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113

INTERNATIONAL JOURNAL OF RESEARCH AND

ANALYSIS VOLUME 4 ISSUE 1

2016

WHO CHILDBIRTH CHECKLIST 2012: IMPACT ON

MATERNAL AND NEWBORN CARE EVALUATION

Dr. V. L. Deshmukh1, Dr. P. D. Chahande

2, Dr. Tejashree Shirale3

, K.Y.Yeilkar4

1 Associate Professor Government Medical College and Hospital Aurangabad.Mob.No.888889073

2 Assistant professor Government Medical College and Hospital Aurangabad. Mob.No. 9096047076

3 Resident doctor at Government Medical College and Hospital Aurangabad. Mob.No.8381042767

4 Head and professor of Department of Obstetrics and Gynaecology,

Government Medical College and Hospital Aurangabad Mob.No.9823270103

INTRODUCTION

Reducing childbirth associated mortality is

top global priority but simple and effective methods

to achieve it are severely lacking. Most of the

350,000 maternal deaths ,1.2 million intrapartum-

related stillbirths and 3.1 million neonatal deaths that

occur each year could be avoided through the

delivery of timely interventions. It is proven to be

effective and affordable. (1,2,3,4,5) Poor quality of

care in an institutional birth is major contributory

factor. (6,7,8) Integration of checklist based programs

into clinical practice has been shown to reduce deaths

and complications in intensive care medicine and

surgery (9,10,11,12). In obstetrics major cause of

maternal and perinatal mortality occur within a

narrow time window i.e.24 hrs after birth. So to

reduce it and to improve quality of care WHO

established a checklist –based childbirth safety

programme. It is simple, effective, low cost and with

minimal interventions (13,14,15).

It is to be used at 4 critical junctions in process of

childbirth. These are as follows:

1. On admission.

2. Just before pushing or before caesarean.

3. Soon after birth (Within 1 hour ) .

4. Before discharge.

Checklist attached.

Aims and Objective of the study are:

1) To maximize the likelihood of successful

checklist practice adoption in clinical practice.

2) To find out its impact on maternal and newborn

care in low income settings.

METHODOLOGY:

We conducted a observational

interventional Case Control Study. It was for 4 month

duration i.e from 1st October 2015 to 31

st January

2016. These Case Control study was carried out at

tertiary care set up with written informed risk

consent and Local ethical committee approval .Out of

100 women as a sample size 50 patients were

selected on even dates as Cases and 50 patients were

on odd dates as Control. In Cases, WHO safe

childbirth checklist was attached from admission and

completely followed till discharge and control group

received routine care at tertiary care center.

Outcome :

Primary outcome considered as successful

delivery of essential childbirth practices at each birth

event and

Secondary outcome as

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1) Observed deaths including maternal

death, newborn death, stillbirth.

2) Frequency of medication administered

with and without checklist.

3) Counseling practices with and without

checklist study was performed.

Data collected during each phase of study by self.

Analysis were done by using SPSS software. For

qualitative analysis chi square test was applied and

for quantitative analysis ‘t’ test applied. Data is

considered significant when p value is < 0.05.

Result :

Total number of 100 birth events were observed

during 4 months baseline period with 50 patients

with childbirth checklist and 50 patients without

childbirth checklist . The checklist was observed to be

used by health professional at least 95%of time each

of four checklist pause points in patients with

checklist.. Demographic characteristics of women and

newborn are shown in table 1.There was no

significant differences in the two groups .

We observed that the average rate of successful

delivery of essential practices at each birth event

increased from an average of 23 practices at base line

(95% CI) .As it’s a tertiary care centre average of 23

practices were practiced .It was increased to an

average of 29 practices afterwords (95%CI ,p <0.001)

as shown in figure 1.

.

Figure 1: Average rate of successful delivery of

essential childbirth practices with and without

checklist (p<0.001).

Table1 Demographic characters of mother

and newborn in cases and control

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control cases

AGE 24.22(+/-4.22) 23.46(+/-3.58)

PARITY 0 22 25

1-3 20 20

>4 8 5

UNBOOKED CASES 32 36

PREVIOUS LSCS 7 6

SEX OF NEWBORN MALE 26 27

FEMALE 24 23

BIRTH WEIGHT <1500 3 4

1500-

2500

24 20

>2500 23 26

MULTIPLE BIRTH 1 1

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A. On Admission;

C. Soon after birth (within one hour);

Figure 2 .Changes in rates of delivery of specific

childbirth practices with and without the safe

childbirth checklist;(2a)On admission;(2b)From

pushing until delivery;(2c)Soon after birth (within

one hour);(2d);Before discharge.

B. From pushing until delivery;

D. Before discharge.(p <0.001)

Figure 2. Shows the rate of successful completion of

individual practices with and without the safe

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childbirth checklist. There was significant

improvement in delivery of every practice.Significant

increase in practices like presence of birth companion

or encouraged, use of partograph, intrapatum

counseling, postpartum counseling, exclusive breast

feeding (p value <0.001).There was no difference in

observed maternal and neonatal deaths during this

study period.

DISCUSSION

The novel checklist- based childbirth safety

program has lead to a marked increase in delivery of

essential childbirth practices linked with improved

maternal,fetal,and newborn outcomes.

Firstly, being the tertiary care set up

around 22-23 essential childbirth practices were

already followed. It was found that there is marked

increase in adherence to accepted clinical practices at

any given birth event and 29 out of 29 individual

practices were delivered with significantly greater

frequency.. These results suggest the potential of use

of safe childbirth checklist programe to improve

maternal and perinatal outcome is very effective.

Secondly, the successful adherence of

essential practices has improved assessment of

mothers and newborn. These has lead obviously to

early and timely detection of risk factors and

interventions whenever needed. These are also likely

to reduce the morbidity to both mother and newborn.

Thirdly, timely and judiciously use of

antibiotics and magnesium sulphate has lead to the

improved outcomes .In this study use of safety

childbirth checklist lead to improved awareness of

appropriate indications for antibiotics ,administration

of magnesium sulphate to at risk patients.

Unnecessary and unindicated use of antibiotics was

limited.

Fourthly, The low risk patients in the

population are large enough so the obstetric

complications e.g. obstructed labour can occur up to a

good figure.(6) Emphasis on importance of

monitoring and evaluation of process of childbirth by

use of partograph is one of the important component

of checklist. Adequate preparation in planning of

resources and taking all due care of logistic element

verifying the eligibility of every patient and managing

every stage by partograph leads to definitely positive

outcome .

Encouragement of birth companion and

counseling them regarding warning signs and

symptoms of process of childbirth also helps in early

detection of complications.(21,22) In our study these

was achieved successfully. Most women welcomed

the idea of birth companions as they were

emotionally secured. We found out fear of having to

deal with angry family demanding the explanation

and compensation for any loss (maternal,fetal

,neonatal) is reduced because of birth companion. She

witnessed the labour throughout. Also it was found

that prior perception about unpredictable behavior of

staff can be nullified because of birth companion.

Simple and effective approach can

strengthen the already existing system e.g.,routine

washing of hands with soap and water and wearing

clean and sterile gloves, the monitoring the women

and newborn after delivery for at least one hour ,the

most crucial period of childbirth process.

Counselling regarding exclusive

breastfeeding is an important factor to reduce infant

mortality rate and neonatal morbidity

(23,).Neonatologist presence was assured .It ensures

the golden minute opportunity in needy cases. All

these leads to meaningful changes in morbidity and

mortality while building stronger health system.

Discussion regarding seeking help for danger signs

and symptoms after discharge was done and

arrangements for follow up were made . Also family

planning counseling and offering options for the same

made this approach complete. The increase in

contraceptive advice is a rapid and cost effective way

to decrease maternal mortality rate . (24,25,26) Thus

the novel checklist –based childbirth safety

programme provide the highest level of possible care

to one and all.

These interventions are comprehensive,

simple and sustainable. The behavior change

fascilitates to the increase adherence to evidence-

based healthcare practices .These study proved that

safe childbirth checklist can produce measurable

change.

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The checklist based approach improves quality of

care during childbirth .It had three primary

mechanisms of effect

(1) As a “checklist” instrument that

reinforced health professionals a core set of essential

practices that must be completed at each and every

birth;

(2) As a “reminder” to complete these

practices at most crucial period – at the bedside of

the patient;and

(3)As a “tool” that highlighted gaps in the

existing system of care at the facility which enabled

the health professional to take steps to effectively

strengthen their own health system and to ensure

adherence to checklist practices .

These checklist based approach has added

advantages of feasibility and affordability .No

additional investments in the form of equipments or

supplies,and no incentives to staff are needed..

CONCLUSION

The avoidable causes of maternal and newborn deaths

and many stillbirths can be overcome by simply

delivery of key evidence based interventions during

childbirth at critical points. In this study

implementation of novel checklist-based childbirth

safety programe lead to improved quality of care by

working as a checklist instrument that reinforced the

essential practices that must be completed. It helps to

detect earlier and treat the pregnancy related

complications in labour .Give an opportunity to

women at risk and discussing for planning and

observing for professional care during labour.

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et al. (2010) Maternal mortality for 181 countries, 1980–

2008: a systematic analysis of progress towards Millennium

Development Goal 5. Lancet 375: 1609–1623.

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Andel G, et al. (2010) Effect of a comprehensive surgical

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1928–1937.

13.Ronsmans C, Graham WJ (2006) Maternal mortality:

who, when, where, and why. Lancet 368: 1189–1200.

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When? Where? Why? Lancet 365: 891–900.

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Urbina L, et al. (2007) Are skilled birth attendants really

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Organization 85: 783–790.

16.Weiser TG, Haynes AB, Lashoher A, Dziekan G,

Boorman DJ, et al. (2010) Perspectives in quality:

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Checklist Item Qualifying Caption

On admission of the

mother to the birth

facility

Does mother need

referral?

□ Yes,

organized

According to facility's criteria

□ No

Partograph started? □ Yes Start plotting when cervix ≥ 4 cm, then cervix

should dilate ≥ 1 cm/hr. Every 30 min: plot heart

rate, contractions, fetal heart rate. Every 2 hours:

plot temperature. Every 4 hours: plot blood

pressure

□ No, will start

when ≥ 4 cm

Does mother need to start

antibiotics?

□ Yes, given Give if temperature > 38oC, foul-smelling vaginal

discharge, rupture of membranes >18 hours, OR

labor >24 hours

□ No


magnesium sulfate?

□ Yes, given Give if (1) diastolic blood pressure ≥110 mmHg

and 3+ proteinuria, OR (2) diastolic blood pressure

≥90 mmHg, 2+ proteinuria, and any: severe

headache, visual disturbance, OR epigastric pain

□ No


anti-retroviral medicine?

□ Yes, given Give if mother is HIV+ and in labor

□ No

□ Supplies available to

clean hands and wear

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gloves for each vaginal

exam

□ Birth companion

encouraged to be present

at birth

□ Confirm that

mother/companion will

call for help during labor

if mother has a danger

sign

Call for help if bleeding, severe abdominal pain,

severe headache, visual disturbance, urge to push,

OR difficulty emptying bladder

Just before pushing (or

before Cesarean)


antibiotics?

□ Yes, given Give if temperature > 38oC, foul-smelling vaginal

discharge, rupture of membranes >18 hours now,

labor >24 hours now, OR cesarean section

□ No


magnesium sulfate?





□ No

Are essential supplies at

bedside for mother?

□ Gloves Prepare to care for mother immediately after birth:

(1) Exclude 2nd

baby, (2) Give oxytocin within 1

minute, (3) Controlled cord traction to deliver

placenta, (4) Massage uterus after placenta is

delivered

□ Soap and

clean water

□ Oxytocin 10

IU in syringe

Are essential supplies at □ Clean towel Prepare to care for baby immediately after birth: (1)

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bedside for baby? Dry baby and keep warm, (2) If not breathing:

stimulate and clear airway, (3) If still not breathing:

cut cord, ventilate with bag-and-mask, (4) shout for

help

□ Sterile blade

to cut cord

□ Suction

device

□ Bag-and-

mask

□ Assistant identified and

informed to be ready to

help at birth if needed?

Soon after birth (within

1 hour)

Is mother bleeding too

much?

□ Yes, shout

for help

If bleeding >500 ml, or if >250 ml and severely

anemic: massage uterus, consider additional

uterotonic, start intravenous line, treat cause

□ No


antibiotics?

□ Yes, given Give if placenta manually removed, or if

temperature >38oC and any: foul-smelling vaginal

discharge. lower abdominal tenderness, rupture of

membranes >18 hours at time of delivery, OR labor

>24 hours at time of delivery

□ No


magnesium sulfate?





□ No

Does baby need referral? □ Yes, According to facility's criteria

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organized

□ No

Does baby need to start

antibiotics?

□ Yes, given Give if antibiotics were given to mother, or if baby

has any: breathing too fast (>60 breaths/min) or too

slow (<30 breaths/min), chest in-drawing, grunting,

convulsions, no movement on stimulation, OR too

cold (temperature <35oC and not rising after

warming) or too hot (temperature >38oC)

□ No

□ Does baby need special

care and monitoring?

Recommended if more than 1 month early, birth

weight <2500 grams, needs antibiotics, OR

required resuscitation


an anti-retroviral

medicine?

□ Yes, given Give anti-retroviral medicine if mother is HIV+

□ No

□ Started breastfeeding

and skin-to-skin contact?

(if mother and baby are

well)

□ Confirm that


call for help if:

Mother has bleeding, severe abdominal pain, severe

headache, visual disturbance, breathing difficulty,

fever/chills, OR difficulty emptying bladder

Baby has fast or difficulty breathing, fever,

unusually cold, stops feeding well, less activity

than normal, OR whole body becomes yellow

Before discharge

Is mother’s bleeding

controlled?

□ Yes

□ No, treat and

delay

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discharge


antibiotics?

□ Yes, given Give if temperature >38oC and any: chills, foul-

smelling vaginal discharge, OR lower abdominal

tenderness

□ No


antibiotics?

□ Yes, give

antibiotics,

delay

discharge, and

give special

care or refer

Give if breathing too fast (>60 breaths/min) or too

slow (<30 breaths/min), chest in-drawing, grunting,

convulsions, no movement on stimulation, too cold

(temperature <35oC and not rising after warming)

or too hot (temperature >38oC), stopped

breastfeeding well, OR umbilical redness extending

to skin or draining pus

□ No

Is baby feeding well? □ Yes

□ No, help and

delay

discharge

□ Family planning

options discussed and

offered to mother

□ Confirm that


call for help after

discharge if:

Mother has bleeding, severe abdominal pain, severe

headache, visual disturbance, breathing difficulty,

fever/chills, OR difficulty emptying bladder

Baby has fast or difficulty breathing, fever,

unusually cold, stops feeding well, less activity

than normal, OR whole body becomes yellow

□ Follow-up arranged for

mother and baby

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Childbirth practice Definition

On admission

Appropriate maternal

referral

Mother assessed for predetermined referral criteria (hemogloblin <7 g/dL

and in labor or suffering from refractory eclampsia) and referred within one

hour after admission if indicated


HIV prophylaxis

Maternal HIV status checked and nevirapine given to mother within one

hour after admission if mother is HIV positive

Birth companion

present or encouraged

Family member or community health worker present with mother or

encouraged to be present if not present

Appropriate

preeclampsia

management

Mother assessed for signs and symptoms of preeclampsia (diastolic blood

pressure >100 mmHg, or diastolic blood pressure >90 mmHg and severe

headache or visual disturbance or epigastric pain) and treated with

magnesium sulfate within one hour after admission if indicated

Partograph use Partograph labeled with mothers name and admission vital signs within one

hour after admission; if in active labor, then partograph charting initiated

within one hour after admission


infection management

Mother assessed for predetermined risk factors and signs of infection

(temperature >38oC/100.4

oF or foul-smelling vaginal discharge or rupture of

membranes at home or labor >24 hours in primigravida or labor >12 hours

in multipara) and treated with antibiotics within one hour after admission if

indicated

Appropriate hand

hygiene

Hands washed with clean water and soap, and clean gloves worn for

admission vaginal examination

Intrapartum counseling Mother and/or birth companion verbally informed within one hour after

admission about danger signs for which they should call for help during

labor: bleeding, severe abdominal pain, severe headache, visual disturbance,

cannot empty bladder every 2 hours, or urge to push

From the time of

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pushing until delivery

Birth helper available

in case of emergency

Assistant identified and informed to be available to assist at delivery in event

of complications

Appropriate newborn

thermal and

resuscitation

management

Newborn assessed and given appropriate immediate newborn care (newborn

dried and kept warm, if not breathing then airway cleared and newborn

stimulated, and if still not breathing then newborn ventilated with bag-and-

mask)

Appropriate

preeclampsia

management




magnesium sulfate before delivery if indicated

Cord cut with sterile

blade

Sterile blade used to cut umbilical cord after birth

Appropriate hand

hygiene

Hands washed with clean water and soap, and clean gloves worn for

delivery

Oxytocin given within

1 minute

Oxytocin 10 IU by intramuscular injection administered to mother within

one minute after delivery



Mother assessed for predetermined risk factors and signs of infection

(temperature >38oC/100.4

oF or labor now >24 hours in primigravida or labor

now >12 hours in multipara) and treated with antibiotics before delivery if

indicated, or antibiotics administered if proceeding to caesarean section

Soon after birth

(within one hour)

Appropriate newborn

referral

Newborn assessed for predetermined referral criteria (birth weight <2

kilograms or gestation <32 weeks or having breathing difficulty if required

bag-and-mask) and referred within one hour after delivery if indicated

Appropriate newborn

HIV prophylaxis

Maternal HIV status checked and nevirapine given to newborn within one

hour after delivery if indicated

Breastfeeding started

within 1 hour

Breastfeeding initiated within one hour after delivery

Appropriate maternal Mother assessed for predetermined signs of infection (if placenta manually

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infection management removed or if temperature >38oC/100.4

oF and labor was >24 hours for

primigravada or >12 hours for multipara) and treated with antibiotics within

one hour after delivery if indicated

Maternal blood loss

assessment

Mother's postpartum blood loss checked within one hour after delivery

Appropriate

preeclampsia

management




magnesium sulfate within one hour after delivery if indicated

Pospartum counseling Mother and/or birth companion verbally informed within one hour after

delivery about danger signs in mother (bleeding, severe abdominal pain,

severe headache, visual disturbance, breathing difficulty, fever or chills,

difficulty emptying bladder) and newborn (fast or difficulty breathing, fever,

unusually cold, stops feeding well, less activity than normal, whole body

becomes yellow) for which they should call for help after delivery

Appropriate newborn


Newborn assessed for predetermined signs of infection (mother given

antibiotics or gestation < 32 weeks or birth weight <1.5 kilograms or

breathing rate >60 breaths/minute or breathing rate <30 breaths/minute or

convulsions or floppy or temperature < 35oC/95

oF despite warming

measures or >38oC/100.4

oF) and treated with antibiotics within one hour

after delivery if indicated

Before discharge

Maternal blood loss

assessment

Mother's postpartum blood loss checked before discharge

Newborn feeding

assessment

Feeding status of newborn checked before discharge



Mother assessed for predetermined signs of infection (temperature

>38oC/100.4

oF and either foul-smelling vaginal discharge or lower

abdominal tenderness) and treated with antibiotics before discharge if

indicated

Family planning Importance of family planning and two or more available options discussed

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options discussed before discharge

Appropriate newborn


Newborn assessed for predetermined signs of infection (newborn breathing

rate >60 breaths/minute or <30 breaths/minute or convulsions or floppy or

newborn temperature <35oC/95

oF despite warming measures or

>38oC/100.4

oF) and treated with antibiotics before discharge if indicated

Discharge counseling Mother and/or birth companion verbally informed before discharge about

danger signs in mother (bleeding, severe abdominal pain, severe headache,

visual disturbance, breathing difficulty, fever or chills, difficulty emptying

bladder) and newborn (fast or difficulty breathing, fever, unusually cold,

stops feeding well, less activity than normal, whole body becomes yellow)

for which they should seek care after discharge

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