Chisang Clinic

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 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, 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.

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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 women’s 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	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: Koshi Zonal 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

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 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 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

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 Chisang 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