minilaparotomy under local...

Minilaparotomy under Local Anesthesia

Learner’s Guide

MCSP is a global USAID initiative to introduce and support high-impact health interventions in 25 priority countries to help prevent child and maternal deaths. MCSP supports programming in maternal, newborn, and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. MCSP will tackle these issues through approaches that also focus on household and community mobilization, gender integration, and digital health, among others. This material was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of MCSP and do not necessarily reflect the views of USAID or the United States Government. January 2018

Minilaparotomy under Local Anesthesia: Learner’s Guide i

Table of Contents Overview ........................................................................................................................................ 1

Before Starting This Course ................................................................................................................................ 1 Training Approach Used ....................................................................................................................................... 1 How People Learn ................................................................................................................................................. 2 Competency-Based Training ................................................................................................................................ 3 Humanistic Training Techniques ......................................................................................................................... 4 Components of the Minilaparotomy Training Package ................................................................................. 4 Using the Minilaparotomy Training Package .................................................................................................... 5

Introduction ................................................................................................................................... 6 Course Design ........................................................................................................................................................ 6 Evaluation ................................................................................................................................................................. 6 Learning Objectives ............................................................................................................................................... 7 Course Syllabus ....................................................................................................................................................... 8

Instructions for Using the ZOE® Gynecological Simulator ..................................................... 16 Contents ................................................................................................................................................................. 16 Assembly ................................................................................................................................................................ 17 Performing Procedures ....................................................................................................................................... 19 Care and Maintenance ......................................................................................................................................... 20

Minilaparotomy under Local Anesthesia Knowledge Assessment ......................................... 21

Checklists for Minilaparotomy Clinical and Counseling Skills ................................................ 25 Using the Checklists ............................................................................................................................................ 25 Checklist for Interval Minilaparotomy Clinical Skills .................................................................................... 26 Checklist for Postpartum Minilaparotomy Clinical Skills ............................................................................ 29 Checklist for Minilaparotomy Clinical Skills for Circulating Nurses ........................................................ 31 Checklist for Minilaparotomy Clinical Skills for Nursing Assistants ........................................................ 33 Checklist for Counseling for Minilaparotomy in the Interval Period ....................................................... 35 Checklist for Counseling for Minilaparotomy in the Postpartum Period ............................................... 37 Checklist for Verbal Anesthesia ........................................................................................................................ 39

Course Evaluation ....................................................................................................................... 41

ii Minilaparotomy under Local Anesthesia: Learner’s Guide

Minilaparotomy under Local Anesthesia: Learner’s Guide 1

OVERVIEW Before Starting This Course Welcome to the minilaparotomy under local anesthesia clinical skills training course! You may benefit from understanding a few things about the course before getting started. First, it will be conducted in a way that is very different from traditional training courses—based on the assumption that you are here because you:

• Are interested in providing minilaparotomy services;

• Wish to improve your knowledge and skills in minilaparotomy service delivery, and thus your job performance; and

• Desire to be actively involved in course activities. Therefore, the course will be very participatory and interactive, helping to create an environment that is conducive to learning. The development and assessment of your skills throughout the course will focus more on your performance than on what you know or have memorized. This is because clients deserve providers who are able to provide safe and effective services, not just knowledgeable about them. A variety of educational technologies will be used to maximize the effectiveness and efficiency of course activities, enhancing your learning experience while conserving valuable resources. All of the course materials focus on the learner. For example, the course content and activities are intended to promote learning, and the learner is expected to be actively involved in all aspects of that learning. The facilitator will create a comfortable environment and promote activities assist the learner in acquiring new knowledge, attitudes, and skills. The competency-based training approach used in this course stresses the importance of cost-effective use of resources, application of relevant educational technologies, and use of detailed (step-by-step) counseling and clinical skills checklists to help learner learn and measure their own progress. Competency-based knowledge questionnaires and the skills checklists assist the facilitator in evaluating each learner’s performance objectively.

Training Approach Used In the context of clinical skills training, the mastery learning approach assumes that all learners can master—or “achieve competency” in—the knowledge and skills required to provide a specific health service, provided that sufficient time is allotted and appropriate training methods are used. The goal of mastery learning is for 100% of those being trained to be competent in providing services by the end of the course. Skill competency means that the provider knows the steps and their sequence and can perform the required skill or activity safely, effectively, and independently at a “beginning level,” which is the goal of the course. Providers will become proficient in a skill only after they have regularly used it in the workplace. Skill proficiency means that the provider knows the steps and their sequence, and efficiently performs the required skill or activity. Key points about the mastery learning approach, as used in this course, include:

• From the outset, learners know (as individuals and a group) what they are expected to learn and where to find the information they need. They have ample opportunity for discussion with the facilitator about course content and their performance. This makes the training less stressful.

• Because people vary in their abilities to absorb new material, and learn best in different ways (e.g., through written, spoken, or visual means), a variety of learning methods are used. This helps to ensure that all learners have the opportunity to succeed.

2 Minilaparotomy under Local Anesthesia: Learner’s Guide

• Self-directed learning enables learner to become active participants in their progress toward course goals. To facilitate this learner role, the clinical trainer serves as a facilitator or “coach,” rather than as a more traditional instructor. Learners are also supported in identifying their own weaknesses and creating individualized plans for success.

• Continual assessment increases learners’ opportunities for learning. Through a variety of techniques, the facilitator keeps learners informed of their progress in learning new information and skills, so that they will know where they need to focus their efforts to achieve competency.

How People Learn

• Training must be relevant. Learning experiences should relate directly to the job responsibilities of the learners.

• People often bring a high level of motivation to training:

• Desire to improve job performance

• Desire to learn

• Desire to improve their life

• People need involvement during training. This can be accomplished by:

• Allowing learners to provide input regarding schedules, activities, and other events

• Using questioning and feedback

• Using brainstorming and discussions

• Providing hands-on work

• Conducting group and individual projects

• Setting up classroom activities or games

• People desire variety. Ways to provide this include:

• Varying the schedule

• Using a variety of audiovisuals aids:

− Slides

− Videotapes

− Overhead transparencies

− Flip charts or blackboards

− Models or real objects

• Using a variety of teaching methods:

− Illustrated lectures

− Demonstrations

− Small group activities

− Group discussions

− Role plays and case studies

− Guest speakers


• People need positive feedback. Positive feedback is letting learners know how they are doing, and providing this information in a positive manner. The facilitator provides positive feedback when she or he does one or more of the following:

• Verbally praising the learner either in front of other learners or individually

• Recognizing appropriate responses during questioning:

− “That’s correct!”

− “Good answer!”

− “That was an excellent response!”

• Acknowledging appropriate skills while coaching in a clinical setting:

− “Very good work!”

− “I would like everyone to notice the incision that was just made. Ilka did an excellent job and your incisions should look like this one.”

• Letting the learners know how they are progressing toward achieving the learning objectives.

Competency-Based Training Competency-based training (CBT) is distinctly different from the traditional educational process; it is learning by doing. How the learner performs is emphasized rather than just what information the learner has acquired. This course focuses on the specific knowledge, skills, and attitudes needed to carry out LEEP service delivery-related tasks. To accomplish CBT successfully, the clinical skill or activity to be taught is first broken down into its essential steps. Each step is then analyzed to determine the most efficient and safe way to teach and learn it, a process called standardization. Once a procedure such as minilaparotomy under local anesthesia has been standardized, competency-based checklists can be developed to measure progress in learning and evaluate the learner’s overall performance of the skill or activity. An essential component of CBT is coaching. Coaching incorporates questioning, providing positive feedback, and active listening to help learners develop specific competencies, while encouraging a positive learning climate. In the role of coach, the facilitator first explains the skill or activity and then demonstrates it using an anatomic model or other training aid, such as a video or a checklist. Once the procedure has been demonstrated and discussed, the facilitator/coach observes and interacts with the learner to provide guidance as she/he practices the skill or activity. The facilitator continues monitoring learner progress—providing suggestions and feedback, as needed, to help the learner overcome problems, build confidence, and work toward greater independence. The coaching process ensures that the learner receives feedback regarding performance:

• Before practice—The facilitator and learner should briefly meet prior to each practice session to review the skill/activity including the steps/tasks that will be emphasized during the session.

• During practice—The facilitator observes, coaches, and provides feedback to the learner as she or he performs the steps/tasks as outlined in the checklist.

• After practice—This feedback session should take place immediately after practice. Using the checklist, the facilitator discusses the strengths of the learner’s performance and also offers specific suggestions for improvement.

When CBT is integrated with adult learning principles and is based on behavior modeling, the result is a powerful and extremely effective method for providing technical training. And, when the use of anatomic models and other teaching aids is incorporated, training time (and training costs) can be significantly


reduced. For example, in a study conducted in Thailand, the traditional IUD training method was compared with one using the CBT approach just described. When trainees were allowed to learn and repeatedly practice with pelvic models, 70% of the 150 trainees were judged to be competent after just two insertions in clients, and 100% by six. By contrast, of the 150 trainees taught without the use of pelvic models, 50% obtained competency only after an average of 6.5 insertions and 10% never achieved competency (i.e., were not qualified) even after 15. Incorporating the use of models (humanistic training) facilitates learning by allowing learners to learn and practice new skills initially in a simulated setting rather than with clients. This reduces stress for the learner as well as minimizes the risk of injury and discomfort to the client. Thus, employing this more humane training approach is an important component in improving the quality of clinical training and, ultimately, service provision.

Humanistic Training Techniques As described above, anatomic models that closely simulate the human body are used by learners for initial skill acquisition in minilaparotomy under local anesthesia and for enabling them to attain skill competency prior to working with clients in the clinical setting.

TERMS USED TO DESCRIBE THE LEVELS OF CLINICAL SKILL PERFORMANCE

Skill Acquisition: Knows the steps and their sequence (if necessary) to perform the required skill or activity but needs assistance

Skill Competency: Knows the steps and their sequence (if necessary) and can perform the required skill or activity

Skill Proficiency: Knows the steps and their sequence (if necessary) and efficiently performs the required skill or activity

For example, before a learner performs a clinical procedure with a client, two learning activities should occur:

• The facilitator should demonstrate the required skills and client interactions several times using an anatomic model and other appropriate training aids.

• While being supervised, the learner should practice the required skills and client interactions using the model and actual instruments in a simulated setting that is as similar as possible to the real situation.

Only when skill competency and some degree of skill proficiency have been demonstrated should the learner have her/his first contact with a client.

Components of the Minilaparotomy Training Package This clinical training course is built around use of the following components:

• Need-to-know information contained in a reference manual

• A Learner’s Guide for course participants containing questionnaires and checklists that break down the skill or activity (e.g., counseling or minilaparotomy) into its essential steps

• A Facilitator’s Guide including questionnaire answer keys, checklists, and detailed information about conducting the course


• Well-designed audiovisual materials, such as anatomic models and other training aids

• Competency-based performance evaluation The reference manual designed for use in this course is Minilaparotomy under Local Anesthesia. It is organized into 11 chapters and 8 appendices and contains essential information on the following topics: counseling; informed choice; eligibility, precautions, and client assessment; recommended infection prevention and control; anesthesia; the surgical procedure; postpartum minilaparotomy; postoperative recovery, discharge, and follow-up; management of complications; and mobile outreach services.

Using the Minilaparotomy Training Package As described above, when CBT is combined with behavioral modeling, it is particularly well-suited to providing technical training, such as minilaparotomy under local anesthesia and counseling. In designing the training materials for this course, particular attention has been paid to making them “user-friendly” and to permit the learners and facilitator the widest possible latitude in adapting the training to the learners’ (group and individual) learning needs. For example, at the beginning of each course, an assessment is made of each learner’s knowledge and clinical skills. The results of this precourse assessment are then jointly used by the learners and facilitator to adapt the course content as needed so that the training focuses on acquisition of new information and skills. A second feature relates to the use of the reference manual and facilitator and learner guides. The reference manual is designed to provide all of the essential information needed to conduct the course in a logical manner. Because it serves as the “text” for the learners and the “reference source” for the facilitator, special handouts or supplemental materials are not needed. In addition, because the manual contains only information that is consistent with the course goals and objectives, it becomes an integral part of all classroom exercises—such as giving an illustrated lecture or providing problem-solving information. The Learner’s Guide, on the other hand, serves a dual function. First, and foremost, it is the “road map” that guides the learner through each phase of the course. It contains the course syllabus and schedule as well as all supplemental printed materials (precourse questionnaire, individual and group assessment matrix, checklists, and course evaluation) needed during the course. The Facilitator’s Guide contains the same material as the guide for the learner as well as materials specifically for the facilitator. This includes the course outline, precourse questionnaire answer key, midcourse questionnaire and answer key, and competency-based qualification checklists. In keeping with the training philosophy on which this course is based, all training activities, whether in the classroom or clinic, will be conducted in an interactive, participatory manner. This requires that the role of the facilitator continually change throughout the course. For example, she or he is an instructor when presenting a classroom demonstration; a facilitator when conducting small group discussions or using role plays; and shifts to the role of coach when helping learners practice a procedure. Finally, when objectively assessing performance, she or he serves as an evaluator. In summary, the CBT approach used in this course incorporates a number of key features. First, it is based on adult learning principles, which means that it is interactive, relevant, and practical. Moreover, it requires that the clinical trainer facilitate the learning experience rather than serve in the more traditional role of an instructor or lecturer. Second, it involves use of behavior modification (modeling theory) to facilitate learning a standardized way of performing minilaparotomy under local anesthesia and counseling patients. Third, it is competency-based. This means that evaluation of the learner is based on how well the learner performs the procedure or activity, not just on how much has been learned. Fourth, where possible, it relies heavily on the use of anatomic models and other training aids (i.e., it is humanistic) to enable learners to practice repeatedly the standardized way of performing the skill or activity before working with clients. Thus, by the time each learner’s performance is evaluated by the facilitator using the checklist, every learner should be able to perform every skill or activity competently. This is the ultimate measure of clinical training.


INTRODUCTION Course Design This clinical training course is designed for specialists in surgery, general practitioners, or other clinicians, such as clinical officers. The course builds on each learner’s past knowledge and takes advantage of her/his high motivation to accomplish the learning tasks in the minimum time. Training emphasizes doing, not just knowing, and uses competency-based evaluation of performance. This training course differs from traditional courses in several ways:

• During the first day of the course, learners demonstrate their knowledge of the management of minilaparotomy services by completing a written test (precourse questionnaire). In addition, learners’ skills in performing a pelvic examination, using the uterine elevator, and performing other steps in minilaparotomy are assessed through use of a pelvic model that closely simulates the real situation.

• Classroom and clinic sessions focus on key aspects of service delivery (e.g., counseling of clients, how to provide services and manage side effects and other health problems).

• Progress in knowledge-based learning is measured during the course using a standardized written test (midcourse questionnaire).

• Clinical skills training builds on the learner’s previous family planning experience. Learners first practice on the anatomic model. In this way, they learn more quickly the skills needed to perform minilaparotomy competently with clients.

• Progress in learning new skills is documented using detailed checklists for clinical skills.

• Evaluation of each learner’s performance is conducted by a facilitator using competency-based skills checklists.

Successful completion of the course is based on mastery of both the content and skills components, as well as satisfactory overall performance of minilaparotomy counseling and clinical skills.

Evaluation This clinical training course is designed to produce qualified minilaparotomy service providers. Qualification is a statement by the training institution(s) that the learner has met the requirements of the course in knowledge, skills, and practice. Qualification does not imply certification. Personnel can be certified only by an authorized organization or agency. Qualification is based on the learner’s achievement in three areas:

• Knowledge—A score of at least 85% on the midcourse questionnaire

• Skills—Satisfactory performance of minilaparotomy counseling and clinical skills

• Practice—Demonstrated ability to provide minilaparotomy services in the clinical setting Responsibility for the learner becoming qualified is shared by the learner and the facilitator. The evaluation methods that will be used in the course are described briefly below:

• Midcourse questionnaire. This knowledge assessment will be given at the time in the course when all subject areas have been presented. An 85% or more correct score indicates knowledge-based mastery of the material presented in the reference manual. For those scoring less than 85% on their first attempt, the facilitator should review the results with each learner individually and guide her/him on using the reference manual to learn the required information. Learners scoring less than 85% can take the midcourse questionnaire again at any time during the remainder of the course.


• Counseling and Clinical Skills Checklists. The facilitator will use these checklists to evaluate each learner as he or she counsels clients and performs minilaparotomy with clients. Evaluation of the counseling skills of each learner may be done with clients; however, it may be accomplished at any time during the course through observation during role plays using learners or volunteers. Evaluation of the clinical skills usually will be done on the last day of the course (depending on class size and client caseload).

In determining whether the learner is qualified, the facilitator(s) will observe and rate the learner’s performance for each step of the skill or activity. The learner must be rated “satisfactory” in each skill or activity to be evaluated as qualified.

• Provision of Services (Practice). During the course, it is the facilitator’s responsibility to observe each learner’s overall performance in providing minilaparotomy services. This provides a key opportunity to observe the impact on clients of the learner’s attitude—a critical component of high-quality service delivery. Only by doing this can the facilitator assess the way the learner uses what he or she has learned.

It is recommended that, if possible, graduates be observed and evaluated in their institution by a course facilitator using the same counseling and clinical skills checklist within 3 to 6 months of qualification. (At the very least, the graduate should be observed by a skilled provider soon after completing training.) This postcourse evaluation activity is important for several reasons. First, it not only gives the graduate direct feedback on her/his performance, but also provides the opportunity to discuss any startup problems or constraints to service delivery (e.g., lack of instruments, supplies, or support staff). Second, and equally important, it provides the training center, via the facilitator, key information on the adequacy of the training and its appropriateness to local conditions. Without this type of feedback, training easily can become routine, stagnant, and irrelevant to service delivery needs.

Learning Objectives By the end of the training course, the learner will be able to:

1. Understand the principles and requirements for performing minilaparotomy under local anesthesia.

2. Provide effective counseling about minilaparotomy under local anesthesia.

3. Understand and apply the principles of informed choice for voluntary sterilization.

4. Explain eligibility, precautions, and client assessment for minilaparotomy under local anesthesia.

5. Use recommended infection prevention and control practices in the provision of minilaparotomy that minimize the risk of postoperative infections and contracting hepatitis B and HIV/AIDS.

6. Understand the principles of and requirements for the use of local anesthesia, including the importance of emotional preparation of the client and continual communication during surgery.

7. (Surgeon) Perform standard minilaparotomy procedures, including both interval and postpartum procedures, under local anesthesia.

8. (Nurse) Prepare the client for surgery and assist the surgeon during the minilaparotomy procedure.

9. Perform routine postoperative management for minilaparotomy, including discharge, follow-up, and appropriate management of side effects and other health problems.

10. Recognize and manage surgical and anesthesia-related complications.

11. Describe the basic requirements of mobile outreach services for minilaparotomy.


Course Syllabus Course Description This 12-day clinical training course is designed to prepare the learner to counsel individuals concerning minilaparotomy and to become competent in performing minilaparotomy under local anesthesia, managing surgical complications, and providing routine follow-up care.

Course Goals

• To influence in a positive way the attitudes of the learner toward the benefits and appropriate use of minilaparotomy

• To provide the learner with method-specific counseling skills for minilaparotomy, including verification of informed consent

• To provide the learner with the knowledge and skills needed to perform minilaparotomy under local anesthesia

• To provide the learner with the knowledge and skills needed to manage surgical complications and provide routine follow-up care

• To provide the learner with basic knowledge about mobile outreach services for minilaparotomy

How to Structure the Course for Postpartum ML/LA, for Interval ML/LA, or for Both The materials provided in this learning resource package can be used to structure training courses that cover both postpartum and interval ML/LA, or focus only on postpartum ML/LA skills, or only on interval ML/LA skills. While this decision will be mainly based on the training needs, the different versions provide flexibility for conducting courses at facilities with different capacities. For instance, facilities that provide labor and delivery services exclusively can participate as learning sites for postpartum ML/LA, while facilities where mostly interval procedures are provided can conduct interval ML/LA training. Similarly, providers can be trained on the required technique(s) (either or both), depending on the facility or clinic where they are working. While the basic knowledge and skills required for both for postpartum and interval ML/LA are the same, there are a few minor differences in the procedure itself, in addition to a few differences in confirming client eligibility and scheduling. Below are some of the points that facilitators should plan for when they are designing an interval or postpartum only ML/LA.

• The reference manual, as well as the learner and facilitator guides, covers all of the information required for both interval and postpartum ML/LA, and no additional resources are required for adaptations.

• Facilitators can use the sample 6-day schedule and modify it as needed to conduct either a postpartum ML/LA or interval ML/LA course. The 12-day training allows learners to practice with both interval and postpartum clients. However, the decision about the duration of the course should be determined to ensure that all learners have sufficient practice time to reach competency on real clients.

• Facilitators should work with other stakeholders and partners in choosing the sites with sufficient numbers of cases for each type of client.

• A flowchart outlining the differences for service provision and application of the procedure for interval and postpartum ML/LA is provided at the end of this section (Setting Up Training and Clinical Service Provision for INTERVAL or POSTPARTUM Minilaparotomy).


Training/Learning Methods

• Illustrated lectures and group discussions

• Individual and group exercises

• Role plays

• Simulated practice with anatomic (pelvic) model

• Guided clinical activities (pre-operative assessment and minilaparotomy under local anesthesia)

Training Materials

This guide is designed to be used with the following materials:

• Reference manual: Minilaparotomy under Local Anesthesia

• Minilaparotomy kits

• Anatomic (pelvic) models

• PowerPoint presentations and job aids

Learner Selection Criteria Learners for this course should be clinicians (a team of a surgeon and a nurse) working in a health care facility (clinic or hospital) that provides women’s health services, including family planning. The facility should have an anticipated caseload sufficient to support the provision of minilaparotomy services. Throughout this guide, and in other components of the learning resource package, the term “surgeon” is used to describe the person performing the procedure—it could be a specialist in surgery, a general practitioner, or other clinician (such as a clinical officer who has been trained in the procedure).

Evaluation

Learner

• Precourse Clinical Skills Assessment (completed by facilitator)

• Pre- and midcourse questionnaires

• Checklists for Minilaparotomy Counseling and Clinical Skills for surgeons, circulating nurses, and nursing assistants (used by the learner to acquire and practice skills during the course, and completed by the facilitator for qualification at the end of the course)

Course

• Course Evaluation (completed by learner)

Course Duration

• Twenty-four sessions in a 2-week (12 days) sequence.

• The course schedule included here for both postpartum and interval minilaparotomy skills is for 12 days, which can be modified as needed to ensure that all learners acquire competency.


• If the course is designed separately to cover only postpartum or only interval minilaparotomy skills, then course duration can be 6 days, but again, it can be modified as needed.

• Sample course schedules are provided for 12 days (both postpartum and interval), and 6 days (either postpartum only or interval only).

Suggested Course Composition

• Five surgical teams (10 learners)

• Two facilitators

• One counseling/infection prevention/clinic management facilitator Note: The course size will be limited by the available operating room (OR) space and the number of potential minilaparotomy clients per session at the clinical training sites.

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or t

o se

t up

OR

, was

te d

ispo

sal,

and

inst

rum

ent

proc

essi

ng.)

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Bei

ng p

repa

red

for

emer

genc

ies:

Gro

up

1: L

ist

emer

genc

y eq

uipm

ent;

Gro

up

2: L

ist

emer

genc

y dr

ugs;

Gro

up

3: L

ist

skill

s re

quir

ed t

o re

spon

d to

em

erge

ncie

s.

Rev

iew

: Rec

ogni

zing

and

man

agin

g in

trao

pera

tive

com

plic

atio

ns

OR

Pra

ctic

e:

Gro

up

3: A

ssis

t/pe

rfor

m M

L/LA

;

Gro

up

1: P

ract

ice

clie

nt c

ouns

elin

g,

pre-

op a

sses

smen

t, an

d cl

ient

pr

epar

atio

n;

Gro

up

2: O

bser

ve IP

C p

ract

ices

be

fore

and

aft

er s

urge

ry.

Lear

ners

ass

ess

each

oth

er’s

pe

rfor

man

ce u

sing

che

cklis

ts.

P.M

. (3

ho

urs

)

Exe

rcis

e: R

evie

w t

he a

sses

smen

t m

atri

x to

iden

tify

indi

vidu

al a

nd g

roup

le

arni

ng n

eeds

.

Dis

cuss

ion

: Fun

dam

enta

ls o

f m

inila

paro

tom

y un

der

loca

l an

esth

esia

(M

L/LA

)

Dem

on

stra

tio

n: In

terv

al

min

ilapa

roto

my:

Ani

mat

ed v

ideo

Pelv

ic m

odel

Rev

iew

of d

ay’s

act

iviti

es

To

ur

of c

linic

al w

orki

ng a

rea

P.M

. (3

ho

urs

)

Dis

cuss

ion

: Key

feat

ures

of M

L/LA

, in

clud

ing:

Elig

ibili

ty

Pr

ecau

tions

Clie

nt a

sses

smen

t

Dis

cuss

ion

: Pai

n m

anag

emen

t

Dem

on

stra

tio

n: T

echn

ique

for

loca

l an

esth

esia

usi

ng Z

OE

pelv

ic m

odel

Cla

ssro

om

Pra

ctic

e: S

urge

on/n

urse

te

ams

prac

tice

ML/

LA u

sing

pel

vic

mod

els

and

chec

klis

ts.

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

Dis

cuss

ion

: Fam

ily p

lann

ing

coun

selin

g:

C

ouns

elin

g sk

ills

M

etho

d-sp

ecifi

c co

unse

ling

In

form

ed c

onse

nt

U

se o

f Bal

ance

d C

ouns

elin

g St

rate

gy P

lus

(BC

S+)

Ro

le P

lay:

Div

ide

into

tea

ms

to

prac

tice:

Cou

nsel

ing

ML/

LA A

ccep

tor

and

Ver

ifyin

g In

form

ed C

hoic

e an

d C

onse

nt

Lear

ners

ass

ess

each

oth

er’s

pe

rfor

man

ce u

sing

che

cklis

ts.

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

OR

Pra

ctic

e:

Gro

up

2: A

ssis

t/pe

rfor

m M

L/LA

;

Gro

up

3: P

ract

ice

clie

nt, c

ouns

elin

g,

pre-

op a

sses

smen

t, an

d cl

ient

pr

epar

atio

n;

Gro

up

1: O

bser

ve IP

C p

ract

ices

be

fore

and

aft

er s

urge

ry.

Lear

ners

ass

ess

each

oth

er’s

pe

rfor

man

ce u

sing

che

cklis

ts.

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

Dis

cuss

ion

: Diff

eren

ces

betw

een

inte

rval

and

pos

tpar

tum

(PP

) M

L/LA

:

Cou

nsel

ing,

pre

oper

ativ

e pr

epar

atio

n

Tec

hniq

ue

C

omm

on c

ompl

icat

ions

Tim

ing

of t

he p

roce

dure

Hos

pita

l sta

y

Dem

on

stra

tio

n: P

ostp

artu

m M

L/LA

us

ing

mod

el

Pra

ctic

e: P

P M

L/LA

usi

ng m

odel

R

evie

w o

f day

’s a

ctiv

ities

Ass

ign

men

t: C

hapt

ers

1, 4

, 6, 7

A

ssig

nm

ent:

Cha

pter

s 2,

3, 8

; A

ppen

dix

B A

ssig

nm

ent:

Cha

pter

5; A

ppen

dice

s C

, D, E

, F

Ass

ign

men

t: C

hapt

er 8

; App

endi

x A

Ass

ign

men

t: C

hapt

er 9

; App

endi

x G

12

Min

ilap

aro

tom

y u

nd

er L

oca

l An

esth

esia

: Lea

rner

’s G

uid

e

MIN

ILA

PA

RO

TO

MY

UN

DE

R L

OC

AL

AN

ES

TH

ES

IA (

ML

/LA

) T

RA

ININ

G C

OU

RS

E S

CH

ED

UL

E (

Sta

nd

ard

Co

urs

e: 1

2 d

ays,

24

sess

ion

s, 6

ho

urs

per

d

ay)

Day

6

Day

7

Day

8

Day

s 9,

10,

& 1

1 D

ay 1

2

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Pha

rmac

olog

y of

dru

gs

for

pain

man

agem

ent

OR

Pra

ctic

e:

Gro

ups

1 a

nd

2: P

erfo

rm M

L/LA

;

Gro

up

3: O

bser

ve/a

ssis

t:

Sett

ing

up p

roce

dure

roo

m

T

raffi

c flo

w in

OR

Surg

ical

att

ire

D

econ

tam

inat

ion

of

inst

rum

ents

/glo

ves

H

andl

ing

cont

amin

ated

was

tes

St

erili

zatio

n

Faci

litat

ors

asse

ss p

erfo

rman

ce u

sing

ch

eckl

ist.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Ro

le P

lay/

Dis

cuss

ion

: Tra

nsfe

r fr

om O

R t

o di

scha

rge

D

isch

arge

pre

para

tion

R

evie

w o

f rec

ordk

eepi

ng s

yste

m

OR

Pra

ctic

e:

Gro

ups

1 a

nd

3: P

erfo

rm M

L/LA

;

Gro

up

2: O

bser

ve:

Se

ttin

g up

pro

cedu

re r

oom

Tra

ffic

flow

in O

R

Su

rgic

al a

ttir

e

Han

dlin

g co

ntam

inat

ed w

aste

s

HLD

Faci

litat

ors

asse

ss p

erfo

rman

ce u

sing

ch

eckl

ist.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Qua

lity

serv

ice:

A

sses

sing

and

impr

ovin

g qu

ality

of

volu

ntar

y st

erili

zatio

n (V

S) s

ervi

ces

OR

Pra

ctic

e:

Gro

ups

2 a

nd

3: P

erfo

rm M

L/LA

;

Gro

up

1: O

bser

ve a

nd a

ssis

t as

ne

eded

ML/

LA p

roce

dure

s pe

rfor

med

by

Gro

up(s

) 2

and/

or 3

.

Ass

ista

nts

wor

k w

ith t

he O

R s

taff

to

set

up O

R, w

aste

dis

posa

l, an

d in

stru

men

t pr

oces

sing

.

Faci

litat

ors

asse

ss p

erfo

rman

ce u

sing

ch

eckl

ist.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

OR

Pra

ctic

e

Gro

ups

rota

te a

ccor

ding

to

lear

ners

’ ne

eds.

Faci

litat

ors

asse

ss p

erfo

rman

ce fo

r q

ual

ifica

tio

n u

sing

che

cklis

t.

Intr

odu

ctio

n t

o A

ctio

n P

lan

(D

ay 9

): S

tart

ing/

expa

ndin

g M

L/LA

se

rvic

es a

t le

arne

rs’ f

acili

ties

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

OR

Pra

ctic

e

Gro

ups

rota

te a

ccor

ding

to

lear

ners

’ ne

eds.

Faci

litat

ors

asse

ss p

erfo

rman

ce fo

r q

ual

ifica

tio

n u

sing

che

cklis

t.

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

Dem

on

stra

tio

n/D

iscu

ssio

n:

Pr

oble

m s

olvi

ng in

IPC

A

dis

cuss

ion

of t

he IP

C p

robl

ems

lear

ners

enc

ount

er in

the

ir o

wn

clin

ics,

and

sol

utio

ns t

o ad

dres

s th

em

Dis

cuss

ion

: Pos

tope

rativ

e re

cove

ry

and

follo

w-u

p ca

re:

Po

st-o

pera

tive

mon

itori

ng

Po

st-o

pera

tive

disc

harg

e

Fo

llow

-up

Pra

ctic

e S

essi

on

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

Dis

cuss

ion

: Man

agem

ent

of

com

plic

atio

ns:

Gro

up

1: A

nest

hesi

a co

mpl

icat

ions

;

Gro

up

2: I

ntra

-ope

rativ

e co

mpl

icat

ions

;

Gro

up

3: P

osto

pera

tive

com

plic

atio

ns.

Mid

cour

se Q

ues

tio

nn

aire

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Rev

iew

of c

ases

Dis

cuss

ion

: Qua

lity

of c

are

stan

dard

s in

VS

serv

ices

:

R

evie

w n

atio

nal s

tand

ards

, and

/or

Id

entif

y ke

y in

dica

tors

for

qual

ity

of c

are

stan

dard

s

Rev

iew

res

ults

of m

idco

urse

qu

estio

nnai

re w

ith g

roup

and

in

divi

dual

lear

ners

.

Dis

cuss

ion

: Mob

ile M

L/LA

ser

vice

s

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Day

s 9–

11: R

evie

w o

f cas

es

Dev

elo

pin

g A

ctio

n P

lan

s: L

earn

ers

wor

k in

the

ir c

linic

tea

ms.

The

y dr

aft

an a

ctio

n pl

an o

utlin

ing

next

ste

ps fo

r st

artin

g/ex

pand

ing

ML/

LA s

ervi

ces

at

thei

r fa

cilit

ies:

Fu

rthe

r tr

aini

ng n

eeds

Fa

cilit

y pr

epar

edne

ss

M

onito

ring

and

eva

luat

ion

Q

ualit

y as

sura

nce

Faci

litat

ors

revi

ew q

ualif

icat

ion

proc

ess

with

indi

vidu

al le

arne

rs a

nd

plan

follo

w-u

p ac

tiviti

es.

Rev

iew

of d

ay’s

act

iviti

es

P.M

. (3

ho

urs

)

Tea

m P

rese

nta

tio

ns

of A

ctio

n

Pla

ns

and

Gro

up D

iscu

ssio

n:

St

artin

g/ex

pand

ing

ML/

LA

serv

ices

A

ddre

ssin

g pr

oble

ms

and

cons

trai

nts

to V

S se

rvic

e de

liver

y in

lear

ners

’ ow

n cl

inic

set

tings

Co

urs

e S

um

mar

y

Co

urs

e E

valu

atio

n b

y le

arne

rs

Clo

sin

g C

erem

on

y

Ass

ign

men

t: C

hapt

er 1

0; A

ppen

dix

H

A

ssig

nm

ent:

Cha

pter

11

13

Min

ilap

aro

tom

y u

nd

er L

oca

l An

esth

esia

: Lea

rner

’s G

uid

e

Min

ilap

aro

tom

y u

nd

er L

oca

l An

esth

esia

Sam

ple

Co

urs

e S

ched

ule

for

6 D

ays:

Thi

s sa

mpl

e 6-

day

sche

dule

can

be

used

for

eith

er in

terv

al [

I] o

r po

stpa

rtum

[PP

] M

L/LA

co

urse

s. F

or a

tra

inin

g co

urse

to

incl

ude

both

inte

rval

and

pos

tpar

tum

ML/

LA, u

se t

he 1

2-da

y sc

hedu

le.

MIN

ILA

PA

RO

TO

MY

UN

DE

R L

OC

AL

AN

ES

TH

ES

IA (

ML

/LA

) T

RA

ININ

G C

OU

RS

E (

6 d

ays,

12

sess

ion

s, 6

ho

urs

per

day

)

Day

1

Day

2

Day

3D

ay 4

D

ay 5

Day

6

A.M

. (3

ho

urs

)

Wel

com

e an

d

Intr

odu

ctio

ns

Ove

rvie

w o

f th

e C

ou

rse:

Goa

ls

O

bjec

tives

Sche

dule

Cou

rse

mat

eria

ls

Le

arne

r ex

pect

atio

ns

Pre

cou

rse

Qu

esti

on

nai

re

Dis

cuss

ion

: Ove

rvie

w o

f FP

and

volu

ntar

y st

erili

zatio

n (V

S)

prog

ram

s in

the

cou

ntry

Rev

iew

of i

ndiv

idua

l and

gro

up

asse

ssm

ent

mat

rix

Pre

cou

rse

Ski

ll A

sses

smen

t

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Pre

pari

ng t

o ob

serv

e th

e su

rger

y

Dem

on

stra

tio

n b

y F

acili

tato

r: [

I o

r P

P]

ML/

LA

with

clie

nt

Exe

rcis

e: R

evie

w fa

cilit

ator

’s

dem

onst

ratio

n.

Cla

ssro

om

Pra

ctic

e:

Surg

eon/

nurs

e te

ams

prac

tice

ML/

LA u

sing

pel

vic

mod

els

and

chec

klis

ts.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Pha

rmac

olog

y of

dr

ugs

and

pain

man

agem

ent

OR

Pra

ctic

e: D

ivid

e in

to 3

gr

oups

(su

rgeo

n/nu

rse

team

s):

Gro

up

1: A

ssis

t/pe

rfor

m

ML/

LA; G

rou

p 2

: Pra

ctic

e cl

ient

cou

nsel

ing,

pre

-op

asse

ssm

ent,

and

clie

nt

prep

arat

ion;

Gro

up

3:

Obs

erve

IPC

pra

ctic

es b

efor

e an

d af

ter

surg

ery.

Lear

ners

ass

ess

each

oth

er’s

pe

rfor

man

ce u

sing

che

cklis

ts

and

rota

te g

roup

s.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Dis

cuss

ion

: Pos

t-op

erat

ive

reco

very

, dis

char

ge, a

nd

follo

w-u

p

OR

Pra

ctic

e: D

ivid

e in

to 3

gr

oups

(su

rgeo

n/nu

rse

team

s):

Gro

up

2: A

ssis

t/pe

rfor

m

ML/

LA; G

rou

p 3

: Pra

ctic

e cl

ient

cou

nsel

ing,

pre

-op

asse

ssm

ent

and

clie

nt

prep

arat

ion;

Gro

up

1:

Obs

erve

IPC

pra

ctic

es b

efor

e an

d af

ter

surg

ery.

Lear

ners

ass

ess

each

oth

er’s

pe

rfor

man

ce u

sing

che

cklis

ts

and

rota

te g

roup

s.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

Rev

iew

res

ults

of m

idco

urse

qu

estio

nnai

re w

ith g

roup

and

in

divi

dual

lear

ners

.

Dis

cuss

ion

: Int

rodu

ctio

n of

ac

tion

plan

: Sta

rtin

g/ e

xpan

ding

M

L/LA

ser

vice

s

OR

Pra

ctic

e: G

roup

s pr

ovid

e M

L/LA

ser

vice

s; fa

cilit

ator

s as

sess

per

form

ance

usi

ng

chec

klis

ts. G

roup

s ro

tate

ac

cord

ing

to t

he le

arne

rs’

need

s.

A.M

. (3

ho

urs

)

Age

nda

and

open

ing

activ

ity

OR

Pra

ctic

e: G

roup

s pr

ovid

e M

L/LA

ser

vice

s; fa

cilit

ator

s as

sess

per

form

ance

usi

ng

chec

klis

ts. G

roup

s ro

tate

ac

cord

ing

to t

he le

arne

rs’

need

s.

Faci

litat

ors

asse

ss p

erfo

rman

ce

for

qual

ifica

tion

usin

g ch

eckl

ists

.

P.M

. (3

ho

urs

)

Dis

cuss

ion

: Fun

dam

enta

ls o

f M

L/LA

Dem

on

stra

tio

n: [

I o

r P

P]

ML/

LA w

ith a

nim

ated

vid

eo

and

on t

he Z

OE

pelv

ic m

odel

Dis

cuss

ion

: How

to

use

the

chec

klis

ts

Dis

cuss

ion

: The

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Setting Up Training and Clinical Service Provision for INTERVAL or POSTPARTUM Minilaparotomy

INTERVAL ML/LA Procedure:

Suprapubic incision (3 cm transverse incision, approximately 3 cm above pubic symphysis)

Use uterine elevator to locate the fallopian tubes

Use the INTERVAL ML/LA Checklist

Follow the same steps for:

Postoperative recovery and follow-up care

Management of complications

Infection prevention and control

POSTPARTUM ML/LA Procedure:

Subumbilical incision (3 cm transverse incision, approximately 1 cm below the uterine fundus)

No need to use the uterine elevator

Use the POSTPARTUM ML/LA Checklist

INTERVAL Minilaparotomy

FP counseling conducted and client chooses tubal ligation (TL) (interval)

POSTPARTUM Minilaparotomy

FP counseling during antenatal care

(Decision for postpartum TL made before onset of labor, if possible)

Conduct client assessment, confirm she is eligible for TL

Schedule: Any time (interval) Schedule:

Immediately after delivery to 7 days after delivery

(If > 7 days: Delay procedure until 42 days or more after childbirth; use interval technique)


INSTRUCTIONS FOR USING THE ZOE® GYNECOLOGIC SIMULATOR The ZOE gynecologic simulator is a full-sized, adult female lower torso (abdomen and pelvis). It is a versatile training model developed to assist health professionals to teach and practice the processes and skills needed to perform many gynecologic, obstetric and family planning procedures. The ZOE model is ideal for demonstrating and practicing the following:

• Bimanual pelvic examination including palpation of normal and pregnant uteri

• Vaginal speculum examination

• Visual recognition of normal cervices and cervical abnormalities

• Uterine sounding

• IUD insertion and removal

• Diaphragm sizing and fitting

• Laparoscopic inspection and occlusion of fallopian tubes (Falope rings or other clips)

• Minilaparotomy (both interval and postpartum tubal occlusion)

• Treatment of incomplete abortion using manual vacuum aspiration (MVA)

Contents The contents of the ZOE Gynecologic Simulator include the following:

Item Quantity

Normal ante- and retroverted uteri with transparent tops, attachments for round and ovarian ligaments as well as fallopian tubes and normal patent cervical os for pelvic examination and IUD insertion

2

6- to 8-week uterus (incomplete abortion) with dilated, patent cervical os, which allows passage of a 5- or 6-mm flexible cannula

1

10- to 12-week uterus (incomplete abortion) with dilated, patent cervical os, which allows passage of a 10- or 12-mm flexible cannula

1

Postpartum uterus (20-week size) with attached fallopian tubes for practicing postpartum tubal occlusion by minilaparotomy

1

Cervices (nonpatent) for use in visual recognition:

• Normal cervix

• Cervix with proliferation of columnar epithelium (ectropion)

• Cervix with inclusion (nabothian cyst) and endocervical polyp

• Cervix with lesion (cancer)

1

1

1

1


Item Quantity

Simulated round and ovarian ligaments (set of 2 each) 4

Normal tubal fimbriae and ovaries (2 each) 4

Fallopian tubes for tubal occlusion 10

Extra normal cervices with patent os for IUD insertion/removal 4

Extra cervices for 6- to 8-week and 10- to 12-week uteri (2 of each size) 4

Extra thin cervical locking rings 3

Flashlight with batteries 1

Soft nylon carrying bag 1

Outer Skin The outer skin of the model is foam-backed in order to simulate the feel of the anterior pelvic wall. The entire outer skin is removable to allow the model to be used for demonstration purposes (e.g., performing IUD insertion). The 3-cm incision (reinforced at each end) located just below the umbilicus can be used to insert a laparoscope to look at the uterus, round ligaments, ovaries and fallopian tubes and practice laparoscopic tubal occlusion. This incision also can be used for practicing postpartum tubal ligation by minilaparotomy. The 3-cm incision located a few centimeters above the symphysis pubis is used for practicing interval minilaparotomy. This incision also is reinforced, which allows the skin to be retracted to facilitate demonstration of the minilaparotomy technique.

Cervices The normal cervices have a centrally located, oval-shaped os, which permits insertion of a uterine sound, uterine elevator or IUD. The abnormal cervices are not patent (open) and can be used for demonstration only. Each of the cervices for treatment of incomplete abortion has a centrally located, oval-shaped os, which is dilated to allow passage of a 5- or 6-mm or 10- or 12-mm flexible cannula, respectively. The normal cervices and interchangeable uteri feature the patented “screw” design for fast and easy changing. Assembly To use the ZOE pelvic model for demonstrations or initially to learn how to change the parts (e.g., cervices and uteri), you need to know how to remove the skin.

Removing and Replacing the Detachable Skin and Foam Backing First, carefully remove the soft outer skin and its foam lining away from the rigid base at the “top” end of the model. (“Top” refers to the portion of ZOE nearest to the metal carrying handle located above the umbilicus.) Lift the skin and foam up and over the legs, one leg at a time.


Be as gentle as possible. The detachable skin is made of material that approximates skin texture and it can tear. If you wish to change the anteverted uterus and normal cervix, which are shipped attached to ZOE, first you must remove the uterus. Start by pulling the round ligaments away from the wall. Then grasp the uterus while turning the wide grey ring counterclockwise until the cervix and uterine body are separated. To remove the cervix, turn the thin grey ring counterclockwise until it comes off. You then can push the cervix out through the vagina. To reassemble, simply reverse this process. To replace the skin and foam lining, start by pulling them down around the legs. Then make sure the rectal opening is aligned with the opening in the rigid base. Pull the skin and foam over the top of the model. Finally, make sure both are pulled firmly down around the rigid base, and the skin is smoothly fitted over the foam. Once you understand how ZOE’s anatomical parts fit together, we suggest you change them through the opening at the top of the model. This helps to preserve ZOE’s outer shell as you will have to remove it only for demonstrations or to change the postpartum (20-week size) uterus. The anteverted and retroverted uteri have transparent top halves and opaque lower halves for use in demonstrating IUD insertion. These uteri are supported by round ligaments attached to the pelvic wall. The round ligaments, ovaries, and fallopian tubes are removable. To remove the uterus:

• Unscrew the wide locking ring attached to the uterus using a counterclockwise rotation.

• Unscrew the thin locking ring immediately outside the apex of the vagina.

• The cervix should be pushed through the vagina and removed from the introitus. To reassemble, proceed in reverse order.

Performing Procedures Speculum Examination

• Use a medium bivalve speculum.

• Prior to inserting the speculum, dip it into clean water containing a small amount of soap. (This makes inserting the speculum easier.)

• To see the cervix, fully insert the speculum, angle it posteriorly (as in the human, the vagina in the ZOE model is angled posteriorly), then open the blades fully.


• To increase the diameter of the opening, use the speculum thumb screw (Pederson or Graves specula).

Other Procedures Passing instruments (uterine sound, uterine elevator, dilator, or cannula) through the cervical os: Apply a small amount of clean water containing a drop or two of soap solution to the cervix (just as you would apply it with antiseptic solution in a client). This will make passing the instrument through the cervical os easier. Sounding the uterus, inserting an IUD, and performing interval minilaparotomy or laparoscopy: Use either the normal (nonpregnant) anteverted or retroverted uterus with a cervix having a patent os. Postpartum minilaparotomy (tubal occlusion): Use the postpartum uterus (20-week size) with a cervix having a patent os. Treatment of incomplete abortion using MVA: Use either the 6- to 8-week or 10- to 12-week uteri (incomplete abortion) with appropriate-sized cervix.

Care and Maintenance

• ZOE is constructed of material that approximates skin texture. Therefore, in handling the model, use the same gentle techniques as you would in working with a client.

• To avoid tearing ZOE’s skin when performing a pelvic exam, use a dilute soap solution to lubricate the instruments and your gloved fingers.

• Clean ZOE after every training session using a mild detergent solution; rinse with clean water.

• DO NOT write on ZOE with any type of marker or pen, as these marks may not wash off.

• DO NOT use alcohol, acetone, or Betadine® or any other antiseptic that contains iodine on ZOE. They will damage or stain the skin.

• Store ZOE in the carrying case and plastic bag provided with your kit.

• DO NOT wrap ZOE in other plastic bags, newspaper, plastic wrap, or any other kinds of material, as these may discolor the skin.


MINILAPAROTOMY UNDER LOCAL ANESTHESIA KNOWLEDGE ASSESSMENT Instructions: Circle the letter of the single best answer to each question.

1. Tubal ligation by minilaparotomy is best described as

a. performed on a postpartum or interval basis b. requiring an abdominal incision not more than 5 cm long c. done under local anesthesia and on an outpatient basis d. all of the above

2. When preparing the client for surgery, the staff should tell the client that

a. there will be a lot of pain during the procedure but that she won’t feel it because of the medication she will receive

b. she will probably feel some tugging, pulling, and slight cramping during the procedure c. the doctor is very good and that she will probably not feel anything during the surgery d. even though she might be feeling some cramping and discomfort during the procedure, she should

not mention it during the surgery

3. Prior to performing a minilaparotomy procedure, the surgeon must verify informed consent by

a. noting that the client discussed with the counselor and signed the consent form b. ensuring that the consent form is signed by both the client and her husband c. examining the consent form to see that the client’s signature was witnessed d. reviewing the consent for completeness and talking with the client to ensure that she understands the

procedure she has requested

4. If a pelvic examination was part of the initial pre-operative assessment, then another pelvic examination

a. must be performed before the surgery by the surgeon b. must be performed after the procedure to ensure that the uterus has not been perforated c. is unnecessary d. should be performed by the nurse to check for infection

5. If a systemic or local (pelvic) infection is noted on the day of the surgery

a. the procedure should be performed anyway b. the client should be sent home and told to return when she feels that the infection has been resolved c. laparoscopy should be performed instead of minilaparotomy d. the procedure should be postponed until the client has been treated for the infection and a

temporary method should be prescribed


6. When faced with an obese patient who requests minilaparotomy under local anesthesia, the surgeon should

a. plan to use more assistants during the procedure b. plan the procedure at a facility where general anesthesia and laparotomy can be performed c. suggest that the client to lose weight and ask her to return in 3 months d. use a vertical instead of an horizontal incision

7. After a minilaparotomy procedure, the only acceptable method for processing used instruments is

a. cleaning followed by sterilization b. cleaning, then disinfection with Dettol c. soaking in Dettol for at least 24 hours d. cleaning, followed by sterilization or high-level disinfection

8. The operating room should be cleaned with a disinfectant solution like 0.5% chlorine solution

a. after any contaminated case and weekly b. between all cases and also thoroughly on a monthly basis c. between all cases and thoroughly on a weekly basis d. after all cases with more than 250 ml of blood loss

9. Which one of the following is not a recommended infection prevention practice?

a. in high-volume settings, surgical staff should do a 3-minute scrub every hour or after every four or five cases

b. OR staff should change into clean scrub suits or gowns, caps, and masks inside the OR c. minilaparotomy procedures require sterile surgical gloves d. Chlorhexidine gluconate, iodophors, or alcohols can be used as antiseptics

10. Local anesthesia for minilaparotomy involves

a. using a maximum of 25 ml of 1% lidocaine and adrenaline b. sedating all clients with meperidine 100 mg and diazepam 10 mg c. infiltrating all abdominal wall layers with 1% lidocaine d. use of enough sedation so that the client is asleep

11. When infiltrating 1% lidocaine to produce local anesthesia for a minilaparotomy procedure

a. the surgeon must be sure that only the skin and subcutaneous tissue are infiltrated before starting the procedure

b. the incision may be made as soon as the lidocaine is injected c. epinephrine should always be used along with the lidocaine d. the surgeon must attempt to infiltrate all the layers from the skin to the peritoneum with anesthetic

12. If the uterus is retroverted, the uterine elevator should

a. not be used b. be inserted into the cervix with the tip downward, after which the handle is rotated c. be inserted in the same way as for an anteverted uterus d. be inserted after the abdomen has been opened, so that the uterus can be visualized


13. To minimize complications during both interval and postpartum minilaparotomy, the surgeon should remember to

a. use the uterine elevator in all minilaparotomy cases b. use toothed instruments to prevent intra-abdominal tissue from slipping c. ensure that the client has emptied her bladder prior to surgery d. all of the above

14. The technique used for tubal occlusion is called

a. Pomeroy technique b. Babcock technique c. Carman technique d. Parkland and Irving technique

15. The best time to perform a postpartum minilaparotomy under local anesthesia is

a. any time after the first menstrual cycle b. within the first 48 hours postpartum or more than 6 weeks after delivery c. within the first 6 weeks postpartum d. within the first 7 days postpartum

16. Which one of the following is not a precaution requiring postponement of the procedure until > 6 weeks for postpartum minilaparotomy?

a. age > 35 years old b. severe pre-eclampsia c. prolonged rupture of membranes d. severe hemorrhage (> 500 ml)

17. The following conditions indicate that the client is ready for discharge

a. her partner has arrived to take her home b. she can walk upright with minimal support c. she complains of nausea and vomiting d. she still feels very drowsy

18. During the postoperative period, the staff monitoring the client should

a. check and record vital signs every 15 minutes until the client is stable b. review the record upon receiving the client c. complete the client record form d. all of the above

19. Uterine perforation during a minilaparotomy procedure can be caused by

a. rough manipulation of the uterine elevator b. improper insertion of the uterine elevator c. using the uterine elevator during a postpartum procedure d. all of the above


20. In the minilaparotomy procedure, intra-abdominal bleeding

a. occurs solely in the operating room b. is related to the level of the anesthesia c. may occur in the operating room or at any time in the postoperative period d. usually occurs in women with a previous history of postpartum hemorrhage


CHECKLISTS FOR MINILAPAROTOMY CLINICAL AND COUNSELING SKILLS

USING THE CHECKLISTS The checklists included in this guide for minilaparotomy clinical and counseling skills are used by the learners and facilitators to develop new skills, as well as to assess each learner’s competency in providing minilaparotomy services. Each checklist contains in sequence the tasks performed by the respective clinician when performing a minilaparotomy procedure under local anesthesia. These tasks correspond to the information presented in relevant chapters of the reference manual. During skill acquisition and acquiring competency, checklists are very useful learning tools. Learners use checklists when observing a demonstration; when they are practicing on ZOE models or with role plays; and during service provision on real clients in the clinic. Used consistently, the checklists enable each learner to chart her/his progress and to pinpoint areas for improvement. Furthermore, they are designed to make communication (coaching and feedback) between the learner and facilitator easier and more helpful during learning. The facilitator then uses these checklists to evaluate the performance of each learner as she/he provides minilaparotomy services to one or more clients. Criteria for satisfactory performance by the learner are based on the knowledge, attitudes, and skills set forth in the Learner’s Guide. In general, a learner is expected to satisfactorily perform at least 5–10 minilaparotomy procedures with clients before being evaluated as competent and achieving qualification. When determining competence, the judgment of a skilled facilitator is the most important factor. Thus, in the final analysis, competence carries more weight than the number of procedures performed. Because the goal of this training is to enable every learner to achieve competency, additional training may be necessary. The checklists presented here can be used for five observations, and the facilitators should make enough copies for learners throughout the course.


CHECKLIST FOR INTERVAL MINILAPAROTOMY CLINICAL SKILLS

Place a in case box if step/task is performed satisfactorily, an if it is not performed satisfactorily, orN/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines

Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines

Not Observed: Step or task or skill not performed by learner during evaluation by facilitator

LEARNER ________________________________________________ Course Dates _______________


STEP/TASK CASES

GETTING READY

1. Greet the client respectfully and review her medical record.

2. Verify the client’s identity and check that informed consent was obtained.

3. Ask if the client has emptied her bladder and washed her abdominal and pelvic areas.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

PRE-OPERATIVE TASKS

1. Prepare instrument tray and open sterile instrument pack without touching items.

2. Give IV medication slowly.

3. Wash hands thoroughly with soap and water and dry with clean cloth.

4. Put clean examination gloves on both hands.

5. Perform bimanual pelvic examination and insert speculum.

6. Apply antiseptic solution to the cervix and vagina (two times), insert uterine elevator, identify the site of incision (do not remove the elevator), and dispose of gloves.

7. Put on cap and mask, perform surgical scrub and put on sterile gown and sterile surgical gloves.

8. Apply antiseptic two times to incision area and drape the client for the procedure.

9. Throughout procedure, talk to the client (verbal anesthesia).




STEP/TASK CASES

PROCEDURE

Local Anesthesia

1. Raise a small skin wheal at the center of the incision site, and starting at the center of the planned incision, administer local anesthetic (about 3–5 ml) just under the skin along both sides of the incision line.

2. Without removing the needle from under the skin, insert the needle into the fascia at a 45-degree angle, with the needle directly above the incision line; withdraw the needle slowly while injecting 3–5 ml lidocaine (repeat on other side of incision line).

3. Insert the needle straight down through the rectus sheath to the peritoneum, inject 1–2 ml of anesthetic into the peritoneal layer. (Maximum dose of 1% local anesthetic, e.g., lidocaine, is 3.0 mg/kg.)

4. Massage the skin and tests with tissue forceps.

Abdominal Entry

1. Make a 3-cm transverse incision in the skin about 3 cm above the pubic symphysis.

2. Bluntly dissect subcutaneous tissues down to anterior fascia with retractors.

3. Cut anterior rectus fascia, separate rectus muscles, and identify peritoneum.

4. Check for bowel or other abdominal tissue and push away from planned entry site.

5. Make a small incision in the peritoneum with scissors and enlarge it transversely.

6. Locate uterine fundus and cornu of fallopian tubes utilizing uterine elevator through the sterile drape. Alternatively, use the tubal hook method to grasp the fallopian tube.

7. Identify the midportion of the fallopian tube and gently grasp with a Babcock forceps and bring it to the incision.

8.

9. Identify fimbriae and ligate midportion of fallopian tube with absorbable suture and excise the loop.

10. Repeat procedure on opposite side for second tube.

11. Assure hemostasis, then close fascia and skin in two layers.

12. Dress the wound.


POSTOPERATIVE TASKS

1. Remove the uterine elevator and place in chlorine solution.

2. Dispose of syringe, needle, and scalpel in puncture-proof container.

3. Dispose of waste materials according to guidelines.

4. Remove gloves and dispose of them.




STEP/TASK CASES

6. Check that vital signs are being monitored regularly.

7. Instruct client on wound care and return visit.

8. Record the procedure.


LEARNER IS QUALIFIED NOT QUALIFIED TO PERFORM INTERVAL

MINILAPAROTOMY UNDER LOCAL ANESTHESIA, BASED ON THE FOLLOWING CRITERIA:

• Score on Midcourse Questionnaire__________% (Attach Answer Sheet)

• Counseling and Clinical Skills Evaluation: Satisfactory Unsatisfactory

• Provision of Services (practice): Satisfactory Unsatisfactory

Facilitator’s Signature ____________________________________ Date __________________


CHECKLIST FOR POSTPARTUM MINILAPAROTOMY CLINICAL SKILLS

Place a in case box if step/task is performed satisfactorily, an if it is not performed satisfactorily orN/O if not observed.



Not Observed: Step, task or skill not performed by learner during evaluation by facilitator



STEP/TASK CASES

GETTING READY

1. Greet the client respectfully and review her medical record.

2. Verify the client’s identity and check that informed consent was obtained.

3. Check that the client has voided and thoroughly washed her abdominal and pelvic areas.


PRE-OPERATIVE TASKS

1. Prepare instrument tray and open sterile instrument pack without touching items.

2. Give IV medication slowly.


4. Determine fundal height.

5. Perform surgical scrub, and put on sterile gown and sterile gloves.

6. Clean umbilicus first with antiseptic

7. Apply antiseptic two times to incision area and drape the client for procedure.

8. Throughout procedure, talk to the client (verbal anesthesia).


ML/LA PROCEDURE

Local Anesthesia

1. Raise a small skin wheal at the center of the incision line, and administer local anesthetic just under the skin, along both sides of the incision line.

2. Starting again at the center of the incision line, insert the needle into the fascia with the needle directed toward the transverse half of the incision line.

3. Withdraw the needle slowly while injecting 3–5 ml of lidocaine, repeat on the other half of the incision line. (The maximum dose should not exceed 150 mg for a woman who weighs 50 kg.)

4. Massage the skin and test with tissue forceps.



STEP/TASK CASES

Abdominal Entry

5. Make a transverse skin incision, approximately 3 cm long, about 1 cm inferior to the uterine fundus.

6. Bluntly dissect subcutaneous tissues down to anterior fascia.

7. Cut anterior rectus fascia and identify peritoneum.

8. Check for bowel or other abdominal tissue and push away from planned entry site.

9. Make a small incision in the peritoneum with scissors and enlarge it transversely.

10. Locate uterine fundus and position the incision over the fallopian tube.

11. Identify the midportion of the fallopian tube and gently grasp it with a Babcock or tubal hook and bring it up to the incision.

12. Identify fimbriae and ligate midportion of fallopian tube with absorbable suture and excise.

13. Repeat procedure on opposite side for second tube.

14. When hemostasis is assured, close wounds in layer.

15. Dress the wound.


POSTOPERATIVE TASKS

1. Dispose of syringe in puncture-proof container.

2. Dispose of waste materials according to guidelines.



5. Check that vital signs are being monitored regularly.

6. Instruct client on wound care and return visit.

7. Record the procedure.


LEARNER IS QUALIFIED NOT QUALIFIED TO PERFORM POSTPARTUM


• Score on Midcourse Questionnaire _______________% (Attach Answer Sheet)





CHECKLIST FOR MINILAPAROTOMY CLINICAL SKILLS FOR CIRCULATING NURSES






CHECKLIST FOR MINILAPAROTOMY CLINICAL SKILLS FOR CIRCULATING NURSES

STEP/TASK CASES

PRE-OPERATIVE

1. Ensure that all supplies and equipment for monitoring vital signs are available.

2. Greet the client, review record, and ensure that informed consent was obtained.

3. Position the client flat on her back on operating table.

4. Take and record vital signs.

5. Start IV medication slowly.

6. Prepare vaginal instruments for surgeon.

7. Assist with vaginal exam, prep, and insertion of uterine elevator (for interval procedures).


DURING SURGERY

1. Communicate with and be supportive of the client during procedure.

2. Monitor and record vital signs during procedure.

3. Monitor client’s general condition. Report any increased discomfort or stress to surgeon.


POSTOPERATIVE

1. Provide dressing to cover incision.

2. Record final vital signs before leaving operating room.

3. Assist client onto stretcher.

4. Introduce client to recovery room personnel and ensure that record is complete.



LEARNER IS QUALIFIED NOT QUALIFIED TO ASSIST IN THE PERFORMANCE OF







CHECKLIST FOR MINILAPAROTOMY CLINICAL SKILLS FOR NURSING ASSISTANTS






CHECKLIST FOR MINILAPAROTOMY CLINICAL SKILLS FOR NURSING ASSISTANTS

STEP/TASK CASES

PRE-OPERATIVE

1. Perform a surgical scrub and put on surgical garments.

2. Prepare sterile or high-level disinfected instruments for procedure.

3. Assist surgeon to drape the client.

4. Withdraw local anesthetic from vial held by circulating nurse.

5. Note start time of surgery for circulator to record.


DURING SURGERY

1. Assist during surgery, working as a team with surgeon.

2. Take gauze pieces and instrument count and report findings to circulator.

3. Record end time of surgery for circulator to record.

4. Place dressing on wound at end of procedure.


POSTOPERATIVE

1. Remove drape when wound is dressed.

2. Take used instruments from operating room and place in a bucket for cleaning.

3. Dispose of specimen of tube according to guidelines.


5. Wash hands with soap and water.

6. Prepare instruments and table for next case.



LEARNER IS QUALIFIED NOT QUALIFIED TO ASSIST IN THE PERFORMANCE OF







CHECKLIST FOR COUNSELING FOR MINILAPAROTOMY IN THE INTERVAL PERIOD







STEP/TASK CASES

GENERAL COUNSELING STEPS

1. Greet the client by introducing yourself and warmly welcome her to the clinic.

2. Obtain basic information (name, address, age, etc.).

3. Use the Balanced Counseling Algorithm and Cue Cards.

4. Listen to what the client says about her contraceptive needs.

5. Rule out pregnancy using the counseling card with six questions or a pregnancy checklist.

6. Ask her if she wants to space or limit births.

7. Help the client begin to choose an appropriate method.


STEPS IF THE CLIENT CHOOSES MINILAPAROTOMY

1. Make sure there is no medical condition that would make the client a poor candidate for ML/LA.

2. Clearly discuss the benefits of minilaparotomy: It is permanent (although there is a small chance of failure). It is very effective. It has no long-term effects.

3. Explain the importance of the partner being involved in the decision process.

4. Explain that minilaparotomy does not provide protection against sexually transmitted infections, including HIV/AIDS.

5. Explain common side effects and be sure they are understood fully.

6. Describe the surgical procedure and what the woman should expect during and afterwards. Explain common complications of the procedure.

7. Re-assess the client’s final decision and feelings and decide if she is making an informed decision.

8. Discuss scheduling the procedure and the possible need for contraception prior to minilaparotomy.



STEP/TASK CASES

9. If there are no contraindications based on medical assessment, ask her to sign the consent form.


ON SCHEDULED DAY, BEFORE THE MINILAPAROTOMY PROCEDURE

1. Verify the client’s identification and check that informed consent was obtained.

2. Review client assessment data to determine if the client is an appropriate candidate for minilaparotomy.

3. Ask the woman if she has any questions about the procedure.

4. Explain to the client what will happen next, and what she should expect during the procedure.


AFTER THE MINILAPAROTOMY PROCEDURE

1. After sedation is worn off, and the client is preparing for discharge, give postoperative instructions, orally, and in writing, if appropriate.

2. Provide information on warning signs for medical problems and the need to return to the clinic immediately should any occur.

3. Schedule a follow-up visit within 7 days.

4. Discuss arrangements for discharge.

5. Assure the client that she can return at any time if she has questions or concerns.

6. Have the client repeat all instructions to you.

7. Answer any remaining client questions.

8. Complete the client record.


LEARNER IS QUALIFIED NOT QUALIFIED TO PROVIDE COUNSELING FOR

MINILAPAROTOMY IN THE INTERVAL PERIOD, BASED ON THE FOLLOWING CRITERIA:






CHECKLIST FOR COUNSELING FOR MINILAPAROTOMY IN THE POSTPARTUM PERIOD







STEP/TASK CASES

GENERAL COUNSELING STEPS

1. Greet the client by introducing yourself and warmly welcome her to the clinic.

2. Obtain basic information (name, address, age, etc.) .

3. Listen for the client’s contraceptive needs.

4. Use the Balanced Counseling Algorithm and Cue Cards.

5. Ask her if she wants to space or limit births.

6. Help the client begin to choose an appropriate method.


STEPS IF THE CLIENT CHOOSES MINILAPAROTOMY

1. Make sure there is no medical condition that would make the client a poor candidate for ML/LA.

2. Clearly discuss the benefits of minilaparotomy: It is permanent (although there is a small chance of failure). It is very effective. It has no long-term effects.

3. Explain the importance of the partner being involved in the decision process.

4. Explain that minilaparotomy does not provide protection against sexually transmitted infections, including HIV/AIDS.

5. Explain common side effects and be sure they are understood fully.

6. Describe the surgical procedure and what the woman should expect during and afterwards. Explain common complications of the procedure.

7. Assess the client’s decision and feelings and decide if she is making an informed decision.

8. Discuss when the procedure will be performed (within 7 days of delivery).

9. If there are no contraindications based on medical assessment, ask her to sign the consent form.




STEP/TASK CASES

BEFORE THE MINILAPAROTOMY PROCEDURE

1. Verify the client’s identification and check that informed consent was obtained.

2. Review client assessment data to determine if the client is an appropriate candidate for minilaparotomy.

3. Ask the woman if she has any questions about the procedure.

4. Explain to the client what will happen next, and what she should expect during the procedure.


AFTER THE MINILAPAROTOMY PROCEDURE

1. After sedation is worn off, and the client is preparing for discharge, give postoperative instructions, orally, and in writing, if appropriate.

2. Provide information on warning signs for medical problems and the need to return to the clinic immediately should any occur.

3. Schedule a follow-up visit within 7 days.

4. Discuss arrangements for discharge.

5. Assure the client that she can return at any time if she has questions or concerns.

6. Have the client repeat all instructions to you.

7. Answer any remaining client questions.

8. Complete the client record.


LEARNER IS QUALIFIED NOT QUALIFIED TO PROVIDE COUNSELING FOR

MINILAPAROTOMY IN THE POSTPARTUM PERIOD, BASED ON THE FOLLOWING CRITERIA:






CHECKLIST FOR VERBAL ANESTHESIA






CHECKLIST FOR VERBAL ANESTHESIA

TASK/ACTIVITY CASES

GETTING READY

1. Greet the woman respectfully and with kindness.

2. Tell the client what you are going to do and encourage her to ask questions.

3. Tell the client that she may feel discomfort during some of the steps and you will tell her about any discomfort in advance.

4. Assess the client’s need for pain management medication.


PROCEDURE

1. Explain each step of the procedure prior to performing it.

2. Wait after performing each step or task to prepare the client for the next one.

3. Move slowly, without jerky or quick motions.

4. Use instruments with confidence.

5. Avoid saying things like “This won’t hurt” when it will hurt; or “I’m almost done” when you’re not.

6. Talk with the client throughout the procedure.


LEARNER IS QUALIFIED NOT QUALIFIED TO PERFORM VERBAL ANESTHESIA, BASED

ON THE FOLLOWING CRITERIA:






Course Evaluation (To be completed by Learners) Please indicate your opinion of the course components using the following rate scale: 5–Strongly Agree 4–Agree 3–No Opinion 2–Disagree 1–Strongly Disagree

COURSE COMPONENT RATING

1. The precourse questionnaire helped me to study more effectively.

2. I understand the principles of informed choice for voluntary sterilization.

3. I understand the eligibility criteria, precautions, and client assessment principles and can correctly identify clients who would be appropriate for minilaparotomy under local anesthesia (ML/LA).

4. The role play sessions on counseling skills were helpful.

5. There was sufficient time scheduled for practicing counseling through role play and with clients.

6. The demonstrations helped me gain a better understanding of ML/LA prior to practicing with the anatomic models.

7. The practice sessions with the anatomic models made it easier for me to perform ML/LA when working with actual clients.

8. There was sufficient time scheduled for practicing ML/LA with clients.

9. The interactive, participatory training approach used in this course made it easier for me to learn how to provide ML/LA services.

10. The time allotted for this course, and its different components, was sufficient for learning how to provide ML/LA services.

11. I feel confident in providing local anesthesia to ML/LA clients.

12. I feel confident in performing standard interval ML/LA.

13. I feel confident in performing standard postpartum ML/LA.

14. I feel confident in using the infection prevention and control practices recommended for ML/LA services.

15. I feel confident in conducting postoperative management for ML/LA, including discharge, follow-up, and management of side effects and other health problems.

16. I can describe the basic requirements of mobile outreach services for ML/LA.

(See next page.)


Additional Comments What topics (if any) should be added (and why) to improve the course? What topics (if any) should be deleted (and why) to improve the course? What should be done to improve how this course is conducted? Also, feel free to provide additional explanation for any of your ratings (Items 1 to 16).

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