How to read the guide HOW TO READ THE GUIDE 5 Content In each of the six clinical sections listed Recommendations for the management of Antiretroviral treatment of HIV infection in above there is a series of flow,treatment and The Guide includes routine and emergency care complications at secondary (referral) infants and children in resource-limited information charts which include: for women and newborns during pregnancy. health care level can be found in the following settings,towards universal access: guides for midwives and doctors: Recommendations for a public health labour and delivery,postpartum and post Guidance on routine care,including abortion,as well as key preventive measures approach Web-based public review, monitoring the well-being of the mother and/ Managing complications of pregnancy and 3-12 November 2005 MOH required to reduce the incidence of endemic and or baby. childbirth(WHO/RHR/00.7) other diseases like malaria,anaemia,HIV/AIDS http://www.who.int/hiv/pub/prev_care/en Early detection and management of and TB,which add to maternal and perinatal Managing newborn problems. WHO consultation on technical and complications. operational recommendations for scale-up morbidity and mortality. Preventive measures. Documents referred to in this Guide can be of laboratory services and monitoring HIV Advice and counselling. Most women and newborns using the services obtained from the Department of Making antiretroviral therapy in resource-limited Pregnancy Safer,Family and Community Health, described in the Guide are not ill and/or do not settings.http://www.who.int/hiv/pub/prev_ In addition to the clinical care outlined above, care/en ISBN 92 4 159368 7 have complications.They are able to wait in line World Health Organization,Geneva,Switzerland. other sections in the guide include: when they come for a scheduled visit.However, E-mail:mpspublications@who.int. Malaria and HIV Interactions and their the small proportion of women/newboms who Implications for Public Health Policy. Advice on HIV.prevention and treatment. are ill,have complications or are in labour,need http://www.who.int/hiv/pub/prev_care/en: Support for women with special needs. Other related WHO documents can be ISNB9241593350 urgent attention and care. Links with the community. downloaded from the following links: Interim WHO clinical staging of HIV/AIDS and Drugs,supplies,equipment,universal The clinical content is divided into six sections HIV/AIDS case definitions for surveillance precautions and laboratory tests which are as follows: Medical Eligibility Criteria 3rd edition: African Region.http://www.who.int/hiv/pub/ Examples of clinical records. http://www.who.int/reproductive-health/ prev_care/en Ref no::WHO/HIV/2005.02 Quick check(triage),emergency management Counselling and key messages for women and publications/mec/mec.pdf. HIV and Infant Feeding.Guidelines for families. Selected Practice Recommendations 2nd (called Rapid Assessment and Management decision-makers http://www.who.int/child- adolescent-health/publications/NUTRION/ or RAM)and referral,followed by a chapter on edition:http://www.who.int/reproductive- There is an important section at the beginning SB9241591226.htm emergency treatments for the woman. health/publications/spr/spr.pdf. of the Guide entitled Principles of good care Guidelines for the Management of Sexually ■Post-abortion care. HIV and Infant Feeding.A guide for health-care .This includes principles of good care Transmitted Infections:http://www.who. ■Antenatal care. managers and supervisors http://www.who for all women,including those with special ■Labour and delivery. int/reproductive-health/publications/ int/child-adolescent-health/publications/ needs.It explains the organization of each ■Postpartum care rhr_01_10_mngt_stis/guidelines_mngt_stis. NUTRIT0N/1S8N_92_4_159123_4.htm visit to a healthcare facility,which applies to ■Newborn care. pdf Integrated Management of Adolescent and overall care.The principles are not repeated Sexually Transmitted and other Reproductive adult illness for each visit. Tract Infections:A Guide to Essential Practice: http://www.who.int/3by5/publications/ http://www.who.int/reproductive-health/ documents/imai/en/index.html publications/rtis_gep/rtis_gep.pdf
How to read the guide HOW TO READ THE GUIDE Content The Guide includes routine and emergency care for women and newborns during pregnancy, labour and delivery, postpartum and post abortion, as well as key preventive measures required to reduce the incidence of endemic and other diseases like malaria, anaemia, HIV/AIDS and TB, which add to maternal and perinatal morbidity and mortality. Most women and newborns using the services described in the Guide are not ill and/or do not have complications. They are able to wait in line when they come for a scheduled visit. However, the small proportion of women/newborns who are ill, have complications or are in labour, need urgent attention and care. The clinical content is divided into six sections which are as follows: N Quick check (triage), emergency management (called Rapid Assessment and Management or RAM) and referral, followed by a chapter on emergency treatments for the woman. N Post-abortion care. N Antenatal care. N Labour and delivery. N Postpartum care. N Newborn care. In each of the six clinical sections listed above there is a series of flow, treatment and information charts which include: N Guidance on routine care, including monitoring the well-being of the mother and/ or baby. N Early detection and management of complications. N Preventive measures. N Advice and counselling. In addition to the clinical care outlined above, other sections in the guide include: N Advice on HIV, prevention and treatment. N Support for women with special needs. N Links with the community. N Drugs, supplies, equipment, universal precautions and laboratory tests. N Examples of clinical records. N Counselling and key messages for women and families. There is an important section at the beginning of the Guide entitled Principles of good care A1-A5 . This includes principles of good care for all women, including those with special needs. It explains the organization of each visit to a healthcare facility, which applies to overall care. The principles are not repeated for each visit. Recommendations for the management of complications at secondary (referral) health care level can be found in the following guides for midwives and doctors: N Managing complications of pregnancy and childbirth (WHO/RHR/00.7) N Managing newborn problems. Documents referred to in this Guide can be obtained from the Department of Making Pregnancy Safer, Family and Community Health, World Health Organization, Geneva, Switzerland. E-mail: mpspublications@who.int. Other related WHO documents can be downloaded from the following links: N Medical Eligibility Criteria 3rd edition: http://www.who.int/reproductive-health/ publications/mec/mec.pdf. N Selected Practice Recommendations 2nd edition: http://www.who.int/reproductivehealth/publications/spr/spr.pdf. N Guidelines for the Management of Sexually Transmitted Infections: http://www.who. int/reproductive-health/publications/ rhr_01_10_mngt_stis/guidelines_mngt_stis. pdf N Sexually Transmitted and other Reproductive Tract Infections: A Guide to Essential Practice: http://www.who.int/reproductive-health/ publications/rtis_gep/rtis_gep.pdf N Antiretroviral treatment of HIV infection in infants and children in resource-limited settings, towards universal access: Recommendations for a public health approach Web-based public review, 3–12 November 2005 http://www.who.int/hiv/pub/prev_care/en N WHO consultation on technical and operational recommendations for scale-up of laboratory services and monitoring HIV antiretroviral therapy in resource-limited settings. http://www.who.int/hiv/pub/prev_ care/en ISBN 92 4 159368 7 N Malaria and HIV Interactions and their Implications for Public Health Policy. http://www.who.int/hiv/pub/prev_care/en: ISNB 92 4 159335 0 N Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance African Region. http://www.who.int/hiv/pub/ prev_care/en Ref no:: WHO/HIV/2005.02 N HIV and Infant Feeding. Guidelines for decision-makers http://www.who.int/childadolescent-health/publications/NUTRITION/ ISBN_92_4_159122_6.htm N HIV and Infant Feeding. A guide for health-care managers and supervisors http://www.who. int/child-adolescent-health/publications/ NUTRITION/ISBN_92_4_159123_4.htm N Integrated Management of Adolescent and adult illness http://www.who.int/3by5/publications/ documents/imai/en/index.html HOW TO READ THE GUIDE
STRUCTURE AND PRESENTATION This Guide is a tool for clinical decision-making. Flow charts Use of colour ■Treatments. The content is presented in a frame work of The flow charts include the following information Colour is used in the flow charts to indicate the Advice and counselling. coloured flow charts supported by information 1.Key questions to be asked. ■Preventive measures severity of a condition. and treatment charts which give further details ■Relevant procedures of care. 2.Important observations and examinations to be made. 6.Green usually indicates no abnormal 3.Possible findings(signs)based on information condition and therefore normal care is given. Information and counselling The framework is based on a syndromic approach whereby the skilled attendant elicited from the questions,observations and, as outlined in the guide,with appropriate sheets where appropriate,examinations advice for home care and follow up. identifies a limited number of key clinical signs 4.Classification of the findings. 7.Yellow indicates that there is a problem that These contain appropriate advice and and symptoms,enabling her/him to classify 5.Treatment and advice related to the signs and can be treated without referral. counselling messages to provide to the woman, the condition according to severity and give classification. 8.Red highlights an emergency which requires her partner and family.In addition,a section is appropriate treatment.Severity is marked in included at the back of the Guide to support the immediate treatment and,in most cases, colour:red for emergencies,yellow for less urgent conditions which nevertheless need "Treat,advise"means giving the treatment indicated urgent referral to a higher level health facility. skilled attendant in this effort.Individual sheets (performing a procedure,prescnbing drugs or other are provided with simplified versions of the attention,and green for normal care. treatments,advising on possible side-effects and how to messages on care during pregnancy (preparing a Key sequential steps overcome them)and giving advice on other important birth and emergency plan,clean home delivery. practices.The treat and advise column is often cross- The charts for normal and abnormal deliveries care for the mother and baby after delivery, referenced to other treatment and/or information charts. are presented in a framework of key sequential breastfeeding and care after an abortion)to be Tum to these charts for more information. steps for a clean safe delivery.The key sequential given to the mother,her partner and family at the steps for delivery are in a column on the left side appropriate stage of pregnancy and childbirth. of the page,while the column on the right has interventions which may be required if problems These sheets are presented in a generic format. arise during delivery.Interventions may be linked They will require adaptation to local conditions ASK.CHECK RECORD LOOK,LISTEN FEEL CLASSFY TREAT AND ADVISE to relevant treatment and/or information pages, and language,and the addition of illustrations and are cross-referenced to other parts of the to enhance understanding,acceptability and Guide. attractiveness.Different programmes may prefer a different format such as a booklet or flip chart Treatment and information pages The flow charts are Iinked(cross-referenced)to relevant treatment and/or information pages in other parts of the Guide.These pages include information which is too detailed to include in the flow charts: Structure and presentation
Structure and presentation HOW TO READ THE GUIDE ASK, CHECK RECORD LOOK, LISTEN FEEL SIGNS TREAT AND ADVISE CLASSIFY 1 2 3 4 5 6 7 8 This Guide is a tool for clinical decision-making. The content is presented in a frame work of coloured flow charts supported by information and treatment charts which give further details of care. The framework is based on a syndromic approach whereby the skilled attendant identifies a limited number of key clinical signs and symptoms, enabling her/him to classify the condition according to severity and give appropriate treatment. Severity is marked in colour: red for emergencies, yellow for less urgent conditions which nevertheless need attention, and green for normal care. Flow charts The flow charts include the following information: 1. Key questions to be asked. 2. Important observations and examinations to be made. 3. Possible findings (signs) based on information elicited from the questions, observations and, where appropriate, examinations. 4. Classification of the findings. 5. Treatment and advice related to the signs and classification. “Treat, advise” means giving the treatment indicated (performing a procedure, prescribing drugs or other treatments, advising on possible side-effects and how to overcome them) and giving advice on other important practices. The treat and advise column is often crossreferenced to other treatment and/or information charts. Turn to these charts for more information. Use of colour Colour is used in the flow charts to indicate the severity of a condition. 6. Green usually indicates no abnormal condition and therefore normal care is given, as outlined in the guide, with appropriate advice for home care and follow up. 7. Yellow indicates that there is a problem that can be treated without referral. 8. Red highlights an emergency which requires immediate treatment and, in most cases, urgent referral to a higher level health facility. Key sequential steps The charts for normal and abnormal deliveries are presented in a framework of key sequential steps for a clean safe delivery. The key sequential steps for delivery are in a column on the left side of the page, while the column on the right has interventions which may be required if problems arise during delivery. Interventions may be linked to relevant treatment and/or information pages, and are cross-referenced to other parts of the Guide. Treatment and information pages The flow charts are linked (cross-referenced) to relevant treatment and/or information pages in other parts of the Guide. These pages include information which is too detailed to include in the flow charts: N Treatments. N Advice and counselling. N Preventive measures. N Relevant procedures. Information and counselling sheets These contain appropriate advice and counselling messages to provide to the woman, her partner and family. In addition, a section is included at the back of the Guide to support the skilled attendant in this effort. Individual sheets are provided with simplified versions of the messages on care during pregnancy (preparing a birth and emergency plan, clean home delivery, care for the mother and baby after delivery, breastfeeding and care after an abortion) to be given to the mother, her partner and family at the appropriate stage of pregnancy and childbirth. These sheets are presented in a generic format. They will require adaptation to local conditions and language, and the addition of illustrations to enhance understanding, acceptability and attractiveness. Different programmes may prefer a different format such as a booklet or flip chart. STRUCTURE AND PRESENTATION
Assumptions underlying the Guide ASSUMPTIONS UNDERLYING THE GUIDE 5 Recommendations in the Guide are generic, to the woman's home,if necessary.However services and the community are involved in Adaptation of the Guide made on many assumptions about the health there may be other health workers who receive maternal and newborn health issues. characteristics of the population and the the woman or support the skilled attendant Other programme activities,such as It is essential that this generic Guide is adapted to national and local situations,not only within health care system (the setting,capacity and when emergency complications occur. management of malaria,tuberculosis and the context of existing health priorities and organization of services,resources and staffing). Human resources,infrastructure,equipment, other lung diseases,treatment for HIV,and resources,but also within the context of respect supplies and drugs are limited.However, infant feeding counselling.that require MOH and sensitivity to the needs of women,newboms Population and essential drugs,IV fluids,supplies,gloves and specific training,are delivered by a different and the communities to which they belong. essential equipment are available. provider,at the same facility or at the referral endemic conditions If a health worker with higher levels of skill (at hospital.Detection,initial treatment and High matemal and perinatal mortality the facility or a referral hospital)is providing referral are done by the skilled attendant. An adaptation guide is available to assist national experts in modifying the Guide Many adolescent pregnancies pregnancy,childbirth and postpartum care to All pregnant woman are routinely offered HIV High prevalence of endemic conditions: women other than those referred,she follows testing and counselling at the first contact according to national needs,for different Anaemia the recommendations described in this Guide. with the health worker,which could be during demographic and epidemiological conditions, Stable transmission of falciparum malaria Routine visits and follow-up visits are the antenatal visits,in early labour or in the resources and settings.The adaptation guide Hookworms (Necator americanus and "scheduled"during office hours. offers some alternatives.It includes guidance on postpartum period. developing information and counselling tools so Ancylostoma duodenale) Emergency services("unscheduled"visits)for Women who are first seen by the health worker that each programme manager can develop a Sexually transmitted infections,including labour and delivery,complications,or severe in late labour are offered the test after the HIV/AIDS illness or deteroration are provided 24/24 childbirth. format which is most comfortable for her/him. Vitamin A and iron/folate deficiencies. hours,7 days a week. Health workers are trained to provide Hiv Women and babies with complications or testing and counselling. Health care system expected complications are referred for further HIV testing kits and ARV medicines are care to the secondary level of care,a referral available at the Primary health-care The Guide assumes that: hospital. Routine and emergency pregnancy,delivery and Referral and transportation are appropriate for postpartum care are provided at the primary Knowledge and the distance and other circumstances.They level of the health care,e.g.at the facility near must be safe for the mother and the baby. skills of care providers where the woman lives.This facility could be a Some deliveries are conducted at home, This Guide assumes that professionals using health post.health centre or matemity clinic. attended by traditional birth attendants (TBAs) it have the knowledge and skills in providing It could also be a hospital with a delivery ward or relatives,or the woman delivers alone(but the care it describes.Other training materials and outpatient clinic providing routine care to home delivery without a skilled attendant is must be used to bring the skills up to the level women from the neighbourhood. not recommended). assumed by the Guide. A single skilled attendant is providing care. Links with the community and traditional She may work at the health care centre,a providers are established.Primary health care matemity unit of a hospital or she may go
Assumptions underlying the Guide HOW TO READ THE GUIDE Recommendations in the Guide are generic, made on many assumptions about the health characteristics of the population and the health care system (the setting, capacity and organization of services, resources and staffing). Population and endemic conditions N High maternal and perinatal mortality N Many adolescent pregnancies N High prevalence of endemic conditions: ¡ Anaemia ¡ Stable transmission of falciparum malaria ¡ Hookworms (Necator americanus and Ancylostoma duodenale) ¡ Sexually transmitted infections, including HIV/AIDS ¡ Vitamin A and iron/folate deficiencies. Health care system The Guide assumes that: N Routine and emergency pregnancy, delivery and postpartum care are provided at the primary level of the health care, e.g. at the facility near where the woman lives. This facility could be a health post, health centre or maternity clinic. It could also be a hospital with a delivery ward and outpatient clinic providing routine care to women from the neighbourhood. N A single skilled attendant is providing care. She may work at the health care centre, a maternity unit of a hospital or she may go to the woman's home, if necessary. However there may be other health workers who receive the woman or support the skilled attendant when emergency complications occur. N Human resources, infrastructure, equipment, supplies and drugs are limited. However, essential drugs, IV fluids, supplies, gloves and essential equipment are available. N If a health worker with higher levels of skill (at the facility or a referral hospital) is providing pregnancy, childbirth and postpartum care to women other than those referred, she follows the recommendations described in this Guide. N Routine visits and follow-up visits are “scheduled” during office hours. N Emergency services (“unscheduled” visits) for labour and delivery, complications, or severe illness or deterioration are provided 24/24 hours, 7 days a week. N Women and babies with complications or expected complications are referred for further care to the secondary level of care, a referral hospital. N Referral and transportation are appropriate for the distance and other circumstances. They must be safe for the mother and the baby. N Some deliveries are conducted at home, attended by traditional birth attendants (TBAs) or relatives, or the woman delivers alone (but home delivery without a skilled attendant is not recommended). N Links with the community and traditional providers are established. Primary health care services and the community are involved in maternal and newborn health issues. N Other programme activities, such as management of malaria, tuberculosis and other lung diseases, treatment for HIV, and infant feeding counselling, that require specific training, are delivered by a different provider, at the same facility or at the referral hospital. Detection, initial treatment and referral are done by the skilled attendant. N All pregnant woman are routinely offered HIV testing and counselling at the first contact with the health worker, which could be during the antenatal visits, in early labour or in the postpartum period. Women who are first seen by the health worker in late labour are offered the test after the childbirth. Health workers are trained to provide HIV testing and counselling. HIV testing kits and ARV medicines are available at the Primary health-care Knowledge and skills of care providers This Guide assumes that professionals using it have the knowledge and skills in providing the care it describes. Other training materials must be used to bring the skills up to the level assumed by the Guide. Adaptation of the Guide It is essential that this generic Guide is adapted to national and local situations, not only within the context of existing health priorities and resources, but also within the context of respect and sensitivity to the needs of women, newborns and the communities to which they belong. An adaptation guide is available to assist national experts in modifying the Guide according to national needs, for different demographic and epidemiological conditions, resources and settings. The adaptation guide offers some alternatives. It includes guidance on developing information and counselling tools so that each programme manager can develop a format which is most comfortable for her/him. ASSUMPTIONS UNDERLYING THE GUIDE
PRINCIPLES OF GOOD CARE 四2 COMMUNICATION These principles of good care apply to all contacts between the skilled attendant and all women and their babies:they are not repeated in each section.Care-givers should therefore familiarize themselves with the following principles before using the Guide.The principles concern: ■Communication2 WORKPLACE AND ADMINISTRATIVE Workplace and administrative procedures PROCEDURES Standard precautions and cleanliness ■Organizing a visit5 STANDARD PRECAUTIONS AND CLEANLINESS 5ORGANIZING A VISIT A1
A1 PRINCIPLES OF GOOD CARE PRINCIPLES OF GOOD CARE Communication PRINCIPLES OF GOOD CARE A2 Communicating with the w oman (and her companion) N Make the woman (and her companion) feel welcome. N Be friendly, respectful and non-judgmental at all times. N Use simple and clear languag e. N Encourage her to ask questions. N Ask and pro vide infor mation related to her needs. N Support her in understanding her options and making decisions. N At any examination or before an y procedure: ¡ seek her per mission and ¡ inform her of what you are doing . N Summarize the most impor tant infor mation, including the infor mation on routine laborator y tests and treatments. Verify that she understands emerg ency signs, treatment instr uctions, and when and where to retur n. Check for understanding b y asking her to explain or demonstrate treatment instructions. Privacy and confidentiality In all contacts with the woman and her par tner: N Ensure a priv ate place for the examinat ion and counselling . N Ensure, when discussing sen sitive subjects, that you cannot be o vrheard. N Make sure you have the woman’s consent before discussing with her par tner or family . N Never discuss confidential infor matin about clients with other pro viders, or outside the health facility . N Organize the examination are a so that, during examination, the woman is protected from the view of other people (cur tain, screen, wall). N Ensure all records are confidential and k ept locked away. N Limit access to logbooks and registers to responsible pro viders only . Prescribing and recommending treatments and pre ventive measures for the w oman and/or her bab y When giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home: N Explain to the w oman what the treatment is and why it should be given. N Explain to her that the t reatment will not har m her or her bab y, and that not taking it ma y be more dang erous. N Give clear and helpfu l advice on ho w to take the drug regular ly: ¡ for example: tak e 2 tablets 3 times a day, thus every 8 hours, in the mor ning, afternoon ad evening with some water and after a meal, for 5 days. N Demonstrate the procedure. N Explain how the treatment is giv en to the bab y. Watch her as she does the first treatmen the clinic. N Explain the side-effects to her . Explain that they are not seri ous, and tell her ho w to manage them. N Advise her to retur n if she has any problems or concerns about taking the drugs. N Explore any barriers she or her family m ay have, or have heard from others, about using the treatment, where possible: ¡ Has she or anyone she knows used the treatment or pre ventive measure before? ¡ Were there problems? ¡ Reinforce the cor rect information that she has, and try to clarify the incor rect information. N Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to p urchase this. COMMUNICATION Workplace and administrative procedures A3 PRINCIPLES OF GOOD CARE Workplace N Service hours should be clear ly posted. N Be on time with appointments or infor m the woman/women if she/the y need to wait. N Before beginning the ser vices, check that equipment is clean and functioning and that supplies and dr ugs are in place. N Keep the facility clean b y regular cleaning . N At the end of the ser vice: ¡ discard litter and sharps safely ¡ prepare for disinfection; clean and disinfect equipment and supplies ¡ replace linen, prepare for washing ¡ replenish supplies and dr ugs ¡ ensure routine cleaning of all areas. N Hand over essential infor mation to the colleague who follows on duty . Daily and occasional administrative activities N Keep records of equipment , supplies, drugs and vaccines. N Check availability and functioning of essential equipment (order stocks of supplies, drugs, vacines and contraceptiv es before the y run out). N Establish staffing lists and schedules. N Complete periodic repor ts on bir ths, deaths and other indicators s required, according to instructions. Record keeping N Always record finding s on a clinical record and home-base d recor d. Record treatments, reasons for refer ral, and follow-up recommendation s at the time the obser vation is made. N Do not record conf idential information the home-based record if the woman is unwi lling. N Maintain and file appropr iately: ¡ al clinical reco rds ¡ al other docume ntation. International conventions The health facility should not allo w distribution of free or low-cost suplies or products withi n the scope of the Inter national Code of Mark eting of Breast Milk Substitutes. It should also be tobacco free and suppor t a tobacco-free environment. WORKPLACE AND ADMINISTRA TIVE PROCEDURES Standard precautions and cleanliness PRINCIPLES OF GOOD CARE A4 Observe these precautions to protect the woman and her bab y, and you as the health provider , from infections with bacteria and viruses, including HIV. Wash hands N Wash hands with soap and water : ¡ Before and after caring for a w oman or newborn, and before an y treatment procedure ¡ Whenever the hands (or an y other skin area) are contaminated with blood or other body fluids ¡ After removing the glo ves, because the y may have holes ¡ After changing soiled bedsheets or clothing . N Keep nails shor t. Wear gloves N Wear sterile or highly disinfected glo ves when performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear , blood drawing. N Wear long sterile or highly disinfected glo ves for manual remo val f placenta. N Wear clean glo ves when: ¡ Handling and cleaning instr uments ¡ Handling contaminated waste ¡ Cleaning blood and bod y fluid spills N Drawing blood. Protect y ourself from blood and other body fluids during deliv eries ¡ Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandag e; take care when handling an y sharp instruments (ue good light); and practic e safe sharps disposal. ¡ Wear a long apron made from plasti c or other fluid resistant materia l, and shoes. ¡ If possible, protect y our eyes from splashes of blood. Practice safe sharps disposal N Keep a puncture resistant container nearb y. N Use each needle and syringe only once. N Do not recap, bend or break needles after giving an injection. N Drop all used (disposable ) needles, plastic syringes and blades directly int o this container, without recapping , and without passing to another person. N Empty or send for incinerati on when the container is three-quar ters full. Practice safe waste disposal N Dispose of placenta o r blood, or body fluid contaminated items, in leak-proof container s. N Burn or bury contaminated solid waste. N Wash hands, gloves and containers after disposal of infectious wa ste. N Pour liquid waste do wn a drain or flushable toilet. N Wash hands after di sposal of infectious waste. Deal with contaminated laundry N Collect clothing or she ets stained with blood or body fluids and k eep them separately from other laundr y, wearing gloves or use a plastic bag. DO NOT touch them di rectly. N Rinse off blood or o ther body fluids before washing with soap. Sterilize and clean contaminated equipment N Make sure that instr uments which penet rae the skin (such as ne edles) are adequately sterilized, or that single-use instr uments are disposed of after one use. N Thoroughly clean or disi nfect any equipment which comes into contact with intact skin (according to instr uctions). N Use bleach for clea ning bowls and buck ets, and for blood or bod y flui d spills. Clean and disinfect glo ves N Wash the gloves in soap and water . N Check for damage: Blow gloves full of air ,twist the cuff closed, then hold under clean water and look for air leaks. Discard if damag ed. N Soak overnight in bleach solution with 0.5 available chlorine (made b y adding 90 ml water to 10 ml bleach containing 5% a vailable chlorine) . N Dry away from direct sunlight. N Dust inside with talcum po wder r starch. This produces disinfected gloves. They are not sterile. Good quality latex glo ves can be disinfected 5 or more time s. Sterilize glo ves N Sterilize by autoclaving or highly disinfect by steaming or boiling . UNIVERSAL PRECA UTIONS AND CLEANLINESS Organizing a visit A5 PRINCIPLES OF GOOD CARE Receive and respond immediately Receive ever y woman and newbor n baby seeking care immediately after ar rival (or organize rception b y another pro vider). N Perform Quick Check on all ne w incoming women and babies and those in the waiting room, especially if no-one is receiving them B2. N At the first emerg ency sign on Quick Check, begin emerg ency assessment and management (RAM) B1-B7 for the woman, or examine the ne wborn J1-J11. N If she is in labour , accompany her to an appropriate place and follo w the steps as in Childbirth: labour, delivery and immediate postpartum careD1-D29. N If she has priority signs, examine her immediately using Antenatal car e, Postpartum or Post-abortion care char ts C1-C18E1-E10B18-B22. N If no emergency or priority sign on RAM or not in labour , invite her to wait in the waiting room. N If baby is newly bor n, looks small, examine immediately. Do not let the mother wait in the queue. Begin each emerg ency care visit N Introduce y ourself. N Ask the name of the w oman. N Encourage the companion to sta y with the w oman. N Explain all procedures, ask permission, and keep the woman infor med as much as you can about what you are doing . If she is unconscious, talk to the companion. N Ensure and respect priv acy during examination and discussion. N If she came with a bab y and the bab y is well, ask the companion to tak e care of the baby during the mate rnl examination an d treatment. Care of woman or bab y refer red for special care to secondar y level facility N When a woman or bab y is refer red to a secondary level care facility becaus e of a specific probl em or complications, the underlying assumption of the Guide is that, at refer ral level, the woman/baby will be assessed, treated, counselled and ad vised on follow-up for that par ticular condition/ complication. N Follow-up for that specific condi tion will be either: ¡ organized by the refer ral facility or ¡ written instr uctions will be giv en to the woman/baby for the skilled atendant at the primar y level who refer red the woman/ baby. ¡ the woman/baby will be ad vised to g o for a follow-up visit within 2 w eeks according to severity of the condition. N Routine care continues at the primar y care level where it was initiated. Begin each routine visit (for the woman and/or the bab y) N Greet the woman and offer her a seat. N Introduce y ourself. N Ask her name (and the name ofthe baby). N Ask her: ¡ Why did you come? For y ourself or for y our baby? ¡ For a scheduled (routine) visit? ¡ For specific complain ts about y ou or your baby? ¡ First or follo w-up visi t? ¡ Do you want to in clude your companion or other family membe r (parent if adolescent) in the examinati on and discussion? N If the woman is recently deliv ered, assess the baby or ask to see the baby if not wit h the mother . N If antenatal care, always revise the birth plan at the end of the visit afte r completi ng the char t. N For a postpar tum visit, if she came with the baby, also examine the bab y: ¡ Follow the appropr iate char ts according to pregnancy sta tus/age of the baby and purpose of visit. ¡ Follow all steps onthe chart and in relevant boxes. N Unless the condition of the woman or the baby requires urg ent refer ral to hosp ital, give preventive measures if due even if the woman has a condition "in y ellow" that requires special treatment. N If follow-up visit is within a w eek, and if no other complaints: ¡ Assess the woman for the specific condit requiring follo w-up only ¡ Compare with ear lir assessment and reclassify. N If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): ¡ Repeat the whole assess ment as required for an antenatal, post-abortion, postpartum or newborn visit according to the s chedule ¡ If antenatal visit, revise the bir th plan. During the visit N Explain all procedures, N Ask permission before under taking an examination or test. N Keep the woman infor med throughout. Discuss findings with her (and her par tner). N Ensure priv acy duri ng the examination and discussion. At the end of the visi t N Ask the woman if she has an y questions. N Summarize the most impor tant messa ges with her. N Encourage her to return for a routine visit (tell her when) and if she has an y concer ns. N Fill the Home-Base d Mater nal Record (HBMR) and give her the approp riate infor mation sheet. N Ask her if there are an y poits which need to be discussed and w ould she lik e suppor t for t his. ORGANIZING A VISIT A2 COMMUNICATION A3 WORKPLACE AND ADMINISTRATIVE PROCEDURES A4 STANDARD PRECAUTIONS AND CLEANLINESS A5 ORGANIZING A VISIT These principles of good care apply to all contacts between the skilled attendant and all women and their babies; they are not repeated in each section. Care-givers should therefore familiarize themselves with the following principles before using the Guide. The principles concern: N Communication A2 . N Workplace and administrative procedures A3 . N Standard precautions and cleanliness A4 . N Organizing a visit A5
Communication A2 38V0 COMMUNICATION 8 Communicating with the woman Privacy and confidentiality Prescribing and recommending Demonstrate the procedure. 告 (and her companion】 In all contacts with the woman and her partner: treatments and preventive ■E知lain how the treatment is given to the baby. Watch her as she does the first treatment in Make the woman(and her companion)feel Ensure a private place for the examination measures for the woman and counselling. the clinic. welcome. Be friendly,respectful and non-judgmental at Ensure,when discussing sensitive subjects, and/or her baby Explain the side-effects to her.Explain that they are not serious,and tell her how to 5 all times. that you cannot be overheard. When giving a treatment(drug,vaccine,bednet, Use simple and clear language. Make sure you have the woman's consent condom)at the clinic,or prescribing measures to manage them. before discussing with her partner or family. be followed at home: Advise her to retum if she has any problems or Encourage her to ask questions Explain to the woman what the treatment is concems about taking the drugs. Ask and provide infommation related to her Never discuss confidential information about Explore any bariers she or her family may needs. clients with other providers,or outside the and why it should be given. have.or have heard from others,about using Support her in understanding her options and health facility. Explain to her that the treatment will not harm the treatment where possible: making decisions. Organize the examination area so that,during her or her baby,and that not taking it may be At any examination or before any procedure: examination,the woman is protected from the more dangerous. Has she or anyone she knows used the view of other people(curtain,screen,wall). Give clear and helpful advice on how to take treatment or preventive measure before? seek her permission and inform her of what you are doing. Ensure all records are confidential and kept the drug regularly: →ere there problems? locked away. for example:take 2 tablets 3 times a Reinforce the correct information that Summarize the most important information, she has,and try to clarify the incorrect including the information on routine Limit access to logbooks and registers to day,thus every 8 hours,in the morning. afternoon and evening with some water and information. laboratory tests and treatments. responsible providers only. after a meal,for 5 days. Discuss with her the importance of buying and taking the prescribed amount.Help her to think Verify that she understands emergency signs, about how she will be able to purchase this. treatment instructions,and when and where to retum.Check for understanding by asking her to explain or demonstrate treatment instructions
Communication PRINCIPLES OF GOOD CARE A2 Communicating with the woman (and her companion) N Make the woman (and her companion) feel welcome. N Be friendly, respectful and non-judgmental at all times. N Use simple and clear language. N Encourage her to ask questions. N Ask and provide information related to her needs. N Support her in understanding her options and making decisions. N At any examination or before any procedure: ¡ seek her permission and ¡ inform her of what you are doing. N Summarize the most important information, including the information on routine laboratory tests and treatments. Verify that she understands emergency signs, treatment instructions, and when and where to return. Check for understanding by asking her to explain or demonstrate treatment instructions. Privacy and confidentiality In all contacts with the woman and her partner: N Ensure a private place for the examination and counselling. N Ensure, when discussing sensitive subjects, that you cannot be overheard. N Make sure you have the woman’s consent before discussing with her partner or family. N Never discuss confidential information about clients with other providers, or outside the health facility. N Organize the examination area so that, during examination, the woman is protected from the view of other people (curtain, screen, wall). N Ensure all records are confidential and kept locked away. N Limit access to logbooks and registers to responsible providers only. Prescribing and recommending treatments and preventive measures for the woman and/or her baby When giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home: N Explain to the woman what the treatment is and why it should be given. N Explain to her that the treatment will not harm her or her baby, and that not taking it may be more dangerous. N Give clear and helpful advice on how to take the drug regularly: ¡ for example: take 2 tablets 3 times a day, thus every 8 hours, in the morning, afternoon and evening with some water and after a meal, for 5 days. N Demonstrate the procedure. N Explain how the treatment is given to the baby. Watch her as she does the first treatment in the clinic. N Explain the side-effects to her. Explain that they are not serious, and tell her how to manage them. N Advise her to return if she has any problems or concerns about taking the drugs. N Explore any barriers she or her family may have, or have heard from others, about using the treatment, where possible: ¡ Has she or anyone she knows used the treatment or preventive measure before? ¡ Were there problems? ¡ Reinforce the correct information that she has, and try to clarify the incorrect information. N Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to purchase this. COMMUNICATION