ASSIGNMENT

ON

SkILLED BIRTH (SBA) Module

SUBMITTED TO: SUBMITTED BY:

[Link] [Link]
MSC NURSING LECTURER[CHN] MSC NURSING 1 ST YEAR
VIJAY MARIE COLLEGE OF NURSING VIJAY MARIE COLLEGE OF NURSING
DEFINITION OF SBA:

WHO defines a skilled birth attendant as “an accredited health

professional – such as a midwife, doctor or nurse – who has been educated and
trained to proficiency in the skills needed to manage normal (uncomplicated)
pregnancies, childbirth and the immediate postnatal period, and in the identification,
management and referral of complications in women and newborns.”

Why skilled attendance at birth:

 Most of the obstetric complication are unpredictable.
 Timely life saving support and intervention are a must.
 Absence of midwifery skills- increased chances of casualty.

GOVERNMENT OF INDIA’S SBA INITIATIVE:

In an effort to reduce maternal mortality, the Government of India has taken policy
initiatives to empower the ANMs/LHVs/SNs to make them competent for undertaking
certain life saving measures.
These measures are as follows:
 Permission to use Uterotonic drugs for prevention of PPH.
 Permission to use drugs in emergency situations prior to or to referral for
stabilizing the patient.
 Permission to perform basic procedures at community level in emergency
situations.
However , there is need to train these paramedical
workers in the requisite skills as SBAs.

Objectives:
The overall objective of SBA training is to enhance the knowledge and skill of the
ANMs/ LHV LHVs/ S s/ SNs posted at the outreach centres, sub-centres(SC),
primary health centres( PHC), first referral units(FRUs), so that they are proficient in
the skills needed for: 
 Managing normal( uncomplicated) pregnancies, childbirth and the immediate
postnatal period.
 Identifying and managing complications in women and newborns, and making
referrals
Knowledge based objectives:
By the end of the training, the trainees will be able to understand:
 The care and importance of the women and newborn during the antenatal
period, labour and postnatal period.
 Essential care of the new born and its importance for the health of the baby.
 Clinical features and initial management of the common obstetric complication
during the antenatal period, labour and postnatal period
 Importance of the quality of care provided by midwifery services, and the need
for a client-centred approach, the use of infection prevention practices,
community involvement and provision of a supportive environment for the
mother and family.
Skilled- based objectives:
By the end of the training, the trainees are expected to adapt at the following
skills:
 Measuring the blood pressure, pulse and foetal heart rate(FHR), checking for
pallor and oedema and determining the fundal height, foetal lie and presentation
accurately.
 Performing haemoglobin estimation and testing for proteins and sugar.
 Counselling or birth preparedness, complication readiness, sex during
pregnancy, domestic violence, diet and rest, infant feeding, contraception.
 Conducing pelvic assessment to determine pelvic adequacy.

 Plotting the partograph and knowing when to refer the women..


STRATEGY FOR TRAINING OF SKILLED BIRTH ATTENDANT(ANM/LHV/SN
M/LHV/SN)
1. Trainee’s profile /who is to be trained:
 Only those personal (ANM/SN) who have the core skills who are posted at:
 Functional FRUs or to be upgraded shortly and currently conducting deliver.
 CHCs and currently conducting deliveries.
 Posted at 24hrs PHCs or in a place which is to be upgraded and currently
conducting deliveries.
2. Trainee’s profile /who is to be trainer:
 The trainer should have worked in the training centre/ district hospital in one of
the following capacities, and should have received 2-3 days orientation training
at the state institute of health and family welfare or any other site selected by the
state / district.
 An obstetrician-gynaecologist(MD/Diploma) as master trainer.
 A paediatrician (MD/Diploma)as co- trainer / trainer for sections pertaining to
neonatal health or a Medical Officer(MO) trained in emergency new born
carecare and resuscitation.
 MO, nursing teacher or SN of the district hospital/ training institute.

[Link] site:
 Any district hospital/ Sub- district hospital with adequate caseload and not less
than 150 deliveries per month may be selected.

[Link] of training:
 For staff nurses and LHVs= 2-3 weeks
 For ANM= 3-6 weeks

[Link] material:
 Guidelines for antenatal care and skilled attendance at birth by ANMs/LHVs/SNs,
which serves as a text for all essential and technical information that is needed to
provide skilled attendance at birth. It includes the modules of SBA.
 Handbook for antenatal care and skilled birth attendance by ANMs/LHVs/SNs,
which contains step wise checklists and case studies on the skills that the SBA is
expected to master in order to attain proficiency..
 Trainer‟s guide, which is designed to support the trainer in conducting training
ANMs/LHVs/SNs in a systematic and methodical manner. The trainer should use
this guide in conjunction with the SBA guidelines and handbook, as this will help
to retain focus on coverage and quality.
6. Certification of trainees:
 For the trainees to be certified in SBA skills, he / she will have to be competent.
 Trainers has to score a minimum of 70% both in knowledge based and in all the
skill based [Link] will have to submit a duly signed copy of this
sheet to district CMO at the end of the training.a copy of the same has to be
maintained at the training institution also.
THE TRAINING MATERIAL “GUIDELINES FOR ANTENATAL CARE AND
SKILLED ATTENDANCE AT BIRTH BY ANMS/LHVS/SNS” CONTAINS 3
MODULES. THEY ARE :
•MODULE 1: MANAGEMENT OF NORMAL PREGNANCY, LABOUR AND
POSTPARTUM PERIOD
•MODULE 2: MANAGEMENT OF COMMON OBSTETRIC
COMPLICATIONS
•MODULE 3: ENSURING THE QUALITY OF CARE

MODULE 1: MANAGEMENT OF NORMAL PREGNANCY,

LABOUR AND POSTPARTUM PERIOD
It includes:
 Care during pregnancy –– antenatal care
 Care during labour and delivery- intrapartum period
 Care after delivery- postpartum care

Care during pregnancy- antenatal care

KEY MESSAGES
 Good record-keeping assists in better case management and follow-up.
 Ensure iron- folic acid supplementation to every pregnant woman. first trimester,
unless specifically indicated.
 Do not give a pregnant woman any medication during the first triminister,unless
specifically indicated.
 Adequate rest and diet for the pregnant woman results in better maternal and
neonatal outcomes.
 Recognize that “Every pregnancy is at risk.”
 Ensure that ANC is used as an opportunity to detect and treat existing problems.
 Make sure that services are available to manage obstetric emergencies when
they occur..
 Prepare pregnant women and their families for the eventuality of an emergency.
The important components of ANC are:
1. Early registration
2. Careful history taking
3. Physical examination
4. Investigations(routine, special)
5. Advices;diet,hygiene

Conditions under which a pregnant woman must be referred to a medical

officer/ High risk pregnancy:
Refer the woman to the medical officer if her obstetric history reveals any of the
following:
 previous stillbirth or neonatal loss
 history of three or more spontaneous consecutive abortions
 birth weight of the previous baby <2500 g
 birth weight of the previous baby >4500 g
 hospital admission for hypertension or pre-eclampsia/eclampsia in the previous
pregnancy
 previous surgery on the reproductive tract
 iso-immunization (Rh .ve) in the previous pregnancy

CARE DURING LABOUR AND DELIVERY-INTRAPARTUM

KEY MESSAGES
 Motivate the woman and her family to have a clean and safe delivery.
 Promote and ensure skilled attendance at every birth.
 Promot institutional delivery..
 Let the woman choose the position she desires and feels comfortable in during
labour and delivery..
 Maintain a partograph which will help you in recognizing the need for action at
the appropriate time and thus ensure timely referral.

 Ensure active management of the third stage of labour,which will help in the
prevention of postpartum haemorrhage.
Delivery kit
:: All pregnant women, especially when they are nearning completion of their
term,should be equipped with supplies required for conducting the delivery at
[Link] if the women decided to deliver at home.

If a delivery kit is not available,the following items should be made available

individually to ensure the five "cleans" (i.e. Clean surface, Clean hands, Clean
hands, Clean cord cut, Clean cord tie and Clean umbilical stump):
 A cleanplastic sheet[for ensuring clean surface]
 Soap and clean water (for ensuring "clean hands")
 A new razor blade (for ensuring "clean cord cut")
 A clean piece of of thread [for ensuring "clean cord tie]

The other items that are required during and immediately after
delivery include:
 Home-based antenatal card (for complete information regarding the antenatal
period)
 Clean towels/cloth for washing, drying and wrapping the baby
 Clean clothes for the mother and the baby
 Sanitary pads/clean cloth for the mother
 Food and water for the woman and the support person.

Conducting a normal delivery at home/at the subcenter

Stages of labour

 The first stage of labour starts with the onset of labour pains to the full dilatation
of the cervix. This stage takes about 12 hours in primigravidas and half that time
for subsequent deliveries.
 The second stage starts from the full dilatation of the cervix to the delivery of the
baby. This stage takes about 2 hours for primigravidas and only about half an
hour for subsequent deliveries.
 The third stage starts from after the delivery of the baby and ends with the
delivery of placenta. This stage takes about 15 minutes to half half an hour,
irrespective of whether it is a primigravida or multigravida.
 The fourth stage of labour is the first one hour after delivery of the [Link]
is a critical period as PPH, which is a fatal complication, can occur during this
stage..
Signs of labour:
 Advise the woman to go to the health facility or contact the SBA if she has any
one of the following signs which indicate the start of labour.
 A bloody, sticky discharge P/V
 Painful abdominal contractions every 20 minutes or less.
 The bag of waters has broken, and she has clear fluid coming out P/V

Interventions:
 Explain all procedures, seek permission for examination and carrying out
procedures, and discuss the findings with the woman.
 Keep the woman informed about the progress of labour.
 Praise the woman, encourage her and reassure her that things are going well
 Ensure and respect the privacy of the woman during examinations and
discussions.
 Encourage the woman to bathe or wash herself and her genitals at the onset
labour
 Always wash your hands with soap and water before examining the woman.
 Ensure cleanliness of the birthing area.
 Enema should be given only if there is an indication, e.g. when the woman
complains of constipation on admission or at the onset of labour, or if the woman
wishes to have an enema.
 Encourage the woman to empty her bladder frequently. Remind her every 2
hours or so.
 The presence of a second person or a birth companion of the woman‟s choice in
addition to an SBA is beneficial. Birth companions provide comfort, emotional
support, reassurance, encouragement. On a practical level too, the presence of
a second person is valuable, in that too, in that if at any point during the labour
 additional assistance is required, or in an emergency this second person can be
useful, even if it can be useful, even if it is only to go and and seek help. But one
must ensure cleanliness and concentrate on preventing infection.
 The woman should be allowed to remain mobile during labour,especially the first
stage, as this stage, as this helps in having a shorter and less painful labour.
 The woman should be free to choose any position she desires and feels
comfortable in during labour and [Link] may choose from the left lateral,
squatting, kneeling, or even standing (supported by the birth companion)
positions.
 To relieve the woman of pain and discomfort, a change in position and mobility is
helpful. Encourage the birth companion to massage the woman‟s back if she
finds this helpful, to hold the woman‟ hand and sponge the woman‟s face
between contractions.

Management of the first stage of labour
Monitor the following:
 Contractions. Frequency (once in how many minutes), intensity (how strong),
and duration (for how many seconds does it last) of contractions.
 FHR. The normal FHR is between 120 and 160 beats/minute.
 The presence of any sign that denotes an emergency (such as difficulty in
 breathing, shock, vaginal bleeding, convulsions or unconsciousness).).
 Monitor the following every 4 hours:
 Cervical dilatation (in cm). Unless otherwise indicated, do not perform a vaginal
examination more frequently than once every 4 hours. Never leave the woman
alone, Start maintaining a partograph when the woman reaches active labour.
 The partograph is a graphic recording of progress of labour & salient conditions
of mother and foetus. It is a tool to assess the progress of labour and recognize
need for emergency referral.
 Temperature, Pulse, Blood pressure
 Record the time of rupture of the membranes and the colour of the amniotic fluid.
 Never leave the woman alone.
 If after 8 hours, the contractions are stronger and more frequent, but there is no
progress in cervical dilatation with or without rupture of the membranes, this is a
case of non-progress [Link] the woman urgently to an FRU.
Management of the second stage of labour:
If the cervix is fully dilated or the perineum is thinned-out and bulging, the anus
gaping, with the head of the baby visible,the woman is in the second stage of labour.

 Perineal thinning and bulging

 Visible descent of the foetal head during contractions.
 The upright positions such as standing, sitting, squatting and being on all fours
makes pushing easier. Therefore, if the woman finds it difficult to push, or there
is slow descent of the presenting part, you should help the woman to change her
position.
 During the second stage of labour, the woman should be allowed to push down
when she has contractions if she has the urge to do so.
 Asking the woman to hold her breath and bear down in the second stage of
labour should not be done. Holding the breath can be potentially harmful. It may
reduce the blood flow through the uterus and placenta. It may reduce the supply
of oxygen to the foetus.
 Bearing down efforts are not required until the head has descended into the
[Link], the woman should not be advised to push actively until the
foetal head is distending the perineum.
 Occasionally, the woman feels the urge to push before the cervix is fully dilated.
This should be discouraged as it can result in oedema of the cervix which may
delay the progress of labour.
 To prevent pushing at the end of the first stage of labour (before the cervix is fully
dilated), teach the woman to pant, i.e. to breathe with an open mouth, take in 2
short breaths followed by a long breath out.
 Teach the woman to be aware of her normal breathing. Encourage her to
breathe out more slowly, making a sighing noise, and to relax with each breath.
 It is not advisable to give the woman oxytocins to shorten the second stage of
labour.

MANAGEMENT OF THE THIRD STAGE OF LABOUR

The active management of the third stage of labour consists of the following three
activities.
1. Uterotonic drug
 Giving a uterotonic drug (one that enhances contraction of the uterine muscles)
has been shown to be effective in preventing PPH.
 The drug that is now recommended for use and provided in your kits is Tab.
[Link] drug should be given in a dose of 3 tablets of 200 g each (a
 total dose of 600 g) immediately after the delivery. It should be given either
sublingually or orally. y or orally.
2. Controlled cord traction (CCT)
 This is a technique to assist in expulsion of the placenta and helps to reduce the
chances of a retained placenta and subsequent PPH.
 Ensure that the placenta is delivered completely with all the membranes.
Examination of the placenta, membranes and the umbilical cord.
3. Uterine massage
 This technique helps in contraction of the uterus and thus prevents PPH.
 Immediately after delivery of the baby, massage the uterus by placing your hand
on the woman‟s abdomen until it is well contracted. Repeat the massage every
15 minutes for the first 2 hours.
 Ensure that the uterus does not become relaxed after the massage is stopped.

FRU immediately, day or night, WITHOUT WAITING.

 Excessive vaginal bleeding, i.e. soaking more than than 2 or 3 pads in 20.30
minutes after delivery OR bleeding increases rather than decreases after the
delivery
 Convulsions
 Fast or difficult breathing
 Fever and weakness so that she cannot getout of bed
 Severe abdominal pain
For the following symptoms or signs, the woman should be advised to visit a PHC as
soon as possible.
 Fever
 Abdominal pain
 The woman feels ill
 Swollen, red or tender breasts, or sore nipple
 Dribbling of urine or painful micturition
 Pain in the perineum, or pus draining from the perineal area
 Foul-smelling lochia
CARE AFTER DELIVERY-POSTPARTUM CARE
KEY MESSAGES
--You should make two postpartum visits, one in the first 48 hours and another in the
first
7-10 days, to help ensure that any major complications during the postpartum period
are recognized in time.
-Look out for the symptoms and signs of postpartum haemorrhage, puerperal sepsis
during your postpartum visits, as they are important causes of maternal mortality.
Components of care:
1. Postnatal check-ups
2. History-taking
[Link] of PPH
[Link] [Link]
[Link] and rest
[Link]
[Link] and young child feeding
[Link] care
MODULE 3: MANAGEMENT OF COMMON OBSTETRIC COMPLICATION
KEY MESSAGES

 Educate the woman, her family and the community regarding the danger signals
during pregnancy.
 Organize and ensure local arrangements for transporting the woman to a higher
health facility should the need arise.
 Always refer the woman to the appropriate health facility with her detailed case
record.
 Encourage and prepare the family members for blood donation should the need
rise.
 Do not carry out a vaginal examination in women who have bleeding after 24
weeks of pregnancy.
 Injecting oxytocin can help reduce bleeding in cases of atonic postpartum
haemorrhage.
 Unless proved otherwise, assume that all cases of convulsions during
pregnancy labour and postpartum period are due to eclampsia. The drug of
choice for controlling eclampticfits is injection magnesium sulphate.


Referral for complications during pregnancy, labour and delivery, and th e
postpartum period
 Keep the following points in mind while referring the woman to a higher centre:

 After appropriate management of the emergency, discuss the decision to refer

with the woman and her relatives,especially the people who are decision-makers
in the family.
 Quickly organize transport and possible financial aid.
 Inform the referral centre by phone, if possible.
 Accompany the woman, if possible; otherwise send another other health worker
trained in maternal health care.
 Also send along a relative who can donate blood should the need arise.
 If the referral is being made after delivery, as far as possible, send the baby with
the mother.
 Send the emergency drugs and supplies in the transporting vehicle.
 Write a referral note to the health personnel at the referral centre. The note
should contain salient points about the
-- history
-main clinical findings
medication given (dose, route and time of administration)
other interventions done, if any.
 During the journey:
•• watch the IV infusion.
•• if the journey is long,give appropriate treatment on the way.
•• keep a record of all the IV fluids and medications given, including the given time
•• administration and the condition of the woman from time time to time.

MODULE 3: ENSURING THE QUALITY OF CARE

 Raise the awareness of the community regarding the danger signs during
pregnancy,labour and delivery, and the postpartum period.
 Seek the cooperation of other partners in the community such as self-help
groups, CBOs (Community y based Organisations), non-governmental
organizations, and other community level health functionaries.
Counselling And Supportive Environment:
 Respectful communication with women and their family members ensures better
cooperation.
Supportive care during a normal delivery
 Ensure that the woman has a companion of her choice and, where possible, the
same caregiver throughout labour and delivery. Supportive companionship can
enable a woman to face fear and pain, and reduce loneliness and distress.
 Where possible, encourage companions to take an active role in care. Position
the companion at the head end of the woman to allow her/him to focus on talking
to the woman and caring for heremotional needs.
 Both during and after the delivery/event provide as much privacy as possible to
the woman and her family.

Supportive care during an emergency/complication:

Emotional and psychological reactions of the woman and her family:
The reaction of various members of the family to an emergency situation depends on
the social, cultural and religious situations, the personalities of the people involved
and the gravity of the problem.
General principles of communication and support
Communication and genuine empathy are probably the most important keys to
effective.
Prevention Of Infection
Standard precautions
 Standard precautions should be followed with every client/patient regardless of
whether or not you think the client/patient might have an infection. This is
important because it is not possible to tell who is infected with viruses such as
HIV and the hepatitis viruses, and often infected persons themselves do not
know that they are infected.
 Hand-washing: A general procedure for hand washing should be done.
 Gloves:Wear gloves when there is a risk of touching blood, body fluids,
secretions, excretions or contaminated items during the procedure. Put on clean
gloves
 Patient care equipment: Ensure that reusable supplies/equipment are not used
for the care of another patient until they have been cleaned and reprocessed
appropriately.
 Linen (in a PHC setting):Handle used linen soiled with blood, body
fluids,excretions and secretions in a manner that prevents exposure to the skin
and mucous membranes,and avoids transfer of microorganisms to other patients
and the environment.
 Occupational health and blood-borne pathogens: Take care to prevent injuries
when using needles and other sharp instruments or devices.
Waste disposal
 There is evidence of transmission of infections due to hepatitis B and HIV viruses
via health care waste.
 These viruses can be transmitted through injuries from needles contaminated
with human blood.
The purpose of waste disposal is to:
 Prevent the spread of infection to hospital personnel who handle waste.
 Prevent the spread of infection to the local community..
 Protect those who handle waste from accidental injury..
 Proper handling of contaminated waste (blood or body fluid-contaminated items)
is required to minimize the spread of infection to hospital personnel and the
community.