1. Tubal Ligation (Female Sterilization) Session III-I: Practicing the Minilaparotomy Procedure
Explain: This session covers learning the minlaparotomy procedure through practice on models and clients. You will also have an opportunity to learn the different roles and responsibilities of each team member during a minilaparotomy procedure. Providers must first master all of the minilaparotomy steps on a model before they are evaluated on the model. We shall then demonstrate the procedure on clients before you can begin to practice on clients, under the supervision of trainers, until you are competent enough to provide minilaparotomy with minimal assistance.

2. Objectives By the end of this session, participants will be able to:
Describe the different roles and responsibilities of each member of the surgical team
Describe how these interrelate
Competently perform the different roles and responsibilities assigned to them during model and clinical practice
Demonstrate teamwork during practice on models and clients
Competently perform the suprapubic minilaparotomy procedure on the model and on clients
Competently perform the subumbilical minilaparotomy procedure on the model and on clients
Display empathetic support for the client during and after the minilaparotomy procedure
Use correct infection prevention practices throughout the surgical procedures
Explain:
By the end of this session, participants will be able to:
Describe the different roles and responsibilities of each member of the surgical team
Describe how these interrelate
Competently perform the different roles and responsibilities assigned to them during model and clinical practice
Demonstrate teamwork during practice on models and clients
Competently perform the suprapubic minilaparotomy procedure on the model and on clients
Competently perform the subumbilical minilaparotomy procedure on the model and on clients
Display empathetic support for the client during and after the minilaparotomy procedure
Use correct infection prevention practices throughout the surgical procedure
This session will consist of two parts. In the first part of the session, we will review the roles of each member of the surgical team before, during, and after a minilaparotomy procedure. In the second part of the session, the focus will be on demonstrating the minilaparotomy procedure and introducing you to model practice.
Allow for questions, comments, and points of clarification, and respond to these as needed.

3. Composition of the Surgical Team
What is the composition of the surgical team?
In ideal settings, it should consist of a:
Surgeon
Surgical assistant
Client monitor
Circulating nurse
Recovery room nurse
In most instances, the team has three staff (surgeon, surgical assistant, and client monitor).
Ask: “What is the composition of the surgical team for minilaparotomy?” Allow a few responses, then explain:
In Ideal settings the team includes
Surgeon
Surgical assistant
Client monitor
Circulating nurse
Recovery room nurse
In most instances, the team will have only three members (the surgeon, surgical assistant, and client monitor). Additionally, the recovery room nurse is not considered part of the surgical team in normal settings.. In most instances, the client monitor will be performing the role of a circulating nurse and will be managing the recovery area.

4. Exercise
Inform the participants that they will now do an exercise on the roles of the surgical team members.
Direct them to look at the wall where the labels for the different members of the surgical team have been posted.
Inform them that you will shortly be distributing cards with roles written on them, and their task will be to paste the cards on the spot on the wall where they think is most appropriate. They will have five minutes to post the cards on the wall. If they feel that the task on a card they are holding can be performed by a specific team member, they should paste that card next to the title of that team member. If they feel that the task can be performed by two team members, then they should paste the card between the two team member labels. If they feel that it can be done by all staff, then they should place the card in the center.
Distribute the cards and allow five minutes for the participants to move around and post the cards.
At the end of the five minutes, ask the participants to gather around the wall where the cards were posted. Review each task and discuss which member of the surgical team should perform that task. If a card was not correctly placed, discuss where it should have been posted.
Wrap up the session by reviewing the roles of each member of the team as presented in the session plan

5. Instruments and Supplies Needed for Minilaparotomy Procedure

6. Set-Up of Instruments Used for Inserting the Uterine Elevator
Explain: That you will be demonstrating the minilaparotomy procedure on the models, but first we must learn about the instruments.
Orient the participants to each instrument in the minilaparotomy set and to the set-up of the instruments on the trolleys—one for insertion of the uterine elevator, and the second for the abdominal minilaparotomy procedure.
Ask participants to refer to Handout #17, the list of basic furniture, equipment, instruments, and supplies needed for minilaparotomy, and ask the participants to focus this time on the section with the instruments and review all of the instruments that are needed on the vaginal tray, demonstrating, where applicable, how the instrument should be used and its maintenance to ensure optimal functioning.

7. Instruments for Minilaparotomy Procedure
<Display slide>
Explain:
Name and state the function of each instrument on the instrument tray.

8. Minilaparotomy Procedure Instrument Set-Up
Go through the different set of retractors (Army Navy retractors) on this trolley.

9. Model Practice Explain
You will first learn the steps of the minilaparotomy procedure on the Zoë model. It is important that you treat these models as clients.
It is also important to remember that the client’s rights should be respected at all times during this training.
These rights include the following and must be part of your practice sessions on the model:
The client’s safety and satisfaction are the ultimate goals of quality minilaparotomy services. This include observing their right to privacy and confidentiality.
Always ask for the client’s permission for provider in training to perform or observe the minilaparotomy procedure.
The client should understand her right to refuse care from a training participant without loss or postponement of services to her; the trainer or other staff should perform the procedure instead.
Clients who consent to participate in the training should be informed in advance that they will receive care from a provider-in-training, under the direct supervision of a qualified trainer.
You will be required to demonstrate due respect to the Zoe models: Treat the model as if she were a client; communicate with her effectively throughout the procedure, explaining to her what is being done what and when to expect discomfort, etc. We shall revisit the issue of how to care for the models later during in this presentation.

10. What Is Needed for Model Practice?
Zoë model
Minilaparotomy kit(s)
Supplies (e.g. syringes, needles, antiseptics, gauze, gloves, sutures, drapes, anesthetic vials, etc.)
Buckets
Sharps-disposal containers
List of instruments and supplies
Surgical skills learning guides
An image (on a flipchart) of a tap with running water and soap for handscrub
Explain:
For model practice, you will be assigned to a workstation and you will work as a team, with one of you assuming the role of the client. You should change roles throughout the practice session.
Each workstation will have the following items to enable you to practice:
One Zoë model (covered with a drape)
One minilaparotomy kit (including instruments for insertion of the uterine elevator)
Supplies (e.g. syringes, needles, antiseptics, gauze, gloves, sutures, drapes, anesthetic vials, etc.)
Buckets
Sharps-disposal containers
A list of instruments and supplies
The surgical skills learning guides and observation checklists
An image (on a flipchart) of a tap with running water and soap for handscrub

11. Roles of Each Team Member
In each team:
One member is the client.
One member is the surgeon.
One member is the surgical assistant.
One member is the client monitor.
Explain that you will demonstrate the suprapubic minilaparotomy procedure with the assistance of other co-trainers (one playing the client, one the surgical assistant, another the circulating nurse, and another the client monitor). They should observe each member of the team performing their roles, as discussed earlier.
Inform them that as you demonstrate the procedure, you will also be making a running commentary on what you are doing.

12. Task
The team is to accomplish all of the tasks and steps in the learning guide (starting from preprocedure assessment, all the way through postprocedure instructions).
The surgeon and the surgical assistant should be constantly in a dialogue with the client, comforting her.
Everybody on the team should play his/her role as close to reality as possible (given the limitations of the model).
At the end of the procedure, the team should hold a feedback session:
Using the learning guide
Identifying steps performed correctly and those that need improvement
Team members then should switch roles for the next practice.
Explain:
As a team, you will practice all steps in the learning guides, starting from the preprocedure assessment, preparation of the client, and the minilaparotomy procedure, to giving postprocedure instructions.
As a team member, during the practice sessions, at any one time you should practice all of the steps assigned to you by virtue of the role you are playing—i.e., if you are the surgeon, then practice all of the steps that would be performed by the surgeon, as described in the learning guide.
At the end of the practice session, the team must hold a feedback session. During the feedback time, each member of the team receives feedback from the other team members. The recommended approach for conducting a feedback session is first to allow the participant receiving the feedback to summarize her/his experience—i.e. what they think they did well, areas they think need improvement, or any other issues of importance.
Then each member of the team gives feedback again, focusing on what participants did correctly (as described in the learning guide), areas for improvement, and steps that were missed. The participants then decide on what to concentrate on during the next practice session, until they can competently perform all the steps.
Participants should switch roles after each practice and feedback session.
Please note that each team will be assigned a trainer who will also at the start of the practice sessions demonstrate the procedures again at your respective workstation. The trainer will also provide coaching, as needed.

13. Assessment
Assessment will occur when team members believe they are ready to be assessed by the trainer.
Every participant will have to pass the assessment on the model to be able to practice on clients.
In the assessment, the surgeon has to perform satisfactorily all steps in bold in the learning guide.
Practice and assessments on models will continue at the clinical practice facility as well, until every participant passes the assessment.
Explain:
Once the team feels confident that they can competently perform all of the steps correctly and in the right sequence, using the observation checklist, you should inform the trainer, so that arrangements can be made to assess your team in performing both the suprapubic and subumbilical minilaparotomy procedure.
During the assessment, the surgeon, for example, will be expected to competently perform all steps assigned to that role (these are also printed in bold in the learning guide); likewise, the surgical assistant, client monitor, and circulating nurse will also be expected to competently perform all steps assigned to them.
Once you have been declared competent, we shall prepare for the clinical practice session in the clinical area,
For participants who will require more practice sessions, the model practice sessions and assessment on models will continue, but this time it will take place at the clinical practice facility ,until all participants competently perform the procedures on the model, before they can move to practice on clients.
Review the model practice instructions with the participants. Allow some time for questions, and respond to these as appropriate.

14. Attention
Use the same gentle technique with the model that you would use when examining a client.
Respect and treat the models as real clients.
Drape them to ensure privacy.
Use the talcum powder that is provided with the models as a lubricant, if needed, while inserting gloved fingers or instruments into the vagina of the model.
Do not incise the skin of the model.
Explain:
Treat the models with respect and be gentle, showing empathy when needed, just as you would when examining or performing a procedure on a real client (as described in the learning guide).
Models must be draped to ensure privacy
Use the lubricant provided, such as talcum powder, when inserting the speculum or gloved fingers.
Gently apply the retractors and retract them gently. Do not attempt to widen the procedure area for better exposure beyond the incision by firmly pulling the retractors apart. This will avoid causing irreparable damage to the “abdominal wall” of the model. since the abdominal wall of the model is not elastic and tears easily when subjected to undue traction.
Do not incise the skin of the models.
At the end of the procedure, remember to drape the model.
Inform the participants where to get additional supplies, if needed.