Introduction:
Ever
since Good Health Clinic Nigeria 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, Good Health Clinic Nigeria
has been requested by the local Women’s Group to operate a Birthing Center to
serve women from a 20 kil0meter radius.
With small financial support from our past international volunteers and
other individuals, Good Health Clinic is currently constructing the Birthing
Center within the premises of Good Health Clinic Nigeria. 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 Good
Health Clinic Birthing Center.
Good
Health Clinic
Guidelines
for Birthing Centre Implementation
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 in Nigeria in the Morang district, the nearest hospitals are Family
Planning and Free Maternal Health Care Institute of Health Science.
Family Planning Hospital is in Lagos, and Free
Maternal Health Care is in Abuja. 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 Nigeria is approximately
N15,000 - N100,000, which many people cannot afford.
Aim
Our
aim is to establish a safe and sustainable birthing centre for the population
of Nigeria village and the surrounding area, in order to increase women’s
accessibility to healthcare.
Organisational
Considerations
Catchment
Area: Nigeria village and surrounding community of approximately 20 km diameter
Criteria for
Admission to Birthing Centre
· Low risk
pregnancies only
· 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
Respiratory
Asthma requiring an increase in
treatment or hospital treatment Cystic fibrosis
Haematological
Haemoglobinopathies
– sickle-cell disease, beta-thalassaemia major History of thromboembolic
disorders
Immune
thrombocytopenia purpura or other platelet disorder or platelet count below
100,000
Von
Willebrand’s disease? Bleeding disorder in the woman or unborn baby?Atypical
antibodies which carry a risk of haemolytic disease of the newborn
Infective
Risk
factors associated with group B streptococcus whereby antibiotics in labour
would be recommended
· Hepatitis B/C
with abnormal liver function tests
· Carrier
of/infected with HIV
· Toxoplasmosis –
women 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 specialist
Neurological
Epilepsy,?Myasthenia gravis,?Previous
cerebrovascular accident
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
Previous
complications
· Unexplained
stillbirth/neonatal death or previous death 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 requiring additional 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 and fetal indicaions
· Multiple birth
· Placenta praevia
· Pre-eclampsia or
pregnancy-induced hypertension
· Preterm labour
or preterm prelabour rupture of membranes
· Placental
abruption
· Anaemia –
haemoglobin 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
· Malpresentation
– breech or transverse lie
· Body mass index
at booking of greater than 35 kg/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 (single episode 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
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 Workspace
Building:
· 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 it’s 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
· 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
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 including partogram
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
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
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
towels
Apron
Gum
boots
Catheter
Bed
pan
Bell
Masks
Emergency
transport
Medications
Entonox
Paracteamol
Pethidine/opiods
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: Family Planning and BPKIHS
Business
model and 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
Good
Health Clinic Birthing Centre, Confidentiality Statement
At
Good Health 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 Good Health 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 patient’s care unless required for quality improvement will
not review records. All records will be
kept for the duration of the patient’s 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 Good Health
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.
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 Family
Planning 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 <11g/100mL
– Multivitamins
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 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 <10, the woman should be
referred to hospital for her birth, as low Hb signifies a greater probability
of bleeding during birth and the possible need for blood products which the
clinic cannot provide.
– Blood Glucose
– Urinalysis dipstick – protein check to
rule out pre-eclampsia.
Discuss upcoming delivery with the woman
and go over any concerns or questions she may have.
Encourage financial planning and discuss
costs.
Encourage prompt mobilization towards the
birthing centre as soon as they feel the beginning stages of labour.
Discuss the possibility that they may not
be able to give birth at the clinic, should there any complications with their
labour.
Other
Visits
Reasons for extra visits include, but are
not limited to: high blood pressure, pain in abdomen, and extra blood sugar
checks
Other visits should be at the discretion of
the patient and the SBA providing antenatal care
Intrapartum
Care
No contraindications for admission to
birthing centre as outlined in Tables 1-3
Admission only if in established labour
Discuss birth plan e.g. relatives present,
home food, own advocate during birth
Sign consent form for admission to Good
Health Clinic Birthing Centre (Appendix 7)
Start Packet for Inpatient Delivery
(Appendix 8)
First
Stage of Labour
Definitions:
Latent first stage of labour: A period of
time, not necessarily continuous, when: there are painful contractions and some
cervical change, including cervical effacement and dilatation up to 4 cm.
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 patient’s 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
Vaginal examination offered every four
hours, or where there is concern about progress or in response to the woman’s
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 active maternal 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 woman’s 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 woman’s
emotional and psychological needs.
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 woman’s position, hydration, coping strategies and pain relief throughout
the second stage.
Women’s
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 baby’s head) or the ‘hands poised’ (with hands off the
perineum and baby’s 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
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 minutes
Observations
Blood pressure and pulse
Woman’s 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 (10 international 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
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 woman’s 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 baby’s 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 of birth
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
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 woman’s
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 Good
Health 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 Good Health 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:
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
– 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 mother’s haemoglobin. If no indication for blood 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 sexual intercourse 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
Follow
Up for the Mother
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
Follow
Up for the Baby
Perform a complete physical assessment of
the baby, as outlined in the Complete Physical Assessment 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
Follow
Up for the Mother
Ask about any concerns the mother has had
since the previous appointment
Continue to manage concerns that have
arisen previously
Follow
Up for the Baby
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 baby’s 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 baby’s 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?
– 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