Ever sinceChisang Clinic Bhaunne was inaugurated in Mid-April
2012, the Clinic has been working hard to run a Well Child Clinic
and a Well Woman Clinic between 10 AM and 2PM on different days of
the week. Over the past few months, Chisang Clinic Bhaunne has been
requested by the local Womens Group to operate a Birthing Center to
serve women from a 20 kil0meter radius. With 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 ClinicGuidelines for Birthing Centre
ImplementationDecember 2012Dania Bakhbakhi BMedSci MBChB DRCOGChloe
Rahmun RN BSNMeghan Young RN BSNSonal Bhattarai RN BSNBackground
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.AimOur 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 ConsiderationsCatchment Area: Bhaunne
village and surrounding community of approximately 20 km
diameterCriteria 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 prescribedTable 1:Medical Conditions not permitted at
Birthing CentreDisease AreaMedical Condition
CardiovascularConfirmed cardiac disease Hypertensive
disorder
RespiratoryAsthma 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 Willebrands disease Bleeding disorder in
the woman or unborn babyAtypical 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
ImmuneSystemic lupus erythematosus Scleroderma
Endocrine Uncontrolled Hyperthyroidism Uncontrolled Diabetes
Renal Abnormal renal function Renal disease requiring
supervision by a renal specialist
NeurologicalEpilepsy,Myasthenia gravis,Previous cerebrovascular
accident
GastrointestinalLiver disease associated with current abnormal
liver function tests
PsychiatricPsychiatric disorder requiring current inpatient
care
Gynaecological Myomectomy/ Hysterotomy/fibroids Major
gynaecological surgery
Table 2: Previous complications not permitted at birthing
centrePrevious 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 centreCurrent 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 QualificationsSBA 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 requirementsWorkforce 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 assistantsShift rotations: More staff there may be required
at different times of the year Use booking diary to predict busy
times and to staff accordinglySpecific 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
outVolunteers: 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 programmesSupport groups: Find out more information about
women support groupEquipment and WorkspaceBuilding: Minimum of 300
x 15 square feet Western toilet and adequate bathing facilities for
mother and baby 24 hour supply of clean and hot water and
electricity supply (including emergency lighting) 24 hour
refrigerator for storing medicines Equipment in satisfactory
condition One patient bed per room must be adjustable and allow for
gynaecological examination and delivery i.e. needs to have stirrups
Opaque curtains and dividers to provide patient privacy for each
room Each room must have its own adjustable bright lighting Oxygen
tank and supply to the delivery room, must be secured to solid
object Adequate prevention from occupational hazards No animals in
the clinic All windows and doors should be covered with a minimum
of a net covering Sufficient ventilation Absolutely no smoking on
the premises with an obvious sign at front deskCleaning 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
centreSharps 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 EquipmentItemCost
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 deliveryItemCost
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-partumItemCost
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
AlbendazoleEmergency Vehicle 24 hour availability to allow prompt
transfer to hospital, in case complications or complex
careCollaboration For transfer, partner with nearby hospitals:
Koshi Zonal and BPKIHSBusiness modeland goalsCost/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
staffClinical ConsiderationsChisang Clinic Birthing Centre,
Confidentiality StatementAt 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 CarePatients 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
GuidelinesFirst 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 10. If haemoglobin