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EmONC Knowledge Repository from mentors course

docs/20210106_BreechDeliverySOP.pptx.txt

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+Breech presentation identified
+Identify which type of breech:
+Footling Breech
+Complete or Frank breech: consider options, consent mother for either
+Initiate emergency CS
+OR
+OR
+Vaginal breech extraction
+Step 1. Delivery of buttocks and Legs:
+Once buttocks have entered the vagina/cervix is fully dilated, tell woman to push with contractions
+Let the buttocks deliver until the lower back and then the shoulder blades are seen
+Wrap fetal body in dry towel and gently hold the buttocks in one hand, but do not pull.
+If the legs do not deliver spontaneously, deliver one leg at a time using  Pinard Maneuver**
+Step 2. Delivery of arms:
+Allow the arms to disengage spontaneously one by one
+Assist if necessary using Lovset’s maneuver**
+**Pinard Maneuver: sweeping/external rotation of each thigh combined with
+rotating the pelvis in the opposite direction resulting in the flexion of the knee and the delivery of each leg
+**Lovset’s Maneuver: 
+With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers
+Turn infant 90° to bring the anterior shoulder underneath the symphysis and engage the arm Deliver the anterior arm
+Then do a 180° counter-rotation to engage the posterior arm, which is then delivered
+Step 3. Delivery of the head
+Lay the baby face down with the length of its body over your hand and arm.
+Use Smellie Veit** maneuver to delivery head
+** Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helps to keep the baby’s head flexed.
+**Smellie Veit Maneuver:
+Lay baby face down with the length of its body over your hand and arm
+Place index and middle fingers of this hand on the baby’s maxilla (bone behind upper lip) to bring the neck into moderate flexion
+Use the other hand to grasp the baby’s shoulders
+Gently flex the baby’s head towards the chest, while applying downward pressure on the jaw to bring the baby’s head down until the hairline is visible
+Pull gently to deliver the head
+
+Step 4. Post delivery care:
+Place infant on mom’s abdomen
+Proceed with routing post delivery care
+
+Vaginal Breech Extraction
+

docs/ANC - Focussed antenatal care_.txt

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+A Case Study
+Mum arrives at an ANC clinic in early pregnancy
+
+She inquires about next steps for ANC care
+
+
+She is a 24 yo G2P1+1
+OB hx: She had a prior stillbirth.  By LMP she is 18 weeks pregnant
+Medical history: NAD
+What tests should be ordered now?
+How many times does she need to come for ANC?
+When should she return to clinic?
+What education should she receive?
+What supplements should she receive?
+
+Focussed antenatal care - an overview
+Updated August 2023
+
+Pre-Test
+Section 1
+
+1
+2
+3
+4
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+According to the new ANC care guidelines, how many points of contact should a woman receive in her 2nd trimester?
+01
+01
+B
+
+20-25mg/day
+60-65mg/day
+80-85mg/day
+120-125mg/day
+
+
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+For a pregnant woman without known anaemia, how much iron supplementation does she require?
+
+01
+02
+B
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+First
+Second 
+First or second
+Second or third 
+
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+Preventative anti-worming medication should be administered during which trimester?
+01
+03
+D
+
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+Prior stillbirth
+Prior intrauterine growth restriction
+Prior preeclampsia
+Adolescent woman
+
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+Which of the following women is at high risk for developing gestational diabetes?
+01
+04
+A
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+1
+2
+3
+4
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+In a woman with unknown vaccine status, what is the recommended # of doses of tetanus toxoid vaccine?
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+01
+05
+B
+
+Learning Objectives
+Understand the purpose of comprehensive ANC care
+Demonstrate knowledge regarding the new ANC guidelines
+Be able to recommend preventative measures for all ANC clients
+Understand the principles of effective education during ANC
+
+
+The Facts
+Section 2
+
+ANC care:
+
+52%
+Of women in sub-saharan Africa attend at least 4 ANC visits
+Antenatal care (ANC) is a globally recommended strategy used to prevent neonatal deaths.
+
+In Kenya, over 90% of pregnant women attend at least one ANC visit during pregnancy. However, Kenya is currently among the 10 countries that contribute the most neonatal deaths globally
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+50% 
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+Of women worldwide receive the antenatal care recommended
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+Definitions
+Section 3
+
+The care provided by skilled  health care professionals to pregnant women and adolescent girls in order to ensure the best conditions/outcomes for both mother and baby during pregnancy.  The components of ANC include:
+Prevention and management of pregnancy related or concurrent disease
+Health education and promotion
+Antenatal care (ANC)
+Risk identification
+
+Goals of ANC 
+Educate
+Treat
+Prepare for birth
+Develop birth preparedness and complication readiness plan
+Prepare for newborn
+Help prepare mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically, and socially
+Promote and maintain the physical, mental, and social health of mother and baby by providing education on nutrition, personal hygiene, and birthing process
+Detect and manage complications during pregnancy, whether medical, surgical, or obstetrical;
+
+
+ANC schedule
+Section 4
+
+On November 7th, 2016, the World Health Organization released its comprehensive  recommendations on routine ANC for pregnant women and adolescent girls and this model  entailed 8 visits
+In 2002, the WHO recommended a focused approach to ANC to enhance the quality of care and increase ANC coverage.  The focused ANC (FANC) model entailed 4 ANC visits.  They provided specific guidance on each visit 
+FROM THIS
+TO THIS
+In 2002, the WHO recommended a focused approach to ANC to enhance the quality of care and increase ANC coverage.  The focused ANC (FANC) model entailed four ANC visits occurring between 8 and 12  weeks of gestation, between 24 and 26 weeks, at 32 weeks, and between 36 and 38 weeks.  Guidance on each visit included specific evidence-based interventions for healthy pregnant  women with appropriate referral of high-risk women and those who develop pregnancy  complications.  
+
+Justification for 2016 model:
+Evidence suggesting increased perinatal deaths in 4-visit ANC model 
+Evidence supporting improved safety during pregnancy through increased frequency of  maternal and fetal assessment to detect complications  
+Evidence supporting improved health system communication and support around pregnancy  for women and families 
+Evidence indicating that more contact between pregnant women and respectful,  knowledgeable health care workers is more likely to lead to a positive pregnancy experience
+Evidence from HIC studies indicating no important differences in maternal and perinatal health  outcomes between ANC models that included at least eight contacts and ANC models that  included 11 to 15 contacts 
+
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+Key recommendations for ANC care (2016 guidelines)
+Section 5
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+Nutritional 
+interventions
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+Counselling about healthy eating and keeping physically active during  pregnancy
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+In undernourished populations, nutrition education on increasing daily energy and protein intake 
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+In undernourished populations, balanced energy and protein dietary supplementation is recommended
+
+Supplementation with 60 mg to 65 mg of  elemental iron and 400 mcg (0.4 mg) of folic acid
+
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+- Counselling about healthy eating and keeping physically active during  pregnancy is recommended for pregnant women to stay healthy and  to prevent excessive weight gain during pregnancy. 
+• In undernourished populations, nutrition education on increasing daily  energy and protein intake is recommended for pregnant women to  reduce the risk of low-birth-weight neonates 
+• In undernourished populations, balanced energy and protein dietary  supplementation is recommended for pregnant women to reduce the  risk of stillbirths and small-for-gestational-age neonates. 
+• Daily oral iron and folic acid supplementation with 60 mg to 65 mg of  elemental iron and 400 mcg (0.4 mg) of folic acid is recommended for  pregnant women to prevent maternal anemia, puerperal sepsis, low  birth weight, and preterm birth  - **Health care providers should counsel the clients on the benefits of iron and folic acid during  pregnancy to help enhance adherence. 
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+Maternal and Foetal 
+assessment
+Full blood count testing is the recommended method for diagnosing  anaemia in pregnancy
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+Hyperglycemia first detected at any time during pregnancy should be  classified as either gestational diabetes mellitus (GDM) 
+
+Health-care providers should ask all pregnant women about their use  of alcohol and other substances
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+In high-prevalence settings, provider-initiated testing and counselling  (PITC) for HIV should be considered a routine component of the  package of care 
+
+In  low-prevalence settings, PITC can be considered for pregnant women  
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+Full blood count testing is the recommended method for diagnosing  anaemia in pregnancy. In settings where full blood count testing is not  available, on-site haemoglobin testing with a haemoglobinometer is recommended over the use of the haemoglobin color scale as the  
+method for diagnosing anaemia in pregnancy 
+• Hyperglycemia first detected at any time during pregnancy should be  
+classified as either gestational diabetes mellitus (GDM) 
+• Health-care providers should ask all pregnant women about their use  
+of alcohol and other substances (past and present) as early as possible  
+in the pregnancy and at every antenatal care visit. 
+• In high-prevalence settings, provider-initiated testing and counselling  
+(PITC) for HIV should be considered a routine component of the  
+package of care for pregnant women in all antenatal care settings. In  
+low-prevalence settings, PITC can be considered for pregnant women  
+in antenatal care settings as a key component of the effort to eliminate  
+mother-to-child transmission of HIV, and to integrate HIV testing with  
+syphilis, viral or other key tests, as relevant to the setting, and to  
+strengthen the underlying maternal and child health systems
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+Foetal assessment
+One ultrasound scan before 24 weeks gestation (early ultrasound) is recommended for pregnant women to estimate gestational age, improve detection of foetal anomalies and multiple pregnancy
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+Preventive measures
+Antenatal prophylaxis with anti-D immunoglobulin in non-sensitized  Rh-negative pregnant women at 28 and 34 weeks of gestation to prevent RhD alloimmunization  
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+Preventive anthelminthic treatment is recommended for pregnant  women after the first trimester 
+
+Tetanus toxoid vaccination according to recommended dosing schedule
+
+In malaria-endemic areas, intermittent preventive treatment with  sulfadoxine-pyrimethamine (IPTp-SP)
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+Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil  fumarate (TDF) should be offered as an additional prevention choice  for pregnant women at substantial risk of HIV infection 
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+• Antenatal prophylaxis with anti-D immunoglobulin in non-sensitized  Rh-negative pregnant women at 28 and 34 weeks of gestation to  prevent RhD alloimmunization  
+• Preventive anthelminthic treatment is recommended for pregnant  women after the first trimester as part of worm infection reduction  programmes.  
+• Tetanus toxoid vaccination is recommended for all pregnant women,  depending on previous tetanus vaccination exposure, to prevent  neonatal mortality from tetanus. 
+• In malaria-endemic areas, intermittent preventive treatment with  sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant  women. Dosing should start in the second trimester, and doses should  be given at least one month apart, with the objective of ensuring that  at least three doses are received. 
+• Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil  fumarate (TDF) should be offered as an additional prevention choice  for pregnant women at substantial risk of HIV infection as part of  combination prevention approaches 
+• Each pregnant woman carries her own case notes during pregnancy to  improve continuity, quality of care and her pregnancy experience. 
+• Midwife-led continuity-of-care models, in which a known midwife or  small group of known midwives supports a woman throughout the  antenatal, intrapartum and postnatal continuum, are recommended for 
+
+Tetanus Toxoid Injection
+Time given
+1st injection
+During pregnancy first visit
+2nd injection
+4 weeks after first dose but 2 weeks before delivery
+3rd injection
+6 months after 2nd dose
+4th injection
+1 year after 3rd injection/subsequent pregnancy
+5th injection
+1 year after 4th injection/subsequent pregnancy
+Tetanus Toxoid Vaccination schedule
+If a pregnant woman has not been previously vaccinated or her immunization status is unknown, she should receive two doses of TD vaccine one month apart with the second dose given at least 2 weeks before delivery/childbirth.  2 doses protect against TD infection for 1-3 years.  A third dose is recommended six months after the second dose, which should extend protection to at least 5 years
+Two further doses for women who are first vaccinated against TD during pregnancy should be given after the third dose, in the two subsequent years or during two subsequent pregnancies
+If a woman has had 1-4 TD injections in the past, she should receive one dose of TT during each subsequent pregnancy to a total of 5 doses (5 doses offer protection throughout the childbearing years) 
+
+Preventative measure
+Recommendation
+IFAS
+When anemia in pregnancy (Hgb <11g/dl) is diagnosed, increase dose of elemental iron to 120mg until Hgb rises to normal 
+Vitamin A
+In areas where vitamin A deficiency is considered a significant health problem, Vitamin A should be given daily at 10,000 IU) or weekly at 25,000 IU to prevent night blindness
+IPTp: 
+Intermittent preventive tx with Sulfadoxine pyrimethamine - start at 13 weeks, then give monthly until delivery. 
+ **HIV mothers on cotrimoxazole should not take IPT
+Deworming
+Preventative deworming with single dose Albendazole 400mg or mebendazole 500mg is recommended in pregnant women in hook-worm infested areas AFTER the first trimester.
+Other preventative guidelines
+
+Test
+Consider when….
+Chlamydia
+Increased risk according to local prevalence
+Hepatitis B/C serology and liver function test
+In women who are chronic Hepatitis B or C carriers
+Varicella titers
+In women with no definitive history of chicken pox
+Cervical cancer screening
+If woman is due according to national guidelines - should be performed in 1st trimester
+Gestational diabetes screen - OGTT is preferred method
+Woman is at risk for diabetes (>25 yo, overweight or obese, prior stillbirth or macrosomia, prior gestational diabetes, strong family history, PCOS)
+Ancillary ANC investigations
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+Health system interventions to improve utilization and quality of ANC care
+Each pregnant woman carries her own case notes during pregnancy to  improve continuity
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+Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives supports a woman throughout the  antenatal, intrapartum and postnatal continuum
+
+Group antenatal care provided by qualified health-care professionals  may be offered as an alternative to individual antenatal care
+
+Household and community mobilization and antenatal home visits are recommended to improve  antenatal care utilization and perinatal health outcomes
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+• Each pregnant woman carries her own case notes during pregnancy to  improve continuity, quality of care and her pregnancy experience. 
+• Midwife-led continuity-of-care models, in which a known midwife or  small group of known midwives supports a woman throughout the  antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well-functioning midwifery  programmes (Context-specific recommendation) 
+• Group antenatal care provided by qualified health-care professionals  may be offered as an alternative to individual antenatal care for  pregnant women in the context of rigorous research, depending on a  woman’s preferences and provided that the infrastructure and  resources for delivery of group antenatal care are available (Context specific recommendation (research) 
+• Packages of interventions that include household and community  mobilization and antenatal home visits are recommended to improve  antenatal care utilization and perinatal health outcomes, particularly in  rural settings with low access to health services (Context-specific  recommendation) 
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+Health system interventions to improve utilization and quality of ANC care - cont’
+Task sharing the promotion of health-related behaviours for maternal  and newborn health to a broad range of cadres is  recommended
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+Policy-makers should consider educational, regulatory, financial, and  personal and professional support interventions to recruit and retain qualified health workers in rural and remote areas 
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+Antenatal care models with a minimum of eight contacts are  recommended
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+• Task sharing the promotion of health-related behaviours for maternal  and newborn health to a broad range of cadres, including lay health  workers, auxiliary nurses, nurses, midwives and doctors is  recommended. 
+• Policy-makers should consider educational, regulatory, financial, and  personal and professional support interventions to recruit and retain  qualified health workers in rural and remote areas. 
+• Antenatal care models with a minimum of eight contacts are  recommended to reduce perinatal mortality and improve women’s  experience of care. 
+
+
+Post Test
+Section 6
+
+1
+2
+3
+4
+
+
+According to the new ANC care guidelines, how many points of contact should a woman receive in her 2nd trimester?
+01
+01
+B
+
+20-25mg/day
+60-65mg/day
+80-85mg/day
+120-125mg/day
+
+
+
+For a pregnant woman without known anaemia, how much iron supplementation does she require?
+
+01
+02
+B
+
+First
+Second 
+First or second
+Second or third 
+
+
+Preventative anti-worming medication should be administered during which trimester?
+01
+03
+D
+
+
+Prior stillbirth
+Prior intrauterine growth restriction
+Prior preeclampsia
+Adolescent woman
+
+
+
+
+Which of the following women is at high risk for developing gestational diabetes?
+01
+04
+A
+
+1
+2
+3
+4
+
+
+In a woman with unknown vaccine status, what is the recommended # of doses of tetanus toxoid vaccine?
+
+
+01
+05
+B
+
+Questions?

docs/APH_maternal shock_updated May23.txt

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+A Case Study
+Mum arrives at the facility with strong contractions
+
+Mum describes bleeding as painless but profuse
+
+
+41 yr old G4P3+0 presents with bleeding at 37 weeks
+OB hx: 2 prior SVD, 1 prior CS
+Medical history: uncomplicated
+Abd Exam: baby longitudinal, vertex, FHR 145bpm
+Speculum exam reveals excessive bright red bleeding
+Mum loses consciousness, mum taken to OR
+What is the diagnosis?  What is the most likely underlying cause?
+
+Antepartum haemorrhage/maternal shock
+Updated May 2023
+
+Pre-Test
+Section 1
+
+Complications of preeclampsia
+Uterine rupture
+Uterine fibroids
+Placental abruption
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+The most common cause of antepartum hemorrhage is:
+01
+01
+D
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+Brownish, painful bleeding
+Bright red, painful bleeding
+Brownish, painless bleeding
+Bright red, painless bleeding
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+APH due to placenta previa typically presents as:
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+01
+02
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+Often presents with painless bright red bleeding
+Contractions in the setting of placental abruption are rare
+Vaginal bleeding may be absent to severe
+Delivery of the mom is ALWAYS indicated
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+Which of the following is true regarding placental abruption?:
+
+
+01
+03
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+Always monitor vitals for signs of shock
+Always begin a blood transfusion as fast as possible
+Always perform a digital exam to check for dilation
+Always initiate delivery as soon as possible
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+Which of the following is true regarding the evaluation of a woman with APH?:
+01
+04
+A
+
+Maternal Obesity
+Macrosomia
+Previous placental abruption in prior pregnancy
+Adolescent pregnancy
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+Which of the following contributes to the highest risk for placental abruption?
+
+01
+05
+C
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+Learning Objectives
+Define APH
+Review causes/types of APH
+Establish method of diagnosis for APH
+Discuss management of APH
+Review complications of APH
+effective maternal resuscitation
+
+The Facts
+Section 2
+
+Reducing the Global Burden: 
+antepartum  hemorrhage 
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+20%
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+Of very preterm babies are born in association with APH
+Antepartum hemorrhage (APH) contributes significantly to maternal and perinatal morbidity and mortality globally, particularly in low and middle income countries.  
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+Prevention, early detection, and prompt management cannot be overemphasized to significantly reduce the morbidity and mortality associated with this condition
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+27%
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+Of maternal deaths worldwide are due to obstetric haemorrhage, most of which occur in low- and middle-income countries 
+3-5% of pregnancies are associated with obstetric haemorrhage
+
+Definitions
+Section 3
+
+Bleeding in the pregnant patient
+APH
+Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby
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+Threatened abortion
+This is in contrast to first/second trimester bleeding which is considered threatened abortion
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+PPH
+bleeding following the birth of the baby is postpartum haemorrhage
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+There are no consistent definitions of the severity of APH 
+The amount of blood lost is often underestimated and may not represent the total blood lost (for example in a concealed placental abruption) 
+When estimating the blood loss, it is important to assess for signs of clinical shock
+The presence of fetal compromise or fetal demise is an important indicator of volume depletion
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+
+Severity of APH
+
+In general, the following definitions for APH severity can be used: 
+Spotting
+Staining, streaking or blood spotting noted on underwear or sanitary protection 
+
+Minor haemorrhage
+Major haemorrhage 
+Massive haemorrhage
+Blood loss less than 50 ml that has settled 
+Blood loss of 50–1000 ml, with no signs of clinical shock 
+Blood loss greater than 1000 ml and/or signs of clinical shock
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+Estimating blood loss
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+Some helpful estimates:
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+Partially soaked sanitary towel: ~30ml
+Fully soaked sanitary towel: ~100ml
+Small soaked swab: ~60ml
+Large soaked swab: ~350mL
+½ way soaked chux pad: ~250ml
+Fully kidney dish: ~500mL
+Covering bed: ~1000ml
+Covering bed & spilling onto floor: ~2000ml
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+30ml
+100ml
+60ml
+250ml
+50ml
+1000ml
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+Estimating Blood loss:
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+
+Causes of APH
+Section 4
+
+Causes of APH
+Placenta previa (20%)
+Placental abruption (30%)
+
+Uterine rupture (rare)
+
+Vasa previa (rare)
+Cervical/vaginal lesions
+Unidentified causes
+
+Implantation of the placenta at or near the cervix 
+Complete previa is when the placenta covers the entire opening of the cervix
+Marginal previa (also called low-lying placenta) is when the placenta is close to the opening of the cervix but doesn't cover it
+
+Placenta Previa
+APH due to placenta previa typically results in painless bright red bleeding
+Routine screening for anemia:
+Investigate antenatal anemia (malaria? Underlying bleeding?) This includes a G&Rh
+If she has iron deficiency anaemia, oral iron is first line tx
+Counsel patient on dietary supplementation
+If unable to tolerate oral iron, has poor compliance and is near term, consider IV iron therapy.
+
+Screen for abnormal placentation:
+Perform ultrasonography examination  to screen for abnormal placentation, esp if woman had prior CS or uterine surgery
+Review by obstetrician if abnormal placentation
+If placenta accreta/percreta, involve a multidisciplinary team in preoperative planning.
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+Placental abruption occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery
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+Placenta Abruption 
+APH due to placental abruption can cause:
+Vaginal bleeding (although there might not be any!)
+Abdominal pain
+Back pain
+Uterine tenderness or rigidity
+Uterine contractions, often coming one right after another
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+Most likely to occur in the last trimester of pregnancy, especially in the last few weeks before birth
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+
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+In cases of placental abruption…..
+
+The amount of vaginal bleeding can vary greatly, and DOESN’T necessarily indicate how much of the placenta has separated from the uterus. It's possible for the blood to become trapped inside the uterus
+The amount of vaginal bleeding can vary greatly, and DOESN’T necessarily indicate how much of the placenta has separated from the uterus. It's possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding
+
+Risk Factors 
+Section 5
+
+Risk factors for placental abruption
+
+The most predictive is abruption in a previous pregnancy
+Abruption recurs in 19–25% of women who have had two previous pregnancies complicated by abruption
+Other risk factors for placental abruption include: 
+pre-eclampsia
+fetal growth restriction
+non-vertex presentations
+Polyhydramnios
+advanced maternal age
+Multiparity
+low body mass index (BMI)
+pregnancy following assisted reproductive techniques
+intrauterine infection
+premature rupture of membranes
+abdominal trauma (both accidental and resulting from domestic violence)
+smoking and drug misuse (cocaine and amphetamines) during pregnancy
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+
+Risk factors for placenta previa
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+Previous placenta praevia
+Previous termination of pregnancy
+Multiparity
+Advanced maternal age (>35 years old)
+Multiple pregnancy
+Smoking
+Pregnancy following assisted reproductive techniques
+Deficient endometrium due to presence or history of: 
+Uterine scar
+Endometritis
+Curettage
+Submucous fibroid
+
+
+Management
+Section 7
+
+APH management
+**Digital vaginal examination can cause severe bleeding, making the need for delivery urgent, so IT SHOULD BE AVOIDED
+Shout for help
+Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature)
+If you suspect shock, begin treatment immediately - start a rapid IV infusion (Normal saline or ringers solution) 
+Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly 
+Ensure that blood is available for transfusion, if required 
+Always consider shock - bleeding may be concealed
+
+Management of placenta previa
+Confirm diagnosis
+If a reliable ultrasound examination can be performed, localize the placenta
+Perform exam
+Speculum exam, NOT digital exam to confirm amount of bleeding
+Hydrate
+Restore blood volume by infusing IV fluids (normal saline or Ringer’s lactate)
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+
+In setting of placenta previa, delivery (always via CS) is indicated if:
+Bleeding is heavy and continuous
+Foetus is mature (>37 weeks)
+Foetus is dead or has anomaly not compatible with life 
+Mother’s life is at risk due to excessive blood loss 
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+
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+If bleeding is light or if it has stopped and the foetus is alive but premature (<37 weeks), consider expectant management until delivery or heavy bleeding occurs 
+Important considerations:
+Keep the woman in the hospital until delivery
+Correct anaemia with oral iron therapy
+Ensure that blood is available for transfusion, if required 
+
+Management of placental abruption
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+If bleeding is heavy (evident or hidden), expedite delivery
+If the cervix is fully dilated, perform assisted vaginal delivery if there are no other contraindications
+If vaginal delivery is not imminent, deliver by caeserean section
+If bleeding is light to moderate and the baby is > 37 weeks, course of action depends on FHR:
+If FHR normal, augment labour or perform a caesarean section (if cervix in unfavorable)
+If the foetal heart rate < 100bpm or >180bpm, expedite delivery via AVD or CS
+May consider conservative treatment if:
+Bleeding is minimal, pregnancy is <37 weeks and foetal condition is stable
+In every case of abruptio placentae, be prepared for postpartum haemorrhage 
+
+Bleeding in pregnancy is ALWAYS a danger sign - the amount of bleeding does NOT always tell the whole story
+
+Patients with vaginal bleeding should ALWAYS be delivered in a healthcare facility
+Referral to a higher level facility should be considered to accommodate blood transfusion and CS
+Important reminders regarding APH
+
+Maternal shock
+Section 6
+
+A large loss of blood or fluids prevents your organs from getting the oxygen and nutrients they need to function
+This can lead to organ failure and can be fatal. Prompt treatment increases your chance of survival
+
+
+Hypovolemic Shock
+is a serious medical problem that requires immediate treatment 
+
+Clinical estimates of blood loss are often inaccurate!
+		
+
+
+THEREFORE….
+		 	 	 
+Any blood loss that has the potential to a change in maternal condition or hemodynamic stability is considered PPH. Hemodynamic instability (SHOCK) is an emergency!
+
+
+
+
+				
+			
+		
+
+
+DIAGNOSING SHOCK 
+
+
+
+
+				
+			
+		
+
+
+Shock Index (SI) is obtained by dividing the heart rate with the systolic blood pressure 
+It is important to remember that clinical estimates of blood loss are often inaccurate!
+
+
+Symptoms of hypovolemic shock
+It is important to remember that clinical estimates of blood loss are often inaccurate!
+
+
+Signs of hypovolemic shock
+It is important to remember that clinical estimates of blood loss are often inaccurate!
+
+
+Complications of  hypovolemic shock
+Kidney damage (may require temporary or permanent use of a kidney dialysis machine)
+Brain damage
+Gangrene of arms or legs, sometimes leading to amputation
+Heart attack
+Pituitary necrosis (Sheehan’s syndrome)
+Disseminated intravascular coagulation
+Death
+It is important to remember that clinical estimates of blood loss are often inaccurate!
+
+
+Management of hypovolemic shock
+Always try and determine/treat underlying cause during resuscitation procedures
+Call for help and alert blood bank to put blood on hold in case it is needed
+Get help
+Airway
+Blood
+Fetus
+Assess airway and provide Oxygen if available
+Once mother is stable, confirm foetal status, deliver as indicated
+Insert 2 large bore IVs
+Send blood samples
+Volume replacement with IV fluids
+Blood transfusion as necessary
+Restore of blood volume if, Pulse >100 beats/minute  Or BP <90mm HG Or heavy vaginal bleeding by:
+Give 1 litre of fluids IV over 20 minutes
+Give further 1 litre IV over 30 minutes
+Packed cell volume: cross-matched from the same group if not available group O negative may be given as a lifesaving
+Crystalloid solutions: as ringer lactate, normal saline or glucose 5%. They have a short half-life in the circulation and excess amount may cause pulmonary edema
+Colloid solutions: as dextran 40 or 70, plasma protein fraction or fresh frozen plasma.
+Autologous blood transfusion in ectopic management
+Fix the urinary catheter to monitor input and output
+
+
+
+Comparison of other types of shock
+
+Questions?
+
+Post Test
+Section 13
+
+Complications of preeclampsia
+Uterine rupture
+Uterine fibroids
+Placental abruption
+
+
+
+The most common cause of antepartum hemorrhage is:
+01
+01
+D
+
+Brownish, painful bleeding
+Bright red, painful bleeding
+Brownish, painless bleeding
+Bright red, painless bleeding
+
+
+APH due to placenta previa typically presents as:
+
+01
+02
+D
+
+Often presents with painless bright red bleeding
+Contractions in the setting of placental abruption are rare
+Vaginal bleeding may be absent to severe
+Delivery of the mom is ALWAYS indicated
+
+
+Which of the following is true regarding placental abruption?:
+
+
+01
+03
+c
+
+
+Always monitor vitals for signs of shock
+Always begin a blood transfusion as fast as possible
+Always perform a digital exam to check for dilation
+Always initiate delivery as soon as possible
+
+
+Which of the following is true regarding the evaluation of a woman with APH?:
+01
+04
+A
+
+The amount of bleeding always correlates with the level of emergency 
+10% of all pregnancies will result in APH
+APH is particularly dangerous in Kenya due to underlying anaemia
+APH is defined as any pregnancy bleeding during the 2nd and 3rd trimesters
+
+
+Which of the following is TRUE regarding APH?
+
+01
+05
+C
+
+Maternal Obesity
+Macrosomia
+Previous placental abruption in prior pregnancy
+Adolescent pregnancy
+
+
+Which of the following contributes to the highest risk for placental abruption?
+
+01
+05
+C

docs/CME_Fetal HR basics_20230605.txt

@@ -0,0 +1,392 @@
+A Case Study
+Woman arrives at the facility in labour
+
+Upon subsequent VE, you notice thick meconium
+
+
+25 yo G1P0 reports to healthcare facility ℅ abdominal pain and contractions every 5 minutes
+OB hx: NAD
+Medical history: NAD
+Exam: SVE: 4cm, meconium noted
+Vitals: Temp 36C, BP 110/72 RR 22
+SVE: 9cm
+Fetal doppler performed, FHR 105
+Mum proceeds to fully dilated and delivers an FSB
+What could have been done differently?
+
+Stillbirth/foetal heart rate basics
+Updated June 2022
+
+Pre-Test
+Section 1
+
+
+Every 5 minutes
+Every 10 minutes
+Every 15-30 minutes
+Every hour
+
+
+
+According to the WHO, how often should the FHR be monitored in the first stage of labour?
+01
+01
+C
+
+
+Every 5 minutes
+Every 10 minutes
+Every 15-30 minutes
+Every hour
+
+
+
+According to the WHO, how often should the FHR be monitored in the second stage of labour?
+01
+01
+A
+
+80-120 bpm
+80-160 bpm
+110-160 bpm
+110-180 bpm
+
+
+What is a normal FHR baseline?
+01
+03
+C
+
+
+Tachycardia
+Persistently minimal variability
+Early decelerations
+Meconium
+
+
+Which of the following the number one predictor of foetal compromise?
+01
+04
+B
+
+Umbilical cord compression
+Foetal head compression
+Foetal death
+Foetal hypoxemia
+
+
+
+Upon foetal HR monitoring, what do late decelerations typically indicate?
+
+01
+05
+D
+
+Learning Objectives
+Understand the standard approach to assessing a foetal heart rate pattern
+Understand how to correctly interpret a foetal heart rate baseline
+Demonstrate understanding of foetal heart rate variability
+Interpret foetal heart rate accelerations and decelerations
+Determine the best next steps based upon FHR categories
+
+
+
+
+The facts
+Section 2
+
+Perinatal mortality is a global challenge.  The majority of these were found in low resource settings with limited options to intrapartum fetal heart monitoring devices
+
+Intrapartum hypoxia (often defined as birth asphyxia) has been reported to be associated with ~ 70% of fresh stillbirths and ~ 60% of early neonatal death
+98% of FSBs and early neonatal deaths occur in LMICs
+
+
+a stillbirth costs 10-70% more than a live birth
+
+
+60% of stillbirths occur in rural areas
+
+
+
+~2.6 million third trimester stillbirths/early neonatal deaths  occur annually 
+
+Impact: Globally, an estimated 2.6 million stillbirths and early neonatal deaths occurred in 2013, 98% in low and middle-income countries
+Cost to society:  In addition to the grief, and often the stigma, attached to a stillbirth, there are other costs to parent(s), families and society. These costs are both direct – a stillbirth costs 10-70% more than a live birth with funeral costs generally being passed on to parent(s) and lost income from time taken off work; and indirect due to greatly reduced work productivity.
+
+				
+			
+		
+
+
+The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals
+
+Worldwide, for every 1000 total births, 18.4 babies are stillborn, mostly in low- and middle-income countries. Progress in reducing this rate has been slow and at present speed, 160 years will pass before a pregnant woman in Africa has the same chance of her baby being born alive as a woman in a high-income country today
+
+Stillbirths were not included in the original MDGs and are not tracked by either the UN or the Global Burden of Disease, both of which count burden only after a live birth
+The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030.  Worldwide, this is currently 18.5 stillbirths per 1000 births
+
+
+Definitions
+Section 3
+
+Stillbirth
+As per WHO: Fetal/neonatal death after 28 weeks gestation or fetal weight of 1000g (interchangeable with late fetal death)
+
+A death which occurs after the onset of labour but before birth
+Intrapartum stillbirth (Fresh stillbirth)
+Macerated stillbirth
+A foetal death which occurred prior to the onset of labour, typically >12 hours before birth
+An intrapartum stillbirth is a death which occurs after the onset of labour but before birth. Diagnosis of intrapartum stillbirth needs confirmation of the presence of a fetal heart rate at the onset of labour. In settings where fetal heart rate monitoring is not available, assessment of the skin appearance is frequently used to estimate the timing of the stillbirth. Signs of skin maceration begin at 6–12 h after fetal death and therefore a fresh appearance of the skin with no signs of maceration is judged as a surrogate measure for intrapartum stillbirth
+The intrapartum or fresh stillbirth rate is a useful marker of stillbirths preventable through because of improved care during labour
+
+
+
+
+Many women and providers believe that stillbirth is often inevitable.  However, only ~8% of stillbirths are related to congenital anomalies.  Improved ANC care AND intrapartum care can significantly decrease the burden of stillbirth.
+
+
+
+
+Stillbirth Annual Reduction Rate (ARR) worldwide
+
+Stillbirth prevention via FHR monitoring
+Section 4
+
+Intrapartum stillbirth is a sensitive marker of delay and low quality of care, reflecting scarcity of intrapartum monitoring and delays in the rapid delivery of a compromised fetus. 
+
+
+Identification of certain FHR changes are potentially associated with inadequate fetal oxygenation and may enable timely intervention to reduce the likelihood of hypoxic injury or death. 
+
+Additionally, accurate identification of appropriately oxygenated fetuses may prevent unnecessary intervention		
+Normal labor is characterized by regular uterine contractions, which cause repeated transient interruptions of fetal oxygenation. Most fetuses tolerate this process well, but some do not. The fetal heart rate (FHR) pattern helps to distinguish the former from the latter as it is an indirect marker of fetal cardiac and central nervous system responses to changes in blood pressure, blood gases, and acid-base status
+
+Although some evidence suggests that intrapartum FHR monitoring is associated with a reduction in intrapartum death, a reduction in long-term neurologic impairment has not been proven. All available data are derived from trials comparing techniques (eg, continuous electronic monitoring with intermittent auscultation). No randomized trials have compared intrapartum FHR monitoring with no intrapartum FHR monitoring.
+
+			
+		
+
+
+
+According to the World Health Organisation (WHO) FHR monitoring (FHRM) shall be performed every 15–30 min during the first stage and every 5 min in the second stage of labor
+
+An increasing body of evidence from LMICs suggests that labor monitoring and the use of the partograph is sub-standard 
+An increasing body of evidence from LMICs suggests that labor monitoring and the use of the partograph is sub-standard - Studies from Ghana, Ethiopia, Malawi and Nepal suggest that the FHR was recorded in 25–51% of partographs
+
+According to the Every Newborn Study group: “Sensitive, specific, and simpler methods for detection of fetal compromise during labour could have a major effect on intrapartum stillbirths and early neonatal deaths, as long as linked with emergency obstetric care” 		
+		
+
+
+Intrapartum FHR monitoring
+Section 5
+
+Assessing the fetal heart rate
+
+The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli
+Systematic approach to interpreting the patterns is important
+Differentiating between a reassuring and nonreassuring fetal heart rate pattern is the essence of accurate interpretation
+
+			
+
+
+
+
+One benefit of EFM is to detect early fetal distress resulting from fetal hypoxia and metabolic acidosis
+When fetal hypoxia occurs, there are several changes in the heart rate/pattern that can alert an observing provider
+
+
+
+Interpreting FHR patterns: a systematic approach 
+
+Decelerations
+Variability
+
+
+Baseline
+The heart rate during a 10 minute segment rounded to the nearest 5 beat per minute:
+Bradycardia: Mean FHR < 110 BPM
+Tachycardia: Mean FHR>160 BPM
+
+
+What is the baseline?
+Jacaranda Health Presentation v1 20170606
+24
+
+What is the baseline?
+Jacaranda Health Presentation v1 20170606
+25
+
+Interpreting FHR patterns: a systematic approach 
+
+Decelerations
+2. Variability
+Fluctuations in the fetal heart rate of more than 2 cycles per minute:
+Absent = Amplitude range undetectable
+Minimal = < 5 BPM
+Moderate = 6 to 25 BPM
+
+
+
+
+Baseline
+***Persistently minimal or absent FHR variability appears to be the most significant intrapartum sign of fetal compromise
+
+
+What is the variability?
+Jacaranda Health Presentation v1 20170606
+27
+27
+
+What is the variability?
+Jacaranda Health Presentation v1 20170606
+28
+28
+
+Early decelerations: head compression
+Late deceleration: foetal hypoxia
+Variable deceleration: cord compression 
+
+
+Interpreting FHR patterns: a systematic approach 
+
+3. Decelerations
+Variability
+Baseline
+
+                                      
+
+
+Jacaranda Health Presentation v1 20170606
+30
+
+What type of deceleration is this?
+Jacaranda Health Presentation v1 20170606
+31
+Early
+31
+
+What type of deceleration is this?
+Jacaranda Health Presentation v1 20170606
+32
+Late
+32
+
+What type of deceleration is this?
+Jacaranda Health Presentation v1 20170606
+33
+variable
+33
+
+Recurrent decelerations
+When decelerations occur with 
+> 50% of uterine contractions in any 20 minute segment
+This is an alarming fetal heart rate pattern – action should be taken.
+The observation of recurrent late decelerations with minimal or absent variability should lead to consideration of expeditious delivery
+
+
+
+When is the baby in trouble??
+When these foetal HR patterns are detected, action should be taken
+Minimal variability
+Abnormal baseline
+Recurrent variable decelerations
+Recurrent late decelerations
+This is the number one predictor of foetal compromise**
+
+Tachycardia often indicates fever
+Bradycardia indicates fetal compromise
+Indicates persistent cord compression
+Indicates foetal hypoxia
+					 				
+			
+		
+
+
+When ONLY a foetoscope or doppler is available:
+This is the case in many public facilities
+Listen to the FHR for 3-5 minutes at a time
+Try to visualize the foetal HR as you listen
+Make sure to listen WITH contractions - this is the only way to determine presence and type of deceleration
+A single FHR number ONLY tells you that the baby is currently alive - does not indicate foetal status!!
+
+			
+
+
+
+
+
+FHR monitoring conclusions
+Continual foetal HR monitoring may help detect changes in the normal heart rate pattern during labor
+
+Accurate interpretation is necessary to detect such abnormalities - use a systematic approach:
+Baseline
+Variability
+Decelerations
+If FHR abnormalities are detected, steps can be taken to help treat the underlying problem: this typically involves expedited delivery
+FHR monitoring can also help prevent treatments that are not needed - Ex: can provide reassurance in the setting of meconium 
+
+Questions?
+
+Post Test
+Section 6
+
+
+Every 5 minutes
+Every 10 minutes
+Every 15-30 minutes
+Every hour
+
+
+
+According to the WHO, how often should the FHR be monitored in the first stage of labour?
+01
+01
+C
+
+
+Every 5 minutes
+Every 10 minutes
+Every 15-30 minutes
+Every hour
+
+
+
+According to the WHO, how often should the FHR be monitored in the second stage of labour?
+01
+01
+A
+
+80-120 bpm
+80-160 bpm
+110-160 bpm
+110-180 bpm
+
+
+What is a normal FHR baseline?
+01
+03
+C
+
+
+Tachycardia
+Persistently minimal variability
+Early decelerations
+Meconium
+
+
+Which of the following the number one predictor of foetal compromise?
+01
+04
+B
+
+Umbilical cord compression
+Foetal head compression
+Foetal death
+Foetal hypoxemia
+
+
+
+Upon foetal HR monitoring, what do late decelerations typically indicate?
+
+01
+05
+D

docs/Essesntial newborn care .txt

@@ -0,0 +1,413 @@
+A Case Study
+Mum arrives at the facility with abdominal pain 
+Baby is delivered by SVD crying and active 
+
+
+27 yo G1 arrives at the hospital 
+OB hx: uncomplicated, 39 weeks gestation
+Medical history: uncomplicated
+Exam: baby longitudinal, vertex, SVE: 5cm
+SVD delivery, no complications
+Baby is pink and active
+Vitals: HR: 120 bpm, RR: 32, Sats 97% in air
+Crying and cord is still attached
+What do we do next? What is important?
+Description of well baby 
+
+Essential Newborn Care : Session 2 
+July 2023
+
+Pre-Test
+Section 1
+
+
+10%
+30%
+60%
+80%
+
+
+
+What % of newborns require resuscitation at delivery?
+01
+01
+A
+
+
+<30 seconds
+<1 minute
+1-3 minutes
+> 10 minutes 
+
+
+
+How long should you wait in a well term newborn before cord clamping?
+01
+02
+C
+
+
+Evaporation
+Radiation
+Convection
+Conduction
+
+
+
+What is the main  mechanism of heat loss at delivery  in newborns?
+01
+03
+A
+
+
+Only term newborns
+Any stable newborns (pre-term or term)
+Stable term newborns and stable newborns >1000g 
+All newborns 
+
+
+
+01
+04
+Which newborns are suitable for immediate skin to skin?
+C
+
+
+They will shiver
+Develop hypoglycaemia
+Develop hypoglycaemia and/or respiratory distress
+It is not important
+
+
+
+Why is it important to keep all newborns warm at birth? 
+01
+05
+C
+
+Learning Objectives
+Describe what factors are involved in immediate newborn care that every newborn baby should receive:
+Immediate thermal care 
+Cord care 
+Early breastfeeding 
+Understand how to effectively implement these at every delivery  
+Understand the basics of a complete newborn examination 
+
+
+The Facts
+
+Neonatal facts : 
+
+~10% of all deliveries
+Require basic stimulation and help to breathe  at birth 
+
+~1% of all deliveries
+Require advanced resuscitation techniques
+Approximately 1 million newborns die within the first 24 hours. The top four causes are: 
+Preterm birth
+Intrapartum-related complications
+Infections 
+Birth defects 
+Sub-Saharan Africa and Central and Southern Asia are the regions experiencing the largest numbers of deaths. With an increase in facility deliveries (almost 80% globally) providing essential newborn care is key.				
+~2.3 million 
+Neonatal deaths occur globally each year
+
+~1 million  
+Newborn deaths occur in the first 24 hours. 
+
+Essential Newborn Care: At delivery 
+Rapid Assessment of the newborn at delivery: 
+Is the baby breathing adequately and/or crying?
+ (LOOK AT THE CHEST)
+Is the newborn’s heart rate present?
+(FEEL THE UMBILICAL CORD)
+Is the newborn centrally pink
+(LOOK AT THE TONGUE)
+Is the newborn vigorous and active?
+(LOOK AT THE BABY)
+DO NOT: 
+Hold the baby upside down
+Slap the baby at any time
+Perform routine suctioning of the upper airway
+
+*A non-crying baby will be covered in the neonatal resuscitation session
+
+
+
+If YES to all 4 questions the newborn does NOT need resuscitation
+
+
+
+
+Asses the baby at delivery if all 4 are answered yes the baby does not need resuscitation and can receive simple supportive newborn care after delivery .
+
+Essential Newborn Care: At delivery 
+The first thing at birth to assess: Is the baby crying?
+Approximately 1 in 10 babies (10%) need help to breathe 
+Most newborns require only simple supportive care at and after delivery
+Dry, stimulate, assess for crying, breathing and tone
+
+
+Dry thoroughly and placed skin to skin with mother 
+Warm and dry linen
+Cord clamping delayed for 1-3 minutes
+Baby should breastfeed within the 1st hour of delivery receive only breast milk and no other fluid (if well)
+
+We will go through each of these steps and the clinical importance of each  - please state this lecture is about the essential care for all WELL babies at delivery and beyond 
+
+APGAR score 
+Assessed at 1 minute and 5 minutes of age
+Scored /10
+Appearance
+Pulse
+Grimace
+Activity
+Respiration 
+Is a score given out of 10. 10/10 is the best apgar score and is given to well screaming babies at delivery
+
+Thermoregulation: Newborns and warmth (1)
+Evaporation: - the main route of heat loss after birth
+Newborns are covered in fluid at birth, if left to evaporate the heat energy to convert this will come from the baby’s body - lowering their temperature.                      PREVENTION: Drying the newborn immediately after delivery
+Convection
+This is the transfer of heat from one place to another. Draughts in the delivery room will cause heat loss.                                    PREVENTION: Ensuring no draughts from windows or doors in the delivery room.
+
+Thermoregulation: Newborns and warmth (2)
+3. Conduction
+This is the transfer of heat through contact. Contact of a newborns skin with a cold surface will cause heat loss.                          PREVENTION:  Receiving every baby in a warm dry towel
+4. Radiation
+This is the heat emitted by the baby. Heat can be lost, specifically from the head. PREVENTION: Place a hat on every newborn baby
+
+
+Essential Care  
+
+Thermal care - preventing hypothermia 
+Why is it important if a baby gets cold?
+Newborns generate heat by increasing the breakdown of glucose, leading to: 
+HYPOGLYCAEMIA 
+RESPIRATORY DISTRESS
+To prevent Hypothermia: 
+Dry the baby thoroughly at birth - Drying helps keep the baby warm and stimulates breathing
+Place a hat on all newborns at birth
+Place the  baby skin to skin with mother and cover with a dry cloth 
+DEFINITIONS: 
+Normal temperature is: 36.5 - 37.5℃
+Mild hypothermia: temperature 36 - 36.4℃ 
+Moderate hypothermia: 32 - 35.9℃
+Severe hypothermia: < 32℃
+Hyperthermia: >37.5℃
+
+Can be life threatening
+Even small drops in temperature can increase the likelihood of mortality 
+As we have learned a newly born baby is wet and can become cold even in a warm room.
+Dry the head, body, arms, and legs by gently rubbing with a cloth. Drying the back provides important stimulation to breathe. Wipe the face clean of blood and feces. Remove the wet cloth, place the baby skin-to-skin with the mother, and cover with a dry cloth.
+Warmth from the mother’s body is one of the best ways to keep a baby warm. Position the baby skin-to-skin on mother's abdomen or between her breasts. Turn the baby's head and extend the neck slightly. Cover the baby's head. Remove any wet cloths and keep mother and baby covered with a dry cloth.
+To improve care in your facility - Who is responsible for providing cloths to dry and cover the baby? What to monitor - Are all babies dried thoroughly at birth
+Discuss: A baby is separated from the mother without drying. What happens? The baby can become cold Or The baby will stay warm? When should you dry the baby? Immediately after birth.
+
+
+Skin to skin mother care 
+Term and low-birth-weight neonates who do not have complications and are clinically stable should be put in skin-to-skin contact with the mother soon after birth after they have been dried thoroughly to prevent hypothermia
+Benefits of Skin-to-skin care:
+Keeps babies warm
+Helps prevent infection
+Promotes early breastfeeding and bonding
+Monitoring temperature and breathing helps 
+identify problems early
+Important to help the mother find a comfortable semi-reclining position 
+Ideally continue skin-to-skin contact without interruption for at least one hour. PLease state this is not suitable for unstable babies who require close monitoring and support. This is for well newborns = the majority of births
+
+
+Cord care: Well newborn 
+Delay cord clamping 
+Wait 1 - 3 minutes to clamp or tie and cut the cord 
+Allows the baby to receive blood from the placenta. 
+Wear clean gloves 
+Place clamps or ties around the cord at 2 and 5 fingerbreadths from the abdomen 
+Cut between the clamps or ties with disinfected scissors or blade 
+Leave the cut end of the cord open to air to dry
+Apply chlorhexidine digluconate 7.1% gel to the cord stump
+Highlight: this is cord care for a well crying baby, not requiring immediate resuscitation. 
+Remember to inspect the cord for any bleeding and inform the mother to watch for this. Re-inspect in 4 hours time.
+How long do you wait to clamp or tie and cut the umbilical cord of a crying baby? Clamp or tie and cut the cord immediately or Wait 1 to 3 minutes to clamp or tie and cut the cord.  What actions help prevent infection of the umbilical cord? ->Good hand washing, wearing clean gloves, cutting with sterile scissors Covering the cord to keep it moist
+Apply Chlorhexidine once daily for 7 days or until the cord detaches 
+
+
+Initiate Breastfeeding 
+
+
+
+Initiate within the first hour of birth 
+
+Position stable newborns to attach to the breast
+Show all mothers how to achieve and maintain lactation within the delivery room.  Avoid giving the newborn any other drink or feed except breast milk unless medically indicated
+If time here can discuss how to latch effectively and ensure good suck (see manual)
+Explain breastfeeding in more detail will be covered in the feeding and fluids lecture 
+
+Additional care
+Vitamin K: 
+Give IM vitamin K (phytomenadione) to all newborns.
+Newborns >1.5kg give 1mg IM Vitamin K
+Newborns <1.5kg give 0.5mg IM Vitamin K
+Eye care: 
+Clean each eye with swabs soaked in sterile water from the medial to lateral side immediately after birth
+Apply ointment (e.g. tetracycline ointment) to both eyes once, according to national guidelines.
+Vaccinations:
+Give BCG 0.05ml and oral polio 2 drops at birth or before discharge
+Severe Vitamin K deficiency can result in Haemorrhage & Death - haemorrhagic disease of the newborn
+
+Summary
+Receive the newborn with a dry warm towel
+
+If the newborn does not need resuscitation the following steps should be performed:
+3. Dry and stimulate the newborn vigorously
+
+4. Discard the wet towel and place hat on newborn
+2. Place the newborn on the mother’s chest for skin to skin contact 
+5.  Cover both mother and newborn with a warm dry  towel
+
+7. Cut the cord with a sterile instrument or blade
+
+8. Assist the mother to initiate breastfeeding for stable newborn
+6. Delay cord clamping by 1-3 minutes if the newborn continues to be vigorous and active with a strong cry while being dried and stimulated
+Here mention after the first hour need to instigate additional care: eye cleaning and Vitamin K administration and chlorhexidine to the cord 
+
+Examination of the Newborn (1)
+Respiration - The normal respiratory rate is 30-60 breaths per min)
+Grunting 
+Chest indrawing/recessions
+Apnoea
+Colour  - Normal is pink
+Pallor
+Jaundice 
+Central cyanosis (blue tongue)
+Heart rate - the normal heart rate is 100-160bpm
+Temperature: Normal 36.5-37.5
+Capillary refill time (<2 seconds)
+Femoral pulses: present/absent 
+Posture and Movement
+Opisthotonus 
+Irregular, jerky movements of the body, limbs, (convulsion or spasm)
+Jitteriness 
+Muscle Tone and Alertness:
+Lethargy
+Floppiness
+Irritability
+Drowsiness
+Reduced activity 
+Unconscious 
+Posture: The normal resting posture of a term newborn baby comprises loosely clenched fists and flexed arms, hips, and knees. The limbs may be extended in small babies (less than 2.5kg at birth or born before 37weeks’ gestation. Babies who were in a breech position may have fully flexed hips and knees, and the feet may be near the mouth; alternatively, the legs and feet may be to the side of the body)
+• Opisthotonus (extreme hyper extension of the body, with the head and heels bent backward and the body arched forward). During the examination, look closely for signs of other problems that could cause opisthotonos, e.g. Tetanus, meningitis, bilirubin encephalopathy [kernicterus]
+• Irregular, jerky movements of the body, limbs, (convulsion or spasm)
+• Jitteriness (rapid and repetitive movements that are caused by sudden handling of the baby or loud noises and can be stopped by cuddling, feeding, or flexing a limb)
+
+
+Examination of the Newborn (2)
+Limbs (Upper and lower)
+Abnormal 
+Normal 
+Skin
+Redness/swelling 
+Pustules/blistering
+Bruising/Birthmarks  
+Umbilicus (normal is bluish white in colour day 1 then dries and falls off 7-10 days 
+Red, swollen, draining pus, foul smelling
+Bleeding
+Umbilical hernia 
+Eyes 
+Pus draining, 
+Red/swollen eyelids
+Sub-conjuctival bleeding 
+Head and Face
+Moulding 
+Hydrocephalus
+Fontanelle - sunken, bulging 
+Mouth and nose: 
+Cleft lip/palate - feel for palate
+Tongue tie
+Abdomen and Back
+Distension
+Abdominal wall defects (covered in later session)
+Spina bifida/myelomeningocele
+Weight (normal 2.5-4kg)
+Urine and stool 
+Pass urine in the first 24 hours 
+Meconium in first 24 hours 
+Genitalia and anus
+Patent anus - imperforate
+Indeterminate sex
+Penile abnormalities 
+Feeding
+Assess suck and latch 
+Abnormal position and movement of limbs
+• Baby’s arms or legs move asymmetrically
+• Baby cries when a leg, arm, or shoulder is touched or moved
+• Bone is displaced from its normal position
+• Clubfoot (foot is twisted out of shape or position; e.g. heel is turned
+inward or outward from the midline of the leg)
+• Extra finger(s) or toe(s), polydactyly or syndactily
+
+Questions?
+
+Post Test
+Section 11
+
+
+10%
+30%
+60%
+80%
+
+
+
+What % of newborns require resuscitation at delivery?
+01
+01
+A
+
+<30 seconds
+<1 minute
+1-3 minutes
+> 10 minutes
+
+
+How long should you wait in a well term newborn before cord clamping?
+
+01
+02
+C
+
+Evaporation
+Radiation
+Convection
+Conduction
+
+
+What is the main  mechanism of heat loss at delivery  in newborns?
+01
+03
+A
+
+
+Only term newborns
+Any stable newborns (pre-term or term)
+Stable term newborns and stable newborns >1000g 
+All newborns 
+
+
+Which newborns are suitable for immediate skin to skin?
+
+01
+04
+C
+
+They will shiver
+Develop hypoglycaemia
+Develop hypoglycaemia and/or respiratory distress
+It is not important
+
+
+Why is it important to keep all newborns warm at birth? 
+
+01
+05
+C

docs/HTN disorders_CME_updated Jan2022.txt

@@ -0,0 +1,556 @@
+A Case Study
+Mum arrives at the facility with strong contractions
+
+But experiences adverse outcomes during delivery
+
+
+34 yo G3P0+2 presents at 36 weeks with headache
+OB hx: 2 prior FSBs at term via SVD
+Medical history: HTN on aldomet
+Exam: baby longitudinal, vertex, SVE: cervix closed
+Vitals: BP 160/109, HR 109, RR 20 Urine: protein 3+
+Mum proceeds to develop worsening headache.  Repeat BP 170/115
+FHR pattern shows evidence of foetal compromise
+Diagnosis?  Risk Factors?  What do we do next? 
+
+Hypertensive disorders in pregnancy
+Updated February 2022
+
+Pre-Test
+Section 1
+
+
+Chronic hypertension
+Gestational hypertension
+Preeclampsia without severe features
+Preeclampsia with severe features
+
+
+A woman presents for her ANC visit at 30 weeks.  Her BP at this time is 153/95.  She denies any headache/blurred vision or abdominal pain.  You test her urine and find no protein.  The most likely diagnosis is?
+01
+01
+B
+
+
+Prophylactic blood pressure medication
+Vitamin D supplementation
+Daily low dose aspirin 
+Bed rest starting at 30 weeks
+
+Which of the following has strong evidence to support prevention of preeclampsia in women with prior preeclampsia?
+
+01
+02
+C
+
+
+Platelets <170,000mm3
+Elevated liver enzymes (AST/ALT)
+Creatinine <1.2mg/dl
+Decreased uric acid
+
+
+Which of the following lab abnormalities may aid in the diagnosis of preeclampsia?
+01
+03
+B
+
+
+Labetalol IV
+MgSO4 IV
+Methyldopa PO
+Hydralazine PO
+
+
+Which of the following is a first line medication for intrapartum BP control?
+01
+04
+A
+
+5-10%
+10-20%
+30-40%
+40-50%
+
+
+In women with eclampsia, what % of cases occur postpartum?
+
+01
+05
+D
+
+Learning Objectives
+Classify hypertensive disorders of pregnancy
+Understand risk factors for PIH/eclampsia
+Appropriately diagnose PIH/eclampsia
+Effectively treat PIH/eclampsia
+Prepare and administer MgSO4 to a pre-eclamptic/eclamptic mother
+
+The Facts
+Section 2
+
+Reducing the Global Burden: 
+Hypertensive disorders of pregnancy: 
+
+15%
+of premature births are directly related to hypertensive disorders of pregnancy
+Hypertensive disorders of pregnancy (HDP) is one of the leading causes of maternal and fetal morbidity and mortality worldwide 
+
+10% 
+Of pregnancies globally are complicated by hypertensive disorders of pregnancy 
+12%
+of worldwide global maternal deaths are due to complications of hypertensive disorders of pregnancy
+
+Hypertensive disorders of pregnancy (HDP) is one of the leading causes of maternal and fetal morbidity and mortality worldwide and potentially a critical threat to maternal and infant health
+Despite being a largely manageable condition,  mortality from HDP remains high.
+In the absence of timely and appropriate action, a woman and her infant could die.
+
+
+Definitions
+Section 3
+
+Hypertension in pregnancy 
+Systolic blood pressure greater than or equal to 140 mmHg and/or diastolic blood pressure greater than or equal to 90 mmHg measured on 2 occasions and at least 4 hours apart  
+
+Categories of hypertension in pregnancy
+Chronic hypertension
+		Hypertension confirmed pre- conception or prior to 20 weeks gestation  						
+					 				
+			
+		
+
+Gestational hypertension
+Preeclampsia/
+Eclampsia
+Chronic HTN with superimposed preeclampsia
+New onset hypertension arising after 20 weeks gestation in the absence of proteinuria and other symptoms
+Generally resolves within 3 months postpartum  						
+					 				
+			
+		
+
+Hypertension with proteinuria after the 20th week of gestation in a previously normotensive and non-proteinuric woman  						
+					 				
+			
+		
+
+Features of pre-eclampsia developing in a woman who had hypertension prior to conception  						
+					 				
+			
+		
+
+
+Classification of pre-eclampsia:
+BP of 140/90 mm Hg or more with proteinuria after the 20th week of gestation in a previously normotensive and non-proteinuric women 
+Proteinuria (≥30 mg/mol protein or ≥2 + dipstick)  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+
+Add a short description about your point
+Pre-eclampsia plus any of the following:
+Elevated creatinine >1.2mg/dL
+Elevated liver enzymes
+Epigastric abdominal pain
+Neurological complications (altered mental status, blindness, stroke, clonus, severe headaches)
+Hematological complications (platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis)
+Uteroplacental dysfunction (fetal growth restriction or stillbirth)
+Oligohydramnios 						
+					 				
+			
+		
+
+
+Pre-eclampsia plus evidence of new onset seizure activity 
+
+Preeclampsia WITHOUT severe features
+Preeclampsia WITH severe features
+Eclampsia
+
+Risk Factors 
+Section 3
+
+Extremes of age (maternal age <20 and>35 years)
+Black race
+Family history of Preeclampsia
+Nulliparity (more common in primigravidae)
+Pre-eclampsia in a previous pregnancy
+Diabetes
+Obesity
+Chronic hypertension/Renal disease
+Antiphospholipid syndrome
+Periodontal disease
+Vitamin D deficiency
+Inherited thrombophilias
+Inter-pregnancy interval of >10 years  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+
+Chromosomal abnormalities
+Hydatidiform mole
+Multiple pregnancy
+In-vitro fertilization	
+					 				
+			
+		
+					
+					 				
+
+
+Pregnancy 
+Risk Factors
+
+Maternal
+Risk Factors
+
+Prevention
+Section 4
+
+Assess underlying risk:
+Women may be categorized as high or low risk based on personal/family history, underlying disease and pregnancy associated risk factors
+1
+Prevention measures with STRONG evidence:
+Women at high risk should be started on low dose Aspirin 
+
+Calcium supplementation - 1g/day 
+2
+Prevention measures with MODERATE evidence:
+Vitamin D supplementation 
+3
+Prevention measures include:
+Preventative measures with strong evidence:
+Women at high risk should be started on daily low dose Aspirin at 11 weeks gestation (or as soon as possible thereafter) until 36 weeks gestation
+Calcium supplementation - 1g/day in high risk women and low risk women with poor calcium intake
+
+Preventative measures with moderate evidence:
+Vitamin D supplementation may play a role in preeclampsia prevention through improved vascular function
+
+
+Diagnosing preeclampsia:
+		 	 	 		
+In the absence of proteinuria, new onset hypertension and any of the following may be diagnostic of preeclampsia:
+
+*Important: proteinuria is NOT mandatory for the diagnosis.
+**Some degree of swelling is normal in pregnancy but sudden swelling of the face, hands and legs is strongly suggestive of pre-eclampsia 
+				
+			
+		
+ 						
+					 				
+			
+		
+
+
+Platelet count < 100,000/mm3
+Serum creatinine >1.1mg/dl
+
+Elevated AST/ALT to twice their normal level
+
+Crackling in lungs upon lung exam or pt may have difficulty breathing
+Severe headache/blurring of vision
+Cerebral/visual symptoms
+Pulmonary Edema
+Impaired liver function
+Renal insufficiency
+Thrombocytopenia
+
+CBC                            - LFTs
+Urinalysis                    - Creatinine
+Uric Acid
+
+
+In suspected preeclampsia, work-up should include:
+Thorough personal and family history
+Symptoms which may include: headache, blurred vision, epigastric pain, N/V, sudden swelling, decreased urine output, decreased foetal movement
+Thorough H&P
+Lab investigations 
+Foetal assessment
+CTG reading if over 24 weeks gestation
+Ultrasound assessment including:
+Foetal growth
+BPP including AFI assessment
+Doppers if available
+
+Management
+Section 5
+
+General Principles of preeclampsia/eclampsia treatment:
+Preeclampsia can range widely in terms of severity of disease and obstetric/foetal status.  Treatment should be based upon a woman’s individual circumstance
+Antihypertensives a needed
+Blood pressure control
+MgSO4 in the setting of preeclampsia with severe features/eclampsia
+					 				
+			
+		
+
+Seizure prophylaxis
+02
+Delivery plan based on severity of disease
+Expedite delivery
+03
+01
+
+Blood Pressure Control
+Not ALL women with preeclampsia need blood pressure management during labour.  The following guidelines apply:
+The goal is to lower BP to prevent cerebrovascular and cardiac complications while maintaining utero-placental blood flow  						
+Antihypertensive treatment is indicated for diastolic BP above 110 mm Hg and systolic pressure above 160 mm Hg
+The goal is to maintain diastolic BP between 80 and 100mm Hg and systolic BP between 130 and 150mm Hg 
+Patients with preeclampsia with severe features who have BP below 160/110 mm Hg may benefit from antihypertensive drugs because of the possibility of unpredictable acceleration of the disease
+
+BP Medications
+Intrapartum medications
+		 	 	 	  First-line medications are:
+Nifedipine 10-20mg oral, repeat 10-20mg every 30 minutes (maximum 40mg).  Maintain 10mg q 4-6 hrs
+Hydralazine 5mg IV slowly over 10 minutes.  Repeat 5mg every 20 minutes (maximum 20mg)
+Labetalol 20mg IV slowly over 10 minutes.  Proceed to 40mg then 80mg at 10-20 minute intervals (max of 300mg) 
+	
+					 				
+			
+		
+
+3
+2
+1
+HTN 
+management
+Antenatal medications
+First line agents are:
+Methyldopa: Start at 125mg BD, increase as indicated to max of 500mg QID
+Labetalol Start at 100mg BID, increase as indicated to max of 400mg QID
+Hydralazine: Start at 25mg BD, increase as indicated to max of 100 BD
+Nifedipine (IR): Start at 10mg BD, increase as indicated to max of 40mg BD
+If antepartum HTN, continue BP meds Intrapartum.  For others,  BP management indicated if systolic BP persistently >160 or diastolic BP persistently > 110
+
+
+Seizure prophylaxis
+The basic principles of airway, breathing, circulation (ABCs) should always be followed as a general principle of seizure management
+Active seizures should be treated with intravenous magnesium sulphate as a first-line agent  						
+					 				
+			
+		
+ 						
+Prophylactic treatment with magnesium sulphate is indicated for all patients with preeclampsia with severe features  						
+					 				
+			
+		
+
+Once a patient is started on MgSO4, Magnesium levels, respiratory rate, reflexes, and urine output must be monitored to detect magnesium toxicity  						
+					 				
+			
+		
+
+There is still a significant  risk of seizures following delivery - up to 44% of eclampsia cases have been reported to occur postpartum (the majority occur within the first 48 hours) 						
+					 				
+			
+		
+
+
+Preparation of 4g 20% solution of magnesium sulfate from 50% ampule  					
+Wash hands thoroughly with soap and running water or use 70% alcohol hand rub and air dry
+Using a 20-mL syringe, draw 12 mL of sterile water for injection
+Add 8 mL of MgSO4 50% solution* to 12 mL of water for injection to make 20 mL of 20% solution (4 g per 20 mL)  						
+					 				
+			
+		
+
+
+
+MgSO4 dosing for preeclampsia with severe features or eclampsia
+Loading dose - initially:
+4g of 20% MgSO4 IV over 5 minutes
+4g (20mL) 20% solution (preparation as described previously)
+Followed by:
+If convulsions persist after 15 minutes:
+Maintenance dose:
+10g 50% MgSO4 (5g in each buttock)
+Draw 10mL 50% MgSO4 in two 20mL syringes
+Add 1mL 2% lignocaine to each
+Give deep IM in each buttock
+2g of 20% MgSO4 IV over 5 minutes
+2g (10mL) of 20% MgSO4 (preparation as described previously)
+5gm of 50% MgSO4 IM q 4 hours in alternate buttocks or 1g/hr 20% IV
+Draw 10ml 50% mgSO4 in 20mL syringe
+Add 1mL 2% lignocaine 
+Give deep IM in buttock
+In the IV regimen, the loading dose consists of an initial intravenous dose of 4 g slowly over 5-10 min followed by a maintenance dose of 1-2 g every hour given by an infusion pump.  A gravity fed infusion set can be used in the absence of the pump especially in the developing countries.
+
+If convulsions persist after 15 minutes in a woman >70kg, 
+
+Monitoring for MgSO4 toxicity
+Signs of MgSO4 should be evaluated before each repeat maintenance dose of MgSO4 is given
+Monitor hourly.  Should be >16 RR
+Should be present.  Absent patellar reflexes are the 1st sign of MgSO4 toxicity
+Should be >30cc/hr.  This is best monitored with catheter.  If catheter not possible, instruct mum to urinate in bedpan
+Stop MgSO4, IV ringers lactate 1L over 8 hours, monitor for pulmonary oedema
+Stop MgSO4, mechanical ventilation as needed, give Calcium gluconate 1 gm (10% of 10 ml) IV slowly over 10 minutes
+Respiration
+Patellar reflex
+Urine output
+Mild signs of toxicity
+Severe signs of toxicity
+
+Additional notes on seizure prophylaxis
+Contraindications to MgSo4
+Impaired renal function (consider alternative medication if Creatinine >1.5)
+Myasthenia gravis
+Phenytoin
+May be used if MgSO4 is contraindicated
+Dosage: 10 mg/kg loading dose infused IV slowly, followed by maintenance dose started 2 hours later at 5 mg/kg
+Diazepam
+May be used if MgSO4 is contraindicated
+Loading dose: 20mg IV slowly over 2 minutes
+Maintenance dose: 40mg in 500ml IV fluid titrated to keep woman sedated but rousable
+
+
+Fluid management in women with preeclampsia/
+eclampsia
+Despite peripheral edema, patients with Pre-eclampsia are intravascularly volume depleted  						
+					 				
+			
+		
+
+
+Pulmonary Edema: Aggressive volume resuscitation may lead to pulmonary edema.  						
+					 				
+			
+		
+
+Fluid restriction: Volume expansion has no demonstrated benefit, patients should be fluid restricted when possible 						
+					 				
+			
+		
+
+Measurement of Ins and Outs: Careful measurement of fluid input and output is advisable, particularly in the immediate postpartum period					
+					 				
+			
+		
+
+Fluid selection: If fluids are required, preferably use Ringer’s Lactate or Normal saline. Avoid using Dextrose or Dextrose- Saline infusion  						
+					 				
+			
+		
+
+Pulmonary Edema
+Aggressive volume resuscitation may lead to pulmonary edema. This occurs most frequently 48-72 hours postpartum probably due to mobilization of extravascular fluid 
+Fluid restriction
+Volume expansion has no demonstrated benefit, patients should be fluid restricted when possible, at least until the period of postpartum diuresis. Total fluids should generally be limited to 80mL/h or 1 mL/kg/h 
+Measurement of Ins and Outs
+Careful measurement of fluid input and output is advisable, particularly in the immediate postpartum period. Many patients will have a brief (up to 6 h) period of oliguria following delivery; this should be anticipated and not overcorrected 
+Fluid selection:
+If fluids are required, preferably use Ringer’s Lactate or Normal saline at a rate of 80mls/ hour or 1ml/kg/hr. Avoid using Dextrose or Dextrose- Saline infusion 
+
+
+Delivery recommendations
+Delivery is the definitive treatment for a woman with preeclampsia
+Patients with cHTN, gestational hypertension, preeclampsia with or without severe features should be delivered at 37 weeks unless earlier delivery indicated 
+In patients with preeclampsia with severe features, delivery should be considered at 34 weeks.  
+Prior to 37 weeks, expectant management can be considered in order to treat with steroids for lung maturity 
+Immediate delivery indications: non-reassuring foetal status, severe foetal growth restriction, eclampsia, placental abruption, pulmonary edema, HELLP syndrome, persistent neurological symptoms
+**Mode of delivery should be based on obstetric indication and severity of disease
+In patients with preeclampsia with severe features, delivery should be considered at 34 weeks.  The severity of disease must be weighed against risks of prematurity
+
+Prior to 37 weeks, expectant management can be considered in order to treat with steroids for lung maturity unless immediate delivery indicated
+
+
+
+Continue antihypertensives as long as the diastolic pressure is > 110mmHg.  Pt may need to be discharged on oral antihypertensive and re-evaluated at postpartum visit
+
+Postnatal care
+Continue to monitor urine output – if <500cc/24 hours, limit fluid intake 
+Watch closely for pulmonary oedema
+
+Monitor I&Os
+HTN meds
+Cont MgSO4
+Up to 44% of seizures occur POST delivery: continue MgSO4 for 24 hours post delivery (or 24 hours after the last convulsion)
+
+
+Complications
+Section 6
+
+Complications of preeclampsia include:
+Placental abruption
+
+Disseminated intravascular coagulation
+
+HELLP*
+
+Cerebral hemorrhage
+
+Maternal or foetal death
+*HELLP is a rare complication of preeclampsia which results in hemolysis, elevated liver enzymes, and low platelets.  It can result in severe complications such as excessive bleeding, liver rupture, seizure or stroke
+
+Questions?
+
+Questions?
+
+Post Test
+Section 8
+
+Chronic hypertension
+Gestational hypertension
+Preeclampsia without severe features
+Preeclampsia with severe features
+
+
+A woman presents for her ANC visit at 30 weeks.  Her BP at this time is 153/95.  She denies any headache/blurred vision or abdominal pain.  You test her urine and find no protein.  The most likely diagnosis is?
+01
+01
+B
+
+Prophylactic blood pressure medication
+Vitamin D supplementation
+Daily low dose aspirin 
+Bed rest starting at 30 weeks
+
+Which of the following has strong evidence to support prevention of preeclampsia in women with prior preeclampsia?
+
+01
+02
+C
+
+Platelets <150,000mm3
+Elevated liver enzymes
+Creatinine <1.0mg/dl
+Decreased uric acid
+
+
+Which of the following lab abnormalities may aid in the diagnosis of preeclampsia?
+01
+03
+B
+
+
+Labetalol IV
+MgSO4 IV
+Methyldopa PO
+Hydralazine PO
+
+
+Which of the following is a first line medication for intrapartum BP control?
+01
+04
+A
+
+5-10%
+10-20%
+30-40%
+40-50%
+
+
+In women with eclampsia, what % of cases occur postpartum?
+
+01
+05
+D
+
+Video on preeclampsia/eclampsia management

docs/Infection prevention.txt

@@ -0,0 +1,632 @@
+A Case Study
+Mum arrives at the facility with labour pain
+
+She fails to progress in labour and requires a CS
+
+
+A 32 yo G1P0 @ 39 weeks arrives at your facility ℅ laps
+OB hx: NAD
+Medical history: pregestational diabetes on meds
+Exam: baby longitudinal, vertex, SVE: 4 cm
+Vitals: Temp 37C, BP 137/78 RR 16
+1 day postpartum, the woman develops fever of 39 degrees
+She complains of foul smelling discharge and abd pain
+She is started on antibiotics and recovers fully
+Diagnosis?  What could have prevented her infection? 
+
+Infection Prevention 
+Updated March 2022
+
+Pre-Test
+Section 1
+
+
+Decontamination
+Cleaning
+Antisepsis
+Sterilization
+High level disinfection
+
+
+
+Using pre-surgical hand rub is an example of which of the following?
+01
+01
+C
+
+A set of guidelines used to treat hospitalized patients with known infection
+A set of guidelines used to treat patients with suspected infection
+A set of guidelines that should be used for ALL patients and clients in a healthcare facility
+A set of guidelines used for surgical procedures
+
+
+Standard precautions refer to which of the following?
+
+01
+02
+C
+
+Handwashing with plain soap and clean water is as effective as washing with antimicrobial soaps
+During handwashing, hands should be vigorously rubbed for 60 seconds with soap and plain water 
+Does not need to be performed if using sterile gloves
+Handwashing with plain soap and water is more effective than antiseptic handrub in killing bacteria 
+
+
+Which of the following is true of hand washing procedures?
+01
+03
+A
+
+
+All syringes should be recapped prior to being discarded in the sharps container
+Most needles can be used more than once for cost effectiveness
+Sharps containers should be placed as close to the point of use as possible - ideally within arm’s reach
+Sharps containers should have a fill line at 50% full
+
+
+Which of the following is true regarding proper handling of sharps?
+01
+04
+C
+
+Black waste bin - non-infectious material
+Yellow waste bin - infectious material
+Red waste bin - highly infectious material
+Sharps container
+
+
+After a vaginal exam, used gloves should be discarded in which of the following?
+
+01
+05
+B
+
+Learning Objectives
+Discuss standard and transmissions-based precautions
+List the essential components of infection          prevention
+Discuss steps for appropriate hand washing techniques
+Understand instrument sterilization procedure
+Color code for waste segregation
+
+
+Healthcare associated infections (HCAI) : 
+
+15.6%
+Of all developing countries have a HCAI reporting system
+
+>10%
+Average rate of HCAIs in developing countries (of those who report)
+
+Up to 50%
+Of of neonatal deaths in developing countries can be attributed to HCAIs
+ 
+
+
+HCAIs are a significant problem throughout the world.
+
+Most of these infections can be prevented with readily available, relatively inexpensive strategies 
+				
+4.5%
+Estimated HCAI incidence rate in the United States
+
+7.1% 
+Average rate of HCAI in Europe
+
+
+
+Definitions
+Section 2
+
+Healthcare associated infection (HCAI):
+
+		 	 	 		
+			 (HCAI
+				
+An infection occurring in a patient during the process of care in a health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff
+			
+			
+		
+
+
+**HCAI is acknowledged as the most frequent adverse event in health care, but the global burden remains unknown because of the difficulty of gathering reliable data	
+
+Infection prevention techniques
+Antisepsis
+Reducing the number of microorganisms on skin, mucous membranes or other body tissue by applying an antimicrobial (antiseptic) agent
+
+Process that makes inanimate objects safer to be handled by staff before cleaning (ex; soaking instruments in chloride solution prior to cleaning)
+				
+			
+		
+
+Risks to foetus
+Removing all visible dust, soil, blood or body fluids from inanimate objects as well as removing sufficient numbers of microorganisms to reduce risks for those who  handle the object
+			
+
+A process that eliminates all microorganisms except some bacterial endospores from inanimate objects by boiling, steaming or the use of chemical disinfectants
+				
+			
+		
+Decontamination
+Cleaning
+High level disinfection (HLD)
+Sterilization
+Process that eliminates all microorganisms including bacterial endospores from inanimate objects by high-pressure steam (autoclave), dry heat (oven), chemical sterilants or radiation
+Decontamination is the first step in processing soiled (contaminated) surgical instruments, gloves and other items, especially if they will be cleaned by hand. For example, briefly soaking contaminated items in 0.5% chlorine solution, or other locally available disinfectants, rapidly kills HBV4 and HIV, thereby making the instruments and other items safer to be handled during cleaning. Larger surfaces, such as examination and operating tables, laboratory bench tops and other equipment that may have come in contact with blood or other body fluids also should be decontaminated. Wiping with a suitable disinfectant (e.g., 0.5% chlorine solution or 1–2% phenol) is a practical, inexpensive way to decontaminate them. After instruments and other items have been decontaminated, they need to be cleaned and finally either sterilized or high-level disinfected
+
+Where infection comes from
+Microorganisms are the causative agents of infection. They include:
+Bacteria
+(Ex: Staph aureus)
+(Ex: coronavirus)
+Viruses
+(Ex: Candida albicans)
+Fungus
+Colonization means that pathogenic organisms are present in a person (i.e. they can be detected by cultures or other tests) but are not causing symptoms 
+
+Infection means that the colonizing organisms now are causing an illness or disease in the person
+
+Infection prevention largely depends on placing barriers between a susceptible host and microorganisms
+Protective barriers are physical, mechanical or chemical processes that help prevent the spread of infectious microorganisms from: 
+person to person (patient, healthcare client or health worker)
+equipment, instruments and environmental surfaces to people
+
+
+Transmission
+Section 3
+
+Infection prevention deals primarily with preventing the spread of infectious diseases through:
+Infectious diseases are spread mainly via:
+Airborne
+Blood or body fluids
+Contact (direct or indirect)
+Fecal-oral
+Foodborne
+Animal
+ 
+air, blood or body fluids, and contact
+Airborne: through the air (chicken pox or mumps)
+Blood or body fluids: if blood or body fluids contaminated with HBV or HIV comes in contact with another person, such as through a needlestick, s/he may become infected
+Contact: either direct (touching an open wound or draining pustule), or indirect (touching an object contaminated with blood or other body fluids)
+Fecal-oral: swallowing food contaminated by human or animal feces (e.g., putting your fingers in your mouth after handling contaminated objects without first washing your hands)
+Foodborne: eating or drinking contaminated food or liquid that contains bacteria or viruses (hepatitis A from eating raw oysters)
+Animal- or insect-borne: contact with infected animals or insects through bites, scratches, secretions or waste.
+
+
+
+Infection prevention requires removing one or more of the conditions necessary for transmission of the disease from one host to another by:
+Inhibiting or killing the agent 
+Blocking the agent’s means of getting from an infected person to a susceptible person
+Making sure that people are immune or vaccinated
+Providing health workers with the right protective equipment to prevent contact with infectious agents 
+Preventing the spread of infectious diseases requires removing one or more of the conditions necessary for transmission of the disease from host or reservoir to the next susceptible host by: 
+• inhibiting or killing the agent (e.g., applying an antiseptic agent to the skin before surgery); 
+• blocking the agent’s means of getting from an infected person to a susceptible person (e.g., handwashing or using a waterless, alcohol-based antiseptic handrub to remove bacteria or viruses acquired through touching an infected patient or contaminated surface); 
+• making sure that people (especially healthcare workers) are immune or vaccinated
+• providing health workers with the right protective equipment to prevent contact with infectious agents (e.g., heavy-duty gloves for housekeeping and waste removal staff)
+
+
+Infection prevention can be further broken down into:
+Standard precautions
+Apply to ALL patients and clients attending healthcare facilities
+Should be used ALL the time
+				
+			
+		
+ 	 	 		
+			
+				
+					
+Women should be informed that a standard duration of the laten established and can vary widely from one woman to another 
+				
+			
+		
+ 
+
+Transmission based precautions
+Apply to hospitalized patients with known or suspected infection
+MUST be used in conjunction with Standard precautions
+				
+			
+		
+
+				
+			
+		
+ 
+
+Standard Precautions are designed for use in caring for all people—both clients and patients—attending healthcare facilities. They apply to blood, all body fluids, secretions and excretions, nonintact skin and mucous membranes. Because no one really knows what organisms clients or patients may have at any time, it is essential that Standard Precautions be used all the time
+
+Transmission based precautions are intended for use in patients known or highly suspected of being infected or colonized with pathogens transmitted by: 
+• air (tuberculosis, chicken pox, measles, etc.)
+• droplet (flu, mumps and rubella); or 
+• contact (hepatitis A or E and other enteric pathogens, herpes simplex, and skin or eye infections)
+
+Transmission Based Precautions must be used in conjunction with the Standard Precautions
+If there is any question of an infectious process in a patient without a known diagnosis, implementing Transmission-Based Precautions should be based on the patient’s signs and symptoms (empiric basis) until a definitive diagnosis is made
+
+Key components of Standard precautions:
+
+Handwashing
+Gloves
+Masks, goggles and face masks
+Gowns
+Linen
+Patient care equipment
+Environmental cleaning
+Sharps
+Patient resuscitation
+Patient placement
+
+
+
+
+
+This presentation primarily focuses on STANDARD PRECAUTIONS
+
+Handwashing (or using an antiseptic handrub)
+After touching blood, body fluids, secretions, excretions and contaminated items
+Immediately after removing gloves
+Between patient contact
+Gloves
+For contact with blood, body fluids, secretions and contaminated items
+For contact with mucous membranes and nonintact skin 
+Masks, goggles, face masks
+Protect mucous membranes of eyes, nose and mouth when contact with blood and body fluids is likely 
+Gowns
+Protect skin from blood or body fluid contact
+Prevent soiling of clothing during procedures that may involve contact with blood or body fluids 
+Linen 
+Handle soiled linen to prevent touching skin or mucous membranes
+Do not pre-rinse soiled linens in patient care areas 
+Patient care equipment
+Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to prevent contamination of clothing or the environment
+Clean reusable equipment prior to reuse 
+Environmental cleaning
+Routinely care, clean and disinfect equipment and furnishings in patient care areas 
+Sharps
+Avoid recapping used needles
+Avoid removing used needles from disposable syringes
+Avoid bending, breaking or manipulating used needles by hand
+Place used sharps in puncture-resistant containers 
+Patient resuscitation
+Use mouthpieces, resuscitation bags or other ventilation devices to avoid mouth-to-mouth resuscitation 
+Patient placement 
+Place patients who contaminate the environment or cannot maintain appropriate hygiene in private rooms
+
+
+Hand hygiene
+Section 4
+
+Not only can frequent handwashing reduce the spread of infection from the hands of health workers, but from everyone else’s as well! It is estimated that consistent handwashing with soap and clean water after going to the toilet, handling or changing a dirty baby, or doing other tasks (cleaning vegetables, fresh meat or fish) can reduce diarrheal diseases by 45%, saving the lives of a million children a year
+The Economist
+2002
+
+Handwashing should be done:
+Before:
+Examining (direct contact with) a patient
+Putting on gloves (surgical or for routine procedures)
+After:
+
+Any situation in which hands may become contaminated:
+handling soiled instruments and other items
+touching mucous membranes, blood or other body fluids (secretions or excretions)
+having prolonged and intense contact with a patient
+Removing gloves
+Handwashing should be done before:
+examining (direct contact with) a patient
+putting on sterile or high-level disinfected surgical gloves prior to an operation, or examination gloves for routine procedures such as a pelvic examination. 
+Handwashing should be done after
+any situation in which hands may become contaminated, such as: 
+handling soiled instruments and other items
+touching mucous membranes, blood or other body fluids (secretions or excretions)
+having prolonged and intense contact with a patient
+removing gloves (Hands should be washed with soap and clean water (or an antiseptic handrub can be used) after removing gloves because the gloves now may have tiny holes or tears, and bacteria can rapidly multiply on gloved hands due to the moist, warm environment within the glove)
+
+
+What type of hand wash should be used:
+Handwashing with plain soap and clean water is as effective as washing with antimicrobial soaps 
+Plain soap causes much less skin irritation
+When skin is damaged or frequent handwashing is required, a mild soap (without antiseptic agent) should be used to remove soil and debris
+If antimicrobial action is desired and hands are not visibly dirty, an antiseptic handrub should be used rather than washing hands with medicated antiseptic soap
+					
+				
+			
+		
+
+
+If antimicrobial action is desired (e.g., before an invasive procedure or contact with highly susceptible patients such those with AIDS or newborns) and hands are not visibly dirty, an antiseptic handrub should be used rather than washing hands with medicated antiseptic soap
+
+
+
+Hand washing procedure:
+
+STEP 1: Thoroughly wet hands
+STEP 2: Apply plain soap (antiseptic agent is not necessary)
+STEP 3: Vigorously rub all areas of hands and fingers together for at least 10 to 15 seconds, paying close attention to areas under fingernails and between fingers.
+STEP 4: Rinse hands thoroughly with clean water
+STEP 5: Dry hands with a paper towel and use the towel to turn off the faucet
+
+Antiseptic hand rub:
+More effective 
+Quick and convenient 
+Contain a small amount of an emollient  to protect and soften skin
+Procedure:
+STEP 1: Apply enough antiseptic handrub to cover the entire surface of hands and fingers (about a teaspoonful)
+STEP 2: Rub the solution vigorously into hands, especially between fingers and under nails, until dry
+**Since antiseptic hand rubs do not remove soil or organic matter, if hands are visibly soiled or contaminated with blood or body fluids, handwashing with soap and water should be done first
+
+More effective in killing transient and resident flora than hand washing with antimicrobial agents or plain soap and water
+Quick and convenient 
+Contain a small amount of an emollient protects and softens skin
+Procedure:
+STEP 1: Apply enough antiseptic handrub to cover the entire surface of hands and fingers (about a teaspoonful)
+STEP 2: Rub the solution vigorously into hands, especially between fingers and under nails, until dry
+**Since antiseptic hand rubs do not remove soil or organic matter, if hands are visibly soiled or contaminated with blood or body fluids, handwashing with soap and water should be done first
+
+
+Gloves
+Section 5
+
+There is a chance of hand contact with blood or other body fluids, mucous membranes or non-intact skin
+They perform invasive medical procedures 
+They handle contaminated waste items or: touch contaminated surfaces
+When to wear gloves:
+
+Surgical gloves: used when performing invasive medical/surgical procedures
+Examination gloves used when performing many routine duties
+Utility or heavy-duty household gloves: used when processing instruments, for handling and disposing of contaminated waste; and when cleaning contaminated surfaces
+There are three types of gloves used in healthcare facilities:
+Healthcare workers should wear gloves when:
+**A separate pair of gloves must be used for each patient to avoid cross contamination
+clean examination or utility gloves should be worn by all staff when
+there is a chance of hand contact with blood or other body fluids, mucous membranes or non-intact skin
+they perform invasive medical procedures (e.g., inserting vascular devices such as peripheral venous lines)
+they handle contaminated waste items or touch contaminated surfaces
+There are three types of gloves used in healthcare facilities: surgical, examination and utility or heavy-duty household gloves
+Surgical gloves should be used when performing invasive medical or surgical procedures
+Examination gloves provide protection to healthcare workers when performing many of their routine duties
+Utility or heavy-duty household gloves should be worn for processing instruments, equipment and other items; for handling and disposing of contaminated waste; and when cleaning contaminated surfaces.
+
+
+
+
+Glove Requirements for Common Medical and Surgical Procedures:
+Task
+Are gloves needed
+Preferred gloves
+Acceptable gloves
+Blood pressure check
+No
+Temperature check
+No
+injection
+No
+Drawing blood
+Yes
+Exam
+HLD surgical
+Iv insertion and removal
+Yes
+Exam
+HLD surgical
+Vaginal exam
+Yes
+Exam
+HLD surgical
+Vaginal delivery
+Yes
+Sterile surgical
+HLD surgical
+Handling and cleaning instruments
+Yes
+Utility
+Exam or HLD surgical
+Handling contaminated waste
+Yes
+Utility
+Exam or HLD surgical
+Cleaning blood or body fluid spills
+Yes
+Utility
+Exam or HLD surgical
+
+PPE and drapes
+Section 6
+
+Types of PPE
+
+Gloves - most important physical barrier for preventing the spread of infection
+Masks - should be large enough to cover the nose, lower face, jaw and facial hair
+Respirators - recommended for situations in which filtering inhaled air is important (ex Tuberculosis)
+Eyewear - protects eyes from accidental splash of blood or other body fluid 
+Caps - used to keep the hair and scalp covered so that flakes of skin and hair are not shed into the wound during surgery
+Scrubs - protect the healthcare workers’ clothing
+Surgical gowns - play a role in keeping blood and other fluids, such as amniotic fluid, off the skin of personnel, particularly in operating, delivery and emergency rooms
+Apron - should be worn when cleaning or during a procedure in which blood or body fluid spills are anticipated
+Shoe covers - worn to protect feet from injury by sharps or heavy items that may accidentally fall on them
+
+
+Using Drapes
+Avoid touching 
+drapes
+Avoid cloth 
+if possible 
+Brief timeframe
+Create a work area
+Sterile towel drapes create a work area around the incision which limit the amount of skin that needs to be cleaned and prepped with antiseptic solution prior to a procedure
+This area is only briefly sterile
+Cloth drapes allow moisture to soak through them which can spread organisms from skin into the incision
+Neither gloved hands (sterile or high-level disinfected) nor sterile or high-level disinfected instruments and other items should touch the towel drapes once they are in place
+
+Proper handling of sharps
+Section 7
+
+Safety tips for using needles and syringes
+**Hypodermic needles cause the most injuries to health workers at all levels
+Use each needle and syringe only once
+Do not disassemble the needle and syringe after use
+Do not recap, bend or break needles prior to disposal
+Decontaminate the needle and syringe prior to disposal
+Dispose of the needle and syringe in a puncture-resistant container
+
+
+Sharps container DO’s 
+Sharps container DONT’s
+Put sharps containers as close to the point of use as possible - ideally within arm’s reach
+Attach containers to walls or other surfaces if at all possible
+Mark them clearly so that people will not use them as a garbage container
+Place them at a convenient height so staff can use and replace them easily
+Mark the fill line at the three quarters full level
+
+     Shake a container to settle its contents and make room for more sharps
+     Place containers in high traffic areas 
+     Place containers on the floor or anywhere they could be knocked over or easily reached by a child
+     Place containers near light switches, overhead fans or thermostat controls where people might accidentally put their hand into them
+
+
+
+
+
+
+Waste management
+Section 8
+
+**Contaminated waste may carry microorganisms that can infect hospital personnel and the community at large.  The purpose of appropriate waste management is to:
+Protect people who handle waste items from injury
+Prevent the spread of infection to healthcare workers and the local community
+Dispose of hazardous materials (chemicals/radioactive compounds) safely
+
+Why is waste management important?
+If not disposed of properly, contaminated waste may carry microorganisms that can infect the people who come in contact with the waste as well as the community at large
+The purpose of waste management is to: x protect people who handle waste items from accidental injury, x prevent the spread of infection to healthcare workers who handle the waste, x prevent the spread of infection to the local community, and x safely dispose of hazardous materials (toxic chemicals and radioactive compounds)
+
+
+
+Notes on waste management:
+Place waste containers close to where the waste is generated and where convenient for users
+Use PPE (utility gloves and close toed shoes) when handling waste
+Wash hands or use antiseptic rub after removing gloves when handling waste
+Wash all waste containers with a disinfectant cleaning solution (0.5% chlorine solution plus soap) and rinse with water regularly
+Use personal protective equipment (PPE) when handling wastes (e.g., heavy-duty utility gloves and closed protective shoes)
+Wash hands or use a waterless, alcohol-based antiseptic handrub after removing gloves when handling wastes
+
+
+Processing instruments
+Section 9
+
+Soiled instruments requires special handling and processing:
+
+Minimizes the risk of accidental injury or blood/body fluid exposure to staff
+Provides a high quality end product (sterilized or HLD)
+
+Processing instruments, surgical gloves and other items
+Decontamination
+Soak in .5% chlorine solution for 10 minutes
+
+Thoroughly wash and rinse.  Wear gloves and other protective barriers (glasses or goggles)
+Dry heat
+170 degrees 60 minutes
+Autoclave
+20 minutes unwrapped
+30 minutes wrapped
+Chemical
+Soak 10-24 hours
+STERILIZATION
+PREFERRED
+ACCEPTABLE
+HIGH LEVEL DISINFECTION
+Boil or steam - lid on 20 minutes
+Chemical 
+soak 20 minutes
+Cool.  Use immediately or store
+OR
+OR
+OR
+
+Handling linen
+Section 10
+
+Key principles in processing linen
+Personnel should wear gloves when in contact with soiled linen
+Handle soiled linen as little as possible
+Even when there is no visible contamination, all used linen should be laundered
+Transport soiled linen in plastic bags/containers to laundry area
+Sort soiled linen in laundry area, NOT at the place of use
+			
+
+
+
+
+Housekeeping and laundry personnel should wear gloves and other personal protective equipment as indicated when collecting, handling, transporting, sorting and washing soiled linen
+When collecting and transporting soiled linen, handle it as little as possible and with minimum contact to avoid accidental injury and spreading of microorganisms
+Consider all cloth items (e.g., surgical drapes, gowns, wrappers) used during a procedure as infectious. Even if there is no visible contamination, the item must be laundered
+Carry soiled linen in covered containers or plastic bags to prevent spills and splashes, and confine the soiled linen to designated areas (interim storage area) until transported to the laundry
+Carefully sort all linen in the laundry area before washing. Do not presort or wash linen at the point of use.
+
+
+Questions?
+
+Post Test
+Section 11
+
+
+Decontamination
+Cleaning
+Antisepsis
+Sterilization
+High level disinfection
+
+
+
+Using pre-surgical hand rub is an example of which of the following?
+01
+01
+C
+
+A set of guidelines used to treat hospitalized patients with known infection
+A set of guidelines used to treat patients with suspected infection
+A set of guidelines that should be used for ALL patients and clients in a healthcare facility
+A set of guidelines used for surgical procedures
+
+
+Standard precautions refer to which of the following?
+
+01
+02
+C
+
+Handwashing with plain soap and clean water is as effective as washing with antimicrobial soaps
+During handwashing, hands should be vigorously rubbed for 60 seconds with soap and plain water 
+Does not need to be performed if using sterile gloves
+Handwashing with plain soap and water is more effective than antiseptic handrub in killing bacteria  
+
+
+Which of the following is true of hand washing procedures?
+01
+03
+A
+
+
+All syringes should be recapped prior to being discarded in the sharps container
+Most needles can be used more than once for cost effectiveness
+Sharps containers should be placed as close to the point of use as possible - ideally within arm’s reach
+Sharps containers should have a fill line at 50% full
+
+
+Which of the following is true regarding proper handling of sharps?
+01
+04
+C
+
+Black waste bin - non-infectious material
+Yellow waste bin - infectious material
+Red waste bin - highly infectious material
+Sharps container
+
+
+After a vaginal exam, used gloves should be discarded in which of the following?
+
+01
+05
+B

docs/Management of normal labour.txt

@@ -0,0 +1,768 @@
+A Case Study
+Mum arrives at the facility with difficulty breathing
+
+She experiences worsening pain and feels ready to push
+
+
+42 yo G3P2+0  @ 39-4 weeks gestation arrives at the hospital ℅ laps starting 4 hour ago
+OB hx: 2 prior full term SVD 
+Medical history: history of thyroid disease on meds
+Exam: baby longitudinal, vertex, SVE: 7cm 
+Vitals: Temp 37C, BP 142/78 RR 16
+Mum is taken to the delivery room and begins pushing
+She pushes for 30 minutes without delivery
+FHR pattern shows NO evidence of foetal compromise
+Diagnosis?  What do we do next? 
+
+Management of normal labour
+Updated March 2022
+
+Pre-Test
+Section 1
+
+
+36 weeks
+37 weeks
+39 weeks
+40 weeks
+
+
+
+At which gestational age is a pregnancy considered a term pregnancy
+01
+01
+B
+
+From full dilatation to expulsion of the foetus
+From delivery of the baby, to delivery of placenta
+From onset of labour to full dilatation of the cervix
+Up to one hour after expulsion of placenta
+
+
+Which of the following correctly describes the second stage of labour
+
+01
+02
+A
+
+
+Foetal heart rate baseline
+Foetal heart rate accelerations
+Foetal heart rate variability
+Variable decelerations
+
+
+Which of the following foetal heart rate parameters is MOST accurate in predicting foetal well-being?
+01
+03
+C
+
+
+<2cm dilation over 4 hours in a multiparous patient
+<2cm dilation over 4 hours in a primiparous patient
+Cervical dilation >6cm with ruptured membranes and little to no change after 4 hours of adequate contractions
+Cervical dilation >4cm with ruptured membranes and little to no change after 6 hours of adequate contractions
+
+
+Which of the following is consistent with arrested labour? 
+01
+04
+C
+
+Urine void should be documented within six hours
+
+After an uncomplicated vaginal birth in a healthcare facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth
+
+Bathing of the newborn should be delayed until 24 hours after birth 
+All women who underwent episiotomy should be put on routine antibiotic prophylaxis
+
+
+Which of the following is NOT a recommended practice in the 4th stage of labour? 
+
+01
+05
+D
+
+Learning Objectives
+Distinguish active vs latent labour
+Understand management of labour in different stages
+Be able to effectively and accurately utilize the partograph
+Understand the principles of intrapartum care
+
+
+Pregnancy & childbirth facts in Kenya : 
+
+~85%
+Of births of Kenya are uncomplicated normal deliveries
+
+1 in 5
+Girls will become pregnant before the age of 19 in kenya
+
+80%
+Of women receive antenatal care during pregnancy
+ 
+
+
+Quality maternal healthcare is key for the achievement of the SDGs. This includes: preconception care, antenatal care, intrapartum care and postpartum care
+All pregnancies should be handled with caution. Amongst ‘low risk women’, approximately 25% will develop complications necessitating care from a higher level facility
+				
+140 million
+Women deliver babies each year globally
+
+1.2 million 
+Women in kenya give birth each year
+
+
+
+Intrapartum care for a positive childbirth experience
+Section 3
+
+Intrapartum care for positive childbirth experience:
+		 	 	 		
+			
+				
+					
+Articulates the norms of good practice & the desired end point of a healthy mother and healthy newborn
+Includes giving birth to a healthy baby in a safe environment with birth companion(s) or kind, technically competent clinical staff
+Is  based on the premise that most women want a physiological labour and birth				
+			
+		
+
+
+Articulates the norms of good practice & the desired end point of a healthy mother and healthy newborn
+Includes giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) or kind, technically competent clinical staff
+Is  based on the premise that most women want a physiological labour and birth, and to have a sense of personal achievement and control through involvement in decision-making, even when medical interventions are needed or wanted 
+
+
+WHO intrapartum care model
+
+Definitions
+Section 3
+
+Labour definitions
+Labor: Rhythmic, regular uterine contractions increasing in frequency and intensity, with progressive cervical effacement and dilatation/descent.  This may be spontaneous or induced
+Normal labor: Commences spontaneously at term (37 completed weeks) maintaining the above characteristics resulting in expulsion of a healthy foetus, a complete placenta and a healthy mother 
+Normal labour begins two weeks before or after the estimated delivery dates, in the first pregnancy labour usually ranges from 12-18 hours, subsequent labours are shorter ranging 6-8 hours
+
+
+Pregnancy term definitions
+Preterm pregnancy
+Any pregnancy prior to 37 weeks gestation
+Early preterm: <34 weeks
+Late preterm: 34 weeks - 36+6 days
+Term pregnancy
+Any pregnancy between 37 weeks - 41+ 6 days
+Early term -  37 weeks - 38 + 6 days
+Term - 39 weeks - 40 + 6 days
+Late term - 41 - 41 + 6 days
+Postterm pregnancy
+Any pregnancy after 42 weeks gestation
+
+Stages of labour
+1st stage
+From onset of labour to full dilatation of the cervix 
+
+From full dilatation to expulsion of the foetus
+				
+			
+		
+
+Risks to foetus
+From delivery of the baby, to delivery of placenta 
+			
+
+Up to one hour after expulsion of placenta 
+				
+			
+		
+2nd stage
+3rd stage
+4th stage
+
+Cardinal movements of labour
+
+			
+Engagement
+Descent
+Flexion
+Internal rotation
+Extension
+External rotation
+Expulsion
+
+
+Categories of 1st stage of labour
+LATENT LABOUR
+The period of painful uterine contractions and changes of the cervix, including effacement and dilatation up to 5 cm for first and subsequent labors
+** Women should be informed that a standard duration of the latent first stage has not been established and can vary widely from one woman to another 
+				
+			
+		
+ 	 	 		
+			
+				
+					
+Women should be informed that a standard duration of the laten established and can vary widely from one woman to another 
+				
+			
+		
+ 
+
+ACTIVE LABOUR
+The period of regular painful uterine contractions and more rapid cervical dilation from 5 cm until full dilatation for first and subsequent labors 
+
+**This stage usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors 
+				
+			
+		
+
+				
+			
+		
+ 
+
+
+Intrapartum Care
+Section 3
+
+Care throughout labour and delivery should include:
+Respectful maternity care: care provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth 
+Effective communication: between maternity care providers and women in labor, using simple and culturally acceptable language 
+Birth companion: A companion of choice is recommended for all women throughout labor and childbirth 
+			
+
+
+
+
+
+Principles of effective communication 
+Introduce yourself to the woman and her companion and address the woman by her name
+Offer the woman and her family the information they need in a clear and concise manner, avoid medical jargon; use pictures when needed
+Respect and respond to the woman’s needs, preferences and questions with a positive attitude
+Support the woman’s emotional needs with empathy and compassion, through encouragement, praise, reassurance and active listening
+Ensure that the woman is aware of available mechanisms for addressing complaints
+
+
+Principles of effective communication 
+Support the woman to understand that she has a choice
+Ensure that procedures are explained to the woman, and that verbal and, when appropriate, written informed consent for pelvic examinations and other procedures is obtained
+Encourage the woman to express her needs and preferences, and regularly update her and her family about what is happening
+Ensure that privacy and confidentiality is maintained at all times
+Interact with the woman’s companion of choice to provide clear explanations on how the woman can be well supported
+
+
+Triage:
+All women who present to a healthcare facility with suspected labour should be asked to see a copy of their ANC booklet (if they have one) and should undergo a thorough history and physical which includes:
+Vaginal exam
+      Abdominal exam
+General exam
+History taking
+
+Gestational age, duration since onset of labour pain, any drainage of liquor, relevant medical history, past obstetric history, any current symptoms, social history
+
+This should include overall appearance and disposition of the mother as well as vital signs
+
+Leopold’s maneuver: a common and systematic way to determine the position of a fetus inside the woman's uterus
+
+An initial vaginal exam should be performed either via SVE or SSE depending on clinical presentation
+Fetal exam
+A thorough evaluation of the foetal status should be performed via fetal doppler, fetoscope or CTG assessment
+
+1st stage of labour
+
+Maternal monitoring in the first stage of labour
+		 	 	 		
+
+The tool used for monitoring labour is the PARTOGRAPH and should be initiated in active phase of labour starting when the mum is 5cm dilated.  		 	 	 		
+This graphic representation during the process of labour and can be used to detect abnormal physiology/make appropriate and timely decisions 
+ 						
+					 				
+			
+		
+
+				
+			
+		
+
+				
+			
+		
+				
+					 				
+			
+		
+
+
+Patient info
+Foetal HR
+Amniotic Fluid
+Moulding
+Dilation
+Alert line
+Action  line
+Descent
+
+**The partograph is intended as a guide and is not a substitute for good clinical judgment with respect to the individual women’s circumstances and preferences. 
+Patient info:Fill the name, gravida, parity, hospital number, date, time of admission and the time of rupture of membranes 
+Foetal HR: Record every ½ hour
+Amniotic fluid: Record the colour of the amniotic fluid at every vaginal examination: I: membranes intact, C: membranes ruptured, clear fluid, M: meconium-stained fluid, B: blood-stained fluid 
+Moulding: +: sutures opposed, ++: sutures overlapped but reducible, +++: sutures overlapped and not reducible
+Dilation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4cm 
+Alert line: A line starts at 4cm of cervical dilatation to the point of expected full dilation at the rate of 1cm/hour 
+Action line: Parallel and 4 hours to the right of the line 
+Descent: Done by abdominal palpation: refers to the part of the head which divided into 5 parts.  Recorded as 5/5 (completely above), ⅘, ⅗, ⅖, ⅕, 0/5 (none of head palpable)
+
+		 	 	 		
+
+
+				
+			
+		
+				
+					 				
+			
+		
+
+
+Hours
+Time
+Contractions
+Oxytocin
+Drugs
+Pulse
+Blood pressure
+Temperature
+Urine
+Hours: Refers to the time elapsed since onset of the active phase of labour (observed or extrapolated)		
+Time: Record actual time
+Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds 
+Oxytocin: Record the amount of oxytocin/volume intravenous fluids in drops/minute every 30 minutes when used 
+Drugs: Record any additional medications given 	
+Pulse: Record every 30 minutes and mark with a dot (.) 	
+Blood pressure: Record every 4 hours and mark with arrows 
+Temperature: Record every 2 hours
+Urine: Record each time urine is passed, assess for volume, acetone, protein
+
+
+Foetal heart rate basics:
+For more detailed information regarding foetal heart rate interpretation, see CME on FHR monitoring in labour
+
+
+
+Variability
+Beat to beat variations in FHR:
+Absent: no detectable change in FHR
+Minimal: amplitude<5bpm
+Moderate: 5-26bpm variation
+**MOST accurate predictor of foetal wellbeing
+Accelerations
+Apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline 
+				
+			
+		
+
+Decelerations
+Early: occurs at the same time as contraction
+Late: occurs after contraction
+Variable: abrupt decrease and return of FHR, occurs anytime
+				
+			
+		
+
+Interpretation
+Features associated with GOOD foetal outcomes: Normal baseline, moderate variability, accelerations
+Features associated with POOR foetal outcomes: Absent/minimal variability, abnormal baseline, late/variable decelerations
+			
+		
+
+Action
+If foetal distress identified, efforts to expedite delivery should be made
+				
+			
+		
+
+Baseline
+Approximate mean FHR rounded to nearest 5 bpm
+Bradycardia <110 bpm
+Tachycardia >160 bpm
+				
+			
+		
+
+
+Clinical practices RECOMMENDED in the first stage of labour
+
+Digital vaginal examination at intervals of four hours is recommended for routine assessment in low-risk women 
+Intermittent auscultation of the fetal heart rate with either a Doppler fetoscope for healthy pregnant women in labor 
+Pain relief should be offered to all healthy pregnant women in labour depending on their preferences		
+For women at low risk, oral fluid and food intake during labor is recommended		
+Encouraging the adoption of mobility and an upright position during labor in women at low risk is recommended 
+
+
+
+
+
+
+
+Clinical practices NOT recommended in the first stage of labour
+
+
+A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is unrealistically fast for some women and is NOT recommended for identification of normal labor progress
+Routine perineal/pubic shaving prior to giving vaginal birth is NOT recommended 
+Continuous CTG is NOT recommended for assessment of fetal well-being in healthy pregnant women undergoing spontaneous labor 
+The use of amniotomy alone for prevention of delay in labor is NOT recommended 
+The use of early amniotomy with early oxytocin augmentation for prevention of delay in labor is not recommended 
+The use of intravenous fluids with the aim of shortening the duration of labor is NOT recommended 
+
+
+
+
+
+
+
+Antispasmotic agents (often given in Kenya) are also NOT recommended!
+
+Delays in 1st stage of active labour
+Protracted labour
+Nulliparous: <2 cm dilation in 4 hours
+Multiparous: <2 cm dilation in 4 hours or slowing of progress
+				
+			
+		
+ 	 	 		
+			
+				
+					
+Women should be informed that a standard duration of the laten established and can vary widely from one woman to another 
+				
+			
+		
+ 
+
+Arrest in labour
+With cervical dilation >6cm and ruptured membranes, there is little to no change after 4 hours of adequate contractions
+				
+			
+		
+
+				
+			
+		
+ 
+
+**Consultation with higher level provider warranted if these criteria are met
+
+
+Augmentation in the setting of protracted labour
+For specific dosing regimes, please refer to augmentation/induction CME
+Consider
+Monitor
+  Caution
+Setting
+Augmentation should be based on consideration of the general condition of the woman and her baby, her wishes and preferences, and respect for her dignity and autonomy  						
+
+Women undergoing augmentation of labour, particularly with oxytocin, should NOT be left unattended  				
+Augmentation of labour should be performed with caution as the procedure carries the risk of uterine hyperstimulation, with the potential consequences of fetal distress and uterine rupture  					
+Wherever augmentation of labour is performed, facilities should be available to closely and regularly monitor fetal heart rate and uterine contraction pattern  						
+					 				
+			
+		
+
+
+2nd stage of labour
+
+Principles of the 2nd stage of labour
+Signs of 2nd stage
+When to act
+Urge to push
+Definition
+The second stage is the period of time between full cervical dilatation and delivery of the baby. During which, the woman has an involuntary urge to bear down as a result of expulsive uterine contractions 
+				
+			
+		
+
+Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push 
+				
+			
+		
+
+
+Normal second stage for a primigravida is up to 2 hours and up to 1 hour for a multigravida. When these times are exceeded, assessment should occur by a medical practitioner with the view to correcting dystocia and effecting birth 
+				
+			
+		
+
+Complete dilatation of the cervix, gaping of the anus, presenting part seen at the vulva, urge to push, contractions of short intervals lasting for more than a minute and are occurring every 2-3 minutes, crowning  						
+					 				
+			
+		
+
+
+During 2nd stage, it is important to monitor:
+Descent and progress of presenting part
+FHR: toward the end of and after each contraction (or at least every 5 minutes)
+Temp, BP every 4 hours
+Maternal pulse every 15 minutes (differentiate from foetal pulse)
+Contractions: continuous
+Offer VE only if indicated
+Nutrition/hydration: offer oral fluids between contractions
+Bladder: encourage voiding as needed
+Discomfort and pain: warm perineal compresses may help
+
+Delays in active 2nd stage of labour
+Nulliparous patient
+Insufficient descension/flexion/rotation after 1 hour
+Active phase over 2 hours
+Active and passive phase over 3 hours
+				
+			
+		
+ 	 	 		
+			
+				
+					
+Women should be informed that a standard duration of the laten established and can vary widely from one woman to another 
+				
+			
+		
+ 
+
+Multiparous patient
+Insufficient descension/flexion or rotation after 30 minutes
+Active phase over 1 hour
+Active and passive phase over 2 hours
+**Consultation with higher level provider warranted if these criteria are met
+
+
+Clinical practices RECOMMENDED in the second stage of labour
+
+
+Encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended 
+Women in the expulsive phase of the second stage of labor should be encouraged and supported to follow their own urge to push 
+For women in the second stage of labor, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options 
+
+
+Clinical practices NOT recommended in the second stage of labour
+
+
+		 	 	 		
+Routine or liberal use of episiotomy is NOT recommended for women undergoing spontaneous vaginal birth 
+
+Application of manual fundal pressure to facilitate childbirth during the second stage of labor is NOT recommended 
+
+				
+			
+		
+
+
+
+
+
+
+
+
+3rd stage of labour
+
+Principles of 3rd stage of labour
+From delivery of the baby, to delivery of placenta
+Definition
+There is no room for expectant (physiological) management of third stage due to the risk of immediate postpartum haemorrhage, increased risk for blood transfusion and a flaccid uterus that can undergo acute uterine inversion  						
+					 				
+			
+		
+
+					 				
+			
+		
+
+Active 
+process
+02
+Activities included in 3rd stage of labour include: Active management of third stage of labour (AMSTL) & delayed cord clamping
+Management
+03
+01
+
+Clinical practices RECOMMENDED in the third stage of labour
+
+
+AMSTL:		 	 
+The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births.
+Oxytocin (10 IU, IM/IV) is the recommended uterotonic 
+Carbetocin can be used
+Other injectable uterotonics that can be used include: ergometrine/ methylergometrine, or oral misoprostol (600 μg) 
+Controlled cord traction (CCT) is recommended for vaginal births
+Considered prolonged if no delivery after 30 minutes
+Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes
+
+Note that sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin. 
+				
+			
+		
+
+
+4th stage of labour
+
+Principles of 4th stage of labour
+The first hour after delivery of the placenta  						
+					 				
+			
+		
+
+Definition
+The mother should remain in the labour ward where her condition should be assessed, the perineum, vagina, and cervix should be examined for tears  						
+					 				
+			
+		
+
+					 				
+			
+		
+
+					 				
+			
+		
+
+Maternal 
+exam
+02
+Observe the mum every 15 minutes for vital signs and vaginal bleeding. Monitor the newborn’s condition for bleeding from the cord, maintenance of body temperature and encourage initiation of breastfeeding within the first hour of birth  						
+					 				
+			
+		
+
+Mum+baby
+monitoring
+03
+01
+
+Clinical practices RECOMMENDED in the 4th stage of labour
+
+
+Maternal:		 	 
+Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women 
+All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. 
+Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours
+Urine void should be documented within six hours 
+After an uncomplicated vaginal birth in a healthcare facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. 
+
+
+
+Clinical practices RECOMMENDED in the 4th stage of labour
+
+
+Newborn:		 	 
+Newborns without complications should be kept in skin-to-skin contact (SSC) with their mothers during the first hour after birth to prevent hypothermia and promote breastfeeding 
+All new-borns, including low-birth-weight (LBW) babies who are able to breastfeed, should be put to the breast as soon as possible after birth when they are clinically stable, and the mother and baby are ready 
+All newborns should be given 1 mg of vitamin K intramuscularly after birth
+Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours 
+
+				
+			
+		
+
+All newborns should be given 1 mg of vitamin K intramuscularly after birth (i.e. after the first hour by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated) 
+Vitamin K may also be given orally.  Some studies suggest that oral administration is not as effective as IM administration
+
+
+Clinical practices NOT recommended in the 4th stage of labour
+
+
+		 	 	 		
+Maternal:
+Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth 
+Routine antibiotic prophylaxis is not recommended for women with episiotomy 
+
+Newborn			
+In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should NOT be performed 
+
+
+				
+			
+		
+
+
+
+
+
+
+
+
+Teenage 
+pregnancy
+Section 3
+
+Teenage pregnancy
+Adolescents are less likely to receive prenatal care, and late entry into prenatal care has been correlated with preterm or low-birth-weight delivery and complications from preeclampsia
+Pregnant adolescents are at particular risk for nutritional deficiencies.  Adequate nutrition (including IFAS) during pregnancy is necessary to optimize maternal, fetal, and infant health
+Adolescents are at increased risk for adverse pregnancy outcomes, such as preeclampsia, preterm birth, fetal growth restriction, and infant deaths
+Adolescent mothers are at risk for postpartum depression
+The teenage pregnancy and motherhood rate in Kenya is 18% meaning ~ 1 in every 5 girls between the ages of 15-19 years have either given birth or are pregnant
+
+Questions?
+
+Post Test
+Section 8
+
+
+36 weeks
+37 weeks
+39 weeks
+40 weeks
+
+
+
+At which gestational age is a pregnancy considered a term pregnancy
+01
+01
+B
+
+From full dilatation to expulsion of the foetus
+From delivery of the baby, to delivery of placenta
+From onset of labour to full dilatation of the cervix
+Up to one hour after expulsion of placenta
+
+
+Which of the following correctly describes the second stage of labour
+
+01
+02
+A
+
+
+Foetal heart rate baseline
+Foetal heart rate accelerations
+Foetal heart rate variability
+Variable decelerations
+
+
+Which of the following foetal heart rate parameters is MOST accurate in predicting foetal well-being?
+01
+03
+C
+
+
+<2cm dilation over 4 hours in a multiparous patient
+<2cm dilation over 4 hours in a primiparous patient
+Cervical dilation >6cm with ruptured membranes and little to no change after 4 hours of adequate contractions
+Cervical dilation >4cm with ruptured membranes and little to no change after 6 hours of adequate contractions
+
+
+Which of the following is consistent with arrested labour? 
+01
+04
+C
+
+Urine void should be documented within six hours
+
+After an uncomplicated vaginal birth in a healthcare facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth
+
+Bathing of the newborn should be delayed until 24 hours after birth 
+All women who underwent episiotomy should be put on routine antibiotic prophylaxis
+
+
+Which of the following is NOT a recommended practice in the 4th stage of labour? 
+
+01
+05
+D

docs/Neonatal Emergency Management (Part 1) .txt

@@ -0,0 +1,443 @@
+A Case Study
+Mum arrives at the facility with abdominal pain 
+Baby is delivered by SVD crying and pink
+
+
+32 yo G2 arrives at the hospital 
+OB hx: uncomplicated, 39 weeks gestation
+Medical history: uncomplicated
+Labour History: PROM > 18 hours
+SVD delivery, foul smelling liquor
+1 hour after delivery the baby is grunting and blue
+Exam: grunting, oxygen saturations 85% in air, recessions
+Vitals: HR 180bpm, RR: 70 bpm, temp: 37.5
+What do we do next?
+History of a newborn with sepsis - risk factor of PROM >18hr and foul smelling liquor - ?chorioamnionitis 
+
+Newborn Emergency Management: Session 5 
+July 2023
+
+Pre-Test
+Section 1
+
+
+10%
+5%
+30%
+50%
+
+
+
+What percentage of neonatal deaths could be reduced by improving postnatal care alone?
+01
+01
+C
+
+
+Convulsions/Seizures
+Hypoglycaemia
+Sepsis 
+Birth Asphyxia 
+
+
+
+What is the most common medical emergency to occur in neonatal patients?
+01
+02
+B
+
+
+10-40 bpm
+20-50 bpm
+>60 bpm
+30-60 bpm
+
+
+
+What is the normal range for respiratory rate in newborns?
+01
+03
+D
+
+
+2mls/kg 10% dextrose IV
+5mls/kg 10% dextrose IV
+Feed the baby 30mls formula
+2mls/kg Hartmanns solution
+
+
+
+01
+04
+What is the correct initial management for symptomatic  hypoglycaemia in a newborn?
+A
+
+
+Maternal fever
+PROM >18 hours
+Preterm babies with pre-labour rupture of membranes
+All of the above
+
+
+
+Which of the following are risk factors for neonatal sepsis?
+01
+05
+D
+
+Learning Objectives
+Understand and recognise the clinical features and danger signs of a sick newborn 
+Outline the key steps in the early management and stabilisation 
+Understand the risk factors and clinical features of neonatal sepsis  
+Outline the key management strategies 
+
+
+The Facts
+
+Identification of Sick Newborns 
+~ 70% neonatal deaths
+Could be prevented if proven interventions were implemented effectively with high coverage where they are needed most 
+Early detection of neonatal illness is an important step towards improving newborn survival. It is estimated that 70% of newborn deaths could be prevented through quality improvements in neonatal care. Specifically, up to 30% could be reduced by improving the quality of postnatal neonatal care alone.
+~2.3 million 
+Neonatal deaths worldwide
+~ 30% neonatal deaths
+Could be reduced by improving postnatal care alone
+Reference: Knippenberg R, Lawn JE, Darmstadt GL, et al. Systematic scaling up of neonatal care in countries. Lancet (London, England) 2005; 365: 1087-1098. 2005/03/23. DOI: 10.1016/s0140-6736(05)71145-4.
+
+
+Danger Signs
+
+ESSENTIAL DANGER SIGNS  
+Not feeding well
+Convulsions
+Drowsy or unconscious
+Movement only when stimulated or no movement at all
+Fast breathing (60 breaths per min)
+Grunting
+Severe chest indrawing
+Raised temperature > 37.5 °C
+Hypothermia < 36.5 °C
+Central cyanosis (is the tongue blue?)
+NORMAL OBSERVATIONS:
+Respiratory rate: 30-60 breaths per minute
+Heart rate: 110-160 beats per minute
+Temperature:  36.5-37.5°C
+Saturations: >90% in air
+Colour: Pink
+
+Neonates and young infants often present with non-specific symptoms and signs that indicate severe illness. These signs might be present at or after delivery or in a newborn presenting to hospital or develop during hospital stay. The aim of initial management of a neonate presenting with these signs is stabilization and preventing deterioration. 
+Go through each of these signs and ensure the participants know how to recognise each of these signs. E.g. severe indrawing
+Normal observations from EMONC guidelines (100-160 is helping babies breathe guidance)
+
+
+
+ESSENTIAL DANGER SIGNS:  MANAGEMENT  
+Open and maintain airway
+Give oxygen by nasal prongs if cyanosed, in severe respiratory distress or hypoxaemic (oxygen saturation ≤ 90%) to maintain saturations 90-95%
+Insert venous cannula
+Give Benzylpenicillin and Gentamicin
+If drowsy, unconscious or convulsing, check blood glucose: 
+If glucose ≤ 2.5 mmol/l  give 10% glucose at 2 ml/kg IV and start maintenance fluids
+If you cannot check blood glucose quickly, assume hypoglycaemia and give IV 10% dextrose.  If struggling to insert an IV drip, give buccal glucose 50% 0.4ml/kg and call for help to insert.
+Give phenobarbitone if convulsing: loading dose 20mg/kg IM or IV
+Remember: ALWAYS ABC management first…
+
+CONVULSIONS
+Key clinical features: 
+Twitching
+Abnormal posturing	
+Eye deviation or blinking	
+Lip smacking
+High pitched crying
+Irregular respiration or heart beat or apnoea
+The commonest causes:
+Hypoxic ischaemic encephalopathy (as a result of perinatal asphyxia)
+Intraventricular haemorrhage (<1500g)
+Central nervous system infection
+Hypoglycaemia
+Hypocalcaemia/Hypomagnesemia
+Stroke/ CNS malformations
+Any clinically apparent seizure >3minutes OR brief recurrent seizures
+The presentation of neonatal convulsions is varied/non-specific these babies can present in the postnatal ward, admitted on the NBU and outborn babies presenting to your facility
+A targeted history taking is of utmost importance:
+•Ask the mother if the newborn has had convulsions during this current illness.
+•Clarify what she understands as convulsions and if possible ask her to demonstrate what she saw
+•Use words the mother understands e.g.” “Kushtuka”
+
+
+
+CONVULSIONS vs Other movements 
+Jitteriness, tremors and startles are NOT convulsions and it is important to determine the difference:
+Jitteriness/Tremors: 
+Involuntary, rhythmic, periodic, mechanical oscillations of a body part
+Usually settles on cuddling/holding the baby
+Startles: 
+Startled by a loud noise
+Sudden movement, when they feel like they are falling or other stimuli
+Sudden  extension of  their arms and legs, arch their back, and then curl everything in again (moro)
+
+Discuss the difference between jitteriness and startles to convulsions:
+Jitteriness/tremors: Involuntary, rhythmic, periodic, mechanical oscillations of a body part. Usually settles on cuddling/holding the baby
+Startles: A neonate can be startled by a loud noise, sudden movement, when they feel like they are falling or other stimuli. They suddenly extend their arms and legs, arch their back, and then curl everything in again. The neonate may or may not cry when they do this.
+
+
+CONVULSIONS: MANAGEMENT
+Airway management & oxygen: 
+Neutral position
+Check for secretions, suction if needed 
+Put on oxygen
+Check blood glucose:
+If ≤2.5 mmol/L (or < 47 mg/dl) give IV 10% glucose at 2ml/kg
+If blood glucose monitoring not available give IV 10% glucose at 2ml/kg
+Do full infection screen (blood culture, lumbar puncture, CRP if age is more than 36 hours)
+Take blood for Calcium, Magnesium, U&E’s, FBC
+GIve anticonvulsants
+Give Phenobarbitone 20mg/kg IM = loading dose
+Repeat dose at 10mg/kg ONCE if seizures ongoing >1 hour after the loading dose
+If seizures ongoing:
+If Levetiracetam available -> 30mg/kg (over 15 minutes)
+If not: give Phenytoin with a loading dose 15mg/kg IV 
+Phenobarbitone: It is used in the treatment of neonatal convulsions especially in babies with Birth Asphyxia. In contrast to other age groups,diazepam is dangerous in babies < 1 month and should not be used. This is because there is a higher risk of respiratory depression in this age group; their liver is relatively immature and diazepam tends to accumulate in the body for a longer period of time. For this reason the first line treatment is Phenobarbitone given at a dose of 20 mg/kg IM. (NB: this maintenance dose info (below) could be added into a second management slide if needed)
+Maintenance dose of Phenobarbitone is usually 5mg/kg IM, oral or through nasogastric tube every 24 hours after at least 12 hours of giving the loading dose
+If levetiracetam needed as second line continue maintenance at 30mg/kg/day given in 2 divided dose - 12 hours after loading dose
+If phenytoin given as second line  - maintenance is 5mg/kg/day divided into 2 doses  - as per comprehensive MoH/NEST360 guideline 
+When to stop: 
+If seizure free for 72 hours and normal neurological examination and on 1 drug - can stop
+If on 2 drugs stop phenobarbitone last 
+
+
+
+HYPOGLYCAEMIA - the most common neonatal emergency 
+
+
+
+Key clinical features: 
+Asymptomatic: hypoglycaemia detected by screening infants at risk
+Symptomatic:
+Floppy	
+Lethargic
+Poor feeding 
+Jittery
+Seizures
+Coma
+Apnoea
+
+
+Highest risk babies:
+Birth weight <2500g
+Birth weight >4000g
+Infants of diabetic mothers
+Preterm <37 weeks 
+Maternal beta blocker use
+Perinatal asphyxia
+Late preterm exposure to antenatal steroids
+Babies at risk of infection
+Delayed start to breastfeeding 
+Definition;  Serum blood glucose ≤2.5mmol/l
+Associated with;
+Increased mortality
+Convulsions
+Permanent brain injury
+The duration and number of hypoglycaemic episodes are associated with poor neurological outcomes
+Can occur in up to 10% of healthy newborns and is the most common neonatal emergency 
+
+HYPOGLYCAEMIA - PREVENTION
+
+
+
+1. Feeding:
+Breastfeed immediately after birth 
+If unable to breastfeed should receive alternative feed/IV fluids NO LATER than ONE HOUR after birth
+Breastfeeding  = best option
+EBM via cup or NGT
+Human donor or formula feed
+IV fluids (10% dextrose for babies <24 hours old)
+
+
+2. Other prevention techniques:
+Maintain skin to skin contact
+Keep warm to prevent HYPOTHERMIA which increases glucose metabolism 
+Postpone bath for first 6 hours at least 
+Feed at least every 2-3 hours 
+3. Monitor high risk infants: Blood glucose monitoring 
+All high risk (ideally) need blood glucose at 2 hours of age 
+Measure in ALL sick newborns at time of diagnosis
+If symptomatic measure blood sugar immediately 
+Remember:  breastmilk has > 2x more calories (energy)  than 10% dextrose
+Why the essential newborn care and SVN all have hypoglycaemia prevention by early breastfeeding in their lectures
+Why EBM/breast milk preferred as Breast milk contains 67 kcal / 100ml vs Dextrose 10% (10g of glucose/100mls) contains 34kcal/100mls = Contains almost X2 energy as compared to 10% dextrose
+Discuss: Is blood glucose monitoring available at ALL times are are glucostrips out of stock frequently?
+
+HYPOGLYCAEMIA: MANAGEMENT
+HYPOGLYCAEMIA (NOT symptomatic) 
+Feed immediately via cup or NGT and continue breastfeeding (if effective)
+Give 3 hourly feed volume via cup or NGT
+0.4ml/kg 50% oral glucose while preparing feed	
+Increase frequency of feeds e.g. from 3 to 2 hourly or from 2 to 1 hourly
+Monitor blood glucose 1-2 hrs later and then prior to each feed
+Continue monitoring until 3 consecutive normal measurements 
+
+HYPOGLYCAEMIA (SYMPTOMATIC) OR Blood glucose <1.8mmol/L
+Give dextrose bolus (give 0.4ml/kg 50% oral glucose while preparing)
+2ml/kg of 10% dextrose IV over 5 minutes 
+Give Maintenance IV fluids as per fluid charts
+Monitor Blood Glucose after 30 minutes 
+Start EBM as soon as baby’s condition allows
+
+Symptomatic management: If normal BG on 3 consecutive measurement monitor 6hourly
+
+Rebound hypoglycemia: Remember to comment treating hypoglycaemia and leaving is not good enough, you need to consider the likelihood the blood sugar will drop again if maintenance not given and so need an ongoing plan. So a plan MUST be made for after a dextrose bolus e.g. ongoing IVF fluids, increase feed rate from 3hrly to 2hrly
+ 
+
+
+Neonatal Sepsis
+
+NEONATAL SEPSIS: Risk factors 
+Prolonged rupture of membranes (PROM)>18hrs
+Maternal intrapartum fever (Temp 38⁰C)
+Suspected or confirmed chorioamnionitis (Foul smelling or purulent amniotic fluid)
+Mother on treatment for perinatal sepsis
+Low birth weight babies especially preterm babies with pre labour rupture of membranes
+Severe birth asphyxia
+Definition: Systemic bacterial infection occurring in infants less than 28 days
+Early onset neonatal sepsis (EONS) presents <72 hours of age
+Late onset neonatal sepsis (LONS) presents >72 hours of age
+
+
+NEONATAL SEPSIS: Clinical features  
+Signs and Symptoms
+Systemic symptoms:
+Feeding difficulties
+Convulsions/Seizures
+Temperature >37.5⁰C or <35.5⁰C
+Respiratory distress (RR>60bpm, grunting, severe chest recessions)
+Jaundice <24 hours of age
+Altered tone/change in level of activity
+Circulatory instability: bradycardia, tachycardia (persistent), prolonged capillary refill
+Localising signs:
+Signs of pneumonia
+Many or severe skin pustules
+Periumbilical flare (redness)
+Umbilicus draining pus
+Bulging fontanelle
+Painful joints, joint swelling, reduced movement and irritability if moved
+The signs and symptoms of neonatal sepsis can be subtle, vague and non-specific.
+
+NEONATAL SEPSIS: Diagnosis  
+Investigations: 
+Blood cultures PRIOR to giving antibiotics if possible
+FBC, CRP (as minimum)
+Causative agents
+Early sepsis (<72 hours) - mainly caused by pathogens that colonize birth canal: Group B streptococcus, and Gram-negative enteric bacteria
+Late onset infections community acquired are predominantly Gram positive or Gram-negative bacteria
+Nosocomial infections (forms part of Late onset neonatal sepsis)
+Viral causes of neonatal infections
+Human immunodeficiency virus (HIV) acquired prenatally or through breastfeeding
+Others viruses include: Cytomegalovirus (CMV), Herpes simplex (HSV) Rubella, Varicella (VZV), Hepatitis B, Zika
+
+NEONATAL MENINGITIS 
+Signs and Symptoms
+Drowsy, lethargic or unconscious
+Convulsing
+Bulging fontanelle
+Irritable
+High-pitched cry
+Investigations:
+Lumbar puncture 
+Once the infant has been stabilized
+Ideally within 2 hours of initiating antibiotic treatment
+
+
+NEONATAL SEPSIS: MANAGEMENT
+ All babies with suspected sepsis should receive intravenous antibiotics
+ If antibiotics are started in the first 48 hours use:
+X-Pen/Benzyl Penicillin 50,000iu/kg BD
+ Gentamicin 3mg/kg OD <2kg or 5mg/kg OD ≥2kg IM or IV
+
+Supportive care
+Check blood sugar  - prevent and manage hypoglycaemia 
+Give 2mL/kg 10% dextrose bolus if blood glucose <2.6 and baby symptomatic
+Provide feeding support if needed - NGT feeds 3 hourly or IVF maintenance 
+Give 10mL/kg fluid bolus if shock
+Thermoregulation: aim for body temperature between 36.5 - 37.5
+If baby has fever (T = 38.5) remove from warmer and unwrap
+Provide respiratory support as needed - oxygen if sats <90%
+Remember to ALWAYS include the mother/carer in all conversations about management and explain the reasoning
+If NEC suspected need to add metronidazole  - discussed in SVN lecture
+Metronidazole dose: 7.5mg/kg IV 12 hourly if <7 days old
+Ceftriaxone used as second line or for severe infection - meningitis  - 50mg/kg/IV OD but if severe sepsis or meningitis 80mg/kg IV
+Ceftriaxone also not recommended in severely jaundiced neonates  - cefotaxime is a safer choice 
+Can see antibiotic doses available in the CME manual. 
+Antibiotics should be given for 48-72 hours and then reviewed. The baby should be clinically examined and reviewed for improvement. If well can stop Abx after 72 hours (at least 4 x doses Benzylpenicillin and 2 doses gentamicin)
+If blood cultures have been taken ensure the results have been chased and sensitivities acted upon.
+
+
+Questions?
+
+Post Test
+Section 11
+
+
+10%
+5%
+30%
+50%
+
+
+
+What percentage of neonatal deaths could be reduced by improving postnatal care alone?
+01
+01
+C
+
+
+Convulsions/Seizures
+Hypoglycaemia
+Sepsis 
+Birth Asphyxia 
+
+
+
+What is the most common medical emergency to occur in neonatal patients?
+01
+02
+B
+
+
+10-40 bpm
+20-50bpm
+>60 bpm
+30-60 bpm
+
+
+
+What is the normal range for respiratory rate in newborns?
+01
+03
+D
+
+
+2mls/kg 10% dextrose IV
+5mls/kg 10% dextrose IV
+Feed the baby 30mls formula
+2mls/kg Hartmanns solution
+
+
+
+01
+04
+What is the correct initial management for symptomatic  hypoglycaemia in a newborn?
+A
+
+
+Maternal fever
+PROM >18 hours
+Preterm babies with pre-labour rupture of membranes
+All of the above
+
+
+
+Which of the following are risk factors for neonatal sepsis?
+01
+05
+D

docs/Newborn Feeding and Fluids.txt

@@ -0,0 +1,562 @@
+Newborn Feeding and Fluids : Session 9 
+August 2023
+
+Pre-Test
+Section 1
+
+
+On day 2 after delivery 
+Within the first hour 
+After 6 hours 
+Within 30 minutes 
+
+
+
+When should all mothers be encouraged to start breastfeeding after delivery?
+01
+01
+B
+
+
+It improves the newborns immunity and is safe, clean,affordable and accessible
+It provides all the nutrients a baby needs to 8 months
+It promotes bonding between the mother and baby and causes poor weight gain
+All of the above
+
+
+
+
+Which of the following is TRUE regarding breastfeeding?
+01
+02
+A
+
+
+Baby is <1500g and unable to breastfeed 
+Baby is able to breastfeed and is >1500g
+Baby is unstable and greater than 1500g
+Baby is stable, equal to or above 1500g but cannot breastfeed
+
+
+
+What is the appropriate indication to consider cup feeding?
+01
+03
+D
+
+
+6-8 Fr
+5-6 Fr
+3-4 Fr
+>8Fr
+
+
+
+01
+04
+What is the appropriate size nasogastric tube for a baby <1500g?
+B
+
+
+10% dextrose at 80mls/kg/day + 2ml/kg EBM (trophic feeds) 3 hourly
+0.9% NaCL+10% dextrose 80ml/kg/day
+10% dextrose at 60mls/kg/day 
+Start EBM 80mls/kg day via NGT
+
+
+
+What is the correct feeding regime for Day 1 for an unstable sick baby weighing <1500g? 
+01
+05
+A - trophic feeds to be started but if not tolerated should be stopped until baby more stable 
+
+Learning Objectives
+Describe the benefits of breastfeeding and breastfeeding techniques 
+Demonstrate safe cup feeding, nasogastric tube insertion
+Understand the differing feeding regimes for term and small vulnerable newborns
+Understand the indications for IV fluids 
+
+
+The Facts
+
+Neonatal facts : 
+
+
+
+~800,000* 
+Under 5 deaths could be prevented by the scaling up of breastfeeding to a near universal level 
+~5 million 
+Under 5 deaths occur globally each year (2021)
+
+~2.3 million 
+Neonatal deaths occur globally each year ~6,400 neonatal deaths every day
+
+~40% of infants  
+Under 6 months of age are exclusively breastfed
+Breastfeeding is one of the most effective ways to ensure child health and survival. Globally, only 40% of infants under six months of age are exclusively breastfed
+WHO recommends that:
+Mothers initiate breastfeeding within one hour of birth;
+Infants should be exclusively breastfed for the first six months of life to achieve optimal growth,
+This is not always possible and alternative methods need to be employed to ensure adequate nutrition for all babies. Breastmilk should always be the first choice  .
+Reference: WHO breastfeeding (2018) https://www.who.int/news-room/facts-in-pictures/detail/breastfeeding#:~:text=Breastfeeding%20is%20one%20of%20the,of%20age%20are%20exclusively%20breastfed. 
+Global deaths - https://data.unicef.org/topic/child-survival/neonatal-mortality/ (last updated Jan 2023)
+*https://pubmed.ncbi.nlm.nih.gov/26869575/ - Victora et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect, Lancet, 2016, DOI: 10.1016/S0140-6736(15)01024-7
+
+
+Breastfeeding 
+This section goes through those neonates that are able to breastfeed and the advice for mothers. 
+We will then go onto to discuss the cases of neonates unable to breastfeed from birth ie SVN and sick babies unable to effectively latch 
+
+Breastfeeding: the benefits  
+Breast milk (esp colostrum) builds the baby’s immunity - contains antibodies
+Promotes bonding between mother and baby
+Promotes brain development 
+Better weight gain
+Reduced incidence of hypoglycaemia 
+Less dehydration 
+Faster gastric emptying 
+Is safe, clean, affordable and accessible 
+Provides ALL the nutrients and energy an infant needs for the first 6 months of life 
+A baby who is adequately fed: 
+Breastfeeds for at least 20 – 30 minutes
+Sleeps comfortably between feedings every 2-3 hours
+Has 6-8 wet diapers a day
+Loses no more than 10% of birth weight
+
+
+
+
+
+Breastfeeding technique: positioning and attachment*
+Explain drain one breast completely before switching to the next one - to ensure baby gets the hind milk that is rich in fat
+Emphasize the need for hand hygiene to optimize benefits of breastmilk and prevent infections
+The most appropriate positions for breastfeeding small and sick neonates - Cross-cradle and football positions
+
+
+
+
+
+
+
+*from the Comprehensive Newborn Care Protocols; Integrating Technologies with Clinical Pathways, November 2022
+Talk through this slide, cleaning hands, appropriate positioning and attachment.
+See mentors guide for table of Correct Positioning, Attachment & Suckling
+
+Breastfeeding: Guidance
+Breastfeeding should be commenced within the 1st hour of delivery or as soon as possible after birth  
+Mother’s should be supported and encouraged to maintain breastfeeding and to manage common difficulties e.g.
+Poor attachment 
+Poor positioning  
+Support mothers to recognize and respond to their infants’ cues for feeding i.e. rooting -> fussing -> full cry 
+Guidance must include correct positioning and attachment and ideally given:
+Before delivery
+Immediately after delivery
+During the early postnatal period
+Effectiveness of feeding 
+Wakes and shows feeding readiness cues
+Latches, sucks steadily with audible swallowing 
+Feeds without gagging, choking, turning pale or blue
+Mother reports breast softening 
+
+
+
+
+HIGHLIGHT: 
+Avoid giving water or any other food or fluid in the first 6 months of life 
+If have the mannequin and breast this can be demonstrated within the seminar 
+
+Alternative feeding methods 
+Please comment here that not all are able to effectively breastfeed at birth and if this is the case alternative methods should be used with the proviso that EBM should be used as much as possible 
+
+Baby cannot breastfeed due to critical condition – can be fed EBM via nasogastric tube or cup
+Premature baby who is unable to suck:                       < 1500g birthweight or < 32 weeks gestation
+Storage of breast milk
+To ensure continuous supply of breast milk when baby is not breastfeeding
+To relieve engorged breasts
+To boost the breastmilk supply
+Technique:
+Wash hands
+Clean container to express milk
+“C” grip position to hold breast
+Compress the breast between thumb and finger
+Release and repeat 
+
+
+*from the Comprehensive Newborn Care Protocols; Integrating Technologies with Clinical Pathways, November 2022
+Indications for expressed breast milk EBM*
+
+Indication:
+
+Baby is stable, equal to or above 1500g but cannot breastfeed
+
+
+
+
+
+
+
+
+
+
+
+
+
+Cup feeding 
+*from the Comprehensive Newborn Care Protocols; Integrating Technologies with Clinical Pathways, November 2022
+Technique: 
+Hand hygiene
+Appropriate amount of milk in the cup (e.g. 3hourly feed volume)
+Importance to sit at ~90 degrees support the newborns head, neck and back
+Tip the milk so reaches lips only and allow to lick
+ Continue tilting to allow the newborn to lick 
+
+HIGHLIGHT: 
+Do not cup feed if the baby has fallen asleep - this can cause aspiration and choking 
+
+
+
+
+
+Indications:
+
+Premature babies (usually <  1500g birthweight) requiring NGT feeding
+Baby is on oxygen therapy via nasal catheter – insert in same nostril as nasal catheter
+Baby requires CPAP – insert oral gastric tube (OGT) only
+Baby requires intensive phototherapy
+Nasogastric tube (NGT) feeding  
+Technique for insertion
+
+Select appropriate size NGT/OGT
+Calculate the length for tube insertion
+Measure the distance from the nose to the tragus of the ear
+Then to the midpoint between xiphisternum (epigastrium) and umbilicus 
+(OGT measure from the corner of the mouth)
+Mark the tube at this point
+Lubricate the tip
+Insert through nostril (or mouth) to measured distance
+Secure on cheek (ideally with medical adhesive), chin for OGT
+Confirm the position of the NGT/OGT  
+Appropriate size 
+<1500g ~ size 5-6 Fr
+>1500g ~ 6-8 Fr
+
+*should be minimum size for most effective purpose 
+Should be minimum size for most effective purpose so don’t choose the largest one that fits  - as will likely block the nasal passage rather than be effective as a feeding tube. 
+Lubricate with milk or water
+Secure with tape to cheek if NGT or chin if OGT
+Confirm the position by:
+Aspirate 2mls of the presumed gastric aspirate using a 2mls syringe
+Check that aspirate turns blue litmus paper pink.
+If no aspirate is obtained, inject 2mls of air down the tube using a 2mls syringe and listen over the abdomen with a stethoscope
+Before feeding always confirm the tube is in the correct position by making sure the mark of the measured distance is visible:
+Using the Gastric tube. To be demonstrated to the mother until she is able to do it herself
+ Keep the gastric tube well secured so as to maintain the correct position.
+Use the tube for the purpose it was inserted.
+For feeding purposes
+To prevent gastric distension during oxygen therapy via nasal catheter and CPAP – When used to feed, close it for 30minutes after the feed then open it again.
+Using the tube (if you have time to discuss:)
+1. Confirm the correct volume to feed
+2. Observe hand hygiene protocol
+3. Check correct tube placement
+4. Pour correct volume of EBM needed in a cup
+5. Remove the burrel from a 10 – 20cc syringe
+6. Pinch the end of the NG/OG tube, open it and attach the empty syringe
+7. Pour milk into the empty syringe, remove the pinch & hold the tube above the baby. See fig 3.7.3f
+8. Let the milk flow slowly by gravity - to flow for 10-15mins
+
+
+
+Indications:
+
+Unstable babies unable to safely cup or NGT feed for example: 
+Convulsions
+Coma
+Severe respiratory distress
+Concerns ~ bowel obstruction 
+IV fluids  
+Types of fluid 
+
+10% dextrose  - day 1
+Ideally start day 2 + additives
+2-3mmol/kg Sodium (Na+)
+2-3mmol/kg Potassium (K+)
+2-3mmol/kg Chloride (Cl)
+Calculate total daily volume, calculate electrolyte needs and deduct from total
+Total Parenteral Nutrition (TPN)
+Unlikely to be  available in this setting
+Used to prevent severe nutritional deficits
+Calculate the carbohydrate, lipid and protein need for the baby + electrolytes
+Must be administered ideally through central venous access due to issues with extravasation 
+Unstable babies: Sick baby (convulsions, unconscious, severe respiratory distress evidenced by severe chest wall indrawing, absent bowel sounds
+The guide goes into more details regarding volumes of additives in certain fluids e.g in 0.9% NaCl - but likely beyond the scope of the session.:
+Calculation of drip rate  = ( wt x volume/kg)/ (60x24) = ml/minute 
+
+
+Feeding regimes 
+
+FEEDING: When to initiate feeding?
+
+
+
+
+Assess shortly after birth: 
+
+Weight ≤1.5 kg 
+Weight >1.5 kg  
+If able to breastfeed - breastfeed on demand
+
+If not feed by cup at 60mls/kg/day on cues
+Unstable 
+Stable
+Weight ≤1.5 kg 
+Start EBM 80mls/kg/day trial cup feeds but may require NGT/OGT 
+
+Increase by 20mls/kg/day to max of 180ml/kg/day
+
+
+Weight >1.5 kg 
+Start 10% dextrose IV at 60mls/kg/day 
++
+2ml/kg EBM (trophic feeds) 3 hourly 
+Start 10% dextrose IV at 80mls/kg/day 
++
+2ml/kg EBM (trophic feeds) 3 hourly 
+Initiating feeding depends on the size of the baby and how stable they are. The flowchart tries to simplify as much as possible.
+Need to determine if >1.5kg or <1.5kg
+Need to determine if stable to unstable  -Sick baby (convulsions, unconscious, severe respiratory distress evidenced by severe chest wall indrawing, absent bowel sounds
+>1.5kg start 60mls/kg/day enteral feeds
+Remember those <1500g are likely to be able to adequately breastfeed - therefore need alternative cup or NGT
+Those <1.5kg: Start feeds with 5 mls EBM and increase by 5mls each 3 hourly feed until full 3 hourly feed volume is achieved.
+
+We must balance between the risk of withholding feeds and early feeding for the sick newborn and the preterm/low birth weight.
+What risk factors do you think may influence when to initiate breast milk feeds in these newborns?
+
+FEEDING (Stable neonates >1.5kg)   
+Breast-milk is the best feed for ALL newborns regardless of size 
+Small babies may not have the skills or strength to feed at the breast initially
+Mothers attempting to breastfeed a small baby require extra support and encouragement
+They should be supported to express breastmilk
+NOTE:
+Feed increases 20ml/kg/day help to reach full enteral volumes early.    
+As babies lose weight in the first 7-14 days calculate intake using birth weight until current weight exceeds birth weight.
+General feeding volumes for >1.5kg 
+
+Day of life	Feed/Fluid Volume
+Day 1	60mls/kg/day divided into 2-3 hourly feeds
+Day 2	80mls/kg/day divided into 2-3 hourly feeds 
+Day 3	100ml/kg/day divided into 2-3 hourly feeds
+Day 4	120mls/kg/day divided into 2-3 hourly feeds
+Day 5	140ml/kg/day divided into 2-3 hourly feeds
+Day 6  160ml/kg/day divided into 2-3 hourly feeds
+Day 7  180ml/kg/day divided into 2-3 hourly feeds
+
+
+
+
+FEEDING (Stable Neonates <1.5kg or <32 weeks)
+Mostly likely will require NGT feeds
+Feeds should be advanced slowly 
+Intestinal motility may be impaired  - thus feeding aspirates are common
+Aspirates should not be checked routinely unless  concerns of NEC or feeding intolerance (distended abdomen, vomiting feeds)
+Blood in aspirates - withhold feeds and examine
+Potential regime: 
+
+Day 1: 80mls/kg/day
+Start at 5mls EBM and increase by 5mls each 3 hourly feed until full 3 hourly feed volume is achieved.  
+
+From Day 2:
+Increase by 20mls/kg/day 
+
+Day 2: 100ml/kg/day 
+Day 3: 120ml/kg/day
+Day 4: 140ml/kg/day
+Day 5: 160ml/kg/day 
+Day 6: 180ml/kg/day 
+Please comment in the lecture: Babies <1000g should ideally be started on IVF if safe and appropriate as per comprehensive guideline 
+IV nutrition is not available ie TPN and so if safe can feed - but must observe the aspirates and for NEC. 
+
+But if need to feed on day 1: 
+Example: 1000g baby
+Day 1: 80mls/kg/day → 1kg X 80 = 80ml ÷ 8 feeds/day = 10mls 3hrly feeds. First feed 5mls, then 10mls 3hrly
+
+
+FEEDING (Unstable neonates)
+Start IV fluids and trophic feeds (2mls/kg 3 hourly)
+10% dextrose IV  -> 60mls/kg/day for >1.5kg
+10% dextrose IV -> 80mls/kg/day for ≤1.5 kg
+Remember 10% dextrose has <50% of the calories of EBM 
+Trophic feeds at 2mls/kg 3 hourly help to stimulate the gut
+Day 2 start EBM at 30mls/kg/day via NGT and observe if tolerated 
+Potential regime (≤1.5 kg)
+
+Day 1: 
+Start IV fluids 10% dextrose for the first 24 hours (80mls/kg/day), +  2mls /kg of EBM via NG tube every three hours to stimulate the gut, do not deduct this from the IV fluids
+
+From Day 2:
+Start feeds with EBM at 30mls/kg/day and can reduce IV fluids to keep within the total daily volume
+Remember: We do not have IV nutrition. And 10% dextrose has <50% of the calories EBM has 
+Day 1: 
+Start IV fluids 10% dextrose for the first 24 hours (80mls/kg/day), then give 2mls /kg of EBM via NG tube every three hours to stimulate the gut, do not deduct this from the IV fluids
+
+From Day 2:
+Start feeds with EBM at 30mls/kg/day, then increase 3 hourly feed volumes by
+30mls/kg/day and reduce IV fluids to keep within the total daily volume. 
+IVF stopped when full 3 hourly feed volume achieved appropriate for weight and postnatal age in days.
+If too sick to tolerate the calculated enteral feeds for the day, give trophic feeds (minimal enteral feeding) 10-20ml/kg/day. Drops of breastmilk into the mouth are better than nothing.
+
+
+
+Calculating Feed Volumes 
+
+Day
+Total fluid required/day
+3 hourly EBM Feeds
+1 hourly IVF
+Day 1
+80 x 1.3 = 104mls
+4.3mls
+Day 2
+100 x 1.3 = 130mls
+4.9mls 
+3.8mls
+Day 3
+120 x 1.3 = 156mls
+10mls
+3.3mls
+Day 4
+140 x 1.3 = 182mls
+14.6mls
+2.7mls
+Day 5
+160 x 1.3  = 208ml 
+19.5mls
+2.2mls
+Case: Unstable newborn birth weight = 1.3kg
+Start 30mls/kg/day here and deduct from total volume
+Start at 80ml/kg/day volume of feeds. Increase by 20ml/kg/day to full feeds (180ml/kg/day if on enteral feeds and 150mls/kg/day if on IVF)
+NB: to get 3 hourly volumes divide total by 8
+NB to get 1 hourly volumes divide total by 24
+
+Day 1 = no additional feeds
+Day 2  = 100ml/kg/day total = 30mls/kg/day feed (in 3 hourly volumes) + 70ml/kg/day (in hourly IVF volumes)
+Day 3 = 120ml/kg/day  = 60mls/kg/day feed (in 3 hourly vol) + 80ml/kg/day (in hourly IVF volumes) 
+Day 4 = 140/ml/kg/day total = 90mls/kg/day ( in 3 hourly volumes) + 50mls/kg day (in hourly IVF volumes) 
+
+Cases to discuss 
+Case 1: Stable 1.6kg unable to breastfeed
+What 3 hourly feed for day 1?
+What  3 hourly feed volume for day 2
+Case 2: Stable 1.2kg unable to breastfeed
+What is the starting feed volume?
+What do you increase to for your 3  hourly feed volume for day 1
+What 3 hourly feed volume for day 3?
+Case 3: Unstable 1.1kg baby?
+What fluid volume for day 1
+What fluid and feed volume for day 3
+Remember:
+Stable >1.5kg 
+	Start 60mls/kg/day
+	Increase 20mls/kg/day
+Stable <1.5kg 
+	Start 80mls/kg/day
+	Increase by 20mls/kg/day
+Unstable >1.5kg
+	Start 60mls/kg/day IVF
+	Increase by 20ml/kg/day
+	Start 30mls/kg/day feeds      
+            day 2 (minus from total volume)
+Unstable <1.5kg
+	Start 80mls/kg/day
+	Increase by 20ml/kg/day
+	Start 30mls/kg/day day 2 (minus  
+           from total volume)
+Please note the tables for feeding depending on weight are ALL in the basic paediatric protocols guides (2022 version on pages 59-62
+
+Case 1 answers: 
+(60mls x 1.6) divide by 8 = 12mls
+(80 x 1.6) divide by 8 = 16mls
+Case 2 answers:
+Start at 5mls feed
+(80 x 1.2) divide by 8 = 12mls
+120 x 1.2 divide by 8 = 18mls
+Case 3 answers:
+(80 x 1.1) divide by 24 = 88/24 = 3.7mls 1 hourly IV 10% dextrose
+Feed: (60 x 1.1) divide by 8 = 8mls
+Fluid: (60 x 1.1) divide by 24 = 2.8mls 
+
+Questions?
+
+Post Test
+Section 11
+
+
+On day 2 after delivery 
+Within the first hour 
+After 6 hours 
+Within 30 minutes 
+
+
+
+When should all mothers be encouraged to start breastfeeding after delivery?
+01
+01
+B
+
+
+It improves the newborns immunity and is safe, clean,affordable and accessible
+It provides all the nutrients a baby needs to 8 months
+It promotes bonding between the mother and baby and causes poor weight gain
+
+
+
+
+Which of the following is TRUE regarding breastfeeding?
+01
+02
+A
+
+
+Baby is <1500g and unable to breastfeed 
+Baby is able to breastfeed and is >1500g
+Baby is unstable and greater than 1500g
+Baby is stable, equal to or above 1500g but cannot breastfeed
+
+
+
+What is the appropriate indication to consider cup feeding?
+01
+03
+D
+
+
+6-8 Fr
+5-6 Fr
+3-4 Fr
+>8Fr
+
+
+
+01
+04
+What is the appropriate size nasogastric tube for a baby <1500g?
+B
+
+
+10% dextrose at 80mls/kg/day + 2ml/kg EBM (trophic feeds) 3 hourly
+0.9% NaCL+10% dextrose 80ml/kg/day
+10% dextrose at 60mls/kg/day 
+Start EBM 80mls/kg day via NGT
+
+
+
+What is the correct feeding regime for Day 1 for an unstable sick baby weighing <1500g? 
+01
+05
+A - trophic feeds to be started but if not tolerated should be stopped until baby more stable 
+
+Link for Video on NGT Insertion
+
+https://www.youtube.com/watch?v=8FonfbbOqkU
+
+
+

docs/PPH_Maternal resuscitation_CME_updated Jan2022.txt

@@ -0,0 +1,1060 @@
+A Case Study
+Mum arrives at the facility with strong contractions
+
+But experiences adverse outcomes during delivery
+
+
+34 yr old G4P3+0 presents in labour at 39 weeks
+OB hx: 2 prior SVD, 1 prior CS
+Medical history: uncomplicated
+Exam: baby longitudinal, vertex, SVE: 9cm
+Mum proceeds quickly to fully dilated and within 15 minutes delivers a 4.3kg LFI
+She proceeds to bleed profusely, estimated at 750cc. 
+Diagnosis?  Risk Factors?  What do we do next? 
+
+Postpartum Hemorrhage/maternal resuscitation
+Updated January 2022
+
+Pre-Test
+Section 1
+
+Standard uterotonic administration
+Early initiation of breastfeeding
+Delayed cord clamping
+Postpartum nipple stimulation
+
+
+Which of the following is considered a standard component of AMSTL?
+01
+01
+A
+
+Traumatic lacerations
+Uterine Atony
+Clotting disorders
+Placental abruption
+Retained products of conception 
+
+
+Which of the following is the most common cause  of primary PPH?
+
+01
+02
+B
+
+Postpartum bleeding totaling over 500cc post CS
+Postpartum bleeding totaling over 300cc post vaginal delivery
+Any amount of postpartum bleeding which results in a change in maternal condition
+Postpartum bleeding which requires uterotonic treatment
+
+
+PPH can be defined as which of the following?
+
+01
+03
+c
+
+
+Uterine atony
+Retained placenta
+Uterine inversion
+Genital trauma
+Coagulopathy
+
+
+Which of the following is the 2nd most common cause of PPH?
+01
+04
+D
+
+Every 15 minutes for first 2 hours postpartum
+Every 10 minutes for one hour postpartum
+Every 30 minutes for 4 hours postpartum
+Every hour for 4 hours postpartum
+
+
+How frequently should a woman’s vitals be measured post birth to monitor for PPH?
+
+01
+05
+A
+
+Toxin
+Hypothermia
+Hypovolemia
+Thromboembolism
+
+
+
+Which of the following is the most common cause of primary maternal collapse?
+01
+06
+D
+
+A pregnant patient has a lower oxygen demand
+The gravid uterus of a pregnant patient causes inferior vena cava compression
+It is easier to see chest rise during rescue breaths
+The diaphragm is displaced inferiorly 
+
+
+Which of the following is true regarding CPR in the pregnant patient?
+
+01
+07
+B
+
+Call for help
+Assess danger for both you and the patient
+Assess breathing pattern of the patient
+Check for a pulse
+
+
+What is the first step once you identify a maternal collapse?
+
+01
+08
+B
+
+
+Supine
+Slight right lateral tilt
+Slight left lateral tilt
+Prone
+
+
+Which of the following is the correct position of a pregnant patient during CPR after maternal collapse?
+01
+09
+C
+
+60:2
+100:2
+120:2
+30:2
+
+
+Which of the following is the correct ratio of compressions to breaths during CPR in the pregnant patient?
+
+01
+10
+D
+
+Learning Objectives
+Understand causes of PPH
+Recognize and appropriately diagnose PPH
+Effectively treat PPH
+Prepare and utilize uterine balloon tamponade (UBT) for the treatment of PPH
+Understand steps of manual removal of the placenta
+Understand how to perform effective maternal resuscitation
+
+The Facts
+Section 2
+
+Reducing the Global Burden: 
+Postpartum Hemorrhage 
+
+6%
+
+The worldwide prevalence of PPH is 6% 
+Postpartum haemorrhage (PPH) is the leading cause of maternal mortality, accounting for about a third of all maternal deaths
+
+Maternal collapse is a rare but life threatening event with a wide aetiology. The outcome, primarily for the mother but also for the fetus, depends on prompt and effective resuscitation
+
+
+
+30% 
+
+of maternal deaths worldwide are due to hemorrhage mostly in the immediate postpartum period 
+10.5%
+
+The sub saharan Africa prevalence of PPH is high at 10.5%
+Maternal collapse occurs in between 0.14 and 6 per 1000 births
+Postpartum haemorrhage (PPH) is the leading cause of maternal mortality, accounting for about a third of all maternal deaths.
+Despite being a largely preventable and manageable condition,  mortality from  PPH remains high, especially  in developing countries.
+In the absence of timely and appropriate action, a woman could die within a few hours.
+
+Definitions
+Section 3
+
+Historically, PPH has been defined as:
+PPH
+Any vaginal birth resulting in 500mL or more of blood loss
+
+Any CS birth resulting in 1000mL or more of blood loss
+
+Severe PPH
+Any birth resulting in blood loss of >1000mL 
+
+Very severe PPH
+Any birth resulting in blood loss >1500mL
+
+HOWEVER….
+
+It is important to remember that clinical estimates of blood loss are often inaccurate!
+
+
+
+				
+			
+		
+
+
+THEREFORE….
+		 	 	 
+Any blood loss that has the potential to a change in maternal condition or hemodynamic stability is considered PPH. Hemodynamic instability (SHOCK) is an emergency!
+
+
+
+
+				
+			
+		
+
+
+DIAGNOSING SHOCK 
+
+
+
+
+				
+			
+		
+
+
+Shock Index (SI) is obtained by dividing the heart rate with the systolic blood pressure 
+
+Primary versus Secondary PPH
+01
+01
+02
+Primary PPH
+Primary (immediate) PPH occurs within the first 24 hours after delivery. 
+
+Approximately 70% of immediate PPH cases are due to uterine atony.  					
+Secondary PPH
+Secondary (late) PPH occurs between 24 hours after delivery of the infant and up to 6 weeks postpartum.
+
+Most late PPH is due to retained products of conception, infection, 
+or both. 
+
+
+
+Estimating blood loss
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Some helpful estimates:
+
+Partially soaked sanitary towel: ~30ml
+Fully soaked sanitary towel: ~100ml
+Small soaked swab: ~60ml
+Large soaked swab: ~350mL
+½ way soaked chux pad: ~250ml
+Fully kidney dish: ~500mL
+PPH covering bed: ~1000ml
+PPH covering bed & spilling onto floor: ~2000ml
+
+30ml
+100ml
+60ml
+250ml
+50ml
+1000ml
+
+Estimating Blood loss:
+
+
+Causes of PPH
+Section 4
+
+Causes of primary PPH:
+TONE
+Uterine atony accounts for 70% of all cases of primary PPH
+TRAUMA
+TISSUE
+THROMBIN
+Trauma accounts for 20% of primary PPH
+May include: uterine, cervical or vaginal injury or uterine inversion
+Retained products of conception accounts for 10% of primary PPH
+May include retained placenta or clots
+Coagulopathy accounts for <1% of primary PPH
+May include inherited or acquired coagulopathy
+**Secondary PPH almost ALWAYS caused by infection or retained products of conception
+
+Risk Factors 
+Section 5
+
+**Important to recognize that many women with PPH have NO IDENTIFIABLE RISK FACTORS.  
+
+For others, risk factors may include…
+Maternal age above 35 years
+Parity >3
+Prior uterine surgery
+Previous PPH
+Uterine fibroids
+Pre-eclampsia
+Anemia
+Gestational diabetes
+Multiple pregnancy
+Polyhydramnios
+Antepartum hemorrhage  						
+					 				
+			
+		
+
+Induction of labor
+Prolonged 2nd or 3rd stage
+Retained placenta
+Instrumental vaginal birth
+Macrosomia
+Uterine rupture
+General anesthesia
+Infection after PROM
+Intrapartum fever 						
+					 				
+
+
+Intrapartum 
+Risk Factors
+
+Antenatal
+Risk Factors
+
+Investigate antenatal anemia 
+Oral iron is first line treatment for anaemia
+Counsel patient on dietary supplementation
+If unable to tolerate oral iron, has poor compliance and is near term, consider IV iron therapy
+Antenatal Risk Assessment
+Perform ultrasonography examination  to screen for abnormal placentation
+Review by obstetrician if abnormal placentation
+If placenta accreta/percreta, involve a multidisciplinary team in preoperative planning
+Screen for abnormal placentation
+Routine screening for anaemia
+Routine screening for anemia:
+Investigate antenatal anemia (malaria? Underlying bleeding?) This includes a G&Rh
+If she has iron deficiency anaemia, oral iron is first line tx
+Counsel patient on dietary supplementation
+If unable to tolerate oral iron, has poor compliance and is near term, consider IV iron therapy.
+
+Screen for abnormal placentation:
+Perform ultrasonography examination  to screen for abnormal placentation, esp if woman had prior CS or uterine surgery
+Review by obstetrician if abnormal placentation
+If placenta accreta/percreta, involve a multidisciplinary team in preoperative planning.
+
+
+Prevention
+Section 6
+
+Prevention measures include:
+Assess underlying risk:
+Thorough history taking
+Blood group/antibody screen
+Antepartum Hg assessment
+Screen for abnormal placentation
+1
+Correction of antenatal anaemia:
+Daily iron and folic acid supplementation with 30mg to 60mg of elemental iron and 400 μg  folic acid 
+
+If anaemia persists, consider increased dose of oral iron or IV iron infusions 
+
+2
+AMSTL
+Controlled cord traction
+Prophylactic uterotonic (oxytocin 10IU IM preferred)*
+Uterine massage**
+3
+* If oxytocin unavailable, other acceptable uterotonics include: carbetocin 100μg IM, ergometrine/methyl-ergometrine 0.2 mg IM or misoprostol 600μg orally
+.** technically no longer considered standard component of AMSTL			
+					 				
+			
+		
+
+
+Monitoring for PPH in the 4th stage: 
+		 	 	 		
+**If risk factors for PPH are identified, it is important to monitor the woman for 1 to 2 hours after delivery then 4 hourly for 24 to 48 hours.  						
+					 				
+			
+		
+
+
+Monitor every 30 minutes for first 2 hours postpartum
+Monitor every 15 minutes for first 2 hours postpartum
+
+Once or as clinically indicated
+
+Monitor every 15-30 minutes for first 2 hours postpartum
+Monitor within first 2 hours (should be at least 30mL/hr)
+Urine output
+Fundal Height / Lochia
+Oxygen Saturation
+HR/RR/BP
+Temperature
+
+Management
+Section 7
+
+PPH management ALWAYS depends on the underlying cause…
+
+Tone (uterine atony)
+Tissue (retained products)
+Trauma (lacerations)
+Thrombin (coagulopathy)
+
+
+PPH due to uterine atony
+(most common cause of PPH)
+Shout for help
+Begin Fundal massage
+Insert 2 large bore IVs/start IV fluids (NS or RL)
+Send blood samples for blood group/crossmatch
+Insert catheter
+
+
+Initial Response
+Bimanual uterine compression 
+Uterine balloon tamponade
+Abdominal aorta compression
+Laparotomy
+Antishock garment to buy time for referral 
+
+Further management as needed:
+Ergometrine .2mg IM, repeat q 2-4 hours (max 1g) OR
+Repeat dose of 800mcg misoprostol
+
+Uterotonics - 2nd line
+Carboprost .25mg IM q 15 minutes (max 2mg) OR
+Tranexamic acid 1gm IV
+
+Uterotonics - 3rd line
+Oxytocin 10IU IM or 20-40IU in 1L saline at 60 drops/min OR
+Misoprostol 800mcg per rectum
+
+Begin uterotonics - 1st line
+
+Risk factors include:
+Retained placenta/clots
+Overdistention of the uterus (multiple gestation, polyhydramnios, macrosomia)
+High parity
+Prolonged labor
+Induction or augmentation of labour 
+Precipitous labour (labour lasting less than 3 hours)
+Uterine fibroids in pregnancy 
+Full bladder 						
+					 		
+					 				
+			
+		
+
+
+Bimanual uterine compression
+
+Form a fist
+Place fist in anterior fornix & apply pressure against anterior wall of uterus
+With other hand, press deeply into abdomen behind uterus applying pressure to posterior uterus
+Maintain pressure until bleeding controlled while continuing other resuscitation measures
+
+Please see “other resources” for Global health media video link to bimanual uterine compression
+
+Compression of abdominal aorta
+
+Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left)
+With other hand, palpate femoral pulse to check adequacy of compression:
+Pulse palpated → inadequate
+Pulse NOT palpated → adequate
+Maintain compression until bleeding controlled or patient reaches operating theatre
+
+Please see “other resources” for Global health media video link to Compression of abdominal aorta
+
+
+Uterine Balloon Tamponade
+
+Unroll and attach condom with two cotton strings to Foley catheter
+Fill syringe with clean water & insert syringe into catheter
+With sterile gloves, place two fingers inside cervix, grasp assembled uterine balloon with other hand, slide condom attached to catheter over the two fingers into the cervix, advance into uterine fundus
+Push water from syringe into condom balloon in uterus; continue inflating balloon until bleeding slows significantly or stops (usually 300-500 mL)
+Plug or clamp end of catheter
+
+Please see “other resources” for Global health media video link to Uterine balloon tamponade
+
+
+Non-pneumatic anti-shock garment (*should only be used to stabilize patient for referral to a higher level facility)
+
+Place NASG under woman
+Close segments 1 tightly around the ankles
+Close segments 2 tightly around each calf
+Close segments 3 tightly around each thigh, leave knees free
+Close segment 4 around pelvis
+Close segment 5 with pressure ball over the umbilicus
+Finish closing the NASG using segment 6
+Note: Segments 1, 2, 3 can be applied by two persons simultaneously, segments 4, 5, 6 should only be applied by one.
+
+Please see “other resources” for Global health media video link to Anti-shock garment
+
+
+PPH due to genital tract trauma
+(second most common cause of PPH) 
+Shout for help
+Insert 2 large bore IVs/start IV fluids (NS or RL)
+Send blood samples for blood group/crossmatch
+Insert catheter
+
+Initial Response
+Examine entire gential tract using gauze pads (ensure visualization of apex of tear)
+Classify tear according to anal sphincter
+Repair laceration
+
+Check for vaginal/perineal tearing
+Exam under anesthesia if required
+Apply fundal pressure to visualize entire cervix
+Use ring forceps to fully examine cervix
+Repair identified tear
+
+Check for cervical tear
+Tranexamic acid 1gm IV (100mg/mL) @ 1mL/minute over 10 minutes
+
+May give antifibrinolytic
+
+Risk factors include:
+Precipitous labor
+Assisted vaginal delivery
+Primigravida women 
+Macrosomia				
+					 		
+					 				
+			
+		
+
+Please see video in “other resources” for global health media video regarding cervical tear repair
+
+PPH due to retained tissue
+(third most common cause of PPH) 
+Shout for help
+Insert 2 large bore IVs/start IV fluids (NS or RL)
+Send blood samples for blood group/crossmatch
+Insert catheter
+
+Initial Response
+Give additional 10IU oxytocin
+Apply controlled cord traction 
+If still adherent, consider manual removal of placenta
+Examine placenta for completeness
+If retained placenta:
+Uterine exploration by hand
+Remove fragments by hand, or wide curette 
+If placenta or fragments still adherent, consider laparotomy
+
+Check for retained fragments of placenta
+Consider Tranexamic acid 1gm IV (100mg/mL) @ 1mL/minute over 10 minutes
+
+Initial medication therapy
+
+Risk factors include:
+A full bladder which may hinder delivery of the placenta
+Cord avulsion
+Disorders of placentation which result in invasion of the placenta to the myometrial walls
+Abnormal placenta (extra lobe) 	
+
+Manual removal of the placenta
+
+Perform using a NEW PAIR of sterile gloves
+Hold the umbilical cord with a clamp.  Pull the cord gently with your non-dominant hand
+Insert your dominant hand into the vagina to enter the uterus
+Let go of the cord and move hand to abdomen to support the fundus providing counter-traction to prevent uterine inversion
+Move your fingers until the edge of the placenta is located
+Detach the placenta from the implantation site by making a space between the placenta and uterine wall
+Proceed until whole placenta is detached
+Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it
+
+
+**Notes:
+Single dose of antibiotics should be given at time of procedure - (Ampicillin 2g IV or Cefazolin 1g IV) 
+If placenta cannot be separated, suspect placenta accreta and refer
+Please see “other resources” for Global health media video link to manual removal of placenta
+
+PPH due to coagulopathy
+(4th most common cause of PPH) 
+Shout for help
+Insert 2 large bore IVs/start IV fluids (NS or RL)
+Send blood samples for blood group/crossmatch and full haemogram
+Insert catheter
+
+Initial Response
+Packed red cells for red cell replacement
+Fresh frozen plasma for replacement of all clotting factors (15 mL/kg body weight)
+Cryoprecipitate to replace fibrinogen and factor VIII in case of disseminated intravascular coagulation
+Platelet concentrates (if bleeding continues and the platelet count is less than 20,000)  						
+					 				
+			
+		
+
+If whole blood NOT available:
+In known placenta abruption or eclampsia, aim to treat the cause  						
+					 				
+			
+		
+
+
+Monitor for underlying cause
+Give fresh whole blood, if available, to replace clotting factors and red cells  						
+					 				
+			
+		
+
+
+Give blood products
+
+Risk factors include:
+Abruptio placentae
+Fetal death in utero
+Amniotic fluid embolism
+Existing/inherited coagulation profile disorders 
+
+**Of note, coagulopathies can occur both as a cause and a complication of massive obstetric hemorrhage with Disseminated Intravascular Coagulation (DIC) being the most fatal 
+
+Complications
+Section 8
+
+Complications from PPH can arise as a direct result of low blood volume or resultant damage to organs due to poor perfusion.
+Complications of PPH
+Early Complications
+Anaemia
+Blood transfusion reactions
+Dilutional coagulopathy
+Fatigue
+Myocardial ischemia
+Orthostatic hypotension
+Adult respiratory distress syndrome
+Late Complications
+Anterior pituitary ischemia with delay or failure of lactation (Sheehan syndrome)
+
+Loss of fertility due to hysterectomy
+
+Death
+
+
+
+have demonstrated proven impact on the lives of mothers and babies, 
+are low cost so they can be scaled within resource-constrained government health systems
+are co-designed with govt to be sustainable within the public health system 
+
+Guiding principles
+
+
+This is how we achieve impact and what makes us unque / guiding principles. 
+Govt partnerhsips
+Interventions that are sustainable
+Measuring impact and using it in  smart way
+
+
+Add your title
+Section 3
+Add a short description about what this subsection will cover 
+
+Maternal collapse
+Section 9
+
+Maternal Collapse
+		 	 	 		
+An acute event resulting in a reduced or absent consciousness and potential cardiac arrest.  Maternal collapse can occur at any stage of pregnancy and up to six weeks postnatally
+
+CPR
+Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies in which someone's breathing or heartbeat has stopped			
+					
+				
+			
+		
+
+
+
+Causes of primary maternal collapse:
+4 H’s
+Hypoxia
+Hypovolemia
+Hyperkalemia and other metabolic disorders
+Hyperthermia (least common)
+4 T’s
+Thromboembolism (pulmonary embolism or amniotic fluid embolism) - MOST COMMON
+Toxicity
+Tension pneumothorax (uncommon)
+Cardiac tamponade (uncommon)
+
+
+Management of maternal collapse
+Section 10
+
+DR ABC mnemonic: 
+A clinical tool that offers a structured framework for coping with maternal collapse
+
+	
+		
+
+					 				
+			
+		
+
+
+Assess danger for you and the patient
+Initial response
+
+Airway
+
+Breathing
+D
+Circulation
+R
+A
+B
+C
+
+Step 1:
+Assess danger
+Protect yourself from danger:
+Wear PPE, mask, gloves
+Avoid body fluid spills, sharps
+Notice unstable beds/trolleys
+Protect patient from danger:
+Bring to safe environment for resuscitation
+
+
+D
+R
+A
+B
+C
+
+Step 2:
+Initial response
+Quickly shake the mother and shout her name:
+“Hello Mary, are you ok?”
+If unresponsive: shout for HELP
+
+D
+R
+A
+B
+C
+					 				
+			
+		
+
+
+Step 3: Airway
+First, put the woman in the left lateral tilt to release pressure of the gravid uterus on the vena cava - use a wedge or pillows under the right hip
+Next, open the airway using: head tilt, chin lift or jaw thrust 
+If still not breathing, place an oropharyngeal airway
+Perform suction ONLY if necessary, under direct visualization
+
+
+D
+R
+A
+B
+C
+					 				
+			
+		
+
+		
+
+
+Step 4:  Breathing
+Assessment should be performed within 10 seconds:
+Look for breathing by observing movement of the chest
+Listen for breathing or noisy breathing
+Feel for breathing
+Feel for carotid pulse (if no breathing assume that arrest has occurred)
+
+D
+R
+A
+B
+C
+				
+			
+		
+ 						
+					 				
+			
+		
+
+		
+
+
+IMPORTANT!!
+Interruptions of chest compression are associated with reduced chances of survival
+Chest compressions done with insufficient depth and the wrong rate may also compromise survival
+Step 5: 
+Circulation
+Start chest compressions:
+**If the person HAS a pulse do not do chest compressions
+
+If there is NO pulse or other sign of life start chest compressions as follows:
+Place the heel of the first hand on lower part of sternum (centre of the chest)
+Place heel of second hand on top of the first hand
+Interlock fingers
+Keep arms straight and depress sternum 5-6 cm at a rate of 100-120 compressions per minute
+Change the person doing the compressions every 2 minutes to avoid getting tired
+				
+			
+		
+
+D
+R
+A
+B
+C
+					
+
+
+Continuation of CPR
+
+Continue 30 compressions followed by 2 slow breaths each lasting about 1 second 
+Watch for chest rise with each breath
+Give 100% oxygen if available while performing chest compressions 
+If automated defibrillator is available, connect, assess rhythm, follow directions  
+
+
+
+Difficulty with ABCs in the pregnant patient
+Circulation
+Breathing 
+Airway
+Suctioning is difficult in a pregnant patient - often requires left lateral tilt
+Intubation can be difficult in a pregnant patient
+
+				
+			
+		
+
+Greater oxygen requirement
+Reduced chest compliance
+More difficult to see rise and fall of chest
+More risk of regurgitation and aspiration
+				
+			
+		
+
+				
+			
+		
+
+
+Chest compression difficult because:
+Ribs are flared
+Diaphragm is raised
+Breasts hypertrophied
+Supine position causes inferior vena cava compression by the gravid uterus
+					 				
+			
+		
+ 
+				
+			
+		
+
+
+Post-CPR
+Section 11
+
+Once airway is open and signs of breathing are present…
+
+Count respiratory rate, if >20/minute give oxygen
+Check for the level of Consciousness:
+A-Alert
+Sit patient up if alert
+V - Responds to Voice or command
+P - Responds only to Pain
+U - Unresponsive
+Place in recovery position if unresponsive
+Assess circulation: capillary refill, skin – cold or warm, heart rate/pulse rate, blood pressure, body temperature, level of consciousness, fetal heart rate, urine output
+Insert IV line, take blood for laboratory investigations, start IV fluids
+
+
+Recovery position
+
+**Note: Be prepared to restart CPR immediately if the mother deteriorates or stops breathing normally
+
+
+Please see “other resources” for Global health media video link to Compression of abdominal aorta
+
+
+Perimortem CS
+Section 12
+
+Perimortem Cesarean section
+
+Perimortem CS is the surgical delivery of the fetus, performed at or near death of the maternal patient
+Only performed if the gestation is > 20 weeks
+Done if return of spontaneous circulation does not occur after 4 minutes of effective cardiopulmonary resuscitation
+Delivery should be achieved within 5 minutes of cardiac arrest as this maximizes maternal survival
+It is part of resuscitation performed to try save the mother NOT the baby
+Improves circulation as it takes weight of baby away from maternal vena cava
+In hospital, the procedure should be performed at the site of the cardiac arrest without moving to an operating theatre
+Just need a scalpel as there will be little bleeding 
+The subumbilical midline incision is recommended because it’s faster
+
+
+
+Questions?
+
+Post Test
+Section 13
+
+Standard uterotonic administration
+Early initiation of breastfeeding
+Delayed cord clamping
+Postpartum nipple stimulation
+
+
+Which of the following is considered a standard component of AMSTL?
+01
+01
+A
+
+Traumatic lacerations
+Uterine Atony
+Clotting disorders
+Placental abruption
+Retained products of conception 
+
+
+Which of the following is the most common cause  of primary PPH?
+
+01
+02
+B
+
+Postpartum bleeding totaling over 500cc post CS
+Postpartum bleeding totaling over 300cc post vaginal delivery
+Any amount of postpartum bleeding which results in a change in maternal condition
+Postpartum bleeding which requires uterotonic treatment
+
+
+PPH can be defined as which of the following?
+
+01
+03
+C
+
+
+Uterine atony
+Retained placenta
+Uterine inversion
+Genital trauma
+Thrombopathy
+
+
+Which of the following is the 2nd most common cause of PPH?
+01
+04
+D
+
+Every 15 minutes for first 2 hours postpartum
+Every 10 minutes for one hour postpartum
+Every 30 minutes for 4 hours postpartum
+Every hour for 4 hours postpartum
+
+
+How frequently should a woman’s vitals be measured post birth to monitor for PPH?
+
+01
+05
+B
+
+Toxin
+Hypothermia
+Hypovolemia
+Thromboembolism
+
+
+
+Which of the following is the most common cause of primary maternal collapse?
+01
+06
+D
+
+A pregnant patient has a lower oxygen demand
+The gravid uterus of a pregnant patient causes inferior vena cava compression
+It is easier to see chest rise during rescue breaths
+The diaphragm is displaced inferiorly 
+
+
+Which of the following is true regarding CPR in the pregnant patient?
+
+01
+07
+B
+
+Call for help
+Assess danger for both you and the patient
+Assess breathing pattern of the patient
+Check for a pulse
+
+
+What is the first step once you identify a maternal collapse?
+
+01
+08
+B
+
+
+Supine
+Slight right lateral tilt
+Slight left lateral tilt
+Prone
+
+
+Which of the following is the correct position of a pregnant patient during CPR after maternal collapse?
+01
+09
+C
+
+60:2
+100:2
+120:2
+30:2
+
+
+Which of the following is the correct ratio of compressions to breaths during CPR in the pregnant patient?
+
+01
+10
+D
+
+Additional Video Resources:
+
+Video on uterine compression
+
+Video on aortic compression 
+
+Video on UBT
+
+Video on antishock garment
+
+Cervical tear repair
+

docs/Respectful maternity care_CME_updated June 2022.txt

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+A Case Study
+Mum arrives at the facility with strong contractions
+
+She labours in the hospital but is treated poorly
+
+
+24 yr old G1P0 presents in labour at 39 weeks
+OB hx: this is her first pregnancy
+Medical history: none
+Exam: baby longitudinal, vertex, SVE: 6cm
+Mum has many questions, answers not provided
+Mum undergoes many vaginal exams without consent
+Mum’s legs are slapped open during delivery 
+She delivers a LFI wt 3.2kg, apgars 9/9
+Was this successful?  What could be done differently?
+
+Respectful Maternity Care
+Updated June 2022
+
+Pre-Test
+Section 1
+
+Non-consented care
+Non-confidential care
+Abandonment 
+Physical abuse
+
+
+Repairing a perineal laceration without offering a mum any form of anesthesia is an example of which of the following?
+01
+01
+D
+
+Discrimination
+Non-consented care
+Detention 
+Non-confidential care 
+
+
+
+Telling a mum she must undergo a CS without explaining why is an example of which of the following?
+
+01
+02
+B
+
+Non-consented care
+Discrimination
+Detention
+Physical abuse
+
+
+Forcing a mum to stay in a facility because she is unable to pay her bill is an example of which of the following?
+
+01
+03
+C
+
+
+Provider attitude
+Cost of birthing services
+Cleanliness of facility
+Facility reputation
+
+
+
+
+Which of the following is the biggest predictor of a women’s choice to use facility-based childbirth services?
+01
+04
+A
+
+Not explaining a procedure to a woman in a language she understands is a form of disrespect and abuse 
+We should consider respectful pregnancy and delivery care services as a key solution to reducing maternal mortality
+Respectful maternity care during labour & delivery is a basic human right 
+All of the above are true
+
+
+Which of the following statements is true regarding respectful maternity care?
+
+
+01
+05
+D
+
+Learning Objectives
+Understand the different types of disrespect and abuse during childbirth
+Know the definitions of respectful maternity care and abuse during childbirth
+Understand the problems associated  with disrespect and abuse
+Brainstorm ways to improve this problem in your own facility
+
+
+The Facts
+Section 2
+
+Disrespectful maternity care is a GLOBAL problem:
+
+In Kenya:
+non-dignified, non-consensual care, and physical abuse are the most common types of D&A
+Disrespect and abuse (D&A) in the delivery room is associated with negative delivery experience and poor maternal care quality
+
+Disrespect and abuse are some of the main barrier to achieving improved maternal health outcomes worldwide
+				
+			
+		
+
+
+
+20% 
+
+Of women in kenya report D&A in childbirth
+Every day in countries all around the world….
+ 
+Pregnant women seeking maternity care from the health systems in their countries instead receive ill treatment that ranges from relatively subtle disrespect of their autonomy and dignity to outright abuse: physical assault, verbal insults, discrimination, abandonment, or detention in facilities for failure to pay.
+This is a global problem. Reports and studies of women’s experiences come from countries all around the world.
+Some of us have known about this problem for a long time, and have witnessed or even experienced it ourselves, but we did not know who to tell or what to say.  Perhaps in your facility, some of these behaviors are accepted as “normal” or harmless. In this way, a "veil of silence" has covered up the humiliation and abuse suffered by women seeking maternity care.
+There is little formal research on the prevalence and factors that contribute to this problem, and as a result we don’t know enough about effective interventions to eliminate disrespect and abuse. More research is still needed.
+In addition, to date there is no agreement on what Respectful Maternity Care means.  It is clear, however, when we look at international human rights standards, that disrespect and abuse is a violation of women’s basic human rights.
+
+
+Sustainable development goals and RMC go hand in hand
+SDG 3.1: Ensure health lives and promote well-being for all at all ages: reduce the global maternal mortality ratio to less than 70 per 100,000 live birth
+To achieve the sustainable development 2030 goals developed by the World Health Organization (WHO), stakeholders and relevant institutions should consider respectful pregnancy and delivery care services as a key solution to reducing maternal mortality
+(Goal 3.1: Ensure health lives and promote well-being for all at all ages: reduce the global maternal mortality ratio to less than 70 per 100,1000 live birth), 
+
+Definitions
+Section 3
+
+
+Respectful Maternity Care (RMC):
+
+		 	 	 		
+			
+
+				
+			
+		
+
+is an approach to care which emphasizes the fundamental rights of women, newborns, and families
+
+
+
+Disrespect and Abuse (D&A)
+
+		 	 	 		
+			
+				
+			
+		
+
+
+is defined as abuse, violence, and inhuman or humiliating care that can occur both individually (by health care workers) and structurally (by systematic environmental defects)
+
+Categories of disrespect include:
+Physical abuse
+Non-consensual care
+Non-dignified care/Verbal abuse
+Non-confidential care
+Discrimination
+Abandonment 
+Detention
+We will go over each type of abuse and after some, there will be quotes from real patients
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Physical Abuse
+
+All physical contact with our patients should be as gentle, comforting, and reassuring as possible
+
+Freedom from physical abuse is the right of each of our patients
+Examples include:  hitting, slapping, pushing or roughly touching a woman.  May also include being restrained or laceration repair without anesthesia
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Non-consensual care
+Language, educational, and cultural background may vary among our patients
+All need careful explanation of proposed procedures in a language and at a level they can understand so that they can consent to or refuse a procedure
+The freedom to consent to or refuse care is the right of each of our patients
+Coerced cesarean sections, non-consented vaginal exams, etc are examples of non-consented care
+
+Very important that it is being explained in a language and at the appropriate level.  A birth companion can be useful here
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+“We want nurses who are kind, who would be patient enough to tell us what is happening to us. Most of them (nurses) do not….”
+Two studies described women’s experiences of receiving care without having been given adequate information by their provider in order to make an informed decision. One study found that 55% of women experienced non-consented care for procedures such as labor augmentation, sterilization and cesarean delivery. 
+
+Another study examined overall satisfaction with the quality of maternal and child health services included a random sample of over 400 households. Most women expressed frustration with the lack of comprehensive information given to them when receiving maternity care
+
+
+
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+
+
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+
+
+
+
+
+
+Discrimination
+All women are equally worthy of our respectful care regardless of ethnic background, culture, social standing, educational level or economic status
+
+Discrimination is never okay. Non-discrimination is the right of each of our patients
+
+Discrimination often occurs towards poor or young mothers
+
+This is not always on the basis of race.  Many women are discriminated against because of their HIV status
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Abandonment of care
+A woman in labor or immediately after birth should never be left alone without a way to get ahold of a healthcare provider.
+
+Attentive care is the right of each of our patients
+
+Women should be able to have a companion of their choice to provide continuous support
+
+
+May occur before, during or after labour
+
+A woman in labor or immediately after birth should never be left alone. If you must leave your patient, tell her when to expect your return and how to get help if needed
+
+Attentive care is the right of each of our patients
+
+Women should be able to have a companion of their choice, such as a family member or community doula, with them throughout labor and birth at the health facility to provide continuous support
+
+
+
+
+
+
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+
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+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Detention in facilities
+A woman or her baby should never be forcibly kept in a facility
+
+Freedom from detention is the right of each of our patients
+
+
+This often occurs because of an inability to pay
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Non-dignified care/Verbal abuse
+Every woman we care for is a person of value and is worthy of our respect
+
+We must honor the dignity of each woman
+
+Dignified care is the right of each of our patients
+
+
+
+May include: intentional humiliation,blaming, rough treatment, scolding, shouting and name calling
+
+Every woman we care for is a person of value and is worthy of our respect
+
+We must honor the dignity of each woman in our words, our actions, and all of our non-verbal communication
+
+Dignified care is the right of each of our patients
+
+
+
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+
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+
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+
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+
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+
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+
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+
+
+
+
+
+“I think the attitudes of our nurses are bad because they have no respect or mercy for a patient and they insult patients without been provoked.”
+Eight cross-sectional survey studies measured women’s experiences of negative health worker attitudes. The percentage of women who reported negative attitude ranged widely from 11% to 71%
+
+
+
+
+
+
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+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+Non confidential care
+Patients have a right to privacy and confidentiality 
+
+This includes during counseling, physical examinations, and clinical procedures, as well as in the staff ’s handling of patients’ medical records and other personal information
+
+Confidential care is a right of each of our patients
+
+
+
+
+May include: being examined without partition, being asked private questions in the presence of others, or delivery in public view
+
+Patients have a right to privacy and confidentiality during the delivery of services
+
+This includes privacy and confidentiality during counseling, physical examinations, and clinical procedures, as well as in the staff ’s handling of patients’ medical records and other personal information
+
+Confidential care is a right of each of our patients
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+“There was not enough space in the labor room…and they don’t have the facilities. There were only two rooms and about 4 doctors…you could hear them (doctors) talking to other women.”
+Many studies provide information about violations of women’s privacy or confidentiality by care providers. The often reveal a lack of privacy at facilities due to limited physical space
+
+One study estimated that roughly 20% of women in rural hospitals reported that confidential information—including age, medical history and HIV status—was shared with third parties without their consent
+
+Impact of disrespect and abuse
+Section 4
+
+The concept of “safe motherhood” is usually restricted to physical safety, but safe motherhood is more than just the prevention of death and disability
+
+It is respect for women’s basic human rights
+Disrespect and abuse during facility-based childbirth have a negative impact on skilled birth care utilization
+
+Fear of disrespect and abuse may sometimes be a more powerful deterrent to the use of skilled birth care than geographic and financial obstacles
+A recent population-based study in Tanzania by Kruk and colleagues that examined women’s choices showed that “provider attitude” was the highest predictor, along with availability of commodities, of women’s choice to use facility-based childbirth services. It mattered to women more than cost, distance, and lack of availability of free transport (obstacles often cited in discussions about skilled care utilization).
+
+
+Discussion
+Section 5
+We believe that everyone has a part they can play to promote Respectful Maternity Care. Open discussion will allow us to develop a deeper understanding and to allow us ALL to strategize effective programs, policies and advocacy to ensure that every woman's right to respectful care at birth is upheld.
+
+
+
+
+					 				
+			
+		
+
+
+❝ You just call until you get tired and then you finally deliver by yourself and die. I have even witnessed it myself ❞
+
+Is this a problem that you have seen or heard about in  maternity care facilities in your community or country?
+
+
+Is this a problem that you have seen in your facility?  Is there anybody working on this problem?  What kinds of solutions are being tried and what is working?  What would you suggest to prevent abuse and disrespect of women cared for in your facility?
+
+
+
+
+					 				
+			
+		
+
+
+❝ One nurse told me: 'Lady, can't you see that you are in the way? Go over there, you aren't anything but an animal and talking to you is like talking to an animal❞
+
+What does Respectful Maternity Care look like? What other factors impact Respectful Maternity Care? 
+
+
+What do you think Respectful Maternity Care should look like? That may not be the care that is considered “normal” for your facility or culture. What other factors contribute to respectful care?
+How can providers support respectful care of their patients AND respectful treatment of providers? What has been your experience in introducing this?
+
+
+
+
+					 				
+			
+		
+
+
+“When I got the bill, the doctor said to me, 'Since you have not paid, we will keep you here.”
+
+
+What do healthcare workers need to provide Respectful Maternity Care?
+
+
+
+Health workers should expect respectful treatment:
+Health care workers want to perform their duties well, but they must have administrative support and critical resources to be able to deliver the high-quality services to which patients are entitled. Lack of support, chronic staff shortages and lack of resources can lead to chronic frustration for providers and staff.
+Acknowledging that patients have a right to expect certain things when they come for services is a powerful concept, and has implications for staff behavior and performance. Recognizing that service providers and other staff have needs that must be met if they are to provide quality services can be a motivating force among staff and supervisors. 
+
+
+The Needs of Health Care Workers
+Facilitative supervision and management: Health care staff function best in a supportive work environment in which supervisors and managers encourage quality improvement and value staff. Such supervision enables staff to perform their tasks well and thus better meet the needs of their patients.
+Information, training, and development: Health care staff need knowledge, skills, and ongoing training and professional development opportunities to remain up-to-date in their field and to continuously improve the quality of services they deliver.
+Supplies, equipment, and infrastructure: Health care staff need reliable, sufficient inventories of supplies, instruments, and working equipment, as well as the infrastructure necessary to ensure the uninterrupted delivery of high-quality services.
+
+
+
+Questions?
+
+Post Test
+Section 9
+
+Non-consented care
+Non-confidential care
+Abandonment 
+Physical abuse
+
+
+Repairing a perineal laceration without offering a mum any form of anesthesia is an example of which of the following?
+01
+01
+D
+
+Discrimination
+Non-consented care
+Detention 
+Non-confidential care 
+
+
+
+Telling a mum she must undergo a CS without explaining why is an example of which of the following?
+
+01
+02
+B
+
+Non-consented care
+Discrimination
+Detention
+Physical abuse
+
+
+Forcing a mum to stay in a facility because she is unable to pay her bill is an example of which of the following?
+
+01
+03
+C
+
+
+Provider attitude
+Cost of birthing services
+Cleanliness of facility
+Facility reputation
+
+
+
+
+Which of the following is the biggest predictor of a women’s choice to use facility-based childbirth services?
+01
+04
+A
+
+Not explaining a procedure to a woman in a language she understands is a form of disrespect and abuse 
+We should consider respectful pregnancy and delivery care services as a key solution to reducing maternal mortality
+Respectful maternity care during labour & delivery is a basic human right 
+All of the above are true
+
+
+Which of the following statements is true regarding respectful maternity care?
+
+
+01
+05
+D
+
+Additional Video Resources:
+
+Video on respectful maternity care

docs/Resuscitation of the newborn.txt

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+A Case Study
+Mum arrives at the facility with abdominal pain
+
+She experiences SROM, meconium found on VE
+
+
+27 yo G1 arrives at the hospital ℅ laps x 4 hours
+OB hx: uncomplicated
+Medical history: uncomplicated
+Exam: baby longitudinal, vertex, SVE: 5cm
+Vitals: Temp 37C, BP 142/78 RR 16
+Mum found to be fully dilated
+She pushes and delivers a LFI with respiratory distress
+Baby quickly passed off to receiving nurse
+Diagnosis?  What do we do next? 
+
+Resuscitation of the newborn
+Updated March 2022
+
+Pre-Test
+Section 1
+
+
+10%
+30%
+60%
+80%
+
+
+
+What % of newborn birth asphyxia can be predicted prior to delivery?
+01
+01
+C
+
+Slightly flexed
+Slightly extended
+Neutral
+Fully extended
+Fully flexed
+
+
+During ventilation in neonatal resuscitation, the infant’s head should be:
+
+01
+02
+B
+
+
+Size 0
+Size 1
+Size 2
+Size 3
+
+
+Which size of facemask is appropriate for ventilating a term infant?
+01
+03
+B
+
+
+Ventilation should ALWAYS be preceded by adequate suctioning of the infant’s oro/nasopharynx
+Ventilation should begin with external oxygen, never room air
+Adequate ventilation should always result in appropriate chest rise
+Ventilation mask should cover ONLY the infant’s chin and mouth
+
+
+Which of the following is true regarding ventilation in the setting of neonatal resuscitation?
+01
+04
+c
+
+< 30 beats per minute
+< 60 beats per minute
+< 80 beats per minute
+< 100 beats per minute
+
+
+At what newborn heart rate is it appropriate to begin chest compressions? 
+
+01
+05
+B
+
+Learning Objectives
+Describe the risk factors for birth asphyxia
+Effectively prepare for neonatal resuscitation
+List the steps for neonatal resuscitation
+Understand proper neonatal ventilation techniques
+
+
+Neonatal resuscitation facts : 
+
+5-10%
+Of babies require basic stimulation at birth
+
+3-6%
+Of babies require basic resuscitation techniques
+
+~1%
+Of babies require advanced resuscitation techniques
+ 
+
+
+Each year approximately 10 million babies do not breathe immediately at birth, of which about 6 million require basic neonatal resuscitation. The major burden is in low-income settings, where health system capacity to provide neonatal resuscitation is inadequate				
+~5 million 
+Neonatal deaths occur globally each year
+
+~1 million  
+Of these deaths are related to birth asphyxia
+
+
+
+Definitions
+Section 3
+
+Neonatal Asphyxia:
+		 	 	 		
+The failure to establish breathing at birth is one of the primary causes of early neonatal mortality	
+Neonatal resuscitation:
+Is a set of interventions at time of birth to support the establishment of breathing and circulation 
+	
+				
+					
+				
+			
+		
+
+
+
+Preparation
+Section 3
+
+Important to note:	
+
+
+For many babies, the need for resuscitation cannot be anticipated before delivery. Therefore be prepared for resuscitation at every delivery!
+				
+			
+		
+
+
+
+
+Supplies/
+equipment required for resuscitation:
+A firm stable surface
+Source of heat (e.g., heater, heater lamp or resuscitaire)
+Adequate lighting
+Source of oxygen, flowmeter, tubing and key
+Pulse oximeter
+Suction equipment i.e. suction machine, suction catheters sizes F6, 8, 10
+Bag valve device (ambu bag,) size, 200 to 300 ml for neonates <5kgs
+Face masks sizes 0 and 1, preferably round
+Wall clock
+At least two pieces of warm dry linen
+Syringes and needles/swabs, (preferably 1ml, 2ml and 10mls
+Stethoscope 
+Airways sizes: 000, 00, 0
+Nasal prongs
+Nasogastric tube size F4, F6 and F8 can be used as umbilical catheter
+Scissors and tape  						
+					 				
+			
+		
+
+
+
+The Golden minute
+Section 3
+
+The Golden minute
+Refers to the first 60 seconds of an infant’s life. Within these limited seconds, the infant should begin breathing on his or her own, or interventions must be started…
+
+Only 60% of asphyxiated newborns can be predicted antepartum.  The remaining newborns are not identified until the “Golden Minute,” which is why preparation is CRITICAL
+
+Resuscitation
+procedure
+Section 3
+
+Initial steps:
+Continued resuscitation efforts:
+	
+Position the airway
+Clear secretions only if copious and/ or obstructing the airway
+Ventilate and oxygenate (room air) 
+				
+			
+		
+
+3
+2
+1
+The Golden minute
+Ask yourself these questions:
+Is this a term gestation?
+Is the baby crying or breathing?
+Is there appropriate muscle tone in the baby?
+If the answer is NO to any of these questions, you have one minute to begin resuscitation:
+
+
+Initial resuscitation efforts:
+Dry and stimulate the baby
+Keep warm and maintain normal temperature
+
+
+
+The ABC’s - AIRWAY
+Positioning the neonate:
+Neonate should be placed in ‘sniffing position’ - better at maintaining airway patency
+May need to be supported with a towel at the shoulders to maintain airway patency
+SNIFFING POSITION: neonate positioned on the back with head and neck slightly extended
+
+The ABC’s - AIRWAY
+
+Suctioning
+Routine suctioning is NOT recommended
+Suctioning should be reserved for babies who have OBVIOUS airway obstruction/secretions
+Suctioning can cause bradycardia during resuscitation
+PROCEDURE:
+Discuss with mum or birth companion what is happening
+Using the penguin/bulb sucker:
+Squeeze the bulb suction device and place it in the baby’s mouth
+Release the sucker while in the baby’s mouth to create negative pressure
+Remove from mouth and squeeze secretions onto gauze
+Repeat as necessary
+
+The ABC’s - Breathing
+
+Breathing assessment:  Look→Listen→Feel
+Look at the chest - is there movement?
+Listen for breath sounds - can you hear breaths?
+Feel for air on your cheek - is there air movement?
+It is important to recognize which pattern of breathing is occurring in the neonate:
+Normal breathing pattern
+Gasping for breath
+Not breathing
+
+The ABC’s - Breathing
+Ventilation:
+If gasping or no breathing, recheck the newborn’s position. The neck should be slightly extended
+Infant ventilation bag (200 - 300ml) round face masks 
+Size 0 for preterm
+Size 1 for term infant
+Place the mask on the newborn’s face. It should cover the chin, mouth and nose 
+Ventilation should begin with room air, proceed to oxygen if no improvement 						
+					 				
+			
+		
+
+Ventilation procedure:
+Place mask to cover chin, mouth and nose
+Form a seal
+Squeeze bag attached to them ask with two fingers or whole hand about 40-60 times per minute x 1 minute
+Watch chest for movement
+do not over inflate
+allow baby to breathe out
+If chest is not rising, correct position and try again
+
+The ABC’s - Breathing
+
+Corrective ventilation steps:
+Adjust mask to ensure good seal
+Reposition infant head to slightly extended position
+Suction mouth and nose if secretions now visible
+Open mouth slightly and move jaw forward
+Increase ventilation pressure to achieve chest rise
+Consider airway alternative (intubation)	
+					 				
+			
+		
+
+
+The ABC’s - Circulation
+
+After one minute of ventilation, check infant pulse.  This can be done by:
+Umbilical pulse
+Stethoscope
+Pulse oximeter
+
+HR should be counted over 5-10 seconds
+If estimated at <60bpm, begin chest compressions at ratio of 3 compressions for every 1 ventilation
+
+The ABC’s - Circulation
+Performing chest compressions:
+Use TWO THUMBS technique to compress the chest (1 cm below the line connecting the nipples and the sternum) pushing down 1/3 the depth of the chest 
+Compression rate - 3:1
+Minimize interruptions
+When performing chest compressions, use 100% oxygen during ventilation 
+**Note: chest compressions should ONLY be performed if two providers available
+
+Notes on resuscitation
+Section 3
+
+During neonatal resuscitation, you should NOT:
+Hold the baby upside down
+Slap the baby at any time
+Perform routine suctioning of the upper airway
+Perform routine suctioning of the nose/mouth or trachea EVEN in babies born with meconium stained fluid
+			
+
+
+
+
+
+Use of medications
+Section 3
+
+Medications for neonatal resuscitation
+4
+3
+1
+2
+Considerations
+If blood loss identified
+Blood transfusion may be warranted
+If medications indicated:
+Consider use of epinephrine (adrenaline) +/- volume expanders
+Most newborns improve without medications
+Before considering drugs, check the effectiveness of ventilations/chest compressions
+Medications indicated if bradycardia persists beyond:
+Optimal  ventilation
+Effective chest compressions
+Intubation
+
+Epinephrine (Adrenaline)
+Repeat
+Dosage
+Dilute
+Use
+Use when bradycardia persists despite optimal ventilation, chest compressions and intubation
+				
+			
+		
+
+Adrenaline 1:1000 - dilute to make 1:10,000 by taking 1ml of 1:1000 adding 9 mls of water for injection to make 10 mls 
+				
+			
+		
+
+				
+			
+		
+
+
+		 	 	 						Using the diluted strength, give 0.1ml/kg intravenously  						
+					 				
+			
+		
+ 
+				
+			
+		
+
+		 	 	
+Repeat dose up to 3 times at intervals of 5 minutes  						
+					 				
+			
+		
+
+					 				
+			
+		
+
+
+When to stop resuscitation
+Section 3
+
+		 	 	 Consider stopping after 20-30 minutes of effective resuscitation if the baby: 
+				
+			
+		
+
+
+
+		 	 	 		
+Has no spontaneous respiration or has an occasional gasp
+Pupils are dilated and fixed
+Heart rate is slow or absent
+Colour is not improving with bagging  						
+					 				
+			
+		
+			
+			
+		
+
+
+
+
+
+
+
+
+Questions?
+
+Post Test
+Section 8
+
+
+10%
+30%
+60%
+80%
+
+
+
+What % of newborn birth asphyxia can be predicted prior to delivery?
+01
+01
+C
+
+Slightly flexed
+Slightly extended
+Neutral
+Fully extended
+Fully flexed
+
+
+During ventilation in neonatal resuscitation, the infant’s head should be:
+
+01
+02
+B
+
+
+Size 0
+Size 1
+Size 2
+Size 3
+
+
+Which size of facemask is appropriate for ventilating a term infant?
+01
+03
+B
+
+
+Ventilation should ALWAYS be preceded by adequate suctioning of the infant’s oro/nasopharynx
+Ventilation should begin with external oxygen, never room air
+Adequate ventilation should always result in appropriate chest rise
+Ventilation mask should cover ONLY the infant’s chin and mouth
+
+
+Which of the following is true regarding ventilation in the setting of neonatal resuscitation?
+01
+04
+C
+
+< 30 beats per minute
+< 60 beats per minute
+< 80 beats per minute
+< 100 beats per minute
+
+
+At what newborn heart rate is it appropriate to begin chest compressions? 
+
+01
+05
+B
+
+Video on neonatal resuscitation

docs/Safe neonatal transfer.txt

@@ -0,0 +1,446 @@
+A Case Study
+Mum arrives at the facility with abdominal pain 
+Baby is delivered by SVD crying and active 
+
+
+27 yo G1 arrives at the hospital 
+OB hx: uncomplicated, 27+5 weeks gestation
+Medical history: uncomplicated
+Exam: baby longitudinal, vertex, SVE: 5cm
+SVD delivery
+Baby is pink and active, birth weight 1050g
+Vitals: HR: 120bpm, RR: 60bpm, Sats 90% in air
+Crying 
+What do we do next? What is important?
+Description of extreme prem, will require NICU care and therefore transfer 
+
+Safe Transfer Requirements : Session 7 
+July 2023
+Written with assumed use of transfer from Level 4 to Level 5 in Kakamega so with available resources (i.e. there is no transport incubator with full monitoring, IV pump and giving set availability and mobile CPAP/ventilation) - not gold standard for high resource setting. 
+
+Pre-Test
+Section 1
+
+
+>2500g
+999g-1499g
+<1000g
+>1499-2500g
+
+
+
+01
+01
+What is the definition of a extremely  low birth weight baby (ELBW)
+C
+
+
+
+
+Newborn <1000g and sick unstable <1500g
+Birth asphyxia baby (no convulsions)
+<28 weeks gestation newborn
+Gastroschisis 
+
+
+
+
+Which of the following scenarios DOES NOT require transfer to a neonatal intensive care unit? 
+01
+02
+B
+
+
+
+Wrap in blanket and hat 
+Transport warmer 
+Plastic wrap 
+Kangaroo mother care position with mother 
+
+
+What is the preferred method of thermal care for transfer? 
+01
+03
+D - Kangaroo mother care
+
+
+
+This baby can breastfeed prior to transfer 
+It can  occur in preterm and term babies 
+The abdominal contents are not covered by a sac 
+The baby (ideally) needs to be stabilised with IV cannula and fluids prior to transfer 
+
+
+
+01
+04
+Which of the following statements is FALSE regarding a baby with Gastroschisis?
+
+A
+
+
+Maternal and delivery history 
+Condition of the baby at transfer 
+Management of baby prior to transfer 
+Reason for transfer
+All of the above
+
+
+What is essential  to include in the referral letter and phone communication with the referral site?
+01
+05
+E
+
+Learning Objectives
+Identify which newborns require transfer to another facility (Level 5) 
+Outline the key steps in the early management and stabilisation 
+Understand the key components for a safe transfer: extreme prem, sick term babies and surgical cases
+Determine how to achieve this in your facility 
+
+
+The Facts
+
+Safe Transfer 
+Not all babies are delivered and able to stay in the facility they were born in.  Transfer to their nearest intensive care or surgical unit needs to be safe, planned and well communicated. This is not always easy to achieve. Neonatal interfacility transport is a key aspect of perinatal care.
+~135 million 
+
+Live births in 2020 
+~2.3 million 
+Neonatal deaths worldwide 
+
+Neonatal transport  
+3 delays model 
+Delay in deciding to seek care
+Delay in reaching an appropriate facility 
+Delay in receiving adequate care 
+The phases of delay that affect transport and the timely arrival to specialty neonatal care. Such critical delays are a major contributing factor to neonatal mortality. These delays include: (I) delays in deciding to seek care for reasons that include socioeconomic and cultural factors, (II) delays in reaching an appropriate medical facility, and (III) delays in receiving adequate care once at an appropriate medical facility due to poorly staffed, equipped, and managed facilities
+
+Definitions
+Remember our previous definitions 
+
+LOW BIRTH WEIGHT DEFINITIONS  
+Categorized according to WHO/international guidelines (ICD-10) into 5 groups.
+Low birth weight (LBW) defined : greater than 1499g and less than 2500g
+Very low birth weight (VLBW) :  greater than 999g and less than 1500g
+Extremely low birth weight (ELBW):   less than 1000g
+Appropriate weight for term gestational age: 2500g to 4000g
+Big baby:  defined as birth weight greater than 4000g
+
+Small for Gestational Age Baby: Any baby whose birth weight falls below the 10th percentile for that gestational age
+
+ELBW and sick VLBW ideally need to be managed in a neonatal intensive care unit - and need SAFE transfer
+ELBW ideally need to be managed in an neonatal unit capable of intensive care (NICU) (<1000g). 
+Babies <1500g need to be assessed and if sick consideration needs to be made for transfer to a NICU
+
+PRETERM DEFINITIONS  
+Gestational age: 
+Term birth: delivery occurring between 37 and 42 weeks of gestational age
+Preterm birth: delivery occurring before 37 weeks of gestational age
+Moderate to late preterm: 32 to <37 weeks of gestational age
+Very preterm: 28 to 32 weeks of gestational age
+Extremely preterm: < 28 weeks of gestational age
+Post-term birth: delivery occurring after 42 weeks of gestational age
+
+<28 weeks and sick <32 weeks ideally need to be managed in a neonatal intensive care unit - and need SAFE transfer
+Extreme preterm <28 weeks need NICU 
+Need to consider for <32 weeks depending on how well they are
+
+Surgical: Gastrointestinal  
+
+
+Gastroschisis babies are good babies (likely no other anomalies) with bad guts
+Omphalocele babies are bad babies (i.e likely other genetic anomalies) but good guts 
+
+Pictures from: https://sonographictendencies.com/2016/12/15/omphalocele-vs-gastroschisis/ 
+
+Surgical: Neural tube defects: Spina Bifida
+Occur when the neural tube does not close properly  
+The 2 main most common:  
+Spina bifida (spinal cord defect)              2.    Anencephaly  (brain defect)
+
+
+Myelomeningocele is most likely to 
+need transfer to a neurosurgical unit 
+for review and management 
+
+Highlight the importance of folic acid in pregnancy advised to prevent neural tube defects
+
+Myelomeningocele (sounds like: my-low-ma-nin-jo-seal; hear how “myelomeningocele” sounds)
+When people talk about spina bifida, most often they are referring to myelomeningocele. Myelomeningocele is the most serious type of spina bifida. With this condition, a sac of fluid comes through an opening in the baby’s back. Part of the spinal cord and nerves are in this sac and are damaged. This type of spina bifida causes moderate to severe disabilities, such as problems affecting how the person goes to the bathroom, loss of feeling in the person’s legs or feet, and not being able to move the legs.
+https://www.cdc.gov/ncbddd/spinabifida/facts.html
+Meningocele (sounds like: ma-nin-jo-seal; hear how “meningocele” sounds)
+Another type of spina bifida is meningocele. With meningocele a sac of fluid comes through an opening in the baby’s back. But, the spinal cord is not in this sac. There is usually little or no nerve damage. This type of spina bifida can cause minor disabilities.
+
+Spina Bifida Occulta (sounds like: o-cult-tuh; hear how “occulta” sounds)
+Spina bifida occulta is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, spina bifida occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.
+
+
+Considerations before transport
+
+Who are the most likely transfers?   
+Birth Asphyxia (sick)
+
+Uncontrolled Seizures
+Coma
+Requiring significant respiratory support 
+Premature
+Sepsis (sick)  
+Surgical   
+<32 weeks/<1500g
+Dangers signs 
+Requiring respiratory support - consider: 
+Need for  surfactant
+Need for ventilation/CPAP
+ 						
+					 				
+			
+		
+
+Requiring significant respiratory support
+Cardiovascular instability 
+Coma
+Gastroschisis
+Omphalocele
+CNS malformations
+Neural tube defects 
+Please make a comment this list is NOT an exhaustive list of neonatal cases requiring transfer to an NICU. Use this time for them to discuss their own cases and which ones ideally require transfer to a Level 5.
+Timely referral of the pregnant woman and in utero transport of the undelivered fetus has been shown to improve outcome for a variety of neonatal medical conditions in the developed world, including extreme prematurity and complex congenital malformations - so this should be the first step before delivery if possible!
+If this cannot happen then the baby needs to be stabilised as much as possible before transfer 
+
+Key factors to consider 
+Can the mother and baby be transferred together?
+(Aim as much as possible) to support breastfeeding and thermal control (skin to skin)
+Can the baby be stabilised before transfer?
+Length of time of transport
+Mode of transport - private or ambulance?
+What personnel are available? 
+Doctor/Midwife/Neonatal nurse
+None
+Can discuss: The likely situation is there are no HCP to travel with the baby with minimal equipment so how do you keep warm and give oxygen if in resp distress?
+
+Key factors to consider 
+In the literature  -> neonatal transport:  
+High rates of hypothermia on arrival = increased risk of mortality
+High rates of desaturation = increased risk of mortality 
+What can be done?
+Skin to skin appropriate?  - need for effective thermal regulation
+Need for supplemental oxygen in transport 
+Pulse oximeter/monitoring  in the ambulance 
+Equipment availability and functionality?
+Supplemental Oxygen 
+Pulse oximeter 
+Warmer 
+IV fluids 
+Literature in low-resource settings 
+
+Basic interventions before transport 
+Remember our previous definitions 
+
+Assessment and Stabilisation 
+
+TOPS assessment
+Temperature 
+Oxygen saturations 
+Perfusion (Capillary refill time) 
+Blood sugar 
+Airway and Breathing; Oxygen 
+Clear airway  - only if needed
+Place ALL sick babies on oxygen if possible for transfer - they all will benefit from oxygen if available 
+Feeds/fluid:
+Consider need for IV bolus prior to transfer
+Consider IV fluids for transfer if long and can be done SAFELY
+Consider need for dextrose bolus (2ml/kg 10% dextrose)
+Infection:
+Commence IV antibiotics for presumed neonatal sepsis:
+IV Benzylpenicillin 50,000iu/kg BD
+Gentamicin (3mg/kg OD <2kg OD, 5mg/kg OD >2kg)
+
+TOPS is an acronym for a basic assessment prior to transfer - https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-05060-9 for more information
+Oxygen benefits the prem/septic and HIE babies. 
+Feeds/fluid; make the point that a 28 week baby cannot receive a huge volume of fluid IV as will become unstable and so for transfer this needs to be done safely
+
+Communication
+
+Referral letter 
+Brief maternal/antenatal  history 
+Brief delivery details 
+Overview of condition of the baby 
+Referral site
+Pre-transfer phone call to referral site
+Can you call to prepare for the arrival 
+Brief overview of newborns condition 
+Parents:
+Inform the parents of need for transfer 
+Explain the condition of their baby and the need for higher level care
+Explain the importance of keeping warm throughout, ideally on oxygen and to discuss how best to feed (if appropriate)
+
+
+
+Reminder: Key factors 
+
+Hypothermia - kills
+Baby needs to be kept warm throughout the whole of transfer
+This is whether a premature or a term baby 
+Hypoglycaemia :
+Consider how to feed this baby 
+Length of time of transport 
+Stabilise if possible before transport
+Continue basic supportive care throughout
+Communication: referral letter essential 
+Equipment maintenance and function
+Inform the mother/carers of all decisions made and the process of transfer 
+Ensure the mother is informed of the need for transfer and why and also the process of what will happen
+
+Basic Interventions during transport 
+Remember our previous definitions 
+
+ABC and Thermal care  
+
+Airway 
+Ensure airway patent and suction if required prior to transfer; unlikely to be available during transfer 
+Breathing 
+Place on oxygen via nasal prongs 1-2L/min depending on need
+If possible and available attach pulse oximeter to measure saturations throughout transfer 
+Circulation: 
+Consider need for IV bolus prior to transfer
+Consider IV fluids for transfer if long and can be done SAFELY
+Consider need for dextrose bolus (2ml/kg 10% dextrose) and prepared if needed during transfer
+Thermal care
+Transfer in KMC position with mother where possible 
+If not possible use warmer if  available and functioning 
+
+Need to discuss here - personnel available for transfer - in most cases will likely be transferred with parents alone so no HCP therefore can’t administer care during transfer, need to consider the safety of travelling with an IV drip and fluids running and the risk of them stopping or running through causing fluid overload
+Oxygen benefits the prem/septic and HIE babies. 
+Feeds/fluid; make the point that a 28 week baby cannot receive a huge volume of fluid IV as will become unstable and so for transfer this needs to be done safely
+
+As per the validated standards (Standard 7), neonate should be transferred in KMC position where possible.
+Discuss the appropriateness of KMC position for transfer for thermal care or if warmer/transport incubator equivalent available and functioning - especially for extreme prem babies.
+Discuss if breastfeeding safe and appropriate during transfer 
+
+Surgical cases 
+
+Gastroschisis  
+
+These babies need stabilisation PRIOR to transfer  - this significantly improves their outcome
+Wrap bowel in clingfilm or sterile bag
+NBM and insert NGT for aspiration on free drainage
+Insert cannula and start IVF at 60mls/kg/day
+Consider if IV bolus needed 
+Broad spectrum antibiotics : Benzylpenicillin, Metronidazole and Gentamicin
+Inform the paediatric surgical team directly
+Primary repair can be considered on day 1 if infant is < 6 hours old and all the bowel  is viable
+ If there are signs of sepsis or distended bowels, then a silo bag is applied by the surgeons
+The diagnosis of exomphalos and gastroschisis is often, but not always, made during antenatal ultrasound
+The abdominal abnormality should be covered with cling wrap taking care to prevent kinking or trauma to bowel - prevents heat and fluid loss which is essential for transport 
+Cotton wool adheres to the bowel wall, cannot be fully removed and causes peritoneal granulomas; 
+Moist packs rapidly become cold and lead to hypothermia
+Primary repair is considered on day 1 if infant is less than 6 hours old and all bowel is viable
+ If there are signs of sepsis or distended bowels, then a silo bag is applied by the surgeons (shown in picture) .
+ 4. Counsel and educate parents  - Encourage parental bonding
+
+
+
+
+Omphalocele  
+
+These babies need stabilisation PRIOR to transfer  - this significantly improves their outcome
+
+Wrap bowel in clingfilm or sterile bag
+Prevents heat and fluid loss
+NBM and insert NGT for aspiration on free drainage
+Insert cannula and start IVF@ 60mls/kg/day, 
+Broad spectrum antibiotics : Benzylpenicillin, metronidazole and gentamicin
+Requires paediatrician review for other associated congenital abnormalities
+Small thorax with a varying degree of pulmonary hypoplasia - so respiratory distress is likely 
+Consider the need for oxygen on transfer 
+
+Counsel and educate the parents early and encourage parental bonding
+This defect is most often through the umbilical cord - so there will not be one visible as the contents of the abdominal cavity will be protruding through the defect.
+Cotton wool adheres to the bowel wall, cannot be fully removed and causes peritoneal granulomas; moist packs rapidly become cold and lead to hypothermia - therefore clingfilm ideal as prevents heat loss and fluid loss
+These babies often have associated congenital abnormalities 
+
+
+Myelomeningocele
+Sterility is key in the management of these babies and preventing meningitis and severe sepsis  - this significantly improves their outcome
+Maintain a sterile, latex-free environment
+Place the baby in a side-lying position to avoid pressure on the back lesion.
+Wrap the lesion in a sterile, saline-soaked gauze with an occlusive plastic wrap
+If large defect: Broad spectrum antibiotics : Benzylpenicillin, Metronidazole and Gentamicin
+Urgent neurosurgical review 
+NB: These babies can be born with significant hydrocephalus  depending on severity of the defect 
+The lesion should be dressed to minimize the potential for injury during transport: o Place infant prone, carefully dry upper body and legs, avoiding pressure on the lesion o Wrap lesion with sterile gauze soaked in warm saline o Cover lesion and abdomen with layers of occlusive plastic wrap 
+
+Questions?
+
+Post Test
+Section 11
+
+
+>2500g
+999g-1499g
+<1000g
+>1499-2500g
+
+
+
+01
+01
+What is the definition of a extremely  low birth weight baby (ELBW)
+C
+
+
+
+
+Newborn <1000g and sick unstable <1500g
+Birth asphyxia baby (no convulsions)
+<28 weeks gestation newborn
+Gastroschisis 
+
+
+
+
+Which of the following scenarios DOES NOT require transfer to a neonatal intensive care unit? 
+01
+02
+B
+
+
+
+Wrap in blanket and hat 
+Transport warmer 
+Plastic wrap 
+Kangaroo mother care position with mother 
+
+
+What is the preferred method of thermal care for transfer? 
+01
+03
+D - Kangaroo mother care
+
+
+
+This baby can breastfeed prior to transfer 
+It can  occur in preterm and term babies 
+The abdominal contents are not covered by a sac 
+The baby (ideally) needs to be stabilised with IV cannula and fluids prior to transfer 
+
+
+
+01
+04
+Which of the following statements is FALSE regarding a baby with Gastroschisis?
+
+A
+
+
+Maternal and delivery history 
+Condition of the baby at transfer 
+Management of baby prior to transfer 
+Reason for transfer
+All of the above
+
+
+What is essential  to include in the referral letter and phone communication with the referral site?
+01
+05
+E

docs/Shoulder dystocia_CME_updated May 2022.txt

@@ -0,0 +1,643 @@
+A Case Study
+Mum arrives at the facility with strong contractions
+
+But experiences adverse outcomes during delivery
+
+
+25 yr old G3P2+0 presents in labour at 41 weeks
+OB hx: 2 prior SVD
+Medical history: gestational diabetes, obese
+Exam: baby longitudinal, vertex, SVE: 9cm
+Mum proceeds to dilate fully
+Mum undergoes prolonged second stage
+Head ultimately delivers but shoulders are “stuck” 
+Diagnosis?  Risk Factors?  What do we do next? 
+
+Shoulder Dystocia
+Updated May 2022
+
+Pre-Test
+Section 1
+
+Macrosomic babies
+Gestational diabetes
+PRIOR shoulder dystocia
+Maternal obesity
+
+
+
+The #1 risk factor for shoulder dystocia is?
+01
+01
+C
+
+McRoberts maneuver
+Suprapubic pressure
+Call for help
+Evaluate the need for episiotomy
+
+
+
+Which of the following is the first step in the appropriate management of a shoulder dystocia?
+
+01
+02
+C
+
+20%
+40%
+60%
+80%
+
+
+McRoberts maneuver relieves what percentage of shoulder dystocia cases?
+
+01
+03
+B
+
+
+Brachial plexus injury
+Third- or fourth-degree episiotomy or tear
+PPH
+Soft tissue injury
+
+
+
+The most common maternal complication following a shoulder dystocia is:
+01
+04
+C
+
+Brachial plexus injury
+Third- or fourth-degree episiotomy or tear
+PPH
+Death
+Asphyxia
+
+
+The most common foetal complication following a shoulder dystocia is:
+
+
+01
+05
+A
+
+Learning Objectives
+Understand risk factors associated with shoulder dystocia
+Know the appropriate manoeuvers to effectively manage a shoulder dystocia
+List complications associated with shoulder dystocia
+Describe complications associated with shoulder dystocia
+
+The Facts
+Section 2
+
+Shoulder Dystocia:
+
+5-9%
+
+Of all births result in shoulder dystocia with infant weights of 4-4.5kg
+The overall incidence of shoulder dystocia varies based on fetal weight:
+**Although proportionally more babies undergo shoulder dystocia if they are macrosomic, the overall NUMBER of shoulder dystocia cases occur in babies that are normal weight!
+				
+			
+		
+
+
+
+.6-1.4% 
+
+Of all births result in a shoulder dystocia with infant weights of 2.5-4kg
+This is an important concept because although proportionally more babies undergo shoulder dystocia if they are macrosomic, the overall NUMBER of shoulder dystocia cases occur in babies that are normal weight!
+
+Definitions
+Section 3
+
+Shoulder dystocia is:
+
+		 	 	 		
+			
+The failure of the shoulders to spontaneously deliver following delivery of the baby’s head due to impaction of the shoulders behind the symphysis pubis 
+				
+			
+		
+
+Shoulder dystocia is NOT a soft tissue problem, this is a BONE ON BONE problem
+
+
+Risk Factors 
+Section 4
+
+**Important to recognize that many women with Shoulder dystocia have NO IDENTIFIABLE RISK FACTORS.  
+
+For others, risk factors may include…
+Previous shoulder dystocia
+Diabetes mellitus
+Maternal obesity BMI>30
+Abnormal pelvic anatomy
+Short stature of the mother
+Fetal abnormalities
+Fetal macrosomia in current pregnancy
+Previous large baby
+Induction of labour  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+
+Prolonged first stage of labour
+Prolonged second stage of labour, especially in the multiparous woman
+Assisted vaginal delivery (forceps/vacuum)
+Oxytocin augmentation of labour
+Secondary arrest of contractions/labour  						
+					 				
+			
+		
+ 						
+					 				
+
+
+Intrapartum 
+Risk Factors
+
+Antenatal
+Risk Factors
+Previous shoulder dystocia is the most common risk factor!
+
+
+Prevention of shoulder dystocia
+Section 5
+
+If shoulder dystocia suspected based on risk factors:
+
+
+
+
+EDUCATE: 
+
+Patient and family should be educated about steps that will be taken in event of difficult delivery 
+
+
+
+PREPARE PATIENT:
+
+Patient bladder should be emptied prior to delivery
+
+
+
+
+PREPARE ROOM:
+
+Delivery room should be cleared of clutter to accommodate additional personnel
+
+
+
+DELIVER THROUGH:
+
+Continuing momentum of foetal head delivery until the shoulder is visible
+
+
+
+“Deliver through” method - continuing momentum of foetal head delivery until the shoulder is visible. After controlled delivery of the head, physician proceeds with immediate delivery of the anterior shoulder without stopping to suction oropharynx 
+
+
+Further prevention measures
+GLYCAEMIC 
+CONTROL
+DELIVERY 
+POSITION
+PROPHYLACTIC 
+CS
+Glycaemic control and weight control for at risk patients is helpful in preventing foetal macrosomia
+Patients may also be encouraged to deliver in alternative positions that favour increased pelvic diameters (ex all fours)
+Consider prophylactic CS if:
+Estimated foetal weight >5000g without diabetes or
+Estimated foetal weight >4500g with diabetes
+
+Diagnosis of shoulder dystocia
+Section 6
+
+Shoulder dystocia
+May be diagnosed:
+When there is difficulty with delivery of the face and chin  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+ 						
+When the chin may retract and depress the perineum which is known as the turtle sign  						
+					 				
+			
+		
+	 				
+			
+		
+
+If the anterior shoulder of the baby fails to deliver with normal routine traction  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+
+
+Failure of restitution of the head  						
+					 				
+			
+		
+ 						
+					 				
+			
+		
+
+
+Treatment of shoulder dystocia
+Section 7
+
+HELPERR mnemonic: 
+A clinical tool that offers a structured framework for coping with shoulder dystocia 
+
+Baby should be delivered within 5 minutes of recognizing shoulder dystocia to prevent hypoxic injury!
+				
+			
+		
+
+					 				
+			
+		
+
+
+Call for HELP
+Evaluate the need for episiotomy
+
+Legs - McRoberts position
+
+Suprapubic pressure
+H
+Enter Maneuvers
+E
+L
+P
+E
+R
+R
+Remove posterior arm
+Roll patient to all fours (Gaskin)
+These maneuvers are designed to do one of three things:
+Increase the functional size of the bony pelvis through flattening of the lumbar lordosis and cephalad rotation of the symphysis pubis (i.e. the McRobert’s manoueuvre)
+Decrease the bisacromial diameter (i.e. the breadth of the shoulders) of the fetus through application of suprapubic pressure (i.e. internal pressure on the posterior aspect of the impacted shoulder)
+Change the relationship of the bisacromial diameter within the bony pelvis through internal rotation maneuvers.  						
+					 				
+			
+		
+
+
+Step 1:
+Call for HELP
+There is need to have a multi-disciplinary team and anticipate for neonatal resuscitation and surgical intervention 
+H
+E
+L
+P
+E
+R
+R
+
+Step 2:
+Evaluate the need for episiotomy
+Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required 
+H
+E
+L
+P
+E
+R
+R
+Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder. Because most cases of shoulder dystocia can be relieved with the McRobert's maneuver and suprapubic pressure, many women can be spared this surgical incision  						
+					 				
+			
+		
+
+
+Step 3: (Legs)
+McRoberts position
+This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen
+
+Reduces >40% of shoulder     dystocia
+
+H
+E
+L
+P
+E
+R
+R
+This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This in effect straightens the lumbosacral lordosis, Increases AP diameter of pelvis, Flexes the fetal spine and as a result Reduces >40% of shoulder dystocia. Nurses and family members present at the delivery can provide assistance for this maneuver  						
+					 				
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+Step 4: 
+Suprapubic pressure
+The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a downward and lateral motion on the posterior aspect of the fetal shoulder
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+The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. The aim is to adduct the anterior shoulder. This maneuver should be attempted while continuing downward traction. Initially this is continuous, but may involve a rocking motion 
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+Step 5: 
+Enter Maneuvers
+These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis 
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+Rubin II: apply pressure to posterior aspect of anterior shoulder
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+Rubin II + wood corkscrew:  anterior shoulder pushed towards baby’s chest, posterior shoulder pushed towards baby’s back
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+Reverse woods corkscrew: apply pressure to posterior aspect of posterior shoulder
+
+These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis.
+					
+Rubin Manoueuvre – apply pressure to posterior aspect of anterior shoulder
+Ask the woman not to push while you push the shoulders from behind the scapula toward the face of the baby; this will rotate the shoulders into oblique diameter				
+Rubin II + Wood’s screw maneuver: anterior shoulder pushed towards baby’s chest, posterior shoulder pushed towards baby’s back
+Rotates the posterior shoulder by 180 degrees in a screw like maneuver 
+Success of this maneuver allows easy delivery of that shoulder once it is past the symphysis pubis.
+Reverse Woods corkscrew:  apply pressure to posterior aspect of posterior shoulder
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+Step 6: 
+Remove the posterior arm
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+Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction  						
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+Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction. The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall. Grasping and pulling directly on the fetal arm may fracture the humerus.  						
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+Step 7: 
+Roll patient over (Gaskin maneuver)
+The patient rolls from her existing position to the all-fours position. This usually increases the pelvic diameters  						
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+The patient rolls from her existing position to the all-fours position. This usually increases the pelvic diameters. Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction. In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders  						
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+Maneuvers 
+of Last resort
+Clavicle fracture: Direct upward pressure on the mid-portion of the fetal clavicle 
+Zavanelli maneuver:Cephalic replacement followed by cesarean delivery
+Clavicle fracture: Direct upward pressure on the mid-portion of the fetal clavicle - important that pressure is upward as downward pressure can cause nerve/vessel damage
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+Zavanelli maneuver: Cephalic replacement followed by cesarean delivery - this is an emergency procedure and needs to take place as fast as possible with an obstetrician
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+
+Complications of shoulder dystocia
+Section 8
+
+Maternal Complications of shoulder dystocia include:
+Postpartum Hemorrhage (most common maternal complication)
+Uterine atony
+3rd or 4th degree perineal lacerations
+Vaginal or cervical lacerations
+Trauma
+Uterine Rupture
+Rectovaginal fistula
+Vaginal hematoma
+Bladder injury
+Pubic symphysis separation
+Femoral neuropathy
+Infection
+Endometritis
+Emotional and psychological stress
+Impaired parent-infant attachment 
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+Foetal Complications of shoulder dystocia include:
+Nerve palsies
+Brachial plexus injury (most common foetal complication)
+Erb-Duchenne Palsy 
+Klumpke’s Paralysis 
+Fractures of the clavicle and the humerus 
+Fetal asphyxia and sequelae
+Neurological damage
+Fetal death 
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+Brachial plexus injury
+Erb-Duchenne Palsy – Fifth and sixth cervical roots
+Klumpke’s Paralysis – Eighth cervical and first thoracic roots
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+
+Brachial Plexus injury 
+An injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to arm and hand
+Definition
+Limp or paralyzed arm, lack of muscle control in arm, hand or wrist
+Symptoms
+Brachial plexus injury is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand.  Signs and symptoms may include a limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand
+
+Erb-duchenne Palsy
+A paralysis of the arm caused by injury to C5-C6 in the spinal cord
+Definition
+The arm hangs by the side and is medially rotated, the forearm is extended and pronated
+Symptoms
+Erb's palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves
+The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm
+
+Klumpke’s paralysis
+Partial upper limb palsy affecting C7-T1
+Definition
+Affects primarily the intrinsic hand muscles and wrist flexors.  Classic “claw-hand” appearance with supinated forearm and hyperextended wrist and fingers
+Symptoms
+Klumpke's paralysis is a variety of partial palsy of the lower roots of the brachial plexus - C7-T1
+Symptoms include intrinsic minus hand deformity,paralysis of intrinsic hand muscles, and C8/T1 Dermatome distribution numbness. Involvement of T1 may result in Horner's syndrome, with ptosis, and miosis. Weakness or lack of ability to use specific muscles of the shoulder or arm
+
+Questions?
+
+Post Test
+Section 9
+
+Macrosomic babies
+Gestational diabetes
+PRIOR shoulder dystocia
+Maternal obesity
+
+
+
+The #1 risk factor for shoulder dystocia is?
+01
+01
+C
+
+McRoberts maneuver
+Suprapubic pressure
+Call for help
+Evaluate the need for episiotomy
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+
+
+Which of the following is the first step in the appropriate management of a shoulder dystocia?
+
+01
+02
+C
+
+20%
+40%
+60%
+80%
+
+
+McRoberts maneuver relieves what percentage of shoulder dystocia cases?
+
+01
+03
+B
+
+
+Brachial plexus injury
+Third- or fourth-degree episiotomy or tear
+PPH
+Soft tissue injury
+
+
+
+The most common maternal complication following a shoulder dystocia is:
+01
+04
+C
+
+Brachial plexus injury
+Third- or fourth-degree episiotomy or tear
+PPH
+Death
+Asphyxia
+
+
+The most common foetal complication following a shoulder dystocia is:
+
+
+01
+05
+A
+
+Additional Video Resources:
+
+Video on how to manage shoulder dystocia