UNIT I

OVERVIEW OF HUMAN REPRODUCTIVE HEALTH AND

REPRODUCTIVE RIGHTS / ICPD
1. 1 Introduction
Reproductive Health (RH) dates back to the World Conference on Population held in Bucharest in
1974 where family planning was identified as key to the control of population. This was made an
integral part of maternal and child health. A decade later, at the Population Conference in Mexico in
1984, it was decided that family planning should be integrated into Primary Health care to
ensure effective output. Reproductive Health started in 1994 following the 1994 International
Conference on Population Development (lCPD) held in Cairo, Egypt. When family planning was
found not to have made much impact. A paradigm shift from the traditional maternal and child
health/family planning (MCH/FP) and Population Control to Reproductive Health and Right was
made to be highly significant (United Nation, 1994). The programme of action of the ICPD was
adopted by 178 countries including Nigeria and it has become a globally accepted framework for
national action in the areas of population development, health and human rights. The ICPD
Programme of action endorsed a Reproductive Health approach that address women's and men's
rights and needs throughout their lives. The whole world was convinced that the shift was very
necessary in order to achieve the desired control on Population. This shift gave rise to the concept of
Reproductive Health.
This shift represents one of the greatest developments in the health sector in recent times, with the
entire life cycle of the human being and coverage of both sexes as the focus. the needs of women
before, during and after child bearing age as well as the needs of men were taken into consideration.
The concept is a critical part of people's wellbeing and is central and critical to human development.
It aims at meeting individual Reproductive Health needs rather than simply focusing on
demographic targets. The Nigerian government therefore determined to operationalize the
RH concept for the betterment and quality of life of her citizenry.
1.1.1 Definition of Reproductive Health
Reproductive Health (RH) is a state of complete physical, mental and social wellbeing and not merely
the absence of disease or infirmity in all matters related to the reproductive system and to its
functions and processes.
This implies that people are able to have satisfying and safe sex lives and that they have the
capacity to have children and the freedom to decide if, when and how often to do so (WHO, 1994).

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  It is a culturally and politically sensitive issue that requires attitudinal and behavioural
changes among individuals, couples, families, communities, policy makers and health care
givers.
 It is the group of methods, techniques and services that contribute to Reproductive Health and
wellbeing by preventing and solving reproductive health problems. It also includes sexual
health, the purpose of which is the enhancement of life and personal relations, and not
merely counseling and care related to reproductive and sexually transmitted diseases.
1.1.2 Sexual Health
This is part of Reproductive Health and includes healthy sexual development, equitable and
responsible relationships and sexual fulfillment, freedom from illness, disease, disability, violence,
and other harmful practices related to sexuality. Sexual health is the result of environment that
recognizes respects and exercises these rights.
1.1.3 Sexual Rights:
These are fundamental and universal rights based on the inherent freedom, dignity and equality of all
human beings. Since health is a fundamental human right, sexual health is also a basic human tight.
In order to assure that human beings and societies develop healthy sexuality, sexual rights must be
recognized, promoted, respected and defended by all societies through all means.
1.1.4 Reproductive Rights:
These imply that People are able to have satisfying and safe sex lives, capacity to have children and
the freedom to decide if, when and how often to do so. It is implicit here that the people have the
ability to reproduce, to regulate their fertility and to practice and enjoy sexual relationships.
Additionally, women can safely go through pregnancy and childbirth without health hazards. It also
implies the empowerment of women and young people in the development and implementation of
programs and services, and men assuming greater responsibility for and actively supporting
Reproductive Health.
Reproductive rights are the basic rights of all couples and individuals to decide freely and responsibly
the number, spacing and timing of their children and to have the information and means to do so,
and the right to attain the highest standard of sexual and Reproductive Health. It is the right to make
decisions concerning reproduction that is free of discrimination, coercion and violence, as expressed
in Human Rights Documents.

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1.1.5 Goals of Reproductive Health programme
Overall goal
To create an enabling environment for appropriate action and provide the necessary impetus and
guidance to national and local initiatives in all areas of Reproductive Health
Specific goals are to:
i. Achieve healthy sexual development
ii. Prevent diseases, disabilities and death from sexual and reproductive related causes.
iii. Minimize impact of Reproductive Health related problems through quality services and
appropriate care as may be necessary
iv. Ensure freedom from harmful practices
Objectives of Reproductive Health
1. To reduce maternal morbidity and mortality due to pregnancy and child birth by 50%.
2. To reduce perinatal and neonatal morbidity and mortality by 30%
3. To reduce the level of unwanted pregnancies in all women of reproductive age by 50%
4. To reduce the incidence and prevalence of sexually transmitted infection including the
transmission of HIV infection
5. To limit all forms of gender – based violence and other practice that are harmful to the health
of women and children.
6. To reduce gender imbalance in availability of reproductive health services
7. To reduce the incidence and prevalence of reproductive cancers and other non-communicable
diseases.
8. To increase knowledge of reproductive biology and promote responsible behaviours of
adolescence regarding prevention of unwanted pregnancy and sexually transmitted infection.
9. To reduce gender imbalance in all sexual and reproductive health matters.
10. To reduce the prevalence of infertility and provide adoption services for infertile couples.
11. To reduce the incidence and prevalence of infertility and sexual dysfunction in men and
women.
12. To increase the involvement of men in reproductive health issues
13. To promote research on reproductive health issues.
1.1.6 CONCEPT OF REPRODUCTIVE HEALTH

Reproductive health started in 1994, because family planning was found not to have made
much impact and this resulted in a change / shift. That is a shift/change from being
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numbered centered to being people centered and to achieve the desired control on
population. This shift gave rise to the concept of reproductive health (RH) in 1994
Following the international conference on population development (ICPD) held in cairo,
Egypt.

The shift from the traditional MCH/family planning and population control to reproductive
health and rights was made to be highly significant.

 Program of action was adopted by 178 countries including Nigeria

 Reproductive health considers the entire life cycle of those human being and
coverage of both sexes as the focus
 Reproductive health considers the need of women before, during and after child
bearing age as well as the needs of men.
 It aims at meeting the individual reproductive health needs rather than simply
focusing on demographic targets.
 It is for the betterment and quality of life of the people (Nigeria citizenry for
example)
 It puts individuals health rights and development at the centre of policies,
programme and implementation plans.
 It emphasizes the strategic roles of information, education, community mobilization
and participation, women empowerment and provision of quality care for all persons
including the poor and the marginalized groups.
 It is a life cycle approach, in which reproductive health is not limited to women of
reproductive age extended to include lifetime concerns for both men and women
from birth to old age.
 It is a holistic approach to reproductive needs of the family as it focuses on the needs
of both sexes and all age groups.
 It provides a comprehensive package services, including and family planning, safe
pregnancy and delivery as well as the prevention and treatment of reproductive tract
infections.
 It involves other developmental issues particularly those related to gender inequality.

1.2 INTRODUCTION TO COMPONENTS OF REPRODUCTIVE HEALTH

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The component of reproductive health includes the following:

1. Safe motherhood: - This comprises of

 Prenatal care
 Clean and safe deliveries (by skilled attendants)
 Essential obstetric care (EOC) lifesaving skill
 Prenatal, nata, postpartum care and neonatal / child care and breastfeeding.
2. Family planning information and services
3. Prevention and management of complications of abortions and post abortion care
4. Adolescent reproductive health
5. Prevention and management of STIs, HIV/AIDS and reproduction tract infections
6. Prevention and appropriate management of infertility and sexual dysfunctions in both
men and women.
7. Active discourage and elimination of harmful practices e.g FGM, child marriages,
domestics and sexual violence against women
8. Male involvement and participation in reproductive health issues.
9. Cancers of the reproductive tracts (Male and female)
10. Management of problems associated with menopause and sexual dysfunctions in men
and women
11. Gender equity and equality

1.2.1 ENABLING CONDITIONS FOR REPRODUCTIVE HEALTH

1. Women empowerment and gender equality and equity

2. Elimination of discrimination against the girl child
3. Male involvement and participation
4. Improved education opportunities

1.3 REPRODUCTIVE HEALTH SITUATION IN NIGERIA

The current indicator of reproductive health situation in Nigeria includes the following
issues:

 High maternal mortality

 High prevalence of unsafe abortions

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  Early sexual exposure and risky behavior
 Adolescent Reproductive health – median sexual age at first intercourse (sexual) is
18 years and 112 birth /1000 females of age 15 – 19 years.
 Poor utilization of reproductive health services
 HIV/AIDS prevalence is high
 Low contraceptive use
 High fertility rate
 Infant mortality rate 100 per 1000 live birth (NDHS, 2004)
 High prevalence of harmful practices e.g female genital mutilation in adult women
at 40.5%

The current indicator of reproductive health situation in Nigeria include the following
issues. S

i. High maternal mortality: rate is 545 per 100,000 live birth (FMOH,2008).
This figure masks wide regional disparities which range from 339 per 100,000
live birth in the south-west to 1,716 per 100,000 live birth in the North-East
- Maternal Mortality Ratio Hospital Data: (Sources: Society of Obsteric and
Gynetology of Nigeria SOGON,2004)
Bornu 727/100,000 live births Enugu 809/100,000 live birth

Plateau 846/100,000 live birth Cross River 2,977/100,000 live birth

Lagos 3,380/100,00 live births kano 3,523/100,000 live birth

ii. High prevalence of unsafe abortions. About 600,000 induced abortions are
believed to take place in Nigeria annually.
iii. Early sexual and risky behaviours: over 16 percent of teenage females report
first sexual intercourse by age 15. Among young women ages 20 to 24, nearly
half (49.4 percent) report first sex by age 18. Among teenage males, 8.3
percent report first sex by age 15. Among those ages 20 to 24,36.3 percent
report first sexual intercourse by age 18.
iv. Adolescent Rh: - median sexual age at first intercourse is 18 years and 112
birth/1,000 females of age 5-19 years. Niger adolescents have one of the
highest levels of fertility in the world. (NDHS,2004)
v. High prevalence of harmful practices e.g female genital mutilation (FGM) in
adult women at 40.5%
vi. Poor utilization or reproductive health services: using family planning
methods is 8% for modem, 12% for all methods
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 vii. HIV/AIDS prevalence is 5.6% 6.1 million Nigeria are living with HIV/AIDS.
(WHO,2009)
viii. Low contraceptive use- prevalence rate is 8.9%
ix. High fertility rate: total fertility rate (TFR) (This is average number of
children per women’s life time) in Niger is 4.73 children/women (2011
Estimates). (Source: CLA World Facebook).
x. Infant mortality rate 100 per 1,000 live births. (NDHS, 2004).

Factors associated with current Reproductive Health situation in Nigeria: These include
the indicators highlighted above and others such as gender gaps and right issues. gender
inequality and equity, poor women empowerment, discrimination against the girls-child,
inequalities in resource and power sharing; high rate of unprotected sexual activity,
teenage pregnancy, unsafe abortion and sexually transmitted infections.

The situation depicted above clearly indicates a need for the provision of quality
reproductive health information and services, which are comprehensive in scope, and
delivered in a user-friendly and integrated manner.

1.3.1 FACTORS ASSOCIATED WITH CURRENT REPRODUCTIVE HEALTH

SITUATION IN NIGERIA.

These include the indicators highlighted above and others such as:

 Gender gaps and rights issues e.g gender inequality and equity
 Poor women empowerment
 Discrimination against the girl child
 Inequalities in resources and power sharing
 High rate of unprotected sexual activity
 Teenage pregnancy
 Unsafe abortion
 STD’s

1.3.2 SEXUAL HEALTH AND REPRODUCITVE HEALTH RIGHTS

The international Planned Parenthood federation (IPPF) chapter on sexual and reproductive
rights is grounded in International human rights instruments, which include the following
rights
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 Rights to life
 Right to liberty and security of the person
 Right to equality and to be free from all forms of discrimination.
 Rights to freedom from torture and ill treatment
 Rights to privacy and confidentiality
 Rights to choose whether or not to marry and to form and plan a family
 Rights to the benefits of scientific progress
 Right to freedom of assembly and political participation.
 Rights to freedom of thoughts and opinions.
 Right to information and education
 Right to sexual health care and health protection
1. Right to life: menus among other thing that no woman’s life should be put at risk
reason of pregnancy or any ill health.
2. Right to liberty and security of the person: Recognized that no person should
be subjected to female genial mutilation, forced pregnancy, sterilization or
abortion
3. Right to equality and to be free form all forms of discrimination: this refers
to freedom from all forms of discrimination regardless of sex, gender, sexual
orientation, age, race, social class, religion or physical and emotional disability
(i.e the physically and mentally challenge person) This Secures the right of all
person to equal treatment, entitlement, and equal employment.
4. Right to good reproductive Health and services and to preventive and
curative health care: This is a society of physical, psychological, intellectual
well-being.
5. Right to freedom form torture and ill-treatment i.e from inhumane, degrading
or cruel treatments which extend of freedom form domestic and sexual violence
as well as the right to human dignity.
6. Right to privacy and confidentiality: that all sexual and should be confidential
and all women have the right to autonomous reproductive choices.
7. Right to choose whether or not to marry and to form and plan a family: this
is the right of men and women of marriageable age to marry and form a family
biased on full and free consent. This encompasses the right to decide whether or
not to marry, divorce, have children, the number and spacing of children and the
right to full access to the means of fertility regulation.
8. Right to the benefit of sciences progress: it includes client’s to new
reproductive health technology which are safe, effect, accessible and acceptable.

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 The sexual information should be generated through the process of
unencumbered and yet scientifically ethical inquiry, and disseminated in
appropriate ways at all societal levels.
9. Right to freedom of assembly and political participation: this include the right
of all person to seek to influence communities and government to prioritize
sexual and reproductive health and rights.
10.Right to freedom of thought and opinion: includes freedom from the restrictive
interpretation of religion texts, beliefs, philosophies and custom as tools to curtail
freedom of thought and choices on sexual and reproductive health.
11.Right to information and education: as it relates to sexual and reproductive
health for all, including access to full information on the benefit, risk, and
effectiveness of all method of fertility regulation, in order that all decisions taken
are made on the basic of full-free-informed consent.
12.Right to sexual health care health protection: sexual health care should be
available for prevention and treatment of all sexual concerns, problem and
disorders. Right to the highest possible quality health care, and to be free from
traditional practices which are harmful to health.
1.3.3 STRATEGIES TO IMPROVE REPRODUCTIVE HEALTH

 Strengthening outreach services to youths, men and use community based

approaches
 Improving education for girls and women, improve access to education for girls of
poor families in order to delay early child bearing and improve women
empowerment.
 Targeting public sector subsidiaries to poor families and disadvantaged areas
 Developing effective “patient friendly” referral systems
 Improving quality and availability of essential and Emergency Obstetric care (EOC)
services for the poor.
 Strengthening policies and capacity building
 Training of providers for improved quality of love
 Ensuring availability of emergency care services that also include EOC
 Promoting affordable maternal health services
 Scaling up adolescent sexual and reproductive health information and services
 Providing information and services for different age groups and for both in school
and out school programmes.

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 Improving girls and participation; and broadening then they include receiving a
livelihood activities.
 Strengthening monitoring and evaluation.
 Identifying appropriate indications and tools that will provide information on the
poor e.g. differentiated process indicators, availability of EOC services deliveries by
skilled attendant’se.t.c.
 Auditing maternal deaths at health facility and community level.
 Reproductive age and maternal mortality epidemiological surveillance based on
recommended guideline.
 Reducing unplanned and poorly timed pregnancies and health risks associated with
them
 Including an appropriate of high quality, consumer – oriented family planning
information and services in benefits /services package offered by public and private
providers of extend these services to haired to reach groups through outreach and
social marketing programs.
 Improving prenatal and delivery care and ensuring effective management of obstetric
emergencies e.g WHO has developed clear practice guides on maternal care that can
reduce the health risks of pregnancy delivery and the post partum period.
 Prenatal care and treatment of anaemia, high BP and other complications are very
cost effective
 Ensuring that every pregnant woman is attended to by a trained midwife or qualified
health worker
 Referring to facilities that can manage complications such as haemorhage, obstructed
labour and sepsis, is also required.
 Providing transport and communication and families and communities need to be
motivated to take action to save the life of a mother when an emergency occurs.
 Increasing the number of skilled providers
 Reducing the risks of STI and HIV / AIDS infections.
 Using of condoms and reducing the number of sexual partners are effective
preventive measures that can be supported through targeted invetions for high risk
groups.
 Health education promotion and community mobilization are effective strategies.
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  Screening and counseling for those who are infected
 Addressing harmful practices e.g female genital mutilation (FGM) which is
associated with complications in pregnancy and delivery and with sexual dysfunction
because the practice is culturally ingrained, measures to reduce its need to be worked
on at several levels.
 Engaging the community, practitioners and policy makers. training providers to
recognize the signs of violence
 Using appropriate approaches to treatment and counseling.
 Addressing factors beyond care that affect reproductive health outcomes
 Providing special outreach initiatives.
 Countries need to look beyond the health system to deal with HIV/AIDS problems
e.g poverty reduction, gender inequality.
 Sensitize communities and private sectors on their roles e.g improve communication
(roads and telecommunications) in rural, poor areas.
 Strengthening partnership between traditional birth attendant (TBAs) and skilled
formal providers; build linkages with other reproductive health, nutrition, gender and
adolescent interventions and build a strong referral system and establish maternity
waiting homes for rural women
 Improves quality and availability of essential and emergency obstetric care (EOC)
services for the poor and addresses poverty reduction and gender inequality.
 Strengthening policies and capacities building e.g training of providers for improved
quality of care.
 Ensures availability of drugs, equipment, suppliers and emergency obstetric care
(EOC) services and improves logistics.
 Promotes affordable maternal health services
 Scale up adolescence sexual and reproductive health information and services
 Ensure an appropriate array of high quality a consumer oriented family planning
information and services through outreach to reduce unplanned and poorly timed
prrgnancies and health risk associated with them

1.3.4 BENEFITS OF REPRODUCTIVE HEALTH INTERVENTIONS

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 Improves adolescent RH and reduces unwanted pregnancies and the risk of
contracted HIV/AIDs and other sexually transmitted infections (STI’s)
 Improves the chances of girls continuing in schools and expand their life options.
 Provide Life coping skills including reproductive health education for boys and girls
 Prevents and manages STI’s including HIV/AIDS and its spread
 Prevents sexual spread of HIV
 Provides activities in MCH
 Provides family planning (FP) programme / services
 Addressing missed opportunities to curb the HIV epidemic
 Increases contraceptive choices of access
 Lifesaving care for complications from abortion is an excellent opportunities to
provide contraception, avoiding another unwanted pregnancy.
 Reduces pregnancy –related deaths and illnesses in mothers which increases newborn
and child survival, and improves productivity
 Reduces maternal deaths
 Reduces violence against women.

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13
 UNIT II
INFORMATION, EDUCATION AND COMMUNCATION

2. 1 Advocacy

Advocacy is defined as the act or process of building support for a cause or an issue. An advocacy
campaign is a set of targeted actions in support of a cause or issue. Or It is a set of actions taken by a
group of individuals to organizations working in partnership to build consensus, gain support or
create a favourable environment for introducing or changing specific strategies, programmes or
policies.
2.1.1 Reason for advocacy
Advocacy is usually made to the policy makers and opinion leaders in order to:
 Build support for a cause or an issue.
 Influence opinion leaders and others to support that cause or issue.
 Help tom make arrangement to meet people language and communication need
 Influence change of legislation that affects a cause or issue.
 Advocacy enhance awareness that makes people have the right to make their own decision
regarding their health care.
2.1.2 Qualities of a good advocate
 Dedicated to community and Reproductive health programmes he/she is trying to change.
 Able to bring people together in coalitions and network. The action word in this area is
“TEAM” that is (Together Everyone Achieves More).
 Accessible to the people whose life he/she is trying to affect.
 Possess leadership qualities and can recognize or nurture such qualities in others.
 Have tolerance and perseverance in the face of problems.
2.1.3 Common location for conducting formal and informal health education:
 Institutions: e.g. Universities, secondary and primary schools.
 Corporate establishments e. g Banks, firms etc.
 Service Delivery Points (SDPs) e.g. Hospitals, Clinics, Health Centres.
 Market places.
 Churches and Mosques.
 Community outreach sites.
 Homes e.g. Remand homes, motherless babies homes etc.

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  Brothels and prisons.

2.1.4 Steps in the advocacy process:

 Proper understanding of subject matter for which advocacy is done: The types of ideas and
argument to be used to persuade the audience should be properly understood, language,
personality, channel, time and place used to get the message across clearly and effectively.
 Needs analysis: Identify and clarify issue why advocacy is needed and the expected result e.g,
the problem magnitude, how it can be solved, who and when will the problem be solved.
 Identify support and opposition: among the target audience.
 Select audience: Identify the stakeholders i.e. the primary stakeholders (beneficiaries) those
people who are ultimately affected by the intervention e.g, people ofthe communities, women,
children e.t.c.
 Secondary stakeholders (adversaries): These are the intermediaries that are being used to reach
the target audience and the very stakeholders; partners, policymaker at the government level and
traditional/opinion leaders at the community levels to build greater support.
 Formulate strategies for successful advocacy (partnership)
 Build coalition or constituency: The power of advocacy is seen in the owner of people who
support your goal and course by involving many interest groups to champion the course.
Networking within and outside the organization will build greater support.
 Prepare simple and clear messages, centered on goals.
 Determine communication channels that will be cost effective in relation to the target audience.
Also know the limits and merits of each channel centre on goals and develop good media relations.
 Prepare carefully for meetings and encounters, anticipate the needs and possible questions
that may arise when you meet with target audience.
 Implement the set activities.
 Monitoring and evaluation: This is taking stock of the advocacy efforts.
 Ensure continuity/sustainability of efforts: Advocacy is an on-going process, concentrate on
what works.
2.1.5 Strategies for advocacy
 Coalition building: Aim at achieving alliance to broaden the support and influence significant
offers.
 Build trust with your colleagues and audience.
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  Identify potential oppositions and develop strategies to address them.
 Court the media i.e. identify the journalists, reporters covering your beat/issues, those who
may have relationships with the community may be helpful in propagating the programme,
develop a good relationship with them in order to make breakthrough.
 Identify and cultivate spokesman/person (advocates) e.g. yourself an/or other members of your
coalition who are totally convinced of the issue and are credible source of 'information and can
communicate effectively in a language that is culturally acceptable.
 Learn how to make an impression - convince people and market an idea using a multimedia
approach e.g. by organization political support for an influential politician.
 Make a long-term commitment and develop a suitable vision for the issue. Develop a culture of
reading and intellectual exchange on issues.
 Control your personal biases and be as objective as possible.
 Do not create enemies, learn to identify your opponents and develop a capacity to handle
opposition and resistance.
 When reacting to negative situations, do not give in to combative instincts as this could weaken
your support.
 Develop critical skills such as political analysis, leadership, strategic planning, fund raising,
lobbying, negotiation, alliance building and coalition management.
 Reward participation and positive results.
 Be business-like in planning and implementing the campaign for all your advocacy efforts.
 Do not give up. Persevere and aim at achieving success.
 Develop a culture of reading and intellectual exchange on issues
2.1.6 TOOLS FOR ADVOCACY
1. Lobbying;
Lobby decision makers for support. This is an act of persuading people through presentation of
factual information and good use of communication skills to convince them to support a cause or
see things from your own perspective. This is not bribing or inducement as any act of this amount
to corrupting the powers that be. ltis unethical and may backfire.
Lobbing is an effective tool when in need of something specifically from the legislative
system/lawmakers, decision makers; opinion moulders or groups e.g. a bill that permits more
funding for Reproductive health programmes may be lobbied for.
2. Building networks:
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 Networks refer to a group of individuals or organization working together with a common goal of
achieving changes on policies, laws or programmes for a particular advocacy issue e.g Organize
meetings, rallies, debate with adversaries, Carnival float and rallies of events in relation to your
cause.
3. Media tools:
i. Press releases: This will enhance public education or enlightenment onthe issue or course.
ii. Press conference: To intimate the media about cause and need for action.
iii. Editorials: Write letters to the Editor.
iv. Articles: In newspapers and magazines
v. Appraisals: make television and Radio appearances
vi. Interviews: Televised or printed interviews
4. Testimonies: Testify to previous achievements/positive results on the course/issue in other
parts. This will encourage people to action.
5. Advocacy kit: This is a well packaged information to the stakeholders, group, organization
e.t.c
6. Visit organizations: Visit an organization who has experience in conducting advocacy
activities. This combined with other methods will enhance your success.
2.2 COMMUNITY MOBILIZATION FOR REPRODUCTIVE HEALTH
ACTIVITIES

Definition of a community
A community is a group of people living in the same geographical area/boundary, who may or
may not share a common interest or value. A community may consist of many different sub-groups.
There is usually a leader but many formal and informal leaders may also be present.
Communities are not always homogenous because there may be many different ideas,
languages, views and approaches to life.
2.2.1 Composition of people in the community
People of major influences on Reproductive health behavior in the community are:
 Husbands (Major-decision maker for the family), Families.
 Parents.
 Children.
 Mothers In law/Fathers In-law,
 Priests or Imam/Mallam.
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  Village Head/Chief.
 Traditional Birth Attendants (TBAs) Herbalists.
 Women Leaders.
 Opinion leaders e.g. village committee leader. These groups of people wield power and
influence the behaviour of their people. They set unwritten codes and patterns for them to
copy/follow.
2.2.2 Community Mobilization and Participation
Community Mobilization
Community mobilization is defined as a means of encouraging, influencing and arousing interest
of people to make them actively involved in finding solutions to their problems e.g. Reproductive
health problem such as high Maternal mortality rate, cervical cancer, prostate cancer etc.
Community mobilization involves active participation of all health workers e. g Doctors, Nurses,
Midwives and Community Health Extension Workers (CHEWs). Others include, Chairmen of Local
Government Areas (LGAs), Supervisory Counselors for health, religious group leaders (Imams and
Clergies), market women, women leaders, village heads etc.
2.2.3 Importance of community mobilization for health action
 Early identification of health problems e.g. Reproductive health needs/problems and solutions e.g.
utilization of family planning services.
 Identification of at-risk groups/individual by the community
 Increased level of health workers among community members
 Adaptation of positive Reproductive health behaviours in the community.
 Greater flexibility in implementing Reproductive health activities.
 Development of available community resources for the provision of RH information and services
including monitoring and evaluation.
 Utilization of community social networks such as women groups, village committees, religious
leaders to promote Reproductive health.
 Informed individuals are better equipped for self-reliance and self-care.
 Collaboration and cooperation with health workers in the planning, implementation and evaluation of
Reproductive health activities/programmes.
2.2.4 Steps In community mobilization
 Determine the community to be assessed.
 Conduct community diagnosis to assess their health needs. This is done by exploring the
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 existing information.
 Review, assess and analyze the problem e.g. a health problem on high maternal and neonatal
morbidity and mortality in the community.
 Obtain information from available statistics recorded in the clinics, health centres and maternity
units in the community.
 Use FOCUS Group Discussion (FGD), informal discussion, direct observations, home visit and
interviews.
 Prioritize the Reproductive health issues/problems to be addressed.
 Exchange pleasantries.
 Have a good knowledge of the community e.g. the village, district or a whole local government
area.
 Tell them the purpose of your coming.
 Have a good geographical knowledge e.g. settlement, population, average size of settlements and
distance between them.
 Identify value impediments to communication e.g. hard-to-reach areas e,g, mountains, rivers,
swamps etc.
 Have a good socio-cultural knowledge of the people e.g. occupation, tradition and local
authorities, cultural activities of the people, their beliefs and customs.
 Identify entry point and contact person i.e. whom to approach or contact to gain access e.g. the
elders, village or district heads, women/group leaders, local government chairman/PHC
Coordinator, supervisor for health or opinion leaders in the community.
 Explain the purpose and the procedure.
 Solicit for his/her cooperation and that of the community household heads, and other members
using a network approach.
 Prepare plan of action - Plan for mobilization activities such as who will do what, how, when,
where and with what resources?
 Plan the visit - Inform your host (e.g. elder) about dates, ensure date and time are convenient.
2.2.5 Community Participation
This is when a group of people agree to work together to make the community better. 1t involves
making the community aware of their problems/needs and involving them in solving these problems
or meeting these needs.
2.2.6 Principles of community participation
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  Assessing the health and health related situations.
 Assisting in finding and defining community problem.
 Setting of priorities and proffering solutions to the problems.
 Committing enough time to work with the community.
 Readiness to help the community to understand self.
 Trusting and respecting the community knowledge and power.
 Stimulating and guiding communities to promote the provision of quality
Reproductive health information and activities.
 Persuading communities to adopt and making positive Reproductive health behaviour.
Planning and implementing Reproductive health programme of activities with the community.
2.2.6 Conducting a Community Visit
Purpose: To seek support and commitment.
Steps:
1. Meet with families, communities’ leaders, market women, TBAs. Clergies etc
2. Observe protocols. Use good interpersonal communication skills.
3. Exchange pleasantries/greetings. Introduce self and group members.
4. Show respect, genuine interest and concern in order to penetrate into the community.
5. Tell them your purpose of coming.
6. Inquire about what the people consider their most pressing problems; ask them to arrange these in
order of priority.
7. Ask about any serious or urgent problems affecting e.g pregnant women, women in labour,
postpartum or their babies.
8. Ask about their managements.
9. Ask how you might help the people overcome identified problems.
10. Show commitment. Sensitize and work with them.
11. Conduct awareness campaign; make use of town criers involve the media etc.
12. Talk about what Reproductive Health is all about, the purpose of the program or campaign,
what the governments are already doing about Reproductive Health or that particular health
problem.
13. Let the people know their level of involvement i.e. what the community contribution could
be and how community participation would make a difference to the programme.
14. Work with community to prepare her own plan of action
20
 15. Set up community development committee (if there is none).
16. Assist community to implement action plans e.g. identify community members with typical
interest and orientation.
17. Monitor implementation of action plan.
18. After the visit, arrange a feedback and share the answers obtained.
2.2 7 Factors Influencing Community Participation
i. Interpersonal relationship and skills of healthcare providers
ii. Level of involvement of the community-based health workers in the mobilization of the
community.
iii. Level of commitment of the community in the design, implementation and evaluation of
Reproductive Health activities.
2.2.8 Community Responsibility Towards Safe Motherhood
Establish and maintain development committees to carry out the following responsibilities
towards safe motherhood.
 Include women as committee members.
 Select appropriate traditional birth attendants/VHW for training.
 Establish a village health post where there is none.
 Provide necessary support to TBAs/VHWs in the provision of health care
services.
 Supervise the activities of the TBAs/VHWs including review of monthly record
of work.
 Identity health and health related needs in the community.
 Plan for the health and welfare of the community.
 Liaise with other officials living in the community to provide healthcare and other
developmental activities.
 Support the use of health facilities promptly when needed e.g during pregnancy,
labour and post delivery with their babies.
 Mobilize members to unite to achieve common objectives.
 Involve husbands in procuring services for their wives and children especially
during pregnancy, labour and immediate post-delivery.
 Encourage cultural practices that will improve the development of tile community
e.g breastfeeding support of women during pregnancy and delivery.
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  Review and discourage cultural practices that are harmful to the health of
individuals and do not in the longer term promote the development of the
community e.g gender discrimination, early marriage, female genital mutilation.
 Deliberate on problems which are common and proffer solutions.
 Ensure that all children including girls go to school from the age of 6 years and
remain in school for a minimum of9years.
 Maintain a clean environment at all times and encourage personal hygiene of
members of the community.
2.3 Use of IEC Support Materials
Information, Education, Communication, (lEC) support materials are used by health service providers
for effective communication and to make hearing or counseling session interesting and easier to
understand.
Examples of IEC support materials
1. Paper materials: Posters, flipcharts, wall charts, leaflets, pamphlets, booklets, newspaper
clippings, handbills, flannelgraph.
2. Electronic materials: Radio, television, video machines and films, cassette players/recorders,
computers. overhead projectors, film strips, slides and transparences.
3. Concrete / Real object: cononcrete objects e.g. models, real objects e.g. nutrition materials
such as fruits, vegetables e.t.c
4. Others: Flannelgraph, chalkboard, magic board.
Note: The choice of IEC materials depends on (a) Available resources. (b) Relevance to the topic for
discussion (c) Level of knowledge and Skill of the health educator and that of the audience /
participants. (d) The environment or settings of the venue.
2.3.1 Characteristics of support materials
 The language should be appropriate for the intended audience.
 Support materials should be appealing and captivating.
 Words and pictures should be easy to see and understand.
 Information should be clear and unambiguous.
 Text should address theme.
 Text should be clearly linked to the illustration.
 Message should be timely, relevant, clear, credible and culturally acceptable.
2.3.2 Ways by which lEC support materials can be effectively used.
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 The choice of IEC materials depends on:
a. Available resources
b. Relevance to the topic for discussion
c. Level of knowledge and skill of the health educator and that of the audience/participants.
d. The environment or settings of the venue.
Poster: Display motivational posters in places of high visibility such as clinics; schools, banks,
kiosks, petrol stations, restaurants and eateries.
 Ask permission before pasting your poster.
 Think of what the poster is meant to do and who will see it.
F1ipchart
 Stand where the audience/ group can see the flipchart.
 Always face the audience.
 Hold the flip chart so that the group can see it.
 Point to the picture, not the text.
 Move around the room with the flipchart, if the whole group cannot see it at a time.
 Try to involve the group.
 Ask them questions about the drawing.
 If the flipchart has text, use it as a guide and familiarize yourself with the content.
Booklets
 Go through each page of the booklet with the client. This will allow you to show and tell
about a health practice or problem and answer any of the questions.
 Point to the picture, not to the text that appears on the page. This will help the client
remember what the illustrations represent.
 Observe the clients to see if he/she looks worried or puzzled, if so, encourage him/her to ask
questions about her concerns and discuss it. This will build trust and help establish a good
relationship between you (the provider) and the client. A client will often transfer the
confidence he/she has in her health provider to the method or health practice selected.
 Give the client the booklet to keep and suggest that he/she shares it with others even if she
decides not to use the method or health practice described.
Note: Use of booklets is to support or reinforce verbal message of health workers. They
are not to substitute good interpersonal communication skills but to strengthen the
messages given to client.
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Non-print media:
Examples:
1. Use of songs, traditional dances, jingles, plays, poetry, television, Phone-In radio program
Video tapes, drama etc.
2. On-going assessment, if more than one and ask them questions about what they have seen or
heard.
Ineffective use of support materials occur when service provider gives support materials to the
client before e.g. initiating any rapport or family planning method.
 The support materials are used as substitute for interpersonal communication.
 It is poorly presented e.g. when the materials are placed too far from the audience or if the
provider points to the picture or words which she/he may not be describing at that time.
 The material disrupts the smooth flow of the counseling process.
 In-appropriate material is used in motivational or counseling session.
2.3.4 Designing IEC Support Materials
Health education unit is primarily responsible for the development and processing of IEC materials.
Processing should involve the target audience and service provider. Issues, questions, rumors
concerning clients and service providers must be cleared before designing these materials.
Drafts of the materials are to be shown to clients and service provider several times and revised
according to their suggestions.
Process of designing IEC support materials:
a. Decide the information you want to pass and the key points.
b. Design the material and the message.
c. Conduct pre-test of the material and the message with the intended audience.
d. Revise the materials and if need be, pre-test again until it is acceptable to the intended
audience.
e. Finalize the material by incorporating ideas from the pre-test.
f. Print and distribute the support materials.
2.3.5 Advantages of IEC support materials
1. Enhances learning.
2. Allows active participation.
3. Allows more understanding of subject matter
4. Makes presentation interesting.
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 5. Engages clients attention.
6. Enhances easy remembrance-client will be able to remember what she/he has seen e.g. Mother
breast feeding her baby and other important information.
7. Helps explain sensitive issues such as use of condom.
8. Provides information on side-effects and thus help client cope with minor problems.
9. Provides consistent information to all clients.
10. Reveals service providers interest in the client
11. Stimulates discussions with a group in the clinic (e.g. poster on family planning).
12. Appeals to the senses and therefore learner is able to form a good picture and understanding of
the problem Issue.
13. Douses (relief) tension between the audience and the health educator.
14. Arouses the curiosity of the audience e .g a captivating picture.
15. Stimulates interest by uniting scattered ideas to become one.
16. Encourages expression and audience participation.
17. Retains learning and sustains interest of the participants/ audience for a fairly long period of
time.
2.4 HEALTH EDUCATION IN REPRODUCTIVE HEALTH SERVICES
Introduction
Health education on Reproductive Health and services is a strategy for reaching the individuals,
groups, families, communities etc with health messages that will positively effect a change in their
perception of Reproductive Health.
2.4.1 Definitions of Health Education:
 Health education is defined as a process of passing information to individuals or groups of
people with a view to influencing a positive attitude and behaviour in health related matters
and accept measures that will influence a positive attitude and behaviour in their health,
 Health education is a carefully planned method of activating individuals, families and
communities separately and collectively to make informed decisions on health related
matters.
 It is any designed learning experience that will facilitate conducive healthy behavioral
practices.
 It is a method of changing and improving the inherent poor concept of people towards health
and disease processes.

25
2.4.2 Types of Health Education:
1. Formal Health Education: This is a planned health education that usually takes place in
an organized setting e.g. hospitals, schools, institutions, corporate
establishments/organisations.
2. Informal Health Education: This is an unplanned health education session and it can be in
the following forms:
i. Impromptu health talks to an individual or group.
ii. Routine health education talks during discharge of health services e.g. when attending to a
post-natal woman, supervision of breast feeding etc.
iii. Incidental health education talk i.e. when a situation arises and prompted a health provider
to give health talk e.g. when she observes a malnourished person eating unbalanced diet or
a pregnant woman eating junks. The health provider can use the opportunity to give health
talk on adequate diet or nutrition in pregnancy. Or health talk on harmful cultural practises
on an observed pregnant mother being delivered at home by an unskilled person or
importance of antenatal care, hospital delivery and complications of not using the available
health facility in the community, or health educating an unskilled person or group of
people in the community after an observed unhealthy behaviour.
2.4.3 Formal and informal health education is further divided into:
a. Individual health education: This allows for close interaction and is the best type.
b. Group health education: This is for people of the same educational and social background
e.g. in schools, health centres, establishments such as ministries, banks, factories, etc.
c. Mass media health education: This is basically designed to reach a large population group
at local government, state and national levels e.g.Govemmentprogrammes such as Expanded
Programme on Immunization (EPI), environmental sanitation, Safe Motherhood day,
breastfeeding day, etc.
2.4.5 Methods of Conducting Health Education E.G In Service Delivery Points
(Sdps)
 Talks: This is commonly used - in Service Delivery Points (SDPs).
 Group discussions - a participatory and permissive method e.g. in seminars/workshops.
 Lecture - a didactic type of education where audience sit and listen to the health educator. It

26
 is good for large audience but does not allow for effective participation by listeners/audience.
Others are: Role-play, playlets, film-shows, dramas and demonstration/ skills teaching.
2.4.6 Means Of Communicating Health Education On Reproductive Health.
 Verbal communication.
 Public Address System (PAS) (in community outreach).
 Town criers e.g. in the communities.
 Mass Media e.g. Radio, Television, Internet.
 Music
 IEC materials e.g. posters, handbills, fliers.
 Projectors.
2.4.7 Reproductive health issues requiring health education.
 Sexually transmitted infections (S'I'ls) including HIV/ AIDs
 adolescent Reproductive health.
 antenatal care, natal and post-natal conditions.
 Reproductive tract cancers e.g. breast cancer, cervical cancer, prostate cancer (preventive
measures).
 Unsafe abortion.
 Family planning.
 Prevention of Mother- To-Child Transmission of HI V (PMTCT). Examples of available
Reproductive Health services
 Youth-friendly health services.
 Ante-Natal care services.
 Post-Natal services.
 Baby care services.
 Family planning services.
 Voluntary testing counselling services for HIV positive persons.
 Post Abortion Care (PAC) services.
2.4.7 Examples of health education topics on Reproductive health:
These include: Diet/nutrition in pregnancy, immunization (pregnant mothers, infants), personal /
environmental hygiene, water supplies and sanitation, post-natal exercises, exclusive breastfeeding,
prevention of anaemia in pregnancy, infection prevention, unsafe abortion, child-spacing, malaria
control in pregnancy, antenatal care, sexually transmitted infections (STls), HIV/AIDs preventive
27
measures, care of the newborn, cervical cancer screening/prevention, self breast examination (SBE),
self prostate examination (SPE), and ropausal and menopausal syndromes (sets of symptoms in and
ropause and menopause), infertility, Prevention- of Mother- To-Child Transmission (PMTCT) of
HIV, ageing and coping processes.
2.4.8 Locations for conducting health education talks.
These include: Service Delivery Points (SDPs). Schools, institutions/establishments, market places,
churches, mosques, open fields, halls, homes and brothels.
Exercises:
2.4.9 Steps in conducting health education talk in RH services.
There are five steps and they are as follows:
Step 1: Assessment: - Identify the needs / problems of the people of the community..
 Assess the target audience e.g. pregnant mothers, youths/adolescents, e.t.c.
 Assess their needs i.e. identify the type of behavioural change that is needed to address the
health problem/concern.
 Review available information on cultural/social characteristics, health status and health
seeking behaviours of the community e.g. the group of people that came for the talk e.g. mode
of dressing, status i.e. educated, elites, illiterates, age group, their health seeking behaviour by
their attendance.
Step 2 Analysis
 Analyse the observed Reproductive health needs/problems or concerns of the target audience
to diagnose their problems. e.g. "Why mothers do not attend ante-natal clinics", "Reasons for
the pregnant mothers' preference for TDAs at delivery".e. t.c
 Determine the level of knowledge of the audience from the information gathered.

Step3 Planning
 Plan, prepare and organise for the health talk in terms of the topic, appropriate I.EC material,
etc.
 Identify appropriate place e.g. hall, open filed, classroom, Out Patient Department (OPD) etc.
 Fix the time and duration/length of the health talk.
 Prepare the objectives and contents of the health talk.
 Master the contents.
Step4 Implementation

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  Execute planned actions.
 Create rapport, greet client. Explain reasons for the health talk.
 Conduct the talk e.g. personal hygiene, diet in pregnancy, ante-natal care e.t.c,
 Ensure friendly and informal atmosphere.
 Use appropriate IEC materials e.g. posters.
 Use interpersonal communication (IPC) skills.
 Demonstrate key issues.
 Encourage active participation.
 Ask open ended questions
 Encourage questions.
Step 5 Evaluation - Assess programme success/achievement (e.g, low incidence of polio in
immunization programme, reduction in maternal and neonatal morbidity and mortality, etc).
 Evaluate the effectiveness of the talk e.g. administer pre and post test.
 Highlight key points - what exactly you want them to understand and practise.
 Encourage audience to respond to questions raised - to ensure clarity and understanding of
topic.
 Suggest personal and group action plans.
 Observe audience reactions - cbanges in their behaviour e.g. going to the clinics for antenatal
care or health centres for delivery.
 Listen to comment on gains of the health talk by the audience - to reveal /ascertain acceptance
and readiness to change.
Advantages of health education in Reproductive Health:
1. Creates awareness on existing and available Reproductive health needs and services.
2. An excellent avenue for motivating individuals, groups, communities to adopt positive
Reproductive health behaviour e.g. "health talk on importance of environmental hygiene in the
prevention of malaria in pregnancy.
3. Affords people the opportunity of addressing a specific Reproductive health problem e.g.
infertility.
4. Increases client load at service delivery points - many clients/patients hear for the first time
talk on reproductive health at the service delivery points e.g. health talk on self-breast
examination for early detection of breast cancer, teenage pregnancy as one of the

29
 consequences of risky behaviours of adolescent/young persons.
5. Encourages people - young and old, male and female to access information and services related
to their Reproductive health needs and concerns.
6. Acquaints the people with the various Reproductive health services e.g health talk on post
abortion care, family planning etc.
7. Enables people acquire the necessary knowledge and skills needed to effect a behavioural
change e.g. health talk on STls. The knowledge that having multiple partners is a risk factor
for transmission of S'Tls- _ and HIV I AIDs will let the affected person have a change of
mind to such behaviour.
8. Facilitates community mobilization and participation in matters affecting their Reproductive
health e.g. health talks on the reduction of mate mal and neonatal morbidity and mortality.
2.5 COUNSELING CLIENTS IN REPRODUCTIVE HEALTH
The meaning of counseling:
Counseling is a person to person, face to face interraction in which the provider (counselor) gives
adequate information which will enable a client (counselee) make an informed decision about
his/her health.
Other meanings of counseling include:
 Face to face "talk" with the aim of assisting the client /patient.
 Listening to, or being attentive while patient / client is narrating story / problem and
consequently guiding to make a useful decision.
 A tradition labelled "helping profession" that has to do with the remediation of school
children's, student's e.t.e socio- personal and vocational problems.
 Understanding the client's problems, abilities, traits, strengths as the case may be.
 Assisting the client understand his / her problems and taking appropriate decisions.
Importance of counseling
1. Counseling helps the clients to understand his/her feelings and deal with her specific
personal concerns.
2. Effective counseling. empowers a client to make her own decision. It helps him/her to
clarify feelings and thinking.
3. Counseling motivates: It encourages a client and their families to adopt new health
behaviour such as visiting a clinic or trained birth attendant. Through motivation, the client
is persuaded to be more favourably disposed to the formal health sector.

30
 4. Counseling educates: Provides specific information and gives information that states the
facts objectively. Education assists clients in making decisions by expanding their
knowledge base.
5. Prevention of conditions such as stress, and diseases such as HIV / Aids, cancer e. t.c
 Abstinence from early sex, faithfulness to one's spouse.
 Prevention of risky life-styles such as alcoholism, drug addiction e.t.c
 Prolongs life, maintains health
Skills and techniques of counseling
 Praise and encouragement.
 Questioning.
 Paraphrasing and summarizing.
 Active listening.
 Coping with specific needs.
 Use of support materials.
 Observation.
 Explaining in language the clients understand.
 Reflecting.
 Non-verbal responses.
 Clarification
2.5.1 Application Of Counselling Skills In Reproductive Health
a. Praise and encouragement:
This is speaking to a client using words that motivate and assure client that you
approve of her. Praise and encouragement helps build a client's confidence and reinforce
desired behaviour, Praise elicits feelings of selfworth in clients, which in turn empowers
them to make the right decision or execute the right task with enthusiasm.
Example: A client comes in after several hours of labour
Midwife / health worker's possible responses: "you did well to come here for help, and for
different situation" e.g in the labour room.
Midwife's possible responses:
Good, you are pushing well. Well done.
b. Questioning:
Questioning is a technique for learning from the client specific information, or general
31
 feelings and concerns. It is used for screening and education sessions
Types of 'questions
Open-ended e.g. what treatment/care are you hoping to receive during this visit?
1. Open-ended question: assist health provider to elicit in-depth responses from clients.
Open-ended question begin with "how" "what" "when" and '<tell me about etc.
2. Close-ended question: elicit short answers, often with "yes" or "no" it is used to clarify
understanding of information given or make a point e.g. do you want another family
planning method? Or is the meaning of that word clear?
3. Probing questions: that intend to discover the truth on a problem/concern or hidden
information about an issue/problem/concern e.g. did yow- husband complain about
the method? Be gentle and non- judgemental when asking probing questions.
4. Leading questions that start a discussion to the main issue/problem e.g. you mean you
want to have another method of contraception? leading questions is suggestive and
puts idea into the respondent. e.g "Don't you think midwives are wonderful, is this not
beautiful?"
Advantages:
1. For screening.
2. In counseling.
3. Helps determine whether clients understand what they are being told.
4. Helps un-cover fears and concerns, preferences and areas of knowledge deficit.
c. listening and response:.
 Active listening is the act of hearing and trying to interpret your client's words. Often
we think we listen but-we are not really hearing our client's responses.
 Paying attention to un- interrupted responses is one of the best ways.
 We can come to know our clients and make appropriate responses to their question
and concerns.
Example:
Client: I think a woman should have as man children as God gives her.
Possible responses:
Health provider: You think a woman should have as many children as God gives her? Do you
think God wants you to stay healthy to take care of your children?
Client: It's my duty to care for them.
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 Health provider: You see, it is your duty to care for your children, these are some ways we can
make sure you stay well to help your children grow well. She then listens.
d. Paraphrasing:
Paraphrasing is restating what client has said to you i.e. restating or repeating the
client's message simply, It is an effective way to make sure that you and the client understand
each other. It also shows that you are listening carefully to what is being said. If you have
misunderstood the message, the client has an opportunity to clarify the point she was trying to
communicate.
Example of paraphrasing:
Provider: What I hear you saying is that "you are not getting the support you need from
the health ministry to make these changes? Is this correct? In other words, you said that
women are often reluctant to discuss these topics with male doctor?
Possible responses:
Provider: It sounds you've been bleeding for some time and you think the bleeding might be a cause
for concern.
Provider: You've made a good decision to come and talk about it.
Client: I want to use the pills but my friend said it can cause breast cancer.
Provider: You have some questions about what you have heard about the pills, and you want to
find out what is true?
Advantages paraprasing
1. It ensures clear understanding of the basic messages of the client/patient.
2. It supports the client and encourages him or her to continue speaking.
3. Reflection and
4. acknowledgement:
Reflection: This is similar to summarizing and paraphrasing. Reflection is a process of reflecting
client's emotions back to them. This is making an informed guess about the client's message for
the client to deny or confirm.
Advantages:
i. It ensures clear understanding of client's message.
ii. It assist the health provider (counselor) to clear up confusion if the client's responses are not
understandable or vague.
Example:

33
Client: I am using the IUCD but my sister says that with Norplant, my menses will be normal and
there will be no uterine cramps.
Provider: If I may understand-you, you are thinking of changing your lUCD to Norplant because
Norplant will be more comfortable for you
Acknowledgement:

 This is a verbal recognition of fears, concerns or satisfaction?

 Reflection and acknowledgement validates the client's feelings and show
empathy and respect of the provider.

Example l:

Client: “I feel that I am being tom in bits with my husband, the new baby and my
little boy wanting me to do thing.

Provider: You sound confused by competing responsibilities. It seems as if there are

a lot of demands on you.

Example 2:

Client: This clinic is too far away.

Why can't you people build one in my village?

I had to look for someone to take care of my children and I had to cook for
them and I had to wake up mid night to begin my journey here.

Provider: it sounds like you are tired from the work and travel.

 These hardships are frustrating

 You did well to come

The midwife may reflect words of feelings expressed so long as they are the client's
words and feelings not what the midwife thinks she should say.

f. Observations:

This is looking and listening to the client's behaviour, reaction and physical
appearance. This allows the Midwife to evaluate her educational level, socio-
economic level, state of mind (distressed, agitated or calm) and whether she has
family support.

g. Translating into simple language:

34
Making a complex concept or procedure comprehensive to the client according to her
level of education and information needs.

Clients will be less fearful and better prepared for the decisions that will benefit their
health if they fully understand what has happened, what is going to happen, what is
being required of them and why?

Avoid medical terms e.g The FIMBRATED END OF FALLOPIANTUBES capture

the ovum for transfer into the uterus.

COPING WITH SPECIAL NEEDS

Being able to handle special problems whose situation are unusual without imposing
ones own values or judging e.g

- 12 year old pregnant school girl

- Patient with V.V.F high-risk mother.
- Woman in labour who has STI or HIV positive
- Prostitutes etc.

Use the following ACRONYM to emphasis this point "KISS".

K - KEEP

I - IT

S - SIMPLE and

S - SENSIBLE

Using the acronyms GATEHER, ROLESAND CLEAR

Explain basic counseling techniques and proces5 in Reproductive Health. eg.

in the Ante-natal clinic using GATHER

G Greet the client politely, and warmly, introduce yourself and offer
him/her a seat.

Ensure auditory and visual privacy. Assure her of confidentiality of your

discussions. Encourage her to feel free to discuss any concerns she may
have about her current pregnancy and future delivery or any

Reproductive health concerns.

A Ask about herself, her family, home situation, her birth plan (if any).
Assess her knowledge and needs. Ask about any complaints she may
35
 have, what she would do if she develops any complications in pregnancy
during child birth or how she would recognize danger signs, Ask how
she is feeling and how you can help.

T Tell her what is going to happen during her visit and about any other
specific issues concerning her condition, problems/concerns. Tell her
about appropriate diet and nutrition in pregnancy, importance of
personal hygiene/self- care, rest and exercise in pregnancy. Tell her
about effects of STIs/HIV/AIDS in pregnancy the need for VCT and
PMTCT, importance of tetanus toxoid vaccination in pregnancy. IPT for
malaria and use of ITNs, care of the breast and exclusive breast feeding.
Danger signs in pregnancy and /or child birth how born Importance of
having a skilled birth attendants (BA) at her delivery. Tell her about
mama Kits and where to get one need to have some laboratory tests
done. Importance of compliance win medication, method of use and
health advise given. Explain the importance of reporting early it there
any problem. Examine her.

H Help her to be comfortable to understand her situation to make a

decision, or find a solution to a problem tensing and questioning are
important here). Help her to make a birth plan. Advise her to involve the
male partner in her birth plan.

E Examine the client to: (1) Confirm gestational age and if the baby is
alive. (2) Detect abnormalities such anaemia, PIH, multiple pregnancy,
STIs etc. Explain about benefits of goal-oriented antenatal care. Explain
any prepost procedure care or instructions including use and side-effects
of drug, nutritional content of local food, nutritional needs of pre-natal
mothers, etc.

Explain the need to have some laboratory tests done.

Retire visit, follow up. Refer client if there is any complication detected
that cannot be managed in your facility e.g refer for VCT if at risk of
HIV/AIDS, and no service at your clinic. Explain this to clinics and her
relatives. Refer for laboratory investigations if need be e.g. VDRI or RPR and
others as needed antenatal appointment or referral if any abnormality is
detected and cannot be managed at your facility or if she requested to be
referred.

Reassure (Laure your finding on her progress)

36
GATHER, ROLES and CLEAR for effective counseling

ROLES

E Relax

G Open-up

L Learn forward

E Eye contact

CLEAR

C - Clarify

L - Listen

E - Encourage

A - Ask question

R - Repeat

Responsibilities of provider in counseling:

- Provider should assist the client to make choices

- Provider should adhere strictly to the concept of confidentiality, which must be
made clear to the client and understood by the client.
- Provide conducive environment and proper sitting arrangement
- Ensure adequate record keeping of counseling sessions
- A provider must make a conscious effort to incorporate the processes and
techniques of effective counseling.

Types of responses that contradict objective of counseling:

 Advice client/patient.
 Disclose with sympathy (the same thing happened to me)
 Ignore client e.g when he/she comes in, or ignores client for a long time, or
does not ask client what he/she wants.
 Order, direct, command.
 Warm, scold, threaten, re-prim and client.
 Persuade, implore.
 Judge, criticize.
 Butter up/pamper.
37
  Insult/shame.
 Analyze.
 Reassure, sympathize.
 Question why?
 Distract or joke.
 Use ambiguous and unfamiliar language
 Do not ask client if she has any question.
 Force client to choose a particular method.
 Give guiding or leading response.

Example of counseling song:

- When you counsel (2ce)

- Do not judge (2ce)
- It will help you better, (2ce)
- Don't advice.
- De suggests.

Qualities of a good health care provider in counseling:

 Passion for work and desire to help people.

 Respect for people,

 Comfortable with expression of feelings (Do not query or disapprove)

 Self-awareness o1 one S values and limitations.

 Fairness to all (don't force your value on population, groups e.g. individuals of
different age, ethnicity, education, gender race, class or religion).

 Empathy for clients (do not judge/condemn)

 Supportive attitude towards clients.

 Ability to maintain confidentiality.

 Professionalism (do not divulge client's information)

 Tolerance for other people’s values.

38
  Unbiased attitudes towards various clients/patient's problems or concerns

Rights of the client in Reproductive health services

These rights include:

(Example, in a family planning service):

Discuss with every family planning client his/her right to:

 Courtesy: To be treated with respect when receiving services.

 Confidentiality: To be assured her information will be kept secret

 Information: To learn about the use, benefits of family planning or non-

availability of contraceptives

 Access: To obtain services, regardless of sex, creed, colour, marital status or

location.

 Choice: To decide freely whether to practice family planning and which

method to use.

 Safety: To be able to practice safe and effective family planning

 Privacy: 1o have a private environment during counseling or services

 Continuity: To receive contraceptive services and supplies for as long as

needed.

 Opinion: To express views on the services offered.

Advantages of Reproductive health counseling:

 Generates more demand for Reproductive Health services.

 Improves quality of life.

 Opportunities for behavioural change communication may increase

 Increases clients visit to heath facilities

 Assists during health worker's visit to institution, communities and

organizations

 Assists health care providers to explore other opportunities relevant to the local
institution.

39
COUNSELING GROUPS WITH SPECIAL NEEDS

Examples:

1. Family Planning Services:

Encourage voluntary acceptance of family planning and the freedom of choice that
could lead to an informed decision and adoption of a family planning method.

Menopausal women and andropausal men: counsel on couping with syndromes such
as hot

Thus she, headaches, palpitation, loss of libido etc.

Adolescents

Adolescents are those between 10 and 19 years (WHO), they undergo physical
emotional and hormonal changes that influence their sexuality. Quite often,
adolescents take emotional risk as well as risks related to pregnancy and
STIs/HIVIAIDs, often subject to peer pressure and influence. They engage in
indiscriminate premarital sexual activities. It is therefore, pertinent to inform and
educates adolescents on their sexuality as a God given right and the need for them to
safeguard it.

- Be friendly and accommodating

- Be non-judgmental.
- Ensure confidentiality.
- Discuss career and life goals, advantages of finishing school and achieving the
goals.
- Encourage discussion of feelings and beliefs.
- Give comprehensive information on sexual and Reproductive Health and
sexuality.
- Risks of early child bearing and abortion
- Arrange clinic sessions in the evenings, at the weekends and at times
convenient for them e.g (Youth Friendly Health Clinic) and use visual aids
- Use peer educations to motivate and educate other adolescents.

4 Males (for men’s' involvement in Reproductive Health):

- Make men feel welcome in the clinic.

- Use visual aids that show male examples,
40
 - Find out the concerns of men and emphasize the benefit of Reproductive health
in dealing with these concerns, eg symptoms of prostatic enlargement, STis
economic status, children education, wife's health etc. Dispel misconceptions.
- Emphasize how men can be supportive of their partners use of family planning
for example, reminding her to take the pills or helping to insert the diaphragm.
- Use men as outreach workers to motivate for use of condom, abstinences,
vasectomy, and other

Reproductive health care services.

Arrange clinic sessions in the evenings or at the weekends, at a time convenient for
men. Encourage male-friendly health services.

5. Sexual violence:

Sexual violence is any form of sexual gestures/activity not consented to by the victim
e.g sexual harassment or rape. Rape victims may present with physical and
psychological trauma such as bleeding, swelling, lacerations or medical conditions
such as STIs/HIV/AIDs) and emotional shocks.

- Show empathy.
- Assist the victim to regain confidence.
- Be non-judgmental.
- Encourage victims to report to law enforcement agency
- Provide opportunities for victims to tell stories related to their experience.
- Mention consequences of sexual violence and how to deal with them.
- Highlight risk preventive strategies for example, advise clients to avoid
walking alone in dark alleys, indecent exposure etc.

6. Breast feeding mothers

Counsel on exclusive breast feeding. positioning and attachment of baby at breast

feeding

7 Post Abortion: Counsel on family planning

8 Men and women with special diseases such as cancer, diabetes and sickle-cell:
counsel on coping needs, rest, compliance with drugs etc.

Benefits of effective counseling to clients:

- Client patients have control over his/her own life.

- Feels more confident (than before) to make choice.
41
 - Adopt healthy development and behaviour change.
- Clients feel good: This is rewarding in that it will encourage the client to help
him/her self-plan the future.
- It makes client adapts.

Exercises:

Discuss how you would counsel a male to be involved in Reproductive health

INTERPERSONAL COMMUNICATION (IPC)

Introduction:

Most of the reasons why most patients/clients do not attend health facilities is the
poor treatment received from the health care providers. Therefore there is need to
adopt the inter-personal communication skills to improve the damaged image of
health care providers and encourage clients to make use of health facilities.

Definition:

Inter-personal communication is person to person, face to face, verbal and non-verbal

exchange of information, ideas, feelings through a loud audible means (voices)
between individuals more people or small group.

The use of all communication skills: using Acronyms' CLEAR and ROLESs

CLEAR is used for verbal communication.

C - Clarify.

L - Listen.

E - Encourage.

A - Acknowledge.

R - Repeat/Reflect.

ROLES are used for non-verbal communication.

R - Relax.

O - Open up

L - Lean forward (lean towards client).

E - Eye contact.
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S - Sit squarely and smile (where applicable).

PROCESS OFINTERPERSONALCOMMUNICATIONIN
CLINICMANAGEMENT:

Health care providers interact with clients/patients at various levels of clinical

management, within or outside

A health facility and for a number of reasons. For example for routine nursing care
e.g antenatal care, family planning clinic, counseling community outreach services,
youth -friendly health clinic and for community mobilization. At whatever level one
interacts with one's clients, one should employ the following interpersonal
communication skills and demonstrate qualities of a good health care provider as
follows:

1. Establish rapport:

 Welcome and greet the patient with a smile.

 Offer him/her a seat.

 Introduce yourself.

 Call client/patient by name

 Sure privacy and assure confidentiality (especially interaction for counseling

purpose).

2. Employ good listening skills:

 Listen to what the client has to say with minimal interruption

 Concentrate on the client

 Make/maintain eye contact

 Squarely or maintain a comfortable distance between you and the client patient

 Relax and lean a little forward

 Show responses which show interest e.g. How? When? You mean it? etc.

 Use encouraging statements such as yes, go on, I'm listening, I see! and head
nodding

 Do not seem to be in a hurry e.g. looking at your watch or telling the client you
have an appointment or you have closed to new comers.
43
 3. Use simple language that is understood by the client:

Start with simple questions.

Use this acronym to remember "KISS".

K - eep

I - t

S - imple and

S - ensible

4. Ask open-ended questions:

These are questions, which elicit more responses. They demand thought and
expression of feelings concerns. They also provide the health professional with
adequate information (if properly used) to assess the client's needs for making
appropriate intervention e.g.

 Would you like to tell me how you feel about this pregnancy?

 Would you tell me the type of food you take everyday?

EFFECTIVE COMMUNICATION PROCESS

(i)Effective non-verbal communication process:

People often communicate their thoughts and feelings without speaking a word. The
health care provider physical posture, facial expressions and gestures express his/her
thoughts and feelings as much as

His/her words do.

Certain types of non-verbal communication, or body language, encourage open

communication and facilitate learning types of non-verbal communication that health
providers can use to facilitate client's patients interest or compliance include:

 Maintaining appropriately contact with client patient

 Showing interest in what is being said, 1or example, by nodding head or
smiling
 Standing in front of clients/patients without placing any barriers, such as desk
or podium, between themselves and clients/patients sounding in relaxed, yet
confident postures

44
  Demonstrating enthusiasm about health education talk by moving around and
gesturing
 Avoiding distracting movements, Such as tapping their feet, pacing back and
front.

Effective health care provider will also pay attention to the non-verbal
communication of their clients/patients. For example, a person's body language may
indicate that they are uncomfortable discussing a certain topic or is bored or
distracted during the period of counseling and health talk.

(ii) Effective verbal communication process:

The style and tone with which someone delivers and elicits information can
communicate as much to the listener as the words that are being spoken. A provider's
verbal communication style should capture the interest of clients/patients, as well as
convey the provider's interest in what clients patients have to contribute to the
conversation. They can help client to maintain interest by;

 Varying the pitch, tone and volume of their voices, as well as by speaking
clearly.
 Encouraging questions and letting clients answer each other’s questions in a
clinic talk
 Emphasizing important points by speaking slowly and summarizing at the end
of important point.
 Avoiding the repetition of phrases, such as, "Do you understand? Or is that
clear?
 Making smooth transitions from one point to another and making connections
between various point, whenever possible.
 Giving clear directions so that clients are not confused about what is expected
of them, posting written directions in a visible place, whenever/wherever
possible in the clinic.
 Using language that is easily understood and is culturally acceptable to the
clients.

5 Clarify client's statements to avoid Mis-interpretation by:

(i) Paraphrasing:

Paraphrasing or restating what someone has said to you, is an effective way to make
sure that you and the speaker understand each other. It also shows that you make sure
that you are listening carefully to what is being said. If you have understood,
providers have an opportunity to clarify the point they were trying to communicate.
45
Example of paraphrasing

Provider: What I hear you saying is that, you're not getting the support you need
from the health ministry to make these changes, is this correct?

(ii) Praise and encouragement:

Praise - Gives client's approval.

Encouragement - Gives confidence to succeed something

Praise and encouragement arc more effective in helping a client act

Areas where IPC is required in health activities:

1. Community outreaches 'needs assessment e.g in the clinic antenatal, planning

clinics, out-patient department, and pharmacy.
2. Health education talks, counseling and other information giving in health
facilities.
3. In advocacy efforts for motivation/promotion of Reproductive Health issues
e.g. prevention of Sexually Transmitted Infections (STIs) scolding.
4. Counseling in private homes/clinics.
5. Meetings and discussion groups on Reproductive Health issues.

APPLICATIONOFIPCIN CLINICAL MANAGEMENT

 Welcome client warmly

 Be friendly e.g. greet client/patient, and shake hands (if appropriate) with a
smile Ask about family’s welfare.
 Offer him/her a seat.
 Introduce yourself
 Call him/her name or address client by title e.g Chief, Doctor etc.
 Provide privacy and assure confidentiality (especially if visit is for counseling
e.g HIV villainy counseling).
 Mind your non-verbal responses while interacting with clients.
 Plan and arrange schedules to avoid tensions.
 Answer their questions satisfactorily.
 Exhibit positive non-verbal cues
 Ask simple open-ended questions e.g. would you like to tell me how you feel?
 Praise him/her for coming to the clinic.
 Listen attentively to what the client has to say.
 Do not distract client’s action/act.
 Do not interrupt client while talking,
46
  Do not permit interruption by others.
 Do not put words in client's/patient's mouth.
 Make/maintain eye contact.
 Sit squarely and maintain a comfortable distance from the client/patient.
 Relax and lean a little forward.
 Use simple language
 Take time to listen
 Do not be in a hurry to dispose your client patient (e.g. looking at your watch)
answer it repeatedly.(watch) answer if they ask questions repeatedly
 Allow client to finish his/her thoughts
 Do not discuss other clients
 Use encouraging statements such as really, I see, yes, go on with head nodding
etc.
 Paraphrase and summarize.
 Praise and encourage client/patient
 Reflect and acknowledge client's/patient's responses

Exercises

i. Explain five strategies in overcoming communication barriers

ii. Discuss how you would counsel woman in your family paining clinic.

BEHAVIOURAL CHANGE IN COMMUNICATION (BCC)

Definition of behavioral change:

This is the process of educating, persuading and disseminating information to people,

to positively advance their behavioral patterns about a particular (health) issue.

Behavioral change model

Individuals go through a series of steps or "stages" before a particular behaviour

change becomes on going or permanent health provider is to intervene in specific
ways during each of the stages in effort to help the client’s progress from stage to
stage

Stages of behavioural change:

There are five stages of behavioural change and they are as follows

Stage l: Pre- Contemplation:

Client does not perceive the risk and base on intention of changing behaviour e.g
having multiple sexual partners and He/she is unaware that a given problem exists, or
47
on some level, or client may know that there is a problem, but deny that the potential
consequences are as serious as they appear He/she may also understand that are
behavior is risky. Finally, client may be aware of the risk, but still decided not to
change his/her behaviour

Behaviour change does not happen during this stage. Client is usually not open to
heading suggestions about solving the problem during this stage because they do not
believe it is relevant.

Health provider's intervention:

Ty to help client sec that he/she is at risk, or susceptible e.g a 30 year old woman who
has multiple sexual partner and does not use female condom and does not see her
risks for HIV and other STIs, the provision of tactics of HIV/AIDs victims, could be
provided on brochures, leaflets for women of her age, who live in a her community.

Do not push a client to see what may be obvious to you but provide as much
information as you can and let client discover the risk involved in his/ her action

Stage 2: Contemplations-There are some risks but still not ready to make change

Health provider's Intervention:-

 Continue the interventions from the previous stage

 Continue to try to show client that he/she is susceptible
 If this is feasible, having her speak with other people again with a similar
background to hers, who have acted HIV or other STs, or experienced an un-
intended pregnancy by engaging in similar behaviour
 Letting the client evaluate the potential consequences (both positive and
negative) of changing her

48
 UNIT III: QUALITY CARE

3.0 BASIC CONCEPTS OF QUALITY CARE

The primary health care values to achieve Health for all require health systems that "put people at the
center of health care what people consider desirable, ways of living as individuals and what they
expect for their societies, that is, what people value constitute important parameters for governing the
health sector.
The concept is implied in professional code of practice of each health discipline but along with
licensing, professional credentials, internal audit and external inspection, standards of care and quality
as expected by consumer are still not achieved. Nurses/Midwives are keys in establishing a culture for
excellence in most health care organizations.
3.1.1 Definition of Terms:
Quality:
 Quality is defined as "doing the right things at the right time, for the right people and doing them
right first time.
 Quality is meeting Or exceeding requirements of the consumer/client,
 It simply means "Doing the right thing right at the right time.
Quality of care:
 Quality of care is defined as the provision of safe, effective and user-friendly health services.
 It is the degree to which health services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current professional practice Institute of Medic me
(200 1).
 Quality of care is the degree to which maternal health services for individuals and populations
increase the likelihood of timely and appropriate treatment for the purpose of achieving desired
outcomes that are both consistent with current professional knowledge and uphold basic
Reproductive rights Hulton et al(2000).
 High quality of care of materiality services involves providing a minimum level of care to all
pregnant women and their newborn babies and a higher level of care to those who need it.
 It is giving the best possible medical outcome, and providing care that satisfies women, their
families and their Care providers. Such care should maintain sound managerial and financial
performance and develop existing services in order to raise the standards of care provided to all
women" (Pittrof al. 2002).
3.1.2 Importance Of Quality In Health Care
49
 1. Quality of Health care affects
 Outcome (morbidity. mortality, disability).
 Patient satisfaction.
 Health worker satisfaction and motivation.
 Health seeking behavior.
 Utilization of services including HF deliveries).
 Timing of presentation at health facility.
 Willingness pay for care.
2. Good quality of care leads to:
 Higher standards.
 Patient satisfaction,
 Better relations between colleagues, patients and communities w serve.
 Increase use of ourfacilities.
 More funds.
 Staffsatisfaction,
3. Poor quality health services can: Waste money, waste time, waste lives.
Characteristics of a good quality care
 Safe: Avoids injury to patients
 Effective: Based on evidence of effectiveness and avoiding services that have been shown to
be ineffective.
 Patient-centered; Offers care which is responsive and respectful to the patient.
 Timely: Ensures that waiting time is minimal especially for potentially serious disorders.
 Efficient:Uses resources wisely.
 Equitable: Provides care that does not vary due to personal circumstances or characteristics,
On the whole, quality is a whole system concept that is; every individual in the organization
regardless of functions or position should be encouraged to find ways to improve quality.
3.1.3 Elements of quality of care (WHO, parameters 1995)
 Accessibility and availability of service
 Technical competence of the provider
 Make available and use essential supplies and equipment
 Interpersonal relationship i.e good quality client-provider interaction
 Appropriate consellation of services
50
  Choice of Reproductive Health services
 Quality Information to client
 Involve client in decision making
 Comprehensive care and linkage with other stakeholders
 Support health care provider
 Continuity of care and follow-up
3.1. 4 Models of quality of care
There are three models:- (1) Perspectives (2)Elements (3)Health system.
1. Perspectives:
Quality care is viewed in the following perspectives
i. Women and families
ii. Health care providers
iii. Managers
iv. Client perspectives i.e. what the client; expects: - These include the followings:

 Availability of skilled health personnel

 Warm reception

 Respect and dignity.

 Clean environment.

 Privacy and confidentiality.

 Right to info/informed decision.
 Good health outcome.
 Accessibility, afford ability and availability.
 Timeliness and continuity i.e. No delays
 Access to care: Geographical access, financial access.
Organizational access.
 Amenities: Features of services that enhance the clients or patient's
satisfaction,
Important: Never take your client for granted (reduction of maternal mortality does not lie in
professionalism only but in the system to health facilities).
2. Elements: These Include:
51
 i. Technical competence: The knowledge of the health care provider makes
correct diagnosis and treatment.
ii. Interpersonal relations.
iii. Equity: - Fair provision: No preference/preferential treatment e.g Her
Excellency.
iv. Effectiveness: -Produce the desired results; In a way that gets the result that you want.
v. Efficiency:-Greatest benefits within resources available.
vi. Patient', centeredness, this means;
 Patient should be involved in making decisions.
 Give respect for cultural values, beliefs and attitudes.
 Reflect needs of individual and local community.
 Services should be User-friendly.
 Ability to communicate effectively with patient
 Safety i.e No harm, care and treatments given are beneficial and safe.
3.2 Strategies for achieving and sustaining provision of quality Reproductive Health
(RH) Services:
1. Management committee should agree on quality improvement of Reproductive health services
2. Improvement Teams: Bring together members from different departments e.g maternity,
laboratory, outpatient, surgical, medical, pharmacy X-ray etc.
3. Obtain commitment of facility managers.
4. Responsiveness to client's needs and concerns.
5. Improvement of work conditions in facilities.
6. Appropriate consultation of services.
7. Promoting accessibility, availability and acceptability of services.
8. Capacity building to improve technical competence of provider e.g Refresher courses,
seminars/workshops etc.
9. Provide quality information to clients.
10. Involvement in decision-making'.
11. Supporting health care providers in their demands.
12. Provision 0f wider range of Reproductive health services.
13. Maintenance of accurate records.
14. Quality measurement: Measures all functions or operations.
52
 15. Using set standard, performance monitoring and taking corrective measures.
16. Cost of quality by collecting data on profitability of corrective action.
17. Motivation service provides and reward for quality services.
18. Quality awareness educate staff on cost of lion-quality goods providers
19. Peer review.
20. Corrective action: Solicit staff input for corrective action planning.
21. Team work: Work as a team with other department e.g, pharmacy etc.
22. Establish "Zero defect" programme: The goal is error free work.
23. Zero defect day; Devote a day to recognizing and publicizing the value.
24. Supervisor training: All managers need to understand quality improvement concept
25. Goal setting: this is established by work groups.
26. Error cause removal; Solicit input on problems that prevent error free work,
27. Recognition: Praise those who meet the goals.
28. Quality councils and change: Required repetition of the process.
29. Appropriate tools must be made to meet the specific objectives and outcome of
reproductive Health services.
3.3 Tools for Quality Care

Appropriate tools must be used to meet specific objectives and outcomes of reproductive health services .
this methods and tools are listed in the table below

Data collection method Data collection tools

In-depth interviews Questionnaire
Exit interviews/interview of client/client Questionnaire
feedback
Focus group discussion FGD topic guide
Direct observations of providers performance Checklist
Review of records Data collection sheet
Review of service statistics Data collection sheet
Patient's complaint/Incidents Suggestion box and meeting with health
committee
Clients/Household surveys Questionnaire
Staff satisfaction Suggestion box/meeting with health

53
 committee
Laboratory reports Data collection sheet
Clinical audit Data collection sheet
Nursing audit Data collection sheet
Accreditation visit by Professional Bodies, Meeting with health committee
Quality Control Agencies
Peer review/Self assessment Checklist
Operation Research/Household Surveys Questionnaire
Effective Supervision Checklist
Client flow analysis of health facility Data collection sheet Checklist
Mystery client/silent observer Checklist
Standard Approaches e.g Client-Oriented Data collection sheet
Provider Efficient (COPE) Checklist
Continuous Quality Improvement, Data collection sheet
Follow-up services Data collection sheet
EXAMPLES OF METHODS AND TOOLS USED FOR QUALITY ASSESSEMENT
1. In-depth Interview and Focus Group Discussion:
This is done with clients or patients, people in the community, health care providers, managers etc.
In depth exploration of:
 Access to and use of services
 Barriers and enablers to using care
 Barriers and enablers to providing quality of care
 Perceptions of quality of care
 Expectations of quality of care
2. Clients Exit Interview:
Interview clients after they have used services e.g. after antenatal visit, after discharge from
maternity, after postnatal visit using Questionnaire
Questions about:·
Care they received
 Perceptions of the care
 Satisfaction
 Concerns and complaints
54
 3. Observation:
Observations (direct participatory) of provision of care using checklists:
Antenatal care History taking
Postnatal care Examination
Intrapartum care Investigation
Postnatal care communication
Family Planning services prescription and treatment
Dispensing of drugs Nursing care
4. Patient complaints and incidents:
 Complaints/suggestion box
 Letters
 Meetings
5. Household Survey: This includes questions on:
 Care provided
 Perceptions of quality
 Reasons for use and non-use of services
 Reasons for choice of services
3.4 Application of the Concept of Quality Care In Reproductive Health Service Delivery
1. Client-Centred:
The client is the central focus in any service delivery system and his/her satisfaction is an important
indication of service quality.
Health care providers should take steps or measures to meet with the needs of clients in relation to
their Reproductive health.
Clients' satisfaction determines the overall effectiveness and success of specific health service and
quality programmes in a population group.
Clients' satisfaction with a service influence their health behaviour and utilization of health facilities.
It is important to note that client views of what constitute good quality of care must be assessed and
understood by service providers who should take steps or measures to meet their desires for
satisfactory service. Clients rights must also be respected.
The following rights of clients in relation to service delivery are applied as follows:
 Information: Providers should inform client where to access service, when and how? Give
health education talks, provide information through counseling, using IPC skills and
55
 relevant educational materials e.g In a family planning clinic-posters on family planning,
display of various contraceptives, information on barriers (Physical or otherwise) that
hamper client access to and utilization of available services should be made known to
client.
 Choice: Giving of informed consent on the appropriate methods e.g contraceptives allow
client to make an informed choice and ask questions about his/her concern.
 Confidentiality: On client problems/concerns.
 Privacy: e.g During counseling on family planning or HIV positive clients, during
delivery, physical examination etc should be provided e.g use of screens or making use
of special rooms.
 Dignity: Client/patient should be treated witb dignity, respect, without any
discrimination, answer client's question comfortably etc.
2. Continuity of care: Clients should have continuity of service through follow-up, giving of
appointments, making available e.g. Required Contraceptives on appointment dates etc.
3. Efficiency I Effectiveness: Health care provider should use appropriate equipment and
supplies, establishment should provide conducive working environment, provider should also
plan ber daily routine, create rapport with clients, provides needed service in good time, use
resources wisely to avoid wastage or shortage of supplies.
4. Safety: Protect from injury, observe universal precautions when attending to clients, don't use
expired drugs, maintain aseptic technique e.g when conducting deliveries, inserting IUD etc.
Service providers should protect themselves and the clients through universal precaution e.g
wearing of protective coverings e.g gloves, aprons etc.
 Use aseptic technique for processing equipment and materials e.g decontamination,
sterilization etc processes.
 Advise clients to maintain personal hygiene e.g during vulva toileting after delivery or feeling
for IUCD strings.
 Reporting of complications or adverse side-effect or services, medications etc.
 Early or prompt referral of patient for further care.
5. Equitable services- Providing care that does not vary due to personal circumstances or
characteristics e.g provision of family planning services for men or youth Friendly
Reproductive health services etc.
6. Comprehensive care and linkage with other stakeholders' e.g Complement Reproductive
56
 Health service with services from other sectors e.g nutrition, mass-media involvement in
creating awareness on Reproductive health issues, community mobilization and participation
in Reproductive health issues etc.
7. Improved professional performance: (Technical quality) though capacity building e.g
training of midwives in Life Saving Skills (LSS). Seminars/workshops for health providers to
intimate them with new technological devices in order to meet with International standards of
provision of quality reproductive Health services.
8. Timely: Provide services in good time by promptly attending to clients e.g a woman in
labour.
 Manage time effectively,
 Organize work to avoid undue delay of clients/patients.
Manage client's flow effectively to ensure that waiting time is minimized e.g in ante-natal clinic.

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 UNIT IV: SAFE MOTHERHOOD

4.0 CONCEPT OF SAFE MOTHERHOOD

The term “safe Motherhood” means ensuring that all women receive the care they need to
be safe and healthy throughout pregnancy and childbirth. It encompasses social and cultural
factors, as well as addresses health systems and health policy.

All events that make pregnancy unsafe, irrespective of the gestation or outcome are part and
parcel of safe motherhood. The 5th MDG is to improve maternal and health

Addressing this goals means ensuring that all women and their children receive the care
they need to be safe and healthy throughout pregnancy, labour and after childbirth.

The achievements of these goals are in the safe motherhood initiative (SMI) that was
formulated in 1987 at the conference jointly sponsored by the world Bank in collaboration
with WHO and UNFPA in Nairobi and the integrated management of childhood illness
(IMCI) strategy to reduce U – 5 (Under 5 years) mortality jointly developed by WHO and
UNICEF (FMOH, 2002).

4.1.1 DEFINITION

Safe motherhood is defined as an initiative that guarantees a woman’s successful

completion of the physiological processes of pregnancy and childbirth without suffering any
injury or loss of her life or that of her baby.It is a world wide effort that aims to increase
attention to and reduce the devastating numbers of women that suffer death or serious
illness every year.

The extent of maternal mortality and morbidity was reviewed with strategies and costs
required to ensure safe pregnancy and delivery for all.This initiative was adopted in Abuja
Nigeria in 1990.

The lunch of the SMI was seen as a major milestone in the race to reduce the burden of
maternal mortality and morbidity by one half (11/2) by the year 2015.

4.1.2 Other Approach to Safe Motherhood

1. Making Pregnancy Safer: - This is WHO new strategy to safe motherhood. It is a
strategy for action. Recognizing that an estimated 50% of the women in the world do
58
 not have access to such skilled care, WHO decided to concentrate on assisting
countries to achieve their safe motherhoods. In 2000, with this goal/aim in mind,
WHO lunched its new initiative “Making Pregnancy Safer” (MPS)is one of the 11
high peorirty areas of work of the world health organization.

4.1.3 Community Responsibility Towards Safe Motherhood

Establish and maintain development committees to carry out the following responsibilities
towards safe motherhood.
 Include women as committee members.
 Select appropriate traditional birth attendants/VHW for training.
 Establish a village health post where there is none.
 Provide necessary support to TBAs/VHWs in the provision of health care
services.
 Supervise the activities of the TBAs/VHWs including review of monthly record
of work.
 Identity health and health related needs in the community.
 Plan for the health and welfare of the community.
 Liaise with other officials living in the community to provide healthcare and other
developmental activities.
 Support the use of health facilities promptly when needed e.g during pregnancy,
labour and post delivery with their babies.
 Mobilize members to unite to achieve common objectives.
 Involve husbands in procuring services for their wives and children especially
during pregnancy,labour and immediate post-delivery.
 Encourage cultural practices that will improve the development of tile community
e.g breastfeeding support of women during pregnancy and delivery.
 Review and discourage cultural practices that are harmful to the health of
individuals and do not in the longer term promote the development of the
community e.g gender discrimination, early marriage, female genital mutilation.
 Deliberate on problems which are common and proffer solutions.
 Ensure that all children including girls go to school from the age of 6 years and
remain in school for a minimum of 9years.

59
  Maintain a clean environment at all times and encourage personal hygiene of
members of the community.
4.2 PRENATAL CARE

This is the advice, supervision and attention given to a pregnant woman from the time of
conception is confirmed until the beginning of labour in order to ensure safe pregnancy,
labour and puerperium. Antenatal care is a part of preventive medium and should be
conducted by both the Midwife and the Doctor, each with clearly defined roles towards the
achievement of the same goals.
4.2.1 Aim of antenatal care
1. To promote and maintain good physical and mental health during pregnancy through
health education on nutrition, hygiene etc.
2. To promote an awareness of the socio-logical aspects of childbearing and the
influence these may have on the family.
3. To build up a trusting relationship between the family and the care-givers, which will
encourage client to participate in and make informed choices about the care she
receive.
4. To monitor the progress of pregnancy in order to ensure maternal health and normal
fetal development.
5. To reduce maternal and perinatal mortality.
6. To recognize deviation from the normal and provide prompt management and
treatment as required or referring the woman to appropriate health team.
7. To ensure that a live, mature, healthy baby when the woman reaches the end of
pregnancy.
8. To help and support the mother in her choice of infant feeding: to promote breast
feeding and advise on preparation for lactation.
9. To offer the family advice on parenthood. Either within a planned programme or on
individual basis.
10. Providing a holistic approach to the woman’s care that meets her individual needs.
4.2.2 Process of Ante-natal care
Booking
Women are encouraged to start antenatal visit as soon as pregnancy is suspected or they
miss their menses for two months. This is necessary to confirm pregnancy and plan for
60
appropriate care. To ascertain baseline data recording of vital signs – B/P, blood values,
urinalysis and fetal development. This will serve as a standard to assess as the pregnancy
progress. It also helps to assess the level of health of the women. Patient could attend
antennal clinic in either at health centre, hospital or maternity homes. During this period a
comprehensive history is taken. These provide important information about the woman’s
general and reproductive health, both past and present. This starts by history taking.
History taking
The aim of history taking is not just for record keeping but it is a means of assessing the
health of the woman. To know what toguide against in her management and method of
delivery. Decisioncan be made if she will require hospital confinement.
Great patience is needed when taking history of a new patientespecially primigravida.
Patient must be prepared to give accurate details of herself:
 Gain her co-operation
 Provide privacy
 Ensure friendliness and kindness.
 Ask direct questions.
 Do not help her to answer question
 Use simple non-technical language.
History is taken in the following areas.
Social History: should include the woman’s name, address, age, occupation, religion,
marital status and race (if need be). Social status, income, any social or financial problems
should be recorded. Home condition is enquired.
Family History: This is to detect if there is any disease that runs inthe family or hereditary
conditions e.g. Diabetes which may showfor the first time in pregnancy, sickle cell disease,
Hypertension,mental disorders that can lead to psychosis in pregnancy orpuerperium
twining in family, Tuberculosis, venereal diseases, etc.
Personal History should include:
Medical History: Ask if she has certain diseases e.g. Cardiac disease, Diabetes,
hypertension, Rubella, kidney disease, venereal disease etc.
Surgical History
Any previous operations in the Abdomen, uterus or other areas including D & C which will
be complicated by perforation leading to rupture uterus in labour. Caesarean section leaves
61
scar tissue which may not stretch well in labour. Others are hysterectomy, myometomy or
accident injury to the legs or joints or any blood transfusion.
Obstetric History:
Menstrual history: Regularity of cycle, volume, duration and dysmenorrhoea.
Previous Pregnancies: What ever the out come, abortion; miscarriage - if yet at what age of
pregnancy cause, where, in the hospital or at home, complete or incomplete, any D & C,
blood transfusion. Bleeding after 28 weeks, if pregnancy was normal or complicated by e.g.
vomiting etc. If she carries the pregnancy tillterm.
Labour: if normal pre or post mature delivery. Type of deliveryforceps or vacuum delivery.
Spontaneous on set or induced, was itprolonged ,date, hemorrhage etc where she delivered,
was the babyalive or dead, if dead, why? Any perineal tear or episiotomy.
Puerperium: Was the puerperium uneventful? Was she wellthroughout,any haemorrhage,
lochia discharge. Did she breast feed her baby and was she delayed for any reason. Others
complications like sepsis, psychosis, venous thrombosis, Pyrexiaetc.
Baby’s History: Method of birth, Pre, Post or at term. Weight atbirth, alive, still birth,
perinatal death or neonatal death.Method offeeding, breastfed, how long, weaning
method.Illness afterdelivery, congenital malformation, Birth injuries etc.Alive or dead–If
dead at what age and the cause.Place of delivery Home or Hospital.
History of Present Pregnancy
Last menstrual period (LMP) –to calculate expected Date ofDelivery (EDD). Any morning
sickness, bleeding, exposure torubella, etc. Feeding pattern, social habit e.g. smoking or
takesalcohol, parity – grande multiparous is prone to complication.
Advice to the Pregnant Woman
Mother craft talk should be an integral part of antenatal care.Mothers want the best for their
babies so they are ready to learnand comply with the instructions that promote their health
and thatof the baby. Health instruction should be given in a simple andinteresting manner.
Hygiene:
Pregnant woman should imbibe practice that promote personal andenvironmental hygiene.
Bath regularly, clothing especially underwears must be kept clean. Home surroundings,
cooking utensilsshould be kept clean.

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Fresh Air & sunshine: Women are encouraged to have adequatesunshine (e.g.women in
Purdah) morning sunshine generatesvitamin D which is necessary for development of
bones. Fresh airis essential at night and overcrowding should be avoided.
Recreation and Exercise: Mild exercise should be encouragedstrenuous exercises, lifting
of heavy weight should be avoided. Sheshould not climb high object as this may cause
loosing of balanceand fainting, long standing predisposes to varicose veins.
1. It provide a change of scenery
2. It stimulate appetite and aid elimination
3. it stimulate circulation and induces
4. Sleep.
5. Restores good abdominal muscle tone.
Travel: This should be discouraged from traveling on longdistance depending on the age of
the pregnancy.
By road: at early and late pregnancy
Train: Late Pregnancy
Air: Late Pregnancy. Otherwise at low attitude.
Rest and Sleep: A pregnant woman must have adequate rentduring the day. Adequate rest
conserves energy and increasescirculation of blood circulation to the uterus. One to two
hoursduring the day and about nine hours in the night. A good warmbath in the night and a
cup of warm drink induces natural sleep.
Suitable clothes: ClothingWomen can be as elegant and femine as at any time even
inpregnancy. She can enjoy a normal social life provided it will notinterfere with the
pregnancy. Dresses that are loose and cool willallow normal expansion of uterus. Dresses
must be neat,comfortable of washable materials and attractive. Brassiere shouldbe the one
with big cup, loose, bread, long and adjustable straps. Itshould not depress the nipples.
Maternity corsets if not tight are good as this restores laxed abdominal muscles.
All clothing must be kept clean by washing especially the underwears.
Shoes: Low heels with broad base 4.5cm are advisable.
Bowels: Because of the effect of progesterone there is laxity in the alimentary canal but this
should not lead to constipation. Plenty of fluids roughages should be encouraged during and
in between meals. A cup of water early moving is good. Roughages, whole wheel bran fruits
and vegetables also mild exercises will aid

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eliminations. She should form good habit of opening bowels e.g. in the mornings.
Care of the teeth: the previous belief that calcium is withdrawn from the mother’s teeth to
is baby is not true. Instead the calcium is withdrawn from the mother’s bones. Care of the
teeth is however important is pregnancy. She should eat a lot of food that contain calcium
flouride.
Bathing: a pregnant woman needs to keep her skin clean and active. A daily bath is ideal. A
cold bath is comfortable especially on a hot day and a warm bath is suitening and will make
her relax well.
Alcohol: It is advisable to stop during pregnancy. Intake is related to vitamin deficiency
(mineral) Major cause of coronary health disease, stroke & chronic bronchitis, lungs and
other cancers.
Smoking: Smoking is associated with reduced fertility, earlymenopausal, placenta praevia,
abroption, premature labour, low birth weight, wheezing in early childhood, Otitis media
etc.
This can lead to reduction of oxygen concentration volume in pregnancy and leading to
abortion. Smoking is habit forming; smokers do not eat well resulting to reduced nutrition to
the baby and herself. She should reduce the smoking to the barest minimumor stop it
completely if possible.
Marital relation: Sexual Intercourse coitus should be discouraged in early pregnancy
especially cases of previous abortions as thiscan lead to premature uterine contractions.
Prostaglandin in semen can aid uterine contraction in late pregnancy. Vaginal deodorant
slower the normal vaginal PH and growth of microorganisms. If it has to be the husband
should to be gentle and adapt safe position.
Care of the breast: Breast must be well developed; nipples must be erect with loose areola
tissues. She should keep the breast clean by washing with soap and water with particular
attention to the nipples. Good nutrition helps to develop the breast and prepare the breast for
lactation in puerperium. Nipples should be pulled out and olive oil applied to moisten them.
Malformation should be corrected during pregnancy. Good well supporting brassiere must
be worn; cup should berooming without depressing the nipples.
Drugs: Should be advised to take only those drugs that were prescribed by doctor.

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Diet in Pregnancy
The midwife needs to advise a pregnant woman on good diet inquality and not quantity. Her
diet need not to be changed but improvement on types, preparation and preservation. The
aims ofdiet in pregnancy should provide for the needs of the growingfetus, maintenance of
maternal health, alleviation of minor disorders, physical strength and vitality during labor
and successful lactation.
Necessary food stuff nutrients are:
Protein, Carbohydrate, Fat, Vitamins, Minerals, Fluids andRoughages.Emphasis must be put
on the preparation in order topreserve the nutrients.
General examination of the ante-natal patients
The general examination of the ante-natal patient is embarked upon after the routine
examinations have been completed. These are as follows:
The blood pressure is checked and recorded, the weight and height are estimated and
documented, the urinalysis is checked and findings are noted and recorded. Any abnormal
finding is reported to the doctor and investigation of such abnormality is done and necessary
treatment accorded.
Preparation
Ensure patient empties her bladder, Create some privacy by screening the patient, Explain
procedure to the patient, Patient removes all her clothes and under wears, she then covers up
with a wrapper or a sheet, the patient lies on the couch in a dorsal position, the midwife
communicates with her in an understanding language and friendly approach that promotes
adequate relaxation.
Procedure
Examination is done by observing the patient from head to toe appearance, gait, posture,
complexion.
The Head
Is examined to note personal cleanliness, presence of dandruff andlice, untidy hair-do,
Abnormal swelling.
The Eyes: are observed for inflammation, discharge, pallor,abnormal growth, and infection.
The Ears
They are examined for: the location, the number, equality,cleanliness, abnormal discharge
and abnormal contour.

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The Nose
The nose is observed to note the size and shape and to detect:discharge, disease and
abnormality.
The month
The lips are examined for pallor: dryness, cracks and sores.The mouth is observed for bad
breath and angular stomatities. Theteeth are examined for the shape. dental hygiene or sores,
thetongue is examined for pallordryness, coatedness, sores
The face
The countenance of the face is examined for puffiness which maybe due to anemia,
malnutrition, chronic nephritis, nephroticsyndrome, pre-exlampsia.
The Neck
This is observed for previous scar. It is palpated for any growth,distended jugular veins,
enlarged lymph glands
The Upper limbs
The upper limbs are checked for:equality, abnormality.The hands are examined for: pallor
and puffiness which can beelicited through a handshake with the patient. The fingers
areexamined for shape, size, pallor, abnormality and puffiness
especially around the ring finger if she wears one. The nail bedsare also examined for
pallor.The patient now assumes a sitting up position for the examinationof the breasts.
The breasts
These are first inspected for Shape, size, equality, cleanliness, abnormality, changes due to
pregnancy such as enlargement, pigmentation of primary areola,
Montgomery tubercules, appearance of secondary areola, visible engorged veins; the nipples
are examined for the shape, size, protactility. The ducts are tested for patency by expressing
the breast fluid
Palpation
The breast are each palpated. Any feeling of undue lump or irregular mass should be
reported to the doctor.
Advice
The patient is advised on the Care of the breast which focus on
 The Diet: The type of food she should take must be rich in protein such as eggs,
beans, fish meat, melon. Minerals and vitamins such as green vegetables, carrots

66
 eggs, fruits with plenty of fluids. The quality of breast milk produced will depend on
the quality of good intake.
 Breast Hygiene: She is advised to pay particular attention to breast care during bath
times. The nipples should be washed with soft cloth or cotton wool and mild soap.
They are pulled out and later rolled between the thumb and index finger to get them
toughened the nipples are then dried firmly with a soft towel and little oil such as
kernel oil or olive oil is rubbed on them to soften them and prevent crust formation.
 Expression of colostrums: Colostrums is expressed from thebreasts from the 34th
week of pregnancy in order to maintain thepotency of the ducts and thereby
preventing breast engorgement inthe puerperium.
 Breast Support: She is educated on the need to keep thebreasts well supported with
good, adjustable, firm, cotton material,wide strapped brassier which is large enough
to accommodate thebreasts during the progressive enlargement of the breast.
The Back: While the woman is still in a sitting up position, herback is examined for
detection of – curvature of spine e.g. scoliosiskyphosis, abnormal swelling e.g. lymphoma,
lateral protrusion ofthe abdomen as in case of multiple pregnancy. Sacral oedema andother
abnormalities such as spinal bifida occur.The patient is later told to lie back on the couch
with themidwife assisting her, so as to examine the abdomen.
The lower limbs
These are examined for cleanliness: Athlete’s foot and foot drop,equality of legs and toes,
curvature of legs, pallor of the soles offeet, varicosity of the legs.Each leg is lifted up the
fingers of the right hand are run under theposterior aspect of the leg and thigh to confirm or
excludevaricosity. Simultaneously, the vulva is viewed quickly to note.Oedema, Varicose
veins, excessive and unhealthy vaginaldischarge, warts, hair follicle infection, bleeding.
The patient is then interviewed if she has any undue vaginalirritation or purulent vaginal
discharge.To demonstrate the presence of oedema in the ankle, the right
thumb is pressed against the pre-tibial area and quickly run overthe pressed area to elicit any
pitting.
The general examination is now completed and the womandresses up. She is commended
where necessary and she enquiresfor clarification of any existing problem.

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Patients with abnormal findings are referred, All findings arerecorded in the patients ante-
natal notes, Routine drugs are givene.g. (haematinics and antimalaria), Appointment is
given for thenext visit and a thorough explanation is outlined to this effect.
3.5.1 Investigations
Blood test – Hb estimation at booking, 28 – 32 weeks and after 36weeks before labour.
More frequently if there is abnormality.
PCV, FBC are also checked. Rhesus factor genotype and bloodgroup are determined. Others
are wasser man’s Khan test. VDRL,HIV.
Urinalysis: Test urine for glucose, albumin, acetone. Furtherlaboratory test may be done if
there are abnormalities detected. If Rhesus positive antibody titre is checked at booking, 28,
32, 36and before labour starts.
Vaginal Examination is done at book or at least once duringpregnancy. May be done early
for the following, - to diagnosepregnancy, exclude pelvic tumor, to determine gestational
agebefore 16 weeks.
X-ray may be required to ascertain maturityUltrasound scanDoctor may do pelvic
assessment on all primigravidae between 36-38 weeks.
Abdominal examination
a. Aims: To observe signs of pregnancy, to assess fetal sign andgrowth, To assess fetal
health, to detect any deviation from normal,to diagnose the location of fetal parts.
Preparation:
1. Ensure that patient empties her bladder
2. Let the patient lie in the supine position on the couch, withone pillow under her head.
Her arms should be by her sidesto prevent traction of abdominal muscles.
3. Draw the screen in order to ensure privacy.
4. Talk to the patient nicely to aid relaxation.
5. The examiner’s arms and hands should be relaxed.
Three ways of obtaining information required are: -Inspection, palpation, Auscultation
1. Inspection: note the size and shape of the abdomen
a. Size: Should correspond with the supposed period of gestation.If much larger
or smaller:-
i. Review the date of the last normal menses

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 ii. Note the size of the patient. If dates are correct but uterus islarge,
possibilities are: multiple pregnancy, polyhydramnios,a large fetus, a
fetus plus uterine fibroid.
2. Shape: Should be longitudinally ovoid. This is clear in mostprimigravidae.
Round: is due to multiparity, transverse lie, obesity,polyhydramnios.
In addition to the above, note on inspection: Pigmentation, scars,striaegravidarum, The
quality of the muscles of abdomen and thecontour.
3. Fetal Movement: This is evidence that the fetus is alive. It alsoaids in the diagnosis
of position as the back will be on the oppositeside where movement is seen.
4. Contour of the abdomen: (a) Normal is dome –shape (b)Pendulous abdomen is
common with multigravid woman. (c) whenlightening has taken place the uterus sag
forward and uterus ismore prominent e.g. when standing. (d) Depression at
theumbilical level suggestoccipito posterior (e) skin-scar, stiaegravidarum, Linea
Nigera are observed.
Palpation;
Aim
1. To observe signs of pregnancy. To determine fundal heightSize and growth of the
fetus. This should correspond with theperiod of gestation.
2. To ascertain fetal parts of the fetus is in different parts of theuterus, also the lie and
attitude of the fetus.
3. Relationship of presenting part to the pelvis: how to palpatethe uterus. Detect any
deviation from normal.
The hands should be clean and warm, cold hands do not have necessary acute sense of touch
and tend to induce contraction ofthe abdominal muscles. Arms and hands should be relaxed
and thepads NOT THE TIPS of the fingers are used with delicateprecision moving smoothly
over the abdomen without lifting them.Erratic and sudden pressure and rough manipulation
are irritatingand can cause contractions making detection of fetal partsimpossible.
Abdominal palpation is done by the following maneuvers: (thoughnot by mean the order)
a. Estimation of fundal height
b. Fundal palpation – To determine the part of the fetus in thefundus.
c. Lateral palpation
d. Pelvic palpation (lower pole palpation)

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Fundal height:
1. Method: The ulnar border of the left hand is placed at the upper border of the fundus
in order to locate the highest point of the fundus. As many fingers of the left, hand as
can be accommodated are laid flat between the upper border of thefundus and the
xiphisternum. The distance between fundus and xiphisternum is estimated in fingers
breadth. At 36weeks gestation no fingers can be inserted.
Using MC Donald’s technique – A measuring tape that has centimeter is used. After
locating the fundal height, the zeroend of the tape is paced on the symphysis pubic
and stretchedto the height of fundus. The measurement on the tape isrecorded as the
fundal height. It is more accurate between 20-31 weeks gestation.
2. Fundal palpation: This manoeuvre will help to determine whether the presentation
is cephalic or breech and the lie longitudinal or transverse. In 95% of cases the
breech will being the fundus and this denotes a cephalic presentation. When the head
is in the fundus, the presentation is breech. While facing the woman’s head “walk”
up both hands, one on either side of the uterus and lay them flat on the fundus of the
uterus to feel what is lying there.
3. Lateral Palpation: This maneuver is useful to locate the fetal back as an aid to
diagnosis of position.
Method: while still facing the patient’s head or feet, the hands are placed on both sides of
the uterus at about umbilical level. Pressure is applied with the palms of alternate hands to
differentiate the degree of resistance between the two sides of the uterus. One hand is used
to steady the uterus and press the fetus over towards the examining hand which determines
the presence of the broad resistant back or the small parts that slip under the examining
fingers. By using a rotary movement of the fingers:
a. The back may be mapped out as a continuous smooth resistant mass from the breech
down to the neck.
b. The limbs are noted as small irregularities which are often felt to move.
4. Pelvic palpation: This is the most important maneuver inabdominal palpation
because of its value in the diagnosis of presentation of the fetus, engagement of its
fetal head and disproportion between head and pelvis. It should not cause discomfort
to the women.

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Method: The midwife stands on the patient’s right with herthighs against the couch, her
body, turned at the waist facing towards the women’s feet. Using both hands, the midwife
finds out what is in the lower pole of the uterus as follows:
The sides of the uterus, just below the umbilical level a regrasped snugly between the palms
of the hands, the fingersheld close together, pointing downwards and inwards. Whatever is
in the lower pole can then be held between both hands. In most cases it is the head that is in
the lower pole and is recognized as follows:
i. It is smooth, round and hard.
ii. It is ballotable (if not engaged).
iii. It is separated from the trunk by a groove (the neck)
Occasionally it is the breech; which is
i. Less hard
ii. More irregular
iii. The lower limbs are nearer to it.
Pawlik’s grip
This method of palpating the lower pole of the uterus is most effective when the head is not
engaged.
Method: The midwife, standing on the patient’s right, faces the woman’s head and using
the right hand, grasps the lower pole of the uterus with the thumb on the woman’s right side
and the `fingers on the left side of the uterus. Fingers and thumb must be sufficiently far
apart to accommodate the fetal head.
Engagement of the head
Definition: Engagement means when the widest diameter of the presenting part has passed
through the pelvic brim. In some women engagement does not take place before term. In
some African women it occurs during the first stage of labour.
Recognition of engagement
i. The head or breech is not mobile
ii. Less of the head will be felt per abdomen
Auscultation
The fetal heart sounds are like the ticking of a watch under apillow. The rate may be double
that of the mother’s heart beastobserved at the wrist. About 140 beat per minute.
Procedure

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Place Pinard’s stethoscope over the back of the fetus and supportwith the pinna of the ear
while the right hand feels maternal pulseat her wrist.
Head fitting
From the 36 week onwards, it is essential to assess the pelviccapacity in every pregnant
woman. In a normal pelvic briminclination of 600 the head should engage from 36 week,
but in some African women with pelvic inclination of over 80 the headdoes not engage until
labour has been in progress for some hours.
The following methods of assessments are considered
Sitting the patient up.
Ensure that the bladder is empty while patient lies on the couch, grasp the fetal head with
the right hand as in pawlik’s grip. Rest the ulna border of the examining hand, with the 4th
and last fingers on the symphysis pubis. The woman is asked to sit up without assistant and
to lean forwards for a short time. Herdiaphragm and abdominal muscles tend to press the
fetus downwards. The thumb, index and middle fingers feel the head go through the pelvis.
Any overlap (which is suggestive of cephalo – pelvic disproportion will be felt by the
fingers on the
symphysis pubis)
With the Patient Standing: Let the patient stand up with her feet slightly apart. Face her
and grasp fetal head gently. Let her lean forward slightly holding the edge of the couch with
both hands. Push the head backward and downward gently. The titled pelvis makes the entry
through the pelvic brim ‘direct’ in the absence of cephalo -pelvic disproportion.
Calculation of expected date of delivery (EDD)
Add seven days to the first day of the last menstrual period to get the day. Add nine months
to the month or count three months backwards from the month to get the month. Example:
10th January2008.
LMP 10: 1: 2008
10 1
+7 +9
17 10 2008
EDD = 17th Oct 2008.

72
If the figure is more than 12, then you move the extra number to the following year. If the
day is more than that of the particular month the extra date is recorded for the following
month.
On-going Antenatal care:
Subsequent visit: the usual routine procedure involves all those at booking with the
exception of full history taking. Never the less enquires are made about her health every
visit. Frequency depends on the age of the pregnancy. She should visit every 4 weeks
until28 weeks, every 2 week until 36 weeks and every week until onset of labour. If there is
any complication she should visit more frequently.
 General examination to rule out anaemia, oedema, varicoseveins etc, urinalysis,
blood pressure,
 Weight – to ensure the progressive and normal increase as explain earlier. During
each visit the woman is given counsel on health promotion.
4.4 MANAGEMENT OF LABOUR

Labour may be managed actively or expectantly. Active management of labour involves the use of
utero-tonic drug. Expectant management of labour is allowing the placenta to deliver using gravity and
maternal pushing. This is not advocated because of risk of postpartum haemorrhage.
Proper management of labour results in successful outcome both for the mother and baby. The use of
partograph to monitor the progress of labour and for clinical decision making has been proven as a
must use tool in the skillful management of labour.
4.4.1 Management of 1st stage labour
 Provide woman centred care and be flexible enough to satisfy client's needs.
 Take history of onset of labour.
 Conduct physical assessment by general examination.
 Check temperature, pulse, respiration and blood pressure.
 Observe psychological state of tile woman whether calm, anxious or apprehensive.
 Abdominal examination: Inspect the abdomen and take note of shape, size and scarf any.
 Palpate abdomen-estimate height of fundus to confirm gestational age" not- th:.-: lie,
presentation, and engagement of the presenting part.
 Auscultate foetal heart to check position and normal foetal heart rate, which is between 120-160
beats per minute, Ifthe heart rate is above 160 or below 120 beats per minute, the baby may be

73
 having problems.
 Viginal examination - inspect the vulva for varicose veins, previous scar, from genital mutilation
and or epi~iotoIl1Y, vulva warts, vaginal discharges, and liquor amnii.
 Perform vaginal examination under asepsis to confirm abdominal findings.
 Note the degree of cervical application to the presenting part and effacement.
 Check cervical consistency and degree of dilation.
 Identify phase if active, record findings on the partograph.
 Continuously interpret the partograph.
 Identify problems and take appropriate action.
 inform client and relations of her progress in labour and i f necessary reason for referral
 Attend to bowels, perineal care and personal hygiene.
 Instruct client to empty her blader.
 Test urine specimen for albumin and acetone.
 Encourage the woman to take oral fluids and liquid diet as required.
 Give sips of nourishing fluid/fruit juices.
 Reassure, give emotional support and encouragement.
 Asses pain level and effectiveness of comfort throughout labour.
 Encourage woman to move about during labour if no contra indication
 Deliver in the position they find most comfortable i.e dorsal. left lateral, squatting, knee-
chest.etc.
 Avoid of pubic hair and enemas during labour
 Avoid routine episiotomy unless clearlly indicated
 Ensure that a clean deiivery kit is avaliable for every delivery e.g. mama / midwifery
kit.
 Ensure the 6 cleans at delivery
1. Clean hands,
2. Clean delivery surfaces
3. Clean blade to cut cord
4. Clean string to tie cord
5. Clean cloth to wrap baby
6. Clean cloth for mother.
Monitor maternal and foetal conditions i.e vital signs and foetal heart rate hourly, and every 30
74
 minutes in active labour
Note: First stage of labour should not exceed 16 hours irrespective of the gravida.
4.4.2 Relief Of Pain In Labour
Pain relief in labour should actually start alternately. There are 2 methods Pharmacological and-Non-
pharmacological methods. '. ,
Non-Pharmacological methods:
 Teach deep breathing exercises.
 Teach how to relax, foot and pelvic exercises to help her relax.
NOn- Drug techniques:
Examples
1. Education on relaxation exercise during contractions. The woman is encouraged to tighten the
abdominal. muse les
 Control breathing deer breathing is taking at the beginning and end of each contraction, a
slow deep abdominal breathing is adopted when she is urging to push and is not yet to
push, she should start to pant i.e in blow, in-blow.
At delivery: When it is time to push, rake deep breaths until the urge to push is very strong, then bear down
by grunting and exhaling with each push. She should hold breaths for less than 6 seconds for effective
pushing efforts.
2. Distraction : e.g watching television, listening to music, focusing on a picture or meaningful
objects e.g spouse.
3. Cutaneous stimulation: e.g massaging of arms, legs, back, shoulders and forehead by spouse or
loved relative promotes relaxation and distracts attention from pains
4. Maintenance of cordial nurse/client relationship in labour
5. Reassures clients frequently to help relax
6. Rub her back during contractions
7. Frequently change clients position
8. Encourage her to move about when membranes have not ruptured
The pharmacological method
 Administer prescribed pain relieving drugs e.g pentazocine (Fortwin) 30mg IM especially
in the first stage of labour
 Administer prescribed sedatives and hypnoties to relieve anxiety where necessary
 Use inhalations anaesthesia e.g Nitrous oxide in the 2nd stage of labour where

75
 applicable.

4.4.3 Preparation For Birth

Prepare sets of instruments and supplies for delivery:

 Identify a helper and review the emergency plan.

 Wash hands

 Prepare the area for delivery.

 Prepare an area for ventilation e.g. flat or table surface.

 Prepare sets of instruments and supplies for delivery such as

 1 stainless steel placental bowl,

 2 scissors, 2 straight artery forceps (Kelly clamps).

 1 clean cloth drape to place over the woman's abdomen,

 4 cotton balls (three to prep-skin for oxytocin injection):

 6 gauze compresses (4x4).

 5 cc syringe and needle for oxytocin.

 Clean cloth to cover the baby.

 Clean cloth to dry the baby.

 Clean plastic or cloth drape to place under the woman's buttocks.

 Umbilical tape. (stored in covered stainless steel container). Include ventilation bag-
mask, suction device, stethoscope, timer.

 Assemble all supplies and equipment,

4.4.4 Management of Secondstage of Labour
Note: Second stage is maximum 0/30 minutes irrespective of the gravida.
 Check frequency of contractions, strength and duration
 Monitor vital signs and foetal heart rate
 Note mother's uncontrollable urge to push
 Check pointing anus
 Clean up sweats on the face if present
 Check foetal head visible at the vulva

76
  Note nausea and/or vomiting
 Perform vaginal examination to confirm full dilatation of the cervix
Conducting delivery:
 Position patient on her back with her two legs flexed and open.
 Swab the vulva with antiseptic lotion.
 Monitor progressive descent of the presenting part on the perineum
 Instruct her to take up fast deep breathing in and out.
 Encourage her to pant at the crowning of the head.
 Deliver the head gently, and feel for cord round the neck.
 If present but loose, slip over the head.
 If tight, clamp in two places and cut between clamps.
 Slip the clamped ends to either side of the neck.
 Support the head and allow for external restitution.
 Extract mucus from the airways.
 Deliver the rest of the body.
 Note time of delivery and baby's sex.
 Administer oxytocin 10 units 1M.
 Keep baby warm in a wrapper/towel or baby's shawl.
 Place baby on mother's abdomen, and clear the airways.
 Clamp cord in two places and cut in between, (if not already done as in cord round the neck).
 Allow baby to suckle at the breast immediately at birth or with in 30 minutes of birth.
Note: if the cervix is fully dilated and the baby does not come out after 15 minutes in
multiparae and 30 minutes in priutiparae perform vacuum extraction if there is no contra
indication to it. otherwise refer immediately.
4.5 Emergency Obstetric Care
This is an urgent skillful care given in an emergency to save lives of mother and/or baby and
to prevent complication
4.5.1 Types Of Emergency Obstetric Centres
1. Basic Emergency Obstetric Care (BEOC) Centre: This is a centre that competently has
the ability to perform competently on a regular basis (usually at least quarterly) certain
basic procedures, targeted at obstetric complications.
2. Basic Emergency Obstetric Comprehensive (BEOC) Centre: This is a centre that has the
77
 ability to perform all functions in basic category including caeserea section and blood
transfusion, care and resuscitation of Low Birth Weight babies e.t.c. At least one such
centre is recommended for a population 0f 500,000 i.e. one comprehensive centre should
have 4 basic centres referring to it.
4.5.2 Signal Functions Used to Identify Basic and Comprehensive Essential Obstetric
Care Services
Basic Essential Obstetric Care
This includes the following and are carried out by Nurse/ Midwives and Physicians to:
 Administer Parenteral Antibiotics
 Administer Parenteral Oxytocics
 Administer Parenteral Anticonvulsants for Pre-eclampsia / Eclampsia
 Perform manual removal of placenta
 Evacuate retained products
 Perform assisted vaginal delivery.
4.5.3 Comprehensive Essential Obstetric Care:
This is carried out by Physicians
 In addition to all services included in Basic EOC,
 Caesarean Section,
 Safe blood transfusion (screened and cross-matched blood).
obstetric, conditions that require emergency care include:
 Shock and post partum haemorrhage
 Sepsis (Puerperal sepsis)
 Obstructed labour, ruptured uterus, retained/adherent plancenta.
 Eclampsia, foetal distress and maternal distress.
 Puerperal sepsis
4.5.4 Description Of Sepsis As One Of The Conditions That Require Emergency Care

EXAMPLE: PUERPERAL SEPSIS

Sepsis I Infection is one of the major causes of maternal mortality and this occurs mostly in
the puerperium.
Definition of puerperal sepsis: This is any bacterial infection of the genital tract which

78
occurs after the birth of the baby, usually after the first 24 hours.
Pueral fever: This is a temperature of at least 380C on more than two occasions apart after
delivery excluding the first 24 hours till 14 days postpartum
Common causes
1. Malaria fever
2. Upper respiratory tract infection e.g catarrh
3. Pneumonia
4. Engorged breasts / Mastitis
5. Acute pyelonephritis
6. Endometritis (infection occurring inside the utrine lining)
7. Thrombophlebitis at the infusion site
8. Acute viral hepatitis
9. Deep venous thrombophletis
10. Tonsillitis / pharyngitis
11. Septi pelvic thrombophlebitis
Signs and symptoms
1. Fever temperature 380C or more (this is the cardinal sign)
2. Other features depend on the causes e.g
a. Headache
b. Joint pain
c. Bitter taste
d. Weakness
e. Cough, catarrh,
f. Chest pain
g. Nocturia
h. Dysuria
i. Painful breastfeeding
j. Jaundice
Management:

1. Rapid initial assessment – Brief history e.g, of labour, onset of fever at time of
delivery multiple vaginal examinations, manual removal of placenta etc
2. General examination
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 i. Skin Pallor, pyrexia;
ii. Throat - tonsils, pharynx;
iii. Breast – swollen, inflamed and painful, nipples are flat;
iv. Chest – reduced air entry, crepixtations;
v. Abdomen – lower abdominal pain, flank pain,
vi. Muscle / skeletal – swollen hands, fore arms / painful calf
vii. Vulva – foul smelling lochia
Investigations
i. Full blood count, PCV, WBC, Platelets
ii. Blood film for malarial parasites
iii. Breast milk
Treatment
i. Antimalarial - Artemisin based combination Therapy (ACT)
ii. Breast engorgement – Hot compress, express milk
iii. Give analgesics / antipyretics
iv. Infective mastitis - IV Ampicillin, Cloaxicillin 1 gram 6 hourIy IV Metronidazole 500ml,
8 hourly x 48 hours
v. Endometritis / pyelometritis – preferably refer because of complications
COMPLICATIONS
1. Cerebral malaria
2. Meningitis
3. Septicaemia
4. Acute renal failure
5. Pelvic abscess
6. Breast absess
4.5.5 Material For Emergency Obstetric Care
1. MEDICAL SUPPLIES
 Suction machine with nasal tubes (various sizes)
 Airbus bag (baby and adult), obstertric forcepts
 Manual vacuum extractor with its various sizes
 Cuscos vaginal sspeculum, blade, hot water bottle
 Artery forcepts, sponge forceps, oxygen cylinder

80
  Blood pressure cuff
 Face mask (adult and baby for oxygen administration)
 Vulsellum forceps
 Intraveneous giving set, scalp vein needle
 Catgut of various sizes, episiotomy scissors
 Gloves, sutures, uterine containers and dipsticks
 Vaginal speculum, calibrated small jug
 Mucus extractor, bulb syringe
 Blood giving set, foley’s catheter
 Tape measure, pinards sthethoscope
 Kocker’s forceps, cord scissors
 Endo-tracheal tube (various sizes)
 Vacuum extractor
 Torniqet, syringes and needles
 Plaster, straight scissors
 Needle holder
 Receive / kidney dishes
 Cannulae (various sizes)
 Guaze and cotton wool
2. Drug
ANTI- ANTI-MALARIA OXYTOCICS ANTICONVULSANT
ALLERGICS

Epinephrine Quinine Eregomethrine Diazepam

Antibiotics Dihydrocholride 0.2mg for IM of Magnesium suphate
Ampicillin Sulfadoxine IV use Intra-venous (IV)
Gentamicin Pyrimethamine Misoprostol Solutions
Metronidazole Disinfectant and 100mcg Glucose 5%, 50%
Procaine Benzyl Antiseptics 200mcg Normal saline
Penicillin or Chlorhedine Oxytocin Ringers lactate
Benzathine Iodine 10IU for IV or Sterile water for injection
Benzylpenicillin Surgical spirit IM use tetanus toxoid

81
 ANAESTHETICS ANALGESICS (stored in cold box)
Lidocaince Paracetamol
Pentacozine

3. Supplies for infection prevention

Chlorine, Clean towels, Clean water supply. Face mask, Face shield, Gloves (high-
level) disinfected or sterile), Plastic or rubber aprons. Protective eyewear, Puncture-
proof container
Receptacle for soiled linens, Separate containers for general and medical waste,
disposal and contaminated, instruments, Soap
4. Furnishings
Clock (or watch)
Screens/ Curtains for privacy (if needed) Drape or blanket to cover woman
Examination surface (table or bed with washable surface and clean linen) Light
source, Pillow
5. Record forms
Patient records or forms
Referral forms.
Set of instruments and supplies for suturing
Instruments Supplies
(stored in covered stainless steel container) 4 cotton balls
1 needle holder 6 guaze compresses (4 x 4 Diazepam)
1 scissors Emergency tray, epinephrine, IV fluids
1 tissue forceps without teeth Gloves (high – level disinfected or sterile)
5 ce syringe and needle Magnesium sulphate, oxytocin,
ergometrine protective eyewear, syringes,
needles
4.4.5 Supplies for Emergency Tray
Diazepam, Epinephrine, gloves (high level disinfected or sterile), IV fluids, Magnesium
Sulphate,
4.5.6 Emergency Drill
Definition -

82
A drill is a response to a planned simulated event. examples of common obstetric and
neonatal drills
1. Massive obstetric haemorrhage
2. Shoulder dystocia
3. Eclampsia
4. Maternal collapse and Cardio-Pulmonary Resuscitation (CPR)
5. Neonatal resuscitation
6. Cord prolapse
7. Crash Caesarian Section
Aims of a drill
 To train the staff ( e.g. staff in the maternity unit).
 Test our local systems and protocols for responding to emergencies.
 Test our professional team work and individual's skills, behaviour and knowledge.
4.5.7 Reasons for drills
 To improve management of obstetric emergencies.
 It is recommended by World acclaimed colleges.
 Requirement for passing examination e.g. examinations in Medical schools.
 To achieve reduction in maternal and neonatal mortalities (e.g. CEMACH)
CEMACH is a Confidential Enquires into Maternal and Child Health practices which
may be adopted to identify the cause of a maternal death. (A Questionnaire form is given to
be filled by staff in the various departments concerned in the management of the patient i.e.
from the security man from the gate of entry to all the processes she passed through until her
death).
4.5.8 Problems associated with running a drill
1. Busy units: It is difficult to run drills in a busy unit. This is because all staff and
attention will be driven to the drill.
2. Shortage of dedicated staff: There is difficulty in getting a dedicated risk
management staff.
3. Consumes time and energy: When planning and conducting drills, a substantial
amount of time is demanded e.g. burning a house down to practice a drill.
4. Limitation of staff: Each drill may only include a few staff.
4.5.9 Advantages of a drill
83
  Management follows Evidence-Based Medicine (EBM)
 Members of staff are summoned faster
 Resuscitation process is better organized.
 Drugs are prepared and administered more quickly e.g. in eclampsia - Simplification
and reduction of tasks.
 Useful educational activity.
 Perinatal emergency drill allows risks to be identified without exposure of real
patients to inadequate care.
 Allows a greater sense of reality
 Provide controlled experience for all staff and promotes team work practices within a
clinical unit.
 Can identify and correct potential deficiencies in the care of patients.
 Drills could be the life saving moves to save a loved one.
4.5.10 Information to staff on drill i.e tells the staff or observers around that:
1. You are about to take part in a simulated obstetric emergency.
2. The patient is an actor so please stimulate any invasive procedures.
3. Say aloud what you are doing e. g. "I am setting an intravenous line"
4. Everything else that you might do in this situation should be carried out as normal.
5. Any intravenous drugs or fluids should be prepared as normal but delivered into the
receptacle beside the

4.6 POSTPARTUM CARE

Postnatal care is often referred to as the "Clnderrela" of maternity service. It is the care
given to the mother from We time of completion of delivery of placenta up to 6 weeks
postpartum i.e, the period between the time of delivery up to six weeks later, It is the period
of adjustment when the organs altered during pregnancy return to their pregravid state.
Prominent features during this period include: Breastfeeding, involution of the uterus, return
of Reproductive organs to their pre-gravid state and other cares given to mother and baby
during the puerperium.
4.6.1 Principles Of Post Natal Care
1. Promote personal hygiene especially hand washing with soap and water.
2. Counsel on use of' ITNs to prevent malaria attack.
84
 3. Manage anaemia and promote nutrition give mother vitaminA, give 200,000 IU as a
single dose; Iron and Folic acid for up to 6 months after delivery.
4. Encourage immediate breastfeeding and early mother / child bonding except for mothers
who choose not to breast feed their infants because of their status.
5. Promote personal hygiene especially hand washing with soap and water.
6. Educate mother and the community on danger signals in the postpartum period e.g. fever,
chills etc.
7. Provide counseling on a range of options for healthy child spacing.
8. Complete Tetanus Toxoid immunization for mother if required.
9. Refer complications such as bleeding, infections etc.
10. Counsel on care of the newborn: -
 Measure and record weight, check Temperature and Apex-beat.
 Check feeding and support optimal feeding practices particularly exclusive
breastfeeding.
 Promote hygiene especially that of the eye, skin and cord care.
 Ensure warmth e.g. skin-to skin care (or kangaroo mother care). Facilitate birth
registration.
 Encourage routine immunization.
11. Assess for danger signs in the newborn such as: (i) Inactivity - moves legs or only
when stimulated. (ii) Feels too hot or cold. (iii) Vomit after most or all feeds. (iv) Refuses
to suck or sucks poorly. (v) Has rapid or difficult breathing, (vi) Chest retractions. (vii)
Redness or swelling around the umbilicus. (viii) Has a swollen stomach, convulsions,
fever, or signs of infection.

4.6.2 Indications For Postnatal Care

 Continuity of mother and child good healthcare
 Maintenance of lactation
 Monitoring of 'immunization To know if baby is thriving well
 To do Acetowhite test (for cervical cancer)
 To counsel on family planning.
4.6 3 Management Of Postnatal Care
Immediate care:
85
  Create rapour and welcome mother and baby to postnatal ward.
 Establish mother-baby contact.
 Check vital signs – temperature, pulse, respiration and blood pressure.
 if the blood pressure is high post partum, give sedative such as valium 5mg
intramuscularly or orally to prevent development of post partum eclampsia.
 Palpate uterus for consistency and expel blood clots to ensure that uterus remains
well contracted.
 Check perineal pad for bleeding, clean mother up and cbange sanitary pad / towel.
 Measure fundal height with tape measure.
 Check lochia: - note colour, quantity and odour.
 Check vulva for haematoma, laceration and bleeding.
 Encourage patient to pass urine.
 Give bed pan to empty bladder.
 Monitor intake and output and record on chart.
 Offer mother a warm nourishing drink or food (if not already given in the labour
room).
 Allow mother to rest.
 Incase of caesarean section, in addition to the above nursing care, inspect
abdominal wound for bleeding.
 Check vital signs more frequently.
4.6.4 Subsequent care (in the first 10 days) Principles of care:
 Check mother's vital signs i.e. temperature, pulse, respiration and blood pressure.
 Advise on nourishing diet.
 Provide VitaminA: 200,000 IU as a single dose to the mother after delivery. Give
Iron and Folic acid for up to six months after delivery.
 Advise on personal hygiene for self and baby
 Supervise, exclusive breast feeding
 On discharge check haemoglobin level
 Counsel on family planning
 Inform her of post-natal visits/appointment
 Advise to report any discomforts or abnormality even before appointment date i.e. if
she experiences any of these conditions - excessive vaginal bleeding, loss of appetite,
86
 insomnia, fever, difficulty in urination, lower abdominal pains, offensive vaginal
discharges or problem with exclusive breastfeeding.
ASSESSEMENT/EXAMINATION OF THE BABY:
 Assess baby's weight
 Measure the head circumference and length
of the baby Examine the baby from head to
toe
 Head: look and feel the fontannels and sutures for bulging, depression
or closure and shape. Note: size of the head, swelling and
moulding/caput succedaneum
 Skin for colour (normal pinkish), blue or yellow and for septic spot.
 Note obvious abnormalities e.g. mongolism, microcephally, cleft palate or hare lip,
spinal bifida or extra digits.
 Eyes: for discharges, jaundice conjunctiva, heamorrhage, dullness of'the pupils,
(cataract) and angles of the eyes for features of Down's Syndrome.
 Nose: for nasal discharge or blockage
 Face: for asymmetry, shape and size of facial features.
 Mouth: for cleft palate and hare lip, size/shape of the mouth and lower lip to exclude
receeding chin.
 Ears: for location (low set ears are associated with renal abnormalities and Down's
syndrome) check shape, size of ears. Note any accessory auricle.
 Neck: for enlargement of the neck (tumors, haematoma, enlarged thyroid), fractured
clavicle
 Abdomen: umbilical stump to ensure that it is securely clamped and for signs
of bleeding/infection or distention.
 External genitalia: note size and shape of labia, in male feel scrotum (un-
descended testes), urethral opening, note if central to the tip of the penis
(exclude hypospadias, epispasdias).
 Anus: if baby has passed mecomum, if anus is patent.
 Limbs: length of.arms and legs, hands and feet for extra digits, webbing, palmer and
plantar markings.
 Ankle: for talipes and lips for dislocation using ORTOLANI'S TEST This is based
87
 on a gentle flexion of the
 legs and abduction/adduction of the lips. An audible-click indicates the replacement
of the head of the femur into the accetabulurn of the dislocated hip.
 Spine: check for defects e.g. spinal bifida or meningocele.
 Continue checking for temperature, respiration and apex beat.
 Observe skin for physiological jaundice after 24 hours up to 4 6 days (Birth baby
after 12 hours of birth).
 Avoid infecting the cord and chilling the baby.
 Urinary output: note frequency and odour. If strong odour, supervise baby's
feeding, suggest more frequent breast- feeding.
 Stools: note colour, texture, odour and frequency. Colour changes from
blackish to yellowship within 2 -3 days.
 Check baby's weight on alternate days. Baby may lose some weights in the
first 4 6 days and gain gradually after.
 Care of umbilical cord:The aim of care of the cord is to prevent haemorrhage,
infection and getting the cord to dry and separate.
 After the initial treatment at birth, check the cord at hourly interval for: (i) Bleeding
(ii) Slipped off ligatures (iii) Inspect for wetness or signs of infection.
 Subsequent care: Keep the cord clean and city. Clean with sterile water or (boiled
cooled water). It can be cleaned with Hibitane lotion 1 :200. The cord may be left
uncovered to keep it dry
 Do not cover cord with pampers/nappkin or clothing. Expose to air to dry and chip
oft Observe daily for swelling bleeding or abnormal discharges.
 Advise the mothers against the use of'herbs, cow dung on the cord to avoid infection,
 Teach mother the care of the cord and tell her that normally, cord falls offin 5 to 10
days.
 Feeding: Supervise breastfeeding, suggest feeding on demand.
 Give appointment for a return visit in 6 weeks.
 Advise mother to report if there is any difficulty or change in baby's condition.
 Advise on care of the baby and the following:
 Exclusive breastfeeding for 6 months, no Pacifier or water.
 Prevention of infection.
88
  Personal .and environmental hygiene.
Things to note when providing postpartum care
1. Access vital signs Temperature, Pulse, Respiration and Bood pressure:
2. Educate clients and the community on the danger signals in the post-partum
period ego fever, chills, foul smelling vaginal discharge, anaemia, bleeding,
facial swelling, hand swelling, elevated blood pressure, headaches, decreased
urinary output, convulsions or fits, coma, signs of shock (sweating, coldness,
clammy hands, fainting attacks, weak rapid pulse), soft uncontracted uterus,
placenta not delivered within 30 minutes of delivery Where possible, detect
and treat asymptomatic bacteriuria with antibiotics.
3. Detect and manage post-partum haemorrhage, retained placenta, puerperal
sepsis and eclampsia.
4. Manage anaemia and promote nutrition. Give vitamin A, 200,000 IV as a
single dose to the mother after delivery. Iron and folic acid for up to 6 months
after delivery.
5. Encourage, immediate breastfeeding and early mother/child bonding, except
for HIV infected mothers who choose opt to breastfeed their infants in order to
prevent MTCT.
6. Educate mother and the community on the danger signs for new born.
7. Provide counseling and a range of options for healthy child spacing.
8. Complete tetanus toxoid immunization for mother if required.
9. Refer complications such as: bleeding, infections etc.
10. Counsel on care of the newbom

4.6 MANAGEMENT OF THE NEW BORN

4.6.1 immediate PostPartum Care

The first one hour after delivery should be spent in the labour room by the mother and the
baby to ensure adequate rest to dictate and manage immediately in case of abnormality such
as post-partum hemorrhage, shocks or sudden collapse.

Physiological and psychological adjustment begins immediately after delivery.

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The care is given as follow: -

 Encourage immediate breast feeding and early mother / child bonding except for
HIV positive mother who chose not to breastfeed their infant in other to prevent
MTCT.
 Maintain mother – baby contact
 Check vital sign, temperature, pulse, respiration and blood pressure.
 Observe the uterus, note position consistently and fundal height
 Check lochia, note the colour, quantity and odour.
 Check vulva, perineum for laceration, episiotomy site (if given) and bleeding
 Give the bed pan for patient to empty her bladder, this will aid contraction of the
uterus to involution.
 Monitor intake and output and record.
 Clean mother and change cloth
 Given warm nourishing food or drink
 Allowed mother to rest by ensuring quite environment and later transfer to the
postnatal ward

Things to know when providing new born care

1. Adhere strictly to infection prevention standard during delivery and encure

cleanliness and at after delivery.
2. Keep the cord clean and dry
3. Avoid cold (neonatal hypothamia) by immediately drying and covering the baby
and do not bath the baby until 24hours after the birth of the baby
4. Keep the mother and the baby together ( for effective bonding or skin to skin
/kangaroo contact)
5. Administer prophylactic eye care to prevent eye infection
6. Encourage early breastfeeding and exclusive breastfeeding for about 6 month
7. Detect the following danger sign in the new born: - breathing difficulties, or not
breathing at all, yellowness of the skin / eye (Jaundice) convulsions, hypothermia
(cold) fever / chills, inability to suck (poor sucking), inactive or rigid neonat,
diarhoea or constipation, redness or pulse from the umblical cord, red, swollen
eye with purulent discharge and treat or refer for treatment.
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 8. Educate staff and community on the danger signs for new borns.
9. Refer complicated childhood illnesses

4.7 GENDER ISSUES

The term gender is used to describe the various characteristic assigned to women and men
by a given society.
4.7.1 Definitions of sex
 Sex is defined as the state of being male or female. Itis biologically determined.
 Sex is the biological differences/characteristics between individual that made them
male or female. It also refers to sexual activity, including sexual intercourse.
 Sex is the biological definition of who we ate as male or as female. At birth, boys are
identified by the presence of penis and girls by the vulva.
 People are born male and female but learnt to be boys and girls who develop into
men and women. They are taught what the appropriate behaviour roles and activities
for them and how they should relate to other people. These learned behaviour is
what makes up gender and determine gender roles. Sex and its associated functions
are programmed genetically.
4.7.2 Definitions of Gender
Gender refers to the socially constituted roles and responsibilities of women and men
within a given culture or location.
 Gender refers to roles, attitudes and behaviours and values ascribed by the society to
males and females. This learned behaviour is what makes up gender and determines
gender roles.
 Gender describes the characteristics of men and women which are socially
constructed in contrast to those characteristics which are biologically determined.
While the terms for gender are masculine and feminine (man and woman) people are
born male and female but learnt to be boys and girls who develop into men and
women. They are taught what the appropriate behaviour and attitudes, roles and
activities for them and how they should relate to other people.
 Gender is how an individual or society defines 'females' or 'male'
4.7.3 Differences Between Sex and Gender
 Sex (male/female) is biologically determined while gender (Man or woman) I

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 socially and culturally constructed, learned and transmitted during the process of
socialization.
 Sex is universal while gender differs within / between cultures.
 Sex is permanent. Gender is dynamic and it changesover time, it is influenced by a
wide range of socio-economic factors.
 Sex and its associated biological functions are programmed genetically while
gender and power relating are learned, changeable over time and have wide
variations within and between cultures. Gender attitudes and behaviours are learnt
and can change. It determines how individual act as men and women, our dressing,
values beliefs etc.
 Gender identity of who we are as man or as woman differs from culture to culture
some parts of Eastern and Southern Nigeria, this is not practicable in the north. Also
while Fulani men plait their hairs and wear earing’s this is not culturally practiced in
the Southern part ofNigeria.
 Gender determines to a large extent women's and men's differential access to
resources and power and these are related in the political, economic and social
structure of a society.
4.7.4 Sex and Gender roles

Sex roles
These are roles performed by males or females as a result of their biological attributes. Sex
roles is a function which a male or female assumes because ofthe basic physiological or
anatomical differences, It is biologically determined and is performed by only one of the
sexes e.g women give birth to children while men make women pregnant.
Gender roles:
Gender roles reflect the behaviours and relationships that societies believe are appropriate
for an individual based on her sex. These gender roles are learned, rather than inherent, and
vary from culture to culture-and from generation to generation. They are subject to changes
over a period of time by socio-economic, religion and political dictate of the society.
Gender roles refers to society's evaluation of behaviour as masculine or feminine e.g.
cooking is feminine while hunting is masculine in most societies. Gender roles includes
those responsibilities assigned to individuals on the basis of socially determined
characteristics such as ideologies, values, attitudes, beliefs and practices, for example,
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traditionally, women are assigned to organizing and support work while men are given high
status tasks, decision making and energy demanding jobs.
Gender roles are a powerful feature of social organizations, not only describing how man
and woman are expected to behave but also influencing power relations decision-making
authority and individual responsibility.
4.7.5 Gender stereotypes:
This term emerges from the confusion between sex roles and gender roles. IT is the rigidly
held and over simplified beliefs that males and females possess distinct physiological traits
and characteristics.
Gender stereotypes results when it is believed that gender roles are based on biological
differences rather than socially constructed expectation
Examples of sex and gender roles:
 Women are more emotional than men
 Men are more logical and rational than women
 It is more important for boys to go to school than for girls
 Men should not display their emotions
 The place for a woman is at home and (Kitchen) taking care of her children
 Men should make decisions in a family
 Women are not expected to express their sexual desires or talk about sex
Examples of sex and gender roles:
Sex roles:
Males:
 Produce sperm
 Impregnate women
Female:
 Produce ova
 Carry pregnancy
 Deliver babies
 Breast feed babies
Gender roles:
Male:
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  Hunt
 Provide for the family
 Do construction work
 Should always be in control and never show emotions.
 Must never take "No" for an answer from a sexual partner.
 Must be the head of the home and make decisions.
 Must never accept infertility as his fault as its never the man's fault to if a woman
fails to conceive.
 Can only determine the number of children.
 Must always have his way wherever he wants regardless of the woman's state of
health. Man must bear male children and never accepts that he is the determinant
of a male child.
Females:
 Fetch water.
 Cook food.
 Rare and care for the children.
 Must be emotional and must be very sensitive.
 Must always yield to partners sexual demand.
 Must be obedient to decisions taken by spouse.
 Must bear /accept responsibility for her infertility as a man cannot be infertile.
 Must have as many children as society/spouse demands regardless of her health.
 Must never complain about sexual harassment.
 Must accept responsibility fornot bearing a male child.
4.7.6 Gender Issues That Affect Reproductive Health
Discrimination: This is unequal or unfair treatment of females based on their sex (female)
rather than on their skills, talents and capabilities.
 Society expects women to 'give birth and rear the child irrespective of her fertility
status.
 Men are traditionally decision makers regarding the number of children a woman
should bear and whether or not she can use family planning methods.
 On the same note opinion of adolescent girls are generally not sought even on those
issues that affect them directly e.g time to marry, who to marry and when to have
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 children.
 Access to family planning can be difficult for a woman because of her restricted
mobility. Women are not expected to express themselves sexually.
 Economic needs sometimes force women into situations where their health can be
compromised e.g exchanging sex for money or promotion.
Education:
Girls do not have the same opportunities for education as boys do.
 Girls are withdrawn more frequently from school for economic reasons, early
marriage and other reasons than boys. Until recently certain school subjects such as
mathematics, physics, and chemistry were regarded as male subjects while social
sciences, home economics and language were considered female subjects.
 Male-Child preference: Male children are valued more than female children. Most
families prefer to have male children instead of females. This is the result of
Nigeria's patriarchal system which emphasizes the role of a male child in ensuring
that the family lineage is maintained many homes have broken because wives have
been boosted out of their matrimonial homes especially by fathers and mothers in-
law for not bearing male child or children. Male siblings are given more and better
opportunities than female siblings.
 Poorly paid / Unpaid jobs: More value is attached to the tasks men perform, and
they also get better pay for performing those tasks like cooking, child care, sweeping,
hawking and others assign? to girls/w0p1en.
Nutrition:
some cultures place taboos on foods that have high nutritional value for girls e.g. bush meat,
snails. Food sharing men and boys are given greater and better portion of food than women
or girls.
Politics:
Female participation in politics low because of the long history of their exclusion from
publicdecision making which is preserveexclusively for men. Women in politics are often
referred to as people of easy virtue.
4.7.8 Identifying Gaps In Gender Roles:
 Unequal or limited access to resources e.g women perform two-thirds (2/3rds) of
the world's work.
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  Where-as women earn 1/10 of the world's income.
 Discriminatory employment opportunities against women or lack of employment
opportunity.
 Poor educational status of the girl-child.
 Lack of or, in-effective girl child policy.
 Negative socialization process of the girl-child and the boy-child.
 Non-implementation of International/National instrument on women fundamental
rights including Reproductive health rights.
 Women are less fairly/favourably treated compared to men. Virtually, it includes all
issues ranging from right to life, inheritance, education, participation in decision
making, political structures of the society.
4.7.8 Gender Equality and Equity
Gender Equality:
This means equal treatment of women and men in laws and policies and inaccess to
resources and services within families, communities and society at large.
Gender Equity:
This means fairness and justice in the distribution of benefits andresponsibilities between
women and men, and often requires women specific projects and programmes to end
existing inequalities.
Gender In-Equality:
This is the law of nature that ensures that women have less control over their sexuality due
to poverty and patriarchal strong holds and restrictions in choices and decisions that affect
their lives. Advancing gender equality and equity the empowerment of women and ensuring
women's ability to control their own fertility are cornerstones of population and
development relatedprogrammes. (e.g ICPD programme of Action).
4.7.8 Steps in bridging the gap in gender roles:
1. Awareness creation for better understanding of how gender roles are socially dictated.
Knowledge of how these roles are performed by different genders in other societies,
cultures without any grave consequences.
2. Advocacy at various levels-national, state, local government, and communities to
policy makers, opinion leaders, legislators etc.
3. Linkages: With relevant sectors e.g health, education, women affairs, ministry of
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 justice, etc.
4. Lobbying the government to implement existing national and international
instruments on fundamental human and Reproductive rights.
5. Collaboration on networking with relevant Non-Governmental Organization(NGO)
6. IEC and Behavioural Change in Communication (BCC) involving community
mobilization and campaign.
7. Providers involvement: Providers should be sensitive to gender issues and sexual
concerns. They should be sensitive to gender and sexuality issues.
8. Provision of information that restores the self-esteem, self-confidence and dignity of
girls thereby making them feel of equal values to their male counterparts.
9. Appreciation of the contributions both sexes make with and outside the home, valuing
same in terms of paid labour or services
10. Encouraging education for girls-up to tertiary level
11. Campaign against those practices that support any form of gender discrimination
because culture is dynamic hence gender roles and responsibilities of men and
women should be socially constructed and maintained within a given culture.
12. Focus on gender based determinants of health.
4.7.9 Ways of Promoting Gender Issues In The Community:
 Conduct present assessment in the community especially those relating to gender.
 Collect and analyze information on women's health programmes.
 Focus on innovative interventions to promote women's health and well being.
 Promote women's equal rights to information and services.
 Promote equal Reproductive rights.
 Eliminate discrimination against girls and women in areas of access to food,
education and health services.
 Enact policy that will reduce minimum age of consent to marriage.
 Establish Youth-Friendly Health Services.
 Design programmes to meet older women's needs.
 Form technical support group that will constantly liaise with local government
area, development committees, men, women associations, age grades, religious
organization on status and actions taken on gender issues such as: violence against
women, girl-child education, female genital mutilation, men's health S'I'Is,
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 HIV/AIDs etc.
 Advocate stoppage of early child/teenage pregnancy
 Emphasize male involvement in gender issues
 Advocate equal opportunity to all (male and female) on (man and women) through
information, education and communication systems that are understandable by the
people of the community Inform and educate women on their rights
 Counsel key members of the community, In-Laws e.t.c. On gender issues such as'
female genital mutilation, nutrition, adolescent lifestyle education, men's health
STIs, HIV / AIDs, menopause and andropause

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 UNIT V: LIVE SAVING SKILLS
5.0 MATERNAL MORTALITY

INTRODUCTION:
Maternal mortality is the most extreme consequence of poor maternal health complications of
pregnancy and childbirth and are the leading cause of disability and death among women between
the ages of 15-49 years.
Definition Maternal Mortality: This is the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related
to, or made worse by the pregnancy or its managements WHO, ( 1996).
Global trends in maternal mortality: Maternal mortality is among the health indicators that
reflects the greatest disparity between rich and poor. Maternal health remains a regional and global
scandal, with the odds that a sub-Saharan African woman will die from complications of pregnancy
and childbirth during her life time at 1: 16 compared to 1:3,800 in the developed world. The
UNMDG report 2007 implies that in developed countries, maternal deaths are rare. It is noted that
the average lifetime risk for a woman dying of pregnancy related causes is between 1 in 4,000 and
10.000 whereas in developing countries, maternal death rates are 200 times higher.
The average risk is between 1:15 and 1:20. Maternal mortality is among the health indicators that
reflect the greatest disparity between rich and poor. Poor Reproductive health is a neglected
tragedy because those who suffer it are neglected people, poor un-influential, powerless, un-
educated, rural percent and above all women who die needless deaths through pregnancy and
childbirth processes.
It is estimated that for every woman that dies more than 25 others have a debilitating injury, often
with life long consequences and 16 cases of maternal illness was also documented following
childbirth.
5.1 INTERPERSONAL COMMUNICATION (IPC)
Introduction:
Most of the reasons why most patients/clients do not attend health facilities is the poor
treatment received from the health care providers. Therefore there is need to adopt the inter-
personal communication skills to improve the damaged image of health care providers and
encourage clients to make use of health facilities.
Definition:

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 Inter-personal communication is person to person, face to face, verbal and non-verbal
exchange of information, ideas, feelings through a loud audible means (voices) between
individuals more people or small group.
The use of all communication skills: using 'Acronyms' CLEAR and ROLES
CLEAR is used for verbal communication.
C Clarify.
L Listen.
E Encourage.
A Acknowled
R Repeat/
ge.
ROLES is used for non-verbal communication.
R Relax
O Open up.
L Lean forward (lean towards client).
E Eye contact.
S Sit squarely and smile (where applicable).
5.1.2 PROCESS OF INTERPERSONAL COMMUNICATION IN CI,-INIC MANAGEMENT:
Health care providers interact with clients/patients at various levels of clinical management, within or
outside a healthy facility and for a number of reasons. For example, for routine nursing care
e.g. antenatal care, family planning clinic, counseling services, community outreach
services, youth -friendly health clinics and for community mobilization. At whatever level
one interacts with one's clients, one should employ the following interpersonal
communication skills and demonstrate qualities of a good health care provider as follows:
1. Establish rapport:
 Welcome and greet the patient with a smile.
 Offer him/her a seat.
 Introduce yourself.
 Call client/patient by name.
 Ensure privacy and assure confidentiality (especially interaction for counseling
purpose).
2. Employ good listening skills:
 Listen to what the client has to say with minimal interruption
 Concentrate on the client
 Make/maintain eye contact
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  Sit squarely or maintain a comfortable distance between you and client/patient
 Relax and lean a little forward
 Show responses which show interest e.g. How? When? You mean it? etc.
 Use encouraging statements such as yes, go on, I'm listening, I see! and head
nodding.
 Do not seem to be in a hurry e.g. looking at your watch or telling the client you have
an appointment or you have closed to new comers.
3. Use simple language that is understood by the client:
 Start with simple questions,
 Use this acronym to remember - "KISS",
K eep
I t
S imple and
S ensible
4. Ask open-ended questions:
These are questions, which elicit more responses. They demand thought and expression of
feelings and concerns, they also provide the health professional with adequate information
(if properly used) to assess the client's needs for making appropriate intervention e.g,
 Would you like to tell me how you feel about this pregnancy?
 Would you tell me the type of food you take everyday?
5.1.3 EFFECTIVE COMMUNICATION PROCESS
(I) Effective non-verbal communication process:
People often communicate their thoughts and feelings without speaking a word. The
health care provider's physical posture, facial expressions and gestures express his/her
thoughts and feelings as much as his/her words do.
Certain types of non-verbal communication, or "body language," encourage open
communication and facilitate learning. Types of non-verbal communication that health
providers can use to facilitate client's /patient's interest or compliance include:
 Maintaining appropriate eye contact with client/patient
 Showing interest in what is being said, for example, by nodding head or smiling
 Standing in front of clients/patients without placing any barriers, such as desk or
podium, between themselves and clients/patients.
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  Standing in relaxed, yet confident postures
 Demonstrating enthusiasm about health education talk by moving round and
gesturing
 Avoiding distracting movements, such as tapping their feet, pacing back and front.
Effective health care provider will also pay attention to the non-verbal communication of
their clients/patients. For example, a person's body language may indicate that they are
uncomfortable discussing a certain topic or is bored or distracted during the period of
counseling and health talk.
(ii) Effective verbal communication process:
The style and tone with which someone delivers and elicits information can
communicate as much to the listener as the words that are being spoken. A provider's
verbal communication style should capture the interest of clients/patients, as well as
convey the provider's interest in what clients/patients have to contribute to the
conversation. They can help client to maintain interest by:
 Varying the pitch, tone and volume of their voices, as well as by speaking clearly.
 Encouraging questions and letting clients answer each other's questions in a clinic
talk.
 Emphasizing important points by speaking slowly and summarizing at the end of
important point.
 Avoiding the repetition of phrases, such as, "Do you understand? Or "Is that clear?
 Making smooth transitions from one point to another and making connections
between various point, whenever possible.
 Giving clear directions so that clients are not confused about what is expected of
them; posting written directions in a visible place, whenever/wherever possible in the
clinic.
 Using language that is easily understood and is culturally acceptable to the clients. 5.
Clarify client's statements to avoid mis-interpretation by:
(i) Paraphrasing:
Paraphrasing or restating what someone has said to you, is an effective way to make sure
that you and the speaker understand each other. It also shows that you make sure that you
are listening carefully to what is being said. If you have understood, providers have an
opportunity to clarify the point they were trying to communicate.
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Example of paraphrasing:
Provider: What I hear you saying is that, you're not getting the support you need from the
health ministry to make these changes, is this correct?
Praise and encouragement:
Praise - gives clients approval
Encouragement - Gives confidence to succeed in something.
Praise and encouragement are more effective in helping a client acknowledge and solve
problems than scolding.
5.1.4 Areas where IPC is required in health activities:
1. Community outreaches/needs assessment e.g. in the clinic santnatal, postnatal, baby
welfare and family planning clinics, out-patient department, pharmacy,
2. Health education talks, counseling and other information giving in health facilities
3. In advocacy efforts for motivation/promotion of Reproductive Health issues e.g.
male involvement in prevention of Sexually Transmitted Infections (STIs)
4. Counseling in private homes/clinics.
5. Meetings and discussion groups on Reproductive Health issues.
5.1.4 APPLICATION OF IPC IN CLINICAL MANAGEMENT
 Welcome client warmly.
 Be friendly e.g., greet client/patient, shake hands (if appropriate) with a smile.
 Ask about family's welfare.
 Offer him/her a seat.
 Introduce yourself.
 Call him/her name or address client by title e.g Chief, Doctor etc.
 Provide privacy and assure confidentiality (especially if visit is for counseling e.g.
HIV voluntary counseling).
 Mind your non-verbal responses while interacting with clients.
 Plan and arrange schedules to avoid tensions.
 Answer their questions satisfactorily.
 Exhibit positive non-verbal cues.
 Ask simple open-ended questions e.g. would you like to tell me how you feel?
 Praise him/her for coming to the clinic.
 Listen attentively to what the client has to say.
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  Do not distract client's action/act.
 Do not interrupt client while talking.
 Do not permit interruption by others.
 Do not put words in client's/patient's mouth.
 Make/maintain eye contact.
 Sit squarely and maintain a comfortable distance from the client/patient.
 Relax and lean a little forward.
 Use simple language.
 Take time to listen.
 Do not be in a hurry to dispose your client/patient (e.g. looking at your watch)
answer if they ask questions repeatedly.
 Allow client to finish his/her thoughts
 Do not discuss other clients
 Use encouraging statements such as really, I see, yes, go on with head nodding etc.
 Paraphrase and summarize.
 Praise and encourage client/patient.
 Reflect and acknowledge client's/patient's responses.
5.1.5 BEHAVIOURAL CHANGE IN COMMUNICATION (BCC)
Definition of behavioural change:
This is the process of educating, persuading and disseminating information to people, to
positively influence their behavioural patterns about a particular (health) issue.
Behavioural change model
Individuals go through a series of steps or "stages" before a particular behaviour change becomes on
going or permanent. The health provider is to intervene in specific ways during each of the stages in
an effort to help the client’s progress from stage to stage.
Stages of behavioural change:
There are five stages of behavioural change and they are as follows:
Stage I: Pre- Contemplation:
Client does not perceive the risk and has 110 intention of changing behaviour e.g having
multiple sexual partners. He/she is unaware that a given problem exists, or on some level, or client
may know that there is a problem, but deny that the potential consequences are as serious as they
appear. He/she may also understand that the behaviour is risky, Finally, client may be aware of
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the risk, but still decided not to change his/her behaviour. Behaviour change does not happen
during this stage. Client is usually not open to heading suggestions about resolving the problem
during this stage because they do not believe it is relevant.
Health provider's Intervention-
Try to help client sec that he/she is at risk, or susceptible. e.g A 3D year old woman who has
multiple sexual partners and does not use female condom and does not see her risks for HIV
and other STIs, the provision of statistics of HI V I AIDs victims, could be provided on
brochures, leaflets etc for women of her age, who live in her community.
 Do not push a client to see what may be obvious to you but provide as much information
as you can and let client discover the risk involved in his/her action.
Stage 2: Contemptation.- There are some risks but still not ready to make change.
Health provider's Intervention
 Continue the interventions from the previous stage
 Continue to try to show client that he/she is susceptible.
 If this is feasible, having her speak with other people again with a similar backgr-ound to hers,
who have contracted HIV or other S'TIs, or experienced an un-intended pregnancy by
engaging in similar behaviours.
 Letting the client evaluate the potential consequences (both positive and negative) of
changing her behavior through awareness building and value classification exercises e.g.
talking through her feelings, if possible with a trusted friend
 Positively reinforce any steps the client makes and encourage her to continue
talking with a trusted friend.
 Do not pressurize client, counsellor is to support clients to come to their own
conclusions and decisions.
 When client realizes that there is a problem, he/she may consider changing and
if encouraged the more, client may totally give up.
Stage III: Preparation:
Determination : When client understands risk, he/she is motivated, decides and agrees
to make a change through the following:
 Takes steps that will help her to make a change
 Experiments by making smaller changes leading to longer or n:ore long lasting
ones
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  Relapse is possible here.
Health provider's intervention: Continue with the previous stage intervention.
Whenever possible, continue to provide "real life" opportunities for client to speak with
people who will help him/her to see the susceptibility and the potential benefits of
changing this behaviour.
 Help client develop a plan that identifies and limits obstacles to changing
behaviour, that will not make a given situation worse, and that they believe will
work.
 Let client continue to reflect on her values and commitment to implementation
of her plans.
 Do not be critical towards any relapses, but encourage client to continue to do
what he/she was able to do before.
 Again, don't pressurize. Pressure from counselors will make client to be
overwhelmed and relapse to a previous stage.
Stage 4 Action
 Client has changed the behaviour and is continuing to do so for at least a short period
of time
 Relapse is possible
Health provider intervention
 Provide as much positive reinforcement to the client as possible e.g. include
interventions from previous stages, such as provision of current up- to-date
information about the risk behaviour, making reference to support groups, and/or
facilitating on-going contact with the individuals who helped her to see her
susceptibility at an earlier age.
 Praise progress, and help client identify and develop support for keeping up the new
behaviuor
 Be patient when relapse occurs.
 Remind her of her previous successes and that change is possible
 Encourage her to continue trying.
Stage 5 Maintenance:
 Change in behaviour is ongoing; and has become part of her life
 Relapse is possible
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  Intervention: Provide as much reinforcement to the client as possible
 Help client recognize the "triggers" (cause or contribution fact) to relapse and practice
skill to help, him/her resist a return to former behaviour.
 If possible and appropriate, suggest follow-up visits to check clients progress and
provide any additional support that may be needed by them.
 Be patient when relapse occurs. Remind her of her previous successes, and encourage
her that change is possible. Encourage her to continue trying.
Note: Relapse or recycle may occur and the client starts all over from stage 1, Health
provider should not relent in persuading and ensuing that change is maintained.
Medium (channels) for behavioural change in communication include the following:
 Health talk, role-play, Focus Group Discussion (FGD), playlette. jingles, film show
entertainment, long 'running serialized dramas on television, radio, short drama,
demonstration/return demonstration, situation analysis, games e.g "Pathway to
Change" game, statistical reports etc.
Visual-Aids for behavioural change in communication:
 Audio
 Real object e.g an AIDs patient
 Wall charts e.g "pathway to change" charts
 Pamphlets/handbills
 Overhead projector
 Cue cards
 Illustrative models
 Radio/television
 Photographist e.g of victims )
 Radio, Television, dekstop computers, Laptop
Steps for behavioural change in communication:
1. Preparation:
 Select appropriate date
 Choose a quiet environment to ensure privacy (for individual or couple) e.g
corner of the clinic or private room
 Prepare seating arrangement, recognize group or community leaders e.g
male/female, group or community leaders
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  Gather visual/aids that are relevant to the culture ofthe area or person.
2. Introduction:
Greet client, introduce self and encourage client or group to introduce self/selves.
Explain the process: Use simple language
Allow client to speak first
3. Motivational information: Discuss the health benefits of the consequences of topic
to be discussed e.g family
planning, multiple sex-partner, risky sexual behaviour, cultism, alcoholism etc.
Issues for behavioural change:
 Reproductive health issues.
 General behaviour of people.
 Government policies on health and others.
 Government issues e.g policy making, budgeting.
5.1.6 INTERVENTION ACTIVITIES FOR BEHAVIOURAL CHANGE E.G
STIS / HIV/AIDS CLIENTS/PATIENTS
 Example: Modeling And Reinforcement to Combat HIV (MARCH)
 Along-running serial drama on HN / AIDs.
Explain the process:
 Allow client to speak first.
 Assure client of confidentiality of informations.
 Allow client to say all about his/her Reproductive health concern that brought her to the
clinic/health centre or motivational centre
 Explain the key issues in the Reproductive health issues complained of e.g observed cancer
 Apply interactions according to the stages of behavioural change.
Other categories of people that need to change behaviour:
 Individuals, families, countries
 Public, private, workers (with particular reference to health workers) market women and
men, bankers, contractors, business men and women, educationist, policy makers and
leaders in government.
Expected areas/issues for behavioural changes:
 Morals, socials, health, policies, politicking, finance/budgeting, administration.
Strategies for behavioural change:
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 1. Entertainment through Modeling And Reinforcement to Combat HIV (MARC I-I) strategy.
This is a long running serialized drama on radio, or print i.e entertainment through this
medium.
2. Community-based activities and small-group reinforcement activities e.g serial group
listening discussion activities.
3. Use of "Pathway to change" game and chart
4. Use of mass media e.g Radio and television information, education and propaganda on
behavioural change.
5.2 COMMUNITY OUTREACH
Definition of community outreach
This is a way of conducting a community visit by health worker to assess their needs and providing
possible approaches to provide partnership for the care of their members.
5.2.1 Major clients for community outreach:
(i) Women: Starting from the very young to old age. These include women who were brought in with
serious complications of abortion, labour and delivery e.g sepsis/ infection, bleeding/anaemia or those
who lack confidence or unfamiliar with health care system, high parity e.t.c.
(ii) Men: with Reproductive Health problems e.g sexual dysfunction.
(iii) Poor/ Paupers.
(iv) Literate or Illiterate.
(v) Unemployed.
(vi) Traders etc.
(vii) Individual clients who have major influences in the community.
(viii) Children e.g newborns, toddlers and school age.
5.2.2 Ways of influencing the client:
In most communities in Nigeria, husbands and older relatives have a lot of say in how affairs
relating to women and children are conducted.
Husbands especially decide how to spend family income and what the priorities are. Others are
the chief opinion leaders of the community who wield power and influences, which might
determine the behaviour of individuals. They set unwritten codes and patterns for others to
copy/follow.
5.2.3 Reasons for community outreach:
The community is where we find the clients we are trying to help and who come to use our clinics

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in their own natural situation and environment.
 It is also where all the people and things that influence their health reside. We must
therefore, see our clients as part of a whole community.
 To understand provider's concerns and constraints and to form a picture of barriers,
motivator and enablers that play a part in client's choices providers must first understand the
community in which she lives.
 The distances or barriers that separate women from care are causes of maternal mortality,
Midwives need to move into their Into their client's communities to learn how they
might assist people there to find solution to their immediate needs and concern.
 It is time to "bridge the gap" that separates the care givers in the community such as
TBAs and their counter parts, in the formal health sector (Midwives).
 Without community participation, the midwife's Clinic- Based- Safe Motherhood
Initiative will not impact on the current mortality ratio.
 To assess people with special skills e.g. leaders, storytellers, artists, performers,
teachers, TBAs leaders etc.
 To assess natural resources e.g. Land, water, crops.
 Infrastructure e.g. buildings, roads, materials, transportation, communication.
 Availability of work, earnings, cost of living, existing health facilities etc.
5.2.3 Process of community outreach:
 Visit and talk with village leaders e.g. the chiefs, village head, school teacher, TBAs,
Priests/Imams.
 Talk to members of the community.
 Observe customs and routine of the community, the clothes they wear, the things
they talk about, what they eat, numbers of children, the living condition, the radio
programmes they listen to, etc.
 Hold meetings with local women to introduce yourself and purpose of your visit.
 Ask for what they consider their most pressing individual problem and ask them to
arrange these in order of priority.
 Ask how you might help them.
5.2.4 Reasons for community assessment:
 To understand community attitudes, beliefs and taboos pertinent to child-bearing and
to determine whether they are helpful, or harmful or irrelevant to health.
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  Through listening actively to the needs of the families and discussing problems, you
are able to determine priorities and undertake care, which will promote safe
motherhood.
 To become aware of community perceptions and informations, needs regarding
prevention of maternal mortality.
 To understand the community's strengths and weaknesses.
 To understand and learn from traditional care providers and to exchange ideas with
them.
 To understand the situation of women in the community and grow to appreciate their
difficulties of daily survival and what coping strategies they have adopted.
 To answer some pressing questions relating to maternal and child health that need to
be addressed
 Identify what is in this community, regarding its practices, resources and
understanding that will enable women to achieve safe motherhood i.e. healthy
pregnancy and delivery with a positive outcome.
Detect what is in this community that prevents women from achieving safe
motherhood.
Identify the cause incase it is observed that large numbers of women come in with
stillbirth from a particular geographical area.
5.2.5 STEPS NECESSARY FOR PLANNING AND CONDUCTlNG A COMMUNITY
OUTREACH.
1. Steps in planning community outreach:

 Ask yourself why you are going into the community?

 Identify what you want to know and want to achieve by this visit.

 Identify the community (may be one with the greatest need).

 Learn as much as you can about the community.

 Determine what information already exists.
 Review, assess and analyze the existing information (e.g available statistics from clinics
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 particularly maternal and neonatal morbidity and mortality).
 Determine who in the community you need to approach to gain access?
 Plan the visit. Inform your hosts about dates.
 Make sure the date and time are convenient and request that the people you wish to meet are
informed of your visit.
 use interpersonal Communication Skills to become introduced to the people. Talk to the people
and get to know and understand them who can introduce you. The village headman or the TBA?
 Get their interest and acceptance by letting them define their own needs and priorities.
 Use problem solving steps to assist them in finding solutions.
 Plan ways of getting information from the community and these include: (1) Survey
(2) Questionaire (3) Private Interviews (4) Observation Checklist.
2. Steps in conducting community outreach:
There are no set rules 'or approach to going into community. Approaches to visiting community
and getting accepted will depend on the community i.e its past experiences, present, the culture
and their perception of the visitors.
The visitors must use good interpersonal communication skills and show respect, genuine interest
and concern in order to penetrate into the community.
However, the following steps may be taken.
Example: A schedule of visit to the village head or home visit to a pregnant woman.
1. Greet and exchange greetings in the locally accepted way.
2. Introduce yourself
3 Ask the head of tile family to introduce the family members.
4. Tell them the purpose of the visit
5. Ask the people about themselves if in a home visit, ask them wether there is anyone pregnant
and if so, ask how many weeks. Ask if she has attended antenatal clinic, if she has changed her
diet and work/chores. Tell about services available at the PHC and to go there if she has any
problems. Plan another visit in two weeks.
6. Maintain good relationship with the people and the families.

7. Detect the problems affecting the people, family or mother and baby (if a nursing mother is
present).

Steps for investigating observed problems (e.g Incidence of stillbirth):

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 Find out from delivery registry, local TBAs or traditional healers who are mothers of stillborn
and where they lives

 Talk to TBA, other health providers who attendee to the women during antenatal, labour Or
delivery or others who attended to the mothers, what they noticed, and the state or condition of
mother and foetus at time of delivery

 Ask about anormalies observed during pregnancy e.g. contracted pelvis, anaemia, PIH etc.

 Focus on the TBAs how they attend to complications in pregnancy, labour and after delivery.

 TBA's referral system if there is any?

 Their perceptions of why stillbirths occur.

 Eating habits.
 Work habits during pregnancy.
 Illnesses during pregnancy particularly malaria, PIH, anaemia, problems during labour e.g.
abnormal bleeding
 Water supply and sanitation e.g. changes in water supplies and waste disposals.
5.2.6 PROCESS OF GETTING INFORMATION FROM THE PEOPLE
 The simplest and most informed way is to talk to them and observe them
 Organized ways to elicit information include:
 Survey, questionnaires.
 Focus Group Discussions (FGDs).
 Private interviews.
 Observation Check-list. Whichever the health worker e.g midwife wants to use to gather as
much useful information as possible will depend on what she wishes to find out from the
community.
Things to find out on a visit:
 Nutrition and health: Focusing on women's health, e.g. Nutrition and their problems
during pregnancy, these are some of the things the midwife would want to know about
the village she wishes to visit or what she wants to find once she gets there.
Needs:
 Current local health practices, problems and their direct causes particularly as these relate to
women's health.
 Contributory factors to the well-being of pregnant women.
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  What people feel to be their biggest problems and needs (whether health related or
otherwise).
 Level of knowledge on the topic.
Social factors:
 Traditions, customs and practices that affect women's health.
 Traditional form of healing.
 Community relations and dynamics; how do people relate to each other.
 Traditional form of education and communication.
 Leadership structure.
 Economic status of majority.
 Resources
 Major information sources: Radio, Television, newspaper, traditional media - town criers
 Health infrastructure, look at the access to and use of it.
5.3.0 PROBLEM SOLVING METHODS

This is a tool for systematic assessment of clients with a view to identifying their needs or
problems and taking appropriate actions.
 It is a way of thinking about the care and the steps to follow in giving a care.
 It is a step-by- step way of finding and taking care of problems. Ithelps the health
worker to work in an organized and thorough way; by getting and carefully
organizing information, the health provider can better identify the problem(s) that the
woman/patient has, then plan and provide the care.
 To provide care in an organized way, the health care provider! midwife and anyone
else who is caring for women/patient can use the problem solving method.
5.3.2 STEPS IN PROBLEM SOLVING METHOD
There are four (4) steps as follow:
1. Ask and Listen
2. Look And Feel
3. Identify The Problem/Needs
4. Take Appropriate Action.

1. Ask and Listen: This is done through history taking to identify possible related
problems such as anemia and Pregnancy Induced Hypertension (PIH)
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 2. Look and Feel: Through observations and clinical examinations.
3. Identify problems: For example, look for problems requiring additional care e.g
signs of malnutrition, general appearance, colour of skin, goi tel', infection, dysuria,
temperature, pre-eclampsia, blood pressure, oedema, proteinuria, reflexes, anaemia,
haemoglobin,conjuctiva/palms or tongue palour etc.
4. Take appropriate action :Provide appropriate health promotion and counseling and
give treatment(s) e.g in the areas of nutrition and micro-nutrients, rest and avoidance
heavy physical work.
5.3.3 APPLICATION OF PROBLEM SOLVING METHOD (PSM) IN MATERNITY
CARE
Awoman going to the midwife for the first time may not yet have an emergency but
have problem(s).
The problem solving method can be applied by the nurse/midwife taking specific
steps to find whatiswrong witha mother and to decide how best to care for her.
STEP l: Ask And Listen:
This is the initial step that must be taken when seeing a woman.
 Welcome her and make her comfortable to provide aconducive atmosphere fortalk.
 Provide a private area for talk; commend her for coming to the clinic/hospital.
 Ask relevant questions in a kind and interested way.
 Ask her the reason she came to see you.
 Listen carefully to all herresponses.
 Admit her response as important and helpful in finding out the problems and possible
solutions.
 Don't fright ten or discourage her with your actions.
 Note the important points in order to remember her answers.
Example: Take medical history in a way that allows you to identify possible
problems, particularly anaemia and Pregnancy Induced Hypertension (PIH) (pre-
eclampsia).
 Admit a woman in labour and take the history oflabour to find out her experiences
since the labour started.
 Ask the following questions and listen:
 When did your labour pain began?
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  Have you been examined at an antenatal clinic?
 Take her complete antenatal history, her past pregnancies, any medical problems she
may have had.
 Ask ifher bag of water (membranes) have ruptured (broken).
 Whether she had a discharge or bloody mucus (show)?
 Ask other questions relating to her feeding, previous pregnancies, deliveries and
expectations in this present pregnancy and delively.
STEP 2: Look And feel
Examine the areas of the woman's 'relate to the information already learnt in step One -
"ASK AND LISTEN" Example, if a woman complains of dizziness, you would want to
examine her conjunctiva, check her neck for raised jugular vein and other signs of anaemia.
Or a woman at booking for antenatal care, being her first time visit; this will enable you to
detect any other problems the woman herself has Dot detected or recognized.
STEP 3: Identify The Problem/Needs
Based on the information collected from the first two steps, identify their problems. Identify
her other needs beside the ones that caused her ttl come to you; for example, she may need
information on good nutrition, in pregnancy, how to relive constipation or haemorrhoid
pain, how to receive immunization for her children or family planning information.
STEP 4: Take Appropriate Action
Highlight the problems and take action in order of priority. Example, medical treatment will
be needed first for a woman who has a retained placenta and is bleeding heavily, the
bleeding must be stopped byconducting a manual removal of the placenta before laboratory
tests can be done. More treatments, counseling, education or referral can later be done.

For medical treatments, follow standards and protocols of practice when taking care of the
problem.with treatments or medicines. Give all medicines with caution during pregnancy.
Other examples include:
 Education: The woman should be helped to learn the information she must know to
take proper care of herself
 Counseling: Help the woman to understand the problems and work with her to
develop ways to deal with them. For medical treatment; follow standards and
protocols of practice when taking careof the problem 'With treatment or medicines.
Give all medicines with caution during pregnancy.
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  Laboratory tests /Investigations: Collect more information about the problem(s)
 Referrals: Other resources available in the area, such as doctors, women groups,
charity groups, hospital and education programmes must be used to help her solve
problems.
Plan for follow-up: Return visit is important. Explain why 'she needs to return. The
time she should return will depend on the duration of improvement, this maybe 24
hours, 3 days, 2weeks or later appointments. She should be seen frequently until she is-
out of danger incase of a serious complication from the problem.
Recordings: When the recordings are good and complete the care is usually good and
complete. Therefore, all symptoms, problems, counseling needs, physical examination,
laboratory information, treatments given and date to return for care should be clearly
and carefully written in her record,
Repeat the process as necessary: Remember to check whether the problem(s) is
solved, that is if itremains the same or getting worse when the woman returns. She
might need a different medication or treatment or even be referred to a hospital /
doctor give a clear report on the woman. Record your actions to give a clean report
on the woman. This will help other providers give continued quality care.
5.3.4 PROBLEMS AND PEOPLES' RESPONSIBIILITIES TOWARDS THEM
 Encourage people to change their habits and ways of living and health practices that
are detrimental to health e.g. smoking.
 Encourage people to judiciously and adequately use health services provided for
them.
 Encourage people to undertake various practical self help programmes and measures.
to improve their own health status.
 Encourage people to make their own choices and decisions about health matters after
providing them with learning experiences which influences
 Bring together appropriate personnel e.g. health education and communication to
guide People into action that helps maintain healthy life-styles and practices.
5.3.5 EIGHT PROBLEM SOLVING APPROACHES INNURSING
 Trial and Error:
 It is the oldest method of solving problems
 It is the problem solving method 'whereby an individual is faced with a problem, and
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 tries a number of approaches until a solution is found.
 If the first approach fails, the person tries another and it's effect evaluated.
This process is continuous until a satisfactory solution is attained
 Trial and error method cannot be relied upon because it is not scientific based.
 Authority/Experience:
This is born out of trial and error method
 It is by virtue of success, age experience or some combination of these; some people
become known and an: accepted as authority in certain problem areas. Thus, when
people are faced with a similar problem they simply apply the same approaches used
by the so called authority.
 Like in trial and error method, authority is used in pre-literate society because there
was no written record. This approach has no scientific base:
 Common Sense:
 This involves the use of common knowledge about a particular situation to solve
problems.
 In common sense, facts gathering method is superficial It is used in rapidly changing
society. It can be dangerous.
 intuition/Empirical evidence:
 This is the understanding or learning of things without the conscious use of
reasoning.
 it is also known as the sixth sense, instinct, feeling or suspicion.
 It is viewed by some as a form of guessing and as such itis an inappropriate basis
for nursing decisions.
 Reference to Precedence:
 This approach lacks scientific base and it cannot be predicted. In precedence, people
who are faced with a problem refer to what others have tried. They achieve some
results based on chance sometimes:
 Problem Solving:
 It could be used to solve quite a number of problems in nursing practice. The
steps involved include:
i. Recognising the problem by asking and listening
ii. Looking and feeling in order to identify the problem .
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iii. State the problem.
iv. Investigate the problem e.g, collect data for the purpose of investigating the problem.
Find possible solution derived from your data.
v. Take appropriate action/formulate alternatives.
 Nursing Process;
 It is the systematic collection and validation of data:
 Its purpose is to identify clients' health care status and actual or potential health
problems.
 Nursing process is cyclical that is, its components follow logical sequence i.e.
Assessment, Diagnosis, Planning, Implementation and Evaluation.
 Research process;
The research process has series of activities a researcher undertakes while conducting a
research in order to find solution to an existing problem. It is a scientific method of finding
solutions to an existing problem.
5.4 FOCUSED ANTENATALCARE
Definitions of Focused Antenatal Care:
Focused ANC is all approach to antenatal care that emphasizes evidenced-based, goal
directed-actions, and family-centred care, quality rather than quantity, of visits and care by
skilled providers.
 This is a qualitative care given to a pregnant woman by a skilled or trained health
provider to promote the health and survival of mother and child.
 Focused antenatal care refers to minimum number of 4 antenatal clinic visits, each of
which has specific items of client assessment, education and care to ensure the
prevention of, or early detection and prompt management of complications.
5.4.1 Reasons for Focused Antenatal Care:
1. All pregnant women are at risk of developing Complications
2. More attention are given to individuals in the “high risk” group but the "risk"
approach to ANG is no longer considered effective in detecting which woman will
have problems especially in pregnancy and labour. An "At Risk Pregnancy" is the
pregnancy with exciting conditions that may complicate the pregnancy and may lead
to permanent disabilities or death.
3. Many pregnant women ill Nigeria have the following in common.
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 i. Do not appreciate the importance and benefits of ANC
ii. Attend ANC just to obtain a registration card in case of unexpected
emergency.
iii. Stay away from health facilities because of poor provider attitudes, unfriendly
policies e.g. compulsory blood donation for ANC services, inability to pay for
services, inaccessibility and non-availability of services and skilled attendant
4. ANC increases the likelihood that a skilled attendant will be present at birth.
(WHO/UNICEF 2004)
5. In many countries, ANC is the only time women contact the health care system.
Therefore, ANC is a unique platform for providing a variety of health services
Overal Goal: To ensure good outcome of pregnancy, labour and puerperium Specific
goals:
1. Health promotion and education/counseling
2. Prevention of complications of pregnancy and child birth
3. Early detection and prompt management /treatment of existing complications and
problems
4. Skilled attendant at birth: Give care from skilled attendant and enhance continuity of
care.
5. Birth-preparedness and complication /emergency readiness
Advantages of focused antenatal care over traditional model of antenatal care
1. Focused ante natal care is disease detection and not risk assessment. Risk approach is
not an efficient or effective strategy for reduction of maternal mortality because "risk
factors cannot predict complications and usually are not direct causes of
complication. The risk approach is identified to be ineffective to predict who' will
develop a problem or complication. Ineffective approach also include Palpating fetal
position before 36 weeks gestation to detect malpresentation in labour /birth,
assessment of ankle oedema to screen for pre- eclampsia, measurement of maternal
height, and palpating foetal position before 36 weeks to detect malpresentation in
labour. Note: ‘Peripheral*oedema is evident in 80% of normal pregnancies. half of
which involve the lower extremities." (Cho and Atwood 2002) "Peripheral oedema is
defined as oedema ofthe feet, ankles, or hands
2. Focused antenatal care services gives evidence-based and goal-directed actions.
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 3. It addresses most prevalent health issues affecting women and newborns.
4. Adjusted for specific populations/regions
5. Appropriate to gestational age and based on firm rationale
6. Gives family centred care based on each woman's specific needs and concerns,
circumstances e.g socioeconomic, health profile, history, physical examination, and
testing from available resources.
7. The number of ANC visits are reduced without affecting outcome for mother or
baby.
8. It focused on content and quality rather than quantity (number) of visits. Traditional
antenatal care includes approximately 12 clinic visits whereas focused antenatal care
is only 4 visits.
9. It includes minimum of four visits i.e. visits reduced to four in all except if there is a
complication or complaints that warrants the visit.
10. Focused antenatal care is an entry points to other critical services.
11. Traditional ANC was developed in the early 1900s.lt emphasized the number and
frequency of visits.
12. Focused ANC is an entry point to other critical services e.g. Skilled Attendant at
Birth (SAB), Tetanus prevention, family planning, birth planning and complication
readiness, malaria prevention and treatment, STIs prevention and treatment, maternal
and infant nutrition, child health, PMTCT, TB detection and treatment, post abortion
care etc.

5.4.5 Components of focused antenatal care:

A. Health promotion, education and counseling as follows:

 Inform and educate the woman with health messages and counseling
appropriate to individual needs, concerns, circumstances, gestational age
and most prevalent health issues.

 Support the woman in making decisions and solving actual or anticipated

problems

 Involve partner and family iI1 supporting and adopting healthy practices.
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5.5.5 Health Education topics to be addressed are as follows:
1. Malaria control in pregnancy though the use of Intermittent Preventive Treatment
(IPT)
 Use of Insecticide Treated Nets (ITNs) and other methods' of environmental
sanitation practices to eliminate breeding sites for mosquitoes and personal
protection.
2. Diet and Nutrition: Advice on balanced diet.
 Prevention and treatment of anaemia.
3. Care of common discomforts
4. Use only prescribed drugs. Avoid use of potentially harmful substances (e.g
herbs, unprescribed drugs).
Advise on tobacco and cigarette smoking and effects of alcohol intake,
5. Infection prevention hygiene e.g. Hand washing before preparing food, eating,
drinking.
6. Hygiene personal and environmental e.g. Use safe drinking water, handle and store
food safely, practice good dental hygiene
7. Rest and activity- Tell clients to:
 Decrease the amount of heavy work and increase rest time.
 Avoid lying on back late in pregnancy to prevent decreased blood supply to
the placental site. Advise to lie on her side.
 Maintain good body posture and avoid overexertion.
 Sexual relations and safer sex
 Reassure clients that sexual intercourse will riot harm the foetus.
 Have sexual relationship with only one partner who is free from HIV and STIs
or practice abstinence if desirable For those at risk of STls and HIV, use
condoms correctly and consistently.
8. Emphasize/Stress the importance of delivery by skilled attendant
9. Birth/delivery preparedness
10. Early and exclusive breast feeding and immunization
11. HIV / AIDs prevention and care, and role of VCT and MTCT
12. Prevention of other endemic disease/deficiencies e.g. Hookworm infestation
13. Postpartum child spacing (family planning)
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 14. Postnatal care
15. Danger signs in pregnancy and during labour
B. Prevention of complications of pregnancy and childbirth
C. Early detection and treatment of existing complications and problems. These
include conditions such as:
1. Malaria history and physical examination for fever and accompanying signs and symptoms,
region where woman lives, whether complicated or uncomplicated,
2. Severe anaemia by physical examination and testing.
3. Pre-eclampsia through measurement of blood pressure.
4. HIV through voluntary counseling and testing, and prevention ofMTCT.
5. Sexual transmissible infections including Syphilis testing.
6. Screening for tuberculosis.
D. Care from skilled attendant and continuity of care:This should be provided by a trained
provider who:(i) Has formal training and experience, (ii) Has knowledge, skill and qualification
to deliver safe, effective maternal and newborn health care, (iii) May be a Midwife or a Doctor.
E. Birth Planning/Preparedness and Complication Readiness
The purpose is to develop birth plan, the exact plan for normal birth of the baby and
establishing a financial plan/scheme.To achieve this, arrangements are made in advance by
women and family (with help of a skilled provider). This is reviewed/revised at every visit.
Advantages of Birth Preparedness
 It ensures timely and appropriate care
 Choice for facility or place of birth: home or health facility for birth, appropriate site for
emergencies and how to get there.
Recognition of danger signs
Danger signs during pregnancy
 Vaginal bleeding
 Difficulty in breathing
 Fever
 Severe abdominal pain.
 Severe headache/blurred vision
 Convulsions/loss of consciousness
 Labour pains before 37 weeks
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  Fits or convulsions
 Loss of consciousness
 Severe headaches
 Blurred vision
 Swelling of the face, hands and legs
 Abdominal pains
 Fever and chills
 Severe vomiting
 Weakness, lethargy and breathlessness
 Decreased or absent fetal movement
 Dysuria and suprapubic pain
 Draining of liquor from vagina without labour
 Foul-smelling vaginal discharge
 Premature labour pains

5.5.6 ANAEMIA IN PREGNANCY

Anaemia is a common medical condition in which there is reduction below normal in the quality
and quantity' of the red blood cells (Haemoglobin below 10gm/dl/100mls)(less than 10g/dl) of
bloods resulting in the decreased oxygen carrying capacity of tile blood.
Anaemia results when there is inadequate production of, or excessive destruction of red blood
cells. Physiologic anaemia occurs in pregnancy when there is haemodilution i.e. increased
plasma volume (45%) and decreased erythrocyte volume (25%).
Prevalence in pregnancy - Up to 50% in developing countries.
Clinical features of anaemia
Symptoms Signs
Weakness/tiredness Pallor of'conjuctiva, gums. tongue, nail beds,

Dizziness and or palms and soles of the feet

Breathlessness on mild exertion Hepatomegaly

Spleenomegaly
Pedal oedema (Swelling oflegs)
Prominent neck vein (in severe anaemia)

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125
 DIAGNOSIS OF ANAEMlA
 Screening of patient for anaemia.
 Ask and listen: ask if she eats non-nutritive foods and not pica
 their pregnancy has been closely spaced,
 If she bruises easily
 If she had haemorrhage with any pregnancy
 Social and dietary history taking in Including date of last menstrual period
 Physical examination - examine the conjunctiva, tongue, lips, palms of the hands nail beds and soles
of the feet for pallor.
 Blood specimen is obtained for sickling cells, malaria parasite (MP) Haemoglobin if8 gms or below,
 Estimation of Packed Cell Volume (PCV) of blood
 Stool is examined for ova of worms and parasites especially for hookworm-Approximately 44
million Women are simultaneously pregnant and infected with hookworm. All estimated
three to 5million of these pregnant women harbour hookworm infections that adversely
influence intrauterine growth rates, prematurity, and birth weight, as well as anaemia and its
consequences. Hookworm causes loss of blood and, therefore, iron in the stools, resulting in
maternal anaemia.

Urine specimen for culture and sensitivity.

Chest X Ray to rule out pulmonary tuberculosis especially in unbooked patients.
In severe anaemia, observe for signs of heart failure such as breathlessness (very marked
dyspnoea), cough, oedema of ankles, enlarged liver and spleen, prominent jugular veins due to
raised blood pressure, observe for signs of congestion in Lie bases of the lungs such as
breathlessness and tiredness.
DEGREES OF ANAEMIA

Mild, moderate and severe

Mild anaemia:
The haemoglobin level is below 10.4 11.9gm/dl i.e. 8.1g/dl
 Management:
 She is better managed as an outpatient
 Dietary advice is given on sources of iron e.g increased consumption of dark green vegetables
e.g Ugu vegetable, intake of food rich in protein, and vitamins
 Iron supplements e.g ferrous sulphate tabler(200mg) thrice daily plus folic acid tablet
(Smg) daily
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  Treatment of malaria and worm infestation if identified during investigation of blood
and stool.
Moderate anaemia
This is when the haemoglobin estimation is or below 8.1gm/dl (i.e. between 7g/dl to 8.1g/dl)

>- Management
 Higher dose of iron supplement of ferrous sulphate (200mg) thrice daily, folic acid,
5mg daily throughout pregnancy; is given,
 Advise on foods rich in iron, protein and vitamin C (use of locally available and
affordable foods).
 Treat malaria and worm infestation (if present after investigation)
 Check haemoglobin at every visit for the rest of the pregnancy.
Severe anaemie;
 This is when the haemoglobin level is 6g/dl or below
 Haematocrit 20% or less
 There is increased incidence of preterm labour, fetal distress, low birth weight and
increased risk of perinatal mortality.
management of mild to moderate anaemia
If the haemoglobin estimation is less than 8gm, re-book the patient.
If the patient is 28 weeks on first visit with haemoglobin ofless than. 8gms she is referred to the
doctor or hospital for complete investigation and treatment.
 If the haemoglobin drops to 7gms/dl on 311y visit, treat for malaria and give iron supplement
of ferrous sulphate 320mg daily. (60mg elemental iron) thrice daily.
 Advice on diet rich in iron, protein vitamin C and folic acid.
 Check haemoglobin at every visit until it rises above 8gms/dl. If it does not improve after one
week, irrespective of her gestational age.
 Refer immediately for further medical management
 If signs of heart failure are present i.e dyspnoea, enlarged spleen, liver, and oedema of the -
ankles and limbs, refer immediately to the hospital (if in a health centre)
Nursing management of severe anaemia
 Admit for rest if HB is below 6gm.
 Start an IV infusion using a large-bore cannula or needle.
 Infuse normal saline or Ringer's lactate at the rate of 1 Lover 8 hours.
 Avoid giving sedatives.
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  Refer urgently for transfusion. (If not in the hospital).

 Prop patients in bed allow for easy breathing and prevent congestion of the lungs.

 Monitor maternal and foetal heart rates closely.

 Check temperature, 4 hourly, pluse and foetal heart rate half hourly.
 Monitor intake and output charts.
 Record any abnormal variations.
 Give high protein diet rich in green vegetables and vitamin C
 Give fresh fruits and nourishing drinks to augument the diet.
 Treat for hookworm, if in endemic area- give mebendazole
 Provide iron (120mg) and folate (400 mcg) by mouth daily for six months.
 Take blood for grouping and crossmatching
 If haemoglobin is less than 7 g/L, this is a life threatening complication and urgent referral is needed
 Start an IV infussion using a large-bore cannula or needle before referral.
 Infuse Normal Saline or Ringer's Lactate at the rate of 1L over 8 hours. (refer with IV infusion
isitu)
Medical management
 Transfuse with packed cells, if necessary,
 Manage as for severe/complicated malaria ia diagnosed
 Treat for any heart failure that has resulted from severe anaemia
In labour:
 Maintain strict asepsis
 Give antibiotics if membranes have ruptured for more than 12 hours
 Watch for signs of heart failure
 Prevent delayed labour
 Give episiotomy to shorten the second stage
 Give syntometrine intramuscularly after delivery of the baby
 Deliver the placenta by controlled cord traction
 Examine intake and output chart in the first 48 hours post partum
Follow-up:
 Re-check haemoglobin 48 hours post delivery
 Advice on nutrition
 Continue with iron therapy if still pale
 Explain the importance of keeping post-natal appointment

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Advice on discharge:
 Give information on food rich in iron, protein and vitamins.
 Advice on use of iron supplements to augment diet
 Educate on taking of iron drugs after meals with fruit juices or vitamin C to enhance absorption
 Remind her on family planning
 Advice on keeping of aseptic techniques in order to avoid infection
Effect of anaemia on the foetus
 Increased incidence of preterm labour
 Fetal distress
 Low birth weight
 Increased risk of perinatal mortality rate
Effect of anaemia the mother
 Increased incidence of maternal morbidity and mortality rate
 Maternal distress (in labour)
 Increased risk of post partum haemorrhage
 Worsen existing maternal condition
Prevention of anaemia in prggnancy:
 identification of risk factors for haemorrhage and managing them appropriately.
 use of iron supplements for all pregnant women throughout pregnancy
 identification and treatment of malaria and worm infestations
 Prophylactic treatment of malaria and worm infestation
 Check for other signs of infections or diseases e.g Urinary tract infections, and pulmonary
tuberculosis
 Check haemoglobin
 Emphasize personal and environmental hygiene
 Advise on sleeping under treated nets to prevent mosquito bite
 Advise on child spacing after delivery.
 Focused ante natal care (four visits) with health education
 Give health education about prevention of malaria
 Use of insecticides Treated Nets (ITN s)
 All pregnant women should sleep under ITNs
 Educate on nutrition.
 Advise to eat adequate diet rich in Iron, Folate and Vitamin C and Avoid drinks that decrease

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 iron absorption e.g. tea, coffee
 Provide micronutrient supplementation for up to 3 months after delivery
 Minimum of 60mg of elemental iron and 400 meg of folate daily
 Prevent malaria and hookworm infestation.
 Presumptive treatment of hookworm infection
 For all women living where hookworm prevalence is greater than 20%, if the woman has not
received to have hookworm infection:
 prescribe Mebendazole 100 mg by mouth twice daily for three days OR
 give albendazole 400 mg by mouth once
 mebendazole should be avoided in the first trimester

5.5.6 MALARIA IN PREGNANCY

Overview
Malaria is a major health problem in Africa, Asia, Central America, Oceania and South
America. Malaria cause about 15% of anaemia; Malaria is a febrile illness caused by Plasmodium- a
parasite transmitted through the bite of an infected female anopheles mosquito. It is a common
complication in the tropical environment and one of the major causes of high maternal and neonatal morbidity
and mortality rates in the tropics.
Malaria is more frequent and complicated during pregnancy.
in malaria endemic areas, malaria during pregnancy may account for the following factual
conditions:
Facts about malaria in pregnancy
 2 -15% of maternal anaemia
 11 % of maternal mortality
 8 - 14% of low birth weight newborns
 8 -36% of preterm births
 13 - 70% intrauterine growth retardation
 30% of preventable" low birth weight newborns
 5% congenital malaria in newborns
 3-5% of newborn deaths
 3-8% of infant deaths.
 1 0,000 MM due to malaria per year.
 30mil1ion cases yearly.
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Significance of malaria during pregnancy
 Each year more than30 million women living in malaria - endemic areas become pregnant and are at
risk for malaria infection.
 Of the estimated 300 million malaria cases each year worldwide, more than 90% occur in sub-
Saharan Africa.
 In Africa 1 person dies of malaria every 10 minutes
 Malaria results in approximately 10,000 maternal deaths and 75,000 to 200,000 infant deaths each year.
 Malaria is more frequent and complicated
 Malaria accounts for 11% of maternal deaths in Nigeria
Mode of transmission:
When infected female Anopheles mosquito bites an, it drops the parasites into the blood; these parasites
reproduce in the human blood. When these mosquitos bite infected person, it carries the parasites in its
stomach and goes on to bite and infect its new victim.
Populations most affected by malaria:
 Children Under 5 years of age Pregnant women
 Unborn babies
 immigrants from low transmission areas
 HIV infected persons
Groups of women mostly affected by malaria:
 Women in first or second pregnancies
 HIV infected women
 Adolescents (10 -19 years)
 Women with sickle cell disease
 All pregnant women with unexplained anaemia;
General signs and symptoms of malaria:
 High-grade fever (temperature 380C+)
 Shivering, chills and rigors
 Headaches
 Myalgia (muscle pains)
 General body and joint pains
 Gastro intestinal disturbance such as
 nausea and vomiting Loss of appetite
 Lethargy, weakness

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  False labour pam
In severe infection
 Pallor due to excessive destructive of the red blood cells
 Dehydration
 Patients is ill looking
 Vomiting, prostration
Note : Convulsion with blood pressure is due to malaria
Classification of malaria
a. Uncomplicated
b. Complicated

Signs and symptoms of signs and symptoms of complicated malaria

uncomplicated malaria (life
–threatening) malaria
 Symptoms and signs of uncomplicated
 Fever (38oC or more) malaria plus the following:
 Shivering / chills / rigors  Anaemia
 Headache  Jaundice
 Muscle/joint pain  Difficulty breathing or breathlessness
 Nausea and vomiting  Sleepiness or drowsiness
 False labour pains  Very dark urine
 Enlarged spleen  Confusion
 Dizziness  Coma
Laboratory diagnosis
 Laboratory examination of thick and thin blood film from a fingerprick may show malaria
parasites
 Haemoglobin estimation may show anaemia
 Rapid Diagnostic Tests (RDTs)
Nursing management
 Apply Problem Solving method –ASK and LISTEN, LOOK and FEEL etc,
 Reassure patient and her relatives
 Take history - ask about the condition of environment where patient lives e.g area with

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 stagnant water, bushy etc.
Ask and listen
 Ask about netting in their house or whether-she sleeps under the net, when she iast had febrile
illness if she is on malaria prophlaxis. Ask if she has headache, general body pain, fever, general
malaise, nausea and vomiting, false labour pains, dizziness, loss of appetite
 Assess or observe general appearance if looking ill, pale, lethargic or weak
 Assess patient for pyrexia (temperature 380c or more), vomiting, joint or abdominal pains and
uterine contractions.
 Check for signs of dehydration (dry lips, skin and fur-coated tongue) and anaemia.
 Take and record temperature, pulse respiration and blood pressure.
 Falpate abdomen and check foetal heart rate or tone.
 Expose to fan or tepid sponge the patient.
 Obtain urine specimen and test for glucose, protein and acetone.
 Take blood sample for Packed Cell Volume (PCV), Haemoglobin estimation, full blood count
and malaria parasites.
Look and feel
 If she is febrile, pale or jaundiced.
 check abdomen for liver or spleen enlargement
Identify problem and take appropriate action
 If febrile, give antipyretic e.g Paracetamol x 5 days.
 Tepid sponge, fan or expose the patient
 Second-line therapy for non-response to chloroquine: (i.e if patient does not tolerate
chloroqnine or does not respond to chloroquine). Give Artemisine/Artesunate based
combination drug e.g Sulfadoxine Phyrimetsamine (SP).
TREATMENT OF MALARIA IN PREGNANCY:
New regimen for managing malaria in pregnancy (National guideline for treatment)
1. Intermittent Preventive Treatment (IPT) : This is. a current dose of Sulfadoxine 500mg +
Pyrimethamine 25mg (SP). A single adult dose is 3 tablets given two times during pregnancy
and three times for HIV positive pregnant women.
2. Regimen for uncomplicated adult malaria:
 Artesunate Combination Therapy (ACT)
 Artesunate + Amodiaquine HCL. i.eArtesunate 4mg/kg once daily x 3 days +
Amodiaquine 10mg base /kg on days l,2and3,OR
 Artesunate + Mefloquine: Artesunate 4mglkg once-daily x 3 days + Mefloquine 25mg base
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 /kg (l5mg/kg on day 2, 1 Omg/kg on day 3), OR
 Mefloquine 8.3mg/kg daily x 3 days. OR
 Artesunate + Clindamycin (10 mg I kg body weighttwice daily) for 7 days.
 Artemeter (200mg)+Lumefantrine (120mg) combination (Coartem) 4Tablets twice
daily x 3 days i.e 1.5/9 mg/kg twice daily x 3days
3. Regimen for treating severe ADULT malaria (complicated malaria):
Severe adult malaria is life threatening. It can affect the brain (cerebral malaria) and cause
convulsions. Pregnant women are more prone to complicated malaria or severe malaria
than non-pregnant women.
a. Treatment with Quinine
 Give first (loading) dose of IV Quinine: 20mg/kg in 1/2, litre of fluid (e.g
Normal Saline 9% or Ringer's Lactate) given over 4 hours (maximum dose
1,200mg)
 Maintenance dose: 8 hours after commencing the initial dose, give 10mg / kg in
1/2 a litre of fluid over 4 hours (maximum 600mg) 8 hourly x 7 days
 Repeat l0mg/ kg 8 hourly until the patient can take orally.
 If patient is taking oral drugs change to SPSTAT. OR give oral
Quinine(10mg/kg) to complete 7 day therapy
 Quinine Dihydrosulphate (quinine tablet 300m) 20mg/kg loading dose, then
l0mg /kg 8 hourly x 7 days. (this is applicable in first, second and third
trimesters).
b. Treatment with Artesunate Combination Therapy (ACT)
 1M Artemether 3.2mg first day, then 1.6mg/kg daily for a minimum of 3 days and then
oral therapy to complete a 7 days course
 IV/M Artesunate 2.4mg/kg followed by 1.2mg/kg at 12 and 24 hours then, 1.2mgl kg
daily x 6 days (this is applicable in second and third trimesters)
 Artesunate+ Amodiaquine RCL. i.e Artesunate 4mg/kg once daily x 3 days +
Amodiaquine 10mg base/kg en days 1,2and3,OR
 Artesunate + Mefloquine: Artesunate 4mg/kg once daily x 3 days + Mefloquine 25mg
base /kg (l5mg/kg on day 2,1 Omg/kg on day 3), OR
 Mefloquine 8.3mglkg daily x 3 days. OR
 Artesunate + Clindamycin (10 mg / kg body weight twice daily) for 7 days.
 Artemether (200mg)+Lumefantrine (120 mg) combination (Coartem) 4Tablets twice
daily x 3days i.e 1.5/9 mg/kg twice daily x 3 days
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N.B in the first trimester: the following treatments can also be given
 Quinine 10 mg salt/kg body weight three times daily+ Clindarnycin 10mg/ kg body weight twice
daily for 7 days
 Lf Clindamycin is not available, use Quinine only.
 Anesunate+Clindamycin Therapy (ACT) can be used if it is the only effective treatment
available.
 Nursing management:
o Reassure patient and her families
o Encourage patient to take plenty of fluids and fruits
o Advise to continue on her native drugs.
o If woman is conscious, give 3 tablets of Sulfadoxine Pyrimethamine
o She is then reviewed in 24 hrs.
o If no improvement, refer
o If woman is unconscious or convulsing
o Give Diazepam 1 Omg IV slowly over 2 minutes.
o Infuse loading dose of Quinine Dihydrochloride 20 mg/kg body weight in IV fluids
ofnormal saline, or Ringer's Lactate over 4 hours.
o Wait 4 hours after completing the loading dose.
o Then, infuse Quinine Dihydrochloride 10 mg I kg body weight over 4 hours
o Repeat every 8 hours for 7 days.
Precautions on use of Quinine
 Loading dose should not be used if patient has received quinine in the last 24 hours or
mefloquine in the last 7 days
 Maintenance dose of quinine should be halved (1/2) in patients with renal failure after 2 days
 After switching to oral SP, quinine administration is stopped
 Treathypoglycaemia if present with 5% Dextrose (1 ml/kg/ bodywt).
 Other treatments like blood transfusion and respiratory support are given depending on the
severity and or presence of complications of malaria.
 Encourage intake of routine ANC drugs
 Review daily, if no improvement after 48 hours Refer
INTERMITTENT PREVENTIVE TREATMENT
(IPT)
Definition: Intermittent Preventive Treatment (IPT) is the use of anti-malarial drugs given in divided
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doses at predefined intervals after quickening to clear a presumed burden of parasites.
Intermittent Preventive Treatment (IPT) IPT is a current dose of SP given two times during
pregnancy. (Three doses to HIV positive pregnant women).These current doses clear the placenta of
parasite at each dose. The majority of foetal growth occurs between 24 and 36 weeks of gestation. So
if the woman receives the recommended doses after quickening, the parasites will be cleared from the
placenta, improving adverse outcomes (Draft, 2004).
This treatment is based on the assumption that every pregnant woman living in malaria endemic
areas has malaria parasite in the blood or placenta, whether or not she has symptoms of malaria. Even
though a pregnant woman with malaria may not have symptoms, malaria can still affect her and her
un-born child,
The recommended drug by WHO for IPT is Sp. A single adult dose is 3 tablets 0: Snlphadoxine,
500mg - Pyrimethamine 25mg each.
The World Health Organization (WHO) recommends that all pregnant women should receive 2
doses as Directly Observed Therapy (DOT) at scheduled ANC visits during the second and third
trimesters. The 2 doses of SP shall be given at least one month apart i.e. Two doses after quickening
is recommended at 4 weekly (monthly) intervals and that special attention should be given to ~IV
positive pregnant mothers, women in their first and second pregnancies, pregnant adolescents (10 -19
years), and women with sickle cell disease.
NURSING RESPONSIBILITY TOWARDS GIVING SULPHADOXINE- PYRIMETHAMINE (SP)
 Ensure woman is at least 16 weeks pregnant and that quickening has occurred.
 Give SP as follows:
First dose of SP is given at the first ANC visit after quickening (> 16 weeks of gestation)
 Second dose: at least one month after the first dose (during scheduled ANC visit)
 Give third dose of SP to HIV positive pregnant women
 Inquire about use of SP in the last 4 weeks
 Inquire about allergies to SP or other Sulfa drugs (especially severe rashes)
 Explain to the woman what you will do and address her questions
 Give as Directly Observed Therapy (DOT)
 Provide cup and clean water
 Dispense dose and directly observe patient swallow 3 tablets of SP
 Record dose given on clinic card
 Watch for any reaction or vomiting
 Remind her on when to return for next dose and visit
 Advice to come to hospital if she has signs of malaria or other danger signs
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  Reinforce the importance of using Insecticide Treated Nets (ITN)
Contra-indications to giving SP
 Do not give during the first trimester (1st 12 weeks of pregnancy)
 Ensure that quickening has occurred and woman is at least 16 weeks pregnant
 Do not give to woman with reported allergy to SP.
 Do not give to women taking Co-trimoxazole or other Sulfa drug
 Do not give more frequently 4 weekly. Be sure that one month has elapsed since the last dose
of SP.
Note: Intermittent Preventive Treatment (IPT) given 3 times during pregnancy is effective for women
with HIV/AIDS because this infection reduces a woman’s resistance to malaria.
Do not give SP after 36 weeks because of risk of neonatal jaundice and delayed Patent Doctus
Arteriosus.
Effectiveness of SP:
 Good safety profile
 Good efficacy in Reproductive age women in most areas
 Good programme feasibility
 Good compliance - it can be delivered as single dose treatment under observation by the health
worker.
 High level of IPT acceptance by pregnant women.
Side-effects of SP
 Nausea, vomiting, urticaria rashes headaches and insomnia.
Effects of malaria on:
1. Pregnant women
i. Abortions miscarriages
ii. Risk All women in malaria endemic area are at risk
iii. preterm labour
iv. Hypoglycemia particularly in 2nd and 3rd trimester
v. Increase risk of HI V transmission from mother to child
Severe maternal anaemia- malaria causes up to 15 percent of anaemia in pregnancy .

vi. Asymptomatic infection

vii. Renal failure,
viii. Cerebral malaria.
ix. Maternal death in Africa, anaemia due to malaria causes up to 10,000 maternal deaths

137
 annually.
(2) Unborn babies:
 Placental in sufficiency parasites hide inside the placenta and interferes with the integrity of the
placenta.
 Reduced oxygen and nutrients to the baby
 Spontaneous abortion, increases

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 (3) Newborn:
 Preterm delivery
 Low birth weight
 Neonatal mortality- single greatest risk factor for death during first month of life
 Stillbirth
(4)Family
 Poor family relationship
 Decreased income for the family
(4) Communities
 Decreased manpower for development
 Increased school drop-outs due to frequent absenteeism from school.
 Drains already scarce resources
 Causes preventable deaths
 Increased maternal neonatal and infant mortality rates.
(5) Nation

 Drains financial reserve for development.

 Causes low productivity and slow national growth.

PREVENTION OF MALARIA IN PREGNANCY
WHO strategies-
1. Health Education
2. IPT
3. ITN
Health Education:
i. Educate with signs and symptoms of malaria in pregnancy
ii. Advise on taking prophylactic Iron/folic vitamins and Iodine supplements
iii. Counsel to sleep under ITN throughout pregnancy and after childbirth with the newborn.
iv. Advice on taking of Co-trimoxazole for urinary tract infection or for prophylaxis in HIV mother
v. Pregnant women in malaria-endemic areas should sleep under Insecticide- Treated net.
vi. Health educate on environmental sanitation clearing of drainages, cutting of grass, filling pot-holes,
proper disposal of refuse etc
vii. Netting of all windows and outdoors
viii. Educate on need to report early any symptom of malaria for prompt treatment.

139
 ix. Educate on the importance of finishing the course of treatment for it to be effective
x. Immediate/early referral of women with complicated malaria for specialized management in order to
avoid further complications and consequent maternal death.
xi. Counsel on nutrition
xii. Counsel on ITN and to come back for the next IPT
xiii. use of insect repellant.
2. Intermittent Preventive Treatment (lPT): give SP after quickening at 10 weeks
3. Consistently sleeping under an ITN. This can:
 Decease severe malaria by 45%
 Reduce premature births by 42%, and
 Cut all-cause - child mortality by 17% to 63%
1. Give presumptive treatment for hookworm - Give mebedazole in second and third trimester. :

HYPERTENSIVE DISORDERS OF PREGNANCY

This is the term used for all hypertensive conditions occurring during pregnancy. These conditions include
chronic hypertension/essential hypertension, chronic hypertension with super-imposed pre-eclampsia, and
eclampsia. These occur in 7 to 10 percent of all pregnancies and can result in life threatening complications
for mothers and child.
Hypertension: Is defined as high blood pressure.
It is diagnosed by single measurement of Diastolic Blood Pressure (DBP) of 110mmHg on two
consecutive measurements of DBP 90mmHg taken 4 hours apart.
Classification
1. Chronic/Essential hypertension
2. Chronic hypertension with super-imposed pre-eclampsia
3. Gestational hypertension
4. Pre-eclampsia
5. Eclampsia
Description by classification:
1. Chronic / Essential hypertension: Chronic hypertension is known hypertension before pregnancy or
high blood pressure greater than 140/90mmhg before 20 weeks of pregnancy. Essential hypertension
is persistently high blood pressure prior to pregnancy. It should be noted that a blood pressure taken
prior to 20 weeks is considered to be the woman’s normal baseline blood pressure. If a woman’s

140
 blood pressure is above 140/90mmHg, or if her normal blood pressure is raised by 30/15mmHg
without proteinuria or oedema before 20 weeks of pregnancy, she probably has chronic or essential
hypertension. The rise in blood pressure is not pregnancy induced but may be due to other
physiological causes. This classification may improve, worsen or remain static but ,a woman with
either chronic or essential hypertension is prone to complications such as super-imposed pre-eclampsia,
placental abruption, sub-aracznoid haemorrhage, cardiac or renal failure, maternal death, foetal
compromise at risk of placental insufficiency, foetal death, small for date babies, preterm labour, or
still birth .
2. Chronic hypertension with super –imposed pre-eclampsia.
In this classification, the women has:
 Pre-existing hypertension before 20 weeks of pregnancy
 There is sudden increase in pre-existing hypertension
 Urine contains protein
 Blood investigation reveals thrombo-cytopaenia and abnormal liver enzymes
 proteinuria is greater than 0.3 gin 24 hours
 There is relative risk of pre-eclampsia, depending on the degree of protein and oedema, this condition
is managed as pre-eclampsia.
3. Gestational hypertension / Pregnancy Induced Hypertension (PHI): PIH is high blood pressure
(hypertension) developing after 20 weeks of pregnancy in a previously normotensive non-proteinuric
woman. It is pregnancy induced. The blood pressure was triggered by pregnancy. Gestational
hypertension is the commonest medical complication of pregnancy and it is a major cause of maternal
death especially when it progresses into eclampsia.
Epidemiology: Gestational hypertension occurs in 16-24 percent of first pregnancies and 12- 15 percent
of subsequent pregnancies. Most diagnosed after 34th week.
Aetiology: The exact cause is unknown but theories on it are:
 Uterine vascular changes
 Endothelial dysfunction:
 Circulatory factors
 Immunologic response
 Coagulation disorder
Other factors are:
Genetic Daughters 4 – 5 times more likely to develop pre-eclampsia than Daughters-In-Law Genes are said

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to be either recessive or dominant model with incomplete penetrate.
Groups of women at risk of gestational hypertension
 Women of low socio – economic status
 Family proness to hypertension
 Maternal age and parity (too old, too young).
 Elderly primiparae and grand multiparae.
 History of chronic renal conditions or chronic pyelonephritis.
 Previous history of pregnancy induced hypertension.
 Women who fail to attend ante-natal clinic regularly (this prevents early diagnosis and prompt
management
Signs and Symptoms
 Blood pressure of 140/90muttg and above after 20 weeks of pregnancy
 Proteinuria
 Oedema or swelling of hands face and feet
 Hypa-reflexia
 Heartburn
 Frontal headache

Signs of severe pre-eclampsia may follow and these include, epigastric pain, visual problems,
dizziness

Steps for detecting gestational hypertension:

Ask and listen:
 History taking: Using the problem solving methods - take a good symptom history
 Ask about foetal movement - ask; if she as had any of these e.g. Epigastric pain headaches dizziness,
visual disturbances, oedema of the hands, feet and face.
 Look if patient responds positively to questions asked.
 Observe oedema of face, hands (ring tight finger) feet, sacrum and vulva.
 Check for raised blood pressure of 140/90mmhg and above
 Measures abdominal girth-
 Test urine for protenuria in' particular and note other abnormalities
 Collect 24 hours urine specimen to the laboratory for placental function test
 Test biceps and patellarreflexes and note nature of the reflexes 3 or4.
 Feel, palpate the abdomen 'for weeks of gestation. Note signs of labour if she has had convulsions.

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  Measure abdominal girth'
 Reassure the woman, husband and family
 Explain to the woman her condition and advice on rest for at least 2 hours during the day and to
sleep for 8hours at night
 Document and interpret all your findings and institute prompt action and possible referral.
In the absence of complications, patient is best managed as an outpatient; with frequent/Weekly review
of investigations and monitoring of foetal wellbeing. she may have home management, patient; and family
are educated for home management This includes 4 hourly monitoring of blood pressure.
 Diazepam 5-10mg is given to ensure adequate rest and sleep. If there is complication or if blood
pressure does not subside, patient is admitted.
Look and feel
Take the blood pressure at every visit if elevated, check if she is nervous. Find a place for her to rest on her
side for 20 minutes. Repeat the blood pressure. If elevated, check for oedema pressing the tibial bone above
the woman's ankle, check the hands and face for swelling, if present, refer.
Check the biceps and/ or the partella reflexes. If the reflexes are brisick (+ 3, on + 4), refer
 Daily assessment of weight
 Urine testing for protein by dipstick
 Foetal movement counts
 Advise on activity restriction
 Advise her to rest in the left lateral position several times daily
 Educate her to report symptoms such as severe headaches, visual disturbances, and right upper quadrant
or epigastric pain.
 None stress tests are done twice weekly.
 Weekly visit to the physician. If the woman's blood pressure does not improve with bed rest or there
is foetal compromise or signs of severe pre-eclampsia, refer immediately with complete medical record,
or if blood pressure increases to above 160/l00mmHg and there is significant rise in protein (+++) refer for
hospital management.
Grading of reflexes in pre - eclampsia
Testing of reflexes is very important in a pregnant woman to detect hypereflexia which can indicate many
diseases of the nervous system.
Reflexes are usually given a grade of 0 to +4 as follow
0 = no response

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 +1 = low but without normal response
+2 = average or normal response
+3 = brisker than average
+4 = very brisk, hyperactive, abnormal, may have rhythmic tremors (clonus)
 Checking the reflexes.
A reflex hammer is used to check the deep tendon reflexes e.g. the biceps and patellar reflexes. Using a
Reflex Hammer
 Hold the hammer loosely between your thumb and index finger
 Bring the hammer down onto the tendon in a rapid, smooth movement
 Tap quickly and firmly
 Lift the hammer back up quickly
 Watch for how fast the response is. It is the speed of the response, not how far the limb moves, that
tells you if her reflexes are normal. In checking reflexes, always check both sides (both arms or both
legs)
Check that the response is similar on both sides.
There are many reflexes that you can check but those of more importance in diagnosing pre eclampsia in a
pregnant woman are the biceps and patellar reflexes.
For the biceps reflex, bend the woman's arm about halfway, feel for her tendon with your fingers on the
inside of her elbow,
You will be able to feel this response from the tendon through your thumb strike your thumbnail which is
positioned over the tendon. This causes the biceps muscles to contract. The slight contraction may or may
not be seen at the women's elbow.
For the patellar reflex, - Place the woman in a sitting position with her legs hanging freely feel for her
tendon right below the kneecap (patellar) strike the tendon with a quick firm tap and lift up immediately. The
side of your hand or knuckle can also be used to tap the tendon.
NB: A woman with pre eclampsia who has hyper reflexia (+3 or+4) is at very high risk of having
seizures.
Management in the hospital
(Gestational hypertension is managed as pre-eclampsia)
 She is admitted for rest
 Nurse patient on the left lateral position to improve blood flow to the placental sites,
 Reassure and give opportunity for the woman and her family to express fears, anxieties and other
reaction related to the woman's condition

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  Encourage patient on compliance by explaining the various tests to be conducted, frequency of blood
pressure readings, foetal movement counts, and frequent questions on how she feels.
 Place patient on complete bed rest
 Monitor blood pressure 4 hourly (day and night)
 Test urine for protein
 Assess oedema daily
 Evaluate weight and patella reflexes daily
 Monitor foetal movements
 Ensure and maintain quiet environment.
 Make available oxygen, sunction machine, pads for bed rails etc.
 Observe patient closely and document your findings.
 Do not advise her on Diuretics or Anti-Hypertensive in your management of this patient.
 Incase of seizures. maintain clear airways. Prevent injury and inform doctor immediately.
Investigations:
 None stress tests are done twice weekly
 Bio- physical profile is estimated
 Amniotic fluid index is checked weekly
 Complete blood count
 Creatinine and liver enzyme tests weekly
In serious cases of gestational hypertension, Active therapy may be instituted in serious cases e.g
Antihypertensive and diuretics may be ordered to control severe hypertension.
Anti-hypertensive are used due to their reduction of renal and placental blood flow).
 Hydralazine 5-10mg intravenously slowly over 2 minutes
 Labetolol20mg intravenously. This is repeated every 30 minutes
 Nifedipine, 10mg orally to be repeated every 30 minutes.
Corticosteroid are ordered to promote lung maturity in the foetus of less than 34 week of gestation.
Method of labour and delivery:
 When mother and foetus are stabilized, the mode of delivery depends on the cervix, parity,
maternal and foetal conditions.
 If blood pressure is well controlled, she is allowed for spontaneous onset of labour or induction with
favorable clinical assessment i.e delivery is initiated by induction of labour with high doses of
oxytocin because magnesium sulphate relaxes smooth muscles and hence uterine contractions

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 diminishes.
 If the following conditions are present i.e general wellbeing, packed cell volume, degree of
gestational hypertension, foetal gestational age, and heart rate/rhythm, favourable cervix, and
adequate pelvis. the second stage is shortened by giving episiotomy and baby delivered vaginally but
45 percent of delivery is usually by Caesarian Section (CIS).
 Third stage: Active management with Syntocinon rather than Ergometrine Com
Complication of Gestational Hypertension
 Severe pre-eclampsia and eclampsia
 Hepatitis, jaundice
 Pulmonary oedema
 acute and chromic renal failure
 Abruptio placentae
 Disseminated intramuscular coagulopathy
 Maternal death
 Perinatal morbidity and mortality

HAEMORRHAGE IN OBSTETRICS
Obstetric haemorrhage is blood loss or bleeding during pregnancy labour, or within 42 days of termination of
a pregnancy
Haemorrhage in pregnancy, labour and the early post-partum period is a major cause of maternal mortality
worldwide. Haemorrhage is the number one cause of maternal death in Nigeria, Sixty percent of all
pregnancy related deaths are said to occur during the first 24 HOURS AFTER DELIVERY (Li, 1996).
Haemorrhage in the first 4 hours after delivery accounts for the single largest number of maternal deaths. More
than 150,000 maternal deaths are due to obstetric haemorrhage, accounting for 25% of maternal mortality.
The commonest type of haemorrhage that is of serious concern is bleeding immediately after delivery
(primary postpartum haemorrhage ) and is a major cause of maternal mortality worldwide.
• Signs and symptoms of haemorrhage in obsterics:
• 1. Bleeding per vaginam (acute blood loss or minimal bleeding for long period).
•
Note: light bleeding takes longer titan 5 minutes for a clean pad or cloth to be soaked. Heavy bleeding
takes less than 5 minutes for a cean pad or cloth to be soaked
Its takes just 2 hours for a woman to die from uncontrollable bleeding.
2. Pale conjuctiva

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 3. Dizziness / fainting attacks
4. Shock - characterized by cold / c1amy skin, low blood pressure, rapid feeble pulse
5. Abdominal tenderness and pain (in ruptured uterus and abruptio placentae)
Common causes of obsteric haemorrhage:
(I) In pregnancy
 Ectopic pregnancy
 Gestational trophoblastic diseases causing e.g. molar pregnancy / hydatidiform mole.
 Ante-partum haemorrhage due to abruptio placentae, or placenta praevia
 Abortion (spontaneous / induced).
(II). Intra and postpartum:
 Atony of the uterus
 Retained placenta and/or membranes
 Ruptured uterus
 Coagulation failure (hypofibrinogenaemia)
 Lacerations, Perineal, vagina1 and cervical lacerations
The major causes of haemorrhage in the first 24 hours after birth are uterine atony. retained products of
conception and vaginal lacerations. This is an area where improved maternal care can save marry lives.
Predisposing factors:
These are risk factors that should put the health care provider especially the midwife at alert during
pregnancy, labour and post partum.
Past illnesses or surgery:
 Previous caesarean section, (CIS) or surgery on the uterus to remove fibroids or dilatation and
curettage
 Blood clothing problems (Hypofibrinogenaemia)
 Anaemia
 Hepatitis
Previous histories of :
post partum haemorrhage, ruptured uterus, inverted uterus, retained placenta and five or more previous pregnancies.
Problems in present pregnancy:
 Placenta praevia
 Placenta abruption
 Pre-eclampsia /eclampsia

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  Foetal death in utero
 Multiple pregnancy
 Polyhydrammios, abdominal pain, contraction, bleeding, induced labour (by medicines or herbs)
 Prolonged labour
 Chorioammionitis and precipitate labour (lasting 3 hours or less)
Management of haemorrhage in obstetrics
The rule is that the slightest case of vaginal bleeding in pregnancy must be reported by the patient.
Nursing management
 Reassure the woman and her relatives
 Inform the doctor
 Take history of bleeding.
 Examine the vulva, for amount of bleeding or products of conception, trauma or laceration. Examine uterus for
contraction or retained placenta if just delivered.
 Do not perform vaginal examination
 Check bladder if full
 Keep patient warm and treat for shock if present,
 Stabilize patient with intravenous infusion of normal saline or Ringer's lactate, 1L to run over 8 hours if bleeding
is moderate. lf bleeding is severe e.g in abroptio placentae, give at least 2L in the first hour, the first 1 L at the
rate of 15-20 minutes
 Relief pain with e.g. Fortwin 30mg IM
 Check vital signs of pulse, respiration and blood pressure
 Transfer or refer patient immediately, if no improvement in patient's condition, (in the company of a midwife)
for specific management.
Consider the following causes for specific management (1)
ECTOPIC PREGNANCY
Types:
(a) Un-ruptured ectopic
Signs / Symptoms:
1. Light bleeding
2. Symptoms of early pregnancy
3. Abdominal and pelvicpain
4. Closedcervix.

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Ruptured ectopic:
 Signs/Symptoms:
1. Signs of shock
2. Collapse
3. Weakness;
4. Pulse 100 beats / minute or
more,
5. Systolic blood pressure of90mmHg or less .
6. Acute abdominal and pelvic pain
7. Rebound abdominal tenderness
8. Pallor due to severe bleeding
Management
 If un-ruptured, set IV infusion of Normal Saline or Ringer's Lactate 1litre in 6 to 8 hours. Refer for
laparotomy.
 If ruptured and in shock set IV line and infuse Normal Saline or Ringer's lactate 1Iitre in 5-20 minutes as
rapidly (as possible).
 Repeat 1litre every 30 minutes at rate of 30 mil/min (1L 6 - 8 hours) when pulse slows to less than 100 beats ,
per minute and Systolic lie BP increases to 100 mmHg Or more.
 Record time and amount of fluids given.
 Transfer immediately for laparotomy .
2. MOLAR PREGNANCY
This manifests as hydatidiform mole
Signs/Symptoms:
1. Heavy bleeding
2. Dilated cervix,
3. Uterus large than dates and softer than normal
4. Partial expulsion of products of conception which resembles grapes,
Management
 If diagnosis is certain and MVA is available -perform Manual Vacuum Aspiration (have three syringes cocked
and ready for use). If cervical di1atation; is needed, use a paracervical block.
Once MVA is started, infuse oxytocin 20 units in 1L of Normal Saline or Ringer'S Lactate at 60 drops per minutes to
prevent haemorrhage.
 if diagnosis is not certain and / or MVA is not available, stabilize with infusion and refer immediately.

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 Bleeding after 22 weeks of pregnancy or in labour before childbirth
3. ABRUPTIO PLACENTAE
Signs / symptoms
 severe bleeding after 22 weeks of pregnancy
 intermittent or constant abdominal pain
Management
Reassure patients if conscious

 Check vital signs - blood pressure, pulse, respiration and temperature

 Treat for shock if present
 Start IV infusion (two if possible) using a large-bore cannula.
 Rapidly infuse normal saline or Ringer's Lactate at the rate of 1 L in 15 - 20 minutes
 Give at least 2L of fluid in the first hour.
 Refer urgently for surgical intervention.
(4) PLACENTA PRAEVIA
Signs/ Symptoms
 Vaginal bleeding may be revealed or concealed.
 Abdominal pain.
Management
 Give necessary nursing care
 Stabilize with IV infusion (as above) and refer immediately
(5) RUPTURED UTERUS
Signs / Symptoms
 Bleeding, (intra-abdominal and/ or vaginal)
 Severe abdominal pain (may decrease Liter rupture)
Management
 Start IV infusion (two if possible) using a large-bore cannula,
 Rapidly infuse normal saline or Ringer's lactate at the rate of 1 L in 15 - 20 minutes.
 Give at least 2 L of fluid in the first hour.
 Refer urgently for surgical intervention
(6) ABORTION
Overview of Abortion

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Introduction
Abortion is the commonest cause of bleeding in early pregnancy and is one of the major causes of maternal
deaths worldwide.
Definition:
Abortion is termination or loss of a pregnancy before 24 weeks of gestation.
Incidence
Worldwide, an average of 35 in 1000 women of childbearing age (15-49 years) have an abortion each year.
However, this rate changes from 10 per 1000 women in some countries to around 80 per 1000 women in
others.
Despite variations in the legal statues of abortions in developed and developing countries, overall rates are
quite similar for both. Worldwide, of the approximately 210 million pregnancies that occur each year, an
estimated 38% are unplanned and a further 22% result in abortions. In developing countries, Nigeria
inclusive, 182 million pregnancies occur yearly, with an estimated 36% unplanned and 20% ending in
abortions.
In Nigeria, it is estimated that about 40% of maternal deaths are from abortion and its complications. The
gestational age at which pregnancy is usually terminated is between 6-12 weeks.
Abortion can lead to death contributing about 29% or cases in maternal mortality as well as maternal morbidity e.g
Reproductive health infections and infertility. These unnecessary and highly preventable complications can
occur, from miscarriages and induced abortions and or its management. The proportion of pregnancies ended
by abortion is greatest at the beginning and at the end of a woman's child bearing life. The provision of quality post
abortion care and counseling will contribute immensely to the reduction of maternal mortality. Henshaw et al, (1999).
FACTS ABOUT ABORTION:
Worldwide:
 46 million per annum
 35/1000 women aged 15-49.
 Lowest rate (7/1 00) in Belgium and Netherlands
In Africa:
 Total 5 Million per annum mostly illegal ;
Example:
 South Africa - 0.8
 West Africa 1.6
In Nigeria:
 610,000 (40% of West Africa)

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  25/1000 women aged 15-44
 60% performed by non-physician
 750 % are < 24 years of age.
Causes of abortion:
1. Maternal causes.-
 Maternal ill-health such as malaria, anaemia diarrhea /dysentery, tuberculosis, pyelonephritis, hypertension,
diabetes.
 Hormonal imbalance
 Uterine malformation e.g Bi-cornuate uterus
 Uterine infections e.g endometritis
 Submucous fibroids
 Cervical incompetency
 Exposure to teratogenic chemicals
 Effect of certain drugs e.g Oxytocin, Prostaglandin
 Emotional disturbance or extremes of emotions such as grief or fright
 Violent exercises.
2. Foetal causes:
 Gross foetal malformation/mal-development
 Chromosomal abnormalities.
3. Social conditions-such as
 Teenage pregnancy or unwanted pregnancy
 Un-met family needs
 Rape etc.
Signs and symptoms of Abortion
 History of missed period precede vaginal bleeding
 the cardinal signs is bleeding per vaginam this may be slight or profuse depending on the nature of the
abortion.
 Pains patient may complain of backache and intermittent lower abdominal pain
 Membranes may rupture and part of the products of conception may protrude the dilating cervical os
(inevitable leabortion)
 Bleedmg may be profuse and products retained in incomplete abortion
 Reddish brown/yellowish green foul smelling vaginal discharge (in septic abortion)

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 On abdominal palpation, there is localized or generalized rebound and/or tenderness. If it is complicated with
septicaemia, patient looks toxic and jaundiced.
 Excessive blood loss will lead to anaemia; and shock
 Signs of shock cold, clammy skin and extremities, rapid feeble pulse, and lowered blood pressure, air hunger
respiration.
 The general condition of the patient depends on the amount of blood loss and type of abortion.
Classification / Specific management of abortion:
(1) SPONTANEOUSASORTION:
This is the loss of a pregnancy before 24 weeks of pregnancy (it is otherwise stermed as miscarriage) it
usually occurs naturally its own without any interference or may result due to disease or accident.
Stages of spontaneous abortion
(i) Threatened abortion: This may progress to term or cannot be saved and become inevitable
Signs and Symptoms
(1) Light bleeding
(2) Closed cervix
(3) Uterus corresponds to dates
Management
 Woman is usually managed in the clinic
 Advise to avoid hard work and intercourse.
 Do not give hormones or tokolytics
 If bleeding does not stop
 Refer immediately (maybe ectopic pregnancy, twins, or molar pregnancy)
(II) Inevitable abortion: The abortion is imminent and the pregnancy cannot be saved
Signs and Symptoms
(1) Heavy bleeding
(2) Progressive dilation of the cervix
(3). Uterus smaller than or corresponds to dates
Management
If pregnancy is less than 16 weeks, perform Manual Vacuum Aspiration (MVA)
 If MVA is not available
 Stabilize and refer urgently

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  Give Ergometrine 0.5mg 1M (repeat after 15 minutes if necessary)

 OR Misoprostol 400mg orally (repeat once after 4 hours, if necessary)

If pregnancy is greater than 16 weeks

 Await sponteneous expulsion of products of conception.

 If necessary to help expulsion, infuse Oxytocin 40 units in 1L of Normal Saline or

Ringer's Lactaterun at 40 drops per minutes.

 Perform MVA to remove any remaining products of conception.

(iii) Incomplete abortion: Products of conception are not completely expelled.
Usually the foetus is expelled but the placenta and membranes are retained.
Signs and Symptoms
(1) Persistent heavy bleeding
(2) Dilated cervix
(3) Uterus smaller than dates
Management
If bleeding is light to moderate and pregnancy is less than 16 weeks
 Use ring forceps, if available, to remove products of conception
protruding through cervix.
 Give Ergometrine O.5mg IM (repeat after 15 minutes
 OR Misoprostol 400mg by mouth (repeat once after <4 hours if
necessary)
If bleeding is heavy and pregnancy is less than 16 weeks
 If MVA is available, perform MVA.
 If MVA is not available, perform curettage
 If MVA and curettage are not available stabilize with infusion and refer urgently.
If bleeding is heavy and pregnancy is greater than 16 weeks
 If MVA is available infuse Oxytocin 40 units in 1L Normal Saline or Ringer's
Lactate 40 drops per minutes until expulsion of products of conception occurs.
 If necessary, give Misoprostol 200ug vaginally every 4 hours until expulsion (do not
give more than 800ug)
 Perform MVA to remove any remaining products of conception.
 Refer urgently.
(iv) Complete abortion: The whole products of conception is expelled completely
Complete abortion is commoner before the 8th week of pregnancy
Signs and Symptoms
(I) Light bleeding
(2) Closed cervix
(3)Uterus smaller than date
(4) Uterus softer than normal

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Management
 Observe for heavy bleeding
 Give Ergometrin O. 5mg 1M OR Misoprostol 400ug orally
 Refer immediately if bleeding does not stop
(v).Missed abortion: The foetus dies and is retained. There is painless brownish vaginal
discharge. Manage as septic abortion.
Habitual abortion: This is when there had been three or more consecutive spontaneous
abortions.
Management: Patient is admitted and confined to bed as soon as pregnancy is confirmed.
Shirodicalstitches may be applied at a fixed time by the obstetrician to keep the pregnancy till
term and removed before she falls into labour.
(2) INDUCED ABORTION:
This is purposeful or deliberate termination of pregnancy either by the woman herself or
someone else with the aim or intention of other than live born infant, or to remove a dead
foetus. Pregnancy may be induced for therapeutic or criminal purposes. induced abortion may
be therapeutic or criminal as follow:
(i) Therapeutic abortion: This is carried out by a qualified medical practitioner in
the interest of the mother's life or her total wellbeing. The indication for this is
usually medical conditions threatening the mother's life or is likely to cause gross
foetal abnormalities e.g cardiac disease grade four.
(ii) Criminal/Unsafe abortion: This is illegal procurement of abortion, usually
performed by unqualified persons (quacks) or persons lacking; necessary skills or
in an environment lacking minimal infection prevention standard or both and
having little regard for the consequences.
Septic abortion: Is an abortion complicated by infection. Usually sequel of
incomplete abortion that is criminally induced. Criminal or unsafe abortion is
responsible for about 40 percent of maternal mortality in Nigeria.
Signs and Symptoms
(1) Fever / Chills
(2)Foul-Smelling vaginal discharges
(3) Tender uterus.
Management
 Immediately give ampicillin 2g IV every 6 hours plus Gentamicin 5mg/kg body weight
IV every 24-hours plus Metronidazole 500mg IV every 8 hours untill woman is fever-
free for 48 hours.
 Prior to 16 weeks, if MVA is available, perform MVA
 If after 16 weeks, and MVA is not available give antibiotics and refer immediately.
Nursing management of a patient with abortion
NB: The rule is that the slightest cases of vaginal bleeding in pregnancy must be reported by
the patient
 Reassure patient and relatives.

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  Take history of last menstrual period to determine the (if conscious) gestational age of
the pregnancy.
 Show empathy.
 Do not perform vaginal examination,
 Treat for shock if in shock – place patient in dorsal position and elevate foot of bed.
 Give Oxygen 6 – 8 litres per minutes if necessary.
 Keep patient warm
 Check vital signs temperate, pulse, Respiration and Blood pressure. Take Pulse and
Respiration ¼ hourly.
 Prevent hyprovolaemia by giving rectal fluid intravenous fluid (Normal Saline 0.9% in
500mls at 40 drops per minute.
 If patient is bleeding with cloths or products of conception, give Ergomethrine 0.5mg
or Misoprostol 400mg by mouth (repeat once after 4 hours if necessary) Synthometrine
1ml.
 Attempt to remove the placenta.
 If patient is having painful contraction, give analgesics e.g Fortwin 30mg
intramuscularly
 If conscious, give Paracetamol two tablets (1 em) thrice daily for 3 days start
antibiotics e.g Ampicillin 500mg stat then 250mg 6 hourly for 5 days.
 Give sedative e.g Valium 1 Omg orally.
 Put patient on complete bed rest continue with close observation of vital signs.
 Check abdomen for contraction and vagina for blood toss and offensive vaginal
discharges
 Check for evidence of attempted intervention
 Perform manual vacuum aspiration MVA if available, if MVA is not available and
pain persists or patient's condition does not stabilize within 24 hours of nursing
intervention
 Refer immediately for higher medical management.
 If referred or discharged counsel on family planning
 Counsel on safer sexual activities if septic abortion.
UNSAFE ABORTION
Definition
Unsafe abortion is defined as a procedure for the termination of an unwanted pregnancy
either by persons lacking the necessary skills or in an environment lacking minimal
medical standards or both.
Unsafe abortion is a response to an unplanned/unwanted pregnancy, which should have been
prevented by access to quality family planning / child spacing services amongst others.
Methods used
 Use of drugs, e.g. Ergometrine, Quinine, Blue or Potash
 Vaginal interference such as insertion of sharp objects into the uterus e.g. bicycle
spoke

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Incidence of unsafe abortion worldwide:
 20 million yearly
 More than 70,000 women die yearly, 23,000 of these occur in Sub-Saharan Africa
 1 out of 8 deaths related to pregnancy is due to unsafe abortion (WHO estimate).
 Unsafe abortion accounts for 13% of all maternal death world wide
 40% of maternal death occur in Nigeria
 For every maternal death 15 20 maternal morbidities occur
 Up to 50% of the hospital resources are used in treating women admitted for
complications of unsafe abortion. Illegal and unsafe abortions occur amongst young
adolescents, poor women and rural women who usually try to induce their own
abortions or use the services of unskilled practitioners applying sometimes highly
dangerous traditional methods. 20 of 46 million induced abortions worldwide are
unsafe.
An estimated 46 million women around the world have abortions each year. Over 20
million of these abortions are performed illegally and under unsafe conditions. There
are about 610,000 unsafe abortions in Nigeria annually 40% of maternal deaths occur
in Nigeria.
Groups commonly affected include:
 Marital Women - for every maternal death 15 - 20% maternal morbidities occur.

 Students

 Divorcees up to 50% of the hospital resources are used in treating women admitted
for complications of unsafe abortion

 Single girls
 Unemployed
 Widows
 Commercial Sex Workers
underlying reasons for induced abortions include:
1. The non-usage of any family planning method by women, married and un-married
or their partners.
2. The use of a method that provides insufficient protection against pregnancy.
3. Failure of a contraceptive method,
4. Lack of access to contraception or to a method.
5. Unwanted pregnancy due to financial difficulties, desire to continue schooling,
fear of parent's reaction to a pregnant teenager at school
6. Lack of knowledge about Reproductive system
7. Single marital status
8. Too many children
9. Abandonment by the partner responsible for the pregnancy
10. Pregnancy resulting from incest
11. Lack of information to the public

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Complications of unsafe abortion
Immediate effect:
 Shock
 Severe vaginal bleeding
 Infection of the Reproductive tract, vaginitis, endometritis, salpingitis, oovritis
 Jaundice from septicaemia
 Intra-abdominal injury
 Uterine perforation
 Peritonitis

After effect:
 Ectopic pregnancy
 Infertility
 Chronic pelvic pain
 Pelvic inflammatory disease (PID)
 Marital disharmony
 Emotional instability
 Post abortion syndrome
 Habitual abortion
 Proness to cancer 0f the cervix and the uterus
Prevention of unsafe abortion
(To individual)
i. Health education and counseling.
 Counsel on the role of contraceptives to help women and men
reconcile their sexual lives and their desire for children.
 Counsel on utilization of family planning services and limited number of children.
ii. Abortion can be prevented by avoiding pregnancy through
appropriate, counseling and refraining from unplanned sexual
relations.
iii. Advise on keeping the pregnancy and baby, fostering and adoption, or sending babies
to foster homes/institutions.
STRATEGIES FOR PREVENTION OF UNSAFE ABORTIONS
1. Increase / improve family planning counseling services
2. Government must ensure that family planning commodities be available, accessible
and affordable at all levels of care.
3. Laws should be more liberal and accompanied by a broad range of policies and
programmes to enhance Reproductive Health services. Improve sexuality and
contraceptive education.
4. Expand support services for women and their families. Provision of access to quality
post abortion services through the use of manual vacuum aspiration for treatment of
complications.
5. Post abortion services must be established throughout the Federation to offer
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 contraceptive counselling, education and services promptly to women who have had
an abortion and encourage adolescents to delay sexual activity.
6. Young people must have access to relevant information and education on sexuality
and family life issues as well as quality Reproductive Health services including
family planning.
7. Liberalising abortion - where unsafe abortion exists, government must endeavour to
create a consensus amongst the people in favour of addressing its harmful, social and
health consequences.
8. Follow up and counsel on post abortion family planning needs: Help her select and
obtain the most appropriate family planning method, if desired.
9. Comprehensive Reproductive Health care outlets e.g User-friendly outlets alternative
to abortion.
10. Identify other RH services needed e.g. tetanus prophylaxis or booster, treatment for
STI and / or cervical cancer screening.
11. Keeping the pregnancy, or taking baby to foster home after delivery
Treatment of unsafe abortion
 Examine for signs of infection uterine, vaginal or bowel injury.
 If infection is present start with antibiotics e.g. Give Ampicillin 2G IV 6 hourly plus
Gentamicin 5mg / kg body weight IV every 24 hours. Plus Metronidazole 500mg IV
every 8 hours until fever subsides or for 48 hours.
 Perform MVA if available. If not available, refer.

5.6. 0MANUAL REMOVAL OF PLACENTA

This is an emergency action taken by the midwife to manage post partum haemorrhage and
prevent maternal death.
Equipment: Intravenous supplies. analgesic/anesthetic, soap and water, sterile elbow-length
surgical gloves, antiseptic lubricant-,
Delivery pack, Oxytocin injection, BP apparatus, watch clock, an assistant and emergency
transport, system (already provided).
procedure:
This procedure should be conducted under supervision for junior Midwives.
 Treat for shock if present, if conscious, reassure and encourrage for co-operation
 Explain procedure to patient.
 Maintain aseptic technique.
 Give Pethidine 50 mg and Valium 10mg separately or Phenobarbitone 30mg, to relax the
woman
 Start an IV normal saline or ringer's lactate to prevent shock
 Position the woman in the dorsal position (her back) with her knees flexed.
 Clean the external genitalia
 Empty the bladder.
 Catheterize if she cannot void (pass urine)

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 Rub the uterus to make it contract.
 Attempt removal, apply Controlled Cord Traction (CCT) - hold the cord with a clamp, use
firm steady pull on the curd while supporting the contracted uterus i.e support the uterus by
placing one lid above the symphysis pubis, press against the lower pan of the uterus
 Apply a firm, steady pull on the cord. Do not pull too hard
 If no success of CCT in 30 minutes
 Put on sterile gloves (use long gloves if available)
 Lubricate the examining gloved hand with clean, cooled, boiled water
 Use the non-examining finger to hold the umbilical cord firmly,

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STEP I

 Insert the examining hand (with the thumb folded into the palm) into the vagina

 Move the fingers laterally until the edge of placenta is located

 Follow the cordup to the placental edge.

 Do not take your handout until you have separated the placenta and arc bringing it out.

 Do not take your hand in and out of the uterus, because this increases the risk of infection.

STEP II

 Let go off the cord and use your band to hold the uterus firmly through the abdomen. This will
stop the uterus from moving up and helps to keep it contracted.

 Feel the placenta to figure out its exact location in the uterus.

 Find the edge of the placenta.

 Slip your extended fingers tightly between the edge of tile placenta and the uterine wall.

STEP III
 With your palm facing the placenta, use a sideways slicing or Movement to gently detach the
placenta from the implantation site with the edge of your hand.
 Proceed slowly all around the placental bed until the whole placenta is detached from the
uterine wall

 Never claw with the tips of your fingers because the placenta could tear. You will feel a spongy
tissue, which will let go as the placenta separates from the uterus. Gently remove slowly to
ensure completeness. After removal, rub the uterus to contract

 Give Oxytocin 20 units in I L fluids of Normal Saline at 60 drops per minute to aid contraction.

 If no injectable Oxytocin, give Misoprostor 200mcg orally and 400mcg sublingualy. Ask an
assistant to rub the uterus to contraction. Do not give ergometrine as its causes ionic
contractions

 Put the baby to the breast

 Examine the placenta for completeness

 Give antibiotics e.g ampicillin 1gm stat and 500mg 6 hourly for 5 days or give intramuscular
Benxyl penicilin 1.2 mega units 6 hourly for 24 hours.

 Follow with procain penicillin 1.2 mega unit and streptomycin 1gm daily for 5 days

 Check for bleeding, contracted uterus and full bladder, recheck Hgd 2 – 3 hours after bleeding
has stopped.

 If Hgb is less 7gldl, refer or transfuse. If Hgb is 7.11gldl treat anamea with iron and folate.\

 Avoid forceful CCT and fundal pressure, as they may cause uterine inversion or cord
detachement.
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  Check vital signs hourly until normal

 Continue with intraveneous infusion. Give a total of 3litres for 24 hours to replace fluid loss
from bleeding and prevent shock

 If bleeding stop, continue with basic care.

 Stop IV infusion after 24 hours, If condition is normal

 Encourage breask feeding to ensure that uterus remains contracted

 Give analgesic e.g paracetamol 1g tds for 3 days to lessen abdominal and perennial pain

 Vulva swabbing 3 times daily for three days

 Teach her how to do it after discharge.

 Educate and encourage nutritions and easily digestable food and drink plenty of fluid daily.

 If bleeding persist or does not stop perform bi-manual compression of the uterus.

Labour may be managed actively or expectantly. Active management of labour involves the use of utero-tonic drug.
Expectant management of labour is allowing the placenta to deliver using gravity and maternal pushing. This is not
advocated because of risk of postpartum haemorrhage.
Proper management of labour results in successful outcome both for the mother and baby. The use of partograph to
monitor the progress of labour and for clinical decision making has been proven as a must use tool in the skillful
management of labour.
The partograph is a tool used for monitoring the progress of labour in order to promptly detect deviation from normal
delivery that develops as labour progresses. The partograph is basically a graphic representation of the events of
labour plotted against time.
Note: the partograph is a tool for monitoring labour only. It does not help to identify other risk factors which may have
been present before labour started except those which will continue to manifest during labour e.g. raise blood pressure.
WOMEN WHO DO NOT QUALIFY FOR PARTOGRAPH
1. 9-10 cm cervical dilation
2. Elective Caesarean Section
3. Emergency Caesarean Section on admission
4. Gesfational age less than 30 weeks
5. Ante - Parium haemorrhage
6. Severe Pregnancy Induced Hypertension (PIH) e.g. Severe pre - eclampsia and eclampsia
7. Malpresentation and abnormal lie e.g. Breech, face, brow, and transverse lie.
8. Confirmed Cephalo - Pelvic Disproportion (CPD)
It consists of 3 parts as follow:
1. The foetal condition : Observations charted are the foetal heart rate, membranes, liquor and
moulding of the foetal skull.
2. The progress of labour: Observations charted are the cervical dilatation, decent of the foetal
head through abdominal palpations and uterine contractions at frequency of 10 minutes duration.
3. The maternal condition : Observations charted are pulse, blood pressure and temperature.
Others include mine (volumes, protein, acetone) drugs and intravenous fluids, oxytocin regimen.

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 Note: A partograph chart must only be started when a woman is in active labour i.e when cervical
dilatation is 4cm.
 The graph is useful in hospitals and maternities to help identify women whose labour is not
progressing well.
 Charting on the partograph starts from the active phase. The contractions must be 3 in 10 minutes,
each lasting 20 seconds or more. Cervical dilatation must be from 4cm.
The diration of contractions are up to 20 seconds, 20 - 40 seconds, and more than 40 seconds e.g.
The woman is having 3 contractions in ten minutes lasting 30 seconds.
Patient's information: Fill out name, gravida, para, hospital number, date and time of ruptured
membranes or time elapsed since rupture of membranes (if rupture occurred before charting on the
partograph began)
 Foetal heart rate: Record half hourly,
 Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination as indicated
thus:
I: Membranes Intact
R: Membranes Ruptured
C: Membranes ruptured, Clear fluid
M: Meconium Stained fluid
B: Blood Stained fluid
Moulding:
1: Sutures apposed
2: Sutures overlapped but reducible·
3: Sutures overlapped and not reducible
Cervical dilatation: Assessed at every vaginal examination and marked with a cross (x) begin plotting
on the partograph at 4 cm,
Alert line:This starts at 4cm of cervical dilatation to the point of expected full dilatation at the rate of
1cm per hour. Action line: Parallel and four hours to the right of the alert line.
Descent assessed by palpation:
This refers to the part of the head (divided into five parts) palpable above the symplysis pubis recorded as
a circle (0) at every abdominal examination at 0/5, the sinciput(s) at the level of the symplysis pubis.
Hours: This is the time that elapsed since onset of active phase of labour (observed extrapolated)
Time: Record actual time.
Contractions: Plot contractions per 10 minutes below the time and on the left hand side. Chart every half
hourly, count the number of contractions in a 10 minutes time period, and their duration in seconds.
Squares are numbered from 0 – 5. Each square represents one contraction, the squares below show the key to the 3
ways the strength of contractions are recorded on the partograph.

Dots are for mild contractions of less than 20 seconds duration

Diagonal lines indicate moderate contractions of 20 to 40 seconds duration

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 Solid color represents strong contractions of longer than40 seconds
Time: Record actual time. .
Oxytocin: Record the amount of oxytocin per volume, IV fluids in drops per minute, every 30 minutes when
used. Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and with a dot (.)
THE FOETAL CONDITION
Fetal heart rate, membranes, liquor (amniotic fluid), and moulding of tile fetal skull bones give information
about how the baby is doing during the labour.
Fetal heart rate
Listening to and recording the fetal heart rate is a safe and reliable way of knowing that the fetus is well-listen
to the fetal heart rate for a full minute immediately after the strongest part of the contraction, with the woman
lying on her back.
The fetal heart rate is recorded at the top of the partograph. There are spaces to record the fetal heart rate every
half hourly, each square .represents 30 minutes check and record the fetal rate at least every hourly, and every
half hourly, when possible, when there are problems, you may listen to the fetal heart after every contraction.
Membranes and liquor (Amniotic fluid)
The state of the liquor or amniotic fluid can assist in assessing the fetal condition. the following observations are
recorded on the partograph immediately below the fetal heart rate recordings. The observations are made at each
vaginal examination as follows:'
If the membranes are ruptured:
 Liquor is clear, write the letter 'C' for clear
 Liquor is blood stained write the letter 'B'
 Liquor is meconium stained, write letter 'M'
 Liquor is absent, write the letter' A' for absent.
These may be signs of fetal distress (the baby is in trouble). Listen to the fetal heart rate every 5 to 15
minutes if:
 membrane are ruptured.
 liquor has thick green or black meconium .
 liquor is absent at the time membranes ruptures.
Moulding of the foetal skull bones
The amount of moulding helps you 10 know how well the pelvis is making room for the fetal head. Moulding is evaluated
each time you do a vaginal examination. Moulding when the head is still high is a sign of disproportion (baby is too big for
mother's pelvis).
RECORDING THE MOULDING:
0 = bones arc separated and the sutures can be felt easily
+ = bones are just touch ing each other
++ = bones are overlapping, can be separated easily with pressure from your finger: REFER if descent and
labour is not progressing
+++ = bones are overlapping. cannot be separated easily with pressure from your
finger. REFER.
if Moulding is ++ or +++ REFER.
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Points to remember:
 Listen to the fetal heart rate for a full minute immediately after the strongest part of a contraction, with the
woman lying on her back.
 Record the fetal heart rate at least every hour in the first stage of normal labour
 Normally the fetal heart rate is between 120 and 160 beats in a minute
 Moulding when the head is still high is a sign of disproportion (baby is too long for mother's pelvis). REFER
IMMEDAITELY.
THE MATERNAL CONDITION
All the observations on the mother's condition are recorded at the bottom of the partograph. All entries are made on the
time line at which the observations are made.
 Pulse, blood pressure, and temperature Take the blood pressure 2 hourly temperatures and pulse every 2 hours.
 Urine: Ask the mother to pass urine every hours. Look at the urine for amount and concentration.
Concentrated urine is a sign of dehydration. The protein and acetone should be tested on admission in hospital
and at maternities if possible. Protein in the urine may be a sign of pregnancy induced hypertension. Acetone in
the urine may be a sign of dehydration e.g. hyperemesis gravidarum.
 Drugs and rehydration fluid: Chart these when you give them.
 Oxytocin: There is a separate column for oxytocin above the column for rehydration fluids and drugs.
Oxvtocin in labor is used only when a doctor is available to manage the infusion and when cesarean section
facilities arc present.

VAGINAL EXAMINATION
Indications:
 Feel the thinning, shortening (effacement) and opening of the cervix.
 Feel the position of the presenting part.
 Feel (assess) caput, moulding, and bag of waters (Liquor and membranes), and
 Feel (asses) the pelvic sizes on admission
 Decide whether a woman is a labour
 Monitor progress of labour
 Figure pout the presentation or position

 Make Sure the CORD IS NOT PROLAPSED

 Do a vaginal examination every hours when a woman is in active labour.
Procedure:
 Explain to the woman what you are going to do. Gather your equipment. (Do an abdominal examination before
doing a vaginal examination)
 Ask the woman to lie on her back with her knees bent and her legs spread apart. Look at the woman's genitals
for discharge. Remember, breech presentation may have yellowish or greenish stained liqour. Meconium
discharge from the vagina may be a serious warning sign.
 Wash your hands with soap and water and put on sterile or high-level disinfected gloves, if available
 Clean the genital area.
 Use cotton balls or cloth squares and antiseptic solution or soapy solution to wipe the woman's genital area
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 from front to back.
 Repeat the wiping from front to back until the genital area is clean.
 Dip-the index and middle fingers of your gloved hand into an Antiseptic lubricant
 Hold the woman's labia apart with the thumb and index finger of your other gloved hand. Gently insert the 2
fingers of your hand into the woman's vagina. Once your fingers are inserted, do not take them out until the
examination is finished; this decreases the-risk of infection
 feel the woman's vagina. Move your fingers around the vaginal wall. Feel for hard scarring. Move your fingers
to the back of the vagina. Feel for stool in the rectum
 Feel the vaginal walls and cervix:
 Feel the cervix with the tips of your fingers. Check its firmness and thickness and decide how much the cervix
has thinned; thinning of the cervix is effacement. Determine how much the cervix has opened; opening of the
cervix is dilatation.
 Measure the dilataion in cm: complete dilatation is 10 cm
 Cervical effacement (thinning) and dilatation (opening) allow the baby to pass out of the uterus. Full
effacement happens when the cervix is very, very thin (it is as thin as the skin on a mango). Complete
dilatation occurs when the cervix is no longer felt.
 Feel the bag of waters (membranes)
 The membranes may be intact until the cervix is fully dilated and may need to be artificially ruptured (ARM)
with a sterile instrument. The membranes feel like a full balloon
 If the membranes are ruptured. the water (amniotic flu id or liquor) should be clear, If the water is stained
from the meconium (stool of the baby) or if there is very little or no water, the baby may be distressed. The
meconium may indicate hypoxia (too little oxygen to the brain). Meconium is frequently seen in breech
presentation
 Feel the presenting part of the baby and use this information with your abdominal examination findings to con
firm (identify) which part or the baby is at the cervix:
 A vertex presentation means that the head is at the cervix
 A breech presentation means (he buttocks or legs are at the cervix
 A transverse presentation means the baby is lying sideways in the uterus, and an arm or shoulder may
be at the cervix.
 If the head is at the cervix, feel the fontanelles to decide the position of the baby. The anterior fontanelle is a
diamond shaped joining of four sutures. The posterior fontanelle is a triangle joining of three sutures. In a well-
flexed vertex presentation, only the posterior fontanelle is felt. If the head is not well flexed (deflexed), both
fontanelles are felt.
 Feel for caput and moulding. Feel the suture lines for separation; severe overlapping of the bones can be a sign
that the head will not fit through the pelvis of the woman (cephalopelvic disproportion).
 Feel how far the baby has progressed into the pelvis. Compare this finding to your abdominal palpation of
descent of the baby's head
 Feel for the absence of the umbilical cord; the cord is prolapsed when it drops through the cervix before the
presenting part: it will feel like a soft, pulsating cord.
 Remove your hand from the woman's vagina. Help her turn to a comfortable position
 Explain your findings to the woman and her family. Record your findings on the labour graph (partograph).
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 Note: At the vaginal examination, record the following
 Colour of amniotic fluid
 Cervical dilatation;
 Descent (Can also be assessed abdominally).
 If the cervix is not dilated on first examination it may not be possible to diagnose labour.
 If contractions persist, re-examine the woman after four hours for cervical changes. At this stage, if there is
effacement and dilatation, the woman is in labour; if there is no change, the diagnosis is false labour.
 In the second stage of labour, perform vaginal examinations once every hour.
Cervical dilatation:
This is assessed at every vaginal examination and marked with a cross (X) on the partograph. Begin plouting on the
partograph at 4cm.
5.7.0 MANAGEMENT OF OBSTRUCTED LABOUR: VACUUM EXTRACTION
VACUM EXTRACTION
Vacuum extraction is the method used by the midwife to assist the mother, in her efforts to deliver her term, vertex
baby vaginally. Vacuum extraction can however be used only where there is a doctor to back-up in case if it fails.
otherwise, screen and refer immediately. Vacuum extraction is considered a safer method than forcep delivery
How vacuum extraction works
When the vacuum extraction cup is applied on the baby’s head, a vacuum (suction) inside the suction cup
pulls against the skin of the baby’s head. It pulls the skin of the scalp into the suction cup. The skin forms
a cuput suceedneum, which fills up the inside of the suction the inside of the suction cup. The caput
suceedenium gives a grip or hold on the scalp without hurting the skull borne. The suction from the
vacuum extraction might cause the periosteum to pull away from the skull bones a little sometimes,
causing a very small amount of bleeding (sub-periosteal haemorrhage). The midwife uses the vacuum
extractor to guide the head of the baby while the mother pushes.
Types of vacuum extractor
1. Metal cup extractor e.g. The Maimstrom vacuum extractor
2. soft Cup Extractor
there are three types of soft cup extractor namely:
a. Mityvac Vacuum
b. Silastic Obstetrical Vacuum Cup
c. Columbia medical incorporated (CMI) Vacuum Cup
Description of use of parts
The metal cup extractor include a rubber tubing (B) containing a metal chain that ends in a handle connected to
the cup.
The rubber tubing (A) goes through the handle and into a glass container, which is filled with a pressure gauge. A
hand pump takes out air and makes the Vacuum. The pump (hand, foot or electrical) is attached to a short piece of
rubber tubing (C) and the glass container. A wire basket supports and protects the vacuum bottle. The pump pulls
air from the glass bottle, creating a vacuum. The vacuum pressure is reduce by loosen the tap (D). The handle is
used to pull with each contraction.
SOFT CUP EXTRACTOR
The soft cup extractors include a plastic vacuum tubing (B) connecting the clip to the mucus trap. The rubber vacuum
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tubing (A) connects the mucus trap to the pump. To create a vacuum with the hand held pump, squeeze the pump
handles together, (Electrical pumps are also available). To reduce vacuum pressure, pull the vacuum release finger
(D) toward you and hold until you get the pressure you need. Use the traction handle to pull with contraction (E).
a. The mityvac vacuum extractor: The mityvac cup is dome shape, soft and reusable about 5 times. Other
soft cups can fit on the mityvac vacuum pump. Test the cup each time before using it as described
on gape.
b. The Silastic obstetrical vacuum cup: The Silastic cup can be fitted to various pumps, is
trumpet shaped, soft, and may be reused up to 5 timer. The cup must be tested each time
before used as described on
c. The CMI Vacuum cup: The Columbia Medical Inc. (CMI) hand held vacuum pump is autoclavable by gas or
steam methods. An electric model is also available. The mucus trap on the hand held model is optional. The
cup shown on this model is dome shaped, soft, and pre-packaged sterile and disposable. A cup which is
trumped shaped soft is also available. A cup model with a shape similar to the to the Malmstrom
cup is now available in both stainless steel and rigid polyvinyl .Any cup either reused or new, must
be tested prior to use.
Indications for using a vacuum extractor:
1. Delay in the second stage of labour: The mother must actively push without progress for 30
minutes in the primigravida, or 20 minutes in the multigravida,
2. Foetal distress in the second stage of Labour: the baby is alive or newly dead
(feotal heart stopped during labour)
Other indications for assisted delivery other than vacuum extraction (to be managed by a doctor)
 Maternal distress: Severe anaemia, hypertension, pre-eclampsia, heart 'problem, asthma,
diabetes, tuberculosis and malnutrition
 Rigid or small pelivic outlet.
 Transverse arrest of the foetus
 Large baby
 Dispropotion due to deflexion of the foetal head
Conditions for using a vacuum:
The midwife practicing vacuum extraction must be skilled and experienced:
The midwife is expected to have used the vacuum extractor on 5 to 8 normal deliveries for proficiency,
Primiparas are to be chosen at the end of first stage when the cervix is fully dilated and the baby begins
to descend through the pelvis. This will assist the midwife in the practice of vacuum extraction before
attempting more difficult deliveries.
Before earring out vacuum extraction, the abdominal findings must always include:
 Term (full size) baby
 Vertex presentation
 Ruptured membranes
 No cephalopelvic disproportion i.e. ensure
(a) No foetal skull moulding
(b) No caput and
1/5 or 0/5 on abdominal palpation.
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  Baby is alive or foetal heart stopped during labour.
 Contractions present
 Full dilatation and effacement of the cervix (anterior lip may be an
exception)
 Make sure that another midwife is available to take care of the baby.
 Instrument must be in good working order,
Contra indications to the use of a vacuum extractor:
Do not try Vacuum extraction if there is:
 No contractions
 Cephalopelvic disproportion / Foetal pelvic disproportion (large baby)
 Foetal skull moulding 2+ or more
 Caput formation
 Non-vertex presentation (all types)
 Incomplete cervical dilatation
 Gestational age less than 37 weeks.
 Unengaged presenting part.
 Disengagement of the vacuum extractor (the Cup pops off) 3 times
 Failure of efforts after 15 minutes or 5 contractions, whichever comes first.
Using a vacuum extractor:
Equipment:
 Delivery set up
 Vacuum extractor
Procedure:
Evaluate the woman's condition abdominally and vaginally (look and feel) to ensure that the conditions
for carrying out a vacuum extraction are present.
1. Explain to the Woman and her family what you are going to do and the reason for doing it.
2. Prepare equipment - Connect pump, tubing, mucus tap and cup.
 Use the largest cup available
 Test vacuum on the palm of your hand by squeezing the pump handle to start the evacuum.
 Hold the cup on your most skulled hand, you should feel the suction on your hand.
 Release the pressure
3. Position the woman on her back with her legs bent.
4. Ensure the bladder is emptied. If she is not able to urinate catheterize to avoid delay in second
stage due to a full bladder
5. Perform a vaginal examination to determine the baby's position and presentation.
 Locate the posterior fountannel. Place the cup on a well- flexed head. If the head is not well
flexed, apply the cup anyway. With correct direction of pull, the head will flex.
 Gently pull down on the perineum to make space for the cup
 Separate the labia with the fingers of your other hand.
 Hold the cup with your most skilled hand.
 Apply the cup insert the extractor cup gently into the vagina.
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  Wipe the baby's scalp clean with dry quaze
 Remember the positions of the posterior fontanelle, gently press the cup downward and inward
into the vagina until the cup touches the scalp.
 Press the cup up against the part of the baby's scalp that is easiest to reach
 Pass a finger gently around the edge of the cup to ensure that none of the mother's tissue has
been caught under the cup.
 Raise the pressure by squeezing the pump 'handle to raise the pressure to 100mm Hg.
(Millimeters of Mercury).
Note: if you are using the metal cup see instructions on how to raise and manage the pressure
 Recheck to ensure that no maternal tissue has been drawn under the edge of the cup, because this will
cause the cup to pull off and damage the mother's tissues'.
 Wait for the next contraction.
 As the next contraction begins, raise the vacuum pressures to 400mmHg (15inches Hg). The maximum
pressure of 600mmHg (22inchcs) should never be exceeded.
 Bring the foetal head down with a contraction
 Pull downward towards your kneels until the vertex clears the symphysis pubis
 Encourage the mother to push long and steadily with a contraction.
- As the mother pushes, pull downward on the handle firmly and straight. (see baby's head rotate at the speed
and direction of a normal delivery).
 Do not twist and turn the cup or the handle, this will cause the cup to pop off. The baby's scalp could be
injured (bruising, bleeding, swelling), when the cup pops off.
When a contraction stops:
 Reduce the pressure to 100mmHg. Do not pull
 Encourage the mother to breathe slowly and deeply to relax
 Ask an assistant to check the foetal heart rate .
 Repeat the pulling - bring the foetal head down with a contraction until the head clears the svmphysis
pubis. Usually, 2 or 3 times is sufficient. Progress must be seen with each contraction.
 With each contraction, guide the head straight out. The head should progress over the perineum. Do not
allow pressure to remain at maximum levels (600mmHg) for more than 10 minutes total. Too much
pressure can cause bleeding into the skull or serious scalp damage e.g (Sub-periosteal haemorrhage)
 Deliver tile baby, An episiotomy may be necessary in the primipara to decrease resistance of the
perineum before the baby's head crowns.
 When the baby's head begins to crown during the next contraction, with the pressure at 600mmHg. Pull
Upward.
 After the head has delivered release the pressure and continue with the delivery.
 Perform active management of third stage of labour to deliver the placenta, (give Oxytocin 10 units 1M
(within l minute of delivery), deliver placenta by CCT, rub the uterus 10 contraction).
 Check the birth canal for tears / lacerations following childbirth and repair episiotomy
 After the delivery, care for equipment
THE MALMSTROM VACUUM EXTRACTOR

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 USING THE METAL CUP EXTRACTOR (MALMSTROM)
This extractor is used with continuous pressure in the cup
Procedure
 Close the pressure release valve.
 Ask your assistant to pump the pressure and carefully watch the gauge.
 Raise the pressure to 200mmHg
 Recheck to make sure no maternal tissue has been caught in under the cup.
 After 2 minutes, raise the pressure to 300mmHg, increase the pressure by 100mmHg every 2
minutes until the pressure reaches 600mmHg. Recheck to make sure no maternal tissue is caught
under the cup. At this time, the scalp is sucked into the cup and a caput succedeneum is produced.
If the pressure is increased too quickly with the metal cup, the suction will be poor and the cup
will pull off.
 Never exceed the maximum pressure of 600mmHg
 Bring the foetal head down with a contraction as the mother pushes long and steady.
 Pull on the handle firmly and straight. Do not twist or turn the cup or handle for this will cause the
cup to pop off.
DIAGRAMMATIC PRESENTATION OFTHE PROCEDURE

Using the cup

 First Pull: Downward to move the head by flexion under the symphysis and to reach the perineum
 Second Pull: Downward pull as in the first pullprogress must be seen.
 Third Pull: Straight out for the head to progress over the perineum
 Fourth Pull: Pull up to help the mother deliver the head of the baby.
 When the contraction stops do not pull however continue the pressure at 600mmHg
 Encourage the mother to breathe slowly and deeply to relax between contractions
 Have an assistant take the foetal heart rate.
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 Pull with contractions until the head begins to crown, Do not allow the pressure to remain at maximum
levels (600mmHg) for more than 10 minutes.
 Deliver the baby.
Failed vacuum extraction:
 Classify a failed vacuum extraction if :
o Foetal head does not advance with each pull.
o Foetus is undelivered after three pulls with no descent or after 30minutes.
o Cup popped off the head twice at the proper direction of pull with a maximum negative
pressure.
o Every application should be considered a trial of vacuum extraction. Do not Persist if there is no
decent with every pull.
o If vacuum extraction fails, proceed to arrange for a caesarean section.
Note: A vacuum extractor in capable hands is much saver for both the mother and baby than a long
delay in delivery and /or a long journey to the hospital.
Dangers of vacuum extraction
Mother:
i. Cervical, vaginal or perineal laceration
ii. 3rd degree tears
iii. Haemorrhage /shock
Baby
i. Caput suceedaneum
ii. Cephal haematoma
iii. Intra-cranial injury
Care of the vacuum extractor
 The vacuum extractor set is delicate therefore avoid dropping it on hard surfaces
 Store in a clean, dry and covered area,
Cleaning: After delivery procedure, decontaminate and clean in readiness for the
next uses as follows:
 Wipe the pump, tubes, and dry with soft clean cloth damped with
decontamination solution e.g Jik.
 Clean out any fluids that went into the pump during the delivery by pumping
warm water through the pump.
 It is important to do this as soon as possible
 Do not allow fluids to dry inside the pump. This may stop the pump from
working.
 To dry it, pump air until the inside of the equipment is completely dry

 If you are using a reusable cup or tubing, decontaminate it, and then wash with soap and water.
Rinse very well, drain tubing and dry completely.
 Sterilize or high-level disinfect the cup and tubing before using for a delivery.

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PUMP GAUGES AND MEASURES
Some pump gauges show the safe pressure zones with different colours.
Red means the pressure is too high and is dangerous. Not Safe on the vacuum conversion table, the
maximum pressure line is marked to remind you that this is the highest pressure you can use with a
vacuum extractor. Check the table below and circle the measures that are on your vacuum extractor.
VACUUM CONVERSION TABLE

5.8
mmHg Inches Hg 1b/in square Kg/cm squared
760 29.9 14.7 1.03
700 27.6 13.5 0.95
600 23.6 11.6 9.82 Maximum pressure

500 19.7 9.7 line

0.68
400 15.7 7.7 0.54
300 11.8 5.8 0.41
200 7.9 3.9 0.27
100 3.9 1.9 0.13
MANAGEMENT OF 3RD STAGE LABOUR: THE USE OF OXYTOCIN DRUGS/MISOPROSTOL
MANAGEMENTOF 3RD STAGE Of LABOUR:

This stage may last up to 30 minutes.

Process: Within I minute of the birth of the baby, palpate the abdomen to rule out the presence of an additional baby(s)
and give Oxytocin 10 IU units 1M. It has' minimal side effects, and can be used in all women. If Oxytocin is not
available, give Ergometrine 0.2 mg 1M or oral Misoprostol (600ug). Make sure there is no additional baby(s) in the
uterus before giving these medications.
 Encourage to pass urine, if not, catheterize if bladder is full.
 Deliver the placenta and membranes using Controlled Cord Traction (CCT). This is done by placing one hand
over the lower half of the uterus and with the other hand, apply steady tension on the cord until the placenta and
membranes are delivered.
 Expel blood clots to make the uterus contract.
 Inspect perineum, vulva and vagina for lacerations.
 Clean the client up.
 Check vital signs-Temperature, pulse, respiration and blood pressure.
 Feel uterus for firmness.
 Make mother comfortable and offer her a drink.
 Give baby to mother to breast feed (if not already initiated at delivery).
 Examine placenta and membranes for completeness.
 Estimate blood loss and record your findings.
 Recheck blood pressure: this stage may last lip to 30 minutes here. If placenta does not come out after 30
minutes remove manually.
 Avoid application of fundal pressure throughout labour.
Active Management of Third Stage(A MTSL): Active management of third stage helps to prevent haemorrhage: and

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it includes the following actions:
1. Immediate Oxytocin.
2. Controlled Cord Traction (CCT) with counter traction to the uterus:
3. Uterine massage(alter delivery of tile placenta).

How to perform (AMTSL):

This is performed within one minute (60 seconds) of delivery as follows:
1. Quickly palpate the abdomen to ensure there is no second baby.
2. Give Oxytocin 10 IU Intravenously (or Misoprostol600mcg 3 tablets)
3. Deliver placenta by Controlled Cord Traction (CCT).
a. Wait for strong uterine contraction
b. Apply CCT and counter traction above the pubic bone.
(Note): If placenta does not descend, await next contraction and re-apply (CCT)
4. Massage uterus after delivery of the placenta. (Ask the woman to continue to massage the uterus
for 15 minutes and every 15 minutes for the next two hours).
Expectant management of labour: This is allowing the placental to deliver using gravity and maternal
pushing. This is not advisable because of risk of postpartum haemorrhage.
Advantages of AMTSL over expectant management:
It decreases the following:
 PPH up to 70%
 Length of the third stage of labour
 Need for blood transfusion
 Postpartum anaemia.
 Need for therapeutic uterotonic drugs
 Need for referrals and transportation.
5.8 Repair of tears / lacerations
If is important to note that women die of blood loss from simple tears or lacerations that are not found or
repaired.
REPAIR OF TEARS OF THE CERVIX
Procedure Examine the woman carefully and repair lacerations or rears. The commonnest site of cervical tears
are at angles 9 and 3'oclock.
 Locate the apex (top) of the wound by running your linger through the whole wound. Gently grasp the cervix
with ring or sponge forceps at angles 12 and 6 O'clock. Place the first suture of about 1cm (1/2 inch) above the
apex of the wound in the vagina. Hold the thumb forceps in the other hard. Use the forceps to pull the needle
through the tissue. Never use your fingers to avoid pricking your fingers or breaking your gloves. This will
increase your risk of getting a blood borne infection e.g HIV or Hepatitis B Use chromic catgut 2 0 or 30 (or
polyglycolic) suture.
 Tie the suture off with a square knot and mm off the short thread to about 1cm,
 Suture the vaginal mucosa using interrupted stiches sewing down to the hymeneal ring.
 The needle then goes through the vaginal mucosa, behind the hymeneal ring, and is brought out of the wound.
 Use continuous suturing as you suture the muscle layer. Look inside the cut for the muscle layer this looks a

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 little red in colour and feels to touch. It is important to sew muscle to muscle.
 Feel the bottom of the cut. The suture should come through first above the bottom of the cut. When you reach
the end of the wound or cut, you have closed the deep muscle layer.
 As soon as you reached the very tip of the wound, turn the needle over the start to sew upwards the vagina
using continuous stiches to close the tissues under the skin. This tissue is not to touch and has the same colour
as the vagina mucosa. (it is the sub-cutical tissue).
 You are now making a second layer of stiches. This second layer of suture will leave the wound about 0.25cm
(1/4 inch) open. This will eventually close up when healing occurs.
 NB: Always pull the suture through with your thumb forceps. Do not use your finger feel for the tip of the
needle
 Now move the suture again from the perineal part of the wound back to the vagina behind the hymeneal end to
be secured, tied up and cut.
 Tie off the suture with a square knot
 Make one end and a half square knots. Cut the 2 ends of the suture off, leaving about 1cm to secure it so that it
does not pull apart.
 Examine to see that no gauze, sanitary pad or instrument is left in the woman’s vagina
 Clean her up and make her comfortable
 Advise the woman to wash the area with warm saline water 3 to 4 times daily or keep her perineum clean and
dry.
 She should not put anything in the vagina or use boiling baths
 Return visit after one week to check for healing of the wound
 Check the perineum, look for redness, pus, loosening or opening of the sutures or haematoma. If any of these
is present, or if bleeding persists refer her.
 Record findings, care and medications at the back of labour form
PERI - URETHRAL TEARS
Tears around the clitoris and urethra can bleed very profusely and can be very difficult to repair hence refer the
patient. Before referral, pack the vulva firmly with sanitary pads, or bandages and have her keep her legs
pressed together. Wrapper may be tied round her legs to keep the legs firmly together. If you must repair the
laceration yourself, place a catheter in the bladder to help identify the urethra and keep it from accidentally
suturing the office or damaging it. Incase of laceration of the anterior part of the upper urethra, interrupted
sutures can be used. Continue to make interrupted sutures for the full length of the laceration. Remember, the
most important thing is to control the bleeding. If blood continues to ooze from the laceration. Press gauze
firmly on it for a couple of minutes.
 Carefully take off the gauze
 If the bleeding stopped clean and dry the woman, make her comfortable.
 If the bleeding continues, press gauze on the wound with steady pressure for at least ten Minutes. Do
not look, normal clothing time is usually about 7 minutes. If she still continues to bleed, add
more stiches to control the bleeding
5.9 MANAGEMENT AND TREATMENT OF SHOCK
Shock is defined as collapse due to acute peripheral circulatory failure. It is characterized by failure of the
circulatory system to maintain adequate perfusion of the vital organs.
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Shock is an emergency in which the body’s circulation does not work normally and organs such as the
heart, lungs are affected due to lack of oxygen, so when a woman is bleeding profusely, there will be
reduced blood supply to important organs including hearts and lungs, hence there will not be enough
blood to be pump by the heart and this lead to low blood pressure.
OBSTETRIC CONDITION ASSOCIATED WITH SHOCKS
 Bleeding in early pregnancy e.g ectopic or molar pregnancy, abortion.
 Bleeding in late pregnancy due toe.g uterine atony, tearof genital track, retained placenta and
placenta products and ruptured uterus.
 Infection due to e.g unsafe or septic abortion, endometriosis, amnionitis.
 Trauma, uterine rupture, injury to the uterus from unsafe abortion, tears and laceration from the
genital track,
SIGNS AND SYMPTOMS OF SHOCK
 Rapid feeble pulse (100/min or more)
 Low blood pressure (below 90/60mmHg)
 Pallor (congetival, palms, lips)
 Sweating, cold and clammy skin
 Rapid shallow respiration (30 bits per minute or more)
o Eye – dull
o Face – pale, sweaty
 Nausea, vomiting, weakness, anxiety, restlessness, thirsty
 Unconsciousness
 Scanty urine output (less than 30miles per hour)
 Confusion, anxiousness
Principles of shock care
 Keep airways open
 Keep woman breathing
 Keep heart beating
 Monitor shock position
 Control bleeding
 Keep woman hydrated
 Move gently
 Prevent loss of body heat
 Give nothing by mouth
 Keep calm and be reassuring
Nursing management
Mobilize all available human and material resources
Immediate care:
 Start immediate resuscitation
 Keep airways open.
 Turn head to one side with the jaw lifted up to prevent falling down of the tongue.

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  Check vital signs (pulse, blood pressure, respiration, temperature in this order.
 Keep warm. ,
 If unconscious, position on the side to minimize aspiration if vomiting occurs.
 Elevate legs

 Check breathing and give Oxygen by face mask (if available)

 Raise foot end of bed (if possible)

 Find out the cause of the shock and take appropriate action
 Perform Cardio-Pulmonary Resuscitation (CPR)
 Maintain vital signs
 Control bleeding (if any)
 Hydrate by setting up Intravenous Infusion using I or 2 large bore cannula (16 gauge or bigger)
 5% Dextrose, Normal Saline or Ringers Lactate depending on the condition.
 Note:5% Dextrose/Saline in water provides energy and rehydrate. Give 2,500cc to a 45-70kg
person in 24hours.
 Or give 5% Dextrose/Saline: This helps to maintain water and salt balance and at the same time
provides energy.
 Give2,500cc in 24hrs to a 75-70kg person
 Normal Saline (Sodium Chloride 0.9% Isotonic Saline); this is given to replace blood loss and
fluid loss during bleeding or diarrhoea. When the woman is not able to take enough oral fluids,
(by mouth). Give 1 OOOcc to 45-70kgperson in 24 hours.
 Ringers Lactate: This is given to replace fluid loss due to diarrhoea or when a woman is in shock.
Give 1,000cc of Ringers Lactate first and follow with 1,500cc of Dextrose 5% in water. 1,500cc is
given to a person with 45-70kg in 24 hours.
 Don't infuse too much intravenous solution too fast to prevent heart failure but if the woman is
near shock or is bleeding profusely run 500cc of fluid intravenously as fast as it will go. Then
shortly at 100cc per hour.
 Check her vital signs every 5 minutes.
Subsequent care
 Collect blood for haemoglobin, grouping and cross matching
 Nil per oral
 Monitor vital signs
 Catheterize the bladder, to obtain urine for testing
 Maintain intake and output chart
 Administer Oxygen at 6-8 liters per minute by cannula or mask
 Assess clotting status
After stabilization
 Determine the cause of shock
 Manage and treat according to the cause of shock
 If heavy bleeding is suspected as the cause of shock transfuse immediately (after grouping, cross
matching and screening of the blood)
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  If infection is suspected, collect samples of blood, urine and pus for microscopic culture
 Administer antibiotics for the first 48 hours e.g Ampicillin 2gm IV Six hourly plus Gentamycin
5mg/kg/body weight iv every 24 hour
 Metronidazole 500mg IV eight hourly.
 If due to trauma, prepare for surgical intervention.
 Continue observation of vital signs to assess if condition is stabilizing
 If condition fails to stabilize or improve, refer for further medical management.

ANTI SHOCK GARMENT (ASG)

Anti-shock garment is used in the control of haemorrhage.
It is made from an elastic material, and when applied, it looks like a TROUSSER.
It is divided into segments labelled 1,2, 3, 4 & 5 from the leg to the navel.
Advantages of anti-shock garment:
1. Efficient and safer for the patients
2. Effective, simple and easy to apply
3. Stabilizes the patient while the doctor is looking for cause and source of bleeding.
4. Can keep patient alive while being transported or transferred.
5. May control bleeding and reduce need for blood transfusion
6. Can be applied by any trained health worker
7. Patient in the state of shock may benefit
Mechanism of action of Anti-Shock Garment
Diverts blood from lower extremities of the body to the vital organs like kidney, heart, lungs and brain.
This results in translocation of up to 11.5 litres of blood from the lower body to the vital organs.
It reduces haemorrhage in the tower body by overcoming the pressure in the capillary and venous
system (15.25mm Hg.), thereby reducing blood flow to the lower parts of the body and decreasing
arterial perfusion pressure to the uterus. This is comparable to that achieved by ligation of the internal
iliac arteries.
INDICATIONS FOR ASG
Patients with severe blood loss with the signs and symptoms of shock e.g blood pressure 80/50mmHg,
rapid pulse 100 beats per minute if avaliable or absence of pheripheral pulses and un-recordable blood
pressure.
Contraindications
 Pregnant patient with a live foetus.
 When bleeding is from the chest region.
 Patient with heart disease.
Who to apply the ASG
 Doctors
 Nurses/Midwives
 CHEW
 Other health care personnel including drivers.
Procedures
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Rules: It must be applied by a single person it is better applied on a flat surface.
Application:
NB: It is advisable that the likely user of this device watch at least a practical demonstration session
before frying it because 'wrongful application will not achieve the expected result on the patient:

 Patient should be made to lie on flat surface

 Put on a pair of surgical gloves

 Open the ASG on a flat surface

 Apply 22, 33, 4 & 5 the patient should be placed on it and milking sure that the part of ASG
labelled Navel (5) matches the patient's navel

 wrap the garment from each end starring from the lowermost part of the leg (labeled 1) to the navel region,
(You must ensure that Numbers 1 and 2 parts of the garment are below the knees: number 3 on-the thigh:
number 4 on the pubic region: number 5 on the patient's navel, and the two flaps of number 6 applied
over number 5) Do this one at a time on each side.
 Observations: Monitor the patient's pulse rare and blood pressure every 15 minutes until she is stable
(i.e pulse below 100 beats/minutc and or BP greater than 90/50mmHg),
 monitor the urinary output hourly,
 Resuscitate the patient with intravenous fluids e.g normal saline or ringer's lactate and/or blood as required
(give 3mls of fluids for evcry 1ml of blood loss) to run fastly within 15 – 20minutes (use blue cannula)
 If you can not handle the patient then, refer the patient to the nearest health care facility with a doctor
while still on ASG
5.10 RESUSCITATION OF THE NEWBORN
A baby who is not crying or breathing well will be gasping or not breathing at all. Such baby would need
to be helped to breathe by ventilation. Delay in ventilation may lead to brain damage or preventable
death.
Goal: The goal of resuscitation of the newborn is to ensure that the baby survives.
Aims and objectives of resuscitation
1. To establish and maintain a clear airway
2. Ensure effective circulation of blood
3. Correct acidosis in the blood
4. Prevent hypoglycaemia, hypothermia and bleeding.
Symptoms and signs of babies having problems
 No breathing.
 Irregular breathing with respiratory pauses.
 Rapid breathing: more than 60 breaths in, 1 minute.
 Slow breathing: less than 30 breaths in 1 minute.
 Indrawing of the chest with each breath.
 Gasping, grunting (noisy breathing), flaring of the nostrils.
 Blue or pale skin colour. (Blue lips and tongue are serious of lack of oxygen. This baby needs
Oxygen immediately, if available, at a high flow rate).
 Meconium in the amniotic fluid at birth.
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  Baby who scores less than 7 points at five minutes after birth In APGAR scoring.
Note: A baby with any of the problems listed above needs urgent resuscitation and care.
Condition in the mother that can Head the problems in a baby:
1. Ante-partum: Lack of antenatal care, ante partum bleeding during 2nd stage, anaemia,
malaria,PIH, poly / oligohydramnias, PROM, twins
2. Intra-partum: Arrival for delivery, caesarian section, genetic disorders, foetal distress, induction
/augumentation, mal presentation, meconlum-stained liquor, preterm labour, prolonged labour,
shoulder dystocia.
3. Medical condition: Diabetes, kidney disease, heart disease.
Possible conditions in the baby:
1. Poor Oxygen circulation in the uterus: e.g. in heart disease, bleeding, over dosage of Oxytocin
hence uterus not relaxing.
2. Placental factors e.g premature placental separation reduced Oxygen circulation to the baby and
post maturity.
3. Umbilical cord compression e.g. cord round the neck, short cord, prolapsed corder knot.
ABCS OF RESUSCITATION
Note: Delay in resuscitation may lead to brain damage or preventable deaths.
This care is given in the "Golden minute','- First 1 minute of birth.
Apgar Score is done at 1 minute after birth.
Resuscitation must be started as soon after birth as possible (at least within 30 seconds of birth) .
Therefore, Apgar' Score is NOT used to decide if resuscitation is needed. Apgar Score is used to
evaluate the results of resuscitation.
 Resuscitation must start immediately the need arises.
 Examine breathing and skin colour to know if baby is having problems.
Apply ABCS of resuscitation as follows:
A. AIRWAY - Make sure the airway is open. Position the baby. Suction the mouth and nose, and if
there is meconium suck the pharynx (back of throat).
B. BREATHING- Stimulate to initiate breathing. Use mouth to mouth or Ambu bag to blow in air as
necessary. Give Oxygen, if available.
C. CARDIAC FUNCTION - Make sure the heart is beating. Stimulate the baby. Do chest
compressions when necessary,
S. SHOCK - Make sure the baby is Warm and dry. Dry the baby. Warm the baby with a blanket, a
light. or the mother's skin.
Preparation for newborn resuscitation: This should always be done before delivery.
Materials and equipment:
1. Clean gloves,
2. 2 cloths - one to dry and one to wrap the baby.
3. Small towel/cloth to roll up and put under baby's shoulders
4. Suction bulb (e.g bulb syringe) .
5. Mucus suction catheter (Delee)
6. Flat surface (e.g. table)
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 7. Watch with second hand, baby hat/cap.
8. Oxygen, if available
9. If doing mouth-to-mouth,-small bowl with soap and water, small towel, 3 gauze.
10. If usingAmbubag,-NewbomAmbubag
STEPS FOR NEWBORN RESUSCITATION:
Resuscitation is given in the "Golden minute" i.e. Within First One minute of birth
Step 1: Place the baby on its back on a clean, warm, flat surface or a place prepared for resuscitation.
If meconium is present: Sunction baby immediately after delivery before doing any rubbing or
stimulation.
Afterwards, maintain the first five steps of care as follows:
1. DRY: Quickly dry the baby with a towel or a cloth, from head to toe, until most of the amniotic
fluid is gone, (head last to prevent rapid heat loss from the head). Take away the wet towel.
2. WARM: Warm the baby by quickly wrapping with a warm dry towel or cloth': Keep the chest
uncovered to see the baby's breathing. Cover the head with the cloth or a hat/cap if one is
available. You can also put a light over the baby to provide extra heat if you have one.
3. POSITION: Position the head with the neck. Place a small rolled towel or cloth under the baby's
shoulders so the head is slightly extended in the "sniffing" position. This is the best position to
keep the airway open/clear.
4. SUCTION: Suction with a bulb syringe or mucus extractors.
Suction the mouth first, before the baby gasps or cries to remove the largest amount of secretions
and then the nose. If the nose is suctioned first, it may cause gasping and inhaling of secretions i.e.
the baby may breathe in, and will breathe in what is in the mouth (the mouth has more secretions
than the nose).
Suction only while pulling suction tube out, NOT while putting it in. For bulb, compress or
squeeze before inserting the tip in the mouth, or nose. Release compression to suction before
withdrawing it. Remove from mouth and compress bulb again to expel contents. If it is a sunction
device with a tube and reservoir, insert the tube into the side of thy baby's mouth not more than
5cm beyond the lips. Repeat for each nostril. Do not insert suction tube or bulb more than 5cm into
the mouth or 2- 3cm into the nose.
5. STIMULATE: Stimulate breathing. Rub your hand up and down the baby's spine once or twice to
stimulate the baby. This can be done without removing the cloth or towel. Quickly check breathing
and decide if ventilation is needed.
Note: Time for "decision to start resuscitation" to "time to start ventilation" should be no more than 30
seconds.
Remember: While you do the first 5 steps of immediate care you are looking at the baby's breathing and at
the same time counting the heart rate. Note that the baby's heart rate can easily and quickly be figured by
counting it for 15 seconds and multiplying by 4, or for 30 seconds and multiplying by 2.
Look if: Airway is open and clear, breathing present but no cry, if heart rate is below 100 and baby is
limp with blue or pale skin; Start ventilation.
Step 2:-
Breathe for baby.
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 1. If using bag and mask, position the head slightly extended and supporting the chin, place the
mask to cover the mouth and nose but not the eyes and let it make a tight seal on the face so that
air will enter the baby's lungs without leakage. Allow the rim of the mask to rest on the tip of the
chin. Maintain a firm seal between the mask and the face while squeezing the bag to provide a
gentle movement of the chest; do this by holding the mask on the face with the thumb and index
finger on top of the mask. Use the middle finger to hold the chin up towards the mask. Use the
4th and 5th fingers along the jaw to lift it forwards and help keep the airway open.
Form and maintain a tight seal by pressing tightly on the top of the mask and gently holding the
chin towards the mask. Do not push the mask down unto the face to maintain the head position.
Squeeze the bag to produce a gentle movement of the chest, as if the baby were taking an easy
breath.
Squeeze the bag harder to deliver more air with each breath if need be.
Give 40 breaths per minute counting aloud, "one. .. two ... three. i.e. squeeze the bags as you count
one .. .and release while you count two; three ... Repeat these counts.
2. If using mouth-to-mouth resuscitation. wipe baby's face with (a) Gauze wet with soapy water, (b)
Gauze wet with clean water. Then cover mouth and nose with a dry gauze. Cover the baby's chin, mouth and
nose and make a good seal. Do not rise up during the evaluation. Lift head only I ~2cl1l and turn slightly to
observe the chest.
3. if not using mouth-to-mouth, place the index and the middle fingers below the apex of the sternum
 Do 2 test breaths to observe if the chest rises,
 Compress Ambu bag or breathe into the baby using a MOUTHFUL OF AIR ONLY with each
breath.
 if the chest does not rise: Suction the mouth and nose, reposition the baby and check the seal
between the baby's face and the mask (or your mouth). Venti late the baby again for I minute ( 40
breaths).
 Suction again and repeat the breath, noting the rising of'the chest. If the chest rises, see if the baby is
making any attempt to breath unaided. If baby starts to breath, continue to support with warmth,
stimulation and oxygen till be the baby is pink and crying.
Step 3:
 If baby is still not breathing:
 Blow 5 shot fast and gentle breaths into the baby.
 If the chest rises. Breathe 40times in 1 minute for the baby. Make sure the chest is rising and falling)
 Re-check respirations- Observe for respiration and feel/listen for heart beat.
 Administer Oxygen if available at the rate of 10 litres/min and is best given nasally by a single tube face mask
because babies breathe through their nostrils and not their mouths.
 When the baby starts breathing, move the Oxygen from the nose.
 Repeat these 2 steps and continue to support with warmth and Oxygen therapy until baby breaths on its own
and heart rate increases to over 100.
 If breathing is normal (30-60 breaths per minute). there is no in drawing of the chest or grunting, and the
Apgar is 7 or more, and the body is pink- Keep baby warm, clamp and cutt the cord, place baby skin-to-skin
on mother's chest to encourage breastfeeding.
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  Monitor baby with mother, monitor vital signs- Temperature, heart rate (of more than 100b/m),
 Breathing- listen for grunting, look for chest in drawing, colour- note the colour of the lips, face, body hands
and feet. Monitor behaviour- alertness posture and movement, open eyes, flexed arms, legs e.t.c.
Step 4:
I f baby docs not breathe after one minute of ventilation, or If the airway is clear and open but no heart beat or
respiration or baby limps and skin is blue and cold continue with improved ventilation and CALL FOR HELP.
 Keep baby warm still.
 Maintain the position to keep airways open.
 Stimulate as necessary.
 Start artificial respiration as did earlier.
 Administer Oxygen if available.
 Observe for rising of the chest.
 If baby is still not breathing re-position the baby:
 Suction again and try another breath, watching for the chest to rise. If the chest rises,
place your index and middle fingers on the centre of the chest just below the nipple line
under the syrnpyxsternum (an imaginary line drawn between the baby's nipple). This will
place your fingers over the baby's heart.
 Push the chest down I.5cm (114 l/2inch) at a rate of 100-120 heart beats/minute, counting
1 and 2 and 3 and 4, 5 and 6th count should be a breath so that the blow would be 1,2,3,
4and 5 and so on.
 Check the heartrate by feeling the pulse in the umbilical cord if no pulse can be felt listen
over the left chest with a stethoscope and count the heartbeat. A heartbeat of I 00 beats per
minute is normal, lf less than 100 beats per minute or sounds slower than your pulse rate, it
is slow. Continue ventilation.
 D0 5 heart compressions and 1 breath, and continue to repeat this until it is done 5 times)
then check the baby's breathing and heart rate again.
 If the heart rate is more than 80, stop the compression continue artificial respiration until
the baby is breathing and the heart rate is more than 1 OObl min. Keep baby warm.
 When baby is pink, have the mother put the baby to breast, put !n skin-skin contact with
mother for continue warmth, stimulation, love and energy.
 Observe breathing frequently, take axillary temperature and rewarm if temperature is less
than 36°C.
Step 5:
If baby is breathing with difficulty and Apgar are 6 or less: There may be serious problems. (i)
Institute emergency transfer plan for advanced care such as endotrachial intubations,
supplemental Oxygen e.t.c. (ii) Refer for special care and observe referral guidelines. (iii)
Transfer mother and baby. (iv) Give starting dose of Antibiotics. (For a baby 2kg or more:
Ampicillin 50mg/kg 1M and Gentamicin Smg/kg IM. For a baby less than 2kg.: Ampicillin
50mg/kg 1M and Gentamicin 4mg/kg 1M). (v) Keep the baby warm during transport. (vi) Give
Oxygen during transport if available.
Step 6:;
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If there is no heartrate, gasping or breathing at all after 10 minutes of ventilation; the baby
cannot be revived, STOP ventilation.
1. Counsel and care for the mother and family psychologically
2. Advice the mother on breast care and family planning.
Post procedure tasks:
1. Dispose of disposable sunction catheters and mucus extractors in a leak proof container or
plastic bag.
2. For baby pump and mask or bulb syringe, decontaminate with 0.5% Chlorine (e.g.Jik)
allow to dry after rinsing.
3. Clean resuscitative equipment and supplies (catheter, facemask, cloths, table), Follow the
infection prevention guidelines. Do high-level disinfection of suction and catheters.
4. Dispose of gloves and put in plastic waste or plastic bags.
5. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.
Document resuscitation by recording the following:
(a) Condition of the baby at birth.
(b) Procedures used to start breathing.
(c) Time from delivery to start of spontaneous breathing
(d) Observations during and after resuscitation
(e) Outcome of resuscitation
(f)In case of failed resuscitation, possible reasons for failure
(G) Names of providers involved and comments.
IMMEDIATE POSTPARTUM CARE:
The first one hour after delivery should be spent in the labour room by the mother and baby to ensure
adequate rest and to detect and manage immediately incase of abnormalities such as post partum
haemorrhage, shock, or sudden collapse.
Physiological and psychological adjustment begins immediately after delivery.
The care is given as follows-
 Encourage immediate breastfeeding and early mother / child bonding except for HIV
positive mothers who choose not to breastfeed their infants in other to prevent MTCT.
 Maintain mother-baby contact
 Check vital signs temperature pulse, respiration and blood pressure
 Observe the uterus, note position consistency and fundal height
 Check lochia, note the colour, quantity and odour
 Check vulva, perineum for laceration, episiotomy site (if given) and bleeding
 Give bed pan for patient to empty her bladder, this will aid contraction of the uterus to
involution
 Monitor intake and output and record
 Clean mother and change clothes
 Give warm nourishing food or drink
 Allow mother to rest by ensuring quite / environment and later transfer to the postnatal

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 ward.
Things to note when providing newborn care
1. Adhere strictly to infection prevention standards during delivery and ensure cleanliness at, and
after delivery.
2. Keep the cord clean and dry.
3. Avoid cold (neonatal hypothermia) by immediately drying and covering the baby, and do not
bathe the baby until 24 hours after the birth.
4. Keep the mother and baby together (for effective bonding or "skin-to-skin' / kangaroo contact).
5. Administer prophylactic eye care to prevent eye infection.
6. Encourage early breastfeeding, and exclusive breastfeeding for about 6 months (except for HIV
positive women who choose not to breastfeed).
7. Detect the following danger signs in the newborn - Breathing difficulties or not breathing at all,
yellowness of the skin/eyes (jaundice), convulsions, hypothermia (cold), fever/chills, inability to
suck (poor sucking), inactive or rigid neonate, diarrhoea or constipation, redness or pus from the
umbilical cord, red, swollen . eyes with purulent discharge and treat or refer for treatment:
8. Educate staff and community on the danger signs for newborns.
9. Refer complicated childhood illnesses.

NEWBORN CARE SONG (use counseling song tone)

We love new born (2ice)

They come wet,
They get cold, and get hungry, So we all must help them
(2ice), Wash your hands,
Get them dry,
Keep them warm,
Breastfeed them, and keep them clean
5.10.2 CARDIO - PULMONARY RESUSCITATION (ADULT):
This is bringing back to life of the heart and lungs that are not functioning by performing gentle
movements on the heart to make the heartbeat, and breathing into the person to make the person breath
on its own. Cardio Pulmonary reaction includes both adult and infants who are having trouble living.
Indications for resuscitation
Resuscitation is an important lifesaving skill. The midwife may need to use resuscitation skills in the
following conditions:-
1. Blockage of the airways. If the airway is completely blocked air (Oxygen) cannot get into the lungs
and into the blood. A couple of minutes after the lungs stops, the heart will stop.
2. Injury to the brain e.g. from an accident (car accident, falling etc) over dosage of street drugs and
other drugs
3. Stroke or severe shock can depress the respiratory centre in the brain
4. injury to the chest can affect the tissues of the lungs and cause the lungs to collapse causing
pneumothorax
5. Effects of drugs e.g. anti-depressants and narcotics can depress the respiratory centre in the brain.

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 6. Electrocution: This can paralyze the diaphragm and other respiratory muscles.
7. Drowning or suffocation, any of these will block oxygen supply to the lungs,
8. Patient's heart not beating: The heart will not beat and there will be reduced blood circulation
throughout the body due to:
 Cardiac arrest: if there is heart attack or myocardial infarction there will be no circulation of blood
throughout the body.
 Severe shock due to a large haemorrhage or injury to the heart.
 Drugs which have the side-effects of decreasing contractions of the heart.
9. Respiratory arrest: Breathing will stop for any ofthe reasons listed above.
ABCS for helping a person who is having trouble living:
A Airways: Make sure the airway is open
B Breathing: Make sure the person is breathing
C Cardiac function Make sure the heart is beating
S Shock: Make sure the person is kept warm,
Procedure for Cardio-Pulmonary resuscitation
 Restore breathings: If patient has a pulse Give breath every 5-6 seconds
 If no pulse: Locate compression landrail Trace the ribs, place finger on sternum, one finger width
below nipple line
 Perform compressions with 2 hands, one on top of the other heel of one hand and on lower half of the
sternum.
 Compress the chest at 80-1 00 per minute
 Compression dept should be between 4-5cm (1-21/2 inches)
Ratio of compressions to breaths with one rescuer is 15 compressions to 2 breaths.
Application of ABCS of resuscitation
Procedure
A -Airway: make sure the airway is open
 Speak to the person
 ASK: "Are you all right?" Roll the person onto his/her back
 Roll over as a unit so that the whole body rolls at the same time
 Call for help from anyone who may be close
 ASK again: "if he/she is all right?" Look into his/her mouth to make sure the airway is open
 Clear the nose and mouth with your fingers of anything you can see or feel
 Move the head into a position that will prevent the tongue from falling into the throat
 Place one hand on the person's forehead and press firmly backward
 With your other hand, press the fingers under the jaw near the chin, life the chin forward unit the
teeth are almost closed.
 If the person has loose false teeth (dentures) remove them.
B Breathing make sure the person is breathing
Look at the person's chest. Now that the head is in a position where the tongue is not blocking the
airway, the person may begin to breathe independently.
 If not breathing, quickly kneel at the side.
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  Pinch the nose closed with your fingers and breathe into the mouth.
 If air does not either adjust the position of his/her head and try again. .'

 Does the air enter the chest easily?

 If not, do the Heimlich maneuver.
 Then clear the mouth and nose again, reposition the head and breathe again.
 Try to breathe into the person again.
 Take a breath after each breath you blow into the person.
C Cardiac function make sure the heart is beating
 After giving 2 quick breaths, check to see if the heart is beating. Feel for the person's pulse
(heartbeat) on her neck at the carotid pulse.
 If the person has a pulse, do not do cardiac compressions.
 If the person has a pulse, but is not breathing, do only respiratory resuscitation.
 Breathe into the person's mouth at approximately 12 times per minute (once every 5 -6
seconds)
 If the person does not have a pulse, breathe for her and help her heart to contract.
Procedure
Locate compression landrail trace the ribs into notch, place finger on sternum. One finger with elbow below nipple
line. Place your palm above the bottom of the cage.
 Place your other hand (either into a fist or with fingers stretched) on top of your bottom hand.
 Keep your arms straight with your elbows locked.
 Press straight down over your hands.
 As you lean forward, press the chest 4-5cm (11/2 – 2 inches)
 Press down and release for equal time (set a rhythm)
 Count 1 and 2 and 3 and 4 and 5, up to 15
 Do not stop (pause) between compressions
 Do not lift your hands up off the chest
 Compress the heart at 80 to 100 beats per minute.
 After 15 compressions, stop and give the person 2 breaths
 Pinch the nose and keep the head in its slightly tipped back position.
 After the 2 breaths, locate the proper hand position on the chest and give 14 more compressions
 Keep repeating the pattern of 15 compressions followed by 2 breaths
 Do 4 or 5 complete cycles in one minute.
 After a minute or so, stop and re-check the person's carotid pulse
 If she has a heartbeat, look to see if he/she is breathing independently
 If there is no heart beat and no breathing, continue with the cycle of 15 compressions and 2 breaths.
 If there is a heartbeat but no breathing, continue with the breathing at the rate of about 12 times per minute.
Get someone around you to help relieve you
S Shock make certain the person is kept warm
 Wrap in a blanket or dry cloths while resuscitating the person to prevent shock from cold.
 Get someone around you to organize transportation

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  Travel with patient to the hospital for further care.

5.11 HEIMLICH MANEUVER .

Heimlich Maneuver is the term used in prevention of death by choking. It is an action used on a
choking person to prevent death. The object caught in the throat is pressed up into the mouth by pressing
on the abdomen below the xiphoid process. .
Choking - a blockage of the breathing passage or a feeling of tightening around the neck. Choking Stops
breathing and keeps oxygen from getting to the brain and other vital organs. Blockage of the airway may
be caused by spasm of the larynx from an irritating gas.
Most commonly adults choke on bites of food. It may be that they inhalate or laugh while eating. A piece
of food gets Slicked into the airway. Children may choke on food in the same way. They often choke on
nuts, fish bones, fruit pits, and pieces of toys, or small objects found around the home. Infants may choke
on milk when sucking from a bottle. They often choke when feeding from a bottle while lying on their
backs unattended.
If a foreign body is blocking the airway (trachea or larynx) the Heimlich maneuver can be used to
remove it
Causes of choking
In: (a) Adults:
Inhalation of food particles during eating e.g Food particles, water, saliva, fish
bones
(b) Infants:
Nuts, fish bones, fruits, pieces of toys, pins coins, milk from bottle feeding.
Clinical manifestation of a person who is choking:
a. Grabbing of the throat.
b. Inability to speak.
c. Agitated and (move his arms wildly) restlessness.
d. The face may become pale.
e. Slowly clammy skin, low blood pressure, slow pulse rate, no signs of breathing.
f. The person gradually loses consciousness and dies from hick of oxygen to the brain.
Procedures for:
a. Conscious person choking.
b. Unconscious person choking.
Indication for maneuver:
This action can be used on
 Adult
 Children or infants
 Unconscious person.
 Conscious persons
Procedure for conscious and unconscious person choking:
In a conscious person
1. Stand behind the person where she sits or stands. Keep telling her that you are helping her. help control the person's
feeling of panic.
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 2. Place your arms around the person, holding your hands together on her Lipper abdomen just below the xiphoid
process and above her navel.
3. Form your hand into a first against the abdomen
4. Grasp your lists with your other hand,
5. Press your fist into the victim's abdomen with a quick inward and upward thrust.
6. Continue to make the quick thrusting movements with your fists until you have loosened the object from
the throat
7. If the person loses consciousness, help her to the floor or ground and lie her on her back.
In an unconscious person
If you are with the person when he/she chokes, the person is unable to speak. She may become agitated and move the
arms wildly. The face may become purple. The person gradually loses consciousness and is at risk of dying from lack
of oxygen to the brain.
1. Position the person's head back to move the longue out of the way.
2. Open the person's mouth and see if you can see the obstruction. Wipe the mouth to try to take out the object.
3. Kneel at the feet of a small child or over the thighs of an adult.
4. Place your hands over one another. Press the heel (palm) of the lower hand in the middle of the person's
abdomen a Iii tie above the navel.
5. Make certain that your hands are not placed too high where you might press on the top of the xiphoid or the
ribs.
6. Press quickly into the abdomen and upward toward the head. The force of the thrust should be right in the center
of the body.
7. Thrust (press inward and upward) 6 to 10 times one after the other. Thrust more gently in an infant or child.
8. The person may be coughing or making a crowing sound now. Have him spit the object out. Look into the
mouth again to see if you call help remove the object.
9. If the person continues to crow (partial blockage of the airway), or there is no response, repeat the series of
thrusts, until she is relieved.

5.12 HYDRATION AND REHYDRATION

HYDRATION AND REHYDRATION

Hydration and rehydration are terms used h the management of emergency conditions such as
shock, hemorrhage, severe fluid loss etc

Definition of terms:

 Hydration: Is the process of giving water and salts to replace what has been lost in the
process of dehydration

 Dehydration: Is dryness of the body when the output of water and salts is greater than
intake.

 Rehydration is the replacement of water and salts lost in dehydration.

 Infusion: A liquid being put into the body through a vein for medical treatment.

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  Intravenous: Into a vein

 Peripheral veins: vessels away from the centre of the body (such as veins on the arms and
legs).

Methods of Rehydration

- Intravenously e.g Intravenous infusion.

- Orally e.g Oral Rehydration Salt Solution (ORS)

- Rectally e.g fluids given in the rectum.

Types and Dosages:

 Dextrose 5% in Normal Saline

Give this solution to provide some energy for the body and to help maintain the body's
water and salts balance. Give 2500 ml in 24 hours to a 45-70kg person.

 Normal Saline (Sodium Chloride 0.9%, Isotonic Saline)

Give this solution to replace blood loss and in fluid loss during diarrhea, bleeding or when
the woman is not able to take enough oral rehydration fluids by mouth. Give 1000 ml of
Normal Saline first and follow with 1500 ml of Dextrose 5% in water. Give 2500 ml in 24
hours toa45-70kg persons.

 Ringer's Lactate

Give this solution to replace fluid loss due to diarrhea, severe bleeding or when a woman is
in shock.

Give 1000ml of ringer's Lactate first and follow with 1500 ml of Dextrose 5% in water.
Give 1500ml 24hours to a 45 to 70kgperson.

Guidelines for starting in IV or Oral Rehydration Solution (ORS)

Start an IV infusion (two if possible):

- Use a large-bore needle (16-gauge or largest available),

- Rapidly infuse 5% Dextrose Ringer's Lactate or Normal Saline at the rate of 1L in-15-20
minutes.

Note: If shock is due to bleeding, aim to replace two to three times the estimated fluid loss.

Only if unable to start an IV infusion (for whatever reason), give the woman ORS according to the
following guidelines:
 If the woman is able to drink, is conscious, and is not having (or has not recently had)
convulsions, give ORS 300-500mLin 1 hour by mouth.
 f the woman is on IV infusion and she asks for something to drink, ORS is the ideal drink for
her. If she doesn't like the taste of the ORS, add some litres twice (orange, lime, lemon) to
change the taste. If she vomits, give any locally available liquid she can drink e.g coconut
water, light soup, weak tea and water left after cooking rice, yam, potato or maize.
 Explain the importance of oral re-hydration that it can be used to prevent dehydration and
replace fluid loss e.g from diarrhea.
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  Record the time and amount of fluids taken
 Preparing sugar and salt solution form locally available materials.
 The ORS sachet may not be available when needed, then, it can be prepared as follows:
Note: Unless the woman is fully conscious and alert, do NOT give fluid by
mouth.
Preparation of Oral Rehydration Solution (ORS)
Materials needed:
 Drinking water (potable water)
 Sugar, Salt
 Container to measure (e.g. soft drink or beer bottle
 Container for mixing
 A cup and a teaspoon.
Procedure:
 Wash your hands and all the utensils
 Measure 1000cc (llitre) of drinking water
 Put into the mixing container
 Add 10 level teaspoons of sugar and 1 level teaspoon of salt to the water. (if it is cube sugar, use
5 cubes) Stir the mixture well and taste. Sugar and salt solution should never taste saltier than
tears. Give the woman to drink as much as she wanted. (It tastes like coconut water, if prepared
well).
 Mix fresh solution everyday in a clean container
 Record the amount of fluid taken.
If the woman is unable to drink, is unconscious, or is having (or has recently had) convulsions,
give
 ORS 500 mL rectally over 20-30 minutes, according to the following guidelines:
 Fill an enema jug/can with 500mL of fluid.
 Run water to the end, of the tube and clamp off.
 Insert the lubricated tube about 10cm (3-4 inches) into the rectum.
 Run the water in slowly.
Note: It will take 20-30 minutes for the water to run into the woman. i.r it is ran too rapidly, she
will get abdominal cramps and push the water out
5.13 MANAGEMENT OF SEPSIS AND CONTROL OF INFECTION IN
THE MATERNITY UNIT

INTRODUCTION

Sepsis is a major cause of death among mothers in developing countries. Most diseases are caused by
microorganism. Such organisms are living things that cannot be seen with naked eye. Some
microorganisms are normal flora normally present on people's skin, respiratory intestinal and genital
tracts. Others are pathogens not normally found on or in human body and are usually associated with
disease. All micro organisms including normal flora, can cause infection or disease if certain conditions
exist such as when Normal floras are introduced into an area of the body in which they are not normally
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 found. '
DEFINITION OF TERMS

Sepsis: This is a serious condition that happens when harmful genus or microorganisms enter into the
body system and multiply (grow) thereby causing sickness or serious disorders to the body.
Microorganisms: These are organisms that can be seen only with the magnification of a microscope.
Microorganisms exist everywhere in the environment in people, animals, plants, soil, air, water and
other solutions.
FACTS ABOUT INFECTION PROCESS

Contaminated clothing to home from the facility:

 Health care provider contract infection and spreads them to family members and other
members of the community,
DESCRIPTION OF DISEASE TRANSMISSION CYCLE
1. Causative organism/Infective agent: - This is a pathogenic organism, i.e. organism capable of
causing disease e.g. bacteria, fungi, viruses, protozoa, rickettsiae, parasites and helminths.
2. Reservoir-This Is the term used for any person, plant, animal, substance, or location that provides
nourishment for micro-organisms and enables further disposal of the organism.
It is where the agent lives, survives, grows and/or multiplies e.g. people, solutions, water, formites
(such as instruments, equipment, linen and other items used in chemical procedures, animals, plants,
air or soil. Infection may be prevented by eliminating the causative organism from the reservoir.
Organism exist it rough the respiratory tract, the gastro-intestinal tract, the genito-urinary tract and
the blood. An infected host must shed organisms to another or to the environment before transmission
can occur.
3. Portal or place of exit (i.e a portal or mode of exit from the reservoir):
This is the point or spot from which the infective agent leaves the reservoir e.g. infective agent could
leave the blood stream, broken skin, toe, punctures, cuts, surgical sites, or rashes) mucous
membranes, eyes, nose, mouth, lungs vagina, penis, anus, blood, excretions, secretion or body fluids.
4. Mode of transmission: This is the way or means by which the infective agent moves from the
reservoir to the susceptible host e.g. sexual intercourse as in HIV, or air / droplets as in influenza
or tuberculosis, direct contact such as touch, Indirect contact such as food as in salmonella typhi,
Vectors: e.g. mosquitoes as in malaria, yellow fever.
Organisms may be transmitted through sexual contact, skin-to-skin contact, percutaneous
infection or infectious particles carried in the air. (A person who carries, or transmits an organism
and who does not have apparent signs and symptoms of infection is called a CARRIER).
5. Portal or place of entry: This is the route by which the infectious agent moves into the
susceptible host e.g blood stream, broken skin, (e.g. punctures, cut, rash) eyes, nose, mouth etc
(like the place of exit). A portal of entry is needed for the organ ism to gain access to the host.
This could be by Inhalation: Through the mouth and nose to the respiratory tract
Ingestion: Through the mouth to the alimentary tract
Inoculation: Through the skin or mucous membrane to deeper tissues.
6. Susceptible host: For infection to occur, the host must be susceptible (i.e. not possessing immunity

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 to a particular pathogen). The immune suppressed person has much greater susceptibility than
normal healthy host.

Note: The easiest infection control in a health facility is action directed at the mode of transmission.
PROCESS OF INFECTION TRANSMISSION:

i. Endogenous transfer of infection: Endogenous: -Infection is literally from within i.e. the
causative organism comes from another part of the victim's own body. A patient or his/her
attendants may inadvertently or carelessly transfer commensal organisms from their non-sites
where they are harmless, to another site in the body such as a wound, can cause infection.

ii. Nosocomial infection: This is infection acquired in hospital, whether originating from a patient, a
member of hospital staff or equipment. It may be either endogenous (self infection) or exogenous.
Cross infection is exogenous transfer from an infected patient to an un infected one. It usually
manifest 24 to 48 hours after a hospi tal admission.
Iii, Opportunistic infection: Thisis an infection caused by organisms of low pathogenesis or even
commensal which take advantage oflowered immunity however caused, whether by disease, drugs or
by treatment. Note: all infections are opportunistic
iv, Exogenous infection:This Is infection originating outside the body i.e. acquired from another person
or object, is across infection. Exogenous infection is a means of nosocomial infection.
Common types of sepsis
1. Endometritis or Metritis: Inflammation of the endometrium of the uterus
2. Chorioamnionitis. This is inflammation (swelling and redness of the chorion and amnion. It is the
inflammation of the entire ammotic sac (bag of waters).
3. Chronic pelvic infection - An infection that has been in the reproductive tract for a long time and
has not been adequately treated or treated at all.
4. Masti tis, breast abscess- infection I inflammation of the breast.
5. Puerperal sepsis - An infection that causes 'swelling, pain, redness, foul swelling discharge in the
reproductive tract during labour or after delivery.
6. Peritonitis - inflammation of the peritoneum
7. Wound cellulitis
CAUSES OF SEPSIS:

1. Germs found in the following areas of the body.

a. Lower genital tract or bowel.

b. Nose, mouth or hands of health care provide.

c. Blood and body fluids.

2. Formites: instruments, clothes, medicines, herbs etc.

3. Unsterile needles/syringes.

4. Scarifications, Circumcision

5. Retained products of conception e.g placental tissue or membranes.

6. Unsterile operative procedures e.g. Infection from C/S or episiotomy

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PRE- DISPOSING FACTORS TO SEPSIS

 Multiple-sexual partners

 Population growth

 Unsafe abortion/criminal abortion

 Retained products of conception - Increased poverty

 Malnutrition

 Expansion of the population into 'remote areas

 Poor personal hygiene

 Environmental degradation

 Inadequate or deteriorating public health infrastructures which leads to easier spread of

diseases/infections. e.g. public toilet/latrine

 Improved transport system

 Overcrowding

 Misuse or inappropriate use of antibiotics which leads to resistance of body to infection

 HIV infection which destroys body immune system

 Poor infection control and infection prevention programme

 Failure of health care providers to observe universal precautions

 Traumatic delivery

 Poor hand washing technique

 Frequent or unclean vaginal examination

 Improper perineal care during or after pregnancy

 An unclean delivery

 Sexua I intercourse after rupture of membranes

 Retained placental tissue / membranes

 Anaemia, Tuberculosis

 Pelvic Inflammatory Diseases (PIDs)

SIGNS AND SYMPTOMS OF SEPSIS

 Body temperature of 380C and above
 Fever / chills and rigor
 Swelling of affected part e.g mastitis (infection of the breast)
 Redness and tenderness of the area e.g. tender uterus inseptic abortion, amnionitis,
metritis
 Purulent / Foul smelling discharges e.g. from the vagina in pelvic sepsis
 Pain from affected part e.g. PID

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  Absent bowel sound e.g peritonitis
 Erythema and oedema beyond edge of incision e.g. Wound cellulitis
PREVENTION OF SEPSIS
 Give advice on diet during pregnancy to prevent anemia
 Discourage introduction of foreign bodies e.g. herbs into birth canal
 Conduct delivery under aseptic technique
 Discourage use of dirty linen to cover the baby's cord
 Encourage early breastfeeding
 Avoid female circumcision and scarification
 Male circumcision should be done under hygienic condition.
TREATMENT OF SEPSIS
 Give copious fluid.
 Give full course doses of ant i-malarial.
 Give analgesic such as Paracetamol 2 tablets, 6 hourly for 5 days.
 Give antibiotics e.g. tabs Septrin, 500mg twice daily and flagyl400mgs t.d.s. or Ampiclox caps
500mgs 6 hourly and400mg Flagyl both for 5 to 7 days.
 Severe cases of infection may require parenteral antibiotics e.g. I.m or I.V Ampiclox 500mgs 6
hourly or I.V Augumentin 375mg 8 hourly for 5 days.
 Metronidazole (Flagyl) l00mls to run for lhour every 12 hourly these are given for 3units in 48
hours and then changed to oral.
 Refer immediately.

INFECTION CONTROL MEASURES

Principles of infection prevention practices: consider every person potentially infectious (e.g. patients,
staff e.t.c.)
(1) BODY PROTECTION
(A) Hands:
 Keep nails short clean and polish free
 Avoid wearing wristwatches and jewelry especially rings with ridges or stones. Artificial nails
must not be worn.
 Hands should be decontaminated before direct contacts with the patients and after any activity or
contacts that contaminate the hands, including following removal of gloves.
 Hands should be washed with soap under running water in all patient areas, treatment rooms,
shice and kitchen.
Hand washing: There are 3 kinds:
a. Hand washing with plain soap and running water: This is routine hand washing. At least 10-15
sees. should be spent on washing each finger including the finger nails, before rubbing the hands
against each other.
b. Hand washing with antiseptic and running water: This removes transients micro-organisms and

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 soil.
c. Alcohol handscrub: can be used, when hand washing v:,ith soap and water is not possible or
practical. Routine hand washing with plain soap and running water or 10-15 seconds is usually
sufficient. The soaps to be used must be kept drained and dry to avoid contamination, liquid soap
with dispenser may be a viable option. Frequent hand washing with soap between client
examinations or after touching instruments and other materials is a very important precautions and
should be remembered a tall times by all clinical staff. Some basic rules to follow are:
Wash your hands before examining every client.
i. Wash your hands before putting on sterile gloves for clinical procedures
ii. Wash your hands after examining every client.
iii. Wash your hands after handling used objects, e.g. instruments
iv. Wash your hands after touching body fluids (blood, secretions)
v. Wash your hands after removing gloves.
vi. Rinse hands thoroughly with clean water
vii. Dry hand with drier or clean towel
PROCESS OF CORRECT HANDWASHING
Hand washing with soap and clean water is the easiest way to prevent transferring germs/infections:
The steps in hand washing techniques are:
1. Remove all jewelries
2. Wet hands and apply soap (liquid or bar).
3. Rub palms together-Palm to palm, fingers interlaced. i.e Back of fingers to opposing palms with
fingers interlaced
4. Rub right palm over the back of the left hand- Back of left fingers to opposing right palms with
fingers interbalaced. Repeat till is for the back of the right hand
5. Rub your hands around your thumb i.e Rubbing of right thumb clasped in left palm.
6. Repeat this for the left thumb.
7. Rub the fingernails of one hand against the palm of the other hand, rubbing backwards and
forwards of tips of fingers, fingernails and thumbs of right hand in left palm. Repeat this for the
second fingernails.
8. Rub both hands up to the wrist.
Note: Use of towels to dry hands should be with caution - use the towels to turn off the faucit and air dry
your hands. Do not use shared towel otherwise, shared towel should be kept clean, dry and replaced
regularly.
(II) Use of gloves
Things to note about gloves and gowns;
Gloves and gowns are not required to be worn to check blood pressure or temperature, or to give
injections.
Gloves for specific procedures:
i. Examination gloves: are single-use disposable latex gloves
ii. Examination glove for pelvic examination, insertion of IUCD, blood drawing, starting IV infusion,
manual vacuum aspiration (MVA) wound dressing.
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iii. Surgical gloves: are latex gloves that are sized to fit the hand. If surgical gloves are reusable, they
should be decontaminated, cleaned, and either sterilized or high-level disinfected before use.
iv. High-level disinfected surgical glove: for repair of cervical or perineal tears and high-level
disinfect surgical, elbow-length for bi-manual compression of uterus, manual removal of placenta,
and vaginal delivery
v. Utility gloves: are thick household gloves for handling / cleaning instruments, contaminated
wastes, and cleaning blood spills or body fluid.
Wear gloves before touching anything wet - broken skin, mucous membranes, blood or other body
fluids, secretions or excretions.
B. Body attire: Wear surgical attire e.g. high-level disinfected/ sterile surgical plastic or rubber
apron/gown. Polythene nylon can be used to cover the lower arms up to the elbow e.g. in manual removal
of the placenta during tears of gloves.
 Face and head: Use of face mask/face shield e.g. artificial lens or plastic goggles.
 Avoid splashes of liqour or blood on the face e.g. while conducting delivery or any surgical
procedures, hold your head away while rupturing membranes, clamping and cutting of the
umbilical cord, If there is a splash on your face, wash immediately with plenty of water. Wearing
of caps to protect the head.
 Foot protection e.g. use of boots, covered shoes, or plastic bags (e.g. cocoyam leaves to
improvise in the community),
2. USE OF SAFE WORK PRACTICES e.g. Not recaping or bending needles. Proper instrument
processing and proper disposal of medical waste e.g. Dispose needles, syringes, cotton wool and
other blood soaked materials in a safe manner e.g. needles in cartons or plastic containers.
3. DISPOSAL OF WASTES
The purpose of waste disposal is to:
 Prevent the spread of infection to providers who handle the waste;
 Prevent the spread of infection to the local community
 Protect those who handle waste from accidental injury.
 Handling non-contaminated waste (e.g., paper from offices, boxes) poses no infectious risk
and can be disposed of according to local guidelines.
REFUSE SEWAGE DISPOSAL
REFUSE DISPOSAL: Refuse are organic matter/materials such as: leaves, food reminants and
inorganic objects such as bottles, tins and variety of discarded objects.
Refuse or solid wastes can be described as substances produced in all daily activities in homes,
agricultural and livestock activities and in industries. They include gabage or kitchen wastes, paper,
leaves, empty cans, broken bottles, glass, plastics and food reminants,
Wastes both solid and liquid must be handled and disposed of with care so that they do not constitute
danger to public health. Solid wastes if not properly disposed of will lead to offensive conditions such as
bad smells, fly and mosquito breeding, proliferation of rats, and the spread of infections diseases, In
discriminate disposal of refuse will also lead to fire 0utbreak and injuries especially to children around
METHODS OF REFUSE DISPOSAL '
The choice of a method for disposal of refuse will depend on the physical characteristics of the
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 locality e.g. the topography of the area, the character; quality and quantity of the waste, and the
community.
Methods commonly used are:
a. Controlled Tipping/Sanitary Landfill: This method is useful in land reclamation of gullies. Refuse
is pilled up in 2 millimeter layers and covered daily with 2-2,5cm of soil or sand.
b. Composting: This involves the breaking down of organic matters by micro-organisms to a
perishable limits under suitable environmental condition. It is a mixture of compostible refuse and
other nitrogen rich decomposable wastes (e.g. night soil) is heaped for several months with
periodic turning. The end product, manure is used in gardening or farming, there could be odour
and fly nuisance if not properly managed .
c. Incineration: Here refuse is sorted and combustible matters are dried up and burned in a large
incinerator maintained at 900"-1200°C.The disadvantage of this method is air pollution.
d. Disposal or Baging: This method is popular in coastal areas. Refuse is dumped directly into the
waters of a river or sea at a distance to prevent refuse being carried back to shore by tides and
causing nuisance. For toxic or radioactive wastes, therese are sealed in water tight containers and
buried in deep seas. Water pollution is the main disadvantage oftbis method.
e. Mechanical destructor: This is a plant used for treating refuse. After sorting out all that could work
against the machine, what remain is fed into it for pulverization and the end product used as
manure or buried in small area of land. This method is very useful in big cities where the volume
of reufse generated daily is enormous and the running cost is very high.
f. Burning: This involves burning of refuse in an open air or in an incinerator. It is the best method
to dispose contaminated waste. It prevents people and animals from collecting used supplies and
reusing.
g. Burying: Waste materials are buried underground e.g. Placental tissue. When burying
contaminated waste, use a pit that is in a safe location, is correctly filled in and is covered. A safely
located pit has a fence round it, is at least 50metres from any water source, downhill from any
wells, not in a flood area and has a water level more than 4metres below surface.
Other methods include
i. Indescrimate dumping on farm lands and
ii. Burying
Both methods are common in rural areas.
SEWAGE DISPOSAL
Definition: Sewage are human wastes inform of urine, faeces, vomits, blood e.t.c. Methods of sewage
disposal: these are-
 Water closet toilet: Feaces-which are deposited by the users are flushed with water into the septic
tank. This is common in cities.
 Pit latrine system: Small hut is usually constructed over a pit that.is covered leaving a small hole
through which feaces is emptied into the pit.
 Bucket latrine: In this method, feaces is collected in a bucket which will be empited by a paid
sewage collector.
 Ventilated Latrine: This is also a special type of latrine.
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  Chemical Closet Toilet System: It has similar features like the-water closet system but here,
chemicals are poured on the feaces which act on the feaces.
 Other methods of sewage disposal are Dumping in the river and streams, forest, bushes, borehole
latrine, trench latrine e.t.c.
 Proper handling of contaminated waste (blood or body fluid-contaminated items) is required to
minimize the spread of infection to providers and the community. Proper handling means:
 Wearing utility gloves, to handle wastes.
 Transporting solid contaminated waste to the disposal site in covered containers. Disposing of all
sharp items in puncture-proof containers; -
 Carefully pouring liquid waste down a drain or flushable toilet;
 Burning or burying contaminated solid waste e.g. in ways that children will not have access
to them.
 Washing hands, gloves and containers after disposal of infectious waste.
Important: The Laboratory is responsible for protecting staff against all real hazards of waste at all
stages of disposal, including transportation and disposition. All infectious waste that may be
contaminated e.g. (glassware, blood collection tubes, specimens and other solid or liquid waste or
refuse must be discarded into "biohazard" labelled containers that do not leak and have solid, tight-
fitting covers that are applied before transportation from the Laboratory work area). Before pouring
liquid waste in a sink, toilet or latrine, think about where the drain empties. It is dangerous for liquid
medical waste to run through open gutters or sewers.
STEPS TO TAKE IN CASE OF OUT BREAK OF COMMUNIICABLE DISEASES
 Disease Surveillance; and notification of the local health authority
 Isolation of all infected persons.
 Thorough screening to ensure all those affected are identified and quarantined.
 observe carefully for early signs in those that may be incubating the disease
 Mass immunization of those not affected with the appropriate Vaccine.
 Adequate records and statistics kept for planning purposes
 Health education On how to protect themselves and on ways of prevention
 Improvement of environmental sanitation.
 Advocacy to the significant people in the community on health education on communicable
diseases.
 Concurrent disinfection of stool, urine, vomitus and other body discharges
 Laboratory investigations to identify the causative organisms
 Continued surveillance of the population after the epidemic is under control
 Control measures should be directed at the infective agents, reservoirs and routes of
transmission.
 Community awareness and education on the causes and prevention of the cause of the outbreak
(e.g. cholera) and other communicable diseases.
Care of equipment, instruments, contaminated surfaces and other items:
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  Dispose needles, syringes, cotton wool and other blood. soaked materials in a safe manner e.g.
needles, in cartons or plastic containers.
Dispose wastes by burning or burying in ways that children will not have access to them.
INSTRUMENT PROCESSING
Through the contamination, cleaning, high level disinfection or sterilization.
Decontamination is the first step in handling used items; it reduces risks of HBV and HIV Aids. All
delivery and family planning instruments must be decdontaminated for ten minutes before washing in
soapy water, sodium hypochloride, 0.5% (chlorine, bleach) (one to six parts of water water) is best, rinse
in clean water and finally be allowed to boiled for 20 minutes, after boiling point. Ethanol 7% alcohol
70%, formaldehyde 4%, hydrogen peroxide 6% polyvodone iodine, 2.5% are also used for high level
disinfection by chemicals.
METHOD OF PROCESSING
Get three bows of water.
1. Decontamination: in the first bowl containing sodium hypochloride 0.5% (JIK). Put one part of
jik to six part of wate. Decontaminate by immersing the instrument completely in it for ten
minutes.
2. Cleaning: Second bowl Containg soapy water
 Use soapy water eith brush to scrup the hinges of the instruments
 Remove all visible blood, body flud, and dirts.
 Wash with soap and water
 Third bowl contasining clean water: - rise with clean water; air or towel dry
3. High level disfcetion: destroys all viruses, bacteria, parasites, fungi, and some endospores.
4. Sterilization: Destroys all microorganism including endospores
FACTORS NECCESARY FOR CLEANING AND STERILIZATION OF INSTRUMENTS
1. The time necessary for action
2. The concentration of killing agents
3. Optimum acidity or alkalinity for activity or killing agent
4. Optimum temperature
5. The number of organisms presents
6. The physical state of the materials from which it is necessary to remove the bacterial, blood,
pulse, mucus and dirts acts as a protective coat for the bacterial and limit the action of killing
agents.
7. Direct contact between all surfaces of the object to be sterilize and the killing agents
8. Antagonist substances neutralizing the activity of the killing agent
9. Impurities diluting the agents
10. Inactivation of the agents by time
5.14 POST ABORTION CARE

POST ABORTION CARE (PAC):

This is an approach for reducing morbidity and mortality from incomplete and unsafe abortion and the
resulting complications and for improving women's sexual and Reproductive Health lives.
Indications for Post Abortion Care: (PAC)
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 1. Each year, 20 million unsafe abortion OCC4rs worldwide
2. More than 70,000 women die as a result of unsafe abortion
3. One out of every eight death related to pregnancy is due to unsafe abortion
ELEMENTS OF PAC

There are five elements of post abortion care and they are as follows:
1. Treatment: of incomplete and unsafe abortion and abortion related complications that are potentially
life threatening. PAC model recognizes that high quality treatment uses Manual Vacuum Aspiration
(MVA) whenever possible and depending on local conditions, and includes standard infection
prevention precautions, informed consent, appropriate pain management, sensitive physical and
verbal patient contact and follow-up care.
2. Counseling: to identify and respond to woman's emotional and physical health needs and other
concerns. Counseling in essential in the sense that women and their service providers identify and
address broader emotional and physical health
3. Contraceptive and family planning services to:
 Encourage the practice of birth spacing
 Practice birth spacing including emergency contraceptive
 Acess a wide range of contraceptive methods where authorize
 Prevent unwanted pregnancy. These are effective strategies for preventing future unwanted
pregnancies and unsafe abortion and helping women achieve their Reproductive goals.
4. Reproductive and other health services that are provided oii - site and via referrals to other
facilities in provider's network such as:
 Physical health needs and other concerns
 STI/HIV prevention education, screening, diagnosis and treatment, Health education or
Prevention of STIs and HIV/AIDs. Screening for sexual and/or domestic violence
 Immediate treatment as needed and referral for medical/social/economic services and
support.
 Screening for anaemia and treatment.
 Nutrition education hygiene and cancer screening and referral as needed.
 Infertility diagnosis, counselling and treatment.
5. Community and service provider's partnerships to:
 Prevent unwanted pregnancy and unsafe abortion.
 Mobilize resources for timely care for complications from abortion.
 Ensure health services reflect and meet community expe[ l ] [1 ]citations and needs.
Principles of post abortion care:
 Having empathy and respect for patient
 Maintaining positive interaction and complication communication with patients
 Respecting privacy and confidentiality
 Adhering to the voluntary informed consent process.
MANUAL VACUUM ASPIRATION (MVA)
This a procedure carried out to evacuate uterine contents in the management of abortion.

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It is a safe and effective method of uterine evacuation with complete evacuation rates of 95 percent. It is
well accepted by women and in most cases requires low level of pain management such as oral
analgesics, verbal reassurance local para-cervical block, and if desired, light sedation.
Indications for MVA
1. Threatened or imminent abortion
2. Inevitable abortion
3. Incomplete abortion
4. Septic abortion
5. Missed abortion
6. An embryonic pregnancy
7. Hydatidiform mole I molar pregnancy
8. Retained placental products
Methods of vacuum aspiration.
1. Use of electric pump with constant sunction
2. Use of manual syringe for uterus suction
Instruments and materials for MVA
Vaginal speculum
 Tenacullum
 Forceps
 Uterine or O&G Tweezers
 Basins tor antiseptics and tissue
 Needleextenders
 Dilatators of3 to 14mm in diameter
 10cc syringe with spinal needle of22 of 3.5 inches or needle 23
 Local anesthesia (1 % or2%)
 Lidocaine without epinephrine
 Antiseptic solution
 Sterile Gauze (20 pieces)
 Maintain infection prevention - wash hands, sterile field mackintosh, drapes etc.

Preliminary steps before the procedure

 Prepare room, equipment and medication.

 Take a clinical history.

 Explain the Procedure to the patient and tell her what you are doing and why at each step of the
procedure.

 Establish rapport with the patient to make her comfortable

 Perform physical and pelvic examinations.

 Notice how she feels.

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  Let her empty her bladder.

 Position the patient lithotomy or dorsal.

 Engage patient and talk about contraceptives - to distract her and alleviate pains and anxiety.

 Access dilatation of the cervix

 Determine appropriate type of pain management in order to decrease pain and minimize
discomfort e.g. Give paracervical block if necessary.
Precautions:
 Determine uterine size position to exclude fibroids or other anomalies otherwise don't do it.
 Use appropriate cannula size to prevent damage to the cervix, or cause loss of suction or retained
tissue.
Steps for the procedure:
Perform the procedure with confidence and competence
 Insert cannula carefully.
 Do not insert cannula forcefully as this my damage cervix or uterus
 Grasp cervix with ring forcesps. Administer paracervical block and I or other medications if
needed. Allow time to take effect.
 Inspect cannual and syringe again to make sure they are in good condition and correct choices
according to uterine size and cervical dilation.
 Hold the cervix to stabilize it and gently insert the cannual. Rotate with gentle pressure if
necessary.
 Push the cannual slowly into the unterie cavity. Measure the uterine depth by the clots visible on
the cannula.
 Attach the prepared syringe to the cannula without contamination,
 Ensure that all the tissue has been withdrawn.
 Send specimen of tissue for pathology.
 Inspect the tissue for villi membranes or foetal parts.
 Take patient's vital signs.
 Allow her to rest comfortably (for at least one hour.)
 Decontaminate all instruments after the procedure.
 Dispose wastes
 Monitor her closely.
 Check for bleeding and cramping if lessened,
Give post procedure instructions as follow:
 Expect some cramps her normal menses should return within 4 to 8 weeks
 Take prescribed medication and should not have sex or put anything into the vagina until a few
days after bleeding has stopped.
 Explain where to seek medical attention if she experiences complications.
 Allow patient to go home when she is stabilized or she feels comfortable to go.
 Inform her about follow-up care.

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  Remind her about all she has been counseled On contraceptives and return to fertility.(i.e.
Contraceptives can delay or prevent pregnancy if she desires)
 Schedule a follow up visit, and inform her where to seek medical attention if she experiences any
of the complications mentioned below:-
o Prolonged cramping (more than a few days)
o Prolonged bleeding (bleeding more than normal)
o Severe or increased pain
o Fever, chills, malaise, fainting
Potential problems affecting PAC services
 Lack of necessary equipment and medicine.
 Lack of adequate staff.
 Lack of training in Post Abortion Care (PAC).
 Problem of communicating with patient.
 Lack of political decision making.
 Inadequate referral systems.
 Inadequate monitoring and follow-up training process.
 Administrative separation of emergency and contraceptive services.
 Resistance to using Manual Vacuum Aspiration.
Intervention strategies
1. Educate community on the danger signs of abortion complications, especially, vaginal bleeding,
foul-smelling vaginal discharge, fever with or without chills, decreased urinary output. e.t.c.
2. Train more staff on PAC services
3. Decentralize Manual Vacuum Aspiration (MVA) services by taking services to the lowest levels
of care in district ·and by training non-medical cadres to provide PAC services (e.g. Nurse-
Midwives, clinical officers)
4. Establish a sustainable supply of MVA instruments and expandable supplies.
5. Provide family planning counseling and services to all post abortion clients irrespective of whether
the abortion was spontaneous or induced.
6. Link post abortion clients to other Reproductive health care services as needed, e.g.: Screening for
sexually transmitted infections and screening for cervical cancer.
7. Establish effective referral system for PAC services
8. Positive political decision making on PAC especially on MVA.
9. Include talk on PAC services during family planning counseling.
10. Strengthen, monitoring and follow-up process on PAC services.
Dangers of MVA
 Prolonged cramping (more than a few days), prolonged bleeding, (more than two weeks)
 Excessive bleeding, more than normal menstrual bleeding
 Severe or increased pain
 fever, chills or malaise
 Fainting

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Note: A woman usually recovers her fertility (infirst trimester abortion) duringfirst 2 weeks following
abortion and durilig the first 4 weeks (in the second trimester abortion) after and abortion.
Advantages of MVA:
 Requires only slight dilation and scrapes gently.
 Lowers risk of complications.
 Lowers cost of services.
 Lowers resources use.
 Decreased need for hospitalization.
 Safe and effective method of uterine evacuation with complete evacuation rates of95%.
 Well accepted by women
 It requires in most cases low level of pain management e.g. Use of oral analgesic, verbal
reassurance, local Paracervical block, and if desired, light sedation with Valium 5mgIM.
 Recovery is fast.
5.15 MANAGEMENT OF NEONATAL EMERGENCIES
This is an urgent skillful care given in an emergency to save lives of mother and/or baby and to prevent
complication
TYPES OF EMERGENCY OBSTETRIC CENTRES
1. Basic Emergency Obstetric Care (BEOC) Centre: This is a centre that competently has the ability
to perform competently on a regular basis (usually at least quarterly) certain basic procedures,
targeted at obstetric complications.
2. Basic Emergency Obstetric Comprehensive (BEOC) Centre: This is a centre that has the ability to
perform all functions in basic category including caeserea section and blood transfusion, care and
resuscitation of Low Birth Weight babies e.t.c. At least one such centre is recommended for a
population 0f 500,000 i.e. one comprehensive centre should have 4 basic centres referring to it.
SIGNAL FUNCTIONS USED TO IDENTIVY BASIC AND COMPREHENSIVE ESSENTIAL
OBSTETRIC CARE SERVICES.
BASIC ESSENTIAL OBSTETRIC CARE
This includes the following and are carried out by Nurse/ Midwives and Physicians to:
 Administer Parenteral Antibiotics
 Administer Parenteral Oxytocics
 Administer Parenteral Anticonvulsants for Pre-eclampsia / Eclampsia
 Perform manual removal of placenta
 Evacuate retained products
 Perform assisted vaginal delivery.
COMPREHENSIVE ESSENTIAL OBSTETRIC CARE:
This is carried out by Physicians
 In addition to all services included in Basic EOC,
 Caesarean Section,
 Safe blood transfusion (screened and cross-matched blood).
obstetric, conditions that require emergency care include:
 Shock and post partum haemorrhage
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  Sepsis (Puerperal sepsis)
 Obstructed labour, ruptured uterus, retained/adherent plancenta.
 Eclampsia, foetal distress and maternal distress.
 Puerperal sepsis
DESCRIPTION OF SEPSIS AS ONE OF THE CONDITIONS THAT REQUIRE EMERGENCY
CARE
EXAMPLE: PUERPERAL SEPSIS
Sepsis I Infection is one of the major causes of maternal mortality and this occurs mostly in the
puerperium.
Definition of puerperal sepsis: This is any bacterial infection of the genital tract which occurs after the
birth of the baby, usually after the first 24 hours.
Puerpeal fever: This is a temperature of at least 380C on more than two occasions apart after delivery
excluding the first 24 hours till 14 days postpartum
Common causes
1. Malaria fever
2. Upper respiratory tract infection e.g catarrh
3. Pneumonia
4. Engorged breasts / Mastitis
5. Acute pyelonephritis
6. Endometritis (infection occurring inside the utrine lining)
7. Thrombophlebitis at the infusion site
8. Acute viral hepatitis
9. Deep venous thrombophletis
10. Tonsillitis / pharyngitis
11. Septic pelvic thrombophlebitis
Signs and symptoms
1. Fever temperature 380C or more (this is the cardinal sign)
2. Other features depend on the causes e.g
a. Headache
b. Joint pain
c. Bitter taste
d. Weakness
e. Cough, catarrh,
f. Chest pain
g. Nocturia
h. Dysuria
i. Painful breastfeeding
j. Jaundice

Management:

3. Rapid initial assessment – Brief history e.g, of labour, onset of fever at time of delivery prolong
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 laabour, multiple vaginal examinations, manual removal of placenta etc
4. General examination
viii. Skin Pallor, pyrexia;
ix. Throat - tonsils, pharynx;
x. Breast – swollen, inflamed and painful, nipples are flat;
xi. Chest – reduced air entry, crepixtations;
xii. Abdomen – lower abdominal pain, flank pain,
xiii. Muscle / skeletal – swollen hands, fore arms / painful calf
xiv. Vulva – foul smelling lochia
Investigations
iv. Full blood count, PCV, WBC, Platelets
v. Blood film for malarial parasites
vi. Breast milk
Treatment
vi. Antimalarial - Artemisin based combination Therapy (ACT)
vii. Breast engorgement – Hot compress, express milk
viii. Give analgesics / antipyretics
ix. Infective mastitis - IV Ampicillin, Cloaxicillin 1 gram 6 hourIy IV Metronidazole 500ml, 8 hourly x 48
hours
x. Endometritis / pyelometritis – preferably refer because of complications
COMPLICATIONS
7. Cerebral malaria
8. Meningitis
9. Septicaemia
10. Acute renal failure
11. Pelvic abscess
12. Breast absess

MATERIAL FOR EMERGENCY OBSTETRIC CARE

5. MEDICAL SUPPLIES
 Suction machine with nasal tubes (various sizes)
 Airbus bag (baby and adult), obstertric forcepts
 Manual vacuum extractor with its various sizes
 Cuscos vaginal sspeculum, blade, hot water bottle
 Artery forcepts, sponge forceps, oxygen cylinder
 Blood pressure cuff
 Face mask (adult and baby for oxygen administration)
 Vulsellum forceps
 Intraveneous giving set, scalp vein needle
 Catgut of various sizes, episiotomy scissors
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  Gloves, sutures, uterine containers and dipsticks
 Vaginal speculum, calibrated small jug
 Mucus extractor, bulb syringe
 Blood giving set, foley’s catheter
 Tape measure, pinards sthethoscope
 Kocker’s forceps, cord scissors
 Endo-tracheal tube (various sizes)
 Vacuum extractor
 Torniqet, syringes and needles
 Plaster, straight scissors
 Needle holder
 Receive / kidney dishes
 Cannulae (various sizes)
 Guaze and cotton wool
6. Drug
ANTI- ANTI-MALARIA OXYTOCICS ANTICONVULSANT
ALLERGICS

Epinephrine Quinine Eregomethrine Diazepam

Antibiotics Dihydrocholride 0.2mg for IM of Magnesium suphate
Ampicillin Sulfadoxine IV use Intra-venous (IV)
Gentamicin Pyrimethamine Misoprostol Solutions
Metronidazole Disinfectant and 100mcg Glucose 5%, 50%
Procaine Benzyl Antiseptics 200mcg Normal saline
Penicillin or Chlorhedine Oxytocin Ringers lactate
Benzathine Iodine 10IU for IV or Sterile water for injection
Benzylpenicillin Surgical spirit IM use tetanus toxoid
ANAESTHETICS ANALGESICS (stored in cold box)
Lidocaince Paracetamol
Pentacozine

7. Supplies for infection prevention

Chlorine, Clean towels, Clean water supply. Face mask, Face shield, Gloves (high-level)
disinfected or sterile), Plastic or rubber aprons. Protective eyewear, Puncture-proof container
Receptacle for soiled linens, Separate containers for general and medical waste, disposal and
contaminated, instruments, Soap
8. Furnishings
 Clock (or watch)
 Screens/ Curtains for privacy (if needed)
 Drape or blanket to cover woman
 Examination surface (table or bed with washable surface and clean linen)

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  Light source,
 Pillow
6. Record forms
Patient records or forms
Referral forms.
Set of instruments and supplies for suturing
Instruments Supplies
(stored in covered stainless steel container) 4 cotton balls
1 needle holder 6 guaze compresses (4 x 4)
1 scissors Diazepam
1 tissue forceps without teeth Emergency tray, epinephrine, IV fluids
5 ce syringe and needle Gloves (high – level disinfected or sterile)
Magnesium sulphate, oxytocin, ergometrine
protective eyewear, syringes, needles

Supplies for Emergency Tray

Diazepam, Epinephrine, gloves (high level disinfected or sterile), IV fluids, Magnesium Sulphate,
Emergency Drill
Definition -
A drill is a response to a planned simulated event. examples of common obstetric and neonatal drills
1. Massive obstetric haemorrhage
2. Shoulder dystocia
3. Eclampsia
4. Maternal collapse and Cardio-Pulmonary Resuscitation (CPR)
5. Neonatal resuscitation
6. Cord prolapse
7. Crash Caesarian Section

Aims of a drill
 To train the staff (e.g. staff in the maternity unit).
 Test our local systems and protocols for responding to emergencies.
 Test our professional team work and individual's skills, behaviour and knowledge.
Reasons for drills
 To improve management of obstetric emergencies.
 It is recommended by World acclaimed colleges.
 Requirement for passing examination e.g. examinations in Medical schools.
 To achieve reduction in maternal and neonatal mortalities (e.g. CEMACH)
CEMACH is a Confidential Enquires into Maternal and Child Health practices which may be adopted
to identify the cause of a maternal death. (A Questionnaire form is given to be filled by staff in the
various departments concerned in the management of the patient i.e. from the security man from the gate
of entry to all the processes she passed through until her death).
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Problems associated with running a drill
1. Busy units: It is difficult to run drills in a busy unit. This is because all staff and attention will be
driven to the drill.
2. Shortage of dedicated staff: There is difficulty in getting a dedicated risk management staff.
3. Consumes time and energy: When planning and conducting drills, a substantial amount of time is
demanded e.g. burning a house down to practice a drill.
4. Limitation of staff: Each drill may only include a few staff.
Advantages of a drill
 Management follows Evidence-Based Medicine (EBM)
 Members of staff are summoned faster
 Resuscitation process is better organized.
 Drugs are prepared and administered more quickly e.g. in eclampsia
 Simplification and reduction of tasks.
 Useful educational activity.
 Perinatal emergency drill allows risks to be identified without exposure of real patients to
inadequate care.
 Allows a greater sense of reality
 Provide controlled experience for all staff and promotes team work practices within a clinical unit.
 Can identify and correct potential deficiencies in the care of patients.
 Drills could be the life saving moves to save a loved one.
Information to staff on drill i.e tells the staff or observers around that:
1. You are about to take part in a simulated obstetric emergency.
2. The patient is an actor so please stimulate any invasive procedures.
3. Say aloud what you are doing e. g. "I am setting an intravenous line"
4. Everything else that you might do in this situation should be carried out as normal.
5. Any intravenous drugs or fluids should be prepared as normal but delivered into the receptacle
beside the
REFERRAL

DEFINITION: referral is a way of sending a client / patient from a lower health facility to a large one for
a better care.

TWO WAY REFERRAL

Two way referral is a process by which a provider sends patient/client to the next level of care for further
management and gets feedback from the referral health facility. It is usually from a lower level health
facility to a higher level facility.

Example: from a Community health post - Basic health centre – Comprehensive health – General
hospital – Teaching / Specialist institution.

Or

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Two way referral system is a valid system in the provision of primary health car. The process entails
upward and downward communications.

Or

Transfer of a client from one provider to another who has the required skills needed to meet its needs. It
can be from a lower to a higher level and vice versa with feedback.

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 DIAGRAM OF THE TWO – WAY REFERRAL SYSTEM

HOSPITAL AND COMPREHENSIVE

DIAGNISTIC SERVICES HEALTH CENTRE

DISTRICT / PRIMARY
HEALTH CENTRE

HEALTH CENTRE

FIRST REFERRAL

HEALTH POST VILLAGE HEALTH WORKER / TRADITIONAL

BIRTH HOMES / MOBILE CLINICS

REASONS FOR REFERRAL

 For continuity of care

 For expert care / management
 On requesting patient or relatives
 To reduce morbidity and mortality rates
 To allow patients receive better care
 To allow fears of an impending danger
 To increase patients satisfaction on the health services render
 To restore confidence in the health care delivery system
 Enhances transfer of knowledge between providers.
 Allows cross fertilization of ideas between health care providers and other health teams

PATHWAY / TYPES OF REFERRAL

1. NORMAL PATHWAY: refers client from the lower health care to the immediate higher health
care institution e.g from primary health care centre to general hospital.
2. Emergency pathway: Refers clients from lower level health care to any higher level health care
institutions regardless of the position or hierarchy depending on the severity of patient’s condition.

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 BARRIERS TO REFERRAL

 Fear of unknown e.g environment strange to patient or un-conducive.

 Misconception about the referred facility.
 Breakdown in communication between the two facilities
 Transportation problem
 Poor access road
 Rigid rules of the health facilities : - difficulties in accessing care (systemic issues)
 Poverty (lack of money)
 Lack of support from family (not given permission to go to facility for care and no one to take
care of the other children at home)
 Ignorance on the part of the family
 Family wants to take mother or baby to a faith healer.
 Attitude of service health provider.
 Mother is alone and needs permission of her husband or family elder.
 Problem not solved e.g death of mother or baby.

5.15 MANAGEMENT OF BREAST FEEDING

Breastfeeding
Breastfeeding is recognized as the Gold Standard of infant feeding. It is the natural way to feed a baby.
Breast feeding is fundamental to the growth, development and health of children. It is also important for
the health of mothers and forms the foundation for a healthy future among other societal benefits.
Composition of breast milk
The breast milk is the only complete food in nature for the infant. It contains water (80-90%), protein
contents contain antibodies, easily digestible fat, carbohydrate as lactose, vitamins and minerals.
Breastfeeding immediately after delivery, aids contraction of the uterus and the rich-protein colostrums
(yellowish milk) protects the baby due to the antibodies content.
Process of breastfeeding
Breastfeeding involves three processes.
1. Production of milk: Milk is produced by the acini cells in the alveoli of the breast lobules. The
production of milk is controlled by the anterior pituitary gland which secrets hormone prolactin
that activates the cells to produce milk. (During pregnancy- in the late pregnancy mille is already
produced and stored in the ampular as colostrum. This is the first milk that the baby takes at birth;
it is highly rich in protein and contains antibodies).
2. Flew of milk: The milk produced is propelled by the basket cells from the alveoli, through the
lactiferous ducts (milk duct) and stored in the ampular which serves as a temporary reservoir for
milk. The milk flows as a result of neuro-hormonal reflex - The effect of the baby's mouth on
the sensitive nipple (the nipple is the sensitive part of the breast that is surrounded by a
darkened area referred to as the areola) also stimulates the release of Oxytocin by the Posterior
Pituitary Gland. Oxytocin causes milk to flow-from the ampula into the small milk ducts in the
nipple.( theOxytocin released also contracts the uterus).
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 3. Withdrawal of milk: This occurs when the baby draws the nipple into the mouth, (lips covering
the areola), coupled with the champing action of the baby's mouth on the nipple, milk draws
freely into the baby's mouth (cheeks swollen and shinning) - this is suckling. The mother also
experiences "Let down-reflex" even when the baby is not with the mother, milk flows freely
from the nipple. (This is more of psychological origin e.g. Thought of baby while at work, or cry
of the baby or site of the baby by the mother).
EXCLUSIVE BREASTFEEDING
Definition:
Exclusive breast feeding is the feeding of infants on breast milk ONLY without adding any other fluid
including water for the first six months of life. It is no other feed or drink, not even water except breast
milk for six months but allowing the infants to receive medication. Exclusive breastfeeding for the first-
six months is recommended all over the world, because it helps the baby to survive and to grow and
develop.
Breastfeed exclusively as follow~:
 Make breastfeeding sole source of baby's feeding up to six months of life
 Do not give baby water or artificial feeds or pacifier
 Breast feed both during the day and at night allowing a long time at each breast each time for six
months.
 Always put baby to breast on demand
 Allow baby to suck until satisfied
Note: Breast milk contains 80 90 percent water and therefore contains all the water a baby needs even in
very hot weather when a baby thirsty. the mother should breastfeed and drink more liquids to
help produce more breast milk. Baby passes urine at least 6 times in 24 hours, thus indicates
that baby is getting enough milk and water:
A breast feeding mother may have to leave her baby at home for a few hours or if a working mother
should manually express breast milk and keep for the baby till she comes back. Breast milks can keep up
to 8 hours if stored in covered cup, kept in a bowl of water or kept cool in a refrigerator.
MANAGEMENT OF BREASTFEEDING
Successful breastfeeding starts from the advise received during ante-natal period as follows:
 Maintain breast hygiene before and after delivery
 Express colostrums during subsequent pregnancies in the last 4 6 weeks of pregnancy to clear the
ducts of epithelial debris
 Give baby first milk - colostrum
 Complete emptying the breast during feeding of the baby to prevent breast engorgement.
 Always wear adequate breast support e.g. fitting brassier or binder
 Stroke breast to empty milk completely after breast feeding
 Do not restrict fluid intake as it has no direct function on breastfeeding
REASONS WHY A MOTHER SHOULD BREASTFEED IN THE FIRST HOUR AFTER
BIRTH
1. Colostrum (yellow) is very high in protein, vitamin and antibodies, which protect the baby from
infection. It is often called the babys first immunization. Colostrum helps to expel meconium and
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 to prevent jaundice.
2. Colostrum contains a very concentration of nutrients and helps prevent low blood sugar in the first
hours of life.
3. Most newborns have a strong sucking reflex and are awake the first hour after birth.
4. The newborn's sucking helps the mother make breast milk.
5. Breastfeeding immediately after delivery aids contraction of the uterus and reduces
bleeding.
6. Immediate skin-to-skin contact helps the baby stay at the best temperature:
7. Early breastfeeding helps the mother and baby, develop a strong relationship.
HOW TO HELP A MOTHER BREASTFEED SUCCESSFULLY IN THE FIRST TIME
 Put the baby in skin-to-skin contact with the mother immediately after birth.
 Do not separate the mother and the baby (to weigh or give other cares) until after the
first breastfeed.
 Do not rush, the first breastfeed takes time.
Mother's position:
Help the mother get into a comfortable position. If she desires, use pillows or folded blankets
under her head if she is lying down or under her arm if she is sitting.
On her back: The mother may wish for her head or shoulders to be supported.
Side-lying: If the mother had a Cesarean delivery, this position may be most
comfortable for her.
Sitting up: This is another position that can be adopted by the mother.
Baby's position:
 The mother should hold the baby close with the head and the body turned to face the breast.
 The baby is facing the breast with baby's nose opposite the nipple.
 The baby's whole body is fully supported. If the baby is lower than the mother's breast, put the
baby on a pillow or folded blanket so the baby and the breasts are at the same level.
TECHNIQUES OF SUCCESSFUL BREASTFEEDING
 Positioning: adopt comfortable position for mother and baby, position mother well with back
supported.
 Attachment: bring baby to the breast and not breast to baby
 Straight line baby's head, back, buttocks, i.e. all to be on a straight line.
 Allow baby's chin to touch the breast (lower lips is turn outwards and more of the areola above the
mouth than below it; there are slow deep sucks with some purses) and abdomen in contact with
mother's.
 Good attachment: Place mouth wide open and allow hip turned outward. This ensures effective
suckling, encourages good flow of milk, prevent cracked nipples and enhance complete emptying
of the breast
 Place most part of the dark part of the breast (areolar) into baby's mouth (baby's cheeks round and
shining).
 Feed baby until one breast feels soft and emptied before putting hirn/her to the other breast. Baby
will come off the breast when satisfied. Use both breasts, the baby should first empty one breast to
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 get the rich hind-milk (the last milk that comes from a breast at feeding) before starting on the
second breast.
 Expressing colostrums during subsequent pregnancies in the last 4-6 weeks of pregnancy to clear
the ducts of epithelial debris
 Complete emptying of the breast during feeding of the baby to prevent breast engorgement.
FOUR STEPS TO SELF ATTACHMENT:
1. Place the baby face down on mother's abdomen.
2. Support the baby as he/she gradually moves towards the breast.
3. Allow the baby time to mount the nipple before fully taking it into mouth. The baby is born with
a natural desire to take in and suck on the full areola and nipple.
4. Allow the baby to suck as long as he/she wants.
TEN STEPS TO SUCCESSFUL BREASTFEEDING FOR MATERNITY SERVICES
(WHO/UNICEF)
Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to ail health care staff.
2. Train all health care staff in skills necessary to implement this policy,
3. Inform all pregnant women about the benefits and management of breast feeding
4. Help mothers initiate breastfeeding within half an hour of birth,
5. Show mothers how to breastfeed, and how to .maintain lactation even if they should be separated
from their infants.
6. Give newborn, infants no food or drink other than breast milk, unless medically indicated,
7. Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day,
8. Encourage breastfeeding on demand,
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants,
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
from the hospital or clinic,
Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a
joint WHO/UNICEF statement published by the World Health Organization, Advantages of breast
feeding
To the baby:
1. Easily digested and efficiently used by baby's body.
2. It gives optimum nutrition as it supplies all the necessary nutrients needed for baby's growth in
the first six months, in the right proportions and at the right temperature.
3. Breast milk contains Vitamin A. Babies low in Vitamin A have poor appetite, eye problems and
more infections.
4. It is a clean source of food. It is germ free as it cannot be contaminated (unlike baby formula).
5. Breast milk helps low birth weight babies gain weight fast; especially premature babies.
6. Breast milk is the easiest food for the baby to digest (easily digestible).
7. It helps baby's mouth, teeth and jaw to develop properly.
8. Promotes proper teeth formation and speech development in the baby.
9. It helps to stabilize the baby's temperature.
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 10. Keeps baby well hydrated during illnesses.
11. It is always a perfect temperature for the baby.
12. Promotes baby's mental development.
13. Breastfed babies are said to have compassion.
14. Immunizes the baby against infectious/diseases because of its antibodies and makes the Immune
system stronger
15. Protects baby from infection e.g. colostrum in the first view days contain antibodies and is very
rich in protein.
16. Offers some protection against allergies.
17. Protects baby from intestinal and respiratory tract infections.
18. Comforts the baby.
19. can contribute to 10% reduction in infant mortality.
To the mother:
1. It is readily available.
2. Saves money- nature's free gift (mother does not need to buy other milk).
3. Fosters healthy mother-child relationship/bonding -allow mother and baby to know each other
(establishes emotional bonding between mother and baby).
4. Breast feeding protects mother from risks of breast and ovarian cancers.
5. Provides contraceptives (LAM) until menses returns or until six months. Gives mother satisfaction
of motherhood-mother feels relaxed and good about her newborn baby.
6. Can prevent pregnancy in the first 6months following delivery.
7. Helps stimulate milk production when baby suckles at the breast there is "neuron hormone reflex
for milk flow. Makes the uterus contract and reduces bleeding.
CONDITIONS AFFECTING BREASTFEEDING
In the mother:
 Breast formation e.g. Nipple: a well formed nipple will aid successful breastfeeding.
 Deffect of the nipple: such as flat, inverted, or retracted nipples will make breastfeeding difficult.
 Fluid intake: Appropriately 90% of breast milk is water hence no need to give extra water to the
baby. The mother needs to drink enough fluid/water when breastfeeding (e.g appropriately 112 -
2litres or more daily).
 Mother's state of mind: The state of mind affects activities of the brain for breastfeeding mothers,
emotion such as anxiety, fear, sadness e. t.c. will affect milk production.
 Serious illness: sometimes, severe illness in a nursing mother causes drastic reduction or failure of
milk production e.g. severe anemia or chronic illness such as cardiac diseases, HIV/Aids e.t.c
 Good nutrition of the mother will also aid successful breastfeeding because malnutrition can make
her to be lethargic and incapable of breast feeding her baby.
 Unwillingness of the mother: This will affect successful breastfeeding
Management:
 Encourage and support mother.
 Give practical advice on how to increase her milk supply particularly to increase the frequently of
breastfeeding.
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Advice her to:
i. Take a warm shower or put hot wet clean clothes on the breasts for 5-1 0 minutes before each
breastfeeding
ii. Hand express a small amount of milk before putting the baby to the breasts. This helps to
soften the area around the nipple (the areola) and helps milk flow, making it easier for the
baby to attach.
iii. Breastfeeding often, at least every 2-3hours. Let the baby is not able to suck, express milk every
2-3hours. (Engorged breasts that are not emptied can become infected).
IV. At each feed, empty the first breast before offering the other breast to the baby. If the breasts still
feel full after abreast feed, encourage the baby to feed longer or expressed breast milk for a few
minutes until the breast feels softer.
v. Help close the milk ducts and make the breasts more comfortable after breastfeeding by putting a
cold cloth on both breasts for 5-10minutes after breastfeeding.
VI. Explain the signs of infection and ask her to watch out for any signs of infection such as redness,
heat, fever and chills, pain or a lump in one breast.
vii. Bath the breasts with warm water before feeds.
viii. Gently stroke with soapy hands towards the nipple, mop up find put the baby to the breasts for few
minutes then, express the rest of the milk.
Advise on other comfort measures:
A. Such as to:
 Avoid tight-fitting bras.
 Apply cold compresses to the breasts between feedings to help reduce swelling and pain.
 Put cold cabbage leaves with clean water.
 Crumble the leaves with your hands to crush veins before using.
 Put one or more leaves on each breast to completely cover them (including under the arm).
Wear a bra or tie on a cloth to hold the leaves in place.
 Wear the leaves until they become soft.
 Take Analgesic e.g. Paracetamol500mg orally, 3times daily for 3 to 5 days (or as needed).
B. Bath the breast with clean water before feeds,
 Gently stir with soapy hands towards the nipple pup and But the baby to the breast for few
minutes, then express the rest of the milk.
 Ensure complete emptying of the breasts at each feeding.
(b) Venues engorgement
This is due to increased blood supply to the breasts.
Features:
Milk does not come out from the nipples and the breasts become tense and painful. The nipple is
flattened, also, no milk will flow or come out.
Management:
Give mild analgesic to relieve pain. e. g Paracetamol I G, 3 times daily for 2·-3days and make effort to
relief tension.
2. PLUGGED MILK DUCT
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Description: This occurs if one of the ducts through which the breast milk flows get stopped up. This
may happen. if one area of the breasts is not emptying well.
Features: Feeling of a lump in one breast which may be sore when touched. Often, it is in the outer part
of the breasts. Usually, there is no redness or heat. (It does not cause fever either):
Management. Reassure the mother that she can reduce the breasts lump and pain.

Advice as follows:
 Before each breastfeeding, put hot, wet, clean clothes on both breasts for 5-10minutes.
 Gently massage the breast that has plugged milk tube; and moves the hand that is doing the
massage over the plugged area towards the nipple.
 Breastfeed from the breasts that has the plugged milk duct first.
 Ensure the baby feeds longer from the breasts that has a plugged milk duct.
 If the plugged milk duct is in the outer breast, use the under-arm hold position while feeding.
This helps to draw more milk from the outer breasts.
 Do not wear a tight bra or tie a cloth tightly around the breasts.
 Explain the signs of breasts infection and the need to see a health worker if she has any of these
signs pains, redness, heat, a lump in the other breast, fever and chills.
3. NOT ENOUGH MILK
Description: This may be due to faulty techniques of breast feeding on the other breast given to the
baby. Features:
 Mother fixed, not breastfeeding the baby as expected often enough.
 Baby is very fussy
 Poor baby attachment.
 Baby is not gaining weight but not sick.
Management:
 Reassure the mother that she can make a lots of milk.
 Counsel and help the mother with position and baby's attachment.
Advice the mother to:
 Rest more.
 Drink more fluids (with every meal and every breastfeeding)
 Feed the baby on demand, at least every 2-3hours, more after if the baby wants to suck.
 Let the baby feed for as long as possible on each breast.
 Feed only at the breast.
 Stay in bed and keep the baby with her so the baby can feed often during the time she is trying to
increase her milk supply.
 Reassure the mother that she has enough milk for the baby.
 Show her a reload of the baby's weight gain (growth chart) and explain that the baby's weight
gain is normal.
 Express a little mille from her breasts to show her that she is producing milk.
 Explain normal growth spurts and changes in the let-down reflex over time.
 To reassure her that the baby is growing well, have her bring him back for weekly weighing, if

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 possible.
 Advice the mother to return, if the problem worsens or if there are any danger signs.
Signs that the baby is getting enough breast milk:
1. The baby passes urine at least 6times in 24hours.
2. You can hear the baby swallow when feeding.
3. The mother breast feels softer after a feed.
4. The baby gain weight over time (after the first week).
5. The baby feels contented after feeding.
4. CRACKED / SORE NIPPLES
Occasionally, the skin around the nipple cracks and becomes painful. The pain increases at breast
feeding, hence the mother is reluctant to feed her baby on the affected breast. Sore nipple is when the
skin covering the surface of the nipple is chipped off leaving a raw area. This is usually due to faulty
technique of breast feeding. It may also be due to trush.
Management: Advice mother to:
 Ensure that the baby latches on (attaches) properly by good positioning to allow the nipple to
be well inside baby's mouth.
 Use different positions while breastfeeding- side lying, cross-cradle hold, under-arm hold. This
moves pressure to different parts of the nipples. Gently express the milk to give the baby.
 Damp the surface with a drop of breast milk and expose to air for 20-30 mins. 6 hourly daily to
aid healing.
 Dampen the nipple with Gentian Violet, same for cracked nipple.
 If sore nipple, take baby of breast for 24 hours to rest the breast
 For sore nipple, expose the breasts to sunshine for 10 minutes 2-3times a day.
 Start feeding with the breast that is less sore (do not stop breastfeeding). Only in severe cases
should the mother stop the rest a nipple for 24hours. During this time she must express breast
milk from the affected breast. She can cup feed the baby with the expressed breast milk and
also breast feed from the breast that has no nipple problem. See mother and baby again in 2-
3days.
5. MASTITIS / BREAST ABSCESS
Description: Mastitis is inflammation of the breast tissue which causes a hot, red and painful area in
the breast. Usually one breast is affected. The symptoms include fever which may be rapid in onset
and may be very high
6. BREAST ABSCESS: This may result from mastitis and usually starts 10 days after birth with
fever, chills, one area of redness and heat, body aches and pains.
Causes: -
(i) Entry of bacteria from cracked nipple.
(ii) Inability of milk to flow well through the milk ducts.
(iii) Milk is high in sugar and when fluids are high ( sugar stays in one place), bacteria grows there
and when bacteria ,increases, the mother gets an infection. Things that slow the flow of breast milk
can cause infection. For example, the mother has engorged breasts; She has a plugged milk duct;
Wears a very tight bra or ties a cloth very tightly around her breasts.
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(iv) The mother's immune system is weak. The mother is in poor health, may be malnourished or
stressed.
Management: Reassure the mother, take the mother's temperature and examine both breasts.
1. Give the mother one of the following medicines by. mouth:
(i) 'Cloxacillin 500mg 6hourly or Erythromycin 250mg 8hourly.
(ii) Amoxycillin 500mg 8hourly or Ampicillin 500mg 6hourly.
2. Advice the mother to:
 Put hot wet clean cloth over the affected area for 5-1 10minutes before breastfeeding
 Gently massage the infected breast from the outer breast towards the nipple, over the
affected area.
 Breastfeed often (every 8hours) starting with the infected breast.
 Feed the baby longer from the infected breast,
 If the infection is in the outer breast, use the under-arm hold while feeding. This draws more milk
from the outer breast.
 Stay in bed and keep the baby with you to feed often.
 Drink lots of water (at least 4litres a day)
(vi) Take Paracetamol for pain (1 G orally, every 4-6hours).
Refer if there is a hard round lump in the breast that does not go away or if the infection does not
get better after 2 days of antibiotics.
For breast abscess; Management include drainage of the abscess, administration of. antibiotics and
analgesics.
7. FLAT OR RETRACTED NIPPLE: will make sucking difficult. Use Woolish Shell '0 draw out the
'nipple and manually express the milk to prevent milk engorgement, For babies cleft lip or palate refer to
paediatric surgeon who corrects the malformations at the appropriate time. If baby is sick take baby to,
the hospital for medical treatment. If there is mouth sore, paint mouth with gentian violet. Give Nystatin
drops according to prescription.
Things to note:
1. Breast milk can be stored:
 Up to 6-10 hours.
 If freezer; 2 weeks.
 If refrigerator; 24-48hour
 If deep freezer; 3 months

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 2. No more formula for my positive baby feeding, Baby; continues daily Nevirapine
until 1 year of breastfeeding and until 1 week after stopping breastfeeding i.e.
Exclusive for 6months; supplementing for 6 months; continue ART. (Baby can stop
Nevirapine at 6 months).
Breast Feeding when the mother is HIV positive making an informed choice:
 The World Health Organization; the Joint United Nations program on HIV / AIDs;
and the United Nations Children's Fund recommend as follows that:
 Health workers should give a woman with HIV all the information on the risks and
benefits of the different feeding options and then support the woman's feeding
choice.
The options are as follows:
Option 1: Exclusive breast feeding, with early weaning or when " Replacement Feeds
meet AFASS criteria. AFASS means, A Acceptability, F Feasibility, A.
Affordability, S Sustainability, S Safe.
Option 2: Expressing breast milk and Heat- Treating it before feeding.
Option 3: Wet nursing by a woman who is Negative.
Option 4:Replacement Feeding with commercial infant formula.
Option 5:Replacement Feeding with Home – Modified Animal milk.

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\
 UNIT VI: INFERTILITY
Definition: Infertility is the inability of a couple to achieve a pregnancy after one year of
regular unprotected sexual intercourse.
Types of Infertility
Infertility is group into two types namely
 Primary infertility
 Secondary infertility
Primary infertility: This refers to a case where a couple has never achieved pregnancy
despite regular, unprotected intercourse for at least 12 months.
Secondary infertility: is when a couple achieved pregnancy before but has subsequently
failed to achieve another pregnancy within 12 months of regular, unprotected intercourse.
Classification of infertility:
 Primary infertility applies to the couple that has never conceived despite regular
unprotected intercourse for at least 12 months
 Secondary infertility is where the female partner had previously conceived but is
subsequently unable to achieve pregnancy after unprotected intercourse.
6.3 CAUSES OF INFERTILITY
In female
A.
 Tubal blockage (commonest cause) and this usually results from STIS, especially
gonorrhoea and chlamydia infection
 Other reproductive tract infections (RTIs) following unsafe induced abortions,
miscarriages and puerperal infections
 Anovula is responsible for about 12 – 20% of cases e.g hypogonardotrophin
 Congenital abnormalities e.g. chromosomal disorders, turners syndrome e.t.c
 Cervical factors e.g. poor mucus quality, cervical stenosis, sperm antibodies
B. Uterine factors:
 Gynaestresia: Abnormal narrowing of the vagina which could result from female
genital utilation FGN or other harmful practices.
 Infection of local caustic passerines e.t.c

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In male
 Poor quality of semen (due to low sperm count – hypospermia, poor mobility or
morphology) this is the commonest cause and is due to the following:
 Reproductive tract infections such as epidymics, orchitis and accessory gland
infection
 Physical factors e.g excessive drinking and smoking
 Drugs and substance abuse
 Physical factors e.g excessive heat, testicular trauma or injury, varicose veins.
 Undescended testes
 Metabolic factors (excessive drinking and smoking substance/drug abuses
 Chronic medical conditions e.g liver cirrhosis, diabetics e.t.c
 Chromosomal disorders e.g disinfectors syndromes
 Vasal or duct blockage, STIs, tuberculosis, surgery
 Erectile failure (cretile impotence) or ejaculatory dysfunction

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  Premature ejaculation
 Hypospadias
5.4 Risk factors associated with infertility
 Occupational hazards e.g radiation in radiographers
 Paint chemicals in paint industry workers
 Pesticides
 Batteries /chemicals by battery chargers and industrial workers
Causes involving male and female
 in frequent sexual intercourse
 wrong timing of coitus
 immunological causes
5.5 Risk factor of infertility
1. Medical factor
 Unsafe abortions
 Delayed diagnosis and treatment of pelvic inflammatory disease (PID)
 Inadequate treatment of pelvic infections
 Female circumcision
2. Social factors
 Multiple sexual partners (Risk of STI, HIV/AIDS)
 Polygamy
 Prostitution
 Advanced age at marriage
 Couple living apart
 Smoking and drinking alcohol
 Wearing tight paints /nylon pants

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5.6 Management of INFERTILITY
General examination: is performed to exclude cardiovascular, respiratory gastro-intestinal or
urological disorder which may all influence infertility.
Assess body shape and stature e.g webbed neck suggest turner syndrome and tall stature is
usual in testicular feminization
 Abnormal breast developed in patient with primary amenorrhea may be an indication
of hypooestrogenimia
 Gentle palpation of the areola of the breast between the thumb and the finger may
elicit agalactorrhea (the discharge may reveal fat or organic disease globules under
the microscope)
 Abdominal examination inspection to confirm findings on investigations. Palpation
to exclude any organamelsy which could indicate systemic disease or pelvic
abnormalities e. g abnormal formation of hymen or any large mass arising from the
pelvis
 Pelvic examination. This is compulsory on all the patients
5.6 INTERVENTIONS FOR INFERTILITY

Assisted Reproductive Technology (ART): This includes all fertility treatment in which both
eggs and sperm arc handled in general, ART procedures involve surgically removing eggs from a
woman's ovaries combining them with sperm in the laboratory, and returning them to the woman's body
or donating them to another woman. They do NOT include treatments in which only sperm are handled
(i.e, intrauterine - or artificial insemination) or procedures in which a woman takes medicine only to
stimulate egg production without the intervention of having eggs retrieved

In-Vitro Fertilization (IVF): In-vitro fertilization/embryo transfer (IVF/ET) - Techniques where

fertilization occur outside the body e g in case of tubal occlusion.

Intracytoplasmic sperm injection (ICSI): For male infertility by injecting the most motile
spermatozoon into an ovum. It is also done in endometriosis or cervical mucus problems, or where male
factor is the main problem.
Artificial or Intra-Uterine Insemination (IUI): only sperm in sperm is involved here

Fertility drugs: These are drugs to stimulate health production without the
intervention of having help retrieved.
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Medical tests: already highlighted

Medical advice:

Use of surrogate mothers

Surrogacy: in surrogacy, law require that the commissioning couple must both be
over the age of 18, married to each other and child genetical related to atleast one
them. This means that either fertile woman can be artificially inseminated with the
sperm of the husband of the commission couple or the commissioning couple can
undergoe an invitro fertilization procedure and produce an embryo.

Donor insemination: This is usually as a result of male failure to produce

spermatozoa or oligoperpamia or ejectulatory failure

Ovulation induction (For women with amenorhoea or

oligomenorrhoea)
Example of ovulatory inducing agents clomifeme works by inducing
feedback than stimulate the release of gonadotrophine Releasing
Hormone (GRH) which in turn leads to an increase in follicle
stimulating Hormone (FSH) and ovarian follicular growth. This can be
effective in up to 80% of appropriately selected women.
Treatment should be limited to six cycle with the lowest effective dose
Side effect of clomefeme: Multiple pregnancy, ovarian hyper
stimulation, hot flushes, abdominal distention, nausea, vomiting,
breast tenderness, head ache, air loss and blood vision.
Gemete intra-fellopian Transfer (GIFT): fertilized egg is placed in
the fallopian tube at e.g zygote stage.
Intra-uterine insemination (IUI):
Adoption : This the last option where all; other intervention failed.
Adoption is a legal procedure where a court declared a person ins is
not a child’s natural parent to be the child legal parent. It is also define
as a legal transfer of a child from his/biological parents(s) to another
person or counble who will now become the psychological parent(s)
STRATEGIES FOR ACHIEVING PREGNANCY
 Have sexual intercourse around the time of ovulation
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 Have sex every other day. Starting one week after the period
and ending one week before the next probable period.
 Keep basal body temperature record or check her cervical
mucus
 Discourage of douching and the use of lubricants
 Educate on how to calculate the fertile period
 Educate on how to recognize signs of ovulation
 Educate on methods of preventing infertility\
 Ensure early diagnosis and treatment of STIs and PIDs.
 Avoid multiple sexual partners especially when IUCD is the
choice of contraception
 Give health education to the clients on the consequences of
untreated or inadequately treated reproductive tract infection
 Promote the use of condom, diaphragm and spermicidal to
prevent unwanted pregnancy.
 Promote community awareness on causes of infertility and ways
of preventing them
 Reduce the incidence of unwanted abortion leading to kin
infertility.
 Counsel women on reduction of incidence of unwanted
pregnancy leading to criminal abortion with the attendant
complications such as blockage of tubes from infection.

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OVERVIEW OF INFERTILITY
Worldwide, couple view infertility as a targeting which carries social
economic and psychological consequences. In 1965, the world Health
Assembly recognized that under the auspices of family placing, building a
family should be the free choice of the individual couple. In 2006, the
United Nation general Assembly adopted the Secretary General’s report
recommending the inclusion of the target to achieve universal access to
Reproductive health under Millenium Development Goals 5 to improve
maternal health. The department of reproductive health and research
recognizes that infertility is a problem in both developed and developing
world.
Report had it that one in four (1:4) ever married women of reproductive age
in most of the developing countries are infertile because of primary or
secondary infertility WHO DHS comparative report 2004.
 MAGNITUDE OF INFERTILITY: Of the approximately 62 million
women of reproductive age in 2002, about 1.2 million, or 2%, had an

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 infertility- related medical appointment within the previous year, and
10% had an infertility related medical visit at some point in the past.
Additionally, 7% of married couples in which the woman was of
reproductive age (2.1million couples) reported that they had not used
contraception for 12 months and the woman had not become pregnant
(2002) National Survey of Family Growth.
 DEFINITION OF INFERTILITY: Infertility is the inability of a couples
to achieve a pregnancy after one year of regular unprotected sexual
intercourse.
 TYPES OF INFERTILITY
1. PRIMARY INFERTILITY: Refers to a case where a couple has never
achieved pregnancy despite regular, unprotected intercourse for at least
12 months.
2. SECONDARY INFERTILITY: Is when a couple ahieved pregnancy
before, but has subsequently failed to achieve another pregnancy within
12 months of regular, unprotected sexual intercourse.
 CLASSIFICATION OF INFERTIITY
- Primary infertility applies to the couple that has never
- Conceived despite regular unprotected intercourse for at least 12 months.
- Secondary infertility is where the female partner had previously
conceived but is subsequently unable to achieve a pregnancy after
unprotected intercourse.
CAUSES OF INFERTILITY IN FEMALE
1. Tubal blockage (commonest cause) and this usually result from STIs,
especially gonorrhea and chlamydia infection.
2. Other reproductive tract infection (RTIs) following unsafe induced
abortions, miscarriage and puerperal infections.
3. Anovula is responsible for labour 15-20% of cases e. g
hypogonadotropic
4. Congenital abnormalities e. g chromosomal disorders, Turners syndrome
etc.
5. Cervical factors e. g poor mucus quality, cervical stenosis, sperm
antibodies
CAUSE INFERTILITY IN MALE
- Poor quality of semen (due to low sperm count – hypospermia, poor
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 mobility or morphology).
- This is the commonest cause and is due to the following.
- Reproductive tract infections such as epidymics, orchitis and accessory
gland infection.
- Physical factors e. g excessive drinking and smoking.
- Drugs and substance abuse.
- Physical factors e. g excessive heat, testicular trauma or injury, variscose
veins.
- Undescended testes.
- Metabolic factors (excessive drinking and smoking substance/drug
abuses)
- Chronic medical conditions e g liver cirrhosis, diabetes etc
- Chromosomal disorders e.g. disinfectors syndrome
- Vassal or duct blockage, SITs, tuberculosis, surgery
- Erectile failure (erectile impotence) or ejaculatory dysfunction
- Premature ejaculation
- Hypospadias
- Risk factors associated with infertility
- Occupational hazard e.g. Radiation in radiographers
- Paint chemicals in industry workers
- Batteries/chemicals by ‘battery charges’’ and industrial workers
- Pesticides

Causes involving males and females

In frequent sexual intercourse
Wrong timing of couse
Immunological couse
RISK FACTORS FOR INFERTILITY
1.medical factors
-unsafe abortions
-delayed diagnosis and treatment of pelvic infections
-inadequante treatment of pelvic infections
2. female circumeision;
3. social factors;

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 -multiple sexual partners [risk of SITs/HIV/AIDs]
-polygamy
-prostitution
-advanced age at marriage
-smoking and drinking alcohol
-wearing tight pant/nylon-pant
DIAGNOSTIC INVESTGATIONS FOR INFERTILITY;
- History taking e.g of pervious sexual partners STIs etc
- General examination to exclude metabolic, endocrine, cardiovascular,
respiratory, gastro-intestinal and neurological problem.
- Total number of viable births (infants born either dead or alive after the
20th completed week of gestation or weighing more than 5,000gms.
- Spontaneous, abortions which may lead to bilateral tubal occlusion.
- Pelvic inflammation disease.
- History of chlamydia trachomoniasis following septic abortions or post
abortion sepsis.
- History of ectopic pregnancy.
- Molar pregnancy
- Number of living children in present union
- Duration of infertility recorded in months
MENSTRUAL OVULATION HISTORY: Is noted e. g regular menses,
oligomenorrhoea (spontaneous menstrual bleeding occurring at intervals of
36 days to 6 months polymenorrhoea (consistent cycle length of less than 25
days).
- Irregular menses (where there is no consistency and any other pattern)
OVULATORY HISTORY:
- History of pelvic inflammatory diseases, the degree of inflammatory
changes is directly related to infertility e. g ectopic pregnancy following
acute salpingitis.
- History of sexually transmitted disease

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