for training yashoda/mamta · 2020-02-05 · 6 introduction to yashoda/mamta rationale: the sudden...

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National Institute of Health and Family Welfare

Trained Nurses Association of India (TNAI)

National Neonatology Forum

Norway India Partnership Initiative (NIPI)

Facilitator’s Guide for training

Yashoda/Mamta

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National Child Health Resource Center, 1 st Floor, National Documentation Center, National Institute of Health and Family Welfare, Baba Gang Nath Marg, Munirka, New Delhi – 110067, India E. mail:

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Foreword

The Norway India Partnership Initiative (NIPI) is a unique support embedded within NRHM processes. The programmes provide strategic, flexible, catalytic, and innovative support to the NIPI focus states of Orissa, Madhya Pradesh, Rajasthan, Bihar and Uttar Pradesh to improve the child health and related maternal health service delivery. As part of the enabling strategy that can maximize the success of Janani Suraksha Yojana (JSY) under NRHM, NIPI has identified an innovative method to improve the quality of care for the newborn and the mother at the facility. “Yashoda/Mamta”, non-medical, voluntary support worker, has been placed at hospitals with high delivery load. Her role is to create a congenial environment for the mother and the newborn in the facility and to counsel the mother about good newborn care practices at home. However, Yashoda/Mamta will be able to effectively execute their responsibilities once they undergo good quality, standardized training. This Guide is meant for trainers to take Yahsoda/Mamta through orientation training with ease, in a participatory, interactive environment. The book also contains information for trainers after each chapter in the form of ‘notes for the trainer’. I hope that this guide will be useful for the trainers. It can also be used by the Yashoda/Mamta mentors for reference while they hand-hold Yashoda/Mamta during her work. Director, NIPI

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Preface

I am happy to bring out this publication through the National Child Health Resource Center (NCHRC). The center was established at National Institute of Health and Family Welfare (NIHFW), New Delhi in the year 2008 with the support of Norway India Partnership Initiative (NIPI).

Norway-India Partnership Initiative (NIPI) is a commitment of Government of India and Government of Norway to collaborate towards achieving the MDG 4 (Reduce by two-third the mortality rate among children under five years). NIPI is being implemented as an integral part of the National Rural Health Mission (NRHM), providing an up-front, strategic, innovative and flexible support to accelerate the efforts of the mission in four NIPI focus states namely Madhya Pradesh, Rajasthan, Bihar and Orissa.

The National Child Health Resource Center (NCHRC) aims to strengthen the focus on child health and mainstreaming the agenda in public health through collating, developing, analyzing and disseminating relevant information and creating a platform for discussion and discourse at national and state level. The Center is functioning with the support of Technical Advisory Group (TAG), which is a group of professionals from premier institutions/ agencies working on child health issues and overall leadership of NIHFW.

“Facilitator’s Guide for Training Yashoda/ Mamta” is intended for the use of trainers involved in the training of Yashoda who is a non-medical, volunteer worker placed at District Hospitals and community health centers to create congenial environment for the mother and newborn baby and help them to understand basic newborn care after leaving the facility. This document is a comprehensive guide that provides interactive guidelines for use by the trainers and can be used as a reference book by the facilitator and ‘Yashoda’. The book provides detailed guidelines which may be modified to suit local needs. Each session in this document presents the topic, describes the session objectives and the learner’s objectives; time, materials, method, steps and the trainer’s notes.

Lastly, we gratefully acknowledge the input, critique and suggestions provided by ‘Trained Nurses Association of India’ (TNAI) and ‘NIPI Secretariat’ in developing this publication.

Prof. Deoki Nandan Director, NIHFW

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Contents

Introduction to Yashoda/Mamta Training…………………………………1 Introduction to Yashoda/Mamta Facilitator’s Guide………………………3 Goal of the training…………………………………………………………5 Settings and Logistics for Training…………………………………………..6 Sessions & Sessions Plan: Day 1

1. Introductory Session………………………………………………….7 2. Review the Purpose of the Training…………………………………..8 3. Status of Maternal and Infant Health and Role of Yashoda ………….13 4. Housekeeping of maternity, post natal ward and labor room……….18 5. Care of the mother before, during and after delivery…………………22 6. Preparations for welcoming the baby…………………………………27 7. Early Initiation of Breast Feeding…………………………………….31 8. Proper positioning while Breast Feeding …………………………….35 9. Exclusive Breast Feeding for six months and Complementary feeding..38 10. Breast Feeding – some common problems…………………………..42

Day 2 11. Keeping the newborn warm………………………………………..45 12. Bathing the newborn………………………………………………48 13. Care of the low birth weight baby…………………………………51 14. Danger signs in newborns…………………………………………55 15. Danger signs in mother……………………………………………59 16. Clean practices to Prevent Infections………………………………63

Day 3 17. Diet of a lactating mother………………………………………………48 18. Immunization……………………………………………………………72 19. Family Planning methods……………………………………………...76 20. People available in the community to help mother………………….81 21. Birth Registration & Record Keeping…………………………………85 22. Principles of Counselling/Interpersonal Communication…………..93

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Introduction to Yashoda/Mamta Rationale: The sudden influx of beneficiaries in public health institutions due to JSY has added to the challenge to provide quality maternal and neonate health care. However, it provides a window of opportunities to improve the RCH services at the facilities. Surveys on JSY show that many of the women stay in the institution for less than 24 hours after delivery, regardless of a normal delivery or a difficult delivery. UNFPA’s and GTZ’s evaluation of JSY in 2007 raised several issues about its benefits and processes for the women. These include: the duration of stay at the facility, the quality of services, the facilities available at the hospital, the safety of mother & child, and the availability of counseling on follow up visit, breastfeeding, immunization, family planning, newborn care and diarrhoea management, etc. The first 24-48 hours after delivery offer a golden opportunity for integrating neonatal care with postpartum care. Many of the conditions responsible for the mother and/or neonate’s death are recognizable in the first 48-72 hours after delivery. This includes: hemorrhage, sepsis, eclampsia (responsible for more than half of the maternal deaths), birth asphyxia, sepsis, hypothermia, and low birth weight/ pre-maturity (responsible for more than 2/3rd of neonatal deaths). Therefore the government of India norms require that mothers stay in the hospital with the newborn for 24-48 hours after delivery. Can a person from the existing facility be found? To make the pregnant women feel welcome at the facility, to make her feel comfortable after delivery, to initiate exclusive and immediate breast feeding, to counsel the mother on basic newborn care, and to motivate the mother to stay at the facility for a longer duration? The hospitals, with increasing volumes of deliveries per day, have not been able to use this opportunity fully due to a shortage of nurses and a poorly managed logistics system. ‘Yashoda’, a dedicated non-clinical support worker, apart from helping motivate mothers to stay for a longer duration, would also assist the nurses with initial care for the mother and the newborn soon after the delivery. Why Yashoda/Mamta, and why not ASHA? It has been observed that in almost 30-40 % of cases, ASHAs do not accompany the pregnant women to the hospital. Even those who accompany do have other responsibilities under NRHM and cannot be away from the community for over 24 hours. If we assume that ASHAs accompany pregnant women to a District hospital where 20-30 deliveries take place a day, in the course of two days, there will be 40-60 ASHAs at the hospital. There is no arrangement for their stay, food,

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or security. These additional people in an already stretched infrastructure can create chaos. The NIPI focus states have engaged ‘Yashoda’ (in all states except Bihar where the same worker is called ’Mamta’) at the facility level for facilitating the initial care that the newborn and the mother require during their stay at the facility, there by addressing the above gaps to some extent.

• Yashoda is not a regular employee of the health system at present. This innovation aims at introduction of a volunteer support worker paid a performance linked incentive, who acts as a catalyst and supports the nursing staff.

• She is not a substitute for the nursing staff or paramedical staff available at the facility. However, with appropriate support and capacity building, it is expected that competent Yashodas/Mamta could be used in future as ‘Newborn Nursing-Aide’ to work in the Sick Newborn Care Units coming up in the District Hospitals and Stabilization Units in the Block hospitals.

Responsibilities of Yashoda/Mamta • Make a congenial environment • Support to nurse in the labour room • Maintaining cleanliness • Assist the nurse in post delivery care • Counsel the mothers and family on basic care of mother and newborn • Information on immunization • Inform about mother care after leaving hospital • Assist mother in understanding the contraceptive options • Provide information on locally available support • Maintenance of daily record register

(The responsibilities are explained in more detail in the document ‘Role of Yashoda/Mamta’)

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Introduction to Yashoda/Mamta Training Training process:

The training will be done in three phases -

Training of trainers:

A one day workshop will be held for the trainers on the day prior to the scheduled

induction training of Yashoda/Mamta. During the workshop, the trainers will be

familiarized with the training course. They will be familiarized with the Yashoda

training kit and how to use the flip chart and handouts. They will also go through

this guide book.

Phase I – Induction training

The induction training will be conducted over 3 days in hospital premises. It s

expected that this 3 day module will set a sound theoretical backing for the

practical skills development of Yashoda. It is also expected that this module

will bring in enhancement of knowledge and an attitude towards good health

practices among Yashoda. It will bring in clarity and ability to focus on key

issues related to child health

Phase II – Hands - on training

The month following the induction training will be the period of hands - on

training wherein the focus will be on enhancement of skills. During this

training, the Yashoda will learn though demonstration and practice while at

work

Phase III - Refresher trainings

Series of two day refresher training sessions will be conducted every 3 months

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Profile of trainers:

The trainers can be ANM, teacher from ANM training school, Nurse, Doctor,

experienced Yashoda or any other medical, paramedical or experienced health

worker.

Profile of trainee:

The trainee ‘Yashoda’ (a foster mother in Indian mythology) is a dedicated non-

clinical support worker, who can help in all the care for the mother and new born.

She is a support worker who is paid a performance linked incentive, acts as a

companion of the mother, supports the nursing staff and acts as a link between

both.

The trainee is a local woman in the age group of 25-50 years. She is at least 8th

pass and may or may not have any working experience. She may or may not

have any health experience. She is a voluntary worker who gets a performance

based incentive and is not a paid employee.

The trainee will work only in the hospital setting for new born and maternal care.

Her main role is providing friendly support, comfort and counseling to mother and

her family and giving dedicated attention to the newborn. She is required to

assist the family in registering the mother as a JSY beneficiary and for registering

the birth of the baby.

She does not have any technical know how to provide any medical or nursing

care to the beneficiaries and is not expected to provide medical or nursing care.

Yashoda will be given appropriate logistics and administrative support, mentoring

and supportive supervision by the Child Health Supervisor (CHS) and Deputy

Child Health Supervisor (DCHS) along with the nursing staff located at the

hospital to fulfil the above tasks.

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Introduction to Yashoda/Mamta Facilitator’s Guide

This book is intended for the use of trainers involved in the training of Yashoda.

This is a comprehensive guide that provides interactive guidelines for use by the

trainers & also provides the trainers with back ground technical information that is

to be imparted to the trainees. This book can be used as a reference book by the

facilitator and Yashoda.

The book provides detailed guidelines but these guidelines are not rigid.

Guidelines may be modified to suit local needs. District, village data needs to be

used during the sessions to make the training more suitable for local needs.

The module is distributed into 22 sessions. Each session mentions the topic,

describes the session objectives and the learner’s objectives, time, materials,

method, steps and the trainer’s notes.

The guide takes the trainees through a journey in the hospital from the time a

mother-to-be enters the hospital, till the time she leaves with her new born.

Through this journey, the trainee needs to understand very clearly her role and

responsibilities and how to perform them.

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Remember some Adult learning principles

The trainees are adult women and the method of learning among adults differs

greatly from children. While teaching adults, the following principles of adult

learning have to be kept in mind:

1. Focus on “real world” problems.

2. Emphasize how the learning can be applied.

3. Relate the materials to the learners’ past experiences.

4. Allow debate and challenge of ideas.

5. Listen to and respect the opinions of learners.

6. Encourage learners to be resources to you and to each other.

7. Treat learners like adults.

8. Give learners “control

9. Provide a safe atmosphere (a cheerful, relaxed person learns more

easily than one who is fearful, embarrassed, or angry)

10. Make a comfortable environment (a person who is hungry, tired, cold,

ill, or otherwise physically uncomfortable cannot learn with maximum

effectiveness)

11. This training must not be just a lecturing exercise but rather should be

highly interactive and practical hands on training.

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Training Goal

To provide good quality standardized training to Yashoda/Mamta for

better care and support to newborns and new mothers as an

intervention for Child care and a contribution to achieve MDG 4

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Setting and logistics for training Institutional arrangements for the Induction training:

The setting of the induction training is the district hospital. A classroom in the

hospital premises that can accommodate about 20 trainees and 3 facilitators will

be used. The maternity ward, post natal ward and labor room of the hospital will

be utilized as training and demonstration rooms for the trainees.

Time schedule: The training will be held from 9 AM to 5 PM or till the defined

agenda for the day is completed on all three days

Checklist of supplies for each trainee

1) YASHODA TRAINING KIT - Flip chart for Yashoda, handouts for Yashoda,

note pad, pencil, pen, and eraser 2) Facilitator’s guide,

Checklist of supplies for the trainer

Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda, Note pad,

pencil, pen, eraser, felt pens in two colors, chalk, white board, duster, wipe,

Access to and LCD (preferred) or an OHP & a CD player.

Other material required for the training

As per session requirements

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Session 1:

Title: Introductory session

Session objectives: To introduce the trainers and trainees to each other

Learners Objectives: After this session, the trainees will be able to:

• Be familiar with the names and professional backgrounds of each other

• Be familiar with the names and professional background of the trainers

Time: 15 minutes

Materials: Blackboard, Chalk, Chart Paper, Pens Setting: Classroom

Method: Discussion

Steps:

1. Ask the trainees to sit in rows facing you. The trainers should be in front of

the group, facing the trainees. Each trainer should introduce

himself/herself and should give a brief background of his/her experience in

new born and maternal care.

2. Ask the trainees to introduce themselves to the trainers and to each other

and give a brief description of their work experience (if they have any).

3. After the last trainee finishes the introduction, thank the trainees and move

on to the next session.

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Session 2:

Title: Reviewing the purpose of this training

Session objectives:

• Familiarize the trainees with the purpose & objectives of this training

• Familiarize the trainees with the objectives of this training and seek their

feedback about the objectives

• Amend the objectives based on their feedback (if required)

• Familiarize the trainees with the methods used in this training

• Orient the trainees towards a participatory method of training

Learner’s Objectives:

After this session, the trainees should be able to:

1. Define the objectives of this training

2. Be satisfied that objectives suggested by them have been incorporated in

the training objectives

3. Be clear about the flow & methods that will be used during this training

4. Engage fully with the trainer and other participants without any hesitation

5. Understand the role of the facilitator

6. Use the flip chart and handout as reference material

Time: 15 minutes

Setting: Classroom

Materials: Black board or chart with objectives of the training program written

therein, trainee’s kit (folder containing Flip chart for Yashoda, Handouts for

Yashoda, a note pad, pencil, pen, eraser)

Method: Discussion

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Special preparation: Chart paper or black board with purpose and objectives of

the training written clearly.

Steps:

1. Inform the participants about the purpose of this training

2. Use the chart (or black board) that enumerates the objectives of the

training to describe each objective.

3. Ask them if they have any other expectation that will not being fulfilled

through this training. If yes, record the comments with the trainees’ name.

If you feel that the comment is valid, amend any previously noted objective

or add the objective and thank the participant.

4. Explain the flow of the training and the methods that will be used

5. Explain that the training is expected to be fully participatory.

6. Now hand over the trainee’s kit to each participant. Explain to them that

this the flip chart and handouts are their main reference material and

should be consulted after each session.

7. Explain the use of the flip chart and handouts and the link between the two

8. They can use the note pad to write down any notes that they want.

9. Describe your role as facilitator.

Trainer’s Notes Q. What is the purpose of this training?

A. The purpose of this training is to create a cadre of dedicated hospital based

workers for maternal and newborn care and support.

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Q. What are the objectives of this training?

A. After this training the trainee should be able to:

1. Use the information regarding status of child health in the state and the reasons for

high infant and maternal mortality rate to understand the importance of her role.

2. Be comfortable with the hospital setting – labour room, maternity ward, post natal

ward, nursery (if required), records section, registration room, immunization room, birth

registration room, water supply and other facilities in the hospital.

3. Enumerate her responsibilities as ‘house keeper’ in the labour room and wards that will

be used by the mother and new born.

4. Demonstrate the activities required to provide care to the mother before, during and

after delivery

5. Demonstrate the preparations needed for the birth of a newborn

6. Demonstrate how to keep the newborn warm

7. Demonstrate how to initiate early breast feeding

8. Counsel the mother what is exclusive breast feeding and how to continue it in sickness

and health

9. Counsel the mother what is complementary feeding and what are the food the baby

should be given

10. Identify common problems with breast feeding and provide support and advice to the

mother regarding these

11. Identify danger signs in mother and newborn and know when and who to refer to

12. Develop good counseling skills

13. Be familiar with the process of registering birth

14. Demonstrate how to maintain her records

15. Counsel the mother and family about the health facilities available in the community

16. Counsel the mother about the appropriate family planning method for her and refer her

to the right place to get it.

17. Use the communication tools provided – flip chart, background information sheets

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Q. How the training will flow and what will be the methods used? A. The training will be mostly hospital based, practical learning and not

theoretical. However, the trainees must be clear about the basic theoretical

concepts behind all the activities they are expected to carry out. The training is

designed to be a journey through the activities Yashoda has to carry out as a

mother enters the hospital and leaves with her newborn.

The training course is simple and task oriented. There will be

background theory sessions to enhance knowledge followed by hospital ward

sessions for skill building/upgradation. Theory sessions will not be lectures,

these will be fully participatory during which the trainees will discuss a given

issue and the trainer will only guide the discussion and sum up the key

messages. There will be several interesting tasks/exercises to keep all

participants involved. Additional tasks may be designed by trainer if the need

is felt.

Q. What is meant by participatory training? A. It is vital for the trainees to understand that they must fully participate in the

process of the training. This can be done by raising questions, narrating their

experiences, presenting their practical problems for discussion with others,

story telling etc. Explain to trainees that their questions will be greatly

appreciated. They must avail this opportunity to remove all doubts they may

have regarding child health issues and must familiarize themselves with the

role they will have to perform as Yashoda.

Q. What is the purpose of the flip chart & handouts? A. The flip chart is provided to Yashoda as a tool for communicating good

health practices to the mothers and the family. It is also to be used as her core

reference material. The flip chart has two parts. The front of the page has

pictures. These pictures display key messages to be communicated to the

mother and family by Yashoda. The back of the page is for her reference. The

handouts provide more details about each issue covered through the flip chart.

These are provided to the Yashoda to upgrade her knowledge so that she is

better informed and can refer to these whenever she needs.

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Key messages Ø The training is designed as a journey of Yashoda with the mother

and newborn as the mother’s friend and support Ø During this training, most of the time will be spent in the hospital. Ø The trainer will be a facilitator and not a lecturer

Q. Who is a training facilitator? A. Training facilitators are usually subject experts & provide training using the

principles of adult education: establish existing knowledge, build on it and

keep it relevant. The role is different from the formal trainer who will take a

more leading role and take the group through an agenda designed to transmit

a body of knowledge.

The basic skills of a facilitator are about following good meeting

practices: timekeeping, following an agreed-upon agenda, and keeping a clear

record. The higher-order skills involve watching the group and its individuals in

light of group dynamics. In addition, facilitators also need a variety of listening

skills including ability to paraphrase; stack a conversation; draw people out;

balance participation; and make space for more reticent group members. It is

critical to the facilitator's role to have the knowledge and skill to be able to

intervene in a way that adds to the group's creativity rather than taking away

from it.

A successful facilitator embodies respect for others and a watchful

awareness of the differences in the attitude and reactions of different persons.

In the event that a consensus cannot be reached then the facilitator would

assist the group in understanding the differences that divide it. Remember that

your role is that of a facilitator and not a lecturer. It is expected that the

participants will talk most of the time and the trainer will be there only to guide

the discussion if required.

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Session 3

Title: Status of maternal and infant health in the state and district & role of

Yashoda

Session objectives:

The trainees should be able to use the information being provided to

understand the rationale for contracting them. They should also be introduced

to the activities they will perform in the ward as dedicated support and care

workers for mother and newborn.

Learners Objectives:


1. Use the information provided on maternal & infant health to explain the

rationale for contracting Yashoda into the system

2. Enumerate the common reasons for maternal

3. Enumerate the common reasons for newborn mortality

4. Enumerate her responsibilities in the hospital

Time: 45 minutes

Training Materials: Facilitator’s guide, Yashoda training kit, black board & chalk

or white board & felt pens in two colors, duster, wipe, access to and LCD

(preferred) or an OHP

Setting: Classroom

Method: Discussion

Steps:

1. Ask a trainee why she chose to become a Yashoda

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2. It is likely that she will talk about maternal and child health.

3. If not, ask another trainee the same question till the topic of maternal &

child health is introduced.

4. Write the proportion of pregnant women & children below 1 year in their

state and district on the board.

5. Write the infant mortality rate and maternal mortality rate in the state on

the board.

6. Ask the participants, what could be the common reasons for high maternal

& infant deaths in their state and district.

7. Note the given reasons on the board.

8. If any reason is missed out, add it.

9. Recap the written reasons.

10. Inform them that most deaths occur in the first 7 days of life and mention

the common reasons of the same

11. State the common reasons for maternal deaths especially in the first 6

weeks after birth.

12. Stress that proper care in the hospital immediately after birth will help

prevent many maternal and newborn problems.

13. Enumerate the various other responsibilities of Yashoda

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Trainer’s notes: Q. Who is Yashoda and what is the rationale behind introduction of Yashoda? A. The birth of a baby is a glorious event in the life of the baby and the

parents. However, pregnancy and the process of birth is a very difficult

process for both the mother and the baby. They need special care before,

during and after the event of birth.

The first 24-48 hours after delivery offer a golden opportunity for

proving care, support and counseling to the mother and her family. Many of

the conditions responsible for the mother and/or neonate’s death are

recognizable in the first 48-72 hours after delivery. This includes: hemorrhage,

sepsis, eclampsia (responsible for more than half of the maternal deaths), birth

asphyxia, sepsis, hypothermia, and low birth weight/ pre-maturity (responsible

for more than 2/3rd of neonatal deaths). Therefore the governments of India

norms require that mothers stay in the hospital with the newborn for 24-48

hours after delivery.

However, we know that in the hospital, all hospital staff is very busy.

The ASHA may get the mother to the hospital, but she may not be able to stay

there with the mother. So, Yashodas have been provided to busy hospitals so

that the new mother feels safe & comfortable & danger signs in newborn and

mother are brought to the notice of the doctor early and treated.

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‘Yashoda’ is a dedicated non-clinical support worker, who can help in all the

care for the mother and new born. She is a support worker who is paid a

performance linked incentive, acts as a companion of the mother, supports the

nursing staff and acts as a link between both.

Yashoda is not a regular employee of the health system at present. She is not

a substitute for the nursing staff or paramedical staff available at the facility.

Q. What is the Status of Child Health in the state & district?

A. ….These indicators are to be added at local level Q. What are the reasons for infant deaths in the first 7 days of life (early neonatal deaths)? A. Birth asphyxia, sepsis, hypothermia, and low birth weight/ pre-maturity Q. What are the reasons for maternal deaths in the first 6 weeks after

delivery (maternal mortality)? A. Hemorrhage, underlying anemia, sepsis, obstructed labor, toxemia

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Key messages Ø The maternal and child health status in the state is poor

Ø Most of the deaths among infants occur in the first 28 days of life and maternal deaths in the first 6 weeks after delivery & yet there is no one to look after the mother and child in the hospital

Ø Yashoda will fill this gap

Ø Yashoda has several responsibilities and all these responsibilities are geared towards making the mother and newborns stay in the hospital comfortable

Q. What are the responsibilities of Yashoda? A. Yashodas have a host of responsibilities:

• Be a friend to the mother & support to the family

• Help register the mother as a JSY beneficiary

• House keeping of the labour room and the maternity and post natal

wards

• Maintain records of the mother and newborn

• Facilitate safety, security, dignity and privacy of the mother

• Provide basic care to the newborn by teaching the mother and family

how to keep the newborn warm, providing breast feeding support to

mother, ensuring immunization at birth

• Identification of danger signs in mother and newborn

• Counsel the mother on early initiation of breast feeding, advantages of

exclusive breast feeding, complementary feeding, mother’s diet,

infection control, immunization, family planning choice etc.

• Ensure that the birth is registered

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Session 4:

Title: House keeping of the maternity & post natal wards and labor room

Session objectives:

It is expected that after this session the Yashoda will be well informed about her

responsibilities as housekeeper of the wards and labour room and will be able to

perform these duties. Learner’s objectives:


1. Perform her supervisory duties to ensure that the support staff in the ward

does their work well – Aayah, ward boy, nurse etc.

2. Perform the activities she will undertake to make the labour room,

maternity and post natal wards comfortable for the mother and newborn.

3. Access the supplies available to her for housekeeping

Time: 1 hour and 10 mins

Materials: Facilitator’s guide, Yashoda training kit, Black board & Chalk or white

board & felt pens in two colours, duster, wipe, access to LCD (preferred) or an

OHP

Setting: Classroom followed by visit to maternity ward, labour room & supplies

section

Training Methods: Discussion followed by demonstration

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Steps: Class room discussion: (Time: 10 minutes)

1. Inform trainees about the objectives of this session. Explain to them that in

the next few minutes you will be enumerating the chores that must be

done to keep the hospital clean and free of germs.

2. Ask the participant one by one to mention one activity she undertakes to

keep her own house clean. Note it on the black board.

3. Explain that the way these tasks need to be done at home, similarly, these

need to be done at the hospital.

4. Enumerate the activities that the trainee will need to perform

Divide the trainees into 3 groups. Each group must have its designated

trainer. One group will then proceed to the maternity ward, one group to the

labour room and one group to the supplies section. The groups will be rotated

so that each group has a chance to spend 10 minutes in the labour room & 10

minutes in the supplies section.

Demonstration in Ward: (40mins)

5. In the ward, the trainer will introduce the trainees to the personnel who are

responsible for housekeeping in the ward.

6. Explain in brief the roles of all the staff.

7. The trainer will demonstrate one by one all the activities that help in

keeping the ward clean and comfortable

8. Demonstrate how to make the bed

9. Let each trainee practice bed making

10. Show trainees how to mix disinfectant in water in the right proportion

Demonstration in Labour room: (10 mins)

11. Introduce the trainees to the ward staff and explain their roles

12. Familiarize the trainees with the equipment

13. Demonstrate the activities Yashoda needs to perform

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Visit to supplies section: (10 mins)

14. Demonstrate the supplies available for housekeeping of the ward

15. Inform the trainees about the procedure for accessing supplies

16. Demonstrate how to fill the stock register

Special Preparations for this session -

The trainer should familiarize himself/herself with the staff of the wards and labor

room beforehand and understand their job charts. Request them to be available

in the ward at the time of this session.

Trainer must know how to make the bed. Trainer must also know how to mix

disinfectant In the right proportion

Also familiarize yourself with the time schedule of sweeping, mopping of the ward

and the place where the supplies are kept.

Make a list of the supplies for your reference.

Study the process of accessing the supplies.

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Trainer’s notes: Q. What are the activities Yashoda has to perform for housekeeping in the ward?

• Each Yashoda should take a round of the wards, labor room and toilets attached to

the wards at the time of shift change to satisfy herself about the cleanliness

• The floor should be mopped by the ‘safai karmchari/Aayah’ with water that contains

a disinfectant mixed in the right proportion.

• The disinfectant should always be available in the ward and trainees should be

shown the store room from where they can access this.

• In case food, water, body fluids or any other material is thrown on the floor, it must

be cleaned at once to prevent flies from swarming in the ward. Yashoda is to

ensure that the Aayah promptly sweeps and mops any spills.

• Other fittings in the ward like door handles, light switches, bedside counters & the

bottom of all incubators, cots and cribs should be cleaned by the Aayah.

• If Aayah is not doing her job, Yashoda should bring this to the notice of the nurse.

• It is important that Yashoda ensures that the bed allotted to a new admission has a

clean sheet and is made well. She must help the nurse in doing this and should be

able to do this by herself.

• In case of soiling of the mother’s bedsheet, the sheet should be changed at once

• Yashoda should ensure that all the electrical fittings in the ward are working. The

store for electrical fittings should be visited.

• The procedure for accessing electrical fittings like bulbs, tube lights etc from

hospital supplies should be explained.

• The trainees need to be informed about the water supply of the hospital. Yashoda

should inform nurse in case there is shortage of water in the ward or toilet.

Q. What activities should Yashoda perform in the labour room? A. Yashoda has to ensure the cleanliness of the delivery table

The bed sheets covering the beds in the waiting room should be clean and fresh

Any spills in the room should be promptly cleaned

Q. What are the supplies available in the hospital for housekeeping? A. Broom, mop, disinfectant, bed sheets, makintosh etc (the trainer needs to add his/her

observations from the hospital)

29

Session 5 Tile: Care of the mother before, during & after delivery Session objectives:

• To explain to the Yashoda about the needs of a mother before, during and

after delivery and her responsibilities during this period.

• Yashoda should be able to demonstrate how to register a woman as a JSY

beneficiary

Learner’s objectives:

After this session, the trainee should be able to:

1. Understand the special needs of women before, during and after delivery

2. Understand her role as supporter and friend of mother and guide for the

family

3. Enumerate her responsibilities towards the mother during the time the mother

is in the hospital

4. Enumerate how she can assist the nurse in her duties towards the care of the

mother

5. Demonstrate how to register a woman as a JSY beneficiary

Time: 1 and a half hour

Setting: Maternity ward followed by JSY registration room followed by classroom

Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda, Note

pad, pencil, pen, eraser, felt pens in two colors, chalk, white board, duster, wipe,

access to and LCD (preferred) or an OHP & a CD player

Method: Demonstration followed by task followed by role play

30

Steps: Demonstration in ward: (Time 30 minutes) Divide the group into 3. A trainer should accompany each group.

1. Take the trainees to the maternity ward.

2. Demonstrate how to greet a pregnant woman and her family

3. Demonstrate the questions that need to be asked to ASHA and the mother to

gather information about the pregnancy

4. Demonstrate how to record the gathered information about the pregnancy

5. Demonstrate how to provide encouragement to the mother

6. Demonstrate how to massage the mothers back to relieve the pain

7. Demonstrate the activities in which Yashoda can assist the nurse for the care

of the mother

Demonstration in JSY registration room: (Time 15 minutes) 8. Take the group to the room where women are registered as JSY beneficiaries

and demonstrate the entire process of registration

Tasks: (Time 15 minutes)

Each group can be divided into smaller groups.

• Get the smaller group (2 or 3) of trainees from your group to register a

mother as JSY, another 2 - 3 trainees to collect and record the pregnancy

related information of a mother.

• The tasks can be exchanged after the two groups are done

• On completion of the task, discuss the tasks

31

Role Play in classroom: (Time 30 minutes)

1. Take the groups back to the classroom

2. Now, the groups will be allotted the following 3 scenarios to prepare:

a. Any one participant of Group I can make a role play of her past

experience in the ward

b. Yashoda welcoming a mother as she enters the hospital and

making her comfortable

c. Yashoda welcoming the family of a mother and advising them about

the preparations required for the arrival of the newborn

The participants can be given 10 minutes to prepare the role plays and 5

minutes each to perform.

3. Discuss the role play and recap the session – Time – 5 minutes

Trainer’s notes:

The Yashoda is the arm of the health system that provides the hitherto missing

support to women and children in a hospital setting. Explain to the Yashoda that - the

hospital is like her second home. A pregnant woman coming to the hospital and her

family are guests. Providing a warm welcome by greeting the mother is essential for

the mother to feel safe when she comes to the hospital for delivery. Providing a

conducive environment will encourage the mother to stay in the hospital for longer

duration (at least 2-3 days). This will help to ensure that the complications are

detected and treated early. As a supportive care provider, Yashoda needs to ensure

the following when the mother gets admitted in the hospital for delivery.

I. Welcome the mother

• Orient her to the maternity ward; be cordial with her family members.

II. Gather basic information

• Gather basic information from ASHA who has accompanied the mother about

completion of ANC checkup, any problem the mother had during pregnancy and

inform the nursing staff for necessary action.

• If there is no ASHA accompanying the mother, enquire from the mother about

gestational age, movement of the fetus, pain, duration of pain and its frequency,

any discharge from the vagina. Record this information.

• Ask the mother if the membrane is ruptured or not. If it is ruptured observe the

colour of the fluid (the normal colour of the amniotic fluid is colour less)

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III. Provide psychological support and physical comfort

• Provide comfort, emotional support, reassurance, encouragement and

praise

• Give back massage to the mother if it gives comfort to her

• Ensure and respect the privacy of the mother during examinations and

discussions

• Ensure cleanliness of the birthing area

• Encourage mother to wash her genitals at the onset of labour

• Never leave the mother alone

• Find out from the nurse whether the mother can have light food. This will

help the mother from the effect of labour such as physiological exhaustion,

which can lead to distress in the baby. If mother is not at risk of requiring

an operation, she can be allowed to have light, easily digested, low fat

food during labour and should be given warm drinks

• Encourage mother to walk around. This helps ease the pain and shorten

the labour

• Encourage mother to urinate frequently

IV. Be a link between the hospital staff, the mother and her family.

• Help the mother to register as a JSY beneficiary

V. Assist the nurse

• Assist the nurse in providing comfortable bed to the mother

• Assist the nurse to avoid over crowding in the ward.

• Assist the nurse for pelvic and vaginal examination of the mother.

• Be available in the labour room if any help is required from you.

• Assist the nurse to keep the labour room clean, well ventilated, adequately

lit and warm for receiving the baby.

33

Key messages Ø Yashoda must be a friend & support for the mother and make the

mother physically comfortable by providing her clean surroundings and back massage

Ø Yashoda must provide a psychologically comfortable environment for the mother by speaking to her gently and encouraging her

VI. Identify signs of discomfort in the mother Observe the mother for any of these signs. If these are present, inform the

nurse immediately:

• If the colour of the liquor (amniotic fluid) is reddish/greenish/dark yellow

• If there is difficulty in breathing,

• vaginal bleeding, convulsions or unconsciousness

VII. Prepare for the delivery and the birth

• Assist the nurse to keep the delivery tray and baby tray ready.

• Keep a warm bed ready to receive the baby.

VIII. Post natal care The post-natal period begins after delivery and includes the first six weeks after

delivery. During this time, the mother is in a delicate state. She has lost a lot of

blood and other nutrients during the delivery process. She is also breastfeeding

her baby and needs good nourishment to produce sufficient milk. Proper attention

has to be paid to the mother’s health. There are many good opportunities during

post-natal period for you to teach new mothers how to take care of themselves

and their babies so that the health of both is maintained.

Help the mother during her post natal period in the hospital

§ Help the mother to change sanitary pad frequently (Every two hours).

Ensure that the mother has enough sanitary napkins

§ Clean the mother and the area beneath her

§ Help the mother to eat and drink

§ Help her to clean the breast and feed then baby

§ Help the mother to keep the baby very close to her all the time

§ Encourage the mother to pass urine

34

Session 6:

Title: Preparations for welcoming the baby

Session objectives:

To impress upon the trainees the importance of making preparations for the

birth of a baby & familiarizing her about the kind of preparations needed


After the session, the trainee should be able to:

1. Communicate to a mother the importance of preparing for the arrival of a

new baby

2. Enumerate the articles required for the preparation

3. Enumerate the practices that are harmful for the mother and newborn

Time: 30 minutes

Setting: Classroom

Materials: A table, 2 trays, some examples of clothes needed for a newborn

baby, a rupee note, bottle of honey, kajal, black board & chalk, Yashoda training

kit, black board & Chalk or White board & felt pens

Training method: Discussion and Task

Steps: Discuss: (Time 10 minutes)

1. Ask the participants if they think it is important to make preparations for

the birth of a baby.

2. Those who agree that it is important to make preparations for the birth can

raise their hands.

35

3. Those who raise their hands should tell the group one by one why they

think it is important.

4. Facilitate the discussion and summarize

Discuss the task: (20 mins)

1. Ask how many participants agree or disagree about each article. Ask them

to raise their hands and count the number.

2. Ask if there are any other articles they would bring for the preparations.

(This will give you an idea about the common beliefs in the community)

3. Note on the board if the group has added any article to the list of

preparations required.

4. Now, stress on the importance of getting each of the desirable items

5. Explain why the undesirable items written on the board should not be used

Task: (Time 10 mins)

Place a table in front of the trainees and place the following articles on it - 2 trays, some examples of clothes needed for a newborn baby, a rupee note,

bottle of honey, bottle of Kajal. 1. Introduce the purpose of this task

2. Ask one trainee to come forward and separate out materials from the

tray into two groups - Tray 1 - containing materials needed for the

newborn, Tray - 2 containing materials not needed by the newborn

3. This exercise should be repeated by at least 4 participants

4. Draw a table on the board with the names of the 4 participants and the

list of articles they selected

Trainer’s notes:

The purpose of this task is to enlist the articles needed for the newborn and

those not needed

36

Special preparations: You can draw a table on the board beforehand with the

name of each participant and the list of articles. E.g:

Name of

trainee

Clothes for

newborn

Money Honey Kajal

For each trainee, tick the articles she selects

Trainers notes:

It is very important to make preparations for the arrival of a new born.

Q. Why is it important to make preparations for the birth of a baby? A.The baby is very fragile immediately after birth. The baby is vulnerable to

cold and both mother and baby are vulnerable to infections. Some articles are

required to save them from cold and infections. Preparations also have to be

made for emergencies.

Q. What are the articles required for the newborn? A. Clothes including socks and cap during winter, old sari or dhoti that has

been washed and dried & money.

Q. Why is it important to keep clothes ready for the newborn? A. The new born is very susceptible to cold (hypothermia). It is important that

the newborn is immediately covered well in accordance with the weather. In

cold weather, socks and cap are required since the baby loses maximum heat

from the feet and head. Old sari/dhoti can be washed, and kept dry to keep the

baby warm and use as nappies.

Q. Why should honey, Kajal not be applied? A. The newborn is very susceptible to infections. Giving honey or applying

kajal can cause infections in the newborn.

Q. Why is money required? A. Money is required for any emergency need of the newborn or the mother.

37

Key messages: Ø It is very important to make preparations for the birth of a baby

Ø Keep articles like – money & clothes ready

Ø Do not use Kajal in the eyes of the newborn and do not give honey

or any such product to the newborn.

38

Session 7

Title: Early Initiation of breast feeding

Session objective:

To ensure that the Yashoda is well aware about the importance of early initiation

of exclusive breast feeding of the newborn


After this session the trainees should be able to:

1. Internalize the benefits of early initiation of breast feeding

2. Be clear about the benefits of giving Colostrum

3. Be clear about the harmful effects of giving pre lacteal feeds to the

newborn

Time: 1 hour Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,

Note pad, pencil, pen, eraser, felt pens in two colors, chalk, white board, duster,

wipe, access to and LCD (preferred) or an OHP & a CD player

Setting: Classroom

Methods: Group discussion Steps: Group discussion: (Time: 30 minutes)

Divide the trainees into 3 groups of 8-9 each. One trainer should be present with

each group who will act as a facilitator. 1. Give the following 3 topics to the groups

a. When should breast feeding be initiated?

39

b. Should Colostrum be given to the newborn?

c. Which other food/drinks should be given to the newborn in the first

few days of life?

2. In each group let the group member chose their team leader and inform

the trainer

3. Ask the groups to discuss these questions among themselves and

formulate answers

4. Ask them to give the written answers on a chart paper with at least 3

points in favor of their answer

Discussion: (Time: 30 minutes)

1. Once the task is completed, ask the team leaders to read out the answers

to the first question given by the groups one by one.

2. Note the answers on the board with the reasons given in favors of the

answer

3. Now ask the team leaders for answers to the second and third questions

and note the answers on the board

4. Let the participants open on the flip chart the page dealing with initiation of

breast feeding

5. Hold up a flip chart in front of the class and show on the flipchart the page

that deals with initiation of breast feeding

6. Explain why breast feeding should be initiated within an hour of the baby’s

birth.

7. Explain the advantages of giving Colostrum

8. Explain how pre lacteal foods can harm the newborn

9. Now discuss the participant’s answers noted on the board and tick them

as right or wrong. Give explanation for each as you go along the list.

10. At the end, ask the trainees if there are any other practices associated

with feeding the newborn that have not been covered.

11. If yes, address the issues raised

40

Trainer’s notes: Q. When should breast feeding be initiated and why?

- Breastfeeding should be initiated within an hour after birth.

- Early breast feeding helps in expulsion of the placenta and reduces bleeding of

the mother.

- Helps the milk to flow and makes more milk

- Helps in mother and baby bonding

- Keeps baby warm and safe from infections

Q. What are the benefits of feeding colostrum to the newborn? A. Colostrum is very rich in all nutrients required by the baby. It s easily digestible by

the newborn & contains large number of antibodies that help the newborn in fighting

off infections.

Q. What are the harmful effects of giving prelacteal feeds? A. In many families, there is a practice of giving honey, water and other such

prelacteal feeds. These external food stuffs transmit infections to the newborn.

Secondly, if the newborn doesn’t suckle enough, the quantity of mother’s milk reduces

and the baby will be malnourished.

There is no benefit whatsoever of giving these other fodds/drinks

41

Key messages Ø Breast feeding must be initiated within 1 hour of birth Ø Colostrum contains all the nutrients a newborn needs and must be

given to the newborn

Ø Prelacteal feeds like honey, water can harm the baby

42

Session 8

Title: Proper positioning while breast feeding

Session objectives:

To build the capacity of the Yashoda to help a mother attain the proper position

for breast feeding


After this session, the trainee will be able to:

1. Help a mother attain a suitable position for breast feeding

2. Demonstrate other appropriate positions for breast feeding

3. Communicate to mother the precautions to be taken while breast feeding

the newborn

Time: 30 minutes

Materials: Facilitator’s guide, Yashoda training kit

Setting: Post natal ward

Method: Video & Demonstration

Steps:

Show the Video on Breast feeding (good attachment & position), in the local

language

Divide the trainees into 3 groups. Each group will be led by a trainer. The teams

should be taken to the Post natal ward and will be allotted different beds where

there is a mother and newborn.

43

1. The trainer will take the group to a mother and newborn and demonstrate

how to initiate breast feeding

2. Demonstrate both - the techniques of initiating breast feeding on a mother

who has had a normal delivery and for a mother who has had a caesarian

section

3. Other positions for initiating breast feeding that can be adopted by the

mother should also be demonstrated.

4. Demonstrate to the trainees the precautions needed while breast feeding

the newborn

Trainers notes: Q. Which positions can be adopted while breast feeding the baby?

A. Different positions of breast feeding –

1. mother supporting the head, body and buttocks of the baby on her arm

2. mother reclining at an angle and breast feeding

3. mother lying down with baby close by

Things to be kept in mind while breast feeding the newborn –

Q. What are the precautions needed while breast feeding the baby? A. Breast feeding is better when:

o The mother is comfortable.

o The baby is cuddled to mother with his/her head held up and with support for the

head, body and buttocks.

- The baby should have the whole of the areola in his/her mouth and not just the nipple.

Baby’s mouth should be wide open and should cover most part of the areole.

- The baby’s chin should be close to the breast

- Complete one breast before offering the other breast.

- Improper positioning while breast feeding could result in nipple biting or injury

- Baby’s face should not be covered; Mother should be able to see the baby and interact

with the baby.

- Mothers under gone surgery can feed lying down or in a semi inclined position till they

recover.

- In the case of twin babies both can be fed simultaneously or one after another.

- Do burping by keeping the baby upright and rubbing or patting the back gently.

44

Key messages Ø Improper position of breast feeding is a common reason for failure to

breast feed or injury to nipple

Ø To attain the proper position, the baby should be close to the mother with her mouth facing the mother’s breast and entire body supported on the mother’s arm

Ø The entire areola should be in the mother’s mouth and not just the

nipple Ø Other positions that are comfortable for the mother can also be

adopted

45

Session 9:

Title: Exclusive breast feeding for six months and complementary feeding

Session objectives:

It is important that during this session the trainees understand what is exclusive

breast feeding for six months, are convinced about its importance and that breast

feeding should be continued during illness. They should also be able to counsel

the mother about how to start complementary foods and what to give as

complementary food.


After this session the trainees should be able to:

1. Communicate to mother what is meant by exclusive Breast feeding

2. Enumerate the benefits of exclusive breast feeding

3. Communicate to mother the importance of breast feeding during her or the

baby’s illness

4. Communicate to mother when to start complementary food and how to start it

Time: 40 minutes Materials: Facilitator’s guide, Yashoda training kit, pin board & pins, or white

board & sticking tape, cut out pictures of a Calf, Cow, Camel, baby Camel, Goat, baby Goat, human baby, woman.

Setting: Classroom

Method: Task followed by Discussion

46

Discuss: (Time: 30 minutes)

1. Ask the participant if there is any difference of opinion with the matching

that has been placed on the board

2. Now explain to participants that the way a cow’s baby or goat’s baby

needs its mothers milk, similarly a human baby needs its mother’s milk

(ensure that each participant understands what you are saying).

3. Encourage the participants to express any difference of opinion (if they

feel that the baby should be given some other food stuff besides mother’s

milk?)

4. If there is any other point of view, note it on the board.

5. Once all opinions are collected, read the list and cross out one by one all

other food/drink mentioned (if any)

6. Explain why other food stuffs are not needed by the human baby.

7. Explain the advantages of exclusive breast feeding as mentioned below

8. Ask a participant if mother should feed the baby if the baby is unwell. Let

her answer in yes or no.

9. Ask how many agree with the answer. Those that agree can raise their

hands.

10. Count the number of hands and inform them if they are right or wrong.

11. Explain why it is required that the mother should breast feed the baby

even when the baby is sick

12. Explain what is complementary feeding and what food can be given when

starting complementary feeds for the baby.

Task: (Time: 10 minutes)

1. Place the cut out animal pictures on a table.

2. Ask one participant to match the pictures of mother and baby.

3. As she matches, let her paste the picture of mother and baby together

on the pin board/white board/ wall

47

Trainers notes:

This session is very crucial. It is imperative that the participants give voice to

all their concerns about exclusive breast feeding and clear all doubts. Breast

feeding is one of the most important interventions for preventing morbidity and

mortality among children.

Q. What is meant by exclusive breast feeding?

A. Exclusive breast feeding means giving the baby only the mother’s milk. No

other food/drink is required by the baby while it is being exclusively breast fed.

Baby does not even require water during this time.

Q. What are the advantages of exclusive breast feeding?

A. There are several advantages -

- Mother’s milk provides all the nutrients required by the baby.

- It is safe. There is no outside source of infection.

- It contains antibodies that help the baby fight off infections.

- It is also easily digestible by the baby.

- It is easily available.

- It is of no cost to the family.

- Breast feeding provides warmth to the baby and prevents baby getting

cold.

- Bodily contact between the mother and baby promotes better emotional

bonding between mother and baby.

48

Key messages Ø The human baby needs only the mother’s milk till 6 months of life

Ø Breast milk contains all the nutrients necessary for the baby, helps fight infections and helps in good emotional development of baby

Ø Mother should continue to feed the baby even if she is sick Ø Baby needs mother’s milk more when he/she is sick

Q. For how long should exclusive breast feeding be continued? A. Exclusive breast feeding should be continued for 6 months.

Q. Why should other fluids like baby formula, water, rice water etc not be used? A. Substances other than the mother’s milk do not contain all the nutrients required by the

baby. If other fluids are given, they will decrease the appetitive of the baby for mother’s milk

even though they are not providing the essential nutrients. Additionally outside food stuffs

are potential carriers of diarrhea. Most often, if baby is being given other liquids, these are

given through a bottle. Bottle is very risky for the baby since a large number of germs may

develop in bottles that are not cleaned adequately. Cleaning a bottle properly is a

cumbersome and tedious task that most mothers are not able to perform.

Q. What is complementary feeding? A. Feeding the baby food other than breast milk at the age of 6 months is called

complementary feeding. Babies should be fed soft, light, well cooked food. You can give

home made soft food prepared with locally available food. (dal, dahlia, rice). Start with liquid

consistency and gradually increase the thickness. Start with 2 times a day and gradually

increase it to 4 times. Breast feeding can continue along with other feeds for at least 2

years. To monitor growth, check the weight of the baby regularly.

Q. Should the mother feed the baby when the baby is sick?

A. Yes, the mother should feed the baby when the baby is sick. It has two major

advantages:

- During sickness the baby needs more fluids which are provided through breast milk

- Breast milk has antibodies that help the baby fight off infections

49

Session 10:

Title: Breast feeding- some possible problems.

Session objectives:

The trainees should be well versed with some common problems that mothers

may encounter during breast feeding and should be able to provide some easy

solutions.


After this session the trainee should be able to:

1. Enumerate common problems that a mother may have during breast

feeding

2. Identify these common breast feeding problems

3. Support the mother to solve these problems

Time: 45 minutes



Divide the trainees into three groups. Each group should be accompanied by a

trainer. Allot one bed to each group on which a mother and newborn are located

Steps:

1. Ask 5 trainees one by one if she has ever encountered a mother who

could not breast feed her child

2. If yes, what was the problem?

3. Note the problems mentioned

50

4. Ask what did the mother do then & what was the solution provided for

these problems?

5. Now, open the flip chart for Yashoda and pointing to the pictures of

inverted/flat nipple, and fullness of breast; ask if they can identify what the

problem is.

6. Using the pictures in the flip chart for reference, explain the simple

solutions given

7. Demonstrate on a mother how to express breast milk by hand.

8. Ask a trainee to practice on the mother.

Trainer’s notes:

Most breast related problems are easy to manage with simple actions. It is

often seen that mothers stop or are never able to initiate breast feeding

although they have a problem that is easily rectifiable.

Q. What are the common problems with breast feeding?

• Inverted or flat nipples

• Fullness and pain in breast

• Cracks and pain in nipples

Reasons and actions required:

• Inverted or flat nipple can be improved with continued suckling of the

breast by the baby.

• Fullness of breast occurs when the baby is not breast fed early or

regularly. Baby is unable to suckle on engorged breast. Hot

fomentation, light massage and expression of some milk by hand

before putting the baby to breast will help.

• Cracked nipples occur due to improper attachment leading to vigorous

sucking by the baby. This can be remedied by application of some

expressed breast milk on the nipple after each feed and correcting the

attachment by proper positioning.

• Slight pain in the breast can be relieved with medicine. If the problems

persist, a doctor or nurse should be consulted.

• Do not use soap to clean the breast/nipple since it can cause cracked

nipples; wash with plain water during the time of bathing.

51

Key messages Ø Inverted/flat nipples will improve with continuous sucking by the

baby

Ø Fullness of breast can be corrected by hot fomentation light hand massage and expressing some breast milk

Ø Cracked nipples can be relieved by application of some breast milk on the nipple after feeding the baby and by correcting the attachment

Ø Drying agents like soap should not be used on the nipples

52

Session 11

Title: Keeping the newborn warm

Session objectives:

This session is designed to impress upon the trainees the importance of keeping

the newborn warm and to teach them how to do it.



1. Communicate to the mother why it is necessary to keep the newborn

warm

2. Enumerate the clothes needed to keep the newborn warm

3. Demonstrate how to wrap the newborn

4. Demonstrate how to clean the newborn after he/she urinates, defecates

5. Demonstrate how to change the newborn’s nappy

6. Demonstrate how to keep the newborn close to the mother

Time: 1 hour

Materials: Facilitator’s guide, Yashoda training kit, 3 doll babies, baby

towels/blankets to wrap baby, 3 pairs of socks, 3 caps for baby


Method: Demonstration and practice

Steps:

53

Divide the trainees into 3 groups – each of 8-9 trainees. Each group should be

accompanied by a trainer. These three groups must now be taken to the post

natal ward.

1. Here the trainer should explain the importance of keeping the newborn

warm

2. Enlist all the methods by which the baby can be kept warm

3. Enumerate the clothes that are needed to keep the newborn warm and

demonstrate the use of the clothes on the doll

4. Demonstrate on the baby doll how to wrap a baby

5. Let each trainee practice on the doll the technique of wrapping the baby

6. Demonstrate on the doll how to clean the baby after it urinates and

defecates

7. Demonstrate on the doll how to change the nappy

8. Let each participant practice how to clean the baby and change the nappy

9. Now demonstrate on a live baby how to wrap the baby

10. Demonstrate on the live baby how to clean and change the baby

11. Each Yashoda should practice wrapping a live baby at least once

12. Trainer will demonstrate how to keep baby very close to the mother

Summing up

13. Ask each participant one measure to keep the baby warm

14. Trainer will now sum up all the measures that should be taken to keep the

baby warm

54

Key messages Ø The newborn is very vulnerable to cold and must be kept warm at all

times Ø Keep the newborn clean, dry & well covered and always very close to

the mother Ø Avoid giving bath on the first day

Trainers notes: Q. Is it necessary to keep the baby warm and why? A. The newborn is very vulnerable to hypothermia (cold) for the first few

months after birth. It is very essential to keep the newborn warm and dry to

prevent her/him from cold.

Q. What are the measures to keep the newborn warm?

• Newborn should be kept in skin to skin contact as far as possible

• Breast feeding the newborn

• Wrap the newborn with a blanket/sheet; ensure to cover the head as

well

• During winters, covering baby with extra layers, socks and caps

• Clean, dry & change the baby after he/she urinates or defecates

• Keep the room warm

• Avoid giving bath on the first day

Q. Why should the baby be kept close to the mother?

• The body warmth of the mother helps the baby keep warm

• Keeping the baby close stimulates better milk output in the mother

• Being close to the mother encourages the baby to feed better

• It is also easier for the mother to breastfeed the baby on demand

55

Session 12

Title: Bathing the new born baby

Session objectives:

Yashoda should be aware about when and how often to bathe the newborn & the

precautions to be taken while bathing the newborn


After the session, the trainees should be able to:

1. Inform the mother when to bathe the newborn

2. Demonstrate how to bathe a new born

3. Enumerate the precautions to be taken while bathing a newborn

Time: 1 hour


Method: Demonstration

Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,


wipe, access to and LCD (preferred) or an OHP & a CD player Steps:

Divide the trainees into 3 groups each led by a trainer. 1. Take trainees to the ward

2. Explain when the newborn should be bathed and why

3. Demonstrate how to bathe a newborn

4. Demonstrate how the cord stump is kept clean and dry

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Key messages Ø Do not bathe the newborn on the first day after birth Ø Do not use and soap, powder or any other perfumed agent on the

baby’s body Ø Keep the cord stump dry and clean

Trainer’s notes: Q. When should the newborn be bathed? A. Newborn babies with normal weight (2.5 KGs) require bath only after the

first day of birth. Small and low birth weight newborns can bathe after the cord

falls off or preferably till baby gains weight to 2000 gms. Till then, daily

cleaning with wet cloth soaked in lukewarm water is adequate.

Q. What are the precautions to take while bathing the newborn? A. Bathe gently and do not rub the baby vigorously. If you do so you may

remove the white film/ vernix caseosa on the body of the newborn which gives

protection to the baby. Support the head of the baby at all times. Keep the

room warm and use luke warm water. Assess the temperature by touching the

water to the exterior aspect of your elbow. Do not use any soap or powder.

Bathe quickly and dry the baby quickly. Do not apply any thing on the cord

stump and allow that to dry naturally. Cover the baby well and keep her/him

close to the mother for breast feeding. Do not apply any powder or perfume on

the baby.

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Trainer’s notes Q. Is it necessary for the mother to eat more after delivery? A. Yes. It is important for a new mother to eat well. This enables her to replenish the

nutrients she has lost during delivery. If mother is breast feeding the baby, it is even

more important for her to eat well. The requirement of the mother increases when

she is producing milk for the baby. This is for her to produce better quality and

quantity of milk.

Q. What should the mother eat?

A. Mother can stay healthy by eating whatever food available locally. She requires

two balanced big meals and two small meals in a day to meet her nutritional

requirement. During breast feeding mother has to take more fluids.

Q. What food should the mother avoid?

A. No food items need to be avoided by the mother. There is no specific ‘hot food/

cold food that mother should or should not eat.

Q. What are the food customs that may harm the mother? A. In some households, various food materials are restricted for the mother in the

false belief that the food material is ‘hot’ or ‘cold’. This limits the variety of food the

mother can partake. This may lead to nutritional deficiencies in the long run.

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Session No. 13

Title: Care of the low birth weight baby

Session objectives:

The trainee should be able to identify a low birth weight newborn by its weight

and take basic care of the low birth weight newborn


After this session, the learner should be able to:

1. Identify a low birth weight baby by its weight

2. take the weight of a newborn using a standard weighing scale available in

the hospital

3. Enumerate special needs of the Low birth weight baby

4. Demonstrate Kangaroo Mother Care position

5. Demonstrate how to express breast milk

Time: 1 hour

Setting: Post natal Ward

Materials: : Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,


wipe, access to and LCD (preferred) or an OHP & a CD player.

Method: Demonstration

Steps:

Form 3 groups. Each group should be led by a trainer. The groups will assimilate

in the post natal ward.

1. Using the flip chart, show the picture of a low birth weight baby

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2. Explain what is meant by low birth weight

3. Mention the characteristics of a low birth weight baby – poor feeding &

increased susceptibility to cold

4. Explain the special needs of such a baby – feeding, keeping warm.

5. Demonstrate KMC on a mother of a newborn

6. Demonstrate KMC on the father of a newborn.

7. Explain the advantages of KMC

8. Demonstrate on a mother how breast milk can be expressed by hand to

feed a weak low birth weight newborn

9. Demonstrate how to take the weight of the baby using the standard

weighing scale available in the hospital

Picture of a standard weighing scale for babies

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Trainer’s notes: What is meant by a low birth weight baby?

Babies weighing less than 2500 gms are known as small babies or low birth

weight babies. Further, babies weighing less than 2000 gms require special

and extra care. Pre term babies are also usually low birth weight & and are

born before time.

What are the special needs of low birth weight babies?

Low birth weight babies are at higher risk of hypothermia (cold), more prone to

infections; poor growth, and ill health. They are at higher risk of jaundice

(turning yellow). Due to their weakness, often they do not suck the breast well.

In the long run, low birth weight babies have more chance of becoming weak/

malnourished.

What is Kangaroo Mother Care (KMC)?

Small babies – low birth weight babies, pre mature babies are prone to cold

and illness very fast. They require this special skin to skin contact known as

‘Kangaroo mother care’. Kangaroo mother care means placing the baby on the

mother’s chest, between the breasts and well covered. There should be skin to

skin contact between the mother and baby. There are several benefits to this

method. This method is simple, cost effective and easy to follow. It keeps the

baby warm through skin to skin contact between adult and baby. Along with

this frequent breast feeding can help the baby to fight illness and grow

healthy. Mothers can practice this while sitting, lying down and as long as

possible. Other family members can also do this and support mother when

possible.

What can be done if a low birth weight baby is unable to suckle?

§ Express breast milk every 2-3 hours and feed baby with ‘palada’ or cup

& spoon

§ Put the baby to the breast to let him lick the nipple and perhaps suckle

a little

§ Once the baby can suckle, he should be put on the breast frequently to

stimulate milk production

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Key messages Ø A low birth weight baby has special needs – is more vulnerable to

cold and may not be able to suckle Ø Keep the low birth weight baby warm and well covered with

Kangaroo mother care Ø If the baby is too weak to suckle properly, feed the baby expressed

breast milk from a katori and palada

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Session 14

Title: Danger signs in new born

Session objectives:

Yashoda should be able to identify a newborn that has danger signs and should

be able to refer such a baby to the appropriate authorities


After this session, trainee should be able to:

1. Distinguish between normal and abnormal appearance and activities of a

newborn

2. Identify danger signs in the newborn

3. Be aware of the authorities she should refer the sick newborn to

Time: 1 hour


Materials: Facilitator’s guide, Yashoda training kit, access to LCD (preferred) or

an OHP Method: Demonstration followed by slide show

Steps: Demonstrate in ward: (Time: 30 minutes)

1. Divide trainees into 3 groups. Each group is to be accompanied by a

trainer.

2. The trainers will demonstrate on a live, healthy newborn:

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• General condition & movements

• Normal cry

• Normal suckling/feeding

• Normal breathing – count the breaths per minute

• Normal colour of lips and skin

• Normal stools of a baby

3. Let the trainees touch the baby’s abdomen & feet to feel the normal

temperature of the newborn

Slide show in classroom: (Time: 30 minutes)

4. Take the trainees into the classroom.

5. Go through the slide show and explain the danger signs in newborns

6. Explain to the trainees that they must be aggressive and vigilant while

identifying danger signs. If there is any doubt, it is better to refer than to

wait since symptoms in newborns progress very fast and the condition can

worsen

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How to assess Hypothermia

• If abdomen is warm & feet are warm & pink, body temperature is normal

• If abdomen is warm & feet are cold, it is cold stress. Cover the baby with

extra clothing

• If both abdomen and feet are cold, it is Hypothermia & the baby requires

urgent attention

Trainer’s Notes: Q. What are the characteristics of a normal newborn? A. The normal newborn has a pink face & feet. He/she is usually in the state of

quiet alertness (eyes open, looking around). The limb movements are smooth

and spontaneous and not unusually jerky. He/she has a vigorous, lusty cry.

The normal Respiratory Rate is 40-60 breaths / minute. The respiratory rate

should be counted by observing the rise and fall of the newborn’s

chest/stomach for a full minute.

What are the danger signs among newborns?

These are the following:

§ Lethargy, not feeding or feeding less

§ Cold to touch

§ Rapid breathing (>60 per minute), grunt, gasping, apnea

§ Abnormal movements, vacant stare

§ Abdominal distension, vomiting

§ Bleeding

§ Jaundice

In the hospital, if Yashoda identifies any of the above signs, she should inform

the nurse immediately. If the mother observes such signs in her newborn at

home, she should immediately inform the ASHA /ANM or AWW for

confirmation of sickness and guidance. During this time, ensure that the baby

is well wrapped, kept warm during transport and continue feeding.

65

Key messages Ø Newborns are prone to rapid progression of illness

Ø Yashoda must be very vigilant and aggressive while looking for danger signs in newborns

Ø Yashoda must note the general condition of the newborn, temperature, respiratory rate, colour of skin or any other

abnormalities

66

Session No. 15

Title: Danger signs in mother

Session objectives:

The trainee should be able to identify signs of danger in the mother



1. Be well informed about the normal physiological changes after delivery

2. Identify and treat some common minor problems mothers face after

delivery

3. Identify danger signs after delivery

Time: 1 hour

Setting: Post natal ward Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,


wipe, access to and LCD (preferred) or an OHP & a CD player Method: Demonstration

Steps:

Divide the participants into 3 groups. A trainer should accompany each group. 1. Take the groups to the post natal ward.

2. Demonstrate the normal physiological changes in a woman after delivery -

Uterine contraction , Normal uterine discharge (bleeding)

3. Explain the common problems a woman might face and the easy

remedies for these.

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4. Using the pictures given in the flip chart for Yashoda, explain the danger

signs and symptoms

5. Once you have explained, let the participants repeat each danger sign or

symptoms till you are satisfied that they have understood and learnt each

sign and symptom

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Trainer’s notes: What are the normal physiological changes in a woman after delivery?

Normally after delivery the uterus (womb) undergoes contraction and becomes smaller and

smaller in size. Sometimes, there may be some after pain (discomfort pain in the abdomen

during breast feeding). The normal uterine discharge (bleeding) for 3-4 weeks for normal

delivery is called Lochia. Usually all women continue to bleed /discharge at least for six

weeks after delivery. The colour of Lochia changes over the weeks from red –yellow-white.

Some women may experience mood changes during the first week.

What are the common problems a woman might face after delivery and how to treat these?

§ Retention of Urine: Hot/Cold water application on the supra public region, sound of

running water may help to initiate urination. Ask the patient to pass urine in squatting

position. If no relief inform to the staff

§ Pain: at the site of the cut which may be due to stitches in the skin. Inform to the staff

§ Swelling of breasts: Hot water fomentation and light massage from periphery towards

nipple help in removing engorgement with free flow milk,

What are the serious signs and symptoms during post natal period?

General condition

§ Mother feels dizzy

§ Looks pale

§ Increase in body temperature

§ Fast or difficult breathing

§ Fits

§ Visual disturbances

Pains

§ Severe pain and tenderness in the abdomen

§ Severe pain in the private part or genital area

§ Severe headache

§ Swollen, red or tender breasts or sore nipple

§ Severe leg pain and tenderness over calf of muscles (pain in the calf muscles)

Mental state

§ Keeping quite or not talking to anyone

§ Not taking care of the baby or refuse to feed the baby,

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Key messages

Ø The Yashoda must be vigilant and aggressive while checking for danger signs in the mother

Ø Refer if the mother has poor general condition – lethargic, is pale, has rapid or slow breathing than normal, has fits, has visual

disturbance, has low or high temperature Ø Refer if the mother has any severe pains Ø Refer if the mother has severe mood swings and is non responsive

towards the baby

Ø Refer if mother has severe bleeding or foul smelling discharge from vagina

Bleeding and Discharge from vagina

§ Excessive bleeding from the vagina

§ Passage of fist size clots

§ Foul smelling discharge from vagina

70

Session No. 16

Title: Clean practices to prevent infection

Session objectives:

To ensure that the Yashoda is well versed with clean practices in ward, to be

practiced by herself, the mother and baby



1. Enumerate infection control practices to be undertaken by Yahsoda in the

ward

2. Enumerate the infection control practices to be taken by themselves

3. Demonstrate how to wash hands properly

4. Enumerate infection control practices to be undertaken by the mother in

hospital and at home

5. Enumerate infection control practices for the baby in hospital and at home

Time: 1 hour


Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,


wipe, access to and LCD (preferred) or an OHP & a CD player Method: Demonstration

Steps:

1. Explain the role of Yashoda in maintaining infection control in the ward

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2. Explain what actions Yashoda can take for their personal hygiene and for

preventing infection to others

3. Demonstrate how to wash hands properly

4. Let each trainee wash her hands as demonstrated

5. Explain infection control measures that a mother should take at hospital

and at her home for herself and the baby

How to wash hands properly

72

Trainer’s notes: Q. Why should we make an effort to prevention infection? A. Small babies are very vulnerable to infections since they are new in this

world and have not yet learnt to fight against the disease causing germs.

Neonatal infection is one of the major causes of neonatal death in our country.

It is possible to prevent infection in the newborn by following some simple

procedures.

Q. What measures can be taken by Yashoda in the ward for infection

control?

• Avoid over crowding in the ward.

• Keep the bed and ward clean calm and free from dust.

• The floor of the ward should be cleaned with water and disinfectant

when required (at least once in each shift)

• Ensure that the files, X ray films etc. are not kept on the baby cot.

• Ensure that mother washes hands after washing bottom of the baby &

after she herself goes to toilet

Q. What personal hygiene measures can Yashoda take to prevent spread

of infection?

• Wash hands before handling the baby.

• Have a bath daily

• Always keep trimmed nails and clean and combed hair

73

What infection control measures should a mother take at home and in the ward for herself and for the baby?

• Persons with infections should not be allowed to come into direct

contact with baby.

• Number of persons handling the baby should be limited.

• Six hours after birth (or) after the baby’s temperature is stable, clean

the baby’s skin with cotton clothes soaked in warm water to remove

blood or other body fluids and then dry the baby. Delay bathing until at

least the second day of life.

• The buttocks and perineal area of the baby should be cleaned each

time the baby’s napkin is changed or as often as required, using cotton

soaked in warm, soapy water and then the area to be dried.

• Ensure that the mother knows correct positioning and attachment for

breast feeding to prevent mastitis and nipple damage.

• Use only clean clothes for baby. Do not use unwashed new clothes

• Keep the umbilical cord of baby clean and dry.

• Instruct family not to apply anything on the cord stump.

• Tell family not to apply anything to the eyes and skin of the baby.

• Advice mother and others who handle baby have short trimmed nails.

• Advise mother to clean her hands and breasts before and after breast

feeding the baby.

• Advise mother and others who handle baby to wash their hands with

soap and water after defecation.

• Advice mother to wash her hands thoroughly before cooking for family

and for the baby

• Counsel mother to exclusively breast feed baby.

• Advise mother and family members to keep the home and surrounding

area clean and free from insects such as mosquito.

• Instruct her to take the baby at 6 weeks to the nearest health centre for

immunization.

• Tell her not to use pacifier.

74

Key messages Ø Simple measures can prevent spread of infection to the baby

Ø Avoid overcrowding around the baby & let very few people handle the baby

Ø Wash hands with soap and water before feeding the baby after washing the baby’s urine or feces, before cooking

Ø Do not apply anything on the cord stamp, always keep the cord stump clean and dry

75

Session 17

Title: Diet of a lactating mother

Session objectives:

To familiarize the trainee about the diet requirements of a breast feeding mother

& to understand the local customs regarding the food practices of breast feeding

mothers



1. Communicate to mother why it is important for a mother to eat well after

delivery

2. Communicate to mother which food items she should consume

3. Explain to family which dietary restrictions can harm the mother

4. Communicate to mother the number of times she should eat in a day

5. Communicate the mother the number of feeds the baby needs in a day

Time: 1 hour Setting: Classroom


Method: Group Task followed by role play

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Steps:

Instructions for group leaders:

• The groups should reach a consensus about the answer to question a.

in the form of a ‘Yes’ or ‘No’ with reasons in support of the answer.

• To answer the question 2, the groups will make small chits of a piece of

blank paper. Each trainee will pick up an empty chit and note down a

food item that the mother should eat in GREEN and a food item the

mother should not eat in RED. These chits will be folded and given to

the team leader.

• The three group leaders will get together and open the chits. Based on

the answers of the three groups, they will prepare a consolidated chart

containing two lists in table format with foods that the mother can eat

and food that the mother cannot eat. If a food item is repeated, in one

list, it needs to be mentioned only once. But if a food item is mentioned

as both food to be eaten and avoided, it should be noted in both lists.

Group Task 1: (Time: 15 minutes)

Divide the trainees into 3 groups. Each group should have a trainer. 1. The trainer will nominate a group leader for the group.

2. Pose the following two questions to all the three groups:

a. Is it necessary for the mother to eat more during the time that

she is breast feeding the baby?

b. What are the food stuffs that she should eat?

c. What are the foodstuffs that she should avoid?

3. Instruct the groups to answer the three questions as explained below

77

Discuss: (Time: 15 minutes)

1. Ask the group leaders to read aloud the answer to question 1.

2. Explain to the participants why a new mother should eat more and how

many meals she should eat in a day

3. Now display the chart with answer to questions 2 and 3, prepared by the

group leaders on the board

4. Go through each food item written

5. Discuss which food items should be consumed by the mother and which

food items should not

6. Ask the trainees about local dietary customs for new mothers

7. Discuss what local dietary customs may harm the mother in the long run

78

Key messages Ø The process of pregnancy and delivery drains on the mother’s

nutritional status and therefore she needs a good, nutritious diet with a variety of food stuffs

Ø She needs to take two large meals and two small meals in a day Ø No food items need to be avoided by the mother

Role play (30 minutes) Instructions for Role play

1. Ask the three groups to prepare a role play with the following three

scenarios:

a. Yashoda advising a new mother in the hospital about what foods

she should eat and what she should avoid while the mother-in-

law insists on following harmful customs

b. Yashoda advising a new mother about the importance of

exclusive breast feeding

c. Yashoda advising a mother about how to breast feed her baby

2. Let the three groups perform the role plays

3. Discuss

4. Praise the groups for putting in the effort

Trainers notes: Q. Which are the foods that mother needs to consume or avoid?

• Mother should have a variety of food rich in calories, proteins, vitamins

and roughage e.g. Cereals in the form of like Rice, Chapati, Pulses,

Green leafy vegetable and fruits & dry fruits (if available).

• Mother should avoid spicy, oily food.

79

Session No: 18

Title: Immunization

Session objectives: To familiarize Yashoda with the immunization schedule and

the impress upon her the importance of giving vaccines



1. Enumerate the vaccines that should be given at birth

2. Enumerate the vaccines that should be given in the first year of life

3. Be familiar with the vaccine schedule in the first year of the infant’s life

Time: 1 hour

Setting: Classroom followed by visit to immunization room Materials: Facilitator’s guide, Flip chart for Yashoda, handouts for Yashoda,


wipe, access to and LCD (preferred) or an OHP & a CD player, Vials of vaccines – DPT, Hepatitis B, BCG, Measles and OPV Method: Demonstration

Steps: 1 hour Classroom demonstration (Time 20 minutes)

1. Ask the trainees if they are aware of the vaccines to be given to the baby

under 1 year

2. Ask a participant whether her own children are immunized? If yes, is she

aware of which vaccines have been given?

80

3. Ask another participant if she know which diseases can be prevented

through vaccination

4. Note her answer on the board

5. Now pick up the vaccine vials one by one and display to the class.

Mention which diseases the vaccine protects against

6. Also mention the route of administration and time schedule of the vaccine

Demonstration in Vaccination room (40 minutes)

7. Divide the trainees into three groups and take them to the vaccination

room.

8. Here demonstrate each of the vaccines

9. Demonstrate the route of administration and site of vaccination

10. Demonstrate the vaccines that need to be given as zero dose

11. Ask the participant to repeat what they learnt

12. Demonstrate how to read and fill an immunization card

13. At the end, inform the participants about the points that must be told to

mothers and family of the newborn in relation to immunization

81

Trainer’s notes Which vaccines are given to children below 1 year of age?

DPT, BCG, Hep B, Measles, OPV

Which diseases do these vaccines protect against?

Name of Vaccine Disease prevented

DPT Diphtheria, Pertussis, Tetanus

BCG severe forms of childhood TB

Measles Measles

OPV Polio

Hep B Hepatitis (Jaundice)

Which vaccines should be given at birth?

Following vaccines are to be given at birth – OPV, Hep B and BCG. Yashoda should

ensure that the newborn gets these before discharge.

What is the importance of the prescribed vaccination schedule?

Timely vaccination of the child can build their immunity and prevent diseases.

Vaccines are given at specific intervals and age of life. The baby needs to be given all the

prescribed vaccinations in the first year of life. The vaccines should be given at the time

prescribed in the schedule. However, if a child has missed a dose, the ANM/nurse/doctor

can decide how the schedule can be modified to benefit the child.

What is the vaccination schedule?

BCG Polio DPT Measles Vitamin A

At

birth

At birth ----- ----- -----

6 weeks 6 weeks 9 months. 6 months

10 weeks 10 weeks 12 months

14 weeks 14 weeks. 18 months.

What is the route of administration of the vaccines?

Most vaccines are injections. Only polio vaccine is oral drops.

Where are vaccines available in the village?

Vaccination days are held at the village where an ANM visits and immunizes all the

children of the village. Ask ASHA/ANM/AWW for information on immunization days

82

Key messages Ø Ensure that the newborn has received zero dose immunization –

vaccines BCG, OPV and Hep B Ø Counsel the mother about the other vaccines that must be given to

the child along with the schedule Ø Impress upon her the importance of getting the child immunized fully

and on time

What information should the Yashoda give to the mother and family about immunization?

• Counsel the mother to immunize her baby with polio drops, BCG Vaccine,

Hepatitis B, DPT and measles vaccines.

• Communicate clearly that these vaccines must be given at the right age and

right dose. The full course must be completed for giving protection to the

child against diseases.

• Advise her to take the baby to the nearest health centre for routine

immunization. Ask her to keep the immunization card safely.

• Explain the immunization schedule to the mother and advise her when and

how many doses of each vaccine is to be given to the child.

• Make it clear to her that the full course of vaccination must be completed at

the right age to protect the child from diseases.

83

Session No. 19

Title: Family Planning methods

Session objectives:

The trainees should be well versed with the birth control options available in the

government health facilities so that they are able to guide the mother properly



1. Understand the risks of frequent pregnancies

2. Enumerate the birth control options available in government health facilities

3. Suggest an appropriate option for a woman after delivery

Time: 45 minutes

Materials: Setting: Classroom

Method: Demonstration followed by role play

Steps: Demonstration (Time: 20 minutes)

1. Ask the participants if they think it is important to space and control births.

Ask the participants to reply in Yes or No.

2. Ask what will happen if a woman has too many children

3. Ask the participants what will happen if a woman has children at a young

age

4. Discuss the answers

5. Ask the participants to mention some birth spacing options. Note these on

the board.

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6. Use the flip chart to show the pictures of the different birth spacing/control

options

7. Now enumerate them

8. Ask participants to repeat what they saw in the flip chart

9. Explain the advantages of the different methods

10. Explain how the methods can be used in different circumstances

11. Recap

12. Ask if abortion should be used as an alternative for birth control.

13. Explain why it should not be used.

Role Play (Time 25 minutes):

1. Divide the participants into three groups. Each group will have a

trainer.

2. Give the following three scenarios to the groups:

a. Yashoda counseling a 30 years old woman who has had

three children and is in the hospital to deliver a fourth one

b. Yashoda counseling a newly married girl who is in hospital to

have her first child

c. Yashoda counseling 25 years old woman who is due for her

second child

3. Let the three groups prepare the role plays in 10 minutes and

perform these in

4. 5 minutes each.

5. Discuss

6. Thank the participants and compliment them

85

Trainer’s notes Q. What is the harm in having frequent pregnancies?

A. Harm to the mother – anaemia, general weakness due to rapid loss of

nutrients

Harm to baby – Mother is unable to give adequate attention, family is

unable to provide well due to demands on family resources

Q. Which are the family planning methods available for new mothers?

• CuT (Copper T)

• Oral Contraceptive pills

• Condom

• Female Tubectomy

• Male vasectomy

86

Q. What are the advantages of each and under which circumstances can these be used? A. CuT is the most suitable method for spacing birth especially in women who

are breast feeding. It is an easily insertable device that can be removed if

more children are desired. It can be done on an OPD basis and can be done

over 10 minutes. E.g – A woman who has one child and is breast feeding the

child.

Oral contraceptive pills are pills that need to be consumed every day.

These are very suitable for birth spacing among newly married women who do

not desire to have children soon. These can also be taken by new mothers

who are not breast feeding. But, these are not to be consumed if the child is

being breast fed. E.g. A newly married woman who wants to delay first child

birth.

Condom is a temporary method of contraception. It is a device that is

used during coitus. It can be easily put and removed by the man using it. It has

the additional advantage of protecting a couple from HIV and STD/RTI.

However, it has a high rate of failure.

Tubectomy and Vasectomy are permanent methods of sterilization.

They are irreversible. So, these methods are useful for couples who have

completed their family. E.g. a couple who has had two children already

Q. Why can’t abortion not be used as an alternative to birth control? A. Repeated abortions are harmful to the health of women. They cause

weakness, blood loss & Anemia.

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Key messages Ø Having more children is a drain on the resources of the family

Ø Having more children also harms the health of the mother Ø Family planning measures like CUT, Condoms,

Vasectomy/Tubectomy can be used to control birth Ø These measures are easily available free of cost in the government

health facilities and are not time consuming

88

Session 20

Title: People available in the community to help the mother and baby

Session Objectives:

The Yashoda should be well informed about the people the mother can seek help

from regarding her and her newborn’s health after she goes back home.


After this session the trainee should be able to enumerate:

1. Who are the persons who can assist a mother regarding her and her

child’s health when she goes back home from the hospital.

2. What are the roles of these persons in the care of the child and mother

Time: 30 minutes

Setting: Classroom

Materials: Facilitator’s guide, Yashoda training kit, Black board & Chalk or White

board and pens in two colors

Method: Discussion & Task

Steps:

1. Explain that taking care of the newborn and mother is the responsibility of

every citizen since the child is the future of the society and the mother is

the creator of the child. However, some staff is provided by the

government for dedicated help and support to the family to take care of

the mother and baby at home.

89

Task

1. Draw a circle on the board. Write newborn and mother in the centre of

the circle. Draw three other circles around it.

2. Ask the participants if they can fill the circles with the names of people

who can take care of the mother and newborn in the community.

3. Let them fill the names. Correct them if there are any mistakes.

4. Ask the participants to note in the circles, the services that each worker

provides. Correct them if wrong and add any that have been missed

out.

5. Similarly, ask the trainee to draw another circle on the board with

mother and baby in hospital.

6. Ask them to draw three other circles around the central circle.

7. Ask the trainee to write in the surrounding circles the people who take

care of the mother and baby in the hospital.

8. Inform where these services are available & inform that services are

free of cost.

9. Ask the trainees to repeat

AWW Does growth monitoring,

organizes camps

ASHA New born care

Counsels mother on health, refers

ANM Treats common

ailments Immunizes, refers

New born & mother at Home

Trainer’s notes – the diagrams can be drawn as

such

Health workers responsible for newborn & mother care at home

90

Trainer’s notes: Community: The ANM/HW (Female) is available on the specified days when

she is scheduled to visit her area. Ask the AWW of your area for the schedule

of the ANM. During these visits, the ANM does the following:

• Examine pregnant and nursing mothers

• Conduct home deliveries.

• Immunize mothers and children below one year

• Distribute iron and folic acid tablets to pregnant and nursing women

• Distribute Vitamin A to children 1 to 5 years of age

• Treat mothers and children for minor ailments and refer them to PHC is

necessary

• Give health teaching about the care of mother and child

At the Sub Centre: Daily clinic is attended by a ANM/Health Worker (F). The

Services provided for mothers and children are as follows:

• Prenatal and postnatal care

• Child health care

• Immunization

• Distribution of iron and folic acid and vitamin A

• Treatment of minor ailments

• Health teaching

The weekly MCH Clinic is attended by the Medical Officer, PHC and/or LHV.

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Key messages Ø The doctor, nurse and Yashoda are responsible for care of the

newborn in the hospital Ø The ANM, AWW & Helper and the ASHA are directly responsible for

care of newborn in the community

Ø Child health services like immunization, growth monitoring & care for common ailments are available free of cost in government facilities like subcenter, Anganwadi, PHC

At the PHC: The following services are available at PHC:

• Daily general clinic attended by the one of the Medical Officer.

• Weekly out patient MCH clinics attended by one of the Medical Officers.

• In patient care

• Referral to the District Hospital

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Session 21

Title: Registration of birth & Record keeping

Session objectives:

Trainees must know how & where to register birth and what is its importance.

Trainees must be clear how to fill their records.


1. After this session, the trainee should be able to:

2. Communicate to mother the importance of registering the birth of her baby

3. Communicate to the mother how and where the birth can be registered

and how the certificate can be obtained

4. Fill completely and accurately the record Yashoda is supposed to keep

5. Know the importance of handing over the record to the next Yashoda who

takes over her duty

Time: 1 hour

Setting: Classroom

Materials: Facilitator’s guide, Yashoda training kit, Black board and Chalk, 6 two

sets of the three sheets – one sheet with one part of exercise on it.

Method: Discussion and Task

Steps:

1. Ask the trainees if they have heard of birth registration.

2. Ask if they think registering a birth is important and why

3. Ask if they know whom to inform if there is a birth in hospital or at home

4. Explain why birth registration is important.

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5. Explain who is to be informed in the hospital and in the community

Trainer’s notes: Q. Is it important to get birth registered? A. Registration of birth is very important for every child. It is the child’s right.

Q. Is birth registration useful?

A. The birth of a baby should be registered within 21 days of the birth. But it

can be registered later also if there is a delay due to any reason. A birth

certificate can only be acquired if the birth is registered. The birth certificate is

required for: Admission in school, getting a ration card, insurance, and

pension. It is essential for getting a marriage or a driver’s license. It may be

required to open a bank account, to apply for and secure formal employment

and to inherit property. A birth certificate may also be needed obtain family

allowances. A birth certificate proves identity and age. You can vote if you

have your birth certificate.

Q. How is a birth registered in a hospital? A. In case of a hospital birth, the medical officer is in-charge of informing

higher authorities. The birth certificate can be obtained from the hospital in a

few days after birth.

Q. How is a birth registered in the community? A. In case of a home birth, the head of household, ASHA, AWW or ANM

(whoever knows about the birth informs the village Panchayat secretary. He in

turn informs the Tahsildar of the Taluka. The Tahsildar issues the birth

certificate free of cost to the family.

94

BCG

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Vaccinatio

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othe

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Name of the

Dat

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Yashoda Daily Reporting Format

Dat

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Adm

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Dat

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sex

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Nam

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Name of the Hospital

Sign

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Sign

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Sl n

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Initi

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Any

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Dur

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Name of the District

Rem

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yash

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Name of the

Record keeping by Yashoda Steps:

1. Display the record sheet

2. Explain the importance of filling the record completely and accurately

3. Explain step by step the process of filling the sheet

4. Make chits with numbers written from 1 to 6.

5. There should only be three chits of each number. Ask each participant to

pick up one chit each from a box.

6. Let them open the chit and see the number written in it.

7. All persons with the same number will collect together.

8. This will form 6 groups of 3-4 Inform each group that they are a team

working in 8 hour shifts by rotation.

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9. In each small group, give one sheet to one trainee

10. Request the trainee not to look at each others sheet but fill the information

in the register and pass on the register as they would do in the hospital

11. Check the entries & discuss

Task - fill the register (20 minutes) Present the following case scenario in three parts (use three separate sheets):

Part I (sheet I)

A pregnant woman, Kamla, age 27 and her family arrived in the hospital on 10/10/08

at 10 in the morning. Kamla’s mother-in-law is very irritable and stubborn. Kamla is

due to deliver her second child. She was admitted at 10.30 in the morning in the ward

on bed number 1. She had labour pains and a nurse and Yashoda care for her.

Part II (Sheet II)

You have just reached the hospital for your duty at 6 pm and bed number 1 is

assigned to you. Kamla, age 27 is admitted on this bed. Kamla’s mother-in-law is very

irritable and stubborn. The Yashoda taking care of Kamla has left in a hurry but has

handed you her register. Kamla delivers a healthy baby boy by normal vaginal delivery

at 7 in the evening on 10/10/08. You & a nurse have to care for them.

Part III (Sheet III)

You have just reached the hospital at 6 in the morning and are assigned bed number

1. Kamla, 27 years of age delivered the previous night. Kamla is accompanied by her

husband and mother-in-law. Her mother-in-law is very irritable and stubborn. Kamla

will be discharged at 12 in the afternoon. You and a nurse have to care for them.

96

Trainer’s Notes

How to fill this register: Name of the district – Mention the name of your district here

Name of the hospital – Mention the name of your hospital here

Sl. No. – The number assigned to the entry as the mothers arrive

Name & Address – Full name and address of the mother (in case there is no house

number, mention the nearby landmark so that a field worker can easily find the

house)

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Age – Age of the mother in completed years. This is important to assess if the mother is old enough to have a safe pregnancy (above 18 years). Aged mothers are also at some risk (>35 years of age). Parity – Number of living children the mother has. This is important to give sound and practical family planning advice to the mother. BPL – Write ‘Yes’ or ‘No’. ‘Yes’ indicates that the mother and her family are below the poverty line. ‘No’ indicates that they are above the poverty line. Date and Time of admission – mention the date of admission in day/month/year format. Also enter the time as – ‘morning’, ‘afternoon’ or ‘evening’. If the mother is admitted at 12.05 midnight, the date must be mentioned as the morning of the next day. For example: 14/10/08, 12.05, morning. Date and time of delivery – This is the time at which delivery takes place. It must be entered in the same format – day/month/year. Also enter the time as – ‘morning’, ‘afternoon’ or ‘evening’. If the mother is admitted at 12.05 midnight, the date must be mentioned as the morning of the next day. For example: 14/10/08, 12.05, morning. Sex of the baby – Entered as ‘boy’ or ‘girl’. If there is any genital anomaly and the doctor says that the sex cannot be determined, this must be mentioned. Weight of the baby – The weight of the baby at birth as taken by the nurse or by yourself must be mentioned here in kgs with two decimal points. E.g 3.25 Kgs Any problem at birth – Mention if the delivery was vaginal or caesarian. If it was vaginal, was it normal or there was use of forceps or any other procedure to deliver the baby. e.g. – Vaginal, normal or vaginal, forceps. This information should be gathered from the nurse. Initiation of breastfeeding – If breast feeding was initiated, write ‘Yes’. If not, write ‘no’. If your entry is a ‘yes’ mention the time after birth when breast feeding was initiated. E.g. Yes, 1 hour after birth. Vaccination – Tick the box if the doses of BCG and OPV are given. If not, put a cross in the appropriate box.

98

Key messages Ø Registering the birth is the right of every child

Date and time of discharge - This is the time at which the mother and baby are discharged from the hospital. It must be entered in the same format – day/month/year. Also enter the time as – ‘morning’, ‘afternoon’ or ‘evening’. If the mother is admitted at 12.05 midnight, the date must be mentioned as the morning of the next day. For example: 14/10/08, 12.05, morning. Duration of stay – Mention how long the mother stays in the hospital in hours. E.g if mother is admitted on 13/10/08 at 1, afternoon and leaves on 15/10/08 at 10, morning, her duration of stay is – 43 hours. Any problem with baby - Mention if the newborn has any problem at birth E.g low birth weight baby, jaundice at birth, discharge from eyes or any such danger signs you have learnt above or congenital anomaly mentioned by the doctor/nurse. This information is to be gathered from the nurse. Any problem with mother – Mention if there is any problem with the mother. E.g mother is suffering from TB, heart disease, bled too much etc. Remarks by Yashoda – This column can be used by you to mention anything special that you notice. Signature of Yashoda – There are three columns in this section. Column 1 is to be signed by the Yashoda who is present at the time of admission. Column 2 is to be signed by Yashoda present at the time of delivery. Column 3 is to be signed by Yashoda present at the time of discharge. Signature of supervisor – The child health supervisor of your hospital will sign this after checking your entries. After filling the relevant columns in this register, Yashoda must remember to hand it to the next Yashoda on duty so that there is a continuum of care.

99

Ø The birth registration certificate will help the individual get admission in school, get a ration card, be able to vote, get a certificate of marriage & have a legal standing for any legal issues

Ø Birth registration should be ensured by Yashoda in hospital Ø In the community, the secretary of the village should be informed

about the birth by the head of the household so that he can start the process of registration

Ø Filling the register accurately and completely is very important for providing continuous care to the mother and baby

Ø It is a record of the Yashoda’s work Ø It is also a record that can be used by appropriate authorities to

compile and analyze maternal and newborn data from the hospital

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Session 22

Title: Principles of Counseling/Interpersonal communication

Session objectives:

Counselling is one of the main roles of Yashoda. The trainees must learn how

to counsel, how to ensure that their advice is relevant and practical & that it

does not antagonize the mother or her family. Trainees must also get an idea

of the hurdles they will face during the counseling

Learner’s objectives


1. Counsel the mother about her own and her newborn’s health

2. Counsel the family

3. Overcome the hurdles she may have while counseling

Time: 1 hour

Setting: Classroom

Materials: Facilitator’s guide, Yashoda training kit, Black board & chalk or

white board and felt pens, two sets of the case scenarios given below.

Method: Role Play & Discussion

Steps:

Divide the trainees into three groups.

101

Role Play - (20 minutes)

Assign the following case scenario to the groups – I part to each group

(use three separate sheets. Do not allow the groups to interact with each

other. Let an active & energetic trainee to assume the role of Kamla’s mother-

in-law and ask her to be stubborn. Let another trainee assume the role of

Kamla. Another trainee can assume the role of Kamla’s husband. In this way,

the family continues to be the same while the nurse and Yashoda change)

Group I (sheet I)

A pregnant woman, Kamla, age 27 and her family arrived in the hospital on

10/10/08 at 10 in the morning. Kamla’s mother-in-law is very irritable and

stubborn. Kamla is due to deliver her second child. She was admitted at 10.30

in the morning in the ward on bed number 1. She had labour pains and a

nurse and Yashoda care for her.

Group II (Sheet II)

You have just reached the hospital for your duty at 6 pm and bed number 1 is

assigned to you. Kamla, age 27 is admitted on this bed. Kamla’s mother-in-law

is very irritable and stubborn. The Yashoda taking care of Kamla has left in a

hurry but has handed you her register. Kamla delivers a healthy baby boy by

normal vaginal delivery at 7 in the evening on 10/10/08. You & a nurse have to

care for them.

Group III (Sheet III)

You have just reached the hospital at 6 in the morning and are assigned bed

number 1. Kamla, 27 years of age delivered the previous night. Kamla is

accompanied by her husband and mother-in-law. Her mother-in-law is very

irritable and stubborn. Kamla will be discharged at 12 in the afternoon. You

and a nurse have to care for them.

102

Discuss each principle of counseling in the context of their

performance –

a. Did the group attempt to build a rapport with the mother and her

family?

b. Did the group make an effort to ask relevant questions and listen

patiently to the answers

c. Did the group give sound and practical advise relevant to the

mother and family’s context?

3. After you discuss the principles of counseling with the trainees, you can

ask a group to again perform role play ‘b’ applying the principles that they

have learnt.

103

Trainer’s Notes:

The following preface can be used to explain to Yashoda why we are trying

to teach her how to interact better with others.

We constantly interact with each other in everyday life. If we are better

informed than the other person, we try to impart our knowledge to them. It

is easy to impart information. But, being informed does not mean that we

will change our attitude or behavior based on that information. In fact, it is

very difficult to change another person’s attitude and behavior however

harmful or wrong it may.

Each one of us has our own idea about how to take care of our health

and our family’s health. All of these ideas may not be incorrect. As a health

counselor, our role is to; be well informed about how to take best care of

ourselves and the community, have a positive attitude and follow in our

own life the healthy behavior that we preach. Only after this, we can think

of trying to instill healthy behavior and best practices among others.

Changing other people’s attitude and behavior cannot be done in a day

and is a long and uphill journey. However, some of the following principles

may help you while you are counseling the mother and family.

104

Q. How can we build a rapport with the mother and her family? A. Build a rapport by greeting, introducing yourself and explaining why you

are in the hospital

Gather information to understand the problem, understand the family’s

circumstances and to develop a care plan.

• This can be done by questioning and listening.

• Speak clearly, use local language, avoid medical words

• Be patient

• Listen to the mother and family

• Ask questions but be careful not to hurt the sentiments of the

mother and family

• Have positive body language and don't make any gestures which

may not be liked by them

• Do not be judgmental

Q. What is Empathy? A. Showing empathy is the ability to put yourself in someone else’s

place and feel how they feel in a situation.

Listening is important.

Most of us are very fond of our own voice and we love to talk.

Especially, if we feel that are more knowledgeable than the other, it is

easy to get carried away while advising. However, we must always

remember that all of us have our own beliefs and circumstance and

may not like to be advised. Often there may be situations where our

receiver may listen but may not be able to follow the given advice since

it is impractical in their circumstances. So, it is very important to

understand the receiver’s circumstances so that we may be able to give

sound, practical advice.

105

Q. But, how can we be better listeners?

• Pay attention to the person, showing interest, and hearing what

is being said.

• Be attentive

• Concentrate on the client (eye contact, lean toward them, nod

your head).

• Don’t interrupt.

• Express your feelings and queries once she/he stops

• Don’t jump to conclusions or diagnosis without hearing what the

person has to say.

• Avoid - not making eye contact, interrupting, jumping to

conclusions, not asking for more information, tapping feet,

shuffling papers, looking outside or making bad gestures,

finishing sentences for the speaker

• Praise the mother if she has done something good (given good

care, came immediately if danger sign appeared, etc.). This

helps raise her self confidence.

• Confirm what you have understood from their expressions

• You may repeat what they have said and felt.

• Acknowledge feelings

106

Key messages Ø To be a good counselor, rapport building by greeting the mother and

her family and being polite and respectful to them is most important

Ø Ask questions and listen to their answers showing interest, and hearing what is being said

Ø Understand the mother’s circumstances Ø Explain the care plan to the mother and family

Ø Counsel giving practical, feasible points that do not offend and are acceptable by the mother and her family

Q. How can we Counsel better?

• Try to explore parent’s understanding of illness or situation to

see what they already know

• You can supplement what they already know instead of talking to

them as if they didn’t know anything.

• It can also identify any beliefs/ practices that may be harmful.

• Correct, misconception of facts:

• Try to convince to avoid or modify the incorrect belief/practices

• Be careful and sensitive when you correct misconceptions- do

not make the person feel stupid.

• Explain the situation clearly in simple language

• Explain the care plan (as understood from the doctor/ nurse)

• What the mother (or father) needs to do?

• Ask the mother to repeat what she has understood in her own

words.

• Encourage to follow the care plan (treatment)

• Summarize and repeat key information

• Follow up as indicated (as informed by the doctor/ nurse)

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