reprolineplus.orgreprolineplus.org/system/files/resources/Private-Maternity-Care... · The development of this toolkit was supported by funding from MSD, through its MSD for Mothers

PMC-QT:

Private Maternity Care – Quality Toolkit May 2016

The development of this toolkit was supported by funding from MSD, through its MSD for Mothers program. The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD. MSD for Mothers is known as Merck for Mothers in the United States and Canada. This toolkit was produced by Jhpiego, in consultation with the Federation of Obstetrics and Gynaecological Societies of India (FOGSI), Association of Obstetricians and Gynaecologists of Uganda (AOGU), Programme for Accessible health, Communication and Education (PACE), Hindustan Latex Family Planning Promotion Trust (HLFPPT), World Health Partners (WHP), and Pathfinder. Jhpiego is an international, nonprofit health organization affiliated with Johns Hopkins University. For more than 40 years, Jhpiego has empowered frontline health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works to break down barriers to high-quality health care for the world’s most vulnerable populations. Published by: Jhpiego Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA www.jhpiego.org © Jhpiego Corporation, 2016. All rights reserved.

A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings iii

Table of Contents

Background .................................................................................................................................1

Introduction ..................................................................................................................................8

Section I: Standards of Care .....................................................................................................12

Core Standards for Quality Assurance .....................................................................................19

Comprehensive Standards for Quality Improvement .............................................................23

Section II: Guidance on Quality Measuring and Monitoring .................................................32

Section III: Guidance on Capacity Building of Health Workers .............................................40

Annexures

Annexure 1: Assessment Tool for Use of Core Technical Standards for Supporting the Quality Assurance

Systems (Accreditation, Regulation etc.) ........................................................................................... 54

Annexure 2: Assessment Tool for Use of Comprehensive Set of Technical Standards for Guiding the

Quality Improvement Process ............................................................................................................ 70

Annexure 3: Boxes with Technical Details of Practices Covered Under Key Standards ..................... 108

Annexure 4: Key Resources Referred During Development of Standards of Care* ........................... 116

Annexure 5: S0Ps for using Standards-Based Assessment Tool .......................................................... 119

Annexure 6: Template for Action Planning ....................................................................................... 124

Annexure 7: Client Case Record Template ....................................................................................... 125

Annexure 8: ANC & PNC Card Template .......................................................................................... 142

Annexure 9: Birthing Register Template ............................................................................................ 144

Annexure 10: Monthly Progress Report Format ................................................................................. 145

Annexure 11: Process for development of the toolkit ....................................................................... 147

References ............................................................................................................................... 152

iv A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings

Abbreviations

AMTSL Active Management of Third Stage of Labor

ANC Antenatal Care

ANCS Antenatal Corticosteroids

APH Antepartum Hemorrhage

ART Anti-Retroviral Therapy

BCC Behavior Change Communication

BEmONC Basic Emergency Obstetric and Neonatal Care

BG Blood glucose

BMW Bio-medical Waste

BP Blood Pressure

BPCR Birth Preparedness and Complication Readiness

CCT Controlled Cord Traction

CEmONC Comprehensive Emergency Obstetric and Neonatal Care

CME Continuing Medical Education

CPD Cephalo-pelvic Disproportion

C-section Cesarean Section

DM Diabetes Mellitus

DVT Deep Vein Thrombosis

EBM Expressed Breast Milk

ENBC Essential New Born Care

ENMR Early Neonatal Mortality Rate

FHR Fetal Heart Rate

FP Family Planning

GA Gestational Age

GDM Gestational Diabetes Mellitus

GoI Government of India

Hb Hemoglobin

HDP Hypertensive Disorders of Pregnancy

HIV Human Immuno-deficiency Virus

HR Human Resource

HTSP Healthy Timing and Spacing of Pregnancy

IUD Intra Uterine Death

IFA Iron and Folic Acid

A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings v

IM Intra Muscular

IMR Infant Mortality Rate

IPTp Intermittent Preventive Treatment in Pregnancy

IV Intra Venous

KMC Kangaroo Mother Care

LMP Last Menstrual Period

LSCS Lower Segment C-Section

MDG Millennium Development Goal

MgSO4 Magnesium Sulphate

MMR Maternal Mortality Ratio

MNT Medical Nutrition Therapy

MRP Manual Removal of Placenta

NBCA Newborn Care Area

OGTT Oral Glucose Tolerance Test

OT Operation Theatre

PE/E Pre-Eclampsia/Eclampsia

PIH Pregnancy Induced Hypertension

PNC Post Natal Care

PNMR Perinatal Mortality Rate

POC Point Of Care

PPE Personal Protective Equipment

PPFP Post-Partum Family Planning

PPH Post-Partum Hemorrhage

PPPG Post-Prandial Blood Glucose

PPROM Preterm Premature Rupture of Membrane

PPTCT Prevention of Parent to Child Transmission

PTB Pre-Term Birth

PV Per Vaginum

QA Quality Assurance

QI Quality Improvement

Rh Rhesus

RI Routine Immunization

RMC Respectful Maternity Care

RPR Rapid Plasma Reagin

RTF Return to Fertility

vi A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings

SBA Skilled Birth Attendant

SGA Small for Gestational Age

TSB Total Serum Bilirubin

USG Ultra-Sonography

A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings 1

Background

Achieving the desired reduction in maternal and child mortality remains the unfinished agenda of the Millennium Development Goals (MDGs) 1–4. This task has remained unfinished despite knowing what works for reducing maternal and child mortality in developing country contexts for many years 5,6. As a mission, countries invested heavily in improving access to skilled care at birth and the surrounding period, leading to a global increase in access to skilled attendants at health facilities during childbirth. However, the reduction in maternal and newborn mortality has not been in sync with the high rate of institutional births achieved. Developing countries represent the greatest need for improved strategies for reducing mortality. As per a 2014 progress report on the MDGs, globally, four out of every five deaths of children under-five occur in Sub-Saharan Africa and South East Asia 7. Analysis of child mortality India reveals that while the infant mortality rate (IMR) has shown steady decline, the early neonatal mortality rate (ENMR) has virtually remained static since throughout last decade 8. No change in these indicators of care during childbirth point towards and urgent need for focus on quality of intrapartum care. Globally, it is estimated that better care during labor and birth as well as improved care of newborns immediately after birth could avert up to 1.49 million maternal and newborn deaths and stillbirths, with more than half of this number being newborn deaths 6. There is an urgent need to bridge the gap between evidence and its translation into practice during provision of care, particularly in resource-constrained settings.

Figure 1: Role of private sector in maternity and family planning care

Source: Family planning, antenatal and delivery care: cross-sectional survey evidence on levels of coverage and inequalities by public and private sector in 57 low- and middle-income countries - Campbell - 2016 - Tropical Medicine & International Health

2 A Practical Toolkit for Improving the Quality of Maternity Care in Private Care Settings

Worldwide, the private sector is an important stakeholder in healthcare services including maternity care. An analysis of DHS data from 57 countries revealed that the private sector provided a substantial proportion of delivery care in low- and middle-income countries. Of those that received services in facilities, the proportion that delivered in the private sector was reported to vary between regions ranging from 9% in Latin America, 20% in Sub-Saharan Africa, 31% in Middle East/Europe, 46% in Asia and 36% overall 10

Moreover, the role of the private sector in maternity services is ever increasing. Another analysis of DHS data from six countries in Asia showed a significant trend towards greater use of private sector delivery care over the last decade 11 It is expected that with rising income levels and improved dispersion of health insurance, the use of private healthcare will further rise. Improvement in quality of care is a felt need across public and private sectors in developing country settings. A systematic review of comparative performance of public and private sectors in lower and middle income countries found that diagnostic accuracy and adherence to medical management standards were worse among private than public sector health facilities. Private practitioners had significantly worse knowledge of correct diagnosis and treatment 12

Specific evidence for quality of maternity services also points towards a need for quality improvement in the private sector. Evidence exists of higher rates of potentially unnecessary procedures, particularly caesarean sections(C-sections), at private than at public settings 11,12. A population-based cluster randomized survey conducted in Delhi found a widespread non-adherence to evidence based maternity care guidelines in both public and private sector facilities 13. A comparative review of quality of Antenatal Care services in Tanzania found technical quality poor in both private and public sectors 14. Moreover, private sector care is poorly regulated in most of developing countries, resulting in a potential compromise in quality of care provision. Around the world, considerable efforts have been made in recent years to improve quality during care provision in antenatal, delivery, and postpartum periods at public sector healthcare facilities. However, despite contributing to care for a significant proportion of institutional deliveries, the private sector has not received similar focus for improving quality of care provision. Standardization of care across the private sector has been difficult. The largely disorganized nature of the private sector has led to non-standardized tools, care protocols, and procedures being used at private sector facilities across the world.


Figure 2: Challenges for quality management in the private sector

What are the challenges in quality management in the private

sector? Quality improvement challenges in the private sector can be categorized as intrinsic and extrinsic influences. Intrinsic factors are the levers of change that lie within the facilities and providers themselves, whereas extrinsic challenges are environmental factors which are external to the facilities and providers but still exert significant influence on the quality of care provision at facilities. Any quality management initiative in the private sector needs to influence both sets of factors in order to foster sustainable improvements in quality of care provision. Intrinsic factors

The success of interventions in the private sector is traditionally measured by the increase in the client base and there are very few incentives to engage with quality improvement processes that may not have an immediate effect on the client inflow into the facilities.

One of the most common intrinsic factors responsible for sub-optimal quality of care is the overall absence of mechanisms for technical updates for private sector service providers. Though infrequent and irregular, OBGYNs themselves have some access to new information through continuing medical education (CME) courses; however, nurses and paramedics working in the private sector work virtually without any access to skills development courses or continuing education for years. This leads to a continuation of outdated clinical practices that have been proven ineffective or harmful as per recent evidence. The specialized nature of currently available CME courses of OBGYNs, which are mostly sponsored and limited independent knowledge advancement opportunities result in inertia in adopting newer practices or techniques that have been proven to be beneficial.


There is limited monitoring of quality of care in the private sector due to the lack of incentives for quality improvement, as well as the absence of systems and capacity to measure and monitor quality. There are limited numbers of standardized tools for recording variables of interest, no unified systems for the reporting of quality of care data, and no mechanisms for monitoring the overall quality of care in the private sector.

The private sector is primarily profit driven and in many cases run by individuals or small- to medium-scale entrepreneurs. This often leads to a lack of adequate investment in essential infrastructure and resources that have high costs of establishment but t do not have a direct and immediately apparent impact on the profits of the institutions.

Extrinsic factors:

A major extrinsic factor leading to poor understanding and measurement of quality of services is the absence of normative guidance on inputs required for quality care provision, as well as benchmarks against which to evaluate the quality of their services.

Another important extrinsic factors affecting the quality of care provision in the private sector is regulatory ability of the system. The capacity of governments and/or their regulatory bodies is typically limited in many countries, and therefore, the responsibility of improving quality of care provision falls on private sector providers themselves.

Capacity of the professional associations, that can lead the quality improvement initiatives in absence of government led initiatives, is also highly variable across contexts. Often, the professional associations consider themselves primarily as technical agencies and do not get involved in processes and systems for quality promotion. Professional associations can play an important role in establishing quality mandates, maintaining focus on strategic priorities for interventions, creating systems for capacity building and mentorship, and monitoring the quality of care for private sector health institutions.

Finally, in developing country settings, there is an overall limited focus on the private sector as a stakeholder for healthcare service delivery for maternity services by the national governments, development community, and other players in the global public health fraternity. This causes a non-alignment of quality improvement approaches between public and private sectors, lack of adequate resources allocated to the private sector, and missed opportunities for sharing performance accountability reports with the private sector. The above, in-turn, is responsible for an absence of quality benchmarks suitable to the need and structure of the private sector, which in itself is an important extrinsic factor affecting quality improvement globally.


What is being proposed to address these challenges?

There is no single solution to quality improvement in the private sector due to the complex nature of the challenges faced by it. Quality of care can be defined from many perspectives—system, providers, clients, and communities. Moreover, there can be many dimensions to a quality improvement strategy including leadership, health workforce, financing, technical capacity, measurement systems, and others. Ideally, any comprehensive quality improvement initiative should address all these dimensions of quality. However, considering the vast spectrum of private sector providers in most settings and that they are, in many instances, largely unorganized and/or unregulated, a comprehensive strategy comprising all the dimensions of quality, although ideal, may be prohibitive in terms of resources and scope of implementation in most settings. In light of these considerations, this toolkit proposes a practical quality management process, along with the required tools and aids, which has been developed and customized for use in private sector health facilities in resource-constrained settings. The proposed quality management process focuses on the dimensions of a. Safety (in terms of minimizing any harm to pregnant women, mothers and their

newborns); b. Effectiveness (in terms of reducing mortality and morbidity); and c. Client centric care (in terms of respectful and dignified care-provision). These components will serve as an important step toward quality improvement for improving health outcomes in the private sector.

Quality Management

Quality Management is a set of processes by which a

desired level of excellence is maintained for a product or

services by an organization. In this context, quality

management is defined as a set of activities to ensure

that the health facility achieves desired level of

excellence, and maintains it with or without external

facilitation.

Quality Management is defined in the toolkit, includes

Quality Assurance (QA) and Quality Improvement (QI).

Quality Assurance

Quality Assurance means the maintenance of a desired

level of quality in service or product. In this context, QA

is being defined as a set of activities to ensure that the

quality of services provided by a health facility is

externally monitored and certified using a set of

essential quality standards.

It is presumed that, by implementing QA, the facilities

will sustainably maintain the quality of services.

Quality Improvement

Quality Improvement is a systematic approach for

analyzing performance and implementing targeted

solutions to improve it. In this context, QI is being

defined as self-performed or externally facilitated

cyclical set of activities to review performance against

desirable standards of care, implement specific activities

to address identified gaps, and periodic monitoring of

adherence to standards.


This practical toolkit proposes a two-step process for quality management in the private sector:

1. The first step of this process is implementing changes that will foster improved quality standards in the health facilities in order to reach to a level which is benchmarked for safety and effectiveness in the respective context. Once a facility reaches a minimum level of normative quality standards, the second step of the process, to sustain the quality of care provision, is initiated. The first step of implementing the toolkit process is largely an internal process, but may require some initial external promotion and facilitation.

2. The second step of the, process, however is largely dependent on the environment in which the health facility is situated. Therefore, the sustenance of the quality in the private health facilities will be a function of the extrinsic factors including the presence of a regulatory, accreditation, and/or other recognition mechanisms and systems, which incentivize the engagement of the private sector to maintain their quality in the intermediate and long term. This proposed quality management cycle uses a specially designed toolkit as the framework for action.

Figure 3: The Two-Step Cycle for Quality Management Process

QI Process

The quality improvement (QI) process proposed in this toolkit is based on a simple quality improvement cycle which uses normative standards to assess gaps in the facilities for developing action plans for improvement, planning and implementation of action plans, and periodically measuring progress. The first step in this process is to engage a facility in the QI cycle. Engagement will include leaders and facility level health workers’ orientation of the QI process. This can be externally initiated and/or facilitated among private sector providers by a QI organization or a professional association. Subsequently, the facility will use the various aids given in this toolkit to run the QI cycle—conducting assessments using standards to identify gaps, addressing gaps through action planning and focused trainings, intervention and measurements on selected metrics to ensure efficient efforts towards progress.


Figure 4: The Quality Improvement Cycle

QA Process Once the facility achieves the desired improvements in quality standards, the facility can be engaged in a continuous, self-sustaining quality assurance (QA) process through various mechanisms like accreditation or regulation. The accreditation process or the regulatory framework can also use the standards of care described in this toolkit as the necessary basic requirement. The QA process will have the potential for linkages with financing schemes, insurance providers, and other funders to ensure sustainable engagement of private providers. While the QI process can be initiated and self-propelled, the QA system may need to be assisted by external facilitators such as the governments, development organizations, or professional associations.

This toolkit contains two sets of standards, one each for QA and QI process.

The set of standards for QA mechanism comprises of 15 core standards which can be used by the governments or accreditation institutions or professional agencies for recognizing/accrediting or regulatory purposes.

The other set of standards is a comprehensive version which can be used for the QI process by the individual facilities or external facilitators, to improve the quality of care process at the private health facilities.


Introduction

This toolkit functions as the set of resources, know-how, and aids to implement the proposed quality management process to improve and sustain the quality of care in private sector institutions. The toolkit can be used in the following ways:

1. The standards, tools, and resources in the toolkit can be self-use by facilities independently to improve their own quality of care.

2. The toolkit can also be used by external facilitators, such as professional associations or government agencies for helping a group of facilities improve their quality in a structured manner.

3. As a part of the quality management cycle, the toolkit can be used by external stakeholders for benchmarking facility-based care against normative standards and establishing continuing quality assurance requirements as a part of an accreditation or regulatory process. The toolkit can also be used by professional associations or similar entities for peer recognition, as well as forging linkages with financing schemes. Such linkages of the quality management cycle to the regulatory, accreditation, or financing schemes will be critical in ensuring sustainable quality assurance in the private sector health facilities.

The proposed toolkit has three components— A. Standards of care, B. Guidance for quality measurement and monitoring, and C. Guidance for capacity building.

Each component of the toolkit is supported by a set of tools for its effective use.

Figure 5: Standards of care as the key component of the toolkit

Figure 6: Description of Core and Comprehensive Standards


A. Standards of care

Standards of care form the key components of the toolkit. The other two components are linked to the standards. Standards are divided into three sections—antenatal care (ANC), intra- and immediate postpartum care, and postnatal care (PNC). As mentioned earlier, this toolkit contains two sets of standards, one each for the QA mechanism and the QI process. For QA system

For the quality assurance system, a set of 15 core standards is proposed (pages 16-24), which can be used by the external agencies to accredit/recognize/empanel or regulate the quality of care at the private health facilities. For QI system

There is a set of 37 comprehensive standards (pages 25-40) which can be used by the facility or external facilitator for undertaking the quality improvement process before engaging in the QA system of accreditation or regulation. This set also includes three standards related to inputs that offer guidance on the availability of essential infrastructural and human resources. There are two tools linked with this component of the toolkit—a standards-based assessment tool (page 65) and a tool for preparing action plans based upon the findings of the assessment. B. Guidance for quality measurement and monitoring

Guidance for quality measurement and monitoring forms the second component group of the toolkit. These metrics are intended to enable the facility clinical and administrative leaders for measuring progress towards compliance to the standards and resultant improved outcomes. There are two types of metrics recommended in the toolkit.

i. Dashboard indicators: A list of ten high-level indicators which have been identified based on their effectiveness in reducing morbidity and mortality, as well as collectability through the system itself (without the need of external surveys). These indicators are global in nature and will serve to provide a dipstick in the facility to understand overall care quality.

ii. Performance indicators: A list of indicators that are directly linked to various standards of care. The facilities, based on their need, can select some of these


indicators to monitor progress on the standards to which they are non-compliant. The facilities will need to collect data on these indicators on a quarterly basis. Tools such as a standardized case sheet template, labor room register, and an antenatal card template to enable the facility to record data required for the indicators in a standardized manner are linked with this component of the toolkit.

C. Guidance for capacity building

Guidance for capacity building of health workers in a structured manner constitutes the third component of the toolkit. This includes course outlines that are fully aligned with the standards of care and focus on care processes included in the standards. A learning resource package including power point presentations, job-aids, and various checklists for self-learning and use by health workers have been included as a set of tools linked to this component of the toolkit.

Use for Quality Improvement

The comprehensive set of 37 standards (pages 25-40) form the technical basis for other toolkit components to complete the facility-intrinsic quality improvement cycle described earlier. The first step in this is facility assessment is using a standards-based assessment tool (page 65) to evaluate areas of non-compliance to the normative standards of care. Non-compliance to the standards can be due to the lack of technical updates or skills among health workers, non-availability of essential supplies, or lack of an enabling environment in the facility. A planning tool is included in the toolkit for preparation of gap-based action plans. Based upon the action-planning tool, the quality improvement process can be facilitated. Typically, the action plans will include plans for clinical updates and skill development of health workers, actions to ensure resource availability, or plans for change in practices and protocols of the facility. While resource availability and changes in protocols will be gap-driven, in order to ensure comprehensiveness, the process for clinical updates and skill development of health workers can be standardized. Progress on quality improvement can be measured using the indicators. Scores on dashboard of indicators can o be compared across facilities in the case of externally facilitated quality improvement programs. The facility will need to collate data on a monthly basis for monitoring dashboard of indicators. Additionally, more in-depth monitoring of quality improvement can be done using the performance monitoring indicators. The facilities will need to collect data on these indicators on a quarterly basis. Tools such as a standardized case sheet template, labor room register, and an antenatal card template can be used to enable the facility to record data required for the indicators in a standardized manner


Use for Quality Assurance

Relevant authorities can use the set of 15 core standards (pages 16-24) in the toolkit as normative benchmarks for regulatory purposes. Professional organizations (like the association of midwives, association of obstetricians) could adapt standards from the toolkit and release them to private healthcare system practitioners to self-regulate in achieving high-quality care and performance. Regulatory authorities could also use the toolkit to standardize care across the region and thus ensure quality of care. These 15 core standards could also be used in an active regulatory system to register, provide licensing or accredit maternity health facilities. Most accreditation systems mandate that institutions follow standard operating procedures and protocols; the standards described in the toolkit can be adapted and contextualized to be used as a part of the accreditation system for maternity healthcare systems. Similarly, the metrics described in the toolkit could also be adapted and used by regulators as part of their management information systems in tracking essential practices amongst private sector providers.


Section I: Standards of Care

Standards of Care form the key component of the toolkit and depict safe care practices to be adhered to at the target health facilities. The standards included in this toolkit cover the full spectrum of care for various times during and after delivery including screening and early diagnosis of conditions, normal care processes, and early and comprehensive management of complications. The standards have the following properties:

Structure of the standards

Each standard consists of two important components—a standard statement and a set of essential elements. The standard statement is a statement related to a normative clinical practice in support of routine care or identification or management of complications. Each essential element describes a component of care/clinical practice under that standard. Essential elements are objective statements, and compliance to them can be assessed by the means of one or more verification criteria included in the standards-based assessment tool.

Clinical Standards

The core standards in this toolkit are broadly classified into three sections—ANC, intra- and immediate postpartum, and PNC. Additionally, three basic standards related to inputs are also included in the toolkit. The standards and essential elements do not include details of an activity or clinical practice. Wherever necessary, references are given to boxes that include details of such processes. These boxes have been included under the technical details of the standards in the last chapter.

Figure 7: Organization of the core standards of care*

* Comprehensive set includes 37 standards of care

Apart from these there are 3 standards related to inputs


Standards related to inputs

There are three standards related to inputs focusing on availability of basic minimum resources which are required for compliance to normative care standards. These include standards related to infrastructural and human resources for normal delivery and caesarean section.

Measuring compliance to the standards

Compliance to the standards can be assessed using the standards-based assessment tool (included under technical details of the standards in last chapter). For a facility to be determined compliant to a standard, it should be found compliant to all the essential elements associated with that standard. In the case that even one essential element is found to be missing, the facility will be determined non-compliant to the respective standard.

Scope of the standards

The standards have progressive levels to cover services provided by various levels of facilities. For the purpose of this toolkit, the standards cover three progressive levels of care facilities:

Facilities providing ANC services only: basic ANC services including routine care, screening of conditions, and pre-referral care for complicated cases. Other sets of standards are not applicable to these facilities.

Facilities providing Basic Emergency Obstetric and Newborn Care (BEmONC): full spectrum of ANC services including screening and basic management of complications; routine care during the intrapartum period and basic management of maternal and newborn complications; full spectrum of PNC services. Some ANC, intra- and immediate postpartum and PNC standards do not apply to these facilities.

Facilities providing Comprehensive Emergency Obstetric and Newborn Care (CEmONC): full spectrum of ANC, intra- and immediate postpartum care, and PNC services. All standards apply to these facilities

Who can use the standards? The standards can be used by:

External agencies for accrediting/rewarding/recognizing, and/or regulating quality of care among private facilities in various settings (QA process). For this purpose, a set of 15 standards has been included in this toolkit (pages 16-24), which can be used by relevant stakeholder(s) for assessing quality among private sector facilities for the purposes of regulation/accreditation/recognition.

Technical focus of the standards The standards focus on normative care and critical clinical practices to ensure safe delivery and

prevention, early detection, and management of major complications amongst mothers and

newborns during pregnancy and childbirth.


Private health facilities to improve their own quality of care or by external facilitators such as development organizations or professional associations to improve the quality of care of a group of private sector facilities (QI). For this purpose, a set of 37 standards has been included in this toolkit (pages 25-40) to move forward for engaging in the regulation/accreditation system.

How to use the standards?

Use of Standards for Quality Improvement

Use of standards for QI by individual health facilities

Individual health facilities can use the standards in a structured manner to develop focused plans for quality improvement. This quality improvement process will have the following steps:

Formal adoption of standards and staff orientation

The facility should conduct an all-staff meeting to formally adopt the standards, express commitment to compliance, and develop immediate plans for following the standards. This meeting can be used to orient all the health workers involved in the process of care during pregnancy and childbirth on the toolkit components. Nodal persons can be identified from within the facility to ensure compliance to various sections of the standards.

Assessment of facility’s compliance to the standards

Immediately following the staff orientation, key care providers from the facility should conduct a baseline assessment of its status of compliance to the standards. This should be conducted using the standards-based assessment tool (page 65) for the applicable standards or essential elements.

Action planning based on gaps

Facility leaders, during the process of assessment of facility compliance, should clearly identify unmet criteria for each essential element or standard. Root cause analysis should be undertaken to identify the underlying reasons behind the non-compliance. An action plan should be prepared to address underlying reasons behind each unmet essential element. Action plans should have clearly assigned responsibilities and timelines for completion of actions.

Implementation of action plan

Implementation of the action plan may include ensuring prioritized availability of resources necessary for compliance to the standards and knowledge and skill building of health workers. This can be led internally by the facility in-charge him/herself. Implementation of the action plan includes prioritizing the availability of missing resources essential for practices included in the standards that were found to be the reasons for non-compliance during assessments. The next step is the skill building of health workers in key practices included in the standards. Traditionally, in-service training programs in the country were long and of foundational nature rather than focusing on key skills. Since major causes of maternal and newborn mortality are widely known, focusing on developing the skills of health workers in practices addressing major


causes of mortality is considered a time and resource efficient intervention that helps rapidly equip institutions with a workforce that is skilled in responding to a major causes of mortality.

Progress assessments

The facilities should monitor their progress based on adherence to the standards using the standards-based assessment tool at six-month intervals. The assessment methodology for the periodic assessments should remain the same as the baseline assessment, and ideally the same person should conduct successive assessments. Action plans based upon the identified gaps should be prepared during each assessment.

Displays to show commitment to quality

The facilities can display the standards summary prominently within the facilities as commitments statements to high-quality service delivery.


Figure 8: Methodology for using standards for quality improvement

Use of standards for QI supported by external facilitators

External facilitators using the toolkit can facilitate the quality improvement process at a larger scale. However, since in this case the facilities themselves are not taking the initiative, the process of using the standards must be approved by a group consensus on the standards before initiating in-facility quality improvement activities. External facilitators should undertake the following steps for using the standards in a target group of facilities:

Collaborative meeting to adapt, prioritize, and adopt the standards

The external facilitator should organize local group meetings of partnering facility clinical leaders to develop a group consensus on the standards. Since the scale of implementation will be larger, the group can review the standards to modify essential elements to align them (if needed) with the local guidelines. The groups can also prioritize collections of standards or individual standards within each group for immediate and intermediate term implementation. The groups should form a local consensus on the frequency of externally facilitated assessments and roles and responsibilities for implementation.


Baseline assessments with external presence

The external facilitators should help facilities plan and conduct their baseline assessments in a way that there is an external presence (representative of an external facilitator or a peer assessor) at the time of assessment to ensure objectivity.

Action planning based on gaps

Based upon the gaps identified through the baseline assessments using the standards-based assessment tool, the facilities should prepare their own action plans. However, since many of the gaps may be common across the group of facilities involved in the process, the external facilitator can support in planning standardized sets of activities such as trainings, procurement of resources, and development of protocols to be implemented in the groups.

Implementation of action plans

External facilitators should periodically follow-up (can be done remotely but through facility visits wherever possible) with the facilities to track the progress of implementation of action plans based upon the standards.

Group trainings for facility staff

External facilitators, wherever possible, can facilitate group trainings for facility staff to improve efficiency, enable cross-learning among participants, and effective skill development. These group trainings can involve key staff trained in a facility setting using the standard course outlines described in the next session.

Periodic assessment

While the facilities are expected to conduct their own periodic assessments at least once every six months, the external facilitators should decide upon an appropriate frequency (once every year) to have a presence in the facilities at the time of periodic assessments using the standards.

Recognition of facilities achieving desired scores

The recommended score to be achieved on standards is 70%. The external facilitator should track the facilities’ achievements on standards as observed during external presence during assessments. The facilities achieving desired scores on the standards should be recognized at peer or public forums. This can be done in the form of an achievement seal or plaque designed locally.

Use of Standards for Quality Assurance through Accreditation/Recognition/

Regulation

Linkages with accreditation or regulatory mechanisms

As mentioned earlier, there is a limited capacity in most of the developing countries to ensure provision of standardized quality of care in the private sector. This is mostly due to the sub-optimal regulatory capacity of the government and/or the professional associations to promote quality, absence of accreditation systems, and non-availability of standardized tools for quality assurance. This toolkit attempts to address some of these gaps by including a simplified set of 15 core standards (pages 16-24), which can be


used by governments and/or accreditation institutions or professional agencies and associations to recognize/accredit private healthcare facilities for regulation of the quality of care. This is critical to ensure mechanisms for provision of sustained standardized care in the private sector. Efforts should be made to incentivize the engagement of private sector facilities in such quality assurance mechanisms through linkages of QA systems like accreditation to health financing schemes of the government, health insurance sector, and/or peer recognition processes for developing a robust regulatory mechanism. This QA system will need to be facilitated by external agencies like national governments, professional associations or accreditation boards. If private healthcare facilities are unable to achieve the desired QA related standards, they can undertake the process of quality improvement (described earlier in the section), to institutionalize and strengthen their quality care process, and then re-engage to develop self-sustaining quality assurance systems. The standards of care form the cornerstone of the quality improvement process by providing a framework planning and implementing actions based upon the needs of health facilities. Prioritization of standards into core standards for quality improvement will enable the external facilitators to easily benchmark the quality of facilities for quality assurance purposes. Core and comprehensive standards with respective essential elements are given in the next section.


Core Standards for Quality Assurance

ANC Standards

Standard 1

Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman

and fetus in all ANC visits

A Establishes gestational age

B Takes appropriate history (medical, surgical, obstetric and personal) and performs general

and systemic examination (Box 1)*

C Records weight of pregnant woman during all ANC visits

D Conducts abdominal examination

E Records fetal heart rate (FHR)

F Performs PV examination during 4th ANC visit (37weeks or more) to check for pelvic

adequacy (Box 2)

Standard 2

Provider screens for key clinical conditions that may lead to complications during pregnancy

A Laboratory facilities/linkage to laboratory facilities are available

B Screens for anemia

C Screens for hypertensive disorders of pregnancy

D Screens for DM (as per relevant national guidelines)

E Screens for HIV

F Screens for hepatitis B (if applicable, as per national guidelines)

G Screens for syphilis

H Screens for malaria

I Establishes blood group and Rh type during first ANC visit

Standard 3

Provider ensures adequate preventive care for key clinical conditions which can lead to complications

in pregnancy

A Ensures adequate preventive care for anemia

B Ensures adequate preventive care for neonatal tetanus by tetanus toxoid vaccination

C Ensures adequate preventive care for pre-eclampsia/eclampsia by calcium

supplementation

D Ensures adequate preventive care for malaria (if applicable, through IPTp in moderate to

high transmission areas of Africa or as per relevant national guidelines)

*Boxes are given on page 109-116


Intra- and Immediate Postpartum Care Standards

Standard 1


and fetus at the time of admission

A Elicits comprehensive obstetric, medical and surgical history and conducts examination

(Box 1)

B Assesses gestational age correctly

C Records fetal heart rate

D Records mother’s blood pressure

E Records mother’s temperature

Standard 2

Provider ensures respectful and supportive care for the pregnant woman coming in for delivery

A Treats pregnant woman and her companion cordially and respectfully (RMC), ensures

privacy and confidentiality for pregnant woman during her stay

B Encourages the presence of birth companion during labor

C Explains danger signs and important care activities to pregnant woman and her companion

during the stay (for the woman and her newborn)

Standard 3

Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly

A Monitors progress of labor regularly on various parameters (Box 9)

B Interprets partograph correctly and adjusts the care according to findings

Standard 4

Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried

immediately)

A Delivers the baby and places on mother’s abdomen to conduct immediate newborn care -

drying and assessment of baby’s breathing

B Performs delayed clamping of cord

C Assesses the newborn for any congenital anomalies

D Ensures early initiation of breastfeeding

E Weighs the baby and administers Vitamin K

Standard 5

Provider performs newborn resuscitation if baby does not cry immediately after birth

A Performs recommended initial steps for resuscitation within first 30 seconds

B Initiates bag and mask ventilation for 30 seconds if the baby is still not breathing

C Takes appropriate action if baby doesn’t respond to ambu bag ventilation after golden

minute

D

Performs next level of resuscitation in babies not responding to initial resuscitation- when chest

rise is seen after bag and mask but heart rate continues to be < 60/pm (only at facilities

where specialist care for newborn or SNCU is available)


Standard 6

Provider performs Active Management of Third Stage of Labor (AMTSL)

A Performs AMTSL and examines the placenta thoroughly

Standard 7

The facility adheres to universal infection prevention protocols

A Instruments and re-usable items are adequately and appropriately processed after each use

B Biomedical waste is segregated and disposed of as per the guidelines

C Performs hand hygiene before and after each procedure, and sterile gloves are worn during

delivery and internal examination

Standard 8

Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)

A Identifies mothers with severe PE/E

B Gives correct first dose of MgSO4 and refers to higher center or manages appropriately (Box 4)

C Facilitates prescription of anti-hypertensives (Box 5)

D Ensures specialist attention for care of mother and newborn

Standard 9

Provider identifies and manages Postpartum Hemorrhage (PPH)

A Assesses uterine tone and bleeding per vaginum regularly after delivery

B Performs initial steps of management as per the protocol in case of PPH

C Manages atonic PPH

D Manages PPH due to retained placenta/placental bits

Standard 10

Provider ensures appropriate care of newborn with small size at birth

A Facilitate specialist care in newborn weighing <1800 gm

B Facilitates assisted feeding whenever required

C Facilitates thermal management including kangaroo mother care (KMC)

(Caesarean Section)

Standard 11

Provider reviews clinical practice related to C-section at regular intervals

A Ensures classification as per Robson’s criteria and reviews indications and complications of C-

section at regular intervals


Postpartum Care Standards

Standard 1

Provider ensures adequate postpartum care package is offered to the mother and newborn

A Ensures at least 4 postpartum visits for the mother

B Conducts proper physical examination of the mother and newborn

C Identifies and appropriately manages maternal and neonatal sepsis

D Identifies and appropriately manages postpartum maternal depression

E Ensures to offer the FP services


Comprehensive Standards for Quality Improvement

ANC Standards

Standard 1


and fetus in all ANC visits

A Establishes gestational age

B Takes appropriate history (medical, surgical, obstetric and personal) and performs general

and systemic examination (Box 1)

C Records weight of pregnant woman during all ANC visits

D Conducts abdominal examination

E Records fetal heart rate (FHR)

F Performs PV examination during 4th ANC visit (37weeks or more) to check for pelvic

adequacy (Box 2)

Standard 2

Provider screens for key clinical conditions that may lead to complications during pregnancy

A Laboratory facilities/linkage to laboratory facilities are available

B Screens for anemia

C Screens for hypertensive disorders of pregnancy

D Screens for DM (as per relevant national guidelines)

E Screens for HIV

F Screens for hepatitis B (if applicable, as per national guidelines)

G Screens for syphilis

H Screens for malaria

I Establishes blood group and Rh type during first ANC visit

Standard 3

Provider ensures adequate preventive care for key clinical conditions which can lead to complications

in pregnancy

A Ensures adequate preventive care for anemia

B Ensures adequate preventive care for neonatal tetanus by tetanus toxoid vaccination

C Ensures adequate preventive care for pre-eclampsia/eclampsia by calcium

supplementation

D Ensures adequate preventive care for malaria (if applicable, through IPTp in moderate to

high transmission areas of Africa or as per relevant national guidelines)

Standard 4

Provider performs adequate management of anemia

A Performs adequate management of anemia (Box 3)


Standard 5

Provider performs adequate management of hypertensive disorders of pregnancy

A Confirms hypertension and identifies pregnant woman with severe PE/E

B Manages hypertension using recommended anti-hypertensives (Box 5)

C In case of severe PE/E, gives correct first dose of MgSO4 and refers to higher center for further

management (Box 4)

Standard 6

Provider performs adequate management of Gestational Diabetes Mellitus (GDM)

A Initiates MNT in all diagnosed GDM cases

B Initiates insulin therapy if required

C Initiates fetal surveillance

D Ensures specialist attention for care of pregnant woman and newborn during labor

Standard 7

Provider performs adequate management of communicable conditions in pregnant woman- HIV,

Malaria and Syphilis

A Appropriately manages HIV seropositive cases (If ART center) (Box 13) or refers to an ART

center (If not ART center)

B Appropriately manages syphilis in pregnant woman and spouse/partner

C Appropriately manages malaria in pregnancy

Standard 8

Provider manages threatened preterm labor

A Identifies threatened PTB

B Essential medicines for managing PTB are available

C Appropriately manages conditions leading to PTB (For GA 24 - 37 weeks)

D Ensures interventions to facilitate fetal maturity and protection if GA is <34 weeks (Box 8)

E Ensures heightened monitoring and care (GA between 34 - 37 weeks)

F Prepares for specialist care for newborn

Standard 9

Provider counsels pregnant woman on care during pregnancy

A Shares a written schedule of ANC visits with the pregnant woman

B Counsels pregnant woman and her husband/partner/companion on BPCR at least during last

trimester

C Counsels pregnant woman and her husband/partner/companion on importance of lifestyle

modification at least during first trimester

D Counsels pregnant woman and her husband/partner/companion on importance of optimal

newborn care at least during last trimester

E Counsels pregnant woman and her husband/partner/companion on postpartum family

planning in all ANC visits


Standard 10






INTRA- AND IMMEDIATE

POSTPATUM CARE STANDARDS

& IPP CARE STANDARDS



Standard 1


and fetus at the time of admission

A Elicits comprehensive obstetric, medical and surgical history and conducts examination

(Box 1)

B Assesses gestational age correctly

C Records fetal heart rate

D Records mother’s blood pressure

E Records mother’s temperature

Standard 2

Provider ensures respectful and supportive care for the pregnant woman coming in for delivery

A Treats pregnant woman and her companion cordially and respectfully (RMC), ensures

privacy and confidentiality for pregnant woman during her stay

B Encourages the presence of birth companion during labor

C Explains danger signs and important care activities to pregnant woman and her companion

during the stay (for the woman and her newborn)

Standard 3

Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly

A Monitors progress of labor regularly on various parameters (Box 9)

B Interprets partograph correctly and adjusts the care according to findings

Standard 4

Provider assists the pregnant woman to have a safe and clean birth

A Conducts PV examination at admission, and every four hours in active labor or as per the

clinical indication

B Performs PV examination in a safe and clean manner (Box 2)

C Allows spontaneous delivery of head by maintaining flexion and giving perineal support;

manages cord round the neck; assists in delivery of shoulders and body

D Performs an episiotomy only if indicated (Box 11)

Standard 5

Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried

immediately)

A Delivers the baby and places on mother’s abdomen to conduct immediate newborn care -

drying and assessment of baby’s breathing

B Performs delayed clamping of cord

C Assesses the newborn for any congenital anomalies

D Ensures early initiation of breastfeeding

E Weighs the baby and administers Vitamin K


Standard 6

Provider performs newborn resuscitation if baby does not cry immediately after birth

A Performs recommended initial steps for resuscitation within first 30 seconds

B Initiates bag and mask ventilation for 30 seconds if the baby is still not breathing

C Takes appropriate action if baby doesn’t respond to ambu bag ventilation after golden

minute

D

Performs next level of resuscitation in babies not responding to initial resuscitation- when

chest rise is seen after bag and mask but heart rate continues to be < 60/pm (only at facilities

where specialist care for newborn or SNCU is available)

Standard 7

Provider performs Active Management of Third Stage of Labor (AMTSL)

A Performs AMTSL and examines the placenta thoroughly

Standard 8

Provider assesses condition of mother and baby before shifting them from labor room

A Looks for signs of infection in baby

B Looks for signs of hypothermia in baby

C Looks for signs of infection in mother

D Records blood pressure of mother

Standard 9






Standard 10

Provider induces labor only when indicated (based on history and findings of examination)

A Induces labor only when indicated (Box 12)

B Uses only recommended technique for induction of labor

C Monitors the progress of labor

D Appropriately manages the hyperstimulation of uterus due to use of uterotonics

Standard 11 (applicable only for CEmONC facility)

Provider augments labor only when indicated (based on history and findings of examination)

A Augments labor only when indicated

B Carefully assesses the condition of pregnant woman before considering augmentation of

labor

C Ensures appropriate supportive care to pregnant woman

D Uses correct technique for augmentation of labor

E Monitors maternal and fetal well-being continuously


Standard 12

Provider identifies and manages HIV in pregnant woman and newborn

A Checks for test results or recommends testing if not done

B Appropriately manages HIV seropositive cases (if ART center) (Box 13) and refers to ART

center (If not ART center)

C Appropriately manages newborn of HIV seropositive mother

Standard 13

Provider identifies and manages severe Pre-eclampsia/Eclampsia

A Identifies mothers with severe PE/E

B Gives correct first dose of MgSO4 and refers to higher center or manages appropriately

(Box 4)

C Facilitates prescription of anti-hypertensives (Box 5)

D Ensures specialist attention for care of mother and newborn

Standard 14

The facility has services available for conducting assisted vaginal delivery as clinically appropriate

A Reviews the pregnant women for suitability for vacuum extraction

B Performs vacuum extraction using recommended procedures

C Identifies failure of vacuum extraction

Standard 15

Provider effectively manages special obstetric conditions- shoulder dystocia and mal-presentations

A Identifies and effectively manages shoulder dystocia

B Effectively manages breech delivery

C Effectively manages other mal-presentations

Standard 16

Provider identifies and manages Postpartum Hemorrhage

A Assesses uterine tone and bleeding per vaginum regularly after delivery

B Performs initial steps of management as per the protocol in case of PPH

C Manages atonic PPH

D Manages PPH due to retained placenta/placental bits

Standard 17

Provider ensures appropriate care of newborn with small size at birth

A Facilitate specialist care in newborn weighing <1800 gm

B Facilitates assisted feeding whenever required

C Facilitates thermal management including kangaroo mother care (KMC)


Standard 18

Provider performs appropriate management of hypoglycemia in newborn

A Identifies neonatal hypoglycaemia

B Manages neonatal hypoglycemia (only at facilities where specialist care for newborn or

SNCU is available)

Standard 19

Provider performs appropriate management of hyperbilirubinemia in newborn

A Identifies neonatal hyperbilirubinemia

B Manages neonatal hyperbilirubinemia (only at facilities where specialist care for newborn or

SNCU is available)

(Caesarean Section)

Standard 20

Provider makes proper preparation and adheres to standard procedure and technique of C‐Section

A Makes correct indication and ensures general preparation for C‐Section

B Adheres to standard procedure and protocols for conducting C-section

Standard 21

Provider ensures appropriate postoperative monitoring course and postnatal care for the mother

A Correctly monitors postoperative course and ensures postnatal care for the mother

Standard 22

Provider reviews clinical practice related to C-section at regular intervals

A Ensures classification as per Robson’s criteria and reviews indications and complications of C-

section at regular intervals


Post Natal Care Standards

Standard 1

Provider ensures adequate postpartum care package is offered to the mother and newborn

A Ensures at least 4 postpartum visits for the mother

B Conducts proper physical examination of the mother and newborn

C Identifies and appropriately manages maternal and neonatal sepsis

D Identifies and appropriately manages postpartum maternal depression

E Ensures to offer the FP services (PPIUCD, PPS)

Standard 2

Provider counsels the mother on care for herself and her newborn

A Counsels mother on routine care for herself and her baby

B Counsels on RTF, HTSP and PPFP

C Counsels on immunization for the newborn


Standards Related to Inputs

Standard 1

Adequately resourced and properly organized labor room is available

A

Adequate number of labor tables are available in labor room (as per the delivery load: 1 for

< 20, 2 for 20-99, 4 for 100-199, 6 for 200-499, use formula for calculation* for > 500 deliveries

per month)

B

Adequate space is available in labor room for placement of required labor tables (labor

tables have a distance of at least 3’ from the side wall, at least 2’ from head end wall, and at

least 6’ in between two tables)

C Adequate privacy is maintained in labor room through use of partition/curtains

D Adequate facility (chair/stool) for birth companions is available

E Adequate number of sterilized delivery trays as per the delivery load are available (at least 2

sets per labor table)

F Functional NBCA is available in labor room (Box 14)

G

NBCA is in the labor room with easy accessibility from the labor tables (if required, can be

accessed from labor tables within 5 seconds) and is open on three sides for ease of

movement

H Labor room has adequate availability of all the necessary supplies (Box 15)

I Functional toilet and washing area with 24-hour running water supply is available

J Labor room has adequate lighting, ventilation and temperature control

*Formula for calculation = {(Projected labor events in a year)*(Average length of stay)}/ {(365)*(Occupancy rate)}

Standard 2

Adequately trained human resources are available in appropriate number

A

Adequate SBA trained staff is available for conducting normal vaginal deliveries (as per

delivery load: 2 nurses for < 100, 4 for 100-200, 8 for 200-500 and 10 for > 500 deliveries per

month)

B Appropriately trained personnel is available for conducing assisted vaginal deliveries

C ObGyn/Specialist is available for complication management

D ObGyn/Appropriately trained staff is available for conducting C-section

E Anesthetist is available for performing C-sections

F Adequately trained support staff is available as per the delivery load

Standard 3 (applicable only for CEmONC facility)

Operation theatre is adequately equipped for conducting C-Section

A Number of OT tables in the OT is appropriate as per the C-section rate

B Adequate supplies and equipment are available in the OT for C-section

C Anesthesia tray with functional Boyle's apparatus is available

D OT has adequate lighting, ventilation and temperature control

E OT complex has provision for separate washing area with 24-hour running water supply

F OT complex has functional toilet and staff resting/changing area

G Functional NBCA is available in the OT (Box 14)

H Adequate supplies and equipment are available for conducting advanced adult and basic

newborn resuscitation


Section II: Guidance on Quality Measuring and

Monitoring

Quality Measurement and Monitoring

Monitoring of the quality in the facilities and the use of data for decision making is an essential element of the proposed quality management cycle. One of the major challenges in measuring the quality of maternity care is the inability of the health system to generate data on indicators related to quality. Therefore there is a dependence on externally conducted surveys to provide feedback on the quality of care. This toolkit proposes to address this gap by proposing a set of simple processes and outcome related indicators, which are not only valid and reliable for measuring quality, but most importantly, data on these indicators can be collected by the system itself for a more internally-led quality management system. Additionally, the toolkit also includes tools to enable facilities to capture data themselves, such as a standardized set of case sheets, labor room registers, and the reporting format.

Metrics

Metrics have been included in the toolkit to help facilities improve efficiency in monitoring change in quality of care to ensure comparability among toolkit user groups. The metrics are divided into two main groups of indicators—universal dashboard indicators consisting of seven process indicators and three outcome indicators, which make a total of 10 dashboard indicators, and an optional set of performance monitoring indicators linked to major standards of care. While the universal dashboard indicators give a guiding framework to all facilities to measure and manage quality, the optional set of performance indicators gives a much more exhaustive list of indicators, which can be used by the facilities to measure quality in specific areas based on their need, epidemiology, and priorities in quality.


Figure 8: Measurement Metrics for Monitoring Quality of Care

Dashboard indicators

Ten dashboard indicators have been proposed as a part of the toolkit. These indicators are included as a broad guidance for regular quality improvement process among the toolkit user groups. The dashboard indicators focus on critical aspects of key evidence-based practices to be performed universally to prevent complications and mortality during childbirth. Thus data on these indicators should be collected and collated on a monthly basis in all the user facilities. These indicators can be used to compare status of change in quality of care during childbirth across a group of facilities.

Performance monitoring indicators

Performance monitoring indicators are more comprehensive in nature than the dashboard indicators and focus on key aspects of the major standards of care. Due to the exhaustive nature of data requirement of these standards, they are kept optional for the facilities. However, monitoring these indicators will give a more in-depth picture of the status of adherence to evidence-based practices. These indicators are primarily meant for individual facilities or smaller groups of facilities to track their own progress on quality improvement and have a limited value for comparison across large groups of facilities. Overall, 26 performance monitoring indicators have been included in the toolkit for the facilities to choose from. It is recommended that the facilities select a set of performance indicators from this list based upon their quality gaps and the compliance status on related standards of care. These indicators can be monitored until the time compliance is achieved on the related standard of care. Facilities then can switch to other sets of indicators.


Structure of the indicators

For the purpose of this toolkit, the indicators have been presented in a tabular manner. The structure of this table includes a statement of indicator itself, a definition of the indicator focusing on the relevance and importance of the indicator, descriptions of numerators and denominators of the indicator, and proposed sources of data.

How to use the indicators

The indicators can be used by both individual facilities and groups of external facilitators. The process of use by different users is being described below.

Individual Facility

Individual facilities can use indicators to monitor change in quality of care using the following process:

Adoption of indicators and standardization of data recording tools

Facility leaders should formally decide to adopt the standards (all dashboard and select performance monitoring indicators) as a commitment to improve quality of care. In order to be able to collect the data required for monitoring these indicators, they should review their data collection tools to understand the feasibility of collection relevant data. If their tools have missing data elements, they should use their tools for inclusion of these elements. Frequency of data reporting should also be decided at the same time. A nodal person should also be identified for the purpose of collating the data and reporting the indicators.

Implementation of revised data tools

The facility should formally start implementing the revised data tools for the purpose of collecting data for the selected indicators.

Data collation

The person responsible for data collation should compile the data from relevant sources on a monthly basis and generate reports on selected indicators.

Review of data

Key stakeholders should periodically review performance on the indicators and decide upon a course of action for improvement.

Data display Wherever feasible, the status of performance on the indicators should be prominently displayed in the facilities in staff areas to keep them aware of the status of performance on key indicators.

Data Collection Tools

A set of tools for data recording and collation has been developed along with the toolkit. This includes

a standardized version of a Client Case Record, a template for a Standard Birthing Register, a template

for a Standard Antenatal Care Card, and a Standard Reporting Form are included as Annexures linked

to this component of the toolkit. (Annexures III-VI)


Dashboard Indicators

S.No. Indicator Definition Numerator Denominator Data

Source

Process indicators

1 Proportion of

pregnant women

whose blood

pressure was

recorded at the

time of admission

This reflects the

practice of

recording BP of

pregnant

women by the

service provider

at the time of

admission

(targeted to

identify cases of

pregnancy

induced

hypertension)

Number of pregnant

women admitted in

the targeted facilities

whose BP was

recorded at the time

of admission during

specified period

Total number of

pregnant

women

admitted in the

targeted

facilities for

delivery during

same period

Case

sheets/

Labor

room

register

2 Proportion of

pregnant women

where FHR was

recorded at the

time of admission

This reflects the

practice of

recording FHR

by the service

provider at the

time of

admission of

pregnant

women to the

facility

(targeted to

monitor the fetal

wellbeing)

Number of pregnant

women admitted in


where FHR was

measured at the time

of admission during

specified period

Total number of

pregnant

women

admitted in the

targeted

facilities for

delivery during

same period

Case

sheets/

Labor

room

register

3 Proportion of

mothers who were

administered

Uterotonics

(Oxytocin/Misoprost

ol) immediately

after delivery for

active

management of

third stage of labor

(AMTSL)

This reflects on

the practice of

oxytocin

administration

as a part of

AMTSL

Number of deliveries

where administered

to women within 5

minutes of delivery

Total number of

deliveries in the

same period

Case

sheets/

Labor

room

register

4 Proportion of

mothers whose

body temperature

was recorded at the

time of discharge

This reflects on

the practice of

recording

temperature of

mothers by the

service provider

at the time of

discharge

(targeted to

identify cases of

maternal sepsis)

Number of pregnant

women admitted in


whose body

temperature was

recorded at the time

of discharge

Total number of

pregnant

women

discharged in

the targeted

facilities after

delivery

Case

sheets/

Labor

room

register


Dashboard Indicators

S.No. Indicator Definition Numerator Denominator Data

Source

5 Proportion of

deliveries where

newborn

temperature was

recorded before

discharge

This reflects on

the practice of

recording

newborn

temperature by

the service

provider at the

time of

(targeted to

identify cases of

neonatal sepsis)


where newborn

temperature was

recorded before

discharge

Total number of

deliveries in the

targeted

facilities

(excluding

deliveries

resulting in IUD

or still birth)

Case

sheets/

Labor

room

register

6 Proportion of

Deliveries for which

Partograph were

used to monitor

progress of labor

This reflects the

use of

Partograph to

monitor progress

of labor


for which Partograph

was used

Total number of

deliver

(excluding

elective

caesarean

sections)

Case

sheets/

Labor

room

register

7 Proportion of

preterm births (<34

wks) where

antenatal

corticosteroids were

administered

This reflects the

practice of

identification

and

administration

of ANCS for PTB

at facility

Number of preterm

deliveries where

antenatal

corticosteroids was

administered

Total number of

preterm

deliveries at

facility

Case

sheets/

Labor

room

register

Outcome Indicators

1 Proportion of

deliveries with

severe

complications in the

targeted facilities

(segregated by

type of

complication: PPH

or severe PE/E or

prolonged labor or

obstructed labor

Reflects the

occurrence of

severe

complications

such as PPH/

severe PE/E/

prolonged

labor/

obstructed

labor

Number of

complications (like

PPH/severe PE/E/

prolonged

labor/obstructed

labor) occurring at

facility during a

specified period

Total number of

deliveries in the

same period

Labor

room

register

2 Proportion of live

births with neonatal

asphyxia

Reflects the

occurrence of

neonatal

asphyxia

among all live

births at facility

Number of new born

with neonatal

asphyxia

Total number of

live births at

facility

Labor

room

register

3 Still birth rate at

facility

Reflects the still

birth rate at

facility

Number of still births

at facility

Total number of

live births at

facility

Labor

room

register


Illustrative set of performance monitoring indicators

(Facilities can identify indicators from the list based on their priorities, for inclusion in their regular quality

monitoring)

S.No Indicator Definition Numerator Denominator Data

Source

ANC Indicators

1 Proportion of

booked deliveries in

which at least 4

ANC visits have

been completed

This reflects if the

required number of

ANCs have been

completed

Number of booked

deliveries in a month

who had all 4 ANCs

completed

Total number of

booked

deliveries in

same month

ANC

card

2 Proportion of cases

where gestational

age was established

during first ANC visit

This reflects the

practice of

gestational age

estimation at first

ANC at facility

Number of cases

where Gestational

age was established

at first ANC in a

month

Total number of

cases at first

ANC in same

month

ANC

card


in which BP was

recorded during all

ANC visits

This reflects the

practice of

recording Blood

pressure during ANC

at facility

Number of all ANC

cases where Blood

pressure was

recorded in a

month

Total number of

all ANC cases in

month

ANC

card


in which FHR was

recorded at least

during last trimester

This reflects the

practice of

recording FHR

during last ANC visit

at facility

Number of all cases

at last ANC visit

where FHR was

recorded in a

month

Total number of

ANC cases in

month

ANC

card


in which Hb

estimation was

done in all ANC visits

This reflects the

practice of Hb

estimation during

ANC at facility

Number of all cases

at all ANC visit

where Hb estimation

was performed in a

month

Total number of

all ANC cases in

month

ANC

card


in which screening

for Gestational

Diabetes Mellitus

was done

This reflects the

practice of GDM

screening at ANC

Number of ANC

cases where GDM

screening was done

in a month

Total number of

ANC cases in

month

ANC

card


in which Ca

supplementation

was prescribed for

prevention of PE/E

This reflects practice

of prescribing Ca

supplementation for

prevention of PE/E

during ANC

Number of ANC

cases in a month

where Ca

supplementation

was prescribed for

prevention of PE/E in

a month

Total number of

ANC cases in

month

ANC

card

Intrapartum Care Indicators


in which gestational

age was established

at the time of

admission

This reflects the

practice of

gestational age

estimation during

admission at facility


where gestation

age was estimated

at admission

Total number of

deliveries in a

month

Labor

room

register


in which mothers

temperature was

recorded at the

time of admission

This reflects the

practice of

recording mothers

temperature during

admission at facility


where mothers

temperature was

recorded at

admission

Total number of

deliveries in a

month

Labor

room

register




monitoring)


Source

10 Proportion of

deliveries in which

birth companion

was allowed to stay

with pregnant

woman inside labor

room during delivery

This reflects the

practice of

encouraging the

presence of birth

companion during

delivery


where birth

companion/s were

allowed to stay with

women during

delivery inside the

labor room

Total number of

deliveries in a

month

Labor

room

register


in which Vitamin K is

administered to

newborns

This reflects the

practice of

administration of

Vitamin K to

newborns


in which Vitamin K

was administered

Total number of

live births in a

month

Labor

room

register


of PPH that were

managed through

the use of oxytocin/

appropriate

uterotonic

This reflects the

practice of

management of

PPH through use of

oxytocin/

appropriate

uterotonic

Number of PPH

cases where

oxytocin/

appropriate

uterotonic was used

for management

Total number of

PPH cases in

month

Labor

room

register


with severe PE/E

which were

managed using

MgSO4 within the

facility

This reflects the

practice of

management of

Pre-

eclampsia/Eclampsi

a using MgSO4 at

facility

Number of Pre-

eclampsia/eclampsi

a which were

managed using

MgSO4

Total number of

deliveries with

Pre-

eclampsia/ecla

mpsia

Labor

room

register

14 Proportion of babies

with small size at

birth in which KMC

was performed

This reflects the

practice of KMC

being given to small

size babies at facility

Number of small

sized babies where

KMC is given

Total number of

small sized

babies in a

month

PNC

card

15 Proportion of

deliveries where

new-born/s breast

fed within one hour

of delivery

This reflects the

practice of initiation

of breast feeding in

newborn within one

hour of delivery

Number of

newborns who were

breast fed within

one hour of delivery

Total number of

live births in a

month

Labor

room

register

16 Proportion of

women counselled

on family planning

in post-partum

period

This reflects the

practice of post-

partum family

planning counselling

at family

Number of mothers

counselled on post-

partum family

planning counselling

Total number of

deliveries in a

month

Labor

room

register

17 Proportion of

asphyxiated

newborns who were

resuscitated in the

labor room

This reflects the

practice of new

born resuscitation in

asphyxiated

newborns

Number of

asphyxiated

newborns who were

resuscitated

Total number of

asphyxiated

babies

Labor

room

register

18 Proportions of

deliveries with

known HIV status

This reflects the

practice of

checking for HIV

status of women

during deliveries


with known HIV

status

Total number of

deliveries in a

month

Labor

room

register

19 Proportion of This reflects the Number of Total number of Labor




monitoring)


Source

caesarean

deliveries at facility

caesarean delivery

rate at facility

caesarean sections

performed

deliveries in a

month at facility

room

register

20 Proportion of LSCS

cases where

prophylactic

antibiotics were

administered

This reflects the

practice of

prophylactic

administration of

antibiotics in LSCS

cases

Number of LSCS

cases where

prophylactic

antibiotics were

administered

Total number of

LSCS cases in a

month

Labor

room

register

21 Proportion of LSCS

cases classified

using Modified

Robson's criteria

This reflects

appropriateness of

performing

caesarean sections

Number of LSCS

cases which were

classified using

modified Robson’s

criteria

Total number of

LSCS cases in a

month

Labor

room

register

22 Proportion of

mothers referred out

of the facility

This reflects referral

rate of mothers at

facility.

Number of mothers

referred out to

higher facilities

Total number of

admission of

women at

facilities for

delivery care

Labor

room

register

23 Proportion of new

born referred out of

the facility

This reflects referral

rate of new-borns at

facility.

Number of new-

borns referred out to

higher facilities

Total number of

live births in a

month

Labor

room

register

PNC Indicators


in which at least 4

PNC visits were

ensured

This reflects the

coverage of post-

natal visits at facility


in which at least four

PNC cases were

ensured

Total number of

deliveries

tracked till six

months of

postpartum

period

PNC

card

25 Proportion of post-

partum cases of

infection that were

managed using

antibiotics

This reflects practice

of management of

infection in post-

partum cases

Number of post-

partum cases of

infection which

were managed

using antibiotics

Total number of

post-partum

cases of

infection

PNC

card


in which newborn

temperature was

taken during

postpartum visits

This reflects the

practice of

recording newborns

temperature during

post-partum visit

Number of

newborns visit during

post-partum visit in

which the

temperature was

recorded

Total number of

newborns seen

during post-

partum visit at

facility

Labor

room

register


Section III: Guidance on Capacity Building of

Health Workers

The third main component of the proposed toolkit is guidance for training of facility-based health workers on life-saving evidence-based practices to improve facility-based health outcomes. This includes course outlines for designing trainings of health workers and a learning resource package including tools linked to the course outlines. The course outlines have been designed keeping in mind alignment with the essential elements of the standards, and these can be adapted or customized based on facilities’ compliance to the standards. Key features of the course outlines are as follows:

Structure of the course outlines

The course outline has been divided into four main areas:

Topic: Defines the broad area of focus for the session.

Content: This part guides the facilitator on the key items to be covered under any given topic and is linked to the objectives of the session.

Methodology: This area proposes the appropriate training methodology for effectively delivering the content for each topic. The methodology varies according to the content of the topic and level of engagement requirement from the participants. Methodology includes a mix of methods such as interactive presentations, role-play by participants, skill demonstration, group discussions, and use of AV aid to ensure that the content is adequately delivered and participants are engaged throughout.

Resources: The area guides on the possible resources required for the proposed training methodology and for effective delivery and content for the participants.

Duration: This area is to be used to assign the time slot for each topic.

Technical focus of the course outlines The course outlines follow the group pattern of the standards of care and focus on key practices during the ANC, intra- and immediate postpartum, and PNC period. Since Caesarean section and related anaesthesia skills are meant to be developed in formal academic environments, the course outlines do not focus on these areas. The course outlines are designed in a way that the flow of the training follows the routine care provision pathway for any client.

Scope of the course outlines To ensure comprehensive coverage of all important areas, the course outlines have been designed keeping in mind the requirements of health workers of CEmONC facilities. Lower level facilities can choose topics based upon the standards applicable to their facilities.

How to use the training course outlines

The course outlines can be used both by individual health facilities to improve knowledge and skills of

their own health workers and also by external facilitators to support a group of facilities.


Individual health facilities

The course outlines are intended to be used as a part of the strategic skill building under the implementation of action plan activity. Once the facility has completed its baseline assessment using the clinical standards, developed an action plan for addressing the gaps, and ensured essential resources as identified through gap analysis, the facility clinical leader should plan a training pathway for the training of all the health workers in the facilities. This pathway can include two approaches:

Group trainings of health workers over two days: All the relevant health workers can be trained over two to three consecutive days to ensure that the facility is saturated with trained providers in a short span. However, this methodology will require frequent post-training follow-up and support to the health workers while they are on the job.

On-the-job training of health workers using the guidance in the course outlines: The course outlines can be broken down into short modules based upon the time availability with the key participants and trainers. These modules can be covered over an extended duration to ensure that the participants are trained on one to two skills at a time and get adequate time to internalize the key messages.

External facilitators

In order to improve time efficiency and contact with better trainers, external facilitators can prefer to use the centralized training methodology, wherein participants from a group of facilities are invited for training at a health facility with adequate delivery loads. The facilitators can then use the course outlines to conduct training of health workers and simultaneously can demonstrate important practices on clients wherever feasible. Key facility staff can be identified as facility-based champions who can take forward the post-training and offer onsite support to the health workers for effective translation of skills into practice.

Learning resource package

A learning resource package has been developed based upon the proposed course outline as a set of

tools linked to this component of the toolkit. This resource package includes specific folders for each

topic on the course outline. Each folder includes power point presentations wherever applicable, job

aids, including self-learning checklists, and videos. Some of these have been sourced from the existing

training programs being implemented by the Government of India and other stakeholders. The learning

resource package has not been included in this document due to its large size and can be accessed

at the following link:

https://www.dropbox.com/sh/5agy7mj4t3w1kfs/AABxUuYy38eZvZZwPS_i5qqNa?dl=0

https://www.dropbox.com/sh/5agy7mj4t3w1kfs/AABxUuYy38eZvZZwPS_i5qqNa?dl=0


Course Outline for ANC

(This includes indicative durations of various sessions. The facilities may want to implement these trainings in a modular manner, based on the availability of providers.)

S.

No. Topic

Duration

(in minutes) Contents Methodology Resources

1 Identification

and

confirmation

of pregnancy

and

registration

15 Brief Introduction - early

signs and symptoms

UPT

Interactive

presentation

Demonstration of

UPT

Video of UPT

Flip charts

Markers

Demonstration

station

UPT video

PPT

2 Focused ANC 30 Timing of focussed ANC:

4 ANC visits

Content:

Surveillance &

screening of

normal conditions

& complications

Preventive care

Management of

conditions

Counselling for

ANC care

Interactive

presentation

Flip charts

Markers

PPT

3

Assessment of

pregnant

woman

15 ANC history taking:

Relevant menstrual

history LMP/EDD

Relevant obstetric

history & Medical &

surgical history

Personal history

ANC Card/MCP card

Interactive

presentations

Video

Role Play

Group exercises

on calculation of

EDD and filling of

ANC card

Flip charts

Markers

PPT

Role play

scenario

ANC card /

MCP card

Case

scenarios

EDD

calculation

exercises

45 ANC examination:

General – Height,

weight , BP, TPR ,

Pallor

P/A – Fundal

height, 4 obstetric

grips (fundal,

lateral, pelvic), FHR

Breast exam

PV examination

Interactive

presentations

Demonstration

and practice

Flip chart ,

Markers

PPT

Demonstration

Station for BP,

PA

Checklists and

job-aids


S.

No. Topic

Duration


4 ANC Lab tests 20 List of Blood tests &

importance

ABO + Rh

Hb gm %

VDRL

HIV

OGTT

Malaria (RDT)

HBSAg

Urine – routine, protein ,

sugar

Demonstration

(optional)

Interactive

presentation

Videos

Demonstration

station for

Sahli’s, urine

protein and

sugar by

dipsticks,

OGTT, malaria

RDT

Videos,

checklists and

job-aids

PPT

5 ANC-

Preventive

care

20 Prevention for:

Anemia

Neonatal tetanus

PE/E

Helminthic infection

Malaria

Infection prevention

Interactive

presentation PPT

6 Minor

disorders in

pregnancy

and their

management

15 Vomiting, Fever, Diarrhoea,

Urinary problems

Interactive

presentation

Flip chart

Marker

PPT

7 Identification

&

Management

of Anaemia

20 Definition of Anemia

Causes

Management of

Anemia

Interactive

presentation

PPT

8 Management

of Gestational

Diabetes

Mellitus

20 Definitions of DM

Management of GDM

Interactive

presentation

PPT

Flip chart

White board

Marker

9 Identification

and

management

of

hypertensive

disorders in

pregnancy

(HDP)

30 Definitions in HDP

Management of severe

PE/E

MgSO4 regime

Interactive

presentation

Demonstrations

on knee jerk and

preparation of

MgSO4

PPT

Demonstration

station

Checklists, job-

aids and video

10 Identification

&

Management

of HIV

15 Management of HIV

HIV testing and

treatment of

spouse/partner

Counselling for lifelong

ART

Interactive

presentation

PPT


S.

No. Topic

Duration


11 Management

of Syphilis

10 Management of Syphilis

Syphilis testing and

treatment of

spouse/partner

Interactive

presentation

PPT

12 Identification

and

Management

of Malaria

15 Identification of Malaria

Management of

Malaria

Interactive

presentation

PPT

13 Identification

and

management

of bleeding

during

pregnancy

30 Identification of

Bleeding in early and

late pregnancy

Management

Interactive

presentation

Case studies

PPT

Case studies

14 ANC

Counselling

15 ANC Counselling- General:

Nutrition – balanced

diet

Rest & general care

Hygiene – Bathing

Exercise /yoga

Work

Sexual activity

Breast care

2 doses of TT

IFA

Importance of health

check-ups /Follow-up

Optimal newborn care

Relationship between

family members &

bonding

Men’s role in care of

pregnant woman

Interactive

presentation

Role plays

PPT on ANC

care

Role play

scenarios

15 ANC counselling BPCR

List of danger signs

Importance of early

identification & taking

timely action

Appropriate referral

centre

Place of delivery,

transport, money,

clothes

Birth companion

Blood donor

Interactive

presentation

Role play

PPT

Role play

scenario

20 ANC counselling –PPFP

HTSP, RTF, FP methods,

counselling approach

and strategy

Interactive

presentation

Role play

PPT

Role play

scenario


S.

No. Topic

Duration


15 Do’s and

Don’ts

15 Game on good and

harmful practices

Discuss how the harmful

practices can be

converted into good

one

Game on good

and harmful

practices

Do’s and

Don’ts written

chits

Bowl

16 Recording

and reporting

20 ANC/MCP card

Registers

Monthly reporting

format and other

relevant documents

Referral protocol

Discussion with

handouts

Handouts


Course Outline for Intrapartum and Immediate

Postpartum Care


S.N Topic Duration Contents Methodology Resources

1. Respectful

Maternity Care

15 RMC

Client rights &

responsibilities

Interactive

presentation

using job-aids

Role play

Brainstorming

& discussion

Job-aid on

clients’ rights

Role play

scenario

Video

2. Assessment at

the time of

admission and

decision

making

A. Triaging

Assessment at

the time of

admission and

decision

making

B. Admission/

Referral

60 History taking

Relevant

menstrual history

LMP/EDD

Relevant obstetric

history & Medical

& surgical history

Personal history

Brainstorming

Interactive

presentation &

discussion

Role play

Video

GoI SBA video

mod 1 PPT on

history taking

Role play

scenario

General physical

examination including

importance of vitals

Interactive

presentation

Demonstration of

BP (vitals) check-

up

PPT

Job-aid on

BP

GoI video on

BP (vitals)

Skill CL on BP

Demonstratio

n station

PA examination

Inspection

Palpation

Estimation of GA

by Fundal height

& imaginary

divisions of

abdomen

Grips

Uterine

contractions

Localization of

FHS &

Auscultation of

FHR

Demonstration Demonstration

station

PV examination

Wearing & removal of

gloves

Demonstration

Interactive

presentation

on assessment

of progress of

labor and

Demonstration

station

PPT



pelvic

adequacy

through PV

examination

Admission protocol

Referral protocol

Maternity case sheet

Interactive

presentation

on both

protocols

Reading of

maternity

case

sheet/group

exercise

Admission

protocol

Referral

protocol

Maternity

case sheet

3. Prevention,

identification

and

management

of PE/E

30 Prevention of PE/E

Identification of

various conditions

under HDP

Management of

severe PE/E

Interactive

presentation

Demonstration

of preparation

of MgSO4

dose

Demonstration

of eliciting

knee jerk

GoI SBA video

on eclampsia

PPT

Flip chart/white

board with

markers

Station for

preparation of

MgSO4 dose

and hammer

(Covered in

ANC package)

Video

4. Identification of

and

management

of threatened

preterm labor

45 Identification of

conditions leading to

threatened PTB

Management of

threatened preterm

birth through ANCS,

MgSO4, Tocolytics,

antibiotics and

preterm newborn care

Interactive

presentation

PPT

Job-aids (GOI

ANCS and

Jhpiego)

5. Stages of labor 10 Stages of labor Interactive

presentation

PPT

6. Ensuring safe

care during 1st

stage of labor

45 Monitoring of 1st stage

of labor plotting &

interpretation of

partograph

Demonstration &

practice of

plotting &

interpreting

partograph

Case studies

Interactive

presentation

Demonstration

station

5 Supportive care during

1st stage of labor

including importance

of birth companion

Interactive

presentation

PPT

20 Protocol for Induction

& augmentation of

labor

Interactive

presentation

PPT and

protocol on

Induction &

augmentation

of labor

30 Prevention, Interactive PPT



identification &

management of

prolonged &

obstructed labor

Ruptured uterus

Importance of

partograph in early

identification of

prolonged &

obstructed labor

presentation

Interpretation of

partographs to

diagnose

prolonged &

obstructed labor

Filled

partographs/

Teaching

partograph with

markers & duster

7. Preparing for

safe birth

15 Trays in LR

Prefilled oxytocin

Counselling of mother

and companion on

danger signs & do’s &

don’ts

Group

exercises on

contents of

tray

Interactive

presentation

on trays,

importance of

prefilled

oxytocin &

danger signs

& Do’s &

don’ts during

labor

Job aid on trays

PPT

GoI video on IP

PPT on IPP

8. Conducting

ND, AMTSL,

ENBC,/NBR

90 ND

AMTSL

ENBC

NBR- Basic &

advanced

Interactive

presentation on

ND, AMTSL &

ENBC including

Inj. Vitamin K

Demonstration &

practice on ND,

AMTSL, ENBC &

NBR

Demonstration

Stations

PPT

Job-aids on

AMTSL, NBR,

BMWM

Skill checklists on

ND, AMTSL,

ENBC & NBR

9. Conducting

complicated

delivery

45 Assisted vaginal

delivery (AVD)-

vacuum extraction

Videos

Demonstration on

conducting AVD-

vacuum

Interactive

presentation

PPT

Videos and skill

stations

Skills checklist

30 Breech delivery

Interactive

presentation

Videos

Demonstration

breech

PPT

Videos and skill

stations

Skills checklist

30 Shoulder dystocia Demonstration of

shoulder dystocia

Interactive

presentation

Videos

PPT

Videos and skill

stations

Skills checklist

10. Review of care

of mother & NB

soon after

birth=4th stage

for first 2 hours

15 Observation of mother

every 15 mins.

Observation of NB

every 15 mins

Prevention of

hypothermia, hypoxia

Interactive

presentation

Demonstration

on

breastfeeding

PPT

Demonstratio

n Station

BF poster and

skill CL



in NB

Breastfeeding

11. Prevention,

identification

and

management

of infection in

mother

20 Prevention,

Identification &

management of

maternal sepsis

Interactive

presentation

PPT

12. Prevention,

identification

and

management

of PPH

60 PPH prevention

strategy from

antenatal to

postpartum period

Identification &

management of shock

and PPH

Blood loss activity

Bimanual uterine

compression, aortic

compression

MRP

Condom tamponade

Interactive

presentation

Blood loss

activity

Demonstration

on Bimanual

uterine

compression,

aortic

compression &

MRP

Condom

tamponade

Video on

aortic

compression

GoI SBA Video

on PPH

PPT

Demonstration

Station for blood

loss activity

Videos

13. Prevention,

identification &

management

of

Hypothermia/h

yperthermia in

newborn

15 Prevention,

identification &

management of

Hypothermia/hyperthe

rmia in newborn

Importance of labor

room preparation, skin-

to-skin contact and

early initiation of

breastfeeding in

prevention of

hypothermia

Interactive

presentation

Group exercise

on prevention of

hypothermia from

woman in labor

till postpartum

period

PPT

Flip chart with

markers

14. Prevention,

identification &

management

of

hypoglycemia

in NB

15 Prevention,

identification &

management of

hypoglycemia in

newborn

Interactive

presentation

Group exercise

on prevention of

hypoglycemia

from woman in

labor till

postpartum

period

PPT

Flip chart with

markers

15. Prevention,

identification &

management

of

infection/neon

atal sepsis in NB

15 Prevention, identification

& management of

infection in NB

Interactive

presentation

Group exercise

on prevention of

infection from

woman in labor

till postpartum

period

PPT

Flip chart with

markers



16. Prevention,

identification &

management

of prematurity

related

complications

(hypothermia &

feeding

problems)

60 Care of small sized

babies (preterm &

SGA)

KMC for prevention of

hypothermia

Assisted feeding

Oro-gastric tube

insertion & feeding

Interactive

presentation

Demonstration of

KMC, EBM, spoon

feeding, oro-

gastric tube

insertion &

feeding

GoI Video on oro-

gastric tube

insertion

PPT

Demonstration

Station

Video

GoI KMC poster

Skill checklists

17. Early

identification &

initial

management

of congenital

malformations

in newborn

10 Early identification &

initial management of

congenital

malformations in

newborn

Interactive

presentation

PPT

18. Identification &

management

of

hyperbilirubine

mia in newborn

15 Identification &

management of

hyperbilirubinemia in

newborn- physiological vs

pathological

Interactive

presentation

PPT

19. Infection

Prevention

45 Sources of infection

Mode of spread of

infection

6 Universal precautions

Hand-wash, PPE,

processing of

instruments, disposal of

sharps, cleaning of

environment and BMW

management

Do’s & Don’ts in IP

Interactive

presentation

Demonstrations

Video

PPT

Demo station

Video on

processing of

instruments

20. Do’s and Don’ts

of all four

stages of labor

15 Game on good and

harmful practices of all

stages of labor

Discuss how the

harmful practices can

be converted into

good one

Game on good

and harmful

practices of all

stages of labor

Discuss how the

harmful practices

can be

converted into

good one

Do’s and Don’ts

written chits

Bowl

21. Caesarean

section

20 Preparation,

procedure and post

caesarean care

Interactive

presentation

Video

PPT

Video

22. Labor room

and OT

organization

and sterilization

30 Infrastructure & layout

HR

Equipment and

supplies

Video on

labor room/OT

organization

Small group

exercise on

labor room

and OT

organization -

Interactive

Video

Flip chart,

markers

Stickers of

equipment &

supplies

Job-aid on

contents of 7



presentation

with labor

room pics

trays

PPT on

contents of 7

trays & PPH &

eclampsia

kits

GoI MNH

toolkit

23. Labor room

team building

15 Importance of LR staff

working as team

BCC

Team building

exercise

Emergency

drill

Script of

emergency

drill

Related

station for

simulation

24. Communicatio

n skills

15 Communication skills-

verbal & nonverbal

BCC

Interactive

presentation

Role

play/video

PPT on

communicati

on skills

Role play

scenario/vid

eo

25. Recording and

reporting

30 Case record

Birthing register

Monthly reporting

format

Data for action-

review of dashboard

indicators

Discussion with

handouts

Case sheets

Birthing register,

monthly

reporting

formats

List of

dashboard

indicators


Course Outline for Postpartum Care



1 Postpartum

care package

30 Definition and

importance of

postpartum period

Elements of post-partum

care

Timing of PNC visits -

within 48 hours, 3rd

day, 7th day, 6

weeks and 6 months

Content:

History &

examination

Management

of any

condition

during PNC

Counselling for

PNC care

Integration with other

services - PPTCT, PPFP

and immunization of

baby

Interactive

presentation

PPTs

Flip charts

Markers

Job-aids

2 Postpartum

examination

30 Examination of mother

General

examination

Breast examination

Per-abdominal

examination

Perineal

examination

Examination of baby

Vitals

Color, respiration,

feeding

Interactive

presentation

PPT

Pictorial

diagrams of

examination

3 Prevention,

identification

and

management

of postpartum

lactational

and breast

complications

20 Identification and

management of

postpartum lactational

and breast conditions

Interactive

presentation

PPT

4 Post-partum

depression/

post-partum

blues

20 Identification and

management

Interactive

presentation

PPT



5 Prevention,

identification

and

management

of DVT

15 Prevention, identification

and management of

DVT

Interactive

presentation

PPT

6 Discharge

Counselling for

routine PNC

care of

Mother and

baby

45 Danger signs for mother

and baby

Nutrition – balanced diet

for mother

Rest & general care

Hygiene

Breast examination and

care

Exercises

Supplementation

PPFP

Breast feed for baby ,

Complimentary feeding

Delayed bathing of baby

Care of the baby’s cord

Rooming in of baby

Immunization for the

baby

Importance and

schedule of Follow-up

Interactive

presentation

Role plays

PPT on

Post-partum

period

Role play

scenarios

Pictorial job-

aid

RI Schedule

SCC for

danger signs

7 Do’s and

Don’ts

15 Game on good and

harmful practices

Discuss how the harmful

practices can be

converted into good one

Game on good

and harmful

practices

Discuss how the

harmful practices

can be

converted into

good one

Do’s and

Don’ts written

chits

Bowl

8 Referral/

Discharge

protocols

15 When to discharge/refer

after normal labor, C-

section

Examination & criteria for

discharge

Interactive

presentation

PPTs


Annexure 1: Assessment Tool for Use of Core Technical Standards for Supporting

the Quality Assurance Systems (Accreditation, Regulation etc.)

ANC Standards

S. No. Standard Verification criteria

Re

spo

nse

(Y

/N/N

A)

Triangulation and Source

(Y/N/NA)

Comments

Applicability

(ANC-Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus in all ANC visits

1.1 Establishes gestational age

1.1.1

Establishes concurrence between LMP

and fundal height for estimation of

gestational age

ANC UPWARDS

1.1.2

Uses an ultrasound scan in the first or

second trimester to confirm gestational

age where possible

ANC UPWARDS

1.2

Takes appropriate history

(medical, surgical, obstetric

and personal) and performs

general and systemic

examination

(Box 1)

1.2.1

Takes appropriate history (medical,

surgical, obstetric and personal) and

performs general and systemic

examination

ANC UPWARDS

1.3 Records weight of pregnant

woman during all ANC visits 1.3.1

Records weight of pregnant woman

during all ANC visits ANC UPWARDS

1.4 Conducts abdominal

examination 1.4.1

Conducts abdominal examinations as

appropriate ANC UPWARDS

1.5 Records FHR 1.5.1

Functional

doppler/fetoscope/stethoscope is

available

ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC-Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1.5.2 Records FHR as appropriate ANC UPWARDS

1.6

Performs PV examination

during 4th ANC visit (37weeks

or more) to check for pelvic

adequacy (Box 2)

1.6.1 Uses correct technique for PV

examination ANC UPWARDS

1.6.2 Rules out CPD and records PV

examination findings ANC UPWARDS

1.6.3 Adequate sterile equipment, gloves and

supplies are available ANC UPWARDS

2 Provider screens for key clinical conditions that may lead to complications during pregnancy

2.1 Testing facilities/linkage to

testing facilities are available 2.1.1

Provision/easy access for following tests -

Hb estimation, proteinuria strips, OGTT,

HIV testing, POC/RPR for syphilis, blood

grouping and typing, blood glucose

estimation, malaria testing, HBsAg and

urine routine and microscopy is available

ANC UPWARDS

2.2 Screens for anemia 2.2.1 Estimates Hb at each scheduled ANC

visit ANC UPWARDS

2.3 Screens for hypertensive

disorders of pregnancy

2.3.1 Functional BP instrument and

stethoscope at point of use is available ANC UPWARDS

2.3.2 Records BP at each ANC visit ANC UPWARDS

2.3.3 Performs proteinuria testing during each

scheduled ANC visit ANC UPWARDS

2.4 Screens for DM (as per

relevant national guidelines) 2.4.1

Uses/Refers for standard 75gm OGTT for

screening of GDM at first ANC visit and

repeats OGTT test at second ANC visit

(24 -28 weeks) if negative in first

screening

ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC-Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

2.5 Screens for HIV

2.5.1

Screens/refers for HIV during first ANC visit

in all cases, and in fourth ANC visit in high

risk cases

ANC UPWARDS

2.5.2 Facilitates testing and treatment of

spouse/partner ANC UPWARDS

2.6

Screens for hepatitis B (if

applicable and as per

relevant national guidelines)

2.6.1 Screens/refers for HBsAg testing during

first ANC visit in all cases ANC UPWARDS

2.7 Screens for syphilis 2.7.1

Screens/refers for syphilis in first ANC visit

in all cases, and in fourth ANC visit in high

risk cases

ANC UPWARDS

2.8 Screens for malaria 2.8.1 Screens for malaria as per the national

guidelines. ANC UPWARDS

2.9 Establishes blood group and

Rh type during first ANC visit 2.9.1

Establishes blood group and Rh type

during first ANC visit ANC UPWARDS

3 Provider ensures adequate preventive care for key clinical conditions which can lead to complications in pregnancy

3.1 Ensures adequate preventive

care for anemia

3.1.1

Prescribes IFA supplementation to all

pregnant woman as per relevant

national guidelines

ANC UPWARDS

3.1.2

Prescribes single dose of albendazole

(400mg) after first trimester (preferably

during the second trimester)

ANC UPWARDS


care for neonatal tetanus 3.2.1

Ensures two doses of tetanus toxoid one

month apart as early as possible ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC-Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

3.3

Ensures adequate preventive

care for pre-eclampsia/

eclampsia

3.3.1 Prescribes calcium supplementation

1.5-2gms per day 20 weeks onwards ANC UPWARDS


care for malaria

3.4.1 Advises all women to sleep under long-

lasting insecticide treated bed nets ANC UPWARDS

3.4.2

Prescribes intermittent prophylaxis

treatment of malaria (if applicable) as

per national guidelines

ANC UPWARDS


Intra- & Immediate Postpartum Care Standards


Re

spo

nse

(Y

/N/N

A)

Triangulation and Sources

(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus at the time of admission

1.1

Elicits comprehensive

obstetric, medical and

surgical history and conducts

examination

(Box 1)

1.1.1 Documents obstetric, medical and

surgical history in case record

BEmONC

UPWARDS

1.1.2

Documents the presentation and lie of

the fetus in the case record at

admission

BEmONC

UPWARDS

1.2 Assesses gestational age

correctly 1.2.1

Assesses and records gestational age

through either LMP or Fundal height or

USG (if available)

BEmONC

UPWARDS

1.3 Records fetal heart rate

1.3.1

Functional

Doppler/fetoscope/stethoscope at

point of use is available

BEmONC

UPWARDS

1.3.2 Records FHR at admission BEmONC

UPWARDS

1.4 Records mother’s blood

pressure


stethoscope at point of use is available

BEmONC

UPWARDS

1.4.2 Records mother`s BP at admission BEmONC

UPWARDS

1.5 Records mother’s

temperature

1.5.1 Functional thermometer at point of use

is available

BEmONC

UPWARDS

1.5.2 Records mother' s temperature at

admission

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

2 Provider ensures respectful and supportive care for the pregnant woman coming in for delivery

2.1

Treats pregnant woman and

her companion cordially and

respectfully (RMC), ensures

privacy and confidentiality

for pregnant woman during

her stay

2.1.1 Curtains are installed in labor room to

ensure privacy to pregnant woman

BEmONC

UPWARDS

2.1.2

Treats pregnant woman and her

companion cordially and respectfully

(RMC), ensures privacy and

confidentiality for pregnant woman

during her stay

BEmONC

UPWARDS

2.2

Encourages the presence of

birth companion during

labor

2.2.1 Encourages the presence of birth

companion during labor

BEmONC

UPWARDS

2.3

Explains danger signs and

important care activities to

pregnant woman and her

companion during the stay

(for the woman and her

newborn)

2.3.1

Explains danger signs and important

care activities to pregnant woman and

her companion during the stay (for the

woman and her newborn)

BEmONC

UPWARDS

3 Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly

3.1

Monitors progress of labor

regularly on various

parameters (Box 9)

3.1.1

Initiates partograph plotting when

cervical dilatation is >=4 cms in

appropriate column on the alert line

BEmONC

UPWARDS

3.1.2 Plots all parameters in the partograph BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

3.2

Interprets partograph

correctly and adjusts the

care according to findings

3.2.1

If parameters are not normal, identifies

complications, records the diagnosis

and makes appropriate adjustments in

the birth plan

BEmONC

UPWARDS

4 Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried immediately)

4.1

Delivers the baby and places

on mother’s abdomen to

conduct immediate

newborn care - drying and

assessment of baby's

breathing

4.1.1 Places two pre-warmed towels on

mother's abdomen before delivery

BEmONC

UPWARDS

4.1.2 Delivers and places the baby on

mother's abdomen

BEmONC

UPWARDS

4.1.3 Dries the baby immediately and wraps

in second warm towel

BEmONC

UPWARDS

4.2 Performs delayed clamping

of cord 4.2.1

If baby's breathing is normal, delays the

clamping of cord for 1-3 minutes till the

cord pulsations stop

BEmONC

UPWARDS

4.3 Assesses the newborn for any

congenital anomalies

4.3.1 Records presence or absence of any


BEmONC

UPWARDS

4.3.2 Ensures specialist attention for

newborns with congenital anomalies

BEmONC

UPWARDS

4.4 Ensures early initiation of

breastfeeding 4.4.1

Initiates breast feeding within one hour

of birth

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

4.5 Weighs the baby and

administers Vitamin K

4.5.1 Baby weighing scale is available BEmONC

UPWARDS

4.5.2 Vitamin K injection is available BEmONC

UPWARDS

4.5.3 Records baby weight and

administration of vitamin K

BEmONC

UPWARDS

5 Provider performs newborn resuscitation if baby does not cry immediately after birth

5.1

Performs recommended

initial steps for resuscitation

within first 30 seconds

5.1.1

Checks for functionality of neonatal

resuscitation kit and availability of

shoulder roll before every delivery

BEmONC

UPWARDS

5.1.2

Performs following steps within first

30 seconds on mothers abdomen:

Suction if indicated; dries the baby and

rubs the back 2-3 times; immediate

clamping and cutting of cord; and

shifting to radiant warmer if baby still

not breathing

BEmONC

UPWARDS

5.1.3

Performs following steps within first

30 seconds under radiant warmer:

Positioning, Suctioning, Stimulation,

Repositioning (PSSR)

BEmONC

UPWARDS

5.2

Initiates bag and mask

ventilation for 30 seconds if

the baby is still not breathing

5.2.1 Functional ambu bag with mask (size 0

and 1) is available

BEmONC

UPWARDS

5.2.2 Initiates bag and mask ventilation for

30 seconds if baby still not breathing

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

5.3

Takes appropriate action if

baby doesn’t respond to

ambu bag ventilation after

golden minute

5.3.1

Functional oxygen cylinder (with

wrench) and new born mask are

available

BEmONC

UPWARDS

5.3.2

Assesses breathing, if baby still not

breathing, continues bag and mask

ventilation; starts oxygen

BEmONC

UPWARDS

5.3.3 Checks heart rate/cord pulsations BEmONC

UPWARDS

5.3.4 Calls for advance help/arranges

referral

BEmONC

UPWARDS

5.4

*Performs next level of

resuscitation in babies not

responding to initial

resuscitation- when chest rise

is seen after bag and mask

but heart rate continues to

be < 60/pm (only at facilities

where specialist care for

newborn or SNCU is

available)

5.4.1

Performs chest compressions at the

rate of 3 compressions to 1 breath till

the heart rate is > 60 beats/minute

*Only at facilities

where specialist

care for newborn

or SNCU is

available



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

6 Provider performs Active Management of Third Stage of Labor (AMTSL)

6.1

Performs AMTSL and

examines the placenta

thoroughly

6.1.1 Palpates mother's abdomen to rule out

second baby

BEmONC

UPWARDS

6.1.2 Administers injection Oxytocin 10 I.U.

IM/IV within one minute of delivery of

baby

BEmONC

UPWARDS

6.1.3 Performs controlled cord traction (CCT)

during contraction

BEmONC

UPWARDS

6.1.4 Performs uterine massage

BEmONC

UPWARDS

6.1.5 Checks placenta and membranes for

completeness before discarding

BEmONC

UPWARDS

7 The facility adheres to universal infection prevention protocols

7.1

Instruments and re-usable

items are adequately and

appropriately processed

after each use

7.1.1 Facilities for sterilization of instruments

are available

BEmONC

UPWARDS

7.1.2 Instruments are sterilized after each use

BEmONC

UPWARDS

7.1.3

Delivery environment such as labor

table, contaminated surfaces and

floors are cleaned after each delivery

BEmONC

UPWARDS

7.2

Biomedical waste is

segregated and disposed of

as per the guidelines

7.2.1 Color coded bags for disposal of

biomedical waste are available

BEmONC

UPWARDS

7.2.2 Biomedical waste is segregated and

disposed of as per the guidelines

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

7.3

Performs hand hygiene

before and after each

procedure, and sterile gloves

are worn during delivery and

internal examination

7.3.1

Performs hand hygiene before and

after each procedure, and sterile

gloves are worn during delivery and


BEmONC

UPWARDS

8 Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)

8.1 Identifies mothers with severe

PE/E

8.1.1 Dipsticks for proteinuria testing in labor

room are available

BEmONC

UPWARDS

8.1.2 Records BP at admission BEmONC

UPWARDS

8.1.3

Identifies danger signs such as severe

headache, blurring of vision, difficulty

breathing, epigastric pain, reduced

urine output; or presence of

convulsions

BEmONC

UPWARDS

8.2

In cases of severe PE/E, gives

correct first dose of MgSO4

and refers to higher center or

manages appropriately

(Box 4)

8.2.1 MgSO4 (at least 14 ampoules) is

available

BEmONC

UPWARDS

8.2.2

Gives correct first dose of MgSO4 (5 mg

with 1 ml of 2% Xylocaine in each

buttock deep IM (10 mg)) and refers to

higher center

BEmONC

UPWARDS

8.2.3

Injection MgSO4 is appropriately

administered (5 mg with 1 ml of 2%

Xylocaine in each buttock deep IM (10

mg); 4gms (8ml) with 12 ml Normal

saline IV slowly followed by

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

maintenance dose of 5mg with 1 ml of

2% Xylocaine in alternate buttock

deep IM every 4 hours for 24 hours after

the last convulsion or delivery

whichever occurs later)

8.3 Facilitates prescription of

anti-hypertensives (Box 5)

8.3.1 Antihypertensive are available BEmONC

UPWARDS

8.3.2

Facilitates prescription or prescribes

anti-hypertensives in case of

hypertension in pregnancy

BEmONC

UPWARDS

8.4

Ensures specialist attention

for care of mother and

newborn

8.4.1 Ensures specialist attention for care of

mother and newborn

BEmONC

UPWARDS

9 Provider identifies and manages Postpartum Hemorrhage (PPH)

9.1

Assesses uterine tone and

bleeding per vaginum

regularly after delivery

9.1.1 Assesses uterine tone and bleeding per

vaginum regularly

BEmONC

UPWARDS

9.2

Performs initial steps of

management as per the

protocol in case of PPH

9.2.1 Calls for help /assistance, while

continuing uterine message

BEmONC

UPWARDS

9.2.2 Starts IV fluids BEmONC

UPWARDS

9.2.3 Manages shock if present BEmONC

UPWARDS

9.2.4 Identifies specific cause of PPH BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

9.3 Manages atonic PPH

9.3.1

Initiates 20 IU oxytocin drip in 1000 ml of

ringer lactate/normal saline at the rate

of 40-60 drops per minute

BEmONC

UPWARDS

9.3.2 Continues uterine massage BEmONC

UPWARDS

9.3.3 If uterus is still relaxed, gives other

uterotonics as recommended

BEmONC

UPWARDS

9.3.4

If uterus is still relaxed, performs

mechanical compression in the form of

bimanual uterine compression or

external aortic compression or balloon

tamponade

BEmONC

UPWARDS

9.3.5

If uterus is still relaxed, refers to higher

center while continuing mechanical

compression

BEmONC

UPWARDS

9.4

Manages PPH due to

retained placenta/placental

bits

9.4.1

Identifies retained placenta if placenta

is not delivered within 30 minutes of

delivery of baby or the delivered

placenta is not complete

BEmONC

UPWARDS

9.4.2

Initiates 20 IU oxytocin drip in 1000 ml of

ringer lactate/normal saline at the rate

of 40-60 drops per minut

BEmONC

UPWARDS

9.4.3 Refers to higher center if unable to

manage

BEmONC

UPWARDS

9.4.4 Performs MRP BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/ N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

10 Provider ensures care of newborn with small size at birth

10.1 Facilitate specialist care in

newborn weighing <1800 gm 10.1.1

Facilitates specialist care in newborn

<1800 gm (refer to FBNC/seen by

pediatrician)

BEmONC

UPWARDS

10.2 Facilitates assisted feeding

whenever required 10.2.1

Facilitates assisted feeding whenever

required

BEmONC

UPWARDS

10.3

Facilitates thermal

management including

kangaroo mother care

10.3.1 Facilitates thermal management

including KMC

BEmONC

UPWARDS

(C-section Standards)

11 Provider reviews clinical practice related to C-section at regular intervals

11.1

Ensures classification as per

Robson’s criteria and reviews

indications and

complications of C-section

at regular intervals

11.1.1

Ensures that all C‐section cases are

classified as per the modified Robson’s

criteria and rates of different

categories are monitored

CEmONC

11.1.2 Reviews all cases of induction and C-

section through a clinical audit CEmONC

11.1.3 Ensures that rate of complications of C-

sections are periodically monitored CEmONC




Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

1 Provider ensures adequate postpartum care package is offered to the mother and newborn

1.1 Ensures at least 4 postpartum

visits for the mother

1.1.1

Ensures minimum 4 postpartum visits for

the mother: after discharge at 2 - 3 days

(If discharged early), 7-14 days, 6 weeks

and 6 months after delivery (or as per

national guidelines)

BEmONC

UPWARDS

1.1.2

Prepares postpartum visit schedule and

shares written record with the mother

and her family

BEmONC

UPWARDS

1.1.3 Ensures additional 2 to 3 visits in cases of

babies with any complication

BEmONC

UPWARDS

1.2

Conducts proper physical

examination of mother and

newborn

1.2.1

Conducts mother’s examination: breast,

perineum for inflammation; status of

episiotomy/tear suture; lochia; calf

tenderness/redness/swelling; abdomen

for involution of uterus, tenderness or

distension

1.2.2

Conducts newborn’s examination:

assesses feeding of baby; checks

weight, temperature, respiration, color

of skin and cord stump



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

1.3

Identifies and appropriately

manages maternal and

neonatal sepsis

1.3.1 Checks mother's temperature

BEmONC

UPWARDS

1.3.2 Gives correct regimen of antibiotics

BEmONC

UPWARDS

1.3.3 Checks baby’s temperature and other

looks for other signs of infections

BEmONC

UPWARDS

1.3.4 Gives correct regime of

antibiotics/refers for specialist care

BEmONC

UPWARDS

1.4


manages postpartum

maternal depression

1.4.1 Makes correct diagnosis of postpartum

maternal depression after ruling out

postpartum blues based on history

BEmONC

UPWARDS

1.4.2 In cases of postpartum blues, provides

emotional support and counsel’s family

on the condition. Follows up in 2 weeks,

and refers for specialist care if required

BEmONC

UPWARDS

1.4.3 In cases of postpartum depression,

provides emotional support and refers

for specialist care

BEmONC

UPWARDS

1.5 Ensures to offer FP services

1.5.1 A basket of choice of PPFP services is

available at the facility

BEmONC

UPWARDS

1.5.2 Provider is trained for PPFP services

being offered at the facility

BEmONC

UPWARDS


Annexure 2: Assessment Tool for Use of Comprehensive Set of Technical Standards

for Guiding the Quality Improvement Process

ANC Standards

S. No. Standard Verification Criteria

Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus in all ANC visits

1.1 Establishes gestational age

1.1.1

Establishes concurrence between LMP

and fundal height for estimation of

gestational age

ANC UPWARDS

1.1.2

Uses an ultrasound scan in the first or

second trimester to confirm gestational

age where possible

ANC UPWARDS

1.2

Takes appropriate history

(medical, surgical, obstetric

and personal) and

performs general and

systemic examination

(Box 1)

1.2.1

Takes appropriate history (medical,

surgical, obstetric and personal) and

performs general and systemic

examination

ANC UPWARDS

1.3

Records weight of

pregnant woman during all

ANC visits

1.3.1 Records weight of pregnant woman

during all ANC visits ANC UPWARDS

1.4 Conducts abdominal

examination 1.4.1

Conducts abdominal examinations as

appropriate ANC UPWARDS

1.5 Records FHR 1.5.1 Functional doppler/fetoscope/ ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

stethoscope is available

1.5.2 Records FHR as appropriate ANC UPWARDS

1.6

Performs PV examination

during 4th ANC visit

(37weeks or more) to

check for pelvic adequacy

(Box 2)

1.6.1 Uses correct technique for PV

examination ANC UPWARDS

1.6.2 Rules out CPD and records PV

examination findings ANC UPWARDS

1.6.3 Adequate sterile equipment, gloves and

supplies are available ANC UPWARDS

2 Provider screens for key clinical conditions that may lead to complications during pregnancy

2.1

Testing facilities/linkage to

testing facilities are

available

2.1.1

Provision/easy access for following tests -

Hb estimation, proteinuria strips, OGTT,

HIV testing, POC/RPR for syphilis, blood

grouping and typing, blood glucose

estimation, malaria testing, HBsAg and

urine routine and microscopy is

available

ANC UPWARDS

2.2 Screens for anemia 2.2.1 Estimates Hb at each scheduled ANC

visit ANC UPWARDS

2.3 Screens for hypertensive

disorders of pregnancy


stethoscope at point of use is available ANC UPWARDS

2.3.2 Records BP at each ANC visit ANC UPWARDS

2.3.3 Performs proteinuria testing during each

scheduled ANC visit ANC UPWARDS

2.4 Screens for DM (as per 2.4.1 Uses/Refers for standard 75gm OGTT for ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

relevant national

guidelines)

screening of GDM at first ANC visit and

repeats OGTT test at second ANC visit

(24 -28 weeks) if negative in first screening

2.5 Screens for HIV

2.5.1

Screens/refers for HIV during first ANC

visit in all cases, and in fourth ANC visit in

high risk cases

ANC UPWARDS


spouse/partner ANC UPWARDS

2.6

Screens for hepatitis B (if

applicable and as per

relevant national

guidelines)

2.6.1 Screens/refers for HBsAg testing during

first ANC visit in all cases ANC UPWARDS

2.7 Screens for syphilis 2.7.1

Screens/refers for syphilis in first ANC visit

in all cases, and in fourth ANC visit in

high risk cases

ANC UPWARDS

2.8 Screens for malaria 2.8.1 Screens for malaria as per the national

guidelines. ANC UPWARDS

2.9

Establishes blood group

and Rh type during first

ANC visit

2.9.1 Establishes blood group and Rh type

during first ANC visit ANC UPWARDS

3 Provider ensures adequate preventive care for key clinical conditions which can lead to complications in pregnancy

3.1 Ensures adequate

preventive care for anemia 3.1.1

Prescribes IFA supplementation to all

pregnant woman as per relevant

national guidelines

ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

3.1.2




ANC UPWARDS

3.2

Ensures adequate

preventive care for

neonatal tetanus

3.2.1 Ensures two doses of tetanus toxoid one

month apart as early as possible ANC UPWARDS

3.3

Ensures adequate

preventive care for

pre-eclampsia/eclampsia

3.3.1 Prescribes calcium supplementation 1.5-

2gms per day 20 weeks onwards ANC UPWARDS

3.4 Ensures adequate

preventive care for malaria

3.4.1 Advises all women to sleep under long-

lasting insecticide treated bed nets ANC UPWARDS

3.4.2

Prescribes intermittent prophylaxis

treatment of malaria (if applicable) as

per national guidelines

ANC UPWARDS

4 Provider performs adequate management of anemia

4.1

Performs adequate

management of anemia

(Box 3)

4.1.1

Provides IFA supplementation to all

pregnant women as per relevant

national guidelines

ANC UPWARDS

4.1.2

Provides therapeutic oral iron in case of

diagnosed severe anemia and refers to

higher facility if further management not

available and/or pregnant woman is

not responding

ANC UPWARDS

4.1.3 Provides parenteral iron therapy if

woman is not responding

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

4.1.4

Performs blood transfusion in woman

with Hb < 7gm/dl beyond 34 weeks of

gestation

CEmONC

4.1.5




BEmONC

UPWARDS

5 Provider performs adequate management of hypertensive disorders of pregnancy

5.1

Confirms hypertension and

identifies pregnant woman

with severe PE/E

5.1.1 Dipstick for proteinuria testing in labor

room is available

BEmONC

UPWARDS

5.1.2 Records BP ANC UPWARDS

5.1.3



breathing, severe epigastric pain,

reduced urine output; or the presence

of convulsions

ANC UPWARDS

5.2

Manages hypertension

using recommended anti-

hypertensives (Box 5)

5.2.1 Provides anti-hypertensives if diastolic BP

is more than 110 mmHg

BEmONC

UPWARDS

5.3

In cases of severe PE/E,

gives correct first dose of

MgSO4 and refers to higher

center if further

management is not

available (Box 4)


available ANC UPWARDS

5.3.2 Gives correct first dose of MgSO4 and

refers to higher center ANC UPWARDS

6 Provider performs adequate management of Gestational Diabetes Mellitus (GDM)



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

6.1 Initiates MNT in all

diagnosed GDM cases 6.1.1 Provides MNT for 2 weeks ANC UPWARDS

6.2 Initiates insulin therapy if

required

6.2.1 Initiates insulin therapy if PPPG >=120

mg/dl after 2 weeks of MNT

BEmONC

UPWARDS

6.2.2 Monitors 2hr PPPG once every week

once insulin dose is stable

BEmONC

UPWARDS

6.2.3 Continues insulin and MNT in such cases

throughout pregnancy

BEmONC

UPWARDS

6.3 Initiates fetal surveillance

6.3.1 Monitors FHR by auscultation in each

ANC visit

BEmONC

UPWARDS

6.3.2 Counsels pregnant woman for Daily

Fetal Activity Assessment

BEmONC

UPWARDS

6.4


for care of pregnant

woman and newborn

during labor

6.4.1

Ensures specialist attention for care of

pregnant woman and newborn during

labor

ANC UPWARDS

7 Provider performs adequate management of communicable conditions in pregnant woman- HIV, Malaria and Syphilis

7.1

Appropriately manages HIV

seropositive cases (If ART

center) (Box 13) or refers to

an ART center (If not ART

center)

7.1.1

Ensures continued ART for those who are

already on ART irrespective of CD4 cell

count

BEmONC

UPWARDS

7.1.2 Initiates lifelong ART for seropositive

pregnant woman who are not on ART

BEmONC

UPWARDS

7.1.3 If not ART center, refers pregnant

woman to ART center for ART initiation ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

7.2

Appropriately manages

syphilis in pregnant woman

and spouse/partner (Box 6)

7.2.1 Facility has easy access to

Penicillin/Erythromycin

BEmONC

UPWARDS

7.2.2 Rules out history of allergy to Penicillin BEmONC

UPWARDS

7.2.3

Manages early and late stage of syphilis

using appropriate doses of Benzathine

Benzyl Penicillin

BEmONC

UPWARDS

7.2.4 If allergic to penicillin, gives erythromycin

in appropriate doses

BEmONC

UPWARDS


spouse/partner using the same guideline

BEmONC

UPWARDS

7.3

Adequately manages

malaria in pregnancy

(Box 7)

7.3.1

Manages malaria in first trimester:

uncomplicated malaria using oral

Quinine and oral Clindamycin for 7 days

or as per national guidelines

BEmONC

UPWARDS

7.3.2

Manages malaria in 2nd and 3rd

trimester: uncomplicated malaria using

Artemether/Lumefantrine OR

Artesunate/Amodiaquine according to

national malaria treatment policy

BEmONC

UPWARDS

7.3.3

Manages severe malaria using

parenteral Artesunate or as per national

guidelines

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

8 Provider manages threatened preterm labor

8.1 Identifies threatened

preterm birth

8.1.1 Establishes that the pregnant woman is

in true labor

ANC UPWARDS

8.1.2 Correctly estimates gestational age ANC UPWARDS

8.1.3 Establishes conditions leading to PTB

(APH, PPROM, severe PE/E, vaginal

infections, uterine over-distension)

ANC UPWARDS

8.2

Essential medicines for

managing PTB are

available

8.2.1 Ensures availability of Dexamethsone,

MgSO4 antibiotics and nifedipine

ANC UPWARDS

8.3


conditions leading to PTB

(For GA 24 - 37 weeks)

8.3.1 Gives erythromycin (or injection penicillin

or any other appropriate antibiotic as

recommended) in case of PPROM

BEmONC

UPWARDS

8.3.2 Gives at least first dose of injection

MgSO4 in case of severe PE/E or

complete dose (if facility available)

ANC UPWARDS

8.4

Ensures interventions to

facilitate fetal maturity and

protection if GA is <34

weeks (Box 8)

8.4.1 Additionally, If GA is 24 - 32 weeks, gives

ANCS for lung maturity and MgSO4 for

neuroprotection if delivery is expected

within 24 hours

BEmONC

UPWARDS (ANCS

at ANC-only

facility also)

8.4.2 If gestational age is 32 - 34 weeks, gives

ANCS for lung maturity and considers

nifedipine as a tocolytic for 24 to 48 hrs

BEmONC

UPWARDS

(ANCS at ANC-

only facility also)



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

8.5

Ensures heightened

monitoring and care (GA

between 34-37 weeks)

8.5.1 If gestational age is between 34-37

weeks, monitors frequently and prepares

for PTB

BEmONC

UPWARDS

8.6 Prepares for specialist care

for newborn

8.6.1 Prepares for specialist attention for

newborn care

BEmONC

UPWARDS

9 Provider counsels pregnant woman on care during pregnancy

9.1

Shares a written schedule

of ANC visits with the

pregnant woman

9.1.1 ANC card/ any other format of written

schedule is available ANC UPWARDS

9.1.2 Briefs the pregnant woman on

scheduled ANC visits ANC UPWARDS

9.2

Counsels pregnant woman

and her

husband/partner/compani

on on Birth Preparedness

and Complication

Readiness (BPCR) at least

during last trimester

9.2.1

Develops a birth plan with the woman

and her husband/partner/companion

including all preparations for normal

birth (Financial/transport planning, birth

companion) and complications

ANC UPWARDS

9.3


and her


on on Importance of

lifestyle modification at

least during first trimester

9.3.1

Provider counsels pregnant woman and

her husband/partner/companion on

balanced nutritious diet, adequate rest,

exercises, maintaining personal hygiene,

substance abuse and domestic

violence

ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

9.4


and her


on on Importance of

optimal newborn care at

least during last trimester

9.4.1

Counsels pregnant woman and her

husband/partner/companion on

importance of exclusive and on

demand breast feeding

ANC UPWARDS

9.4.2



importance of optimal newborn care

including thermal management and

immunization

ANC UPWARDS

9.4.3



identification of warning signs and

when/where/how to seek care

ANC UPWARDS

9.5


and her


on on postpartum family

planning in all ANC visits

9.5.1


her husband/partner/companion on

return of fertility and importance of

healthy timing and spacing of

pregnancy

ANC UPWARDS

9.5.2


her husband/partner/companion on all

available family planning methods and

help them choose appropriate method

ANC UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)


10.1




after each use


are available

ANC UPWARDS

10.1.2 Instruments are sterilized after each use ANC UPWARDS

10.1.3


table, contaminated surfaces and floors

are cleaned after each delivery

ANC UPWARDS

10.2

Biomedical waste is

segregated and disposed

of as per the guidelines



ANC UPWARDS



ANC UPWARDS

10.3



procedure and sterile

gloves are worn during

delivery and internal

examination

10.3.1

Performs hand hygiene before and after

each procedure, and sterile gloves are

worn during delivery and internal

examination

ANC UPWARDS




Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

1 Provider conducts an appropriate and adequate assessment of clinical condition of pregnant woman and fetus at the time of admission

1.1

Elicits comprehensive

obstetric, medical and

surgical history and

conducts examination

(Box 1)

1.1.1 Documents obstetric, medical and

surgical history in case record

BEmONC

UPWARDS

1.1.2

Documents the presentation and lie

of the fetus in the case record at

admission

BEmONC

UPWARDS

1.2 Assesses gestational age

correctly 1.2.1

Assesses and records gestational age

through either LMP or Fundal height

or USG (if available)

BEmONC

UPWARDS

1.3 Records fetal heart rate

1.3.1

Functional Doppler/fetoscope/

stethoscope at point of use is

available

BEmONC

UPWARDS

1.3.2 Records FHR at admission BEmONC

UPWARDS

1.4 Records mother’s blood

pressure

1.4.1

Functional BP instrument and


available

BEmONC

UPWARDS

1.4.2 Records mother`s BP at admission BEmONC

UPWARDS

1.5 Records mother’s

temperature

1.5.1 Functional thermometer at point of

use is available

BEmONC

UPWARDS

1.5.2 Records mother' s temperature at

admission

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

2 Provider ensures respectful and supportive care for the pregnant woman coming in for delivery

2.1

Treats pregnant woman

and her companion

cordially and respectfully

(RMC), ensures privacy

and confidentiality for

pregnant woman during

her stay

2.1.1 Curtains are installed in labor room to

ensure privacy to pregnant woman

BEmONC

UPWARDS

2.1.2

Treats pregnant woman and her

companion cordially and respectfully

(RMC), ensures privacy and

confidentiality for pregnant woman

during her stay

BEmONC

UPWARDS

2.2

Encourages the presence

of birth companion during

labor

2.2.1 Encourages the presence of birth

companion during labor

BEmONC

UPWARDS

2.3

Explains danger signs and

important care activities to

pregnant woman and her

companion during the stay

(for the woman and her

newborn)

2.3.1

Explains danger signs and important

care activities to pregnant woman

and her companion during the stay

(for the woman and her newborn)

BEmONC

UPWARDS

3 Provider monitors the progress of labor in every case by using partograph and adjusts care accordingly

3.1

Monitors progress of labor

regularly on various

parameters (Box 9)

3.1.1

Initiates partograph plotting when

cervical dilatation is >=4 cms in

appropriate column on the alert line

BEmONC

UPWARDS

3.1.2 Plots all parameters in the partograph BEmONC

UPWARDS

3.2

Interprets partograph

correctly and adjusts the

care according to findings

3.2.1

If parameters are not normal,

identifies complications, records the

diagnosis and makes appropriate

adjustments in the birth plan

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

4 Provider assists the pregnant woman to have a safe and clean birth

4.1

Conducts PV examination

at admission and every

four hours in active labor or

as per clinical indication

4.1.1

Records the finding of PV

examination (in Case

sheet/Partograph during active

phase of labor)

BEmONC

UPWARDS

4.2

Performs PV examination in

a safe and clean manner

(Box 2)

4.2.1 Performs hand hygiene with correct

technique

BEmONC

UPWARDS

4.2.2 Wears gloves on both the hands with

correct technique

BEmONC

UPWARDS

4.2.3 Cleans the perineum appropriately

before PV examination

BEmONC

UPWARDS

4.2.4 Soap, running water and sterile

gloves are available

BEmONC

UPWARDS

4.2.5

Antiseptic solution and sterile

gauze/pad in the PV tray are

available

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

4.3

Allows spontaneous

delivery of head by

maintaining flexion and

giving perineal support;

manages cord round the

neck; assists in delivery of

shoulders and body

4.3.1

Allows spontaneous delivery of head

by maintaining flexion and giving

perineal support; manages cord

round the neck; assists in delivery of

shoulders and body

BEmONC

UPWARDS

4.4 Performs an episiotomy

only if indicated (Box 11)

4.4.1 Performs an episiotomy only if

indicated

BEmONC

UPWARDS

4.4.2 Records the reason for episiotomy BEmONC

UPWARDS

5 Provider conducts a rapid initial assessment and performs immediate newborn care (if baby cried immediately)

5.1

Delivers the baby and

places on mother’s

abdomen to conduct

immediate newborn care -

drying and assessment of

baby's breathing

5.1.1 Places two pre-warmed towels on

mother's abdomen before delivery

BEmONC

UPWARDS

5.1.2 Delivers and places the baby on

mother's abdomen

BEmONC

UPWARDS

5.1.3 Dries the baby immediately and

wraps in second warm towel

BEmONC

UPWARDS

5.2 Performs delayed

clamping of cord 5.2.1

If baby's breathing is normal, delays

the clamping of cord for 1-3 minutes

till the cord pulsations stop

BEmONC

UPWARDS

5.3 Assesses the newborn for

any congenital anomalies

5.3.1 Records presence or absence of any


BEmONC

UPWARDS

5.3.2 Ensures specialist attention for

newborns with congenital anomalies

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

5.4 Ensures early initiation of

breastfeeding 5.4.1

Initiates breast feeding within one

hour of birth

BEmONC

UPWARDS

5.5 Weighs the baby and

administers Vitamin K

5.5.1 Baby weighing scale is available BEmONC

UPWARDS

5.5.2 Vitamin K injection is available BEmONC

UPWARDS

5.5.3 Records baby weight and

administration of vitamin K

BEmONC

UPWARDS

6 Provider performs newborn resuscitation if baby does not cry immediately after birth

6.1

Performs recommended

initial steps for resuscitation

within first 30 seconds

6.1.1

Checks for functionality of neonatal

resuscitation kit and availability of

shoulder roll before every delivery

BEmONC

UPWARDS

6.1.2

Performs following steps within first 30

seconds on mothers abdomen:

Suction if indicated; dries the baby

and rubs the back 2-3 times;

immediate clamping and cutting of

cord; and shifting to radiant warmer if

baby still not breathing

BEmONC

UPWARDS

6.1.3

Performs following steps within first 30

seconds under radiant warmer:

Positioning, Suctioning, Stimulation,

Repositioning (PSSR)

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

6.2

Initiates bag and mask

ventilation for 30 seconds if

the baby is still not

breathing

6.2.1 Functional ambu bag with mask (size

0 and 1) is available

BEmONC

UPWARDS

6.2.2 Initiates bag and mask ventilation for

30 seconds if baby still not breathing

BEmONC

UPWARDS

6.3

Takes appropriate action if

baby doesn’t respond to

ambu bag ventilation after

golden minute

6.3.1

Functional oxygen cylinder (with

wrench) and new born mask are

available

BEmONC

UPWARDS

6.3.2

Assesses breathing, if baby still not

breathing, continues bag and mask

ventilation; starts oxygen

BEmONC

UPWARDS

6.3.3 Checks heart rate/cord pulsations BEmONC

UPWARDS

6.3.4 Calls for advance help/arranges

referral

BEmONC

UPWARDS

6.4

*Performs next level of

resuscitation in babies not

responding to initial

resuscitation- when chest

rise is seen after bag and

mask but heart rate

continues to be < 60/pm

(only at facilities where

specialist care for newborn

or SNCU is available)

6.4.1

Performs chest compressions at the

rate of 3 compressions to 1 breath till

the heart rate is > 60 beats/minute

*Only at facilities

where specialist

care for newborn

or SNCU is

available 6.4.2

If the heartrate persists to be

undetectable or < 60 beats/minute,

administers epinephrine (1:10000),

0.1 - 0.3 ml/kg i.v.



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

7 Provider performs Active Management of Third Stage of Labor (AMTSL)

7.1

Performs AMTSL and

examines the placenta

thoroughly

7.1.1 Palpates mother's abdomen to rule

out second baby

BEmONC

UPWARDS

7.1.2 Administers injection Oxytocin 10 I.U.

IM/IV within one minute of delivery of

baby

BEmONC

UPWARDS

7.1.3 Performs controlled cord traction

(CCT) during contraction

BEmONC

UPWARDS

7.1.4 Performs uterine massage

BEmONC

UPWARDS

7.1.5 Checks placenta and membranes for

completeness before discarding

BEmONC

UPWARDS

8 Provider assesses condition of mother and baby before shifting them from labor room

8.1 Looks for signs of infection

in baby 8.1.1 Looks for signs of infection in baby

BEmONC

UPWARDS

8.2 Looks for signs of

hypothermia in baby 8.2.1 Measures baby's temperature

BEmONC

UPWARDS

8.3 Looks for signs of infection

in mother 8.3.1 Looks for signs of infection in mother

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

8.3.2 Functional thermometer at point of

use is available

BEmONC

UPWARDS

8.3.3 Records mother's temperature BEmONC

UPWARDS

8.4 Records blood pressure of

mother

8.4.1

Functional BP instrument and


available

BEmONC

UPWARDS

8.4.2 Records mother's BP

BEmONC

UPWARDS


9.1




after each use


are available

BEmONC

UPWARDS

9.1.2 Instruments are sterilized after each

use

BEmONC

UPWARDS

9.1.3


table, contaminated surfaces and

floors are cleaned after each delivery

BEmONC

UPWARDS

9.2

Biomedical waste is

segregated and disposed

of as per the guidelines



BEmONC

UPWARDS



BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

9.3



procedure, and sterile

gloves are worn during

delivery and internal

examination

9.3.1

Performs hand hygiene before and

after each procedure, and sterile

gloves are worn during delivery and


BEmONC

UPWARDS

10 Provider induces labor only when indicated (based on history and findings of examination)

10.1

Induces labor only when

indicated

(Box 12)

10.1.1 Records the reasons for induction BEmONC

UPWARDS

10.1.2

Performs induction only if C-section

service is available at the facility (or

can be transported without delay to

such a facility - Uganda)

BEmONC

UPWARDS

10.2

Uses only recommended

technique for induction of

labor

10.2.1

Uses only recommended methods for

induction of labor as per the Bishop's

score

BEmONC

UPWARDS

10.3 Monitors the progress of

labor 10.3.1

Records the progress of labor, fetal

heart rate and status of medication in

partograph every 30 minutes

BEmONC

UPWARDS

10.4


the hyper stimulation of

uterus due to use of

uterotonics

10.4.1

Uses betamimetics (terbutaline) for

management of hyperstimulation of

uterus

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

11 Provider augments labor only when indicated (based on history and findings of examination)

11.1 Augments labor only when

indicated

11.1.1

Ensures ambulation of pregnant

woman, presence of birth

companion as methods of improving

progress of labor before considering

augmentation of labor

CEmONC

11.1.2

Augments labor only when there is a

confirmed delay in progress of labor

as identified through partograph

CEmONC

11.1.3 Records the reasons for

augmentation CEmONC

11.1.4

Performs augmentation only when

C-section services are available at

the facility

CEmONC

11.2

Carefully assesses the

condition of pregnant

woman before considering

augmentation of labor

11.2.1

Rules out CPD or presence of any

other reasons which may lead to

obstruction of labor such as

mal-presentation/malposition or

scarred uterus, prior to augmentation

CEmONC

11.3

Ensures appropriate

supportive care to

pregnant woman

11.3.1

Ensures continuous companionship,

adoption of mobility, upright position

and adequate hydration of pregnant

woman

CEmONC

11.4 Uses correct technique for

augmentation of labor 11.4.1

Uses Oxytocin only or Oxytocin with

amniotomy for augmentation of

labor

CEmONC



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

11.4.2

Uses low initial dose and gradual

increase of Oxytocin for

augmentation

CEmONC

11.4.3 Does not use Misoprostol for

augmentation CEmONC

11.5

Monitors maternal and

fetal well-being

continuously

11.5.1 Records maternal and fetal

conditions in the partograph CEmONC

12 Provider identifies and manages HIV in pregnant woman and newborn

12.1

Checks for test results or

recommends testing if not

done

12.1.1 Rapid HIV kits are available BEmONC

UPWARDS

12.1.2 Checks for test results or recommends

testing if not done

BEmONC

UPWARDS

12.2


HIV seropositive cases (if

ART center) (Box 13) or

refers (if not ART center)

12.2.1 If ART center, ART drugs are available BEmONC

UPWARDS

12.2.2 Provides ART for seropositive mother BEmONC

UPWARDS

12.2.3 Links mother and newborn to ART

center for continuous follow-up

BEmONC

UPWARDS

12.2.4 If not ART center, Nevirapine tablet is

available

BEmONC

UPWARDS

12.2.5

Provides Nevirapine to (HIV

seropositive) pregnant woman and

refers her to ARTC after delivery

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

12.2.6 Follows universal precautions during

care of mother and newborn

BEmONC

UPWARDS

12.3


newborn of HIV

seropositive mother

12.3.1 Nevirapine syrup is available BEmONC

UPWARDS

12.3.2 Provides syrup Nevirapine to

newborns of HIV seropositive mothers

BEmONC

UPWARDS

13 Provider identifies and manages severe Pre-eclampsia/Eclampsia (PE/E)

13.1 Identifies mothers with

severe PE/E

13.1.1 Dipsticks for proteinuria testing in

labor room are available

BEmONC

UPWARDS

13.1.2 Records BP at admission BEmONC

UPWARDS

13.1.3



breathing, epigastric pain, reduced

urine output; or presence of

convulsions

BEmONC

UPWARDS

13.2

In cases of severe PE/E,

gives correct first dose of

MgSO4 and refers to

higher center or manages

appropriately (Box 4)


available

BEmONC

UPWARDS

13.2.2

Gives correct first dose of MgSO4 (5

mg with 1 ml of 2% Xylocaine in each

buttock deep IM (10 mg)) and refers

to higher center

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

13.2.3

Injection MgSO4 is appropriately

administered (5 mg with 1 ml of 2%

Xylocaine in each buttock deep IM

(10 mg); 4gms (8ml) with 12 ml

Normal saline IV slowly followed by

maintenance dose of 5mg with 1 ml

of 2% Xylocaine in alternate buttock

deep IM every 4 hours for 24 hours

after the last convulsion or delivery

whichever occurs later)

BEmONC

UPWARDS

13.3 Facilitates prescription of

anti-hypertensives (Box 5)

13.3.1 Antihypertensive are available BEmONC

UPWARDS

13.3.2

Facilitates prescription or prescribes

anti-hypertensives in case of

hypertension in pregnancy

BEmONC

UPWARDS

13.4


for care of mother and

newborn

13.4.1 Ensures specialist attention for care of

mother and newborn

BEmONC

UPWARDS

14 The facility has services available for conducting assisted vaginal delivery as clinically appropriate

14.1

Reviews the pregnant

woman for suitability for

vacuum extraction

14.1.1

Performs vacuum extraction when

indicated: vertex presentation, term

fetus, cervix fully dilated and fetal

head at +2 station, no fetal pole

palpable per abdomen

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

14.1.2

Documents the indication for

vacuum extraction and takes

consent

BEmONC

UPWARDS

14.2

Performs vacuum

extraction using

appropriate technique

14.2.1

Functional vacuum extraction

equipment are available in labor

room

BEmONC

UPWARDS

14.2.2 Ensures that the woman's bladder is

empty

BEmONC

UPWARDS

14.2.3 Uses correct technique for applying

vacuum cup and traction

BEmONC

UPWARDS

14.2.5 Monitors FHR and attachment of the

cup in between contractions

BEmONC

UPWARDS

14.3 Identifies failure of vacuum

extraction

14.3.1

Identifies failure if fetal head does not

advance with each pull or fetus is

undelivered after three pulls with no

descent or after 30 minutes or cup

slips off the head twice at the proper

direction of the pull

BEmONC

UPWARDS

14.3.2 In cases of failure refers the case for a

C-section

BEmONC

UPWARDS

15 Provider effectively manages special obstetric conditions- shoulder dystocia and mal-presentations

15.1

Identifies and effectively

manages shoulder

dystocia

15.1.1

Identifies the case of shoulder

dystocia, keeps calm and shouts for

help (seeks assistance)

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

15.1.2

Performs basic management: with

pregnant woman on her back, asks

her to flex both thighs bringing her

knees towards the chest (Mc Robert's

position). Asks assistants to push her

flexed knees against her chest

BEmONC

UPWARDS

15.1.3 Applies suprapubic pressure BEmONC

UPWARDS

15.1.4 Does not give fundal pressure or pulls

baby's head

BEmONC

UPWARDS

15.1.5 Performs episiotomy if required to

enlarge the vaginal opening

BEmONC

UPWARDS

15.1.6 Ensures specialist attention if basic

management fails

BEmONC

UPWARDS

15.1.7

Tries to deliver posterior arm or

performs internal rotational

maneuvers

BEmONC

UPWARDS

15.1.8

If not being able to manage, refers

the woman for specialist care/C-

section

BEmONC

UPWARDS

15.2 Effectively manages

breech delivery

15.2.1

Attempts breech delivery only when

the facilities of assisted vaginal

delivery and C-section are available

CEmONC

15.2.2 If pregnant woman agrees, conducts

the delivery by C-section CEmONC



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

15.2.3

If pregnant women is willing for

vaginal delivery and there are no

contraindications for vaginal breech

delivery, prepares for the vaginal

breech delivery

CEmONC

15.2.4 Performs episiotomy if required CEmONC

15.2.5

Performs breech delivery using

different maneuvers depending upon

type and presentation of breech

CEmONC

15.3 Effectively manages other

mal-presentations 15.3.1

Identifies other mal-presentations and

ensures appropriate specialist

care/referral for C-section

BEmONC

UPWARDS

16 Provider identifies and manages Postpartum Hemorrhage (PPH)

16.1

Assesses uterine tone and

bleeding per vaginum

regularly after delivery

16.1.1 Assesses uterine tone and bleeding

per vaginum regularly

BEmONC

UPWARDS

16.2

Performs initial steps of

management as per the

protocol in case of PPH

16.2.1 Calls for help /assistance, while

continuing uterine message

BEmONC

UPWARDS

16.2.2 Starts IV fluids BEmONC

UPWARDS

16.2.3 Manages shock if present BEmONC

UPWARDS

16.2.4 Identifies specific cause of PPH BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

16.3 Manages atonic PPH

16.3.1

Initiates 20 IU oxytocin drip in 1000 ml

of ringer lactate/normal saline at the

rate of 40-60 drops per minute

BEmONC

UPWARDS

16.3.2 Continues uterine massage BEmONC

UPWARDS

16.3.3 If uterus is still relaxed, gives other

uterotonics as recommended

BEmONC

UPWARDS

16.3.4

If uterus is still relaxed, performs

mechanical compression in the form

of bimanual uterine compression or

external aortic compression or

balloon tamponade

BEmONC

UPWARDS

16.3.5

If uterus is still relaxed, refers to higher

center while continuing mechanical

compression

BEmONC

UPWARDS

16.4

Manages PPH due to

retained

placenta/placental bits

16.4.1

Identifies retained placenta if

placenta is not delivered within 30

minutes of delivery of baby or the

delivered placenta is not complete

BEmONC

UPWARDS

16.4.2

Initiates 20 IU oxytocin drip in 1000 ml

of ringer lactate/normal saline at the

rate of 40-60 drops per minute

BEmONC

UPWARDS

16.4.3 Refers to higher center if unable to

manage

BEmONC

UPWARDS

16.4.4 Performs MRP BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

17 Provider ensures care of newborn with small size at birth

17.1

Facilitate specialist care in

newborn weighing <1800

gm

17.1.1

Facilitates specialist care in newborn

<1800 gm (refer to FBNC/seen by

pediatrician)

BEmONC

UPWARDS

17.2 Facilitates assisted feeding

whenever required 17.2.1

Facilitates assisted feeding whenever

required

BEmONC

UPWARDS

17.3

Facilitates thermal

management including

kangaroo mother care

17.3.1 Facilitates thermal management

including KMC

BEmONC

UPWARDS

18 Provider performs management of hypoglycemia in newborn

18.1 Identifies neonatal

hypoglycemia 18.1.1

Identifies neonatal hypoglycemia

(Blood Glucose (BG) < 45mg/dl) or

through clinical signs and symptoms)

CEmONC

18.2 *Manages neonatal

hypoglycemia

18.2.1

Allows direct breastfeeding if baby is

able to suck or gives formula feed if

mother is not able to breastfeed the

baby, continues feeding if the baby

responds

BEmONC

UPWARDS

18.2.2

Establishes IV line if blood glucose

level is less than 25 mg/dl and gives IV

bolus of 10% dextrose (2 ml/kg body

weight) followed by IV infusion of 10%

dextrose (100 ml/kg/day)

*Only at facilities

where specialist

care for

newborn or

SNCU is

available 18.2.3

If IV line cannot be established

quickly, gives 2ml/kg body weight of

10% glucose trough gastric tube



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y /

N /

NA

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

18.2.4

If BG level is less than 25 mg/dl 30

minutes after initiation of IV therapy,

repeats the bolus dose and refers to

higher center

19 Provider performs management of hyperbilirubinemia in newborn

19.1 Identifies neonatal

hyperbilirubinemia 19.1.1

Identifies neonatal hyperbilirubinemia

through history (previous baby with

jaundice, G6PD deficiency, Rh

incompatibility), clinical picture of

jaundice (appears in first 24 hours of

life or infant shows symptoms or signs

of a serious illness), and serum bilirubin

level. Jaundice (Total serum bilirubin

(TSB) is > 18 mg/dL or rises by > 5

mg/dL/day)

CEmONC

19.2 *Manages neonatal

hyperbilirubinemia

19.2.1

Begins phototherapy in cases of

serious jaundice as per serum bilirubin

level or clinical condition ( Day 1: on

any part of the body, Day 2: on arms

and legs, Day 3: on hands and feet)

*Only at facilities

where specialist

care for

newborn or

SNCU is

available 19.2.2

Continues phototherapy if serum

bilirubin level is at or above risk factor

level (Day 2: 13mg/dl, Day 3:

16mg/dl, Day 4 and after: 17 mg/dl).

Discontinues phototherapy below

these levels


(C-Section Standards)


Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

(Y/N

)

20 Provider makes proper preparation and adheres to standard procedure and technique of C‐Section

20.1 Makes correct indication

and ensures general

preparation for C‐section

20.1.1

Decides upon the need for C-section

based on indications and mentions

indications in the mother records

CEmONC

20.1.2

Ensures informed consent has been

obtained for the C-section (where

appropriate and possible, obtains signed

written consent from mother to proceed)

CEmONC

20.1.3

Facilitates appropriate pre-anesthetic

check-up including necessary lab tests

of pregnant woman

CEmONC

20.1.4 Ensures counselling on PPFP method and

provides as per request CEmONC

20.2

Adheres to standard

procedure and protocols for

conducting C-section

20.2.1 Prepares the woman for the C‐Section,

inserts an IV line and starts IV fluids CEmONC

20.2.2 Ensures a single dose of prophylactic

antibiotics 15-60 minutes before surgery CEmONC

20.2.3 Correctly performs all steps of the

C-section to deliver the baby (babies) CEmONC

20.2.4 Correctly performs AMTSL and ENBC CEmONC



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC Only/

BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y/N

/NA

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

(Y/N

)

21 Provider ensures appropriate postoperative monitoring course and postnatal care for the mother

21.1

Correctly monitors

postoperative course and

ensures postnatal care for

the mother

21.1.1

Monitors vitals, vaginal/surgical site

bleeding and contraction of uterus and

urine output

CEmONC

21.1.2 Ensures breastfeeding within 1 hour

after delivery CEmONC

21.1.3 Ensures mothers are mobilized within

6-12 hours after surgery CEmONC

21.1.4 Records relevant information in the

mother’s records CEmONC

22 Provider reviews clinical practice related to C-section at regular intervals

22.1

Ensures classification as per

Robson’s criteria and

reviews indications and

complications of C-section

at regular intervals

22.1.1

Ensures that all C‐section cases are

classified as per the modified Robson’s

criteria and rates of different categories

are monitored

CEmONC

22.1.2 Reviews all cases of induction and

C-section through a clinical audit CEmONC

22.1.3 Ensures that rate of complications of

C-sections are periodically monitored CEmONC




Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y|

N/N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1 Provider ensures adequate postpartum care package is offered to the mother and newborn

1.1 Ensures at least 4 postpartum

visits for the mother

1.1.1

Ensures minimum 4 postpartum visits for

the mother: after discharge at 2-3 days

(If discharged early), 7-14 days, 6 weeks

and 6 months after delivery (or as per

national guidelines)

BEmONC

UPWARDS

1.1.2

Prepares postpartum visit schedule and

shares written record with the mother

and her family

BEmONC

UPWARDS

1.1.3 Ensures additional 2 to 3 visits in cases of

babies with any complication

BEmONC

UPWARDS

1.2

Conducts proper physical

examination of mother and

newborn

1.2.1

Conducts mother’s examination: breast,

perineum for inflammation; status of

episiotomy/tear suture; lochia; calf

tenderness/redness/swelling; abdomen

for involution of uterus, tenderness or

distension

1.2.2

Conducts newborn’s examination:

assesses feeding of baby; checks

weight, temperature, respiration, color

of skin and cord stump

1.3


manages maternal and

neonatal sepsis

1.3.1 Checks mother's temperature

BEmONC

UPWARDS

1.3.2 Gives correct regimen of antibiotics

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y|

N/N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

1.3.3 Checks baby’s temperature and other

looks for other signs of infections

BEmONC

UPWARDS

1.3.4 Gives correct regime of

antibiotics/refers for specialist care

BEmONC

UPWARDS

1.4


manages postpartum

maternal depression

1.4.1 Makes correct diagnosis of postpartum

maternal depression after ruling out

postpartum blues based on history

BEmONC

UPWARDS

1.4.2 In cases of postpartum blues, provides

emotional support and counsel’s family

on the condition. Follows up in 2 weeks,

and refers for specialist care if required

BEmONC

UPWARDS

1.4.3 In cases of postpartum depression,

provides emotional support and refers

for specialist care

BEmONC

UPWARDS

1.5 Ensures to offer FP services

1.5.1 A basket of choice of PPFP services is

available at the facility

BEmONC

UPWARDS

1.5.2 Provider is trained for PPFP services

being offered at the facility

BEmONC

UPWARDS

2 Provider counsels the mother on care for herself and her baby

2.1 Counsels mother on care of

herself and the baby

2.1.1 Counsels on danger signs of mother and

baby

BEmONC

UPWARDS

2.1.2 Counsels on exclusive and on demand

breast feeding to mother

BEmONC

UPWARDS

2.1.3

Counsels on the importance of

maintaining hygiene (hand hygiene,

perineal hygiene)

BEmONC

UPWARDS



Re

spo

nse

(Y

/N/N

A)


(Y/N/NA)

Comments

Applicability

(ANC

Only/BEmONC/

CEmONC)

Ob

serv

atio

ns

Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

Y|

N/N

A

# C

he

ck

ed

# P

rac

tic

ed

(Y/N

)

(Y/N

)

2.1.4

Counsels on importance of adequate

nutrition for mother and growth

monitoring for baby

BEmONC

UPWARDS

2.1.5 Counsels on postnatal exercises

2.2

Counsels on return to fertility,

healthy timing and spacing

of pregnancy and PPFP

2.2.1 Counsels on RTF, HTSP and PPFP

BEmONC

UPWARDS

2.3 Counsels on immunization for

the newborn 2.3.1

Counsels on importance of complete

immunization and links them to

immunization services

BEmONC

UPWARDS


Input Standards

S.

No. Standard Verification criteria

Re

spo

nse

(Y

/N/N

A)

Triangulation and

Sources (Y/N/NA)

Comments

Applicability (ANC

Only/BEmONC/

CEmONC) Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

1 Adequately resourced and properly organized labor room is available

1.1

Adequately resourced and

well organized labor room

is available

1.1.1

Adequate number of labor tables are

available in labor room (as per the

delivery load: 1 for < 20, 2 for 20-99,

4 for 100-199, 6 for 200-499, use

formula for calculation* for > 500

deliveries per month) *Formula for calculation = {(Projected

labor events in a year)*(Average length of

stay)}/ {(365)*(Occupancy rate)}

BEmONC Upwards

1.1.2

Adequate space is available in labor

room for placement of required labor

tables (labor tables have a distance

of at least 3’ from the side wall, at

least 2’ from head end wall, and at

least 6’ in between two tables)

1.1.3

Adequate privacy is maintained in

labor room through use of

partition/curtains

BEmONC Upwards

1.1.4 Adequate facility (chair/stool) for birth

companions is available BEmONC Upwards

1.1.5

Adequate number of sterilized delivery

trays as per the delivery load are

available (at least 2 per labor table)

BEmONC Upwards

1.1.6 Functional NBCA is available in the

labor room (Box 14) BEmONC Upwards


S.


Re

spo

nse

(Y

/N/N

A)

Triangulation and

Sources (Y/N/NA)

Comments

Applicability (ANC

Only/BEmONC/

CEmONC) Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

1.1.7

NBCA is in the labor room with easy

accessibility from the labor tables (if

required, can be accessed from labor

tables within 5 seconds) and is open

on three sides for ease of movement

BEmONC Upwards

1.1.8 Labor room has adequate availability

of all the necessary supplies (Box 15) BEmONC Upwards

1.1.9

Functional toilet and washing area

with 24-hour running water supply is

available

BEmONC Upwards

1.1.10 Labor room has adequate lighting,

ventilation and temperature control BEmONC Upwards

2 Adequately trained human resources are available in appropriate number

2.1 Adequately trained human

resources are available in

appropriate number 2.1.1

Adequate SBA trained staff is

available for conducting normal

vaginal deliveries (as per delivery

load: 2 nurses for < 100, 4 for 100-200,

8 for 200-500 and 10 for > 500

deliveries per month)

BEmONC Upwards

2.1.2

Adequately trained personnel are

available for conducing assisted

vaginal deliveries

BEmONC Upwards

2.1.3 ObGyn/Specialist is available for

complication management BEmONC Upwards

2.1.4 ObGyn/appropriately trained staff is

available for conducting C-section CEmONC


S.


Re

spo

nse

(Y

/N/N

A)

Triangulation and

Sources (Y/N/NA)

Comments

Applicability (ANC

Only/BEmONC/

CEmONC) Ca

se r

ec

ord

s

Pro

vid

er

inte

rvie

w

Ph

ysi

ca

l

ve

rific

atio

n

# C

he

ck

ed

# P

rac

tic

ed

( Y

/N )

( Y

/N )

2.1.5 Anesthetist is available for performing

C-sections CEmONC

2.1.6 Adequately trained support staff is

available as per the delivery load BEmONC Upwards

3 Operation theatre is adequately equipped for conducting C-Section

3.1 Operation theatre is

adequately equipped for

conducting C-Section

3.1.1

Number of OT tables in the OT is

appropriate as per the C-section

delivery load

CEmONC

3.1.2 Adequate supplies and equipment

are available in the OT for C-section CEmONC

3.1.3 Anesthesia tray with functional Boyle's

apparatus is available CEmONC

3.1.4 OT has adequate lighting, ventilation

and temperature control CEmONC

3.1.5

OT complex has provision for

separate washing area with 24-hour

running water supply

CEmONC

3.1.6 OT complex has functional toilet and

staff resting/changing area CEmONC

3.1.7 Functional newborn care area is

available in the OT (Box 14) CEmONC

3.1.8

Adequate supplies and equipment are

available for conducting advanced

adult/newborn resuscitation

CEmONC


Annexure 3: Boxes with Technical Details of Practices

Covered Under Key Standards

Box 1: Appropriate surgical and obstetric history

Review of clinical history of the woman in labor of the woman in labor

Danger symptoms/

signs of labor

Vaginal bleeding

Rupture of membranes

Convulsions

Severe headache and

blurred vision

Severe abdominal pain

Respiratory difficulty

Fever

Obstetric history

Number of pregnancies

Number of abortions

Number of normal deliveries

Number of caesarean sections,

forceps, or vacuum

Any intraabdominal surgeries

Number of stillbirths

Number of children alive

Number of newborns who died

during the first month

Number of children who died

after first month

Date and outcome of the last

pregnancy

Questions about current labor

When the painful regular

contractions began

How frequently they are

occurring

If her “bag of waters” broke:

when, what colour, and what

smell it had

Whether she feels the baby’s

movements

Whether she has any doubts

or concerns about her labor,

and responds using easy-to-

understand language

Medical history

Existing conditions:

Cardiovascular disease (eg. hypertension, rheumatic heart disease)

Other conditions (eg. kidney disease, diabetes, thyroid, hematological or autoimmune disorders,

epilepsy, malignancy, severe asthma, HIV, hepatitis B or hepatitis C infection)

Psychiatric disorders, Obesity or underweight and Female genital mutilation

Lifestyle considerations -history of alcohol and drug misuse

Mental Health and psychosocial factors

Experience in previous pregnancies

Recurrent miscarriage

Preterm birth

Pre-Eclampsia/Eclampsia

Rh Incompatibility

Any Uterine surgery

Ante and Postpartum hemorrhage

Puerperal psychosis

Four or more previous births

Stillbirth or neonatal death

Small or large for gestational age baby

Baby with congenital abnormality

Source – adapted from NICE (2008)


Box 2

Steps for PV examination

Do P/V examination only when required/indicated to minimize the infection

Maintain privacy and dignity of women at all times

Ask woman to empty her bladder

Wash the hands properly before & after each vaginal examination

Wears plastic apron and surgical gloves

Explains the woman about the procedure & always take consent before doing it.

Cleans perineum with antiseptic swab, discards the soiled swab in yellow container

Separate labia with the non-examining hands

Uses middle & index finger of Right/Left Hand and inserts them into vagina at 12’ O Clock -6’ O clock

position

Judges the dilatation of cervix-in cms

Assesses the adequacy of the pelvis by noting well curved sacrum and inability to reach both Ischial

spines at the same time

Removes gloves and puts them into 0.5 % chlorine solution

Informs the woman about the progress of labor

Records the information on the partograph, if cervical dilatation is 4cm and above

Box 3

Management of Anemia

Moderate anemia (Hb 7-11.5 g/dl):

Give iron 120 mg once daily and folic acid 400 mcg

once daily for three months

If woman is in the 2nd or 3rd trimester, give

anthelmintic: Mebendazole 500 mg stat orally

Advise about nutrition: animal proteins, legumes,

dark green vegetables, and sources of vitamin C,

IPTp-SP and use of ITNs

Severe anemia (< 7 g/dl):

Refers/admits the woman to the hospital

for evaluation

Gives iron 120 mg daily and folic acid 400

mcg daily

Advises to continue taking FeFo for three

months after delivery

Box 4

Immediate Management of Severe pre-eclampsia/ Eclampsia

MgSO4 is the drug of choice for prevention and control of eclampsia seizure

MgSO4 is a very safe drug with very little side effects. Toxicity due to MgSO4 is rare and can be given

safely even by midwives.

First dose of MgSO4 at peripheral health facility is 5-5 gm of 50% (w/v) in each buttock deep IM.

Immediate referral should be made to ensure that the client reaches higher facility within 2 hrs

At higher facility loading dose of MgSO4 is 4 gm 20% IV (8 ml MgSO4+12 ml of NS/DW in 20 ml syringe

in 5-10 minutes) followed by 5-5 gm 50% in each buttock deep IM with 1 ml of 2% Xylocaine

Continue maintenance dose of MgSO4- 5 g deep IM with 1 ml of 2% Xylocaine in alternate buttocks

every four hours, for 24 hours after birth/last convulsion, whichever is later

Monitor vital signs (pulse, blood pressure, respiration), reflexes, urine output and fetal heart

Toxicity signs- Watch for toxicity signs before every maintenance dose

Urine output less than 25 to 30 ml/hour

Absent knee jerk (DTR)

Respiratory rate <16/minute-

Withhold next dose in case of presence of any toxicity sign. Give antidote – Inj. Calcium gluconate

10 ml 10 % in 10 minutes slow IV for respiratory toxicity


Box 5

Anti-Hypertensive in management of severe Pre-eclampsia/Eclampsia

Anti-Hypertensive need to be given if Diastolic BP >110 mm Hg

Target should be to maintain diastolic BP between 90-100 mm Hg

In case of severe Pre-eclampsia, use of tab Nifedipine or Inj. labetalol is recommended for initial

control of BP

There is no role of diuretics as anti-hypertensive

There is no preferred choice of anti-hypertensive and drugs can be used as per the availability and

experience of the provider.

Start tab Nifedipine as 10 mg stat and can be repeated after 30minutes if BP is not controlled.

Maintenance doses can be given as 10 mg 8 hrly (maximum 80 mg/day). However, Nifedipine should

not be given sub-lingual

Or, Start Inj. Labetalol 20 mg IV bolus and repeat 40 mg IV after 10 minutes if BP is not controlled.

Repeat 80 mg every 10 minutes (Maximum 220 mg/day) with cardiac monitoring till BP is controlled.

Maintenance dose is tab Labetalol 100 mg 12 hrly

Continue BP monitoring

Box 6

Management of Syphilis in Pregnancy

Every pregnant woman to be screened for syphilis as early as possible, preferably in first trimester.

Women who are at high risk for syphilis, should be screened again in the third trimester or at the time

of delivery

Ensure institutional delivery at (FRUs/higher level institutions) of all syphilis-positive pregnant women

Testing of spouse/partner of syphilis-positive women should be mandatory followed by treatment as

per protocol for those found positive

For management of early stage (primary and secondary syphilis of <2 years’ duration; RPR titre< 1:8

approx) syphilis, A single intramuscular

Injection of 2.4 million IU benzathine benzyl penicillin (Drug of choice). If client is allergic to penicillin,

Erythromycin, 500 mg orally, QID for 15 days

OR Azithromycin, 2 gm orally as a single dose can be given

For management of Late stage (tertiary > 2 years or unknown duration, RPR titer>1:8 approx.) syphilis,

A total of three intramuscular injections of 2.4 million IU benzathine benzyl penicillin once a week for 3

weeks should be given. Alternatively, Erythromycin, 500 mg orally, 4 times daily for 30 days can also

be given if client is allergic to penicillin

Benzathine penicillin injection is the only effective treatment for preventing congenital syphilis,

perinatal deaths, stillbirths and preterm deliveries in pregnant women with syphilis.

For the treatment of syphilis during pregnancy, NO PROVEN ALTERNATIVES TO PENICILLIN exists.

All infants of pregnant women treated with a non-penicillin regimen should be treated at birth as if

mother was not sufficiently treated.

Alternative to penicillin should be considered ONLY for those syphilis positive pregnant women who

have a history of severe penicillin allergy (e.g. anaphylaxis)

Erythromycin estolate is contraindicated because of drug-related hepatotoxicity. Only erythromycin

base or erythromycin ethyl succinate should be used.

Follow-up-should be done during postnatal care (PNC) visits and in addition, at 6 months and 24

months after the treatment is administered

The partner or spouse should be treated with the same regimen.


Box 7

Treatment regimens for uncomplicated malaria

When symptoms of malaria are present but there is no evidence of any vital organ being seriously

affected, malaria is said to be 'uncomplicated'. According to the 2010 Guidelines for treatment of

malaria issued by the government of India, the treatment regimens to be followed in pregnant women

with uncomplicated malaria are as follows:

P. falciparum infection

First trimester of Pregnancy: Quinine 10 mg/kg of body weight, three times a day for 7days [11].

It is important to note that Quinine can reduce Blood Sugar, so any woman taking Quinine must eat

something before or immediately after the Quinine pills.

Second or third trimester of pregnancy: ACT or Artemisinin Combination Therapy.

Drugs Number of tablets

Day 1 Day 2 Day 3

Artesunate 50 mg 4 4 4

Sulfadoxine 500 mg+

Pyrimethamine 25 mg 3 0 0

P. vivax infection

As per local guidelines.

Box 8

Conditions that lead to preterm birth:

Antepartum hemorrhage

Preterm premature rupture of membranes

Severe Pre-eclampsia

Infections in the vaginal canal

Over distension of the uterus

Antenatal corticosteroids to be used:

Injection Dexamethasone 6mg IM 12 hourly – total of 4 doses or

Injection Betamethasone 12 mg once a day – total 2 doses

Box 9

Parameters on Partograph:

To measure every 30 mins:

Fetal heart rate

Number of Contractions in a 10 minute interval

Strength of contraction

To measure every 4 hours:

Maternal Blood pressure and Pulse rate

Maternal Temperature

Cervical dilatation (through a PV examination)

Color of liquor

Medications – as provided

Box 10


Birth kit and infection prevention materials:

Sterile tray

Two hemostats (clamps); One scissors

One cord clamp or sterile tape or sterile tie

Four sterile towels (two for baby and two for mother)

Sterile gauze to clean baby’s mouth and nose if needed

One syringewith10IU of oxytocin or misoprostol 600 mcg

Two pairs of sterile or HLD gloves

One plasticcontainerwith0.5%chlorine solution for decontamination

One plastic container with a plastic liner to dispose the placenta

One plastic container with a plastic liner for medical waste (gauze, etc.)

One sharps container at point of use to dispose of needle and syringe

One leak proof container to dispose of soiled linen

Clean plastic or rubber apron and face shields (or mask and goggles)

Closed‐toes hoes

Episiotomy kit (for cases who require episiotomy)

Privacy conditions for the woman:

Ensures that she remains covered with a sheet (as appropriate)

Separates the area with curtains, sheets, or screens, as appropriate

Ensures that the minimum number of individuals are present during birth (the provider/s attending the

birth and a companion—the individual chosen by the woman)

Box 11

Indication for perform episiotomy:

Breech, shoulder dystocia, forceps, vacuum, poorly healed 3rd or 4th degree tear, FGC or fetal

distress.

Assistance in delivering the baby:

Quickly palpates to determine cord around the neck; if it is loose, slides it over the baby’s head; if it is

very tight, clamps it in two places and cuts it before unravelling it from around the baby’s neck

Allows spontaneous external rotation of the head without manipulation

Carefully takes the baby’s head in both hands and applies gentle downward traction until the

anterior shoulder has emerged (no neck holding) and guides the baby’s head and chest upward

until the posterior shoulder has emerged, OR allows the baby pops freely protecting only the head of

the baby, if the woman is in the vertical position

Holds the baby by the trunk and places it onto a dry towel/cloth on the mother’s abdomen


Box 12

Indications for Induction of labor:

Induction of labor is recommended for women who are known with certainty to have reached 41

weeks (> 40 weeks + 7 days) of gestation. (Does not apply to settings where gestational age is not

reliably estimated).

Induction of labor is recommended for women with pre-labor rupture of membranes at term.

IUD.

Inductions are not recommended for:

Induction of labor is not recommended in women with an uncomplicated pregnancy at gestational

age less than 41 weeks.

If gestational diabetes is the only abnormality, induction of labor before 41 weeks of gestation is not

recommended (except in uncontrolled diabetes and placental insufficiency).

Induction of labor at term is not recommended for suspected fetal macrosomia.

Inductions should not be performed solely because of patient or care provider preference.

Ref: WHO recommendations for induction of labor SOGC Clinical Practice Guideline, No. 296,

September 2013 (Replaces No. 107, August 2001) Induction of Labor

Recommended methods/medications for induction:

Low dose Prostaglandins E2 (cervical and vaginal) is effective agents of cervical ripening and

induction of labor for an unfavourable cervix.

(Intravaginal prostaglandins E2 is preferred over intracervical prostaglandins E2)

Prostaglandins are not to be used in settings of vaginal birth after caesarean section.

If prostaglandins are not available, intravenous oxytocin alone should be used for induction of labor.

Amniotomy alone is not recommended for induction of labor.

Immediately after the initiation of intravenous oxytocin, it is advisable to monitor closely the

oxytocin infusion rate, response of the uterus to oxytocin, and fetal heart rate.

Oral misoprostol (25 μg, 2-hourly) or vaginal low dose misoprostol (25 μg, 6-hourly) is recommended

for induction of labor.

Misoprostol is not recommended for women with previous caesarean section.

In the third trimester, for women with a dead or anomalous fetus, oral or vaginal misoprostol is

recommended for induction.

Intracervical Foley catheters are acceptable agents that are safe both in the setting of a vaginal

birth after Caesarean section and in the outpatient setting.

The combination of balloon catheter plus oxytocin is recommended as an alternative method

when prostaglandins (including misoprostol) are not available or are contraindicated.

Sweeping membranes is recommended for reducing formal induction of labor.

Ref: WHO recommendations for induction of labor/SOGC Clinical Practice Guideline, No. 296,

September 2013 (Replaces No. 107, August 2001) Induction of Labor


Box 13

Care and information to an HIV positive mother and her exposed infant

ARVs for mother and baby

All infants born to HIV

positive mothers should

receive a course of

medication for PMTCT,

which is linked to the

drug regimen that the

mother is taking and the

infants feeding method:

Breastfeeding

The infant should

receive once-daily

NVP from birth until

age 6 weeks.

Not breastfeeding

The infant should

receive once-daily

NVP (or twice-daily

AZT) from birth until

age 4–6 weeks.

The mother should be

given Option B+ drugs

for life (see standards

10)

Factors that increase risk

of HIV transmission during

breast-feeding

New HIV infection

during the

breastfeeding period

Mixed feeding (breast

and other feeds)

Breast problems

(mastitis, breast

abscesses, cracked

nipple)

Oral disease in the

infant

Preterm and low birth

weight infants

Maternal nutrition

Future care plan for HIV

positive women

Discusses ongoing

support of counselling

on infant feeding

Provides

Cotrimoxazole for OI

prophylaxis

Discusses need for

Early Infant Diagnosis

at 6 weeks

Discusses plans for

early access to

medical care and

treatment for mother

and infant

Fixes appointment

date for both the

mother and the baby

that coincides with

immunization

schedule

Information on chosen method of infant

feeding

Benefits of exclusive breastfeeding:

Complete diet for infant; Protects against

infectious diseases (diarrhea and

pneumonia)

Protects against allergies in babies;

Reduces risk of maternal hemorrhage

Acts as a natural method of birth spacing

for the first six months

Is free, pre-warmed, clean and safe, and

immediately ready on demand

Gives the mother control; Offers the first

bonding between mother and baby

Risks:

Increases risk of HIV transmission to the

exposed infant and young child

Increased demand on mother’s additional

stores which might be already

compromised

Tips for exclusive breast feeding

Tells the woman to continue exclusive

breastfeeding for at least 6 months

Tells the woman to seek medical advice in

case of breast problems

Encourages the woman to maintain breast

health

Observes the positioning and attachment

of baby and demonstrates proper

positioning and attachment if needed

Tells the woman to avoid pre-lacteal feeds

and mixed feeding

Benefits of replacement feeding

Reduces the risk of HIV transmission to the

exposed infant and young child

Reduces demand on mother’s additional

nutrition stores which might be already

compromised

Risks of replacement feeding

Increases risk of infectious disease in the

infant (contaminated milk or equipment

causes diarrhea and may lead to

malnutrition and death)

It is difficult to ensure cleanliness of feeding

equipment

Formula offers no protection against

infection or allergies as it does not contain

the anti-infective agents that are normally


Care and information to an HIV positive mother and her exposed infant

passed from the mother to the baby

High costs

Over dilution or under dilution may result in

malnutrition

Formula supplies cannot be guaranteed

Tip for replacement feeding

Ensures that woman has decided to not

breastfeed and to rather use replacement

feeding

Assesses affordability, feasibility,

acceptability, sustainability and safety of

replacement feeding

Demonstrates preparation of replacement

feeding from formula.

Asks the mother to repeat the information

and to provide return demonstration

Emphasizes to the mother the importance

of not breastfeeding at all if she has

chosen this method

Explains the risks of bottle feeding and

advises mother to avoid it and use cup:

Using clean dry cup

Not keeping the cup with milk open

Wash the cup after use


Annexure 4: Key Resources Referred During

Development of Standards of Care*

Antenatal standards

1. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy, WHO (2013); http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf

2. Antenatal Care, Opportunities of Africa’s Newborns- Practical data, policy and programmatic support for newborn care in Africa, WHO (2010); http://www.who.int/pmnch/media/publications/oanfullreport.pdf

3. Guideline: Calcium supplementation in pregnant women. WHO (2013); http://apps.who.int/iris/bitstream/10665/85120/1/9789241505376_eng.pdf

4. The diagnosis and treatment of malaria in pregnancy; Royal College of Obstetricians and Gynaecologists (April 2010); https://www.rcog.org.uk/globalassets/documents/guidelines/gtg54bdiagnosistreatmentmalariapregnancy0810.pdf

5. Guidelines for Ante-natal care and skilled attendance at birth by ANMs and LHVs, Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) (2005); http://www.indiannursingcouncil.org/pdf/SBA-MODULE-Guideline-for-Antenatal-Care.pdf;

6. National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus, MoHFW (December 2014); http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/National_Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_Mellitus.pdf ;

7. Screening for Syphilis during pregnancy-Technical and operational guidelines, MoHFW (December 2014); http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/Syphilis_Doc_Low-res_5th_Jan.pdf

8. National Guidelines for Deworming in Pregnancy, MoHFW, GOI (December 2014); http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/_National_Guidelines_for_Deworming_in_Pregnancy.pdf

9. Guidelines for Ante-natal care and skilled attendance at birth by ANMs/LHVs/SNs, MoHFW, GOI (April 2010); http://www.nhp.gov.in/sites/default/files/anm_guidelines.pdf

Intrapartum and Immediate postpartum standards

1. Managing Complications in Pregnancy and Childbirth- A guide for midwives and doctors, WHO(2007); http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf

http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf

http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf

http://www.who.int/pmnch/media/publications/oanfullreport.pdf

http://apps.who.int/iris/bitstream/10665/85120/1/9789241505376_eng.pdf

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg54bdiagnosistreatmentmalariapregnancy0810.pdf

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg54bdiagnosistreatmentmalariapregnancy0810.pdf

http://www.indiannursingcouncil.org/pdf/SBA-MODULE-Guideline-for-Antenatal-Care.pdf

http://www.indiannursingcouncil.org/pdf/SBA-MODULE-Guideline-for-Antenatal-Care.pdf

http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/National_Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_Mellitus.pdf

http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/National_Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_Mellitus.pdf

http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/Syphilis_Doc_Low-res_5th_Jan.pdf

http://nrhm.gov.in/images/pdf/programmes/maternalhealth/guidelines/Syphilis_Doc_Low-res_5th_Jan.pdf

http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/_National_Guidelines_for_Deworming_in_Pregnancy.pdf

http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/_National_Guidelines_for_Deworming_in_Pregnancy.pdf

http://www.nhp.gov.in/sites/default/files/anm_guidelines.pdf



2. WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WHO(2011); http://apps.who.int/iris/bitstream/10665/44703/1/9789241548335_eng.pdf

3. WHO recommendations for the prevention and treatment of postpartum haemorrhage, WHO(2012) ;http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf

4. WHO recommendations for Induction of Labour (2014); http://apps.who.int/iris/bitstream/10665/44531/1/9789241501156_eng.pdf

5. WHO recommendations for Augmentation of Labour(2014); http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf

6. Guidelines on basic Newborn Resuscitation, WHO(2012); http://apps.who.int/iris/bitstream/10665/75157/1/9789241503693_eng.pdf

7. WHO recommendations on interventions to improve preterm birth outcomes, WHO (2015); http://apps.who.int/iris/bitstream/10665/183037/1/9789241508988_eng.pdf

8. Guidelines For The Management Of Breech Presentation Including External Cephalic Version (ECV),NHS (2014); http://www.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11198&type

9. Green top guideline no. 42 Shoulder Dystocia, Royal College of Obstetricians and Gynaecologists (March 2012); https://www.rcog.org.uk/globalassets/documents/guidelines/gtg42_25112013.pdf

10. Threatened Preterm Birth Care A Global Curriculum(2015); http://www.mcsprogram.org/wp-content/uploads/2015/12/Grenier-1.pdf

11. Managing Puerperal Sepsis-Midwifery education module 4, WHO; http://www.who.int/maternal_child_adolescent/documents/4_9241546662/en/

12. Early essential Newborn care, WHO(2014); http://iris.wpro.who.int/bitstream/handle/10665.1/10798/9789290616856_eng.pdf

13. DAKSHATA- Empowering Providers for Improved MNH Care during Institutional Deliveries; Ministry of Health and Family Welfare, Government of India, (April 2015)

14. Guidance Notes on Use of Uterotonics during labour; MoHFW, GOI, (September 2015)

15. Facility based Newborn care operational guide, MoHFW, GOI(2011); http://164.100.130.11:8091/rch/FNBC_Operational_Guideline.pdf

C-section Standards 1. Jhpiego SBMR Global Performance Standards, Sept 2014






http://www.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11198&type

http://www.mcsprogram.org/wp-content/uploads/2015/12/Grenier-1.pdf

http://www.who.int/maternal_child_adolescent/documents/4_9241546662/en/

http://iris.wpro.who.int/bitstream/handle/10665.1/10798/9789290616856_eng.pdf

http://iris.wpro.who.int/bitstream/handle/10665.1/10798/9789290616856_eng.pdf

http://164.100.130.11:8091/rch/FNBC_Operational_Guideline.pdf


Postnatal Standards

1. Managing Complications in Pregnancy and Childbirth- A guide for midwives and doctors, WHO(2007); http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf

2. Pregnancy, Childbirth, Postpartum and newborn care A guide for essential practice, WHO(2006); https://www.k4health.org/sites/default/files/3%20WHO_guide%20for%20essential%20practice%20PCPNC%202006.pdf

3. Postnatal Care, Opportunities of Africa’s Newborns-Practical data, policy and programmatic support for newborn care in Africa, WHO (2010); http://www.who.int/pmnch/media/publications/oanfullreport.pdf

4. DAKSHATA- Empowering Providers for Improved MNH Care during Institutional Deliveries; Ministry of Health and Family Welfare, Government of India, (April 2015)

*Not in chronological order


https://www.k4health.org/sites/default/files/3%20WHO_guide%20for%20essential%20practice%20PCPNC%202006.pdf

https://www.k4health.org/sites/default/files/3%20WHO_guide%20for%20essential%20practice%20PCPNC%202006.pdf

http://www.who.int/pmnch/media/publications/oanfullreport.pdf


Annexure 5: S0Ps for using Standards-Based

Assessment Tool

About Tool A Standards Assessment tool will be used to collect data to assess the practices followed at individual facility at regular intervals (recommended once every 6 months).

Contents of Tool Tool comprises of the following sections:

Facility details/Identifiers

Standards, Components & Verification criteria

Triangulation methods Facility Details/Identifiers:

Data Element Explanation Response

State State name where facility exists. Also

name of province/country can be

added if applicable

Write name of the State

District District Name where facility exists Write name of the district

Facility Name Name of the facility Write name of the facility

Provider/In

Charge name

Name of Provider/ In Charge name Mention name of provider/ In charge

(Labor room) of facility

Date of

assessment

Date when assessment is done in

DD/MM/YYYY format (e.g. 05/09/2012)

Write the date when assessment is done

for the facility

Name of the

assessor

Name of the person(s) who performed

the assessment.

Write name of the assessor(s)

Snapshot of Tool


The number of standards in the tool varies depending on the type of facility. Each standard contains a set of components which should be followed in order to meet the standard. Each component can be verified by verification criteria, which the assessor triangulates by either directly observing clients or through demonstration on models, or triangulated through case records, providers’ interviews and physical verification of the instrument(s)/equipment required to perform a practice. The cells of relevant triangulation methods for each verification criteria have been kept open for data entry, while the other methods which are not relevant for criteria have been shaded dark. The table below explains about each verification criteria and the type of response that should be entered

Triangulation

Criteria Explanation Response

Observation Observation of practices at facility.

This can be done either by directly observing

the practice of provider on clients (if

available) or asking them to demonstrate skills

on models.

If provider correctly performs the skills

according to verification criteria, mark it as ‘Y’.

If provider is not able to practice correctly,

then mark as ‘N’.

If there are no cases for observation, the

response will be NA and other triangulation

methods will be applied.

Observation of any practice performed by

provider has most priority. If the case is

available at facility to observe, there is no

further need to triangulate that practice

through other methods

Y/N/NA

Case records Triangulation of relevant practice through

case records should be done if the

observation is not possible.

At least 5 case records need to be checked.

Number of case records

checked

Number of case records

indicating the performance of

practice

Providers

interview Providers` knowledge is assessed by asking

questions relevant to performing the

practice/skill to be verified.

(E.g. Questions to ask for triangulating the

recording BP at admission: What examinations

you perform at time of admission? Probe

further if BP is measured at admission, also ask

to perform the procedure if performed)

Attempt should be made to interview

maximum number of providers.

Y/N

Physical

Verification Availability of instruments/supplies is checked

physically at intended point of use.

If available mark ‘Y’, if not available mark ‘N’.

Y/N

Decision rules:

Decision rule for triangulation criteria:


If verification is possible by means of observation, no further triangulation is required. The relevant verification criterion is considered as ‘Y’ if the practice/skill observed is being correctly performed on the client as per the standards. If observation is not possible, then go for further triangulation methods as below.

For case records, 50% or more of checked case records should indicate that the practice is performed at the facility.

For Provider interview, all provider(s) interviewed should correctly respond for the verification criteria to be considered as ‘Y’.

For physical verification, the instruments/supplies should be physically checked at intended point of use.

For a verification criteria to be considered as ‘Y’, all relevant triangulations for that particular criteria should indicate the performance of that practice or skill by the provider.

For a standard to be considered as ‘Y’ in the Response column, all the verification criteria under the practice should have score of ‘Y’ in the Score column.

A standard will be scored either 0 or 1 depending on the responses. If the responses of all practices performed under a standard are ‘Y’, then the standard will score 1 point. If one or more responses for practices under a standard is ‘N’, the standard scores 0 points.


Example of decision rule

Interpretations

Verification criteria 1.1.1: Observation was possible and the practice under observation was performed hence the score = ‘Y’. No further triangulation was required.

Verification criteria 1.4.1: Observation was possible and practice under observation was not performed hence the score = ‘N’. No further triangulation was required.

Verification criteria 1.5.1: The instrument could be physically verified at intended point of use, hence the score = ‘Y’.

Verification criteria 1.3.1: Observation was not possible (‘NA’), hence further triangulation was done. a. 5 Case records were checked, out of which 3 indicated practice was performed

(i.e. more than 50%). b. Providers were interviewed and the correct response was obtained.

Since all triangulation methods indicate that practice is being performed at the facility, the score is ‘Y’.

Verification criteria 1.6.3: The instrument could not be physically verifies at intended point of use, hence score = ‘N’.

Verification criteria 1.5.2: Observation was not possible (‘NA’), hence further triangulation was done. c. 5 Case records were checked, out of which 2 indicated practice was performed

(i.e. less than 50%). The practice is negative. d. Providers were interviewed and they gave correct responses.

Since all triangulation methods do not indicate that practice is being performed, the score is ‘N’.

Verification criteria 1.6.1 is ‘N’ ‘since observation was not possible (NA) and provider did not give correct response when interviewed.’


Standard no. 1 will be scored as 0 as verification criteria 1.4.1, 1.5.2, 1.6.1, 1.6.2 & 1.6.3 are ‘N’.


Annexure 6: Template for Action Planning

State: Facility Type: Assessor Name:

District: Facility Name: Date (dd/mm/yyyy):

S.

No

.

Sta

nd

ard

Un

me

t

Ve

rific

atio

n

Crite

ria

Re

aso

n

An

aly

sis

(Sk

ill G

ap

-1;

Re

sou

rce

Ga

p

– 2

, Pro

toc

ol

Pro

ce

ss G

ap

–

3,

Oth

ers

spe

cify

)

Pla

n o

f

Ac

tio

n

Ad

ditio

na

l

Su

pp

ort

ive

Ac

tio

n

Pe

rso

n

Re

spo

nsi

ble

Tim

elin

e

Summary

Total standards

=

Number of Standards

Observed = _______

Number of Standards

Achieved = ______

% Standards Achieved =

________


Annexure 7: Client Case Record Template


















Annexure 8: ANC & PNC Card Template

Registration No.

Name:

Husband Name:

Age:

Address:

Mobile No.

Education:

Religion:

Obstetrics history:

Gravida Parity Abortion Living children

Previous LSCS Yes No

Other complications: _______________________

Lab Tests

Blood group:

HIV:

HBsAg:

VDRL:

Gestational age estimation

LMP : ____/____/________

EDD : ____/____/________

ANC 1 ANC 2 ANC 3 ANC 4

Date:

Gestational Age (in

weeks):

Weight (Kgs):

Vitals

BP:

Pulse:

Temperature:

FHR:

Investigation

Hb:

Urine Sugar:

Urine protein:

Malaria:

USG finding :

Other:

Any complication /

Remarks:

Counselling done:

Calcium

supplementation:

Tetanus Toxoid :

IFA:

Treatment given:


Postnatal Visit Card

Mother

Registration No.:

Name:

Age:

Type of Delivery:

Husband’s Name:

Address:

Mobile No.

Education:

Religion:

PNC 1 PNC 2 PNC 3 PNC 4

Date:

Vitals

BP:

Pulse:

Temperature:

Breast Examination:

Any complication /

Remarks:

Treatment given:

Counselling on

danger sings:

Counselling on

breast feeding:

PPFP counselling:

Baby

Name:

DOB:

Weight at Birth:

Any complication at Birth:

PNC 1 PNC 2 PNC 3 PNC 4

Date:

Vitals

Temperature:

Pulse:

Respiratory Rate:

Heart Rate:

Weight:

Height

Any complication /

Remarks:

Treatment given:

Immunization:

Kangaroo Mother

Care for small baby:


Annexure 9: Birthing Register Template


Annexure 10: Monthly Progress Report Format

Facility: City: State:

Provider name (If applicable): Month and year:

S. No. Data element Numbers in the reporting

month

A Obstetric Services

A1 Total number of normal deliveries in the facility

A2 Total number of assisted deliveries in the facility (Vacuum/Forceps)

A3 Total number of caesarean deliveries in the facility

A4 Number of live births in the facility

A5 Number of still births in the facility

A6 Number of intrauterine deaths in the facility

A7 Number of maternal deaths in facility in the month

A8 Number of new born deaths in facility in the reported month

B Complicated Deliveries Managed

at facility

Referred to

higher

center

B1 Mothers with post-partum hemorrhage

B2 Mothers with sepsis

B3 Mothers with pre-eclampsia

B4 Mothers with eclampsia

B5 Mothers with obstructed labor

B6 Newborns with asphyxia

B7 Number of newborns with sepsis

B8 Number of newborns who were premature births

C Practices

C1 Number of deliveries where partograph was used for monitoring

C2 Number of deliveries where mother’s blood pressure was recorded

at admission

C3 Number of deliveries where mother’s temperature was recorded

at admission

C4 Number of deliveries where oxytocin was given as uterotonic for

active management of third stage of labor

C5 Number of deliveries where misoprostol was given as uterotonic for

active management of third stage of labor

C6 Number of deliveries where baby was dried using clean dry towels

immediately after birth

C7 Number of deliveries where baby was breast fed within 1 hour of

delivery

C8 Number of deliveries where mothers temperature was recorded at

discharge


S. No. Data element Numbers in the reporting

month

C9 Number of deliveries where baby’s birth weight was recorded

after birth

C10 Number of deliveries where Safe Childbirth Checklist was used

C11 Number of deliveries where baby’s temperature was recorded at

discharge

C12

Number of preterm deliveries (<34 weeks) where antenatal

corticosteroids were administered


Annexure 11: Process for development of the toolkit

Jhpiego adopted a consultative approach to develop the key elements of the toolkit. Jhpiego organized a side event during the Global Maternal and Newborn Health Conference held in Mexico in November 2015 to first discuss the concept of the toolkit amongst a core group of key stakeholders in quality of care for the private sector. During this consultation, Jhpiego presented an outline of the toolkit. The group participants provided feedback on the structure and applicability of the toolkit. With the intention of building upon the existing resources, Jhpiego did a landscape review of similar existing resources within and outside Jhpiego, including those from WHO, USAID, guidelines from the Government of India, and various professional organizations, as a first step in the process of the development of the toolkit. Available resources were reviewed for applicability to the developing country context. With the background resources, Jhpiego held an international consultation meeting on the toolkit on December 11-12, 2015 in Delhi. The purpose of this meeting intended to initiate the development of a practical toolkit for improving quality of care during childbirth in the private sector, to validate findings from the landscape review, and to gather additional input from partners, various professional bodies, user segments, government representatives, and experts. This consultation was attended by more than 45 participants from India and Uganda, representing development partners working with private sector healthcare providers, private practitioners from FOGSI, representatives from Association of Obstetricians and Gynaecologists of Uganda (AOGU), representatives from Governments of India and Uganda, professional association of obstetricians and nurses, and members of the National Accreditation Board of Hospitals (NABH). Major objectives of the consultation were:

To reinforce and understand specific needs of private sector institutions in developing countries in order to improve the quality of care during childbirth;

To finalize the scope and components of the toolkit for standardizing care during childbirth in private sector institutions;

To define the outline of subcomponents of various toolkit modules; and

To finalize action‐plans and the schedule of activities for the final toolkit. The participants reviewed the needs of the private sector for quality improvement and defined guiding principles for developing the toolkit. Additionally, they determined that the toolkit components should build upon, adapt, and upgrade existing available tools that have been found to be useful in similar contexts. It was also recommended that the toolkit should be user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. To facilitate further discussions, Jhpiego presented a draft outline of the toolkit to the participants which were endorsed by all participants. Subsequently, the participants worked in smaller groups to define the components and sub-components of the toolkit and discussed the details of the proposed standards. One


Jhpiego staff member was assigned to each group and tasked with the responsibility of coordinating the process of developing the toolkit components. The working groups also developed the plan of action and timelines for content development and finalization in preparation for the next consultation. Following the consultation, based on the recommendations from the groups, Jhpiego prepared drafts of the components of the proposed toolkit, namely a set of quality standards and a customized training course outline, and quality measurement matrices, which were subsequently shared with the respective groups to obtain their feedback and input on the draft versions. As proposed, Jhpiego adopted an iterative approach by incorporating the feedback from the participants on a regular basis to further improve the tools. At each step of developing the toolkit, Jhpiego considered the group’s recommendations to develop one that is user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. Updated drafts of the toolkit components were shared on a regular basis to obtain more input and feedback for further refinement. Additionally, Jhpiego continued developing a repository of references and training material in order to complement the toolkit. The primary focus during this period was to finalize the set of clinical standards which would further help finalize the other two components, specifically the course outline and metrics. As agreed upon in the first consultation, the final draft of the clinical standards was shared with the larger group by mid-February 2016 to obtain their feedback and further input by the end of February. The responses from the participants were considered and incorporated during the brainstorming sessions for refinement of the standards and other components prior to the second consultation. On March 30-31, 2016, Jhpiego, in partnership with the FOGSI, hosted a second consultation on the toolkit for standardizing care during childbirth in private sector institutions with the following objectives:

To share the latest version of the toolkit with the stakeholders;

To finalize the content of various components of the toolkit;

To finalize an action plan with the schedule of activities for field testing of the toolkit; and

To finalize the action plan and way forward for final dissemination. Similar to the first consultation, it included 48 participants representing the private practitioners from FOGSI and AOGU, representatives from the Governments of India and Uganda (GoI and GoU), various development partners working with the private sector healthcare providers in India and Uganda, and members of the National Accreditation Board of Hospitals (NABH). Jhpiego presented the latest version of the toolkit to the participants. The group leaders, in their presentations, unfolded the layout and summary of various components of the toolkit. The vetting of the technical and clinical content of the toolkit’s sub-components was concluded by the working groups. The last recommendations on various components of the standards were recorded for inclusion in the final draft prior to field testing. The participants also engaged in discussions regarding the operational aspects


of the toolkit including the methodology for use and Standard Operating Procedures (SOPs), and grouped some striking recommendations for finalizing the way forward for the field testing and the final roll-out plan of the toolkit. The meeting concluded with development of a field testing plan and suggestions for the global dissemination of the toolkit. For the field testing of the toolkit, it was decided that:

Field testing in India will involve selected FOGSI facilities in Uttar Pradesh and Jharkhand. This will be carried out by the four Local Chapters: three in UP and one in Jharkhand (including assessment of at least three facilities: one self-assessment and two external facility assessments). In Uganda, the field testing will be carried out by PACE Uganda and other development partners (10 facilities each).

The user feedback would be collected based on qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, course outline description, and on metric and dashboards.

Jhpiego will also undertake in-house mock training on the ANC and PNC components.

The said field testing would be conducted by April 30, 2016. After the second consultation, input and feedback from the participants was incorporated into the standards, and accordingly, changes were made in the course outline and quality measurement matrices. The finalized version of the toolkit was shared with the group to initiate the field testing along with the qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, the course outline description, and on metric and dashboards. The toolkit was field tested in nine private sector facilities across two states (Uttar Pradesh and Jharkhand) in India. Out of these, Jhpiego facilitated testing in three facilities, and in the rest of the facilities, local FOGSI champions facilitated the testing. Qualitative user feedbacks were collected from the users. One important feedback was to present the standards in simpler forms. One potential solution discussed was to keep the standards and the standards-based assessment form separate (earlier these were presented in a single sheet). Users also recommended slightly modifying the verification methodology for standards-based assessment tool. Course outlines were generally found to be suitable to facility needs. A few content related suggestions were made that were included. Modifications were also suggested in the data collection and collation tools. Jhpiego reviewed these suggestions and discussed them with the group leaders for potential solutions. Most of the design related suggestions were agreed to. Appropriate content suggestions were accepted; however, those that deviated from the normative guidelines were not included in consultation with the group members. Data collection tools and metrics were revised based upon relevant suggestions. The final toolkit was reviewed again for ease of presentation, correct technical content, and inclusion of relevant implementation information.


List of participants in the toolkit development process

S.No Name Organization

1 Leila Varkey Centre for Catalytic Change

2 Hema Divakar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

3 Sadhana Gupta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

4 Priti Kumar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

5 Nevidita Dutta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

6 Meera Lakhtakia Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

7 Alok Sharma Federation of Obstetrics and Gynaecological Societies of India (FOGSI)

8 Shivi Rawat Hindustan Latex Family Planning Promotion Trust (HLFPPT)

9 Anamika Pandey Hindustan Latex Family Planning Promotion Trust (HLFPPT)

10 Meenakshi Dikshit Population Services International (PSI)

11 Sudhir Maknikar John Snow International (JSI)

12 Dinesh Baswal Ministry of Health and Family Welfare, Government of India

13 P. Krishna Kumari MSD for Mothers India

14 Sai Subhasree

Raghavan Solidarity and Action Against the HIV Infection in India (SAATHI)

15 Varun Solidarity and Action Against the HIV Infection in India (SAATHI)

16 Anita Deodhar Trained Nurses Association of India (TNAI)

17 Evelyn P. Kannan Trained Nurses Association of India (TNAI)

18 Sangamitra Trained Nurses Association of India (TNAI)

19 Sharmila Neogi United States Agency for International Development (USAID)

20 Anuradha Jain United States Agency for International Development (USAID)

21 Mahesh Srinivas Pathfinder International, India

22 Mirazzuddin Ansari Pathfinder International, India

23 Gayatri V.

Mahindroo National Accreditation Board of Hospitals (NABH), India

24 Vikrant Prabhakar ACCESS HEALTH

25 Sujatha Rao ACCESS HEALTH

25 Ajay Gambhir National Neonatology Forum (NNF)

26 Krishan Kumar Population Services International

27 Milly N Kaggwa Program for Accessible Health Communication and Education (PACE),

Uganda

28 Anthony K Mugasa Ministry of Health, Uganda

29 Frank M Kaharuza Association of Obstrticians and Gynaecologists of Uganda (AOGU)

30 Hasifah Nalukwago ProFam UGANDA

31 Mariam Luyiga Program for Accessible Health Communication and Education (PACE),

Uganda

32 Tonny Kapsandui Jhpiego, UGANDA

33 Akhil K. Sangal National Neonatology Forum (NNF), India

34 Miriam Namugeere Ministry of Health, Uganda

35 Parvez Menom Jhpiego, India

36 Sai Barath Jhpiego, India

37 Renu Pandey Jhpiego, India


S.No Name Organization

38 Suranjeen Prasad Jhpiego, India

39 Meshach Kujur Jhpiego, India

40 Dinesh Singh Jhpiego, India

41 Rashmi Asif Jhpiego, India

42 Bulbul Sood Jhpiego, India

43 Deepti Singh Jhpiego, India

44 Somesh Kumar Jhpiego, India

45 Vikas Yadav Jhpiego, India

46 Sudharsanam Jhpiego, India

47 Prasad Bogam Jhpiego, India

48 Sunita Dhamija Jhpiego, India


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