Childbirth Checklist

1 5N
45W
30W
15W
1 5E
3 0E
45E
60E
75E
15S
Best Practices in
Maternal and Newborn Care:
A Learning Resource Package for Essential and
Basic Emergency Obstetric and Newborn Care
Participants Guide
Learning Guides and Checklists
90E
Copyright 2008 by Jhpiego, an affiliate of The Johns Hopkins University. All rights reserved.
For information:
The ACCESS Program
Jhpiego
1615 Thames Street
Baltimore, MD 21231-3492, USA
Tel.: 410-537.1800
The ACCESS Program is the U.S. Agency for International Developments global program to improve maternal and
newborn health. The ACCESS Program works to expand coverage, access and use of key maternal and newborn
health services across a continuum of care from the household to the hospitalwith the aim of making quality
health services accessible as close to the home as possible. Jhpiego implements the program in partnership with
Save the Children, Constella Futures, the Academy for Educational Development, the American College of NurseMidwives and IMA World Health.
www.accesstohealth.org
This publication was made possible through support provided by the Maternal and Child Health Division, Office of
Health, Infectious Diseases and Nutrition, Bureau for Global Health, U.S. Agency for International Development,
under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00. The opinions
expressed herein are those of the editors and do not necessarily reflect the views of the U.S. Agency for International
Development.
TRADEMARKS: All brand and product names are trademarks or registered trademarks of their respective
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BEST PRACTICES IN MATERNAL AND NEWBORN CARE:

A LEARNING RESOURCE PACKAGE FOR ESSENTIAL AND
BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE
PARTICIPANTS GUIDE
LEARNING GUIDES AND CHECKLISTS
Learning Guide: Antenatal History, Physical Examination and Basic Care .......................................... 1
Checklist: Antenatal History, Physical Examination and Basic Care .................................................... 4
Learning Guide: Assisting Normal Birth ............................................................................................... 7
Checklist: Assisting Normal Birth........................................................................................................ 11
Learning Guide: Active Management of the Third Stage of Labor...................................................... 14
Checklist: Active Management of the Third Stage of Labor................................................................ 17
Learning Guide: Assisting a Breech Birth............................................................................................ 19
Checklist: Assisting a Breech Birth...................................................................................................... 22
Learning Guide: Episiotomy and Repair .............................................................................................. 24
Checklist: Episiotomy and Repair ........................................................................................................ 26
Learning Guide: Vacuum Extraction.................................................................................................... 28
Checklist: Vacuum Extraction.............................................................................................................. 31
Learning Guide: Assessment of the Newborn...................................................................................... 33
Checklist: Assessment of the Newborn ................................................................................................ 37
Learning Guide: Postpartum Assessment (History and Physical Examination) and Care ................... 40
Checklist: Postpartum Assessment (History and Physical Examination) and Care ............................. 47
Learning Guide: Postabortion Care Clinical Skills............................................................................... 51
Learning Guide: Postabortion Care Counseling Skills ......................................................................... 54
Checklist: Postabortion Care Clinical Skills......................................................................................... 56
Checklist: Postabortion Family Planning Counseling Skills ................................................................ 58
Learning Guide: Repair of Vaginal Sulcus, Periurethral and Cervical Tears....................................... 60
Checklist: Repair of Vaginal Sulcus, Periurethral and Cervical Tears................................................. 63
Learning Guide: Manual Removal of Placenta .................................................................................... 66
Checklist: Manual Removal of Placenta .............................................................................................. 68
Learning Guide: Internal Bimanual Compression of the Uterus .......................................................... 70
Checklist: Internal Bimanual Compression of the Uterus .................................................................... 72
Learning Guide: Compression of the Abdominal Aorta ...................................................................... 73
Checklist: Compression of the Abdominal Aorta................................................................................. 74
Learning Guide: Newborn Resuscitation ............................................................................................. 75
Checklist: Newborn Resuscitation ....................................................................................................... 78
Learning Guide: Kangaroo Mother Care.............................................................................................. 80
Checklist: Kangaroo Mother Care........................................................................................................ 82
Best Practices in Maternal and Newborn Care

Learning Resource Package
iii
iv

LEARNING GUIDE: ANTENATAL HISTORY,

PHYSICAL EXAMINATION AND BASIC CARE
(To be completed by Participants)
FOR USE WITH MODULE 7
Place a 9 in case box if task/activity is performed satisfactorily, an X if it is not performed
satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step, task or skill not performed by participant during evaluation by facilitator/teacher
LEARNING GUIDE FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC

CARE
STEP/TASK
OBSERVATIONS
GETTING READY
1.
Prepare the necessary equipment.
2.
Greet the woman respectfully and with kindness and introduce yourself.
3.
Offer the woman a seat.
4.
Tell the woman what is going to be done, encourage her to ask questions
and respond supportively.
5.
Provide reassurance and emotional support as needed.
QUICK CHECK
1.
Do rapid check for danger signs, conditions needing emergency treatment.
HISTORY
1.
Ask the woman how she is feeling and respond immediately to any urgent
problem(s).
2.
Ask the woman her name, age, number of previous pregnancies and number
of children, and about any problems she has experienced during this
pregnancy.
3.
Ask the woman about her menstrual history, including LNMP, her
contraceptive history and plans.
4.
Calculate the EDD and gestational age.
5.
Ask the woman if she has felt fetal movements within the last day.
6.
Ask the woman about daily habits and lifestyle (e.g., social support,
workload, dietary intake, use of alcohol, drugs, or smoking, and whether she
has experienced threats, violence, or injury).
7.
Ask the woman about previous pregnancies and breastfeeding history.
8.
Ask the woman about medical conditions, medications and hospitalizations.
9.
Ask the woman if she has experienced any problems or seen another care
provider since her last visit.
10. Ask the woman about HIV status.

11. Ask the woman about tetanus immunization.

CARE
STEP/TASK
OBSERVATIONS
12. Ask the woman if she has taken the prescribed treatment to prevent malaria,
and whether she is using treated bed nets at all times.
13. Ask the woman about other problems or concerns related to her pregnancy.
14. Record all pertinent information on the womans record/antenatal card.
PHYSICAL EXAMINATION
1.
Ask the woman to empty her bladder and save and test the urine.
2.
Observe the womans general appearance, including gait, skin and

conjunctiva for pallor.
3.
Help the woman onto the examination table and place a pillow (if available)
under her head and upper shoulders.
4.
Wash hands thoroughly with soap and water and dry them.
5.
Explain each step of the physical examination to the woman.
6.
Take the womans blood pressure.
7.
Examine the breasts.
8.
Examine abdomen and measure/estimate fundal height.
9.
Palpate to determine lie and presentation (after 36 weeks).
10. Listen to the fetal heart (second and third trimesters).

11. Put examination gloves on both hands.
12. Check external genitalia for sores and/or swelling.
13. Check the vaginal orifice for bleeding and/or abnormal discharge.
14. Check for signs of female genital mutilation (country/population specific).
15. Immerse both gloved hands in 0.5% chlorine solution:
z
Remove gloves by turning them inside out.
z
If disposing of gloves, place in leak-proof container, or if reusing
gloves, submerge in 0.5% chlorine solution for 10 minutes.
16. Wash hands thoroughly with soap and water and dry.
17. Record all relevant findings on the womans antenatal card.
SCREENING PROCEDURES
1.
Put examination gloves on both hands.
2.
Draw blood and do hemoglobin, RPR and HIV tests, interpreting results
accurately.
3.
Empty and soak the test tubes in 0.5% chlorine solution for 10 minutes.
4.
Dispose of needle and syringe in puncture-proof container.
5.
Immerse both gloved hands in 0.5% chlorine solution:

Remove gloves by turning them inside out.
z
Dispose off gloves in leak-proof container or plastic bag.
z
6.
Wash hands thoroughly with soap and water and dry.
7.
Record results on the womans antenatal card and discuss them with her.


CARE
STEP/TASK
OBSERVATIONS
IDENTIFY PROBLEMS/NEEDS
1.
Identify the womans individual problems/needs, based on the findings of

the antenatal history, physical examination and screening procedures.
PROVIDE CARE/TAKE ACTION

1.
Treat the woman for syphilis if the RPR test is positive, provide counseling
on HIV testing and safer sex, and arrange for her partner to be treated and
counseled.
2.
Provide tetanus immunization based on need.
3.
Provide counseling about necessary topics such as nutrition, hygiene, use of

potentially harmful substances, rest/activity, sexual relations/safer sex,
breastfeeding and postpartum family planning.
4.
Provide counseling about the use of insecticide-treated bed nets.
5.
Dispense medication for IPT for malaria according to protocol.
6.
Dispense other necessary medications such as iron and folate.
7.
Develop or review individualized birth plan with the woman; develop or

review her complication readiness plan.
8.
Discuss danger signs and what to do if they occur.
9.
Record the relevant details of care on the womans record/antenatal card.
10. Ask the woman if she has any further questions or concerns.
11. Thank the woman for coming and tell her when she should come for her
next antenatal visit.

CHECKLIST: ANTENATAL HISTORY,

PHYSICAL EXAMINATION AND BASIC CARE
(To be used by the Facilitator/Teacher at the end of the module)
Place a 9 in case box if task/activity is performed satisfactorily, an X if it is not performed
satisfactorily, or N/O if not observed.
Not Observed: Step, task or skill not performed by participant during evaluation by facilitator/teacher
Learner ____________________________________Date Observed _____________________

CHECKLIST FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC CARE
STEP/TASK
OBSERVATIONS
GETTING READY
1.
2.
Greet the woman respectfully and with kindness and introduce yourself.
3.
Offer the woman a seat.
4.
Tell the woman what is going to be done, listen to her and encourage her to
ask questions.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
HISTORY
1.
Ask the woman how she is feeling and respond immediately to any urgent
problem(s).
2.
Ask the woman her name, age, number of previous pregnancies, number of
children, menstrual history including LNMP and contraceptive history.
3.
Calculate the EDD and gestational age.
4.
Ask woman whether she has felt fetal movements within the last day.
5.
Ask woman about daily habits, lifestyle and social support.
6.
Ask the woman about past pregnancies and breastfeeding.
7.
Ask the woman about medical conditions, including HIV status, medications
and hospitalizations.
8.
Ask the woman about tetanus immunization.
9.
Ask the woman if she has taken the prescribed treatment to prevent malaria,
and whether she is using treated bed nets at all times.
10. Ask the woman about other problems or concerns related to her pregnancy.
11. Record all pertinent information on the womans record/antenatal card.
1.
Ask the woman to empty her bladder and save and test the urine.


STEP/TASK
2.
Observe the womans general appearance.
3.
Help the woman on to the examination table and place a pillow under her head
and upper shoulders.
4.
Wash hands thoroughly with soap and water and dry them.
5.
Explain each step of the physical examination to the woman.
6.
Take the womans blood pressure.
7.
Examine the breasts.
8.
Examine abdomen and determine lie and presentation (after 36 weeks).
9.
Measure/estimate fundal height.
OBSERVATIONS
10. Listen to the fetal heart (second and third trimesters).

11. Put examination gloves on both hands.
12. Check external genitalia and vaginal orifice.
13. Immerse both gloved hands in 0.5% chlorine solution and remove gloves.
14. Wash hands thoroughly with soap and water and dry.
15. Record all relevant findings on the womans antenatal card.
SCREENING PROCEDURES
1.
Put examination gloves on both hands.
2.
Draw blood and do hemoglobin, RPR and HIV tests, interpreting results
accurately.
3.
Empty and soak the test tubes in 0.5% chlorine solution for 10 minutes.
4.
Dispose off needle and syringe in puncture-proof container.
5.
Immerse both gloved hands in 0.5% chlorine solution and remove gloves.
6.
Wash hands thoroughly with soap and water and dry.
7.
Record results on the womans antenatal card and discuss them with her.
IDENTIFY PROBLEMS/NEEDS
1.
Identify the womans individual problems/needs, based on the findings of the

antenatal history, physical examination and screening procedures.
PROVIDE CARE/TAKE ACTION

1.
Treat the woman for syphilis if the RPR test is positive, provide counseling on
HIV testing and safer sex, and arrange for her partner to be treated and
counseled.
2.
Provide tetanus immunization based on need.
3.
Provide counseling about necessary self care topics.
4.
Provide counseling about the use of insecticide-treated bed nets.
5.
Dispense medication for IPT for malaria according to protocol.
6.
Dispense other necessary medications such as iron and folate.


STEP/TASK
OBSERVATIONS
7.
Develop or review individualized birth plan with the woman; develop or

review her complication readiness plan, including danger signs.
8.
Record the relevant details of care on the womans record/antenatal card.
9.
Ask the woman if she has any further questions or concerns.
10. Thank the woman for coming and tell her when she should come for her next
antenatal visit.

LEARNING GUIDE: ASSISTING NORMAL BIRTH

(Including Care of the Normal Newborn)
FOR USE WITH MODULE 9 AND MODULE 11
Because immediate care of the newborn is an integral part of the third stage of labor, steps
for immediate care of the newborn cannot be separated from comprehensive care during
labor and childbirth. Therefore, this learning guide contains all of the steps of care for
normal labor and birth, including immediate care of the newborn.
Place a 9 in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily, or
N/O if not observed.
Not Observed: Step or task not performed by participant during evaluation by facilitator/teacher
LEARNING GUIDE FOR ASSISTING NORMAL BIRTH

(Some of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
2.
Encourage the woman to adopt the position of choice and continue

spontaneous bearing-down efforts.
3.
Tell the woman what is going to be done, listen to her, and respond attentively
to her questions and concerns.
4.
Provide continual emotional support and reassurance, as feasible.
5.
Put on personal protective barriers.
ASSISTING THE BIRTH

1.
Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
2.
Put high-level disinfected or sterile surgical gloves on both hands.
3.
Clean the womans perineum with a cloth or compress, wet with antiseptic
solution or soap and water, wiping from front to back.
4.
Place one sterile drape from delivery pack under the womans buttocks, one
over her abdomen, and use the third drape to receive the baby.
Birth of the Head

5.
Ask the woman to pant or give only small pushes with contractions as the
babys head is born. (Put blanket or towel on womans abdomen.)
6.
As the pressure of the head thins out the perineum, control the birth of the
head with the fingers of one hand, applying a firm, gentle downward (but not
restrictive) pressure to maintain flexion, allow natural stretching of the
perineal tissue, and prevent tears.


STEP/TASK
CASES
7.
Use the other hand to support the perineum using a compress or cloth, and
allow the head to crown slowly and be born spontaneously.
8.
Wipe the mucus (and membranes, if necessary) from the babys mouth and
nose with a clean cloth.
9.
Feel around the babys neck to ensure the umbilical cord is not around the
neck:
If the cord is around the neck but is loose, slip it over the babys head;
If the cord is loose but cannot reach over the babys head, slip it
backwards over the shoulders;
If the cord is tight around the neck, clamp the cord with two artery
forceps, placed 3 cm apart, and cut the cord between the two clamps.
Completing the Birth

10. Allow the babys head to turn spontaneously.
11. After the head turns, place a hand on each side of the babys head, over the
ears, and apply slow, gentle pressure downward (toward the mothers spine)
and outward until the anterior shoulder slips under the pubic bone.
12. When the arm fold is seen, guide the head upward toward the mothers
abdomen as the posterior shoulder is born over the perineum.
13. Lift the babys head anteriorly to deliver the posterior shoulder.
14. Move the topmost hand from the head to support the rest of the babys body as
it slides out.
15. Place the baby on the mothers abdomen (if the mother is unable to hold the
baby, ask her birth companion or an assistant to care for the baby).
16. Thoroughly dry the baby and cover with a clean, dry cloth:
Assess breathing while drying the baby and if s/he does not breathe
immediately, begin resuscitative measures (see Learning Guide:
Newborn Resuscitation).
Note time of birth.
17. Ensure the baby is kept warm and in skin-to-skin contact on the mothers
chest, and cover the baby with a cloth or blanket, including the head.
18. Palpate the mothers abdomen to rule out the presence of additional baby(ies)
and proceed with active management of the third stage.
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR
1.
Give oxytocin 10 units IM.
2.
Clamp and cut the umbilical cord after pulsations have ceased or
approximately 23 minutes after the birth, whichever comes first:
Tie the cord at about 3 cm and 5 cm from the umbilicus;
Cut the cord between the ties.
Place the infant on the mothers chest.
3.
Clamp the cord close to the perineum and hold the clamped cord and the end
of the clamp in one hand.
4.
Place the other hand just above the pubic bone and gently apply counter
traction (push upwards on the uterus) to stabilize the uterus and prevent
uterine inversion.


STEP/TASK
5.
Keep light tension on the cord and wait for a strong uterine contraction (two to
three minutes).
6.
When the uterus becomes rounded or the cord lengthens, very gently pull
downward on the cord to deliver the placenta.
7.
Continue to apply counter traction with the other hand.
8.
If the placenta does not descend during 30 to 40 seconds of controlled cord

traction, relax the tension and repeat with the next contraction.
9.
As the placenta delivers, hold it with both hands and twist slowly so the
membranes are expelled intact:
If the membranes do not slip out spontaneously, gently twist them into a
rope and move up and down to assist separation without tearing them.
CASES
10. Slowly pull to complete delivery.

11. Massage the uterus if it is not well contracted. Note time of delivery of
placenta.
Examination of Placenta
12. Hold placenta in palms of hands, with maternal side facing upwards, and
check whether all lobules are present and fit together.
13. Hold cord with one hand and allow placenta and membranes to hang down:
Insert fingers of other hand inside membranes, with fingers spread out,
and inspect membranes for completeness;
Note position of cord insertion.
Examination of Vagina and Perineum for Tears
14. Gently separate the labia and inspect lower vagina for lacerations/tears.
15. Inspect the perineum for lacerations/tears.
16. Gently cleanse the perineum with warm water and a clean cloth.
17. Apply a clean pad or cloth to the vulva.
18. Assist the mother to a comfortable position for continued breastfeeding and
bonding with her newborn. (Further assessment and immunization of the
newborn can occur later before the mother is discharged or the skilled
attendant leaves.)
POST-PROCEDURE TASKS
1.
Place any contaminated items (e.g., swabs) in a plastic bag or leak-proof,

covered waste container.
2.
Decontaminate instruments by placing in a container filled with 0.5% chlorine

solution for 10 minutes.
3.
Decontaminate needles and or syringes:

If disposing of needle and syringe, hold the needle under the surface of a
0.5% chlorine solution, fill the syringe, and push out (flush) three times;
then place in a puncture-resistant sharps container;
If reusing the syringe (and needle), fill syringe with needle attached with
0.5% chlorine solution and soak in chlorine solution for 10 minutes for
decontamination.


STEP/TASK
CASES
4.
Immerse both gloved hands briefly in a container filled with 0.5% chlorine
solution; then remove gloves by turning them inside out:
If disposing of gloves (examination gloves and surgical gloves that will
not be reused), place in a plastic bag or leak-proof, covered waste
container;
If reusing surgical gloves, submerge in 0.5% chlorine solution for 10
minutes for decontamination.
5.
Wash hands thoroughly with soap and water and dry with clean, dry cloth or
air dry.
10

CHECKLIST: ASSISTING NORMAL BIRTH

(Including Care of the Normal Newborn)
FOR USE WITH MODULE 9 AND MODULE 11
Because immediate care of the newborn is an integral part of the third stage of labor, steps
for immediate care of the newborn cannot be separated from comprehensive care during
labor and childbirth. Therefore, this learning guide contains all of the steps of care for
normal labor and birth, including immediate care of the newborn.
Participant __________________________________Date Observed ____________________

CHECKLIST FOR ASSISTING NORMAL BIRTH
STEP/TASK
CASES
GETTING READY
1.
2.
Encourage the woman to adopt the position of choice and continue

spontaneous bearing down efforts.
3.
4.
5.

ASSISTING THE BIRTH

1.
Wash hands thoroughly, put on high-level disinfected or sterile surgical

gloves, and place drapes from the delivery pack on the woman.
2.
Clean the womans perineum, and ask her to pant or give only small pushes
with contractions.
3.
Control the birth of the head with the fingers of one hand to maintain flexion,
allow natural stretching of the perineal tissue, and prevent tears, and use the
other hand to support the perineum.
4.
Wipe the mucus (and membranes, if necessary) from the babys mouth and
nose.
5.
Feel around the babys neck for the cord and respond appropriately if the cord
is present.
6.
Allow the babys head to turn spontaneously and, with the hands on either side
of the babys head, deliver the anterior shoulder.

11

7.
When the arm fold is seen, guide the head upward as the posterior shoulder is
born over the perineum and lift the babys head anteriorly to deliver the
posterior shoulder
8.
Support the rest of the babys body with one hand as it slides out, and place
the baby on the mothers abdomen.
9.
Thoroughly dry the baby and cover with a clean, dry cloth, and assess
breathing. If baby does not breathe immediately, begin resuscitative measures
(see Checklist 7: Newborn Resuscitation).
10. Ensure the baby is kept warm and in skin-to-skin contact on the mothers
chest. Note time of birth.
11. Palpate the mothers abdomen to rule out the presence of additional baby(ies)
and proceed with active management of the third stage.
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR
1.
If no additional baby, give oxytocin 10 units IM within 1 minute of birth.
2.
Clamp and cut the cord approximately 3 minutes after birth.
3.
Wait for a uterine contraction.
4.
With hand above public bone, apply pressure in an upward direction (towards
the womans head) to apply counter traction and stabilize the uterus.
5.
At the same time with the other hand, pull with a firm, steady tension on the
cord in a downward direction (follow direction of the birth canal.)
6.
Deliver placenta slowly with both hands, gently turning the entire placenta
and lifting it up and down until membranes deliver.
7.
Immediately after placenta delivers, massage uterus until firm. Note time of
delivery of placenta.
8.
Examine the placenta, membranes and cord.
9.
Inspect the vulva, perineum and vagina for lacerations/tears and carry out
appropriate repair as needed.
10. Cleanse perineum and apply a pad or cloth to vulva.

attendant leaves.)
12. Massage uterus and check amount of bleeding every 15 minutes (more often
if needed) for 2 hours, making sure the uterus does not get soft after you stop
massaging.
1.
Dispose of contaminated items in a plastic bag or leak-proof, covered waste

container.
2.

12


3.

decontamination.
4.
container;
5.
Wash hands thoroughly.


13
LEARNING GUIDE: ACTIVE MANAGEMENT OF THE

THIRD STAGE OF LABOR
LEARNING GUIDE FOR ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR

(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
Ensure that items necessary to perform active management of the third stage
of labor were adequately prepared before the birth and ready to use.
2.
Ask the woman to empty her bladder when second stage is near (catheterize
only if woman cannot urinate and bladder is full).
3.
Assist the woman into the position of her choice (squatting, semi-sitting).
4.
Explain to the woman (and her support person) what is going to be done,
listen to her and respond attentively to her questions and concerns.
5.
After baby is born, dry from head to toe with a warm, clean cloth.
6.
Assess breathing while drying. If baby is not breathing, begin resuscitation.
7.
If baby is breathing, put in skin-to-skin contact on mothers abdomen and

cover with clean, dry, warm cloth.
8.
Provide continual emotional support and reassurance.
DELIVERING THE PLACENTA

1.
Palpate the mothers abdomen to rule out the presence of another baby.
2.
If no other baby, give 10 IU of oxytocin IM within 1 minute of birth.
3.
Clamp and cut the cord after cord pulsations have ceased or approximately
23 minutes after birth of the baby, whichever comes first.
4.
Place the infant directly on the mothers chest, prone, with the newborns
skin touching the mothers skin. Cover the babys head with a cap or cloth.
5.
Hold cord close to the perineum, with hand or clamp.
6.
Wait for the uterus to contract.
7.
Use one hand to grasp the cord clamp.
8.
Place the other hand just above the pubic bone, on top of the drape covering
the womans abdomen, with the palm facing toward the mothers umbilicus
and gently apply counter-traction in an upward direction (towards the
womans head).
14


STEP/TASK
9.
CASES
At the same time while the uterus is contracted, firmly apply traction to the
cord, in a downward direction, using the hand that is grasping the clamp.
(Follow direction of the birth canal.)
10. Apply tension by pulling the cord firmly and maintaining pressure (jerky
movements and force must be avoided).
11. If the maneuver is not successful within 3040 seconds, stop cord traction,
wait for the next contraction and repeat.
12. When the placenta is visible at the vaginal opening, hold it in both hands.
13. Use a gentle upward and downward movement or twisting action to slowly
deliver the membranes. (If the membranes tear: 1) look for membranes in
upper vagina and cervix, 2) use forceps to clamp on membranes, 3) twist
membranes and delivery slowly.)
14. Hold the placenta in the palms of the hands, with the maternal side facing
upward.
15. Immediately and gently massage the uterus through the womans abdomen
until it is well contracted and no excessive bleeding is coming from the
vagina.
POST-BIRTH TASKS
1.
Teach the mother how the uterus should feel and how to massage it.
2.
To check the placenta for completeness:

z Hold the placenta in the palms of the hands, with the maternal side
facing upward;
z Make sure that all lobules are present and fit together; and
z Place the other hand inside the membranes, spreading fingers out, to
make sure that the membranes are complete.
3.
Gently separate the labia and inspect the lower vagina and perineum for
lacerations that may need to be repaired to prevent further blood loss.
4.
Gently cleanse the vulva and perineum with warm water and a clean
compress, and apply a clean pad/cloth to the vulva.
5.
Assist the mother into a comfortable position for breastfeeding and bonding
with baby.
6.
Before removing gloves, dispose of waste materials in a leak-proof container

or plastic bag and dispose of the placenta by incineration (or place in a leakproof container for burial), after consulting with the woman about cultural
practices.
7.
Place all instruments in 0.5% chlorine solution for 10 minutes for

decontamination.
8.
Decontaminate or dispose of needle or syringe:

z If reusing needle or syringe, fill syringe (with needle attached) with
0,5% chlorine solution and submerge in solution for 10 minutes for
decontamination.
z If disposing of needle and syringe, flush needle and syringe with 0,5%
chlorine solution three times, then place in a puncture-proof container.

15

STEP/TASK
9.
CASES
Immerse both gloved hands in 0,5% chlorine solution. Remove gloves by

turning them inside out.
z If disposing of gloves, place them in a leak-proof container or plastic
bag.
z If re-using surgical gloves, submerge them in 0.5% chlorine solution for
10 minutes for decontamination.
10. Use antiseptic handrub or wash hands thoroughly with soap and water and
dry with a clean, dry cloth or air dry.
11. Record all findings on womans record.
12. During the first 2 hours after delivery of the placenta, monitor the women
every 15 minutes:
z Measure her vital signs.
z Massage her uterus to make sure it is contracted.
z Check for excessive vaginal bleeding.
16

CHECKLIST: ACTIVE MANAGEMENT OF THE

THIRD STAGE OF LABOR
Participant __________________________________Date Observed ____________________

CHECKLIST FOR ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR
STEP/TASK
CASES
GETTING READY
1.
Prepare oxytocin 10 units in a syringe before second stage.
2.
Ask the woman to empty her bladder when second stage is near.
3.
Assist the woman into the position of her choice (squatting, semi-sitting).
4.
Explain to the woman (and her support person) what is going to be done,
listen to her and respond attentively to her questions and concerns.
5.
After baby is born, dry from head to toe with a warm, clean cloth.
6.
Assess breathing while drying and resuscitate if necessary.
7.
If baby is breathing, put in skin-to-skin contact on mothers abdomen and

cover with clean, dry, warm cloth.
DELIVERING THE PLACENTA

1.
Feel the mothers abdomen to make sure there is no other baby.
2.
If no other baby, give 10 IU of oxytocin IM within 1 minute of birth.
3.
Clamp and cut the cord after cord pulsations have ceased or approximately
23 minutes after birth of the baby, whichever comes first.
4.
Hold cord close to the perineum, with hand or clamp.
5.
Place the other hand just above the womans pubic bone.
6.
Wait for a uterine contraction.
7.
With the hand above the pubic bone, apply pressure on uterus in an upward
direction (toward the womans head).
8.
At the same time, with the other hand, pull with a firm, steady tension on the
cord in a downward direction (below direction of the birth canal).
9.
If placenta does not descend, release tension on the cord (still holding cord)
and wait for next contraction.
10. Repeat controlled cord traction as in Steps 7 and 8 above.

17
CHECKLIST FOR ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR

STEP/TASK
CASES
11. Deliver placenta slowly with both hands.

12. Deliver membranes by gently turning the entire placenta so membranes
twist. Move membranes up and down until they deliver.
13. If membranes tear: 1) look for membranes at upper vagina and cervix; 2) use
forceps to clamp on membranes; 3) twist membranes and deliver slowly.
14. Immediately after placenta delivers, massage uterus until firm.
POST-BIRTH TASKS
1.
Teach the mother how the uterus should feel and how to massage it.
2.
Look at placenta and membranes to see if they are complete.
3.
Gently inspect the vulva, perineum and vagina for laceration and carry out
appropriate repair if necessary. Proceed with care of the woman.
4.
Gently cleanse the vulva and perineum with warm water and a clean
compress, and apply a clean pad/cloth to the vulva.
5.
Follow infection prevention guidelines for handling of contaminated

equipment and supplies.
6.
Massage uterus and check amount of vaginal bleeding every 15 minutes

(more often if needed) for 2 hours.
7.
Make sure uterus does not get soft after you stop massaging.
8.
Continue with normal care for mother and newborn.
9.
Record information.
NOTE: Step No. 3 under Delivering the Placenta: Clamp and cut the cord approximately 3
minutes after babys birth. If no clock or watch, or no light to see a watch, wait for pulsation to
stop. Three (3) minutes gives the baby the fullest possible benefit for placental transfusion.
18

LEARNING GUIDE: ASSISTING A BREECH BIRTH

FOR USE WITH MODULE 9 AND SUPPLEMENTARY MODULE 9.2
LEARNING GUIDE FOR ASSISTING A BREECH BIRTH
STEP/TASK
CASES
GETTING READY
1.
2.
3.
Ensure that conditions for breech delivery (complete or frank, adequate size
pelvis for this fetus, no previous C-section or CPD, flexed head) are present.
4.
5.
ASSISTING THE BIRTH

1.
Use antiseptic handrub or wash hands thoroughly with soap and water and dry
with a clean, dry cloth or air dry.
2.
3.
Place one sterile drape from delivery pack under the womans buttocks, one
over her abdomen, and use the third drape to receive the baby.
4.
Clean the womans perineum with a cloth or compress, wet with antiseptic
solution or soap and water, wiping from front to back.
5.
Place clean drape beneath womans hips.
6.
Catheterize the bladder if necessary.
7.
When the buttocks have entered the vagina and the cervix is fully dilated, tell
the woman she can bear down with contractions. Do episiotomy if necessary.
8.
As the perineum distends, decide whether an episiotomy is necessary (e.g., if

perineum is very tight). If needed, provide infiltration with lignocaine and
perform an episiotomy.
9.
Let the buttocks deliver until the lower back and then the shoulder blades are
seen.
10. Gently hold the buttocks in one hand, but do not pull.
11. If the legs do not deliver spontaneously, deliver one leg at a time:
z Push behind the knee to bend the leg.
z Grasp the ankle and deliver the foot and leg.
z Repeat for the other leg.
19

STEP/TASK
CASES
12. Hold the newborn by the hips, but do not pull.

13. If the arms are felt on the chest, allow them to disengage spontaneously:
z
After spontaneous delivery of the first arm, lift the buttocks towards the
mothers abdomen to enable the second arm to deliver spontaneously.
z
If the arm does not deliver spontaneously, place one or two fingers in the
elbow and bend the arm, bringing the hand down over the newborns
face.
14. If the arms are stretched above the head or folded around the neck, use
Lovesets maneuver:
z
Hold the newborn by the hips and turn half a circle, keeping the back
uppermost.
z
Apply downward traction at the same time so that the posterior arm
becomes anterior, and deliver the arm under the pubic arch by placing
one or two fingers on the upper part of the arm.
z
Draw the arm down over the chest as the elbow is flexed, with the hand
sweeping over the face.
z
To deliver the second arm, turn the newborn back half a circle while
keeping the back uppermost and applying downward traction to deliver
the second arm in the same way under the pubic arch.
15. If the newborns body cannot be turned to deliver the arm that is anterior first,
deliver the arm that is posterior:
z
Hold and lift the newborn up by the ankles.
z
Move the newborns chest towards the mothers inner leg to deliver the
posterior arm.
z
Deliver the arm and hand.
z
Lay the newborn down by the ankles to deliver the anterior shoulder.
z Deliver the arm and hand.
16. Deliver the head by the Mauriceau Smellie Veit maneuver:
z
Lay the newborn face down with the length of its body over your hand
and arm.
z
Place first and third fingers of this hand on the newborns cheekbones.
z
Place second finger in the newborns mouth to pull the jaw down and
flex the head.
z
Use the other hand to grasp the newborns shoulders.
z
With two fingers of this hand, gently flex the newborns head toward the
chest
z
At the same time apply downward pressure on the jaw to bring the
newborns head down until the hairline is visible.
z
Pull gently to deliver the head.
z
Ask an assistant to push gently above the mothers public bone as the
head delivers.
z
Raise the newborn, still astride the arm, until the mouth and nose are
free.
17. Wipe the mucus (and membranes, if necessary) from the babys mouth and
nose with a clean cloth.
18. Place the baby in skin-to-skin contact on the abdomen of the mother, dry the
baby, assess the babys breathing and perform resuscitation if needed.
19. Administer a uterotonic (the uterotonic of choice is oxytocin 10 IU IM)
immediately after birth of the baby, and after ruling out the presence of
another baby.
20


STEP/TASK
CASES
20. Clamp and cut the cord after cord pulsations have ceased or approximately 2
3 minutes after the birth of the baby, whichever comes first.
21. Place the infant directly on the mothers chest, prone, with the newborns skin
touching the mothers skin. Cover the babys head with a cap or cloth.
23. Perform controlled cord traction.
24. Massage uterus until contracted.
25. Examine the placenta:
z
Hold placenta in palm of hands, with maternal side facing upwards, and
check whether all lobules are present and fit together.
z
Hold cord with one hand and allow placenta and membranes to hang
down.
z
Insert fingers of other hand inside membranes, with fingers spread out,
and inspect membranes for completeness.
26. Check the birth canal for tears and repair if necessary.
27. Repair episiotomy if necessary.
28. Gently cleanse the perineum with warm water and a clean cloth.
29. Apply a clean pad or cloth to the vulva.
attendant leaves.)
1.

2.

3.

z
z
decontamination.
4.
z
container;
z
5.
air dry.

21
CHECKLIST: ASSISTING A BREECH BIRTH

Participant ____________________________________Date Observed __________________

CHECKLIST FOR ASSISTING A BREECH BIRTH
STEP/TASK
CASES
GETTING READY
1.
2.
3.
Ensure that conditions for breech delivery (complete or frank, adequate size
pelvis for this fetus, no previous C-section or CPD, flexed head) are present.
4.
5.
6.
7.

ASSISTING THE BIRTH

1.
Clean the womans perineum.
2.
Catheterize the bladder if necessary.
3.
When the buttocks have entered the vagina and the cervix is fully dilated, tell
the woman she can bear down with contractions.
4.
Let the buttocks deliver until the lower back and then the shoulder blades are
seen.
5.
Gently hold the buttocks in one hand, but do not pull.
6.
If the legs do not deliver spontaneously, deliver one leg at a time.
7.
Hold the newborn by the hips, but do not pull.
8.
If the arms are felt on the chest, allow them to disengage spontaneously.
9.
If the arms are stretched above the head or folded around the neck, use
Lovesets maneuver.
10. If the newborns body cannot be turned to deliver the arm that is anterior first,
deliver the arm that is posterior.
22

CHECKLIST FOR ASSISTING A BREECH BIRTH

STEP/TASK
CASES
11. Deliver the head by the Mauriceau Smellie Veit maneuver.

12. Give 10 IU oxytocin intramuscularly.
13. Clamp and cut the cord after cord pulsations have ceased or approximately 2
3 minutes after the birth of the baby, whichever comes first.
15. Perform controlled cord traction.
16. Massage uterus until contracted.
17. Check placenta for completeness.
18. Check the birth canal for tears and repair tears or episiotomy, if necessary.
bonding with her newborn.
1.

2.
Decontaminate instruments by placing in a container filled with 0.5%

chlorine solution for 10 minutes.
3.
4.
5.
air dry.

23
LEARNING GUIDE: EPISIOTOMY AND REPAIR

LEARNING GUIDE FOR EPISIOTOMY AND REPAIR

STEP/TASK
CASES
GETTING READY
1.
2.
Tell the woman what is going to be done and encourage her to ask questions.
3.
Listen to what the woman has to say.
4.
Make sure that the woman has no allergies to lignocaine or related drugs.
5.
Provide emotional support and reassurance, as feasible.
ADMINISTERING LOCAL ANESTHETIC

1.
Cleanse perineum with antiseptic solution.
2.
Draw 10 mL of 0.5% lignocaine into a syringe.
3.
Place two fingers into vagina along proposed incision line.
4.
Insert needle beneath skin for 45 cm following same line (preferably 1 ", 22gauge).
5.
Draw back the plunger of syringe to make sure that needle is not in a blood
vessel.
6.
Inject lignocaine into vaginal mucosa, beneath skin of perineum and deeply into
perineal muscle.
7.
Wait 2 minutes and then pinch incision site with forceps.
8.
If the woman feels the pinch, wait 2 more minutes and then retest.
MAKING THE EPISIOTOMY

1.
Wait to perform episiotomy until:

Perineum is thinned out
34 cm of the babys head is visible during a contraction
2.
Place two fingers between the baby's head and the perineum.
3.
Insert open blade of scissors between perineum and two fingers and cut
mediolaterally the perineum and posterior vagina
4.
If birth of head does not follow immediately, apply pressure to episiotomy site
between contractions, using a piece of gauze, to minimize bleeding.
5.
Control birth of head and shoulders to avoid extension of the episiotomy.
24

LEARNING GUIDE FOR EPISIOTOMY AND REPAIR

STEP/TASK
CASES
REPAIRING THE EPISIOTOMY

1.
Ask the woman to position her buttocks toward lower end of bed or table (use
stirrups if available).
2.
Ask an assistant to direct a strong light onto the womans perineum.
3.
Apply antiseptic solution to area around episiotomy.
4.
Using 2/0 or 3/0suture, insert suture needle just above (1 cm) the apex of the
episiotomy.
5.
Use a continuous suture from apex downward to level of vaginal opening.
6.
At opening of vagina, bring together cut edges.
7.
Bring needle under vaginal opening and out through incision and tie.
8.
Use interrupted sutures to repair perineal muscle, working from top of perineal
incision downward.
9.
Use interrupted or subcuticular sutures to bring skin edges together.
10. Wash perineal area with antiseptic, pat dry, and place a sterile sanitary pad over
the vulva and perineum.
1.
Dispose of waste materials (e.g. blood-contaminated swabs) in a leak-proof

container or plastic bag.
2.
Decontaminate instruments by placing in a plastic container filled with 0.5%

3.
Decontaminate or dispose of syringe and needle:

z If reusing needle or syringe, fill syringe (with needle attached) with 0.5%
chlorine solution and submerge in solution for 10 minutes for
decontamination.
z If disposing of needle and syringe, flush needle and syringe with 0.5%
4.
Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
z If disposing of gloves, place in leak-proof container or plastic bag.
z If reusing surgical gloves, submerge in 0.5% chlorine solution for 10 minutes
to decontaminate.
5.
Wash hands thoroughly with soap and water and dry with clean, dry cloth or air
dry.

25
CHECKLIST: EPISIOTOMY AND REPAIR

Participant______________________________ Date Observed_______________________

CHECKLIST FOR EPISIOTOMY AND REPAIR
STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
5.

MAKING THE EPISIOTOMY

1.
Clean perineum with antiseptic solution.
2.
Administer local anesthesia.
3.
Wait to perform episiotomy until the perineum is thinned out and the babys head
is visible during a contraction.
4.
Insert two fingers into the vagina between the babys head and the perineum.
5.
Insert the open blade of the scissors between the perineum and the fingers and
make a cut in a mediolateral direction.
6.
Control birth of the head to avoid extension of the episiotomy.

REPAIRING THE EPISIOTOMY

1.
Apply antiseptic solution to area around episiotomy.
2.
Use a continuous suture from apex downward to repair vaginal incision.
3.
At the level of vaginal opening, bring cut edges together.
4.
Bring needle under vaginal opening and out through incision and tie.
5.
Use interrupted sutures to repair perineal muscle, working from top of perineal
incision downward.
6.
Use interrupted or subcuticular sutures to bring skin edges together.
26

CHECKLIST FOR EPISIOTOMY AND REPAIR

STEP/TASK
7.
CASES
Wash perineal area and cover with a sterile sanitary napkin.

1.
Before removing gloves, dispose of waste materials in a leak-proof container or

plastic bag.
2.
Place all instruments in 0.5% chlorine solution for decontamination.
3.
If reusing needle or syringe, fill syringe (with needle attached) with 0.5%
chlorine solution and submerge in solution for decontamination. If disposing of
needle and syringe, place in puncture-proof container.
4.
Remove gloves and discard them in a leak-proof container or plastic bag if

disposing of or decontaminate them in 0.5% chlorine solution if reusing.
5.


27
LEARNING GUIDE: VACUUM EXTRACTION

LEARNING GUIDE FOR VACUUM EXTRACTION

STEP/TASK
CASES
GETTING READY
1.
Prepare and test the necessary equipment.
2.
Tell the woman (and her support person) what is going to be done, listen to her
and respond attentively to her questions and concerns.
3.
4.
Review to ensure that the following conditions for vacuum extraction are
present:
z
Vertex presentation
z
Term fetus
z
Cervix fully dilated
z
Head at least at 0 station or no more than 2/5 palpable above the
symphysis pubis
5.
Make sure an assistant is available.
6.
Put on personal protective equipment.
PRE-PROCEDURE TASKS
1.
with a sterile cloth or air dry.
2.
3.
Clean the vulva with antiseptic solution.
4.
Catheterize the bladder, if necessary.
5.
Check all connections on the vacuum extractor and test the vacuum on a
gloved hand.
VACUUM EXTRACTION
1.
Assess the position of the fetal head by feeling the sagittal suture line and the
fontanelles.
2.
Identify the posterior fontanelle.
3.
Apply the largest cup that will fit, with the center of the cup over the flexion
point, 1 cm anterior to the posterior fontanelle.
28


STEP/TASK
4.
Check the application and ensure that there is no maternal soft tissue (cervix or
vagina) within the rim of the cup:
z
If necessary, release pressure and reapply cup.
5.
Have the assistant create a vacuum of 0.2 kg/cm2 negative pressure with the
pump and check the application of the cup.
6.
Increase the vacuum to 0.8 kg/cm2 negative pressure and check the application
of the cup. Do NOT exceed 600 mm Hg in red zone.
7.
After maximum negative pressure has been applied, start traction in the line of
the pelvic axis and perpendicular to the cup:
z
If the fetal head is tilted to one side or not flexed well, traction should be
directed in a line that will try to correct the tilt or deflexion of the head
(i.e., to one side or the other, not necessarily in the midline).
8.
With each contraction, apply traction in a line perpendicular to the plane of the
cup rim:
z
Place a gloved finger of the non-dominant hand on the scalp next to the
cup during traction to assess potential slippage and descent of the vertex.
z
Do NOT pull between contractions.
9.
CASES
Between each contraction have assistant check:

Fetal heart rate
z
Application of the cup
z
10. With progress, and in the absence of fetal distress, continue the guiding pulls
for a maximum of 30 minutes.
11. Perform an episiotomy, if necessary, for proper placement of the cup (see
Learning Guide for Episiotomy and Repair). If episiotomy is necessary for
placement of the cup, delay until the head stretches the perineum or the
perineum interferes with the axis of traction.
12. When the head has been delivered, release the vacuum, remove the cup and
complete the birth of the newborn.
13. Clamp and cut the cord after cord pulsations have ceased or approximately 2-3
minutes after birth of the baby, whichever comes first.
15. Perform active management of the third stage of labor to deliver the placenta:
z
Give 10 IU oxytocin intramuscularly.
z
Perform controlled cord traction.
z
Massage uterus.
16. Check the birth canal for tears following childbirth and repair, if necessary.
17. Repair the episiotomy, if one was performed (see Learning Guide for
Episiotomy and Repair).
18. Provide immediate postpartum and newborn care, as required.
1.

or plastic bag.
2.
Place all instruments in 0.5% chlorine solution for 10 minutes for

decontamination.

29

STEP/TASK
CASES
3.
If fluids are in pump, clean by pumping water through the pump.
4.
Dry pump by pumping air until no moisture is felt where pump connects to
tubing.
5.
If cup and tubing are reusable, decontaminate with 0.5% chlorine solution for
10 minutes.
6.
Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by

turning them inside out:
z
If disposing of gloves, place them in a leak-proof container or plastic bag.
z
If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10
7. Use antiseptic handrub or wash hands thoroughly with soap and water and dry
8. Record the procedure and findings on womans record.
30

CHECKLIST: VACUUM EXTRACTION

Participant _____________________________________ Date Observed ________________

CHECKLIST FOR VACUUM EXTRACTION
STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
Ensure that the conditions for vacuum extraction are present.
5.
Make sure an assistant is available.
6.

PREPROCEDURE TASKS
1.
Use antiseptic handrub or wash hands thoroughly and put on high-level

disinfected or sterile surgical gloves.
2.
Clean the vulva with antiseptic solution.
3.
Catheterize the bladder, if necessary.
4.
Check all connections on the vacuum extractor and test the vacuum.
VACUUM EXTRACTION
1.
Assess the position of the fetal head and identify the posterior fontanelle.
2.
Apply the largest cup that will fit.
3.
Check the application and ensure that there is no maternal soft tissue within
the rim of the cup.
4.
Have assistant create a vacuum of negative pressure and check the application
of the cup.
5.
Increase the vacuum to the maximum and then apply traction. Correct the tilt
or deflexion of the head.

31
CHECKLIST FOR VACUUM EXTRACTION

STEP/TASK
CASES
6.
With each contraction, apply traction in a line perpendicular to the plane of the
cup rim and assess potential slippage and descent of the vertex.
7.
Between each contraction, have assistant check fetal heart rate and application
of the cup.
8.
Continue the guiding pulls for a maximum of 30 minutes. Release the

vacuum when the head has been delivered.
9.
Perform an episiotomy, if necessary, for placement of the cup.
10. Complete birth of newborn and delivery of placenta.

11. Following childbirth, check the birth canal for tears and repair, if necessary.
Repair the episiotomy, if one was performed.
12. Provide immediate postpartum and newborn care, as required.
POSTPROCEDURE TASKS
1.

or plastic bag.
2.
Place all instruments in 0.5% chlorine solution for decontamination.
3.
Decontaminate vacuum pump and appropriate parts.
4.

disposing of, or decontaminate them in 0.5% chlorine solution if reusing.
5.
Use antiseptic handrub or wash hands thoroughly.
6.
Record procedure and findings on womans record.

32

LEARNING GUIDE: ASSESSMENT OF THE NEWBORN

Not Observed: Step or task not performed by learner during evaluation by facilitator/teacher
LEARNING GUIDE FOR ASSESSMENT OF THE NEWBORN

STEP/TASK
CASES
GETTING READY
1.
2.
Tell the mother what you are going to do, encourage her to ask questions and
listen to what she has to say.
HISTORY (Ask the following questions if the information is not available on the mothers/babys record.)
Personal Information (First Visit)
1.
What are your name, address and phone number?
2.
What are the name and sex of your baby?
3.
When was your baby born?
4.
Do you have access to reliable transportation?
5.
What sources of income/financial support do you/your family have?
6.
How many times have you been pregnant and how many children have you
had?
7.
Is your baby having a particular problem at present? If Yes, find out what the
problem is and ask the following additional questions:
z
When did the problem first start?
z
Did it occur suddenly or develop gradually?
z
When and how often does the problem occur?
z
What may have caused the problem?
z
Did anything unusual occur before it started?
z
How does the problem affect your baby?
z
Is the baby eating, sleeping, and behaving normally?
z
Has the problem become more severe?
z
Are there other signs and conditions related to the problem? If Yes, ask
what they are.
z
Has the baby received treatment for the problem? If Yes, ask who provided
the treatment, what it involved, and whether it helped.

33

STEP/TASK
8.
CASES
Has your baby received care from another caregiver? If Yes, ask the following
additional questions:
z
Who provided the care?
z
Why did you seek care from another caregiver?
z
What did the care involve?
z
What was the outcome of this care?
The Birth (First Visit)

9.
Where was your baby born and who attended the birth?
10. Did you have an infection (in the uterus) or fever during labor or birth?
11. Did you bag of water break more than 18 hours before the birth?
12. Were there any complications during the birth that may have caused injury to
the baby?
13. Did the baby need resuscitation (help to breath) at birth?
14. How much did the baby weigh at birth?
Maternal Obstetric History of Any Previous Birth
15. Are all of your children still living?
16. Have you breastfed before?
Maternal Medical History (First Visit)
17. Do you suffer with diabetes?
18. During pregnancy, did you have any infectious diseases such as hepatitis B,
HIV, syphilis or TB?
Present Newborn Period (Every Visit)
19. Does the baby have any congenital malformation (birth defect)?
20. Has the baby received newborn immunizations for polio, TB and hepatitis B?
21. Do you feel good about your baby and your ability to take care of him/her?
22. Is your family adjusting to the baby?
23. Do you feel that breastfeeding is going well?
24. How often does the baby feed?
25. Does the baby seem satisfied after feeding?
26. How often does the baby urinate?
27. When was the last time the baby passed stool? What was the color/consistency?
Interim History (Return Visits)
28. Is your baby having a problem at present? Has he/she had any problem since
the last visit? If Yes, ask the follow-up questions under item 7 above
29. Has your baby received care from another caregiver since the last visit? If Yes,
ask the follow-up questions under item 8 above.
30. Have there been any changes in your address or phone number since the last
visit?
31. Have there been any changes in the babys habits or behaviors since the last
visit?
34


STEP/TASK
CASES
32. Have you been able to care for the baby as discussed at the last visit?
33. Has the baby had any reactions or side effects from immunizations,
drugs/medications or any care provided since the last visit?
EXAMINING THE NEWBORN
Assessment of Overall Appearance/Well-Being (Every Visit)
1.
Again, tell the mother what you are going to do, encourage her to ask questions
and listen to what she has to say.
2.
Wash hands thoroughly with soap and water and dry with a clean dry cloth or
air dry.
3.
Wear clean examination gloves if the baby has not been bathed since birth, if
the cord is touched, or if here is blood, urine and/or stool present.
4.
Place the baby on a clean warm surface or examine him/her in the mothers
arms.
5.
Weigh the baby.
6.
Count the respiratory rate for one full minute and observe whether there is
grunting or chest indrawing.
7.
Measure the temperature.
8.
Observe color, noting any central cyanosis, jaundice or pallor.
9.
Observe movements and posture.
10. Observe level of alertness and muscle tone.

11. Observe skin, noting any bruises, cuts and abrasions.
Head, Face and Mouth, Eyes
12. Examine head, noting size and shape.
13. Examine face, noting facial features and movements.
14. Examine mouth, noting intactness of tongue, gums and palate.
15. Examine eyes, noting any swelling, redness, or pus draining from them.
Chest, Abdomen and Cord, and External Genitalia
16. Examine chest, noting regularity and symmetry of movements.
17. Examine abdomen and cord.
18. Examine genitals and anus.
Back and Limbs
19. Examine back, noting any swelling, lesions, dimples or hairy patches.
20. Examine all limbs.
21. Decontaminate gloves before removing them, then if disposing of them, place
in a plastic bag or leak-proof, covered container; if reusing them,
decontaminate them in 0.5% chlorine solution.
22. Wash hands thoroughly with soap and water and dry them with a clean, dry
cloth or allow them to air dry.
Breastfeeding (Every Visit)

35

STEP/TASK
CASES
23. Help the woman feel relaxed and confident throughout the observation.
24. Look for signs of good positioning:
z
Mother is comfortable with back and arms supported;
z
Babys head and body are aligned and abdomen turned toward mother;
z
Babys face is facing breast with nose opposite nipple;
z
Babys body is held close to mother;
z
Babys whole body is supported.
25. Look for signs of good attachment:
z
Nipple and areola are drawn into babys mouth;
z
Mouth is wide open;
z
Lower lip is curled back below base of nipple.
26. Look for signs of effective suckling:
z
Slow deep sucks, often with visible or audible swallowing;
z
Baby pauses occasionally.
27. Look for signs of finishing breastfeed:
z
Baby should release breast him/herself;
z
Feeding may vary in length from 4 to 40 minutes per breast;
z
Breasts are softer at end of feeding.
Mother-Baby Bonding (Every Visit)
28. Look for the following signs of bonding:
Mother appears to enjoy physical contact with baby;
Mother caresses, talks to, and makes eye contact with baby;
Mother responds with active concern to babys crying or need for attention.
36

CHECKLIST: ASSESSMENT OF THE NEWBORN

Learner ____________________________________Date Observed _____________________

CHECKLIST FOR ASSESSMENT OF THE NEWBORN
STEP/TASK
CASES
GETTING READY
1.
2.
Tell the mother what you are going to do, encourage her to ask questions and
listen to what she has to say.
HISTORY (Ask the following questions if the information is not available on the mothers/babys record.)
Personal Information (First Visit)
1.
What are your name, address and phone number?
2.
What are the name, sex and birth date of your baby?
3.
4.
5.
had?
6.
Is your baby having a particular problem at present?
7.
Has your baby received care from another caregiver?
The Birth (First Visit)

8.
Where was your baby born and who attended the birth?
9.
Did you have an infection (in the uterus) or fever during labor or birth?
10. Did you bag of water break more than 18 hours before the birth?
11. Were there any complications during the birth that may have caused injury to
the baby?
12. Did the baby need resuscitation (help to breath) at birth?
13. How much did the baby weigh at birth?
Maternal Medical History (First Visit)
14. Did you have diabetes or any infectious diseases such as hepatitis B, HIV,
syphilis or TB during pregnancy?

37

STEP/TASK
CASES
Newborn Period (Every Visit)

15. Does the baby have a congenital malformation (a deformity at birth)?
16. Has the baby received newborn immunizations such as for polio, TB and
hepatitis B?
17. Are you and your family adjusting to having and caring for the baby?
19. How often does the baby feed and is it satisfied after feeding?
20. How often does the baby urinate?
21. When was the last time the baby passed stool? What was the color/consistency?
Interim History (return Visits)
22. Is your baby having a problem at present? Has he/she had any problem since
the last visit?
23. Has your baby received care from another caregiver since the last visit?
24. Have there been any changes in your address or phone number since the last
visit?
25. Have there been any changes in the babys habits or behaviors since the last
visit?
26. Have you been able to care for the baby as discussed at the last visit?
27. Has the baby had any reactions or side effects from immunizations,
drugs/medications or any care provided since the last visit?
EXAMINING THE NEWBORN
Assessment of Overall Appearance/Well-Being (Every Visit)
1.
Again, tell the mother what you are going to do, encourage her to ask questions
and listen to what she has to say.
2.
Wash hands thoroughly and put on clean examination gloves, if necessary.
3.
Place the baby on a clean warm surface or examine him/her in the mothers
arms.
4.
Weigh the baby.
5.
Measure respiratory rate and temperature.
6.
Observe color, movements and posture, level of alertness and muscle tone, and
skin, noting any abnormalities.
7.
Examine head, face and mouth, and eyes, noting any abnormalities.
8.
Examine chest, abdomen and cord, and external genitalia, noting any
abnormalities.
9.
Examine back and limbs, noting any abnormalities.
10. Remove gloves and discard them in a leak-proof container or plastic bag if
11. Wash hands.
Breastfeeding (Every Visit)
38


STEP/TASK
CASES
12. Help the woman feel relaxed and confident throughout the observation.
13. Look for signs of good positioning.
14. Look for signs of effective attachment and suckling.
15. Look for signs of finishing breastfeed.
Mother-Baby Bonding (Every Visit)
16. Look for signs of bonding.

39
LEARNING GUIDE: POSTPARTUM ASSESSMENT (HISTORY AND

PHYSICAL EXAMINATION) AND CARE
LEARNING GUIDE FOR POSTPARTUM ASSESSMENT (HISTORY AND PHYSICAL
EXAMINATION) AND CARE
STEP/TASK
CASES
GETTING READY
1.
2.
Greet the woman respectfully and with kindness.
3.
Tell the woman (and her support person) what is going to be done, listen to
her attentively and respond to her questions and concerns.
4.
Provide continual emotional support and reassurance, as possible.
HISTORY (Ask the following questions if the information is not available on the womans record.)
Personal Information (Every Visit for items followed with an *; First Visit
for other items)
1.
What are your name and age, and the name of your baby?
If the woman is less than 20 years old, determine the circumstances
surrounding the pregnancy (e.g., unprotected sex, multiple partners,
incest, sexual abuse, rape, sexual exploitation, prostitution, forced
marriage or forced sex).
2.
What are your address and your phone number?
3.
4.
5.
had?
6.
How many of your children are still living?
40


STEP/TASK
7.
Are you having a particular problem at present?* If Yes, find out what the
problem is and ask the following additional questions:
z
When did the problem first start?
z
Did it occur suddenly or develop gradually?
z
When and how often does the problem occur?
z
What may have caused the problem?
z
Did anything unusual occur before it started?
z
How does the problem affect you?
z
Are you eating, sleeping and doing other things normally?
z
Has the problem become more severe?
z
Are there other signs and conditions related to the problem? If Yes, ask
what they are.
z
Have you received treatment for the problem? If Yes, ask who provided
the treatment, what it involved, and whether it helped.
8.
Have you received care from another caregiver?* If Yes, ask the following
z
Who provided the care?
z
Why did you seek care from another caregiver?
z
What did the care involve?
z
What was the outcome of this care?
CASES
Daily Habits and Lifestyle (Every Visit for items followed with an *; First
Visit for other items)
9.
Do you work outside the home?*
10. Do you walk long distances, carry heavy loads or do physical labor?*
11. Do you get enough sleep/rest?*
12. What do you normally eat and drink in a day?*
13. Do you eat any substances such as dirt or clay?
14. Do you smoke, drink alcohol or use any other possibly harmful substances?
15. Whom do you live with?
16. Has anyone ever prevented you from seeing family or friends, stopped you
from leaving your home or threatened your life?
17. Have you ever been injured, hit or forced to have sex by someone?
18. Are you frightened of anyone?
Present Pregnancy and Childbirth (First Visit)
19. When did you have your baby?
20. Where did you have your baby and who attended the birth?
21. Did you have any vaginal bleeding during this pregnancy?
22. Did you have any complications during this childbirth, such as convulsions
(pre-eclampsia/eclampsia), cesarean section or other uterine surgery, vaginal
or perineal tears, episiotomy or defibulation?
23. Were there any complications with the baby?

41

STEP/TASK
CASES
Present Postpartum Period (Every Visit)

24. Have you had any heavy bleeding since you gave birth?
25. What color is your vaginal discharge and how often do you need to change
your pad/cloth?
26. Have you had any problems with bowel or bladder function (e.g.,
incontinence, leakage of urine/feces from vagina, burning on urination,
inability to urinate when urge is felt, constipation)?
27. Do you feel good about your baby and your ability to take care of her/him? If
No, ask the following additional questions:
z
Are you feeling sad or overwhelmed?
z
Are you not eating or sleeping well?
z
Have you been crying or feeling more irritable than usual?
Previous Postpartum History (First Visit)
30. Have you breastfed a baby before? If Yes, ask the following additional
questions:
z
For how long did you breastfeed your baby(ies)?
z
Did you have any previous problems breastfeeding?
31. Did you have any complications, such as convulsions (pre-eclampsia/
eclampsia) or postpartum depression/psychosis following previous births?
Contraceptive History (First Visit)
32. How many more children do you plan to have and how long do you want to
wait until the next pregnancy?
33. Have you used a family planning method before? If Yes, ask the following
Which method(s) have you used?
Did you like the method(s) and why?
Which method did you like the most and why? (if more than one method
used)
Would you like information about other methods?
34. Are you going to use family planning in the future?
Medical History (Every Visit for items followed with an *; First Visit for
other items)
35. Do you have any allergies?
36. Have you been tested for HIV? If Yes, ask whether the result was positive.
37. Have you had anemia recently (within the last 3 months)? If Yes, obtain
additional information about signs and symptoms and possible cause.
38. Have you been tested for syphilis? If Yes, ask whether the result was positive
and if and when and with what she was treated.
39. Have you had any chronic illness/condition, such as tuberculosis, hepatitis,
heart disease, diabetes or any other chronic illness?
42


STEP/TASK
CASES
40. Have you ever been in hospital or had surgery/an operation?

41. Are you taking any drugs/medications, including traditional/local
preparations, herbal remedies, over-the-counter drugs, vitamins and dietary
supplements?*
42. Have you had a complete series of five tetanus toxoid immunizations?
43. When did you have your last booster of tetanus toxoid?
44. Do you have a problem at present? If Yes, ask follow-up questions under
Personal Information item 7, above.
45. Have you had any problems since your last visit?
46. Has your address or phone number changed since your last visit?
47. Have your daily habits or lifestyle (workload, rest, dietary intake) changed
since your last visit?
48. Have you received care from another caregiver since your last visit? If Yes,
ask who provided the care, what care was provided and what the outcome of
care was.
49. Have you taken drugs/medications prescribed and followed the
advice/recommendations (plan of care) provided at your last visit?
50. Have you had any reactions to or side effects from immunizations or
drugs/medications given at your last visit?
Assessment of General Well-Being (Every Visit)
1.
Observe gait and movements, and behavior and facial expressions.

If not normal for the womans culture, ask if she has:
- Been without food or drink for a prolonged period
- Been taking drugs/medications
- Had an injury
2.
Observe general cleanliness, noting visible dirt and odor.
3.
Check skin, noting lesions and bruises.
4.
Check conjunctiva for pallor.
Vital Signs Measurements (Every Visit)

5.
Have the woman remain seated and relaxed.
6.
Measure blood pressure, temperature and pulse.
Breast Examination (Every Visit)

7.
Explain the next steps in the physical examination to the woman and obtain
her consent to proceed.
8.
Ask the woman to empty her bladder.
9.
air dry.

43

STEP/TASK
CASES
10. Ask the woman to uncover her body from the waist up, and have her lie
comfortably on her back.
11. Check the contours and skin of the breasts, noting dimpling or visible lumps,
scaliness, thickening, redness, lesions, sores and rashes.
12. Gently palpate breasts, noting tenderness and swelling, and areas that are red
and hot.
13. Check nipples, noting pus or bloody discharge, cracks, fissures or other
lesions, and whether nipples are inverted.
Abdominal Examination (Every Visit)
14. Ask the woman to uncover her stomach.
15. Have her lie on her back with her knees slightly bent.
16. Look for old or new incisions on the abdomen:
z
If there is an incision (sutures) from cesarean section or other uterine
surgery, look for signs of infection.
17. Gently palpate abdomen between umbilicus and symphysis pubis, noting size
and firmness of uterus.
18. Check whether bladder is palpable above the symphysis pubis.
Leg Examination (Every Visit)
19. Grasp one of the womans feet with one hand and gently but firmly move the
foot upwards toward the womans knee, and observe whether this causes pain
in the calf.
20. Repeat the procedure on the other leg.
Vaginal Examination (Every Visit)
21. Ask the woman to uncover her genital area and cover or drape her to preserve
privacy and modesty.
22. Ask the woman to separate her legs while continuing to bend her knees
slightly.
23. Turn on the light and direct it toward genital area.
24. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
25. Put new examination or high-level disinfected gloves on both hands.
26. Touch the inside of the womans thigh before touching any part of her genital
area.
27. Separate labia majora with two fingers, and check labia minora, clitoris,
urethral opening, and vaginal opening, noting swelling, tears, episiotomy,
defibulation, sores, ulcers, warts, nits, lice, or urine or stool coming from
vaginal opening.
28. Palpate the labia minora, noting swelling, discharge, tenderness, ulcers,
fistulas, irregularities and nodules.
29. Look at perineum, noting scars, lesions, inflammation, or cracks in skin,
bruising, and color, odor and amount of lochia.
44


STEP/TASK
CASES
30. Immerse both gloved hands briefly in a container filled with 0.5% chlorine
z
container.
z
31. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
CARE PROVISION
Note: Individualize the womans care by considering all information gathered
during assessment.
HIV Counseling
1.
If the woman does not know her HIV status or has not been tested for HIV,
provide HIV counseling, covering:
z
Individual risk factors for HIV/AIDS
z
How the virus is transmitted
z
Local myths and false rumors about HIV/AIDS
z
HIV testing and the results
Breastfeeding and Breast Care

2.
Based on the womans breastfeeding history, provide information about the

following:
z
Exclusive breastfeeding on demand
z
Comfortable positions for breastfeeding and use of both breasts
z
Adequate rest and sleep
z
Extra fluid and food intake
z
Breast care.
Complication Readiness
3.
Review the womans complication readiness plan with her (or develop one if
she does not have one), covering:
z
Arrangements made since last visit
z
Changes
z
Obstacles or problems encountered
Mother-Baby-Family Relationships
4.
Encourage family involvement with the newborn and assist the family to
identify challenges/obstacles and devise strategies for overcoming them.

45

STEP/TASK
CASES
Family Planning
5.
Introduce the concepts of birth spacing and family planning:

Discuss the womans previous experience with and beliefs about
contraception, as well as her preferences.
z
Discuss the lactational amenhorrea method and its benefits, and provide
necessary counseling if client chooses this method.
z
Advise on the availability and accessibility of family planning services.
z
Nutritional Support
6.
Provide advice and counseling about diet and nutrition:

All postpartum women should eat a balanced diet and a variety of foods
rich in iron and vitamin A, calcium, magnesium and vitamin C;
z
Women who are breastfeeding should:
- Eat two additional servings of staple food per day
- Eat three additional servings of calcium-rich foods
- Drink at least eight glasses of fluid (two liters) each day (including
milk, water and juices)
- Eat smaller more frequent meals, if necessary
- Avoid alcohol and tobacco
- Try to decrease amount of heavy work and increase rest time
z
Self-Care and Other Healthy Behaviors

7.
Provide advice and counseling about:

Prevention of infection/hygiene
z
Rest and activity
z
Sexual relations and safer sex
z
Immunizations and Other Prophylaxis

8.
Give tetanus toxoid (TT) based on womans need.
9.
Dispense sufficient supply of iron/folate until next visit and counsel the
woman about the following:
z
Eat food rich in vitamin C
z
Avoid tea, coffee, and colas
z
Possible side effects and management
10. Dispense medications as follows:

z
Antimalarial tablets (based on region/population-specific need)
z
Mebendazole (based on region/population-specific need)
z
Vitamin A (based on region/population-specific need)
z
Iodine (based on region/population-specific need)
Return Visits
11. Schedule the next postnatal visit:
z
Make sure the woman knows when and where to come.
z
Answer any additional questions or concerns.
z
Advise her to bring her records with her to each visit.
z
Make sure she understands that she can return any time before the next
scheduled visit if she has a problem.
z
Review danger signs and key points of the complication readiness plan.
z
Thank the woman for coming.
46

CHECKLIST: POSTPARTUM ASSESSMENT (HISTORY AND PHYSICAL

Not Observed: Step or task not performed by facilitator/teacher during evaluation by facilitator/teacher
Participant ___________________________________Date Observed ___________________

CHECKLIST FOR POSTPARTUM ASSESSMENT (HISTORY AND PHYSICAL EXAMINATION)
AND CARE
STEP/TASK
CASES
GETTING READY
1.
2.
Greet the woman respectfully and with kindness.
3.
Tell the woman (and her support person) what is going to be done, listen to
her attentively, and respond to her questions and concerns.
4.
Provide continual emotional support and reassurance, as possible.

HISTORY (Ask the following questions if the information is not available on the womans record.)
Personal Information (Every Visit for items followed with an *; First Visit
for other items)
1.
What are your name and age, and the name of your baby?
2.
What are your address and your phone number?
3.
4.
5.
had?
6.
How many of your children are still living?
7.
Are you having a particular problem at present?*
8.
Have you received care from another caregiver?*
Daily Habits and Lifestyle (Every Visit for items followed with an *; First
Visit for other items)
9.
Do you work outside the home?*
10. Do you walk long distances, carry heavy loads or do physical labor?*
11. Do you get enough sleep/rest?*
47

AND CARE
STEP/TASK
CASES
12. What do you normally eat in a day?*

13. Do you eat any substances such as dirt or clay?
14. Do you smoke, drink alcohol or use any other possibly harmful substances?
15. Who do you live with?
16. Has anyone ever prevented you from seeing family or friends, stopped you
from leaving your home, or threatened your life?
17. Have you ever been injured, hit or forced to have sex by someone?
18. Are you frightened of anyone?
Present Pregnancy and Childbirth (First Visit)
19. When did you have your baby?
20. Where did you have your baby and who attended the birth?
21. Did you have any vaginal bleeding during this pregnancy?
22. Did you have any complications during this childbirth?
23. Were there any complications with the baby?
Present Postpartum Period (Every Visit)
24. Have you had any heavy bleeding since you gave birth?
25. What color is your vaginal discharge and how often do you need to change
your pad/cloth?
26. Have you had any problems with bowel or bladder function?
27. Do you feel good about your baby and your ability to take care of her/him?
Previous Postpartum History (First Visit)
30. Have you breastfed a baby before?
31. Did you have any complications following previous childbirths?
Contraceptive History (First Visit)
32. How many more children do you plan to have?
33. Have you used a family planning method before?
34. Are you going to use family planning in the future?
Medical History (Every Visit for items followed with an *; First Visit for
other items)
35. Do you have any allergies?
36. Have you been tested for HIV?
37. Have you had anemia recently?
38. Have you been tested for syphilis?
39. Have you had any chronic illness/condition, such as tuberculosis, hepatitis,
heart disease, diabetes or any other chronic illness?
48


AND CARE
STEP/TASK
CASES
40. Have you ever been in hospital or had surgery/an operation?

41. Are you taking any drugs/medications, including traditional/local
preparations, herbal remedies, over-the-counter drugs, vitamins and dietary
supplements?*
42. Have you had a complete series of five tetanus toxoid immunizations?
43. When did you have your last booster of tetanus toxoid?
44. Do you have a problem at present?
45. Have you had any problems since your last visit?
46. Has your address or phone number changed since your last visit?
47. Have your daily habits or lifestyle (workload, rest, dietary intake) changed
since your last visit?
48. Have you received care from another caregiver since your last visit?
49. Have you taken drugs/medications prescribed and followed the
advice/recommendations (plan of care) provided at your last visit?
50. Have you had any reactions to or side effects from immunizations or
drugs/medications given at your last visit?
1.
Observe gait and movements, and behavior and facial expressions.
2.
Observe general hygiene, noting visible dirt and odor.
3.
Check skin, noting lesions and bruises.
4.
Check conjunctive for pallor.
5.
Have the woman remain seated and relaxed, and measure her blood pressure,
temperature and pulse.
6.
Explain the next steps in the physical examination to the woman and obtain
her consent to proceed.
7.
Ask the woman to empty her bladder.
8.
9.
Ask the woman to uncover her body from the waist up, have her lie
comfortably on her back, and examine her breasts, noting any abnormalities.
10. Ask the woman to uncover her stomach and lie on her back with her knees
slightly bent.
11. Look for old or new incisions on the abdomen, and gently palpate abdomen
between umbilicus and symphysis pubis, noting size and firmness of uterus,
and check whether bladder is palpable above the symphysis pubis.
12. Examine the womans legs, noting any calf pain.
13. Ask the woman to uncover her genital area, cover or drape her to preserve
privacy and modesty, and ask her to separate her legs.

49

AND CARE
STEP/TASK
CASES
14. Turn on the light and direct it toward genital area.

15. Wash hands thoroughly and put new examination or high-level disinfected
gloves on both hands.
16. Inspect/examine labia, clitoris, and perineum, noting lochia, scars, bruising
and skin integrity.
17. Immerse both gloved hands briefly in a container filled with 0.5% chlorine
z
container.
z
18. Wash hands thoroughly.
CARE PROVISION
Note: Individualize the womans care by considering all information gathered
during assessment.
1.
If the woman does not know her HIV status or has not been tested for HIV,
provide HIV counseling.
2.
Based on the womans breastfeeding history, provide information about

breastfeeding and breast care.
3.
Review the womans complication readiness plan with her (or develop one if
she does not have one.
4.
Encourage family involvement with the newborn and assist the family to
identify challenges/obstacles and devise strategies for overcoming them.
5.
Introduce the concepts of birth spacing and family planning, including LAM.
6.
Provide advice and counseling about diet and nutrition.
7.
Provide advice and counseling about self-care.
8.
Give tetanus toxoid (TT) based on womans need.
9.
Dispense sufficient supply of iron/folate until next visit and counsel the
woman about taking the pills.
10. Dispense other medications based on need.

11. Schedule the next postnatal visit.
50

LEARNING GUIDE: POSTABORTION CARE CLINICAL SKILLS

Place a in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily, or
Not Observed: Step or task or skill not performed by learner during evaluation by facilitator/teacher
LEARNING GUIDE FOR POSTABORTION CARE CLINICAL SKILLS

STEP/TASK
CASES
INITIAL ASSESSMENT
1.
Assess patient for shock and other life-threatening conditions.
2.
If any complications are identified, stabilize patient and transfer if necessary.
3.
Treat the patient respectfully and with kindness.
4.
Take a reproductive health history.
5.
Perform indicated laboratory tests.
GETTING READY
1.
Tell the patient what is going to be done and encourage her to ask questions.
2.
Tell patient she may feel discomfort during some of the steps and that you will
tell her in advance.
3.
Check that patient has thoroughly washed her perineal area and has recently
emptied her bladder.
4.
Determine that required equipment and sterile or high-level disinfected

instruments and cannulae are present.
5.
Check MVA syringe and charge it (establishes vacuum).
6.
Put on apron, wash hands thoroughly with soap and water and dry with clean,
dry cloth or air dry.
7.
Put new examination or sterile or high-level disinfected gloves on both hands.
8.
Arrange sterile or high-level disinfected instruments on sterile tray or in highlevel disinfected container.
MVA PROCEDURE
1.
Explain each step of the procedure prior to performing it.
2.
Perform bimanual pelvic examination to confirm uterine size, position and

degree of cervical dilation.
3.
Insert the speculum.
4.
Check the vagina and cervix for tissue fragments and remove them.

51

STEP/TASK
CASES
5.
Apply antiseptic solution two times to the cervix (particularly the os) and
vagina.
6.
Put tenaculum or vulsellum forceps on posterior lip of cervix.
7.
Correctly administer paracervical block (if necessary):

Fill a 10 ml syringe with local anesthetic (1% without epinephrine).
z
With tenaculum or vulsellum forceps on the cervix, use slight traction and
movement to help identify the area between the smooth cervical
epithelium and the vaginal tissue.
z
Insert the needle just under the epithelium and aspirate by drawing the
plunger back slightly to make certain the needle is not penetrating a blood
vessel.
z
Inject about 2 ml of a 1% local anesthetic just under the epithelium, not
deeper than 23 mm at 3, 5, 7 and 9 oclock.
z
Wait a minimum of 24 minutes for the anesthetic to have maximum
effect.
z
8.
Gently apply traction on the cervix to straighten the cervical canal and dilate
the cervix (if needed).
9.
While holding the cervix steady, insert the cannula gently through the cervix
into the uterine cavity until it just touches the fundus (not >10 cm). Then
withdraw the cannula slightly away from the fundus.
10. Attach the prepared syringe to the cannula by holding the end of the cannula in
one hand and the syringe in the other. Make sure the cannula does not move
forward as the syringe is attached.
11. Evacuate contents of the uterus by rotating the cannula and syringe from 10 to
12 oclock and moving the cannula gently and slowly back and forth within
the uterine cavity.
12. If the syringe becomes half full before the procedure is complete, close the
valves and detach the cannula from the syringe. Remove only the syringe,
leaving the cannula in place:
z
Push the plunger to empty POC into the strainer after measuring volume.
z
Recharge syringe, attach to cannula and pinch valve(s).
13. Check for signs of completion (red or pink foam, no more tissue in cannula or
gritty sensation.) Withdraw cannula and MVA syringe gently.
14. Remove cannula from MVA syringe and push the plunger to empty contents
into strainer.
15. Rinse the POC with water or saline.
16. Inspect tissue removed from uterus and ensure it is POC.
17. When the signs of a complete procedure are present, remove forceps or
tenaculum and speculum.
18. Perform bimanual examination to check size and firmness of uterus.
19. Re-insert speculum and check for bleeding.
20. If uterus is still soft or bleeding persists, repeat steps 411.
POST-MVA TASKS
1. Let patient lie on her side in a comfortable position.
52


STEP/TASK
CASES
2. Before removing gloves, dispose of waste materials and soak instruments and
MVA items in 0.5% chlorine solution for 10 minutes for decontamination.
3. Immerse both gloved hands in 0.5% chlorine solution and remove gloves by
turning inside out:
z
If disposing of gloves, place in leak-proof container or plastic bag.
z
4.
Attach used cannula to MVA syringe and flush both with 0.5% chlorine
solution. Detach cannula and soak them in chlorine solution for 10 min.
5.
Empty POC into utility sink, flushable latrine or toilet or container with tightfitting lid.
6.
air dry.
7.
Check for amount of bleeding and if cramping has decreased, at least once
before discharge.
8.
Instruct patient regarding postabortion care (e.g., when patient should return to
clinic).
9.
Discuss reproductive goals and, as appropriate, provide family planning.
10. Tell her when to return if follow-up is needed and that she can return anytime
she has concerns.

53
LEARNING GUIDE: POSTABORTION FAMILY PLANNING

COUNSELING SKILLS
LEARNING GUIDE FOR POSTABORTION FAMILY PLANNING

COUNSELING SKILLS
STEP/TASK
CASES
INITIAL INTERVIEW
1.
Greet woman respectfully and with kindness.
2.
Assess whether counseling is appropriate at this time (if not, arrange for her to be
counseled at another time).
3.
Assure necessary privacy.
4.
Use effective interpersonal communication (two-way communication, active

listening, appropriate non-verbal communication). Encourage patient to ask
questions.
5.
Obtain biographic information (name, address, etc.).
6.
Ask if she was using contraception before she became pregnant. If she was, find
out if she:
z
Used the method correctly
z
Discontinued use
z
Had any trouble using the method
z
Has any concerns about the method
7.
Provide general information about family planning.
8.
Explore any attitudes or religious beliefs that either favor or rule out one or more
methods.
9.
Give the woman information about the contraceptive choices available and the
risks and benefits of each:
z
Show where and how each is used.
z
Explain how the method works and its effectiveness.
z
Explain possible side effects and other health problems.
z
Explain the common side effects.
10. Discuss patients needs, concerns and fears in a thorough and sympathetic
manner.
11. Help patient begin to choose an appropriate method.
54

LEARNING GUIDE FOR POSTABORTION FAMILY PLANNING

COUNSELING SKILLS
STEP/TASK
CASES
PATIENT SCREENING
1.
Screen patient carefully to make sure there is no medical condition that would be
a problem.
2.
Explain potential side effects and make sure that each is fully understood.
3.
Perform further evaluation (physical examination), if indicated. (Non-medical

counselors must refer patient for further evaluation.)
4.
Discuss what to do if the patient experiences any side effects or problems.
5.
Provide follow-up visit instructions.
6.
Assure patient that she can return to the same clinic at any time to receive advice
or medical attention.
7.
Ask the patient to repeat instructions.
8.
Answer patients questions.

55
CHECKLIST: POSTABORTION CARE CLINICAL SKILLS

Place a in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily,
or N/O if not observed.
Participant ____________________________________Date Observed _________________

CHECKLIST FOR POSTABORTION CARE CLINICAL SKILLS
STEP/TASK
CASES
GETTING READY
1.
Tell patient what is going to be done and encourage her to ask questions.
2.
Tell patient she may feel discomfort during some of the steps and that you will
tell her in advance.
3.
Check that patient has thoroughly washed her perineal area and has recently
emptied her bladder.
4.
Determine that required equipment and sterile or high-level disinfected

instruments and cannulae are present.
5.
Check MVA syringe and charge it (establishes vacuum).
6.
Put on apron, wash hands thoroughly with soap and water and dry with clean,
dry cloth or air dry.
7.
Put new examination or sterile or high-level disinfected gloves on both hands.
8.
Arrange sterile or high-level disinfected instruments on sterile tray or in highlevel disinfected container.
MVA PROCEDURE
56
1.
Explain each step of the procedure prior to performing it.
2.
Perform bimanual pelvic examination to confirm uterine size, position and

degree of cervical dilation.
3.
Check the vagina and cervix for tissue fragments and remove them.
4.
Apply antiseptic solution two times to the cervix (particularly the os) and
vagina.
5.
Put tenaculum or vulsellum forceps on posterior lip of cervix.
6.
Correctly administer paracervical block (if necessary).
7.
Dilate the cervix (if needed).
8.
While holding the cervix steady, insert the cannula gently through the cervix
into the uterine cavity.

CHECKLIST FOR POSTABORTION CARE CLINICAL SKILLS

STEP/TASK
9.
CASES
Attach the prepared syringe to the cannula by holding the end of the cannula in
one hand and the syringe in the other.
10. Evacuate contents of the uterus by rotating the cannula and syringe and
moving the cannula gently and slowly back and forth within the uterine cavity.
11. Inspect tissue removed from uterus and ensure it is POC.
12. When the signs of a complete procedure are present, withdraw the cannula and
MVA syringe and remove forceps or tenaculum and speculum.
13. Perform bimanual examination to check size and firmness of uterus.
14. Re-insert speculum and check for bleeding.
15. If uterus is still soft or bleeding persists, repeat steps 411.
POST-MVA TASKS
1.
Before removing gloves, dispose of waste materials and soak instruments and
MVA items in 0.5% chlorine solution for 10 minutes for decontamination.
2.
turning inside out:
z
z
3.
air dry.
4.
Check for amount of bleeding and if cramping has decreased at least once
before discharge.
5.
Instruct patient regarding postabortion care (e.g., when patient should return to
clinic).
6.
Discuss reproductive goals and, as appropriate, provide family planning.


57
CHECKLIST: POSTABORTION FAMILY PLANNING

COUNSELING SKILLS
Participant ____________________________________Date Observed __________________

CHECKLIST FOR POSTABORTION FAMILY PLANNING
COUNSELING SKILLS
STEP/TASK
CASES
INITIAL INTERVIEW
1.
Greet woman respectfully and with kindness.
2.
Assess whether counseling is appropriate at this time (if not, arrange for her to be
counseled at another time).
3.
Assure necessary privacy.
4.
Obtain biographic information (name, address, etc.).
5.
Ask if she was using contraception before she became pregnant. If she was, find
out if she:
z
Used the method correctly
z
Discontinued use
z
Had any trouble using the method
z
Has any concerns about the method
6.
Provide general information about family planning.
7.
Explore any attitudes or religious beliefs that either favor or rule out one or more
methods.
8.
Give the woman information about the contraceptive choices available and the
risks and benefits of each:
z
Show where and how each is used.
z
Explain how the method works and its effectiveness.
z
Explain possible side effects and other health problems.
z
Explain the common side effects.
9.
Discuss patients needs, concerns and fears in a thorough and sympathetic

manner.
10. Help patient begin to choose an appropriate method.

58

CHECKLIST FOR POSTABORTION FAMILY PLANNING

COUNSELING SKILLS
STEP/TASK
CASES
PATIENT SCREENING
1.
Screen patient carefully to make sure there is no medical condition that would be
a problem (complete Patient Screening Checklist).
2.
Explain potential side effects and make sure that each is fully understood.
3.
Perform further evaluation (physical examination), if indicated. (Non-medical

counselors must refer patient for further evaluation.)
4.
Discuss what to do if the patient experiences any side effects or problems.
5.
Provide follow-up visit instructions.
6.
Assure patient she can return to the same clinic at any time to receive advice or
medical attention.
7.
Ask the patient to repeat instructions.
8.
Answer patients questions.


59
LEARNING GUIDE: REPAIR OF VAGINAL SULCUS, PERIURETHRAL

and CERVICAL TEARS
Place a in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily, or N/O
if not observed.
LEARNING GUIDE FOR REPAIR OF VAGINAL SULCUS, PERIURETHRAL

AND CERVICAL TEARS
STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
5.
6.
REPAIR OF VAGINAL SULCUS TEAR (and PERINEAL TEAR)

1.
2.
3.
4.
Draw 10 ml of 0.5% lignocaine into a syringe.
5.
Place two fingers into vagina along proposed incision line.
6.
Insert needle beneath skin for 45 cm following same line.
7.
vessel.
8.
perineal muscle.
9.
Wait 2 minutes and then pinch incision site with forceps.
10. If the woman feels the pinch, wait 2 more minutes and then retest.
11. Using 2/0 suture, insert suture needle just above (1 cm) the apex of the
episiotomy.
12. Use a continuous suture from apex downward to level of vaginal opening.
13. At opening of vagina, bring together cut edges.
60


AND CERVICAL TEARS
STEP/TASK
CASES
14. Bring needle under vaginal opening and out through incision and tie.
15. If there is a sulcus tear on the other side of the vagina, repeat steps 1114.
16. If there is a perineal wound, put the needle through the vaginal mucosa behind
the hymenal ring and bring the needle out at the top of the perineal wound.
17. Use interrupted sutures to repair perineal muscle, working from top of perineal
incision downward.
18. Use interrupted or subcuticular sutures to bring skin edges together.
19. Wash perineal area with antiseptic, pat dry, and place a sterile sanitary pad over
REPAIR OF PERIURETHRAL TEAR
1.
Place a catheter in the bladder. This will help identify the urethra and keep from
accidentally sewing the urethra shut or damaging it.
2.
3.
Position tissue edges together. (Approximate edges.)
4.
Insert needle (1 cm needle) from the bottom and slightly to one side of the tear to
the top of the tear.
5.
vessel.
6.
Inject lignocaine as you withdraw.
7.
Wait 2 minutes and then pinch site with forceps to check for anesthetic effect.
8.
Place interrupted sutures the length of the tear, spaced approximately 1 cm apart
for the full length of the tear.
9.
If blood continues to ooze from the laceration, press gauze firmly over the wound
for 12 minutes, until bleeding stops.
REPAIR OF CERVICAL TEAR

1.
Clean the vagina and cervix with antiseptic solution.
2.
Grasp both sides of the cervix using ring or sponge forceps (one forceps for each
side of tear). Do not use toothed instruments as these can cut the cervix and cause
more bleeding.
3.
Place the handles from both forceps in one hand. Pull the handles toward you so
that you can more clearly see the tear.
3.
Place the first suture 1 cm above the apex of the tear and tie.
4.
Close with a continuous suture, including the whole thickness of the cervix each
time the suture needle is inserted.
5.
If a long section of the cervix is tattered, under-run it with a continuous suture.
1.
Dispose of waste materials (e.g., blood-contaminated swabs) in a leak-proof

2.


61

AND CERVICAL TEARS
STEP/TASK
CASES
3.

z
decontamination.
z
If disposing of needle and syringe, flush needle and syringe with 0.5%
4.
z
z
If reusing surgical gloves, submerge in 0.5% chlorine solution for 10 minutes
to decontaminate.
5.
dry.
62

CHECKLIST: REPAIR OF VAGINAL SULCUS, PERIURETHRAL AND

CERVICAL TEARS
Place a a in case box if step/task is performed satisfactorily, an r if it is not performed satisfactorily, or N/O
if not observed.
Participant_____________________________________ Date Observed___________________

CHECKLIST FOR REPAIR OF VAGINAL SULCUS, PERIURETHRAL AND CERVICAL TEARS
(Some of the following steps/task should be performed simultaneously.)
STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
5.
6.
Put on personal protective equipment

REPAIR OF VAGINAL SULCUS TEAR (and PERINEAL TEAR)

1.
2.
3.
4.
5.
Insert needle beneath skin for 45 cm with two fingers guiding the proposed line.
6.
vessel.
7.
perineal muscle.
8.
Wait 2 minutes and then pinch incision site with forceps, waiting 2 minutes more,
retesting, and injecting additional lignocaine if she then still feels pinch.
9.
Using 2/0 suture, insert suture needle just above (1 cm) the apex of the
episiotomy, and suture continuously downward to the vaginal opening.
10. At opening of vagina, bring together cut edges.

11. Bring needle under vaginal opening and out through incision and tie.
63

STEP/TASK
CASES
12. If there is a sulcus tear on the other side of the vagina, repeat steps 1114.
13. If there is a perineal wound, put the needle through the vaginal mucosa behind
the hymenal ring and bring the needle out at the top of the perineal wound.
14. Use interrupted sutures to repair perineal muscle, working from top of perineal
incision downward.
15. Use interrupted or subcuticular sutures to bring skin edges together.
16. Wash perineal area with antiseptic, pat dry and place a sterile sanitary pad over
REPAIR OF PERIURETHRAL TEAR
1.
Place a catheter in the bladder.
2. Draw 10 ml of 0.5% lignocaine into a syringe.

3.
Position tissue edges together. (Approximate edges.)
4.
Insert needle (1 cm needle) from the bottom and slightly to one side of the tear to
the top of the tear.
5.
vessel.
6.
Inject lignocaine as you withdraw.
7.
Wait 2 minutes and then pinch site with forceps to check for anesthetic effect,
retesting and injecting additional lignocaine if necessary.
8.
Place interrupted sutures the length of the tear, spaced approximately 1 cm apart
for the full length of the tear.
REPAIR OF CERVICAL TEAR

1.
Clean the vagina and cervix with antiseptic solution.
2.
Grasp both sides of the cervix using ring or sponge forceps (one forceps for each
side of tear) and pull to more clearly see tear.
3.
Close with a continuous suture, including the whole thickness of the cervix each
time the suture needle is inserted.
4.
If a long section of the cervix is tattered, under-run it with a continuous suture.

1.
64
Dispose of waste materials (e.g., blood-contaminated swabs) in a leak-proof



STEP/TASK
2.

3.

z
decontamination.
z
If disposing of needle and syringe, flush needle and syringe with 0.5%
4.
z
z
If reusing surgical gloves, submerge in 0.5% chlorine solution for 10 minutes
to decontaminate.
5.
dry.
CASES

65
LEARNING GUIDE: MANUAL REMOVAL OF PLACENTA

if not observed.
LEARNING GUIDE FOR MANUAL REMOVAL OF PLACENTA

STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
Start IV of normal saline or Ringers Lactate.
5.
Ask the woman to empty her bladder or insert a catheter, if necessary.
6.
Give anesthesia (IV pethidine and diazepam, or ketamine).
7.
Give a single dose of prophylactic antibiotics:

Ampicillin 2 g IV PLUS metronidazole 500 mg IV, OR
z
Cefazolin 1 g IV PLUS metronidazole 500 mg IV
z
8.
MANUAL REMOVAL OF PLACENTA

1.
Wash hands and forearms thoroughly with soap and water and dry with a
clean, dry cloth or air dry.
2.
Put high-level disinfected or sterile surgical gloves on both hands. (Note:

elbow-length gloves should be used, if available.)
3.
Place high-level disinfected drape beneath the womans buttocks.
4.
Hold the umbilical cord with a clamp.
5.
Pull the cord gently until it is parallel to the floor and hold firmly.
6.
Place the fingers of the other hand into the vagina and into the uterine cavity,
following the direction of the cord until the placenta is located. Let go of the
cord and use the abdominal hand to support/stabilization of the fundus.
7.
Move the fingers of the hand in the uterus laterally until the edge of the
placenta is located (while continuing to provide counter-traction.)
8.
Keeping the fingers tightly together, ease the edge of the hand gently between
the placenta and the uterine wall, with the palm facing the placenta.
66

LEARNING GUIDE FOR MANUAL REMOVAL OF PLACENTA

STEP/TASK
9.
CASES
Gradually move the hand back and forth in a smooth lateral motion until the
whole placenta is separated from the uterine wall:
z
If the placenta does not separate from the uterine wall by gentle lateral
movement of the fingers at the line of cleavage, suspect placenta accreta
and arrange for surgical intervention.
10. When the placenta is completely separated:

z
Palpate the inside of the uterine cavity to ensure that all placental tissue
has been removed.
z
Slowly withdraw the hand from the uterus bringing the placenta with it.
z
Provide counter-traction to the uterus by pushing it above the symphysis
pubis in the opposite direction of the hand that is being withdrawn.
z
Immediately after removal of placenta massage the uterus through the
abdomen.
11. Give oxytocin 20 units in 1 L IV fluid (normal saline or Ringers lactate) at 60
drops/minute.
12. Have an assistant massage the fundus to encourage atonic uterine contraction.
13. If there is continued heavy bleeding, give ergometrine 0.2 mg IM or give
prostaglandins.
14. Examine the uterine surface of the placenta to ensure that it is complete.
15. Examine the woman carefully and repair any tears to the cervix or vagina, or
repair episiotomy.
16. Clean perineum and place clean pad against perineum.
POSTPROCEDURE TASKS
1.
Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by

z
z
2.
air dry.
3.
Monitor vaginal bleeding and take the womans vital signs:

Every 15 minutes for 1 hour
z
Then every 30 minutes for 2 hours
z
4.
Make sure that the uterus is firmly contracted.

67
CHECKLIST: MANUAL REMOVAL OF PLACENTA

if not observed.
PARTICIPANT ____________________________________ DATE OBSERVED __________________
CHECKLIST FOR MANUAL REMOVAL OF PLACENTA
STEP/TASK
CASES
GETTING READY
1.
2.
3.
4.
Ask the woman to empty her bladder or insert a catheter.
5.
Give anesthesia.
6.
Give prophylactic antibiotics.
7.

MANUAL REMOVAL OF PLACENTA

1.
Wash hands and forearms thoroughly and put on high-level disinfected or

sterile surgical gloves (use elbow-length gloves, if available).
2.
Hold the umbilical cord with a clamp and pull the cord gently.
3.
Place the fingers of one hand into the uterine cavity and locate the placenta.
4.
Provide counter-traction abdominally above the symphysis pubis.
5.
Move the hand back and forth in a smooth lateral motion until the whole
placenta is separated from the uterine wall.
6.
Withdraw the hand from the uterus, bringing the placenta with it while
continuing to provide counter-traction abdominally.
7.
Give oxytocin in IV fluid.
8.
Have an assistant massage the fundus to encourage atonic uterine contraction.
9.
If there is continued heavy bleeding, give ergometrine by IM injection or

prostaglandins.
10. Examine the uterine surface of the placenta to ensure that it is complete.
68

CHECKLIST FOR MANUAL REMOVAL OF PLACENTA

11. Examine the woman carefully and repair any tears to the cervix or vagina or
repair episiotomy.
1.

2.
3.
Monitor vaginal bleeding, take the womans vital signs and make sure that the
uterus is firmly contracted.

69
LEARNING GUIDE: INTERNAL BIMANUAL COMPRESSION OF THE

UTERUS
if not observed.
LEARNING GUIDE FOR INTERNAL BIMANUAL COMPRESSION OF THE UTERUS

STEP/TASK
CASES
GETTING READY
1.
2.
3.
BIMANUAL COMPRESSION
1.
Wash hands thoroughly with soap and water and dry with a clean cloth or air
dry.
2.
3.
Clean the vulva and perineum with antiseptic solution.
4.
Insert one hand into the vagina and form a fist.
5.
Place the fist into the anterior vaginal fornix and apply pressure against the
anterior wall of the uterus.
6.
Place the other hand on the abdomen behind the uterus.
7.
Press the abdominal hand deeply into the abdomen and apply pressure against
the posterior wall of the uterus.
8.
Maintain compression until bleeding is controlled and the uterus contracts.
1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning
them inside out.
z
z
2.
70
Wash hands thoroughly with soap and water and dry with a clean cloth or air
dry.

LEARNING GUIDE FOR INTERNAL BIMANUAL COMPRESSION OF THE UTERUS

STEP/TASK
3.
CASES

Every 15 minutes for 1 hour
z
Then every 30 minutes for 2 hours.
z
4.
Make sure that the uterus is firmly contracted.

71
CHECKLIST: INTERNAL BIMANUAL COMPRESSION OF THE UTERUS

if not observed.
PARTICIPANT_________________________________ DATE OBSERVED _____________________

CHECKLIST FOR INTERNAL BIMANUAL COMPRESSION OF THE UTERUS
STEP/TASK
CASES
GETTING READY
1.
2.
3.

BIMANUAL COMPRESSION
1.
Wash hands thoroughly and put on high-level disinfected or sterile surgical

gloves.
2.
Clean vulva and perineum with antiseptic solution.
3.
Insert fist into anterior vaginal fornix and apply pressure against the anterior
wall of the uterus.
4.
Place other hand on abdomen behind uterus, press the hand deeply into the
abdomen and apply pressure against the posterior wall of the uterus.
5.
Maintain compression until bleeding is controlled and the uterus contracts.

POSTPROCEDURE TASKS
1.
Remove gloves and discard them in leak-proof container or plastic bag if

2.
3.
Monitor vaginal bleeding, take the womans vital signs and make sure that the
uterus is firmly contracted.
72

LEARNING GUIDE: COMPRESSION OF THE ABDOMINAL AORTA

if not observed.
LEARNING GUIDE FOR COMPRESSION OF THE ABDOMINAL AORTA

STEP/TASK
CASES
GETTING READY
1.
2.
Note: Steps 1 and 2 should be implemented at the same time as the following steps.
COMPRESSION OF THE ABDOMINAL AORTA
1.
Place a closed fist just above the umbilicus and slightly to the left.
2.
Apply downward pressure over the abdominal aorta directly through the
abdominal wall.
3.
With the other hand, palpate the femoral pulse to check the adequacy of
compression:
z
If the pulse is palpable during compression, the pressure is inadequate;
z
If the pulse is not palpable during compression, the pressure is adequate.
4.
Maintain compression until bleeding is controlled.
1.

Every 15 minutes for 1 hour;
z
Then every 30 minutes for 2 hours.
z
2.
Palpate the uterine fundus to ensure that the uterus remains firmly contracted.

73
CHECKLIST: COMPRESSION OF THE ABDOMINAL AORTA

if not observed.
Participant _____________________________________Date Observed _________________

CHECKLIST FOR COMPRESSION OF THE ABDOMINAL AORTA
STEP/TASK
CASES
GETTING READY
1.
2.

COMPRESSION OF THE ABDOMINAL AORTA

1.
Place a closed fist just above the umbilicus and slightly to the left.
2.
Apply downward pressure over the abdominal aorta directly through the
abdominal wall.
3.
With the other hand, palpate the femoral pulse to check the adequacy of
compression.
4.
Maintain compression until bleeding is controlled.

1.
Monitor vaginal bleeding, take the womans vital signs, and ensure the uterus
is firmly contracted.
74

LEARNING GUIDE: NEWBORN RESUSCITATION

Place a 9 in case box if task/activity is performed satisfactorily, an X if it is not performed satisfactorily, or
Not Observed: Step, task or skill not performed by learner during evaluation by teacher
LEARNING GUIDE FOR NEWBORN RESUSCITATION

STEP/TASK
CASES
GETTING READY
Note: Newborn resuscitation equipment should be available and ready for use at all births. Hands should be
washed and gloves worn before touching the newborn.
1.
Quickly dry and wrap or cover the newborn, except for the head, face and
upper chest.
2.
Place the newborn on its back on a clean, warm surface.
3.
4.
RESUSCITATION USING BAG AND MASK

1.
2.
Position the head in a slightly extended position to open the airway.

Clear the airway by suctioning the mouth first and then the nose:
Introduce catheter no more than 5 cm into the newborns mouth and
suction while withdrawing catheter.
z
Introduce catheter no more than 3 cm into each nostril and suction while
withdrawing catheter.
z
Do not suction deep in the throat because this may cause the newborns
heart to slow or breathing to stop.
z
Be especially thorough with suctioning if there is blood or meconium in
the newborns mouth and/or nose.
z
If the newborn is still not breathing, start ventilating.
z
3.
Quickly recheck the position of the newborns head to make sure that the neck
is slightly extended.
4.
Place the mask on the newborns face so that it covers the chin, mouth and
nose.
5.
Form a seal between the mask and the newborns face.
6.
Squeeze the bag with two fingers only or with the whole hand, depending on
the size of the bag.
7.
Check the seal by ventilating two times and observing the rise of the chest.

75

STEP/TASK
8.
CASES
If the newborns chest is rising:

Ventilate at a rate of 40 breaths/minute.
z
Observe the chest for an easy rise and fall.
z
9.
If the newborns chest is not rising:

Check the position of the head again to make sure the neck is slightly
extended.
z
Reposition the mask on the newborns face to improve the seal between
mask and face.
z
Squeeze the bag harder to increase ventilation pressure.
z
Repeat suction of mouth and nose to remove mucus, blood or meconium
from the airway.
z
10. Ventilate for 1 minute and then stop and quickly assess if the newborn is
breathing spontaneously.
11. If breathing is normal (3060 breaths/minute) and there is no indrawing of the
chest and no grunting:
z
Put in skin-to-skin contact with mother.
z
Observe breathing at frequent intervals.
z
Measure the newborns axillary temperature and rewarm if temperature is
less than 36 C.
z
Keep in skin-to-skin contact with mother if temperature is 36 C or less.
z
Encourage mother to begin breastfeeding.
12. If newborn is breathing but severe chest indrawing is present:
z
Ventilate with oxygen, if available.
z
Arrange immediate transfer for special care.
13. If there is no gasping or breathing at all after 20 minutes of ventilation, stop
ventilating.
POSTPROCEDURE TASKS
1.
2.
Dispose of disposable suction catheters and mucus extractors in a leak-proof

container or plastic bag. Catheters and mucus extractors that are not
disposable should be filled with 0.5% chlorine solution and soaked for 10
minutes.
For reusable catheters and mucus extractors:
Place in 0.5% chlorine solution for 10 minutes for decontamination.
z
Wash in water and detergent.
z
Use a syringe to flush catheters/tubing.
z
Boil or disinfect in an appropriate chemical solution.
z
3.
Take the valve and mask apart and inspect for cracks and tears.
4.
Wash the valve and mask and check for damage first with 0.5% chlorine
solution and then with water and detergent and rinse. (Some types of masks
may be soaked for 10 minutes in chlorine solution without damage.)
5.
Select a method of sterilization or high-level disinfection:

Silicone and rubber bags and patient valves can be boiled for 10 minutes,
autoclaved at 136 C or disinfected in an appropriate chemical solution
(this may vary depending on the instructions provided by the
manufacturer).
6.
76
air dry.


STEP/TASK
7.
After chemical disinfection, rinse all parts with clean water and allow to air
8dry.
8.
Reassemble the bag.
9.
CASES
Test the bag to make sure that it is functioning:

Block the valve outlet by making an airtight seal with the palm of your
hand and observe if the bag re-inflates when the seal is released.
z
Repeat the test with the mask attached to the bag.
z
DOCUMENTING RESUSCITATION PROCEDURES

1.
Record the following details:

Condition of the newborn at birth
z
Procedures necessary to initiate breathing
z
Time from birth to initiation of spontaneous breathing
z
Clinical observations during and after resuscitation measures
z
Outcome of resuscitation measures
z
In case of failed resuscitation measures, possible reasons for failure
z
Names of providers involved
z

77
CHECKLIST: NEWBORN RESUSCITATION

Place a 9 in case box if task/activity is performed satisfactorily, an X if it is not performed satisfactorily, or
Not Observed: Step, task or skill not performed by learner during evaluation by facilitator/teacher
Learner ________________________________________ Date Observed ________________

CHECKLIST FOR NEWBORN RESUSCITATION
STEP/TASK
CASES
GETTING READY
1.
Quickly wrap or cover the newborn and place on a clean, warm surface.
2.
Tell the woman (and her support person) what is going to be done and
encourage them to ask questions.
3.

RESUSCITATION USING BAG AND MASK

1.
Position the head in a slightly extended position to open the airway.
2.
Clear the airway by suctioning the mouth and nose.
3.
Position the newborns neck and place the mask on the newborns face so that
it covers the chin, mouth and nose. Form a seal between mask and newborns
face.
4.
Ventilate at a rate of 40 breaths/minute for 1 minute and then stop and quickly
assess if the newborn is breathing spontaneously.
5.
If breathing is normal, and there is no indrawing of the chest and no grunting,

put in skin-to-skin contact with mother.
6.
If newborn is not breathing, breathing is less than 30 breaths/minute or severe

chest indrawing is present, ventilate with oxygen if available. Arrange
immediate transfer for special care.
7.
If there is no gasping or breathing at all after 20 minutes of ventilation, stop

ventilating.
POSTPROCEDURE TASKS
1.
78
Place disposable suction catheters and mucus extractors in a leak-proof

container or plastic bag. Place reusable catheters and mucus extractors in 0.5%
chlorine solution for decontamination. Then, clean and process.

CHECKLIST FOR NEWBORN RESUSCITATION

STEP/TASK
2.
Clean and decontaminate the valve and mask and check for damage.
3.
4.
Record pertinent information on the mothers/newborns record.
CASES

79
LEARNING GUIDE: KANGAROO MOTHER CARE

LEARNING GUIDE FOR KANGAROO MOTHER CARE

STEP/TASK
CASES
GETTING READY
1.
2.

Explain to the mother (and her support person) the benefits of KMC:
Newborns breathing becomes more regular and stable.
z
Newborns temperature becomes normal and stable.
z
Newborns immunity is improved.
z
Infections of newborn are reduced.
z
Newborn breastfeeds better and gains weight faster.
z
Mother/parent becomes more attached to her baby emotionally.
z
Mother/parent feels more confident caring for small, fragile newborn.
z
3.
Tell the mother (and her support person) what is going to be done.
4.
Listen to her/their questions and respond attentively.
5.
Place baby between mothers breasts:

Mother and newborn chest-to-chest
z
Newborns feet below mothers breasts
z
Newborns hands above mothers breasts
z
Place cloth between babys legs to collect urine and stool
z
6.
Wrap the mother and newborn together:

Use a long piece of cloth.
z
Put the center of the cloth over the newborns and mothers chest.
z
Wrap both ends of the cloth around the mother, under her arms, to her
back.
z
Cross cloth ends behind mother and tie ends in secure knot.
z
If the cloth is too long, bring both ends of cloth to front and tie the ends in
a knot under the newborn.
z
Wrap should be tight so the newborn does not slip out when the mother
stands, but leaves room for the newborn to breathe.
z
Support the newborns head by pulling the wrap up to just under the
newborns ear.
z
7.
80
Have the mother put on a loose blouse or dress over the baby.

LEARNING GUIDE FOR KANGAROO MOTHER CARE

STEP/TASK
8.
CASES
Explain to the mother/caretaker:

That to sleep, she should keep her upper body raised (about 30 degrees) to
keep the baby in a head-up position
z
That to breastfeed, she should loosen cloth and feed newborn on demand,
at least every 2 hours
z
To use KMC continuously
z
That another family member may replace her for skin-to-skin contact for
short periods of time
z
To continue KMC until the baby weighs at least 2500 grams
z

81
CHECKLIST: KANGAROO MOTHER CARE

Participant _____________________________________ Date Observed ________________

CHECKLIST FOR KANGAROO MOTHER CARE
STEP/TASK
CASES
GETTING READY
1.
2.
Explain to the mother (and her support person) the benefits of KMC.
3.
Tell the mother (and her support person) what is going to be done.
4.
Listen to her/their questions and respond attentively.
5.
Place baby between mothers breasts.
6.
Wrap the mother and newborn together using a long cloth, and tie the ends of
the cloth behind the mother in a secure knot.
7.
Have the mother put on a loose blouse or dress over the baby.
8.
Explain to the mother/caretaker:

That to sleep, she should keep her upper body raised (about 30 degrees) to
keep the baby in a head-up position
z
That to breastfeed, she should loosen cloth and feed newborn on demand,
at least every 2 hours
z
To use KMC continuously
z
That another family member may replace her for skin-to-skin contact for
short periods of time
z
To continue KMC until the baby weighs at least 2500 grams
z
82


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1 5N

BEST PRACTICES IN MATERNAL AND NEWBORN CARE:

Best Practices in Maternal and Newborn Care

Best Practices in Maternal and Newborn Care

LEARNING GUIDE: ANTENATAL HISTORY,

LEARNING GUIDE FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC

Prepare the necessary equipment.

Offer the woman a seat.

Provide reassurance and emotional support as needed.

Do rapid check for danger signs, conditions needing emergency treatment.

Calculate the EDD and gestational age.

Ask the woman about previous pregnancies and breastfeeding history.

Ask the woman about medical conditions, medications and hospitalizations.

10. Ask the woman about HIV status.

LEARNING GUIDE FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC

Observe the womans general appearance, including gait, skin and

Explain each step of the physical examination to the woman.

Take the womans blood pressure.

Examine the breasts.

Examine abdomen and measure/estimate fundal height.

Palpate to determine lie and presentation (after 36 weeks).

10. Listen to the fetal heart (second and third trimesters).

Put examination gloves on both hands.

Dispose of needle and syringe in puncture-proof container.

Immerse both gloved hands in 0.5% chlorine solution:

Wash hands thoroughly with soap and water and dry.

Best Practices in Maternal and Newborn Care

LEARNING GUIDE FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC

Identify the womans individual problems/needs, based on the findings of

PROVIDE CARE/TAKE ACTION

Provide tetanus immunization based on need.

Provide counseling about necessary topics such as nutrition, hygiene, use of

Provide counseling about the use of insecticide-treated bed nets.

Dispense medication for IPT for malaria according to protocol.

Dispense other necessary medications such as iron and folate.

Develop or review individualized birth plan with the woman; develop or

Discuss danger signs and what to do if they occur.

Record the relevant details of care on the womans record/antenatal card.

Best Practices in Maternal and Newborn Care

CHECKLIST: ANTENATAL HISTORY,

Learner ____________________________________Date Observed _____________________

Prepare the necessary equipment.

Offer the woman a seat.

Calculate the EDD and gestational age.

Ask woman about daily habits, lifestyle and social support.

Ask the woman about past pregnancies and breastfeeding.

Ask the woman about tetanus immunization.

Best Practices in Maternal and Newborn Care

CHECKLIST FOR ANTENATAL HISTORY, PHYSICAL EXAMINATION AND BASIC CARE

Observe the womans general appearance.

Explain each step of the physical examination to the woman.

Take the womans blood pressure.

Examine the breasts.

Examine abdomen and determine lie and presentation (after 36 weeks).

Measure/estimate fundal height.

10. Listen to the fetal heart (second and third trimesters).

Put examination gloves on both hands.

Dispose off needle and syringe in puncture-proof container.

Wash hands thoroughly with soap and water and dry.

Identify the womans individual problems/needs, based on the findings of the

Learner ________________Date Observed _

Participant ______________Date Observed