Guidelines For Basic and Comprehensive InService Final

Guidelines for In-Service Training in
Basic and Comprehensive Emergency

Obstetric and Newborn Care

Prepared by:
Blami Dao

Jhpiego Corporation is an international, non-profit health organization affiliated with The Johns Hopkins
University. For more than 36 years, Jhpiego has empowered front-line health workers by designing and
implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for
women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works
to break down barriers to high-quality health care for the worlds most vulnerable populations.

Published by:
Jhpiego
Browns Wharf
1615 Thames Street
Baltimore, Maryland 21231-3492, USA
www.jhpiego.org

Copyright 2012 by Jhpiego. All rights reserved.

The following reviewers contributed to the development of these guidelines:
Julia Bluestone
Catherine Carr
Sheena Currie
Barbara Deller
Patricia Gomez
Yolande Hyjazi
Rosemary Kamunya
Jean Pierre Rakotovao
Kusum Thapa

Guidelines for EmONC In-Service Training iii
TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS ........................................................................................ iv
1. RATIONALE FOR THE GUIDELINES ..................................................................................... 1
2. TRAINING GOAL AND OBJECTIVES ..................................................................................... 2
3. PRE-TRAINING PREPARATION ............................................................................................. 3
4. COMPONENTS AND CONTENT OF TRAINING IN EMONC .................................................. 5
5. TRAINING DURATION AND SCHEDULES ........................................................................... 11
6. COURSE MATERIALS ........................................................................................................... 20
7. ANATOMIC MODELS ............................................................................................................ 22
8. VIDEOS AND PRESENTATIONS .......................................................................................... 23
9. JOB AIDS ............................................................................................................................... 24
10. DOCUMENTATION OF ACTIVITIES ................................................................................... 24

APPENDIXES
APPENDIX A: ORGANIZATION OF MATERNITY SERVICES ................................................. 25
APPENDIX B: EQUIPMENT AND SUPPLIES LIST .................................................................. 27
APPENDIX C: PRACTICUM LOGBOOKS FOR DOCUMENTING SKILLS PERFORMED
WITH CLIENTS .......................................................................................................................... 30
APPENDIX D: SAMPLE ACTION PLAN FOR LEARNERS ...................................................... 32
APPENDIX E: TRAINING EVALUATION QUESTIONNAIRE ................................................... 33
APPENDIX F: TRAINING INFORMATION SYSTEM: DATA RECORDING FORM .................. 34

iv Guidelines for EmONC In-Service Training
ABBREVIATIONS AND ACRONYMS

AMTSL Active management of the third stage of labor
BEmONC Basic emergency obstetric and newborn care
CEmONC Comprehensive emergency obstetric and newborn care
CPR Cardiopulmonary resuscitation
CTS Clinical Training Skills
EmONC Emergency obstetric and newborn care
EONC Essential obstetric and newborn care
ETT Endotracheal intubation
HBB Helping Babies Breathe
IP Infection prevention
LRP Learning resource package
MgSO4 Magnesium sulfate
MNH Maternal and newborn health
MVA Manual vacuum aspiration
OR Operating room
PAC Postabortion care
PPH Postpartum hemorrhage
SBM-R Standards-Based Management and Recognition
TIMS Training Information Monitoring System

Guidelines for EmONC In-Service Training 1
1. RATIONALE FOR THE GUIDELINES

Few developing countries will meet their targets for Millennium Development Goals 4 and 5 by
2015.
1
One reason they will fall short is that only about 61% of women globally give birth with a
skilled attendant. In some countries in sub-Saharan Africa and South Asia the rate is closer to 50%,
with even lower rates in rural areas.
2
A compounding problem is that many skilled attendants
(doctors, nurses and midwives) do not have the knowledge and skills needed to prevent, recognize
and manage the major causes of maternal and newborn deaths: hemorrhage, infection, pre-
eclampsia/eclampsia, obstructed labor and newborn asphyxia.

The components of emergency obstetric and newborn care (EmONC) were delineated in the early
1990s by WHO, UNICEF and UNFPA.
3
These signal functions are interventions that must be
available to all women at the time of birth in order to address the common but unpredictable causes
of maternal and newborn mortality. In outlining the EmONC interventions, WHO, UNICEF and
UNFPA recommended that all providers become capable of managing these common complications
in order to decrease need for referral and improve outcomes. The signal functions for EmONC are
listed below:

SIGNAL FUNCTIONS FOR EMERGENCY OBSTETRIC AND NEWBORN CARE
Basic Emergency Obstetric and Newborn Care
(BEmONC):
Parenteral treatment of infection (antibiotics)
Parental treatment of pre-eclampsia/eclampsia
(anticonvulsants)
Parental treatment of postpartum hemorrhage
(uterotonics)
Manual vacuum aspiration of retained products of
conception
Vacuum-assisted delivery
Manual removal of the placenta
Newborn resuscitation
Comprehensive Emergency Obstetric and
Newborn Care (CEmONC):
All components of BEmONC
Surgical capability
Blood transfusion

Many countries are working to train more skilled providers in emergency obstetric and newborn care
to increase access to these services. However, few countries have the funds or human resources that
are needed to implement quality in-service training. Training that does not translate into the
improvement of patient care wastes those scarce resources and can cost lives.

Quality training in EmONC (and in any health-related field) goes beyond bringing together
providers for classroom and clinical practice for several days. Evidence suggests that training works
when it is competency-based and quality-focused and when it addresses transfer of learning to

1
Hogan MC et al. 2010. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards
Millennium Development Goal 5. Lancet (375): 16091623.
2
Crow S, Utley M, Costello A and Pagel C. 2012. How many births in sub-Saharan Africa and South Asia will not be
attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy and Childbirth (12): 4.
3
Penny S and Murray S. Training initiatives for essential obstetric care in developing countries: A state of the art
review. Health Policy and Planning 15(4): 386393.

2 Guidelines for EmONC In-Service Training
practice through post-training follow-up.
4
Clinical practice and feedback must be sufficient for the
development of clinical decision-making and psychomotor skills.
5
Evidence also reinforces the
importance of clinically integrated learning interventions, as they have been found to be superior to
classroom-only instruction for generating positive learning outcomes.
6
This type of training ensures
that learnerspracticing clinicians and pre-service educatorsare trained by qualified facilitators in
appropriate classroom and clinical settings for an adequate amount of time, using evidence-based
training materials and approaches. And it emphasizes timely follow-up of the learners in their
workplace, where facilitators can assess how the learners have incorporated their new skills and
knowledge into their management of actual clients.

These guidelines provide the information and guidance needed to implement effective BEmONC
and CEmONC training. Recommendations are made for selecting participants and clinical sites,
training schedules, and where to find the materials and resources needed for effective clinical skills
practice. Use of these guidelines will enable facilitators to train providers who are competent in
evidence-based practices and who will ensure that their facilities offer quality EmONC services.

2. TRAINING GOAL AND OBJECTIVES

The goal of EmONC training is to ensure that health facilities have competent providers who can
offer quality EmONC services. By the end of their training, learners achieve the following specific
objectives and competencies:
1. Identify the evidence basis for EmONC interventions.
2. Demonstrate understanding of clients rights through provision of respectful care to clients and
their families.
3. Utilize positive interpersonal communication techniques with clients and their families.
4. Demonstrate competency (first on anatomic models; then with clients) in EmONC signal
functions.
5. Demonstrate understanding and use of the clinical decision-making process.
6. Formulate action plans describing how they will act as role models and work to institutionalize
evidence-based EmONC knowledge and skills in their own health facilities.

4
Kongnyuy E, Hofman J and van den Broek N. 2009. Ensuring effective Essential Obstetric Care in resource poor
settings. BJOG 116(Suppl. 1): 4147.
5
McGaghie WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduate and
graduate medical education: Effectiveness of continuing medical education: American College of Chest Physicians
Evidence-Based Educational Guidelines. Chest 135(3 Suppl): 62S68S.
6
Coomarasamy A and Khan KS. 2004. What is the evidence that postgraduate teaching in evidence based medicine
changes anything? A systematic review. BMJ (Clinical Research Ed.) 329(7473): 10171022.

3. PRE-TRAINING PREPARATION

Failure to prepare is the worst enemy of quality in any training program. Preparation should start at
least three to six months before the training and should include several activities:
1. Selecting clinical sites
This task is of paramount importance because it will ultimately determine the skills and attitudes
learners will see modeled during the training. The following criteria can be used to select clinical sites:
Buy-in by the clinical sites staff is needed to ensure smooth training.
Clinical site staff must be willing to go through targeted on-the-job technical and skills
updates to be able to model best practices.
Evidence-based clinical standards should be in place at the site (e.g., respectful care, use of
infection prevention practices, use of a partograph and active management of third stage of
labor).
Adequate caseloads that are appropriate to the training (especially surgical cases for
CEmONC) are needed because obstetric emergencies are relatively rare and learners need to
be exposed to as many cases as possible. BEmONC training sites should have at least 1015
deliveries per day, and CEmONC sites should have at least 10 deliveries and two to three
cesarean sections per day. When the caseload is lower than this, night shifts can be organized
or the length of the practicum can be extended so that all learners have the opportunity to
achieve competency. The reality is that in developing countries there are many clinical sites
with a high volume of cases but with poor quality of care, so strengthening of the site will be
needed before training.
Please see Appendix A for a description of key elements in the organization of quality maternity
services.
2. Strengthening and preparing clinical sites
Every facilitators nightmare is that they bring learners to a facility where clinical practices are
below standard or where there are frequent stock-outs of supplies. So, at least two weeks before
the training, the facilitators should work with the clinical site staff on the following tasks:
Ensure that written evidence-based guidelines describing best practices in maternal and
newborn health (MNH) (i.e., infection prevention, use of the partograph, active
management of third stage of labor, and so on) are in place.
Determine whether the facility is woman- and baby-friendly (i.e., the rights of women and
families to respectful care, privacy, confidentiality, the presence of a companion and
autonomy are recognized; mothers and babies are not separated; early and exclusive
breastfeeding is practiced; and so on).
Ensure that training will not unduly disrupt the facilitys work.
Make sure that sufficient supplies and medications such as infection prevention (IP)
equipment (training necessitates an increased number of gloves), delivery sets, suture kits,
oxytocin, magnesium sulfate (MgSO4) are available at the site. The training facilitators may

need to bring some of these medications and supplies to the site to ensure that learners will
be able to manage cases in a timely manner instead of waiting for patients to purchase them
before receiving care.
Refer to the Jhpiego publication Site Assessment and Strengthening for Maternal and Newborn
Health Programs, available at www.accesstohealth.org, for a complete description of effective
strengthening of clinical sites prior to training.
3. Selecting learners
Selection of participants for training should be based on the following criteria:
Qualification as an obstetrician (or general practitioner), nurse and/or midwife, or anesthetist
Work experience as a provider in a facility delivering EmONC services and/or as a faculty
member/tutor in a school of medicine or midwifery
Supervisors written commitment to enable the learner to utilize the knowledge and skills
gained in the course in his/her clinical site and a commitment that the participant will be
deployed in the maternity unit for at least 12 months after training
The best way to select learners is to form a three- to four-person team of providers from each
facility. The suggested composition of the team is as follows:
For BEmONC courses:
An obstetrician, general practitioner, or clinical officer
Two midwives (or nurses/midwives)
The ideal number of learners for the BEmONC course is 1624, depending on the number of
clinical sites available as well as the caseload in each site.
For CEmONC courses:
An obstetrician, general practitioner, or clinical officer with surgical skills
Two midwives (or nurses/midwives)
An anesthetist or a nurse anesthetist
The ideal number of learners is between 16 and 20, depending on the number of clinical sites
available and the caseload at each site.
4. Selecting facilitators
Being a proficient obstetrician, midwife, or anesthetist is not enough to qualify as an
EmONC facilitator. EmONC facilitators must meet the following requirements:
Qualification as a midwife, doctor, or anesthetist trained in EmONC
Qualification as a trainer through a Clinical Training Skills (CTS) course or ModCAL/CTS
Currently working in a facility that delivers EmONC services or has regular
opportunities to maintain clinical skills

One often-asked question is how many facilitators are needed for EmONC training.
For a BEmONC training with 1624 learners, a minimum of three facilitators (two
obstetricians plus one midwife, or one obstetrician plus two midwives) is needed for the
knowledge update component. Since each team of three to four learners should be
supervised by a facilitator during the clinical skills standardization portion of the course
(including work with anatomic models), an additional two or three facilitators (either two to
three midwives or one obstetrician and one or two midwives) will be needed. These
facilitators will remain with the teams throughout the clinical portion of the course. These
facilitators become critically important if the practicum takes place in a very busy facility
where a few facilitators cannot adequately supervise all the learner teams when they are
working with clients.
For a CEmONC training, an additional obstetrician is recommended for sites with many
surgical cases; the number of midwives is the same as for BEmONC. In addition, two
anesthetists (an anesthesiologist and/or a nurse anesthetist) will be needed.
5. Gathering equipment needed for training (see Appendix B)
6. Developing job aids
Simple job aids that remind the learner of key information can be extremely valuable in helping
the learner apply skills on the job. Posters, pocket guides and simple guidelines assist learners
with quick recall and the application of complex skills. For more information, see section 9.

4. COMPONENTS AND CONTENT OF TRAINING IN
EMONC

Any complete EmONC training (and by extension any good clinical training) should include the
following three components:
Knowledge update
Clinical skills standardization, resulting in the acquisition of competencies in specific skills (a list
of competencies is included below)
Follow-up of learners in their sites within three months of the training, ideally by the facilitators
who conducted the course

Jhpiego has applied evidence from a recent integrative review of the literature regarding the techniques,
timing, setting and media used for the delivery of instruction to its EmONC training approach. The
blended approach uses spaced, repetitive questions delivered via mobile phone text messaging (SMS) or
the internet to address key knowledge objectives, followed by clinical practice in simulation and with
clients, and continued follow-up and support after training. The knowledge component of the course
via the internet can be accessed at: http://app.qstream.com/Jhpiego/courses/2042-Basic-Emergency-
Obstetrical-Skills.

Effective blended learning approaches require each component of training to be dependent on
another component.
7
Each piece is linked so that a learner cannot successfully complete the course
and master the content without completing each component in succession. Jhpiego applies this
approach by delivering questions that are repeated over time, confirming completion and knowledge
mastery during the clinical practice and live sessions, linking the follow-up to the use of skills in the
workplace, and recording the use of the skills in a logbook. This ensures that funds invested to train
providers result in skills being applied during service delivery and ultimately in improved maternal
and newborn health outcomes.

Jhpiegos three training components are discussed in further detail below.

KNOWLEDGE UPDATE
This component is computer- and/or classroom-based and includes the evidence basis for best
practices in the management of normal labor and birth as well as the signal functions of EmONC,
demonstrations of key interventions on anatomic models (via video or real-time if in the classroom),
case studies and role plays. The following topics should be reviewed and knowledge assessed before
advancing to the clinical site:

Basic Emergency Obstetric and Newborn Care (BEmONC)
Topics for midwives, doctors and nurses:
Maternal and newborn mortality reduction
Evidence-based practices in maternal and newborn health
Human rights; respectful care of women and their families
Clinical decision-making
Infection prevention practices
Best practices during normal labor and childbirth, including partograph use, active management
of the third stage of labor (AMTSL) and essential newborn care
Care of the mother and baby during the immediate postpartum period
Rapid initial assessment
Management of shock
Vaginal bleeding in early pregnancy and postabortion care (PAC)
Vaginal bleeding in late pregnancy
Headache, blurred vision, loss of consciousness and elevated blood pressure
Management of cord prolapse, breech delivery and shoulder dystocia (optional)

7
Hoffman J and Miner N. 2008. Real blended learning stands up. American Society of Training and Development.
Accessed on February 21, 2012, at: http://www.astd.org/LC/2008/1008_hofmann.htm

Vaginal bleeding after childbirth
Fever during and after childbirth
Newborn sepsis
Improving EmONC through criterion-based audit or other quality improvement approaches
such as Standards-Based Management and Recognition (SBM-R)

Comprehensive Emergency Obstetric and Newborn Care (CEmONC)
Topics for doctors (and midwives in some settings):
All BEmONC topics
Pre-, intra- and postoperative care of obstetric patients
Cesarean section (Misgav Ladach method); surgical treatment of ectopic pregnancy
B-Lynch suture
Blood transfusion
Anesthesia and analgesia in obstetrics
Craniotomy (optional)
Tubal ligation (optional)

Topics for anesthetists:
Maternal and newborn mortality
Evidence-based medicine in maternal and newborn health
Infection prevention
Setup of operating theater
Rapid initial assessment
Management of shock
Review anatomy of respiratory and cardiovascular systems
Review of anatomy of vertebral column and spinal cord
Headaches, blurred vision, convulsions, loss of consciousness or elevated blood pressure
Cardiopulmonary resuscitation (CPR)
Control of the airway; endotracheal intubation
Intravenous fluid therapy, oxygen therapy, drugs used in resuscitation
Normal newborn care and newborn resuscitation
Pre-operative, intraoperative and postoperative evaluation and care

Selecting the correct anesthetic technique, including ketamine and spinal anesthesia
Deciding which cases to refer
Blood transfusion
Improving emergency obstetric care through criterion-based audits

CLINICAL SKILLS STANDARDIZATION
Classroom Practice
Clinical skills standardization begins in the classroom/skills lab as learners use evidence-based,
standardized checklists to become competent in specific skills using anatomic models. Learners must
be judged competent in all skills before proceeding to the clinical setting to care for clients.

Depending on the number of learners and the level of skills they bring to the training, clinical skills
standardization may require up to two days to complete for all learners. Stations are set up for each
skill that learners will master (e.g., newborn resuscitation, normal birth, AMTSL, immediate
newborn care, suturing, and so on). After each skill is demonstrated by facilitators, learners practice
in pairs at the station using checklists. Each learner is then assessed by the facilitators for competency
in the skill using models. Anyone who does not attain mastery of the skill in simulation continues to
practice until competent.

Stations for BEmONC skills assessment and mastery (for midwives, doctors and nurses) in the
classroom:
Normal delivery, including AMTSL and immediate newborn care
Management of severe pre-eclampsia and eclampsia using MgSO4
Repair of episiotomy and vaginal and cervical lacerations
Postabortion care and manual vacuum aspiration (MVA)
Management of postpartum hemorrhage (PPH), including manual removal of the placenta,
bimanual compression of the uterus, compression of the abdominal aorta, and condom tamponade
Normal newborn exam
Breech delivery (Mauriceau-Smellie-Veit and Loveset maneuvers) (optional)

Facilitators must make sure that all learners have mastered these skills in simulation before they
move to the practicum at the clinical site(s).

Stations for CEmONC skills assessment (for providers who perform surgery) in the classroom:
All skills stations listed for BEmONC
Cesarean section

Laparotomy
Tubal ligation (optional)
Craniotomy (optional)

Facilitators must make sure that all learners have mastered these skills in simulation before they
move to the practicum at the clinical site(s).

Stations for CEmONC skills assessment (for anesthetists) in the classroom:
Adult resuscitation and intubation
Cardiopulmonary resuscitation
Spinal anesthesia

Facilitators must make sure that all learners have mastered these skills before moving to the
practicum at the clinical sites.

Clinical Practicum
During the practicum facilitators divide learners into groups of three or four, with no more than
four learners per facilitator, and develop rotation schedules in ANC, maternity (triage/admission,
labor, and birth areas, if separate), inpatient antepartum, and immediate postpartum/newborn. It is
important to have a room where anatomic models and supplies can be available for continued
practice and where case studies, partograph rounds, and role plays can be carried out at times when
the service is not busy. Each learner must have a logbook for recording daily activities (Appendix C).

Continual assessment of learners during their clinical work is essential to ensure that each one has an
opportunity to practice various skills with clients. Facilitators should meet daily with each learner to
assess their progress and challenges and to ensure that each has adequate clinical experience and
coaching to become competent in as many skills as possible. The meetings usually take place at the
end of the day. Facilitators should also meet daily as a group to discuss the general progress of
learners and any specific issues that arise during the training.

Last Day of Training
On the last day of the training, learners and facilitators meet again in the classroom. Some important
activities take place during the day:
Learners complete a written knowledge assessment covering the best practices addressed during the
training. They should score at least 85%; if they do not, they should be coached and then take the
assessment again. They should continue to retake the assessment until they reach the required score.
Depending on the setting, learners may need to participate in clinical simulations with models so
that their competency in key skills can be assessed. They should be coached until they reach a
minimum score of 85% for each skill.

Each team of learners (if possible) or each individual learner (if the team members come from
different facilities) will develop an action plan to implement in the three months following the
trainings. Action plans ensure that learners continue to use their new skills and teach them to
colleagues, thereby improving the quality of services at their facilities. Usually, learners are asked
to select up to three clinical practices that they want to improve at their facility and delineate the
steps they will take to achieve the improvements. See Appendix D for a sample action plan.
Facilitators and learners discuss next steps, and facilitators share information about:
The use of the logbooks to record all the skills performed by the learners after the training
and before the follow-up visit;
The implementation of the action plans;
The follow-up visit (including, if possible, dates and process); and
Evaluation of the training.
Learners share their feelings and feedback about the training. Each learner fills out an
anonymous questionnaire assessing several components of the training, including the objectives,
methodology, content, logistics, and so on. Appendix E provides an example of a training
evaluation questionnaire.

FOLLOW-UP OF THE TRAINING
Follow-up and supportive supervision are key to helping providers solve problems and apply new
practices on the job. Using performance standards (harmonized and standardized with training
materials) within a post-training follow-up approach or supportive supervision system can also
support performance improvement.
8

Before leaving the training site learners will develop action plans in which they will select three or
four skills they have acquired and put them into practice in their workplaces. Follow-up takes place
from six weeks to three months after the training, so learners will have had time to practice their new
knowledge and skills and put their action plans into effect. They will then have the opportunity to
discuss their successes and challenges with a facilitator. If the caseloads in the learners health
facilities are low, it may be better to regroup all learners in a busy health facility for two to three days
to conduct the follow-up visit.

An innovative way to follow up learners, either before or after the first visit, is by using mobile phone
technology in a structured way. Options include sending regular SMS messages to remind learners to
use key best practices; texting questions for them to answer to test their retention of knowledge; and
scheduling short phone calls to each team every few weeks to ascertain successes and challenges and
provide coaching even before the actual visit. This form of early and ongoing communication is
being used successfully in many countries; it helps to ensure that the follow-up visit is used to
address the most important issues raised during the mobile phone activities.

8
Examples of EmONC performance standards are available in the EONC Toolkit (forthcoming at www.k4h.org).

When conducting a follow-up visit, you should organize your activities as follows:
1. Assessment of the learners action plan implementation, including successes and challenges
encountered
2. Knowledge assessment for each learner using questions similar to those used in the training
3. Case studies on the partograph and PPH
4. Assessment of skills and attitudes with clients (ideally) or anatomic models (if there are no
clients) using checklists
5. Review of each learners clinical experiences logbook
6. Debriefing with the facility management team
7. Discussion of next steps to ensure that as many elements as possible of BEmONC and/or
CEmONC continue to be practiced in the facility

For more detailed information on how to conduct follow-up of providers, you may wish to consult
Jhpiegos Guidelines for Assessment of Skilled Providers after Training in Maternal and Newborn
Health, available at: www.jhpiego.org/files/GdlnsSkillProvEN.pdf

5. TRAINING DURATION AND SCHEDULES

There is a debate in the EmONC community about the appropriate duration of EmONC trainings.
EmONC training curricula generally range in length from three days to three weeks. It is important
to keep in mind that EmONC training is based on mastery of the EmONC signal functions, and
every training course should result in competent providers. The evidence is clear that sufficient
practice and feedback is essential to the development of the critical thinking and psychomotor skills
required to perform these functions.
9
The knowledge update alone may have little to no impact on
learners clinical practice skills and behaviors.

In countries with scarce human resources, taking any health worker away for training can
compromise the provision of services during the training. To reduce training time and increase
efficiency, Jhpiego now uses an internet-based course built upon repeated questions and feedback
(see section 4). Three options for training schedules are included here: a 12-day BEmONC training
schedule for midwives and obstetricians; an 18-day CEmONC training schedule for midwives and
obstetricians; and an 18-day CEmONC training schedule for anesthetists. The schedules assume
that a blended learning approach will be taken to reduce training time and increase the effectiveness
of training.

9
McGaghie, WC et al. 2009. Lessons for continuing medical education from simulation research in undergraduate
and graduate medical education: Effectiveness of continuing medical education: American College of Chest
Physicians, evidence-based educational guidelines. Chest 135 (3 Suppl) (Mar): 62S68S.
1
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6. COURSE MATERIALS

Since the goal of EmONC training is to teach providers evidence-based best practices, training must be
based on the most up-to-date teaching materials and manuals. This section contains links to the
learning resource packages (LRPs) that facilitators will need in order to organize the BEmONC and
CEmONC courses in a logical way. The LRPs contain schedules, session outlines, knowledge
questionnaires, case studies, role plays, skills checklists and PowerPoint presentations. In addition, links
are provided to several reference manuals that contain global evidence-based guidelines for emergency
obstetric and newborn care. The LRPs are formulated to reflect the information in these manuals.

MATERIALS FOR THE BEMONC COURSE
DOCUMENTS TO PREPARE IN ADVANCE
For each learner: For each facilitator:
Course schedule Course schedule and course outline
Precourse questionnaire Precourse questionnaire and answer key
Midcourse questionnaire Midcourse questionnaire and answer key
Action plan Copy of learners action plan
TRAINING MATERIALS TO DOWNLOAD
For each learner For each facilitator
Best Practices in Maternal and Newborn
Care: A Learning Resource Package for
Essential and Basic Emergency Obstetric
and Newborn Care. Learners Notebook.
http://www.accesstohealth.org/toolres/pdfs
/ACCESS_BPmnclrpPart.pdf
Best Practices in Maternal and Newborn Care:
A Learning Resource Package for Essential and
Basic Emergency Obstetric and Newborn Care.
Facilitators Guide.
http://www.accesstohealth.org/toolres/pdfs/ACCE
SS_BPmncrlpFacil.pdf
Managing Complications in Pregnancy
and Childbirth: A Guide for Midwives and
Doctors. World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RH
R_00.7.pdf
Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential
Practice. WHO, 2006.
http://www.who.int/reproductivehealth/publi
cations/en/
Managing Complications in Pregnancy and
Childbirth: A Guide for Midwives and Doctors.
World Health Organization, 2003.
http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.
7.pdf
Pregnancy, Childbirth, Postpartum and Newborn
Care: A Guide for Essential Practice. WHO, 2006.
http://www.who.int/reproductivehealth/publication
s/en/
Emergency Obstetric Care: Quick
Reference Guide for Frontline Providers.
Jhpiego, 2003.
http://www.jhpiego.org/en/node/477
Emergency Obstetric Care: Quick Reference
Guide for Frontline Providers. Jhpiego, 2003.

MATERIALS FOR THE CEMONC COURSE
DOCUMENTS TO PREPARE IN ADVANCE
Course schedule for midwives, doctors
and/or other clinicians performing surgery
Course schedule and course outline for
midwives, doctors and/or other clinicians
performing surgery
Precourse questionnaire for midwives,
doctors and/or other clinicians performing
surgery
Precourse questionnaire for midwives, doctors
and/or other clinicians performing surgery, and
answer key
Midcourse questionnaire for midwives and
doctors
Midcourse questionnaire for midwives and
doctors, and answer key
Action plan Copy of learners action plans
For each anesthetist: For each facilitator anesthetist:
Course schedule for anesthetists Course schedule for anesthetists
Precourse questionnaire for anesthetists Precourse questionnaire for anesthetists
Midcourse questionnaire for anesthetists Midcourse questionnaire for anesthetists, and
answer key
Action plan Copy of learners action plans
TRAINING MATERIALS TO DOWNLOAD
Emergency Obstetric Care for Doctors and
Midwives. Learners Guide. Jhpiego/MNH
Program and AMDD, 2003.
http://www.jhpiego.org/pt-br/node/445
Emergency Obstetric Care for Doctors and
Midwives. Teachers Notebook Guide.
Jhpiego/MNH Program and AMDD, 2003.
http://www.jhpiego.org/pt-br/node/445
Childbirth: A Guide for Midwives and
http://whqlibdoc.who.int/hq/2000/WHO_RHR
_00.7.pdf
Newborn Care: A Guide for Essential
Practice. WHO, 2006.
http://www.who.int/reproductivehealth/public
ations/en/
http://whqlibdoc.who.int/hq/2000/WHO_RHR_0
0.7.pdf
Newborn Care: A Guide for Essential Practice.
WHO, 2006.
http://www.who.int/reproductivehealth/publicatio
ns/en/
For each learner anesthetist: For each facilitator anesthetist:
Anesthesia for Emergency Obstetric Care.
Learners Guide. Jhpiego/MNH Program
and AMDD Program, 2003.
Anesthesia for Emergency Obstetric Care.
Teachers Notebook. Jhpiego/MNH Program
and AMDD Program, 2003.
Anaesthesia at the District Hospital (2d ed.),
by Michael B. Dobson. WHO, 2000.
http://whqlibdoc.who.int/publications/924154
5275
Anaesthesia at the District Hospital (2d ed.), by
Michael B. Dobson. WHO, 2000.
http://whqlibdoc.who.int/publications/9241545275
Childbirth: A Guide for Midwives and
http://whqlibdoc.who.int/hq/2000/WHO_RHR
_00.7.pdf
http://whqlibdoc.who.int/hq/2000/WHO_RHR_0
0.7.pdf

MATERIALS FOR FOLLOW-UP OF LEARNERS
For each midwife and doctor: For each anesthetist:
Clinical experience logbook Anesthesia for EmONC clinical experience
logbook
Guidelines for Assessment of Skilled
Providers after Training in Maternal and
Newborn Health. Jhpiego, 2004.
www.jhpiego.org/files/GdlnsSkillProvEN.pdf
Materials for follow-up of health care providers
trained in anesthesia for EmONC can be found
in the EONC Toolkit (forthcoming in 2012; visit
www.k4health.org)
Action plan Action plan
Related standards Related standards

7. ANATOMIC MODELS

Listed below are descriptions and ordering information for anatomic models and other
equipment needed for EmONC trainings. At a minimum, models for childbirth (for practicing
AMTSL, immediate newborn care, and PPH treatment) and newborn resuscitation should be
made available for BEmONC training. Models for lumbar puncture and airway management can
be added for CEmONC training.

DESCRIPTION SOURCE
Childbirth simulator BUYAMAG INC.
www.buyamag.com

GAUMARD SCIENTIFIC
Tel: 001305-971-3790
www.gaumard.com
MamaNatalie (normal birth & vacuum) LAERDAL
www.laerdal.com/mamaNatalie
Pelvic model for breech delivery SUPERIOR MEDICAL
superiormedical.com/l_models.html
Model and equipment for MVA IPAS
www.ipas.org
Fetus model for vacuum extraction PELICAN HEALTHCARE LTD.
www.pelicanhealthcare.co.uk
Tel: 029 2074 7000
Fax: 029 2074 7001
Email: contactus@pelicanhealthcare.co.uk
Model for Cesarean section OPERATIVE EXPERIENCE
www.operativeexperience.com
Model for PPH management: MamaNatalie LAERDAL
www.laerdal.com
Model and equipment for newborn resuscitation:
Helping Babies Breathe (HBB) model NeoNatalie
LAERDAL GLOBAL HEALTH
www.laerdalglobalhealth.com/neonatalie.html

DESCRIPTION SOURCE
Lumbar puncture trainer/simulator for spinal
anesthesia
GAUMARD SCIENTIFIC
Tel: 001305-971-3790
www.gaumard.com

KYOTO KAGAKU
www.kyotokagaku.com
Airway management trainer with stand SIMULAIDS
www.simulaids.com
Tel: 800-431-4310
Fax: 001845-679-8996
E-mail: info@simulaids.com

8. VIDEOS AND PRESENTATIONS

The following videos and presentations are useful in EmONC training to reinforce the key
components of each skill being taught. Learners can view them at their own convenience during and
following training as needed to refresh their knowledge.

DESCRIPTION SOURCES
Active Management of the Third
Stage of Labor: A Demonstration
ACCESS Program
www.accesstohealth.org/toolres/amtslweb/amtsl.html
Vaginal Breech Delivery and
Symphysiotomy
WHO Reproductive Health Library
http://apps.who.int/rhl/videos/en/index.html
Manual Vacuum Aspiration IPAS
www.ipas.org
View video at http://youtu.be/I0daZ8dLXdY
Vacuum Extraction WHO Reproductive Health Library
Vacuum-Assisted Delivery: A Brief
Summary of Key Principles
Clinical Innovations, Inc.
http://www.clinicalinnovations.com/kiwi_video_vad.htm
Tel: 888-268-6222 or 801-268-8200
To order video, go to:
http://www.clinicalinnovations.com/vacca.htm#dvd
Steps to Overcome Shoulder
Dystocia
Caesarean Section Evidence-
Based Surgical Techniques
Spinal Anesthesia www.operationalmedicine.org/ed2/video/spinal.mpg
Labour Companionship: Every
Womans Choice

9. JOB AIDS

A full list of resources, including job aids, can be found in the Essential Obstetric and Newborn Care
(EONC) Toolkit, forthcoming in 2012 on the Knowledge for Health website (visit
http://www.k4health.org/publications-and-resources). The following job aids are especially useful
during training. If possible, each facility represented at the training should have copies of them.

Job Aids in the EONC Toolkit (forthcoming at www.k4health.org):
Positions for Labor (drawings of positions in labor and squatting position for birth), by Victor
Okello (artist); from GOAL, Uganda
Steps to Perform AMTSL (poster)
Steps to Perform MVA (poster)
Algorithm for Management of Preeclampsia/Eclampsia (poster)
Dilution and Mixing of MgSO4 (poster)
Algorithm for Management of PPH (poster)

Other Job Aids:
Positions for Laboring Out of Bed Tear Pad
Cascade Healthcare Products
www.1cascade.com/ProductInfo.aspx?productid=2937
Action Plan Poster
Helping Babies Breathe Action Plan
www.helpingbabiesbreathe.org/docs/ActionPlan.pdf
Large laminated WHO Modified Partograph
(Facilitators can make this by enlarging a printed partograph to about 1 meter x 1 meter and
laminating it.)
Wall chart to demonstrate cervical dilatation
(Facilitators can make this on flipchart paper by drawing circles from 1 cm to 10 cm in diameter.)

10. DOCUMENTATION OF ACTIVITIES

Training in EmONC is an important component of many maternal mortality reduction programs,
and documentation of activities is needed to monitor the impact of training. You will need a system
for collecting data on facilitators, learners and training events so that you can report on activities and
evaluate the program. The system can be solely paper-based or web-based or a combination of both.
Appendix F shows the Training Information Monitoring System (TIMS) Data Recording Form, the
paper-based reporting system developed by Jhpiego for tracking training activities. The data
collected can be entered in a simple Excel spreadsheet.

APPENDIX A: ORGANIZATION OF MATERNITY
SERVICES

Listed below are the components of maternity services that should be assessed and targeted for
improvement in the clinical sites that are used for EmONC training. Included are points that should
be highlighted during the discussion of woman-friendly services on the first day of training and
throughout the training.
1. Staffing
Services should be available 24 hours/day, seven days/week.
Staff with BEmONC skills should stay at the site during their assigned shifts. Staff with
CEmONC skills should be easily available by phone or other means, and able to be at the
site within 20 minutes of being called.
2. Woman-friendly and family-friendly care
Women and their families should always be greeted kindly and with respect, no matter how
busy the service is. Every woman should feel as though she is receiving the highest quality
care, even if labor and birth proceed normally.
Women who present for care should undergo immediate rapid assessment and be triaged
according to the findings of the assessment.
Women have a right to (1) privacy (curtains, if not a separate room); (2) know who is taking
care of them (i.e., the providers name and qualification); (3) consent to care by a student;
(4) the presence of a family member/companion; (5) information about what is happening
and answers to their questions; (6) information about all procedures and informed consent
for each; (7) ambulate and eat/drink as desired if there are no contraindications; (8) assume
the position of their choice for the birth; (9) breastfeed immediately after the birth; and (10)
remain with their baby throughout their stay at the facility.
3. Equipment/supplies
A designated staff member on each shift will be responsible for checking/restocking all
emergency equipment and trays per established guidelines and checklists. All staff members
should have access to emergency equipment at all times (e.g., adult ambu bags and masks, IV
solutions and administration sets, and medications such as oxytocin and magnesium sulfate).
4. Responsibility for client care
To ensure continuity and increase accountability for each clients care, every client is assigned
to a specific staff member (midwife, obstetrician, nurse), and that staff member is responsible
for coordinating all care. This includes maintaining the partograph and other documentation
(i.e., delivery register, referral forms, operative notes, and so on).
If the staff member cannot care for the client (because he or she is assisting at another
delivery or an emergency arises), the clients care should officially be turned over to another
staff member.
Midwifery, nursing and medical students are not counted as regular staff.

Each student must be assigned to a regular staff member.
Each staff member should supervise no more than two students at a time.
Students can provide direct care to the woman/newborn, but only under the direct
supervision of a regular staff member.
If a physical assessment shows the client is progressing normally, staff can instruct family
members about assisting with ambulation, nourishment and other comfort measures. Staff
should continue to assess the woman and maintain the partograph and other documentation
as needed.
5. Documentation
The partograph will be used for every client once active labor has begun. Students may assist
in gathering information for the partograph under the supervision of a regular staff member.
If a client is not in active labor, a chart will be established and updated at least every four
hours or more often if the clients condition warrants.
Specific documentation will be undertaken for women with complications. For example,
documentation for pre-eclampsia/eclampsia includes vital signs (with respirations and
reflexes), presence of convulsions, state of consciousness, presence of headache and
abdominal pain, fetal heart rate and use of medications (time, dose and route).
6. Specific procedures
Routine procedures such as cervical exams, rupture of membranes and normal
birth/newborn care/repair of minor lacerations should be carried out in the same room/bed
throughout the clients care.
Procedures such as MVA should be carried out in the labor ward, not the operating theater,
so as to expedite the womans care and counseling and keep the operating theater open for
urgent cases.
7. Newborn resuscitation
At least one resuscitation corner will be readily accessible to all delivery areas. It will be set up
for immediate use at all times. It should include a table with a clean cover, exam gloves, a
radiant lamp or other means to warm the newborn, oxygen if available, clean towels/cloths to
dry the newborn, suction device, an ambu bag and newborn and premature-size masks, a
clock with second hand and a wall chart for newborn resuscitation (e.g., the Helping Babies
Breathe job aid).
8. Hand-off at end of shift
Providers leaving at the end of their shift will ensure that all materials, supplies and
medications are replenished before they leave and that the newborn resuscitation corner is
ready for use.
Incoming providers will meet with the outgoing staff and receive client assignments and an
update about the status of each client, using the partograph and/or other documentation as a
guide.
Incoming providers will immediately introduce themselves to clients.

APPENDIX B: EQUIPMENT AND SUPPLIES LIST

The list below shows the standard equipment and supplies that are needed for training courses, both
in the classroom and in the clinical setting. Learners will need basic supplies to simulate what they
will find in the hospital, and these items can be kept and used for future training courses. After
assessing the clinical site, facilitators may want to donate certain equipment, supplies and
medications to the facility so that learners are able to care for clients according to global standards.

ITEMS
NUMBERS NEEDED
Learners Facilitators Facility* Total
Examination
Adult sphygmomanometer 1 per team 2
Adult stethoscope 1 per team 2
Thermometer 1 per team 2
Tape 1 per team 2
Fetoscope 1 per team 2
Delivery
Delivery Kits 1 per team 35
Instrument tray
Cord scissors
Hemostats (2) to clamp cord, or cord
clamps

Sponge forceps (2)
Galipot bowls for cotton/antiseptic for
perineal cleansing; placenta bowl
1 per model

35

Plastic sheet to place under mother and
clean cloths for draping
34 per
model

5

Clean cloths to dry and cover baby 34 per
model

2 dozen

Plastic apron 1 per team 5
Head covers 1 per learner 100
Masks 1 per learner 100
Glovessterile 6 pairs per
learner
3 dozen,
various
sizes

Glovesnon-sterile 2 boxes per
team

10 boxes

Barrier goggles 1 per learner 1 per
facilitator

Gauze4-inch x 4-inch squares in giant
package, non-sterile and not individually
wrapped
4 packages
per team
6 boxes

Oxytocin vials 1 per team 50

ITEMS
NUMBERS NEEDED
Syringe and needle (3 cc syringe with 20 or
21 gauge needle)
1 per team 50

Amniotic hook or Kocher clamp 1 per team 35
Episiotomy
Sponges (foam blocks) of upholstery quality
(8 inch x 4 inch x 4 inch)should not tear
easily when thread pulled through. Please
test!
3 per learner 2

Suture needlesreusable, round body,
half-circle suture needles either with suture
already attached or with an eye so suture
can be pulled through eye.
50

50

Rolls/spools of regular sewing thread (good
quality so goes through practice sponge
easily). Needed only if suture needles do
not have suture attached.
10
rolls/spools
per team

Episiotomy/laceration repair kitsinclude
metal tray or container with needle holder,
episiotomy scissors, non-toothed dissecting
forceps, towel clips, stitch scissors, sponge-
holding forceps, long straight artery forceps
1 per team

3

10 cc syringe with 1.5-inch needle (pretend
filled with 0.5% lidocaine); or lidocaine 1%
and sterile water for injection, for dilution to
0.5%.
1 per

50

Infection Prevention
Plastic buckets 3 per team 6
Large steamer pot with lid (for steaming/
boiling)

1

Plastic bucket for chlorine solution 1 per model
(childbirth
and
newborn)

6

Heavy cleaning gloves 2 pairs
Toothbrush 6
Puncture-proof container for sharps
disposal
1 per
childbirth
model

6

Plastic bucket for paper disposal 1 per model
(childbirth
and
newborn)
0 6

Bottles of alcohol and glycerin gel for hand
cleansing
1 per station 0 6

Dish/liquid soap 1 per
classroom
0 5
Individual towels 12 per 12 per

ITEMS
NUMBERS NEEDED
learner facilitator
PPH, PE/E and other EmONC Management
Foley bladder catheter 1 per model 0 5
Condom idem 0 5
Suture idem 0 5
IV fluids administration set idem 0 10
Adult ambu bag with mask 1 0 1
Oxytocin 10 IU idem 0 50
Cesarean tray, if CEmONC 1 per 46
learners
0 3
Vacuum extractor 1 per 46
learners
0 1
MVA kit 1 per team 0 1
NeoNatalie kits, including models, ambu
bags/masks, and mucous extractors; or
separate models and equipment
1 per 46
learners
0 1
Antihypertensives 0 Based on
# of cases
at training
sites, if
stockouts
are
anticipated

Magnesium sulfate 0 idem
Antibiotics for treatment of maternal and
newborn infection
0
idem
Chlorhexidine 4% for newborn cord care 0 idem
*Numbers needed for each facility will depend on what is found during the clinical site assessment; some facilities are
well-equipped while others will have no spare equipment for use by learners.

APPENDIX C: PRACTICUM LOGBOOKS FOR
DOCUMENTING SKILLS PERFORMED WITH CLIENTS

Practicum Logbook for Nurses/Midwives and Obstetricians (to be filled out during EmONC training)
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8
Partograph
Normal delivery
Active management of
third stage of labor

Episiotomy and/or
repair of
episiotomy/laceration

Vacuum-assisted
delivery

Manual vacuum
aspiration

Manual removal of the
placenta

Bimanual
compression of the
uterus

Compression of
abdominal aorta

Condom tamponade
Cesarean section*
Laparotomy for extra-
uterine pregnancy*

Laparotomy for uterine
rupture*

*For obstetricians only

Practicum Logbook for Anesthetists (to be filled out during EmONC training)
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8
Treatment of shock/adult
resuscitation

Cardiopulmonary
resuscitation

Establish IV line
Control of the airway/
endotracheal intubation

Setup of operating room
Preoperative care
Spinal anesthesia
Ketamine anesthesia
General anesthesia
Postoperative care
Blood transfusion
Case referred

APPENDIX D: SAMPLE ACTION PLAN FOR
LEARNERS

Learner Name:
Country of Residence:
Training Attended:
Name of Facility:
Date:
Based on what you learned during this training, please write down three things that you would
like to change at your facility over the next year:
Goal #1
Goal #2
Goal #3
List the actions/steps needed to achieve the goal, along with the date that each activity is
completed. Include the names of colleagues who will assist you and list the specific tasks they
are assigned.
Goal #1
ACTIVITIES/STEPS DATE
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR ASSIGNED
TASKS
DATE
COMPLETED

Goal #2
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR TASKS
DATE
COMPLETED

Goal #3
PLANNED
COLLEAGUES WHO WILL
ASSIST AND THEIR TASKS
DATE
COMPLETED

APPENDIX E: TRAINING EVALUATION
QUESTIONNAIRE

PLEASE EVALUATE THE
FOLLOWING STATEMENTS
STRONGLY
AGREE
AGREE UNDECIDED DISAGREE STRONGLY
DISAGREE
1. For the work I do, the training
was appropriate.

2. Training facilities and
arrangements were
satisfactory.

3. The facilitators/teachers
were knowledgeable and
skilled.

4. The facilitators/teachers
were fair and friendly.

5. The training updated my
knowledge and skills.

6. Training objectives were met.
7. Teaching aids were useful.
8. Practice in the clinical areas
was important and helpful.

Please answer the following questions. Use the back for more writing space if needed.
1. What was the most useful part of the training course for you?

2. What, if any, part of the training course was not useful to you?

3. What suggestions do you have for improving the training course?

4. Other comments:

APPENDIX F: TRAINING INFORMATION MONITORING
SYSTEM: DATA RECORDING FORM

Guidelines For Basic and Comprehensive InService Final

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