Interval ,0

Postpartum D Post Abortion Z'.)

Supportive Supervision Checklist

uH'C.

r;-:-Name of the supervisor ­

C4: Facility Name ­ U Block District

C7 : Date of visit -

Data of previous 'tontn from facility

D1 Number of deliveries in facility

~ft-<. u 3: Level of supervisor - Block/ Dist rict/ State /Nationa l / Oth er

CS: Facility Type - SC/ Non 24 *7 PHC /24*7 PHC/Non- FRU CHC/FRU • . CHC/SDH/DH/AREA HOSP/other I ,Do/3A51 .f?/rRff' C6: Fac,lity Level - Ll/ L2/ L3

CS: Name of Facility in-charge/nodal officer ­ C9: Designat ion of In-charge­

02 Number of new-borns

immu nized before discharge 0 El.5: Mifepristone + Misoprostol (MMA) 'I- E3.5: Sterile cord cutting equipment / E8.3: Refrigerator ~

E Drugs/supplies availability (If possible, verify physically)

El : Reproductive Health _E3: New Born Health E7. Antibiotics /

El.1: IUCD 375, 38~ E3 .1: lnj. Vit Kl(l mg/ml) E.7 .1 Antibiotics as per RMNCH +A SXSfY Matrix ( Amoxycli llin, Ampicillin, Ampicillin, Gentamicin, Metronidazole, Trimethoprim &Su lpha methoxazole, ' Cef rtiaxone (oral/lM/IV as applicable)

y

El.2: 0CP w E3.2: Mucus Extractor ES: Other essential supplies °1­ &equipments(check

functionality & utilization)

D

/

El.3: ECP E3.3: Bag and mask f- E8.1 Weighing Machine O~ (240 ml) w it h both pre & t erm mask (size 0,1),. Q/

...,,.-­El.4: Condoms J.-....-E3.4: Clean linen/towels for receiving new boi/ E8.2: Hub cutter with needle destroyer 0" ~

Total Deliveries ~ Normal I

Assisted Vaginal Delivery

C-section

Referred ou t cases

Live births

El.6: MVA Kit/EVA :x... E3.6: Designated Newborn Care Corner/ , f( · l l E8.4: RTI/STI Kit I).{ 03 IPD load I 'I-- i E2: Maternal Health E3.7: Functional Radiant Warmer / UV ~ E8.5: Bleaching Powder ty­

E2.l: lnj. 0xytocin (check whether stored E8.6: Oxygen Cyli nder functional I04 OPDload l/~C ] 9-_ E4: Child Health ~

in cold box/refrigerator) / -E2.2: Tab Misoprostol Cf E4.1 ORS V E8.7: BP apparatus with stethoscope 9-"'D5 IUCD inserted i n facility

--· ­ 1 E2.3: Anti hypertensive (alpha fl--, -F4.2: Zinc (10mg & 20 mg) E8.8: Thermometer t!---­methyldopa/Labetalol or Nifedipine) ~

D6 Sterilization done

Female interval steril ization }(.

Female postpartum steril ization /" Male sterilization 'I-.

D7 No. of clients received CAC services D8 No of women received IFA tab D9 No. of ANC clients with high

risk conditions 83D10HR d_ep~oyed/posted in Labor Room

E2.4: lnj. Magnesium Sulfate

~ E4.3: Syp Salbutamol/Salbutamol Nebulizing Solution

\l­ E8.9: PPI UCO Forceps 0,.-/

v E2.5: lnj. Tetanus Toxoid 1Q/ E4.4: Tablet Albendazole ~ E8.10: Fetoscope/ Doppler rn--­E2.6: Sterile pads ~v E.5: Adolescent Health E8.11: Autoclave/Boiler a----­E2.7: IFA Tablet

E2.8: Pregnancy Test Kit (only at sub-tt-- ES.l: Dicyclomine

D l.-£5.2: Weekly Iron folic acid supplementation

g.--­, E8.12: Running water

E8.13: Soap

~ g_...-----­

centres and with ASHAs) \....-"" tablets

E2 .9: Functional Blood Bank/blood storage units t E 5.3 Tablet Albendazole

./

.--E8.14: Color coded bins and bags~ u.-­E2.10: Haemoglobinometer 0,,-­ E6: Vaccines E8.15: Electricity back-up u----·

" E2.ll: Urine albumin kit lU/ E6.l: BCG cg..-­ E8.16: Toilett ear LR) D E 2.12: Blood grouping typing g_ E6.2: 0 PV 0--­ ~

E 2.13:HIV screen ing 6l_ EG.3: Hep B g.. E 2.14:Hepatitis B screening [J. E6.4: DPT ,(L.. E8.17: Cold box, ILR, Deep freezer D E2 .15: Partograph

E2.16: Protocols displayed in LR --·

;;... ~

E.6.5: Measles

E.6.6: Syrup Vit. A

Q__.. P'\

present for vaccine storage as per requirement V

E2.l7: IV Fluids -­ ·­, E 2.18 lni Dexam@rhasone

,\fr

m E.6.7: Pentavalent vaccin~ (in relevant states) E.6.8 JE Vaccine /where re :evantl

B- E 8.18 MCP cards

~ ~ D -

-I

MO

ANM/Sta ff nurse

Post I Trained in I ed SBA/ I PPIUCD I NSSK

BEmOC

3.~,,.,, t PJ+rv

1 Fl. Ante Natal Care

Fl.l Blood Pressure Measured during ANC visits

Response

0/'fes D No D NA

Fl.2 Ha emoglobin measured during ANC visits Q_,Xes D No D NA

FL.3 Blood Glucose measured during ANC visits Q__yes D No D NA

Fl.4 Urine Albumin measured during ANC visits lP--"1es D No D NA

Fl.5 Appropriate management/referra l of high risk clients (identified on the basis of High BP/ Blood sugar/ Haemoglobin} '13-Yes D No D NA

Fl.6 Family Planning Counsel ling happening during ANC visit s -8-Yes D No D NA

F2. Intra­ F2.1 Fetal Heart Rate {FHR} recorded at t he time of admission 0-----Yes D No partum and Immediate post-partum practices

F2.2

F2.3

F2.4

f2.S

Mother's temperature and BP recorded at the t ime of admission

Partograph used to monitor progress of labor

Antenatal corticosteroids used for preterm labour

M agnesium Sulphate used to manage severe Pre-eclampsia and Ecla mpsia cases

Cv- Yes

~ Yes

~ Yes D

QI.. Yes

D 0

No

0

No No r:g..---ffA

No

F2.6 Uterotonic (Oxytocin or Misoprosto l} given to mother immediately after birth of baby \ ~ Yes 0 No

F3. Essentia l F3.1 Newborn ca re corner adequately equipped (bag-and-mask, rad iant warmer, mucous extractor, shoulder ro ll, thermometer, clock, Oxygen source) I 0 Yes 0 No new born care (ENBC) and New­born Resuscitation (NBR)

F3.2

F3.3

F3.4

F3.S

F3.6

Early initiation of breastfeeding practices

Practice of skin to skin contact being promoted

Babies dried with clean and sterile sheets/towels just after delivery

Provider aware about the steps of new-born resuscitation (Positioning, suctioning, stimulation, repositioning , PPV using Ambu bag)

New-barns given BCG,OPV, Hep-B within 24 hours of birth /

I {

l I

-" fl/ r , 0 0

0

0 0

Yes

Yes

Yes

Yes

Yes

0 0

0

0 0

No No

No

No No

F4. Family F4.1 Family planning counselling being done rn.-r'es 0 No

Planning F4. 2 Postpartum IUCD insertions being done 0 Yes i9--'1'Jo

FS. Client

F4.3

F4.4

F4.5

F.5.1

Interval IUCD insertions being done

Steri lization proce dures being done (Fixed Day Services or Fixed day Camps)

Postpartum st erilization being done

Privacy during delivery?

I I

I I

f )..._. ) ,( ," l/"'

. A I JLl_rufY

f IIV I V

0 G 0

0

Yes B-rlo 0 NA

Yes D--No Yes CD-No

Yes 0 No Satisfaction F.5.2

F.5.3

Is transport being provided for drop back?

Staff was well behaved with you during your stay?

I I

I \.

0 Yes

._Q_yes

0

0

No

No

F.5.4 Were you informed about the procedures before they were undertaken 0---Yes 0 No

F.5.5 Free diet provided? .a-,yes (!---1i:fo

F.5.6 Would you suggest visiting this fa cility to your relatives/friends? ID---Yes D No

,. ­F6. Facility ~F6.1 Is utilization of untied fund adequate? D Yes D No \ rv A mechanisms

F6.2 Awareness generation (use of IEC/BCC)- Posters, audio visual aids, display of citizen charter? D Yes D Noand others \ F6.3 Is grievance redressal mechanism in place? ID--Tu D No \

F7 F 7.1 xclusive breastfeeding practised upto six months (no water) D Yes D No Functionality F.7.2 Complementary feeding practised /) D Yes D No/

~ --- ' )

J of programs

F.7.3 ORS and Zinc available with ASHAs and distributed in community I ?-"'e,.- ':,.~ D---Yes D Noat community \ y ­

F.7.4 Growth monitoring at AWW centers and VHNDs ~ g-yes D No F.7.5 Malnourished children referred to Nut ritional Rehabi litation Centres CVY'es D No F.7.6 Incentives to ASHAs for delaying and spaci ng of births

/ D Yes D No

F.7.7 Incentives to ASHAs for accompanying clients for PPIUCD insertions I rviA-- "' ,,_:r ~ s ,,.l,,,,__~ ....J-.o '1Yd" . ~)L.'~) D Yes D No ,,rv v tt~ .F.7.8 Weekly IFA supplementation (WIFS) '-- V

I!) Yes Q/No F 7.9 Community based distribution of Misoprostol for PPH prevention D Yes~ D NA

F7.10 Home-based new born care by ASHA 0----ffl O No

F.7.11 HBNC kits available with ASHA -0.----'r'es D No

F7.12 Referrals of sick newborns or newborns with danger signs being undertaken D Yes D No

F.7.13 Home delivery of contraceptives by ASHAs ~D No D NA F.7.14 Menstrual hygiene practices being promoted g.-yes D No D NA F.7.15 VHNDs being conducted on a monthly basis (Services include ANC, Growth Monitori ng, Immunization, Health Messages etc) ,0"'ves D No F7.16 JSSK (JSSK entitlements being given?) D Yes aYNo F7.17 JSY (JSY entitlem ent s being given?) D Yes o-No

F7.18 Rashtriya Bal Swasthya Karyakram operational D Yes~

Major findings from last visit

Action taken on interventions/

activities identified from last visit

Plan of Action

Major findings from this visit Intervention/ Activities identified Level of intervention Responsibility Timeline

Reproductive Health/Family Planning Maternal Health

Newborn Health

Child Health

Adolescent Health

J'>~ -~ o1)h ·ge-Sig ~