Skilled Birth Attendants

1
Skilled Birth Attendants
Strategies in BHUTAN
2
Skilled Birth Attendants

• At home
• ANMs
• HAs
• BHWs
• Basic EmOC
• CBT trained doctors and nurses
• GNMs
• ANMs
• ANs
• ACOs

3
Skilled Birth Attendants

• Comprehensive EmOC
• All the above
• OB/GYNs
• EmOC trained doctors
• Surgeons (only C/S)

4
Scope of practice Home delivery

• Recognize malpresentation and refer immediately
• Use partograph and recognize prolonged or
  obstructed labor and refer immediately
• Recognize severe PIH/impending eclampsia and
  refer immediately
• Active management of 3rd stage of labor for all
  deliveries (10 units oxytocin by IM route)

5
Scope of practice Home delivery

• Manual check removal of placenta if separated
  (CCT) and refer or perform MRP under sedation
• IV infusion of oxytocics in case of PPH (with or
  without retained placenta)
• Recognize perineal and cervical tears and repair
  them or refer
• Recognize uterine rupture and evacuate
  immediately
• Start IV fluids, IV antibiotics and
  anti-convulsants where needed
• Basic neonatal resuscitation

6
Scope of practice Basic EmOC

• All of above, plus
• Give blood transfusion
• Manage eclampsia
• Perform assisted vaginal delivery
• Prepare for C/section
• Advanced neonatal resuscitation
• Perform MVA or evacuation of uterus

7
Antenatal period

• Recognize women with high risk factors
• Women with anaemia
• Grand multi-paras
• Women with mal-presentations
• Women with medical conditions
• Women with previous c/section
• .. and refer in time to EmOC centers

8
Referral

• Antenatal period
• Birth planning and emergency preparedness
• Place of birth
• Money for transportation and hospital stay (food,
  clothes, etc)
• Where and by whom to transport (community
  participation)
• Family attendants and blood donors
• Etc etc
• Recognition of high risk factors
• Waiting homes (?)

9
Referral

• In labor/postpartum
• Communicate to the nearest EmOC Center for
  ambulance
• Immediately evacuate the patient and accompany
  with emergency drugs and kits
• Bring blood donors

10
Issues

• Regulations
• Standards
• Already developed and trained
• Need to strengthen support and supervision to
  ensure compliance or practice

11
Issues (contd)

• Training (pre-service, in-service, CBT)
• Additional skills to existing providers
• Improve use of partograph
• Active management of 3rd stage
• MRP
• Improve management of PPH and shock
• Management of eclampsia with MgSO4
• Improve management of infection in pregnancy and
  postpartum period including management of PROM

12
Issues (contd)

• Supervision and monitoring
• Maternal death investigations
• Strengthen midwifery standard audit
• EmOC reporting (monthly)
• Hospital case reviews/clinical meetings
• Near-miss case reviews
• Monitoring visits of EmOC facilities by Safe
  Motherhood Program