Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker. It was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: Saving Mothers and Babies was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in this book 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. It addresses: the basic principles of mortality audit, maternal and perinatal mortality, managing mortality meetings, ways of reducing maternal and perinatal mortality rates, This book should be used together with the Perinatal Problem Identification Programme (PPIP).
4. Contents
Acknowledgements 5 Neonatal mortality 43
The ratio of stillbirths to early neonatal
Introduction 7 deaths 46
Perinatal care index 47
About the EBW Healthcare series 7 Case study 1 47
Why decentralised learning? 7 Case study 2 48
Books in the EBW Healthcare series 7 Case study 3 49
Format of the courses 9 Case study 4 50
Contributors 10
Updating the course material 11 4 Maternal and perinatal mortality
Contact information 11 audits 51
1 Introduction to maternal and perinatal Audit 51
mortality 12 Perinatal mortality meetings 53
Perinatal mortality reports 56
Mortality 12 Perinatal problem identification
Audit 15 programme (PPIP) 57
Birth register 17 Case study 1 59
Low birth weight 19 Case study 2 60
Case study 1 20 Case study 3 61
Case study 2 20 Case study 4 61
Case study 3 21 PPIP classifications of perinatal deaths 62
Case study 4 22
5 Finding solutions to maternal and
2 Maternal mortality 23 perinatal mortality 64
Mortality ratio 23 Finding solutions 64
Causes of maternal death 25 Avoidable factors associated with
Confidential enquiry 27 maternal deaths 66
Avoidable factors 28 Preventing maternal deaths 67
Case study 1 32 Avoidable factors associated with
Case study 2 32 perinatal deaths 68
Case study 3 33 Preventing perinatal mortality 70
Case study 4 34 Case study 1 73
PPIP classification of maternal deaths 35 Case study 2 73
3 Perinatal mortality 36 Case study 3 74
Perinatal mortality 36
Stillbirths 40
5. Acknowledgements
We acknowledge all the participants of Saving Editor-in-Chief of the Perinatal Education
Mothers and Babies courses who have made Programme: Prof D. L. Woods
suggestions and offered constructive criticism.
Editors of Saving Mothers and Babies: Prof D L
It is only through constant feedback from
Woods, Prof R C Pattinson, Dr D H Greenfield
colleagues and participants that the content of
Perinatal Education Programme courses can Contributors: Prof G Theron, Prof H de Groot,
be improved. Ms H Louw. .
Funding towards this publication was
generously provided by Eduhealthcare.
6. Introduction
ABOUT THE EBW families and places of work, and the content
frequently fails to address the real healthcare
HEALTHCARE SERIES requirements of the poor, rural communities
who face the biggest healthcare challenges.
EBW Healthcare publishes an innovative
To help solve these many problems, a self-
series of distance-learning books for
help decentralised learning method has been
healthcare professionals, developed by the
developed which addresses the needs of
Perinatal Education Trust, Eduhealthcare,
professional healthcare workers, especially
the Desmond Tutu HIV Foundation and the
those in poor, rural communities.
Desmond Tutu TB Centre, with contributions
from numerous experts.
Our aim is to provide appropriate, affordable BOOKS IN THE EBW
and up-to-date learning material for
healthcare workers in under-resourced areas, HEALTHCARE SERIES
so that they can manage their own continuing
education courses which will enable them to Maternal Care addresses all the common
learn, practise and deliver skillful, efficient and important problems that occur
patient care. during pregnancy, labour, delivery and the
The EBW Healthcare series is built on puerperium. It covers the antenatal and
the experience of the Perinatal Education postnatal care of healthy women with normal
Programme (PEP), which has provided pregnancies, monitoring and managing
learning opportunities to over 60 000 nurses the progress of labour, specific medical
and doctors in South Africa since 1992. Many problems during pregnancy, labour and the
of the educational methods developed by PEP puerperium, family planning and regionalised
are now being adopted by the World Health perinatal care. Skills workshops teach clinical
Organisation (WHO). examination in pregnancy and labour, routine
screening tests, the use of an antenatal card
and partogram, measuring blood pressure,
WHY DECENTRALISED detecting proteinuria and performing and
repairing an episiotomy.
LEARNING?
Maternal Care is aimed at healthcare workers
in level 1 hospitals or clinics.
Continuing education for healthcare workers
traditionally consists of courses and workshops
Primary Maternal Care addresses the
run by formal trainers at large central hospitals.
needs of healthcare workers who provide
These teaching courses are expensive to attend,
antenatal and postnatal care, but do not
often far away from the healthcare workers’
7. 8 SAVING MOTHERS AND BABIES
conduct deliveries. It is adapted from theory for women during pregnancy, labour and
chapters and skills workshops from Maternal delivery. It also presents improved methods
Care. This book is ideal for midwives and of providing infant care with an emphasis
doctors providing primary maternal care on kangaroo mother care and exclusive
in level 1 district hospitals and clinics, breastfeeding.
and complements the national protocol of
antenatal care in South Africa. Saving Mothers and Babies was developed in
response to the high maternal and perinatal
Intrapartum Care was developed for doctors mortality rates found in most developing
and advanced midwives who care for women countries. Learning material used in this book
who deliver in district hospitals. It contains is based on the results of the annual confidential
theory chapters and skills workshops adapted enquiries into maternal deaths and the Saving
from the labour chapters of Maternal Care. Mothers and Saving Babies reports published in
Particular attention is given to the care South Africa. It addresses the basic principles
of the mother, the management of labour of mortality audit, maternal mortality,
and monitoring the wellbeing of the fetus. perinatal mortality, managing mortality
Intrapartum Care was written to support meetings and ways of reducing maternal and
and complement the national protocol of perinatal mortality rates. This book should
intrapartum care in South Africa. be used together with the Perinatal Problem
Identification Programme (PPIP).
Newborn Care was written for healthcare
workers providing special care for newborn Birth Defects was written for healthcare
infants in regional hospitals. It covers workers who look after individuals with birth
resuscitation at birth, assessing infant size and defects, their families, and women who are at
gestational age, routine care and feeding of both increased risk of giving birth to an infant with a
normal and high-risk infants, the prevention, birth defect. Special attention is given to modes
diagnosis and management of hypothermia, of inheritance, medical genetic counselling,
hypoglycaemia, jaundice, respiratory distress, and birth defects due to chromosomal
infection, trauma, bleeding and congenital abnormalities, single gene defects, teratogens
abnormalities, as well as communication with and multifactorial inheritance. This book
parents. Skills workshops address resuscitation, is being used in the Genetics Education
size measurement, history, examination and Programme which trains healthcare workers in
clinical notes, nasogastric feeds, intravenous genetic counselling in South Africa.
infusions, use of incubators, measuring blood
glucose concentration, insertion of an umbilical Perinatal HIV enables midwives, nurses
vein catheter, phototherapy, apnoea monitors and doctors to care for pregnant women and
and oxygen therapy. their infants in communities where HIV
infection is common. Special emphasis has
Primary Newborn Care was written been placed on the prevention of mother-to-
specifically for nurses and doctors who infant transmission of HIV. It covers the basics
provide primary care for newborn infants in of HIV infection and screening, antenatal
level 1 clinics and hospitals. Primary Newborn and intrapartum care of women with HIV
Care addresses the care of infants at birth, care infection, care of HIV-exposed newborn
of normal infants, care of low-birth-weight infants, and parent counselling.
infants, neonatal emergencies, and common
minor problems in newborn infants. Childhood HIV enables nurses and doctors
to care for children with HIV infection. It
Mother and Baby Friendly Care describes addresses an introduction to HIV in children,
gentler, kinder, evidence-based ways of caring the clinical and immunological diagnosis
8. INTRODUCTION 9
of HIV infection, management of children 2. Pre- and post-tests
with and without antiretroviral treatment,
There is a multiple-choice test of 20 questions
antiretroviral drugs, opportunistic infections
for each chapter at the end of the book.
and end-of-life care.
Participants are encouraged to take a pre-test
before starting each chapter, to benchmark
Childhood TB was written to enable
their current knowledge, and a post-test after
healthcare workers to learn about the primary
each chapter, to assess what they have learned.
care of children with tuberculosis. The book
covers an introduction to TB infection, Self-assessment allows participants to monitor
and the clinical presentation, diagnosis, their own progress through the course.
management and prevention of tuberculosis
in children and HIV/TB co-infection. 3. Question-and-answer format
Childhood TB was developed by paediatricians
with wide experience in the care of children Theoretical knowledge is presented in a
with tuberculosis, under the auspices of the question-and-answer format, which encourages
Desmond Tutu Tuberculosis Centre at the the learner to actively participate in the
University of Stellenbosch. learning process. In this way, the participant
is led step by step through the definitions,
Child Healthcare addresses all the common causes, diagnosis, prevention, dangers and
and important clinical problems in children, management of a particular problem.
including immunisation, history and Participants should cover the answer for a few
examination, growth and nutrition, acute and minutes with a piece of paper while thinking
chronic infections, parasites, skin conditions, about the correct reply to each question. This
and difficulties in the home and society. Child method helps learning.
Healthcare was developed for use in primary
care settings. Simplified flow diagrams are also used, where
necessary, to indicate the correct approach to
Adult HIV covers an introduction to HIV diagnosing or managing a particular problem.
infection, management of HIV-infected adults
at primary-care clinics, preparing patients for Each question is written in bold, like this,
antiretroviral (ARV) treatment, ARV drugs, and is identified with the number of the
starting and maintaining patients on ARV chapter, followed by the number of the
treatment and an approach to opportunistic question, e.g. 5-23.
infections. Adult HIV was developed by
doctors and nurses with wide experience in 4. Important lessons
the care of adults with HIV, under the auspices
of the Desmond Tutu HIV Foundation at the
University of Cape Town. Important practical lessons are emphasised by
placing them in a box like this.
FORMAT OF THE COURSES 5. Notes
NOTE Additional, non-essential information is
provided for interest and given in notes like this.
1. Objectives These facts are not used in the case studies or
The learning objectives are clearly stated at the included in the multiple-choice questions.
start of each chapter. They help the participant
to identify and understand the important
lessons to be learned.
9. 10 SAVING MOTHERS AND BABIES
6. Case studies CONTRIBUTORS
Each chapter closes with a few case
studies which encourage the participant The developers of our learning materials are a
to consolidate and apply what was learned multi-disciplinary team of nurses, midwives,
earlier in the chapter. These studies give the obstetricians, neonatologists, and general
participant an opportunity to see the problem paediatricians. The development and review of
as it usually presents itself in the clinic or all course material is overseen by the Editor-
hospital. The participant should attempt to in-Chief, emeritus Professor Dave Woods,
answer each question in the case study before a previous head of neonatal medicine at the
reading the correct answer. University of Cape Town who now consults to
UNICEF and the WHO.
7. Practical training
Perinatal Education Trust
Certain chapters contain skills workshops,
which need to be practised by the participants Books developed by the Perinatal Education
(preferably in groups). The skills workshops, Programme are provided as cheaply as possible.
which are often illustrated with line drawings, Writing and updating the programme is both
list essential equipment and present step-by- funded and managed on a non-profit basis by
step instructions on how to perform each the Perinatal Education Trust.
task. If participants aren’t familiar with a
practical skill, they are encouraged to ask an Eduhealthcare
appropriate medical or nursing colleague to
demonstrate the clinical skill to them. In this Eduhealthcare is a non-profit organisation
way, senior personnel are encouraged to share based in South Africa. It aims to improve health
their skills with their colleagues. and wellbeing, especially in poor communities,
through affordable education for healthcare
workers. To this end it provides financial
8. Final examination
support for the development and publishing of
On completion of each course, participants the EBW Healthcare series.
can take a 75-question multiple-choice
examination on the EBW Healthcare website, The Desmond Tutu HIV Foundation
when they are ready to.
The Desmond Tutu HIV Foundation at the
All the exam questions will be taken from University of Cape Town, South Africa,
the multiple-choice tests from the book. The is a centre of excellence in HIV medicine,
content of the skills workshops will not be building capacity through training and
included in the examination. enhancing knowledge through research.
Participants need to achieve at least 80%
in the examination in order to successfully The Desmond Tutu Tuberculosis Centre
complete the course. Successful candidates The Desmond Tutu Tuberculosis Centre at
will be emailed a certificate which states Stellenbosch University, South Africa, strives
that they have successfully completed to improve the health of vulnerable groups
that course. EBW Healthcare courses are through the education of healthcare workers
not yet accredited for nurses, but South and community members, and by influencing
African doctors can earn CPD points on the policy based on research into the epidemiology
successful completion of an examination. of childhood tuberculosis, multi-drug-
Please contact info@ebwhealthcare.com or resistant tuberculosis, HIV/TB co-infection
+27 021 44 88 336 when you are ready to take and preventing the spread of TB and HIV in
the exam. southern Africa.
10. INTRODUCTION 11
UPDATING THE COURSE CONTACT INFORMATION
MATERIAL
EBW Healthcare
EBW Healthcare learning materials
are regularly updated to keep up with Website: www.ebwhealthcare.com
developments and changes in healthcare Email: info@ebwhealthcare.com
protocols. Course participants can make
important contributions to the continual Telephone: +27 021 44 88 336
improvement of EBW Healthcare books Fax: +27 088 021 44 88 336
by reporting factual or language errors,
Post: 87 Station Road, Observatory, 7925,
by identifying sections that are difficult to
Cape Town, South Africa
understand, and by suggesting additions or
improvements to the contents. Details of
alternative or better forms of management Editor-in-Chief: Professor Dave Woods
would be particularly appreciated. Please send Website: www.pepcourse.co.za
any comments or suggestions to the Editor-in-
Chief, Professor Dave Woods. Email: pepcourse@mweb.co.za
Telephone: +27 021 786 5369
Fax: +27 021 671 8030
Post: Perinatal Education Programme,
PO Box 34502, Groote Schuur, Observatory,
7937, South Africa