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