Child Health Division, NRHM, Haryana

in technical collaboration with

RAPID

Assessment

18 – 22 November, 2013

District Mewat

Facility Readiness Assessment for

Essential Newborn Care and Resuscitation

1

Table of Contents

Sr. No. Content

1. Objectives

2. Materials and Methods

3. List of facilities visited

4. General findings of District

5. Quantitative findings of facilities

6. Qualitative findings of facilities

6 a. Al Afia Hospital Mandi DH

6 b. PHC Tauru

6 c. PHC M P Ahir

6 d. CHC Nuh

6 e. PHC Ghaseda

6 f. PHC Ujhina

6 g. ChC Punhana

6 h. PHC Pinagwan

6 i. PHC Biwan

6 j. PHC Nagina

6 k. CHC Firozpur Zirka

6 l. S/c Rathibas (Khori DH)

6 m. S/c Kankar Kheri

6 n. S/C Rawali

6 o. S/c Raniyala

7 Status of FBNC

Objectives:

1. Qualitative and quantitative assessment of readiness of our health facilities for essential

newborn care and resuscitation.

2. To assess the quality of essential newborn care provided to each and every neonate

immediately after birth.

2

3. To understand the existing knowledge, skills, attitudes and practices of the health service

providers.

4. On job trainings to the service providers on novelties in essential newborn care and

resuscitation.

Materials and Methods

1. A structured and tested assessment tool has been used to assess the facilities on 8

parameters viz. facility identification and infrastructure, availability of services,

human resource, Equipment and supplies, Register and client case records, protocols

and guidelines, individual case records, knowledge and practices.

2. Knowledge and skill assessment has been done on the newborn simulators

(mannequins).

3. The current and ideal practices in essential newborn care and resuscitation have been

demonstrated to the service providers on the mannequins.

Our teams visited 15 facilities in the district, from 18th Novenber, 2013 to 22nd November,

2013 including General Hospital, all CHCs and PHCs and the delivery huts with monthly

delivery load of 3 or more. Following is the list of facilities visited:

Sr. No. Name of Facility

1. Al Afia Hospital Mandi DH

2. PHC Tauru

3. PHC M P Ahir

4. CHC Nuh

5. PHC Ghaseda

6. PHC Ujhina

7. ChC Punhana

8. PHC Pinagwan

9. PHC Biwan

10. PHC Nagina

11. CHC Firozpur Zirka

12. S/c Rathibas (Khori DH)

13. S/c Kankar Kheri

14. S/C Rawali

15. S/c Raniyala

Quantitaive Findings of District Mewat:

NAME OF THE FACILITIES INFRASTRUCTURE

DELIVERY AND

NEWBORN CARE

SERVICES

ESSENTIAL DRUGS,

EQUIPMENT AND

SUPPLIES

PROTOCOLS AND

GUIDELINES

KNOWLEDGE

ABOUT

INFECTION

PREVENTION

PROVIDER

K0WLEDGE AND

SKILLS

REGISTERS AND

CLIENT CASE

RECORDS

FACILITY’S

OVERALL

AVERAGE

DISTT AVG 65 81 64 52 27 50 40 54

PHC TAURU 67 78 72 30 29 54 41 53

PHC UJJINA 67 83 66 60 0 35 32 49

SC GHAGAS 53 72 43 70 0 40 27 43

SC RANAYALA 63 72 54 60 14 40 0 43

PHC BIWAN 55 72 57 50 0 40 8 40

PHC GHASERA 37 75 54 10 14 39 50 40

SC RATHIWAS 47 67 46 10 0 29 0 28

NAME OF THE

FACILITIES INFRASTRUCTURE

DELIVERY AND

NEWBORN CARE

SERVICES

ESSENTIAL

DRUGS,

EQUIPMENT AND

SUPPLIES

PROTOCOLS AND

GUIDELINES

KNOWLEDGE

ABOUT INFECTION

PREVENTION

PROVIDER

K0WLEDGE AND

SKILLS

REGISTERS AND

CLIENT CASE

RECORDS

FACILITY’S

OVERALL

AVERAGE

GH MANDIKHERA 100 94 70 80 100 75 65 83

CHC PUNHANA 76 83 75 60 57 64 63 68

CHC NUH 78 89 78 60 57 59 44 66

PHC NAGINA 67 89 75 60 43 54 46 62

CHC FP ZIRKA 78 83 77 60 29 56 46 61

PHC PINAGWAN 76 89 74 60 0 49 66 59

SC RAWALI 51 83 48 70 29 61 59 57

PHC MP AHIR 65 80 70 40 29 54 47 55

DISTT AVG 65 81 64 52 27 50 40 54

1

1

2

3

4

5

6

7

8

61

60

60

57

56

53

52

49

48

43

42

39

38

36

36

31

61

58

59

0 20 40 60 80

PKL

KNL

MWT

HSR

FTB

KTL

GUR

JND

KKR

PWL

SNP

SRS

BWN

NNL

PNP

YNR

ROUND 2 ROUND 1

9

10

11

12

13

14

15

16

17

18

19

20

21

0

20

40

60

80

100

KEEPBABYWAR

M

INITIATEBF

MONITORI

NGTHE

BABY

ROUND 1

49

48

43

42

36

36

36

35

31

26

24

23

22

22

22

17

52

33

55

0 20 40 60

KNL

HSR

JND

PKL

KTL

PWL

MWT

KKR

NNL

BWN

PNP

SNP

FTB

YNR

SRS

GUR

ROUND 2 ROUND 1

22

45

38

37

36

36

34

33

30

26

26

20

18

13

11

10

9

50

37

34

0 20 40 60

PKL

HSR

MWT

JND

KNL

KKR

FTB

NNL

SNP

GUR

BWN

KTL

PWL

YNR

SRS

PNP

ROUND 2 ROUND 1

23

Qualitative Findings of Individual Facilities of Mewat:

PHC Nagina

1. Well-equipped labour room with established NBCC.

2. Injection Vitamin K for newborns is not available.

3. Infection prevention protocols are not followed as per guidelines.

4. Case sheets for delivery cases are not maintained. Records are kept in registers only.

5. Notes on essential newborn care are not maintained.

6. Knowledge of staff nurses about essential newborn care and resuscitation is good.

7. Skills of staff nurses about essential newborn care and resuscitation are below

average.

Recommendations

1. Provide injection vitamin K for newborns and administer to all the neonates. (1 mg

for full term and 0.5 mg for babies weighing <1500 gm, IM in antereo-lateral aspect

of mid-thigh.)

2. Follow infection prevention protocols as per guidelines.

3. Maintain case files for mother and babies in each delivery including partograph.

4. Write detailed notes on essential newborn care as discussed during the visit.

5. Promote peer learning to improve knowledge and continuous practice to sharpen

skills.

CHC Nuh

1. Well maintained labour room with established NBCC.

2. Injection Vitamin K for newborn is not available in facility.

3. There is improper segregation of bio-medical waste.

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4. Infection prevention protocols are not followed as per guidelines.

5. Shoulder roll for newborn resuscitation is not avaialable.

6. Wall clocks with seconds hand are not available at before all the delivery tables and

NBCC.

7. Record keeping in individual case sheets is not satisfactory. Partographs not

maintained properly.

8. Knowledge of staff nurses about essential newborn care and resuscitation is good.

9. Skills of staff nurses about essential newborn care and resuscitation are below average

and need improvement.

10. Newborn Stabilization Unit is yet not established, due to dearth of skilled staff,

despite availability of equipment (Radiant Warmer, Phototherapy Unit and Newborn

Incubator).

Recommendations

1. Make injection Vitamin K available and start administering to every newborn(1 mg to

full term and 0.5 mg to babies weighing <1500 g, IM in antero-lateral aspect of mid-

thigh are the recommended doses.).

2. Segregate biomedical waste as per CPCB guidelines in various colour coded bags

only.

3. Follow infection prevention protocols in accordance with guidelines.

4. Prepare shoulder roll with sterile baby sheer as suggested during the visit.

5. As there are partitions between all the available delivery tables, provide a separate

wall clock with seconds hand before each delivery table. Kindly provide one wall

clock with seconds hand at NBCC also.

6. Improve individual case records and partograph as discussed in detail during visit.

7. Knowledge and skills can only be improved by peer learning and continuous practice.

25

8. If FBNC skilled staff is available in future, try to establish and functionalize the

Newborn stabilization unit (NBSU).

PHC Tauru

1. Skills of staff nurses regarding essential new born care is good

2. Immunisation at birth and vitamin K administration is in practice

3. Major concern is Infection prevention protocols are not being followed. Autoclave is

non functional. Blood stains bag and mask, weight machine and radiant warmer.

4. Case sheets need improvement especially baby notes, term and preterm mentioning,

complication and associated high risk factors during ANC and intrapartum care.

Partographs are filled but need improvements

5. Baby weighing machine not properly functional

6. Baby sheets, sleepers and surgical cap not available in the labour room.

7. Staff nurses not trained in NSSK and IMNCI

8. Shoe cover need to be made available in the labour room.

9. Surgical blade for cord cutting is available but not used for cord cutting

10. Every baby is shifted to new born care corner despite good cry

11. Skills for resuscitation need improvement

12. Skin to skin contact should be initiated immediately in a Normal baby and

breastfeeding initiation should be done within half an hour of delivery.

CHC Punhana

1. Well maintained labour room with availability of records and registers.

2. Well established NBCC

3. Vitamin K not available in the facility

4. Elbow operated tap should be made available in the labour room.

5. Staff nurses not trained in IMNCI.

6. Case sheets are maintained properly but lack notes for new born care.

7. Well maintained partographs with referral of the cases with obstructed labour

8. Digital thermometer in the labour room not available

26

9. Suctioning of every new born is done despite of good cry, this practice needs to be

discontinued.

10. Practice of shifting every new born to the radiant warmer despite good cry, Skin to

skin contact need to be practiced for normally breathing baby.

SC Ghagas

1. NBCC is not established.

2. AMBU bag and mask size 0 & 1 are not available.

3. Wall clock is not available in labour room.

4. Vitamin K is not available.

5. Knowledge of ANM is good for,

a. ANC

b. Identification of high risk pregnancies

c. Identification if infection in new-born

d. Special care for Low Birth Weight new-borns

6. Knowledge of ANM is not adequate for,

a. Essential new-born care

b. Neonatal resuscitation

7. Immediate cord cutting in practice.

8. Oxytocin given after delivery of placenta.

PHC Ujjina

1. Generator is available but fuel not available.

2. Staff nurse do not know temperature settings of radiant warmer.

27

3. ZERO size mask is not available.

4. Humidifier and flow meter for O₂ cylinder is not available.

5. Lab services compromised due to vacant post of LT. Identification of RH

incompatibility related high risk pregnancies hampered.

6. Case records of delivery and new-born services provided need improvements. Sample

record discussed with MOIC.

7. Suction of every new-born is in practice.

8. Infection prevention and hygiene practices not followed.

9. Shoulder roll is not available at NBCC.

10. Knowledge of staff nurses is average for,

a. Identification of labour.

b. Identification of high risk pragnancies.

c. Monitoring of labour progress.

d. Immediate care for normal new-born.

e. Identification of infection in new-born.

f. Special care for low birth weight new-borns.

g. Neonatal resuscitation.

11. Knowledge of staff nurses is not adequate for,

a. AMTSL.

12. Trainings of staff nurses is not completed.

a. NSSK trained staff nurse = 0

b. IMNCI trained staff nurse = 0

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13. Vitamin K is not available.

14. DHIS -2 reporting for labour room data requires attention.

PHC Biwan

1. Facility not a 24*7 delivery point.

2. New-born care corner is not established.

3. Room thermometer is not available.

4. Distilled water level in O₂ humidifier not maintained.

5. Mask size “1” not available.

6. Haemoglobinometer never used to measure Hb. Apparatus is brand new and packed.

7. Autoclave is not available.

8. Spot lamp is not available.

9. Inj. Vit. K available but not given to new-borns.

10. Expired mucus extractor found in labour room.

11. PHC is not a cold chin point. Birth doses are not given to new-borns delivered in the

facility.

12. Oxytocin and Methergine both used together.

13. Suction of every new-born is in practice.

14. Oxytocin is used for induction of labour.

15. Infection prevention and hygiene practices are not followed in labour room.

16. Partograph is not filled.

17. Staff nurse do not know about normal range of Heart rate and respiratory rate in new-

born.

29

18. Staff nurse do not know about kangaroo mother care.

19. Shoulder roll is not available.

20. Knowledge of staff nurse is not adequate for,

a. ANC.

b. Active management of third stage of labour.

c. Immediate care for new-born.

21. Knowledge of staff nurse is average for

a. Identification of high risk pregnancy.

b. Identification of labour.

c. Monitoring of labour progress.

d. Identification of infection in new-born.

e. Neonatal resuscitation.

PHC Pinagwan

1. One Staff nurse is required for 24*7 functioning of the PHC.

2. Hand washing station is not appropriate for six step method of hand washing.

3. Infection prevention does need Improvements.

4. Documentation of the baby notes needs few improvements.

5. Ensure vitamin K availability and administration to every newborn

6. Postnatal ward need repair.

7. Skills and practices need regular follow ups.

SC Ranayala

1. Only one ANM is available.

30

2. Newborn care corner not established.

3. Oxygen available but supply is not functional.

4. Ensure availability of mucous extractor as only one is available.

5. No case sheets available at the facility, no baby notes available.

6. Hand washing station is not appropriate for six step method of hand washing.

7. Infection prevention needs improvements.

8. Ensure Vitamin K’s availability and administration.

9. Skills and practices need regular follow ups.

CHC Firozpur Zirka

1. Well maintained and spacious labour room with proper illumination and

ventilation.

2. Separate designated space for ANC and PNC wards.

3. Infection prevention practices need to be improved especially disinfection and

sterilization of AMBU Bag and mask.

4. NBCC not in appropriate place needed to be replaced according to given

suggestion.

5. SBA emergency protocols not displayed in LR need to be displayed properly.

6. ENCR skills in SNs found to be below standards. Proper orientation was given

which needed to be followed up for knowledge retention.

7. 2% Gluteraldehyde solution (Sidex Solution) needed to be procured for proper

disinfection and sterilization procedures.

8. Only one delivery set available in CHC, More delivery sets needed to be procured

in accordance with delivery load.

Delivery Hut Khori (PHC Tauru)

1. Good accessibility of delivery hut from catchment village

31

2. No designated place for NBCC, Need to be established as per given suggestions

during the visit.

3. Cord clamp, mucous extractor and case sheets not available in facility.

4. BP apparatus not functional needed to be changed.

5. Infection prevention practices needed to be improves as per orientation given

during the visit.

6. Available ANM not SBA trained, needs training soon.

7. Vitamin K and ORS not available.

8. SBA and ENCR protocols needed to be displayed as per given suggestions.

Al Afia General Hospital,Mandikhera

1. Gluteraldehyde not available.

2. Disposable surgical blades for cord cutting are not available.

3. Case records are well maintained but notes on essential newborn care to be included

in chronological order.

4. Mucous Extractor available but not utilized.

5. Immediate cord cutting in practice.

6. Early initiation of breast feeding not in practice.

7. Knowledge of 2 out 3 staff nurses about essential newborn care.

8. Partographs filled but interpretation for timely referral to be followed.

SC Rawali (CHC FirozpurZirka)

1. Both ANMs not trained in SBA and IMNCI.

2. Only one trained in NSSK. (One recruited 3 months back)

3. Record keeping is not good. Records are maintained in simple registers. Baby notes

with services provided to the newborn are not written anywhere in the records.

Immediate intervention done - case records and partographs made available from

CHC.

4. Newborn Care Corner not setup. 150 watt infrared available that is to fixed.

5. Bag and Mask not available.

6. Oxygen Cylinder not available.

32

7. Mucous Extractor, Baby Sheets, Vitamin K, Surgical Blade, Suction Catheter &

Shoulder roll not available.

8. New delivery table to be made available.

9. One more bed for post natal ward to be made available.

10. Rusted instruments in Delivery set and IUCD set.

11. Skills for essential newborn care and resuscitation not adequate.

12. Protocols available but not followed.

13. Housekeeping/disinfection protocols to be followed.

PHC MP Ahir

1. Radiant warmer not functional since the day was installed. Staff nurses do not

know how to work with radiant warmer also.

2. Autoclave not functional since the last round of Rapid (April).

3. Vitamin K injection is not being given.

4. Nishchaya kits not available for pregnancy test.

5. Room thermometer is not available in labor room.

6. Spot lamp not available.

7. Baby sheets are available in very less quantity (3) with a delivery load around 40

to 60 per month.

8. Birth dose BCG not being given.

9. IV oxytocin is being given for delivery for all. It should not be given without

direct supervision of MO unless indicated clearly.

10. Steps of AMTSL is not being followed properly. Need to supervise the same.

Delivery Hut Ghasera

1. Average of 50 delivery per month, with one set of rusted delivery instruments.

2. Machintosh was not found on delivery table, with cracked delivery table.

3. NBCC not established, with partially established at wrong place.

4. Mask “0” not available.

5. Ambu bag was broken down.

6. No autoclave available at the delivery hut.

7. Invertor available, but was not functional as not connected with supply line of facility.

33

8. Infection prevention very poor.

9. Basic IEC material were not displayed inside the delivery hut.

10. Since last two days light was not coming, so delivery instruments were being used

without boiling at all, (no disinfectant / gluteraldehyde / bleaching powder was being

used).

11. Vit-k is not available.

12. No birth dose of Hep-B, OPV, Vit-k, or BCG is being given.

13. No 24 hour services for delivery care.

14. Partograph was not available to be filled. Staff nurses do not know how to fill

partograph. Need refresher SBA training.

15. Out of two, only one was trained in NSSK, who also require refresher training as

skills of both staff nurses were poor and were not in chronology.

16. Oxytocin is being used to induce labor for all delivery patients.

17. Privacy of delivery room is not maintained.

18. Room thermometer for labor room was not available.

19. Separate slipper were available, but were not in use as they were of big size for staff

nurses.

20. Only 1 baby sheet was available with a delivery load of average 50 delivery per

month. At least 15 to 20 baby sheets should be available and should be autoclaved

before use to clear to wrap baby.

21. Cradle was present inside the delivery cum postpartum ward.

22. Yellow bag was not being used for placenta disposal.

23. As per staff nurse, they were out of stock of yellow bag because they already used it

in place of Macintosh. Currently health facility was out of stock of Macintosh.

24. Immediate cord cutting and suction for all newborn was in practice. Immediate cord

cutting should not be done in newborn with normal cry and breath. It should be done

with a delay of 1 to 3 minute.

25. Milking of cord was in practice, this practice should be discouraged.

26. Surgical blade should be used to cut the cord.

34

35

Status of Facility Based Newborn Care

NBSU

Designated

NBSU

Establis

hed

Functional(FBNC Trained

staff Nurse)

Radiant

Warmers

Photothe

rapy

Units

CHC Firozpur

Zirka

Yes No (Two

available)

1 1

CHC Nuh No (One

available)

1 1

CHC Punhana No (One

available)

1 1

36

Newborn Care corners (NBCC) (n=15)

NBCC

Establish

ed

NBCC

with

Radiant

Warmers

NBCC

with 200

W bulb

NBCC not

established

NBCC at

appropriat

e place

10 10 1

(Pinagwan

both)

5 (Raniyala,

Ghagas,

Rahtiwas/Kh

ori, Biwan,

Rawali)

9

(Need to

shift NBCC

in Ghasera)

Newborn Corners (NBCC)

(n=15)Self Inflating

Bag

Mask ‘0’ Mask ‘1’ Shoulder

Roll

Available 13 11 11 5

Not available 2 (Ghagas,

Rawali)

4 (Ghasera,

Ujhiana,

Ghagas,

Rawali

4 (MP ahir,

Ghagas,

Biwan,

Rawali

10

37

Newborn Corners (NBCC)

(n=15)Baby

Sheets

Mucus

Extractors

Suction

Machine

Suction

Catheter

Oxygen

Cylinder

Available 10 13 15 13 13

Not

available

5 (Tauru,

Ghasera,

Raniyala,

Rathiwas,

Rawali

2

(Raniyala,

Rawali)

2

(Ghagas,

Rawali)

2

(Raniyala,

Rawali)