Download Guidelines for In-Service Training in Basic and Comprehensive

Guidelines for In-Service Training in
Basic and Comprehensive Emergency
Obstetric and Newborn Care
Prepared by:
Blami Dao
Jhpiego Corporation is an international, non-profit health organization affiliated with The Johns Hopkins
University. For more than 36 years, Jhpiego has empowered front-line health workers by designing and
implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for
women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works
to break down barriers to high-quality health care for the world’s most vulnerable populations.
Published by:
Jhpiego
Brown’s Wharf
1615 Thames Street
Baltimore, Maryland 21231-3492, USA
www.jhpiego.org
Copyright 2012 by Jhpiego. All rights reserved.
The following reviewers contributed to the development of these guidelines:
Julia Bluestone
Catherine Carr
Sheena Currie
Barbara Deller
Patricia Gomez
Yolande Hyjazi
Rosemary Kamunya
Jean Pierre Rakotovao
Kusum Thapa
TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ........................................................................................ iv
1. RATIONALE FOR THE GUIDELINES ..................................................................................... 1
2. TRAINING GOAL AND OBJECTIVES ..................................................................................... 2
3. PRE-TRAINING PREPARATION ............................................................................................. 3
4. COMPONENTS AND CONTENT OF TRAINING IN EMONC .................................................. 5
5. TRAINING DURATION AND SCHEDULES ........................................................................... 11
6. COURSE MATERIALS ........................................................................................................... 20
7. ANATOMIC MODELS ............................................................................................................ 22
8. VIDEOS AND PRESENTATIONS .......................................................................................... 23
9. JOB AIDS ............................................................................................................................... 24
10. DOCUMENTATION OF ACTIVITIES ................................................................................... 24
APPENDIXES
APPENDIX A: ORGANIZATION OF MATERNITY SERVICES ................................................. 25
APPENDIX B: EQUIPMENT AND SUPPLIES LIST .................................................................. 27
APPENDIX C: PRACTICUM LOGBOOKS FOR DOCUMENTING SKILLS PERFORMED
WITH CLIENTS .......................................................................................................................... 30
APPENDIX D: SAMPLE ACTION PLAN FOR LEARNERS ...................................................... 32
APPENDIX E: TRAINING EVALUATION QUESTIONNAIRE ................................................... 33
APPENDIX F: TRAINING INFORMATION SYSTEM: DATA RECORDING FORM .................. 34
Guidelines for EmONC In-Service Training
iii
ABBREVIATIONS AND ACRONYMS
AMTSL
Active management of the third stage of labor
BEmONC
Basic emergency obstetric and newborn care
CEmONC
Comprehensive emergency obstetric and newborn care
CPR
Cardiopulmonary resuscitation
CTS
Clinical Training Skills
EmONC
Emergency obstetric and newborn care
EONC
Essential obstetric and newborn care
ETT
Endotracheal intubation
HBB
Helping Babies Breathe
IP
Infection prevention
LRP
Learning resource package
MgSO4
Magnesium sulfate
MNH
Maternal and newborn health
MVA
Manual vacuum aspiration
OR
Operating room
PAC
Postabortion care
PPH
Postpartum hemorrhage
SBM-R
Standards-Based Management and Recognition
TIMS
Training Information Monitoring System
iv
Guidelines for EmONC In-Service Training
1. RATIONALE FOR THE GUIDELINES
Few developing countries will meet their targets for Millennium Development Goals 4 and 5 by
2015.1 One reason they will fall short is that only about 61% of women globally give birth with a
skilled attendant. In some countries in sub-Saharan Africa and South Asia the rate is closer to 50%,
with even lower rates in rural areas.2 A compounding problem is that many skilled attendants
(doctors, nurses and midwives) do not have the knowledge and skills needed to prevent, recognize
and manage the major causes of maternal and newborn deaths: hemorrhage, infection, preeclampsia/eclampsia, obstructed labor and newborn asphyxia.
The components of emergency obstetric and newborn care (EmONC) were delineated in the early
1990s by WHO, UNICEF and UNFPA.3 These “signal functions” are interventions that must be
available to all women at the time of birth in order to address the common but unpredictable causes
of maternal and newborn mortality. In outlining the EmONC interventions, WHO, UNICEF and
UNFPA recommended that all providers become capable of managing these common complications
in order to decrease need for referral and improve outcomes. The signal functions for EmONC are
listed below:
SIGNAL FUNCTIONS FOR EMERGENCY OBSTETRIC AND NEWBORN CARE
Basic Emergency Obstetric and Newborn Care
(BEmONC):
• Parenteral treatment of infection (antibiotics)
• Parental treatment of pre-eclampsia/eclampsia
(anticonvulsants)
• Parental treatment of postpartum hemorrhage
(uterotonics)
• Manual vacuum aspiration of retained products of
conception
• Vacuum-assisted delivery
• Manual removal of the placenta
• Newborn resuscitation
Comprehensive Emergency Obstetric and
Newborn Care (CEmONC):
• All components of BEmONC
• Surgical capability
• Blood transfusion
Many countries are working to train more skilled providers in emergency obstetric and newborn care
to increase access to these services. However, few countries have the funds or human resources that
are needed to implement quality in-service training. Training that does not translate into the
improvement of patient care wastes those scarce resources and can cost lives.
Quality training in EmONC (and in any health-related field) goes beyond bringing together
providers for classroom and clinical practice for several days. Evidence suggests that training works
when it is competency-based and quality-focused and when it addresses transfer of learning to
1
Hogan MC et al. 2010. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards
Millennium Development Goal 5. Lancet (375): 1609–1623.
2
Crow S, Utley M, Costello A and Pagel C. 2012. How many births in sub-Saharan Africa and South Asia will not be
attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy and Childbirth (12): 4.
3
Penny S and Murray S. Training initiatives for essential obstetric care in developing countries: A “state of the art”
review. Health Policy and Planning 15(4): 386–393.
Guidelines for EmONC In-Service Training
1
practice through post-training follow-up.4 Clinical practice and feedback must be sufficient for the
development of clinical decision-making and psychomotor skills.5 Evidence also reinforces the
importance of clinically integrated learning interventions, as they have been found to be superior to
classroom-only instruction for generating positive learning outcomes.6 This type of training ensures
that learners—practicing clinicians and pre-service educators—are trained by qualified facilitators in
appropriate classroom and clinical settings for an adequate amount of time, using evidence-based
training materials and approaches. And it emphasizes timely follow-up of the learners in their
workplace, where facilitators can assess how the learners have incorporated their new skills and
knowledge into their management of actual clients.
These guidelines provide the information and guidance needed to implement effective BEmONC
and CEmONC training. Recommendations are made for selecting participants and clinical sites,
training schedules, and where to find the materials and resources needed for effective clinical skills
practice. Use of these guidelines will enable facilitators to train providers who are competent in
evidence-based practices and who will ensure that their facilities offer quality EmONC services.
2. TRAINING GOAL AND OBJECTIVES
The goal of EmONC training is to ensure that health facilities have competent providers who can
offer quality EmONC services. By the end of their training, learners achieve the following specific
objectives and competencies:
1. Identify the evidence basis for EmONC interventions.
2. Demonstrate understanding of clients’ rights through provision of respectful care to clients and
their families.
3. Utilize positive interpersonal communication techniques with clients and their families.
4. Demonstrate competency (first on anatomic models; then with clients) in EmONC signal
functions.
5. Demonstrate understanding and use of the clinical decision-making process.
6. Formulate action plans describing how they will act as role models and work to institutionalize
evidence-based EmONC knowledge and skills in their own health facilities.
4
Kongnyuy E, Hofman J and van den Broek N. 2009. Ensuring effective Essential Obstetric Care in resource poor
settings. BJOG 116(Suppl. 1): 41–47.
5 McGaghie WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduate and
graduate medical education: Effectiveness of continuing medical education: American College of Chest Physicians
Evidence-Based Educational Guidelines. Chest 135(3 Suppl): 62S–68S.
6 Coomarasamy A and Khan KS. 2004. What is the evidence that postgraduate teaching in evidence based medicine
changes anything? A systematic review. BMJ (Clinical Research Ed.) 329(7473): 1017–1022.
2
Guidelines for EmONC In-Service Training
3. PRE-TRAINING PREPARATION
Failure to prepare is the worst enemy of quality in any training program. Preparation should start at
least three to six months before the training and should include several activities:
1. Selecting clinical sites
This task is of paramount importance because it will ultimately determine the skills and attitudes
learners will see modeled during the training. The following criteria can be used to select clinical sites:

Buy-in by the clinical site’s staff is needed to ensure smooth training.

Clinical site staff must be willing to go through targeted on-the-job technical and skills
updates to be able to model best practices.

Evidence-based clinical standards should be in place at the site (e.g., respectful care, use of
infection prevention practices, use of a partograph and active management of third stage of
labor).

Adequate caseloads that are appropriate to the training (especially surgical cases for
CEmONC) are needed because obstetric emergencies are relatively rare and learners need to
be exposed to as many cases as possible. BEmONC training sites should have at least 10–15
deliveries per day, and CEmONC sites should have at least 10 deliveries and two to three
cesarean sections per day. When the caseload is lower than this, night shifts can be organized
or the length of the practicum can be extended so that all learners have the opportunity to
achieve competency. The reality is that in developing countries there are many clinical sites
with a high volume of cases but with poor quality of care, so strengthening of the site will be
needed before training.
Please see Appendix A for a description of key elements in the organization of quality maternity
services.
2. Strengthening and preparing clinical sites
Every facilitator’s nightmare is that they bring learners to a facility where clinical practices are
below standard or where there are frequent stock-outs of supplies. So, at least two weeks before
the training, the facilitators should work with the clinical site staff on the following tasks:

Ensure that written evidence-based guidelines describing best practices in maternal and
newborn health (MNH) (i.e., infection prevention, use of the partograph, active
management of third stage of labor, and so on) are in place.

Determine whether the facility is woman- and baby-friendly (i.e., the rights of women and
families to respectful care, privacy, confidentiality, the presence of a companion and
autonomy are recognized; mothers and babies are not separated; early and exclusive
breastfeeding is practiced; and so on).

Ensure that training will not unduly disrupt the facility’s work.

Make sure that sufficient supplies and medications such as infection prevention (IP)
equipment (training necessitates an increased number of gloves), delivery sets, suture kits,
oxytocin, magnesium sulfate (MgSO4) are available at the site. The training facilitators may
Guidelines for EmONC In-Service Training
3
need to bring some of these medications and supplies to the site to ensure that learners will
be able to manage cases in a timely manner instead of waiting for patients to purchase them
before receiving care.
Refer to the Jhpiego publication Site Assessment and Strengthening for Maternal and Newborn
Health Programs, available at www.accesstohealth.org, for a complete description of effective
strengthening of clinical sites prior to training.
3. Selecting learners
Selection of participants for training should be based on the following criteria:

Qualification as an obstetrician (or general practitioner), nurse and/or midwife, or anesthetist

Work experience as a provider in a facility delivering EmONC services and/or as a faculty
member/tutor in a school of medicine or midwifery

Supervisor’s written commitment to enable the learner to utilize the knowledge and skills
gained in the course in his/her clinical site and a commitment that the participant will be
deployed in the maternity unit for at least 12 months after training
The best way to select learners is to form a three- to four-person team of providers from each
facility. The suggested composition of the team is as follows:

For BEmONC courses:
–
An obstetrician, general practitioner, or clinical officer
–
Two midwives (or nurses/midwives)
The ideal number of learners for the BEmONC course is 16–24, depending on the number of
clinical sites available as well as the caseload in each site.

For CEmONC courses:
–
An obstetrician, general practitioner, or clinical officer with surgical skills
–
Two midwives (or nurses/midwives)
–
An anesthetist or a nurse anesthetist
The ideal number of learners is between 16 and 20, depending on the number of clinical sites
available and the caseload at each site.
4. Selecting facilitators

4
Being a proficient obstetrician, midwife, or anesthetist is not enough to qualify as an
EmONC facilitator. EmONC facilitators must meet the following requirements:
–
Qualification as a midwife, doctor, or anesthetist trained in EmONC
–
Qualification as a trainer through a Clinical Training Skills (CTS) course or ModCAL/CTS
–
Currently working in a facility that delivers EmONC services or has regular
opportunities to maintain clinical skills
Guidelines for EmONC In-Service Training
One often-asked question is how many facilitators are needed for EmONC training.

For a BEmONC training with 16–24 learners, a minimum of three facilitators (two
obstetricians plus one midwife, or one obstetrician plus two midwives) is needed for the
knowledge update component. Since each team of three to four learners should be
supervised by a facilitator during the clinical skills standardization portion of the course
(including work with anatomic models), an additional two or three facilitators (either two to
three midwives or one obstetrician and one or two midwives) will be needed. These
facilitators will remain with the teams throughout the clinical portion of the course. These
facilitators become critically important if the practicum takes place in a very busy facility
where a few facilitators cannot adequately supervise all the learner teams when they are
working with clients.

For a CEmONC training, an additional obstetrician is recommended for sites with many
surgical cases; the number of midwives is the same as for BEmONC. In addition, two
anesthetists (an anesthesiologist and/or a nurse anesthetist) will be needed.
5. Gathering equipment needed for training (see Appendix B)
6. Developing job aids
Simple job aids that remind the learner of key information can be extremely valuable in helping
the learner apply skills on the job. Posters, pocket guides and simple guidelines assist learners
with quick recall and the application of complex skills. For more information, see section 9.
4. COMPONENTS AND CONTENT OF TRAINING IN
EMONC
Any complete EmONC training (and by extension any good clinical training) should include the
following three components:

Knowledge update

Clinical skills standardization, resulting in the acquisition of competencies in specific skills (a list
of competencies is included below)

Follow-up of learners in their sites within three months of the training, ideally by the facilitators
who conducted the course
Jhpiego has applied evidence from a recent integrative review of the literature regarding the techniques,
timing, setting and media used for the delivery of instruction to its EmONC training approach. The
blended approach uses spaced, repetitive questions delivered via mobile phone text messaging (SMS) or
the internet to address key knowledge objectives, followed by clinical practice in simulation and with
clients, and continued follow-up and support after training. The knowledge component of the course
via the internet can be accessed at: http://app.qstream.com/Jhpiego/courses/2042-Basic-EmergencyObstetrical-Skills.
Guidelines for EmONC In-Service Training
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Effective blended learning approaches require each component of training to be dependent on
another component.7 Each piece is linked so that a learner cannot successfully complete the course
and master the content without completing each component in succession. Jhpiego applies this
approach by delivering questions that are repeated over time, confirming completion and knowledge
mastery during the clinical practice and live sessions, linking the follow-up to the use of skills in the
workplace, and recording the use of the skills in a logbook. This ensures that funds invested to train
providers result in skills being applied during service delivery and ultimately in improved maternal
and newborn health outcomes.
Jhpiego’s three training components are discussed in further detail below.
KNOWLEDGE UPDATE
This component is computer- and/or classroom-based and includes the evidence basis for best
practices in the management of normal labor and birth as well as the signal functions of EmONC,
demonstrations of key interventions on anatomic models (via video or real-time if in the classroom),
case studies and role plays. The following topics should be reviewed and knowledge assessed before
advancing to the clinical site:
Basic Emergency Obstetric and Newborn Care (BEmONC)
Topics for midwives, doctors and nurses:

Maternal and newborn mortality reduction

Evidence-based practices in maternal and newborn health

Human rights; respectful care of women and their families

Clinical decision-making

Infection prevention practices

Best practices during normal labor and childbirth, including partograph use, active management
of the third stage of labor (AMTSL) and essential newborn care

Care of the mother and baby during the immediate postpartum period

Rapid initial assessment

Management of shock

Vaginal bleeding in early pregnancy and postabortion care (PAC)

Vaginal bleeding in late pregnancy

Headache, blurred vision, loss of consciousness and elevated blood pressure

Management of cord prolapse, breech delivery and shoulder dystocia (optional)

Vacuum-assisted delivery
7
Hoffman J and Miner N. 2008. Real blended learning stands up. American Society of Training and Development.
Accessed on February 21, 2012, at: http://www.astd.org/LC/2008/1008_hofmann.htm
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Guidelines for EmONC In-Service Training

Vaginal bleeding after childbirth

Fever during and after childbirth

Newborn resuscitation

Newborn sepsis

Improving EmONC through criterion-based audit or other quality improvement approaches
such as Standards-Based Management and Recognition (SBM-R)
Comprehensive Emergency Obstetric and Newborn Care (CEmONC)
Topics for doctors (and midwives in some settings):

All BEmONC topics

Pre-, intra- and postoperative care of obstetric patients

Cesarean section (Misgav Ladach method); surgical treatment of ectopic pregnancy

B-Lynch suture

Blood transfusion

Anesthesia and analgesia in obstetrics

Craniotomy (optional)

Tubal ligation (optional)
Topics for anesthetists:

Maternal and newborn mortality

Evidence-based medicine in maternal and newborn health

Infection prevention

Setup of operating theater

Rapid initial assessment

Management of shock

Review anatomy of respiratory and cardiovascular systems

Review of anatomy of vertebral column and spinal cord

Headaches, blurred vision, convulsions, loss of consciousness or elevated blood pressure

Cardiopulmonary resuscitation (CPR)

Control of the airway; endotracheal intubation

Intravenous fluid therapy, oxygen therapy, drugs used in resuscitation

Normal newborn care and newborn resuscitation

Pre-operative, intraoperative and postoperative evaluation and care
Guidelines for EmONC In-Service Training
7

Selecting the correct anesthetic technique, including ketamine and spinal anesthesia

Deciding which cases to refer

Blood transfusion

Improving emergency obstetric care through criterion-based audits
CLINICAL SKILLS STANDARDIZATION
Classroom Practice
Clinical skills standardization begins in the classroom/skills lab as learners use evidence-based,
standardized checklists to become competent in specific skills using anatomic models. Learners must
be judged competent in all skills before proceeding to the clinical setting to care for clients.
Depending on the number of learners and the level of skills they bring to the training, clinical skills
standardization may require up to two days to complete for all learners. “Stations” are set up for each
skill that learners will master (e.g., newborn resuscitation, normal birth, AMTSL, immediate
newborn care, suturing, and so on). After each skill is demonstrated by facilitators, learners practice
in pairs at the station using checklists. Each learner is then assessed by the facilitators for competency
in the skill using models. Anyone who does not attain mastery of the skill in simulation continues to
practice until competent.
Stations for BEmONC skills assessment and mastery (for midwives, doctors and nurses) in the
classroom:

Normal delivery, including AMTSL and immediate newborn care

Management of severe pre-eclampsia and eclampsia using MgSO4

Repair of episiotomy and vaginal and cervical lacerations

Postabortion care and manual vacuum aspiration (MVA)

Vacuum-assisted delivery

Management of postpartum hemorrhage (PPH), including manual removal of the placenta,
bimanual compression of the uterus, compression of the abdominal aorta, and condom tamponade

Normal newborn exam

Newborn resuscitation

Breech delivery (Mauriceau-Smellie-Veit and Loveset maneuvers) (optional)
Facilitators must make sure that all learners have mastered these skills in simulation before they
move to the practicum at the clinical site(s).
Stations for CEmONC skills assessment (for providers who perform surgery) in the classroom:

All skills stations listed for BEmONC

Cesarean section
8
Guidelines for EmONC In-Service Training

Laparotomy

Tubal ligation (optional)

Craniotomy (optional)
Facilitators must make sure that all learners have mastered these skills in simulation before they
move to the practicum at the clinical site(s).
Stations for CEmONC skills assessment (for anesthetists) in the classroom:

Adult resuscitation and intubation

Cardiopulmonary resuscitation

Spinal anesthesia

Newborn resuscitation
Facilitators must make sure that all learners have mastered these skills before moving to the
practicum at the clinical sites.
Clinical Practicum
During the practicum facilitators divide learners into groups of three or four, with no more than
four learners per facilitator, and develop rotation schedules in ANC, maternity (triage/admission,
labor, and birth areas, if separate), inpatient antepartum, and immediate postpartum/newborn. It is
important to have a room where anatomic models and supplies can be available for continued
practice and where case studies, “partograph rounds,” and role plays can be carried out at times when
the service is not busy. Each learner must have a logbook for recording daily activities (Appendix C).
Continual assessment of learners during their clinical work is essential to ensure that each one has an
opportunity to practice various skills with clients. Facilitators should meet daily with each learner to
assess their progress and challenges and to ensure that each has adequate clinical experience and
coaching to become competent in as many skills as possible. The meetings usually take place at the
end of the day. Facilitators should also meet daily as a group to discuss the general progress of
learners and any specific issues that arise during the training.
Last Day of Training
On the last day of the training, learners and facilitators meet again in the classroom. Some important
activities take place during the day:
 Learners complete a written knowledge assessment covering the best practices addressed during the
training. They should score at least 85%; if they do not, they should be coached and then take the
assessment again. They should continue to retake the assessment until they reach the required score.

Depending on the setting, learners may need to participate in clinical simulations with models so
that their competency in key skills can be assessed. They should be coached until they reach a
minimum score of 85% for each skill.
Guidelines for EmONC In-Service Training
9

Each team of learners (if possible) or each individual learner (if the team members come from
different facilities) will develop an action plan to implement in the three months following the
trainings. Action plans ensure that learners continue to use their new skills and teach them to
colleagues, thereby improving the quality of services at their facilities. Usually, learners are asked
to select up to three clinical practices that they want to improve at their facility and delineate the
steps they will take to achieve the improvements. See Appendix D for a sample action plan.

Facilitators and learners discuss next steps, and facilitators share information about:


The use of the logbooks to record all the skills performed by the learners after the training
and before the follow-up visit;

The implementation of the action plans;

The follow-up visit (including, if possible, dates and process); and

Evaluation of the training.
Learners share their feelings and feedback about the training. Each learner fills out an
anonymous questionnaire assessing several components of the training, including the objectives,
methodology, content, logistics, and so on. Appendix E provides an example of a training
evaluation questionnaire.
FOLLOW-UP OF THE TRAINING
Follow-up and supportive supervision are key to helping providers solve problems and apply new
practices on the job. Using performance standards (harmonized and standardized with training
materials) within a post-training follow-up approach or supportive supervision system can also
support performance improvement.8
Before leaving the training site learners will develop action plans in which they will select three or
four skills they have acquired and put them into practice in their workplaces. Follow-up takes place
from six weeks to three months after the training, so learners will have had time to practice their new
knowledge and skills and put their action plans into effect. They will then have the opportunity to
discuss their successes and challenges with a facilitator. If the caseloads in the learners’ health
facilities are low, it may be better to regroup all learners in a busy health facility for two to three days
to conduct the follow-up visit.
An innovative way to follow up learners, either before or after the first visit, is by using mobile phone
technology in a structured way. Options include sending regular SMS messages to remind learners to
use key best practices; texting questions for them to answer to test their retention of knowledge; and
scheduling short phone calls to each team every few weeks to ascertain successes and challenges and
provide coaching even before the actual visit. This form of early and ongoing communication is
being used successfully in many countries; it helps to ensure that the follow-up visit is used to
address the most important issues raised during the mobile phone activities.
8
Examples of EmONC performance standards are available in the EONC Toolkit (forthcoming at www.k4h.org).
10
Guidelines for EmONC In-Service Training
When conducting a follow-up visit, you should organize your activities as follows:
1. Assessment of the learners’ action plan implementation, including successes and challenges
encountered
2. Knowledge assessment for each learner using questions similar to those used in the training
3. Case studies on the partograph and PPH
4. Assessment of skills and attitudes with clients (ideally) or anatomic models (if there are no
clients) using checklists
5. Review of each learner’s clinical experiences logbook
6. Debriefing with the facility management team
7. Discussion of next steps to ensure that as many elements as possible of BEmONC and/or
CEmONC continue to be practiced in the facility
For more detailed information on how to conduct follow-up of providers, you may wish to consult
Jhpiego’s Guidelines for Assessment of Skilled Providers after Training in Maternal and Newborn
Health, available at: www.jhpiego.org/files/GdlnsSkillProvEN.pdf
5. TRAINING DURATION AND SCHEDULES
There is a debate in the EmONC community about the appropriate duration of EmONC trainings.
EmONC training curricula generally range in length from three days to three weeks. It is important
to keep in mind that EmONC training is based on mastery of the EmONC signal functions, and
every training course should result in competent providers. The evidence is clear that sufficient
practice and feedback is essential to the development of the critical thinking and psychomotor skills
required to perform these functions.9 The knowledge update alone may have little to no impact on
learners’ clinical practice skills and behaviors.
In countries with scarce human resources, taking any health worker away for training can
compromise the provision of services during the training. To reduce training time and increase
efficiency, Jhpiego now uses an internet-based course built upon repeated questions and feedback
(see section 4). Three options for training schedules are included here: a 12-day BEmONC training
schedule for midwives and obstetricians; an 18-day CEmONC training schedule for midwives and
obstetricians; and an 18-day CEmONC training schedule for anesthetists. The schedules assume
that a blended learning approach will be taken to reduce training time and increase the effectiveness
of training.
9
McGaghie, WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduate
and graduate medical education: Effectiveness of continuing medical education: American College of Chest
Physicians, evidence-based educational guidelines. Chest 135 (3 Suppl) (Mar): 62S–68S.
Guidelines for EmONC In-Service Training
11
Reading Assignment
Reading Assignment
12
Presentation and
Discussion: AMTSL
Skill Demonstration:
MVA using model
Review of the day’s
activities
Presentation and
Discussion: Infection
prevention practices
Review of the day’s
activities
Reading Assignment
Presentation and
Discussion: Immediate
newborn care
Review of the day’s
activities
Presentation and
Discussion: Managing
prolapsed cord (optional)
Presentation and
Discussion: Postabortion
care
Presentation and
Discussion: Womanfriendly care
Case Study: Interactive
cases studies
Presentation and
Discussion: Headaches,
blurred vision, convulsions,
loss of consciousness,
elevated blood pressure
Presentation and
Discussion: Bleeding in
late pregnancy
Agenda of the day
Warm-up
DAY 3
LUNCH
Case Studies: Vaginal
bleeding in early
pregnancy
Presentations and
Discussion: Vaginal
bleeding in early
pregnancy
Clinical Simulation:
Emergency drill
• Selected learners take
part
• Remaining learners
observe
Presentation and
Discussion: Rapid initial
assessment, managing
shock, resuscitation and
emergency management
Agenda of the day
Warm-up
DAY 2
LUNCH
LUNCH
Presentation and
Discussion: Evidencebased medicine in maternal
and newborn health
Precourse Knowledge
Questionnaire
Review of precourse
questionnaire
Presentation and
Discussion: Maternal and
newborn mortality
reduction
Basic and Comprehensive
EmONC
Opening: Welcome and
introductions
Overview of the course
(goals, objectives,
schedule)
Review course materials
Identify learners’
expectations and norms
DAY 1
Reading Assignment
Skill Demonstration:
Clean and safe childbirth
using model (includes
AMTSL and immediate
newborn care)
Review of the day’s
activities
LUNCH
Exercise: Plotting and
interpreting the partograph
Presentation and
Discussion: Plotting and
interpreting the partograph
•
Normal labor
•
Unsatisfactory
progress in labor
•
Prolonged active
phase
•
Obstructed labor
Presentation and
Discussion: Normal labor
and childbirth
•
Ambulation
•
Nutrition
•
Support person
Agenda of the day
Warm-up
DAY 4
Skills Practice with
Models: Learners practice
in pairs using model
Review of the day’s
activities
LUNCH
Skills Practice with
Models: Learners practice
in pairs using model
Skill Demonstration:
Newborn resuscitation
using model
Presentation and
Discussion: Basic
newborn resuscitation
Case Studies: Fever after
childbirth
Presentation and
Discussion: Fever during
and after childbirth
Agenda of the day
Warm-up
DAY 6
Guidelines for EmONC In-Service Training
Reading Assignment
Case Studies: Vaginal
bleeding after childbirth
Review of the day’s
activities
Skill Demonstration:
Manual removal of
placenta, bimanual
compression of the uterus,
abdominal aortic
compression, condom
tamponade using models
Presentation and
Discussion: Vaginal
bleeding after childbirth
LUNCH
Skill Demonstration:
Vacuum extraction using
model
Presentation, Discussion
and Videotape: Vacuum
extraction
Skill Demonstration:
Breech delivery using
model (optional)
Presentation, Discussion
and Videotape: Breech
delivery (optional)
Skill Demonstration:
Episiotomy and repair of
cervical tears using checklist
Presentation and
Discussion: Care of the
mother in the postpartum
period
Agenda of the day
Warm-up
DAY 5
BEMONC FOR MIDWIVES AND OBSTETRICIANS: 12-DAY COURSE SCHEDULE
COURSE SCHEDULE FOR 12-DAY CLASSROOM/CLINICAL BEMONC WORKSHOP: MIDWIVES AND OBSTETRICIANS
KNOWLEDGE UPDATE AND CLINICAL SKILLS STANDARDIZATION
13
Instructions for Clinical
Practice
Review of the day’s
activities
Skills Mastery with
Models: Learners
demonstrate mastery of
skills using model
Clinical Practice
Review of the day’s
activities
Clinical Practice
Review of the day’s
activities
LUNCH
Clinical Practice
Review of the day’s
activities
LUNCH
Closing Ceremony
Course Evaluation
Course Summary
Guidelines for EmONC In-Service Training
Clinical Practice
Review of the day’s
activities
LUNCH
LUNCH
LUNCH
Agenda and opening
activity
DAY 12
LUNCH
Clinical Practice
DAY 11
Next Steps: Discussion
of use of logbook; followup via mobile phone and
visits
Clinical Practice
DAY 10
Skills Practice with
Models: Learners practice
in pairs using model
Clinical Practice
DAY 9
Group Work: Develop
action plans
Clinical Practice
DAY 8
Midcourse Knowledge
Questionnaire
Agenda and opening
activity
DAY 7
BEMONC FOR MIDWIVES AND OBSTETRICIANS: 12-DAY COURSE SCHEDULE
Ambulation
Nutrition
Support person
Skill Demonstration:
Breech delivery using model
Videotape: Breech delivery
Presentation and
Discussion and
14
LUNCH
Guidelines for EmONC In-Service Training
LUNCH
Case Studies: Vaginal
bleeding after childbirth
Skill Practice: Manual
removal of placenta;
bimanual compression
of the uterus, abdominal
aortic compression,
learners practice in
pairs using model
Skill Demonstration:
Manual removal of
placenta, bimanual
compression of the
uterus, abdominal
aortic compression,
condom tamponade
Skill Demonstration:
Episiotomy and repair and
repair of cervical tears
using learning aid
Skill Practice: Episiotomy
and repair and repair of
cervical tears; learners
practice in pairs using
learning aid
Presentation and
Discussion: Vaginal
bleeding after childbirth
Discussion: Care of the
woman and newborn in the
postpartum period
LUNCH
LUNCH
DAY 6
Agenda and opening activity Agenda and opening
activity
Presentation and
DAY 5
LUNCH
LUNCH
•
•
•
Presentation and
Discussion: Plotting and
interpreting the partograph
Presentation and
Normal labor
Discussion: Postabortion •
care
•
Unsatisfactory progress
in labor
Skill Demonstration: MVA
•
Prolonged active phase
using model
•
Obstructed labor
Videotape: Postabortion
Exercise:
Plotting and
care photoset
interpreting
Skill Practice: MVA;
the partograph
learners practice in pairs
using model
Case Studies: Vaginal
bleeding in early
pregnancy
Presentations and
Discussion: Vaginal
bleeding in early and late
pregnancy and labor
Agenda and opening activity
Presentation and
Discussion: Normal labor
and childbirth
DAY 4
Skill Practice: Breech
delivery; learners practice
in pairs using model
Presentations and
Discussion: Rapid initial
assessment, recognizing and
managing shock, adult
resuscitation, monitoring
blood transfusion
Demonstrations:
•
Handwashing
•
Decontamination
•
Sharps handling
•
Waste disposal
•
Instrument handling and
preparation
Agenda and opening
activity
DAY 3
Presentation and
Discussion: Averting maternal
death and disability; basic and
comprehensive EmONC
Review and Discussion:
Review site assessment
findings and discuss
improving provider
performance, quality of care
and team approach to
EmONC
Precourse Knowledge
Questionnaire
Review clinical experience
Identify individual and group
learning needs
Agenda and opening activity
Opening: Welcome and
introductions
Overview of the course
(goals, objectives, schedule)
Review course materials
Identify learners’ expectations
Presentation and
Discussion: IP practices
DAY 2
DAY 1
CEMONC FOR MIDWIVES AND OBSTETRICIANS: 18-DAY COURSE SCHEDULE
COURSE SCHEDULE FOR 18-DAY CLASSROOM/CLINICAL CEMONC WORKSHOP: MIDWIVES AND OBSTETRICIANS
KNOWLEDGE UPDATE AND CLINICAL SKILLS STANDARDIZATION
Agenda and opening activity
Presentation and
Discussion: Endotracheal
intubation
Agenda and opening activity
Presentation and
Discussion: Normal
newborn care
•
Preventing infections
•
Thermal protection
•
Basic newborn
resuscitation
•
Breastfeeding
•
Best practices
Skill Practice: Endotracheal
intubation; learners practice
in pairs using model
15
LUNCH
LUNCH
Skills Practice with Models: Presentation and
Learners practice in pairs
Discussion: Obstetric surgery
using model
•
Cesarean section
•
Laparotomy
•
Postpartum
hysterectomy
Skill Practice: Newborn
resuscitation; learners practice
in pairs using model
Skill Demonstration:
Newborn resuscitation using
model
DAY 8
DAY 7
Skill Demonstration:
Endotracheal intubation
using model
Review of the day’s activities
Discussion: Being prepared
for an emergency
Clinical Simulation:
Emergency drill
•
Selected learners take
part
•
Remaining learners
observe
Skill Practice: Adult
resuscitation; learners
practice in pairs using model
Skill Demonstration: Adult
resuscitation using model
Review of the day’s activities
Role Play: interpersonal
communication during EmONC
Presentation and
Discussion: Human rights
and EmONC:
•
Feeling a sense of
urgency
•
Accountability for one’s
actions
•
Respect for human life
•
Recognizing women’s
right to life, health,
privacy and dignity
Presentation and
Discussion: Changing
obstetric and midwifery
practice
LUNCH
Skills Practice with
Models: Learners practice
in pairs using model
Agenda and opening
activity
DAY 9
LUNCH
Clinical Experience Log
Book
Instructions for Clinical
Practice
Skills Practice with Models:
Learners practice in pairs
using model
Midcourse Knowledge
Questionnaire
Agenda and opening activity
DAY 10
Presentation and
Discussion: Normal labor
and childbirth
•
Assessing descent,
Presentation and
dilatation, position
Discussion: Headaches,
•
Second stage; need for
blurred vision, convulsions,
episiotomy
loss of consciousness,
•
Active management of
elevated blood pressure
third stage
Case Study: Pregnancy•
Immediate newborn and
induced hypertension
postpartum care
Presentation and
Skill Demonstration: Clean
Discussion: Managing
and safe childbirth using model
prolapsed cord
Skill Practice: Clean and safe
Review of the day’s
childbirth; learners practice in
activities
pairs using model
Review of the day’s activities
Discussion: Changing
attitudes toward post
abortion care services
LUNCH
Clinical Practice
DAY 12
Skills Practice with
Models
Review of the day’s
activities
Case Study: Fever
after childbirth
Presentation and
Discussion: Fever
during and after
childbirth
Guidelines for EmONC In-Service Training
LUNCH
Clinical Practice
DAY 11
Skill Practice: Vacuum
extraction; learners practice
in pairs using model
Review of the day’s
activities
Skill Demonstration:
Vacuum extraction using
model
Presentation, Discussion
and Videotape: Vacuum
extraction
CEMONC FOR MIDWIVES AND OBSTETRICIANS: 18-DAY COURSE SCHEDULE
Clinical Practice
LUNCH
Clinical Practice
DAY 14
Presentation and
Discussion: Craniotomy
Review of the day’s activities
Videotape: Cesarean
section (Misgav Ladach
method)
Presentation and
Discussion—continued
Obstetric surgery
•
Cesarean section
•
Laparotomy
•
Postpartum
hysterectomy
Clinical Practice
LUNCH
Clinical Practice
DAY 15
Skills Practice with
Models: Learners practice
in pairs using model
Clinical Practice
16
LUNCH
Clinical Practice
DAY 16
Tour of Clinical Facilities
Note: Shaded areas indicate common modules for obstetricians, midwives and anesthetists
Clinical Practice
LUNCH
Clinical Practice
DAY 13
Review of the day’s activities
Presentation and
Discussion: Pre- and
postoperative care principles
Presentation and
Discussion: Pain
management and analgesia
and anesthesia in EmONC
Closing Ceremony
Course Evaluation
Course Summary
LUNCH
Next Steps: Logbook;
on-the-job learning;
planning mentoring visits
Presentations: Action
plans
Group Work: Develop
action plans
Presentation and
discussion: Criteriabased audit
Presentation and
discussion: EmONC
indicators
Agenda and opening
activity
DAY 18
Clinical Practice
Guidelines for EmONC In-Service Training
Clinical Practice
LUNCH
Clinical Practice
DAY 17
Clinical Practice
CEMONC FOR MIDWIVES AND OBSTETRICIANS: 18-DAY COURSE SCHEDULE
17
LUNCH
Presentation and
Discussion: Averting
maternal death and
disability; basic and
comprehensive EmONC
Review and
Discussion:
Review site assessment
findings and discuss
improving provider
performance, quality of
care and team approach
to EmONC
Precourse Knowledge
Questionnaire
Review clinical
experience
Identify group and
individual learning needs
Agenda and opening activity
Opening: Welcome and
introductions
Overview of the course
(goals, objectives,
schedule)
Review course materials
Identify learner
expectations
LUNCH
Presentation and
Discussion: Rapid initial
assessment; recognizing and
managing shock; adult
resuscitation; and monitoring
blood transfusion
Demonstration:
•
Handwashing
•
Decontamination
•
Sharps handling
•
Waste disposal
•
Instrument handling and
preparation
Presentation and
Discussion: Infection
prevention practices
DAY 2
DAY 1
LUNCH
Presentation and
Discussion: Review of
physiology of respiratory
and cardiovascular
system; physiological
changes in pregnancy
Demonstration:
Resuscitation tray
LUNCH
Demonstration and
Skills Practice on
Models:
•
IV cannulation
•
Bag and mask
ventilation
•
CPR
Learners practice in pairs
Presentation and
Discussion:
•
CPR
•
Control of airway
•
Principles of oxygen
therapy
•
Intravenous fluid
therapy
Presentation and
Discussion: Review of
anatomy of respiratory
and cardiovascular
system
Presentation and
Discussion: Drugs used
in resuscitation:
adrenaline, ephedrine,
atropine
Agenda and opening
activity
DAY 4
Agenda and opening
activity
DAY 3
DAY 5
LUNCH
Presentation and
Discussion: Review of
anatomy of vertebral
column and spinal cord
Anesthetic Evaluation:
Exercise Two:
•
Intra-operative patient
Case Study: Intraoperative breathing
difficulty and bradycardia
Presentation and
Discussion: Intraoperative evaluation and
care
Presentation and
Discussion: Vaginal
bleeding after childbirth
Agenda and opening
activity
DAY 6
Guidelines for EmONC In-Service Training
LUNCH
Demonstration and
Practice: Evaluation and
care of preoperative patient
Anesthetic Evaluation:
Exercise One:
Preoperative patient
Case Study: Preoperative
case studies
Presentation and
Discussion:
•
Evaluation and care of
preoperative patient
•
Selecting the correct
anesthetic technique
Agenda and opening activity
CEMONC FOR ANESTHETISTS: 18-DAY COURSE SCHEDULE
COURSE SCHEDULE FOR 18-DAY CLASSROOM/CLINICAL CEMONC WORKSHOP: ANESTHETISTS
KNOWLEDGE UPDATE AND CLINICAL SKILLS STANDARDIZATION
18
LUNCH
Anesthetic Evaluation:
Exercise Three:
•
Postoperative patient
Presentation and
Discussion: Deciding
which cases to refer
Case Study:
Postoperative breathing
difficulty
Presentation and
Discussion: Evaluation
and care of postoperative
patient
Presentation and
Discussion: Drugs used
in anesthesia
Agenda and opening
activity
DAY 7
Role Play: Interpersonal
communication during
EmONC
Review of the day’s
activities
Presentation and
Discussion: Ethical
issues and EmONC:
•
Feeling a sense of
urgency
•
Accountability for
one’s actions
•
Respect for human
life
•
Recognizing women’s
right to life, health,
privacy and dignity
Presentation and
Discussion: Changing
obstetric and midwifery
practice
LUNCH
Skill Practice: Endotracheal
intubation; learners practice
in pairs using model or
cadaver
Skill Demonstration:
Endotracheal intubation
using model
Presentation and
Discussion: Endotracheal
intubation (ETT)
Agenda and opening activity
DAY 8
Discussion: Being prepared
for an emergency
Review of the day’s activities
Clinical Simulation:
Emergency drill:
•
Selected learners take
part
•
Remaining learners
observe
Skill Practice: Adult
resuscitation; learners
practice in pairs using model
Skill Demonstration: Adult
resuscitation using model
LUNCH
Clinical Practice:
Intra-operative
evaluation, monitoring
and care
LUNCH
Review the Results of
the Midcourse
Questionnaire
Instruction on Clinical
Experience Logbook
Instructions on Clinical
Practice
Midcourse Questionnaire
Discussion and Skills
Practice: Difficult ETT and
spinal anesthesia
Presentation and
Discussion: Setting up
operating room
Demonstration in
Operating Room:
•
Resuscitation
equipment
•
Ketamine
anesthesia
•
Spinal anesthesia
•
Intra-operative care
Agenda and opening
activity
DAY 10
Skill Practice with
Models: Learners practice
in pairs using models
Review of the day’s
activities
Skill Demonstration and
Practice: Newborn
resuscitation using
models; learners practice
in pairs
Presentation and
Discussion: Normal
newborn care; basic
newborn resuscitation
Agenda and opening
activity
DAY 9
Demonstration: Fluids
used for resuscitation
Review of the day’s
activities
Case Study: Pregnancyinduced hypertension
Presentation and
Discussion:
Headaches, blurred
vision, convulsions, loss
of consciousness,
elevated blood pressure
LUNCH
Clinical Practice in OR
Agenda and opening
activity
DAY 12
Demonstration and
Skills Practice: Lumbar
puncture and spinal
anesthesia; learners
practice in pairs
Review of the day’s
activities
Role Play: Spinal
anesthesia:
Communicating with
conscious patient
Presentation and
Discussion:
Spinal anesthesia
Guidelines for EmONC In-Service Training
LUNCH
Tour of Model District
EmONC Facility:
•
Emergency reception
area:
– Rapid assessment
– Management of
shock
•
Labor room and postdelivery ward:
– Preoperative
evaluation and care
– Postoperative care
•
Operating room:
– Setting up OR
– Intra-operative
evaluation and care
– Immediate
postoperative care
Agenda and opening activity
DAY 11
Case Study: Ketamine
anesthesia in obstetric
practice; obstructed labor
Review of the day’s activities
Skill Demonstration on
Models: Ketamine
anesthesia
Presentation and
Discussion: Ketamine
Anesthesia
CEMONC FOR ANESTHETISTS: 18-DAY COURSE SCHEDULE
DAY 14
DAY 13
Clinical Practice
Downtime: Case studies or
discussion of actual cases
Clinical Practice in Or
Downtime: Case studies
or discussion of actual
cases
Clinical Practice
Downtime: Case studies
or discussion of actual
cases
LUNCH
Clinical Practice in OR
DAY 15
Discussion: Maintaining
operating room (OR)
readiness
Review of the day’s
activities
Demonstration:
Infection prevention:
•
Instrument and linen
preparation
•
High-level
disinfection
•
Sterilization
Clinical Practice
(continued): Intraoperative evaluation,
monitoring and care
Clinical Practice
Downtime: Case studies
or discussion of actual
cases
LUNCH
Clinical Practice in OR
DAY 16
Tour of the Hospital
EmONC Facility
•
Emergency reception
area
•
Labor room/ward
•
Antenatal and postdelivery area
Review of the day’s
activities
19
Note: Shaded areas indicate common modules for anesthetists, obstetricians and midwives
LUNCH
LUNCH
Clinical Practice in OR
Video Films: Cesarean
section
Review of the day’s activities
Skill Practice on
Models: CPR, newborn
resuscitation, ventilation
Review of the day’s
activities
Clinical Practice in OR
Presentation and
Discussion: Obstetric
surgery:
•
Cesarean section
•
Laparotomy
•
Hysterectomy
•
Salpingectomy
Clinical Simulation
(emergency
drill/clinical
simulation):
Management of severe
pre-eclampsia and
collapse
Closing Ceremony
Course Evaluation
Course Summary
LUNCH
Next Steps: Logbook; onthe-job learning; planning
mentoring visits
Presentations: Action
plans
Group Work: Develop
action plans
Presentation and
Discussion: Criteriabased audit
Presentation and
Discussion: EmONC
indicators
Agenda and opening
activity
DAY 18
Downtime: Case studies
or discussion of actual
cases
Clinical Practice in OR
Guidelines for EmONC In-Service Training
Clinical Practice
Downtime: Case studies or
discussion of actual cases
LUNCH
Clinical Practice in OR
DAY 17
Discussion: Setting up
district OR and anesthesia
services and facilities
Review of the day’s activities
Tour of Model District
EmONC Facility
(continued)
CEMONC FOR ANESTHETISTS: 18-DAY COURSE SCHEDULE
6. COURSE MATERIALS
Since the goal of EmONC training is to teach providers evidence-based best practices, training must be
based on the most up-to-date teaching materials and manuals. This section contains links to the
learning resource packages (LRPs) that facilitators will need in order to organize the BEmONC and
CEmONC courses in a logical way. The LRPs contain schedules, session outlines, knowledge
questionnaires, case studies, role plays, skills checklists and PowerPoint presentations. In addition, links
are provided to several reference manuals that contain global evidence-based guidelines for emergency
obstetric and newborn care. The LRPs are formulated to reflect the information in these manuals.
MATERIALS FOR THE BEMONC COURSE
DOCUMENTS TO PREPARE IN ADVANCE
For each learner:
For each facilitator:
•
Course schedule
•
Course schedule and course outline
•
Precourse questionnaire
•
Precourse questionnaire and answer key
•
Midcourse questionnaire
•
Midcourse questionnaire and answer key
•
Action plan
•
Copy of learners’ action plan
TRAINING MATERIALS TO DOWNLOAD
For each learner
For each facilitator
•
Best Practices in Maternal and Newborn
Care: A Learning Resource Package for
Essential and Basic Emergency Obstetric
and Newborn Care. Learner’s Notebook.
http://www.accesstohealth.org/toolres/pdfs
/ACCESS_BPmnclrpPart.pdf
•
Best Practices in Maternal and Newborn Care:
A Learning Resource Package for Essential and
Basic Emergency Obstetric and Newborn Care.
Facilitator’s Guide.
http://www.accesstohealth.org/toolres/pdfs/ACCE
SS_BPmncrlpFacil.pdf
•
Managing Complications in Pregnancy
and Childbirth: A Guide for Midwives and
Doctors. World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RH
R_00.7.pdf
Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential
Practice. WHO, 2006.
http://www.who.int/reproductivehealth/publi
cations/en/
•
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors.
World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.
7.pdf
Pregnancy, Childbirth, Postpartum and Newborn
Care: A Guide for Essential Practice. WHO, 2006.
http://www.who.int/reproductivehealth/publication
s/en/
Emergency Obstetric Care: Quick
Reference Guide for Frontline Providers.
Jhpiego, 2003.
http://www.jhpiego.org/en/node/477
•
•
•
20
•
Emergency Obstetric Care: Quick Reference
Guide for Frontline Providers. Jhpiego, 2003.
http://www.jhpiego.org/en/node/477
Guidelines for EmONC In-Service Training
MATERIALS FOR THE CEMONC COURSE
DOCUMENTS TO PREPARE IN ADVANCE
For each learner:
For each facilitator:
•
Course schedule for midwives, doctors
and/or other clinicians performing surgery
•
Course schedule and course outline for
midwives, doctors and/or other clinicians
performing surgery
•
Precourse questionnaire for midwives,
doctors and/or other clinicians performing
surgery
•
Precourse questionnaire for midwives, doctors
and/or other clinicians performing surgery, and
answer key
•
Midcourse questionnaire for midwives and
doctors
•
Midcourse questionnaire for midwives and
doctors, and answer key
•
Action plan
•
Copy of learners’ action plans
For each anesthetist:
For each facilitator anesthetist:
•
Course schedule for anesthetists
•
Course schedule for anesthetists
•
Precourse questionnaire for anesthetists
•
Precourse questionnaire for anesthetists
•
Midcourse questionnaire for anesthetists
•
Midcourse questionnaire for anesthetists, and
answer key
•
Action plan
•
Copy of learners’ action plans
TRAINING MATERIALS TO DOWNLOAD
For each learner:
For each facilitator:
•
Emergency Obstetric Care for Doctors and
Midwives. Learner’s Guide. Jhpiego/MNH
Program and AMDD, 2003.
http://www.jhpiego.org/pt-br/node/445
•
Emergency Obstetric Care for Doctors and
Midwives. Teacher’s Notebook Guide.
Jhpiego/MNH Program and AMDD, 2003.
http://www.jhpiego.org/pt-br/node/445
•
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and
Doctors. World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR
_00.7.pdf
Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential
Practice. WHO, 2006.
http://www.who.int/reproductivehealth/public
ations/en/
•
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors.
World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR_0
0.7.pdf
Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential Practice.
WHO, 2006.
http://www.who.int/reproductivehealth/publicatio
ns/en/
•
•
For each learner anesthetist:
For each facilitator anesthetist:
•
Anesthesia for Emergency Obstetric Care.
Learner’s Guide. Jhpiego/MNH Program
and AMDD Program, 2003.
http://www.jhpiego.org/en/node/444
•
Anesthesia for Emergency Obstetric Care.
Teacher’s Notebook. Jhpiego/MNH Program
and AMDD Program, 2003.
http://www.jhpiego.org/en/node/444
•
Anaesthesia at the District Hospital (2d ed.),
by Michael B. Dobson. WHO, 2000.
http://whqlibdoc.who.int/publications/924154
5275
•
Anaesthesia at the District Hospital (2d ed.), by
Michael B. Dobson. WHO, 2000.
http://whqlibdoc.who.int/publications/9241545275
•
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and
Doctors. World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR
_00.7.pdf
•
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors.
World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR_0
0.7.pdf
Guidelines for EmONC In-Service Training
21
MATERIALS FOR FOLLOW-UP OF LEARNERS
For each midwife and doctor:
For each anesthetist:
•
Clinical experience logbook
•
Anesthesia for EmONC clinical experience
logbook
•
Guidelines for Assessment of Skilled
Providers after Training in Maternal and
Newborn Health. Jhpiego, 2004.
•
Materials for follow-up of health care providers
trained in anesthesia for EmONC can be found
in the EONC Toolkit (forthcoming in 2012; visit
www.k4health.org)
www.jhpiego.org/files/GdlnsSkillProvEN.pdf
•
Action plan
•
Action plan
•
Related standards
•
Related standards
7. ANATOMIC MODELS
Listed below are descriptions and ordering information for anatomic models and other
equipment needed for EmONC trainings. At a minimum, models for childbirth (for practicing
AMTSL, immediate newborn care, and PPH treatment) and newborn resuscitation should be
made available for BEmONC training. Models for lumbar puncture and airway management can
be added for CEmONC training.
DESCRIPTION
Childbirth simulator
SOURCE
BUYAMAG INC.
www.buyamag.com
GAUMARD SCIENTIFIC
Tel: 001305-971-3790
www.gaumard.com
MamaNatalie (normal birth & vacuum)
LAERDAL
www.laerdal.com/mamaNatalie
Pelvic model for breech delivery
SUPERIOR MEDICAL
superiormedical.com/l_models.html
Model and equipment for MVA
IPAS
www.ipas.org
Fetus model for vacuum extraction
PELICAN HEALTHCARE LTD.
www.pelicanhealthcare.co.uk
Tel: 029 2074 7000
Fax: 029 2074 7001
Email: [email protected]
Model for Cesarean section
OPERATIVE EXPERIENCE
www.operativeexperience.com
Model for PPH management: MamaNatalie
LAERDAL
www.laerdal.com
Model and equipment for newborn resuscitation:
Helping Babies Breathe (HBB) model NeoNatalie
LAERDAL GLOBAL HEALTH
www.laerdalglobalhealth.com/neonatalie.html
22
Guidelines for EmONC In-Service Training
DESCRIPTION
SOURCE
Lumbar puncture trainer/simulator for spinal
anesthesia
GAUMARD SCIENTIFIC
Tel: 001305-971-3790
www.gaumard.com
KYOTO KAGAKU
www.kyotokagaku.com
Airway management trainer with stand
SIMULAIDS
www.simulaids.com
Tel: 800-431-4310
Fax: 001845-679-8996
E-mail: [email protected]
8. VIDEOS AND PRESENTATIONS
The following videos and presentations are useful in EmONC training to reinforce the key
components of each skill being taught. Learners can view them at their own convenience during and
following training as needed to refresh their knowledge.
DESCRIPTION
SOURCES
Active Management of the Third
Stage of Labor: A Demonstration
ACCESS Program
www.accesstohealth.org/toolres/amtslweb/amtsl.html
Vaginal Breech Delivery and
Symphysiotomy
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Manual Vacuum Aspiration
IPAS
www.ipas.org
View video at http://youtu.be/I0daZ8dLXdY
Vacuum Extraction
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Vacuum-Assisted Delivery: A Brief
Summary of Key Principles
Clinical Innovations, Inc.
http://www.clinicalinnovations.com/kiwi_video_vad.htm
Tel: 888-268-6222 or 801-268-8200
To order video, go to:
http://www.clinicalinnovations.com/vacca.htm#dvd
Steps to Overcome Shoulder
Dystocia
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Caesarean Section EvidenceBased Surgical Techniques
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Spinal Anesthesia
www.operationalmedicine.org/ed2/video/spinal.mpg
Labour Companionship: Every
Woman’s Choice
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Guidelines for EmONC In-Service Training
23
9. JOB AIDS
A full list of resources, including job aids, can be found in the Essential Obstetric and Newborn Care
(EONC) Toolkit, forthcoming in 2012 on the Knowledge for Health website (visit
http://www.k4health.org/publications-and-resources). The following job aids are especially useful
during training. If possible, each facility represented at the training should have copies of them.
Job Aids in the EONC Toolkit (forthcoming at www.k4health.org):

Positions for Labor (drawings of positions in labor and squatting position for birth), by Victor
Okello (artist); from GOAL, Uganda

Steps to Perform AMTSL (poster)

Steps to Perform MVA (poster)

Algorithm for Management of Preeclampsia/Eclampsia (poster)

Dilution and Mixing of MgSO4 (poster)

Algorithm for Management of PPH (poster)
Other Job Aids:

Positions for Laboring Out of Bed Tear Pad
Cascade Healthcare Products
www.1cascade.com/ProductInfo.aspx?productid=2937

Action Plan Poster
Helping Babies Breathe Action Plan
www.helpingbabiesbreathe.org/docs/ActionPlan.pdf

Large laminated WHO Modified Partograph
(Facilitators can make this by enlarging a printed partograph to about 1 meter x 1 meter and
laminating it.)

Wall chart to demonstrate cervical dilatation
(Facilitators can make this on flipchart paper by drawing circles from 1 cm to 10 cm in diameter.)
10. DOCUMENTATION OF ACTIVITIES
Training in EmONC is an important component of many maternal mortality reduction programs,
and documentation of activities is needed to monitor the impact of training. You will need a system
for collecting data on facilitators, learners and training events so that you can report on activities and
evaluate the program. The system can be solely paper-based or web-based or a combination of both.
Appendix F shows the Training Information Monitoring System (TIMS) Data Recording Form, the
paper-based reporting system developed by Jhpiego for tracking training activities. The data
collected can be entered in a simple Excel spreadsheet.
24
Guidelines for EmONC In-Service Training
APPENDIX A: ORGANIZATION OF MATERNITY
SERVICES
Listed below are the components of maternity services that should be assessed and targeted for
improvement in the clinical sites that are used for EmONC training. Included are points that should
be highlighted during the discussion of woman-friendly services on the first day of training and
throughout the training.
1. Staffing

Services should be available 24 hours/day, seven days/week.

Staff with BEmONC skills should stay at the site during their assigned shifts. Staff with
CEmONC skills should be easily available by phone or other means, and able to be at the
site within 20 minutes of being called.
2. Woman-friendly and family-friendly care

Women and their families should always be greeted kindly and with respect, no matter how
busy the service is. Every woman should feel as though she is receiving the highest quality
care, even if labor and birth proceed normally.

Women who present for care should undergo immediate rapid assessment and be triaged
according to the findings of the assessment.

Women have a right to (1) privacy (curtains, if not a separate room); (2) know who is taking
care of them (i.e., the provider’s name and qualification); (3) consent to care by a student;
(4) the presence of a family member/companion; (5) information about what is happening
and answers to their questions; (6) information about all procedures and informed consent
for each; (7) ambulate and eat/drink as desired if there are no contraindications; (8) assume
the position of their choice for the birth; (9) breastfeed immediately after the birth; and (10)
remain with their baby throughout their stay at the facility.
3. Equipment/supplies

A designated staff member on each shift will be responsible for checking/restocking all
emergency equipment and trays per established guidelines and checklists. All staff members
should have access to emergency equipment at all times (e.g., adult ambu bags and masks, IV
solutions and administration sets, and medications such as oxytocin and magnesium sulfate).
4. Responsibility for client care

To ensure continuity and increase accountability for each client’s care, every client is assigned
to a specific staff member (midwife, obstetrician, nurse), and that staff member is responsible
for coordinating all care. This includes maintaining the partograph and other documentation
(i.e., delivery register, referral forms, operative notes, and so on).

If the staff member cannot care for the client (because he or she is assisting at another
delivery or an emergency arises), the client’s care should officially be turned over to another
staff member.

Midwifery, nursing and medical students are not counted as regular staff.
Guidelines for EmONC In-Service Training
25

Each student must be assigned to a regular staff member.

Each staff member should supervise no more than two students at a time.

Students can provide direct care to the woman/newborn, but only under the direct
supervision of a regular staff member.

If a physical assessment shows the client is progressing normally, staff can instruct family
members about assisting with ambulation, nourishment and other comfort measures. Staff
should continue to assess the woman and maintain the partograph and other documentation
as needed.
5. Documentation

The partograph will be used for every client once active labor has begun. Students may assist
in gathering information for the partograph under the supervision of a regular staff member.

If a client is not in active labor, a chart will be established and updated at least every four
hours or more often if the client’s condition warrants.

Specific documentation will be undertaken for women with complications. For example,
documentation for pre-eclampsia/eclampsia includes vital signs (with respirations and
reflexes), presence of convulsions, state of consciousness, presence of headache and
abdominal pain, fetal heart rate and use of medications (time, dose and route).
6. Specific procedures

Routine procedures such as cervical exams, rupture of membranes and normal
birth/newborn care/repair of minor lacerations should be carried out in the same room/bed
throughout the client’s care.

Procedures such as MVA should be carried out in the labor ward, not the operating theater,
so as to expedite the woman’s care and counseling and keep the operating theater open for
urgent cases.
7. Newborn resuscitation

At least one resuscitation corner will be readily accessible to all delivery areas. It will be set up
for immediate use at all times. It should include a table with a clean cover, exam gloves, a
radiant lamp or other means to warm the newborn, oxygen if available, clean towels/cloths to
dry the newborn, suction device, an ambu bag and newborn and premature-size masks, a
clock with second hand and a wall chart for newborn resuscitation (e.g., the Helping Babies
Breathe job aid).
8. Hand-off at end of shift
26

Providers leaving at the end of their shift will ensure that all materials, supplies and
medications are replenished before they leave and that the newborn resuscitation corner is
ready for use.

Incoming providers will meet with the outgoing staff and receive client assignments and an
update about the status of each client, using the partograph and/or other documentation as a
guide.

Incoming providers will immediately introduce themselves to clients.
Guidelines for EmONC In-Service Training
APPENDIX B: EQUIPMENT AND SUPPLIES LIST
The list below shows the standard equipment and supplies that are needed for training courses, both
in the classroom and in the clinical setting. Learners will need basic supplies to simulate what they
will find in the hospital, and these items can be kept and used for future training courses. After
assessing the clinical site, facilitators may want to donate certain equipment, supplies and
medications to the facility so that learners are able to care for clients according to global standards.
ITEMS
NUMBERS NEEDED
Learners
Facilitators
Facility*
Total
Examination
Adult sphygmomanometer
1 per team
2
Adult stethoscope
1 per team
2
Thermometer
1 per team
2
Tape
1 per team
2
Fetoscope
1 per team
2
1 per team
3–5
1 per model
3–5
Plastic sheet to place under mother and
clean cloths for draping
3–4 per
model
5
Clean cloths to dry and cover baby
3–4 per
model
2 dozen
Plastic apron
1 per team
5
Head covers
1 per learner
100
Masks
1 per learner
100
Gloves—sterile
6 pairs per
learner
3 dozen,
various
sizes
Gloves—non-sterile
2 boxes per
team
10 boxes
Barrier goggles
1 per learner
Gauze—4-inch x 4-inch squares in giant
package, non-sterile and not individually
wrapped
4 packages
per team
6 boxes
Oxytocin vials
1 per team
50
Delivery
Delivery Kits
•
Instrument tray
•
Cord scissors
•
Hemostats (2) to clamp cord, or cord
clamps
•
Sponge forceps (2)
Galipot bowls for cotton/antiseptic for
perineal cleansing; placenta bowl
Guidelines for EmONC In-Service Training
1 per
facilitator
27
ITEMS
NUMBERS NEEDED
Learners
Facilitators
Facility*
Syringe and needle (3 cc syringe with 20 or
21 gauge needle)
1 per team
50
Amniotic hook or Kocher clamp
1 per team
3–5
Total
Episiotomy
Sponges (foam blocks) of upholstery quality
(8 inch x 4 inch x 4 inch)—should not tear
easily when thread pulled through. Please
test!
3 per learner
Suture needles—reusable, round body,
half-circle suture needles either with suture
already attached or with an eye so suture
can be pulled through eye.
50
Rolls/spools of regular sewing thread (good
quality so goes through practice sponge
easily). Needed only if suture needles do
not have suture attached.
10
rolls/spools
per team
Episiotomy/laceration repair kits—include
metal tray or container with needle holder,
episiotomy scissors, non-toothed dissecting
forceps, towel clips, stitch scissors, spongeholding forceps, long straight artery forceps
1 per team
3
1 per
50
3 per team
6
10 cc syringe with 1.5-inch needle (pretend
filled with 0.5% lidocaine); or lidocaine 1%
and sterile water for injection, for dilution to
0.5%.
2
50
Infection Prevention
Plastic buckets
Large steamer pot with lid (for steaming/
boiling)
Plastic bucket for chlorine solution
1
1 per model
(childbirth
and
newborn)
6
Heavy cleaning gloves
2 pairs
Toothbrush
Puncture-proof container for sharps
disposal
6
1 per
childbirth
model
6
Plastic bucket for paper disposal
1 per model
(childbirth
and
newborn)
0
6
Bottles of alcohol and glycerin gel for hand
cleansing
1 per station
0
6
Dish/liquid soap
1 per
classroom
0
5
Individual towels
1–2 per
1–2 per
28
Guidelines for EmONC In-Service Training
ITEMS
NUMBERS NEEDED
Learners
Facilitators
Facility*
learner
facilitator
1 per model
0
5
Condom
idem
0
5
Suture
idem
0
5
IV fluids administration set
idem
0
10
Adult ambu bag with mask
1
0
1
idem
0
50
Cesarean tray, if CEmONC
1 per 4–6
learners
0
3
Vacuum extractor
1 per 4–6
learners
0
1
MVA kit
1 per team
0
1
NeoNatalie kits, including models, ambu
bags/masks, and mucous extractors; or
separate models and equipment
1 per 4–6
learners
0
1
Antihypertensives
0
Based on
# of cases
at training
sites, if
stockouts
are
anticipated
Magnesium sulfate
0
idem
Antibiotics for treatment of maternal and
newborn infection
0
Chlorhexidine 4% for newborn cord care
0
Total
PPH, PE/E and other EmONC Management
Foley bladder catheter
Oxytocin 10 IU
idem
idem
*Numbers needed for each facility will depend on what is found during the clinical site assessment; some facilities are
well-equipped while others will have no spare equipment for use by learners.
Guidelines for EmONC In-Service Training
29
APPENDIX C: PRACTICUM LOGBOOKS FOR
DOCUMENTING SKILLS PERFORMED WITH CLIENTS
Practicum Logbook for Nurses/Midwives and Obstetricians (to be filled out during EmONC training)
DAY 1
DAY 2
DAY 3
DAY 4
DAY 5
DAY 6
DAY 7
DAY 8
Partograph
Normal delivery
Active management of
third stage of labor
Episiotomy and/or
repair of
episiotomy/laceration
Newborn resuscitation
Vacuum-assisted
delivery
Manual vacuum
aspiration
Manual removal of the
placenta
Bimanual
compression of the
uterus
Compression of
abdominal aorta
Condom tamponade
Cesarean section*
Laparotomy for extrauterine pregnancy*
Laparotomy for uterine
rupture*
*For obstetricians only
30
Guidelines for EmONC In-Service Training
Practicum Logbook for Anesthetists (to be filled out during EmONC training)
DAY 1
DAY 2
DAY 3
DAY 4
DAY 5
DAY 6
DAY 7
DAY 8
Treatment of shock/adult
resuscitation
Cardiopulmonary
resuscitation
Establish IV line
Control of the airway/
endotracheal intubation
Setup of operating room
Preoperative care
Spinal anesthesia
Ketamine anesthesia
General anesthesia
Postoperative care
Blood transfusion
Case referred
Newborn resuscitation
Guidelines for EmONC In-Service Training
31
APPENDIX D: SAMPLE ACTION PLAN FOR
LEARNERS
Learner Name:
Country of Residence:
Training Attended:
Name of Facility:
Date:
Based on what you learned during this training, please write down three things that you would
like to change at your facility over the next year:
Goal #1
Goal #2
Goal #3
List the actions/steps needed to achieve the goal, along with the date that each activity is
completed. Include the names of colleagues who will assist you and list the specific tasks they
are assigned.
Goal #1
ACTIVITIES/STEPS
DATE
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR ASSIGNED
TASKS
DATE
COMPLETED
DATE
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR TASKS
DATE
COMPLETED
DATE
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR TASKS
DATE
COMPLETED
Goal #2
ACTIVITIES/STEPS
Goal #3
ACTIVITIES/STEPS
32
Guidelines for EmONC In-Service Training
APPENDIX E: TRAINING EVALUATION
QUESTIONNAIRE
PLEASE EVALUATE THE
FOLLOWING STATEMENTS
1.
For the work I do, the training
was appropriate.
2.
Training facilities and
arrangements were
satisfactory.
3.
The facilitators/teachers
were knowledgeable and
skilled.
4.
The facilitators/teachers
were fair and friendly.
5.
The training updated my
knowledge and skills.
6.
Training objectives were met.
7.
Teaching aids were useful.
8.
Practice in the clinical areas
was important and helpful.
STRONGLY
AGREE
AGREE
UNDECIDED
DISAGREE
STRONGLY
DISAGREE
Please answer the following questions. Use the back for more writing space if needed.
1. What was the most useful part of the training course for you?
2. What, if any, part of the training course was not useful to you?
3. What suggestions do you have for improving the training course?
4. Other comments:
Guidelines for EmONC In-Service Training
33
APPENDIX F: TRAINING INFORMATION MONITORING
SYSTEM: DATA RECORDING FORM
34
Guidelines for EmONC In-Service Training