Reduction of maternal and infant mortality is linked with the quality of care during pregnancy and child birth. Skilled attendance in every pregnancy and during birth is a proven strategy for ensuring quality of services and for reducing maternal mortality. Training of midwifes and orientation of doctors is the key step which will help in providing skilled attendance during every pregnancy and birth taking place at public health facilities.
Objectives of the guidelines will only be achieved if there is a proper coordination, planning and decision making among all the key stakeholders within the state for conducting this training and utilizing the trained doctors at appropriate places. This Trainer’s Guide shall provide facilitators and resource persons the standard technical content and design of BEmOC training. The overall objective of the training is to enhance the skills of MOs in assessing and managing conditions related to pregnancy, childbirth, postpartum and newborn care.
During clinical practice/ hands on practice, trainee has to use the case sheets, which have been given in the workbook. During these clinical sessions, trainer has to observe how the trainee is performing the skills along with the findings on the case sheets filled by the trainee; trainer has to certify the skill as “satisfactory/unsatisfactory”. Session plan in the trainers’ guide summarizes only the Objectives, Activities, Points of emphasis and Case studies with answers while session plan of the trainees’ handbook contains Objectives, Activities, Notes and Key Messages and Case studies. Ensure that any notes for participants you wish to use, are prepared in advance and are made available to your trainees at the beginning of the module/session Proceedings of a session: Objectives – what the trainee will be able to do, on completion of each session. Activities – interactive sessions, case studies, CDs, hands on demonstrations and charts. Key messages/notes – (given in the handbook) emphasize important points in the concerned session which should be discussed with the trainee.
GUIDELINES for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers will serve as Textbook: It has three modules and 24 Annexures to guide the Trainer’s and Trainee’s and aid in provision of Essential and Emergencey Obstetric procedures and Newborn Care at the facilities. WORKBOOK for TRAINING of Medical Officers in Pregnancy Care and Management of Common Obstetric Complications is for Practising and recording the case scenarios during the Practical: Enable trainers to have the first hand information about various tasks performed by trainee Case studies to stimulate your analytic and decision-making skills in relation to selected Essential and EmONC likely to be faced in field settings To keep the records whenever carrying out any procedure under the supervision of the designated supervisor Knowing the weak areas of the trainee and improving upon them during the training period The activities in the workbook are to be performed under the supervision of the supervisor initially, whose remarks will guide the trainees in improving their skills while practising independently. The trainees are expected to keep the records in this workbook whenever you carry out any procedure under the supervision of the designated supervisor. The trainee’s may add more items after discussion with your supervisor, whenever required. The trainees’ must show the record to the supervisor after he/she has observed the procedure and request him/her to give the remarks and suggestions regarding where you need to improve your competencies.
Will be added when on-site from NIHFW
Equipments necessary for practicing skill are available at the facilities at the identified institutions Ensuring that the Standard protocols are being followed at the selected sites/institutions All the protocols/flowcharts should be displayed at the selected sites/institutions Share the list of trainers & RCH Officers at the State and Districts for follow up on trainees’ status 1 skilled supervisor (Nurse tutor) and one quality supervisor for 10 facilities for Supportive supervision at the District & Block Levels. QA cell for supportive supervision at the State level
Both these activities are very important and as such the MOs deputed for the training must practice these sincerely, so that they can replicate them at their health facility. Any patient being referred from one facility to another must have a referral slip , giving details as in Annexure II of the Guidelines. All the patients admitted for pregnancy and delivery care, should be given a properly filled discharge slip , while getting discharged from health facility as in Annexure III of the Guidelines.
Skills’ assessment should be conducted as an integral component of performance during the posting and practicing of the skills.
If they perform > 70% of the important tasks (as mentioned in recommended critical client practice in Annexure II) satisfactorily, they can be certified for having completed the training successfully.
For each session in the guidelines: Activities as well as case scenarios for each session have been provided, which have to be performed as asked for. Notes are given which summarize each session. Key messages are provided.
Follow routine infection prevention practices during pregnancy and child birth. Appropriately use steps to prevent infections during pregnancy, child birth and postpartum period.
Strengthening of the Medical Colleges where training is to be conducted
Introduction to training guidelines, session plans & role of trainers dr. dinesh baswal
Basic Emergency Obstetric CareIntroduction to Training Guidelines, Session Plans & Role ofTrainersMarch 07, 2011Dr. Dinesh Baswal,Assistant Commissioner, Maternal Health Division,Ministry of Health & Family Welfare201-D, Nirman BhawanNew Delhi
What is EmOC ? The Signal functions…• Parenteral antibiotics• Uterotonic drugs• Parenteral anticonvulsants• Manual removal of placenta• Removal of retained products• Assisted vaginal delivery• Neonatal resuscitation• Cesarean delivery• Blood transfusion BasicEmOCComprehensiveEmOC
Why EmOC?• Most of the obstetric complications can and should bemanaged at PHCs.• Evidence from States indicates surge in the utilization ofinstitutional delivery services at 24 x 7 PHCs which are closerto the poor women in rural areas.• Provision of services for management of obstetriccomplications at these facilities will prevent delays intreatment.• Capacity strengthening of MOs posted at these facilities indiagnosing and managing obstetric complications isnecessary.• The BEmOC training will help them in the re-orientation ofskills in diagnosing and managing obstetric complication.
Whats new?• To improve skills of providers, training of ANMs/LHVs/SNs asSBA has already been in place but the MOs who are also thesupervisors of this training need to be reoriented on theskills.• A guideline on Pregnancy Care and Management of CommonObstetric Complications for Medical officers working at PHCand CHC level was prepared for this purpose in the year 2005.• However, states could not implement it because of lack oftraining tools.• A 10 days’ package for Medical officers is now in place butnow the guidelines are also prepared as a facilitating tool.
Duration of Training• Residential training of 10 days’ duration.• Out of 10 days, a minimum of 4-5 days shouldbe spent in the LR as 24 hours emergencyduty.• Follow the training schedule and sessionplan, as per the guidelines.
Eligibility Criteria for Trainers• Faculty of Obstetrics/Gynaecology and Paediatrics from themedical colleges/district hospitals/identified traininginstitutes shall be the main trainers.• Nominated trainers must undergo orientation training.– Only willing personnel should be nominated as trainers.– The trainers need to spare extra time for this programme.– Not more than 50% of the faculty should be involved in thetraining process at any point in time.• The other staff such as Senior Resident/Registrar, etc., cansupervise the trainee.• One trainer can take up maximum two trainees and the batchsize would be of 4 to 5 trainees each.
Training Site Requisites (Annex I)• Hospital attached to a Medical College which is recognized by MCI andfollows the norms of service delivery as laid down in “Guidelines forPregnancy Care and Management of Common Obstetric Complications byMedical Officers”.• Medical College which has sufficient strength of trainers and is impartingtraining to post graduate students in Obstetrics and Gynecology.• Has proper infrastructure and its readiness as per Annexure 1 of theguidelines.• Has a minimum delivery load of 150 every month and has facility forconducting C-section and other obstetrics related surgical interventions.• Follows all protocols and practices, especially use of Partograph andactive management of third stage of labour. (AMTSL).• The clinical protocols such as AMTSL, Immediate management of PPH,Eclampsia and Essential Newborn Care etc. are displayed prominently inthe labour room premises.
Annexure I : Checklist for Training SiteReadinessCHECKLISTS•Pre training site Readiness•Daily training site preparedness(for Theory & Practical Sessionsincluding Equipments and Drugs)•Log book•
Training Methodology• Training methods should be interactive sessions, discussions, bedside teaching, demonstration of skills, case studies, etc.• Flexible schedule with less stress on didactic lecture or class roomteaching, more priority to be given to clinical practice.• Trainer should limit himself/herself to impart knowledge/skills asper the guidelines.• Training curriculum has been divided into 10 different sessions.• Theory lectures can be scheduled as per the convenience of trainer.Emphasis should be on “Hands on” practice.• Sufficient teaching material, partographs, case sheets, stationery,etc., are available.• Duty register of the trainees should be made available at suitableplaces.• Trainer has to ensure that the quality of the training is maintained.
The Training Resource Pack• GUIDELINES for PregnancyCare and Management ofCommon ObstetricComplications by MedicalOfficers (Textbook)• WORKBOOK for TRAININGof Medical Officers inPregnancy Care andManagement of CommonObstetric Complications
The Training Resource Pack• TRAINEES HANDBOOK forTRAINING of MedicalOfficers in Pregnancy Careand Management ofCommon ObstetricComplications• TRAINERS HANDBOOK forTRAINING of MedicalOfficers in Pregnancy Careand Management ofCommon ObstetricComplications
LR Roster• A Labor Room Roster should be prepared byall the trainer’s at the training sites• The Training site should be checked as per theday’s training site checklist a day in advance• Trainer’s should ascertain that the traineesfollow the Labor Room Roster• The Labor Room Roster should be madeavailable to the Site visiting teams fromCentre or State
Expectations from the ToT Facilitators• Handholding to:Ensure that the Trainers abide by the Guidelines andQuality training is imparted through• Pre training – Ensuring that all protocols are in place,Training Load calculation• Training – Pre-approval of Site Readiness through Siteinspection• Post Training – Regular Follow up of trainees in practicingacquired skill setEnsuring that the expected outcomes are deliveredM & E field visits using the ChecklistsQuarterly M & E reports to be shared with the RCHOfficer at the State Level and GoI
Expectations from Master Trainers• All the Sessions are delivered as per the Session Plan and thelectures are delivered using standardised presentations in the 21hour schedule• Trainees must learn to discharge/make referral of the patientsduring and after training as per the Annexure II and III of Trainee’sWorkbook given in the Guidelines.• The trainees should ensure privacy of the woman and respect herrights.• Ensure Record Keeping by the Trainees which includes:– Record of all their activities in the Trainee’s Hand Book & Workbook and complete the specified number of activities as inAnnexure II (Recommended Client Practice by Trainee).– Attendance records have to be maintained, kept certified by thetrainer/supervisor and kept with the trainer.– A copy of the records related to certification will be maintainedat the training institution as in Annexure IV (Record/Assessment form for the Trainee).
Session Plan• Stick to the Session Plan• Presentations using theStantardized templates to beprovided by GoI• Maintain uniformity by followingthe “Guidelines for Pregnancy Careand Management of CommonObstetric Complications byMedical Officers”• Trainees are to be posted at Antenatal OPD/LR/Post Natal ward orany other relevant place duringthe practice session (minimum of6-8 hours per day)
Session Plan Contd…• Maximum efforts should beundetaken to give hands ontraining to enhance skills ratherthan didactic lectures• Session should be interactive• The trainers should be flexiblein following the suggestedlecture schedule and it can beheld at any point of time in theday depending on the situation
Annexure II : Recommended ClientPractice by Trainee• The trainers will ensure andmonitor quality and practicing ofthese skills• Trainee should keep a dailysigned Cumulative Client PracticeRecord.• This record will be utilized byTrainer for certification• In case there is no client/patienton whom any of the above skillscannot be performed, then thetrainer should use models orinnovative approaches suggestedto enable the trainees to performthe skills.
Annexure II : Referral Slip (Trainee’sHandbook)Trainee must learn todischarge/make referral of thepatients during and after training:• Both these activities are veryimportant and as such the MOsdeputed for the training mustpractise these sincerely, so thatthey can replicate them at theirhealth facility.• Any patient being referred fromone facility to another must havea referral slip, giving details as inAnnexure II.
Annexure III : Discharge Slip (Trainee’sHandbook)• All the patientsadmitted for pregnancyand delivery care,should be given aproperly filled dischargeslip, while gettingdischarged from healthfacility as in AnnexureIII.
• Skills’ assessment should be conducted as an integralcomponent of performance during the posting andpracticing of the skills.• Assessment criteria are “Satisfactory/Unsatisfactory”as per the assessment of the trainer.• During clinical sessions, trainer has to certify thefindings on the case sheets filled by the trainee.• In case the trainer is not available or is off dutyduring performance of skills suitable supervisorshould be deputed for the same.Assessment & Certification
Assessment & Certification …• The trainer must supervise at least 25% of the numberof cases mentioned in recommended client practice asin Annexure II.• In situations where enough cases are not available,hands on practice should be given onmannequins/models.• The trainees will be graded as satisfactory / needs re-orientation as per their overall performance. (> 70 % issatisfactory as per Annexure II)• Those trainees certified as “unsatisfactory” will have torepeat 7 days of the training at the respective traininginstitute before satisfactory completion of the training.
Training Session Assessment(Workbook)• Page 1.1 of theWorkbook• The details of theTraining Session shouldbe recorded by thetrainee• The result of theAssessment need to bementioned and signed bythe trainers
Annexure IV : Record/ Assessmentform for the Trainee (Pg 73 trainer’s)• Trainee to be assessed on the 17activities of the RecommendedClient Practice by Trainee in givenin the Trainer’s Handbook• Observe the Trainee’s for all the 17tasks stated in the this annexureand grade the same as satisfactoryor unsatisfactory• If a trainee is satisfactory for 70 %or more of the tasks i.e. a minimumof 12 tasks the trainee can becertified otherwise he/she willneed reassessment and will have torepeat the course for 7 days at theinstitution at a later date
Expectations from MOs• The trainees should adhere to the schedule as per the sessionplan• Trainees are expected to go through the topics of the sessionsgiven in “Guidelines for Pregnancy Care and Management ofCommon Obstetric Complications by Medical Officers”,beforehand and discuss these with the trainers during thesessions.• Each trainee must fill in his/her observations in the casesheets (given in the workbook) during practice sessions,which would be certified on the spot by thetrainer/supervisor.• The trainees must work at least for 5 days in the LR for 24hours emergency duties as per the roster.
Expected Outcomes of BEmOCTraining“Skilled EmOC personnel”• Provide quality care and counseling to the woman during antenatal,intranatal and postpartum period.• Identify danger signs during pregnancy, delivery and postpartum periodalong with the danger signs in the newborn and provide supportive careprior to referral.• Monitor labour using partograph.• Practice active management of third stage of labour.• Provide step wise essential newborn care to all the new borns and newborn resuscitation, if required.• Make referral of complicated cases after initial management andstabilization of the patient.
Annexure 3Trainers’ and Trainees’ Feedback FormTrainer’s and trainee’s feedbackshould be recorded and provided tothe training teams and Centre forcontinuous improvement of theBEmOC Training
Way Forward for NIHFW• Ensure development of National Trainer’s Pool to meetshortcomings of Trainers in the States• States which have surplus Trainer’s pool can be identified by NIHFWand these trainers can be resourced for deficient States• NIHFW should keep track of the trainings and inform the GoI of thetrainings being rolled out the State and District level a week inadvance so that arrangements for on-site visit of the training can beplanned.• NIHFW needs to continuously assess the need of the MasterTrainers for each State and need to build the pool of trainers in theState
Way forward for Trainers• RCH Nodal Officer should liaison with the Medical College for smoothconduction of quality transformative training• RCH Nodal Officer will also keep a database of Master Trainers andcontinuously get feedback from them• Rational Deployment of Trained Personnel in the Priority Facilities viz.24 x 7 PHCs• Feedback from trainer / trainees for continuous improvement oftraining (Annexure III: Trainer’s & Trainees feedback form)• Assisted Delivery equipments to be available at the facilities at theidentified institutions• Training has to be rolled out within 3 months to minimize inherentlosses• The Training Plan and list of trained MOs should be shared on anongoing basis with the Maternal Health Division of the GoI• Monitor trainees for practicing skills after the training• Training Plan for trainer’s Need to identify those who are practicing andthose not practicing• Of one batch how many are certified, training to know wastage factorand know whether right candidates are identified