TANZANIA NURSING AND MIDWIFERY COUNCIL

STANDARDS OF PROFICIENCY FOR MIDWIFERY PRACTICE IN TANZANIA

Revised, 2014

Tanzania Nursing and Midwifery CouncilP.O.Box 6632Dar es SalaamTanzania

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All rights reserved. No part of this publication may be reproduced, storedin a retrieval system or transmitted, in any form or by any means,electronically, mechanical, photocopying or otherwise without permissionfrom TNMC

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TABLE OF CONTENTS

FOREWORD.........................................................................................................3PREFACE.............................................................................................................5

- The rationale............................................................................................5ACRONYMS .........................................................................................................6DEFINITION OF TERMS ......................................................................................7INTRODUCTION ..................................................................................................8SCOPE OF PRACTICE ........................................................................................9Rationale...............................................................................................................9STANDARDS......................................................................................................11

STANDARD 1 : ...............................................................................................11STANDARD 2: ................................................................................................11STANDARD 3: ................................................................................................12STANDARD 4: ................................................................................................12STANDARD 5:.................................................................................................14STANDARS 6: ................................................................................................14STANDARD 7:.................................................................................................15STANDARD 8:.................................................................................................15

REPAGING IN THE TABLE OF CONTENTS DURING TYPE SETTING

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FOREWORD

These standards of proficiency for midwifery practice in Tanzania were

developed by working group assembled by the Tanzania Nursing and Midwifery

Council constituted by Midwives from education and practice settings. With

mandate from the Nursing and Midwifery Act, 2010, the Council realized a need

to review the existing standards in order to accommodate new trends and

support the initiative to ensure Tanzanians are receiving quality and safe

services.

The elements in the standard proficiency indicate the acceptable parameters for

professional practice, areas of competencies, core competences and standards

for midwifery education and practice. They have been developed to be in line

with the scope of practice of midwives in a Tanzanian context. In addition, these

standards will help educators when they prepare their curriculum, as they

prescribe expected competencies and proficiency of the midwives in Tanzania.

Ultimately, they will also assist in monitoring and evaluating the quality of

midwifery care.

It is the TNMC hope that these standards of proficiency for midwifery will be

used in midwifery education and practice in order to improve the quality of care

provided to individuals, families and communities in Tanzania.

Dr. Khadija Innocensia MalimaTNMC - Chairperson

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PREFACE

Midwifery services are undergoing many changes in response to political,

social,technical scientific and diseases trends and changes. In addition, reviewed

priorities guided by national and international decisions such as the Millennium

Development Goals, Task Shifting, MAM and the vision 2025 have necessitated

TNMC to think of a need to review standards of proficiency for midwifery practice

in Tanzania.

This document consists of the following:

- The scope of Midwifery practice

- The rationale

- The standards

- Areas of competences

- Core competences

TNMC hopes that this document will provide necessary guidance to midwifery

trainer who will subsequently be able to prepare midwives capable of functioning

competently.

Lena MfalilaRegistrar

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ACRONYMS/ABBREVIATIONS

AIDS Acquired Immune Deficiency SyndromeAPH Ante Partum Hemorrhage

BF Breast Feeding

DPH Diastolic Blood Pressure

DHS Demographic Health Survey

FP Family Planning

FHR Fetal Heart Rate

FANC Focused Antenatal Care

HIV Human Immune Deficiency Virus

HE Health Education

HB Hemoglobin

IPC Infection Prevention Control

IEC Information Education Communication

I.V Intravenous Infusion

I.M Intramuscular Injection

LCVE Lower Cavity Vacuum Extraction

MVA Manual Vacuum Aspiration

NM Nurse Midwife

PPH Post Partum Hemorrhage

PAC Post-abortal Care

PIH Pregnancy Induced Hypertension

TNMC Tanzania Nursing and Midwifery Council

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DEFINITION OF TERMS

StandardThe desirable and achievable level of performance against which actual practiceis compared

ProficiencyIs a level beyond being competent at which the midwife has a deepunderstanding of the situations and she/he knows the right action she/he shouldtake based from experience. A proficient professional knows what might happenand what aspects of a situation might be the most important and key inperformance.

CompetenceIs the combination of knowledge, skills and attitude that enable an individual toperform a specific task to a defined level of proficiency.

Midwife-

Means a person who is authorized by license issued under the Nursing andMidwifery Act 2010 to give care and supervision of women during pregnancy,labour, post partum period and caring for newborn babies.

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INTRODUCTION

Maternal health is one of the main global health challenges and reduction of thematernal mortality rate remains a key indicator of performance of health servicesand is the target for the 5th Millennium Development Goals. Studies have shownthat the rise in maternal mortality rate (MMR) is mostly affecting developingcountries and about 47% of global maternal mortality occurs in Africa, with thehighest rate in Sub-Saharan countries including Tanzania. It also shows that 85%of all maternal deaths are direct results of complications arising duringpregnancy, delivery and postpartum period.

According to the TDHS report (2010) maternal mortality rate has remained highdespite an evident decline since 2004/2005. It is estimated the 454 per 100,000live birth occur and the neonatal mortality rate stands at 26 per 1000 live birth.Studies have identified a number of factors, which contribute to the situation,outstanding being unskilled attendants in health care settings.

In Tanzania, qualified Nurses/Midwives account for about 60% of all skilledattendants who provide midwifery care and other reproductive health services.Therefore, effective involvement of the nurses and midwives may helpaddressing this challenge. The Tanzania Nursing and Midwifery Council decidedto review these standards of Proficiency for Midwifery practice for Enrolled andRegistered Midwives in Tanzania so that they can guide educators and serviceproviders in the process of developing competent midwives.

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SCOPE OF PRACTICE

Midwifery is an autonomous, self-regulating profession whose interventions are

based on scientific principles of practice. A midwife is a responsible and

accountable professional who gives necessary support, care and advice during

pregnancy, labour, postpartum period and provides care to the newborn and

infant. This care includes preventive measures, promotion of normal physiologic

labour and birth, detection of complications and carrying out emergency

measures. Additionally, a midwife is an advocate for evidence-based midwifery

practices and can also be valuable in advancing public health policy regarding

women’s health, maternal and child health care. The legal framework allows the

midwives to make independent decisions and carry out life saving interventions.

A midwife works in various settings including health facilities, work places,

schools and community. Midwifery practice embraces compassion, empathy,

commitment, responsibility, accountability and leadership. It aims at achieving

excellent and quality care to ensure optimal wellbeing of women in childbearing

age and their families, thus reducing maternal, perinatal and infant morbidity and

mortality.

RationaleStandards of proficiency for midwifery practice in Tanzania have been developed

to address political, technical, social changes, the millennium development goals,

and the vision 2025. It will equip registered and enrolled midwives with all

necessary competencies to diagnose, manage and early referral of the

complications to save lives of mothers and new born and ultimately reduce

maternal and infant morbidity and mortality ratio.

Areas of competency

Health promotion

Application of Focused Antenatal Care

Prevention and treatment of conditions

Collaboration with stakeholders

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Counseling and communication skills

Monitoring progress of labor by using partograph documentation of

relevant information

Management of HIV/AIDS in pregnancy, labour and postpartum

Management of first, second and third stage of labour

Newborn resuscitation

Comprehensive Post Abortal Care

Life saving skills procedures

Management of hemorrhage and shock

Management of PIH and Eclampsia

Infection, prevention and control

Pharmacology and prescription of medicine

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STANDARDS

STANDARD 1: The midwife practices in accordance with ethical and legalframework related to midwifery practice that form the basis of high quality,culturally relevant, appropriate care for women, newborns, andchildbearing families.

Core Competencies

Applies the principles, beliefs, norms and values found in the Codeof Ethics to ensure provision of care in line with the ethos of theprofession

Familiarizes her/himself with the legal, statutory, and ethicalprinciples and parameters, which guide Midwifery and other healthprofessionals.

Protects clients from violation of their privacy and confidentiality Ensures confidentiality and security of written and verbal

information acquired in professional capacity. Respects the values, customs, and beliefs of individuals and

community Maintains confidentiality of all information shared by the woman. Works in partnership with women and their families, enables and

supports them in making informed choices about their health.

STANDARD 2: Midwives provides scientifically based high quality antenatalcare to maximize health during pregnancy and that includes early detectionand treatment or referral of complications.

Core competencies

Communicates effectively with women and their families throughout the

antenatal, intrapartum and postnatal periods

Formulates accurate nursing diagnosis to clarify client’s needs includinglearning, information, counseling and reach valid, reliable andcomprehensive conclusions

Determines client-centered goals for care in collaboration with the client,family and other members of the health care team

Creates an enabling environment that is therapeutic to meet the client’sneed for privacy, confidentiality, well-being and dignity.

Determines the effectiveness of midwifery care interventions based onintended client outcomes

Applies focused antenatal care Identify deviations from normal during the course of pregnancy and initiate

the referral process for conditions that require higher levels of intervention

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STANDARD 3: The midwife integrates nutrition concept to meet the womanneeds during pregnancy, labor, delivery and post delivery

Core competence

Ability to perform nutritional assessment. Applies prenatal Information, Education, Communication and counseling

relating to nutrition Utilize nutritional knowledge to provide appropriate diet including fluids

during labour, delivery and post delivery

STANDARD 4: The midwife provides appropriate management to thewoman during labour, delivery and ensures safe motherhood.

Core competencies

Manage the woman in labour

o Applies knowledge and skills to monitor FHR, Check vital signsMonitor contractions, assess cervical dilation and descent,interpret the findings and document accurately.

o Monitor and take care of the urinary bladdero Utilizes partograph to document and monitor progress of labouro Communicate information to individuals/groups accurately and

in accordance with organization policies to providepsychological support

o Clarifies written orders for nursing care with co-workers, clientsand family.

o Documents and communicates assessment findings usingstandard procedure.

o Utilizes the information to detect any problem associated withlabour and delivery to all stages

o Identifies different positions used in labouro Assist/conducts safe delivery in various positionso Observes any risk and complications to both mother and

newborn

Manage second stage of labouro Monitor maternal and fetal conditiono Use appropriate positiono Use proper mechanism during deliveryo Encourage to bear downo Observe privacy and comfortability

Applies Active management of third stage of labouro Administer oxytocic drugs according to existing protocols

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o Demonstrate knowledge and skills on active management ofthird stage of labor

o Utilizes knowledge skills and principles to examine theplacenta accurately

o Evaluate perineum and observe blood losso Respond efficiently and effectively to any complication which

may arise.

Manage PPH effectively

o Initiates client care and life saving measures and activities inaccordance to the client’s condition.

o Implements critical care activities according to the physiologicalprocesses requiring to be supported for the sustenance of thevital body functions (eg I/V fluids, observation, mobilizeavailability of blood).

o Implements nursing interventions to reduce pain promoteoptimum health and prevent complications resulting in disabilityor permanent damage.

o Evaluate immediately the nursing interventions and the careprovided subsequent to the critical and emergency care.

o Consult other professionals or refer where applicable

Demonstrate ability to resuscitate the newborn Assesses and score the newborn immediately after birth Initiates immediate neonatal care and resuscitation

measures in accordance to the protocols. Evaluates the intervention and detect any anomaly and acts

accordingly. Consult other professionals or refer where applicable

Manages PIH and Eclampsia

o Utilizes interpersonal and client-provider interaction skills inconducting assessment to the clients and foetal condition

o Initiates clients care and life saving measures in accordancewith her condition and protocols of care.eg maintain clearairway, monitor intake and output, prescribe and administermedicine etc.

o Implements nursing intervention to prevent and manageconvulsion, promote optimum health and prevent complicationsresulting in disability or permanent damage.

o Consults doctor or /refer where applicable

Applies comprehensive Post Abortal Care (PAC)

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o Utilizes communication, interpersonal and client-providerinteraction skills in conducting assessment to the clients withabortion.

o Initiates clients care and life saving measures in accordancewith her condition and protocols of care.

o Implements nursing intervention to reduce pain promoteoptimum health and prevent complications resulting in disabilityor permanent damage.

o Utilizes interpersonal communication skills in educating andcounseling individuals, families, groups and communities onfamily planning use and the importance of early health seekingbehavior.

o Applies principles of IPC throughout midwifery care

STANDARD 5: The midwife applies the body of scientific knowledge toprovide efficient post partum care to the mother, the baby and the family atlarge.

Core competencies Performs direct observation to the mother and newborn Initiates immunization accordingly. Utilizes communication, interpersonal and client provider interaction skills

in providing accurate information and support in:- Nutrition- Breast feeding according to her status- HIV/AIDS issues- Hygiene- Family planning- Exercises- Postnatal check up- Pre-registration birth certificate

Consult whenever necessary

STANDARS 6: The midwife integrate the concept of Infection PreventionControl and pharmacology in the management of neonate and the mothercore competences

Counsel and screen couples for infectious diseases before conception Care of high risk neonate Applies principles of IPC Administer medicine appropriately regarding the existing protocols. Provision of health education relating to maternal and neonatal infection

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STANDARD 7: The midwife utilizes integrated multi-sectral approach inprovision of community midwifery services

Core competencies

Utilizes communication, interpersonal and client-providerinteraction skills in providing appropriate information onmidwifery and reproductive health information to the community.

Sensitizes individuals, families and communities on reproductivehealth issues

Collaborates with other stakeholders to provide midwifery andreproductive health care to the community.

Coordinates and monitor health services outcome Demonstrate ability to utilize scientific knowledge base and

skills to provide continuum of care before and after delivery

STANDARD 8: Advocate for the rights and responsibilities of providers tomake the practice settings safe for the midwives, other care providers,client and family.

Core competencies Communicate with colleagues on safety and human rights at the work

place Recognize the health and safety hazards at the work places and advocate

for the appropriate interventions Take part in establishing standard operating and safe working procedures

to promote health and safety of clients , midwives and the public

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APPENDICES

APPENDIX 1: STANDARD MANAGEMENT PROTOCOL OF OBSTETRICLIFE THREATENING CONDITIONS.

CONDITION TREATMENTS ANDMANAGEMENT PROTOCOL

1.HAEMORRHAGE

(a)APH

Urgently mobilize staff availableAssess patientResuscitate with intravenous fluidsNormal saline/ringer lactate 500mlsfastAdminister diclofenac 75mg i.m startObtain blood for hemoglobin,grouping and cross matchingMobilize availability of bloodGive oxygen if availableUrgently referMonitor vital signsAssess for signs of shock and treat

(b) PPHIdentify cause of bleeding andmanage accordinglyResuscitate with intravenous fluidsNormal saline/ringer lactate 500mlsfastOxytocin/Misoprostol/ErgometrineCatheterization.Broad spectrum antibiotics +metronidazoleAnalgesicsNotify doctors or ReferPromote normal breathingObtain blood for haemoglobin,grouping and cross matchingMobilize availability of bloodMonitor and record vital signs

(c)SHOCK(due to pain,Sepsis, andhemorrhage)

Assess the patient comprehensively(vital signs, intake and output, renalfunction, signs for shock)Ensure clear airwayTreat shock according to the causeAdminister Intravenous fluidsNormal saline/Ringer lactate fastBroad spectrum antibioticsMetronidazole 400mg 8hrly for fivedays

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Paracetamol 1g 8hrl for three daysMonitor Hb and Mobilize availabilityof bloodNotify doctors or Refer whereapplicable

22.ANAEMIA

MILDHB 10g/dl

Assess the patient’s condition andmanage accordinglyAdminister Tabs fersolate, TabsFolic acidPerform nutrition assessment andcounsellingDo deworming appropriatelyInvolve family members in managingthe patientMonitor foetal condition

MODERATEHB 7-10g/dl

Assess the patient’s condition andmanage accordinglyAdminister Tabs fersolate,Tabs Folic acidPerform nutrition assessment andcounselingDo deworming appropriatelyInvolve family members in managingthe patientMonitor foetal conditionMonitor the patient closelyInform the doctor or refer the patient

SEVERE ANEMIAHB below 7g/dl

Assess the patient and identify thecause of anaemiaFrusemide 80mg IV startOxygen if availableEnsure clear airwayInsert urinary catheterMobilize availability of bloodMonitor vital signs and recordPromote normal breathing eg.PositioningBlood for grouping and crossmatchingInform the doctor or refer the patientMonitor foetal conditionClosely monitor the patient

MALARIA Provide antimalarial prophylaxis

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(a)prophylaxis according to existing MoHSWguidelines

(b)TherapeuticAdminister antimalarial drugsaccording to existing MoHSWmalaria treatment guidelineQuinine tabs 10mg/kg/or i/v quinine10/kg in 5%Dextrose in case ofsevere malaria

AnalgesicsMonitor intake and outputMonitor maternal and foetal condition

(PIH)Pregnancy InducedHypertension(a)MILD

140/90mmHg

Advice bed restAdminister Methyldopa (Aldomet)250 Mg 8 hrly 7 daysAssess urine for albuminAssess facial oedemaMonitor intake and output

(b)SEVEREPIH>160/100mmHg

Administer Magnesium Sulphate 10gI/m with lignocaine (5mg eachbuttock) as per protocolKeep vein openKeep airway clearMonitor maternal and foetal conditionMonitor intake and outputAssess for facial oedemaAssess urine for albuminMonitor and record convulsionsAssess for visual problem

(c)ECLAMPSIA Administer Magnesium Sulphate10g I/m with lignocaine(5g eachbuttock) or Administer I.V as perprotocolAdminister Hydralazine 10mg i.v /i.mif DBP >110DiazepamKeep vein openPromote normal breathingKeep airway clearMonitor maternal and foetal conditionMonitor intake and outputAssess for facial oedemaAssess urine for albumin, sugar andketones

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Monitor and record convulsionsAssess for visual problem

INCOMPLETEABORTION

Administer AntibioticsAdminister AnalgesicsAdminister I/V fluidsPerform MVACounsel the patient on FamilyplanningTake history, identify findings andmanage appropriately using the skillof ask and listen, look and feel andtake appropriate actionMonitor vital signsPromote normal breathing

BIRTH ASPHYXIA Utilize the Golden Minute skill Maintain warmth Positioning Clearing airway Stimulating breathing Ventilate using bag and mask

Oxygen therapyMonitor vital signs and referwhenever necessary

NEONATALSEPSIS

Assess the neonate’s conditionMonitor vital signsMonitor intake and outputEncourage feedingAdminister prescribed AntibioticsAdminister antipyretic drugs asprescribedAdminister I/v fluids

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APPENDIX 2

MEDICINES AND SUPPLIES FOR MIDWIVES

Ant- malaria Iron drugs Ant- helminthes Misoprostol I/V fluids Antibiotics Ant convulsant Ant hypertensive Anesthetic drugs Valium Pethidine Eye ointment Oxygen Hydrocortisone Aminophylline Ant-diuretics (e.g. lasix.) Steroids(e.g.dexamethazone) Ant-histamine(e.g. promethazine) Adrenaline Vitamins Analgesics (e.g. paracetamol,Asprin) Antiseptic Disinfectant Glucostics Albustics Multistics

NB: With this HIV/AIDS pandemic a procedure should be followed as perNational protocol and guidelines on the management of HIV/AIDS test.

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APPENDIX 3

MINIMAL ESSENTIAL DRUGS LIST FOR MIDWIVESDRUG GROUP KIND OF DRUGS AMOUNTLOCAL ANESTHETICDRUGS

Lignocane 2% 10 vials

ANALGESICS Acetysalicylic Acid tablets A tin of 1000 tabletsParacetamol tablets/inj A tin of 1000 tablets

Inj. 10 vialsInj. Pethidine 10 ampoulesDiclofenac tabs/inj Tin of 500 tablets

Inj.10 ampoulesBrufen tablets 500 tabletsTramadol 50 tablets

HAEMATINICS Ferrous sulphate 1000 tabletsIron dextran injection 100 ampoulesFolic acid 1000 tablets

ANT BACTERIAL Amoxylline capsules 500 capsulesAmpicilline caps./inj 500 capsules/10 vialsCiproflaxin tabs 500 capsuleChloromphenical caps/inj 500 capsule/10 vialsGentamycin inj 100 ampoulesMetronidazole inj/tablets 500 tablets/10 vialsSilver nitrate eye drops 10 tubesSulphamethoxazoletablets

200 tabs

Tetracycline eye ointment 10 tubesSTEROIDS Dexamethazone inj 20 ampoules

Hydrocortisone inj 10 ampoulesANT MALARIA SP (Observe MoHSW

treatment guideline)Tin of 1000 tabs

ALU(Observe MoHSWtreatment guideline)

1000 tablets

Quinine (ObserveMoHSW treatmentguideline)

500 tables20 ampoules

Amodiaquine (ObserveMoHSW treatmentguideline)

500 tablets

ANTHELMINTHICS Mebendazole 1tin of 500 tabletsAlbendazole 1 tin of 500 tablets

ANT CONVULSANT Diazepam tabs/inj 500 tablets/20 ampoulesMagnesium Sulphate 10 vials

DIURETICS Frusemide tabs/inj 100 tabs/20 ampoulesAprinox 100 tabs

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OXYTOCICS Oxytocin inj 100 ampoulesMisoprostol 50mg- 20 tabs

100mg- 20 tabs200mg- 20 tabs

Ergometrine 0.2mg – 50 ampoulesI/V FLUIDS Ringer lactate 20 liters

Normal Saline 20 litersDextrose Saline 10 litersDextrose 5% 10 liters

ANT COAGULANTS Aspirin tablets 500 tablets

ANT HISTAMINE Epinephrine inj 20 ampoulesPiriton tabs/inj 50 tabs/20 ampoulesPromethazine tabs/inj 50 tabs/20 ampoules

BRONCHODILATOR Aminophyline tabs/inj 50 tabs/20 ampoulesANT HYPERTENSIVE Hydrallazine inj/tabs 20 ampoules/20tabs

Nifedipine tabs 20tabsVACCINES DTP/HB-hip (penta) Depends on needs

Poliomyelitis ‘’BCG vaccine ‘’Measles ‘’PCV13 ‘’Rotarix ‘’

VITAMINS Vitamin A capsules Tin of 1000 tabsVitamin K

ANTISEPTIC Chlorohexidine 1 gallonPovidone Iodine 1 gallonSavlone 1 gallonDitto 1 gallonCentrimide 1 gallonHibiten 1 gallonMethylated spirit 1 gallon

DISINFECTANTS Chlorine based soln-JIK 20 ltsCidex 2% 1 gallonHand sanitizers 50 bottles

REAGENTS Albustics According to the needGlucosticsMultistics

MEDICAL SUPPLIES Gloves-examination 20boxesSurgical gloves 20pairsGynecological gloves 10pairsUtility gloves 10 pairsCannula-different sizes 20pcsI/v giving set 20pcsCatheters-different sizes 10pcs

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Suction tubes –Adult/neonate

10pcs

Penguin 10pcsRyles tube different size 5pcsUrinal bags 10 bagsCotton wool 10 rollGauze 3 rollSutures Catgut 0,1,2 5 pcsAmbubag different sizesfor Adults

3pcs

Neonate ambubagsdifferent

3pcs

Cord tie 100pcsPlaster 10rolssBandage different sizes 50pcsCrepe bandage differentsizes

10 pcs

Standard containers forwaste management

10 pcs (Consider need)

Standard safety box forsharps

10 boxes (Consider need)

EYE OINTMENTS Tetracycline Vials or tube 50Chloramphenicol Vials or tube 50

Family planning materials

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APPENDIX 4

STANDARD MANAGEMENT PROTOCOL

A: LOWER CAVITY VACUUM EXTRACTION

Prepare the mother and equipment for the procedure Empty the bladder Asses level of descent of the foetal head Check fetal heart rate Record starting and finishing time Apply vacuum extractor cup correctly when the head is at the level of 1/5

or 0/5 Assistant to apply vacuum pressure gradually from 0.2kg/mm2 to

maximum of 0.8kg/cm2 Apply gentle and continuous traction during uterine contraction following

the sacral curve. Encourage the woman to bear down during contraction Maintain traction during uterine relaxation Repeat traction with each uterine contraction until crowning of the fetal

head Deliver the baby and placenta Look for any vaginal tears/bleeding and take action Assistant to resuscitate the baby as per protocol Repair the episiotomy immediately Clean and comfort the patient Examine placenta

Stop the procedure if: The head does not crown Cup slips three times Record starting and finishing time

REMEMBER: To adhere to infection prevention and control protocol

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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOURThe midwife should offer to every woman:

Oxytocin 10 iu within I minute after childbirth Deliver the placenta by controlled cord traction and counter pressure to

the uterus Massage the uterus through abdomen after delivery of the placenta During recovery palpate the uterus through the abdomen every 15

minutes for two hours to make sure its firm and monitor the amount ofvaginal bleeding

Encorage the mother to empty bladder

REMEMBER:- Before administering oxytocin palpate the uterus to exclude

another baby- Examine the placenta to ensure completeness- Do not give ergometrine to women with pre-eclampsia, eclampsia, or

high blood pressure because it increases the risk of convulsions andcerebral vascular accidents

B: MANUAL REMOVAL OF RETAINED PLACENTAAs soon as the diagnosis of retained placenta is made

Call for assistance to set I.V fluids Normal saline/Ringer lactate addoxytocin 20 i.u in one litre to run for 30 minutes or Misoprostol rectally

Insert another I.V Ringer’s lactate in the second arm Catheterize the bladder Fill the uterus to make sure it is firm and contracted Look at the genitalia for tears of the cervix or vagina Try to deliver the placenta by controlled cord traction If the placenta cannot be delivered by controlled cord traction, proceed by

checking vital signs, which are: TPRIf the placenta has not come out, do manual removal

STEPS FOR MANNUAL REMOVAL OF PLACENTA If the patient is not in shock give injection pethidine 100mg or diazepam

10mg i/v slowly Maintain traction of the cord with left hand Insert right hand along the cord up to the placenta Work for a detected or separate area of the placenta Insert fingers in between the placenta and uterus-the palm facing the

placenta Gently relieve the cord traction Using the left hand support the fundus and steady the uterus abdominally Detach the placenta gently with a side ways slicing movement

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When the placenta is completely separated, massage the uterus by lefthand while the placenta is gently withdrawn

The placenta should be checked immediately for completeness Give Oxytocin drug 10 IU i/v Observe bleeding and vital signs

IF THE BLEEDING PERSIST AND THE UTERUS IS SOFT Do bi manual compression Mobilize availability of blood Consult doctor or Refer

IF THE BLEEDING CONTINUES AND THE UTERUS IS CONTRACTEDInspect for genital laceration and manage according to the management protocolfor repair of lacerations.

If bleeding continues and the placenta still undelivered Do bi manual compression Arrange for referral Mobilize blood availability Give antibiotics Monitor vital signs Continue monitoring and recording blood loss Administer IV fluids

BI-MANNUAL COMPRESSION OF THE UTERUS Start intravenous infusion Insert the fingers of the right hand into the vagina like a cone, and then the

hand is formed into a fist Place the fist into interior vaginal fornix, the elbow resting on the bed The left hand placed behind the uterus abdominally, the fingers pointing to

wards the cervix The uterus is brought forward and compressed between the palm of the

left hand and the fist in the vagina If bleeding persists, a clotting disorder must be excluded then Mobilize availability of blood Consult a doctor or refer

REMEMBER: To adhere to the standards precaution of IPCTo observe signs of hemorrhage and shock

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C: MANNUAL VACUUM ASPIRATION Should be performed below 12 weeks of gestation Provide psychological support and counseling to the woman Prepare the woman and equipment Perform MVA procedure as per authorized guidelines and protocol Counsel and provide family planning Adhere to standard precaution of IPC Monitor vital signs

D: NEW BORN RESUSCITATION Dry the baby Provide warmth by appropriate clothing /use of incubator /Kangaroo care. Position the baby with the neck in a slightly extended position Suck the mouth and nose if necessary Make sure the baby is breathing Stimulate to initiate breathing

IF THE BABY IS STILL NOT BREATHING Use ambu bag to ventilate as necessary for one minute and assess If breathing is normal (30-60/min) or there is no in-drawing of chest

continue with normal care of the baby. Give oxygen if there is a sign of cyanosis Make sure the heart is beating Do chest compression when necessary

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APPENDIX 5

ESSENTIAL OBSTETRIC FUNCTIONS (LIFE SAVING SKILLS) NEEDED BYMIDWIVES TO SAVE LIVES OF MOTHERS ARE:

1. ANTENATAL IDENTIFICATION, ASSESSMENT AND TREATMENT Prevention and treatment of anemia and malaria Prevention and treatment of pregnancy induced hypertension (oedema,

protenuria, hypertension gestosis) Prevention and treatment of STI, including HIV/AIDS Counseling and testing

MONITORING LABOUR PROGRESS History taking and physical examination Use of partography Documentation, analysis and interpretation

PREVENTION AND TREATMENT OF HAEMMORHAGE Active management of third stage of labour Manual removal of placenta Bi-manual compression of the uterus

MANAGEMENT OF DIFFICULT DELIVERIES Vacuum extraction (Lower cavity Vacuum extraction)

RESUSCITATION (ABC) Infant resuscitation Adult resuscitation

REPAIR OF EPISIOTOMIES AND LACERATIONo Episiotomieso Cervical lacerationso Perineal laceration

HYDRATION AND REHAYDRATION Intravenous fluid therapy Oral fluids Keeping of Intake and output

MANAGEMENT OF SEPSIS Antibiotics Analgesics High level disinfection

POST ABORTAL CARE History taking and counseling MVA

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Antibiotics Analgesics Family planning

GENERAL MANAGEMENT Maintain good interpersonal communication Make correct assessment and diagnosis Prescribe the correct drugs Adhere to standard precaution of IPC Explain to the patient for her consent Involvement of family in care - Consider social cultural aspect Prepare essential equipment and supplies Administer the drugs correctly according to TNMC schedule Observe drugs reaction Maintain safety to client, provider and environment. Documentation, analysis and interpretation Follow up Refer when necessary.