Perinatal Education Programme
Maternal Care Manual 2006
Editor-in-chief: Prof D L Woods
Editor of the Maternal Care Manual: Prof G B Theron
Members of the Editorial Board: Dr D H Greenfield, Ms H H Louw, Prof G B Theron, Prof H A van Coeverden de Groot, Prof D L Woods
AIM OF THE PERINATAL EDUCATION PROGRAMME
The aim of the Perinatal Education Programme (PEP) is to improve the care of pregnant women and their newborn infants in all communities of Southern Africa. Although the Programme was written as a distance learning course for both midwives and doctors, it is also used in the training of medical and nursing students.
The authors of the Perinatal Education Programme consist of nurses, obstetricians and paediatricians. This ensures a balanced, practical and up-to-date approach to clinical problems. Many colleagues at other South African universities and health services were also consulted with a view to reaching consensus on the management of most perinatal problems.
If all three levels of perinatal care are to be efficiently provided within a perinatal health care region, continuous education and training of all staff is essential. Unfortunately this often is achieved in the tertiary care hospitals only and not in the secondary or primary care centres. The providers of primary care in rural areas usually have the least training as they are furthest away from the training hospitals. It is not possible to send teachers to all these areas for long periods of time while staff shortages and domestic reasons make it impractical to transfer large numbers of doctors and nurses from primary and secondary care centres to tertiary hospitals for training. Ideally all medical and nursing staff should have regular training to improve and update their theoretical knowledge and practical skills. One way of meeting these needs in continuing education is with a self-help, outreach educational programme. This method allows students to take responsibility for their own learning. They can study at a time and place which suits them. Students can also study at their own pace. The education programme should be cheap and, if possible, not require a tutor.
PERINATAL EDUCATION PROGRAMME MANUALS
Initially the Perinatal Education Programme was presented as 2 manuals. The first manual deals with problems experienced by women during and after pregnancy (Manual 1: Maternal Care – Units 1-15) while the second manual deals with problems in the newborn infant (Manual 2: Newborn Care – Units 16-30). Both manuals should be studied to improve your knowledge of all aspects of perinatal care.
Now 5 supplementary manuals have been prepared to address further common and important problems related to both pregnant women and their newborn infants.
MANUAL 3: PERINATAL HIV/AIDS
The HIV epidemic is spreading at an alarming pace through South Africa, increasing the maternal and infant mortality rate, and adding to the financial burden of providing health services to all communities. Nowhere is the devastating effect of this infection more obvious than in the transmission of HIV from mothers to their infants. In order to decrease this risk, all health care workers dealing with mothers and infants will need to receive additional training. Manual 3 was written to address this challenge (Units 31-35).
This manual will enable midwives, nurses and doctors to care for pregnant women and their infants in communities where HIV infection is present. Special emphasis has been placed on counselling and a clear understanding of the routes of mother-to-infant transmission.
Units have been written on HIV infection, antenatal, intrapartum and infant care, and counselling. Colleagues from a number of hospitals and universities in South Africa have been invited to review and comment on the draft document in order to achieve a well balanced document. It is hoped that this training opportunity will help to stem the tide of HIV infection in our children.
MANUAL 4: PRIMARY NEWBORN CARE
This manual was written specifically for nurses and doctors who care for newborn infants at primary care clinics and hospitals. Most of the educational material is selected from Manual 2 (which was developed in response to the need for improved management of newborn infants receiving special care in the level II nurseries of regional hospitals). The Primary Newborn Care manual consists of 5 units which address care of infants at birth, care of normal infants, care of low birth weight infants, emergencies, and important problems in newborn infants (Units 36-40).
MANUAL5: MOTHER AND BABY FRIENDLY CARE
With the recent technological advances in modern medicine, the caring and humane aspects of looking after mothers and infants are often forgotten. This manual (Units 41-45) describes better, gentler, kinder, more natural, evidence-based ways that care should be given to women during pregnancy, labour and delivery. It similarly looks at improved methods of providing infants care with an emphasis on kangaroo mother care and exclusive breast feeding. A number of medical and nursing colleagues in South Africa contributed to this manual.
MANUAL 6: SAVING MOTHERS AND BABIES
The manual was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in the manual is based on the results of the annual confidential enquiries into maternal deaths and the Saving Mothers and Saving Babies reports published in South Africa. The five units address the basic principles of mortality audit, maternal mortality, perinatal mortality, and managing mortality meetings. and ways of reducing maternal and perinatal mortality rates (Units 46-50). Professor Bob Pattinson was invited to co-edit this manual which should partner the Perinatal Problem Identification Programme (PPIP).
MANUAL 7: BIRTH DEFECTS
This manual (Units 51-56) was written for health care workers who look after individuals with birth defects, their families, and women who are at increased risk of giving birth to an infant with a birth defect. Special attention is given to modes of inheritance, medical genetic counselling, and birth defects due to chromosomal abnormalities, single gene defects, teratogens and multifactorial inheritance. This manual will be used in the Genetics Education Programme which has been developed to train health care workers in genetic counselling.
MANUAL 8: PRIMARY NEWBORN CARE
The manual addresses the care of women during their pregnancy and the puerperium. It does not include care in labour. The manual was written for medical and nursing staff who work at antenatal and postnatal clinics only (Units 1-63). The content is similar to the antenatal and postnatal care units in the Maternal Care manual.
FORMAT OF THE PERINATAL EDUCATION PROGRAMME
Throughout this Programme the student takes full responsibility for his or her own progress. This method teaches the student to become self-reliant and confident.
1. THE OBJECTIVES
At the start of each unit the learning objectives are clearly stated. They help the student to identify and understand the important lessons to be learned. For easy recognition, the title page with the unit's objectives is printed on blue paper.
2. QUESTIONS AND ANSWERS
Theoretical knowledge is taught by a problem solving method of learning which encourages the student to actively participate in the learning process. An important question is asked, or problem posed, followed by the correct answer or explanation. In this way, the student is led step by step through the definitions, causes, diagnosis, prevention, dangers and management of a particular problem. It is suggested that the student cover the answer for a few minutes with a piece of paper or card while thinking about the correct reply to the question. This method helps learning. Simplified flow diagrams are also used, where necessary, to indicate the correct approach to diagnosing or managing a particular problem. Copies of these flow diagrams may be of value in the labour ward or nursery. Different forms of text are used to identify particular sections of the Programme:
EACH QUESTION IS WRITTEN IN BOLD CAPITALS AND IS IDENTIFIED WITH THE NUMBER OF THE UNIT, FOLLOWED BY THE NUMBER OF THE QUESTION, e.g. 40-23.
*** Additional, non essential, information is provided for interest and given in italics. This is not used in the case studies or included in the multiple choice questions.
3. CASE PROBLEMS
A number of clinical presentations in story-form are given at the end of each unit so that the student can apply his/her newly learned knowledge to solve some common clinical problems. This exercise also gives the student an opportunity to see the problem as it usually presents itself in the clinic or hospital. A brief history and/or summary of the clinical examination is given, followed by a series of questions. The student should attempt to answer each question before reading the correct answer. The knowledge presented in the cases is the same as that covered earlier in the unit. The cases, therefore, serve to consolidate the student's knowledge.
4. MULTIPLE CHOICE TESTS (not included on website)
An in-course assessment is made at the beginning and end of each unit in the form of a test consisting of 20 multiple choice questions. The aim of the multiple choice tests is to allow students to monitor their own progress by determining how much they know before starting a unit and how much they have learned at the end of the unit. The results will help the student decide whether they have successfully learned the important facts in that unit and will also draw the student's attention to the areas where their knowledge is inadequate. The multiple choice tests are printed on yellow paper for easy recognition while the correct answers are printed on pink paper. Both are found at the back of the manual.
In the multiple choice tests the student is asked to choose the single, most correct answer to each question or statement from 4 possible answers. A separate sheet is provided for recording the test answers before (pretest) and after (post test) the unit is studied. For convenience, tear out the answer sheet before answering the questions. Students usually mark their own pretests and post tests when both have been completed. The pink sheet with the correct answers also indicates which section should be restudied for each incorrect post test answer.
It is strongly advised that the Programme is studied by a group of students and not by individuals alone. Each group of 5 to 10 students should be managed by a local co-ordinator who is usually a senior nurse. The local co-ordinator arranges the time and venue of the group meetings (usually every 3 weeks). At the meeting the unit just studied is discussed and the pretests and post test are done. The skills workshops should also be demonstrated and practiced at the meetings. A special PEP booklet describes how to manage a PEP course.
THE IMPORTANCE OF A CARING AND QUESTIONING ATTITUDE
A caring and questioning attitude is encouraged. The welfare of the patient is of the greatest importance while an enquiring mind is essential if students are to continue improving their knowledge and skills. The student is also taught to solve practical problems and to form a simple, logical approach to common perinatal problems.
ENGLISH AND AFRIKAANS
The Maternal Care and Newborn Care manuals, as well as the Perinatal HIV/AIDS manual, are available in both English and Afrikaans. The content of both language versions are the same. The other supplementary manuals are currently available in English only.
To be most effective, the whole Perinatal Educational Programme must be used under the control and supervision of a co-ordinator. Using part of the Programme out of context will be of limited value only, while changing part of the Programme may even be detrimental to the student’s perinatal knowledge. Therefore, a copyright has been registered so that no portion of the Programme can be altered. In addition, the whole Programme cannot be copied without permission. For teaching and management purposes only, parts of the Programme may be photocopied provided that recognition to the Programme is acknowledged. If the routine care in your clinic or hospital differs from that given in the Programme, you should discuss it with your staff.
On completion of each manual the student may write a formal multiple choice examination to asses the amount of knowledge that they have acquired. All the questions will be taken from the tests at the end of each unit. The results of the in-course testing will not count towards the final assessment. Neither will the practical skills be tested in the final assessment. Credit for taking part in the Programme will only be given if the final examination is successfully completed. A separate examination is written for each manual and a certificate will be given to students who pass each final examination. A mark of 80% is needed to pass the final examinations. A gold PEP badge is available to students who pass both the Maternal Care and Newborn Care examinations while a silver PEP badge is awarded to students who pass either of the two above examinations plus the examination of one of the supplementary manuals. Official recognition and possible salary or post adjustments for successful students will have to be negotiated with the regional authority in each area.
UP-DATING OF THE PROGRAMME
Based on the comments and suggestions made by students and other authorities, the units and skills workshops of the Programme will be regularly edited to make them more appropriate to the needs of perinatal care and to keep the Programme up to date with new ideas and developments. Everyone studying the Programme is invited to write to the editor-in-chief with suggestions as to how the manuals could be improved.
USE OF THE PROGRAMME AS A WORK MANUAL
It is hoped that as many students as possible will use the Programme as a work manual after they have completed the course. The flow diagrams should be most useful in managing difficult problems and for planning management. A further benefit of the Programme will be to standardize the documentation and management of certain clinical problems. This is particularly useful when patients are referred within or between health care regions. It is further hoped that all those who use this Programme will enjoy learning about new and better methods of caring for mothers and newborn infants. Every opportunity to share knowledge with both patients and colleagues should be used. By doing this you will find your career more fulfilling and you will help to improve the perinatal care of all in Southern Africa.
PERINATAL EDUCATION TRUST
The Perinatal Education Programme is provided at cost, and both funded and managed on a non-profit basis by the Perinatal Education Trust.
Detailed information on the Perinatal Education Programme is available on the website http://www.pepcourse.co.za/
Further information on the Perinatal Education Programme, or requests for additional copies of the Programme, should be addressed to:
Perinatal Education Programme
FAX (021) 671 8030
COMMENTS AND SUGGESTIONS
The Perinatal Education Programme has been produced by a group of perinatal specialists, after wide consultation with colleagues who practice in both rural and urban settings, in an attempt to reach consensus on the care of mothers and newborn infants. However, the Programme is designed so that it can be improved and altered to keep pace with current developments in health care. Students using the Programme can make an important contribution to its continual improvement by reporting factual or language errors, by identifying sections that are difficult to understand, and by suggesting improvements to the contents. Details of alternative, or better forms of management, would be particularly appreciated. Please send any comments or suggestions to the Editor-in-Chief at the above address.
All rights reserved. No part of this Perinatal Education Programme may be altered in any way without the written permission of the editorial board of the Perinatal Education Trust. To facilitate the improvement of perinatal care in Southern Africa, however, parts of the Programme may be reproduced for teaching purposes provided due acknowledgement is given and the material is not sold for financial profit. While the advice and information in the Programme are believed to be accurate, the editorial board cannot accept responsibility or liability for any errors or omissions that may have been made.
ISBN 0 7992 1362 4
Edited by Aldo Campana,