Appendix C
The Essential Competencies of a Skilled Birth Attendant

SKILLS FOR MANAGEMENT OF COMPLICATIONS AT DOMICILIARY/PRIMARY LEVELS

Maternal haemorrhage: A skilled attendant should be able to diagnose various causes of antepartum and postpartum bleeding, including abortion (see below), as well as recognize the possibility of internal haemorrhage due to ectopic pregnancy. For antepartum and internal hemorrhage, a skilled attendant should stabilize and transfer the woman immediately. Skilled attendants can reduce the likelihood of postpartum hemorrhage by promoting the normal mechanisms of placental delivery and by using active management of this stage when appropriate (including administration of a prophylactic oxytocic with or immediately after delivery of the infant, early cord clamping and cutting, and controlled cord traction). Manual removal of placenta, uterine massage, and aortic or bimanual compression are also options. When the bleeding requires emergency care, skilled attendants can stabilize the woman by giving intravenous fluids and can transfer her to a referral facility.

Sepsis: A skilled attendant should prevent infection by ensuring that the woman gives birth in a safe, clean environment, maintaining the highest possible standards of hygiene and infection control, and using clean or sterile equipment, including gloves. For women who develop an increased risk of sepsis during delivery (e.g., if membranes have been ruptured over a



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Improving Birth Outcomes: Meeting the Challenge in the Developing World Appendix C The Essential Competencies of a Skilled Birth Attendant SKILLS FOR MANAGEMENT OF COMPLICATIONS AT DOMICILIARY/PRIMARY LEVELS Maternal haemorrhage: A skilled attendant should be able to diagnose various causes of antepartum and postpartum bleeding, including abortion (see below), as well as recognize the possibility of internal haemorrhage due to ectopic pregnancy. For antepartum and internal hemorrhage, a skilled attendant should stabilize and transfer the woman immediately. Skilled attendants can reduce the likelihood of postpartum hemorrhage by promoting the normal mechanisms of placental delivery and by using active management of this stage when appropriate (including administration of a prophylactic oxytocic with or immediately after delivery of the infant, early cord clamping and cutting, and controlled cord traction). Manual removal of placenta, uterine massage, and aortic or bimanual compression are also options. When the bleeding requires emergency care, skilled attendants can stabilize the woman by giving intravenous fluids and can transfer her to a referral facility. Sepsis: A skilled attendant should prevent infection by ensuring that the woman gives birth in a safe, clean environment, maintaining the highest possible standards of hygiene and infection control, and using clean or sterile equipment, including gloves. For women who develop an increased risk of sepsis during delivery (e.g., if membranes have been ruptured over a

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Improving Birth Outcomes: Meeting the Challenge in the Developing World prolonged period, or the woman has been exposed to an infectious substance/situation), skilled attendants can also monitor women after delivery, educate women and their families on the signs of infection, and if sepsis develops, administer antibiotics. Skilled attendants can also recognise sepsis due to unsafe abortion Pre-eclampsia and eclampsia: Skilled attendants can identify elevated blood pressure and proteinuria as signs of pre-eclampsia. Such cases should be provided with emergency care and referred for higher-level care. If eclampsia occurs during delivery, skilled attendants can provide potentially life-saving care: administering anticonvulsant drugs, inducing labor by rupturing membranes, and correctly positioning an unconscious woman for delivery. Skilled attendants should also be able to administer anticonvulsant drugs and stabilize a woman to prevent her condition from worsening, and refer her for higher-level care. Prolonged or obstructed labor: A skilled attendant can use a partograph to monitor the progress of labor, identify prolonged or obstructed labor, and take appropriate and timely action. If labor is long or difficult, skilled attendants provide supportive care throughout the process. If prolonged labor is due to ineffective contractions, careful augmentation with oxtocin is an option. For other causes, such as shoulder dystocia or prolapsed cord, skilled attendants can provide emergency care. In some cases, experienced providers can use a vacuum extractor to save the lives of both mother and infant. In all cases of prolonged and obstructed labor, skilled attendants must be able to refer severe cases promptly to higher-level care. Addressing abortion complications: A skilled attendant can play an important role in facilitating women’s access to the appropriate measures for managing unsafe abortion. These include providing treatment for or referring women who present with signs of inevitable, incomplete, and septic abortions, according to the attendant’s level of skill. In circumstances where abortion is not against the law, skilled attendants have a role to play in protecting women’s health. While not promoting abortion as a method of family planning, they may advocate to ensure that services are safe and accessible. Family planning counseling and methods should be provided in the postabortion period, as well as other reproductive health counseling as needed. Preventing neonatal deaths: A skilled attendant can take appropriate measures to prevent neonatal death: tetanus toxoid immunization during pregnancy, assessing the baby’s condition at birth, and resuscitating, if necessary. Preventing neonatal hypothermia, taking appropriate measures

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Improving Birth Outcomes: Meeting the Challenge in the Developing World to prevent nosocomial infection, and supporting early and exclusive breastfeeding. The skilled attendant can identify and provide initial care for sick and/or low-birth-weight infants, and refer them safely. Skilled attendants can also support the mother in providing appropriate care of a moderately preterm or low-birth-weight infant who does not have a life-threatening condition. Conditions that can complicate pregnancy and childbirth (e.g., anemia, malaria, HIV/AIDS): Skilled attendants can take a range of appropriate measures to prevent these conditions, including: providing routine iron and vitamin supplementation; providing prophylactic malaria treatment and antihelminthic drugs; and providing nutrition education. In addition, skilled attendants with access to laboratory facilities can diagnose and treat anemia, malaria, and sexually transmitted infections; they can also provide counseling to encourage women to seek voluntary HIV testing, as well as advise mothers who have or suspect they have HIV/AIDS on infant feeding options. Skilled attendants can administer antiretroviral therapies, where available, to women with HIV, before or during delivery. ADDITIONAL SKILLS AT THE FIRST REFERRAL LEVEL In addition to those skills outlined above, the attendant at the first referral level should have the following skills: Induction of labor Surgical intervention (i.e., cesarean section, laparatomy in case of ectopic pregnancy, emergency hysterectomy, dilation and curettage) Destructive operations (e.g., craniotomy) Diagnosis and management of diabetes, chronic hypertension, cardiac disease, kidney disease, and other common chronic conditions during labor and birth. ATTITUDINAL AND COGNITIVE SKILLS Along with technical competency in clinical care, skilled birth attendants need to understand local customs so that they can work with communities in making healthy choices—that is, promote practices that are benign or beneficial and explain why other practices are harmful and discourage their use. In order to support women and their families in making decisions about health, skilled attendants must have the ability to communicate effectively with women and their families (i.e., listen as well as speak, and speak clearly, simply, and respectfully). Indeed, in some contexts, these communi-

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Improving Birth Outcomes: Meeting the Challenge in the Developing World cation and interpersonal skills can be the determining factor in whether skilled attendants are accepted in communities and their services utilized. In addition, it is important for skilled attendants to use cognitive skills that facilitate problem solving and quick, decisive action. In the context of identifying essential competencies for skilled attendants, the International Confederation of Midwives has developed a “framework for decision-making.” This framework calls on skilled attendants to take the following actions to ensure high-quality care: Gather information—through interviews, dialogue, observation, and clinical examination—and decide what is relevant to the situation(s); Identify signs and symptoms of serious and/or life-threatening conditions and develop a plan of care, balancing speed with attention to details; and Evaluate the effectiveness of actions taken and modify or adapt the plan of care when needed, in individual cases and when a similar situation arises in the future. Excerpted with permission from Skilled Care During Childbirth Information Booklet. New York: Family Care International, Inc. 2002. Prepared by Mia MacDonald with Ann Starrs.