58–0.79) ƒ Fewer operative vaginal deliveries OR 0.73 (95% CI 0.62–0.88) ƒ Less postpartum depression at 6 weeks OR 0.12 (CI 0.04–0.33) ƒ Offer oral fluids throughout labor and childbirth

Source: Neilson 1998.

28 Best Practices: Postpartum

Mother Newborn ƒ Close monitoring and ƒ Babies should begin surveillance during first 6 breastfeeding as soon as hours postpartum: possible after birth ƒ Parameters: (preferably within the first − Blood pressure, pulse, hour) vaginal bleeding, uterine hardness ƒ Colostrum should be given ƒ Timing: to the baby and not thrown − Every 15 minutes for 2 away hours − Every 30 minutes for 1 hour − Every hour for 3 hours

29 Position in Labor and Childbirth

ƒ Allow freedom in position and movement throughout labor and childbirth ƒ Encourage any non-supine position: ƒ Side lying ƒ Squatting ƒ Hands and knees ƒ Semi-sitting ƒ Sitting

30 Position in Labor and Childbirth (cont.)

Use of upright or lateral position compared with supine or lithotomy position is associated with: ƒ Shorter second stage of labor (5.4 minutes, 95% CI 3.9–6.9) ƒ Fewer assisted deliveries (OR 0.82, CI 0.69–0.98) ƒ Fewer episiotomies (OR 0.73, CI 0.64–0.84) ƒ Fewer reports of severe pain (OR 0.59, CI 0.41–0.83) ƒ Less abnormal heart rate patterns for fetus (OR 0.31, CI 0.11–0.91) ƒ More perineal tears (OR 1.30, CI 1.09–1.54) ƒ Blood loss > 500 mL (OR 1.76, CI 1.34–3.32)

Source: Gupta and Nikodem 2000.

31 Support of Woman

ƒ Give woman as much information and explanation as she desires ƒ Provide care in labor and childbirth at a level where woman feels safe and confident ƒ Provide empathic support during labor and childbirth ƒ Facilitate good communication between caregivers, the woman and her companions ƒ Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia, and fewer operative deliveries

Source: WHO 1999.

32 Presence of Female Relative during Labor: Results

RCT in Botswana: 53 women with relative; 56 without

Labor Outcome Experimental Control p Group (%) Group (%) Spontaneous vaginal 91 71 0.03 delivery Vacuum delivery 4 16 0.03 Cesarean section 6 13 0.03 Analgesia 53 73 0.03 Amniotomy 30 54 0.01 Oxytocin 13 30 0.03

Source: Madi et al 1999.

33 Presence of Female Relative during Labor: Conclusion

Support from female relative improves labor outcomes

Source: Madi et al 1999.

34 Harmful Routines

ƒ Use of enema: uncomfortable, may damage bowel, does not change duration of labor, incidence of neonatal infection or perinatal wound infection ƒ Pubic shaving: discomfort with regrowth of hair, does not reduce infection, may increase transmission of HIV and hepatitis ƒ Lavage of the uterus after delivery: can cause infection, mechanical trauma or shock ƒ Manual exploration of the uterus after delivery

Sources: Nielson 1998; WHO 1999.

35 Harmful Practices

ƒ Examinations: ƒ Rectal examination: Similar incidence of puerperal infection, uncomfortable for woman ƒ Routine use of x-ray pelvimetry: Increases incidence of childhood leukemia ƒ Position: ƒ Routine use of supine position during labor ƒ Routine use of lithotomy position with or without stirrups during labor

36 Harmful Interventions

ƒ Administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled ƒ Sustained, directed bearing down efforts during the second stage of labor ƒ Massaging and stretching the perineum during the second stage of labor (no evidence) ƒ Fundal pressure during labor

Source: Eason et al. 2000.

37 Inappropriate Practices

ƒ Restriction of food and fluids during labor ƒ Routine intravenous infusion in labor ƒ Repeated or frequent vaginal examinations, especially by more than one caregiver ƒ Routinely moving laboring woman to a different room at onset of second stage ƒ Encouraging woman to push when full dilation or nearly full dilation of cervix has been diagnosed, before woman feels urge to bear down

Sources: Nielson 1998; Ludka and Roberts 1993.

38 Inappropriate Practices (cont.)

ƒ Rigid adherence to a stipulated duration of the second stage of labor (e.g., 1 hour) if maternal and fetal conditions are good and there is progress of labor ƒ Liberal or routine use of episiotomy ƒ Liberal or routine use of amniotomy

39 Practices Used for Specific Clinical Indications

ƒ Bladder catheterization ƒ Operative delivery ƒ Oxytocin augmentation ƒ Pain control with systemic agents ƒ Pain control with epidural analgesia ƒ Continuous electronic fetal monitoring

40 Normal Labor and Childbirth: Conclusion

ƒ Have a skilled attendant present ƒ Use partograph ƒ Use specific criteria to diagnose active labor ƒ Restrict use of unnecessary interventions ƒ Use active management of third stage of labor ƒ Support woman’s choice for position during labor and childbirth ƒ Provide continuous emotional and physical support to woman throughout labor

41 Demonstrations

ƒ Normal labor and birth including newborn care ƒ Active management of third stage of labor ƒ Use of vacuum extractor for assisting birth ƒ Episiotomy and repair ƒ Review of learning guides ƒ Demonstration by teacher/facilitator ƒ Practice by learners ƒ Return demonstration

42 References

Carroli G and Belizan J. 2000. Episiotomy for vaginal birth (Cochrane Review), in The Cochrane Library. Issue 2. Update Software: Oxford. Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematic review. Obstet Gynecol 95: 464–471. Gupta JK and Nikodem VC. 2000. Woman’s position during second stage of labour (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, MD. Lauzon L and Hodnett E. 2000. Caregivers' use of strict criteria for diagnosing active labour in term pregnancy (Cochrane Review), in The Cochrane Library. Update Software: Oxford.

43 References (cont.)

Ludka LM and Roberts CC. 1993. Eating and drinking in labor: A literature review. J Nurse-Midwifery 38(4): 199–207. Madi BC et al. 1999. Effects of female relative support in labor: A randomized control trial. Birth 26:4–10. Neilson JP. 1998. Evidence-based intrapartum care: Evidence from the Cochrane Library. Int J Gynecol Obstet 63 (Suppl 1): S97–S102. World Health Organization Safe Maternal Health and Safe Motherhood Programme. 1994. World Health Organization partograph in management of labour. Lancet 343 (8910):1399–1404. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.

44 Best Practices in Managing Labor Using the Partograph

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Discuss the importance of using a partograph ƒ Understand how to fill in a partograph ƒ Understand how to use a partograph in decision-making

2 Usefulness of the Partograph

ƒ Assessment of fetal well-being ƒ Assessment of maternal well-being ƒ Assessment of progress of labor

3 Measuring Fetal Well-Being during Labor

ƒ Fetal heart rates and pattern ƒ Degree of molding, caput ƒ Color of amniotic fluid

4 Measuring Maternal Well-Being during Labor

ƒ Pulse, temperature, blood pressure, respiration ƒ Urine output, ketones, protein

5 Measuring Progress of Labor

ƒ Cervical dilatation ƒ Descent of presenting part ƒ Contractions ƒ Duration ƒ Frequency ƒ Alert and action lines

6 Using the Partograph

ƒ Patient information: Name, gravida, para, hospital number, date and time of admission, and time of ruptured membranes ƒ Fetal heart rate: Record every half hour ƒ Amniotic fluid: Record the color at every vaginal examination: ƒ I: membranes intact ƒ C: membranes ruptured, clear fluid ƒ M: meconium-stained fluid ƒ B: blood-stained fluid

7 Using the Partograph (cont.)

ƒ Molding: ƒ 1: sutures apposed ƒ 2: sutures overlapped but reducible ƒ 3: sutures overlapped and not reducible ƒ Cervical dilatation: Assess at every vaginal examination, mark with cross (X) ƒ Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour ƒ Action line: Parallel and 4 hours to the right of the alert line

8 Using the Partograph (Descent)

ƒ Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis

9 Using the Partograph (Timing)

ƒ Hours: Time elapsed since onset of active phase of labor (observed or extrapolated) ƒ Time: Record actual time ƒ Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds ƒ Less than 20 seconds: ƒ Between 20 and 40 seconds: ƒ More than 40 seconds:

10 Using the Partograph (Drugs)

ƒ Oxytocin: Record amount per volume IV fluids in drops/min. every 30 min. when used ƒ Drugs given: Record any additional drugs given

11 Using the Partograph (Vital Signs and Urine)

ƒ Temperature: Record every 2 hours ƒ Pulse: Record every 30 minutes and mark with a dot (•) ƒ Blood pressure: Record every 4 hours and mark with arrows ƒ Protein, acetone and volume: Record every time urine is passed

12 The Modified WHO Partograph

13 Sample Partograph for Normal Labor

14 Partograph Showing Obstructed Labor

15 Partograph Showing Inadequate Uterine Contractions Corrected with Oxytocin (Oxytocin should have been started 2 hours earlier—Hour 2)

16 Practice

Now let’s practice use of the partograph with simulated situations

17 Best Practices in Care for Assisted Breech Birth

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To identify best practices for managing breech birth: ƒ Procedures to assist in delivery ƒ Post-procedure tasks

2 Indications for Vaginal Breech Birth

ƒ Frank or complete breech presentation ƒ Cervix completely dilated ƒ No evidence of cephalopelvic disproportion

3 Breech Presentations

4 Overall Tasks

ƒ Plot all parameters on partograph during labor ƒ Start an IV infusion ƒ Provide emotional support and encouragement ƒ Perform all maneuvers gently and without force

5 Procedure: Delivery of Buttocks and Legs

ƒ Once buttocks are in vagina, tell woman she may push. ƒ Perform episiotomy if perineum is tight. ƒ Allow buttocks to deliver until shoulder blades are seen. ƒ Gently hold buttocks in one hand, but do not pull. Do not hold by flanks or abdomen as this may cause kidney or liver damage.

6 Holding the Baby at the Hips

7 Procedure: If Legs Do Not Deliver Spontaneously

ƒ Deliver one leg at a time ƒ Push behind the knee to bend the leg ƒ Grasp the ankle and deliver the foot and leg ƒ Repeat for other leg ƒ DO NOT PULL THE BABY WHILE THE LEGS ARE BEING DELIVERED!

8 Procedure: Normal Delivery of the Arms

ƒ If the arms are felt on the chest: ƒ Allow arms to disengage spontaneously ƒ After delivery of first arm, lift buttocks toward mother’s abdomen ƒ If arm does not delivery spontaneously, place one or two fingers in elbow and bend arm, bringing down over baby’s face

9 Procedure: If Arms Are Stretched above the Head: Loveset Maneuver

ƒ Hold baby by hips and turn half circle ƒ Keep back uppermost while downward traction brings posterior arm into anterior position ƒ Flex first (now anterior) arm as on previous slide ƒ Deliver second arm by half circle turn, keeping back uppermost and repeat to deliver other arm

10 Procedure: If the Baby’s Body Cannot Be Turned to Deliver Anterior Arm First

ƒ Lift baby up by ankles. ƒ Move baby’s chest towards woman’s inner leg. The shoulder that is posterior should deliver. ƒ Deliver the arm and hand. ƒ Lay the baby back down by ankles so that anterior shoulder now delivers with arm and hand.

11 Procedure: Delivery of the Head

As Shown on Next Slide: ƒ Lay baby face down with length of body over your arm and hand ƒ Place 1st and 3rd fingers on baby’s cheekbone and 2nd finger in baby’s mouth to pull jaw down and flex head ƒ Use other hand to grasp baby’s shoulders ƒ With 2 fingers of this hand, flex baby’s head toward chest while pulling on jaw ƒ Pull gently to deliver head ƒ NOTE: Ask an assistant to push above the woman’s pubic bone as the head delivers to help keep head flexed

12 Procedure: Delivery of the Head

13 Procedure: If Head Is Entrapped

ƒ Catheterize bladder ƒ Have an assistant hold the baby while you apply Piper forceps ƒ Wrap baby in cloth or towel and hold baby up ƒ Use forceps to flex and deliver the baby’s head ƒ Apply firm pressure above the woman’s pubic bone to flex baby’s head

14 Post-Procedure Tasks

ƒ Suction baby’s mouth and nose if necessary ƒ Clamp and cut cord ƒ Keep baby warm and dry ƒ Perform active management of the third stage of labor ƒ Examine the woman carefully for tears of the vagina, perineum and cervix, and repair episiotomy

15 Best Practices in Vacuum Extractor-Assisted Birth

Best Practices in Maternal and Newborn Care

Updated by Annie Clark, CNM

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

1) State indications and contraindications for the use of the vacuum extractor. 2) State complications associated with vacuum extractor use for mother and baby. 3) Compare advantages and disadvantages of vacuum extractor versus forceps. 4) Compare advantages and disadvantages of soft cups and metal cups.

During clinical practice session: ƒ Demonstrate the steps for using the vacuum extractor using fetal and pelvis models and a skills checklist, including identification of the flexion point. ƒ Describe the care of a vacuum extractor, tubing and pump after use.

2 What is a vacuum extractor?

3 Clinical and Technical Principles

4 Correct Application of the Cup

Courtesy of: Aldo Vacca, M.D. 5 Location of the Flexion Point

Courtesy of: Aldo Vacca, M.D. 6 Placement of the Vacuum Cup

7 Mechanism of Labor

ƒ Flexion ƒ Synclitism ƒ Descent ƒ Internal Rotation ƒ Extension ƒ Restitution

8 STATION

Station is the relationship of the lowermost part of the presenting part to an imaginary line drawn between the ischial spines.

9 ENGAGEMENT

Engagement is defined as the point when the widest diameter of the presenting part (in a cephalic occipital presentation, the biparietal diameter) has passed through the pelvic inlet. In most circumstances, when the head is engaged, the lowermost part of the presenting part is at the level of ischial spines, or 0 station. FLEXION

When flexion is complete, the shortest anteroposterior diameter, the suboccipitobregmatic (dotted line), is passing through the pelvic inlet. The solid dark line indicates the mentoccipital diameter.

11 SYNCLITISM

Courtesy of: Williams Obstetrics. 12 ACOG Forceps Classification (Often applied to vacuum-assisted births)

Outlet: 1. Scalp is visible at the introitus without separating the labia. 2. Fetal skull has reached the pelvic floor. 3. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position. 4. Fetal head is at or on the perineum. 5. Rotation does not exceed 45 degrees.

13 ACOG Forceps Classification

Low: 1. Leading point of fetal skull is at station > +2 cm and not on the pelvic floor. 2. Rotation is 45 degrees or less (left or right occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior. 3. Rotation is greater than 45 degrees. Mid-pelvic: 1. Station is above +2 station but head is engaged.

14 Pulling Downward

15 Pulling Horizontal

16 Pulling Straight Up

17 Crowning

18 Metal Cups Metal Cups ADVANTAGES DISADVANTAGES

ƒ Posterior metal cups ƒ More difficult to apply are effective for: ƒ More uncomfortable ƒ Posterior position ƒ Higher incidence of fetal ƒ Large baby scalp injuries ƒ Significant caput ƒ Deflexed head ƒ Can be autoclaved ƒ Already available in many locations where newer cups cannot be purchased ƒ Still used and available

19 Advantages of Disadvantage of Soft Cups Soft Cups

ƒ Easier assembly and ƒ Higher rate of delivery application failure ƒ Faster from application to effective traction ƒ Less pronounced chignon ƒ Fewer superficial scalp injuries ƒ Less retinal hemorrhage

20 Mityvac Vacuum Pump

ƒ No electricity required ƒ Trigger vacuum release for complete control throughout delivery by midwife or assistant ƒ Precision gauge color coded, calibrated in cm and inches of Hg ƒ Minigrip contoured handle ƒ May be autoclaved or gas sterilized

21 Care of Vacuum Extractor Pump, Cup and Tubing

ƒ Pistol style pump is cleaned with a damp cloth (if pump is contaminated, wipe with 0.5% chlorine, then immediately with clear water). ƒ When fluid trap is used, it prevents fluid from being sucked into pump. ƒ If fluid is in pump, immerse in distilled water, pump until water expelled is clear, squeeze handles to air dry; do not leave fluid in the pump. ƒ Do not use soap or other cleaning solutions; they affect operation of pump. ƒ Cup and tubing should be soaked in 0.5% chlorine for 10 minutes, washed with soapy water and rinsed with clean water. Cup should be autoclaved. Tubing should be soaked for another 20 minutes in 0.5% chlorine, rinsed with clean water and air dried.

22 Complications – Newborn Caput

ƒ Results from pressure applied CAPUT to fetal scalp from: ƒ Dilating cervix ƒ Pelvic soft tissue ƒ Vacuum ƒ Caput occurs at vacuum cup application site; also called chignon ƒ Interstitial hemorrhages and fluid accumulate to form caput; longer 2nd stage and longer procedure leads to more accumulation ƒ Makes tissue more vulnerable to abrasion, laceration, hematoma ƒ Resolves spontaneously in a few days 23 Complications – Newborn Cephalhematoma

Cephalhematoma: ƒ Vessel ruptures between periosteum and outer edge of fetal skull ƒ Hemorrhage is self- limited since periosteum is attached to edges of cranial plates ƒ Most common over parietal bone; does not cross suture lines ƒ Takes 4–6 weeks to resolve ƒ Mean incidence 6% with VE deliveries

24 Cephalhematoma

ƒ May calcify and cause deformity (rare) ƒ Increase in bilirubin has been reported ƒ Not associated with long-term sequelae ƒ A vacuum chignon located over one of the parietal bones can be mistaken for cephalhematoma ƒ Over-diagnosed, as much as 4 fold ƒ Same incidence whether vacuum is intermittent or continuous ƒ Increased with higher station, increasing degree of asynclitism, greater time from application to delivery ƒ No increase with spontaneous rotation

25 Complications – Newborn Retinal Hemorrhage

Retinal hemorrhage: ƒ Retinal hemorrhage less when: ƒ 2nd stage less than 1 hour ƒ C/S ƒ Breech birth ƒ Forceps ƒ May result from changes in intracranial venous pressure ƒ Not increased with non-reassuring fetal heart rate ƒ Rate with vacuum higher than normal birth ƒ With vacuum, hemorrhage more common in right eye ƒ Transient sign ƒ No long term consequences ƒ Pathophysiology unknown

26 Complications – Newborn Scalp Injuries

Scalp injuries: ƒ Bruising and swelling are common ƒ Cup disengagement contributes to abrasions, bruising, bleeding, swelling ƒ Incidence is greater if: ƒ Vacuum procedure lasts longer than 10 minutes ƒ 2nd stage is longer than 2 hours ƒ Cup application is paramedian ƒ With metal cup, twisting causes cookie-cutter or semi-circumferential laceration

27 Complications – Newborn Intracranial Hemorrhage

Intracranial hemorrhage: ƒ Occurs in 1 of 860 VE deliveries, 1 of 1,900 spontaneous deliveries ƒ Higher when delivery is by vacuum, forceps or C/S as compared to normal vaginal delivery ƒ If C/S is before labor starts, incidence is not increased, suggesting that cause is related to abnormal labor rather than mode of delivery ƒ Rate markedly decreased with soft plastic cups

28 Complications – Newborn Subgaleal (Subaponeurotic) Hemorrhage

ƒ Collection of blood under scalp ƒ Potential space can accom- modate half or more of the blood volume of the neonate ƒ May cause coagulopathy, difficult to control ƒ Mortality almost 1 in 4 ƒ Risk factors: use of vacuum, primpara, macrosomia, prolonged labor, CPD, prematurity, male gender, birth in Africa ƒ Occurs in approximately 1 in 1,000 VE deliveries

29 Subgaleal Hemorrhage (cont.)

ƒ More likely to occur when vacuum applied over anterior fontanelle ƒ Watch for early signs of shock such as pallor, hypotonia, tachycardia, tachypnea, increasing head circumference ƒ Late signs include anemia and boggy, ballotable cranium ƒ Do hourly head circumference for 8 hours ƒ Draw a baseline umbilical cord hematocrit

30 Complications – Maternal

Perineal, vaginal and cervical lacerations are more likely with: ƒ Nullipara ƒ Use of forceps ƒ Use of episiotomy ƒ Posterior presentation ƒ Prolonged delivery time ƒ Increased birth weight ƒ Midpelvic station ƒ Greater than 45 degrees of rotation

31 Advantages of Vacuum Compared to Forceps – Baby and Delivery Factors

ƒ Less force to fetal head ƒ Allows autorotation of fetal head ƒ Can be used to correct deflection and asynclitism ƒ Augments pushing and assists vaginal delivery

32 Advantages of Vacuum Compared to Forceps – Maternal and Provider Factors

ƒ Fewer reproductive tract injuries, less maternal genital trauma including anal sphincter tears ƒ Less maternal discomfort during and after delivery ƒ Less anesthesia is necessary ƒ Less maternal blood loss ƒ Easier to learn

33 Advantages of Forceps Compared to Vacuum

ƒ No contractions are needed ƒ Easier to apply with caput ƒ Used with breech presentation ƒ Pre-term use less controversial ƒ Less difficult to apply to deflexed head ƒ Rotation of fetal head accepted practice ƒ Less incidence of shoulder dystocia

34 Effectiveness

ƒ Vacuum failure rates range from 2–27% ƒ Metal cups have slightly higher success rates than plastic cups, but also higher rates of adverse outcomes ƒ Greater failure rate of vacuum versus forceps when the position was posterior and silastic cup was used ƒ Highest VE success rate with a non- metal cup was with the M-cup, which has a delivery rate as high as forceps

35 Question ??

What are the primary indications for use of the vacuum extractor?

36 Indications

1. Non-reassuring fetal heart rate, the most important indication, may include bradycardia, tachycardia, repetitive deep variables or late decelerations. 2. Maternal exhaustion is an indication when the mother is unable to complete second stage spontaneously because of inadequate expulsive efforts or ineffective bearing down.

37 Requirements for Use of a Vacuum Extractor ƒ Vertex presentation ƒ Term fetus ƒ Cervix fully dilated ƒ Head at least 0 station or no more than 2/5 above symphysis pubis ƒ Ruptured membranes ƒ Adequate pelvis – no clinical evidence of CPD (no severe molding)

38 Contraindications to Use of Vacuum Extractor

ƒ Incompetent or inexperienced provider ƒ Severe caput ƒ Prematurity (less than 37 weeks) ƒ Malpresentation (breech, footling, face, brow, shoulder, transverse) ƒ Inability to achieve proper suction ƒ Uncertainty concerning fetal position ƒ Suspicion of CPD ƒ Known or suspected fetal coagulation defect ƒ Prior failed forceps ƒ OP position of fetus and no posterior cup available

39 Do Not Continue to Pull If:

ƒ The head does not advance with each pull ƒ The fetus is undelivered after three contractions without reducing pressure between contractions ƒ The fetus is undelivered after 20 minutes when pressure is reduced between contractions ƒ The cup comes off the head and scalp laceration or abrasion is seen. ƒ The cup comes off the head twice

40 References

Lurie S et al. 2005. Maternal and neonatal effects of forceps versus vacuum operative vaginal birth. International Journal of Gynecology and Obstetrics 89: 293–294. Pope C et al. 2006. Vacuum Extraction on eMedicine Web site, accessed on 12 September 2007: www.emedicine.com/med/topic3389.htm. Vacca A. 2003. Handbook of Vacuum Delivery in Obstetric Practice. Vacca Research: Brisbane, Australia. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Geneva: WHO.

41 Best Practices in Immediate Care of the Newborn

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objective

ƒ Define essential elements of early newborn care ƒ Discuss best practices for promoting newborn health ƒ Use relevant data and information to develop appropriate recommendations for essential newborn care

2 Newborn Deaths

Every year: ƒ 8.1 million infant deaths ƒ 4 million neonatal deaths ƒ 40% of all under-five mortality ƒ Eight neonatal deaths every minute ƒ 4 million stillbirths ƒ Under-five and under-one mortality has declined significantly – but NMR has declined little

3 Question ??

ƒ What are the main causes of newborn mortality?

4 Causes of Newborn Death

Other 3% Congenital Sepsis/ 14% pneumonia 27% Asphyxia 7% Infection 36% Sepsis Tetanus 11% 7%

Diarrhoea Preterm 3% 28%

5 Risk by Week of Life for the First 5 Years: The Early Postnatal Period

The riskiest Risk of death per each week of life during the week of life first 5 years of life, based on global average mortality rates 35 30 25 25 20 15 10 (global average) (global 5 1.66 0.54 0.14 0 Early neonatal (Day Late Neonatal (Day Post-neonatal (1 - Age 12-59 months

Weekly risk of death per 1000 live births 1000 live per death of risk Weekly 0-6) 7-28) 11 months)

Source: Lawn Addis presentation based on global ENMR, NMR 2000 estimates, IMR and U5M in State of the World’s Children.

6 Newborn Deaths

ƒ Birth process was the antecedent cause of 2/3 of deaths due to infections: ƒ Lack of hygiene at childbirth and during newborn period ƒ Home deliveries without skilled birth attendants ƒ Birth asphyxia in developing countries: ƒ 3% of newborns suffer mild to moderate birth asphyxia ƒ Prompt resuscitation is often not initiated or procedure is inadequate or incorrect

7 Newborn Deaths (cont.)

ƒ Low birth weight: ƒ An extremely important factor in newborn mortality ƒ Hypothermia and newborn deaths: ƒ Significant contribution to deaths in low birth weight infants and preterm newborns ƒ Social, cultural and health practices delaying care to the newborn ƒ Countries with high STI prevalence and inconsistent prophylactic practices: ƒ Ophthalmia neonatorum is a common cause of blindness

8 Newborn Deaths (cont.)

Place of childbirth: ƒ Up to 2 out of 3 childbirths in most developing countries occur at home ƒ Only half are attended by skilled birth attendants

Strategies for improving newborn health should target: ƒ Birth attendant, families and communities ƒ Health care providers within the formal health system

9 Question ??

ƒ What is the essential care for a newborn immediately after birth?

10 Essential Newborn Care Interventions

ƒ Clean childbirth and cord care: ƒ Prevent newborn infection ƒ Thermal protection: ƒ Prevent and manage newborn hypo/hyperthermia ƒ Early and exclusive breastfeeding: ƒ Started within 1 hour after childbirth ƒ Initiation of breathing and resuscitation: ƒ Early asphyxia identification and management

11 Essential Newborn Care Interventions (cont.)

ƒ Eye care: ƒ Prevent and manage ophthalmia neonatorum ƒ Immunization: ƒ At birth: Bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO) ƒ Identification and management of sick newborn ƒ Care of preterm and/or low birth weight newborn

12 Cleanliness to Prevent Infection

ƒ Principles of cleanliness essential in both home and health facilities childbirths ƒ Principles of cleanliness at childbirth: ƒ Clean hands ƒ Clean perineum ƒ Nothing unclean introduced vaginally ƒ Clean delivery surface ƒ Cleanliness in cord clamping and cutting ƒ Cleanliness for cord care

13 Cleanliness to Prevent Infection (cont.)

ƒ Infection prevention/control measures at health care facilities and after discharge ƒ Caretaker and all others should wash hands before touching or caring for baby ƒ Avoid contact with sick children and adults

14 Question ??

ƒ What are the key principles and practices in cord care?

15 Cord Care

ƒ Do not apply dressings or substances of any kind ƒ If cord bleeds, re-tie ƒ Usually falls off 4–7 days after birth ƒ Until the cord falls off, place the cord outside the nappy to prevent contamination with urine/feces ƒ Wash with soap and clean water only (if soiled)

16 Thermal Protection

ƒ Newborn physiology: ƒ Normal temperature: 36.5–37.5°C ƒ Hypothermia: < 36.5°C ƒ Stabilization period: 1st 6–12 hours after birth: − Large surface area − Poor thermal insulation − Small body mass to produce and conserve heat − Inability to change posture or adjust clothing to respond to thermal stress ƒ Increased hypothermia: ƒ Newborn left wet while waiting for delivery of placenta ƒ Early bathing of newborn (within 24 hours)

17 Hypothermia Prevention

ƒ Deliver in a warm room ƒ Dry newborn thoroughly and wrap in dry, warm cloth ƒ Give to mother as soon as possible: ƒ Skin-to-skin contact first few hours after childbirth ƒ Promotes bonding ƒ Enables early breastfeeding ƒ Check warmth by feeling newborn’s feet every 15 minutes ƒ Bathe after temperature is stable (after 24 hours)

18 Early and Exclusive Breastfeeding

ƒ Early contact between mother and newborn: ƒ Enables breastfeeding ƒ Rooming-in policies in health facilities prevents nosocomial infection ƒ Best practices; ƒ No prelacteal feeds or other supplement ƒ Giving first breastfeed within 1 hour of birth ƒ Correct positioning to enable good attachment of the newborn ƒ Breastfeeding on demand ƒ Psycho-social support to breastfeeding mother

WHO 1999.

19 Early and Exclusive Breastfeeding (cont.)

ƒ Starting to breastfeed: ƒ Colostrum is the first milk secreted and is important for the baby for nutrition and disease protection ƒ Most babies are ready to feed 15-55 minutes after birth; success at the first feeding often indicates successful later breastfeeding ƒ Self-attachment: ƒ Place baby face down on mother’s abdomen ƒ Support baby as it moves toward breast ƒ Allow the baby time to mouth the nipple before taking it into the mouth

Source: SNL 2004.

20 Early and Exclusive Breastfeeding (cont.)

Signs that baby is getting enough milk: ƒ The baby passes urine at least 6 times in 24 hours ƒ You can hear the baby swallow the feeding ƒ The mother’s breast feels softer after a feed ƒ The baby gains weight over time (after the first week) ƒ The baby seems content after feeding

Source: SNL 2004.

21 Breathing Initiation and Resuscitation

ƒ Spontaneous breathing (> 30 breaths/min.) in most babies: ƒ Gentle stimulation, if at all ƒ Newborn resuscitation may be needed: ƒ Fetal distress ƒ Thick meconium staining ƒ Vaginal breech deliveries ƒ Preterm ƒ Effectiveness of routine oro-nasal suctioning unknown: ƒ Biologically plausible advantages – clear airway ƒ Potentially real disadvantages – cardiac arrhythmia ƒ Bulb suctioning preferred (but every baby should have own bulb to prevent infection transmission)

Source: Hamilton 1999.

22 Povidone-Iodine for Conjunctivitis: Objective and Design

ƒ Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya ƒ Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine ƒ More infections in silver nitrate than povidone- iodine, OR 1.76, p < 0.001 ƒ More infections in erythromycin than in povidone- iodine OR 1.38, p=0.001

Source: Isenberg, Apt and Wood 1995.

23 Povidone-Iodine for Conjunctivitis: Conclusion

Povidone-iodine: ƒ Is good prophylaxis ƒ Has wider antibacterial spectrum ƒ Causes greater reduction in colony- forming units and number of bacterial species ƒ Is active against viruses ƒ Is inexpensive

Source: Isenberg, Apt and Wood 1995.

24 Immunization

ƒ BCG vaccinations in all population at high risk of tuberculosis infection ƒ Single dose of OPV at birth or in the 2 weeks after birth ƒ HBV vaccination as soon as possible where perinatal infections are common

25 Counseling

Even if the mother is being discharged a few hours after childbirth, she should be counseled about: ƒ Exclusive breastfeeding ƒ Hygiene – eye and cord care ƒ Thermal protection ƒ Danger signs and what to do about them

26 Role Play

Conduct and discuss role play as described in handout.

27 Question ??

What are the newborn danger signs?

28 Complication Readiness Plan

Newborn danger signs: ƒ Breathing difficulty ƒ Pallor ƒ Convulsion, spasms, loss of ƒ Diarrhea consciousness, or arching ƒ Persistent vomiting or of back abdominal distension ƒ Cyanosis (blueness) ƒ Not feeding or poor sucking ƒ Hot to touch (fever) ƒ Pus or redness of ƒ Cold to touch umbilicus, eyes or skin ƒ Bleeding ƒ Swollen limb or joint ƒ Jaundice (yellowness) ƒ Floppiness ƒ Lethargy

29 Summary

The essential components of normal newborn care include: ƒ Clean delivery and cord care ƒ Thermal protection ƒ Early and exclusive breastfeeding ƒ Monitoring ƒ Eye care ƒ Immunization

30 References

Bell TA et al. 1993. Randomized trial of silver nitrate, erythromycin and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 92: 755– 760. Chen J. 1992. Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin, and no prophylaxis. Pediatr Infect Dis J 11: 1026–1030. Child Health Research Project and Maternal and Neonatal Health Program. 1999. Reducing Perinatal and Neonatal Mortality. Report of a meeting in Baltimore, MD, 10–12 May. Ganges F. 2006. Normal Newborn Care, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April).

31 References (cont.)

Hamilton P. 1999. Care of the newborn in the delivery room. Br Med J 318: 1403–1406. Isenberg SJ, Apt L and Wood M. 1995. A controlled trial of povidone- iodine as prophylaxis against ophthalmitis neonatorum. N Engl J Med 332: 562–566. Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, MD. Saving Newborn Lives (SNL). 2004. Care of the Newborn: Reference Manual. Save the Children: Washington, D.C. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. WHO: Geneva.

32 Best Practices in Postpartum Care of the Mother

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objective

By end of the session, participants will be able to: ƒ Describe the significance of postpartum care ƒ Describe client assessment during the postpartum period ƒ Describe the elements of care provision of the postpartum mother

2 Basic Postpartum Care Provision

ƒ Mother and baby should be seen at 6 hours after birth, and again before discharge if in a facility; or approximately 6 hours after birth if delivered at home ƒ Every mother and baby should be visited again by a provider or trained community health worker by 72 hours after birth

3 When is the mother most vulnerable? (Evidence from Matlab, Bangladesh)

160 140 120 100 80 60 40 20

Deaths per 1000 person year 1000 person per Deaths 0

1 7 5 ncy 3- -90 ar 2 a 8-42 -180 e Day Day 2 43 Y Day y 91 81-36 Day y 1 Da Da Day

During pregn

4 4 Million Newborn Deaths - When? Up to 50% of neonatal deaths are in the first 24 hours

75% of neonatal deaths are in the first week – 3 million deaths

5 Source: Lawn JE et al. 2005. Lancet, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths). Neglected Area of Care

ƒ Few women in Africa receive postpartum care. ƒ An estimated 70% of women in developing countries, do NOT receive postpartum care. ƒ In a study by Forte et. al. of 29 countries, those women who received PPC receive it within 2 days, but for the other nine countries, the peak of PPC occurs 7–41 days after birth.

(Forte A et al. 2006. Postpartum Care Levels and Determinants in Developing Countries. )

6 Basic Postpartum Care Provision (cont.)

During every visit: During return visit: ƒ Assessment of condition of ƒ Make necessary changes to mother and baby care plan (based on ƒ Provide all elements of basic assessment) care package ƒ Review and update mother’s ƒ If abnormal s/s (based on and newborn’s complication assessment), provide readiness plan additional care ƒ Reinforce key messages ƒ Integrate maternal and ƒ Replenish supply of newborn care visits when supplements and drugs/ possible medications

Note: Information gathered through assessment should be taken into consideration during care provision.

7 Question ??

ƒ What basic care should be included in care of the postpartum mother?

8 Basic Postpartum Care Provision (cont.)

ƒ Ongoing supportive care up to discharge ƒ Basic care package: ƒ Breastfeeding and breast care ƒ Complication readiness plan ƒ Support for mother-baby-family relationships ƒ Family planning ƒ Nutritional support ƒ Self-care and other healthy practices ƒ HIV counseling and testing ƒ Immunizations and other preventive measures

9 Breastfeeding and Breast Care

ƒ Early and exclusive breastfeeding (if HIV- or HIV status unknown; or HIV+ woman makes informed decision to exclusively breastfeed) ƒ Feeding guidelines ƒ Additional advice for woman ƒ Breast care ƒ Breastfeeding information and support – provide as needed

10 Question ??

ƒ For how many months is it recommended that a woman should continue breastfeeding?

11 Breastfeeding and Breast Care (cont.)

Feeding guidelines: ƒ Breastfeed exclusively for first 6 months – no other food or fluids ƒ Breastfeed on demand day and night – every 2–3 hours during first weeks

12 Breastfeeding and Breast Care (cont.)

Additional advice: ƒ Choose position that is comfortable and effective ƒ Use both breasts at each feed; do not limit time at either ƒ Ensure adequate sleep/rest – take nap when baby sleeps ƒ Ensure adequate food/fluid intake – glass of fluids per feed; extra meal per day

13 Breastfeeding and Breast Care (cont.)

Breast care: ƒ To prevent engorgement, breastfeed every 2–3 hours ƒ Wear supportive (but not tight) bra or binder ƒ Keep nipples clean and dry ƒ Wash nipples with water only once per day – no soap ƒ After breastfeeding, leave milk on nipples and allow to air dry

14 Complication Readiness Plan

At first visit after birth: Components: ƒ Introduce concept and ƒ Appropriate health care each element facility for emergency care ƒ Assist in developing plan ƒ Emergency transportation ƒ Emergency funds Return visits: ƒ Decision-maker/decision- ƒ Check arrangements made making process ƒ Note changes and ƒ Support person/ problems companion ƒ Blood donor ƒ Danger signs for mother and newborn 15 Complication Readiness Plan (cont.)

ƒ Danger signs: ensure that woman and family know danger signs for her and her newborn that indicate need to enact complication readiness plan

16 Question ??

ƒ Turn to the person sitting next to you and make a list of the maternal postpartum danger signs. ƒ After 4 minutes, one or two pairs can volunteer to read their list.

17 Complication Readiness Plan (cont.)

Maternal danger signs:

ƒ Vaginal bleeding (heavy or ƒ Foul-smelling discharge sudden increase) from vagina or tears/ ƒ Breathing difficulty incisions ƒ Fever ƒ Pain in calf, with our without swelling ƒ Severe abdominal pain ƒ Verbalization/behavior ƒ Severe headache/blurred indicating she may hurt self vision or baby; hallucinations ƒ Convulsions/loss of consciousness

18 Support for Mother-Baby-Family Relationships

ƒ As soon as possible after birth, discuss issues mentioned on following slides with woman and, if she permits, partner/family ƒ Return visits, check progress made in integrating care of baby into daily life

19 Support for Mother-Baby-Family Relationships (cont.)

ƒ Bonding: ƒ Encourage touching, holding, exploring ƒ Encourage rooming-in ƒ Challenges: ƒ Discuss woman’s increased need for rest and (if breastfeeding) intake of food/fluids ƒ Discuss woman’s increased workload

20 Support for Mother-Baby-Family Relationships (cont.)

ƒ Support: ƒ Encourage sharing in care of newborn ƒ Assist in devising strategies for overcoming challenges ƒ Information: ƒ Discuss key aspects of postpartum and newborn care ƒ Encourage questions

21 Support for Mother-Baby-Family Relationships (cont.)

ƒ Encouragement and praise: ƒ Help build confidence ƒ Provide reassurance that woman is capable of caring for newborn

22 Family Planning

Discuss: ƒ Birth spacing – healthy timing and spacing: ƒ Intervals of 2–5 years beneficial to women and babies ƒ Woman’s previous experience, beliefs, preferences regarding contraception ƒ Safe methods for postpartum women – benefits and limitations of each ƒ Available methods and how to access them

23 Family Planning (cont.)

Discuss (cont.): ƒ Return of fertility after birth: ƒ Variable ƒ Ovulation can occur before menstruation resumes ƒ Women who are not breastfeeding may ovulate by 21 days ƒ 5–10% of women conceive within first year postpartum ƒ Women who breastfeed exclusively for 6 months ovulate by 7 months (due to lactational amenorrhea)

24 Family Planning (cont.)

ƒ Discuss (cont.): ƒ Benefits of LAM and how to use LAM successfully, for women who choose this method ƒ Dual protection with condoms ƒ Assist the woman in choosing a method that best meets her needs and fertility goals ƒ Ensure that she receives an appropriate method or has access to the service

25 Nutritional Support

General guidelines: ƒ Eat balanced diet including variety of foods each day ƒ Have at least one extra serving of staple food per day ƒ Try smaller, more frequent meals if necessary ƒ Take micronutrient supplements as directed: ƒ Folic acid, vitamin A, zinc, calcium, iron and other nutrients if micronutrient requirements cannot be met through food sources

26 Nutritional Support (cont.)

Guidelines for breastfeeding women: ƒ Per day: ƒ Two extra servings of staple food per day ƒ Eat a diverse diet with animal products and fortified foods – no specific foods should be eaten or avoided ƒ Drink in response to thirst—excessive fluids not needed ƒ Give Vitamin A supplement where deficiency is common – Two 200,000 unit doses should be given ƒ Use iodized salt ƒ Decrease workload; increase rest ƒ Also, avoid alcohol and tobacco, which can decrease milk production

27 Self-Care and Other Healthy Practices

Tips: ƒ Individualize messages based on woman’s history and other relevant findings ƒ Encourage woman’s partner to be present during these discussions

28 Self-Care and Other Healthy Practices (cont.)

Prevention of infection/hygiene: ƒ Good general hygiene (handwashing, safe food and water preparation/handling, bathing and general cleanliness) ƒ Good genital hygiene – especially important for postpartum women because more susceptible to infection

29 Self-Care and Other Healthy Practices (cont.)

Good genital hygiene (cont.): ƒ Keep vulvar/vaginal area clean and dry ƒ Wash hands before and after touching ƒ Wash genitals after using toilet ƒ Change pads 6 times/day in first week; then 2 times/day

30 Self-Care and Other Healthy Practices (cont.)

Rest and activity: ƒ Increase rest time: ƒ All postpartum women need additional rest to speed recovery ƒ Breastfeeding women need even more rest ƒ Wait at least 4 to 5 weeks to resume normal activity; start back gradually

31 Self-Care and Other Healthy Practices (cont.)

Sexual relations and safer sex: ƒ Avoid sex for at least 2 weeks and until it is comfortable ƒ Increased susceptibility to STIs during postpartum period ƒ Abstinence or mutually monogamous sex with uninfected partner – only sure protection ƒ Consistent use of condoms ƒ Avoidance of sexual practices that may further increase risk of infection (e.g., anal sex)

32 HIV Counseling and Testing

ƒ 1st visit: ƒ Ensure confidentiality of testing and all HIV- related discussion ƒ Provide pretest counseling ƒ Return visit (after testing): provide post- test counseling

33 Immunization and Other Preventive Measures

ƒ Tetanus toxoid immunization ƒ Iron/folate supplementation ƒ Region/population-specific preventive measures, e.g., malaria prevention

34 Immunization and Other Preventive Measures (cont.)

Tetanus Toxoid Immunization Schedule

TT Injection Due

TT 1 At first contact with woman of childbearing age or as early as possible in pregnancy (at 1st ANC visit)

TT 2 At least 4 weeks after TT 1

TT 3 At least 6 months after TT 2

TT 4 At least 1 year after TT 3

TT 5 At least 1 year after TT 4

2-34 35 Immunization and Other Preventive Measures (cont.)

Iron/folate supplementation: ƒ To prevent anemia, prescribe: iron 60 mg + folate 400 mcg orally once daily for 3 months ƒ Dispense supply to last until next visit ƒ Eat foods rich in vitamin C, which help iron absorption ƒ Avoid tea, coffee and colas, which inhibit iron absorption ƒ Possible side effects of iron/folate – black stools, constipation and nausea

36 Immunization and Other Preventive Measures (cont.)

In areas of endemic disease/deficiency: ƒ Insecticide-treated nets (ITNs) for malaria – both mother and baby should sleep under one ƒ Presumptive treatment for hookworm infection ƒ Vitamin A supplements ƒ Iodine supplements

37 Scheduling a Return Visit

ƒ Advise her to bring her partner or other companion with her if possible ƒ Ensure that she understands that she should not wait for next appointment if she or newborn is having problems or develops any danger sign ƒ Review maternal and newborn danger signs and complication readiness plan

38 Case Study

ƒ Divide participants into groups of 3 or 4 ƒ Each group should read the Case Study: Postpartum Care and answer the questions ƒ Reassemble the group and discuss the answers

39 Summary

Postpartum care provision includes: ƒ Ongoing supportive care up to discharge ƒ Basic care provision for mother and newborn: ƒ Breastfeeding and breast care ƒ Complication readiness plan ƒ Support for mother-baby-family relationships ƒ Newborn care ƒ Family planning ƒ Nutritional support ƒ Self-care and other healthy practices ƒ HIV counseling and testing ƒ Immunizations and other preventive measures ƒ Care is individualized according to woman’s and newborn’s needs, history and other findings

40 References

Ganges F. 2006. Postpartum Care, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, MD. Li XF et al. 1996. The postpartum period: The key to maternal mortality. International Journal of Gynecology and Obstetrics 54(1): 1–10. World Health Organization (WHO). 2003. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. WHO: Geneva. World Health Organization (WHO). 1998. Postpartum Care of the Mother and Newborn: A Practical Guide. WHO: Geneva.

41 Best Practices in Breastfeeding Support

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

By end of the session, participants will be able to: ƒ Define exclusive and non-exclusive breastfeeding ƒ Counsel mother and family on breastfeeding ƒ State interventions during labor, birth and postpartum that positively and negatively affect breastfeeding ƒ Recognize correct attachment and effective sucking ƒ Counsel mother on the management of breastfeeding problems

2 Question ??

What is “exclusive breastfeeding”?

3 Definitions

ƒ Exclusive breastfeeding means that for the first 6 months the baby is breastfed exclusively. Nothing else is given to the baby to eat or drink during this time. ƒ If the baby is given water, breast milk substitute such as formula or cereal, the baby is not exclusively breastfed. This is not recommended.

4 Question ??

What are the general benefits of breast- feeding for the infant?

5 Benefits to Baby

ƒ More easily digested ƒ Adapts to needs of growing infant ƒ Promotes optimal brain development ƒ Supports immune system to prevent infections ƒ Provides some protection against allergies ƒ Decreases risk of Sudden Infant Death (SIDS)

6 Question ??

What are the general benefits of breast- feeding for the mother?

7 Benefits to Mother

ƒ Promotes uterine involution ƒ Promotes maternal-infant bonding ƒ Promotes child spacing (contraceptive effect) ƒ Convenient ƒ Economic

8 Question ??

What are the intrapartum and postpartum interventions that may affect lactation?

9 Practices that Promote Breastfeeding

ƒ Initiate breastfeeding within 1 hour ƒ Immediate skin-to-skin contact ƒ Avoid routine newborn care until after infant has had first feed ƒ Avoid separation of mother and baby ƒ Allow feeding on demand ƒ Evaluate attachment and assist as needed

10 Practices that Negatively Impact Breastfeeding

ƒ Medications during labor and birth ƒ Separation of infant from mother ƒ Prelacteal feeds ƒ Delay in initiating breastfeeding ƒ Timed feeds or feeding intervals ƒ Use of artificial nipples ƒ Gift packs with breast milk substitute

11 Question ??

What are the components of correct attachment and effective sucking?

12 Attachment and Sucking

ƒ Alignment of infant’s ear, shoulder, hip (in cradle hold) ƒ Infant’s lips everted (like fish lips) when attached ƒ Infant’s tongue forward and cupped ƒ Areola compressed ƒ Can hear infant swallow

13 Question ??

What are the general benefits of breast- feeding for the infant?

14 Positions for Effective Breastfeeding

ƒ Cradle position ƒ Cross-cradle position ƒ Football clutch position ƒ Side lying position

SEE HANDOUT

15 Additional Advice

ƒ Choose position that is comfortable and effective ƒ Use both breasts at each feed; do not limit time at either ƒ Ensure adequate sleep/rest – take nap when baby sleeps ƒ Ensure adequate food/fluid intake – glass of fluids per feed; extra meal per day

16 Hand Expression of Breast Milk

1. Press in toward the chest, and 2. Squeeze fingers together

SEE ILLUSTRATION IN HANDOUT

17 Practice

ƒ Participants divide into groups of two ƒ Have one participant play the role of support person for woman who needs to express breast milk – using handout

18 Preventing and Managing Problems

ƒ SEE HANDOUTS ƒ Sore or cracked nipples: ƒ Be sure baby is attaching and sucking correctly ƒ Start feeding the baby on the less sore breast ƒ Keep breasts clean and dry between feeds ƒ Take paracetamol for pain ƒ Do not stop breastfeeding ƒ If mother is HIV-positive, baby should not drink from a cracked or bleeding nipple

19 Preventing and Managing Problems (cont.)

ƒ SEE HANDOUTS ƒ Baby “not getting enough milk”: ƒ Reassure mother that she can make sufficient milk ƒ Reassure mother than as long as baby urinates at least 6 times per day, the baby is getting sufficient milk ƒ Follow weight of baby ƒ Rest more ƒ Increase fluid intake ƒ Feed baby on demand ƒ Let baby suck as long as it wants to

20 Preventing and Managing Problems (cont.)

ƒ SEE HANDOUTS ƒ Engorgement – swollen fullness of breasts: ƒ Take paracetamol 500 mg three times per day ƒ Use cold compresses between feeds ƒ Use warm compress 10–15 minutes immediately before feed ƒ Hand express a little milk before feed to improve attachment ƒ Feed frequently, at least every 2–3 hours ƒ Empty one breast completely before offering other breast ƒ Explain to seek medical help if redness, sore area, fever

21 Preventing and Managing Problems (cont.)

ƒ Mastitis – infection of breast: ƒ Give antibiotics (cloxacillin 500 mg by mouth 3/day for 10 days OR erythromycin 250 mg by mouth 3/day for 10 days ƒ Encourage to continue breastfeeding ƒ Support breasts with binder or bra ƒ Apply cold compresses between feeds ƒ Give paracetamol 500 mg by mouth as needed

22 Preventing and Managing Problems (cont.)

ƒ Breast abscess – fluctuant swelling with pus: ƒ Give antibiotics (cloxacillin 500 mg by mouth 3/ day for 10 days OR erythromycin 250 mg by mouth 3/day for 10 days ƒ Refer to incise and drain breast ƒ Encourage to continue breastfeeding ƒ Support breasts with binder or bra ƒ Apply cold compresses between feeds ƒ Give paracetamol 500 mg by mouth as needed

23 References

Clark A and Beck D. Breastfeeding: A Lesson Plan. Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, MD.

24 Best Practices in Postpartum Family Planning and Birth Spacing

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Define postpartum contraception ƒ Explain the benefits of birth spacing ƒ Discuss postpartum return of fertility ƒ Describe the timing and initiation of key contraceptive methods ƒ Describe WHO’s Medical Eligibility Criteria for Contraceptive Use

2 Definitions

ƒ Postpartum contraception is the initiation and use of family planning methods during the first year after delivery: ƒ Post-placental – within 10 minutes after placenta delivery ƒ Immediate postpartum – within 48 hours after delivery (e.g., voluntary sterilization) ƒ Early postpartum – 48 hours up to 6 weeks ƒ Extended postpartum – 48 hours up to 1 year after birth

3 Question ??

ƒ According to DHS surveys, what percentage of women do not want another pregnancy within the 2 years after childbirth? ƒ 12-20% ƒ 42-45% ƒ 62-67% ƒ 92-97%

4 Unmet Need: Fertility Preferences of Postpartum Women

ƒ According to many DHS surveys*: ƒ 92–97% of women do not want another child within 2 years after giving birth ƒ But 35% of women had their children spaced at 2 years apart or less ƒ 40% of women who intend to use a FP method in the first year postpartum are not using one

*Source: Ross JA and Winfrey WL 2001.

5 Birth Spacing

ƒ Time interval from one child’s birth date until the next child’s birth date ƒ Healthy timing and spacing of pregnancy: ƒ Both infants and mothers are more likely to survive if couples space their births 3 to 5 years apart ƒ This means that couples should wait 2 years after the birth of their last baby before trying to conceive

WHO Technical Consultation on Birth Spacing, Geneva, Switzerland 13–15 June 2005.

6 Source: FHI 2000.

7 Birth Spacing Saves Mothers’ Lives

ƒ Healthy timing and spacing of pregnancies has positive effects on maternal health and newborn outcomes ƒ Women who have their babies at 27- to 32- month intervals are: ƒ More likely to avoid anemia ƒ More likely to avoid 3rd trimester bleeding ƒ More likely to survive childbirth

8 Contraception after Childbirth: Basic Care and Services

Basic care should include: ƒ Discussion of contraceptive needs: ƒ Considering client’s reproductive goals ƒ Information and counseling about methods, their effectiveness rates, and side effects ƒ Short- and long-term method choices

9 Contraception after Childbirth: Basic Care and Services (cont.)

ƒ Assurance of contraceptive re-supply with access to follow-up care ƒ Integration with other maternal-infant child care: ƒ ANC and postpartum visits ƒ Newborn care ƒ Immunizations ƒ HIV/STI prevention: ƒ To help clients assess their risk and make necessary changes in behavior and choose appropriate FP method

10 Counseling

Main goals of FP counseling: ƒ To help women (and couples) decide if they want to use a contraceptive method ƒ With the client’s permission, include partner ƒ Birth spacing/limiting ƒ If she does want contraception, to help her choose an appropriate method, taking into consideration whether or not she is breastfeeding ƒ To prepare her to use the method effectively ƒ To help the woman develop a transition plan from LAM to another method ƒ To discuss return to fertility

Source: Solter/Pathfinder 1998.

11 Return to Fertility

ƒ During pregnancy, the cyclic function of the ovaries is suspended due to presence of placental hormones ƒ During early postpartum: ƒ Inhibiting effects of estrogen and progesterone are removed ƒ Levels of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) gradually rise ƒ Ovarian function begins again

12 Return to Fertility: Effect of Lactation

Non-lactating women: ƒ Will menstruate within 12 weeks ƒ On average, first ovulation 45 days after delivery ƒ Risk of pregnancy

13 Return to Fertility: Effect of Lactation (cont.)

Breastfeeding women: ƒ Period of infertility longer for exclusive or nearly exclusive breastfeeding: − On-demand feeding blocks ovulation ƒ Return to fertility not predictable ƒ Likelihood of menses and ovulation is low during first 6 months ƒ Ovulation may occur prior to menses

14 Breastfeeding Women

ƒ Protected for at least 6 months if using LAM: ƒ Fully or nearly fully breastfeeding ƒ Less than 6 months postpartum ƒ Menses has not returned ƒ Protected up to 6 weeks if not using LAM: ƒ At 6 weeks can use combined methods ƒ At 6 weeks can use progestin only methods safely or TL ƒ All non-hormonal methods are safe for mother and baby ƒ Can use IUD

15 When to Introduce Methods in Breastfeeding Women

LAM COC POC IUD BTL Con- doms @Deliv. OK NO NO OK OK NO

3 wks OK NO NO NO NO OK

6 wks OK NO OK OK** OK OK

6 mths OKOK OK OK OK OK

>6mths NA OK OK OK OK OK

16 Non-Breastfeeding Women

ƒ Contraception should be started at the time of or before first intercourse ƒ Combined hormonal methods should not be used until after 3 weeks postpartum

17 When to Start Contraception

Timing depends on: ƒ Breastfeeding status ƒ Method of choice ƒ Reproductive goals

18 Medical Eligibility Criteria for Contraceptive Use (MEC)

ƒ Covers 17 contraceptive methods, 120 medical conditions ƒ Addresses who can use contraceptive method based on medical methods ƒ Gives guidance to providers for clients with medical problems or other special conditions

http://www.who.int/reproductive-health/publications/mec/mec.pdf

19 Purpose of the Medical Eligibility Criteria (MEC)

ƒ To guide family planning practices based on the best available evidence ƒ To address and change misconceptions about who can and cannot safely use contraceptive methods ƒ To reduce medical policy and practice barriers (i.e., not supported by evidence) ƒ To improve quality, access and use of family planning services

20 What is answered by the MEC?

Identifies which contraceptive or family planning method can be safely used in the presence of a given individual characteristic or medical condition

21 WHO Medical Eligibility Criteria Classification Categories

With clinical With limited Classification judgment clinical judgment Use method in any Yes 1 circumstances Use the method

Generally use: Yes 2 advantages outweigh risks Use the method

Generally do not use: No 3 risks outweigh advantages Do not use the method

No 4 Method not to be used Do not use the method

22 Postpartum Contraception for HIV-Positive Women

ƒ Important information for HIV+ women: ƒ Correct and consistent use of male and female condoms can reduce risk of STI/HIV transmission ƒ Using another contraception in addition to a condom (dual method use) reduces the chance of pregnancy, thus avoiding mother-to-child transmission

23 Summary – Contraception and HIV Acquisition ƒ Male condoms proven effective; female condoms’ effectiveness may be similar to male condoms ƒ Spermicides (N-9) not effective against HIV: ƒ N-9 in WHO MEC is category 4 for HIV-positive people ƒ IUDs and hormonals do not increase HIV acquisition from findings of observational studies

24 Integration of HIV with FP

ƒ HIV prevention should be an integral part of FP services to help clients assess their risk and make necessary changes in behavior. ƒ FP providers should encourage clients to seek VCT to prevent HIV transmission to partners, to improve quality of life if HIV- positive, and to prevent HIV transmission to future children.

25 Postpartum FP and HIV

ƒ HIV-positive women who are not breastfeeding need a family planning method immediately ƒ HIV-positive women who are breastfeeding may practice LAM, but will need to choose another method at 6 months when they stop breastfeeding ƒ Counsel all women (even when status is unknown) about the importance of postpartum FP: ƒ Significance of safer sex and dual protection ƒ Available contraceptive choices ƒ Healthy timing and spacing if future pregnancy desired ƒ Surgical contraception if no future pregnancy desired

26 Contraceptive Challenge Game

ƒ Divide participants into groups of 3 or 4. ƒ One representative from each group closes her/his eyes and reaches into a bag that contains small envelopes that contain one contraceptive method [COCs, POPs, condom, IUD, implant, a picture of breastfeeding (for LAM), a picture of a man (for vasectomy), and a representative picture for tubal ligation], and selects one.

27 Contraceptive Challenge Game (cont.)

ƒ For the contraceptive chosen, each group must tell: advantages, disadvantages, timing and breastfeeding considerations. ƒ Groups that provide correct information get a small prize or an applause. ƒ After information is given for each method, those that are actual contraceptives are passed around the room for each learner to handle/examine.

28 Non-Hormonal Methods

ƒ Non-hormonal methods: ƒ LAM ƒ Barrier methods ƒ Periodic abstinence (fertility awareness, SDM) ƒ Male and female sterilization ƒ IUDs (Copper)

All non-hormonal contraceptive methods can be used safely by breastfeeding women

29 What is the Lactational Amenorrhea Method (LAM)?

ƒ Exclusively or nearly exclusively breastfeeding: ƒ On demand around the clock feeding (every 2–3 hours) ƒ No supplemental infant feeding ƒ Menses has not returned ƒ Less than 6 months postpartum ƒ If any of these three factors change, FP is needed to prevent pregnancy ƒ Begin planning for FP method to transition to at 6 months

30 Lactational Amenorrhea Method

For women who exclusively breastfeed: ƒ Fertility is delayed during the first 6 months postpartum ƒ More than 98% protection from pregnancy ƒ Effective, safe contraception suitable for most women: ƒ Non-hormonal ƒ Non-invasive ƒ Can be used as a transitional method until couple decides on or meets criteria for another method ƒ Can be used by HIV+ mothers in addition to condoms; LAM is consistent with WHO guidelines for HIV+ women

31 Transition from LAM…

ƒ Before 6 months: ƒ Assist the woman in planning for transition to another FP method post LAM ƒ At 6 months or when any one of the criteria is not met, women will need to begin another FP method: ƒ At 6 months: − Weaning from exclusive breastfeeding often starts − Less suckling/less prolactin—ovulation no longer inhibited − Menses and ovulation more likely

32 Advantages of LAM

ƒ Breastfeeding practices required by LAM have other health benefits for mother and baby: ƒ Bonding, protects baby from diseases, healthiest food for baby, etc. ƒ Universally available ƒ Can be used immediately after childbirth ƒ No supplies or procedures needed ƒ Bridge to other contraceptives ƒ No hormonal side effects

33 Disadvantages of LAM

ƒ No protection against STIs ƒ Effectiveness after 6 months uncertain ƒ Exclusive breastfeeding may not be convenient for some women ƒ Small chance of MTCT during breastfeeding if mother is HIV-positive

34 Barrier Methods: Condoms

ƒ When used consistently and correctly, male condoms are highly effective against pregnancy and STIs/HIV ƒ A latex sheath or covering made to fit over erect penis ƒ 97% effective in preventing pregnancy when used correctly every time

35 Advantages of Condoms

ƒ Prevent STIs, including HIV/AIDS as well as pregnancy when used correctly and with each act of intercourse ƒ Can be used soon after childbirth ƒ No hormonal side effects ƒ Can be stopped any time ƒ No need for health provider or clinic visit ƒ Usually easy to obtain and sold in many places ƒ Anyone can use if not allergic to latex

36 Disadvantages of Condoms

ƒ A man’s cooperation is needed ƒ May decrease sensation ƒ Poor reputation—associated with immoral sex, extra-marital sex or prostitution ƒ May be embarrassing/uncomfortable to purchase or ask partner to use ƒ Can be weakened if stored too long, in too much heat or humidity, or if used with oil-based lubricants—may break during use ƒ Some men or women may be allergic to latex

37 Fertility Awareness Methods

ƒ Based on awareness of or ability to determine fertile time of menstrual cycle ƒ Include: ƒ Basal body temperature/cervical secretions ƒ Calendar calculations ƒ Standard Days Method (SDM) − Cycle beads ƒ Periodic abstinence during fertile period

38 Fertility Awareness Methods/SDM

ƒ Advantages: ƒ Inexpensive ƒ Not necessary to acquire supplies at clinic/ dispensary ƒ Disadvantages: ƒ Most methods unreliable in postpartum women ƒ Postpartum women, especially when breastfeeding, need to have 4 menstrual cycles, the most recent cycle is 26 to 32 days long ƒ Partner’s cooperation needed in periodic abstinence

39 Male Sterilization: Vasectomy

ƒ A safe, convenient, highly effective and simple form of contraception for men that is provided under local anesthesia in an out-patient setting ƒ Vasectomy is safer, simpler, less expensive and equally effective as FS (tubal ligation) ƒ Vasectomy is popular in the US and UK

Source: www.maqweb.org;Technical briefs.

40 Male Sterilization: Vasectomy (cont.)

ƒ Not effective until after 3 months ƒ Can be timed to coincide with the postpartum period when fertility is reduced: ƒ Ideal with LAM ƒ If not using LAM, couple will need to use another contraceptive method during the first 12 weeks ƒ Follow local protocols for counseling couples in advance and obtaining informed consent

41 Male Sterilization: Vasectomy (cont.)

ƒ Highly effective in preventing pregnancy (99.6 to 99.8% effective) ƒ Comparable to FS, implants, IUDs in preventing pregnancy ƒ Not effective immediately—WHO recommends use of backup contraception for 3 months after the procedure

42 Vasectomy: Safety

ƒ Very safe, with few medical restrictions ƒ Major morbidity and mortality rare ƒ Adverse long-term effects not been found ƒ Minor complications (e.g., infection, bleeding, post-operative and/or chronic pain 5–10%) ƒ No-scalpel (NSV) technique has lower incidence of bleeding and pain than incisional technique ƒ Morbidity and mortality rare

43 Vasectomy: Crucial Programmatic Facts

ƒ Men in every region, cultural, religious and SE setting show interest in vasectomy, despite common assumptions about negative male attitudes or societal prohibitions (MAQ) ƒ However, men often lack full access to information and services, especially male- centered programming, which has been shown to result in greater uptake of vasectomy

44 Postpartum Female Sterilization

ƒ Ideally done within 48 hours after delivery ƒ May be performed immediately following delivery or during C/section ƒ If not performed within 1 week of delivery, delay for 4–6 weeks ƒ Follow local protocols for counseling clients and obtaining informed consent in advance: ƒ Discuss during ANC

45 Female Sterilization: Effectiveness

ƒ Highly effective, 99.5% comparable to vasectomy, implants, IUDs ƒ Risk of failure (pregnancy), while low: ƒ Continues for years after the procedure ƒ Does not diminish with time ƒ Is higher in younger women ƒ No medical condition absolutely restricts a person's eligibility for FS

46 IUD

ƒ IUDs are among the most reliable and cost-effective long- acting method of contraception available to women today. The IUD offers a level of protection comparable to female sterilization with the added advantage of easy and rapid reversibility. ƒ The IUD prevents pregnancy by preventing fertilization; the mechanism of action of copper IUDs is spermicidal. Copper causes a sterile body inflammatory reaction resulting in biochemical and cellular changes that are toxic to sperm in the uterine cavity, rendering the sperm incapable of fertilization.

47 IUDs (Cu-T)

ƒ IUDs can be inserted: ƒ Immediately after delivery of the placenta ƒ During C/section ƒ Within 48 hours of childbirth ƒ If not inserted within 48 hours, insertions should be delayed for 4–6 weeks ƒ Expulsion rates can be higher than with interval insertions: ƒ Some studies show that insertion within 10 minutes of placenta delivery is better than other times before hospital discharge ƒ High fundal placement has lower expulsion rates

48 Important Programmatic Characteristics of IUDs

ƒ Effectiveness is comparable to FS ƒ 12–13 yrs with CU-T (approved) ƒ Cheaper to provide than other methods ƒ Quickly and completely reversible ƒ Very safe for most women (including immediately postpartum, postabortion, or interval; breastfeeding; young; and nulliparas)

49 IUDs: Programmatic Considerations

ƒ More service cadres can provide (because it is non-surgical) ƒ Choice: Long-acting methods that can be used long-term, non-permanent; providing a woman with a PPIUD prior to discharge is less than half as expensive as providing in outpatient settings ƒ Good option for HIV+ women ƒ Most cost-effective method of all reversible methods if used for 2 or more years

50 Dispelling Myths about IUDs

IUDs: ƒ Do not cause abortion ƒ Do not cause infertility ƒ Are unlikely to cause discomfort for male partner ƒ Do not travel to distant parts of the body ƒ Are not too large for small women ƒ May offer protection against endometrial and cervical cancer

51 Common Concerns about IUDs: New Information

ƒ Pelvic Inflammatory Disease (PID) ƒ Infertility ƒ HIV/AIDS

52 Medical Evidence: Low PID Rates and Infertility among IUD Users

ƒ First 20 days: highest risk due to insertion ƒ Beyond 20 days: PID risk is same as if no IUD: ƒ 99.8% of women with IUDs have no problems with PID ƒ IUD use NOT associated with infertility: ƒ The real culprit is chlamydia trachomatis (and GC), not the IUD!

53 IUD Use and HIV: Three Main Questions

ƒ Does IUD increase risk of HIV acquisition by the woman using it? ƒ Does use of IUD by HIV-infected women increase their other health risks? ƒ Does the HIV-infected IUD user increase risk to sero-negative male partner?

54 IUD Use and HIV: Three Main Questions (cont.)

ƒ Does IUD increase risk of HIV acquisition by the woman using it? ƒ NO ƒ Does use of IUD by HIV-infected women increase their other health risks? ƒ NO ƒ Does the HIV-infected IUD user increase risk to sero-negative male partner? ƒ NO

55 WHO Medical Eligibility Criteria: HIV/AIDS and Copper IUDs

3rd Ed 2004 2nd Ed. Category HIV/AIDS Category I C

High risk of HIV 3 2 2

HIV-infected 3 2 2

AIDS 3 3 2

Clinically well on ARV therapy 2 2

56 Cu-IUD Side Effects

ƒ Heavier menses in the first few months ƒ Increased cramping and menstrual pattern changes in the first few months ƒ Low expulsion rate, when occurring usually within the first 3 months

57 Summary: IUD

ƒ Comparable in safety, effectiveness to FS ƒ Can be inserted during the postpartum period ƒ Risk of PID very small, even in high STI settings ƒ Does not increase risk of infertility ƒ Safe for women with no children ƒ Safe (and a good choice) for HIV-infected women or women with AIDS doing well on ARVs and who do not desire pregnancy

58 Hormonal Methods

ƒ Progestin-only contraceptives: ƒ Implants ƒ Injectables ƒ Progestin-only pills (POPs) ƒ Combined estrogen-progestin methods: ƒ Combined oral contraceptives (COCs) ƒ Monthly injectables (Mesigyna, Cyclofem)

59 Question ??

When can a breastfeeding woman begin using a progestin-only contraceptive?

60 Progestin-Only Contraceptives: Breastfeeding Women

ƒ No effect on breastfeeding, breast milk production or infant growth and development ƒ WHO recommends a delay of 6 weeks after childbirth before starting progestin-only methods as infants may be at risk of exposure to the progestin

61 Implants

ƒ Norplant (not produced since 2006): ƒ 6 capsules, effective 7 years ƒ 1-year failure rate 0.05% (1 pregnancy/2,000 users) ƒ 5-year failure rate 1.6% ƒ Jadelle: ƒ 2 rods, effective 5 years ƒ 1-year failure rate 0.05%; 5-year failure rate 1.1% ƒ Implanon: ƒ 1 rod, effective 3 years; with failure rate 0.07/100 ♀ years (<1%)

62 Progestin-Only Injectable

ƒ Safe to use immediately PP if not breastfeeding ƒ Safe to use after 6th week postpartum if breastfeeding ƒ Injection of: ƒ 150 mg DMPA IM every 3 mos. ƒ 104 mg DMPA subQ every 3 months ƒ NET EN 200mg every 2 months ƒ Women of any age and parity can use it (MEC Cat. 1, age 18–45) ƒ Safe to use immediately PAC

63 Questions ??

ƒ When can a breastfeeding woman begin using a combined (estrogen-progestin) contraceptive? ƒ When can a non-breastfeeding woman begin using a combined (estrogen- progestin) contraceptive?

64 Combined Estrogen-Progestin Methods: Breastfeeding Women

ƒ DO NOT use within the first 6 weeks postpartum ƒ NOT recommended during first 6 months postpartum due to diminished quantity of breast milk, decreased duration of lactation and possible adverse affects on infant growth

Source: WHO 2004.

65 Combined Estrogen-Progestin Methods

Breastfeeding Non-breastfeeding ƒ DO NOT use combined ƒ NOT recommended to estrogen-progestin use combined methods within the estrogen-progestin first 6 weeks methods during the postpartum first 3 weeks ƒ NOT recommended postpartum during the first 6 ƒ Safe to start after 3 months postpartum weeks post-delivery

66 Women Eligible for COCs without Restriction

Examples: ƒ Adolescents ƒ Nulliparous women ƒ Postpartum (3 weeks, if not breastfeeding) ƒ Immediately postabortion ƒ Women with varicose veins ƒ Any weight (including obese)

Source: WHO, Medical Eligibility Criteria for Contraceptive Use, 3rd Ed. 2004.

67 Women Who Should Not Use COCs

ƒ Breastfeeding (<6 weeks postpartum) ƒ Smoke heavily AND are over age 35 ƒ At increased risk of cardiac valvular disease ƒ Have certain pre-existing conditions (e.g., breast cancer, liver disease, high risk of CV disease) ƒ Pregnant (but no proven negative effects on fetus if taken accidentally)

68 Emergency Contraception

ƒ Methods of preventing pregnancy after unprotected sexual intercourse ƒ Regular birth control pills used in a special higher dosage: ƒ ECPs are a higher dosage of the same hormones found in daily birth control pills ƒ Within 120 hours (5 days) of unprotected sex (but as soon as possible after unprotected sex) ƒ IUDs can also be used 5 days after unprotected sex ƒ Distinct from RU-486 (The Abortion Pill) ƒ Millions of unintended pregnancies and abortions could be averted with EC

69 Types of ECPs

ƒ Progestin-only OCs – levonorgestrel-only, in preferred regimen one dose of 1.5 mg (or can be in 2 doses of 0.75mg, 12 hrs apart) →88% reduction in risk (1/100 will get pregnant) ƒ Combined OCs: 2 doses of pills containing ethinyl estradiol (100 mcg) and levonorgestrel (0.5 mg) taken 12 hrs apart →75% reduction in risk (2/100 will get pregnant)

70 Question ??

Within what time after intercourse will emergency contraceptive be effective?

71 ECP Effectiveness and Time

ƒ ECPs are effective up to 120 hours (5 days), and thought to be slightly more effective during first 24 hours. ƒ This offers providers and women more flexibility of use, particularly when ECPs are not given in advance of need.

72 Possible Mechanisms of Action of ECPs

Depending on when used during cycle, may:

ƒ Inhibit or delay ovulation ƒ Affect sperm and ovum function ƒ Prevention of implantation is an unlikely effect

EC pills do not interrupt an established pregnancy

73 Withdrawal (Coitus Interruptus)

ƒ A traditional family planning method in which the man completely removes his penis from the vagina, and away from the external genitalia of the female partner, before he ejaculates ƒ CI prevents sperm from entering the woman’s vagina, thereby preventing contact between spermatozoa and the ovum

74 CI: Effectiveness

ƒ When used perfectly, effectiveness can be as high as 95% ƒ With typical usage, effectiveness about 75–81% ƒ However, CI is better than no method at all!

75 CI or Withdrawal (cont.)

This method may be appropriate for postpartum women and couples: ƒ Who are highly motivated and able to use this method effectively ƒ With religious or other reasons for not using other methods of contraception ƒ Who need contraception immediately and have entered into a sexual act without alternative methods available ƒ Who need a temporary method while awaiting the start of another method ƒ Who have intercourse infrequently

76 Advantages of CI

ƒ If used correctly, does not affect breastfeeding and is always available for primary use or use as a back-up method ƒ Involves no economic cost or use of chemicals ƒ No health risks associated directly with CI: ƒ Men and women who are at high risk of STI/HIV infection should use a condom with each act of intercourse

77 Disadvantages of CI

ƒ Does not provide protection against STIs ƒ Requires the man’s self control ƒ May reduce the pleasure of intercourse ƒ During withdrawal, some sperm may have already entered into the woman’s vagina

78 To save lives, parents should wait until their baby is 2 years old before they try to get pregnant again : of life. WHO, Rivers Source

79 References

Campbell et al. 1993. Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol Jul;169(1): 55–60. Conde-Agudelo et al. 2006. Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. JAMA 295: 1809–1823. DaVanzo et al. 2005. The effects of birth spacing on infant and child mortality in Matlab, Bangledesh as reported in WHO Technical Consultation on Birth Spacing, Geneva, Switzerland 13–15 June. Desgrees-Du-Lou A, Msellati P, Viho I, Yao A, Yapi D, Kassi P, et al. 2002. Contraceptive use, protected sexual intercourse and incidence of pregnancies among African HIV-infected women. DITRAME ANRS 049 Project, Abidjan 1995–2000. International Journal of STD & AIDS 13(7): 462–468.

80 References (cont.)

Farley et al. 1992. Intrauterine devices and pelvic inflammatory disease: An international perspective. Lancet 339: 785–788. Hatcher et al. 2004. Contraceptive Technology, 18th Revised Edition. Ardent Media: New York. Huffman S L and Labbok MH. 1994. Breastfeeding in family planning programs: A help or a hindrance? International Journal of Gynaecology and Obstetrics 47 Suppl S23–31; discussion S31. O’Hanley et al. 1992. Postpartum IUDs: Keys for success. Contraception 45: 351–361. Ross JA and Winfrey WL. 2001. Contraceptive use, intention to use and unmet needs during the extended postpartum period. International Family Planning Perspectives 27: 20–27.

81 References (cont.)

Rutenberg N amd Baek C. 2005. Field experiences integrating family planning into programs to prevent mother-to-child transmission of HIV. [Review] [12 refs]. Studies in Family Planning 36(3): 235–245. Rutsein et al. 2004. Systematic Literature Review and Meta-analysis between Inter-pregnancy or Inter-Birth Intervals and Infant and Child Mortality. Catalyst Consortium Report. Solter C. 1998. Module 3: Counseling for Family Planning Services Medical Services. Pathfinder International. Available at: http://www.pathfind.org/pf/pubs/mod3.pdf. Tao M, Xu W, Zheng W, et al. 2006. Oral contraceptive and IUD use and endometrial cancer: A population-based case-control study in Shanghai, China. Cancer 119: 2142– 2147. World Health Organization (WHO). 2004. HIV Transmission through Breastfeeding: A Review of Available Evidence. WHO: Geneva.

82 References (cont.)

Web Sites: ƒ http://www.FHI.org Sarah (Winter 1996, Vol. 16, No. 2). IUDs Block Fertilization. Network. Family Health International. Retrieved on 2006-07-05. ƒ http://www.pathfind.org/pf/pubs/mod3.pdf Solter Cathy Module 3 Counseling for Family Planning Services Medical Services Pathfinder International 1998 ƒ Medical Eligibility Criteria for Contraceptive Use Third Edition. 2004. accessed at http://www.who.int/reproductive- health/publications/mec/index.htm ƒ World Health Organization Maternal Newborn health http://www.who.int/reproductive- health/publications/msm_98_3/postpartum_care_mother_newborn. pdf ƒ Report of a technical consultation on birth spacing http://www.who.int/reproductive-health/MNBH/index.htm

83 Other Helpful Resources

ƒ http://www.fhi.org/en/RH/Pubs/servdelivery/index. htm ƒ http://www.who.int/reproductive- health/publications/mec/mec.pdf ƒ http://www.reproline.jhu.edu/ ƒ http://www.engenderhealth.org/wh/fp/index.html ƒ http://www.maqweb.org/iudtoolkit/

84 Best Practices in Preventing Mother-to-Child Transmission of HIV Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To discuss best practices for antenatal, intrapartum and postpartum care of the HIV-positive mother to reduce mother-to- child transmission ƒ To describe the evidence supporting these practices

2 HIV-Related Counseling Issues during Pregnancy

ƒ Educate/counsel regarding HIV and pregnancy: ƒ Impact of HIV on pregnancy and pregnancy on HIV ƒ Maternal health ƒ Long-term health of mother and care for children ƒ Perinatal transmission ƒ Use of antiretrovirals and other drugs in pregnancy ƒ Counseling before pregnancy is important: ƒ However, antenatal care may provide the first opportunity for education and counseling regarding HIV

3 WHO’s Four-Prong Approach to PMTCT

Uninfected Parents to be

I. Primary prevention of HIV HIV-infected woman

II. Prevention of unintended pregnancy Pregnant HIV- infected woman

III. Prevention of MTCT HIV-infected infant

IV. Linkage to Care and Support AIDS and Death 4 Question ??

When does most transmission of HIV from mother to child occur?

5 Timing of Mother-to-Child Transmission of HIV

During pregnancy (5-10%)

During labor and delivery (10-20%)

During breastfeeding (5-10%)

6 Question ??

What are some of the effects of HIV infection in the mother on the pregnancy and health of the newborn?

7 Adverse Pregnancy Outcomes and Relationship to HIV Infection

Pregnancy Outcome Relationship to HIV Infection

Spontaneous abortion Limited data, but evidence of possible increased risk Stillbirth No association noted in developed countries; evidence of increased risk in developing countries Perinatal mortality No association noted in developed countries, but data limited; evidence of increased risk in developing countries Newborn mortality Limited data in developed countries; evidence of increased risk in developing countries Intrauterine growth Evidence of possible increased risk restriction

Source: Anderson 2001. 8 Adverse Pregnancy Outcomes and Relationship to HIV Infection - 2

Pregnancy Outcome Relationship to HIV Infection

Low birth weight Evidence of possible increased risk Preterm delivery Evidence of possible increased risk, especially w/ more advanced disease Pre-eclampsia No data Gestational diabetes No data Amnionitis Limited data; more recent studies do not suggest an increased risk; some earlier studies found increased histologic placental inflammation, particularly in those with preterm deliveries Oligohydramnios Minimal data Fetal malformation No evidence of increased risk

Source: Anderson 2001. 9 Risk Factors for MTCT

Viral Maternal ƒ Viral load (the higher ƒ Maternal the viral load, the immunological status greater the risk of HIV ƒ Maternal nutritional transmission) status ƒ Viral genotype and ƒ Maternal clinical status phenotype (including co-infection with an STI) ƒ Viral resistance ƒ Behavioral factors ƒ Antiretroviral treatment

10 Risk Factors for MTCT (cont.)

Obstetrical Fetal ƒ Prolonged rupture of ƒ Prematurity membrane (longer than 4 ƒ Genetic hours) ƒ Multiple pregnancy ƒ Mode of delivery ƒ Intrapartum hemorrhage Infant ƒ Obstetrical procedures ƒ Breastfeeding ƒ Invasive fetal monitoring ƒ Gastrointestinal tract factors ƒ Immature immune system

11 Question ??

What points are important when counseling an HIV-positive pregnant woman?

12 Counseling HIV-Positive Pregnant Women

ƒ Effect of pregnancy on HIV infection ƒ Effect of HIV on pregnancy outcome ƒ Risk of transmission to fetus and infant ƒ Treatment options in pregnancy ƒ Interventions to prevent mother-to-infant transmission ƒ Infant feeding options ƒ Disclosure of results to partner ƒ Need for follow-up of mother and child ƒ Future fertility and contraceptive options Antenatal Care

ƒ ANC allows interaction between the health facility and sexually active women to: ƒ Provide information on HIV ƒ Promote safer sex practices ƒ Provide opportunity for the pregnant woman to know her HIV status ƒ Reduce social stigmatization ƒ Identify and treat STIs ƒ Provide malaria prophylaxis (IPT) ƒ Provides opportunities to discuss the interventions for reducing the risk of MTCT

14 Question ??

What measures can you take during antenatal care (ANC) of an HIV-positive woman to reduce the risk of transmission of HIV?

15 Antenatal Interventions to Reduce MTCT

ƒ HIV testing and counseling services ƒ Behavior change communication: ƒ Sexual ƒ Injection drug use ƒ Alcohol use and smoking ƒ Prevention of new infections in pregnancy ƒ Identification and treatment of STIs (genital ulcers and abnormal vaginal discharge)

16 Antenatal Interventions to Reduce MTCT (cont.)

ƒ Prevention and treatment of anemia (balanced diet and nutritional supplementation) ƒ Avoiding invasive testing procedures in pregnancy: ƒ Amniocentesis ƒ Chorionic villus sampling ƒ Cordocentesis ƒ External cephalic version

17 Antenatal Interventions to Reduce MTCT (cont.)

ƒ Antiretroviral prophylaxis: ƒ During pregnancy ƒ In labor ƒ Postpartum ƒ (ARVs should be provided to the mother for her health as well as for the health of the baby) ƒ Physical examination to detect any signs of HIV-related illness

18 Antenatal Interventions to Reduce MTCT (cont.)

ƒ Iron and folate ƒ Multivitamin supplementation ƒ Tetanus toxoid immunization ƒ Intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) for malaria, in endemic areas, as per WHO recommendations

19 Antenatal Interventions to Reduce MTCT (cont.)

ƒ Mebendazole at first visit in areas of high worm prevalence ƒ Isoniazid (INH) prophylaxis for tuberculosis (TB) if indicated ƒ Pneumocystis carinii pneumonia (PCP) prophylaxis, in women with clinical signs of AIDS or CD4 counts of below 200 mm3 ƒ Psychological support

20 Case Study

ƒ Divide participants into groups of four ƒ Provide case study on PMTCT during ANC ƒ Each group should discuss and record answers to questions ƒ Following group work, reassemble group for discussion of answers

21 Question ??

What measures can you take during labor and delivery to reduce the risk of transmission of HIV?

22 Intrapartum Interventions to Reduce MTCT

ƒ Use of universal IP precautions ƒ Application of good infection prevention practices during pelvic examinations and delivery ƒ Avoiding unnecessary artificial rupture of membranes ƒ Avoiding prolonged labor and prolonged rupture of membranes

23 Intrapartum Interventions to Reduce MTCT (cont.)

ƒ Avoid unnecessary trauma during delivery: ƒ Unnecessary episiotomy ƒ Fetal scalp electrode monitoring ƒ Forceps delivery ƒ Vacuum extraction

24 Vaginal vs. Caesarean

Risk Concern Vaginal Cesarean

Blood loss - Increased Increased in HIV+ women; Infection - antibiotic prophylaxis recommended No evidence of Reduces risk of MTCT if increased MTCT with performed before labor onset MTCT ARV Rx and adequate viral load Mortality - Increased

Resource Requires greater resources - issues (supplies, equipment, staff)

25 Intrapartum Interventions to Reduce MTCT (cont.)

ƒ Minimize risk of PPH (to protect mother’s health and decrease provider exposure to blood): ƒ Active management of 3rd stage: − Administer oxytocin immediately after delivery − Controlled cord traction − Uterine massage ƒ Repair any genital tract lacerations ƒ Carefully remove all products of conception

26 Eligible Women Remain on Therapy

Women who are eligible for ARV therapy should be on, and should remain on, this therapy throughout pregnancy

Source: WHO 2006. 27 Effective ARV for Mother Who Is not Eligible for ARVs

Antenatal: ƒ AZT from 28 weeks of pregnancy, plus ƒ AZT and 3TC + Sd-NVP intrapartum, plus ƒ AZT and 3TC for 7 days postpartum

AZT = zidovudine 3TC = lamivudine Sd-NVP = single dose nevirapine

Source: WHO 2006. 28 ARV for the Newborn

For 7 days: ƒ Sd-NVP, plus ƒ AZT If the mother receives less than 4 weeks of AZT during pregnancy, the newborn should have 4 weeks rather than 1 week of AZT

Source: WHO 2006. 29 When no ARV before Labor

ƒ When delivery occurs within 2 hours of a woman’s taking Sd-NVP, the infant should receive Sd-NVP immediately after birth and AZT for 4 weeks ƒ To reduce NVP resistance, the mother should receive a nucleoside reverse transcriptase inhibitor (NRTI), such as AZT and 3TC, for 7 days postpartum if she receives Sd-NVP during labor

Source: WHO 2006. 30 ARVs are not only for the baby!

In settings where ARVs are available for the treatment of the mother, these should be given according to local protocol

31 Infant Feeding Options for the HIV Infected Mother

“A little bit of this and a little bit of that is not best for the baby! ”

Exclusive Exclusive formula breast Feeding Feeding

Avoid mixed feeding !

32 Breastfeeding

ƒ For HIV survival, all women for whom replacement feeding is not acceptable, feasible, affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed their infant for 6 months ƒ Exclusive breastfeeding should be encouraged among all women, regardless of HIV status ƒ A woman should be supported in her infant feeding decision; the choice is hers

33 Ongoing Care

All HIV infected mothers should be linked to care and support to help keep them in the best health possible

34 PMTCT as an Entry Point for Care and Support

Psychosocial support Basic clinical care Palliative care (mother, infant)

Planning for PMTCT Prevention and Rx the future of OIs (including FP)

Income support Access to ARVs

Nutritional Support

35 Newborn

ƒ Handle with gloves until maternal blood and secretions have been washed off ƒ Wash newborn after birth, especially face ƒ Avoid hypothermia ƒ Give antiretroviral agents, if available ƒ Watch for anemia ƒ Follow up infant for infection

36 Immediate Care of the Neonate

ƒ Cut cord under cover of a lightly wrapped gauze swab, to prevent blood spurting ƒ Handle all babies, regardless of the mother’s HIV status, with gloves until maternal blood and secretions are washed off ƒ All babies, irrespective of HIV status, should be kept warm post-delivery

37 Immediate Care of the Neonate (cont.)

ƒ Do not suction the newborn with a nasogastric (NG) tube unless there has been meconium- stained liquid. Where suctioning is required: ƒ Use a mechanical suction unit (at a pressure below 100mm Hg) or bulb suction, if possible, rather than the mouth operated suction. Do not use the bulb syringe for another baby. ƒ Attach the baby to the mother’s breast only if the mother has made a prior decision to breastfeed.

38 Immediate Care of the Neonate (cont.)

ƒ If the mother has decided not to breastfeed, place the baby on the mother’s body for skin-to-skin contact. Provision should be made to provide the mother with infant formula. ƒ Vitamin K should be administered as per national guidelines. ƒ BCG should be administered according to the national/WHO immunization guideline. ƒ Antibiotic or 1% silver nitrate eye ointment should be administered as prophylaxis against ophthalmia neonatorum according to the national/WHO immunization guideline.

39 Question ?

What breastfeeding issues must be considered when helping an HIV-positive mother to decide whether or not to breastfeed?

40 Breastfeeding Issues

ƒ Warmth for newborn ƒ Nutrition for newborn ƒ Protection against other infections ƒ Risk of HIV transmission ƒ Contraception for mother ƒ AFASS - the mother who is infected with HIV should breastfeed unless replacement feeding is acceptable, feasible, affordable, safe and sustainable (AFASS)

41 Breastfeeding Recommendations

If the woman is: ƒ HIV-negative or does not know her HIV status, promote exclusive breastfeeding for 6 months ƒ HIV-positive, meets AFASS criteria, and chooses to use replacement feedings, counsel on the safe and appropriate use of formula ƒ HIV-positive and chooses to breastfeed, promote exclusive breastfeeding for 6 months

42 Goals of FP for HIV-Infected Women

ƒ Prevention of unintended pregnancy ƒ Appropriate child spacing to reduce maternal and infant morbidity and mortality

43 Special Considerations for Choosing FP Method

ƒ Effectiveness ƒ Safety/side effects ƒ Effect on HIV transmission or progression ƒ Effect on STI transmission or acquisition ƒ Ease of use ƒ Non-contraceptive benefits ƒ Potential interactions with other medications

44 Condoms and HIV

Male or female condoms combine protection from...

STDs!

Pregnancy! HIV re-infection!

45 Key Take-Away Points

ƒ Women with HIV infection require routine antenatal care provided in accordance with national protocols. ƒ HIV can be transmitted from an infected mother to her child during pregnancy, labor and delivery, or through breastfeeding. ƒ Antiretroviral prophylaxis regimens reduce the risk of MTCT in both breastfeeding and non- breastfeeding women.

46 Key Take-Away Points (cont.)

ƒ Women should be monitored for signs or symptoms of progressive HIV/AIDS, and opportunistic infections, particularly tuberculosis (TB). ƒ Use of universal precautions protects health care providers from HIV and other blood-borne infections.

47 Key Take-Away Points (cont.)

ƒ Replacement feeding or exclusive breastfeeding should be recommended to reduce the risk of MTCT during the postnatal period. ƒ Decisions about infant feeding options should be made before delivery or when the mother leaves the clinic or hospital after delivery.

48 Photo by ‘Dipo Otolorin Photo by ‘Dipo

49 References

Anderson J (ed). 2001. A Guide to the Clinical Care of Women with HIV, 2nd ed. U.S. Department of Health and Human Services, Health Resources and Services Administration: Rockville, Maryland. Coutsoudis A et al. 1999. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: A prospective cohort study. Lancet 354: 471–476. DeCock K et al. 2000. Prevention of mother-to-child transmission in resource-poor countries: Translating research into policy and practice. J Am Med Assoc 283(9): 1175–1182. Dunn D et al. 1992. Risk of HIV-1 transmission through breastfeeding. Lancet 340(8819): 585–588.

50 References (cont.)

Ganges F. 2006. HIV and Pregnancy: Preventing Mother to Child Transmission, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Gray G. 2000. The PETRA Study: Early and Late Efficacy of Three Short ZDV/3TC Combinations Regimens to Prevent Mother-to-Child Transmission of HIV-1. XIII International AIDS Conference, Durban, South Africa. International Perinatal HIV Group. 1999. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1. N Engl J Med 340(14): 977–987. Mandelbrot L et al. 1996. Obstetric factors and mother-to-child transmission of human immunodeficiency virus type 1: The French perinatal cohorts. Amer J Obstet Gynecol 175(3 pt 1): 661–667.

51 References (cont.)

Piwoz E. 2006. HIV and Infant Feeding: A Technical Update, a presentation at the CORE Group PMTCT and infant feeding SOTA, Washington, D.C. (20 November). Semprini AE et al. 1995. The incidence of complications after cesarean section in 156 women. AIDS 9: 913–917. Shaffer N et al. 1999. Short-course ZDV for perinatal HIV-1 transmission in Bangkok, Thailand: A randomized controlled trial. Lancet 353: 773–780. Sperling RS et al. 1996. Maternal viral load, ZDV treatment, and the risk of transmission of HIV type 1 from mother to infant. N Engl J Med 335(22): 1621–1629.

52 References (cont.)

UNICEF/UNAIDS/World Health Organization (WHO) Technical Consultation on HIV and Infant Feeding. 1998. HIV and Infant Feeding: Implementation of Guidelines. WHO: Geneva. World Health Organization (WHO). 2006. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infections in Infants in Resource-Limited Settings: Towards Universal Access. WHO: Geneva. World Health Organization (WHO). 2005 (revision). Antiretroviral Drugs and the Prevention of Mother-to-child Transmission of HIV In Resource Limited Settings. WHO: Geneva. World Health Organization (WHO)/Joint United Nations Programme on HIV/AIDS (UNAIDS). 1999. HIV In Pregnancy: A Review. WHO/UNAIDS: Geneva.

53 Rapid Initial Assessment, Shock, Resuscitation and Emergency Management Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To discuss best practices for the initial assessment of obstetrical patients ƒ To discuss best practices in the management of shock ƒ To discuss adult resuscitation ƒ To describe an emergency tray/trolley ƒ To discuss the management of emergencies and emergency drills

2 Definition

A quick check of a woman’s condition when she presents with a problem to rapidly determine her degree of illness

3 Question ??

What would you include in a rapid initial assessment?

4 Assess Condition

ƒ Airway and breathing ƒ Circulation (signs of shock) ƒ Vaginal bleeding (early or late pregnancy or after childbirth) ƒ Unconscious or convulsing ƒ Dangerous fever ƒ Abdominal pain

5 ABC of Adult Resuscitation: What To Do!

Airway: check airway: if not breathing: Clear airway, position head back to prevent tongue falling back, place in airway

Breathing: no breath chest movements Help client breath by ventilating ( mouth to mouth, mouth to mask, Ambu bag) with/or without oxygen

Circulation no pulse or heartbeat: Begin cardiac massage and check response (5:1 heart compressions : respiration effort)

6 Assess Airway and Breathing

ƒ Danger signs: ƒ Look for: − Cyanosis − Respiratory distress ƒ Examine: − Skin: Pallor − Lungs: Wheezing or rales ƒ Consider: ƒ Severe anemia ƒ Heart failure ƒ Pneumonia ƒ Asthma

7 Assess Circulation

ƒ Examine: ƒ Skin: Cool and moist ƒ Pulse: Fast (110 beats/min. or more) and weak ƒ Blood pressure: Low (systolic less than 90 mm Hg) ƒ Consider shock even if blood pressure is normal

8 Definition of Shock

ƒ Failure of circulatory system to maintain adequate perfusion of vital organs ƒ LIFE-THREATENING ƒ REQUIRES IMMEDIATE AND INTENSIVE TREATMENT

9 Question ??

When would you anticipate shock?

10 When to Expect or Anticipate Shock

ƒ Bleeding: ƒ Early pregnancy (e.g., abortion, ectopic pregnancy, molar pregnancy) ƒ Late pregnancy or labor (e.g., placenta previa, abruptio placentae, ruptured uterus) ƒ After childbirth (e.g., ruptured uterus, uterine atony) ƒ Infection (e.g., unsafe or septic abortion, amnionitis, metritis) ƒ Trauma (e.g., injury to uterus or bowel during abortion, ruptured uterus)

11 Question ??

What are the signs and symptoms of shock?

12 Symptoms and Signs of Shock

ƒ Fast, weak pulse (110 beats/min. or more) ƒ Low blood pressure (systolic less than 90 mm Hg) ƒ Pallor (inner eyelids, palms, around mouth) ƒ Sweatiness or cold clammy skin ƒ Rapid breathing (30 breaths/min. or more) ƒ Anxiousness, confusion, unconsciousness ƒ Low urine output (less than 30 mL/hour)

13 Question ??

What are the very first things you would do if you come upon a patient in shock?

14 Immediate Management of Shock

ƒ Shout for help—mobilize personnel ƒ Monitor vital signs ƒ Position woman onto her side ƒ Keep woman warm ƒ Elevate her legs ƒ Collect blood for testing

15 Specific Management

ƒ Start IV infusion (two if possible): ƒ Infuse fluids at a rate of 1 L in 15–20 min., then give at least 2 L of fluids in first hour ƒ If shock results from bleeding, more rapid infusion is necessary ƒ Monitor vital signs ƒ Catheterize bladder ƒ Give oxygen at 6–8 L/min. ƒ Blood work: Hemoglobin, cross-match ƒ Manage specific cause

16 Shock: Further Management

ƒ Continue IV infusion at 1 L in 6 hours and oxygen at 6–8 L/min. ƒ Monitor closely ƒ Perform lab tests for hematocrit, blood grouping, Rh typing and cross-match ƒ If facilities available, check serum electrolytes, serum creatinine and blood pH

17 Question ??

What could you do to help your staff be ready for an emergency?

18 The Emergency Team

ƒ Remember: Everybody can resuscitate when necessary ƒ Have a recognized team who are trained and ready for emergencies ƒ The roles: Charge Person Runner Supplier Assistant

19 Responsibilities – Person One: Charge Person

ƒ Receives patient ƒ Does quick assessment/rapid appraisal and decides on management steps ƒ Stabilizes patient (massages uterus, gives oxytocin, initiates immediate resuscitation, gives directions to others) ƒ Stays with patient until specialized care arrives or referral ƒ Documents findings and action taken

20 Person Two: Runner

ƒ Sounds alarm, telephones or runs to inform doctor when alarm is raised ƒ Brings emergency tray or trolley to site ƒ Assists as needed (e.g., gathers equipment, starts, administers emergency drugs, ventilation, cardiac massage, etc.) ƒ Monitors vital signs ƒ Records vital signs and treatment given

21 Person Three: Supplier

ƒ Checks emergency tray at beginning of each shift ƒ Brings emergency tray to site of emergency ƒ Brings protective wear to site when alarm is raised ƒ Brings trolley/drip stands, etc., as needed ƒ Takes sample to labs ƒ Calls lab technician if bedside lab work necessary

22 Person Four: Assistant

ƒ Cares for newborn if well ƒ Reassures relatives/friends – escorts family members away from bed; keeps family informed of situation ƒ Assists with crowd control as needed ƒ Assist in clean up of patient

23 Question ??

What should be included on an emergency tray?

24 Emergency Tray/Trolley

Items List:

ƒ Ambu bag + face mask ƒ Torniquet ƒ Airway ƒ Gloves ƒ Sphygmanometer ƒ Syringes and needles ƒ Stethoscope ƒ Emergency packs: ƒ e.g., PPH, eclampsia ƒ Cotton swabs ƒ Iv fluids ƒ Gauze dressings ƒ Drugs ƒ Plaster ƒ Oxygen source + tube ƒ Scissors ƒ Foley catheter

25 O/G Emergency Packs

ƒ Surgical/for shock ƒ Medical/e.g., eclampsia ƒ IV Fluid 1l (N/S or rl) ƒ Iv fluid 1l (D/S or rl) ƒ IV Cannula (X2) ƒ Iv cannula (X2) ƒ Blood-giving set ƒ Administration set ƒ Specimen cont (G/xm) ƒ Specimen container ƒ Foley catheter ƒ Pair of gloves ƒ Pair of gloves ƒ Foley catheter ƒ Drugs: ƒ Drugs: ƒ Oxytocin 20 u (x2) ƒ Mag so4 ƒ Ergot 0.2mg (X 2) ƒ NIFEDIPINE 20mg ƒ HYDRALAZINE 20mg ƒ Calcium gluconate

26 Implementing a Rapid Assessment Scheme

ƒ Train ALL staff to react in agreed-upon fashion when woman arrives at facility with obstetric emergency or pregnancy complication ƒ Practice clinical drills or emergency drills with staff to ensure readiness at all levels ƒ Ensure that access is not blocked, equipment is in working order and staff are properly trained to use equipment

27 Implementing a Rapid Assessment Scheme (cont.)

ƒ Develop norms and protocols to distinguish a real emergency and how to react immediately ƒ Clearly identify women in waiting room who need prompt or immediate attention ƒ Agree on schemes by which women with emergencies can be exempted from payment, at least temporarily

28 Team Work

ƒ Roles and responsibilities are defined on each shift ƒ PROMPT RESPONSE to emergency call ƒ Regular training ƒ Emergency tray must always be in readiness

29 Emergency Drill: Demonstration

ƒ Scenario (role play) selected, such as the one on emergency drill handout ƒ Roles of patient and family can be played by participants ƒ Roles described on previous slides are played by trainers or by pre-assigned participants who have practiced roles ƒ At a pre-designated time, a bell is rung, and role play begins ƒ Following role play, the group (observers, role players and four emergency drill participants) discusses: ƒ What elements made this an effective teaching tool? ƒ How could this drill have been improved? ƒ When and how can you use such a drill in your teaching?

30 THANK YOU

31 References

Averting Maternal Death and Disability (AMDD) Program/ Jhpiego. 2003. Emergency Obstetric Care for Doctors and Midwives: A Course Notebook for Trainers. Jhpiego: Baltimore, MD. Deganus S. 2006. Emergency Preparedness and Resuscitation in OB, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April).

32 OPTIONAL SLIDES

33 Manage Specific Cause

ƒ Of vaginal bleeding ƒ Of unconsciousness or convulsions ƒ Of dangerous fever ƒ Of severe abdominal pain

34 Manage Specific Cause: Heavy Bleeding

ƒ Stop bleeding (use oxytocics, uterine massage, bimanual compression, aortic compression, surgery) ƒ Give IV fluids ƒ Transfuse as soon as possible ƒ Manage cause of bleeding: ƒ First 22 weeks of pregnancy: Abortion, ectopic or molar pregnancy ƒ After 22 weeks or during labor but before childbirth: Placenta previa, abruptio placentae or ruptured uterus ƒ After childbirth: Ruptured uterus, uterine atony, genital tract tears, retained placenta or placental fragments ƒ Reassess condition

35 Manage Specific Cause: Infection

ƒ If facilities available, collect samples of blood, urine, pus for culture ƒ Give antibiotics to cover aerobic and anaerobic infections until fever-free for 48 hours (DO NOT GIVE BY MOUTH): ƒ Penicillin G 2 million units OR ampicillin 2 g IV every 6 hours ƒ PLUS gentamicin 5 mg/kg body weight IV every 24 hours ƒ PLUS metronidazole 500 mg IV every 8 hours ƒ Reassess condition

36 Manage Specific Cause: Trauma

Prepare for surgical intervention

37 Transfusion

Risks of transfusion of whole blood or plasma: ƒ Transfusion reaction (skin rash to anaphylactic shock) ƒ Transmission of infectious agents (HIV, hepatitis B and C, syphilis, Chagas disease) ƒ Bacterial infection if blood is improperly manufactured or stored ƒ Risks increase with increase in volume transfused

38 Transfusion Risks

To minimize risk of transfusion: ƒ Effective donor selection ƒ Screening for infectious agents ƒ Quality assurance programs ƒ High-quality blood grouping, compatibility testing, component separation, storage and transport ƒ Appropriate use of blood and blood products

39 Principles of Clinical Transfusion

ƒ Transfusion is only one element of managing woman ƒ Follow national guidelines for decision to transfuse, weighing: ƒ Risks and benefits for individual patient ƒ Expected degree of improvement ƒ Indications for transfusion ƒ Alternative fluids for resuscitation ƒ Ability to monitor patient

40 Monitoring the Transfused Woman

ƒ Monitor the woman before transfusion, at onset, 15 min. after start, every hour and at 4-hour intervals after completing the transfusion ƒ Monitor: ƒ General appearance ƒ Temperature ƒ Pulse ƒ Blood pressure ƒ Respiration ƒ Fluid balance ƒ Note volume infused, unique donation numbers, adverse effects

41 Management of Transfusion Reaction

ƒ Stop infusion ƒ Continue IV fluids ƒ Minor adverse effects: ƒ Give promethazine 10 mg by mouth

42 Best Practices in the Management of Bleeding in Early Pregnancy and Postabortion Care

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To describe best practices for diagnosis of vaginal bleeding in early pregnancy ƒ To describe best practices for management of vaginal bleeding during early pregnancy ƒ To list postabortion family planning options

2 Case Study

Have everyone read Case Study 1 and discuss in group

3 Definition: What is bleeding in early pregnancy?

Vaginal bleeding that occurs during the first 22 weeks of pregnancy

4 Rapid Initial Assessment

ƒ Rapid evaluation of woman’s general condition including vital signs (pulse, blood pressure, respiration, temperature) ƒ If shock suspected, immediately begin treatment ƒ If woman is in shock, consider ruptured ectopic pregnancy ƒ Start an IV infusion and infuse IV fluids

5 What May Cause Bleeding . . .

. . . in early pregnancy?

6 Bleeding in Early Pregnancy: Diagnosis of Abortion

ƒ Threatened abortion ƒ Complete abortion ƒ Inevitable abortion ƒ Incomplete abortion ƒ Ectopic pregnancy ƒ Molar pregnancy

7 Management of Threatened Abortion

ƒ Medical treatment usually not necessary. ƒ Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary. ƒ If bleeding stops, followup in antenatal clinic. Reassess if bleeding recurs. ƒ If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound). Persistent bleeding, esp. in the presence of uterus larger than expected, may indicate twins or molar pregnancy. Do not give medications such as hormones (e.g., estrogens or progestins) or tocolytic agents (e.g., salbutamol or indomethacin) as they will not prevent miscarriage.

8 Management of Inevitable Abortion

ƒ If pregnancy is <16 weeks, plan for evacuation of uterine contents. If evacuation not immediately possible: ƒ Give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary); ƒ Arrange for evacuation as soon as possible. ƒ Ensure follow-up after treatment.

9 Management of Inevitable Abortion (cont.)

ƒ If pregnancy is ≥ 16 weeks: ƒ Await spontaneous expulsion of products of conception and then evacuate uterus to remove any remaining products of conception ƒ If necessary, infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min to help expulsion of products of conception

10 Management of Incomplete Abortion: < 16 Weeks

ƒ If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix. ƒ If bleeding heavy, evacuate uterus: ƒ Manual vacuum aspiration (MVA) is preferred method. Sharp curettage should be done only if MVA not available ƒ If evacuation not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours if necessary) ƒ Ensure follow-up of the woman after treatment.

11 Management of Incomplete Abortion: ≥ 16 Weeks

ƒ Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of POC occurs ƒ Evacuate any remaining products of conception from uterus by dilatation and curettage ƒ If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg ƒ Ensure follow-up of the woman after treatment

12 Management of Complete Abortion

ƒ Evacuation of the uterus usually not necessary ƒ Observe for heavy bleeding ƒ Ensure follow-up of woman after treatment

13 Follow-Up after Abortion

ƒ Tell woman that spontaneous abortion is common. ƒ Reassure woman that chances for subsequent successful pregnancy are good unless there has been sepsis or unless cause of abortion is identified that may have an adverse effect on future pregnancies (rare).

14 Follow-Up after Spontaneous Abortion

ƒ Encourage her to delay next pregnancy until completely recovered. ƒ Provide counseling for women who have had unsafe abortion. If pregnancy not desired, certain FP methods can be started immediately (within 7 days) if: ƒ There are no severe complications requiring further treatment ƒ Woman receives adequate counseling and help in selecting most appropriate FP method

15 Question ??

What methods of family planning can be used postabortion and how long after the abortion do you need to wait to begin each method?

16 Family Planning Methods after Postabortion Care

Type of FP Advise to Start Method Hormonal Immediately Condoms Immediately IUD Immediately Or If infection present or suspected, delay insertion/surgery until cleared Voluntary If Hb < 7 g/dL, delay until anemia Tubal Ligation improves Provide interim method (e.g., condom)

17 Ectopic Pregnancy: Clinical Diagnosis

ƒ Symptoms: ƒ Pain: 90–100% of patients ƒ Amenorrhea/abnormal menses: 75–95% ƒ Irregular bleeding: 50–80% ƒ Pregnancy symptoms: 10–25%

Weckstein 1987.

18 Ectopic Pregnancy: Clinical Diagnosis (cont.)

ƒ Signs: ƒ Afebrile ƒ Abdominal tenderness: 80–95% ƒ Rebound tenderness: 45% ƒ Palpable mass: 50% (often opposite side) ƒ Normal sized uterus: 71% ƒ Use combination testing to increase sensitivity and specificity

19 Ectopic Pregnancy

ƒ Pregnancy that is outside the uterine cavity ƒ Can be in the tube, ovary, abdomen or other locations ƒ Treated surgically by removal of the pregnancy or tube ƒ Also treated medically, although not available in developing countries ƒ If ruptures, can lead to hemorrhage and death

20 Signs and Symptoms of Unruptured Ectopic Pregnancy

ƒ Symptoms of early pregnancy: ƒ Irregular spotting or bleeding ƒ Nausea ƒ Swelling of breasts ƒ Bluish discoloration of vagina and cervix ƒ Softening of cervix ƒ Slight uterine enlargement ƒ Increased urinary frequency ƒ Abdominal and pelvic pain

21 Signs and Symptoms of Ruptured Ectopic Pregnancy

ƒ Collapse and weakness ƒ Fast, weak pulse (≥ 110/minute) ƒ Hypotension ƒ Hypovolemia ƒ Acute abdominal and pelvic pain ƒ Abdominal distension ƒ Rebound tenderness ƒ Pallor

22 Differential Diagnosis for Ectopic Pregnancy

ƒ Threatened abortion ƒ Acute or chronic PID ƒ Ovarian cysts ƒ (torsion or rupture) ƒ Acute appendicitis ƒ Remember: A ruptured ectopic pregnancy could be life-threatening!

23 Management of Ectopic Pregnancy

ƒ Cross-match blood ƒ Arrange for immediate laparotomy ƒ After surgery, prior to discharge, counsel on prognosis for fertility, and family planning needs ƒ Provide iron supplements for at least 6 months

24 Signs and Symptoms of Molar Pregnancy

ƒ Heavy bleeding ƒ Dilated cervix ƒ Uterus larger than dates ƒ Uterus softer than normal ƒ Partial expulsion of products of conception that resemble grapes ƒ Sometimes: nausea/vomiting, cramping, early onset pre-eclampsia

25 Molar Pregnancy

ƒ If diagnosis of molar pregnancy is certain, evacuate the uterus: ƒ Use vacuum aspiration: − Risk of perforation using a metal curette is high − Have three syringes cocked and ready for use as uterine contents are copious and must be evacuated rapidly ƒ Infuse oxytocin 20 units in 1 L IV (NS or RL) at 60 drops/minute to prevent hemorrhage once evacuation is under way ƒ Subsequent management: ƒ Use contraception for at least 1 year ƒ Follow up every 8 weeks for at least 1 year to monitor for trophoblastic disease or choriocarcinoma

26 Summary

ƒ Vaginal bleeding in early pregnancy could be caused by: ƒ Threatened abortion ƒ Incomplete abortion ƒ Complete abortion ƒ Ectopic pregnancy ƒ Molar pregnancy ƒ Diagnosis can often be made clinically, saving time and expense

27 References

Ganges F. 2006. Bleeding in Early Pregnancy, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Jongen V. 1996. Ectopic pregnancy and culdo-abdominocentesis. Int J Gynecol Obstet 55: 75–76. Musnick RA. 1982. Clinical test for placenta in 300 consecutive menstrual aspirations. Obstet Gynecol 60: 738–741. Weckstein LN. 1987. Clinical diagnosis of ectopic pregnancy. Clin Obstet and Gynecol 30(1): 236–244. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva.

28 Best Practices in Postabortion Care

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Describe the initial assessment of a woman bleeding in early pregnancy ƒ Define the stages of abortion ƒ Describe pain management in postabortion care ƒ Discuss postabortion family planning ƒ Describe the management of problems that may occur with Manual Vacuum Aspiration

2 RAPID Initial Assessment

ƒ Rapid evaluation of woman’s general condition including vital signs (pulse, blood pressure, respiration, temperature) ƒ If shock suspected, immediately begin treatment ƒ If woman is in shock, consider ruptured ectopic pregnancy ƒ Start an IV infusion and infuse IV fluids

3 Question ??

What are the signs and symptoms of incomplete abortion?

4 Initial Assessment

Signs and symptoms of incomplete abortion: ƒ A missed period or delayed menstrual bleeding ƒ Vaginal bleeding ƒ Cramping or lower abdominal pain ƒ Passage of pregnancy tissue

5 Initial Assessment (cont.)

Screening for serious complications: ƒ Signs of shock ƒ Signs and symptoms of severe bleeding ƒ Signs and symptoms of infection/sepsis ƒ Signs and symptoms intra-abdominal injury

6 Initial Assessment (cont.)

History: ƒ Medical history ƒ LMP ƒ Vaginal bleeding (amount and duration) ƒ Cramping (duration and severity) ƒ Fever, chills or general malaise ƒ Abdominal and shoulder pain ƒ Tetanus vaccination status

7 Initial Assessment (cont.)

Examination: ƒ General examination ƒ Abdominal examination ƒ Pelvic examination

8 Question ??

What are the stages of abortion?

9 Stages of Abortion

ƒ Threatened abortion ƒ Inevitable abortion ƒ Incomplete abortion ƒ Complete abortion

NOTE: Bleeding in pregnancy can also be caused by ectopic or molar pregnancies.

10 Bleeding in Early Pregnancy: Management of Threatened Abortion

ƒ Medical treatment usually not necessary. ƒ Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary. ƒ If bleeding stops, followup in antenatal clinic. Reassess if bleeding recurs. ƒ If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound). Persistent bleeding, esp. in the presence of uterus larger than expected, may indicate twins or molar pregnancy.

Do not give medications such as hormones (e.g. estrogens or progestins) or tocolytic agents (e.g. salbutamol or indomethacin) as they will not prevent miscarriage.

11 Management of Inevitable Abortion

ƒ If pregnancy is < 16 weeks, plan for evacuation of uterine contents. If evacuation not immediately possible: ƒ Give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary); ƒ Arrange for evacuation as soon as possible. ƒ If pregnancy is ≥ 16 weeks: ƒ Await spontaneous expulsion of products of conception and then evacuate uterus to remove any remaining products of conception ƒ If necessary, infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min to help expulsion of products of conception

12 Management of Incomplete Abortion: < 16 Weeks

ƒ If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix. ƒ If bleeding heavy, evacuate uterus: ƒ Manual vacuum aspiration (MVA) is preferred method. ƒ If evacuation not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours if necessary). ƒ Ensure follow-up of the woman after treatment.

13 Management of Incomplete Abortion: ≥ 16 Weeks

ƒ Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of POC occurs ƒ Evacuate any remaining POC from uterus by dilatation and curettage ƒ If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg ƒ Ensure follow-up of the woman after treatment

14 MVA: Pain Management

Keys to pain management: ƒ Supportive attention from staff before, during and after the procedure ƒ A provider who is comfortable working with patients who are awake and is trained to handle instruments gently ƒ Selection of an appropriate level of pain medication ƒ Use of verbacaine

15 MVA: Pain Management (cont.)

Tips for working with patients who are awake: ƒ Explain each step of the procedure prior to performing it ƒ Wait a few second after performing each task ƒ Move slowly, without jerky or quick motion; use instruments with confidence ƒ Talk with the patient throughout the procedure

16 MVA: Pain Management (cont.)

The need for supplemental medication or paracervical block depends on: ƒ The emotional status of the patient ƒ How open (dilated) the cervix is ƒ Anticipated length of the procedure

17 Problems and Complications during MVA

Technical problems: ƒ Syringe full ƒ Cannula withdrawn prematurely ƒ Cannula clogged ƒ Syringe does not hold vacuum Procedural problems: ƒ Little, if any, tissue ƒ Incomplete evacuation

18 Management of Problems and Complications during MVA

Syringe full: ƒ Close the pinch valve of the syringe ƒ Disconnect the syringe from the cannula ƒ Empty the syringe into a container ƒ Re-establish a vacuum in a syringe, reconnect and resume the aspiration

19 Management of Problems and Complications during MVA (cont.)

Cannula withdrawn prematurely: ƒ Remove the syringe and cannula ƒ Close the pinch valve of the syringe ƒ Detach the syringe from the cannula, empty the syringe,then re-establish the vacuum in the syringe ƒ Reinsert the cannuula ƒ Reconnect the syringe release the valve and continue aspiration

20 Management of Problems and Complications during MVA (cont.)

Cannula clogged: ƒ Close the pinch valve ƒ Remove the syringe and cannula ƒ Remove the material from the opening in the cannula using a sterile or HLD forceps ƒ Reinsert the cannula, attach a prepared syringe and release the pinch valve

21 Complications during MVA

ƒ Uterine perforation ƒ Cervical perforation ƒ Shock, severe vaginal bleeding and post- MVA infection ƒ Air embolism

22 Postabortion Family Planning

What all PAC patients should understand: ƒ They can become pregnant again before the next menses ƒ There are safe methods to prevent or delay pregnancy ƒ Where and how they can obtain family planning services and methods

23 Factors Limiting Provision of Postabortion Family Planning Services

ƒ Health care staff may have misconceptions about which contraceptive methods are appropriate. ƒ Providers of emergency postabortion care may NOT view the provision of contraceptive services as their responsibility. ƒ In hospitals, there may be administrative divisions (Ob/Gyn and FP services).

24 Factors Limiting Provision of Post- abortion Family Planning Services (cont.)

ƒ Often, emergency PAC and FP services are not coordinated ƒ Women who have been treated for incomplete abortion may not realize that their fertility will return soon ƒ Women may not know where FP and other reproductive health services are available

25 Postabortion Family Planning (cont.)

Components of good postabortion FP care: ƒ Information and counseling about methods, their characteristics, effectiveness and side effects ƒ Choice of methods ƒ Assurance of contraceptive resupply ƒ Access to follow-up care

26 Question ??

What methods of family planning can be used postabortion and how long after the abortion do you need to wait to begin each method?

27 PAC Contraceptive Methods

These methods can be started immediately for every woman who meets criteria: ƒ Oral contraceptives ƒ Progestin-only contraceptives ƒ Patches ƒ Implants ƒ Condoms

28 PAC Contraceptive Methods (cont.)

These methods can be started once infection is ruled out or resolved: ƒ Female sterilization ƒ IUD ƒ Fertility awareness methods

29 Postabortion Family Planning (cont.)

Postabortion family planning should be based on an individual assessment of every woman’s situation: ƒ Her personal characteristics, needs and reproductive goals ƒ Her clinical condition

30 Summary of FP Methods after Postabortion Care

Type of FP Advise to Start Method Hormonal Immediately Condoms Immediately IUD Immediately Or If infection present or suspected, delay insertion/surgery until cleared Voluntary If Hb < 7 g/dL, delay until anemia Tubal Ligation improves Provide interim method (e.g., condom)

31 Best Practices in the Management of Bleeding in Late Pregnancy

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ To describe best practices for the diagnosis and management of abruptio placentae ƒ To describe best practices for the diagnosis and management of placenta previa

2 Definition

Vaginal bleeding that occurs: ƒ After 22 to 28 weeks of pregnancy (late) (in most African countries 28 weeks) ƒ During labor before childbirth

3 Question ??

What are the most common causes of bleeding in late pregnancy?

4 Bleeding in Late Pregnancy: Antepartum Hemorrhage

ƒ Abruptio placentae ƒ Placenta previa ƒ Others: Vasa praevia, cervical, vaginal diseases

5 Question ??

What is an abruptio placentae?

6 Bleeding in Late Pregnancy: Abruptio Placentae

Definition: Detachment of normally located placenta from uterus before fetus is delivered

7 Abruptio Placentae

REVEALED CONCEALED

8 Abruptio Placentae (cont.)

9 Bleeding in Late Pregnancy: Diagnosis of Abruptio Placentae

ƒ Bleeding (may be Symptoms sometimes retained in uterus) present: after 22 weeks ƒ Shock gestation ƒ TENSE/TENDER UTERUS ƒ INTERMITTENT OR ƒ Decreased/absent fetal CONSTANT movements ABDOMINAL PAIN ƒ Fetal distress or absent fetal heart sounds ƒ Ultrasound confirmation

10 Management of Abruptio Placentae

ƒ Assess clotting status, e.g., bedside clotting test. (No clot after 7 minutes, or soft clot that breaks down easily, suggests coagulopathy.) ƒ Manage shock ƒ Transfuse as necessary ƒ If bleeding is heavy, deliver as soon as possible: ƒ If the cervix is fully dilated, deliver by vacuum extraction ƒ If vaginal delivery not imminent, deliver by C/section ƒ Note: In every case of abruptio placentae, be prepared for postpartum hemorrhage.

11 Management of Abruptio Placentae (cont.) ƒ If bleeding is light to moderate (the mother is not in immediate danger), the course of action depends on fetal heart sounds: ƒ If fetal heart sounds are normal or absent, rupture membranes with amniotic hook or Kocher clamp: − If contractions are poor, augment labor with oxytocin − If cervix is unfavorable, perform cesarean section ƒ If fetal heart sounds abnormal (< 100 or > 180 beats/min): − Perform rapid vaginal delivery − If vaginal delivery not possible, deliver by immediate C/section

12 Question ??

What is placenta previa?

13 Bleeding in Late Pregnancy: Placenta Previa

ƒ Placenta previa: Implantation of placenta at or near cervix ƒ Three types: ƒ Low placental implantation ƒ Partial placenta previa ƒ Complete placenta previa

14 Placenta Previa

15 Question ??

How would you diagnose placenta previa? What are the symptoms and signs?

16 Bleeding in Late Pregnancy: Diagnosis of Placenta Previa

ƒ Bleeding after Symptoms sometimes 22–28 weeks present: gestation ƒ Shock ƒ Bleeding may be precipitated by intercourse ƒ Relaxed uterus ƒ Fetal presentation not in pelvis/lower uterine pole feels empty ƒ Normal fetal condition

17 Bleeding in Late Pregnancy: Confirming Placenta Previa ƒ Localize placenta with ultrasound, if available ƒ If placenta previa is confirmed: ƒ Plan delivery if fetus is mature ƒ Manage expectantly if fetus is less than 37 weeks and bleeding is not life-threatening ƒ If diagnosis is uncertain: ƒ Manage expectantly as placenta previa until 37 weeks gestation ƒ If pregnancy is 37 weeks or more, examine under double-set up

18 Bleeding in Late Pregnancy: Expectant Management of Placenta Previa

ƒ Assess amount of bleeding: ƒ Do not perform a vaginal examination ƒ If bleeding is heavy and continuous, deliver by cesarean section regardless of gestation ƒ Consider expectant management if: ƒ Bleeding is light or has stopped ƒ Fetus is alive but less than 37 weeks gestation

19 Bleeding in Late Pregnancy: Expectant Management

ƒ Keep woman in hospital until delivery ƒ Correct anemia with oral iron ƒ Ensure blood is available for transfusion ƒ If bleeding recurs, weigh benefits and risks for woman and fetus of further expectant management versus delivery

20 Inpatient vs. Outpatient Expectant Management: Study Objective

Determine safety, efficacy and costs of inpatient and outpatient management of symptomatic placenta previa

Design: Randomized controlled trial

Wing, Paul and Millar 1996. 21 Inpatient vs. Outpatient Expectant Management: Study Criteria

Inclusion criteria: Exclusion criteria: ƒ Singleton gestation ƒ Hemodynamic instability ƒ Gestational age 24–36 ƒ Other vaginal bleeding weeks ƒ Three or more episodes of ƒ Intact membranes bleeding before presentation ƒ Normal fetal anatomic ƒ Obstetric complications survey ƒ Serious underlying medical ƒ Reactive nonstress test disorder ƒ Lack of telephone contact ƒ Lack of resources to return Source: Wing, Paul and Millar 1996. rapidly to hospital

22 Maternal Outcome Measures

Inpatient Outpatient Significance

Time pregnancy 38.1 ± 23.5 33.1 ± 22.6 p = 0.44 prolonged

Total hospital stay 28.6 ± 20.3 10.1 ± 8.5 p < 0.0001

Total episodes of 2.7 ± 2.4 2.3 ± 1.1 p = 0.45 bleeding

Transfusion 4 (14.8%) 1 (3.8%) p = 0.67

Source: Wing, Paul and Millar 1996.

23 Inpatient vs. Outpatient Expectant Management: Study Conclusion

Outpatient management of stable preterm patients with placenta previa is possible if the patient understands danger signs and self-care and is able to return to the hospital if necessary.

Source: Wing, Paul and Millar 1996.

24 Bleeding in Late Pregnancy: Delivery for Placenta Previa

ƒ Plan delivery by cesarean section if: ƒ Hemorrhage is severe enough to cause risk to mother ƒ Fetus is at least 37 weeks gestation ƒ Fetus is dead or cannot survive ƒ Major praevia ƒ Vaginal delivery may be possible with low placental implantation ƒ Women with placenta previa are at high risk for postpartum hemorrhage and placenta accreta/ increta

25 Case Study: Bleeding in Late Pregnancy

ƒ Facilitate the reading and answering of Case Study: Bleeding in Late Pregnancy ƒ Discuss answers and questions that arise during discussion

26 Summary

ƒ Vaginal bleeding in late pregnancy and labor can be catastrophic: ƒ Evaluate rapidly ƒ Resuscitate if patient in shock ƒ Differentiate abruptio placentae and placenta previa because of difference in mode of delivery

27 References

Ganges F. 2006. Bleeding in Late Pregnancy, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, MD. Wing DA, Paul RH and Millar LK. 1996. Management of the symptomatic placenta previa: A randomized, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 175(4): 806–811. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva.

28 Best Practices in the Management of Bleeding after Childbirth

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

By end of session, participants will be able to: ƒ Describe the significance of postpartum hemorrhage ƒ Discuss the causes of postpartum hemorrhage ƒ Discuss the prevention of postpartum hemorrhage ƒ Describe the management of postpartum hemorrhage

2 Vaginal Bleeding after Childbirth

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 of postpartum hemorrhage (PPH), which causes more than one-quarter of all maternal deaths worldwide.

3 Definition

ƒ Vaginal bleeding in excess of 500 mL or any amount sufficient enough to cause cardiovascular compromise ƒ Primary and secondary PPH ƒ Facts: ƒ Estimated amounts of blood loss are notoriously low, often half the actual loss ƒ The lower the Hb level, the poorer is the woman’s tolerance of blood volume loss

4 Question ??

What are the causes of postpartum hemorrhage?

5 The Causes

ƒ Atonic uterus ƒ Retained placenta or fragments ƒ Tears of uterus, cervix, vagina, perineum ƒ Coagulation defects ƒ Inversion of uterus ƒ Infection (delayed PPH)

6 Management

ƒ This is a life-threatening complication, which must be managed promptly and effectively. ƒ Get all the help you can. ƒ Prevention is the best management.

7 Question ?

What measures can we take to prevent postpartum hemorrhage?

8 Prevention

CLIENT CARE ƒ Prevent prolonged labor ƒ Active management of the third stage of labor ƒ Avoid perineal/vaginal trauma ƒ Monitor closely

EMERGENCY PREPAREDNESS ƒ Have emergency PPH pack ready

9 ICM/FIGO Joint Statement on Active Man- agement of the Third Stage of Labor (AMTSL)

ƒ AMSTL has been proven to reduce the incidence of postpartum hemorrhage, reduce the quantity of blood loss and reduce the use of transfusion ƒ AMSTL should be offered to all women who are giving birth ƒ Every attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out AMSTL

10 Prevention: Be Prepared

ALL women are at risk of PPH! Women who are predisposed to fatal consequences of PPH include women with: ƒ Over-distended uterus (twins, big baby, polyhydraminios) ƒ Prolonged labor ƒ Severe pre-eclampsia/eclampsia ƒ Prolonged intrauterine death ƒ APH ( weakens) ƒ Anemia (weakens)

11 Question ??

What are the first things you should do when you encounter a woman with bleeding after third stage (postpartum hemorrhage)?

12 General Management Steps

ƒ CALL FOR HELP ƒ Perform rapid evaluation (vital signs BP, pulse, RR, pallor and cause) ƒ Massage uterus ƒ If shock is present, start immediate resuscitation: ƒ Start IV infusion 1 liter/15 min. ƒ Take blood for grouping and cross-matching ƒ Give oxygen ƒ Elevate foot end and keep woman warm

13 IV Fluid Replacement: In Shock

ƒ Start resuscitation with intravenous fluids (normal saline or Ringer’s lactate) ƒ Use large-bore cannula (16 or bigger) ƒ Volume to give: ƒ First 1,000 mL ( 500 ml x 2) rapidly in 15–20 min. ƒ GIVE AT LEAST 2000 mL ( 500 X 4 ) IN FIRST HOUR ƒ Aim to replace 2–3x the volume of estimated blood loss ƒ If condition stabilizes, then adjust rate to 1,000 mL/6 hrly ƒ Monitor BP, pulse every 15 min. and urine output hourly (> 30 mL/hr) ƒ Avoid dextrans; they interfere with grouping and cross- matching as well as with coagulation of blood

14 Management: Rapid Assessment

Assess for s/s of following conditions and perform appropriate action before proceeding with additional care: ƒ Uterine atony (uterus soft/not contracted) ƒ Tears of perineum, vagina, cervix ƒ Retained placenta or placental fragments ƒ Ruptured or inverted uterus ƒ Delayed postpartum hemorrhage (PPH)

15 Vaginal Bleeding after Childbirth: Management

ƒ If s/s of uterine atony: ƒ Massage uterus ƒ Start IV infusion (plus oxytocin 20 units/liter IV fluids) or ORS ƒ Give oxytocin 10 units IM* ƒ Ensure urination (catheterize if needed)

*If not able to start IV

16 Vaginal Bleeding after Childbirth: Management (cont.)

ƒ If bleeding continues: − Perform bimanual compression of uterus OR compression of abdominal aorta (per next two slides) − Give additional oxytocics, e.g., misoprostol, ergometrine, prostaglandins if available. − If bleeding continues, facilitate urgent referral/transfer ƒ If bleeding stops, proceed with additional care, plus measure woman’s hemoglobin in 2 or 3 hours

17 Internal Bimanual Compression of the Uterus

ƒ Wearing HLD gloves, insert hand into vagina; form fist ƒ Place fist into anterior fornix and apply pressure against anterior wall of uterus ƒ With other hand, press deeply into abdomen behind uterus, applying pressure against posterior wall of uterus ƒ Maintain compression until bleeding is controlled and uterus contracts

18 Compression of Abdominal Aorta

ƒ Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left) ƒ With other hand, palpate femoral pulse to check adequacy of compression: ƒ Pulse palpable = inadequate ƒ Pulse not palpable = adequate ƒ Maintain compression until bleeding is controlled

19 Atonic Uterus! First action is to massage uterus

DOSE & CONTRA- DRUG CONT. DOSE MAX DOSE ROUTE INDICATION

OXYTOCIN IM 10 U OR IV 20 u in Not > 40 U No IV admin., not IV 20 U in 1000 1,000 mL at infused at even slow IV ml NS at >60 40 drps/min. rate of 0.02– push unless IV drp/min OR 5- 0.04 U/min. fluids are 10 U slow IV running push ERGO- IM OR IV Repeat 0.2 Five doses High BP METRINE Slowly 0.2 mg mg after 15 (Total 1.0 Heart disease min. if mg) required every 4 hours

20 Atonic Uterus (cont.)

CONT. MAX CAUTIONS & DRUG DOSE & ROUTE DOSE DOSE CI

MISOPROSTOL ORAL/SL 200 mg 2000 mg Asthma (CYTOTEC) INTRAVAG Every 4 Heart Dis* RECTAL hours 200–800 mcg (600mcg)

PROSTAGLANDIN IM only 0.25 mg Total 8 Asthma F2a 0.25mg Every 15 Doses=2 Heart Dis* minutes mg

21 Question ??

If a woman with postpartum hemorrhage has no signs of atonic uterus, what should you do?

22 Management of PPH

ƒ If no s/s of uterine atony: ƒ Examine vagina, perineum, cervix for tears ƒ Start IV infusion or oral rehydration solution (ORS) – if woman is conscious ƒ Keep woman warm; elevate legs ƒ Ensure urination (catheterize if needed) ƒ Proceed with assessment

23 Additional Management (cont.)

ƒ If s/s of tears: ƒ If extensive tears (3rd or 4th degree), facilitate urgent referral/transfer ƒ If 1st or 2nd degree tears, perform repairs ƒ If s/s of retained placenta, perform appropriate management to deliver placenta ƒ If s/s of retained placental fragments, perform appropriate management to remove fragments

24 Local Anesthesia

Lidocaine: ƒ Only use in concentration of 0.5% (drug is usually available in 1% and 2% preparations) ƒ If more than 40 mL is required, add adrenaline to delay dispersion ƒ MAX safe dose is 4mg/kg BW for plain and 7mg/kg BW with adrenaline ƒ Anesthetic effect can last for 2 hrs ƒ Dose can be repeated after 2 hr PRN ƒ Avoid injecting into vessel

25 Retained Placenta

ƒ If you can see the placenta, ask the woman to push it out ƒ If you can feel the placenta in the vagina, remove it ƒ If the placenta is still not delivered: ƒ Give oxytocin 10 units IM (if not already given for AMTSL) and attempt CCT with the next contraction ƒ Catheterize the bladder using aseptic technique if not already done ƒ If CCT unsuccessful, attempt manual removal of the placenta

26 Managing Retained Placenta

ƒ Ensure bladder is empty ƒ Apply controlled cord traction; If it fails, ƒ Repeat oxytocin 10u IM: If no success of CCT in 30 min: ƒ Attempt manual removal of placenta: − Give Pethidine and diazepam or Ketamine − Give antibiotics: (Ampicillin 2g + Metronidazole 500 mg) − Perform procedure and examine placenta for completeness − Give Oxytocin 20 U/1,000 mL NS or RL at 60 dpm − Monitor BP, pulse, pad and urine output closely − Add ergot or prostaglandin if bleeding continues − Transfuse PRN and treat for anemia

27 Anesthesia and Analgesia for Short Procedures < 30 Minutes

ƒ Pethidine 1mg/kg BW IM or ƒ Ketamine for procedures ƒ IV slowly (max 100 mg dose) < 60 min: ƒ Dose 6-10 mg/kg BW by IM or ƒ Give Promethaxine IV bolus or IV Infusion (Phenergan) if vomiting ƒ 2 mg/kg BW IV slowly last for occurs) 15 min Plus ƒ 200 mg in 1 liter D/S at 20 dpm ƒ Diazepam 10mg IV at rate of infusion for longer procedures 1mg every 2 min. ƒ Give atropine 0.6 mg IM as pre-medication ƒ Monitor RR closely; stop if ƒ Give O2 6-8l/min by mask RR<10/min ƒ Add diazepam 10 mg IV to DO NOT MIX THE TWO avoid hallucinations DRUGS IN SAME SYRINGE CONTRAINDICATED IN HIGH BP AND HEART DISEASE 28 Retained Placenta (cont.)

ƒ If bleeding continues, ACT NOW! Facilitate urgent referral/transfer ƒ If bleeding stops, continue with basic care ƒ 2 to 3 hours after bleeding stops, measure the woman’s hemoglobin: ƒ If Hgb less than 7g/dL, facilitate urgent transfer ƒ If Hgb is 7–11g/dL, treat anemia with iron/folate ƒ DO NOT give ergometrine as it causes tonic contractions ƒ AVOID forceful CCT and fundal pressure as they may cause uterine inversion

29 Vaginal Bleeding after Childbirth: Management (cont.)

If s/s of retained placental fragments: ƒ Give uterotonic drug according to guidelines ƒ Assess cervix for dilation

30 Vaginal Bleeding after Childbirth: Management (cont.)

ƒ If cervix is not dilated, facilitate urgent referral/transfer ƒ If cervix is dilated, perform appropriate management to remove fragments/tissue: ƒ If bleeding continues, perform bimanual compression of uterus OR compression of abdominal aorta ƒ NOTE: Very adherent tissue may be placenta accreta. Efforts to extract fragments that do not separate easily may result in heavy bleeding or uterine perforation, which usually requires hysterectomy.

31 Vaginal Bleeding after Childbirth: Management (cont.)

ƒ If s/s of ruptured uterus, facilitate urgent referral/transfer ƒ If s/s of inverted uterus, perform manual correction of inverted uterus

32 Vaginal Bleeding after Childbirth: Additional Management

ƒ If bleeding continues, facilitate urgent referral/transfer ƒ If bleeding stops, proceed with additional care, plus measure woman’s hemoglobin in 2 or 3 hours: ƒ If hemoglobin is less than 7g/dL, facilitate urgent referral ƒ If hemoglobin 7–11g/dL, treat anemia with iron/folate

33 Case Study

ƒ Adisa Mohammed was rushed to your clinic by her family. She delivered at home 2 hrs ago and has since been bleeding profusely. She is now very weak. You are the health worker at the clinic: ƒ What first steps will you take? ƒ What rapid assessments will you undertake (history and examination)?

34 Case Study (cont.)

ƒ You note that she is very pale and barely alive. Her BP is 80/50 mmHg and Pulse 110/ min. Her uterus is lax and she is still bleeding actively PV. You are told that the placenta was delivered after the baby was born. ƒ What next resuscitative actions and assessments will you undertake?

35 Group Work

ƒ Participants will divide into groups of 3 or 4. ƒ Half of the groups will receive Case Study 1: Vaginal Bleeding after Childbirth and the other groups will receive Case Study 2: Vaginal Bleeding after Childbirth. ƒ Groups will read case studies and answer questions. ƒ Larger group will reassemble and discuss each case study.

36 THANK YOU

37 References

Deganus S. 2006. Vaginal Bleeding after Childbirth, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). World Health Organization (WHO). 2006. Essential Medicines for Reproductive Health. WHO: Geneva. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva. www.globalhealthlearning.org – course on Preventing Postpartum Hemorrhage.

38 Best Practices in Inspection and Repair of Vaginal Sulcus, Periurethral and Cervical Tears Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Define types of tears ƒ Describe the anesthesia needed for repair ƒ Describe the suture needed for repair ƒ Discuss some tips for repair ƒ Provide post-procedure counseling

2 Objectives of Repair of Vaginal Sulcus, Periurethral and Cervical Tears

ƒ Prevent blood loss ƒ Facilitate return of genital tract to sexual and reproductive health

3 Question ??

What is the difference between a vaginal sulcus, periurethral and cervical tear?

4 Definitions

ƒ Vaginal Sulcus Tear(s): One or more lacerations/tears of one or both sides of the vagina ƒ Periurethral Tear(s): One or more lacerations/ tears near the urethra ƒ Cervical Tear(s): One or more lacerations/ tears of the cervix

5 Question ??

What anesthesia is generally used for repair of a vaginal sulcus or periurethral tear?

6 Anesthesia for Repair of Vaginal Sulcus or Periurethral Tear

ƒ Anesthesia of choice - 0.5% lignocaine. ƒ Use approximately 10 mL of lignocaine. If more than 40 mL is needed, add adrenaline to the solution. Do not use more than 50 mL. ƒ Aspirate to be sure that no vessel is penetrated. ƒ Anesthetize at least 2 minutes prior to suturing, and test that anesthesia has been effective.

7 Question ??

What anesthesia is generally used for repair of a cervical tear?

8 Anesthesia for Cervical Tear

ƒ Anesthesia is not required for most cervical tears: ƒ Emotional support and encouragement is needed. Relief of anxiety is important in reducing discomfort. ƒ If tears are high and extensive, give pethidine and diazepam IV slowly (do not mix in same syringe) or use ketamine.

9 Suture

ƒ For vaginal sulcus tear, use 2–0 chromic or vicryl suture ƒ For periurethral tears, use 3–0 or 4–0 chromic or vicryl suture ƒ For cervical tears, use 0 chromic suture

10 Tips

ƒ Start suture 1 cm above apex of vaginal or cervical tear to catch any vessels that may have retracted ƒ Insert a catheter before beginning repair of periurethral tears to prevent damage to urethra ƒ Always use forceps, NEVER your fingers, to handle/maneuver needle

11 Post-Procedure Counseling

ƒ Change pad/cloths frequently to keep wound dry ƒ Do sitz/warm soapy baths 3–4 times per day ƒ Do not insert anything in the vagina ƒ Get rest and good nutrition ƒ Delay intercourse to avoid breaking sutures ƒ Do not return for suture removal as they are absorbable ƒ Return after 4–6 days for check-up

12 Reference

World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva.

13 Best Practices in Management of Headache, Convulsions, Loss of Consciousness or High Blood Pressure Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Discuss best practices for diagnosing and managing hypertension, pre-eclampsia and eclampsia ƒ Describe strategies for controlling hypertension ƒ Describe strategies for preventing and treating convulsions in eclampsia

2 Problem

Pregnant or recently postpartum woman who: ƒ Has elevated blood pressure ƒ Complains of headache or blurred vision ƒ Is found unconscious or convulsing

3 What’s her problem?

What do you think may be wrong?

4 What is her problem?

It may be severe pre-eclampsia or eclampsia.

5 High Blood Pressure

ƒ Classifications: ƒ Chronic hypertension ƒ Pregnancy-induced hypertension: − Pregnancy-induced hypertension without proteinuria − Mild pre-eclampsia − Severe pre-eclampsia − Eclampsia

6 Questions ??

ƒ What is pre-eclampsia?

ƒ When can it occur?

7 Pre-Eclampsia

ƒ Woman over 20 weeks gestation with: ƒ Diastolic blood pressure > 90 mm Hg AND ƒ Proteinuria ƒ Predisposes woman to develop eclampsia

8 Mild Pre-Eclampsia

ƒ Two readings of diastolic blood pressure 90-110 mm Hg 4 hours apart after 20 weeks gestation ƒ Proteinuria up to 2+ ƒ No other signs/symptoms of severe pre- eclampsia

9 Severe Pre-Eclampsia

ƒ Diastolic blood ƒ Other signs and pressure > 110 mm symptoms Hg sometimes present: ƒ Epigastric ƒ Proteinuria > 3+ tenderness ƒ Headache ƒ Visual changes ƒ Hyperreflexia ƒ Pulmonary edema ƒ Oliguria

10 Predicting Pre-eclampsia: What do the studies* tell us?

ƒ Those women who developed gestational hypertension at an earlier gestational age were more likely to progress to pre-eclampsia ƒ Approximately 15–25% of women initially diagnosed with gestational hypertension will develop pre-eclampsia ƒ It is difficult to predict who will develop pre- eclampsia

*Sources: Saudan et al. 1998; Moutquin et al. 1985.

11 Questions ??

ƒ What is “eclampsia”?

ƒ When can it occur?

12 Eclampsia: Typical Signs

ƒ Convulsions occurring after 20 weeks gestation in a woman without a previously known seizure disorder. (Can also occur in first few days postpartum.) ƒ Proteinuria 2+ or more ƒ Blood pressure 90 mm Hg or more: ƒ A small proportion of women with eclampsia have normal blood pressure

13 Strategies for Preventing Eclampsia

ƒ Antenatal care and ƒ 3.4% of women with recognition of severe pre-eclampsia hypertension will have a convulsion ƒ Identification and ƒ Eclampsia is the treatment of pre- number one cause of eclampsia by skilled in-hospital maternal attendant death in Nepal ƒ Timely delivery

14 More Study Results

Another study by Chesley and Sibai in 1987 concluded: ƒ Cannot use 2nd trimester mean arterial pressure or diastolic pressure to predict eclampsia ƒ Eclampsia is abrupt in onset, without warning signs in about 20% of women

Source: Chesley and Sibai 1987.

15 Question ??

What should be your initial response when you find a woman in late pregnancy who is convulsing?

16 Initial Assessment and Management of Eclampsia

ƒ Shout for help – mobilize personnel ƒ Rapidly evaluate breathing and state of consciousness ƒ Check airway, blood pressure and pulse ƒ Position on left side ƒ Protect from injury but do not restrain ƒ Start IV infusion with large-bore needle (16-gauge) ƒ Give oxygen at 4 L/minute DO NOT LEAVE THE WOMAN UNATTENDED

17 Antihypertensive Drugs

Drugs: Principles: ƒ Hydralazine ƒ Initiate anti- hypertensives if ƒ Labetolol diastolic blood ƒ Nifedipine pressure > 110 mm Hg ƒ Maintain diastolic blood pressure 90–100 mm Hg to prevent cerebral hemorrhage

18 EMERGENCY!!!

Question: ƒ What do you do if a woman is suddenly convulsing?

19 Management during a Convulsion

ƒ Give magnesium sulfate IM ƒ Gather emergency equipment (O2, mask, etc.) ƒ Position on left side ƒ Protect from injury but do not restrain

DO NOT LEAVE THE WOMAN UNATTENDED

20 Anticonvulsive Drugs

ƒ Magnesium sulfate ƒ Diazepam ƒ Phenytoin

21 Post-Convulsion Management

ƒ Prevent further convulsions ƒ Control blood pressure ƒ Prepare for delivery (if undelivered)

22 Studies to Be Reviewed

For severe pre-eclampsia: ƒ Magnesium sulfate vs. placebo

For eclampsia: ƒ Magnesium sulfate vs. diazepam ƒ Magnesium sulfate and outcome of labor

23 Magnesium Sulfate

ƒ Use magnesium sulfate in: ƒ Women with eclampsia ƒ Women with severe pre-eclampsia necessitating delivery ƒ Start magnesium sulfate when decision for delivery is made ƒ Continue therapy until 24 hours after delivery or the last convulsion, whichever occurs last

24 Monitoring Hourly

Assess Normal Findings

Level of consciousness Sleepy but arousable Should be maintained Diastolic blood pressure between 80–100 mmHg Respiratory rate 16 breaths/minute or more Deep tendon reflexes Minimal but present Fetal heart sounds (if Decrease in variability undelivered)

25 Monitoring Hourly (cont.)

Assess Abnormal Findings Management

Discontinue Lungs Pulmonary edema magnesium sulfate

Falls below 30 mL/hour Discontinue Urine output or 120 mL/4 hours magnesium sulfate

Uterus (after Atonic uterus Consider oxytocin for delivery) (postpartum bleeding) 24 hours after delivery

26 Principles of Management

ƒ Timing and route of delivery: condition of mother vs. maturity of fetus ƒ Assessment of fetus: evidence of fetal compromise ƒ Control of convulsions ƒ Control of hypertension ƒ Referral due to other organ complications: pulmonary, renal, central nervous system

27 Summary

ƒ There are many manifestations of increased blood pressure in pregnancy ƒ It is not possible to predict which patients are at risk for severe pre-eclampsia or eclampsia ƒ Vigilant care is needed to make the diagnosis ƒ Once the diagnosis is made, appropriate treatment can reduce morbidity and mortality ƒ Anticonvulsants should be used, with magnesium sulfate being the first line ƒ Antihypertensives should be employed as needed ƒ Close monitoring is needed for side effects

28 References

American College of Obstetricians an Gynecologists. 1996. Technical Bulletin Hypertension in Pregnancy. #219. Chesley LC and Sibai BM. 1987. Blood pressure in mid-trimester and future eclampsia. Am J Obstet Gynecol 157(5): 1258–1561. Coetzee E, Dommisse J and Anthony J. 1998. A randomised controlled trial of intravenous magnesium sulphate versus placebo in the management of women with severe pre-eclampsia. Br J Obstet Gynaecol 105: 300–303. Deganus S and Ganges F. 2006. Headache Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Duley L and Henderson-Smart D. 2000a. Magnesium sulphate versus diazepam for eclampsia (Cochrane Review), in The Cochrane Library, Issue 4. Update Software: Oxford.

29 References (cont.)

Leveno KJ et al. 1998. Does magnesium sulfate given for prevention of eclampsia affect the outcome of labor? Am J Obstet Gynecol 178(4): 707– 712. Moutquin J et al. 1985. A prospective study of blood pressure in pregnancy: Prediction of pre-eclampsia. Am J Obstet Gynecol 151: 191– 196. Saudan P et al. 1998. Does gestational hypertension become pre- eclampsia? Br J Obstet Gynaecol 105: 1177–1184. Szal SE, Croughan-Minihane MS and Kilpatrick SJ. 1999. Effect of magnesium prophylaxis and pre-eclampsia on the duration of labor. Am J Obstet Gynecol 180: 1475–1479. Villar MA and Sibai BM. 1989. Clinical significance of elevated mean arterial blood pressure in second trimester and threshold increase in systolic and diastolic blood pressure during third trimester. Am J Obstet Gynecol 160: 419–423.

30 References (cont.)

Witlin AG, Friedman SA and Sibai BM. 1997. The effect of magnesium sulfate on the duration of labor in women with mild pre-eclampsia at term: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol 176(3): 623–627. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva.

31 OPTIONAL SLIDES

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Magnesium Sulfate vs. Placebo in Women with Pre-Eclampsia: Objective and Design

ƒ Objective: To evaluate the effectiveness of magnesium sulfate vs. placebo ƒ Design: Double-blinded prospective RCT ƒ Tertiary referral obstetrics unit in South Africa ƒ 822 women with severe pre-eclampsia necessitating delivery randomly assigned to placebo or magnesium sulfate ƒ Data from 699 women evaluated

Source: Coetzee, Domisse and Anthony 1998.

33 Magnesium Sulfate vs. Placebo in Women with Pre-Eclampsia: Results

In women with severe pre-eclampsia, eclampsia occurred 11 times less often in women receiving magnesium sulfate than in women receiving placebo

Source: Coetzee, Domisse and Anthony 1998.

34 Magnesium Sulfate vs. Placebo in Women with Pre-Eclampsia: Results (cont.)

No Convulsions Convulsions Magnesium 1 (0.3%) 344 (99.7) sulfate No magnesium 11 (3.2%)* 329 (96.7%) sulfate

* RR 0.09, 95% CI (0.01–0.69)

Source: Coetzee, Domisse and Anthony 1998.

35 Magnesium Sulfate vs. Placebo in Women with Pre-Eclampsia: Results (cont.)

No significant difference in: ƒ Need for antihypertensive therapy ƒ Number of cesarean sections performed ƒ Number of live births vs. stillbirths ƒ Average gestational age ƒ Birthweight at delivery ƒ Number of maternal deaths

Source: Coetzee et al 1998.

36 Magnesium Sulfate vs. Diazepam for Eclampsia: Study Objective and Design

ƒ Objective: To assess effects of magnesium sulfate compared with diazepam when used for the care of women with eclampsia ƒ Design: Randomized controlled trial

Source: Duley and Henderson-Smart 2000a.

37 Magnesium Sulfate vs. Diazepam: Recurrence of Convulsions

Convulsions No Convulsions Total

Magnesium 71 547 618 sulfate Diazepam 160 458 618

RR 0.45, 95% CI 0.35-0.58

No differences in maternal morbidity and borderline decrease in maternal mortality

Source: Duley and Henderson-Smart 2000a.

38 Magnesium Sulfate and Effect on Labor: Objective and Design

ƒ Objective: Evaluate effect of magnesium sulfate on labor ƒ Design: ƒ Study period: March 1995 to June 1996; randomized term mildly pre-eclamptic women to receive magnesium sulfate 6 g bolus then 2 g/hour or saline ƒ Cervical ripening agents/oxytocin at physician’s discretion ƒ Women taken off protocol if developed severe pre- eclampsia

Source: Witlin, Friedman and Sibai 1997.

39 Magnesium Sulfate and Effect on Labor: Results

ƒ Outcome: Length of labor, duration of latent and active phases, first and second stages ƒ Results: ƒ No difference in duration of oxytocin: magnesium sulfate group 14.1 hours vs. 13.5 hours ƒ Slightly higher dose of oxytocin required in magnesium sulfate group: 13.9 mU/min vs. 11.0 (p=0.036) ƒ No significant postpartum hemorrhage or side effects

Source: Witlin, Friedman and Sibai 1997.

40 Magnesium Sulfate and Effect on Labor: Conclusion

Slightly higher doses of oxytocin required in magnesium treated groups, but no difference in labor and no adverse effects

Source: Witlin, Friedman and Sibai 1997.

41 Case Study

ƒ Divide participants into groups of 4 or 5 ƒ Each group should read Case Study: Pregnancy-Induced Hypertension and answer the questions ƒ Reassemble the larger group and discuss case study and questions

42 Best Practices in Management of Fever after Childbirth

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Objectives

By the end of the session, the learner will be able to: ƒ Discuss the prevalence of postpartum infection ƒ Describe risk factors for and diagnosis of postpartum infection ƒ Discuss strategies for preventing postpartum infection ƒ Describe clinical treatment approaches ƒ Describe programmatic approaches for prevention and treatment

2 Question ??

Please consider during this presentation: Would you consider the use of the partograph an important intervention for reducing post- partum infection?

3 Prevalence of Postpartum Infections

Country Author Prevalence

Nepal NSMP (2002) 11%

Zaria, Nigeria Harrison (1985) 7.9%

Zaria, NG (Home Harrison (1985) 14.9% births)

Kenya Plummer (1994) 20% Indonesia (Home Gulardi (2003) 14% births) Viet Nam Ngoc (2005) 4.6%

5–20% of women develop a PP infection

4 Distribution of Maternal Deaths; Khan et al.; WHO Analysis of Causes of Maternal Deaths; Lancet April 2006. Asia-Specific Distribution Unclassified 6% Haemorrhage Other Indirect 31% 12%

Other Direct 2%

Embolism 0% Hypertensive 9% Ectopic Preg 0%

Sepsis Anaemia Obstructed 12% 13% Abortion Labor 6% 9%

5 Question ??

What are some natural barriers to maternal infection?

6 Natural Barriers to Maternal Infection

ƒ Amniotic fluid is a wonderful culture medium! ƒ Placental membranes form a barrier at the uterine level ƒ Mucus plug (progesterone-induced) at the cervical level ƒ Lochia (postpartum discharge) is a natural effluent which keeps pathogens flowing outward ƒ Increased pelvic blood flow at the systemic level

7 Risk Factors for Postpartum Infections

ƒ Frequent vaginal examinations ƒ Prolonged and obstructed labor – Length of Labor ƒ Prelabor rupture of membranes – Length of ROM ƒ Cesarean section (OR at least 2.0)

ƒ Preterm birth ƒ Maternal anemia ƒ Episiotomies, vacuum ƒ Micronutrient deficiencies extractions, forceps ƒ Sexually transmitted delivery, uterine revision infections (any procedure) ƒ Poor maternal hygiene

8 Question ??

What are some causes of fever after childbirth?

9 Fever after Childbirth: Differential Diagnosis

Metritis, Metritis, Metritis ƒ Pelvic abscess ƒ Cystitis ƒ Peritonitis ƒ Acute pyelonephritis ƒ Breast engorgement ƒ Deep vein thrombosis ƒ Mastitis ƒ Pneumonia ƒ Breast abscess ƒ Atelectasis ƒ Wound morbidity: ƒ Uncomplicated malaria ƒ Wound abscess ƒ Severe/complicated malaria ƒ Wound seroma ƒ Typhoid ƒ Wound hematoma ƒ Wound cellulitis ƒ Hepatitis When you hear hoof beats… 10 Postpartum Infections and Subsequent Maternal Morbidity

ƒ Pelvic inflammatory disease ƒ Chronic pelvic pain ƒ Dysmenorrhea, menorrhagia ƒ Infertility

11 Prevention Strategies at the Time of Childbirth

ƒ Reduce the length of labor: ƒ Partograph ƒ Ambulation ƒ Labor support ƒ Appropriate controlled augmentation of labor ƒ Reduce the time of rupture of membranes: ƒ Delay artificial rupture of membranes ƒ Shorten labor ƒ Reduce the number of vaginal exams: ƒ Partograph helps to schedule VE, limit “duty check”

12 Prevention Strategies at the Time of Childbirth (cont.)

ƒ Infection prevention practices for every delivery: ƒ Handwashing ƒ Minimum manipulation ƒ High-level disinfected or sterile gloves for examination ƒ Avoid unnecessary procedures (e.g., episiotomy) ƒ Nothing unclean inside vagina (e.g., traditional practices of inserting twigs, leaves, etc.)

13 Prevention Strategies in Pregnancy and Labor

ƒ Other possible strategies: ƒ Vitamin A supplementation ƒ Prophylactic antibiotics (for C-sections)

14 Vitamin A and Postpartum Infections and Mortality

ƒ Low dose Vitamin A given during 2nd and 3rd trimester substantially reduces risk of postpartum infections in populations of Vitamin A deficient women (Dibley, Indonesia 1999) ƒ Overall, the current evidence is not conclusive enough to warrant Vitamin A supplementation in pregnancy (Kolsteren 2001) ƒ In populations with Vitamin A deficiency, programs to increase Vitamin A or Beta carotene must be initiated (Villar 2003)

15 Providing Prophylactic Antibiotics for Cesarean Section: Cochrane Review

ƒ Objective: To determine which antibiotic regimen is most effective in reducing infectious morbidity in women undergoing cesarean section ƒ Methods: 51 randomized controlled trials ƒ Outcomes: Fever, wound infection, urinary tract infection, other serious infections, adverse reactions, cost, newborn outcomes

Source: Hopkins and Smaill 2000.

16 Providing Prophylactic Antibiotics for Cesarean Section: Cochrane Review (cont.)

Results: ƒ Ampicillin and 1st generation cephalosporin have similar efficacy in reducing postoperative endometritis: ƒ No need for more broad spectrum agents ƒ Single dose is same as multiple doses ƒ Need randomized controlled trial to test optimal timing (pre- operative vs. at cord clamp)

Hopkins and Smaill 2000. 17 Managing Metritis: Cochrane Review

ƒ Objective: To assess the effects of different regimens and their complications in the treatment of endometritis ƒ Methods: 41 randomized controlled trials ƒ Outcomes: duration of fever, treatment failure, other complication (infectious), drug reaction, costs

Source: French and Smaill 2000.

18 Managing Metritis: Cochrane Review (cont.) Results: ƒ Combination antibiotics are necessary for metritis ƒ Should include a penicillin (ampicillin), an aminoglycoside (gentamicin) and clindamycin/ metronidazole ƒ Single daily dosing of gentamicin is effective ƒ Continued oral antibiotics after clinical improvement is not necessary in cases of uncomplicated endometritis

Source: French and Smaill 2000.

19 Case Studies

ƒ Divide participants into groups of 4 or 5 ƒ Give one-third of groups Case Study 1: Fever, one-third of groups Case Study 2: Fever, and the remaining groups Case Study 3: Fever ƒ Groups will read their case study and answer the questions ƒ Finally, the group will be reassembled to discuss Case Studies

20 Antibiotics for Metritis

ƒ IV antibiotics: ƒ Ampicillin every 6 hours ƒ Gentamicin every 24 hours ƒ Metronidazole every 8 hours ƒ Continue until fever-free for 48 hours ƒ No oral antibiotics after treatment: ƒ Not proven to add any benefit ƒ Only add to expense

21 Postpartum Infections: Summary

ƒ Postpartum infection/sepsis remains an important cause of maternal morbidity and mortality ƒ Three biggest risk factors are: ƒ Prolonged labor, prolonged ROM and multiple exams (Ahhh, the partograph!) ƒ Most common diagnosis of postpartum fever is: ƒ Metritis ƒ Antibiotics: Less is more!

22 References

French LM and Smaill FM. 2004. Antibiotic regimens for endometritis after delivery. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001067. DOI: 10.1002/14651858.CD001067.pub2. Hopkins L and Smaill F. 1999. Antibiotic prophylaxis regimens and drugs for cesarean section. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001136. DOI: 10.1002/14651858.CD001136. Smith J. 2006. “Postpartum Infections: How Can We Prevent Them? How Do We Manage Them?” Presentation at MotherNewBorNet Meeting, India. (July). Taha TE et al. 1997. Effect of cleansing the birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi: Clinical trial. British Medical Journal Jul 26;315(7102): 216–219. World Health Organization (WHO). 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva.

23 Best Practices in Care of the Newborn with Problems

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

By the end of the session, the learner will be able to: ƒ Discuss key elements in recognizing the newborn with problems ƒ Discuss the recognition and management of the newborn needing resuscitation ƒ Discuss the recognition and management of the low birth weight newborn ƒ Describe the key elements of Kangaroo Care ƒ Discuss the recognition and management of sepsis in the newborn

2 Management of Newborn Problems

ƒ Education of families to recognize danger signs ƒ Working with families to develop/revise complication readiness plan ƒ Early recognition and appropriate management: ƒ Preparation at every birth ƒ Immediate assessment and care ƒ Resuscitation if needed ƒ Special care for LBW, premature and sick newborns

3 Minimum Preparation for EVERY Birth

These should be available and in working order: ƒ Two blankets or towels plus small cloth to position head ƒ Heat source ƒ Mucus extractor ƒ Self-inflating bag of newborn size ƒ 2 masks (for normal and small newborns) ƒ 1 clock (or watch) ƒ At least one person skilled in newborn resuscitation present at birth

4 Signs of Good Health at Birth

Objective measures: Subjective measures: ƒ Breathing** ƒ Vigorous cry ƒ Heart rate above 100 ƒ Pink skin beats/minute ƒ Good muscular tone ƒ Good reactions to stimulus **Assessing breathing FIRST; Taking time to assess all of the above delays resuscitation if needed

5 Case Study

ƒ Divide participants into groups of 3 or 4 ƒ Each group should read the Case Study: Newborn with Problems and answer the questions ƒ Reassemble the group to discuss the answers

6 Immediate Care of the Newborn

ƒ Assess breathing ƒ Keep head in a neutral position ƒ IMMEDIATELY assess respirations and need for resuscitation

7 Birth Asphyxia

ƒ Definition: Failure to initiate and sustain breathing at birth ƒ Magnitude: ƒ 3% of 120 million newborns each year in developing countries develop birth asphyxia and require resuscitation ƒ An estimated 900,000 of these newborns die as a result of asphyxia

8 Factors Associated with Asphyxia

ƒ Fetal distress: ƒ Meconium ƒ Abnormal presentation ƒ Prolonged or obstructed labor: ƒ Prolonged rupture of membranes ƒ Complicated, traumatic or instrumental delivery ƒ Severe maternal infections ƒ Maternal sedation, analgesia or anesthesia ƒ Antenatal or intrapartal hemorrhage ƒ Preterm or post-term birth ƒ Congenital anomalies

WHO 1998.

9 Who Will Need Resuscitation?

ƒ About 3–10% of all newborns ƒ Sometimes the need for resuscitation can be predicted, but often it cannot, so... PREPARE FOR RESUSCITATION AT EVERY BIRTH

10 Equipment

11 What about….?

Oxygen ƒ Room air is sufficient in most cases Cardiac Massage ƒ Dangerous when done incorrectly ƒ Slow heart rates in NB almost always respond to breathing assistance only Drugs ƒ Very rarely needed if prompt and sufficient ventilation provided

12 Steps in Resuscitation

ƒ Anticipate need for resuscitation at every birth; be prepared with equipment in good condition ƒ Prevent heat loss (dry newborn and remove wet clothes) ƒ Assess breathing ƒ Resuscitate: ƒ Open airway: − Position newborn − Clear airway ƒ Ventilate ƒ Evaluate Source: WHO 1998.

13 Assess Breathing

Newborn crying?

Yes No

Provide • Chest is rising • Not breathing/ routine care symmetrically gasping • Frequency >30 • Breathing < 30 breaths/min. breaths/min.

Provide Immediately start routine care resuscitation

14 Open Airway

ƒ Position newborn on its back ƒ Place head in slightly extend position ƒ Suction mouth then nostrils: ƒ 5 cm into the mouth ƒ 3 cm into each nostril Do not suction deep into the throat as this may cause the heart to slow or breathing to stop

Source: WHO 2000.

15 Ventilate

ƒ Select appropriate mask size to cover chin, mouth and nose with a good seal ƒ Squeeze bag with two fingers or whole hand; look for chest to rise ƒ If chest not rising: ƒ Reposition head and mask ƒ Increase ventilation ƒ Repeat suctioning

Source: WHO 2000.

16 Evaluate

After ventilating for about 1 minute, stop and look for spontaneous breathing

If no breathing, breathing If newborn starts is slow (< 30 breaths/ crying/breathing min.) or is weak with spontaneously severe indrawing • Stop ventilating • Do not leave newborn Continue ventilating • Observe breathing until spontaneous • Put newborn skin-to-skin cry/breathing begins with mother and cover them both

17 Harmful and Ineffective Resuscitation Practices

Practices to be avoided include: ƒ Routine aspiration of the newborn’s mouth and nose as soon as the head is born ƒ Routine aspiration of the newborn’s stomach at birth ƒ Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation ƒ Postural drainage and slapping the back: dangerous

Source: WHO 1998. 18 Harmful and Ineffective Resuscitation Practices (cont.)

ƒ Squeezing the chest to remove secretions from the airway ƒ Routine giving of sodium bicarbonate to newborns who are not breathing ƒ Intubation by an unskilled person ƒ Some traditional practices: ƒ Putting alcohol in newborn’s nose ƒ Sprinkling or soaking newborn with cold water ƒ Stimulating anus ƒ Slapping the newborn Source: WHO 1998.

19 Infection Prevention for Resuscitation

ƒ Handwashing ƒ Use of gloves ƒ Careful suctioning if using a mucus extractor operated by mouth ƒ Careful cleaning and disinfection of equipment and supplies: ƒ Do not reuse bulb—difficult to clean, poses risk of cross- infection ƒ Correct disposal of secretions

20 Documentation

Details of the resuscitation to be recorded include: ƒ Identification of newborn ƒ Condition at birth ƒ Procedures necessary to initiate breathing ƒ Time from birth to initiation of spontaneous breathing ƒ Clinical observations during and after resuscitation ƒ Outcome of resuscitation ƒ In case of failed resuscitation, possible reasons for failure ƒ Names of health care providers involved

21 Post-Resuscitation Tasks: Successful Resuscitation

ƒ Do not separate mother and newborn ƒ Leave newborn skin-to-skin with mother ƒ Measure temperature, count breaths, observe for in-drawing and grunting every 15 minutes for 2 hours ƒ Encourage breastfeeding within 1 hour after birth

22 Post-Resuscitation Tasks: Unsuccessful Resuscitation

ƒ Inform patients fully ƒ Provide counseling, as needed ƒ If culturally appropriate, allow parents private time with dead newborn ƒ Burial should be arranged according to regulations and parents’ wishes

23 Summary of Resuscitation: Principles of Success

ƒ Readily available personnel ƒ Skilled providers ƒ Coordinated team ƒ Resuscitation tailored to newborn response ƒ Available and functioning equipment ƒ Avoidance of harmful and ineffective practices ƒ Follow rules for infection prevention

24 Immediate Care of the Newborn: Warmth

ƒ Lay newborn on mother’s abdomen or other warm surface ƒ Immediately dry newborn with clean (warm) cloth or towel ƒ Remove wet towel and wrap/cover newborn, except for face and upper chest, with a second towel/cloth

25 Immediate Care of the Newborn: Warmth (cont.)

ƒ Delay bath for at least 24 hours. ƒ Blood and amniotic fluid on newborn are not a risk to newborn, but are a risk to caregiver. Wear gloves and an apron when caring for the newborn. ƒ In areas with high HIV prevalence, consider bathing earlier to reduce risk of maternal- fetal transmission, and to reduce risk to caregiver and to other newborns.

26 The Low Birth Weight Newborn

ƒ Birth weight = Gestation duration + intrauterine growth ƒ Less than 2500g: ƒ Most low birth weight newborns in developing countries are term or near term (small for gestation age) ƒ Increased risk of hypothermia, hypoglycemia and poor growth

27 The Preterm Newborn

ƒ Born before 37 weeks ƒ Associated problems with prematurity: ƒ Feeding ƒ Respiratory ƒ Jaundice ƒ Intracranial bleed ƒ Hypoglycemia ƒ Temperature instability

28 Principles of Management for Low Birth Weight and Preterm Newborns

For stable LBW and preterm newborns: ƒ Warmth ƒ Feeding ƒ Detection and management of complications

29 Feeding

Early and exclusive breastfeeding: ƒ Breast milk = best nourishment ƒ Already warm temperature (if given directly from breast) ƒ Facilitated by kangaroo care

30 Warmth

As for all newborns: ƒ Lay newborn on mother’s abdomen or other warm surface ƒ Dry newborn with clean (warm) cloth or towel ƒ Remove wet towel and wrap/cover (including the head) with a second dry towel ƒ Bathe after temperature is stable

31 Warmth: Problem with Incubators

ƒ Potential source of infection ƒ Often temperature controls malfunction ƒ Often share incubator for more than one newborn ƒ Often not the best method for keeping baby warm ƒ Need alternative method: skin-to-skin care

32 Definition of Kangaroo or Skin-to-Skin Care

ƒ Early, prolonged and continuous skin-to- skin contact between a mother and her low birth weight newborn ƒ This could begin in the facility or after early discharge and continue at home

33 Eligibility for Continuous Kangaroo Mother Care

ƒ Willingness of mother to do KMC ƒ Baby should be in stable condition: ƒ No major illness present such as sepsis, pneumonia, meningitis, respiratory distress, convulsions ƒ (Intermittent KMC under observation can be used for sick baby until baby is fully stable.)

34 How to Use Kangaroo Care

ƒ Newborn’s position: ƒ Held upright (or diagonally) and prone against skin of mother, between her breasts ƒ Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways ƒ Newborn’s clothing: ƒ Usually naked except for nappy and cap ƒ May be dressed in light clothing ƒ Mother covers newborn with her own clothes and added blanket or shawl

35 How to Use Kangaroo Care (cont.)

ƒ Newborn should be: ƒ Breastfed on demand ƒ Supervised closely and temperature monitored regularly ƒ Mother needs lots of support because kangaroo care: ƒ Is very tiring for her ƒ Restricts her freedom ƒ Requires commitment to continue

36 Effectiveness of Kangaroo Care

ƒ Randomized controlled trial ƒ Conducted in three tertiary and teaching hospitals in Ethiopia, Indonesia and Mexico ƒ Study effectiveness, feasibility, acceptability and cost of Kangaroo Mother Care when compared to conventional methods of care

Source: Cattaneo et al 1998.

37 Benefits of Kangaroo Care

ƒ Is efficient way of keeping newborn warm ƒ Helps breathing of newborn to be more regular; reduces frequency of apneic spells ƒ Promotes breastfeeding, growth and extra-uterine adaptation ƒ Increases the mother’s confidence, ability and involvement in the care of her small newborn ƒ Seems to be acceptable in different cultures and environments ƒ Contributes to containment of cost— salaries, running costs (electricity, etc.)

Sources: deLeeuw et al. 1991; Karlsson 1996; Lamb 1983; Ludington-Hoe et al. 1993; Ross 1980.

38 General Principles

ƒ Sepsis can appear any time from birth to end of newborn period ƒ Sepsis is primary diagnosis for babies with multiple findings ƒ Sepsis is more likely if associated with history of rupture of membrane for 18 hours or longer ƒ Signs of sepsis and asphyxia can coexist

39 Types of Newborn Infections

ƒ Localized: ƒ Umbilical cord infection – No pus/discharge with enduration less than 1 cm; no signs of sepsis ƒ Skin infection – Fewer than 10 pustules or covering less than half the body ƒ Eye infection – No pus, more than 7 days old ƒ General sepsis – infections more serious than the above or with signs of sepsis

40 General Sepsis

Signs may be difficult to recognize because they are not specific, but may include: ƒ Difficulty waking the baby ƒ Not able to suck ƒ Rapid or slow breathing or indrawing ƒ Periods of apnea > 20 seconds ƒ Pale, gray or blue color ƒ Rigid or limp limbs ƒ Severe jaundice ƒ Distended abdomen ƒ Signs of severe eye, skin or cord infection

41 Care for Newborn with Sepsis

ƒ Give starting dose of antibiotics: ƒ For a baby 2 kg or more: Ampicillin 50 mg/kg IM and gentamicin 5 mg/kg IM ƒ For a baby < 2 kg: Ampicillin 50 mg/kg IM and gentamicin 4 mg/kg IM ƒ Refer, following referral guidelines* ƒ Encourage breastfeeding, but use cup or spoon or syringe if unable to suck ƒ Keep baby warm * If referral is impossible, continue antibiotics for 10–14 days, giving ampicillin every 12 hrs if < 7 days old and every 8 hrs if > 7days old and giving gentamicin once daily.

42 Summary

ƒ Skilled care at all births when possible ƒ Have equipment available and working ƒ Quick assessment (breathing, etc.) ƒ Begin resuscitation immediately if needed: ƒ Ventilate ƒ Reassess frequently ƒ Skin-to-skin care to keep baby warm—especially LBW babies ƒ Sepsis is the primary diagnosis for the newborn with multiple findings

43 References

Cattaneo et al. 1998. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 8: 976– 985. de Leeuw R et al. 1991. Physiologic effects of kangaroo care in very small preterm infants. Biology of the Neonate 59: 149–155. Ganges F. 2006. “Managing Newborn Problems,” a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. (April). Karlsson H. 1996. Skin-to-skin care: Heat balance. Arch Dis Child 75: F130–132. Lamb ME. 1983. Early mother-neonate contact and mother-child relationship. J Child Psychol Psychiatry 24(3): 487–494.

44 References (cont.)

Ludington-Hoe SM et al. 1994. Kangaroo care: Research results, and practice implications and guidelines. Neonatal Network 13(1): 19–27. Ross GS. 1980. Parental responses to infants in intensive care. The separation issue re-evaluated. Clin Perinatol 7: 47–60. World Health Organization (WHO). 2003. Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives. WHO: Geneva. World Health Organization (WHO). 1998. Basic Newborn Resuscitation: A Practical Guide. WHO: Geneva.

45 Best Practices in Kangaroo Mother Care (KMC)

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives

ƒ Define Kangaroo Mother Care (KMC) ƒ Describe the benefits of KMC ƒ Assist and counsel the mother in the use of KMC

2 Question ??

ƒ What is Kangaroo Mother Care?

3 Kangaroo Mother Care

ƒ Is used for small for dates or premature infants ƒ Has three parts: 1. Skin-to-skin contact between the baby’s front and the mother’s chest – starts at birth and continues day and night 2. Exclusive breastfeeding – begins right after birth and continues “on demand,” at least every 2 hours 3. Support to the mother and baby – whatever the mother or baby needs is done without separating them

4 Question ??

ƒ How does KMC help the baby?

5 KMC Helps the Baby

ƒ Breathing becomes regular and stable ƒ Temperature becomes normal and stable ƒ Immunity is improved ƒ Infections are reduced ƒ Breastfeeds better ƒ Gains weight

6 Question ??

ƒ How does KMC help the mother?

7 KMC Benefits the Mother

ƒ Helps her to bond with her baby ƒ Helps her feel confident in caring for a small, fragile newborn

8 Question ??

ƒ Who wants to demonstrate KMC? The teacher will provide a doll and a long cloth. If no one in the class can demonstrate, the teacher will demonstrate on a student.

9 How to Use KMC (Use the Learning Guide to Guide the Demonstration)

ƒ Put the baby between the mother’s breasts ƒ Wrap the baby and mother together ƒ Tie the ends of the cloth into a secure knot behind the mother ƒ Have the mother put on a loose blouse or dress over the baby

10 Advice to the Mother/Family

ƒ To sleep, the mother should keep her body raised about 30 degrees so the baby is in a heads-up position ƒ Use KMC continuously ƒ Breastfeed on demand, at least every 2 hrs ƒ Another family member can replace the mother for short periods of time ƒ Continue KMC until the baby weighs at least 2,500 grams

11 Midwifery Education: Opportunities and Challenges

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Objectives

ƒ Discuss goals in educating midwives ƒ Define core competencies and their role in curriculum development and design ƒ List the challenges in educating midwives, and some possible ways to address these challenges

2 What are some roles of midwives?

3 Roles of Midwives

Education should prepare midwives to function as: ƒ Caregivers ƒ Decision-makers ƒ Communicators ƒ Community leaders ƒ Managers

4 Professional Development Continuum

ƒ Begins with undergraduate education ƒ Continues throughout professional practice ƒ Includes in-service training and/or continuing education ƒ Providers should be life-long learners

5 What is a core competency and why is it important in midwifery education?

6 Core Competencies

ƒ Aspects of a subject or discipline that are common to all students, essential to practice and essential to master in order to graduate from an academic program and enter into practice. ƒ Each core competency for an academic program will encompass cognitive (knowledge), psychomotor (skills) and affective (values and behaviors) domains that are observable and can be appraised.

7 Defining Core Competencies

ƒ What is the job description for the position the student may hold after graduation? ƒ What knowledge, skills and attitudes are experienced health professionals in that cadre applying in the workplace? ƒ What are the licensing requirements in the related field? ƒ What are the global standards for core competencies?

8 Effective Approaches

ƒ Is teaching and learning a science or an art? ƒ Probably a little of both. ƒ Effective teaching is a learned ability. ƒ There are concepts and principles based on research that can help make teaching and learning more effective. ƒ What are some of the approaches that you have used and found to be effective?

9 Teaching and Learning Are More Effective When . . . #1

ƒ Students are ready and want to learn. ƒ Students are aware of what they need to learn (i.e., clear learning objectives or outcomes). ƒ New KSAs build on what students already know or have experienced. ƒ Students are active and participate in their learning.

10 Teaching and Learning Are More Effective When . . . #2

ƒ Students are encouraged to apply critical thinking and alternative approaches supported by sound reasons. ƒ New KSAs are realistic, relevant and can be put to immediate use. ƒ New knowledge, skills and attitudes are demonstrated to students, applied by students and integrated into the students’ world.

11 Teaching and Learning Are More Effective When . . . #3

ƒ Numerous opportunities are given for students to practice and to receive feedback on their performance. ƒ Feedback to students on their performance is immediate, constructive and nonjudgmental. ƒ Teaching is interesting, pleasant and exciting.

12 Teaching and Learning Are More Effective When . . . #4

ƒ A variety of teaching methods and techniques is used. ƒ Teaching moves step- by-step from simple to complex, and is organized, logical and practical.

13 Teaching and Learning Are More Effective When . . . #5

ƒ Ideas and concepts are presented clearly, alternative explanations are presented and teachers check frequently for students’ understanding. ƒ The learning environment is realistic, relevant and one of trust, mutual respect, relative calm, helpfulness, freedom of expression and acceptance of different opinions and approaches.

14 The Approaches

1. Adult learning 2. Participatory learning 3. Deep learning 4. Experiential learning 5. Problem-based learning 6. Mastery learning 7. Life-long learning

15 What Are Some of the Challenges You Face in Teaching?

ƒ Divide into groups of three or four ƒ On a flip chart, write the three top challenges you face in teaching ƒ Beside each challenge write one solution/ approach to overcome ƒ After 15 minutes, report back to the large group

16 Challenges #1

ƒ Information overload (adding new content to the curriculum) ƒ Large numbers of students and insufficient numbers of teaching staff ƒ Limited opportunities to practice and master skills

17 Challenges #2

ƒ Poor monitoring of students’ progress, leading to limited opportunities for providing feedback to students ƒ Facilities used for clinical practice that are not always representative of the facilities, such as outpatient clinics, where graduates will work

18 Challenges #3

ƒ The need to develop competencies that are difficult to teach, such as decision-making, problem solving, ethics and values ƒ The difference between the ideal world, where all resources are available, and the real world, where resources and technology are scarce

19 Challenges #4

ƒ Poor quality materials and equipment, and limited access to computers and up-to-date reference materials ƒ Little coordination between different teaching units and different levels of study, and between theoretical and practical portions of academic programs

20 Challenges #5

ƒ Practical experiences that are separated from, and do not always reflect, the associated theoretical experiences ƒ High turnover of teaching staff

21 Challenges #6

ƒ Teachers who have no formal training in educational theories or methodologies ƒ Lack of incentives for teachers to improve their own performance

22 Summary

ƒ Effective undergraduate education should offer a balance of theoretical and practical experiences. ƒ Students should be aware of the core competencies they will develop within courses in the curriculum. ƒ Teachers should participate in a faculty development program to develop teaching competencies.

23 References

Schaefer L et al. 2000. Advanced Training Skills for Reproductive Health Professionals. Jhpiego: Baltimore, MD.

Sullivan R et al. 1998. Clinical Training Skills for Reproductive Health Professionals, second edition. Jhpiego: Baltimore, MD.

World Health Organization (WHO) and Jhpiego. 2005. Effective Teaching: A Guide for Educating Healthcare Providers. WHO: Geneva.

24 Best Practices in Nutritional Care of the Pregnant and Lactating Woman

Adapted from a presentation by Eleonore Fosso Seumo, Ph.D. Academy for Educational Development

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Objectives

ƒ Explain why nutrition is important for pregnant and postpartum women ƒ Describe the indicators of maternal nutrition and their significance ƒ Explain the nutritional requirements for pregnant and postpartum women ƒ Demonstrate how to effectively carry out nutritional counseling for pregnant and postpartum women

2 PART 1

Nutritional Care for Pregnant Women

3 Why is nutrition important for pregnant women?

ƒ Malnutrition in pregnant women affects birth outcomes ƒ Maternal malnutrition may lead to: ƒ Increased risk of fetal, neonatal and infant death ƒ Intrauterine growth restriction, low birth weight and prematurity ƒ Birth defects ƒ Cretinism ƒ Brain damage ƒ Increased risk of infection

4 Why is nutrition important for pregnant women? (cont.)

Special considerations for HIV-positive women: ƒ HIV-positive women tend to gain less weight than HIV- negative women during pregnancy. ƒ Wasting during pregnancy is more common in HIV-infected women than in the general population. ƒ Anemia is often more severe in HIV-infected women than in other women. Anemia in HIV-infected women is an independent predictor of more rapid HIV progression and mortality.

5 Why is nutrition important for pregnant women? (cont.)

Malnutrition during pregnancy may increase the risk of MTCT by: ƒ Resulting in low fetal stores of some nutrients. This may increase the vulnerability of infants to HIV. ƒ Impairing the integrity of the placenta, the genital mucosal barrier and the gastrointestinal tract. Transmission of HIV from mother to infant may be facilitated. ƒ Causing low serum retinol (Vitamin A) levels that are associated with an increased risk of MTCT.

6 2. Indicators of Maternal Nutritional Status

Indicators of malnutrition include: ƒ Weight gain ≤ 11.5 kg ƒ Weight gain ≤ 1 kg/month in the last trimester of the pregnancy ƒ Hemoglobin level < 11 g/dL ƒ Vitamin A deficiency ƒ Presence of goiter ƒ Presence of clinical signs of micronutrient deficiencies

7 Indicators of Nutritional Status

ƒ Micronutrient deficiencies ƒ Iron deficiency occurs when an insufficient amount of iron is taken in or absorbed to meet the body’s requirements. Anemia is the major clinical manifestation of iron deficiency: ƒ The pregnant woman is moderately anemic if Hb < 7–11 g/dL ƒ The pregnant woman is severely anemic if Hb < 7 g/dL

8 Micronutrient Deficiencies

ƒ Night blindness may be a sign of Vitamin A deficiency in the pregnant women ƒ Causes of vitamin A deficiency include: ƒ Inadequate intake ƒ Recurrent infections ƒ Frequent reproductive cycling and short intervals between pregnancies

9 Micronutrient Deficiencies (cont.)

ƒ Iodine deficiency: The most common sign is goiter (enlargement of the thyroid). ƒ The cause of iodine deficiency is the consumption of water and foods grown on iodine-deficient soil. ƒ Iodine deficiency during pregnancy negatively affects the development of the fetus and results in the birth of cretins. The mental retardation resulting from iodine deficiency during pregnancy is irreversible.

10 Indicators of Nutritional Status: HIV-Positive Women

ƒ An HIV-positive woman’s nutritional status before and during pregnancy influences both her health and survival and that of her newborn child. HIV infection increases energy requirements because of elevated resting energy expenditure. ƒ The indicators of malnutrition in HIV- infected pregnant women are the same as in the non-infected pregnant women.

11 3. Nutritional Requirements of Pregnant Women

ƒ The physiological changes that occur during pregnancy require extra nutrients for adequate gestational weight gain in order to support the growth and development of the fetus. ƒ Energy requirements: ƒ An additional 300 kcal per day ƒ Three meals and one snack

12 Nutritional Recommendations for Pregnant Women

ƒ Weight gain: 12–16 kg ƒ Daily additional energy intake: One extra meal each day ƒ Diversified diet: fruits, vegetables, cereals, grains, meat, and fish ƒ Iron and folic acid supplementation: 60 mg of iron and 400 mcg of folic acid every day ƒ Daily consumption of iodized salt ƒ Prevention and treatment of malaria ƒ Provide presumptive hookworm treatment

13 Nutritional Care for HIV-Positive Women

Goals: ƒ Maintaining or increasing weight – Encourage diversified diet ƒ Preventing food-borne illnesses – Ensure that food and water are not contaminated and that storage and handling are safe ƒ Referring for appropriate HIV care and treatment ƒ Promptly treating opportunistic infections and managing the symptoms that affect food intake

14 Nutritional Requirements of HIV-Positive Women

Special considerations for HIV+ women: ƒ Increased energy requirements: ƒ For asymptomatic: − Increase energy requirements by 10% Î At least 3 meals and 2 snacks every day ƒ For symptomatic: − Increase energy intake by about 20% to 30% Î At least 4 meals and 2 snacks every day

15 Nutritional Care for HIV-Positive Women (cont.)

ƒ Food safety: ƒ Drinking water ƒ Handwashing ƒ Cooking and storing food ƒ Management of AIDS-related symptoms – Management of food/nutrition and drug interactions: ƒ Maintain food intake ƒ Eat and drink more to replace nutrients lost ƒ Psycho-social support

16 4. Key Actions for Health Workers

1. Assess the nutritional status of all pregnant women 2. Treat – Educate and provide nutrition counseling 3. Carry out follow-up counseling sessions

17 Nutritional Assessment

Components: ƒ Physical assessment: Steady weight gain during pregnancy ƒ Dietary assessment: Foods regularly consumed and frequency of meals, foods available and affordable, food intolerance and aversions to related symptoms, hygiene and food preparation and handling practices, vitamin and mineral supplements, and alternative practices ƒ Medication profile: Medication and supplementation she is taking ƒ Psychosocial

18 2. Education – Counseling

The health worker should always: ƒ Congratulate the pregnant woman for the positive actions/practices that she is already implementing. ƒ Propose options that are acceptable, affordable, and feasible for the woman. ƒ Encourage the pregnant woman to try new options that could help improve her nutritional status. The health worker should highlight the benefits the pregnant woman should expect when she implements the recommended actions.

19 Education – Counseling (cont.)

Counsel on (this applies to all women): ƒ Increasing food intake and frequency of meals ƒ Reducing workload ƒ Taking iron and folic acid tablets, and taking the full dose ƒ Promoting consumption of foods that enhance iron absorption ƒ Managing side effects that are diet-related ƒ Diversifying diet ƒ Providing presumptive hookworm treatment, starting the second trimester ƒ Preventing and treating malaria

20 Education – Counseling (cont.)

For HIV-positive women: ƒ If symptomatic and wasting: ƒ Screen for causes and treat as needed ƒ Counsel on increased food consumption ƒ Refer for ARV treatment and family food assistance as needed ƒ If symptomatic and not wasting, counsel on: ƒ Dietary management of complications such as diarrhea, vomiting, anorexia and thrush ƒ Dietary management of food and drug interactions ƒ If asymptomatic, counsel on: ƒ Increasing food intake ƒ Hygiene and food safety ƒ Providing psycho-social support and referral to community support groups

21 Education – Counseling (cont.)

ƒ Nutritional care for malnourished pregnant women ƒ If Anemic: treat anemia. ƒ Messages for the pregnant woman: ƒ Take 120 mg iron + 400 mcg folic acid every day for 3 months. Drink orange, pineapple or citrus juice while taking iron and folic acid. Restrict consumption of tea, coffee and cocoa.

22 Education – Counseling (cont.)

ƒ Nutritional messages for malnourished pregnant women: ƒ Eat more than three meals and one extra snack per day ƒ Rest more

23 3. Follow-Up Counseling Session

ƒ Monitor the pregnant woman’s weight gain and counsel accordingly ƒ Monitor adherence and compliance to iron and folic acid intake ƒ Research and treat micronutrient deficiencies ƒ Follow up on the management of symptoms, food/nutrition and drug interactions affecting food intake and nutrient absorption for the HIV-positive women

24 PART 2

Nutritional Care for Lactating Women

25 Breastfeeding

ƒ Exclusive breastfeeding should be encouraged among all women regardless of HIV status ƒ For HIV-free survival of infants, all women for whom replacement feeding is not acceptable, feasible, affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed for 6 months ƒ A woman should be supported in her infant feeding decision; the choice is hers

26 1. Why is nutrition important for lactating women?

1. Lactation places high demands on maternal stores of energy, protein and other nutrients 2. Maternal micronutrient malnutrition can negatively affect breast milk composition: ƒ Inadequate maternal intake of water-soluble vitamins can affect breast milk concentration

27 Why is nutrition important for lactating women? (cont.)

Special consideration for HIV-positive women: ƒ Little is known about the effect of breastfeeding on the health and nutrition of HIV-positive women ƒ Multivitamin supplementation may delay the progression of HIV disease

28 2. Indicators of Maternal Nutritional Status

Indicators of good nutritional status: ƒ Hemoglobin level ≥ 12 g/dL ƒ Absence of clinical signs of micronutrient deficiencies

29 3. Nutritional Requirements of Lactating Women

ƒ Requirements for energy and water-soluble vitamin are higher during lactation than during pregnancy and are proportional to the intensity and duration of breastfeeding ƒ Energy requirements: ƒ An additional 500 kcal per day ƒ 4 meals per day

30 3. Nutritional Requirements of Lactating Women (cont.)

ƒ Protein requirements: ƒ An extra serving of protein food such as meat, fish, poultry, beans or lentils each day ƒ Micronutrient requirements: ƒ WHO recommends giving breastfeeding women a high dose of vitamin A (200,000 IU) within 6 weeks after delivery to increase breast milk content of vitamin A

31 3. Nutritional Requirements of Lactating Women (cont.)

ƒ Special considerations for HIV-infected lactating women are the same as for HIV- positive pregnant women ƒ Energy requirements: ƒ If asymptomatic: Increase energy intake by 10% Î 4 meals and one snack ƒ If symptomatic: Increase energy intake by about 20% to 30% Î 4 meals and 2 or 3 snacks ƒ Consumption of a diversified diet to meet the micronutrients needs

32 Nutritional Care for HIV-Positive Lactating Women

ƒ Food safety, dietary management of AIDS- related symptoms, dietary management of food and nutrition and drug interactions, and psycho-social support are similar to those of HIV-infected pregnant women

33 4. Key Actions for Health Workers

ƒ Key actions that health workers take to enhance the nutritional status of breastfeeding women are similar to those for pregnant women ƒ The health worker will adapt the content of the assessment and counseling to the situation of the breastfeeding woman

34 References

Allen LH. 1994. Maternal micronutrient malnutrition: Effects on breast milk and infant nutrition, and priorities for intervention. SCN News (11): 21–24. Coutsoudis A et al. 2001. Are HIV-infected women who breastfeed at increased risk of mortality? AIDS 15: 653–655. Institute of Medicine (U.S.). 2002. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein, and Amino Acids (Macronutrients). National Academy Press: Washington, D.C. Institute of Medicine (U.S.). 2000. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. National Academies Press: Washington, D.C. Institute of Medicine (U.S.). 1998. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academies Press: Washington, D.C.

35 References (cont.)

Institute of Medicine (U.S.). 1991. Nutrition during Lactation. National Academy Press: Washington, D.C. Ladner J et al. 1998. Pregnancy, body weight and human immunodeficiency virus infection in African women: A prospective cohort study in Kigali (Rwanda), 1992-1994. Pregnancy and HIV Study Group (EGE). International Journal of Epidemiology 27:1072–1077. Nduati R et al. 2001. Effect of breastfeeding on mortality among HIV-1 infected women: A randomised trial. Lancet 357: 1651–1655. Newell M. 2001. Does breastfeeding really affect mortality among HIV-1 infected women? Lancet 357:1634–1635. Newell ML, Leroy V and Dabis F. 2005. The Breastfeeding and HIV International Transmission Study Group. Mortality among HIV-1- infected women according to children’s feeding: An individual patient data meta-analysis. AIDS. NRC, Recommended Dietary Allowances, 9th ed. 1980. National Academy of Sciences, National Research Council: Washington, D.C.

36 References (cont.)

Papathakis P and Rollins N. 2005. HIV and Nutrition: Pregnant and Lactating Women. Consultation on Nutrition and HIV/AIDS in Africa: Evidence, Lessons and Recommendations for Action. World Health Organization: Durban, South Africa, 10–13 April. Van Der Sande MA et al. 2004. Body mass index at time of HIV diagnosis: A strong and independent predictor of survival. Journal of Acquired Immune Deficiency Syndrome 37:1288–1294. World Health Organization (WHO). 2001. Effect of Breastfeeding on Mortality among HIV-Infected Women. WHO: Geneva. World Health Organization (WHO). 1995. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series 854. WHO: Geneva. World Health Organization (WHO)/FAO. 1973. Energy and Protein Requirements. WHO Technical Report Series, No. 522. WHO: Geneva.

37 Performance and Quality Improvement

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Objectives

By the end of the session, the learner will be able to: ƒ Define the Standards-Based Management and Recognition (SBM-R) model ƒ Describe the four steps of the SBM-R model ƒ Practice the use of the tool: standards and identification of gaps ƒ Practice identification of interventions and action plan

2 What is Standards-Based Management and Recognition (SBM-R)?

ƒ Practical management approach for improving performance and quality of health services ƒ Based on use of operational, observable performance standards for on-site assessment ƒ Must be tied to reward or incentive program when standards are accomplished ƒ The whole team needs to be involved (not only clinicians or administrators) ƒ Consists of four basic steps

3 The Four Steps of SBM-R

Set Implement Standards Standards 1 2

4 3 Recognize Measure Achievements Progress

4 STEP 1: Setting Standards Desired Performance

Set Standards 1

5 Question ??

How would you define/set clinical standards in a certain area?

6 How to Define Desired Performance: Standards

Client Preferences

Provider Inputs

Service Delivery Guidelines

National Policies/Priorities

Tool of Performance Standards

7 Performance Standards

The standards tell providers not only WHAT TO DO but also HOW TO DO IT

8 Performance Assessment Tool (sample from Tanzania tool for FANC)

Session 1: Focused Antenatal Care (FANC)

Standard Verification Criteria Y, N, NA Comments

1. The provider Observe in the reception conducts a routine rapid area or waiting room if assessment of pregnant the person that receives women the pregnant woman: Asks if she has or has had: ƒ Vaginal bleeding ______ƒ Headache or visual changes ______ƒ Breathing difficulty ______ƒ Severe abdominal pain ______ƒ Fever ______ƒ Immediately notifies the health provider if any of these conditions is present ______

9 Summary Form of Assessment Tool (sample from the Tanzania Tool for FANC)

SECTIONS STANDARDS

Focused Antenatal Care 19 Information, Education and Communication 4 (IEC) Infection Prevention 5 Management Systems 9

Human, Pharmacy and Laboratory resources 9

TOTAL 46

10 Filling Out the Tool

ƒ Methods used to collect the information: structured direct observation, review of service and administrative records and documents, and interviews ƒ Immediately register the information collected ƒ Register “Yes”, “No” or “Not Applicable” in the corresponding column ƒ Write down all pertinent comments, in a clear and concise fashion, highlighting issues and possible causes

11 Filling Out the Tool

ƒ Register “Yes” if the item exists or is performed as it is described ƒ Register “No” if the item does not exist or is performed incorrectly or incompletely ƒ Register “NA” when the item requires a condition that does not exist ƒ Register “N/O” when the standard was not observed or not performed

12 Step 2: Implementing Standards Measurement of Actual Performance

Set Implement Standards Standards 1 2

13 Implementation Standards Cycle

Desired performance

Cause Gap analysis

Actual performance

Intervention identification & implementation

Model Adapted from the International Society for Performance Improvement 14 Baseline Assessment

ƒ Determines actual level of performance using the performance assessment tool ƒ Establishes actual performance in percentage terms by area and total ƒ Helps to identify performance gaps ƒ Once gaps are identified, then identify their causes

15 Initial Identification of Gaps

Identify gaps by marking “N” for: ƒ Practices not performed at all ƒ Practices performed incorrectly or incompletely In the comments column: ƒ If possible, summarize potential causes why not done correctly ƒ If there is one or more “N,” the standard is not accomplished

16 Implementation Cycle

Desired performance

Cause Gap analysis

Actual performance

Intervention identification & implementation Model Adapted from the International Society for Performance Improvement

17 Question ??

ƒ What might be some causes of “gaps”? ƒ What are some factors that might affect performance?

18 Why Gaps? Factors of Performance

Know how to Knowledge, do (Capability) skills, information Be enabled to do Resources, (Opportunity) tools, capacity

Want to do Inner drive, (Motivation) incentives

19 Causes and Intervention Design

MOTIVATION INCENTIVES

Strengthening of Management Resources, Capacity Systems, Provision of Resources

Knowledge, Training, Communication Skills, Information

Appropriate Types of Causes Interventions

20 Interventions Can Be. . .

ƒ …Rapid interventions ƒ …Interventions based on local resources ƒ …Interventions that require external support

21 Remember that…

ƒ …There are factors that are under our control and there are factors that are outside of our control (resources, technical expertise, policies) ƒ …We can begin the changes by addressing the factors that are under our control and produce rapid results ƒ …We need to identify the sources of external assistance for the factors that are outside of our control

22 Step Three: Measure Progress

Set Implement Standards Standards 1 2

3 Measure Progress

23 Case Study: A Performance Gap

ƒ The clinical protocols/standards require that AMTSL be used at each birth ƒ You find that AMTSL is never being used ƒ You determine that all service providers know how to perform AMTSL, but no oxytocin nor ergometrine is available in the delivery area ƒ What is the Desired Performance, Actual Performance, Gap, (probable) Cause, Proposed Intervention?

24 Case Study

SBM-R Exercise: ƒ Desired performance: AMTSL every birth ƒ Actual performance: AMTSL not performed ƒ GAP: No AMTSL ƒ Cause: No uterotonic ƒ Intervention: Meet with administrator with request to order oxytocin and keep it stocked in delivery area

25 Steps to Measure Progress

Using the same tool and process: ƒ Measure progress (internal monitoring) after 2 or 3 months of interventions ƒ External evaluation (regional and central MOH) for official recognition when standards have been accomplished

26 Showing Results – by Facility One Hospital in Guatemala

GOAL: 85%

27 Showing Results – by Facilities Seven Hospitals in Malawi

100 90 80 70 60 50 40 30 20 10 0 CDH SJH LCH MCH QECH ZCH LH

2002 2002 2003 Ext 03-04 Ext 04

28 Showing Results – by Section of the Tool 13 Health Centers Brazil

100

80

60

(%) 40

20

0

re ion ling Total tu ruc RH Care t Counse fra-s anagement In M tion Prevent fec In

Baseline 12 Months 15 Months

29 Showing Results in Pictures

Privacy curtains Water and Organized supply cabinet suggestion box in client waiting room

Handwashing supplies

30 Baby's father participates

Privacy

Skin-to-skin Infection Prevention

31 Showing Results - Use of Indicators example from Guatemala

FACILITY TYPE INDICATOR 2001 2003

Health Post EMNC norms and protocols 3% 44% Center Hospitals available onsite Hospitals Perform adequate 0% 100% decontamination of instruments Adequate supplies and equipment for EmONC in labor & 29% 63% delivery rooms Linkage to a community health committee 14% 63%

Source: PQI Instruments 32 Step Four: Recognize and Reward Achievements

Set Implement Standards Standards 1 2

4 3 Recognize Measure Achievements Progress

33 Ways to Provide Recognition

ƒ Feedback ƒ Social recognition ƒ Material recognition

34 Recognizing the Team Honduras

35 Conferred by the Ministry of Health to Mzuzu Central Hospital in recognition of the achievement of standards of excellence in Infection Prevention practices Year 2004

______Secretary for Health

36 Summary

ƒ Four-step process ƒ Not as complicated as it may sound ƒ Puts the power in the hands of local providers and managers ƒ Evidence-based standards ƒ Requires multiple sources of supervision and support

37 PQI Around the World (Jhpiego and ACCESS Programs)

Burkina Faso, Malawi, Mozambique, Ghana, Tanzania Guatemala, Honduras, Jamaica Indonesia, Afghanistan, Pakistan

38 References

Averting Maternal Death and Disability (AMDD) Program. Improving Emergency Care through Criterion-Based Audit and Quality Improvement for Emergency Obstetric Care: Leadership Manual and Toolbook. At: http://www.amdd.hs.columbia.edu. Maximizing Access and Quality (MAQ). 2000. Managing Programs to Maximize Access and Quality: Lessons Learned from the Field. MAQ Papers, Vol. 1, No. 3. At: http://www.maqweb.org/maqdoc/vol3.pdf. Necochea E and Bossemeyer D. 2005. Standards-Based Management and Recognition – A Field Guide: A Practical Approach for Improving the Performance and Quality of Health Services. Jhpiego: Baltimore: MD. World Health Organization (WHO). 2005. Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer. WHO: Geneva.

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