Transcript
Page 1: MCHA Supervision Tool - Kambia

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MCHA Supervision Tool

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Contents Page

MCHA Supervision Tool - Introduction Page 3

Antenatal Care Scenario Page 4

Antepartum Haemorrhage Scenario Page 5

Breech Scenario Pages 6 - 7

Cord Prolapse Scenario Page 8

Eclampsia Scenario Page 9

Malaria/Anaemia Scenario Page 10

Maternal Resuscitation Scenario Page 11

Multiple Births Scenario Page 12

Neonatal Resuscitation Scenario Page 13

Normal Labour Scenario Pages 14 - 15

Partograph Scenario Page 16

Post-natal Care Scenario Page 17

Post-partum Haemorrhage- Placenta in Scenario Page 18

Post-partum Haemorrhage- Placenta out Scenario Page 19

Pre-eclampsia Scenario Page 20

Prolonged Labour Scenario Page 21

Sepsis/STI Scenario Page 22

Shoulder Dystocia Scenario Page 23

MCHA Supervision Report Form Pages 24 - 35

Facilities Checklist Pages 36 - 37

Partograph Pages 38 - 50

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MCHA Supervision Tool - Introduction

Purpose of this tool:

The tool was designed to use as a platform for supervision and identify training needs for Maternal and Child

Health Assistants. The tool is based on obstetric complications presented in scenario cases and questions

formulated around this. It is important to note the purpose of the tool is not to criticise but to offer support

and revision where knowledge is limited. It should be used to allow on the job training and promote better

working relations between staff at PHU and create a positive learning environment. It also allows the DHMT to

collate data and highlight areas where further assistance is required and respond to these training needs.

How to use the tool:

As the mentor conduct one to one supervision with a MCHA and find a quiet room to avoid disturbance.

Introduce yourself, explain the purpose of the tool and how it works. Select two scenarios to use per MCHA

without telling the MCHA the scenario you are using. Start by asking the name of the MCHA, record their

initials and the facility you are in at the top of the page. Each scenario should allow for 12 supervisions.

Once you have recorded these details, commence the supervision by reading the case scenario, highlighted in

bold font. Allow time for the MCHA to understand the information presented, repeat the scenario if

necessary. Once understood, follow on by asking the questions printed in bold. As the MCHA provides the

correct answer, mark the sheet with a tick for correct answers and an ‘X’ for incorrect answers provided. It is

encouraged that this tool is interactive and you offer prompts so it is not seen as a ‘test’ but rather supported

learning.

Once all the questions have been asked, count up the marks for correct answers and calculate a percentage.

The pass mark for each scenario is set at 65%. Once the supervision is complete, highlight areas where the

MCHA has performed well and offer constructive feedback. If appropriate use this opportunity to provide

some training. Ask the MCHA if they have any questions or concerns and address these.

Once the MCHAs have been supervised write a detailed report of the findings using the ‘MCHA Supervision

Report Form’ as a template. Fill in all sections of the form, highlighting which scenarios were used, the mark

achieved and whether this achieved a pass or a fail. In the ‘comments’ box extend details of the supervision

and identify areas of strengths and areas for improvement per MCHA supervised.

It is also encouraged that you perform a facilities review using the ‘Facilities Review’ sheet, which will allow

you to gather more information about the PHU and identify where support is required. Summarise your

findings under the ‘facilities review’ section on the MCHA Supervision Report Form.

At the end of the visit write a brief summary of findings that will be useful information for the DHMT to act

on. If any teaching took place at the visit highlight this under this section. Any major concerns identified

should be fed back to the DHMT as a matter of urgency. It is good practice to follow up on MCHA’s that have

been identified as requiring further support. Remember we are all continuous learners and people respond

well with good mentorship and supervision!

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Antenatal care

Ask: What is the ideal time to book a patient in for ante-natal care? - 16 weeks gestation.

Ask: What history do you take from a patient at booking? - Gravid and parity of patient - Current gestation - Previous obstetric history- previous operations

Ask: Which infections do you screen for at booking? - HIV - Check for symptoms of STI

Ask: what checks do you perform on the patient at booking? - Perform vital signs - Height - Weight - Palpate for gestation, FH check

Ask: Which medications should you offer women at booking? - Albendazole - Fefol - Tetanus vaccine

Ask: What do you offer for malaria prophylaxis? - SP - Bed nets

Ask: What advice should you give about location of delivery at booking? - Advice women that she should deliver in PHU or hospital

Ask: How many visits comprise Focused Antenatal Care (FANC) and at what gestation? - 4 visits - Booking (16/40) (4 months) - 24-28/40 (6/7 months) - 30-32/40 (8 months) - 36-38/40 (9 months)

Ask: What would you check at a routine ante-natal check? - Vital signs - Urine check if possible - Check for anaemia - Palpation, gestation, lie, FH,

Ask: If a woman presented with history of recurrent abdominal pain what would the management be?

- Referral for further investigations

Score (Out of 26)

Percentage (Score/26) x 100

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Antepartum haemorrhage

Give scenario: 35 years, G6 P4+1 dead. 30 weeks pregnant walks into ANC. Complaint: Vaginal bleeding

Ask: What would you like to ask this patient about their symptoms? - Duration of symptoms - Quantify the bleeding - Abdominal pain - Trauma to abdomen - Collapse, dizziness

Say: the patient says bleeding is fresh and red with some large clots as big as her hand for one day. No abdominal pain, no trauma and no history of collapse.

Give vital signs: PR 120bpm, BP 110/80, T 37.0, RR 20 Ask: Which of the vital signs are abnormal? - PR 120

Ask: Can you explain how you would examine this patient? - Head- anaemia - Breasts-check for abnormalities - Abdomen- FH, HOF, lie, presenting parts - Vagina- vaginal loss/ discharge, pain - Hands and feet- pallor, oedema

Give examination findings: Pale conjunctiva and palm pallor, no abnormalities of breasts. FH heard, HOF 29cms, no abdominal pain. Fresh red vaginal bleeding no signs of STI or other infections.

Ask: what is the diagnosis? - Antepartum haemorrhage/ placenta previa

Ask: How would you approach management of this emergency? - ABC approach - Call for help - Airway - Breathing - Circulation- 2 large bore cannulas and IV fluids

Ask: Once stabilised, what would be your next step? - Referral to hospital

Ask: What is the clinical difference in presentation between placenta previa and placental abruption? - Placenta previa usually painless bleeding, placental abruption painful

Total (Out of 19) Percentage (Score/19) x 100

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Breech

Give scenario: G2 P1 20 years old, 38 weeks pregnant. Previous vaginal delivery. Admission with regular contractions, draining meconium stained liquor

Ask: What would like to ask this patient? - For ANC card - Duration of contractions - Ask about fetal movements

Ask: How would you examine this patient?

Performs head to toe examination

- Head -anaemia - Breasts-check for abnormalities - Abdomen- HOF, lie, presentation, FH - Vagina- vaginal examination/check discharge - Limbs – pale/odema - Vital signs

Give examination findings: Say: No signs of anaemia and breasts normal. Abdominal palpation, fundal height 37cm, long lie, breech and 2/5ths palpable. FH heard Vaginal examination: Cervix 8cm dilated, membranes ruptured meconium liquor draining presenting part breech no limbs felt suspected flexed.

Ask: What is the diagnosis and is this patient in true or false labour? - Breech in true labour.

Management

Ask: How would you manage this patient? - Call for help! If midwife at unit should be in attendance - Open partograph - Monitor maternal vitals - Monitor fetal heart rate

Ask: Does a vaginal examination need to be performed before pushing commenced? Give a reason for your answer.

- YES - To confirm full dilation prior to pushing to avoid the risk of head

entrapment with a partially dilated cervix.

Ask: What is the most important to remember during breech birth? Hands off the breech!

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Breech

Ask: If the legs do not deliver with maternal effort, how can delivery of the legs be assisted?

- If the legs are extended, assist the delivery by flexing the fetal knees by putting pressure on the back of the knee.

- Once legs are delivered, hands off and encourage the mother to push.

Say: Once the legs are delivered, what manoeuvre can be used to assist delivery of the arms?

- Lovesett’s: Hold the baby over the pelvis with the thumbs over the back, turn the baby with the back upwards 180 degrees so that the posterior arm now becomes anterior and is released under the symphysis pubis. The baby is then turned a 180 degrees in the opposite direction and the other arm is released in the same way.

Ask: How do you assist delivery of the head? - Support the weight of the baby on your arm. The first and third finger should

be placed on the baby’s cheek bones. With the other hand apply pressure to the baby’s occiput with the middle finger and place the other fingers on the fetal shoulders.

- Apply gentle downward pressure to create flexion and deliver the head.

Ask: Can you name 2 complications of breech delivery (2marks) - Failure to deliver the head. - Head entrapment during pre-term birth. - Nuchal arms: This where one or both arms are extended and trapped

behind the fetal head - Cord prolapse - Neonatal resuscitation

Total (Out of 24)

Percentage (Score/24) x 100

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Cord Prolapse

Give scenario: 24yrs, G2 P1, presents with abdominal pain 39 weeks pregnant. No previous obstetric complications. HOF 39cms, contracting, cephalic, longitudinal lie. You undertake VE and find cervix to be dilated to 4cms

Ask: What is your diagnosis? Is this true or false labour? - This patient is in true labour

Ask: What is your management plan? - Open partograph - Do vitals maternal and fetal - Repeat VE in four hours time

Say: After 2 hours, the membranes break and the patient complains she can feel a pulsing sensation between her legs

Ask: What do you think the problem is? - Cord prolapse, this is an emergency

Ask: How do you proceed? - Call for help - Put on gloves and carry out vaginal examination - If cord outside of vagina, gently place it back inside

Say: Examination reveals pulsatile cord in vagina, cervix dilated to 5cms, head at 2/5

Ask: what would you do next? - Position patient on all fours with buttocks pointing upwards - Try to push the presenting part away from the cervix - Refer to tertiary unit for C-section

Ask: why should you avoid over handling the cord? - Could damage the cord and harm the baby

Ask: If woman’s cervix is fully dilated, what would be the next step? - If the woman is fully dilated, delivery should be expedited - The baby will need to be resuscitated

Ask: If the cord is not pulsating, what has happened? What should the next step be?

- The baby has died - The woman should deliver in the safest way possible

Total (Out of 16) Percentage (Score/16) x 100

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Eclampsia

Give scenario: 16 years, G2P1, twin pregnancy, brought to PHU by family unconscious, they say she has had a fit at home. On arrival, she has another convulsion.

Ask: How do you proceed?

Call for help

ABC technique

Put woman in recovery position to protect airway

Give magnesium sulphate as per protocol

Site IV line

Check vitals

Give vital signs: BP 170/105, HR 110, T 37.0 FH heard

Ask: Which vital signs are abnormal? - BP - HR

Say: Now that convulsion has been managed and vitals taken, what is the next step?

Treat hypertension with anti-hypertensive

Insert urinary catheter for fluid balance monitoring

Refer to tertiary unit

Ask: What is the most likely cause of fitting? - Eclampsia

Ask: What is the cure for eclampsia and pre-eclampsia? - Delivery of the baby

Ask: Can you name three risk factors for eclampsia? (3 marks) - Age (<16 or >35) - Multiple pregnancy - Primigravida - No antenatal care - High BP before pregnancy - Previous history

Total (Out of 16)

Percentage (Score/16) x 100

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Malaria/ Anaemia

Give scenario: 22 years, female. G1P0. 24 weeks pregnant Complaint: Fever, joint pains, feeling very tired for 3 days.

Ask: What would like to ask this patient about her symptoms? - Dizziness - Chest pain/ breathlessness - Cough - Eating and drinking

Say: The patient does not have any other symptoms Give vital signs: PR 105, BP 120/80, T 38.1, RR 18 Ask: which vital signs are abnormal?

- T 38.1 - PR 105

Ask: How would you examine this patient? - Head- anaemia - Breasts-check for abnormalities - Abdomen- FH, HOF, lie, presenting parts - Vagina- vaginal loss/ discharge - Hands and feet- pallor, oedema

Give examination findings: febrile, pale conjunctiva and palmer pallor. No abnormalities of breasts. HOF 24cms, long lie, ceph, FH heard. No vaginal loss.

Ask: what investigations would you like to do? - Malaria RDT

Say: Malaria RDT is positive Ask: What is the diagnosis?

- Malaria - Anaemia

Ask: How would you manage this patient? - Starts antimalarial medication - Starts ferrous sulphate tabs - Offers advice re: diet/ bed nets - Follow up to check for resolution

Ask: If the patient said she was dizzy with chest pain, what would you suggest? - The patient has symptomatic anaemia and requires a transfusion - Refer to hospital

Ask: In first trimester which antimalarial should be given? - Quinine. ACT can be harmful to baby

Ask: How is malaria prevented in pregnancy? - Bed nets - Fansidar (SP) should be taken twice

Total (Out of 23) Percentage (Score/23) x 100

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Maternal Resuscitation

Give scenario: 27 year old woman has been in labour at home, apparently progressing well. Her family brings her in as she became drowsy at home and has lost consciousness. When you approach the patient, she appears lifeless and does not respond to voice

Ask: How do you proceed? - Call for help - Shake and shout patient to check for response - Position patient on her back, manually move the uterus to the side to relieve

pressure on the intra-abdominal vessels

- A: Performs head tilt and chest lift/ remove any obvious obstruction from mouth

- B: Check for breath sounds and feel for air movement Say- the patient is not breathing

- C: Give 30 chest compressions followed by 2 rescue breaths - Demonstrates effective chest compressions or able to describe effective compressions

(Straight arms, 4-5 cms depth, 100 compressions/ minute) - Demonstrates or describes effective rescue breaths (sealed nose and mouth, head tilt,

chin lift)

Say: After 4-5 minutes the patient makes some signs of response Ask: What position would you put the mother in? - Put the patient into the recovery position. Give oxygen if available

Ask: Should the patient stay in PHU? - No, a patient who has lost consciousness is very sick and should be

transferred to hospital

Ask: If the patient did not respond to resuscitation, how should you proceed? - A caesarean section should be performed if the patient is in hospital. This

is important as it relieves the pressure of the uterus off the mothers blood vessels

Can you name 2 causes of cardiopulmonary arrest and how you would treat them? (2 marks)

- Hypoxia- Give oxygen if available - Hypovolemic- Reduced circulating volume. Give IV fluids and blood - Thrombosis- Blood clot in lung causing breathing problems. Give oxygen - Toxicity- Poisoning with native herbs or other poisons. Give IV fluids

Total (Out of 11) Percentage (Score/11) x 100

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Multiple Births

Give scenario: G2 P1 26 years old, 37 weeks pregnant. Previous vaginal delivery. Admission with strong regular contractions

Ask: Is there anything else you would like to ask about the patient before you examine her? - ANC card - Duration of contractions - Ask about vaginal loss, discharge/liquor/bleeding - Ask about fetal movements

Ask: How do you undertake examination of this patient? - Performs head to toe examination

- Head- anaemia - Breasts –check for abnormalities - Abdomen- HOF, lie, presentation FH - Vagina- vaginal examination check for any fluid loss - Limbs- pale/odema - Vital signs

Give examination findings: No signs of anaemia, breasts normal. Abdominal palpation, fundal height 40cm, suspected twin pregnancy, lie of first twin long lie, cephalic and 0/5ths palpable. FH heard x2 Vaginal examination: Cervix fully dilated, membranes ruptured clear liquor draining presenting part cephalic, 0/5

Give vital signs: BP 115/65 PR 89bpm Temp 37.0C RR18 Ask: Are these normal?

- Yes

Ask What is the diagnosis? - Multiple pregnancy in true labour

Management Ask: How would you manage this patient?

- Open partograph - Monitor maternal vitals - Monitor fetal heart rate

Ask: Can you talk me through the delivery? - The birth of the first twin is performed as that of a singleton birth. - Stabilise lie of second twin whilst presenting parts descend - Break membranes to encourage descent of second twin

Ask: How soon should you expect the delivery of the second twin once the first twin is born? - 30 minutes from delivery of first twin

Ask: What is the management if there is a delay in delivery of the second twin? - Referral to hospital

Ask: How should the third stage of labour be managed? Give a reason for your answer. - Active management (oxytocin administration) - Higher risk of PPH in multiple pregnancy

Score (Out of 22) Percentage (Score/22) x 100

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Neonatal Resuscitation

Give scenario: G1 P0 16 year’s old, term pregnancy. Rapid vaginal delivery of male infant. Born in poor condition. Heart rate 110bpm, no respiratory effort, poor colour and tone

Ask: What is the diagnosis? - Neonatal resuscitation

Management

Ask: Which is the initial management? - Take note of the time of the delivery - Dry and stimulate the baby - Call for help

Ask: Can you explain how you would you actively resuscitate a baby?

- Check airway, clear any obstruction - Place head in a neutral position - Administer 5 slow inflation breaths - Re-assess the baby. HR, tone, colour and respiratory effort. - If HR below 60bpm commence chest compressions. 3

compressions to 1 ventilation breaths

Ask: How often should you be assessing the baby? - Every 30 seconds

Ask: If heart rate improves after compressions but no respiratory effort what should be done?

- Continue giving ventilation breaths

Ask: If resuscitation successful what should be done next with the baby? - Assess the baby for possible fractures - Keep warm - Feed early - Observe the baby - Document

Total (Out of 16)

Percentage (Score/16) x 100

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Normal Labour

Give scenario: G1 P0 19 years old, 39 weeks pregnant. Presented with regular uterine contractions that started 6 hours ago

Give: vital signs: BP 125/65 PR 89bpm Temp 36.8C Respirations 18

Ask: Are these vitals normal? - Yes

Ask: How do you undertake head to toe examination of this patient?

- Head- anaemia - Breasts-check for abnormalities - Abdomen- HOF, FH, palpation, lie, presentation - Vagina- vaginal examination/check for discharge - Limbs- pale/ oedema

Say: No signs of anaemia, no abnormalities in breasts. Abdominal palpation, fundal height 38cm, long lie, cephalic and 3/5ths palpable. FH heard. Vaginal examination: Cervix 6cm dilated, membranes intact presenting part cephalic

Ask: Is this true or false labour? - True labour

Ask: How would you manage and monitor this patient? - Open partograph - Monitor maternal vitals - Monitor fetal heart rate

Ask: How often would you monitor maternal and fetal vitals and how often you would perform vaginal examinations?

- Maternal vitals to be undertaken 4 hourly - Vaginal examinations to be undertaken 4 hourly - Fetal heart rate to be auscultated every 30 minutes

Ask: How many centimetres per hour is acceptable cervical dilatation? - 1cm per hour

Ask what is needed for a delivery? - PPE gloves, apron - Delivery instruments (clean) cord clamps and scissors - Space and equipment to resuscitate a baby if required.

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Normal Labour

Ask: What assessment needs to be undertaken for mother and baby after delivery.

- Mother: - Monitor vaginal bleeding - Palpate fundus (firm and below umbilicus) - Vital signs ( BP, PR, Temp and Respirations)

- Baby: - Full check after birth including Apgar Score - Keep warm (kangaroo care best) - Early feed

Ask: What else needs to be documented? - Record of birth, complete partograph - Time of delivery - Estimated blood loss - Sex - Weight

Total (Out of 28)

Percentage (Score/28) x 100

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Partograph

Give scenario: Patient attends 38 weeks pregnant. G3 P2+ 0. Patient is complaining of abdominal pains for last 4 hours. You undertake examination. Longitudinal lie, cephalic presentation, descent 3/5. Vaginal examination: cervix 4 cms dilated, descent 3/5, no moulding

Ask: What will you do now? - Open partograph, patient is in true labour Ask: Can you plot the following findings on the partograph?

Time Cervix FHR Liquor Moulding Descent Contractions (/10mins)

Maternal pulse

Maternal BP

Temperature

4pm 4cms 155 Membranes intact, bulging

0 3/5 3 Mild

80 120/90 37.0

Note: Give one mark per correct plot. Give mark if variable plotted correctly but not against correct time (10 marks available). Write figure attained.

Ask: How will you manage this patient? When will you next perform vaginal examination, maternal vitals and fetal heart rate? - VE after 4 hours - Maternal pulse and BP every 4 hours - Foetal heart every 30 mins Say: After 4 hours you repeat the examination and get the following findings. Please plot these on the partograph

Time Cervix FHR Liquor Moulding Descent Contractions (/10mins)

Maternal pulse

Maternal BP

Temperature

8pm 6cms 170 Clear liquor

0 2/5 4 Moderate

90 120/90 37.0

Note: Give one mark per correct plot. Give mark if variable plotted correctly but not against correct time (10 marks available). Write figure attained.

Ask: What does the partograph show? - Ineffective dilatation of the cervix - Alert line crossed

Ask: What action should you take next? - Alert line crossed so patient should be referred

Ask: What is the likely cause of poor progression? - Obstructed labour

Total (Out of 28) Percentage (Total/28)x100

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Postnatal care

Ask: How would you examine lactating mother in first post-natal check after delivery? - Perform maternal vital signs. - Head- anaemia check eyes and palm pallor. - Breasts- good milk supply, mother happy with latching baby. Check for

pain/ infection - Abdomen- check uterus well contracted. - Lochia- check for bleeding - Perineum- check stitches/ tears

Ask: If a mother complains of leaking urine what would you advise? - Refer if ongoing problem

Ask: If a woman presents with dizziness, chest pain and breathlessness, what would you do?

- Refer patient to hospital (patient could have severe anaemia or blood clot in lung)

Ask: How do you examine the baby? - Head- check for trauma, abnormalities, and sunken fontanelles. - Eyes- check for discharge - Nose- check nostrils - Mouth- sucking reflex, cleft palate and tongue tie - Chest looking for any abnormalities - Abdomen- look for distension, umbilical cord signs of bleeding/infection - Genitalia & anus- look for abnormalities and patency. - Limbs- extra digits or any abnormalities. - Back- look for straight spine

Ask: what would you do if the mother is complaining of fever and ongoing vaginal bleeding 6 weeks postnatal?

- Perform vital signs - Check lochia- if heavy and offensive treat with antibiotics and refer - Check for anaemia

Ask: What would you do if mother said baby is loosing weight? - Weigh baby - Observe feeding- check baby latching correctly/ milk supply - Advise re: nutrition for mother - Arrange follow up

Ask: What immunisation would you offer the baby at first visit? - BCG

Ask: What advise should you offer the mother at 6 week post-natal check? - Family planning advice

Score (Out of 26) Percentage (Score/26) x100

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Post-Partum Haemorrhage- placenta in

Give scenario: G3 P2 29 years old, 39 weeks pregnant. Previous vaginal deliveries. Woman presents to PHU delivers baby, then she begins to bleed heavily vaginally.

Ask: what is the diagnosis of this patient? - Primary PPH retained placenta (Bleed within first 24hrs of delivery)

Ask if you were on your own what would you do? - Call for help

Ask: what approach would you use to assess the patient? - ABC approach - Airway - Breathing - Circulation obtain IV access (2 large bore cannulae) and commence IV fluid

Management Ask: How would you manage this patient?

- Massage the uterus - Administer 10iu oxytocin IM - Empty the woman’s bladder and insert catheter. - Monitor maternal vital signs

Ask: If bleeding continues what would be the next step? - Refer - Examine and if placenta partially separated and bleeding uncontrolled perform manual

removal

Ask: for demonstration of manual removal. - Use long gloves. - Insert whole hand into cervix following the umbilical cord, support the fundus with the

other hand. - Slip the internal hand between the separated part of the placenta and the uterine wall

and gently remove the placenta by moving the hand in a back and forth movement. - Once separated, grab the placenta and membranes and remove from the uterus. - Check for retained products, by examination of the uterus and placenta/membranes. - Once removed massage the uterus.

Ask: what management is required post manual removal to avoid the risk of infection? - Administration of IV antibiotics

Ask: Does this patient require referral to hospital? Give reason for your answer. - Yes. - Ongoing management of PPH

Ask: Can you identify three risk factors for PPH (identifies any 3 from list)- 3 marks) - Prolonged labour - Quick labour - Multiple pregnancy - Mismanagement of third stage - Multi parity G5 > - Age - Previous history of PPH

Total (Out of 24) Percentage (Score/24) x100

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Post-Partum Haemorrhage- placenta out

Give scenario: G7 P6 37years old, 38 weeks pregnant. Previous vaginal deliveries with PPH with last baby. Woman presents to PHU and delivers quickly, has active management for third stage. After delivery of the placenta and membranes she begins to bleed heavily vaginally.

Ask: what is the diagnosis of this patient? And ask if you were on your own what would you do?

- Primary PPH (Bleed within first 24hrs of delivery) - Call for help

Ask: what approach would you use in this emergency? - ABC approach - Airway - Breathing - Circulation – 2 large bore cannulae IV fluids

Management Ask: How steps would you take to manage the bleeding?

- Massage the uterus to expel clots - Administer second dose of oxytocin - Empty the woman’s bladder and insert catheter - Check for cause of bleeding and attempt to control- tears or retained products

Ask: How do you monitor condition of mother? - Frequent monitoring of vital signs (every 15 minutes)

Ask: If bleeding does not stop after initial management, what would do next? - Refer to hospital - Bimanual compression

Ask: Can you demonstrate how to undertake bimanual compression - One hand into the woman’s vagina and a fist formed - One hand on the fundus abdominally and pressure applied to press the walls

of the uterus together to minimise bleed.

Ask the trainee to name the four possible causes of vaginal bleeding post birth - Uterine atony - Trauma to vagina, perineum, cervix - Retained tissue, placenta or membranes - Clotting abnormalities

Ask: Can you identify three risk factors this patient has predisposing to PPH? - Previous history of PPH - Age - Parity

Total (Out of 22) Percentage (Score/22) x 100

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Pre- Eclampsia

Give scenario: Primip, 15 years of age. 38 weeks gestation Complaint: Oedema of hands and face, headache

Ask: Is there anything else you would like to ask about the patient before you examine her? - Duration of symptoms - Convulsions - Fetal movements

Say: Swollen hands and feet for 3 days, no history of convulsions, fetal movements felt Ask: How do you undertake examination of this patient?

- Head- anaemia - Breasts0check for abnormalities - Abdomen- HOF, FH, palpation, lie, presentation - Vagina-check for discharge/bleeding - Limbs- oedema, palmer pallor - Vitals

Give examination findings: No anaemia, breasts normal. HOF 34cms, FH heard. Cephalic presentation, longitudinal lie. No vaginal loss. Oedema of face, hands and feet

Give vital signs: BP 169/90, PR 90, RR 20, T 37.0 Ask: Which vital sign is abnormal?

- BP 169/90

Ask: Can you think of a urine test that would be useful? - Urinalysis for proteinuria

Say: You do urinalysis and protein is present (3+) Ask: What is the diagnosis?

- Severe pre-eclampsia

Management Ask: How would you manage this patient?

- Starts antihypertensive medication - Correctly names antihypertensive medication (methyldopa) and gives correct dose

(500mg) - Repeats BP after 1 hour - Refer to hospital

Ask: If this patient started fitting, what would you do? - Call for help - ABC management approach - Recovery position - Start magnesium sulphate protocol

Ask: Can you name three risk factors for pre-eclampsia/ eclampsia? (3 marks) - Age (<16 or >35) - Multiple pregnancy - Primigravida - No antenatal care - High BP before pregnancy

Score (Out of 23) Percentage (Score/23)x100

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Prolonged labour

Give scenario: G3 P2 24 years old, term pregnancy Previous x2 vaginal deliveries. Presented with history of irregular contractions for a few days but now regular since 01:00.It is now 08.00 am

Ask: Is there anything else you would like to ask about the patient before you examine her? - Ask for ANC card - Enquire about vaginal loss bleeding, discharge or membrane rupture. - Ask about fetal movements

Ask: How would you go about examining this patient?

- Undertakes head to toe examination - Head- anaemia - Breasts-check for abnormalities - Abdomen- HOF, FH, palpation, lie, presentation - Vagina- vaginal examination/check for discharge - Limbs pale/odema

Give vital signs: BP 110/72 PR 80bpm Temp 36.9C Respirations 14

Ask: Are these normal vitals? - Yes

Say: No signs of anaemia, no complaints with breasts. Abdominal palpation, fundal height 39cm, long lie, cephalic. 3/5ths palpable FH heard Vaginal examination at 08:00am: Cervix 5cm dilated, membranes ruptured clear liquor draining presenting part cephalic

Ask: Is this true or false labour? - True labour

Management

Ask: How would you manage this patient? - Open partograph - Monitor maternal vitals - Monitor fetal heart rate

Ask: How often would you monitor maternal vitals and how often you would perform vaginal examinations. Also ask how often you would listen to the fetal heart?

- Maternal vitals to be undertaken 4 hourly - Vaginal examinations to be undertaken 4 hourly - Fetal heart rate to be auscultated 30 minutely

Say: Repeat vaginal examination at 12:00pm Cervix is 6cm dilated, membranes ruptured now draining meconium presenting part cephalic 3/5ths

Ask: if this is acceptable progress?

- No

Ask what needs to be done and why? - Referral to hospital - Reason: slow progress - Meconium present

Ask what documentation needs to be completed? - Referral letter to PHU

Total (Out of 21)

Percentage (Score/21) x 100

Page 22: MCHA Supervision Tool - Kambia

22

STI/ Sepsis

Give scenario: 20 years of age, G3P2, 2 previous normal vaginal deliveries. 30 weeks pregnant Complaint: Abdominal pain, temperature

Ask: What would you like to ask this woman? - Duration of symptoms - Offensive discharge - Pain passing urine - Cough

Say: the patient says she has offensive discharge for 2 days Give vital signs: PR 110, BP 120/70, T 38.2, RR 20

- PR 110 and T 38.2 Ask: Can you explain how you would examine this patient?

- Head- anaemia - Breasts-check for abnormalities - Abdomen- HOF, FH, palpation, lie, presentation, discharge - Vagina-check discharge - Limbs- oedema, palmer pallor

Give examination findings: - No signs of anaemia, no complaints with breasts. Warm, generalised abdominal

tenderness, FH heard, HOF 30cms, offensive vaginal discharge

Ask: How would you diagnose this woman? - STI

Ask: How would you initially manage this patient? - Insert cannula and give fluids - Start antibiotics - Give PCM/ analgesia - Observe - Monitor observations

Ask: One hour later, you repeat vitals. BP 90/70, PR 150, T 39 RR 24. What is the diagnosis?

- Severe sepsis

Ask: What would you next? - Give fast IV fluids - Refer to hospital

Total (Out of 19) Percentage (Score/19) x 100

Page 23: MCHA Supervision Tool - Kambia

23

Shoulder dystocia

Give scenario: 24 years, G1P2. Has just delivered the head of her baby. The body has not delivered following the next contraction. Routine traction has not led to delivery

Ask: What is the problem? - Shoulder dystocia. This is an emergency

Ask: How do you proceed?

- Call for help

- Put the patient into McRobert’s position- on back with her knees raised up as far as possible towards chest,

- Attempt to deliver baby

Say: the baby still does not deliver, what do you do next?

- Apply suprapubic pressure- ask helper to press heel of hand onto anterior shoulder

- Attempt to delivery baby

Say: the baby still does not deliver. How can you make more space?

- Perform episiotomy

Say: following these manoeuvres, the baby is delivered

Ask: if the baby had not delivered, what would you try next? - Insert hand into vagina along baby’s back and push the anterior

shoulder towards baby’s chest to free it from behind the symphysis pubis

- Try to deliver posterior shoulder - Turn the woman on all fours and try the above manoeuvres

again - Fracture the baby’s collar bone to decrease the width of the

shoulders and deliver the baby- this should be undertaken by a doctor or midwife

Ask: what is a baby delivered following this complication likely to need? - Neonatal resuscitation

Total (Out of 12)

Percentage (Score/12) x 100

Page 24: MCHA Supervision Tool - Kambia

24

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

1.

2.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 25: MCHA Supervision Tool - Kambia

25

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

3.

4.

Comments

MCHA

Scenario Percentage

3.

4.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 26: MCHA Supervision Tool - Kambia

26

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

5.

6.

Comments

MCHA

Scenario Percentage

5.

6.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 27: MCHA Supervision Tool - Kambia

27

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

7.

8.

Comments

MCHA

Scenario Percentage

7.

8.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name …………………………… Signature ……………………………….

Page 28: MCHA Supervision Tool - Kambia

28

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

9.

10.

Comments

MCHA

Scenario Percentage

9.

10.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 29: MCHA Supervision Tool - Kambia

29

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

11.

12.

Comments

MCHA

Scenario Percentage

11.

12.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 30: MCHA Supervision Tool - Kambia

30

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

13.

14.

Comments

MCHA

Scenario Percentage

13.

14.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 31: MCHA Supervision Tool - Kambia

31

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

15.

16.

Comments

MCHA

Scenario Percentage

15.

16.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 32: MCHA Supervision Tool - Kambia

32

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

17.

18.

Comments

MCHA

Scenario Percentage

17.

18.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 33: MCHA Supervision Tool - Kambia

33

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

19.

20.

Comments

MCHA

Scenario Percentage

19.

20.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name …………………………… Signature ……………………………….

Page 34: MCHA Supervision Tool - Kambia

34

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

21.

22.

Comments

MCHA

Scenario Percentage

21.

22.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 35: MCHA Supervision Tool - Kambia

35

MCHA Supervision Report

Date:

Facility: Training Mentor:

MCHA

Scenario Percentage

23.

24.

Comments

MCHA

Scenario Percentage

23.

24.

Comments

MCHA

Scenario Percentage

1.

2.

Comments

Facilities Review-

Summary

Name ……………………………

Signature ……………………………….

Page 36: MCHA Supervision Tool - Kambia

36

Facilities Checklist

Examination area with enough space to see the

patient with chairs (for MCHA and patient) and

table

BP machine

Thermometer

Stethoscope

Device with second hand available

Delivery room with delivery bed, clean

Delivery kit available

- 2 x Cord clamps

- 1 x cord scissors

- 1 x episiotomy scissors

- Cord ties

Clean swabs

Gloves

Sterilisation equipment

Weighing scales- baby

Source of electricity

Source of clean water

Catheters

Syringes

Needles

Water for injection

Cannulas

IV fluids

Sutures

Needle holder

Equipment for neonatal resus

Suction bulb

Ambubag and mask

Page 37: MCHA Supervision Tool - Kambia

37

Clean space for resuscitation

Adult ambubag

Sharps bin

Clinical waste bin

Veronica bucket and soap for hand washing

Partographs

Essential medications

Oxytocin

Misoprostol

Magnesium sulphate

Antibiotics

- Amoxicillin

- Mentronidazole

- Gentamycin

- Erythromycin

ACT

Methyldopa

Hydralazine

Diazepam

Lidocaine

Paracetamol

Novalgin

Ferrous sulphate

Vitamin A

Calcium gluconate

Family planning:

- COCP

- POP

- Injectable

- Implant

Drugs well organised and in date

Page 38: MCHA Supervision Tool - Kambia

38

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 39: MCHA Supervision Tool - Kambia

39

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 40: MCHA Supervision Tool - Kambia

40

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 41: MCHA Supervision Tool - Kambia

41

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 42: MCHA Supervision Tool - Kambia

42

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 43: MCHA Supervision Tool - Kambia

43

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 44: MCHA Supervision Tool - Kambia

44

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 45: MCHA Supervision Tool - Kambia

45

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 46: MCHA Supervision Tool - Kambia

46

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 47: MCHA Supervision Tool - Kambia

47

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 48: MCHA Supervision Tool - Kambia

48

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 49: MCHA Supervision Tool - Kambia

49

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")

Page 50: MCHA Supervision Tool - Kambia

50

PARTOGRAPH

Name Gravida Para Hospital no.

Date of Admission Time of admission Ruptured membranes hours

200

190

180

170

Fetal heart 160

rate 150

140

130

120

110

100

90

80

Liquor

Moulding

10

9

8

7

6

5

4

3

2

1

0Hours 0 1 2 3 4 5 6 7 8 9 10 11 12

Time

5

Contractions 4

per 10 mins. 3

2

1

OxytocinU/LDrops/min.

Drugs given and IV fluids

180

170

160

Pulse 150

140

and 130

120

BP 110

100

90

80

70

60

Temp oC

protein

Urine acetone

volume

Ce

rvix

(Plo

t "X

")

De

scen

t o

f Hea

d(P

lot "

O")


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