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Saving Mothers and Babies: Introduction


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker. It was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: Saving Mothers and Babies was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in this book is based on the results of the annual confidential enquiries into maternal deaths and the Saving Mothers and Saving Babies reports published in South Africa. It addresses: the basic principles of mortality audit, maternal and perinatal mortality, managing mortality meetings, ways of reducing maternal and perinatal mortality rates, This book should be used together with the Perinatal Problem Identification Programme (PPIP).

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Saving Mothers and Babies: Introduction

  1. 1. Saving Mothersand BabiesA learning programmefor professionalsDeveloped by thePerinatal Education Programme
  2. 2. SavingMothersand BabiesA learning programmefor professionalsDeveloped by thePerinatal Education
  3. 3. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Saving Mothers and Babies:A learning programme for professionalsVersion 1.0.0First published by Electric Book Works in 2008Text © Perinatal Education Programme 2008Getup © Electric Book Works 2008ISBN (paperback): 978-1-920218-29-4ISBN (PDF ebook): 978-1-920218-60-7All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand
  4. 4. ContentsAcknowledgements 5 Neonatal mortality 43 The ratio of stillbirths to early neonatalIntroduction 7 deaths 46 Perinatal care index 47 About the EBW Healthcare series 7 Case study 1 47 Why decentralised learning? 7 Case study 2 48 Books in the EBW Healthcare series 7 Case study 3 49 Format of the courses 9 Case study 4 50 Contributors 10 Updating the course material 11 4 Maternal and perinatal mortality Contact information 11 audits 511 Introduction to maternal and perinatal Audit 51 mortality 12 Perinatal mortality meetings 53 Perinatal mortality reports 56 Mortality 12 Perinatal problem identification Audit 15 programme (PPIP) 57 Birth register 17 Case study 1 59 Low birth weight 19 Case study 2 60 Case study 1 20 Case study 3 61 Case study 2 20 Case study 4 61 Case study 3 21 PPIP classifications of perinatal deaths 62 Case study 4 22 5 Finding solutions to maternal and2 Maternal mortality 23 perinatal mortality 64 Mortality ratio 23 Finding solutions 64 Causes of maternal death 25 Avoidable factors associated with Confidential enquiry 27 maternal deaths 66 Avoidable factors 28 Preventing maternal deaths 67 Case study 1 32 Avoidable factors associated with Case study 2 32 perinatal deaths 68 Case study 3 33 Preventing perinatal mortality 70 Case study 4 34 Case study 1 73 PPIP classification of maternal deaths 35 Case study 2 733 Perinatal mortality 36 Case study 3 74 Perinatal mortality 36 Stillbirths 40
  5. 5. AcknowledgementsWe acknowledge all the participants of Saving Editor-in-Chief of the Perinatal EducationMothers and Babies courses who have made Programme: Prof D. L. Woodssuggestions and offered constructive criticism. Editors of Saving Mothers and Babies: Prof D LIt is only through constant feedback from Woods, Prof R C Pattinson, Dr D H Greenfieldcolleagues and participants that the content ofPerinatal Education Programme courses can Contributors: Prof G Theron, Prof H de Groot,be improved. Ms H Louw. .Funding towards this publication wasgenerously provided by Eduhealthcare.
  6. 6. IntroductionABOUT THE EBW families and places of work, and the content frequently fails to address the real healthcareHEALTHCARE SERIES requirements of the poor, rural communities who face the biggest healthcare challenges.EBW Healthcare publishes an innovative To help solve these many problems, a self-series of distance-learning books for help decentralised learning method has beenhealthcare professionals, developed by the developed which addresses the needs ofPerinatal Education Trust, Eduhealthcare, professional healthcare workers, especiallythe Desmond Tutu HIV Foundation and the those in poor, rural communities.Desmond Tutu TB Centre, with contributionsfrom numerous experts.Our aim is to provide appropriate, affordable BOOKS IN THE EBWand up-to-date learning material forhealthcare workers in under-resourced areas, HEALTHCARE SERIESso that they can manage their own continuingeducation courses which will enable them to Maternal Care addresses all the commonlearn, practise and deliver skillful, efficient and important problems that occurpatient care. during pregnancy, labour, delivery and theThe EBW Healthcare series is built on puerperium. It covers the antenatal andthe experience of the Perinatal Education postnatal care of healthy women with normalProgramme (PEP), which has provided pregnancies, monitoring and managinglearning opportunities to over 60 000 nurses the progress of labour, specific medicaland doctors in South Africa since 1992. Many problems during pregnancy, labour and theof the educational methods developed by PEP puerperium, family planning and regionalisedare now being adopted by the World Health perinatal care. Skills workshops teach clinicalOrganisation (WHO). examination in pregnancy and labour, routine screening tests, the use of an antenatal card and partogram, measuring blood pressure,WHY DECENTRALISED detecting proteinuria and performing and repairing an episiotomy.LEARNING? Maternal Care is aimed at healthcare workers in level 1 hospitals or clinics.Continuing education for healthcare workerstraditionally consists of courses and workshops Primary Maternal Care addresses therun by formal trainers at large central hospitals. needs of healthcare workers who provideThese teaching courses are expensive to attend, antenatal and postnatal care, but do notoften far away from the healthcare workers’
  7. 7. 8 SAVING MOTHERS AND BABIESconduct deliveries. It is adapted from theory for women during pregnancy, labour andchapters and skills workshops from Maternal delivery. It also presents improved methodsCare. This book is ideal for midwives and of providing infant care with an emphasisdoctors providing primary maternal care on kangaroo mother care and exclusivein level 1 district hospitals and clinics, breastfeeding.and complements the national protocol ofantenatal care in South Africa. Saving Mothers and Babies was developed in response to the high maternal and perinatalIntrapartum Care was developed for doctors mortality rates found in most developingand advanced midwives who care for women countries. Learning material used in this bookwho deliver in district hospitals. It contains is based on the results of the annual confidentialtheory chapters and skills workshops adapted enquiries into maternal deaths and the Savingfrom the labour chapters of Maternal Care. Mothers and Saving Babies reports published inParticular attention is given to the care South Africa. It addresses the basic principlesof the mother, the management of labour of mortality audit, maternal mortality,and monitoring the wellbeing of the fetus. perinatal mortality, managing mortalityIntrapartum Care was written to support meetings and ways of reducing maternal andand complement the national protocol of perinatal mortality rates. This book shouldintrapartum care in South Africa. be used together with the Perinatal Problem Identification Programme (PPIP).Newborn Care was written for healthcareworkers providing special care for newborn Birth Defects was written for healthcareinfants in regional hospitals. It covers workers who look after individuals with birthresuscitation at birth, assessing infant size and defects, their families, and women who are atgestational age, routine care and feeding of both increased risk of giving birth to an infant with anormal and high-risk infants, the prevention, birth defect. Special attention is given to modesdiagnosis and management of hypothermia, of inheritance, medical genetic counselling,hypoglycaemia, jaundice, respiratory distress, and birth defects due to chromosomalinfection, trauma, bleeding and congenital abnormalities, single gene defects, teratogensabnormalities, as well as communication with and multifactorial inheritance. This bookparents. Skills workshops address resuscitation, is being used in the Genetics Educationsize measurement, history, examination and Programme which trains healthcare workers inclinical notes, nasogastric feeds, intravenous genetic counselling in South Africa.infusions, use of incubators, measuring bloodglucose concentration, insertion of an umbilical Perinatal HIV enables midwives, nursesvein catheter, phototherapy, apnoea monitors and doctors to care for pregnant women andand oxygen therapy. their infants in communities where HIV infection is common. Special emphasis hasPrimary Newborn Care was written been placed on the prevention of mother-to-specifically for nurses and doctors who infant transmission of HIV. It covers the basicsprovide primary care for newborn infants in of HIV infection and screening, antenatallevel 1 clinics and hospitals. Primary Newborn and intrapartum care of women with HIVCare addresses the care of infants at birth, care infection, care of HIV-exposed newbornof normal infants, care of low-birth-weight infants, and parent counselling.infants, neonatal emergencies, and commonminor problems in newborn infants. Childhood HIV enables nurses and doctors to care for children with HIV infection. ItMother and Baby Friendly Care describes addresses an introduction to HIV in children,gentler, kinder, evidence-based ways of caring the clinical and immunological diagnosis
  8. 8. INTRODUCTION 9of HIV infection, management of children 2. Pre- and post-testswith and without antiretroviral treatment, There is a multiple-choice test of 20 questionsantiretroviral drugs, opportunistic infections for each chapter at the end of the book.and end-of-life care. Participants are encouraged to take a pre-test before starting each chapter, to benchmarkChildhood TB was written to enable their current knowledge, and a post-test afterhealthcare workers to learn about the primary each chapter, to assess what they have of children with tuberculosis. The bookcovers an introduction to TB infection, Self-assessment allows participants to monitorand the clinical presentation, diagnosis, their own progress through the and prevention of tuberculosisin children and HIV/TB co-infection. 3. Question-and-answer formatChildhood TB was developed by paediatricianswith wide experience in the care of children Theoretical knowledge is presented in awith tuberculosis, under the auspices of the question-and-answer format, which encouragesDesmond Tutu Tuberculosis Centre at the the learner to actively participate in theUniversity of Stellenbosch. learning process. In this way, the participant is led step by step through the definitions,Child Healthcare addresses all the common causes, diagnosis, prevention, dangers andand important clinical problems in children, management of a particular problem.including immunisation, history and Participants should cover the answer for a fewexamination, growth and nutrition, acute and minutes with a piece of paper while thinkingchronic infections, parasites, skin conditions, about the correct reply to each question. Thisand difficulties in the home and society. Child method helps learning.Healthcare was developed for use in primarycare settings. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toAdult HIV covers an introduction to HIV diagnosing or managing a particular problem.infection, management of HIV-infected adultsat primary-care clinics, preparing patients for Each question is written in bold, like this,antiretroviral (ARV) treatment, ARV drugs, and is identified with the number of thestarting and maintaining patients on ARV chapter, followed by the number of thetreatment and an approach to opportunistic question, e.g. 5-23.infections. Adult HIV was developed bydoctors and nurses with wide experience in 4. Important lessonsthe care of adults with HIV, under the auspicesof the Desmond Tutu HIV Foundation at theUniversity of Cape Town. Important practical lessons are emphasised by placing them in a box like this.FORMAT OF THE COURSES 5. Notes NOTE Additional, non-essential information is provided for interest and given in notes like this.1. Objectives These facts are not used in the case studies orThe learning objectives are clearly stated at the included in the multiple-choice questions.start of each chapter. They help the participantto identify and understand the importantlessons to be learned.
  9. 9. 10 SAVING MOTHERS AND BABIES6. Case studies CONTRIBUTORSEach chapter closes with a few casestudies which encourage the participant The developers of our learning materials are ato consolidate and apply what was learned multi-disciplinary team of nurses, midwives,earlier in the chapter. These studies give the obstetricians, neonatologists, and generalparticipant an opportunity to see the problem paediatricians. The development and review ofas it usually presents itself in the clinic or all course material is overseen by the Editor-hospital. The participant should attempt to in-Chief, emeritus Professor Dave Woods,answer each question in the case study before a previous head of neonatal medicine at thereading the correct answer. University of Cape Town who now consults to UNICEF and the WHO.7. Practical training Perinatal Education TrustCertain chapters contain skills workshops,which need to be practised by the participants Books developed by the Perinatal Education(preferably in groups). The skills workshops, Programme are provided as cheaply as possible.which are often illustrated with line drawings, Writing and updating the programme is bothlist essential equipment and present step-by- funded and managed on a non-profit basis bystep instructions on how to perform each the Perinatal Education Trust.task. If participants aren’t familiar with apractical skill, they are encouraged to ask an Eduhealthcareappropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcare is a non-profit organisationway, senior personnel are encouraged to share based in South Africa. It aims to improve healththeir skills with their colleagues. and wellbeing, especially in poor communities, through affordable education for healthcare workers. To this end it provides financial8. Final examination support for the development and publishing ofOn completion of each course, participants the EBW Healthcare series.can take a 75-question multiple-choiceexamination on the EBW Healthcare website, The Desmond Tutu HIV Foundationwhen they are ready to. The Desmond Tutu HIV Foundation at theAll the exam questions will be taken from University of Cape Town, South Africa,the multiple-choice tests from the book. The is a centre of excellence in HIV medicine,content of the skills workshops will not be building capacity through training andincluded in the examination. enhancing knowledge through research.Participants need to achieve at least 80%in the examination in order to successfully The Desmond Tutu Tuberculosis Centrecomplete the course. Successful candidates The Desmond Tutu Tuberculosis Centre atwill be emailed a certificate which states Stellenbosch University, South Africa, strivesthat they have successfully completed to improve the health of vulnerable groupsthat course. EBW Healthcare courses are through the education of healthcare workersnot yet accredited for nurses, but South and community members, and by influencingAfrican doctors can earn CPD points on the policy based on research into the epidemiologysuccessful completion of an examination. of childhood tuberculosis, multi-drug-Please contact or resistant tuberculosis, HIV/TB co-infection+27 021 44 88 336 when you are ready to take and preventing the spread of TB and HIV inthe exam. southern Africa.
  10. 10. INTRODUCTION 11UPDATING THE COURSE CONTACT INFORMATIONMATERIAL EBW HealthcareEBW Healthcare learning materialsare regularly updated to keep up with Website: www.ebwhealthcare.comdevelopments and changes in healthcare Email: info@ebwhealthcare.comprotocols. Course participants can makeimportant contributions to the continual Telephone: +27 021 44 88 336improvement of EBW Healthcare books Fax: +27 088 021 44 88 336by reporting factual or language errors, Post: 87 Station Road, Observatory, 7925,by identifying sections that are difficult to Cape Town, South Africaunderstand, and by suggesting additions orimprovements to the contents. Details ofalternative or better forms of management Editor-in-Chief: Professor Dave Woodswould be particularly appreciated. Please send Website: comments or suggestions to the Editor-in-Chief, Professor Dave Woods. Email: Telephone: +27 021 786 5369 Fax: +27 021 671 8030 Post: Perinatal Education Programme, PO Box 34502, Groote Schuur, Observatory, 7937, South Africa