HAND WASHING

TECHNIQUE Routine hand washing Careful hand washing Hygienic hand rub MAIN PURPOSE Cleansing AGENTS Non medicated soap Non medicated soap Alcohol RESIDUAL EFFECT Short

Cleansing after patient contact Disinfection after contamination Pre-operative disinfection

Short

Short

Surgical hand disinfection

Antibacterial soap Alcoholic solutions

Long

STEPS OF HAND WASHING

Ensure handwashing for 5 minutes before surgical procedures

Ministry of Health & Family Welfare Government of India

INFECTION PREVENTION
Puncture Proof Container

Hand washing Use of protective attire

Hand Washing

Safe Disposal Unit

ainer Transparent plastic cont with a locking system

Proper handling and disposal of sharps

Protective Attire

All Needles and Sharps I.V. Cannulas Broken Ampoules All Blades

Ensuring general cleanliness (walls, floors, toilets, and surroundings) Bio-Medical Waste disposal - Segregation - Disinfection - Proper storage before transportation - Safe disposal
Disposal Bag

Needle Destroyer

Yellow Bag
Human tissue Placenta and PoCs Waste swabs / bandage Other items (surgical waste) contaminated with blood

Black Bag
Kitchen waste Paper bags Waste paper / thermocol Disposable glasses & plates Left over food

Red Bag
Disinfected catheters I.V. bottles and tubes Disinfected plastic gloves Other plastic material

Ministry of Health & Family Welfare Government of India

PREPARATION OF 1 LITRE BLEACHING SOUTION

Wear utility gloves and plastic apron.

Take 1 litre of water in plastic bucket.

Make thick paste in a plastic mug with 3 level tea-spoons of bleaching powder and some water from the bucket.

Mix paste in the bucket of water to make 0.5% chlorine solution.

Maintain same ratio for larger volumes.

Ministry of Health & Family Welfare Government of India

PROCESSING OF USED ITEMS

DECONTAMINATION
Soak in 0.5% chlorine solution for 10 minutes

Thoroughly wash and rinse Wear gloves and other protective barriers

Preferred Method Sterilisation

Acceptable Method High Level Disinfection (HLD)

Chemical Soak for 10 - 24 hrs.

Autoclave 106 kPa pressure 121 C 20 min. unwrapped 30 min. wrapped

Dry Heat 170 C 60 min.

Boil or Steam Lid on 20 min.

Chemical Soak for 20 min.

(use immediately or store)

Cool

Ministry of Health & Family Welfare Government of India

ANTENATAL EXAMINATION
FUNDAL HEIGHT
Preliminaries
Ensure privacy Woman evacuates bladder Examiner stands on right side Abdomen is fully exposed from xiphi-sternum to symphysis pubis Patients legs are straight Centralise the uterus
Fundal height in cms. corresponds to weeks of gestation after 28 weeks
36 wk 32 wk 28 wk 24 wk 20 wk 16 wk
weeks

Correct dextrorotation

Ulnar border of left hand is placed on upper most level of fundus and marked with pen

Measure distance between upper border of pubic symphysis and marked point

GRIPS
Legs are slightly flexed and seperated for obstetrical grips

Fundal Grip

Lateral Grip

First Pelvic Grip

Second Pelvic Grip

Fetal heart sound is usually located along the lines as shown

Ministry of Health & Family Welfare Government of India

THE SIMPLIFIED PARTOGRAPH

Identification Data
Name: Date & Time of Admission: W/o: Date & Time of ROM: Age: Parity: Reg. No.:

Foetal heart rate

200 190 180 170 160 150 140 130 120 110 100 90 80

A) Foetal Condition

Amniotic uid B) Labour

t Aler n Actio

Cervic (cm) (Plot X)

10 9 8 7 6 5 4 Hours Time 5 4 3 2 1

10

11

12

Contraction per 10 min.

C) Interventions
Drugs and I.V. uid given

Pulse and BP

180 170 160 150 140 130 120 110 100 90 80 70 60

D) Maternal Condition

Temp (C)

Initiate plotting on alert line

Ministry of Health & Family Welfare Government of India

Refer to FRU when ALERT LINE is crossed

KANGAROO CARE

Place baby prone on mothers chest in an upright and extended posture, between her breasts, in skin to skin contact

Cover the baby with mothers pallu or gown. Wrap baby-mother with added blanket/shawl.

Keep room warm. Breastfeed frequently.

Ministry of Health & Family Welfare Government of India

VAGINAL BLEEDING BEFORE 20 WEEKS

Threatened abortion
c/o pain abdomen and light bleeding P/V No h/o expulsion of PoC O/E uterus soft, corresponds to POG, os closed

Incomplete abortion
c/o pain abdomen and excessive bleeding P/V h/o expulsion of PoC O/E uterus size smaller than POG, os may be open

Complete abortion
c/o light bleeding h/o pain abdomen, bleeding P/V with expulsion of PoC O/E uterus size smaller than POG, os closed
Observe for 4 - 6 hrs.

Advise rest at home Consult /Refer to M.O. for ANC

If bleeding stops

If bleeding does not stop or in shock

If bleeding continues

If bleeding stops

Consult / Refer to M.O.

Establish I.V. line and give I.V. fluids rapidly Consult / Refer to M.O. with referral slip

Consult / Refer to M.O.

Reassure and advise to take rest at home

Ministry of Health & Family Welfare Government of India

ANTEPARTUM HEMORRHAGE VAGINAL BLEEDING AFTER 20 WEEKS

PLACENTA PREVIA
(Placenta lying at or near os)

ABRUPTIO PLACENTAE
(Detachment of normally placed placenta before birth of fetus)

Establish I.V. line Start I.V. Fluids Monitor vitals - PR, BP

NO P/V TO BE DONE
Refer to FRU Arrange for blood donors

Ministry of Health & Family Welfare Government of India

ECLAMPSIA
Convulsions BP 140/90 mmHg Proteinuria

Immediate Management

Position woman on her left side Ensure clear airway (use padded mouth gag after convulsion is over) Do gentle oral suction Give Inj. Magnesium Sulphate 5g (10ml, 50% ) in each buttock deep I.M.

Delivery imminent

Delivery not imminent

Conduct delivery and refer to FRU

Refer immediately to FRU

Ministry of Health & Family Welfare Government of India

Management of PPH
Shout for Help: Mobilise available health personnel. Quickly evaluate vital signs: Pulse, BP, Respiration. Establish I.V. Line (draw blood for blood grouping & cross matching) Infuse rapidly Normal Saline/Ringer Lactate 1L in 15-20 minutes. Give Oxygen @ 6-8 L per minute by mask (if available) Catheterize the bladder. Check vital signs and blood loss (every 15 minutes). Monitor fluid intake and urinary output.

Give Inj. Oxytocin 10 IU, I.M. (if not given after delivery) Start Inj. Oxytocin 20 IU in 500 ml R/L @ 40-60 drops per minute (in other hand) Check to see if placenta has been expelled

Placenta not delivered Retained placenta Continue Inj. Oxytocin 20 IU in 500 ml, R/L @ 40-60 drops per minute

Placenta delivered Massage the uterus to expel the clots Examine placenta & membranes for completeness

Complete Refer to FRU

Not Complete

Feel the consistency of uterus per abdomen

Continue Inj. Oxytocin 20 IU in 500 ml, R/L @ 40-60 drops per minute

Uterus well contracted (Traumatic PPH)

Soft and flabby uterus (Atonic PPH)

Refer to FRU

Bimanual compression of uterus Pack the vagina and refer to FRU Continue Inj. Oxytocin 20 IU in 500 ml, R/L @ 40-60 drops per minute Continue Inj. Oxytocin 20 IU in 500 ml R/L / DNS-I/V Administer another uterotonic drug (Inj. Methergine / Tab. Misoprostol)

Patient still bleeding

Refer to FRU

Ministry of Health & Family Welfare Government of India

Active Management of Third Stage of Labour

(AMTSL)

After the birth of the baby, exclude the presence of another baby and give Injection Oxytocin 10 units I.M.

Once the uterus is contracted, apply cord traction (pull) downwards and give counter-traction with the other hand by pushing uterus up towards the umbilicus.

Uterine massage to prevent atonic PPH

Ministry of Health & Family Welfare Government of India

NEWBORN RESUSCITATION
Birth
No meconium - dry the baby Meconium present - suction mouth and nose (if baby is not crying) and dry the baby Not breathing well Initial steps Cut the cord immediately Place on firm, flat surface Provide warmth Position baby with neck slightly extended Suction mouth and then nose Stimulate, reposition

Assess breathing

Breathing well / crying

Routine care Place the baby on mothers abdomen Wipe mouth and nose Clamp & cut the cord (after 1 - 3 min. of birth) Keep baby with mother Initiate breastfeeding Watch colour and breathing Breathing well

Assess breathing
Not breathing well Provide bag and mask ventilation for 30 sec., ensure chest rise. Make arrangements for referral

Assess breathing
Not breathing well Call for help and make arrangements for referral Continue bag and mask ventilation Add oxygen, if available

Breathing well

(Umblical pulsation: check for 6 sec. and multiply by 10)

Assess Heart Rate

Continue bag and mask ventilation heart rate 100 If breathing well, slowly discontinue ventilation and provide observational care

heart rate < 100 Observation / Care Provide warmth Continue ventilation with oxygen Provide advanced care (chest compression, medication and intubation, if M.O. / trained personnel are available) Observe colour, breathing and temperature Initiate breastfeeding Watch for complications (convulsions, coma, feeding problems ) Refer when complications develop

Ministry of Health & Family Welfare Government of India

BREAST FEEDING

Baby well attached to the mothers breast

1. Chin touching breast (or very close) 2. Mouth wide open 3. Lower lip turned outward 4. More areola visible above than below the mouth

Baby poorly attached to the mothers breast

Ministry of Health & Family Welfare Government of India

ANTENATAL CHECKUP
Registration and Antenatal checkups during pregnancy: Necessary for well being of pregnant woman and foetus Help in identifying complications of pregnancy on time and their management. Ensure healthy outcomes for the mother and her baby

Preferred Time for Antenatal Checkups*

Registration & 1st ANC 2nd ANC 3rd ANC 4th ANC In first 12 weeks of pregnancy Between 14 and 26 weeks Between 28 and 34 weeks Between 36 and term

* Provide ANC whenever a woman comes for check up

FIRST VISIT
Pregnancy detection test Fill up MCH Protection Card & ANC register Give filled up MCH Protection Card & Safe Motherhood booklet to the pregnant woman Patients past and present history for any illness/complications during this or previous pregnancy Physical examination (weight, BP, respiratory rate) & check for pallor, Jaundice & oedema

CHECK UP AT ALL VISITS (From 1st to 4th)

Physical examination Abdominal palpation for foetal growth, foetal lie and auscultation of Foetal Heart Sound Counselling:
Nutritional Counselling Educate woman to recognise the signs of labour Recognition of danger signs during pregnancy, labour and after delivery or abortion Encourage institutional delivery/ identification of SBA/avail JSY benefits Identify the nearest functional PHC/FRU for delivery and complication management Pre Identification of referral transport and blood donor To convey the importance of breastfeeding, to be initiated immediately after birth For using contraceptives (birth spacing or limiting) after birth/abortion

ADVISE
Laboratory investigations At SC:
- Haemoglobin estimation - Urine test for sugar and proteins - Rapid malaria test (in endemic areas) -

At PHC/CHC/FRU:
Blood group, including Rh factor VDRL, RPR, HBsAg & HIV testing Rapid malaria test (if unavailable at SC) Blood sugar( random)

Give Iron/Folic acid tablets and two doses of TT injection

Ministry of Health & Family Welfare Government of India

POSTNATAL CARE
Post natal care ensures well being of the mother and the baby. Postnatal care
1st Visit 2nd Visit 3rd Visit 4th Visit 1st day after delivery 3rd day after delivery 7th day after delivery 6 weeks after delivery

Additional visits for Low Birth Weight babies on 14th, 21st and 28th days

Mother

SERVICE PROVISION DURING VISITS

Check:
Pallor, pulse, BP and temperature Urinary problems and vaginal tears Excessive bleeding (Post partum Haemorrhage) Foul smelling discharge (Purperal sepsis)

Care of the breast and nipples Counsel and demonstrate good attachment for breast feeding Advice on Exclusive Breast Feeding for 6 months Provide IFA supplementation to the mother Advise for nutritious diet and use of sanitary napkins Motivate and help the couple to choose contraceptive method

Newborn

Check temperature, jaundice, umblical stump and skin for pustules Observe breathing, chest indrawing, convulsions, diarrhea and vomitting Confirm passage of urine (within 48 hours) and stool (within 24 hours) Counsel on keeping the baby warm Keep the cord stump clean and dry Observe suckling by the baby during breastfeeding Make more visits for the Low Birth Weight babies Emphasise on importance of Routine Immunisation

NOTE: Manage the complications and refer if needed

Ministry of Health & Family Welfare Government of India