Apply your prior experience along with what you have ...



Tubal Ligation (Female Sterilization):Facilitator’s Guide to the Training Resource Package Table of ContentsOverview of the Female Sterilization Facilitator’s Guide33Purpose of the Training Resource Package for Female Sterilization?3Using the Training Resource Package to Develop and Deliver Training3Overview of the Design of the Training Resource Package for Female Sterilization (see Diagram, page 2)4Learning Objectives4Facilitator’s Guide4Illustrative Female Sterilization Session Plan with Illustrative Training Schedule5Presentation (PowerPoint slides) 6Handouts7Evaluation Tools8Conducting Clinical Practice9References10AppendicesAppendix A: Role Plays’ Instructions Observation Checklist and ScenariosAppendix B: Illustrative Competency-Based Checklist for Female SterilizationAppendix C: Answer Key for Female Sterilization Case Studies 00Training Resource PackageTraining Resource PackageFemale Sterilization:Facilitator’s Guide to the Training Resource PackageOverview of the Female Sterilization Facilitator’s GuideThis method-specific facilitator’s guide is designed to complement the General Facilitator’s Guide to the Training Resource Package. The general guide provides an overview of the TRP materials and how they are intended to be used as well as overall guidance on how to conduct effective training in different types of settings and with different audiences. There are additional resources to assist you with adapting training and training materials to the specific needs of your audience in the Conducting Training section of the TRP website. There is also guidance on how to use each of the training techniques, such as case studies and role plays that are incorporated into the TRP session plans.In this method-specific facilitator’s guide you will find additional information on how to use the training materials and techniques specific to female sterilization that are available in the female sterilization module of the TRP. Most importantly, you will also find method-specific tools and answer keys that support delivery of training. Purpose of the Training Resource PackageThis training module is designed to support health care workers in developing the knowledge, skills and attitudes needed to provide accurate information and counseling on female sterilization to clients and promote voluntary and informed choice. In addition, it can also be used to train physicians, nurses, midwives and other health care providers to perform minilaparotomy procedures for female sterilization, if this is appropriate to their scope of practice and job description. Ideally, a surgeon (a physician or clinical officer) and a surgical assistant (a nurse or midwife with skills in operating theater management) should be trained as a team. It is designed to actively involve the trainees in the learning process. Training sessions include the use of PowerPoint presentations, skills practice in the form of role plays, case studies and discussions, as well as clinical practice, with anatomic models and clients, using objective competency-based skills checklists. At the end of this module, the trainee will be able to describe female sterilization as an effective FP method, counsel and screen clients seeking female sterilization, respond to rumors and misconceptions about female sterilization, provide services for female sterilization clients, recognize and manage common side effects and complications, and provide follow up care for female sterilization acceptors, as appropriate to their scope of practice and job description. Using the Female Sterilization Module to Develop and Deliver TrainingAll the materials needed to develop a curriculum for female sterilization training are included in the TRP module on female sterilization. The diagram following the Table of Contents shows how the different components of the module fit together. As described in the General Facilitator’s Guide and other resources in the Conducting Training section of the TRP, each component of the female sterilization module may be adapted to fit the circumstances in the country where they will be used, the trainers who will be conducting training, and the level of expertise and skills of the trainees. The module can be adapted to fit any style of training, for example, face-to-face or self-study combined with clinical practicum and on-the-job training. It can also be adapted to meet the purpose for training: refresher training; training new providers; pre-service education. It can be used as a stand-alone course on a single method or as part of a comprehensive course in FP. Whenever possible, the module and its materials should be translated into the local language.Overview of the Design of the Technical Resource Package Module on Female SterilizationIn order to understand the design of the module, it is helpful to see the diagram on page two. The basic design includes the following:The Learning Objectives By the end of the training, as appropriate to their scope of practice and job description, trainees will be able to:Describe the characteristics of female sterilization in a manner that clients can understand, including What female sterilization is and how it worksEffectivenessSide effectsNon-contraceptive health benefitsOther characteristics (lack of protection from sexually transmitted infections, including HIV, ease of use, etc.)Possible health risks (side effects and complications)Demonstrate the ability to:Screen clients for medical eligibility for female sterilization useCounsel clients on female sterilizationAddress common concerns, misconceptions, and mythsConduct postoperative care, discharge, and follow-up for female sterilization clients in a way that enhances safety, satisfaction, and acceptanceDescribe when to perform the minilaparotomy procedureExplain how to manage side effects and complicationsDemonstrate use of recommended pain management regimensDemonstrate on anatomical models and on clients how to competently perform the minilaparotomy procedureFacilitator’s Guide This Facilitator’s Guide – which you reading right now - contains information on the module design, a description of the materials, learning objectives, instructions and answer keys for role plays, case studies, games and pre- and post-tests, as well as a sample course evaluation form. It also includes a detailed competency-based checklist for insertion and removal of female sterilization. However, it does not contain the illustrative session plan and training schedule for training in female sterilization, described in the next section. It has its own tab in the module – Illustrative Module Session Plan. The Training Resource Package General Facilitator’s Guide provides overall guidance on how to conduct effective training in different types of settings and with different audiences which may be helpful to you. There are still more resources to assist you with adapting training and training materials to the specific needs of your audience in the Conducting Training section of the TRP website. Illustrative Module Session Plan with Illustrative Training ScheduleThe session plan and training schedule are found in the Illustrative Module Session Plan tab within the module. The session plan summarizes how the resources and documents in the module should be used to achieve the learning objectives. Each section of the session plan addresses a module topic, such as characteristics of the method or medical eligibility. The slides to be shown with each section and appropriate handouts are identified. The female sterilization module is divided into five sessions:Session I is on the characteristics of female sterilization and includes key points for providers and clients, effectiveness, mechanism of action, health benefits of female sterilization, types of female sterilization procedures, timings of the procedure, method effectiveness and safety of the method, and side effects and complications.Session II contains information on who can have sterilization, medical eligibility for the use of female sterilization, screening/client evaluation for eligibility (checklist) for contraceptive use, use of female sterilization by postpartum and postabortion women and by women with HIV, and preoperative client assessment.Session III gives information on providing female sterilization; it covers counseling for female sterilization use, preoperative client assessment and client preparation for minilaparaotomy, the anatomy and physiology of the female reproductive system (including the anatomy of the anterior abdominal wall relevant to female sterilization), pain management, the minilaparotomy procedure itself, postoperative care, and preparing for problems and managing side effects and complications. Other areas covered in this session include the roles of the different members of the surgical team and practice of the minilaparotomy procedure on models and clients to gain competency.Session IV is a separate session on infection prevention relevant to minilaparotomy procedure. It covers hand hygiene, use of appropriate barriers, abdominal preparation for minilaparotomy, establishing and maintaining a sterile field, instrument processing for reuse, maintenance of operation area and waste disposal. NOTE: Although infection prevention is covered separately as the last session in the session plan, when planning and delivering the course, infection prevention must be covered before participants learn how to perform the minilaparotomy procedure. This is reflected in the illustrative training schedule where infection prevention is covered after session IIIC.The Illustrative Training Schedule provides a snapshot of the breakdown of the female sterilization module by day, time, and topic covered. For example:DAY 1TimeTopicMethodResources8:00–8:15Welcome and IntroductionLearning ObjectivesDiscussion/BrainstormingSession I, Introduction Slides 1 and 28:15–8:45PretestTestEvaluation Tool: The Female Sterilization PretestDAY 1TimeTopicMethodResources9:00–10:30Session I, continuedWhat Is Female Sterilization?Interactive PresentationBasic Slide Set, Session I, Slides 3–7Key Points for Providers and ClientsPresentation/DiscussionBasic Slide Set, Session I, Slides 9, 10 ,11 & 12Presentation (PowerPoint slides)The PowerPoint presentation includes technical information on the module topic. There are three types of slides:Slides conveying most of the technical information are pale green:The pale green slides with a pink header are Basic Slides that include basic information needed by most, if not all, providers and simple illustrations.The pale blue advanced slides present research that supports the recommendations in the Global Handbook and the Training Resource Package and can be included or excluded by the facilitator as appropriate. They are especially appropriate for physicians who may desire additional information from supporting research studies. The text for these slides can be found in the speaker’s notes, rather than in the session guide.148971029845HandoutsRole plays The female sterilization module includes a set of role play scenarios that enable trainees to practice using the knowledge and skills they are learning. Each role play describes a typical client scenario and the tasks specific to that scenario. The role play scenarios along with the observation guide, are included in both the facilitator’s guide and in the Handouts tab of the module. In addition, Facilitating Role Plays in the Conducting Training section of the TRP includes, role play observation checklists, and general instructions for the observer, provider, and client roles.Case studiesThe module also includes case studies with progressive case descriptions and questions that enable trainees to analyze a situation and think through how to apply their newly learned technical information. The answer keys for the case studies are in this method specific facilitator’s guide, while the case studies themselves are in the Handouts tab of the module. See Using Case Studies in the Conducting Training section of the TRP website.Job aids/technical handoutsThe female sterilization module includes job aids that describe how and when to perform important provider tasks—for example, screening checklists and job aids for explaining method effectiveness. Learning activities in the modules give trainees opportunities to practice using these job aids so they can more easily incorporate use of these tools at the workplace. Counseling toolsThe female sterilization module activities can be used with a variety of counseling approaches and job aids. The term counseling tool in TRP materials refers to the counseling tool or job aid that trainees will be using. Examples include WHO’s Balanced Counseling Strategy counseling cards or other approaches and tools. Facilitators should incorporate activities that enable trainees to use the counseling tool or job aids that they use at work (or will use after the learning intervention). Games and activitiesThis module contains a review game that provides a fun way for trainees to review module content. Instructions for the game are provided in the session plan, and the answer key is provided in this female sterilization facilitator’s guide. Evaluation ToolsThe female sterilization module contains several options for evaluating trainees including pre- and post-tests which contain objective questions, with instructions for scoring the tests. The module also contains competency-based skills checklists and an optional review games and instructions for evaluating role plays and case studies.Pre- and Post-testsThe pre-test knowledge evaluation should be given at the beginning of the course and again at the end of the course (post-test). The trainee’s pre- and post-test scores should be compared to measure changes in knowledge. The pre-test contains the same test items as the post-test. The pre- and post-tests are objective and comprised of true/false and multiple-choice questions. Instructions are given on how to score the tests. There are also two case studies included with the post-test. Grade the case studies separately. The case studies are a good way to determine whether trainees are able to apply the knowledge they have gained. Competency-based Skills ChecklistsTrainers may observe trainees practicing and applying skills, tools, and techniques during the session. This can be done through direct observation of clinical skills, role plays, simulations, or case studies. A competency-based checklist is developed by breaking down the clinical skill or activity to be taught into its essential steps. Each step is then analyzed to determine the most efficient and safe way to perform and learn it. These checklists make learning the necessary steps or tasks easier and evaluating the learner’s performance more objective. In addition to using checklists to learn a skill, trainees and trainers keep track of progress in the clinical area by using checklists. The checklists contain enough detail to permit the trainer to evaluate and record the overall performance of the skill or activity. Using checklists in competency-based clinical training:Ensures that trainees have mastered the clinical skills and activities, first in simulated practice with anatomical models or role plays, and then with clients;Ensures that all trainees will have their skills measured according to the same standard; andForms the basis for follow-up observations and evaluations. Criteria for satisfactory performance by the trainees are based on the knowledge, attitudes, and skills demonstrated and practiced during training. In preparing for formal evaluation by the trainer, trainees can familiarize themselves with the content of the checklist by critiquing each other’s skills. When evaluating the performance of a trainee, the trainer will judge each step of the skill to be:1 = Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted2 = Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently3 = Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary)Not observed: Step, task, or skill not performed by the trainee during evaluation by the trainer. An Illustrative Competency-based Skills Checklist for Female Sterilization can be found in Appendix C.Course EvaluationsThe course evaluation is an important first step in determining the success of a training program. Trainees reactions help determine the effectiveness of a program and how it can be improved. The Course Evaluation can’t measure the ability to apply the learning, changes in attitudes or beliefs, organizational impact, or the trainer’s technical knowledge. A Sample Course Evaluation can be found in the Conducting Training/Facilitator’s Materials section of the TRP.Rapid evaluations can be done quickly determine trainee’s reactions to the day’s session. Ask the following:How valuable was today’s session for you using a 5-point scale?What are the most important things you learned today? How do you plan to apply those ideas to your job?If you choose not to use the course evaluation form, a quick alternative at the end of training (or during) is to put up two flip charts. On one flip chart write, “Here are some things we found especially useful in the training.” On the other write, “Here are some suggestions for how the training could be even better.” Make sure the trainer leaves the room while the trainees are writing. Review Exercises and GamesAn interesting way to measure what trainees have learned is through the use of review exercises and games. One of these can be found under the evaluation tools section of the website.Conducting Clinical PracticeEnsuring an effective and safe clinical practice experience is both essential and challenging. The following are key points to consider when designing the clinical practicum. For more information on each of these areas please refer to “General Resources on Training”; there are several documents listed there that will provide additional guidance. The clinical practice site must expose trainees to adequate numbers of cases as well as a supportive environment that reinforces the standards taught in the classroom. Clear criteria for site selection are needed. Clinical sites may need to be prepared for this role and that can take time and resources. Expert clinical trainers are needed at the site, in order to ensure adequate supervision of trainees. Not only must they be expert clinicians, they also need mentoring skills. These individuals may need to be developed as well. Standards for certification of learners – the level of skill they must demonstrate in order to independently, without supervision, perform a procedure - needs to be determined in advance. Case load, the number of trainers, the number of trainees, the complexity of the skill and time available are all factors to be taken into consideration. The time available for clinical training, as well as the ratio of trainers to trainees are additional important planning considerations. Further information on conducting clinical practice is available in the Conducting Training section of the TRP. ReferencesThe main references for the female sterilization module as well as for other modules of the TRP are the World Health Organization’s four cornerstones of family planning guidance:Family Planning: A Global Handbook for Providers (2018 update). This book serves as a quick-reference resource for all level of health care workers. It provides practical guidance on delivering family planning methods appropriately and effectively. The Medical Eligibility Criteria for Contraceptive Use (5th edition 2015). This resource provides guidance on whether people with certain medical conditions can safely and effectively use specific contraceptive methods. Selected Practice Recommendations for Contraceptive Use (3rd Edition 2016). This resource provides guidance on how to use contraceptive methods safely and effectively, once they are deemed to be medically appropriate. WHO Medical Eligibility Criteria Wheel for Contraceptive Use (2015) is a tool that makes it easy to identify medical eligibility for use of family planning methods. A: Role Play Instructions, Observation Checklist, and ScenariosProvider Instructions for Role PlaysPretend that you are meeting the client for the first time. Ask the client for his or her name, sex (male or female), and age. Pretend that there is a health center nearby to which you can refer the client, if needed. Remember to:Assess the client’s reproductive health (RH) goals, concerns, and fertility intentionsAddress the primary and secondary reasons for the client’s visitFacilitate the client’s decision-making processIntegrate information and services related to other RH issues, as appropriateHelp the client act on her or his decision(s)Apply your prior experience along with what you have learned from the training and use job aids and tools as appropriate to address the client’s concerns. Observer Instructions for Role PlaysPrior to the start of the interaction: Review the Role-Play Observation Checklist, so that you are familiar with the behaviors that you are observing and where they appear on the checklistReview the case-specific issues on the observer information sheet for the role playWhile observing the interaction between the provider and client, remember to:Use the observation checklist to take notes on what happens during the interactionRecord how well the provider addresses the case-specific issues in the space providedBe prepared to give feedback to the provider regarding how well he or she addressed the client’s needsPay particular attention to whether the provider:Helped the client deal with anxietyFacilitated communication with a partnerAllowed the client to make an informed decisionEnsured that the client met the medical eligibility criteria for the method she choseHelped the client carry out her decisionClient Instructions for Role PlaysPrior to the start of the interaction: Read the client information sheet and make sure that you understand your character’s situation.Pick a name for your character. Tell the provider your name, age, and whether you are male or female.During the interaction, offer information only when the provider asks relevant questions. Use the information given in your client information sheet to respond to the provider’s questions. Feel free to ask questions of the provider.Role-Play Observation ChecklistCase: ____________________________ Provider: _______________________________ Client: _______________________________ Observer: _______________________________ Date: ___________________________Overall: Communicate Effectively and Maintain Rapport Shows respect and avoids judging client Maintains relaxed, friendly, and attentive body posture and eye contact Uses simple, clear language Uses open-ended and probing questions correctlyListens carefully to client (paraphrases and reflects)Asks client about feelings (and shows empathy)Encourages client participation Explains what will occur during visit and procedures Ensures client understanding and corrects misunderstandings Uses job aids appropriately Offers to involve client’s partnerRecords data according to protocolsEstablish Rapport and Assess Client’s Needs and ConcernsGreets client appropriately Ensures confidentiality and privacy and that client is comfortableAsks about reason for visit Asks about client’s partner(s), children, family, sexual behavior, healthAsks about plans to have children, desire for FP (e.g., spacing, limiting)Explores STI risk and what client does to avoid STIsIdentifies areas to evaluate during physical exam (if indicated) Provide Information and Options Related to Client’s ConcernsAdvises on preventing STIs (i.e., abstain, have fewer partners, use condoms) Advises on achieving desired pregnancy as safely as possibleExplains benefits of FP and healthy birth spacingHelps client identify FP methods suited to her or his needsGives information on FP methods of interestResponds to other client questions or concerns YesNoN/AHelp Client Make an Informed Decision or Address a ProblemAsks client if he or she has any questions about methods of interestAsks client to choose a methodUses screening checklist to determine if client can use the methodAgrees on decision or plan in partnership with client Provide Assistance to Support Client’s DecisionGives contraceptive method and condoms for dual-method use, if needed..Explains and/or demonstrates correct use Asks client to explain or demonstrate correct use, and reinforces client’s understanding and/or corrects client’s demonstration Reminds client about side effects and reasons for returningGives treatment, supplies, medications (as indicated) Role-plays or rehearses negotiation skills and helps client plan approachArranges follow-up, resupply, and referral to other services, as needed Case-Specific Observations or Questions: YesNoN/AFemale SterilizationRole Play Scenario 1—Client is interested in and eligible for female sterilizationFemale Sterilization Scenario 1—Client Information SheetFemale Sterilization Scenario 1—Observer Information SheetClient Description You are a 31-year-old female who is married to a 35-year-old man. You have four children and as a couple do not want to have any more children. You have been using an implant for the last two and a half years and have been happy with it, but now it will need to be replaced soon. A provider at your local clinic gave you a pamphlet on family planning options and suggested you discuss permanent options with your partner since you don’t want any more children. by a nurse at the antenatal clinic. You are interested in exploring female sterilization and are now visiting the family planning clinic with your husband. Offer this information only when the provider asks relevant questions:You have been married for 10 years to your husband. You have four children and do not want any more.You have been using Implanon Next for 2.5 years and have been happy with it.You feel healthy and have no health problems.Make note of whether the provider performs these case-specific tasks:Asks about the client’s reproductive health goals, fertility intentions, and life plansEnsures that the client understands the contraceptive options described and has made an informed choice to use female sterilization Determines the client’s medical eligibility using the female sterilization screening checklistDescribe the female sterilization surgery and follow-up procedures and makes sure the client understandsMakes certain that the client understands the transient side effects and possible complications, including the minor risk of failureOffers couples counselingMethods for which the client is eligible:Male and female sterilizationCOCsDMPA or NET-ENImplantsMale or female condoms Standard Days Method?Female SterilizationRole Play Scenario 2—Client is interested in and is not yet eligible for female sterilizationFemale Sterilization Scenario 2—Client Information SheetFemale Sterilization Scenario 2—Observer Information SheetClient Description You are a 31-year-old woman who works full-time. You have been married for 8 years, and you and your husband have two children. He is currently unemployed and your family is having some financial hardship because of this. You had previously talked about having three children,but can’t afford to have another child right now because of your financial problems. You are using COCs right now but last month your menses was a few days late and you were very concerned that you were pregnant, though this proved not to be the case. This made you think about how difficult having another child would be right now. You mentioned this to a friend who told you how effective female sterilization was at preventing pregnancy. You have now come to the family planning site to learn more about the method and possibly to have the procedure.Offer this information only when the provider asks relevant questions:You are interested in female sterilization.You do not want any more children right now because of your family’s financial difficulties.If your husband gets another job and your family’s economic situation improves then you might be interested in having a third child, but you aren’t sure if he will get another job or not.You have been happy with COCs but occasionally when you are very busy at work you forget to take them or are very late taking them.You are most interested in female sterilization because it is so effective and because you don’t have to remember to do anything regularly.You feel healthy and have no medical problems.You have heard that if you change your mind about female sterilization later you can have another surgery to undo it.Make note of whether the provider performs these case-specific tasks:Asks about the client’s reproductive health goals, fertility intentions, and life plansAssess whether the client has discussed her fertility intentions with her husband and offers couple counselingExplains contraceptive options available, focusing on ones with few user requirements and high effectivenessEnsures the client understands that female sterilization is a permanent method and is irreversible and corrects the misunderstanding that female sterilization can be reversedVerifies that if the client would still be happy with a permanent method of contraception if her economic situation changes and they could afford an additional childDescribes the female sterilization procedure and ensures the client understands possible side effects and complications that may be associated with the procedure.Methods for which the client is eligible:COCs*DMPA or NET-EN ImplantsIUDMale or female condoms*Standard Days Method?**Although the client is medically eligible, these methods would not be appropriate because the she wants a method that is very effective and requires little user effort.Female SterilizationRole Play Scenario 3—Client is interested in but not eligible for female sterilization Female Sterilization Scenario 3—Client Information SheetFemale Sterilization Scenario 3—Observer Information Sheet Client Description You are a 20-year-old woman who is unmarried and has never been pregnant. You are a full-time student and are excited about additional schooling and your eventual work. You are not in a relationship but have had casual boyfriends in the past. You are not sure if you ever want to get married, and do not think you want to have children. Your friend recently got pregnant and had to leave school, and you are very worried this could happen to you. You’ve heard about female sterilization from a family planning brochure and come to the family planning clinic to find out more.Offer this information only when the provider asks relevant questions:You are in school and do not think you ever want children because they will disrupt your school and planned career.You do sometimes have sexual intercourse with casual boyfriends and are very concerned that you could accidentally get pregnant like your friend recently did.You haven’t talked to your friends or family about your concerns or not wanting children. You are not currently using any form of family planning.You feel healthy and have no health problems.Make note of whether the provider performs these case-specific tasks:Asks about the client’s reproductive health goals, fertility intentions, and life plansEnsures the client understands other contraceptive options she can use, which are described in the FP brochure.Ensures that the client understands possible side effects and complications, including the risk of regret should she decide she wants children in the futureScreen client for medical eligibility using the checklistHelps the client assess her risks of contracting STIs, including HIV and reviews the benefits of using condoms (dual protection) to prevent HIV/STIsMethods for which the client is eligible:COCsDMPA or NET-ENImplantsIUDMale or female condoms Female SterilizationRole Play Scenario 4—Managing Complications of Female SterilizationFemale Sterilization Scenario 4—Client Information SheetFemale Sterilization Scenario 4—Observer Information SheetClient Description You are a 41-year-old woman with three teenage boys and a two-year-old girl (who was a surprise baby following the removal of an IUD). You and your husband have been using condoms every time you had sex, but you didn’t feel they are reliable enough and you do not want more children so you had a mini-laparotomy to perform female sterilization last week. Yesterday you noticed that your incision was red and very sore, and today you can see pus draining from it and you have a high fever. Offer this information only when the provider asks relevant questions:You had a mini-laparotomy procedure 5 days ago.She has been taking baths every day since the day after the procedure.You don’t have a thermometer, but you feel achy and chilled and your body feels very warm, so you think you have fever.Your incision looks red and is has foul smelling discharge.You are otherwise healthy and do not have any health problems.Make note of whether the provider performs these case-specific tasks:Reassess the client’s reproductive health goals, fertility intentions, and life plansFinds out more about the client’s complaints and then reassure the clientEvaluates the client’s general condition, including the condition of the surgical wound, to confirm extent of the wound infectionExplains the findings to the client, the possible cause(s) of the infection, and the recommended treatmentReviews possible complications of female sterilization and reassures the clientCounsels and provides treatment for wound infectionReviews post-procedure instructions with the clientAppendix B: Illustrative Competency-Based Skills Checklist*Note: This illustrative competency based checklist or observation checklist is from the module on Female SterilizationObservation Checklist for the Suprapubic Minilaparotomy ProcedureThis checklist is to be used for assessing providers’ competency at the end of the model and clinical practice during the minilaparotomy skills training. It includes only the critical tasks and steps of the procedure that all team members need to implement in a harmonized manner or simultaneously for proper procedure performance. Each team member observed must perform all of her/his steps correctly and in the proper sequence to be considered compliant to the standard steps of suprapubic minilaparotomy. The scoring for the provider should be recorded in one of the last four columns bearing the abbreviation for that provider’s role during the procedure—S for surgeon, SA for surgical assistant, M for client monitor, and CN for circulating nurse.This form will be used to record one observation per service provider.Use the following rating scale:2Competently performed: Step performed correctly in proper sequence 1 Needs improvement: Step performed correctly but out of sequence 0 Not done or done incorrectly: Step omitted or not performed correctly Training event date Assessor’s name:Participant’s name:Participant’s role:11334752108200072072547625002719070527050040386004318000Surgeon Surgical assistant Client monitor Circulating nurse OBSERVATION CHECKLIST FOR SUPRAPUBIC MINILAPAROTOMYTASK/STEPPREPROCEDURE ASSESSMENT STEPS—PREPROCEDURE ROOMSSAMCNReviews the information in the client’s record with her, and reviews her reproductive health and pertinent general medical history; verifies the absence of pregnancy and infection by history; reviews the physical examination and pelvic assessment in her record.Ensures that the client has been appropriately counseled for minilaparotomy; verifies informed consent, and asks what questions she has about the procedure.Gives the client oral (PO) or rectal sedation and analgesia. (Note: If IV and/or IM drugs are selected, administration should be done in the operating room, just after the client is comfortable on the surgical table.)PREPROCEDURE STEPS—OPERATING ROOMSSAMCNCommunicate with the client, informing the client about what will be done to her before it happens and what she can expect to feel. Explain to the client what you are doing at each step; ask her to tell you if she experiences discomfort; remind her to take deep breaths and relax.Monitors the client’s vital signs at the beginning of the procedure, every 15 minutes during the procedure, and at the end.INSERTING THE UTERINE ELEVATORSSAMCNWashes hands thoroughly with soap and water and dries them with a clean, dry cloth, or air-dries them and performs the alcohol-based surgical handrub.Puts sterile gloves onto both hands.Cleans the cervix and the vagina with iodine solution two times, using two pieces of gauze.While applying gentle traction the tenaculum, passes the uterine elevator through the vagina and into the cervix up to the cervical guard, using the no-touch technique.Continues communicating with the client.PROCEDURE TASKSPREPARING THE ABDOMEN SSAMCNWashes hands with soap and water, dries them, and then applies alcohol-based handrub and gently rubs hands together until dry. Prepares the abdomen twice with iodine solution. Cleanses the skin, starting from the operative site and working outward in a circular motion. INFILTRATING WITH LOCAL ANESTHESIASSAMCNInfiltrates each layer of the abdominal wall (skin, subcutaneous tissue, fascia, and peritoneum). Prior to injecting, aspirates to ensure that the needle has not entered a blood vessel. Anesthetizes the full length of the incision site (3–5 cm). Waits two minutes for the anesthetic to take effect.ENTERING THE ABDOMENSSAMCNIncises the skin transversely 3– 5cm.Bluntly dissect the subcutaneous tissue with a hemostatic forceps.Expose the fascia using the two retractors, keeping the retractors horizontal throughout the opening of the abdominal wall.Extends the fascial opening on both sides so that it is slightly larger than or about the same length as the skin incision.Slightly elevates the peritoneum with a Kelly forceps and confirms that it is translucent, indicating that the abdominal viscera (omentum, bowel, or bladder) are not sticking to it. Elevates the peritoneum further with a second Kelly forceps and makes a small opening between the two forceps with scissors.Checks the underlying structures to ensure that bowel, omentum, or bladder were not entered or injured.Holds the retractors horizontally and simultaneous pulls them up.ACCESSING AND OCCLUDING THE TUBESSSAMCN Gently presses the handle of the uterine elevator slightly inward and downward, to bring the fundus of the uterus upward toward the incision site and closer to the abdominal wall.With the hand that is not holding the uterine elevator, gently slides the tubal hook around the uterine fundus to one side of the uterus toward the anterior wall and then pulls the tubal hook horizontally and out through the incision.Gently grasps the tube with Baby Babcock forceps and confirms that it is the tube by following the tube along its length and locating the fimbriated end.Holds the middle-third portion of the fallopian tube with the Babcock forceps and keeps it vertical.Gently pulling one segment of the tubal loop with a tissue forceps and using an absorbable suture (0 atraumatic catgut), passes the needle through an avascular segment of the mesosalpinx, makes a tie on one side of the tube with a square knot about 2 cm below the tip of the tubal loop, then places a second tie around the other side of the loop with a square knot.Cuts the upper portion of the loop above the ligature, leaving 0.5 cm tubal stump.Inspects the tubal stump prior to cutting the ligature, to be sure that there is no bleeding, then cuts the suture and gently returns the tube to the abdomen.CLOSING THE WALLSSAMCNCloses the fascia with number 0 absorbable suture, then the skin with absorbable or nonabsorbable suture.POSTOPERATIVE TASKSSSAMCNWashes hands thoroughly with soap and water and dries them with a clean, dry cloth or air-dries them and applies alcohol-based handrub.CLIENT RECOVERYSSAMCNAssesses the client, provides postprocedure instructions, and discharges her when she is fully awake, lucid and can stand and walk without support (usually after up to two hours of observation).TOTALComments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Observation Summary (Tick as appropriate): Model practice satisfactory Yes ___ No ___ NA ___Clinical practice satisfactoryYes ____ No ____Competent in minilaparotomy _____Not competent in minilaparotomy _____Action Plan (check all that apply) ____ Make phone call within the next month to provide guidance and assess initiation of services____ Schedule training follow-up visit in 3–6 months____ Could become competent with additional experience (more cases) supervised by a competent provider/trainer____ Other (specify)_____________________________________________________________________Assessor’s name and signatureDate:Source: EngenderHealth. 2016. Minilaparotomy curriculum. New York.Observation Checklist for the Subumbilical Minilaparotomy ProcedureThis checklist is to be used for assessing providers’ competency at the end of the minilaparotomy skills training. It includes only the critical tasks and steps of the procedure that all team members need to implement in a harmonized manner or simultaneously for proper procedure performance. Each team member observed must perform all of her/his steps correctly and in the proper sequence to be considered compliant to the standard steps of subumbilical minilaparotomy. The scoring for the provider should be recorded in one of the last four columns bearing the abbreviation for that provider’s role during the procedure—S for surgeon, SA for surgical assistant, M for client monitor, and CN for circulating nurse.This form will be used to record one observation per service provider.Use the following rating scale:3Competently performed: Step performed correctly in proper sequence 2 Needs improvement: Step performed correctly but out of sequence 1 Not done or done incorrectly: Step omitted or not performed correctly Training event date Assessor’s name:Trainee’s name:Trainee’s role:11906252108200039433504318000274764552705007207254762500Surgeon Surgical assistant Client monitor Circulating nurseOBSERVATION CHECKLIST FOR SUBUMBILICAL MINILAPAROTOMYTASK/STEPPREPROCEDURE ASSESSMENT STEPS—PREPROCEDURE ROOMSSAMCNReviews the information in the client’s record with her, and reviews her reproductive health and pertinent general medical history.Ensures that the client has been appropriately counseled for minilaparotomy; verifies informed consent, and asks what questions she has about the procedure. (Note: if it was not done on the same day by the same provider)Gives the client oral (PO) or rectal sedation and analgesia. PREPROCEDURE STEPS—OPERATING ROOMSSAMCNCommunicates with the client, informing the client about what will be done to her before it happens and what she can expect to feel. Explain to the client what you are doing at each step; ask her to tell you if she experiences discomfort; remind her to take deep breaths and relax. Gives the client IV sedation and/or mild systemic analgesia, if this is the regimen selected.Monitors the client’s vital signs at the beginning of the procedure, every 15 minutes during the procedure, and at the end.PROCEDURE TASKSPREPARING THE ABDOMEN SSAMCNWashes hand with soap and water, dries them with sterile towel or air-dries them, and performs the alcohol-based surgical handrub.Prepares the abdomen twice with iodine solution soaked on a swab. Cleans a wide area, starting from the operative site and working outward in a circular motion.INFILTRATING WITH LOCAL ANESTHESIASSAMCNInfiltrates each layer of the abdominal wall (skin, subcutaneous tissue, fascia, and peritoneum) 1–2 cm below the umbilicus. Anesthetizes the full length of the incision site (2–4 cm).Note: The amount of local anesthetic should not exceed the maximum safe dose—4.5 mg/kg, or 300 mg (30 ml of 1% lidocaine).Waits two minutes for the anesthetic to take effect.ENTERING THE ABDOMENSSAMCNIncises the skin 1–2 cm below the umbilicus transversely. Using a hemostatic forceps, dissect the subcutaneous tissue gentlyExtends the fascial opening on both sides so that it is slightly larger than or about the same length as the skin incision. Elevates the peritoneum with artery forceps and makes a small opening in it with scissors, and checks the underlying structures to ensure that bowel, omentum, or bladder were not entered or injuredACCESSING AND OCCLUDING THE TUBESPushes the uterus toward the opposite side of the tube being accessed to appear below the incision, or uses retractors to gently move the incision to be above the tube being accessed. Gently slides the tubal hook around the uterine fundus to one side of the uterus toward the anterior wall and then pulls the tubal hook horizontally and out through the incision.Gently grasps the tube with Baby Babcock forceps and confirms that it is the tube by following the tube along its length and locating the fimbriated end.Holds the Baby Babcock forceps in its middle-third position and keeps it vertical. Gently pulling one segment of the tubal loop and using absorbable suture (0 atraumatic catgut), passes the needle through an avascular segment of the mesosalpinx, makes a tie on one side of the tube with a square knot about 2 cm below the tip of the tubal loop, and then places a second tie around the other side of the loop with a square knot.Cuts the upper portion of the loop above the ligature, leaving 0.5 cm of the tubal stump.Inspects the tubal stump prior to cutting the ligature, to be sure that there is no bleeding, then cuts the suture and gently returns the tube to the abdomen.CLOSING THE ABDOMENCloses the fascia with number 0 absorbable suture, and then the skin with absorbable or nonabsorbable suture.POSTOPERATIVE TASKSSSAMCNWashes his/her hands thoroughly with soap and water and dries them with a clean, dry cloth, or air-dries them, and applies alcohol-based handrub.CLIENT RECOVERYSSAMCNAssesses the client, provides postprocedure instructions, and discharges her when she is fully awake, lucid and can stand and walk without support (usually after up to two hours of observation). Provides her with a sweetened drink.Provides postprocedure instructions Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Observation Summary: Model practice satisfactoryYes ____ No ____Clinical practice satisfactoryYes ____ No ____Competent in minilaparotomy _____Not yet competent in minilaparotomy _____Action Plan____ Make phone call within the next month to provide guidance and assess initiation of services____ Schedule training follow-up visit in 3–6 months____ Could become competent with additional experience (more cases) supervised by a competent provider/trainer____ Other (specify)_____________________________________________________________________________Assessor’s nameAssessor’s signatureDateAppendix C: Answer Key for Female Sterilization Case Studies (Medical Eligibility Criteria and Post-Operative)Postoperative Care Case Studies Answer KeyCASE 1Alice is 37 years old (para 5+0); her last delivery was three years ago. She is married and has been using the IUD since her last delivery. She is currently menstruating and complains of some lower abdominal discomfort and heavy bleeding. She is a known hypertensive patient who is being followed up at the district hospital. However, she has not returned for follow-up at the district hospital for the past year; she gives several reasons for her nonattendance. She continues to take medication for hypertension. She is interested in female sterilization. Her spouse is in agreement with the decision to use a permanent family planning method. Her blood pressure at the time of the visit to the family planning clinic was 160/130 mmhg.Possible Answers:Category: Client can be classified as MEC category D, or DelayReasons:Client has severe hypertension, which must be controlled before she is ready for the minilaparotomy procedure. The hypertension needs urgent attention.If further review and investigations confirm other major complications related to hypertensive disease (renal, vascular, cardiac, stroke, etc.), then the client will require special attention.Management:The provider should take a complete history, do a physical examination, and, if applicable, refer the client for effective management of her hypertension.If bleeding is confirmed to be heavy (from history and physical examination), request a hemoglobin test. The client may require treatment for the bleeding and for lower abdominal pain, if severe. Counsel the client to continue to use the IUD while her blood pressure is being controlled. Providers should also give information on other contraceptive methods, such as vasectomy, as part of the method mix. Review the client’s condition after a period of one week, and if the blood pressure is controlled, book her for the minilaparotomy procedure. On the day of the surgery, the client should be advised to take her medication for hypertension. Other preparation is similar to that for all other clients.CASE 2Happyness is 28 years old (para 4+0). Her last delivery was four months ago. All of her deliveries were by cesarean section. She has not had her period and is currently breastfeeding. Her older children are doing well. The couple have discussed and made a decision that they want female sterilization. Upon her discharge from the postnatal ward, she was advised to visit the family planning clinic. At the clinic, the couple were referred directly to the minilaparotomy theater for counseling and the procedure.Possible Answers:Category:The client can be classified as category S, Reasons:Client has no medical condition except for the history of several previous abdominal surgeries. She has had four previous caesarean sections, and all seem to have been uncomplicated.Management:At the family planning clinic, the client should booked for surgery as an interval procedure. The procedure should be done at a facility with capability of performing a laparotomy under general anesthesia. Past medical history should include an inquiry about the outcome of all four cesarean sections. During the assessment in the clinic, the provider should ascertain that the client is not pregnant, since she is not using any modern contraceptive method except for the lactational amenorrhea method. If the provider is sure that the client is not pregnant, then she should be booked for surgery. The provider must also perform a physical examination, including a pelvic examination.The client should receive instructions on how to prepare for surgery. She should receive counseling on the procedure and on the possibility of needing general anesthesia. On the day of the surgery, she should come with someone to take care of the baby and also to escort her home. Instructions should include when she can stop taking meals and drinks orally, what to wear, and how to prepare the operation site. Note: A history of multiple abdominal surgeries is an indication for laparotomy under general anesthesia. (Other conditions that warrant use of general anesthesia include obesity and extreme nervousness or anxiety.)CASE 3Cynthia is 35 years old (para 3+0); her last delivery was four years ago, and she is using Depo-provera for family planning. She has not had her menses for the last six months. Her last injection was given three months ago, and she is currently due for another injection. However, last week, when she went for the injection at the family planning clinic, she also complained of excessive thirst, frequency in urination, and generalized weakness. She was diagnosed as having diabetes mellitus and was referred for review by the medical doctor at the hospital. The doctor reviewed her case and prescribed some medications that were not in stock at the hospital. She has purchased the drugs from a private pharmacy. Cynthia was also informed that her blood pressure was moderately high and that the prescribed medication would also control her blood pressure. She is currently visiting her husband at his workplace. She has decided to visit the family planning clinic at the regional referral hospital for a tubal occlusion and also visit the medical clinic for a check-up (or a second medical/specialist opinion). She has told the family planning clinic staff that she wants the tubal occlusion before she visits the medical clinic. Her blood pressure is 130/90 mmHg. A random blood sugar evaluation has not been done.Possible Answers:Category:Category C—that is, the provider must exercise some level of caution by taking necessary precautionsReasons:Client is a newly diagnosed diabetic and is on medication. She also has mild hypertension.Management:The family planning provider should take a good history and perform a physical examination. This will provide information on whether the client has been investigated and confirm that her medical condition is uncomplicated diabetes mellitus and mild hypertension. The surgical team should verify the medication that the client is on, so that they can review the pain management regimen, if needed, etc. The client should be requested to have a random blood sugar analysis. She can then be booked for an interval minilaparotomy procedure once the diabetes is well-controlled. The client should also be counseled on the procedure and possible complications associated with the procedure, particularly if her blood sugar is not well-controlled. She should receive instructions on how to prepare for the surgery. On the day of the surgery, the surgical team should again assess the client’s condition, including blood pressure monitoring and blood sugar levels. In the postoperative period, instead of giving her a sweetened drink, other alternatives with a lower glycemic index should be provided.CASE 4Gift is 28 years old (para 3+0); her last delivery was six years ago. Her last menstrual period was seven days ago. (Her periods normally last for three days, are regular, and are not heavy, with no pains.) Four weeks ago, she attended a mobile outreach camp on family planning and other services, where she opted for female sterilization after counseling. She had the procedure performed, but by the end of the procedure, she was informed by the surgical team that they could not access one of her tubes. She was therefore referred to the hospital for management. Postoperatively, she has had no problems. She is not using any family planning method currently. She has no other health-related complaints and wants the other tube occluded as advised.On examination, she is judged to be obese (weight 80 kg, height 150 cm); her blood pressure and other vital signs reveal no anomalies.Possible Answers:Category:Category C—the provider needs to take some precautions, as the client recently had abdominal surgery. Reasons:The client has just had abdominal surgery, which was not successfully completed for some reasons not mentioned in the case study.There is a possibility that the procedure would have to be abandoned due to inadequate pain management, low level of experience of the surgical team, a tube that has been damaged by pelvic inflammatory disease and is adhering to the pouch of Douglas, etc.Management:The provider needs to take a good history and physical examination and if possible try and get more information from the outreach team that performed the procedure. This kind of information is ideally also likely to be on the referral note. The provider should examine the scar to confirm that it has healed well. The provider should also ascertain that the client is not in the luteal phase of the menstrual cycle, and if she has had unprotected sex during this period, that she has not conceived. If it is confirmed that she has not conceived, the client should be booked for the procedure and if necessary counseled and offered a temporary method during waiting period before surgery. The procedure should be planned for when the client is in the proliferative phase of her menstrual cycle. During counseling, the client should be informed of the possibility of using general anesthesia. The procedure should be done at a facility where it is possible to monitor clients under general anesthesia. Client should be given instructions on how to prepare herself for surgery.CASE 5Salma is 39 years old (para 4 +0). Her last delivery was two years ago. All of her children are doing well. She is currently menstruating. The couple have been using male condoms. They have made a decision to have female sterilization. Salma does not have any other medical problem, apart from what she refers to as being overweight. Her main purpose for coming to the mobile outreach camp was to seek tubal occlusion as a method of family planning. On examination, she is judged to be obese (weight 80 kg, height 150 cm); her blood pressure and other vital signs reveal no anomalies.Possible Answers:Category:The client can be classified as category C—that is, the procedure can be done, but there is need to take some precautions.Reasons:From the history, the client is obese. Obesity is one of the indications for using general or regional anesthesia for pain management. Management:The provider should take the client’s history and perform a physical examination. The client should be informed that because of her condition, the procedure should be performed at a facility where a higher level of care, particularly for pain management, can be delivered safely. If she cannot have the procedure soon, then she should be advised to use temporary methods as she waits for the procedure. At the facility where the procedure is to be performed under general anesthesia, the client should be assessed and prepared for surgery. After the procedure but before discharge, the client should be referred to the nutritionist or related departments for the obesity.CASE 6Sita is 25 years old (para 2+1). Her last delivery was three years ago. She is currently on highly active antiretroviral therapy and antituberculosis treatment. She is married, and her husband is also HIV-positive. They are currently using the male condom. Her last menses was two months ago; it has been irregular. The couple have decided that they need an effective and permanent method of family planning. On her last visit to the medical clinic, she asked the clinic staff to assist her in obtaining the family planning method of her choice, which is female sterilization. She has been referred to the minilaparotomy theater for the procedure.Possible Answers:Category:The client can be classified as MEC category S, that the condition requires special attention. Reasons:It is not clear whether the client is only under treatment for pulmonary tuberculosis or has other complications related to tuberculosis. Extrapulmonary tuberculosis is likely to require special attention.Management:The provider should take a good history and conduct a physical examination to determine the general condition of the client and refer her to a facility with a specialist and equipment to undertake further evaluation and that can provide specialized care, if needed, during and after the procedure. The couple should also be informed of the availability of vasectomy as an alternative if the capacity to perform the procedure is within the facility. In view of the stressful situation, the couple should be well counseled and given time, to avoid the possibility of subsequent regret.During the waiting period, the client should be on a temporary method. Postoperative Care Case Studies Answer KeyCase 1What is your impression and what will you do for this client?Take a good history about the presenting problem on examination of the abdomen confirm your diagnosis. Most probably a normal postoperative period with loose protruding stitch, counsel client and prepare to remove stitch if it non-absorbable suture. Assess level of satisfaction with the method of choice. Remind client to visit the facility if she experiences any other problem or misses her mensesCase 2What will you do for her at this visit?Take a good history; exploring with client for signs of complications, self-care, rest, and infant care activities. Perform complete physical examination including pelvic; check incision. Encourage client to rest, counsel based to findings from the client’s history. Counsel re HIV/STI prevention. Remind client to report to the facility if she experiences missed menses or menstrual irregularities, abdominal or pelvic pain. Case 3What is your impression, and as a non-medical staff member, how will you manage this case?The client is likely to have a wound infection. Counsel client and treat infection by cleaning and dressing the wound or contact the surgeon or physician/clinical officer available to treat the infection and give the client instructions for self-care.For prevention, ensure that infection prevention practices are adhered to during minilaparotomy. Case 4What is your impression, and how will you, as a non-medical staff member, manage this case?It is highly likely that the client has internal hemorrhage. Contact the surgeon or physician/clinical officer immediately, to manage the condition. That should include hospitalization for further examination and treatment. ................
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