mcha supervision tool - kambia
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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
Normal Labour Scenario Pages 14 - 15
Partograph Scenario Page 16
Post-partum Haemorrhage- Placenta in Scenario Page 18
Post-partum Haemorrhage- Placenta out Scenario Page 19
Pre-eclampsia Scenario Page 20
Sepsis/STI Scenario Page 22
MCHA Supervision Report Form Pages 24 - 35
Facilities Checklist Pages 36 - 37
Partograph Pages 38 - 50
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!
4
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
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
6
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!
7
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
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
9
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
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
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
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
11
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
12
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
13
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
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.
15
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
16
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
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
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
17
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
18
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
19
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
20
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
- 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
21
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
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
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
table
Delivery room with delivery bed, clean
Delivery kit available
Partographs
38
PARTOGRAPH
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Antepartum Haemorrhage Scenario Page 5
Breech Scenario Pages 6 - 7
Cord Prolapse Scenario Page 8
Eclampsia Scenario Page 9
Malaria/Anaemia Scenario Page 10
Normal Labour Scenario Pages 14 - 15
Partograph Scenario Page 16
Post-partum Haemorrhage- Placenta in Scenario Page 18
Post-partum Haemorrhage- Placenta out Scenario Page 19
Pre-eclampsia Scenario Page 20
Sepsis/STI Scenario Page 22
MCHA Supervision Report Form Pages 24 - 35
Facilities Checklist Pages 36 - 37
Partograph Pages 38 - 50
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!
4
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
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
6
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!
7
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
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
9
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
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
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
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
11
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
12
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
13
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
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.
15
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
16
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
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
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
17
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
18
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
19
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
20
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
- 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
21
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
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
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
table
Delivery room with delivery bed, clean
Delivery kit available
Partographs
38
PARTOGRAPH
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160
Date of Admission Time of admission Ruptured membranes hours
200
190
180
170
140
130
120
110
100
90
80
Liquor
Moulding
10
9
8
7
6
5
4
3
2
1
0 Hours 0 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
180
170
160