> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/appendix-operational-definitions-for-bemonc-signal-functions.md). # Appendix: Operational definitions for BEmONC signal functions *This appendix is a full copy of the operational definitions for BEmONC signal functions listed in* [*Table 1*](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/1-background.md)*, based on* ***“EmONC signal function operational definitions and specific considerations”*** [*(EmONC Digital Guide, 2025)*](https://emonc.org/assets/tools/en/signal-functions-operational-definitions.pdf)*.* ## Obstetric signal functions ### Administer medications to treat postpartum hemorrhage **Uterotonics** (oxytocin alone as the first choice) are used to treat postpartum hemorrhage (PPH) most commonly caused by uterine atony, i.e., failure of the uterus to contract adequately following delivery. In settings where oxytocin is unavailable, the use of other injectable uterotonics or oral misoprostol is recommended. Parenteral (i.e., injectable) oxytocin, along with tranexamic acid and other components, are key elements of the WHO recommended treatment bundle for the management of PPH. Note that the use of uterotonic medications as part of active management of the third stage of labor is not counted towards performance of this signal function. ### Administer parenteral antibiotics (maternal) **Parenteral antibiotics** are used for suspected or established severe maternal infections of the pelvic organs (e.g. the uterus, fallopian tubes, the ovaries) or upper urinary tract. Their use is also recommended in cases of maternal generalized bacteremia and septicemia (i.e., presence of bacteria in the bloodstream). ### Administer magnesium sulfate **Magnesium sulfate** is given to women diagnosed with severe pre-eclampsia or eclampsia to prevent and treat convulsions. ### Remove retained products of conception **Retained products of conception (POC)** can occur as a result of an incomplete spontaneous or induced abortion. Vacuum aspiration entails inserting an appropriately sized cannula into the uterus, creating vacuum in a plastic syringe, connecting it to the cannula and removing the POC with gentle aspiration using a rotating movement. POC can also be removed by dilatation and evacuation. Medical management with misoprostol is another way to remove retained POC. ### Perform manual removal of retained placenta This procedure addresses **retained placenta** or fragments of the placenta. The manual removal of retained placenta is recommended if the placenta has not been expelled within 30 minutes after birth, especially in cases of heavy bleeding. It entails antiseptic procedure, pain relief, and insertion of sterile gloved hand into the uterus to locate the edge of the placenta, separating the placenta in its entirety from the uterine wall and removing it. Manual removal of placenta should only be attempted at the BEmONC level when there is hemorrhage. ### Perform assisted vaginal birth **Assisted vaginal birth** is performed during the second stage of labor to deliver the baby for indications of fetal distress or prolonged second stage of labor. Prerequisite conditions are a skilled health provider, fully dilated cervix and a presenting fetal head that has descended sufficiently. Assisted vaginal birth can be performed using a **vacuum extractor** (ventouse) or forceps. At the Level 1/ BEmONC level, only the vacuum extractor (ventouse) should be used and only if the head is on the perineum. **Forceps** can also be used at Level 2/CEmONC and Level 3/Intensive EmONC when indicated and providers are trained in their use. ### Provide IV fluid replacement therapy **Intravenous (IV) replacement fluids** during pregnancy and labor as replacement therapy or in the postpartum period to treat shock are the first-line treatment for hypovolemia (i.e., a severe decrease in the volume of blood circulating in the body) due to antepartum or postpartum hemorrhage, sepsis or other cause. In case of postpartum hemorrhage it maintains the circulation whilst interventions to control bleeding are performed and assessment is made for whether blood transfusion is needed. ### Administer antenatal corticosteroids The administration of **antenatal corticosteroids** to women at risk of imminent preterm birth is used to stimulate fetal lung maturation and refers to dexamethasone or betamethasone administered by intramuscular injection for women at risk of imminent preterm birth (anticipated within the subsequent 7 days) from 24 weeks to 34 weeks gestation. At the Level 1/BEmONC level, the first dose of antenatal corticosteroid should be given to the woman prior to transfer to a Level 2/CEmONC or Level 3/Intensive EmONC facility. ## Neonatal signal functions ### Perform newborn resuscitation with bag and mask Basic **newborn resuscitation** at the time of birth comprises a set of interventions required to establish breathing and circulation in a newborn who is not spontaneously breathing/crying at birth. This procedure includes providing positive-pressure ventilation with a bag and mask equipment of an appropriate size (i.e., it does not refer to simple stimulation by rubbing, drying). ### Initiate and support early and exclusive breastfeeding All women should be supported to **initiate breastfeeding as soon as possible after birth**, within the first hour after delivery. Women should receive practical support to enable them to initiate and establish breastfeeding and manage common breastfeeding difficulties. Mothers should also be given support and practical training on how to express breast milk as a means of maintaining lactation in the event of there being separated temporarily from their infants. In the case of small and sick newborns, breastmilk is especially important to protect vulnerable babies from infection and problems with the gut, as well as support neurodevelopment and overall growth. ### Administer parenteral antibiotics (newborn) **Parenteral antibiotics** are used for suspected or established infections including the clinical syndromes of sepsis, meningitis or pneumonia in newborns based on clinical presentation diagnosed via clinical algorithm or confirmed via positive blood culture. At the BEmONC level, antibiotics may be given at least as an intramuscular dose as pre-referral treatment. At a Comprehensive and Intensive EMoNC levels, antibiotics may be given as intravenous doses or infusions. ### Practice immediate kangaroo mother care for preterm and LBW infants **Kangaroo mother care** (KMC) is an evidence-based approach to care of preterm and/or low birthweight (LBW) infants involving continuous and prolonged skin-to-skin contact with the mother (or other caregiver) in an upright position. The aim is for early initiation of KMC (immediate KMC) and for continuous performance (>18 hours per day). At BEmONC level, KMC can be provided for most of the day for small babies who do not require higher-level care. KMC provided at a Comprehensive or Intensive care level would be provided alongside other supportive care. Other key components of KMC are support for exclusive and early breastmilk provision and timely discharge from the hospital with appropriate follow-up. When babies are not in KMC position with the mother or another care-giver, appropriate thermal care should be provided. ### Administer oxygen therapy with pulse oximetry Small and sick newborns with hypoxia require appropriate **oxygen therapy**. Pulse oximetry determines the presence of hypoxia (low blood oxygen) and hyperoxia (overly high blood oxygen), and guides health workers to administer oxygen therapy within safe limits. At the BEmONC level, safe oxygen therapy with pulse oximeter monitoring may be initiated only in order to stabilize and transport the newborn to Comprehensive or Intensive EmONC level. At a Comprehensive and Intensive care level, oxygen therapy would involve administration of oxygen via appropriately sized neonatal nasal prong using low-flow metres with pulse oximetry, air oxygen blenders and humidifiers. ### Provide thermal care with radiant warmer or incubator Preterm newborns and/or LBW infants at risk of hypothermia who are unstable or who cannot be cared for in KMC require **thermal care using a clean incubator or under a radiant warmer** (or equivalent warming device). Close temperature monitoring is also required. ## Referral signal function ### Arrange ambulance, with trained and equipped provider, to a facility that can provide definitive care Arrange **ambulance transfer** (emergency referral), with a trained care provider who is equipped to perform interventions addressing maternal and newborn emergencies, to a facility at which capacity to provide definitive care has been confirmed in advance. * **Arrange** = ability to rapidly coordinate a functioning ambulance, fuel, driver, provider, and necessary equipment. * **Ambulance** = a vehicle that permits monitoring and intervention as needed during transport. * **Provider** = a healthcare provider, in addition to the vehicle's driver, who would typically be responsible for caring for maternal and/or newborn emergencies in the context being evaluated. * **Trained** = possessing adequate training, based on local norms and regulations, to perform the maternal and newborn interventions: * *Maternal*: provision of IV fluids, control of bleeding w/external maneuvers—uterine massage, compression, aortic compression, administration of uterotonics. * *Newborn*: maintenance of body temperature through ongoing KMC and covering neonate, ensuring airway patency through positioning or head tilt/chin lift and monitored by observation through transport, performance of neonatal basic life support—to include maintenance of respiratory support via O2 and bag mask ventilation, including monitoring through observation and vital signs with pulse oximetry; includes neonatal CPR as well for HR < 60. * **Equipped** = access to care tools required to perform maternal and newborn interventions listed under "trained." * **Capacity** = current presence of space, necessary provider types and access to essential interventions (medications, procedures) required to provide definitive care. * **Definitive care** = comprehensive and conclusive care for a patient's specific condition. * **Confirmed** = verified through communication with receiving facility in real-time. --- # Agent Instructions This documentation is published with GitBook. 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