rapid assessmentnhmharyana.gov.in/writereaddata/userfiles/file/ch/panchkula_repor… · child...

Child Health Division, NRHM, Haryana

in technical collaboration with

Rapid

Assessment

07 Nov, 2013 to 9 Nov, 2013

&

13Nov,2013 to 14 Nov, 2013

District Panchkula

Facility Readiness Assessment for Essential

Newborn Care and Resuscitation

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Table of Contents 1. Objectives: ............................................................................................................................... 2

2. Materials and Methods ............................................................................................................ 2

3. General findings of district Panchkula are as follows: ...................................................... 3

3. a. Overall Training Status ..................................................................................................................... 4

3. b. Status of Newborn Corners ............................................................................................................... 4

3 c. Availability of equipment and instruments in NBCCs (n=19) ........................................................... 4

3 d. Status of Designated Newborn Stabilization Units (NBSUs) ............................................................ 5

4. Quantitative Analysis of various facilities (n= 19) .............................................................. 5

5. Facility wise Qualitative Findings ...................................................................................... 19

1. GH Panchkula ............................................................................................................................... 19

2. CHC Kalka .................................................................................................................................... 19

3. CHC Raipur Rani ......................................................................................................................... 20

4. PHC Hangola ................................................................................................................................. 21

5. PHC Kot ......................................................................................................................................... 21

6. PHC Morni .................................................................................................................................... 21

7. PHC Barwala ................................................................................................................................. 22

8. PHC Nanakpur .............................................................................................................................. 22

9. PHC Punjore ................................................................................................................................. 22

10. PHC Surajpur ........................................................................................................................... 22

11. Urban Slum Dispensary, Sector- 19 ........................................................................................ 23

12. SC Jaloli ..................................................................................................................................... 23

13. SC Maranwala ........................................................................................................................... 24

14. SC Karanpur ............................................................................................................................. 24

15. SC Bargodam ............................................................................................................................ 24

16. SC Ramgarh .............................................................................................................................. 25

17. SC Nadda Sahib ........................................................................................................................ 25

18. SC Mauli .................................................................................................................................... 25

19. Saketri ........................................................................................................................................ 25

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1. 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.

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.

2. 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 19 facilities in the district, from 7th November, 2013 to 9st November, 2013

and 13th November 2013 to 14th 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:

S.No. Name of Facility

1 GH Panchkula

2 CHC Kalka

3 CHC Raipur Rani

4 URCH sector 19

5 PHC Pinjore

6 PHC Kot

7 PHC Morni

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8 PHC Nanak pur

9 PHC Surajpur

10 PHC Hangola

11 PHC Barwala

12 SC Saketri

13 SC Nada Sahib

14 SC Karapur

15 SC Baadgodam

16 SC Maadwala

17 SC Mouli

18 SC Jalouly

19 SC Ramgarh

3. General findings of district Panchkula are as follows:

1. Effective hand washing not in practice.

2. Birth preparedness before delivery is still not in practice.

3. Skin to skin contact between mother and baby not in practice.

4. Milking of cord (in some facilities) still in practice.

5. Injection Vitamin K is not administered to every newborn.

6. Improper segregation of bio-medical waste. Yellow bags are not used.

7. Shifting of every baby to Newborn Corner is still in practice.

8. Case sheets are not available in the Sub-Centers.

9. Record keeping in delivery rooms has scope for improvement.

10. Partograph are filled but need quality improvement and proper interpretation.

11. Disinfection protocols are not followed as per guidelines. Non availability of regular

disinfectant in many facilities.

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3. a. Overall Training Status

No. of Birth attendants SBA NSSK IMNCI

63 57 50 49

Total Percentage 90 79 77

3. b. Status of Newborn Corners

No. of

Facilities

Visited

Newborn Corners

with Radiant

Warmer

Newborn

Corners with

200 W bulb

Total

NBCCs

Established

NBCCs still not

established

19 9 8 15 4 (SC Bargodam,

Marawala, USD 19 and

Karanpur)

3 c. Availability of equipment and instruments in NBCCs (n=19)

Sr.

No.

Equipment/Instrument Available (No. of

Facilities)

Not available (No. of

Facilities)

1. Self-Inflating Bag 19 0

2. Mask Size ‘1’ 19 0

3. Mask Size ‘0’ 19 0

4. Shoulder Roll 16 3

5. Suction Catheter 13 6

6. Disposable Mucus Extractors 17 2

7. Suction Machine 18 1

8. Oxygen Cylinder 12 7

9. Baby Sheets 18 1

10. Disinfectant 18 1

11. Vitamin K 17 2

12. NBCC at appropriate place 12 7

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Score 75% and Above Score 51% to 74% Score 50% and less

3 d. Status of Designated Newborn Stabilization Units (NBSUs)

Sr. No. Name of Institution Status

CHC Kalka Functional

CHC RaipurRani Established but Not Functional

4. Quantitative Analysis of various facilities (n= 19)

NAME OF THE

FACILITIES

INFRASTRUCT

URE

DELIVER

Y AND

NEWBOR

N CARE

SERVICE

S

ESSENTIA

L DRUGS,

EQUIPMEN

T AND

SUPPLIES

PROTOCOL

S AND

GUIDELINE

S

KNOWLEDG

E ABOUT

INFECTION

PREVENTIO

N

PROVIDER

K0WLEDG

E AND

SKILLS

REGISTER

S AND

CLIENT

CASE

RECORDS

FACILITY’

S

OVERALL

AVERAGE

GH

PANCHKULA 90 89 80 70 57 52 56 71

PHC

BARWALA 69 83 72 80 57 62 58 69

PHC

NANAKPUR 76 83 70 60 86 51 56 69

CHC KALKA 92 100 79 40 57 57 44 67

PHC PINJORE 78 89 68 60 43 54 66 65

PHC KOT 76 78 70 60 57 55 55 64

PHC

SURAJPUR 76 83 68 60 43 55 66 64

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PHC MORNI 69 78 69 80 43 59 52 64

PHC

HANGOLA 67 78 74 70 57 45 46 62

URCH SEC 19 65 83 64 50 57 58 55 62

District

Average 67 80 65 59 44 51 32 57

SC SAKETRI 59 83 58 60 43 57 6 52

CHC RAIPUR

RANI 71 83 67 70 0 40 29 52

SC

RAMGARH 59 78 51 70 29 49 0 48

SC JALOULY 59 78 59 40 43 47 10 48

SC

MARWALA 59 78 59 40 43 47 10 48

SC NADDA

SAHIB 53 67 53 80 29 54 0 48

SC MOULI 57 67 53 60 43 47 0 47

SC

KARANPUR 57 78 61 40 43 44 0 46

SC BAR 47 67 46 30 14 40 0 35

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Figure 1. KNOWLEDGE ABOUT EFFECTIVE ANC

Figure 2. KNOWLEDGE OF DETECTION OF HIGH RISK MOTHERS

0

20

40

60

80

100MINIMUM 4 VISITS

BIRTH PLAN

TT AND IFA

HIGH RISK MOTHERDETECTION

DANGER SIGN

PROMOTE EBF

ROUND 1

020406080

100PREVIOUS CS

5 OR MOREDELIVERIES

LESS THEN 2YEARS BIRTH…

AGE OF PRIMI <18OR >30 YEARS

PREVIOUS STILLBIRTH

PREVIOUSNEONATAL DEATH

PREVIOUSINSTRUMENTAL…

H/O ABORTIONSOR OTHER…

H/ONEONATAL/INFA…

ROUND 1

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Figure 3. KNOWLEDGE ABOUT LABOUR PROGRESS

Figure 4. LABOUR PROGRESS MONITORING KNOWLEDGE

0

20

40

60

80

100

REGULARUTRINE

CONTRACTION

DILATION OFCERVIX

DISCHARGE OFBLOOD AND

MUCUS

BREAKING OFWATERS AND

RUPTIORMEMBRANE

ROUND 1

020406080

100FETAL HEARTBEAT

COLOUR OF…

DEGREE OF MOLDING

DILATION OF CERVIX

DESCENT OF HEADUTERINE…

MATERNAL BP

MATERNAL…

MATERNAL PULSE

ROUND 1

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Figure 5. RECORDING OF OBSERVATIONS

Figure 6. KNOWLEDGE ABOUT 3 STAGE OF LABOUR MANAGEMENT

0

20

40

60

80

100

ONPARTOGR

APH

ONPATIENTCLINICALRECORDS

ON PIECEOF PAPER

ROUND 1

60

80

100

IMMEDIATE

OXYTOCIN

CCTUTRINE

MASSAGE

ROUND 1

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Figure 7. KNOWLEDGE ABOUT IMMEDIATE CARE TO NEWBORN WITHIN 1 Hr

Figure 8. KNOWLEDGE ABOUT SIGN AND SYMPTOMS OF SEPSIS/INFECTION IN

NEWBORN

0

20

40

60

80

100BREATHING OF BABY

DRY THE BABY

OBSERVE FOR COLOR OFBABY

WEIGHT THE BABY

CARE FOR UMBLICALCORD

INITIATE BF WITH IN 30MIN

EXAMIN NEWBORNWITHIN 1 HRS

ADMINISTER VIT K

ROUND 1

0

20

40

60

80

100

LESS MOVEMENT(POOR MUSCLE

TONE)

POOR OR NO BF

HYPO/HYPERTHERMIA

RESTLESSNESS/IRRITABILITY

DIFFICULTY/FASTBREATHING

INFECTION ONEYE/THROAT/SKIN

DEEPJAUNDICE

SEVEREABDOMINALDISTENTION

ROUND 1

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Figure 9. KNOWLEDGE OF MANAGEMENT ABOUT INFECTION IN NEWBORN

Figure 10. KNOWLEDGE ABOUT MANAGEMENT OF LBW (<2.5 KG) BABIES

0

20

40

60

80

100

EXPLAIN SITUATIONTO MOTHER

CONTINUE TO BF

KEEP AIRWAYS OPENBEGIN ANTIBIOTICS

REFER

ROUND 1

0

20

40

60

80

100WARMTH OF BABY

PROVIDE EXTRASUPPORT TO MOTHER

FOR BF

MONITOR ABLITY TOBF/SUCKING CAPACITY

OF BABY

MONITOR BABY FORFIRST 24 Hr

ENSURE INFCETIONPREVENTION

REFER

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Figure 11. KNOWLEDGE ABOUT SIGN AND SYMPTOMS OF BIRTH ASPHYXIA

Figure 12. KNOWLEDGE ABOUT STEPS OF RESUSCITATION

0

20

40

60

80

100

DEPRESSEDBREATHING

FLOPPINESS

NOT CRIED AT BIRTH

DELAYED CRYING ATBIRTH

HEART RATE BELOW100

CENTRAL CYNANOSIS

ROUND 1

020406080

100CALL FOR HELP

EXPLAIN SITUATION TOMOTHER

PLACE NEWBORN FACEUP

WRAP OR COVER BABYEXCEPT FACE AND…

EXTENDED POSITION OFNECK OF NEWBORN

SUCTION MOUTH THENNOSE

START VENTILATIONUSING BAG AND MASK

ROUND 1

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Figure 13. KNOWLEDGE ABOUT RESUSCITATION STEP CONT…

Figure 14. Knowledge about what to do if newborn start breathing after initial resuscitation

0

20

40

60

80

100

PLACE BABY MASKAND FORM SEAL

ENSURE APPROPRIATESEAL

VENTILATE 1 OR 2TIMES FOR CHEST

RISING

VENTILATE 40-60 PERMINUTE

DETERMINESPONTINIOUSBREATHING

ROUND 1

0

20

40

60

80

100KEEP BABY WARM

INITIATE BFMONITORING THE

BABY

ROUND 1

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Figure 15. What to do ? If Newborn is not breathing after initial Resuscitation

Figure 16. Over all Readiness of facilities in Infrastructure

0

20

40

60

80

100

CONTINUETO

VENTILATE

ADMINISTER

OXYGEN

ASCESSNEED FORSPECIAL

CARE

INTUBATEBABY

REFERBABY

ROUND 1

92 90

78 76 76 76 71 69 69 67 67 6559 59 59 59 57 57 53

47

0

20

40

60

80

100

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Figure 17. Availability of Protocols Guideline at Facilities

Figure 18. Knowledge of Infection Prevention

80 80 8070 70 70 70

60 60 60 60 60 60 5950

40 40 40 4030

0

20

40

60

80

100

80 80 8070 70 70 70

60 60 60 60 60 60 5950

40 40 40 4030

0

20

40

60

80

100

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Figure 19. Registers and Client Case records

Figure 20. ESSENTIAL DRUGS, EQUIPMENT AND SUPPLIES

66 6658 56 56 55 55 52

46 44

32 29

10 10 60 0 0 0 0

0

20

40

60

80

100

PH

C P

INJO

RE

PH

C S

UR

AJP

UR

PH

C B

AR

WA

LA

PH

C N

AN

AK

PU

R

GH

PA

NC

HK

ULA

PH

C K

OT

UR

CH

SEC

19

PH

C M

OR

NI

PH

C H

AN

GO

LA

CH

C K

ALK

A

Dis

tric

t A

vera

ge

CH

C R

AIP

UR

RA

NI

SC J

ALO

ULY

SC M

AR

WA

LA

SC S

AK

ETR

I

SC N

AD

DA

SA

HIB

SC R

AM

GA

RH

SC M

OU

LI

SC K

AR

AN

PU

R

SC B

AR

80 7974 72 70 70 69 68 68 67 65 64 61 59 59 58

53 53 5146

0

20

40

60

80

100

GH

PA

NC

HK

ULA

CH

C K

ALK

A

PH

C H

AN

GO

LA

PH

C B

AR

WA

LA

PH

C N

AN

AK

PU

R

PH

C K

OT

PH

C M

OR

NI

PH

C P

INJO

RE

PH

C S

UR

AJP

UR

CH

C R

AIP

UR

RA

NI

Dis

tric

t A

vera

ge

UR

CH

SEC

19

SC K

AR

AN

PU

R

SC J

ALO

ULY

SC M

AR

WA

LA

SC S

AK

ETR

I

SC N

AD

DA

SA

HIB

SC M

OU

LI

SC R

AM

GA

RH

SC B

AR

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Figure 21. Over All Status of facilities for ENBC/R Skills

Figure 22. Over All Status of facilities for ENBC/R

62 59 58 57 57 55 55 54 54 52 51 51 49 47 47 47 45 4440 40

0

20

40

60

80

100

71 69 69 67 65 64 64 64 62 62 57 52 52 48 48 48 48 47 4635

0

20

40

60

80

100

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Figure 23. FACILITIES CLASSIFICATION FOR ENBC/R FACILITY READINESS

Figure 24. Essential Newborn Care District Average

0

68

32

GOOD (75 AND ABOVE) AVERAGE (51 TO 74 ) POOR (BELOW 50)

6159

5756

545252

51494949

4747

4543

4139

0 10 20 30 40 50 60 70

HSR

PKL

KKR

JND

YNR

GUR

FTB

SNP

NNL

ROUND 1

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5. Facility wise Qualitative Findings

1. GH Panchkula

a) Labour room running along with PNC ward/construction going on for new labour

room

b) RW available at labour room : Unhygenic sheets on RW, Bag of Ambu meconium

stained, 0 size mask not available, Shoulder role not as standard protocol,

Thermometer not available at NBCC

2. CHC Kalka

a) Shoulder role not as per guideline

b) Two Bag and mask available at labour room but one payer of 0 and 1 size mask not

available

c) Tube lights and bulb in labour room out of order

d) No lightning in toilet and hand washing area

e) Thermometer dipped in solution need to kept in dry bottle

f) Chittel dipped in solution need to kept in dry bottle

g) Feeding tubes used for suction

h) Bio medical waste disposal contractor visit facility twice a week need to rationalize as

per contract

i) Room thermometer not available in labour room

j) Only yellow and red bag available in labour room for Bio medical waste segregation

need to put black and bag bucket too.

k) Towel available at hand washing area of labour room need to discourage towel uses

should promote air dry

l) NBSU established need to available Syringe Hub cutter, weight machine,

Laryngoscope set neonate, digital thermometer, room heater, room thermometer,

concealed lights, Stethoscope with neonatal chest piece, shoe rack

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3. CHC Raipur Rani

a) Training of staff nurses not completed.

b) Mucus extractors expired in May-13.

c) Distilled water level in O₂ humidifier not maintained.

d) Good practice of keeping vaccines in labour room to ensure administration of birth

doses. OPV and Hep. B vaccines should have date of opening mentioned on it.

e) Disinfection of Radiant warmer, AMBU bag, suction apparatus not done regularly.

f) DHIS 2 reporting of labour room needs improvements. Records in delivery register

and reported data do not match.

g) Knowledge of staff nurses is average for,

i. ANC

ii. Identification of high risk pregnancies

iii. Identification of true labour pains

iv. Monitoring of labour progress

v. AMTSL

vi. Immediate care for new-born

vii. Special care for low birth weight new-borns

h) Knowledge of staff nurses is not adequate for,

i. Neonatal Resuscitation

ii. Identification of infection/sepsis in new-born

i) Shoulder roll is not available.

j) Wall clock with seconds hand not available at NBCC.

k) Case records need improvements,

i. Details of at birth immunisation

ii. Care provided to new-born

iii. Details of resuscitation if done

iv. Vital signs of new-born

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4. PHC Hangola

a) One staff nurse not trained in SBA and NSSK

b) GPLAD, term preterm and maternal complications not mentioned in the maternal

case sheets

c) Cord cutting with blade, breastfeeding initiation timings not mentioned in the baby

case sheets

d) New Born Care Corner was not located appropriately. NBCC relocated in the labour

room

e) Breast feeding not initiated within half an hour after birth, hand washing not in

practice, Skin to skin contact not initiated

f) Resuscitation chronology not practiced (Position suction stimulation and

repositioning not followed as per protocols)

g) Milking of cord is in practice

h) Every baby is shifted to new born care corner

i) Disinfectants not available

j) Yellow colour coded bag not used for placenta segregation

k) Filling of partograph need improvement

5. PHC Kot

a) Some essential drugs are out of stock

b) Colour coded buckets and bags not available

c) Skills for high risk detection not as per protocols

d) Baby not dried after delivery

e) Spot lamp not functional

f) Case sheets need improvements in term of baby notes on essential new born care

and resuscitation.

6. PHC Morni

a) NBCC well established with radiant warmer, shoulder roll, mucous extractor,

oxygen cylinder, concentrator, bag and mask of both sizes

b) Double gloving in practice

c) Skin to skin contact in practice

d) Practice of re-clamping the cord

e) Immediate cord cutting in practice

f) Inj vitamin K not available and not in practice

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7. PHC Barwala

a) NBCC well established with bag and mask, radiant warmer, shoulder roll, oxygen

cylinder, suction apparatus

b) Practice of skin to skin contact

c) Double gloving in practice

d) Immunization of newborn with BCG, OPV and Hep B in practice

e) Vitamin K in practice

f) Facility having delivery load of about 35-40 deliveries a month. Single delivery

table available and 3 inpatient beds are available

g) Space constraint in facility

h) Case sheets are being prepared for delivery cases. Delivery notes and baby notes

are being recorded

i) Record keeping very good.

8. PHC Nanakpur

a) Well maintained Labour room with well-established NBCC with 200 W bulb as

heat source.

b) Record keeping is good.

c) Knowledge of staff nurse about essential newborn care and resuscitation is good.

d) Skills of staff nurse about essential newborn care and resuscitation is average.

9. PHC Punjore

a) Well maintained PHC

b) Skills and practices for ENCR need regular follow up

c) Promotion of Infection prevention protocols is strictly required

d) Documentation need few improvements regarding baby notes

10. PHC Surajpur

a) PHC running in another SC building

b) No Staff nurse

c) No Hand washing station inside labour room

d) Promotion of Infection prevention protocols is strictly required Skills and

practices for ENCR need regular follow up

e) Documentation need few improvements regarding baby notes

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11. Urban Slum Dispensary, Sector- 19

a) Bleaching powder for disinfection is not available.

b) Baby sheets are not available.

c) NBCC not established.

d) Baby mask of size ‘0’ is not available.

e) Colour coded bags for biomedical waste segregation and disposal are not

available.

f) Disposable surgical blades for cord cutting are not available.

g) Case records are well maintained but notes on essential newborn care are

incomplete.

h) There are issues related to procurement of articles and items required for delivery

and newborn care. Cord clamps, baby sheets, mucus extractors, surgical blades,

disinfectants (bleaching powder) etc. are not available and these items are difficult

to procure in small quantities, moreover, there are no vendors for such items in

local market. Also, medicines are in very limited supply and need to be purchased

locally.

i) Milking of cord is still in practice.

j) Knowledge of one staff nurse about essential newborn care and resuscitation is

good but for other two it is average.

k) Skills of staff nurses for essential newborn care and resuscitation are average

Recommendations

a) Resolve procurement issues related to medicines and other items with Civil

Surgeon’s office. Ensure regular supply of required items and medicines to the

dispensary.

b) Write complete notes on essential newborn care as described during the visit.

c) Promote peer learning to improve knowledge and skills of service providers.

12. SC Jaloli

a) Sub centre running in damaged building

b) Toilet available but not usable


d) Skills and practices for ENCR need regular follow up


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13. SC Maranwala

a) Well maintained Sub Centre

b) Inappropriate Hand washing station


d) Skills and practices for ENCR need regular follow up


14. SC Karanpur

a) Case sheets and partographs not available

b) Delivery register with only address/ male female/ weight and time of birth

mentioned

c) Active management of third stage of labour not done (Inj oxytocin after delivery

not administered)

d) Two hundred watt bulb not available

e) Invertors not functional

f) Oral pills and condom contraceptive not available

15. SC Bargodam

a) NBCC not established at facility

b) Shoulder roll to be prepared as directed

c) Baby sheets are not available

d) Toilet non-functional since 2007

e) Facility having delivery load of about 4-5 deliveries a month

f) Case sheets are not being prepared

g) Partographs are not available and are not being filled

h) Kelly’s pad not available on delivery table

i) Yellow bags not available

j) Biomedical waste segregation not being done

k) Spot lamp non-functional since 3 months

l) Practice of separating newborn and mother despite good cry

m) Practice of re-clamping the cord

n) Immediate cord cutting in practice

o) Inj vitamin K not available

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16. SC Ramgarh

a) Shoulder roll to be prepared as directed

b) Case sheets are not being prepared

c) Partographs are not available and are not being filled

d) Kelly’s pad not available on delivery table

e) Practice of separating newborn and mother despite good cry

f) Practice of re-clamping the cord

g) Immediate cord cutting in practice

h) Mask of size 0 not available

i) Inj vitamin K not available

17. SC Nadda Sahib

a) NBCC not established. It was established as onsite correction with 200 W bulb,

bag and mask of both sizes

b) Shoulder roll to be prepared as directed

c) Case sheets are not being prepared

d) Practice of separating newborn and mother despite good cry

e) Practice of re-clamping the cord

f) Immediate cord cutting in practice

g) IEC material not displayed at appropriate places

h) Hand washing station not appropriate

18. SC Mauli

a) Well maintained labour room, but no NBCC.

b) Immediate cord cutting and milking of cord still in practice.

c) Case sheets for delivery cases are not available.

d) Knowledge of ANM about essential newborn care and resuscitation is average.

e) Skills of staff nurse about essential newborn care and resuscitation are average.

19. Saketri

a) Well maintained labour room with NBCC in a small room adjoining it. NBCC has

all the articles and equipment necessary for newborn resuscitation.

b) Knowledge of ANMs about essential newborn care and resuscitation is good.

c) Skills of ANMs about essential newborn care and resuscitation are average.

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