FORTPORTALOBSTETRICAND% NEONATAL%EMERGENCIES… · FORTPORTALOBSTETRICAND%...

FORT PORTAL OBSTETR IC AND NEONATAL EMERGENCIES TRA IN ING

DAYS

11TH AND 12TH NOVEMBER , 2014

INTRODUCTION

The 2011 Ugandan Demographic Health surveys (UDHS) (Uganda Bureau of Statistics (UBOS) and ICF International Inc, 2012) puts Maternal Mortality Ratio (MMR) at 438 per 100,000 live births and infant mortality rate at 79 per 1000 live births. Access to quality Basic Emergency Obstetric and Neonatal Care (BEmONC) and Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services, which could address some of the direct obstetric causes of maternal death, is available in only a limited number of facilities in Uganda. Uganda’s Ministry of Health acknowledges “HRH [Human Resource for Health] are in short supply, both in numbers and in skills mix, to effectively respond to the health needs in Uganda” (Ministry of Health, Government of Uganda, 2010). It is reasonable to assume that if the overall number of health care workers and their skill mix increased we could, in turn, increase the skilled birth attendance rate and thereby decrease the maternal and newborn mortality and morbidity. Although neither the Liverpool-‐Mulago Partnership (LMP) or the Sustainable Volunteering Project (SVP) obviously can increase the number of health care workers it is reasonable to assume that with some appropriate training we may be able to increase the skill mix.

A core objective of the SVP, since its inception, includes training in emergency obstetric skills. The overall aim of the project is real sustainable change, and we hope teaching improved skills is one way to achieve this. Many volunteers all across Uganda, whether connected to the SVP, other projects, or having travelled to Uganda independently, have realised that this is the case and have given their time to teaching. However this approach has lead to various courses being taught, in different styles and often with different messages. This can be confusing for participants, and often the content of study days and courses is not actually appropriate to the environment in Uganda.

This year LMP has tried to co-‐ordinate the teaching it offers to deliver a consistent, safe and appropriate message. In May 2014, Dr Helen Allot, Consultant Obstetrician and Gynaecologist at Royal Berkshire NHS Foundation Trust, and Obstetric lead of the Reading Kisiizi partnership, ran a practical course on obstetric emergencies in Kampala. Shortly after this a similar course was run in Hoima, but updated for the more rural setting where the highest level of care in the area is a regional referral hospital rather than a national referral hospital. Many of the team who were involved in the running of this training day in Hoima were actually based in Fort Portal and this report describes the evolution of that work and training to run two similar training days in Fort Portal at the beginning of November 2014.

THE FORT PORTAL OBSTETRIC AND NEONATAL EMERGENCIES TRAINING DAYS, NOVEMBER 2014

The course was designed to take participants through a structured approach to the management of obstetric and neonatal emergencies. These are areas identified as a priority in Uganda. It was designed with a knowledge and understanding of working in a challenging and low resource setting.

A 2006 study in the Lancet raised concerns over the ability of health facilities to recognise and treat life-‐threatening complications and that substandard practices contribute directly to maternal deaths, acknowledging that Sub-‐Saharan Africa has the worst death figures (Ronsmans, 2006). With this in mind, the Obstetric and Neonatal Emergencies Training Day aimed to train multi-‐disciplinary staff from multiple cadres and settings including Health Centres and the Regional Referral Hospital. It was hoped that if the day was successful and showed meaningful change it may be run in other locations around the Kabarole district including health centres and possibly some private hospitals to increase skills across the region.

FACULTY

The course was arranged by: Dr Andrew Mullett (Specialist Registrar in Paediatrics), Dr Lesley Milne (Specialist Trainee in Anaesthetics) and Dr Jon Nelson (Specialist Registrar in Obstetrics and Gynaecology). They were helped with organisation and teaching by: Jean Skeen (Senior Midwife), Mary Doyle (Volunteer Midwife from Better Birth Uganda Charity) and Nice Bashabire (Midwife and Coordinator of School of Nursing at Mountains of the Moon University (MMU), Fort Portal). Natalie Tate and Professor Louise Ackers performed post course data entry and analysis.

TRAIN THE TRAINERS?

One of the faculty members was Nice Bashabire who works at MMU and has previously been involved in teaching on these days. It was hoped that by continuing to use Ugandan faculty we would be in essence “training the trainers”, by which we mean that the by continuing to practice these teaching skills and styles they may start to utilise them increasingly in their own teaching within Uganda.

It has initially been the hope of this course’s organisers to involve several other Ugandan trainers from other facilities in the country including several from Mulago who had participated in the original Kampala training day run in May 2014. Unfortunately, though, these individuals felt the remuneration offered to attend and teach on this course was not sufficient and declined to attend. It was the feeling of the organisers of this course and SVP staff that the remuneration being offered was acceptable and so no increase was offered.

PARTNERSHIP

The course was run in partnership between the SVP and MMU, and was targeted at staff from Fort Portal Regional Referral Hospital (FPRRH), students from MMU and was also offered to staff from Bukuuku Health Centre IV (although none were able to attend).

COURSE DESCRIPTION

This one day course was held over two consecutive days to try and allow as many staff members from FPRRH to attend as possible by allowing them to cross cover each other.

In the morning the candidates were given a series of six lectures and tea was provided halfway through. After lunch, also provided, the candidates were divided into five groups and five practical sessions were run simultaneously with the students rotating every 25mins.

CURRICULUM

The maternal mortality ratio (MMR) for Uganda remains high with the leading direct causes of these deaths being: haemorrhage (26%), sepsis (22%), obstructed labour (13%), unsafe abortion (8%) and hypertensive disorders in pregnancy (6%) (Ministry of Health, Government of Uganda, 2010).

These following topics were chosen as they represent complications of childbirth that are life-‐threatening to mothers and babies, and are often managed inappropriately or without thought for potentially devastating consequences. The problems covered are faced daily in all of Uganda, including at FPRRH.

In light of the current global Ebola epidemic and the fact that in the weeks prior to the course Uganda had a confirmed case of Marburg it was also felt that the day should have an overarching theme of good hygiene. To this end the training day facilitators performed a ‘hand washing dance’ at several points throughout the day getting the candidates to join in reminding them of the ‘six steps of hand hygiene’ (i.e. the correct way to wash your hands for maximal pathogen clearance). Faculty also observed and encouraged hand washing during the tea and lunch breaks.

The course focused on practical management of six of the most important Obstetric and Neonatal Emergencies, with lectures being given on each of the following:

1. Sepsis (Dr Lesley Milne) 2. Hypertensive Disease in Pregnancy (Dr Jon Nelson) 3. Post partum haemorrhage (PPH) (Midwife Nice Bashabire) 4. Breech birth (Senior Midwife Jean Skeen) 5. Shoulder dystocia (Dr Jon Nelson) 6. Neonatal resuscitation (Dr Andrew Mullett)

The afternoon practical sessions were as follows:

1. Hypertensive Disease in Pregnancy (Midwife Nice Bashabire and Midwife Mary Doyle)

2. Post partum haemorrhage (PPH) (Dr Lesley Milne) 3. Breech birth (Senior Midwife Jean Skeen) 4. Shoulder dystocia (Dr Jon Nelson) 5. Neonatal resuscitation (Dr Andrew Mullett)

With each of the lectures we felt it was important to have a few “take home messages” and these were highlighted at the end of each lecture. The candidates were then asked to

recount these at the tea break and lunch break to ensure they retained them. These take home messages were also reiterated during the afternoon practical sessions.

The take home messages from the various talks were as follows:

1. Sepsis (Dr Lesley Milne) a. Early recognition b. Early antibiotics and fluids c. Hand washing

2. Hypertensive Disease in Pregnancy (Dr Jon Nelson) a. Control blood pressure b. Treat or prevent seizures c. Fluid balance d. Deliver the baby and placenta

3. Post partum haemorrhage (PPH) (Midwife Nice Bashabire) a. Fluid to resuscitate the mother b. Rub the uterus

4. Breech birth (Senior Midwife Jean Skeen) a. Call for help and prepare b. Hand off the breech c. Allow natural descent

5. Shoulder dystocia (Dr Jon Nelson) a. Call for help b. McRoberts position

6. Neonatal resuscitation (Dr Andrew Mullett) a. Dry the baby b. Position the airway, and re-‐ ��adjust position if required c. Ventilate the baby ��

The team also managed to do some initial analysis of the pre-‐course questionnaires during the morning session so areas of particular weakness could be addressed in more detail in the afternoon. Similarly, they analysis of the post-‐course questionnaires from day 1 were used to inform and alter the teaching for day 2 to address any unmet learning needs.

METHOD OF ASSESSMENT

The faculty created a 20-‐question pre and post-‐course questionnaire. This was a modification of a questionnaire created by the LMP team in Mbarara for a similar course that was being run at a similar time to these courses. The modification was based on covering the topics being taught on our course as well as some comments the Mbarara team made on how their questionnaire had performed.

The same questionnaire was used both before and after the course to determine improvement. The questionnaire consisted of true/false questions (Appendix 1).

Around two weeks after the course all the candidates who had provided their email addresses were emailed both their pre and post course scores along with an educational document explaining and where appropriate providing evidence of the correct answers (Appendix 2). Copies of all of the presentations were also sent out to the candidates for future reference.

RESULTS

The following table shows the pre-‐ and post-‐course scores as well as the score improvement. There were a total of 20 true or false questions in the questionnaires. We have subdivided the results by cadre. Please note that not all candidates returned both questionnaires and therefore have been excluded from statistical analysis. There were 82 complete returns out of a total 85 candidates over the two days.

Cadre Number of Candidates

Pre-‐course Score

Post-‐course Score

Score Imporvement

Nursing Staff 37 11.3 15.6 4.3 Midwives 9 12.0 15.6 3.6 Nursing Students 25 9.0 13.9 4.9

Other Staff 11 12.8 15.4 2.6 Overall 82 10.9 15.0 4.1 Rounded to 1 decimal place.

Paired student T-‐tests were run and were significant for all individual cadres (p<0.05) as well as the overall rating (p<0.01).

The other staff were made up of 2 anaesthetic officers, 1 intern doctor and the rest did not list a cadre.

COURSE FEEDBACK

A post course feedback form was also attached to the post-‐course questionnaire and this was analysed by Professor Louise Ackers (LMP Trustee) and Natalie Tate (LMP project evaluator) (Appendix 3).

The candidates graded all of the lectures and practical sessions on a scale of usefulness (Not Useful, Useful, Very Useful). These are the results:

Lecture Topic Not Useful Useful Very Useful Sepsis 2% 24% 74% Hypertensive disease in pregnancy 1% 16% 82% Post-‐partum Haemorrhage 2% 16% 82% Breech 2% 19% 79% Shoulder Dystocia 1% 18% 80% Neonatal Resuscitation 0% 14% 86% Overall 2% 18% 80% Rounded to nearest whole percentage.

Lecture Topic Not Useful Useful Very Useful Hypertensive disease in pregnancy 0% 19% 81% Post-‐partum Haemorrhage 1% 18% 81% Breech 0% 15% 85% Shoulder Dystocia 0% 12% 88% Neonatal Resuscitation 0% 5% 95% Overall 0% 14% 86%

Rounded to nearest whole percentage.

After the subject specific feedback we also asked three specific questions. Some of the responses are listed below:

Are there any other topics that you feel were missing from this Emergencies in Obstetrics and Newborn Care day that you would have liked to have been covered?

The most common response was Antepartum Haemorrhage (APH).

The next most common responses were variously related to management of neonatal complications, followed by cord prolapse.

What barriers do you foresee that might prevent you from implementing the skills taught today in your everyday practice?

The most common responses were related to staffing levels, provision of equipment and workload of the health care provider.

Do you have any other comments or feedback on the day to help us improve it for next time?

The following is a selection of the comments received:

“Keep it up

“Thumbs up”

“Excellent”

“Well done”

“It has been so good, I have benefited a lot.”

“Time was very short, needs 5 days.”

“Maybe to train other health workers in other districts.”

“I liked the mode of teaching”

“An excellent mode of delivery combining theory and practicals.”

All candidates were given a certificate of attendance at the end of the day (Appendix 4).

LOGISTICS AND COSTINGS

Due to the University of Salford’s support for development of facilities at MMU’s School of Health Sciences skills laboratory including the donation of many obstetric mannequins it was felt appropriate to hold the training days in the facilities at MMU. This was further emphasised by LMP’s continued partnership with the university and the inclusion of MMU staff members in the faculty. However, the health sciences campus is located at Lake Saaka approximately 7km from FPRRH.

The course was offered to all staff working within maternity or neonatology at FPRRH via word of mouth and posters. We approached senior staff members at the hospital including heads of department and the hospital director to get permission to take staff away from their daily duties. The students at MMU were offered the course via means of phone calls and in class announcements via the MMU staff on the faculty. The staff at Bukuuku Health Centre IV were offered the course via informing of the Doctor In-‐Charge and provision of a poster.

Due to the distance it was felt important to provide transport to and from the facility for hospital staff. The university student bus was arranged to pick up candidates from FPRRH at 0830 each day. However, on both days the bus was around 45mins late. This did unfortunately have a significant impact on the running of the day as well as the moral of the candidates attending. It was also noticed by the faculty waiting at the hospital that some of the prospective candidates did not wait and left prior to the buses arrival.

It was felt from previous experience and the local faculty members that in order to ensure attendance it would be important to provide lunch and refreshments to the candidates. Arrangements were therefore made for this via the university’s usual caterers.

Approximate costs to run the two training days were as follows:

Provision Cost Location Hire 0.00 UGX Transport 80,000 UGX Catering 1,200,000 UGX Course materials 50,000 UGX Total 1,330,000 UGX (~£340 GBP)

FUTURE WORK

POST COURSE MENTORING

Dr Andy Mullett, Dr Lesley Milne and Dr Jon Nelson are all continuing to work within FPRRH and are using a co-‐presence principle of working alongside local staff members to reiterate the principles and practice taught on the training days. Midwife Jean Skeen is continuing to work in a local health centre three and is hoping to start working in other local health centres shortly alongside local staff. Nice Bashabire continues to work within the School of Health Sciences teaching the nursing students.

LONGITUDINAL FOLLOW UP OF KNOWLEDGE TRANSFER

The faculty plan to email the questionnaire to all candidates who provided a valid email address 3 months after the course to try and obtain a longer-‐term picture of retention knowledge. It will be specifically requested that they do not refer to the answers provided although the faculty acknowledge that this is a risk and may skew the responses. They will also hand out hard copies to those staff members who they are working alongside who attended the course to try to prevent where possible reference back to the answers provided and to ensure completion.

FUTURE TRAINING DAYS

The faculty hope to be able to arrange similar training days at some of the local larger health centres in the district in the New Year, at which staff from smaller local health centres would also be invited. They also hope to run one at FPRRH to try and encourage more doctors to attend. It should be noted that the intern doctors were unfortunately on strike over pay on the days of the course and this may have affected attendance.

The faculty continue to try to identify local staff members who would be suitable to be part of the faculty in future and possibly run similar training days without the aid of LMP volunteers.

BIBLIOGRAPHY

Aldrich, E. (2014). Policy Brief: Translating evidence from a study on the relationship between transport for emergency obstetric care and maternal health and well-‐being. The Sustainable Volunteering Project & University of Salford. Salford: University of Salford.

Ministry of Health, Government of Uganda. (2010). Health Sector Strategiv Plan III 2010/11 -‐ 2014/15. Government of Uganda, Ministry of Health. Ministry of Health, Government of Uganda.

Ronsmans, C. G. (2006). Maternal Mortality: who, when, where and why? The Lancet , 368, 1195-‐1196.

Uganda Bureau of Statistics (UBOS) and ICF International Inc. (2012). Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.

APPENDIX 1

Candidate Number:

Pre and Post Course Assessments

Please indicate your cadre here:

If you would like to know your pre & post course results please print your email address here:

Question TRUE FALSE Dont Know

Low blood pressure is an early sign in haemorrhage.

Intravenous fluid should be given at a rate of 1 litre every 2 hours in hypovolaemic shock.

Raised respiratory rate is a sensitive measure in shock.

In septic shock patients should be given fluids early and rapidly.

We should be more worried about a patient who responds to voice than one who responds to pain.

Eclamptic fits can only happen before the delivery of the baby.

The correct management with eclampsia is to perform a caesarean section immediately.

In haemorrhage raised heart rate is an early sign.

The majority of cases of shoulder dystocia will resolve with McRoberts’ position alone.

In eclampsia a urine output of more than 30 mls per hour is reassuring.

An unconscious but breathing patient should be kept in the recovery position.

Magnesium sulphate is the drug of choice in prevention of eclampsia.

The most common cause of post partum haemorrhage is vaginal trauma.

You know if a patient is in septic shock because the temperature is always high.

Drying the baby is an important early step in neonatal resuscitation.

Suctioning is a routine part of neonatal resuscitation.

The correct airway position for neonatal resuscitation is the ‘neutral position’.

A single health care worker can successfully manage shoulder dystocia alone.

In breech delivery a “hands off” approach should be used until delivery of the head.

In breech, active pushing should be discouraged until the cervix is fully dilated.

APPENDIX 2

Answers and explanations to pre and post course questionnaires from Obstetric and Neonatal Emergencies Training Day

1. Low blood pressure is an early sign in haemorrhage. False Low blood pressure is a late sign of haemorrhage. The earliest sign is tachycardia. Early in haemorrhage the body compensates for blood loss by increasing the heart rate and systemic vascular resistance in order to maintain blood pressure and hence the tissue perfusion pressure. Eventually, these compensatory mechanisms will fail and only then will blood pressure start to fall. The table below shows the signs that occur during progressive haemorrhage. This is known colloquially as the Tennis Rules due to the % blood loss being the same as the tennis scoring system which can help to remember the percentages.

You can see clearly from here why it is important to try and estimate blood loss accurately. The bodies total circulating blood volume is approximately 5-6L. Therefore, a loss of 2L = 33% and is potentially life threatening.

2. Intravenous fluid should be given at a rate of 1 litre every 2 hours in hypovolaemic shock. False There is no correct rate to give fluids in hypovolaemic shock. Fluids should be given as quickly as possible to restore the circulating volume and restore tissue perfusion. Two large bore cannula’s should be placed in large central veins (normally the antecubital fossa’s), and fluids should be run as quickly as possible. When infusing

large volumes of fluids it is preferable if these are warmed, however delivery of fluids should not be delayed waiting for them to be warmed. Get the next bag warming whilst the first is running in.

3. Raised respiratory rate is a sensitive measure in septic shock. True A raised respiratory rate is a sensitive sign in shock of any type. In septic shock in particular it is one of the diagnostic criteria for the Systemic Inflammatory Response Syndrome (SIRS).

Remember that sepsis is defined by the presence of the SIRS response plus a source of infection. Septic shock is defined as sepsis induced hypotension (despite adequate fluid resuscitation) plus end organ perfusion abnormalities.

4. In septic shock patients should be given fluids early and rapidly. True As you can see from the above answer it is important to fluid resuscitate early and aggressively to maintain tissue perfusion pressures. There is good evidence to show that this can significantly reduce morbidity and mortality (Early goal-directed therapy was introduced by Emanuel P. Rivers, MD, MPH in the New England Journal of Medicine in 2001.)

5. We should be more worried about a patient who responds to voice than one who responds to pain. False The AVPU scale is a very simple and quick way of scoring patients conscious level. The Glasgow Coma Scale (GCS) is still the gold standard but can be lengthy to perform in the emergency situation. It is, therefore, now widely accepted that the AVPU is acceptable in emergencies. To remind you AVPU stands for:

Sepsis and Septic ShockDr Lesley Milne

Fort Portal Regional Referral Hospital

UK Maternal Mortality from Sepsis

2003 - 2005: 0.85 deaths per 100,000 maternities from sepsis

2006 - 2008: 1.13 deaths in 2006–2008 from sepsis

Sepsis is now the most common cause of Direct maternal death.

The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom

Ugandan Maternal Mortality from Sepsis

Pregnancy related sepsis 10%

Infections not related to pregnancy 11%

Total 21%

2nd National Maternal and Perinatal Death Review (MPDR), Ugandan Ministry of Health 2012/2013:

Comparing sepsis globally

American College of Chest Physicians and Society of Critical Care Medicine met in 1991 to reach a consensus on the diagnosis of sepsis and its sequelae.

These definitions have provided a foundation for the common reporting and discussion of sepsis, its complications and treatment.

SIRS: Systemic Inflammatory Response Syndrome

Manifest by two or more of the following conditions:

1. A temperature >38oC or <36oC

2. An heart rate >90 beats per minute

3. A respiratory rate >20 breaths per minute or a PaCO2 <32 mmHg

4. A white blood cell count >12,000/mm3 or <4000/mm3, or the presence of >10% immature forms.

Definitions

Sepsis (Simple):

The systemic response to infection (SIRS)

plus

an infection.

A Alert V Responsive to Voice P Responsive to Pain U Unconscious This indicates a decreasing level of consciousness as you move down the table, the more the conscious level is depressed the more worried you should be.

6. Eclamptic fits can only happen before the delivery of the baby. False Eclamptic fits can happen up to one week post partum. One study found that 44% fits occur postnatally, 38% antepartum and 18% intrapartum (Douglas KA, Redman CWG (1994) Eclampsia in the United Kingdom. BMJ 309:1395–1400)

7. The correct management with eclampsia is to perform a caesarean section immediately. False The decision to perform a caesarean section is based on a number of different factors. The first priority is to stabilise the mother. Delivery is likely to be indicated over the coming hours to days, however vaginal delivery is still the preferred method of delivery unless caesarean is otherwise indicated.

8. In haemorrhage raised heart rate is an early sign. True See answer to question 1.

9. The majority of cases of shoulder dystocia will resolve with McRoberts’ position alone. True A majority of cases of shoulder dystocia will resolve with the McRoberts’ position, with success rates of up to 90% reported (McFarland MB et al. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynaecol Obstet 1996;55:219–24).

10. In eclampsia an urine output of more than 30 mls per hour is reassuring. True A urine output of 0.5ml/kg/hour is considered to be evidence that renal function is maintained, and this is approximate equivalent to 30ml/hour in most patients. It is also reassuring when using magnesium sulphate as it is excreted renally and therefore is unlikely to be accumulating and causing serious side effects like respiratory or neurological depression.

11. An unconscious but breathing patient should be kept in the recovery position. True This will reduce the risk of aspiration of vomit or other secretions and help maintain patency of the airway.

12. Magnesium sulphate is the drug of choice in prevention of eclampsia. True There is good evidence that eclamptic seizures are more likely to stop with magnesium sulphate administration and also that further seizures will be prevented. This is compared to other anti-seizure drugs e.g benzodiazepines or sodium valproate.

13. The most common cause of post partum haemorrhage is vaginal trauma. False It widely accepted that the most common cause is uterine atony, hence why initial management focuses on atony, although all causes should be considered and managed appropriately (FIGO Guidelines: Prevention and treatment of postpartum hemorrhage in low-resource settings; International Journal of Gynecology and Obstetrics 117 (2012) 108–118).

14. You know if a patient is in septic shock because the temperature is always high. False As part of the SIRS response temperature can be high (>38oC) or low (<36oC) (see question 3).

15. Drying the baby is an important early step in neonatal resuscitation. True Babies have a larger surface area to volume ration than older children or adults. When wet they will loose heat very quickly via evaporation dropping their temperature and hindering resuscitation. Hypothermia is a known killer of neonates.

16. Suctioning is a routine part of neonatal resuscitation. False Suctioning is no longer a routine part of neonatal resuscitation. There is now good evidence that its routine use may in fact be detrimental to resuscitation efforts. That is not to say that it may not still occasionally be required, but its use should be saved only for incidences when a something can be seen that may be occluding the airway, such as a blood clot or thick meconium. This can then be removed under direct vision (meaning you can see what you are suctioning). Thin secretions do not need to be suctioned. It may be considered again at the point of using airway adjuncts if you are struggling to get air entry.

17. The correct airway position for neonatal resuscitation is the ‘neutral position’ True The neonate has a number of differences anatomically that impact on the airway. The occiput is larger comparative to the adult and this will tend to flex the head forward and occlude the airway. The tongue is relatively larger in the mouth than in adults. The larynx is more anterior. The neonate that required resuscitation is also likely to have poor muscle tone initially, which will effect the upper airway tone. If the airway is either over or under extended it may therefore occlude. The easiest position to achieve a patent airway and good air entry is therefore the neutral position, which means that the face is parallel to the bed.

18. A single health care worker can successfully manage shoulder dystocia alone. False Whilst there maybe situations where you maybe the only person present at a shoulder dystocia, it is a very difficult emergency to manage alone, hence why your first action should be to call for help.

19. In breech delivery a “hands off” approach should be used until delivery of the head. True Unless a breech extraction is being performed for the second twin, most breech deliveries will occur spontaneous up to delivery of the head. Excessive handling of the baby prior to this point can cause trauma and other complications such as a nuchal arm. However, controlled delivery of the head is recommended to aid flexion and prevent sudden delivery and decompression injuries.

20. In breech, active pushing should be discouraged until the cervix is fully dilated. True This is true for any delivery, but particularly in breech to ensure the presenting part does not slip through a incompletely dilated cervix and then cause entrapment of the after coming head.

APPENDIX 3

Candidate Number:

Are there any other topics that you feel were missing from this Emergencies in Obstetrics and Newborn Care day that you would have liked to have been covered?

What barriers do you foresee that might prevent you from implementing the skills taught today in your everyday practice?

Do you have any other comments or feedback on the day to help us improve it for next time?

How useful did you find the following lectures?

Not Very Useful Useful Very Useful

Sepsis and Septic Shock

Hypertensive Disease in Pregnancy

Post Partum Haemorrhage

Breech

Shoulder Dystocia

Neonatal Resuscitation

How useful did you find the following scenarios?

Not Very Useful Useful Very Useful



Breech

Shoulder Dystocia


Was there anything else you would have liked to have been covered within these lectures?

Sepsis and Septic Shock



Breech

Shoulder Dystocia


APPENDIX 4

EMERGENCY OBSTETRIC AND NEWBORN care

This is to certify that

____________________ COMPLETED A ONE DAY TRAINING WORSHOP ON

November 2014

Professor LOUISE ACKERS – TRUSTEE OF the Liverpool-

mulago partnership

Dr. Edmond Kagambe – deputy

vice chancellor OF MOUNTAINS OF THE MOON

UNIVERSITY

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