LESSON PLANS
FOR CMNH CLINICAL UPDATE FOR HEALTH WORKERS
JULY 2013
AFAR REGION
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MATERNAL AND NEWBORN HEALTH IN ETHIOPIA
PARTNERSHIP
The Mother and Newborn Health Partnership (MaNHEP) was developed in
2009-2013, to demonstrate a community-oriented model for improving
maternal and newborn health care in rural Ethiopia, and to prepare for
acceptance by the Ministry of Health for it’s use nationwide. This initiative
was funded by Bill and Melinda Gates Foundation. Under the leadership of
the Ministry of Health, the initiative was led by Emory University, in
collaboration with John Snow Research and Training Inc., University
Research Co. LLC and Addis Ababa University. It was implemented in three
districts in Amhara and three districts in Oromia regions. During 2012 - 2016,
MaNHEP is being expanded to the Afar region through a collaboration of the
Afar Regional Health Bureau, Micronutrient Initiative and Emory University.
This expansion is made possible through a grant from Canadian
International Development Agency to Micronutrient Initiative.
recognizes the participants as “adult learners” and is based on adult learning
principles.. Use of this method focuses on asking (rather than telling) and
listening (everyone’s experiences are important).
The main curriculum parts are described below.
•
The Lesson Plans are used by the facilitators. The lesson plans
include objectives and homework assignments. They also include
time, teaching methods, content, and materials needed.
•
The Learning Guide is a checklist that the participant uses to
practice skills during training. It lists the important steps involved in a
specific skill in the correct order. It helps participants learn to do new
skills correctly and to guide each other’s performance during
practice.
•
The Reference Text, Safe and Clean Birth and Newborn Care: A
Reference for Health Extension Workers (SCBNC),2 was adapted
from A Book for Midwives: Care for Pregnancy, Birth and Women’s
Health.3 The SCBNC was field tested in 2008, revised with stronger
focus on Essential Newborn Care. The Ethiopian Ministry of Health
endorsed the SCBNC July 2009. The text is compatible with the
World Health Organization regulations that govern health care.
•
The Take Action Card Booklet has many take action cards and is a
reference for use at home and in the community. On the front side
there is a large drawing of a problem / danger sign and on the back
side there are six drawings of actions which respond to the problem
on the front side of the card. The drawings are to remind us of what
was learned. This booklet is an important tool to help families learn to
help each other and know when to refer to the health facility.
COURSE DESCRIPTION
This Community Maternal and Newborn Health (CMNH) Clinical Update for
Health Workers curriculum1 is developed for the continuing education of
health workers (nurses, midwives, and health extension workers). These
health workers stationed at community health facilities will guide the CMNH
and Mothers Nutrition training meetings which are conducted during the
antenatal care visits. The topics and skills focus on responding to maternal
and newborn care and problems that are identified as important in the
community.
The approach is competency based, which means that each participant is
given the opportunity to practice skills as many times as needed to become
competent in doing them. The training methodology includes presentations,
discussions, group work, video’s, demonstrations, role-plays, practice with
models and learning guides, and supervised clinical practice. The training
1
Topics selected and adapted from Safe and Clean Birth and Newborn Care (SCBNC) – Guide for
Trainers and Participants, FMOH, Ethiopia
2
3
SCBNC. Federal Democratic Republic of Ethiopia Ministry of Health (2009).
Adapted with generous permission of the Hesperian Foundation, Berkeley,California, USA (2004)
•
•
•
4
The CMNH and Mothers Nutrition Manual is describes how to
conduct community meetings. The meetings cover the most
dangerous time for the woman and her baby. The meetings are
presented in the same way each time to help the participants
become familiar with the process and know what to expect. This
approach is particularly important for learners who do not read or do
not read well. The woman and her family team are the focus at the
health post or in the home. The Family Health Card and the Take
Action Card are used with discussions and role plays on topics listed
in the table of contents. Selected topics are used during ANC
counseling.
CMNH Key Messages. A reference for community members on
woman and baby problems and actions to save the lives of women
and babies.
Family Health Card 4 Health workers give the Family Health Card
to all the families so that they can practice each of the actions which
will ensure a healthy life style. It enables parents to recognize
useful health actions, enables pregnant mothers to take care of
themselves and their children’s health and to keep track of
children’s growth.
Family Health Card. Federal Democratic Republic of Ethiopia Ministry of Health – Key Actions to
Improving Family Health (2012).
COURSE OBJECTIVES
By the end of the one-week, the participants will be able to demonstrate
the following:
•
•
•
•
•
•
•
•
•
•
Focused culturally sensitivity care during pregnancy care
Counseling and key messages during pregnancy for nutrition,
anemia, malaria, tetanus, hookworm
Care of a woman during Stage 1 of labor and use of the picture
partograph
Care of a woman in Stage 2 of labor and immediate newborn care
including putting baby to breast within one hour of birth
Care of a woman in Stage 3 of labor using misoprostol
Care of a woman and her baby in Stage 4 of labor: first few hours
after birth.
Prevent and take emergency action for too much bleeding after birth
Newborn resuscitation
Care of a woman and her baby during the postpartum period
Throughout all phases of care:
 Recognize danger signs for woman (pregnancy, labor,
postpartum) and newborn
 Take all immediate emergency measures possible
 Provide timely referrals.
 Use Standard Precautions for infection prevention.
 Keep appropriate and complete records.
ADAPTED COURSE SCHEDULE
The CMNH Clinical Update Schedule for facilitators and participants
(nurses, midwives, others) differ to give the facilitators time to practice
teaching. The adapted course schedule illustrates how selected lesson
plans found in this document could possibly be completed. However, class
sessions should be interrupted whenever clinical opportunities present
(e.g., if a woman comes to the health facility in labor or antenatal clinic). If
skills are required that have not yet been covered in class, the facilitator
should do the skill while the participants observe and follow along with their
learning guides. If the skill has been covered in class, one participant
should do the skill with coaching from the facilitator or team partner (based
on the learning guide), while the other participants observe and follow
along with their learning guides.
TOT FOR FACILITATORS
The TOT for Facilitators is 2 weeks. WEEK 1: Facilitators are participants
from two training site updating both their clinical and training skills. They
represent ANC, L&D, PNC, and newborn care from each site. WEEK 2:
Facilitators are trainers preparing their training sites as they teach
participants with the support of MaNHEP team. The clinical training for the
participants is held in two facilities with 8 participants at each facility. The
clinical update continues at both sites until the target number of health
workers are trained.
Note that on the last day of the course, the participants work on a facility
action plan for their area that includes working with community health
workers to inform the community on key maternal and newborn care
messages, track and keep records of pregnant women in their area, visiting
pregnant women at home to encourage ANC attendance (even if they have
not attended ANC before), and to encourage pregnant women and their
families to come to the facility for birth or if not possible to get to the facility,
call Health Extension Worker for the birth. This plan will be part of the
CMNH and Mothers Nutrition activities.
SITE PREPARATION
To prepare for the clinical update, the facilitators brief all relevant staff in the
maternity, OPD/clinic and ANC/PMTCT/PNC clinics about the upcoming
training. The facilitators and all other staff in the areas in the health facility
where the training is undertaken should be role models for the participants
and make sure that what they say is also what they practice! The facilitators
need to ensure that the site is supported with essential supplies:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Tape measures
Urine testing kits
Delivery kits
Fetoscopes
Heavy duty aprons
Newborn ambu bags and masks size 1 and 0
Goggles
Foot covers
Blood Pressure cuffs and stethoscopes
Gloves
Baby blankets
Pre-printed partographs
IP supplies like bleach
Clinical demonstrations models (cloth pelvis, baby and placenta models,
newborn resuscitation models)
• Training and reference materials
CMNH CLINICAL UPDATE SCHEDULE FOR FACILITATORS (sample)
TIME
8 :00 –
8 :30 AM
8:30 AM
– 10:30
AM
Day 1 – Monday
Welcome
Course Overview
•
•
•
•
•
Introductions
Course Objectives
Schedule
Review course materials
Orient to Clinical Practice5i
Day 2 – Tuesday
Day 3 – Wednesday
Day 4 – Thursday
11:00
AM –
1:00 PM
2:00PM
–
5:00 PM
G 1. Prepare to teach ANC
G 2. Prepare teach consulting
During Pregnancy, Before
Baby is Born
G3. Prepare to teach 1st stage
of Labor
G 4. Prepare to teach 2nd,3rd,
4th stages
5:30 PM
6 PM –
10 PM
5
Day 6 – Saturday
Day 7 - Sunday
Review previous day and case review
ANC: (Care during
pregnancy)
Demonstration
CMNH and Mothers
Nutrition :
• During Pregnancy
(Demonstration)
• Facilitators
Responsibilities
• Training Schedule
• Planning
• Site Preparation
• Equipment
TEA BREAK
Care of Mother and
Baby After Birth (PNC
counselling)
(Demonstration)
10:30 AM – 11:00 AM
• Written PreTest
• Tour of labor, delivery,
antenatal clinic
• Videos: Birth in Squatting
Position & Delivery Self
Attachment, Discussion
Day 5 – Friday
1st Stage Labor:
• Supporting Woman in
Labor Demonstration
• Using Picture Partograph
• Before Baby is Born
(Demonstration)
Infection Prevention
(Demonstration)
1:00 PM – 2:00 PM
2nd
3rd,
,
4th Stage of
Labor
(Demonstration)
G 4. Prepare to teach
infection prevention
G 3. Prepare to teach PNC
counseling
G2. Prepare to teach HBB
G1 Prepare to teach EBC
Continue above
Skills checkout
End-Course Evaluation
•
•
•
•
Welcome participants
Preparation of Site
Organize equipment
Facilitator responsibilities
LUNCH BREAK
Emergency Skills :
Helping Baby Breathe
External Bimanual
Compression(EBC)
DEMONSTRATIONS
Continue above
FEEDBACK
CERTIFICATES
Continue above
CLOSING WEEK 1
5:00 to 5:30 PM: Groups gather to review the day/experiences, How do you think the day went?
Facilitators Meeting
CLINICAL
PRACTICE 5 :30 - ?
HOMEWORK
Read Lesson Plans: ANC,
1st, 2nd, 3rd, 4th Stages
Labor
Group 3, 4
Group 1,2
Group 3,4
Groups 1, 2
Group 3, 4
Group 1, 2
Read Lesson Plans &
TAC during pregnancy
and before baby is born,
too much bleeding,
Helping baby breathe,
Read Lesson Plans:
infection prevention, TAC:
Care of Mother & Baby
(PNC),
Review as needed
Clinical practice: Participants divided into teams of 4. Clinical times for labor: 12:30 – 5:00, 6.00 - 10.00 LABOR CLINICAL: 2 participants/patient: one participant managing the labor, second participant providing support.
• Activities during quiet times: Practice skills on models as needed, present cases: history, picture partograph, plan of care, outcome.
• Participants always have Clinical Update Skill Checklists (adapted Learning Guide 2nd, 3rd, 4th Stage) in Labor Ward and (ANC and Mothers Nutrition) in Antenatal Clinic (2 participants/patient).
CMNH CLINICAL UPDATE SCHEDULE FOR HEALTH WORKERS (SAMPLE)
TIME
Day 1 – Monday
Day 2 – Tuesday
Day 3 – Wednesday
Day 4 – Thursday
8 :00 – 8 :30 AM
9 AM Welcome
8:30 AM
– 10:30
AM
11:00
AM –
12:30
PM
1:30 PM
–
5:00 PM
5:30 PM
6 PM –
10 PM
6
Course Overview
• Introductions
• Course Objectives
• Schedule
Written PreTest
• Review course materials
• Orient to Clinical Practice8
Tour of labor, delivery,
antenatal clinic
CLINICAL………..
Video: Birth in Squatting
Position & Delivery Self
Attachment, Discussion
CLINICAL
PRACTICE 5 :30 - ?
HOMEWORK
Read SCBNC Chapter 3:
ANC, Chapter 6B &C : 1st
Stage Labor
ANC: (Care during
pregnancy)
Discussion
2nd , 3rd, 4th
Stage of Labor Too
Much Bleeding After
the Baby Is Born
(Demonstration)
Day 5 – Friday
• Supporting Woman in
Labor
• Using Picture
Partograph
Group 1,2
Group 3,4
Continue from
above
Group 3,4
Day 7 - Sunday
Review previous day and case review
CMNH and Mothers
Nutrition :
During Pregnancy &
Before Baby is Born
(Demonstration)
Care of Mother and Baby
After Birth (PNC
Counseling)
(Demonstration)
10:30 AM – 11:00 AM
TEA BREAK
Antenatal clinic practical 10:30 – 2:00 PM as appropriate
1st Stage Labor:
Day 6 – Saturday
Group 1,2
As needed
Helping Baby Breathe
(Newborn Resuscitation)
(Demonstration)
Infection Prevention
(Demonstration)
12:30 PM – 1:30 PM
Group 1,2
Group 3,4
Group 3,4 Practice ANC,
1st Stage of Labor
Group 1,2 Practice 2nd,
Group 3,4 Practice ANC All Groups Practice Other
3rd, 4th, Stages Of
Counseling,PPH, HBB
Actions (PNC), Infection
Labor
Prevention, HBB
5:00 to 5:30 PM: Groups gather to review the day/experiences, How do you think the day went?
Facilitators Meeting
Group 3, 4
Group 1,2
Group 3,4
Group 1,2
Group 1, 2 : ANC, 1st
Group 3,4 :2nd,3rd, 4th
Group 1,2 ANC counsel
Read SCBNC Chapter
6D, 6E & Learning
Guide: 2nd, 3rd, 4th
Stages Of Labor
Read SCBNC Chap 3
& TAC HBB, During
Pregnancy, Before
Baby Is Born
Read SCBNC Chapter
6E, 2 Prevent Infection
& TAC Too Much
Bleeding, Other Actions
Discuss Facility Action Plan
Post-Update Skills Checkout 6
Written Post-Test and
End-Course Evaluation7
Continue above
Wrap-Up
CERTIFICATES
CLOSING
•
•
•
•
Welcome participants
Preparation of Site
Organize equipment
Facilitator responsibilities
LUNCH BREAK
(selected facilitators and
MaNHEP team prepare for next
group)
Continue above
Group 3,4 PPH, IP
Write Facility Action Plan to:
Share key messages
Identify pregnant women
Labor notification
Post-Update Skills Evaluation: Immediate newborn and woman care, ANC counseling
Done while waiting for skills checkout
8
Clinical practice: Participants divided into teams of 4. Clinical times for labor: 12:30 – 5:00, 6.00 - 10.00 LABOR CLINICAL: 2 participants/patient: one participant managing the labor, second participant providing support.
• Activities during quiet times: Practice skills on models as needed, present cases: history, picture partograph, plan of care, outcome.
• Participants always have Clinical Update Skill Checklists (adapted Learning Guide 2nd, 3rd, 4th Stage) in Labor Ward and (ANC and Mothers Nutrition) in Antenatal Clinic.
• Trainer has Clinical Experiences record book to write all participant clinical experiences.
7
WHAT A LEARNING GUIDE IS AND HOW TO USE IT
A learning guide is a tool that participants will use while participating in the clinical update training in maternal and newborn care.
1. It clearly states all of the important steps involved in a specific skill in the proper order—to help trainees learn to perform new skills correctly and to
guide each other’s performance during practice.
2. It is also a tool for evaluation and can be used by the facilitator to assess whether participants are competent in performing their newly acquired skills.
3. Later, when participants return to their work sites, they can use the learning guides as job aides to remind them of how to perform their new skills
correctly.
Tips for using learning guides effectively:

Always have the learning guide with you in the clinical area; also
bring it to meetings or demonstrations with your trainer.

Read the learning guide before “doing” a skill (with an actual
patient or for demonstration).

If practicing a skill by yourself, after doing a skill, use the learning
guide for self-evaluation.

Write the date you are practicing the skill at the top of the first
empty column. After you have performed the skill, read each step
of the skill again. Put an “” if you performed the step satisfactorily
(according to the guide), and put an “NI” if you need improvement
or more practice

Write any additional comments at the end of the learning guide.
Such comments can be very important if you do not have all the
equipment needed to do an exam, for example, or if there is
something you want to remember that is not covered in the guide.
You may even write about how you feel about the skill or your
performance of it. The main purpose of these comments is to help
you learn, so write whatever is most help to you.

If helping a team partner with a skill, follow the learning guide while
your partner is doing the skill, rate your partner’s performance after
each step of the skill, and give feedback as soon as possible after
your partner performs the skill.

When doing demonstrations of skills in the classroom, use a pencil
to mark the learning guide so you can erase your markings and
reuse the guide in the clinical area.
WORKING IN TEAMS
On the first day of the clinical update training in maternal
and newborn care, participants are put in teams of two
and asked to work together as partners during the entire
training. The team partners take turns—alternating
between doing skills themselves while their partners
evaluate their performance, and evaluating their
partners’ performance while following along with the
learning guide. In this way, all team members have an
opportunity to learn from both types of experiences,
those in which they are performing the skills and those in
which they are evaluating the skills of their partners.
Partners who are evaluating on a given turn can help by
coaching their partners to remember things or providing
guidance on how to do the steps of a skill correctly. The
responsibilities involved in each team partner role are
summarized below.
Responsibilities When You “DO” a Skill:
1. Read the learning guide before doing the skill.
2. Do the skill.
3. After the skill is done:
 If practicing alone, evaluate your performance and fill in the learning
guide.
 If practicing with your team partner, discuss with her your performance
of the steps covered in the learning guide.
Responsibilities When You “Help” with a Skill:
1. Read the learning guide before helping your team partner.
2. While you partner is doing the skill, watch her and follow along with the
learning guide:
 Evaluate her performance based on the steps covered in the learning
guide.
 Help her if any step is forgotten.
3. After the skill is done, provide your evaluation feedback to your team
partner about how the skill was done.
CLIENT’S RIGHTS DURING CLINICAL TRAINING
The following client’s rights should be shared with participants in preparation for their supervised clinical practice with clients:
•
•
•
The rights of the client to privacy and confidentiality
should be considered at all times during a clinical
training course. Always explain to the client about the
role of each person inside the room (eg., participants
and facilitators who are providing or observing care).
The client’s permission must be obtained before
having a participant observe, assist, or perform any
care. If a client does not permit a participant to
provide care or observe, the facilitator or staff member
should perform the procedure.
•
•
A facilitator or trainer should be present during any
client contact in a training situation.
Facilitators and trainers must be discreet in how
coaching and feedback are given during training when
clients are present. Corrective feedback in a client
situation should be limited to errors that could harm or
cause discomfort to the client.
In order to maintain client confidentiality, case studies
and clinical discussions should take place in a private
area, out of hearing of other staff and clients and be
conducted without reference to the client by name.
DO’S AND DON’TS OF TRAINING
The following do’s and don’ts should ALWAYS be kept in mind by the facilitator or trainer. During any learning session:
•
•
•
•
•
•
•
•
•
•
DO maintain good eye contact
DO prepare in advance
DO involve participants
DO encourage participation
DO use visual aids
DO speak clearly and loud enough
DO encourage questions
DO keep it simple
DO give feedback
DO be patient
•
•
•
•
•
DON’T talk to the flip chart
DON’T block the visual aids
DON’T stand, be at the same level as participants
DON’T ignore comments and feedback
DON’T shout at participants
FACILITATOR PREPARATION
RESPONSIBILITY
1.
Prepare staff in Hospital (ANC, L & D, PP Ward as appropriate)
2.
Give information on class dates, class size, when on ward, focus of clinical time
3.
Ask for assistance/cooperation from staff
4.
Ensure sufficient supplies for participants when on the units
5.
Work with staff to ensure high quality care provided (staff models skills taught in training)
6.
Do inventory of teaching equipment, supplies and documents and replace as needed
7.
Assist as needed with logistics such as meals, snacks, accommodation
8.
Prepare classroom (clean, enough, whiteboard/pens, chalk board / chalk, project as needed)
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
FACILIATOR(S)
CMNH CLINICAL UPDATE FOR HEALTH WORKERS
LESSON PLANS
TABLE OF CONTENTS
Topic
Page
 Antenatal Care (Pregnancy Care and Nutrition)……………………………………………………………….………3
 First Stage of Labor: supporting a woman in labor, nutrition, picture partograph……………………10
 Second Stage of Labor: pushing, positions………………………………………………………………..…………….17
 Third Stage of Labor: active management, misoprostol……………………………………………..…………...24
 Fourth Stage of Labor: immediate care of mother and baby birth to 6 hours, breastfeeding……27
 Too Much Bleeding After the Baby is Born (PPH)……………………………………………………………………..30
 Infection Prevention…………………………………………………………………………………………………….………….36
 Helping Baby Breathe……………………………………………………………………………………………….……………..43
 Care and Nutrition of Mother and Baby After Birth…………………………………………………..….………….51
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 1
BLANK PAGE
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 2
Topic: ANTENATAL CARE
Time: 2 Hours
General Objective:
At the end of the session, participants will be able to demonstrate culturally sensitive focused antenatal care (FANC): registration
and record keeping, take a general history, observe and examine [general, breasts, abdominal, genitals], order laboratory tests as
appropriate, identify and take action for danger signs and complications, key messages [danger signs, registration, CMNH meetings,
birth preparation, labor notification, referral], prevention and counseling for [nutrition, breastfeeding, anemia, malaria, tetanus,
hookworm].
Participant Tools:
Handout: Focused ANC: overview, systems review illustration ii, CMNH key messages, Family Health Card; Learning guides: Focused
ANC, CMNH TAC Prevent Problems During Pregnancy and Before Baby is Born.
Homework:
Read Learning Guide. Safe and Clean Birth and Newborn Care 2009 - Chapter 3, including: 3A: Helping Women Stay Healthy; 3B:
Common Changes In Pregnancy; 3C: Learning a Pregnant Woman’s Health History; and 3D: Focused Antenatal Care Checkups.
TIME
CONTENT
5 min
Ask: a participant to volunteer to read the general objective from the flip chart.
10 min
Ask: participants:
• Have you ever seen a pregnant woman do something to keep her blood strong (prevent anemia)?
What did she do?
• Have you ever seen or heard a pregnant woman do something to prevent tetanus or HIV? What did
she do?
• Have you ever seen a pregnant woman eat something special during her pregnancy? What did she
eat? What happened? Why does she eat this?
• Is there anything a pregnant woman does not eat during pregnancy? What? Why?
Say: Women who have good care during pregnancy are more likely to have safer births and healthier
babies. Today we are going to talk about and practice a special way to help a woman during pregnancy
and before the baby is born. It is called focused antenatal care.
Say: There are 4 goals of caring for a pregnant woman (FANC).
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS
NEEDED
Flip chart with
objective
Learning guide:
Pregnancy Care
Page 3
TIME
CONTENT
MATERIALS
NEEDED
(Say each goal and ask participants to tell what happens during that goal)
1. Early detection and treatment of problems and complications
[Tell the pregnant woman: visit health facility by the time you feel the baby kick or before (16 weeks)
and three more times during your pregnancy. Any problems or danger signs will be treated]
2. Prevention of complications and disease
[Tell the pregnant woman: take tetanus injection to prevent tetanus (lockjaw) in you and your baby,
take iron / folic acid to protect against anemia, sleep under mosquito net to prevent malaria, you
and husband get tested for HIV, learn about danger signs, cook food with iodized salt, eat extra
meals]
CMNH key
messages
Family Health
Card
3. Birth preparedness and ready for referral
[Tell the pregnant woman and family: prepare for the baby and for any complication. Be ready to go
to health facility: call for help, transport, money; cover with blanket; lie down if possible; drink fluids;
go directly to health facility (see key messages: referral)]
4. Health promotion
[Tell the pregnant woman and family: attend CMNH meetings: danger signs, referral, care during
pregnancy and nutrition, care before baby is born and nutrition, care after the baby is born and
breastfeeding, helping a baby who has trouble breathing, helping a mother who bleeds too much]
15 mins
History Taking: Ask participants what are the two most important actions to do (after greeting and
making her comfortable) when you first see a pregnant woman? Look at the Systems Review illustration.
Answers: 1) Look at the woman head-to-toe, and ask yourself how does she look? Are there any danger
signs? The systems review picture can help make a quick assessment. 2) Ask the woman how she is
feeling and take action for any danger sign/problem.
Systems review
illustration
Learning guide:
FANC
Ask participants to look at the Learning Guide FANC and read the points 3 – 15, under History: ASK AND
LISTEN.
Say: there are many ways to find out the expected date of delivery. Ask the participants what method
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 4
TIME
CONTENT
MATERIALS
NEEDED
they use? Ask participants to read signs on flipchart and explain how one finds out about the sign. (What
do you ask or do to get the information?)
Flipchart of signs
to decide due
date and
gestation
1. Signs to Decide Due Date and Gestation (make flipchart of factors)
Remember: Due dates are not exact. Women often give birth up to 2 or 3 weeks before or after
their due date. This is safe. We know that for a normal pregnant woman the following signs
usually occur:
4 - 8 weeks
 Breast changes (enlargement, tenderness)

Nausea
6-12 weeks

Awareness of baby's movement
16 - 18 weeks (Multigravida)
18 - 20 weeks (Primigravida)

Baby's heartbeat heard
20 weeks (Fetal Stethoscope)
11 - 12 weeks (Doptone)
22 –24 weeks (Pinnard Fetoscope)
Calendar
Pregnancy
calculator
CASE STUDY
Use the signs and symptoms of pregnancy to find out the gestational age and date of delivery.
 Justina is a primigravida and comes to your clinic on 30 April for the first time in this pregnancy.
 She does not know her LMP.
 She felt breast changes and nausea 25 December.
 Her baby first moved on about 25 March.
 Today you hear the fetal heart rate with a pinnard fetascope.

What is her gestational age?

What is her Expected Date of Delivery ?
2. Use your fingers when the LMP is known
Count 10 fingers saying the months. If the LMP was August 15th , count August 15, September 15, October
15, November 15, December 15, January 15, February 15, March 15, April 15, May 15 + 5 days = EDD May
20.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 5
TIME
CONTENT
MATERIALS
NEEDED
3. Use a Gestation Wheel when the LMP is known
If she knows her LMP, turn the inner circle until the arrow points to her LMP. Hold the inner circle in
this position, and look at the date opposite the arrow at 40 weeks. This is her EDD (expected date of
delivery). To find how many weeks pregnant (gestation) she is, look for today’s date on the outer
circle. Read off the number of weeks opposite today’s date.
EDD CALCULATING EXERCISES
Exercise 1:
Hanna comes to see the midwife for her first visit on 20 April. The first day of her last menstrual period
was 10 November.
1.
What is her date of delivery?
2.
How pregnant is she (gestational age)?
Exercise 2:
Dupe, a G3 P2 comes to the doctor for her first visit on 30 October. She does not remember the date of
her last menstrual period, but she noticed the baby started moving 1 week ago. Use a calendar to answer
the questions below.
1.
What is her date of delivery?
2.
What is the probable date of her last menstrual period?
Exercise 3:
Today is 14 June. Ydnas comes to you for the first time. This is her first pregnancy. She says she has
regular menses but she does not remember when she had the first day of her last menses. She does
remember she felt some breast changes and nausea starting the beginning of March and the baby began
moving yesterday. On examination you measure her uterus at the umbilicus. You cannot yet hear the fetal
heart.
1.
Approximately how many weeks is she today?
2.
When will be her date of delivery?
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 6
TIME
CONTENT
Physical Examination: Trainer demonstrates essential parts of physical examination.
1. Prepare the necessary equipment.
MATERIALS
NEEDED
Flip chart and
markers
Ask participants to look at their learning guide FANC FIRST visit, the Physical Examination section. Ask
participants what equipment and supplies are available where they give FANC?
2. Demonstrate Physical Examination: LOOK and FEEL. Ask participants to read 1 – 11 steps for FIRST
(initial) antenatal examination. ASK any questions?
Tape measure
Facilitator demonstrate these steps 1-11 and demonstrate the following:
MEASURE arm circumference. Less than 23.5 cm indicates chronic undernutrition. iii
FEEL for kidney tenderness at the first FANC or when there are signs of urinary tract
infection:
a. Tell the woman and support person you are going to gently tap her back on both
sides.
b. Close your hand into a fist. With your fist, gently tap on the right and left sides of
the woman’s back, just above her waist where the spine meets the rib case. This is
where the kidneys are located the costovertebral angle (CVA).
c. If there is pain, it is a sign of kidney infection. Usually it is on one side.
d. Explain the finding.
TEST urine for protein when diastolic above 90.
a.
With TEST STRIPS. Dip in urine and compare to chart on bottle. Keep bottle tightly closed, if they
get wet they won’t work. They are expensive, cut each strip in half down its length to make your
supply last longer.
b.
With ACETIC ACID METHOD. Fill test tube 2/3 full of urine and heat from the top of the tube until
the urine boils. Add 4 drops acetic acid 5% (vinegar) to the tube. Heat urine to boiling again. If
cloudiness disappears, there is no protein. If the urine remains cloudy, protein is present. iv
c.
With BOILING. Fill test tube 2/3 full of urine and heat from the top of the tube until the urine
boils. Let it cool. Cloudiness (sediment) in the bottom of the test tube, protein is present. v
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 7
TIME
CONTENT
DEMONSTRATE ABDOMINAL EXAMINATION.
Say: As the baby grows inside the womb, you can feel the
womb grow bigger in the mother’s belly. The top of the
womb moves about two finger-widths higher each month.
At 12 weeks, the top of the womb is usually just above the
mother’s pubic bone. At about 20 weeks, the top of the
womb is usually right at the mother’s bellybutton. At about
32 weeks, the top of the womb is almost up to the mother’s
ribs. Babies may drop lower just before birth.
3.
Ask participants to follow in the learning guide.
MATERIALS
NEEDED
PREPARATION
(place the baby
model with the
head down under a
cloth wrapped
around a volunteer.
Help the volunteer
get in the position
shown here).
Tape measure
a. To feel the womb, have the mother lie on her back with some support under her head and knees.
Your touch should be firm but gentle.
b. Look at the skin for scars.
c. Look at the shape.
d. Feel for size. You may measure by using your fingers or a centimeter tape. Use the method you are
used to that works for you. The uterus grows about 2-finger breadths or 4 centimeters in a month.
• If 20 weeks (uterus to belly button) or more, check FHR
• If 24 weeks (22-26 cm) or more, measure fundal height and compare to expected gestation
• If 32 weeks (uterus almost to ribs or 32 cm) or more check: lie, presentation, descent
4. DISCUSS GENITAL INSPECTION
Many women are embarrassed or feel shy about the pelvic parts of their bodies. They may not want
to talk about them, look at them, or have other people look at them. If the woman is too shy, explain
why you need to ask some questions. Possibly you may wait until delivery to look. Ask the
participants to read the genital inspection in the learning guide.
5. LABORATORY TESTS, according to protocol.
Ask participants to read number 15.
6. IDENTIFY PROBLEMS / NEEDS AND MAKE CARE PLAN
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 8
TIME
CONTENT
MATERIALS
NEEDED
7. TAKE APPROPRIATE ACTION and EVALUATION AND REPEAT PROCESS
Ask participants to read Take Appropriate Action on the Learning Guide Focused First ANC.
Discuss as needed.
8. Discuss HINT below:.
A full history and examination takes 20 minutes, so what should you do if you don’t have this long?
• Always greet and make the woman / family comfortable: privacy, listen, answer, respect
• Look at the woman head-to-toe: danger signs? Problems?
• Ask, look and listen: how she is feeling?
• History - 90% of the problems (risks) can be found from the history. Ask:
o How far away do you live?
o Can you easily get to the health facility if necessary?
o Do you have someone to help you?
o Have you had trouble with your previous pregnancies?
o Do you have a cough?
o Have you had a Caesarean section, tear or cut when giving birth, too much bleeding, too big
baby, too small baby or a baby die?
o Do you want to wait a while before having another pregnancy?
• Examination – look and feel
o Take blood pressure, weigh, and measure arm circumference.
o Look head to toe for any problem: anemia, swelling.
o Look at the abdomen: skin and for scars (make sure bladder is empty)
 Look at shape and feel for size
• If 20 weeks or more, listen for fetal heart rate
• If 24 weeks or more, measure fundal height and compare to expected gestation plus
fetal heart rate
• If 32 weeks or more check: fetal lie, presentation, descent, plus fetal heart rate, fundal
height, compare to gestation
• Identify problems / needs and make care plan
• Take appropriate action, counsel, and give next visit date.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 9
Topic: FIRST STAGE OF LABOR
Time: 2 Hours
General Objective:
At the end of the session, participants will be able to care for a woman in Stage 1 of labor: Admission, support, record on labor
chart, use picture partograph to manage labor.
Participant Tools:
Handout: Picture partograph; Learning guide: Admission in labor
Homework:
Read Reference Text, Chapter 6A: Getting Ready for Labor and Birth; 6B: Giving Good Care during Labor and Birth; 6C: Opening—
First Stage of Labor;
TIME
CONTENT
5 min
Ask a participant to volunteer to read the general objective from the flip chart.
10 min
Ask participants:
• How many of you have had a baby at home? Did you have someone with you to support you during
labor and birth? Did having a support person with you help you? Why did you decide to deliver at
home?
• How many of you have had a baby in the hospital? Did you have someone with you to support you
during labor and birth? Did having a support person with you help you? Why did you decide to deliver
at hospital?
• Do you think having a support person may help a woman in labor? Say more women have normal labor
and delivery when relatives are with them during labor.
Ask: There are 4 stages of labor? (Say each stage, ask participants to tell what happens during that stage)
Part 1 (Stage 1) Womb is Opening: Contractions/pains that open the womb inside the body. This part of
labor is the longest part usually less than 8 hours for a woman who has had a baby before, or up to 12 hours
for a woman giving birth for the first time. It usually starts with mild contractions that do not last long.
Toward the end of this first part the contractions become very frequent, very strong and last about a
minute each.
Part 2 (Stage 2) Pushing the Baby Out: When the womb is completely open, the contractions move the
baby out of the womb and down the vagina. The woman pushes to help move the baby out. This part can
last from a few minutes to over 2 hours. [Obstructed labor may be prevented when the woman waits to
push until womb is completely open.]
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS
NEEDED
Flip chart with
objective
Flipchart with
four stages of
labor
Page 10
TIME
CONTENT
MATERIALS
NEEDED
Part 3 (Stage 3) Birth of Placenta: After the baby is born, the placenta (afterbirth) separates from the
womb and contractions push out the placenta. This is the shortest part of labor and usually lasts 5 – 10
minutes. [PPH is more common if the placenta is not out by 18 minutes. Severe PPH is common if placenta is
not out by 30 minutes.]
Part 4 (Stage 4) First Few Hours After Baby is Born: After the placenta comes out for three hours (up to six
hours), the mother starts to recover from the birth and the baby begins to adjust to the world. The womb
gets hard to stop bleeding, the baby starts to breastfeed. [PPH is the largest cause of maternal death after
delivery, even in normal births. Hypothermia(when the baby is too cold) is dangerous for the baby.]
15 min
History taking: Ask participants what are the four most important questions to ask a woman when you first
see her in labor? Look at the picture partograph. Answers: 1) when did labor pains start? 2) did the bag of
waters break? If yes what color is the water (liquor)? 3) do you have any problems: headache, bleeding,
heartburn, any other? 4) did you take any medicine or herbs to change the contractions (labor pains)?
Physical Examination for Admission in Labor: Trainer demonstrates essential parts of physical examination.
Ask participants to look at their learning guide, the Physical Examination section. Ask “why” questions when
appropriate.
Getting ready:
• Ask the woman to empty her bladder and save the urine (if you are going to test the urine)
• Help the woman onto the bed, mat or examination table and place a pillow under her head and upper
shoulders
• Wash hands with soap and water and dry them
• Explain each step of the physical examination to the woman before you perform it
Look at general well-being:
• Height (shorter than other women in her area)
• Swelling (face and hands), blood pressure
• Tired, worried
• Malnourished (arm circumference below 23.5 cm)
• Anemia (conjunctiva for paleness)
• Hydration
• Signs of infection (temperature, pulse)
CMNH Clinical Update for Health Workers Lesson Plan July 2013
picture
partograph
Learning guide:
Admission in
Labor
Page 11
TIME
CONTENT
Abdominal examination
Use a baby under a cloth on a participant or co-trainer (lying on back with pillow under head/shoulders,
bend knees a little, do some slow deep breathing) covered by a sheet to do a complete abdominal
examination, as in learning guide:
• Look at abdomen and womb for shape, scars, unusual shapes or swelling
• Feel and decide fundal height
• Feel womb for contractions: frequency, duration, strength, relaxation of the womb
• Feel womb:
1. what part of the baby is in the top of the womb,
2. where are the back, arms, legs (lie)
3. what is in the lower uterus, can it be moved? (engagement)
4. Is the head coming first? (presentation and descent)
• Count fetal heart rate as contraction is ending.
• Feel for the bladder.
Vaginal examination
Discuss vaginal examination as described in the learning guide:
Cervical dilatation
• Provide privacy and explain what you are going to do
• Feel baby’s descent by abdominal examination
• Help woman position: on her back, bend her knees, spread legs apart
• Wash hands, put on gloves
• Look for discharge: blood, waters (liquor), meconium
• Clean genital area, lubricate gloved examining fingers
• With other gloved hand separate woman’s labia
• Gently insert 2 fingers of examining hand into vagina and do not remove fingers until the examination is
done
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS
NEEDED
Equipment and
supplies:
Whiteboard/flip
chart
Markers
Model baby and
‘mother’
Sheet to cover
mother, Pillow
Blood pressure
cuff,
stethoscope,
Fetoscope,
‘Examination
table’
Sterile gloves
Soap and towel
Contaminated
waste container
Cervical
dilatation model
Page 12
TIME
CONTENT
MATERIALS
NEEDED
o Feel vagina for moist or hot/dry, scarring
o Feel cervix for thinning (effacement), opening (dilatation)
o Feel if umbilical cord is in cervix or vagina
o Feel bag of waters
o Feel baby’s head / presenting part.
o If vertex feel fontanel’s, position, molding, caput
• When examination finished, remove hand from vagina, look for any discharge on gloves. Remove and
care for gloves using infection prevention guidelines. Wash, dry hands. Help woman get in comfortable
position.
• Explain findings to the woman and her family. Record information.
Focus carefully on how to correctly feel for cervical dilatation: Use the wooden cervical dilatation
model. Ask several participants to practice measuring dilatation by closing their eyes and moving their
fingers around the model, and tell the dilatation. This can be done during clinical practice.
Ask: participants if they have any questions.
Participants do return demonstrations as needed.
10 min
Ask: participants to define first stage of labor. Answer: The first stage of labor begins when contractions start
to open the cervix. It ends when the cervix is completely open. First stage is usually the longest part of labor. It
should not last more than a day and a night (24 hours).
Ask: participants how to decide from the history and examination of the woman if she is in active phase of
first stage of labor. Answer: Contractions mild and about 30 seconds long every 15-20 minutes in low belly or
back (early labor may be called latent phase). Contractions strong and up to 1 minute long every 3-5 minutes
in her belly and her womb gets hard. Later the mother feels contractions never stop (active phase of labor)
Partograph
Background about the Pictorial Partograph. vi The pictorial partograph has the same purpose as the WHO
partograph and that is to identify problems during labor (decide whether the woman can deliver or refer).
•
•
Cervical
dilatation model
Ask: What is a partograph? Why is it used? Answer: The partograph is a tool used to write
information when a woman is in labor. This tool helps identify problems during labor for the woman
and baby and the progress of the labor. It is not a replacement for labor care.
Ask: Has anyone ever used a partograph? If yes, could you explain to us how you used it? Were
there any problems identified for the woman or baby?
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 13
TIME
CONTENT
MATERIALS
NEEDED
Ask: What is the advantage of using a partograph? Answer: All the information can be seen on one chart. It is
very useful when a referral is needed because it shows the doctor and referral staff what has happened.
Explain the picture partograph parts:
FRONT OF THE PICTURE PARTOGRAPH – ‘THE PARTOGRAPH CLOCK’
• Ask: a volunteer to point out the times on the clock.
• Ask: another volunteer to read the instructions and one person to find the time on the clock. [Find
the time on this clock now]
• Ask: one person to find the time on the clock when labor pains started. [before midnight]
• Ask: one person to follow the ‘road’ from the time labor pains started to the time now. How many
black marks were crossed? Count the time now black line. [9 black lines]
• Ask: volunteer to read results of black lines……
• Ask: what result this is? 9, then moderate risk.
Give participants
a picture
partograph with
clock on one side
and delivery
mother on the
other side.
Post in
labor/delivery
ward
Any questions?
BACK OF PARTOGRAPH – DELIVERING MOTHER PICTORIAL PARTOGRAPH
• Ask: a participant to point out the 3 columns of ‘risk’ for mother [low risk mother, risk mother, high
risk mother]
• Trainer to ‘read’ each box in the column for low risk mother [ mother looks well, labor pains less than
8 hours, no or clear water, time of leaking less than 8 hours, not pushing, care for mother: fluids and
rest, no pushing on belly, no injections/IVS, where for care follow birth plan at home or health
facility]
• Ask: a participant to ‘read’ each box in the column for risk mother [ mother tired, labor pains more
than 8 hours, waters yellow or green, time of leaking more than 8 hours, pushing for 1 hour, care for
mother all the above and support and encourage, where for care prepare for referral and go in 1-2
hours if no change]
• Ask: a participant to ‘read’ each box in the column for high risk mother [very tired, weak, labor pains
more than 12 hours, waters thick, time of leaking more than 12 hours, pushing for 2 hours, care for
mother all the above and family team go with woman for referral, refer NOW]
• Ask: participants, what result did we have? [low risk, pains less than 8 hours]. What care would we
help the family team give to the woman? After discussing ask participants if they have any questions.
If more review is needed, ask a volunteer to explain/show the columns.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 14
TIME
20 min
CONTENT
Ask: participants to list actions they can take to help a woman and her support person feel comfortable in
Stage 1 of labor (ask another trainer to put responses on a flip chart or chalk board):
1. Educate the woman and her support person about what happens during labor and delivery. DO NOT try
to educate the woman during a contraction. When she feels the pain of a contraction, she cannot
concentrate on what you are saying. Remember to use words the woman will understand. Labor has 4
parts:
Part 1 Your Womb is Opening: Having contractions/pains that open the womb inside the body. This
part of labor is the longest part usually less than 8 hours for a woman who has had a baby before, or
up to 12 hours for a woman giving birth for the first time.
Part 2 You are Pushing the Baby Out: When the womb is open, the womb is pushing the baby out of
the body. This part can last from a few minutes to over 2 hours.
Part 3 Birth of Placenta: When the baby is born, the womb is pushing out the placenta/afterbirth.
This is the shortest part of labor and usually lasts 5 – 10 minutes.
Part 4 (Stage 4) First Few Hours After Baby is Born: After the placenta comes, the mother starts to
recover from the birth and the baby begins to adjust to the world.
MATERIALS
NEEDED
Equipment and
supplies:
Glass (to show
drinking)
Fan
Chair
Cloth (to cool
woman)
Picture
partograph and
Labor chart
2. Teach the woman and her support person about ways to breathe during labor and delivery
The way a woman breathes can have a strong effect on how her labor will feel. It is important to
continue breathing when you have a contraction. It is a natural response for someone to hold their
breath and tighten their muscles when they feel pain. But that only uses MORE energy and makes the
contractions feel MORE painful. Try to use these breathing methods:
Just before and after EVERY contraction
o
Slow, gentle breathing. Take a VERY deep breath in through the nose and out through your mouth
making a kiss with her lips. As you let your breath out, think about letting all your body relax. It
helps you relax your body as completely as possible before and after a contraction.
3. Teach the woman and her support person how to help the woman relax. Use massage to relieve pain of
contractions (demonstrate how to massage a woman’s back, arms, legs. Have participants practice on
each other).
o
THIS MASSAGE USUALLY FEELS BETTER DURING A CONTRACTION. This can be done when the
woman is on her hands and knees, lying on her side, or sitting in a chair while she is facing the bed.
Ask the woman where the massage feels better. Ask the woman if massaging in a circle with your
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 15
TIME
CONTENT
MATERIALS
NEEDED
palm of the hand, or your fingers feels better, or if steady pressure in those places feels better.
O
THIS MASSAGE USUALLY FEELS BETTER BETWEEN CONTRACTIONS. If a woman’s muscles are very
tired, massaging the muscles of the neck, back, arms or legs may feel very good and help her to
relax more.
4. Help the woman stay cool during labor and delivery
o
Ask those who have had a baby, how did you stay cool during labor and delivery? Answers may
include: Use a cool cloth on the woman’s neck, face and/or chest. Use a hand fan or a firm piece of
paper to fan the woman’s face and body. Encourage the woman to take a shower or bath. Research
shows that when a woman washes during labor, she has fewer infections.
5. Guide the woman and her support person on positions to use during labor.
o
Ask those who have had a baby, what positions were most comfortable for you during labor? When
you help a woman in labor, what positions do they like to use? Reference in SCBNC page 148, 149
for laboring out of bed.
Answers may include for labouring: walking, sitting, sitting on a chair with no arms facing the bed
and the woman sits with her legs open wide, side-lying, hands and knees
6. Use other care to help a laboring woman feel care for and prevent her from getting too tired
• Create privacy for the woman and a comfortable place to labor.
• Encourage the support person to help the woman to:
o Drink at least 1 glass of fluid every hour and eat small amounts of light food if desired.
o Urinate at least every 2 hours.
• Explain to the mother and her family: during labor and birth, the health care provider will be helping:
o Checking you (blood pressure, pulse, temperature), your baby (fetal heart rate), and the progress
of your labor (abdominal and vaginal examination) regularly.
o Cleaning your perineum just before the baby is born.
o Giving you medicine just after the baby is born to reduce the amount of blood you will lose.
o Laying the baby on your abdomen, skin to skin, after drying the baby. This will keep the baby
warm, help the baby breathe, encourage the baby to breastfeed in the first hour after birth and
help the baby to feel safe.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 16
Topic: Second Stage of Labor
Time: 2 Hours
General Objective:
At the end of the session, participants will be able to care for a woman in Stage 2 of labor: help with birth of baby (position of
woman, pushing), immediate newborn care (dry, warm, breathe) and baby to breast
Participant Tools:
Learning guides: Management of Stage 2 and TAC Booklet: Prevent Problems First Actions.
Homework:
Time
Read Reference Text, Chapter 6, including: 6D: Pushing—Second Stage of Labor NOTE: read HIV text
Content
20 mins
Caring for a woman in Stage 2 of labor:
REVIEW:
Ask: what are the 4 important parts of labor. Answers below:
Part 1 (Stage 1) Womb is Opening
Part 2 (Stage 2) Pushing the Baby Out: When the womb is completely open, the contractions move the
baby out of the womb and down the vagina. The woman pushes to help move the baby out. This part can
last from a few minutes to over 2 hours. [Obstructed labor may be prevented when pushing waits until
womb is completely open.]
Part 3 (Stage 3) Birth of Placenta
Part 4 (Stage 4) First Few Hours After Baby is Born
Materials
Learning guide
checklist: Care
During Stage 2 of
Labor
Say: We are going to talk about caring for a woman as she pushes the baby out.
Ask: participants what the signs are that a woman is probably in Stage 2 of labor. Answers:
• The mother feels an uncontrollable urge to push (she may say she needs to pass stool).
• Contractions come less often, but they stay strong or get stronger.
• She may hold her breath or grunt during contractions.
• The mother’s mood changes. She may become sleepy or more focused.
• The mother’s outer genitals or anus begin to bulge out during contractions.
• The mother say she feels the baby’s head begin to move into the vagina.
Ask: participants: How can you support a woman in Stage 2 labor. Answers below:
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 17
Time
Content
•
Fluids. Usually by this time the woman is very tired and has used a lot of water from her body, so
she needs to take sips of water
•
Pass urine. Since this is the time the baby is coming down more, it is important for the bladder to be
as empty as possible so the baby has more room.
•
Position. help the woman get in a position that is comfortable for her for pushing and delivery.
o Ask participants: What positions may be comfortable for pushing and delivery? Answers may
include for birthing (side-lying, semi-sitting, hands and knees, squatting, standing).
o
Ask participants: Why might an upright position help pushing? Answer: When the cervix is fully
dilated and the baby’s head begins to move down into the birth canal, the woman will usually
feel like pushing. Help the mother push effectively (correctly). Encourage her to keep her
mouth and legs relaxed and open.
o
Encourage her to try different positions if descent is slow. These positions have special benefits:
1) Sitting or half sitting. Often the most comfortable position, and makes it easier for the
midwife to guide the birth of the baby's head and observe the perineum. It is important for
the woman to open her legs wide and to pull her knees as close to her body as possible.
2) Hands-and-knees Good when the woman feels labor in her back and the baby is posterior.
Can also help when the baby is occiput posterior and having trouble turning to occiput
anterior.
3) Squatting or standing Helps bring the baby down when the birth is slow or the mother does
not feel like pushing. In this position the pelvis tilts upward and opens by 1 – 2 cm more.
4) Lying on the left side This position is relaxing and may help the woman not to push when
she feels like pushing before she is fully dilated. Research shows that women have fewer
lacerations or smaller lacerations when they use this position for delivery.
o
Positions not to use:
1) Flat on back. It is usually not good for the mother to lie flat on her back during a normal
birth. It can squeeze the blood vessels that bring blood to the baby and the mother so they get
less blood and oxygen. It is much harder for the mother to push when she is lying flat on her
back.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Materials
Page 18
Time
Content
Materials
2) Lithotomy with stirrups. If the woman has her legs up, in lithotomy position, stress is put
on the muscles, connective tissue and skin of her perineum. This encourages more lacerations
or larger lacerations.
•
Confirm cervix is fully dilated. Ask participants: How do you confirm full dilatation? Answer: Do a
vaginal exam or look for head/hair.
o If the cervix is not fully dilated, help the woman not to push, even if she has the urge to push.
Help her not to push by changing positions: hands and knees position or other position and
helping her to blow (demonstrate how to blow) when she has a contraction.
o If the cervix is fully dilated (or you can see head/hair), tell the woman she can push when she
feels the urge to push. Do not ask the woman to hold her breath and push. Let the urge to
push come naturally.
o Encourage the woman to push during contractions and relax between contractions. Talk with
the woman about the following BEFORE the woman is feeling ready to push:
When you are pushing the baby out
o TO push: If you feel you want to push, let the nurse or midwife know so she can check (look
for the head or feel to make sure the womb is completely open.) When you push try not to
hold your breath while pushing or to push for too long without taking a breath, your baby may
not get enough oxygen.
o To NOT push. When the baby’s head is showing (crowning) starting to come out, use some
special breathing so the head is born slowly, your skin has more time to stretch and is less likely
to tear. At this time you will have a very strong feeling to push the baby out quickly. Breathe
quickly by blowing short fast hard breaths in and out through your mouth… when the
contraction ends take a slow gentle breath. It is important to breathe in as much as you
breathe out.
Ask participants if they have any questions.
20 mins
DVD (video) Birth in the Squatting Position (if not shown before)
Watch and discussion
DVD, projector,
computer
Demonstrate second stage of labor management and delivery.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 19
Time
Content
Demonstrate second stage management and delivery of the baby with models and a volunteer as the
laboring woman, using the learning guides.
Trainer demonstrates slowly: Explain to participants that while another trainer reads the demonstration,
you will demonstrate slowly (may be scenario in hospital, health post or home). Need to ask what is
different at various sites?
Materials
Learning guides:
Care During Stages
2 of Labor
Trainer and volunteers prepare for role play: Prevent problems When Baby Is Born and First Actions.
Although the setting is the home, ask participants to think about what actions will be different in the health
facility.
Demonstration: Prevent Problems When Baby Is Born and First Actions
Ask for volunteers to play Ydnas, a family member, and Ydnas=s husband. The Facilitator
plays the birth attendant trained in CMNH and Mothers Nutrition.
Props:
Things for a clean place, things for a clean birth, things for clean cord care, things for
washing, things for clean helpers, waterproof container, cup of liquids with sugar, baby
model, misoprostol
Situation: Explain who the volunteers are pretending to be, and tell the situation to those watching.
Say: Ydnas is in labor at her home for 8 hours. The baby is coming head first and the bag of
water has broken. Someone has called the birth attendant trained in CMNH and Mothers
Nutrition. The birth things are ready.
Actors:
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 20
Time
Content
Materials
Demonstration:
1. Ydnas walks around rubbing her back. The family member is with her and encourages her. Helping
her breathe and relax.
2. Ydnas returns from passing urine (washes birth area). She washes her hands.
3. Ydnas rests on her side. The mother-in-law brings Ydnas tea with sugar.
4. The birth attendant arrives and greets everyone. She looks at the prepared birth things and says:
You all have done so much work. Everything is ready for the baby.
5. Soon Ydnas is rolling side to side. She says: I feel like I need to pass stool. I feel strong pushing
pains—I feel like pushing! Ydnas squats on the mat and wants to push. (family member helps her
in hands and knees position to stop pushing)
6. The birth attendant says: Remember what we agreed to do at the CMNH – Birth to 48 Hour
meetings? First feel or let me look for the baby’s head. We want to be sure the baby is ready to
come out before you start to push. Let me just get ready. I have been trained how to feel to make
sure the baby is ready to come
7. The birth attendant washes her hands with soap and water. She arranges the delivery things, puts
on an apron and gloves, and washes her gloved hands (or uses sterile gloves). Clean cloth under
Ydnas. Wash birthing area.
8. The birth attendant (feels for cervix) waits for a birth pain and encourages Ydnas. The birth
attendant looks and says: Yes, your womb is open and I can see the baby’s hair and head now. The
Equipment and
supplies:
Pillow and sheets
Two (2)
blankets/cloths
Suction device
Baby hat
Scissors (razor
blade)
Two (2) artery
forceps (cord ties)
Ring forceps
Bowl
Gauze
Misoprostol 400
mcg tab
Soft Pelvis
Fetal and placenta
model
Large table or mat
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 21
Time
Content
9.
10.
11.
12.
13.
Materials
baby is about ready to come out.
The birth attendant receives the baby the next time Ydnas pushes in the squatting position. vii (As
the head is coming ask Ydnas to breathe, wipe face, feel for cord), wait for next contraction, allow
the baby’s head to turn, support head as shoulders deliver, support baby as it comes out.) She says
to the family member: Help Ydnas semi-sit.
She holds the baby. Wipes the baby’s face including the nose and mouth. Dries the baby
(removing all blood and fluid) and rubs the back of the baby using one clean cloth. Removes the
first cloth. With the second clean cloth, covers the baby including the head (she does not cover the
face). Put hat on baby. [The baby is crying.] NOTE: If baby has trouble breathing, is gasping or not
breathing see endnote to help baby breathe. viii
Hands the baby to Ydnas and helps her hold the baby close to her.
After the birth of the baby, feels for a second baby. If the birth attendant is sure there is no
second baby, she says: I do not feel another baby. Ydnas, it is time for you to take the
misoprostol. (It is very important that if no one is trained to feel for a second baby or if there is a
second baby, Ydnas should take the medicine as soon as the placenta comes out.)
Ties and cuts the cord. (Milk cord before tie/clamp and cut. Cover cord to prevent splashing.)
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 22
Time
Content
Materials
THIRD STAGE
1. After some time, asks Ydnas to let her mother-in-law hold the baby. She helps Ydnas squat and
pass urine.
2. Helps Ydnas to a semi-sitting position and helps the baby attach to the breast and suck. If the baby
does not suck, use nipple stimulation.
3. Waits for the placenta to come out. She DOES NOT squeeze, push, or press on the womb. She does
not pull on the cord. Delivers the placenta slowly turning gently so membranes all come out.
4. After the placenta comes out, she rubs the womb.
5. She examines the placenta: maternal side, fetal side, membranes and puts the placenta into a
waterproof container that another helper is holding.
6. Helps Ydnas hold baby in good sucking position to breastfeed.
7. The birth attendant hands the baby to Ydnas and helps her hold the baby close to her. Cleans up
things. ix
20. The family member asks Ydnas what she would like to eat and drink. The husband is happy and
goes to tell his friends.
Ask: Any questions about demonstration?
Ask: Why is the World Health Organization now recommending delaying clamping of the cord with third
stage management? Answer: Studies now show that delayed clamping and cutting of the umbilical cord
is helpful to both term and premature babies. There are fewer cases of anemia in term babies at 2
months of age. Remember breast milk has no iron, so delayed cord clamping gives the baby extra
blood/iron that helps the baby until the baby begins to eat other food at 6 months. Immediate cord
clamping can decrease the red blood cells an infant receives at birth by more than 50%.
Summary :
Ask participants: Look at your learning guide (checklist for 2nd, 3rd, 4th stage of labor).
Ask participants to take turns reading the steps. Respond to any questions that come up.
Participants practice demonstration in groups (depending on time, may be done in evening sessions or quiet
times on call): Divide participants in groups of at least 3 per group. Ask them to take turns reading the
learning guide and performing the skill until everyone has performed the skill. After each demonstration,
feedback should be given, as above.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 23
Topic: THIRD STAGE OF LABOR
TIME:
HOURS
General objective:
At the end of the session, participants will be able to care for a woman in Stage 3 of labor: birth of the placenta using misoprostol.
Participant Tools:
Learning guide: Care During Stages 2 and 3 of Labor; TAC Booklet: Prevent Problems after Baby is Born: First Actions & Prevent Too
Much Bleeding at All Births with Misoprostol,
Homework:
Read Reference Text, Chapter 6E: The Birth of the Placenta
TIME
CONTENT
MATERIALS NEEDED
Introduction:
•
•
Ask one participant: Read the objective to the group from the flip chart.
Ask participants: Has anyone used AMTSL (active management of third stage of labor)? Of those who
raise their hands, ask one or two to describe the actions they took to deliver the placenta. Thank
everyone for their experiences.
•
Ask: what are the 4 important parts of labor? (Say each part and ask participants to tell what happens
during that part)
Part 1 (Stage 1) Womb is Opening
Part 2 (Stage 2) Pushing the Baby Out
Part 3 (Stage 3) Birth of Placenta: After the baby is born, the placenta (afterbirth) separates from the
womb and contractions push out the placenta. This is the shortest part of labor and usually lasts 5 –
10 minutes. [PPH is more common if the placenta is not out by 18 minutes. Severe PPH is common if
placenta is not out by 30 minutes.]
Part 4 (Stage 4) First Few Hours After Baby is Born
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 24
TIME
CONTENT
Management of third stage of labor:
Say, We have just seen a demonstration that included the birth of the placenta. This is referred to as the third
stage of labor.
• Ask: What is the third stage of labor? Answer: The time from the birth of the baby until the birth of
the placenta and membranes.
• Ask: How do you usually manage the third stage of labor? With misoprostol, with oxytocin, with
other?
• Ask participants: Look at your CMNH TAC Booklet for First Actions and Prevent Too Much Bleeding At
All Births With Misoprostol. What steps did we see in the demonstration after the birth of the baby?
Answers:
•
•
•
•
•
Check for second baby
Tie and cut cord
Squat and pass urine
Put baby to breast
Wait for placenta
MATERIALS NEEDED
TAC Booklet, Prevent
Problems after Baby is
Born: First Actions.
• Watch for signs of placental separation:
Lengthening of the cord, Gush of blood
from vagina, Womb rises
• Deliver placenta slowly; deliver
membranes gently with turning motion
• Give misoprostol
• Rub wound to keep it hard (contracted)
Ask: What equipment do you need to manage the third stage of labor? Answers:
• Misoprostol 600 mcg tablets or approved oxytocic [Note for discussion: If unable to check for second
baby, give misoprostol or other oxytocic as soon as the placenta is delivered].
• Waterproof container for placenta
Say: The demonstration we have just seen and done can prevent too much bleeding after birth. Misoprostol
causes the womb to contract and prevent bleeding after birth. This is called active management of third stage
of labor.
Ask: When the baby is born, what does the uterus normally do? Answer: The contractions continue and the
womb becomes smaller. This usually causes the placenta to separate from the wall of the womb.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 25
TIME
CONTENT
Ask: What if the uterus is not empty? Answer: If the uterus is not empty the woman continues to bleed.
MATERIALS NEEDED
Infection Prevention – Delivery Things and Disposal of Placenta
•
Ask: How can you make the cord cutting tool safe? Answers: 1) If a new razor blade was used, place
the blade in the container for disposal after decontamination. 2) If scissors or a knife was used, clean
the tool by using infection prevention steps: decontamination, wash with soapy water and rinse, highlevel disinfection, correct storage.
•
Ask: How can you make aprons, linens, and clothing soiled with blood and fluid safe? Answer:
Decontaminate in 0.5% chlorine solution, wash with soapy water and rinse well. Hang in the sun to
dry. x
•
Ask: How can you make disposable soiled things like gauze, cotton, or gloves safe? Answer: Gauze
and cotton: Put in the container for disposal. Gloves: Decontaminate, wash and rinse. Take off gloves
by turning inside out, then put in the container for disposal of burning or bury.
•
Ask: Where is the placenta disposed? Are there any local customs with the placenta? Remember we
talked about ways to dispose of contaminated waste and safe pit for contaminated waste? Can
someone tell us about a safe pit to dispose of contaminated waste?
Note: If the family must dispose of the placenta, put it in a leak proof container and cover with
decontamination solution for 10 minutes. Advise the family to use gloves if they must handle the placenta and
to bury it in the leak proof container if at all possible with the gloves they use in handling the placenta.
Summary can be done by:
• Ask participants: what are the steps to management of third stage of labor?
• Ask participants: do you have any questions?
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 26
TOPIC: Fourth Stage Of Labor: Care Of Mother And Baby During The Time After Birth To 6 Hours
TIME: 1 HOUR
General Objective:
Participants will review and update their knowledge and skills to provide care to women and newborns after birth to 6
hours. This is the first part of postpartum care.
Participant Tools:
CMNH TAC Booklet, SCBNC: A Reference for Health Extension Workers
Homework (to be completed before lesson): Read reference text, Chapter 7: Postpartum Care; Review Learning Guide: Care During Stage 4 of Labor, Last
section, Monitor Mother and Baby (First 6 Hours Postpartum), Bring Learning Guide to session; Review CMNH TAC Booklet, Woman and Baby Problems and
Prevent Problems After Baby is Born.
TIME
5 min
CONTENT
Introduction
Introduce the topic. Ask a participant to volunteer to read the general objective.
MATERIALS NEEDED
Flip Chart with objective
Say, Both the woman and her newborn are in danger during the postpartum period (the six weeks following
delivery). The time of highest risk of death for women and their newborns is after birth. An estimated 65% of
all maternal deaths occur after delivery, and almost 50% of these postpartum deaths occur within the first 24
hours after delivery. The first 24 hours in a newborn’s life is also critical. Two thirds of infant deaths occur
within the first week after birth. More than 50% of all infant deaths happen in the first 24 hours after birth.
Care at critical times during the postpartum period may prevent some of these deaths.
Write Significance of
Postpartum Care for
Women and their
Newborns on flip chart
before session to post on
wall during introduction
Ask: What are the 4 important parts of labor? (Say each part and ask participants to tell what happens
during that part)
10 min
Part 1 (Stage 1) Womb is Opening:
Part 2 (Stage 2) Pushing the Baby Out:
Part 3 (Stage 3) Birth of Placenta:
Part 4 (Stage 4) First Few Hours After Baby is Born: After the placenta comes out for three hours (up to six
hours), the mother starts to recover from the birth and the baby begins to adjust to the world. The womb
gets hard to stop bleeding, the baby starts to breastfeed. [PPH is the largest cause of maternal death after
delivery, even in normal births. Hypothermia is dangerous for the baby.]
Describe the significance of fourth stage of labor care or immediate postpartum care (birth to six hours) for
women and their babies.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Flip chart or board
Markers for flip chart or
Page 27
TIME
CONTENT
MATERIALS NEEDED
board.
Record on flip chart or board. Ask participants to take turns reading the information.
•
Ask: What is immediate postpartum care? Answer: Care given to a woman and her baby as soon as the
baby is born and the placenta is delivered.
•
Ask: Why is immediate postpartum care important to the mother and to the baby? Answer: FOR
MOTHER: After the baby is born, the uterus is contracting and closing off the blood vessels of the
placental site. This time is very important to prevent too much bleeding in the woman. Immediate care
can prevent a life threatening problem. FOR BABY: The newborn baby begins to make changes at birth.
The baby no longer depends completely on the mother’s body for oxygen, warmth and nourishment.
•
Ask: What should be the timing of immediate postpartum care of mother and baby? Answer: First 6
hours as this is when most women have problems and even die. As soon as the baby is born or as soon as
possible after the baby is born if you did not attend the birth. The health worker or TBA may go to the
woman’s home as soon as she is notified of a birth.
Learning guide: CMNH
Birth to 48 hour checklist
20 min
Identify danger signs for women and newborns during the first 6 hours after birth.
• Introduce the topic. Ask participants to answer the following questions. Write responses on flip chart or
board.
• Ask What are the danger signs the first 6 hours after birth?
Postpartum Woman
Newborn Baby
 Too much bleeding
 Trouble breathing: too slow, too fast
 Fever
 Low birth weight, too small
 Abdominal pain
 Not able to suck or not feeding well
 Foul smelling discharge from vagina
 Convulsions, fits, limp, not active
 Convulsions, fits
 Temperature: too hot, too cold
Flip chart or board and
markers
10 min
Immediate Care of Mother and Baby
Describe care of the woman and baby the first 6 hours after birth.
Learning Guide for Stages
2 and 3 and 4 of Labor,
Say, We have learned to monitor the woman for bleeding too much after birth in the first 6 hours. Ask
participants to look in their Learning Guide (checklist) for answers to the following questions:
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 28
TIME
•
•
15 min
CONTENT
Ask: How often should the woman and baby be monitored? Answers: After delivery of placenta, monitor
woman and baby every 15 minutes for 2 hours, every 30 minutes for 1 hour, every 1 hour for 3 hours
MATERIALS NEEDED
Ask: What is the immediate care given? Answer: FOR MOTHER – check blood pressure, pulse, womb to
make sure it is hard and show mother how to rub the womb, check vaginal bleeding. FOR BABY – check
breathing, color, temperature, and sucking. Put newborn baby together with mother after birth skin-toskin and chest to chest (as culturally appropriate) as the first hour after birth is the most important for
bonding and attaching to the breast.
• Record all findings on the labor chart.
Summary:
Review the significance of immediate postpartum care for women and their newborns discussed at beginning
of session.
• Ask participant to read on flip chart: Significance of Postpartum Care for Women and Their Newborns.
•
Ask questions about significance and timing of postpartum care.
Flip chart or TAC Booklet
of:
Danger Signs for
Postpartum Women,
Danger Signs for
Newborns.
•
Summary: Provide participants with paper. Ask the participants to list danger signs for women and their
newborns after birth to 6 hours. When completed, ask participants to read lists.
Paper for participants,
pencils
Significance of Postpartum Care for Women and Their Newborns
Both the woman and her newborn are in danger during the postpartum period (the six weeks following delivery). The
time of highest risk of death for mothers and for newborns is after birth. An estimated 65% of all maternal deaths
occur after delivery, and almost 50% of these postpartum deaths occur within the first 24 hours after delivery. The first
24 hours in a baby’s life is also critical. Two thirds of infant deaths occur within the first weeks after birth. More than
50% of all infant deaths happen in the first 24 hours after birth. Care at critical times during the postpartum period
may prevent some of these deaths.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 29
Topic: TOO MUCH BLEEDING AFTER BABY IS BORN
TIME:
HOURS
General Objective:
At the end of this session, participants will have the knowledge and skills to help prevent and take emergency action for too
much bleeding after birth.
Participant Tools:
Handout: TAC Booklet Two Handed Pressure of the Womb
Homework (to be completed before lesson): Read reference text, Chapter 6E: The Birth of the Placenta—Third Stage of Labor; CMNH TAC Booklet, Prevent
Too Much Bleeding After Baby Born and Bleeding Too Much After Baby Born and Woman Referral
TIME
5 min
55 min
CONTENT
Introduction
Ask a participant to volunteer to read the general objective from the flip chart.
Ask: What is too much bleeding after birth? Answer: PPH is more than 500 ml of vaginal bleeding, however
blood loss of 200 ml in some women is too much. A better definition is any amount of bleeding that causes a
change for the worse in the woman’s condition, such as low systolic BP, fast pulse or signs of shock. The
woman can bleed to death in 2-3 hours if nothing is done to help her.
Say: We cannot predict who will bleed too much after birth based on risk factors because 2/3 of women who
bleed too much after birth have no risk factors. This is why it is important to remember that all women are
considered at risk and prevention must be a part of every birth plan.
MATERIAL NEEDED
Flip chart with
objective
Flip charts/handouts:
Definition of too much
bleeding after birth
How to prevent too
much bleeding after
birth
1 hour
Say: The major causes of hemorrhage in those first hours after birth are uterine atony (soft uterus), and
retained placenta or membranes. Bleeding because the womb is too soft (not contracting), or any condition
preventing contractions of the uterus can cause too much bleeding after birth.
Ask participants: What can stop or weaken uterine contractions causing uterine atony after the baby is born?
Answers: Tired uterus, Full bladder, Prolonged labor, Very large baby, Too many babies, Twins or more, Retained
placenta or membranes, Incomplete separation of the placenta, Excess amniotic fluid, Infection.
Ask participants: What is the normal bleeding like the first days after delivery? Answer:
• It is normal for the womb to get hard and smaller. As the womb gets smaller, it squeezes out any remaining
blood. Usually about one cup of dark red blood comes out soon after the placenta comes out. This bloody
discharge changescolor over the next few days. In about one week, the discharge will be lighter pink or
brownish in color and a smaller amount.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 30
TIME
CONTENT
Ask participants: What is the bleeding like the first days after delivery if it is not normal? Answer
• It is not normal if more than one cup of blood and discharge come out. It is not normal if the womb is soft;
bleeding is continuous: large, fist-sized clots come out; or the woman feels weak and faint. The woman can
bleed to death in two to three hours when the womb is soft.
Ask: What can we do when there is too much bleeding after birth? Answer: We must be sure the womb is
empty and help the womb get hard (contract) into a small, hard ball. Rub the womb, make sure placenta is
complete, Two-handed pressure of the womb (external bimanual compression) may help.
Demonstration: Bleeding Too Much after Baby Is Born
Actors: Ask for volunteers to play Arely and her husband (both trained in CMNH), and two friends. The
Facilitator plays the mother-in-law, who is also trained in CMNH.
Props:
MATERIAL NEEDED
TAC booklet: Bleeding
Too Much After Baby
is Born,
Role play props
Things for a clean place, things for clean helpers, things for washing, cloth with red stain to look like
blood, gloves/hand covers, clean cloth to cover Arely, clean pads (or rags/cloths) for bleeding, cup with
locally available liquids, models, waterproof container, transportation, pretend money
Situation: Explain who the volunteers are pretending to be and tell the situation to those watching. Say: The
family has completed the CMNH meetings. Arely has just given birth with the help of the mother-in-law
and is cleaned up. Arely took misoprostol according to country practice. The placenta is in a
waterproof container. Arely returns from passing urine looking very weak. She says there were two
very big blood clots and now the bleeding is continuous.
Demonstration:
1. The mother-in-law immediately calls for help: Help, someone help us please!!!
2. Right away the mother-in-law helps Arely lie down and rubs Arely’s womb.
3. The husband and a friend come in. The mother-in-law says to the husband: Arely is bleeding too much
and needs to go to the THW. Quick! Get transportation and money!
4. The friend helps Arely put the baby to her breast. The friend asks the mother-in-law: Can you put
something inside Arely’s birth canal to stop the bleeding?
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 31
TIME
CONTENT
MATERIAL NEEDED
5. The mother-in-law says: I learned at the CMNH meetings not to put anything in the birth canal because
this can make Arely more sick.
6. The mother-in-law puts on gloves and continues to rub Arely’s womb. She helps Arely squat and pass
urine and then puts a pad firmly between Arely’s legs.
7. The mother-in-law begins to do a two-hand hold of the womb.
8. The mother-in-law asks one friend to put on gloves. She shows the friend how to do two-hand hold.
9. The mother-in-law places a long cloth between Arely’s legs on the place where they see the bleeding
coming. She then ties another cloth around her waist and pulls the long cloth between her legs tight to
help slow the bleeding.
10. The second friend gives Arely some fluids to drink. The friend puts on gloves and removes the bloodsoiled covers. As the first friend continues to do two-hand hold, she covers Arely with a clean cloth but
does not remove the cloth between her legs.
11. Arely’s husband comes rushing with the transportation and money. They go to the THW.
12. On the way to the THW, the mother-in-law continues the two-hand hold of the womb. The husband
helps Arely with referral by helping her to lie down, covering her, and giving her fluids to drink.
13. The friend washes Arely’s things soiled with blood with soap and water (if in health facility
decontaminate linen if possible). When she is finished, she puts the things out to dry in the sun. She
washes her hands with soap and water.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 32
TIME
CONTENT
Say: We have demonstrated the two-hand hold procedure (external bimanual compression). To perform this
procedure in the home, or during referral:
• Put on hand covers if possible to prevent getting blood on your hands.
• Help the woman lie on her back
• Rub the womb
• Place one hand on the abdomen behind the womb
• Place the other hand flat and low on the abdomen
• Press the hands together
• Hold the womb for at least 10 minutes.
 If the womb is hard and the bleeding stops after 10 minutes, you can stop holding the womb. Check
the bleeding every 5 minutes while continuing to hold the womb.
 If the womb is not hard or there is bleeding, continue the two-hand hold and put pressure on the
perineum. Go to the health facility watching for soft womb or bleeding.
Ask volunteers to read the steps on the flip chart or the TAC Booklet.
Shock Care
Identify signs and symptoms of shock.
Describe action for shock.
SHOCK SIGNS AND SYMPTOMS
• Ask participants: what is shock.
Woman
Newborn
• Ask a volunteer to read symptoms and
signs of shock. Discuss with group.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Heart Rate
Fast
(above 60)
Cold, clammy,
pallor, sweaty
Skin
Cold, pallor
Breath
Fast, shallow
(above 30)
Breathing
Slow
(less than 30)
Brain
(CNS)
Anxious,
restless, weak
Brain (CNS)
Lethargy,
no response
Pulse
Weak, fast
(110 or above)
BP
Low (systolic
below 90)
Skin
MATERIAL NEEDED
Flipchart and pens,
Write two-hand hold
procedure on flip
chart and post on wall
during discussion.
SCNBC Reference
Shock: Overview
Flipchart to post:
Shock signs and
symptoms
Page 33
TIME
CONTENT
MATERIAL NEEDED
Shock Care
Actors: Ask for volunteers to play Kamal, the husband, another family member, and the THW. The Facilitator
plays the family member, Auntie Sue, who attended CMNH and Mothers Nutrition community
meetings.
TAC Booklet: Woman
Referral, Bleeding Too
Much After Baby Is
Born
Role Play Props
Props:
Pretend money, transportation, blanket, cup with liquids to drink, sugar, salt, spoon, Take Action
Card booklet
Situation: Explain who the volunteers are pretending to be, and tell the situation to those watching. Say: I am
Auntie Sue who attended CMNH community meetings. When I see my niece Kamal, who delivered a
baby 6 hours ago, she looks very weak and pale. She is breathing very fast. She is lying in a pool of
blood. Her womb is hard. She cannot walk to the toilet by herself and feels too weak.
Demonstration:
1. As soon as she sees Kamal, Auntie Sue calls for help: Help us! Someone get the driver and
transportation! Kamal looks very weak, as if she is going to faint! Auntie Sue puts Kamal’s baby to her
breast, holds her womb with two hands and puts cloth firmly between her legs.
2. A family member goes for transportation and Kamal’s husband goes for money. They go to the
referral place as soon as transportation is ready.
3. While waiting and on the way to the THW, Auntie Sue:
• Helps Kamal lie down on her side.
• Covers Kamal.
• Prepares a cup of liquid with sugar and salt to drink and gives to Kamal.
• Continues to give Kamal about one cup of the liquid every hour or more often if Kamal wants to
drink during the trip to the referral place.
4. When they arrive at the THW's place, Auntie Sue goes straight to the THW just like she learned in the
CMNH meetings. She does not wait in line. She does not just sit and wait. Kamal is very, very sick and
needs help as soon as possible from people who know best about pregnant women.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 34
TIME
CONTENT
MATERIAL NEEDED
5. Auntie Sue tells the THW: My niece is delivered her baby 6 hours ago. She became very weak about 2
hours ago. She cannot even walk to the toilet alone. She has been bleeding since birth. She took 3
tablets of misoprostol after she delivered the placenta. I have given her one cup of water with sugar
and salt every hour during the journey to this place.
The THW explains everything to the family and shows them where to wait. Auntie Sue and the family listen
carefully to the THW instructions. Auntie Sue and the family do not leave in case they are needed for
something.
Summary:
Ask participants what they will do next when Kamal reaches their health facility? Write responses on flipchart
for discussion. What will they do in health post, health center, hospital? How are they similar? How are they
different?
Practice demonstration during quiet times in clinical or in classroom.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 35
Topic: INFECTION PREVENTION
Time: 2 Hours
General Objective:
Homework:
TIME
3 min
10 min
At the end of the session, participants will be able to use Standard Precautions for infection prevention, as described in the
learning guide, to protect themselves and clients when giving care.
Read SCBNC Chapter 2
CONTENT
MATERIALS NEEDED
Ask one participant to volunteer to read the general objective to the group from the flip chart.
Flip chart with
objective
Describe Standard Precautions for infection prevention.
Flip chart:
Standard
Say: Many infections can be prevented by always using Standard Precautions.
Precautions
Ask participants: What are Standard Precautions? Answer: Routine procedures that protect both health
workers and patients from contact with infectious materials such as blood, body fluids, etc.
Using Standard Precautions means to always:
Consider every person potentially infectious
(even the baby and medical staff).
Wear protective clothing when needed
(gloves, eye protection, aprons, closed
shoes).
Process patient care instruments and
equipment safely.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Masking Tape
Wash your hands correctly.
Prevent injuries with sharps.
Keep the environment clean.
Dispose of wastes safely.
Page 36
10 min
Discuss hand hygiene practices that will prevent infection (when to wash hands, what can be used to
wash hands, fingernail hygiene, etc).
Ask participants:
•
What is the most important infection prevention practice in the world? Answer: Hand washing
•
What percent of germs are killed by washing your hands with plain water? Can anyone guess?
Answer: 50%
•
What percent of germs are killed by washing your hands with soap and water, and then rinsing?
Can anyone guess? Answer: 80%
•
When should you wash your hands? After participants have fully responded, look at information on
the flip chart.
Demonstrate hand washing with soap and water.
15 mins
10 mins
Ask volunteer participant to demonstrate the steps of handwashing, while another participant reads the
steps. After the demonstration, ask observers for feedback. Give any needed suggestions. Congratulate the
participant on her demonstration.
1. Wet hands with running water and apply soap. (Ask: Why should nails be short and why should
handwashing include cleaning under the nails? Answer: Area under nails has the highest germ
count on the hand and can be a place for bacteria and fungi to grow. How short should nails be
kept? Answer: No more than 3 mm.)
2. If using a soap bar, rinse off bar before placing in soap holder.
3. Rub together all surfaces of the hands, including wrists, between fingers, palm and back of the
hands and under fingernails.
4. Wash for 15 seconds (as long as it takes to slowly sing “twinkle, twinkle little star. How I wonder
what you are. Up above the sky so high. Like a diamond in the sky.” May adapt to local song)
5. Rinse under a stream of running water: tap, or pouring water from container.
6. Dry hands: air dry or use clean cloth.
Flip chart:
Always Wash Hands
Equipment/supplies:
Container with clean
water, Soap, Bowl,
Soap bar holder,
Clean cloth,
Container to pour
water.
Describe ways to protect yourself from infection when giving care (use of personal protective equipment
and preventing splashes). Tell participants that you are very impressed with their knowledge about
infection prevention.
Explain that you do have more questions:
• Ask, what personal protection can health care providers use? When should the protection be used?
After participants have fully responded, look at the information on the flip chart.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 37
•
•
10 mins
Ask: How can splashes be dangerous to health care workers? Answer: Splashes of bodily fluids can
carry germs. If the splashes have contact with our eyes or mucus membranes, the germs can enter
our body and infect us.
Ask: Participants to look at “Preventing Splashing of Body Fluids” on flip chart. Ask one participants
to read. Ask participants to compare personal protection for splashing body fluids at facility and
home, any differences, any adaptations of clothing?
PREVENTING SPLASHING OF BODY FLUIDS:
1. Wear protective glasses when there is a chance of getting splashed with body fluids.
2. When cutting umbilical cord: (a) milk cord toward the placenta before tying /clamping, (b)
cover cord with hand/gauze while cutting.
3. Remove contaminated gloves carefully:
a. Rinse the outside of gloves while on your hands in decontamination solution
b. Remove gloves by slowly pulling them down from the cuff, turning them inside out
c. Put gloves in decontamination solution for at least 10 minutes
d. Bury gloves along with other wastes (unless reusing gloves).
Explain methods of safe waste disposal.
Show the flip chart “Ways to Dispose of Contaminated Waste.” Ask participants to take turns reading
the chart.
• Ask: How can you make a pit “safe” to use for contaminated waste? How can you safely dispose of
wastes at home?
• Ask: Where is your pit at the health post? Where is the pit at the hospital?
• Show the flip chart again. Thank participants for their answers and ask if they have additional
questions.
Flip chart:
Ways to Dispose of
Contaminated
Waste
Demonstrate how to process patient care instruments and supplies safely. NOTE BEFORE DOING THIS
DEMONSTRATION MAKE SURE THE FACILITIES HAVE THE EQUIPMENT AND INSTRUMENTS USED FOR
DEMONSTRATION – Essential: cord tie and cord cutting instrument, gloves, apron
10 mins
•
•
•
Before beginning the demonstration, have the demonstration table arranged with all needed
equipment and supplies the same as in the facility.
Ask participants to follow along with their learning guide and tell you what the next step is in the
demonstration.
Explain that in this demonstration you have just completed a delivery. You have your contaminated
instruments and equipment. See materials list and adjust as needed. You are still wearing your
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 38
apron and have on contaminated gloves from the delivery. You will demonstrate doing the 4 steps
for processing instruments and supplies.
Demonstrate how to do the four steps for processing instruments and supplies. Trainer should
demonstrate slowly saying what you are doing:
15 mins
10 mins
Step 1: Decontaminate – kills viruses and many other germs, items safer to handle to during
cleaning, items easier to clean
1. Prepare decontamination solution (if Clorox 5% chlorine, use 9 parts water to 1 part chlorine to
make a 0.5% solution, if JIK 3.5% 6 parts water to 1 part chlorine)
2. Open instruments before putting into solution
3. Put all instruments and supplies into the solution
4. Flush tubing / bulb syringe with solution – 3 times (show how to suck up the water and push it out)
5. With needle attached, flush syringes 3 times and fill before placing in sharps box
6. Place placenta in separate container of decontamination solution and soak for 10 minutes
7. While wearing apron, wipe front of apron with solution. Make sure all visible soil is removed from
gloves you are wearing.
8. Soak items for 10 minutes
9. Remove all items (disposable items in container to bury or burn) and other items in container for
soapy water.
10. Rinse gloves in decontamination solution. Rinse contaminated gloved hands in solution. Remove
and place in solution. (SAFELY REMOVE GLOVES: Pull cuff of first glove part way down using the
other gloved hand. Remove second glove by using gloved fingers from first hand to pull your
second glove off as you turn glove inside out. Completely remove first glove touching only the
inside of the glove.)
Step 2: Clean and Rinse – removes soil (blood, fluids, dirt), reduces germs, makes high-level disinfection
effective
1. Put on gloves. Heavy cleaning gloves if available.
2. Make soapy water solution for cleaning step if not ready.
3. Put disposable items in container to bury or burn if not done above in number 9.
4. Move all items from decontamination solution and put in soapy water solution. Make sure
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Demonstration
Equipment:
- Chlorine or bottle
labeled chlorine
- Dish soap
- Sharps box
- Instrument tray or
kidney dish
- Catheter
- Needle/syringe
- Scissor
- Razor blade
- Hemostat
- 3 plastic pails labeled:
decontaminate,
soapy water, rinse
water
- Small brush like
toothbrush
- Delivery gloves
- Heavy cleaning gloves
- Pot with lid
- Transfer forceps with
string attached
- Container for transfer
forceps
- Waste container
Page 39
10 mins
for demo
10 mins
instruments are open. Wash them.
• Flush tubing / bulb syringe 3 times with soapy water
• Use brush to clean all joints on instruments
5. Put items into clean water once they are washed
• Flush tubing / bulb syringe 3 times making sure all water and dirt are removed
6. Remove placenta from decontamination solution and put in waterproof container for burying
7. Clean apron with soapy water and rinse with clean water, hang to dry
8. Wash and rinse gloves.
9. Remove heavy gloves and hang to dry (depending on type of gloves).
10. Wash and dry hands.
Step 3: High-Level Disinfection (HLD) by Boiling [or Steaming] – kills all germs except some
endospores like tetanus [note trainers use boiling demonstration]
1. Use transfer forceps (cheatle) to put items in boiler/steamer (depending on practice including
tubing, bulb syringes, gloves, syringes)
2. Make sure instruments are open. If disinfecting instrument tray, put tray upside down, on top of all
instruments
3. Put transfer forceps (cheatle) that has a string attached on top of everything (to pick up
instruments after boiling/steaming).
4. Boiling: fill boiler with enough water so that all items are covered
5. Cover pot
6. Bring to boil
7. When boiling starts, time boiling/steaming for 20 minutes
8. After 20 minutes, use cooled disinfected forceps with string to remove instrument tray and fill tray
with HLD instruments
9. Air-dry instruments and supplies
10. Cover instrument tray after instruments are dried
11. Put forceps with string in forceps stand that is high-level disinfected. Remove string.
Step 4: Storage – correct storage is as important as the steps of decontamination, cleaning, and HLD.
1. No solutions. Do not store instruments in solutions. Germs can live and grow in both antiseptic and
disinfectant solutions
2. Clean storage area. Keep storage area clean, dry, and dust-free
3. Off the floor. Packs and containers should be stored up off of the floor
4. No cardboard boxes. Do not use cardboard boxes as they collect dust and insects like to eat and live
in them
5. Date and rotate the items (first in / first out)
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 40
6. Length of storage: Use HLD items immediately or keep them covered in a HLD or sterile container
up to 1 week.
After the demonstration, ask for questions.
For evaluation: Ask each participant to pick one question out of the grab bag or you can just ask the
questions. Copy next page and cut question strips. Fold and place in a bag or basket.
INFECTION PREVENTION GRAB BAG KEY
After performing a delivery, you should wash gloved hands in the sink. (Answer: False, you should wash gloved
hands in 0.5% chlorine solution.)
2. Immediately after delivery, the labor bed should be cleaned with warm soapy water. (Answer: False, the labor
bed should be cleaned with 0.5% chlorine solution.)
3. After delivery, when handling a baby before it has been bathed, what should you wear to prevent infection?
(Answer: Apron and gloves.)
4. What should you do with the placenta until it is buried? (Answer: Put in covered container with 0.5% chlorine.)
5. How do you mix 0.5% chlorine? (Answer: If 5% chlorine, 9 parts water to 1 part chlorine….. If 3.5%, 6 parts water
to 1 part chlorine.)
6. How long should you wash your hands with soap and water? (Answer: 15 seconds, surgical scrub 3 minutes)
7. Using a brush to wash your hands will decrease the risk of infection. (Answer: False, using a brush will increase
the risk of infection.)
8. Killing germs: What percentage of germs does washing your hands with soap and water, and then rinsing, kill?
(Answer: 80%)
9. Killing germs: What percentage of germs does washing your hands with plain water kill? (Answer: 50%)
10. How do you make soapy water solution? (Use small amount of soap detergent or a soap bar and mix it in the
water until some bubbles form)
1.
15 mins
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Infection prevention
grab bag questions
or just ask the
questions (from
below): Cut up
questions so each
question is on its
own piece of paper.
Put questions into a
bag.
Page 41
INFECTION PREVENTION GRAB BAG QUESTIONS
1. After performing a delivery, you should wash gloved hands in the sink. True or false?
2. Immediately after delivery, the labor bed should be cleaned with warm soapy water.
3. After delivery, when handling a baby before it has been bathed, what should you wear to prevent infection?
4. What should you do with the placenta until it is buried?
5. How do you mix 0.5% chlorine?
6. How long should you wash your hands with soap and water?
7. Using a brush to wash your hands will decrease the risk of infection. True or false?
8. Killing germs, two-part question:
a. What percentage of germs does washing your hands with soap and water, and then rinsing, kill?
b. What percentage of germs does washing your hands with plain water kill?
9. How do you make soapy water solution?
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 42
TOPIC: NEWBORN RESUSCITATION (HELPING BABY BREATHE)
TIME: 2 HOURS
General Objective:
At the end of the session, participants will be able to describe signs of a baby having trouble breathing, demonstrate newborn
resuscitation according to the Newborn Resuscitation Learning Guide.
Participants Tools:
Handout: Newborn resuscitation steps, CMNH TAC Booklet Baby Has Trouble Breathing;
Homework (to be completed before lesson):
Read Reference Text, Chapter 6E: Newborn Resuscitation section.
TIME
CONTENT
MATERIALS
NEEDED
Introduction: Ask one participant to volunteer to read the objective to the group from the flip chart.
Ask participants, “Has anyone had the experience of caring for a baby who does not breathe at birth?”
Of those who raise their hands, ask one or two to describe the actions they took to care for the baby.
Thank everyone for their experiences.
Flip chart with
objectives
10 min
Describe possible signs a baby may have trouble breathing at birth.
• Ask participants: How can a woman’s condition cause breathing problems for baby? What are
possible signs that a baby may have trouble breathing at birth? See picture partograph.
Flip chart and
markers
Picture partograph
10 min
Describe how to care for a baby at birth
Flip chart, paper
and markers
15 min
Newborn
Resuscitation Steps
Ask: Someone tell us the steps of immediate newborn care. Ask trainer or participant to put the answers
on a flip chart or board. Answers:
• LOOK at baby breathing while doing steps
• DRY with clean dry cloth
• WARM remove wet cloth and cover with second clean dry cloth
• Delay cord clamping
• Give to mother skin to skin
Ask: Are the immediate newborn care steps the same for all babies. Answer: Yes, we do the same
newborn care steps for all babies. If a baby has trouble breathing we need to also help the baby breathe.
15 min
Describe the preparation needed and why we should be ready all of the time for newborn resuscitation
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 43
TIME
CONTENT
Ask: What preparation must be ready to help a baby breathe. Answers:
• Monitor woman and baby during labor to identify a baby that may have breathing problems – see
picture partograph.
• A warm place with no drafts
• All equipment in one place
• A helper or assistant
• Flat place to help baby breathe
Ask: Why is it important to be ready (equipment ready) to help a baby breathe at all times.
• We can not always tell when a baby will have trouble breathing
• If things are not ready, it takes too much time to start helping the baby breathe and the baby can
get brain damage or even die during that time
Ask: What equipment is needed for newborn resuscitation using an ambu bag? Answer: Pick up each
piece of equipment and ask participants to name it. Lay it on the demonstration table as it is named.
Identify any equipment not named by participants.
• Why should the table be flat? Answer: Puts less pressure in baby’s brain.
• Why do we need 3 clean dry cloths? Answer: One to dry baby, one to warm baby, one to position
baby.
• Why is it so important to cover a baby’s head? Answer: The head size in relation to the body size is
much larger than an adult. More skin is exposed on the head so the baby loses heat quickly
through the head.
30 min
Neonatal Resuscitation: Initial steps of Newborn Care: The First 30 Seconds
Explain to participants. As a participant reads the steps from the learning guide, you will demonstrate
slowly and ask questions.
Dry and Warm
Dry the baby with first cloth from head to toe.
• Ask: Why is it important to dry and warm a baby? Answer: So the baby does not get cold
(hypothermia). Getting cold can make it more difficult for the baby to breath (depress respirations)
and increase the risk of infection and death.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS
NEEDED
Three (3) towels,
cloths, or receiving
blankets: one to
dry, one to wrap,
one for positioning
the baby.
Suction bulb, Apron,
Gauze, Watch with
second hand,
Newborn ambu bag
Masks: size 1
(newborn), 0
(premie)
Clean gloves
Resuscitation
equipment as listed
above, Flat surface,
Newborn
resuscitation model
Page 44
TIME
CONTENT
MATERIALS
NEEDED
Warm the baby by removing first towel and wrapping with second cloth.
• Ask: Why do we remove the first cloth after we use it? Answer: The cloth is wet and will not help
the baby stay warm.
Hint to Quickly Wrap a Baby
Have a rectangular cloth on the infant resuscitation table with the longer side from head to toe.
Make sure there is about 4 inches (10 cm) of cloth above the baby’s head, and about 12 inches
(30 cm) of cloth below the baby’s feet. With 2 quick movements: 1) grasp the top corners of the
cloth and pull it down, covering the baby’s head and arms, and 2) grasp the bottom corners of the
cloth and pull it up, covering the baby’s legs and abdomen up to the umbilicus. This should leave
the face and chest open.
•
•
Ask: Why do we keep the face and upper chest uncovered when we wrap the baby in the 2nd
cloth? Answer: To see baby’s breathing.
Ask: Why is it important to cover a baby’s head? Answer: The head size in relation to the body size
is much larger than an adult. More skin is exposed on the head so the baby loses heat quickly
through the head.
Position by placing a small folded cloth under the baby’s shoulders to that the head is slightly extended
in the “sniffing” position.
• Ask: What happens when the baby’s head is not extended at all or is extended too much (show
this with the model)? Answer: The airway closes so air cannot go in or out.
Suction baby with a bulb syringe.
• Ask: Why do you suction the mouth first then the nose? Answer: The mouth has more secretions
than the nose, so if you suction the nose first the baby may breathe in the mouth secretions.
• Ask: How do you use a suction bulb? Squeeze (compress) bulb before inserting in mouth, release
bulb to suction, remove from mouth and squeeze again to empty contents. Repeat for each nostril
after suctioning the mouth. Do not insert suction bulb or suction catheter more than 5 cm into the
mouth or 3 cm into the nose.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 45
TIME
CONTENT
•
MATERIALS
NEEDED
Ask: If there is meconium in the amniotic fluid, when and how should you suction the baby?
Answer: After delivery, do not suction the head on the perineum:
 If baby is vigorous: No SPECIAL suctioning of baby is needed.
 If baby is NOT vigorous: Suction baby immediately after birth (first mouth then nose).
Stimulate the baby by rubbing up and down baby’s spine with the heel of your hand.
• Ask: To stimulate the baby, do you need to remove the cloth? Answer: No, you can stimulate the
baby through the cloth.
Group Practice on Stimulation:
Ask participants to stand up and get into one or 2 lines, each person facing the other person’s back,
to practice stimulation. Ask for a volunteer on whose back you can demonstrate stimulation. Stand
where everyone can see you. Show: 1) how to use the heel of your hand, 2) the firmness, and 3) the
speed to move your hand. Then ask each person to stimulate the back of the person in front of
them. Check each person doing the stimulation and give advice if help is needed. Then have
everyone turn so the line is going in the opposite direction. Again ask everyone to stimulate the
back of the person in front of them and give help as needed.
45 min
Participants practice the skills of dry, warm, position, suction, and stimulate the baby, and look to see if
the baby is breathing. Ask the participants to work in teams of two. Each team will first train to: dry,
warm, position, suction, stimulate the baby. Ask the participants to time each other. It should not take
more than 30 seconds to do this. Both participants should practice many times so that they feel
confident in performing the tasks.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Materials for each
group:
3 cloths,
Watch with second
hand,
Baby model,
suction bulb
Page 46
TIME
15 min
CONTENT
Breathe for the Baby:
•
•
Ask: how long should it take from the time to decide to start resuscitation to time to start
breathing for the baby? Answer: no more than 30 seconds.
Ask: is oxygen needed to resuscitate a baby? Answer: Most babies can be resuscitated without
oxygen.
MATERIALS
NEEDED
Apron,
Gauze,
Newborn ambu bag
- Masks: size 1
(newborn), 0
(premie)
Clean gloves
(Baby has been dried (wet cloth removed), warmed with second cloth, positioned, suctioned,
stimulated and now is wrapped with chest exposed, positioned in ‘sniffing’ position.)
IF BABY IS NOT BREATHING:
Note to Trainer: Only teach to participants if they have a working Ambu bag at their facility.








Breathe with Ambu Bag:
 Place mask on baby’s face covering mouth and nose
 Form a seal between the mask and the baby’s face
 Squeeze the bag two times and look to see if the baby’s chest moved (rises)
 If chest not rising: reposition, suction, replace mask, squeeze bag two times.
 If chest rises: squeeze bag 40 times/minute and watch chest move up and
down
 Breathe for 1 minute, stop, check if baby is breathing on its own.
 If not breathing 30 times/minute, replace mask and breathe 40
•
times/minute
 If breathing 30 times or more/minute (normal):
•
Put skin-to-skin, watch breathing, normal care
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 47
TIME
CONTENT
WHEN THERE IS NO AMBU BAG – an emergency procedure to help the baby and to teach all family
members.
Look to see if baby is breathing while: Baby has been dried (wet cloth removed), warmed with dry
cloth, positioned, suctioned, stimulated and now is wrapped with chest exposed, positioned in
‘sniffing’ position.
MATERIALS
NEEDED
(for mouth to
mouth: 2 small
bowls one with
soapy water and
one with clear
water)
Breathe Using Mouth to Mouth: see CMNH TAC Booklet Helping Baby Breathe
 If baby is not breathing, call for help
 Wipe mouth and nose
 Rub baby’s back firmly and quickly
 If baby is still not breathing use bulb syringe or mother may mouth suck

FOR NONFAMILY MEMBER: wash baby’s face first with soapy water, then with clear water.
Place gauze over baby’s mouth and nose (health worker if comfortable doing this).


Place or hold baby on firm surface, in sniffing position to keep airway open.
Blow two puffs using only the air in your cheeks and look for chest to rise.
 If chest not rising: reposition, suction, blow two times again
 If chest rises: breathe 40 puffs/minute and watch chest move up and down
 Continue breathing:
If starts to breathe: Put skin-to-skin, watch breathing, rub back, go
to referral site (call doctor) as baby may be sick and need more
help
If not breathing after 20 minutes, stop breathing for the baby,
explain to the mother the baby did not live, and give support.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 48
TIME
CONTENT
MATERIALS
NEEDED
Participants practice in groups: (in classroom or during clinical). Divide participants in groups. Ask them
to take turns reading the learning guide or TAC Booklet and performing the skill until everyone has
performed the skill. After each demonstration feedback should be done:
 Participant does self evaluation first looking at the learning guide
 Observers give feedback next, Then facilitator gives feed back as needed
10 min
Describe care for a baby after resuscitation.
Ask: What should you do after resuscitation?
Answers: REFER, and Place the baby skin to skin, rub baby’s back, do not bathe until at least 24 hours after
baby is born, help the mother with breastfeeding, watch baby for any trouble breathing (not breathing,
flaring nostrils, gasping, change in color)
10 min
How to Help When a Family Loses a Baby. Ask: participants to open the Safe and Clean Birth and
Newborn Care book to When A Family Loses a Baby. Ask participants to read a sentence, repeat
information in their own words:
 If a baby dies, the mother, father, and other family members will have many feelings: Answer
(people have grief different ways.)
 Some feel angry, some try not to think about what happened, and some are overwhelmed with





grief: Answer (people can fell many different ways when there is a death)
For many families, the death of a baby is a spiritual time, when religious practices are important :
Answer (watch and listen for religious or cultural practices that may need support like a religious
person called, etc)
As a health worker, you can support the family in the ways that are used in your community and
also in the ways that feel best to that family : Answer (health worker works and gets to know people
in the community- see and hear needs)
Family members may want someone to talk about their pain, or they may want someone to help
with the work of the household: Answer (family may need someone to be with them to listen or
help do things)
A mother who loses a baby may also need physical help: Answer (the mother will need postpartum
care)
She will have all the needs of any other woman who just gave birth: Answer (offer postpartum care)
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 49
TIME
CONTENT
MATERIALS
NEEDED
 She will also have breast milk and her breasts may become painfully engorged: Answer (she will
need help with painful breasts)
Infection prevention care for reusable equipment (as time permits). See infection prevention lesson plan.
 Bag and mask: Wipe bag with 0.5% chlorine, wash off with soapy, rinse with clear water and air dry.
DO NOT IMMERSE THE BAG IN SOLUTION.
 Mucus extractors, bulb syringes, face masks: decontaminate, wash, rinse, air dry.
 Put the bag and mask back together when everything is dry and test to make sure it is working.
Summary:
Ask participants if any questions.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Page 50
TOPIC: CARE OF MOTHER AND BABY AFTER BIRTH
TIME: 1.5 HOURS
General Objective:
Participants will review and update their knowledge and skills to provide care to women and baby during the 6 weeks after the
baby is born. This is the second part of postpartum care.
Participant Tools:
CMNH TAC Booklet, SCBNC: A Reference for Health Extension Workers.
Homework (to be completed before lesson): Read reference text, Chapter 7: Postpartum Care; Review Learning Guide: Care During Stage 4 Labor. Review
TAC Booklet: Woman and Baby Problems, Prevent Baby Problems After Baby is Born: Other Actions.
TIME
5 min
10 min
CONTENT
Introduction
Introduce the topic. Ask a participant to volunteer to read the general objective.
Say: Both the woman and her newborn are in danger during the postpartum period (the six weeks following
delivery). The time of highest risk of death for women and their newborns is after birth. An estimated 65% of
all maternal deaths occur after delivery, and almost 50% of these postpartum deaths occur within the first 24
hours after delivery. The first 24 hours in a newborn’s life is also critical. Two thirds of infant deaths occur
within the first week after birth. More than 50% of all infant deaths happen in the first 24 hours after birth.
Care at critical times during the postpartum period may prevent some of these deaths.
Describe the significance of postpartum care for women and their babies.
•
Ask: What is postpartum care? Answer: Care given to a woman and her baby from the time of birth until
6 weeks after birth.
•
Ask: Why is postpartum care important to the mother and to the baby? Answer: 1) To prevent any
mother and baby problems, 2) To care for problems, 3) To counsel the woman and her family about
normal care and signs of problems (complications) for both herself and baby, 4) To screen the mother
and baby for any problems.
•
Ask: What should be the timing of postpartum care of mother and baby? Answer: 1) First 6 hours as
this is when most women have problems and even die or As soon as possible after the baby is born to
make sure the baby is breathing and is warm and mother is not bleeding. 2) At least two additional
visits during the first week of life or at least before baby is 6 weeks old to make sure breast feeding is
going well, to assess for problems and counsel about good health habits. 3) At 6 weeks to make sure
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS NEEDED
Flip Chart with objective
Write Significance of
Postpartum Care for
Women and Their
Newborns on flip chart
before session to post on
wall during introduction
Flip chart or board
Markers for flip chart or
board.
Lesson Plan and TAC
Booklet
Page 51
TIME
20 min
CONTENT
woman’s recovery is going well, the baby has no problems and is gaining weight, to counsel the
woman/family about family planning.
Identify danger signs for women and newborns during the postpartum 6 weeks.
• Introduce the topic. Ask participants to answer the following questions. Write responses on flip chart or
board.
•
Ask What danger signs did we talk about in the first 48 hours after birth?
Postpartum Woman
Newborn Baby
 Too much bleeding
 Trouble breathing: too slow, too fast
 Fever
 Low birth weight, too small
 Abdominal pain
 Not able to suck or not feeding well
 Foul smelling discharge from vagina
 Convulsions, fits, limp, not active
 Convulsions, fits
 Temperature: too hot, too cold
 Signs of infection: redness or pus discharge in
eyes. umbilicus, skin
•
What other problems may there be Women and Newborns during the postpartum 6 weeks?
Other Problems for Postpartum Women
Other Problems for Newborns
 General: thrush, skin lesions, weight loss,
persistent cough, painful hemorrhoids
 Bleeding: cord stump, circumcision
 Breast: painful and swollen, cracks on
 Dehydration: tenting skin
nipples, tender & red, soft & yellow area,
 Mother died
no/ little milk
 Not able to move one arm or leg
 Perineum: pain, swelling, bleeding
 Scalp: swelling, depressed or bulging
 Discharge: red
fontanels
 Incontinence: leaking urine or feces (fistula)  Skin: jaundice, color blue or pale
 Woman not interested in her baby, is sad or  Stools & vomiting: watery stools, no stool by
depressed, abused
third day
 Baby died
CMNH Clinical Update for Health Workers Lesson Plan July 2013
MATERIALS NEEDED
Flip chart or board and
markers
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45 min
Describe care visits of the woman and baby immediately after the baby is born.
Say, We have learned to monitor and care for the woman and baby after the baby is born in the first 6 hours.
• Ask: How often should the woman and baby be monitored in the first 6 hours? Answers: After delivery of
placenta, monitor woman and baby every 15 minutes for 2 hours, every 30 minutes for 1 hour, every 1 hour for 3
hours
•
Flip Chart,
Reference text, chapter
7A 7B, Record
participants responses on
flip chart
Ask: What should be monitored immediately after birth if attending the birth? Answers: 1) Check mother’s
blood pressure and pulse.2) Check womb to ensure that it is firm. Show mother how to massage womb. 3) Check
amount of vaginal bleeding. 4) Check baby’s breathing and color.
Say, we are going to watch a role play of care for woman and baby after the baby is born (postpartum care).
Demonstration: Prevent Problems after Baby Is Born
Actors: Ask for volunteers to play Shahlani (who gave birth about 6 hours ago), the mother-in-law, and
the husband. The facilitator plays the birth attendant trained in CMNH.
xi
Props: Tea and sugar, Take Action Card booklet
Situation: Explain who the volunteers are pretending to be, and tell the situation to those watching. Say: We
are in the house of Shahlani and her husband. The family are visiting with Shahlani who had her baby about 6
hours ago. Shahlani has just finished eating and they are having tea.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
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Prevent Problems after Baby Is Born: Other Actions
1. The birth attendant arrives and greets everyone.
2.
The birth attendant looks at the Take Action Card: Prevent Problems after Baby Is Born—
Other Actions with Shahlani. They talk about what to do to prevent problems. The birth
attendant says:
 Bathe yourself as needed. Bathe your baby after 24 hours. Wash around the cord stump
every day beginning tomorrow. Let the cord stump dry in the air.
 Pass urine often. Wash your genitals from front to back each time after you pass urine.
 Drink one cup liquid at least every time you breastfeed. Eat at least four times a day.
 Breastfeed the baby in a good sucking position, at least every two hours during the day. xii
Breastfeed often to give the baby nourishment, and breastfeed at least once during the
night to prevent another pregnancy too soon. xiii
 Do not work or lift anything for 12 days. Keep the baby warm. Sleep with your baby using
bed net (in malaria areas).
 Use a condom when ready for sexual relations.
3. The birth attendant says to Shahlani and family members: You must remember to WATCH
FOR PROBLEMS: xiv
 Bleeding is very serious. It is not normal to bleed too much after birth. Any amount of
continuous bleeding is not normal. Large, fist-sized clots are not normal.
 If Shahlani feels weak or faints, it is very serious.
 REFERRAL is necessary for all problems.
 See the THW after the baby is born to make sure the woman and baby are healthy and to
discuss family planning options.
4. The birth attendant reminds Shahlani and her family to watch for baby problems using the
Take Action Card: Baby Problems. xv All problems and sickness need THW help.
5. After taking tea, the birth attendant says good bye and leaves.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
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•
Ask why is the following care steps we heard in the role play discussed with the postpartum mother and
her family?
 Bathe yourself as needed. Bathe your baby after 24 hours. Wash around the cord stump every
day beginning tomorrow. Let the cord stump dry in the air. Answer: For mother - general
cleanliness and signs of infection. For baby - signs of infection, size of baby (not too small), and
warmth.
 Pass urine often. Wash your genitals from front to back each time after you pass urine. Answer:
Signs of infection, ask about amount of bleeding, feel womb for firmness, look at perineum for
bleeding, clots.
 Drink one cup liquid at least every time you breastfeed. Eat at least four times a day. Answer:
general well being and feels like eating and drinking.
 Breastfeed the baby in a good sucking position at least every two-three hours during the day.
Breastfeed often to give the baby nourishment and breastfeed at least once during the night to
prevent another pregnancy too soon. Answer: latching, position, sucking. Ask about bowel
movement and urination of baby.
 Do not work or lift anything for 12 days. Keep the baby warm. Sleep with your baby using bed
net (in malaria areas). Answer: how mother handles baby, is baby covered warmly, is mother
resting, is there a mosquito net.
 Use a condom when ready for sexual relations. Answer: is husband available to listen to advice,
to prevent infection and too early pregnancy.
•
15 min
Review the learning guide for counselling points during class as time permits or as homework.
Participants will take turns reading of the learning guide checklist. Ask participants about any part that is
not clear. For any questions or concerns, the trainer can ask other participants to respond before she
responds.
• Record all findings on the labor chart.
Summary: Review the significance of postpartum care for women and their newborns discussed at beginning
of session.
Ask participant to read on flip chart: Significance of Postpartum Care for Women and Their Newborns.
Ask questions about significance and timing of postpartum care.
Summary: Provide participants with paper. Ask the participants to list danger signs for women and their
newborns after birth. When completed, ask participants to read lists.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
Flip chart of:
Danger Signs for
Postpartum Women and
for Newborns.
Paper, pencil for
participants
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Significance of Postpartum Care for Women and Their Newborns
Both the woman and her newborn are in danger during the postpartum period (the six weeks following
delivery). The time of highest risk of death for mothers and for newborns is after birth. An estimated
65% of all maternal deaths occur after delivery, and almost 50% of these postpartum deaths occur
within the first 24 hours after delivery. The first 24 hours in a baby’s life is also critical. Two thirds of
infant deaths occur within the first week after birth. More than 50% of all infant deaths happen in
the first 24 hours after birth. Care at critical times during the postpartum period may prevent some of
these deaths.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
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Endnotes
i
Clinical practice: Participants divided into teams of 4. Clinical times for labor: 12:30 – 5:00, 6.00 - 10.00 LABOR CLINICAL: 2 participants/patient: one participant managing the labor, second participant
providing support.
• Activities during quiet times: Practice skills on models as needed, present cases: history, picture partograph, plan of care, outcome.
• Participants always have Clinical Update Skill Checklists (adapted Learning Guide 2nd, 3rd, 4th Stage) in Labor Ward and (ANC and Mothers Nutrition) in Antenatal Clinic (2 participants/patient).
ii
Marshall, M.A., Buffington, S.T., Beck, D.R., Clark, P.A. (2008). Life-saving skills manual for midwives (4th ed). Silver Spring, MD: American College of Nurse-Midwives, Module 1. Introduction
page 1.29.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
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iii
King, M., et al. (2003). Primary mother care and population. Stamford, UK: Spiegel Press. Retrieved from http://www.leeds.ac.uk/demographic.disentrapment.
Marshall, M.A. et al. (2008) Ibid.
v
King, M. et al. (2003) Ibid.
vi
The pictorial (picture) partograph was developed by health workers in Bangladesh. It has been adapted by the MaNHEP project for a trial in Ethiopia. The pictures are some of the same as
in the CMNH TAC Booklet which the community will use.
iv
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vii
“There is evidence that the exposure to mother’s blood from episiotomy (or lacerations) may increase mother-to-child HIV transmission” (WHO, 1999). To “minimize lacerations, mother
should be off her back and helped into a birthing position to minimize tearing – on her side, on her hands and knees, squatting, or semi-sitting….Providers (helpers) can coach the mother to
push the baby out slowly to avoid rapid expulsion and more tearing” (Israel & Kroeger, 2003).
“A woman will often depend on the [birth attendant’s] guidance to moderate her pushing effort, to allow an unhurried, gentle delivery of the head. This can be achieved…short pushing [or
grunting] efforts with periods of panting [or blowing], thus giving the tissues time to relax and stretch under pressure. Using this approach, several contractions or birth pains may occur before
the head crowns and is delivered” (Abstracted from Enkin et al., 2000).
viii. Dry, warm, position, clear airway (mucous extractor), stimulate. If the baby is breathing, give to mother for warmth, stimulation, love and breastfeeding. If the baby has trouble breathing,
is gasping, or is not breathing, help the baby breathe. This baby needs help right away (ventilation with ambu or mouth to mouth).
ix. Clean up things after the baby is born:
• Cord cutting tool: If a new razor blade was used, place the blade in the container for disposal. If scissors or a knife was used, clean the tool by placing it in the household bleach
solution (see endnote about prevent infection before birth, above). If a household bleach solution is not available, place the tool in soap/water solution to soak for ten minutes.
• Other disposable soiled things: put in the container for disposal.
• Aprons, linens, and clothing soiled with blood and fluid: put in a large pail to soak for ten minutes in chlorine bleach solution or in soap and water solution.
• Gloves: take off gloves by turning them inside out. Place the gloves with waste to be burned. Dry all nondisposable things in the sun.
x
Learning Aid 9 – Infection Prevention guidelines for Health Care Equipment. LSS 4th edition page 7.69.
xi
See the list of resources at the beginning of the meeting for a complete list of items for the demonstration.
xii.
An ideal pattern is feeding on demand (that is, whenever the baby wants to be fed) at least 10 to 12 times a day in the first few weeks after the baby is born, and 8 to 10 times a day
thereafter, including at least once at night in the first months. For LAM to be successful, daytime feedings should be no more than 4 hours apart, and night time feedings should be no more
than 6 hours apart. Some babies may not want to breastfeed 8–10 times a day and may want to sleep through the night. These babies may need gentle encouragement to breastfeed
more often so that LAM is successful in preventing another pregnancy (WHO & JHU/CCP, 2007).
LAM is a successful short-term family planning method when the following criteria are always followed:
• The woman’s menstrual periods have not returned,
• The baby is less than six months old, and
• The baby breastfeeds at least 10 times each 24 hours – no bottles, no water, nothing else
“ The baby feeds frequently with no more than 4-hour intervals between any two daytime feeds and no more than 6 hours between any two night time feeds, and the baby is not
receiving regular supplements.” (Farrell, 1995). If the baby does not demand to feed by crying or sucking on the fist, the mother should gently wake the baby and offer her breast to
the baby.
xiii
Signs That a Baby Is Getting Enough Breast Milk:
• The baby feeds at least eight to ten times in 24 hours.
• The baby wets at least six times in 24 hours and the urine is clear to pale yellow in color.
• The baby has frequent yellow, seedy stools after the first days.
• The baby seems contented, with hungry times, quiet awake times, and sleepy times. It is NOT a good sign if a baby sleeps all the time.
CMNH Clinical Update for Health Workers Lesson Plan July 2013
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xiv. Meeting 2 discusses signs of woman problems: too much bleeding; fever; pain of womb, breast, or when passing urine; headaches and fits; bad smelling vaginal drainage; malaria; and
other sicknesses. Other signs of sickness are: unexplained weight loss, chronic diarrhea, chronic thrush or yeast infection, chronic fever, and generalized dermatitis (adapt these HIV/AIDS
signs according to country protocols). Other sicknesses include: malaria, vaginal discharge (sexually transmitted infections), chronic cough with blood (tuberculosis), cough and fever with
dark sputum (pneumonia), and hookworm (parasites) (Israel & Kroeger, 2003; CARE, 1998)
xv. Baby problems include: poor or no sucking, trouble breathing, fits, looks too small, and fever and pus draining from eyes or draining from cord stump.
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