Introduction: Ever since Chisang 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 small financial 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

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 Cardiovascular Respiratory

Medical Condition Confirmed cardiac disease Hypertensive disorder Asthma requiring an increase in treatment or hospital treatment Cystic fibrosis

Haematological

Haemoglobinopathies sickle-cell disease, betathalassaemia major History of thromboembolic disorders Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000 Von Willebrands disease Bleeding disorder in the woman or unborn babyAtypical antibodies which carry a risk of haemolytic disease of the newborn 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

Infective Immune Endocrine Renal

Systemic lupus erythematosus Scleroderma

Uncontrolled Hyperthyroidism Uncontrolled Diabetes Abnormal renal function Renal disease requiring supervision by a renal

specialist Neurological Gastrointestinal Psychiatric Gynaecological Epilepsy,Myasthenia gravis,Previous cerebrovascular accident Liver disease associated with current abnormal liver function tests Psychiatric disorder requiring current inpatient care

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 fourthdegree perineal trauma 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

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

Current pregnancy and fetal indicaions

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 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

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 Antenatal paperwork Gloves Alcohol gel Weighing scale Blood pressure monitor Blood glucose monitor Thermometer Ultrasound Doppler ultrasound Fetoscope Measuring tape

Cost

Stethoscope KY lubricant Speculum Torch Tourniquet Needles Syringe Urine dipstick Sterile universal containers Gynaecology examination bed Examination lighting
Equipment needed for delivery

Item 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

Cost

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 Post natal paperwork Umbilical clamp Basic instrument pack Forceps

Cost

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 24 hour availability to allow prompt transfer to hospital, in case complications or complex care For transfer, partner with nearby hospitals: Koshi Zonal and BPKIHS

Emergency Vehicle Collaboration 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

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.

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

<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 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 Chisang Clinic Birthing Centre (Appendix 7) Start Packet for Inpatient Delivery (Appendix 8)

Intrapartum Care

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 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

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 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 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.

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 fourthdegree 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 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 (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 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 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 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:

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 mothers 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 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?

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