Seminar on Skilled Birth (SBA) ModulePresented by:Ms. Sangita Patir 1st yr. M.Sc. Nursing

Definition of SBA:WHO defines a skilled birth attendant as an accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.

Why skilled attendance at birth:Most of the obstetric complication are unpredictable.

Timely and life saving support and intervention are a must.Absence of midwifery skills- increased chances of casualty.

GOVERNMENT OF INDIAS SBA INITIATIVE:In an effort to reduce maternal mortality, the Government of India has taken policy initiatives to empower the ANMs/LHVs/SNs to make them competent for undertaking certain life saving measures. These measures are as follows: Permission to use Uterotonic drugs for prevention of PPH. Permission to use drugs in emergency situations prior to

referral for stabilizing the patient. Permission to perform basic procedures at community level in emergency situations. However , there is need to train these paramedical workers in the requisite skills as SBAs.

Objectives: The overall objective of SBA training is to enhance the knowledge and skills of the ANMs/ LHVs/ SNs posted at the outreach centres, sub-centres(SC),primary health centres( PHC), first referral units(FRUs), so that they are proficient in the skills needed for: Managing normal( uncomplicated) pregnancies, childbirth and the immediate postnatal period. Identifying and managing complications in women and newborns, and making referrals.

Knowledge- based objectives:By the end of the training, the trainees will be able to understand: The care and importance of the women and newborn during the antenatal period,

labour and postnatal period.Essential care of the new born and its importance for the health of the baby. Clinical features and initial management of the common obstetric complication during the antenatal period, labour and postnatal period. Importance of the quality of care provided by midwifery services, and the need for a client-centred approach, the use of infection prevention practices, community involvement and provision of a supportive environment for the mother and family.

Skilled- based objectives:By the end of the training, the trainees are expected to adapt at the following skills: Measuring the blood pressure, pulse and foetal heart rate(FHR), checking for pallor and oedema and determining the fundal height, foetal lie and presentation accurately. Performing haemoglobin estimation and testing for proteins and sugar. Counselling or birth preparedness, complication readiness, diet and rest, infant feeding, sex during pregnancy, domestic violence and contraception. Conducing pelvic assessment to determine pelvic adequacy. Plotting the partograph and knowing when to refer the women. Conducting safe deliveries, with active management of third stage of labour (AMTSL), using infection prevention practices. Providing essential newborn care and undertaking resuscitation of the newborn. Inserting an intravenous line for the management of shock and PPH and convulsion.

Giving deep intramuscular injection (magnesium sulphate). Preparing sterilized/ high- level disinfected (HLD) gloves and instruments. Follow infection prevention practices.

STRATEGY FOR TRAINING OF SKILLED BIRTH ATTENDANT(ANM/LHV/SN)

1.

2.

3.

Trainees profile /who is to be trained: Only those personal (ANM/SN) who have the core skills who are posted at: Functional FRUs or to be upgraded shortly and currently conducting deliver. CHCs and currently conducting deliveries. Posted at 24hrs PHCs or in a place which is to be upgraded and currently conducting deliveries. Trainers profile / who is to be trainer: The trainer should have worked in the training centre/ district hospital in one of the following capacities, and should have received 2-3 days orientation training at the state institute of health and family welfare or any other site selected by the state / district. An obstetrician- gynaecologist(MD/Diploma) as master trainer/ trainer A paediatrician (MD/Diploma) as co- trainer/ trainer for sections pertaining to neonatal health or a Medical Officer(MO) trained in emergency new born care(ENBC) and resuscitation. MO, nursing teacher or SN of the district hospital/ training institute. Training site: Any district hospital/Sub- district hospital with adequate caseload and not less than 150 deliveries per month may be selected.

4.Duration of training:For staff nurses and LHVs= 2-3 weeks For ANM= 3-6 weeks 5. Training material: Guidelines for antenatal care and skilled attendance at birth by ANMs/LHVs/SNs, which serves as a text for all essential and technical information that is needed to provide skilled attendance at birth. It includes the modules of SBA. Handbook for antenatal care and skilled birth attendance by ANMs/LHVs/SNs, which contains step wise checklists and case studies on the skills that the SBA is expected to master in order to attain proficiency. Trainers guide, which is designed to support the trainer in conducting training of ANMs/LHVs/SNs in a systematic and methodical manner. The trainer should use this guide in conjunction with the SBA guidelines and handbook, as this will help to retain focus on coverage and quality.

6. Certification of trainees: For the trainees to be certified in SBA skills, he / she will have to be competent. i.e, will score a minimum of 70% both in knowledge based and in all the skill based assessment. Trainers will have to submit a duly signed copy of this sheet to district CMO at the end of the training. A copy of the same should be maintained at the training institution also.

THE TRAINING MATERIAL GUIDELINES FOR ANTENATAL CARE AND SKILLED ATTENDANCE AT BIRTH BY ANMS/LHVS/SNS CONTAINS 3 MODULES. THEY ARE : MODULE 1: MANAGEMENT OF NORMAL PREGNANCY, LABOUR AND POSTPARTUM PERIOD

MODULE 2: MANAGEMENT OF COMMON OBSTETRIC COMPLICATIONS

MODULE 3: ENSURING THE QUALITY OF CARE

MODULE 1: MANAGEMENT OF NORMAL PREGNANCY, LABOUR AND POSTPARTUM PERIODIt includes: Care during pregnancy antenatal care Care during labour and delivery- intrapartum period Care after delivery- postpartum care

Care during pregnancy- antenatal care

KEY MESSAGES Good record-keeping assists in better case management and follow-up. Ensure iron- folic acid supplementation to every pregnant woman. Do not give a pregnant woman any medication during the first trimester, unless specifically indicated. Adequate rest and diet for the pregnant woman results in better maternal and neonatal outcomes.

Recognize that Every pregnancy is at risk. Ensure that ANC is used as an opportunity to detect and treat existing problems. Make sure that services are available to manage obstetric emergencies when they occur. Prepare pregnant women and their families for the eventuality of an emergency.

The important components of ANC are:1.2. 3.

4.5. 6.

Early registration Careful history taking Physical examination Investigations(routine, special) Advices: diet, hygiene Complete education, counselling and advice.

Conditions under which a pregnant woman must be referred to a medical officer/ High risk pregnancy: Refer the woman to the medical officer if her obstetric history reveals any of the following: * previous stillbirth or neonatal loss * history of three or more spontaneous consecutive abortions * birth weight of the previous baby 4500 g * hospital admission for hypertension or pre-eclampsia/eclampsia in the previous pregnancy * previous surgery on the reproductive tract * iso-immunization (Rh .ve) in the previous pregnancy

SYMPTOMS AND SIGNS THAT AN ANM MIGHT ENCOUNTER, PROBABLE DIAGNOSIS AND ACTION REQUIRED TO BE TAKEN AT THE SUBCENTRE LEVELSymptom Signs/investigati s on Vomiting Probable diagnosis May be physiological(mor ning sickness) Actions to be taken Advise the woman to eat small frequent meals;avoid greasy food; eat lots of green vegetables and drink plenty of fluids.

Excessive vomiting

The women may be dehydraded.

Hyperemesis gravidarum

If vomiting is excessive in the morning, ask her to eat dry foods such as biscuits or toast after waking up in the morning .Refer the woman to the MO.

Palpitations , easy fatiguability, breathlessne ss at rest Puffiness of the face, generalized body oedema

Conjunctival and/or palmar pallor present

Refer her to the MO for further management.

Sever anaemia Hb level 140/90 mmHg Proteinuria absent BP >140/90 mmHg Proteinuria present

Advise her to have a hospital delivery.

Hypertensive disorder Refer her to the MO. of pregnancy Refer to the MO for antihypertensive medication Pre-eclampsia Advise her on the danger signs of pre-eclampsia and eclampsia and refer to the MO. Reflux Advise the woman to avoid spicy and rich foods. Ask her to take cold milk during attacks. If severe, antacids may be prescribed.

Heart burn and nausea

Increased frequency of urination up to 10.12 weeks of pregnancy

May be physiological due to pressure of the gravid uterus on the Increased Tenderness may urinary frequency of be present at the bladder urination after sides of the Urinary tract 12 weeks, abdomen and back infection(UTI or persistent ) symptoms, Body temperature or burning on may be increased urination Constipation Physiological

Reassure her that it will be relieved on its own.

Give the woman the first dose of ampicillin (1 g orally) and injection gentamicin 80 mg IM stat). Refer the woman to the MO.

Advise the woman to take more fluids, leafy vegetables and a fibre-rich diet. If not relieved, give her Isabgol, tablespoonfuls to be taken at bedtime, with water or with milk. Do NOT prescribe strong laxatives as they may start uterine contractions.

Bleeding P/V, before 20 weeks of gestation

Check the pulse and BP to assess for shock

Threatened abortion/Spontan eous abortion/ Hydatidiform mole/ectopic Pregnancy Spontaneous abortion due to violence

Ask for history of Violence

If woman is bleeding and the retained products of conception can be seen coming out from the vagina, remove them with your finger. Refer to the MO of a24hour PHC Put her in touch with local support groups.

Bleeding P/V, after 20 weeks of gestation

Check the pulse and BP to assess for shock

Antepartum haemorrhage

Do NOT carry out a vaginal examination under any circumstances. Refer to an FRU.

Fever

Body temperature is raised

Site of infection Refer to MO. somewhere,includ ing possible sepsis Malaria Manage according to the NAMP guidelines for malaria in pregnancy

Blood peripheral smear is positive for malarial parasite

Decreased or absent foetal movements (NOTE: foetal movements are felt only after about 4 months of gestation)

FHS heard, and within the normal range of 120-160/ minute FHS heard, but the rate is