to medical clinic

7/29/2019 To Medical Clinic

1/23

Introduction:

Ever sinceChisang Clinic Bhaunne was inaugurated in Mid-April 2012, the Clinic has been working

hard to run a Well Child Clinic and a Well Woman Clinic between 10 AM and 2PM on different days

of the week. Over the past few months, Chisang Clinic Bhaunne has been requested by the local

Womens Group to operate a Birthing Center to serve women from a 20 kil0meter radius. With smallfinancial support from our past international volunteers and other individuals, Chisang Clinic is

currently constructing the Birthing Center within the premises of Chisang Clinic Bhaunne. A

Feasibility Study Team that included a physician from the UK, two nurses from Seattle, WA and a

Nepali nurse, has worked for over two weeks to finalize this Feasibility Study for the Chisang Clinic

Birthing Center.

Chisang Clinic

Guidelines for Birthing Centre Implementation

December 2012

Dania Bakhbakhi BMedSci MBChB DRCOG

Chloe Rahmun RN BSN

Meghan Young RN BSN

Sonal Bhattarai RN BSN

Background

According to UNICEF, between 2006 and 2010, a Skilled Birthing Attendant is present at only

19% of births in Nepal. During this same time, only 18% of births were institutional deliveries.

With the majority of women giving birth at home, the risks of both maternal and fetal morbidity

and mortality are vastly increased.

For the village of Bhaunne in the Morang district, the nearest hospitals are Koshi Zonal and B. P.

Koirala Institute of Health Science.

Koshi Zonal Hospital is in Biratnagar, and BPKIHS is in Dharan. Both hospitals are over an hour

away from the community, making physical accessibility to medical care a challenge.

Additionally, the average cost of a non-complicated delivery in Nepal is approximately $100-

$600, which many people cannot afford.

Aim

Our aim is to establish a safe and sustainable birthing centre for the population of Bhaunne village

and the surrounding area, in order to increase womens accessibility to healthcare.

Organisational Considerations

Catchment Area: Bhaunne village and surrounding community of approximately 20 km diameter

Criteria for Admission to Birthing Centre

Low risk pregnancies only


2/23

Age 18-35

Gestation 37-41 weeks

No significant co-morbidities (See Table 1)

No previous birthing complications (See Table 2)

No previous caesarean sections No current pregnancy complications (See Table 3)

Has been known to clinic from early pregnancy and has attended regular routine check ups

No spontaneous attendances of women in labour. Advise to go straight to hospital in that case.

Has had all the necessary blood tests and investigations e.g. full blood count, urea and

electrolytes, and infection screening

Patient should have been compliant with treatment prescribed

Table 1:Medical Conditions not permitted at Birthing Centre

Disease Area Medical Condition

Cardiovascular Confirmed cardiac disease Hypertensive disorder

RespiratoryAsthma requiring an increase in treatment or hospitaltreatment Cystic fibrosis

Haematological

Haemoglobinopathiessickle-cell disease, beta-

thalassaemia major History of thromboembolic

disorders

Immune thrombocytopenia purpura or other platelet

disorder or platelet count below 100,000

Von Willebrands disease Bleeding disorder in thewoman or unborn babyAtypical antibodies whichcarry a risk of haemolytic disease of the newborn

Infective

Risk factors associated with group B streptococcuswhereby antibiotics in labour would be

recommended

Hepatitis B/C with abnormal liver function tests

Carrier of/infected with HIV

Toxoplasmosiswomen receiving treatment

Current active infection of chicken

pox/rubella/genital herpes in the woman or baby

Tuberculosis under treatment

Immune Systemic lupus erythematosus Scleroderma

Endocrine

Uncontrolled Hyperthyroidism

Uncontrolled Diabetes

Renal Abnormal renal function

Renal disease requiring supervision by a renal


3/23

specialist

Neurological

Epilepsy,Myasthenia gravis,Previous cerebrovascularaccident

Gastrointestinal

Liver disease associated with current abnormal liver

function tests

Psychiatric Psychiatric disorder requiring current inpatient care

Gynaecological Myomectomy/ Hysterotomy/fibroids

Major gynaecological surgery

Table 2: Previous complications not permitted at birthing centre

Previouscomplications

Unexplained stillbirth/neonatal death or previousdeath related to intrapartum difficulty

Previous baby with neonatal encephalopathy

Pre-eclampsia requiring preterm birth Placental abruption with adverse outcome

Eclampsia

Uterine rupture

Primary postpartum haemorrhage requiringadditional treatment or blood transfusion

Retained placenta requiring manual removal in

theatre

Caesarean section

Shoulder dystocia

History of previous baby more than 4.5 kg

Extensive vaginal, cervical, or third- or fourth-degree perineal trauma

Table 3: Current complications in pregnancy not permitted at birthing centre

Current pregnancy andfetal indicaions

Multiple birth

Placenta praevia

Pre-eclampsia or pregnancy-induced hypertension

Preterm labour or preterm prelabour rupture ofmembranes

Placental abruption

Anaemiahaemoglobin less than 10 g/dl at onset

of labour

Confirmed intrauterine death

Induction of labour

Substance misuse

Alcohol dependency requiring assessment or

treatment

Onset of gestational diabetes

Malpresentationbreech or transverse lie


4/23

Body mass index at booking of greater than 35kg/m2

Recurrent antepartum haemorrhage

Small for gestational age in this pregnancy (less

than fifth centile or reduced growth velocity on

ultrasound) Abnormal fetal heart rate (FHR)/Doppler studies

Ultrasound diagnosis of oligo-/polyhydramnios

Antepartum bleeding of unknown origin (singleepisode after 24 weeks of gestation)

Blood pressure of 140 mmHg systolic or 90 mmHg

diastolic on two occasions

Clinical or ultrasound suspicion of macrosomia

Para 6 or more

Recreational drug use

Under current outpatient psychiatric care

Age over 40 at booking Fetal abnormality

Staff Qualifications

SBA training:

3 certified SBAs on staff at any given time

Must be up to date with standardised skilled birthing attendant criteria

Must be in compliance with all Nepali government SBA requirements

Workforce numbers:

3 to 4 skilled birthing attendants

1 Physician on call with 24 hour cover of the clinic e.g. O&G consultant

Part-time ultrasound technician

Interns, including USMLE candidates

Housekeeper/ food prep

2 Nursing assistants

Shift rotations:

More staff there may be required at different times of the year Use booking diary to predict busy times and to staff accordingly

Specific Training:

Episiotomies

Post partum haemorrhage

Neonatal Resuscitation training


5/23

Basic Life support training

Breastfeeding training

Patient education e.g. reducing infection, stool softeners, when stitches come out

Volunteers:

Medical professionals e.g. doctors (O&G, GP, Sexual and reproductive health), midwives, labour

and delivery nurses, nurse practitioners

Students: observation, research and experience

Flow and consistency: partnerships with Universities in Nepal, UK, US and worldwide,

particularly ones with International Health programmes

Support groups:

Find out more information about women support group

Equipment and WorkspaceBuilding:

Minimum of 300 x 15 square feet

Western toilet and adequate bathing facilities for mother and baby

24 hour supply of clean and hot water and electricity supply (including emergency lighting)

24 hour refrigerator for storing medicines

Equipment in satisfactory condition

One patient bed per room must be adjustable and allow for gynaecological examination and

delivery i.e. needs to have stirrups

Opaque curtains and dividers to provide patient privacy for each room

Each room must have its own adjustable bright lighting

Oxygen tank and supply to the delivery room, must be secured to solid object

Adequate prevention from occupational hazards

No animals in the clinic

All windows and doors should be covered with a minimum of a net covering

Sufficient ventilation

Absolutely no smoking on the premises with an obvious sign at front desk

Cleaning and sanitation:

Daily thorough cleaning of facilities with the use of a regimented checklist

Cleaning of individual patient areas after every use e.g. wiping down beds and cleaning up any

spillage of body fluids

Individual disposal bins for sharp equipment, clinical waste and household general waste with

ideally a safe and environmentally friendly method of discard


6/23

Sufficient plumbing and drainage facilities

Hand washing sinks and alcohol gel to be located near clinical workstation

A scrub room

A dirty utility room for dirty linen and sanitary waste

A clean linen closet and laundry bag A sterile laundry facility

Adequate method of sterilisation of reusable instruments e.g. autoclave

Thorough hand washing with water and soap before and after each and every patient contact

including before and after each patient intervention or procedure

Alcohol gel to be applied on entering and leaving the birthing centre

Sharps and Biohazard Disposal:

All sharps including needles, finger sticks, glass, ampules, IV supplies, and specimen containers will

be disposed of in a puncture proof plastic container provided by the clinic. Each container when full

will be disposed of in a 3 meter deep hole, at least 20 meters from the nearest water supply and

building, as recommended by Where Women Have No Doctor. Biohazardous material including

blood and birthing by-products should be disposed of via incineration, or disposed of by the same

method as detailed above.

Equipment Needed and Predicted Cost:

Antenatal Equipment

Item Cost

Antenatal paperwork

Gloves

Alcohol gel

Weighing scale

Blood pressure monitor

Blood glucose monitor

Thermometer

Ultrasound

Doppler ultrasound

Fetoscope

Measuring tape


7/23

Stethoscope

KY lubricant

Speculum

Torch

Tourniquet

Needles

Syringe

Urine dipstick

Sterile universal containers

Gynaecology examination bed

Examination lighting

Equipment needed for delivery

Item Cost

Delivery Paperwork includingpartogram

Long sterile gloves

Sterile gown and mask

Sterile or clean drapes

Clean linen

Birthing bed

Examination lighting

Vomit bowl

Wipes

Towels

Soap

Chlorhexidine wash

Normal gloves

Fetoscope


8/23

Doppler ultrasound and gel

Fetal heart monitor

Ultrasound

Stethoscope

KY lubricant

Speculum

Torch

Tourniquet

Needles

Syringe

Urine dipstick

Sterile universal containers

IV cannulas ideally 18 gauge as a

minimum

Sterile saline flush

Gauze

IV fluids e.g. 0.9% NaCl, 5%

Dextrose, Hartmans (500ml-1L)

Drip stand or hook on wall

Pulse Oximeter

Oxygen masks, supply and tubing

Two bowls to receive afterbirth

Post-partum

Item Cost

Post natal paperwork

Umbilical clamp

Basic instrument pack

Forceps


9/23

Episiotomy scissors

Kochers forceps

Blankets

Cot

Hat

Suction

Blanket warmer

Thermometer

Sterile pad

Blood glucose monitor

Baby weighing scale

Blood pressure monitor

Pulse oximeter

Suture

Suture set

Stitches cutter

Paper towelsApron

Gum boots

Catheter

Bed pan

Bell

Masks

Emergency transport

Medications

Entonox

Paracteamol

Pethidine/opiods


10/23

Non steroidal anti-inflammatories

Antiemetics

Anti Rh-D Immunoglobulin

Oxytocin

Vitamin K Broad spectrum antibiotics

Erythromycin drops for eyes

Albendazole

Emergency Vehicle

24 hour availability to allow prompt transfer to hospital, in case complications or complex care

Collaboration

For transfer, partner with nearby hospitals: Koshi Zonal and BPKIHS

Business modeland goals

Cost/benefit analysis:

Cost of training

Cost of care and supplies to patient

Normal cost for delivery in Nepal:

Aiming to cost around

Cost of doctor

Cost of staff

Clinical Considerations

Chisang Clinic Birthing Centre, Confidentiality Statement

At Chisang Clinic, our goal is to provide the best possible security and privacy measures for each

patient. All patient reports, documents, lab values, and information will be kept confidential by the

staff of Chisang Clinic. Prior to the release of any information, the patient will first be asked for

permission to disclose sensitive material to external parties. Staff members not associated with the

patients care unless required for quality improvement will not review records. All records will be

kept for the duration of the patients life, after which time the records will be destroyed to protect

confidentiality. All records will be kept in a locked, secure area of the clinic with no public access.

Antenatal Care

Patients should be given a choice at outset of care to have their birth at Chisang Clinic Birthing

Center or in the hospital. They should be educated that if something goes wrong during their labour,

outcomes for the woman and baby may be better in an obstetrics unit at hospital. Obstetric units

may be able to provide direct access to obstetricians, anaesthetists, neonatologists and other

specialised care, including epidural analgesia. At any point during pregnancy or delivery, they may

need to be transferred to a hospital for emergency treatment.


11/23

Antenatal Guidelines

First Visit: When the mother first realizes she is pregnant

Start antenatal packet (Appendix 1)

Start antenatal flow chart (Appendix 2) Patient Screening Questionnaire (Appendix 3)

Education for the Mother:

How the baby develops during pregnancy government poster

General Advice About What to Expect During a Healthy Pregnancy (Appendix 4)

Keeping Healthy While Pregnant (Appendix 5)

Danger Signs During Pregnancy (Appendix 6)

Laboratory Tests

Hemoglobin

Hepatitis B

HIV: if positive, refer to Koshi Zonal Hospital, in Biratnagar, for follow up testing

Blood glucose

ABO blood group and antigen test

Urine dip: for proteinuria

Vitamin Supplementation and Medications

Folic Acid 400 mcg per day until the 12th week of pregnancy: this helps prevent neural tube

defects

Iron supplements should not be offered routinely: give only if anaemic or hemoglobin


12/23

Antenatal prophylactic anti-D treatment for all women who are rhesus-D negative check nepali

guidelines

Second Visit: Between 18-20 Weeks

Follow up with first visit and make sure patient has completed required tests. Continue to use Antenatal Flow Chart (Appendix 2) and record observations, VS, weight, fundal

height, and any problems or concerns the expecting mother may have.

Labs: Blood Glucose.

Make plan for next visit.

Third Visit: Between 24-28 weeks

Follow up with second visit

Continue Antenatal Flow Chart (Appendix 2) and record observations, vital signs, weight, fundal

height, and any problems or concern the expecting mother may have. Laboratory Tests:

Haemoglobin

Urine: proteinurea

Blood glucose

Oral Glucose Tolerance Test (OGTT)

OGTT Guidelines Need to look up exact amounts and how often a women needs to come back

for BG checks after diagnosis.

Ultrasound

Make plan for next visit.

Fourth Visit: Between 32-36 Weeks

Follow up with third visit

Continue with Antenatal Flow Chart (Appendix 2) and record observations, vital signs, weight,

fundal height, and fetal presentation.

If fetus is found to be malpositioned through palpation, a confirmation must be done by

ultrasound.

If it is confirmed by ultrasound, give the woman a choice to follow up in one to two weeks for a

repeat ultrasound to check fetal position. If at that time the fetus is still malpositioned the woman


13/23

should be referred to the nearest hospital and told she may not give birth at the clinic; however all

post natal care from the 6 week baby check on are still available to her.

Lab tests:

Haemoglobin:

Normal: >10.

If haemoglobin


14/23

Established first stage of labour: When there are regular painful contractions and progressive

cervical dilatation from 4 cm.

Duration of the first stage labour:

Nulliparous: 8-18 hours Multiparous: 5-12 hours

Assessment

Initial Assesment of a woman in labour should include:

Listening to her story and review clinical records

Physical observation: temperature, pulse, blood pressure, urinalysis

Length, strength and frequency of contractions

Abdominal palpation: fundal height, lie, presentation, position and station

Vaginal loss: show, liquor, blood Assessment of pain

FHR auscultated for a minimum of 1 minute immediately after a contraction

Vaginal examination should be offered if woman is in established labour

Analgesia

Breathing and relaxation techniques

Entonox (50:50 oxygen and nitrous oxide)

Pethidine or opioids

May have side effects including nausea and vomiting and could respiratory depression or

drowsiness in her baby

IV Fluid access

2 large cannulae (at least 18G/Green) to be inserted into a patients veins on admission

Assessment

A pictorial record of labour (partogram) should be used once labour is established

World Health Organization recommends 4-hour action line on partogram, should one be used

Observations (See Partogram: Appendix 9)

Temperature and blood pressure every four hours

Pulse every hour

Documentation of frequency of contractions every thirty minutes

Frequency of emptying the bladder


15/23

Vaginal examination offered every four hours, or where there is concern about progress or in

response to the womans wishes (after abdominal palpation and assessment of vaginal loss).

Intermittent auscultation of the fetal heart after a contraction should occur for at least one minute,

every fifteen minutes, and the rate should be recorded as an average. The maternal pulse

should be palpated if a FHR abnormality is detected to differentiate the two heart rates.Intermittent auscultation can be undertaken by either Doppler ultrasound or Pinard stethoscope.

Second Stage of Labour

Definitions:

Passive second stage of labour: The finding of full dilatation of the cervix prior to or in the

absence of involuntary expulsive contractions.

Onset of the active second stage of labour: The baby is visible with expulsive contractions and a

finding of full dilatation of the cervix or other signs of full dilatation of the cervix. As well as activematernal effort following confirmation of full dilatation of the cervix in the absence of expulsive

contractions.

Duration of the second stage labour

Nulliparous: Birth would be expected to take place within 3 hours of the start of the active second

stage in most women.

A diagnosis of delay in the active second stage should be made when it has lasted 2 hours and

women should be referred to a healthcare professional trained to undertake an operative vaginal

birth if birth is not imminent.

Multiparous: Birth would be expected to take place within 2 hours of the start of the active

second stage in most women.

A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and

women should be referred to a healthcare professional trained to undertake an operative vaginal

birth if birth is not imminent.

Observations

Blood pressure and pulse every hour

Temperature every four hours

Vaginal examination offered every hour in the active second stage or in response to the

womans wishes (after abdominal palpation and assessment of vaginal loss)

Documentation of the frequency of contractions every hour

Frequency of emptying the bladder

Ongoing consideration of the womans emotional and psychological needs.


16/23

Assessment of progress should include maternal behaviour, effectiveness of pushing and fetal

wellbeing, taking into account fetal position and station at the onset of the second stage. These

factors will assist in deciding the timing of further vaginal examination and the need for obstetric

review.

Intermittent auscultation of the fetal heart should occur after a contraction for at least one minute,at least every five minutes. The maternal pulse should be palpated if there is suspected fetal

bradycardia or any other FHR anomaly to differentiate the two heart rates.

Ongoing consideration should be given to the womans position, hydration, coping strategies and

pain relief throughout the second stage.

Womens Position and Pushing in the Second Stage

Women should be discouraged from lying supine or semi-supine in the second stage of labour

and should be encouraged to adopt any other position that they find most comfortable.

Women should be informed that in the second stage they should be guided by their own urge to

push.

If pushing is ineffective or if requested by the woman, strategies to assist birth can be used, such

as support, change of position, emptying of the bladder and encouragement.

Reducing Perineal Trauma

Perineal massage should not be performed by healthcare professionals in the second stage of

labour.

Either the hands on (guarding the perineum and flexing the babys head) or the hands poised

(with hands off the perineum and babys head but in readiness) technique can be used to

facilitate spontaneous birth.

Lidocaine spray should not be used to reduce pain in the second stage of labour.

A routine episiotomy should not be carried out during spontaneous vaginal birth.

Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy

originating at the vaginal fourchette and usually directed to the right side. The angle to the

vertical axis should be between 45 and 60 degrees at the time of the episiotomy.

An episiotomy should be performed if there is a clinical need such as instrumental birth or

suspected fetal compromise.

Tested effective analgesia should be provided prior to carrying out an episiotomy, except in an

emergency due to acute fetal compromise.

Women with a history of severe perineal trauma should be informed that their risk of repeat

severe perineal trauma is not increased in a subsequent birth, compared with women having

their first baby.

Episiotomy should not be offered routinely at vaginal birth following previous third- or fourth-

degree trauma.

Third Stage of Labour


17/23

Definitions:

Third stage of labour: the time from the birth of the baby to the expulsion of the placenta and

membranes.

Prolonged third stage: over 30 minutesObservations

Blood pressure and pulse

Womans general physical condition, as shown by her colour, respiration and her own report of

how she feels

Vaginal blood loss

Recommendation

Active management of the third stage is recommended, which includes the use of oxytocin (10international units [IU] by intramuscular injection), followed by early clamping and cutting of the

cord and controlled cord traction.

Women should be informed that active management of the third stage reduces the risk of

maternal haemorrhage and shortens the third stage.

Pulling the cord or palpating the uterus should only be carried out after administration of oxytocin

as part of active management.

Start completing Postnatal Notes (Appendix 10)

Immediate Cord Care After Birth

When the child the cord pulses and is fat and blue, do not cut at this time.

Gently wipe the lochia off the baby and place on the mothers chest wrapped in a warm blanket.

After a while, the cord will become thin and white, and stops pulsing.

Wash hands thoroughly and use sterile gloves for the procedure.

Tie the cord with clean or sterile string in two places: one 2 cm from the baby and 8 cm from the

baby.

Cut the cord closer to the baby about 2 cm from the first string using a sterile razor blade or

scissors.

Indications for Transfer to More Advanced Healthcare Facility via Ambulance

Need for continuous electronic fetal monitoring or EFM, indicated by:

Significant meconium-stained liquor, and this change should also be considered for light

meconium-stained liquor

Abnormal FHR detected by intermittent auscultation: less than 110 beats per minute, greater

than 160 bpm, any decelerations after a contraction; or uncertainty of presence of fetal heartbeat


18/23

Maternal pyrexia: 38.0C once or 37.5C on two occasions 2 hours apart

Fresh bleeding starting in labour

Oxytocin use for augmentation of labour

The womans request to be transferred

Delay in the first or second stages of labour, diagnosed by: Cervical dilatation of less than 2 cm in 4 hours for first labour

Cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second

or subsequent labours

Changes in the strength, duration and frequency of uterine contractions.

Request for epidural pain relief

Obstetric emergency antepartum haemorrhage, cord presentation/prolapse, postpartum

haemorrhage, maternal collapse or a need for advanced neonatal resuscitation

Retained placenta that cannot be extracted by manual intervention

Malpresentation or breech presentation diagnosed for the first time at the onset of labour, taking

into account imminence of birth

Either raised diastolic blood pressure: over 90 mmHg; or raised systolic blood pressure: over 140

mmHg; on two consecutive readings taken 30 minutes apart

Third- or fourth-degree tear or other complicated perineal trauma requiring suturing

If premature rupture of membranes occurred over 24 hours before onset of labour

Care of Mother and Baby Immediately After Birth

Care of baby

APGAR scores at 1 and 5 minutes should be recorded for all births (See Appendix 11)

If no respirations, stimulate baby, if stimulation ineffective, begin neonatal resuscitation, see

Newborn Resuscitation Guidelines (Appendix 12).

Obtain babys vital signs, see Newborn Vital Signs Guideline (Appendix 11).

Skin-skin contact as soon as possible after birth

Baby dried and covered in warm dry blanket

Initial breastfeeding should be as soon as possible (within 1 hour of birth)

Measurement of head circumference, body temperature and birth weight should be measured

soon after the 1st hour

An examination of the baby should be carried out to ensure no physical abnormality

Apply Erythromycin ointment 0.5-1% or Tetracycline ointment 1% to both eyes within 1 hour ofbirth

Administer Vitamin K 0.5 mg IM, within 1 hour of birth

Complete Postnatal Notes (Appendix 10)

Administer BCG immunisation prior to discharge, see Immunisation Guidelines (Appendix 21)

Needs haemoglobin check before discharge

Care of woman


19/23

Measure temperature, pulse, blood pressure, uterine contractions, lochia

Examine placenta and membranes: assessment of their condition, structure, cord vessels and

completeness

Early assessment of maternal emotional/psychological condition

Record successful voiding of the womans bladder within 6 hours post delivery Perineum Assessment and Repair (Appendix 13)

Complete Postnatal Notes (Appendix 10)

Mothers who arrive in the immediate postnatal phase

Ensure patient has been known to Chisang Clinic during the antenatal period, has attended all

the required antenatal appointments and has had all the necessary investigations

If not, then immediately send mother and baby to nearest hospital via emergency transportation

If patient known to Chisang Clinic, then begin assessment of mother and baby

Please refer to section a) Care of baby and section b) Care of woman above and follow

recommended management plan

If vital signs and observations within normal limits, mother and baby may stay at clinic for further

management

If any of the following occur, mother and baby should be transferred to nearest hospital

Maternal systolic blood pressure greater than 140, less than 90, or diastolic blood pressure

greater than 90

Postpartum haemorrhage, with blood loss greater than 500 ml. See Management of Postpartum

Haemorrhage (Appendix 19).

Maternal collapse

Maternal Pyrexia, defined by a temperature of 38C or greater

Retained placenta

Third or fourth degree perineal tear

Abnormality of baby

Neonatal resuscitation required at any point

Please ensure patient and baby stabilized before transferring to hospital e.g. IV cannula

inserted, fluid resuscitation

Postnatal Care

Postnatal Care of the Mother

Please complete Initial Mother Assessment form in Postnatal Notes (Appendix 10)

Give oral and demonstrational teaching on breastfeeding within 24 hours of birth, prior to

discharge from birthing centre

See General Postpartum Advice (Appendix 18)

Breastfeeding:


20/23

See Breastfeeding Guidelines (Appendix 14) and Breastfeeding Poster

Danger Signs after Giving Birth

See Danger Signs after Giving Birth (Appendix 15)

See Danger Signs in the Newborn (Appendix 20)Perineal Care

Assess mother for perineal pain, discomfort or stinging, offensive perineal odour or dyspareunia.

If the mother is experiencing discomfort, she should be taught that topical cold therapy provides

effective perineal pain relief.

Encourage perineal hygiene, such as frequent sanitary pad changes, frequent hand washing,

and daily bathing to keep the perineum clean.

General Advice

See Keeping Healthy After Giving Birth (Appendix 16)

Postnatal Care of the Baby

Complete Initial Baby Assessment form in Postnatal Notes (Appendix 10)

Complete full body assessment of baby, if any gross abnormalities, especially jaundice, within

first 24 hours, baby may need to be referred to hospital of choice

Prior to Discharge

Provide mother with chance to ask any questions she may have before leaving the clinic. Provide mother with documentation and help if necessary to fill out the appropriate government

forms to be reimbursed for the delivery of her baby.

Postnatal Follow Up

Appointment at First Week

Follow Up for the Mother

Ask about any issues experienced since birth, including the following problems:

See Danger Signs After Giving Birth (Appendix 15)

Signs of mastitis: flu-like symptoms, red, tender and painful breasts, if present, encourage

gentle massage of breast, continued feeding, paracetamol for discomfort and increased fluid intake


21/23

Constipation and haemorrhoids: if no bowel movement three days after birth, give patient a

gentle laxative, encourage increased dietary fibre and fluid consumption in both cases, and

encourage cold packs and paracetamol for pain management

Urinary incontinence: if this is an issue, give teaching on Keagel exercises

Fatigue: if experiencing excessive fatigue, review birthing events and antepartum history, if any

signs indicate haemorrhage, check mothers haemoglobin. If no indication forblood test, provide

teaching on Keeping Healthy After Giving Birth, Appendix 16

Emotional wellbeing: encourage the mother to communicate any changes in mood, emotional

state or behaviour that seem abnormal to her

Discuss plans for contraception following birth and encourage the mother to abstain from sexualintercourse for six weeks postpartum

Follow Up for the Baby

Babies should be assessed for: temperature, heart rate, respiratory rate, colour, regular urination

and stooling, general appetite and breast milk intake, body tone, and irritability.

Assess for jaundice, pale stools and dark urine. If present assess severity, if acute jaundice

present, refer to hospital.

Appointment at Sixth Week


Ask about any new health concerns and review the danger signs and questions asked in the first

week postpartum to ensure no new concerns present

Discuss the resumption of sexual intercourse and ask about any dyspareunia. If present,

encourage water-based gel as lubricant during intercourse


Perform a complete physical assessment of the baby, as outlined in the Complete PhysicalAssessment of the Baby (Appendix 17) and assess social smiling and visual fixing at this time as

well.

Ask about any concerns the mother has had about her child since the last appointment

Administer OPV and DPT immunisations, see Immunisation Guidelines (Appendix 21)

Appointment at Tenth Week


22/23


Ask about any concerns the mother has had since the previous appointment

Continue to manage concerns that have arisen previously


Ask about any concerns the mother has had about the child since the last appointment

Continue to manage concerns that have arisen previously

Measure and plot height and weight on growth chart

Administer OPV and DPT immunisations, see Immunisation Guidelines (Appendix 21)

Appointment at Fourteenth Week

Administer OPV and DPT immunisations to baby, see Immunization Guidelines (Appendix 21)

Appointment at Sixth Month

Measure and plot babys height and weight in growth chart

Appointment at Ninth Month

Administer Measles immunisation to baby, see Immunisation Guidelines (Appendix 21)

Appointment at Twelfth Month

Measure and plot babys height and weight in growth chart

Administer Japanese Encephalitis immunisation to baby, see Immunisation Guidelines(Appendix 21)

Recommendations

Input from O&G consultant from Nepal and overseas, a nurse midwife from Nepal and overseas

before implementation

Financial analyst to ascertain costs of project, including looking over the reimbursement forms

for the clinic and mother

Needs assessment for emergency vehicle for Birthing Centre

Detailed discussion with Skilled Birthing Attendant to answer the following questions:

Do they perform routine amniotomies?

Are they trained in episiotomy and perineal repair?

Do they manage 3rd and 4th degree perineal tears?

What analgesia do they routinely use?


23/23

Can they perform operative deliveries e.g. use vontouse and forceps

Do they use active management of third stage of labour

Do they manually remove placenta?

Do they manage nulliparous women at a community birthing centre?

Visit a similar birthing centre in Nepal

Translate all documentation in Feasibility Study and Appendices into Nepali and adjust where

culturally relevant

Obtain Nepal guidelines for routine births and standards of care

Obtain schedule of immunizations from Nepali government

Obtain government educational materials e.g. posters and leaflets Obtain partogram

Obtain guidelines for Oral Glucose Tolerance Test

to medical clinic

Documents