QI Tools Final SBA

PREFACE
This set of quality improvement tools was developed to support the Government of Nepals efforts to increase
skilled birth attendance in Nepal. It was created to help strengthen inservice training sites that provide quality and
standardized skilled birth attendant (SBA) skills training for the thousands of healthcare providers.
In 2006, the National Health Training Center (NHTC) of the Ministry of Health and Population (MoHP) developed
the Maternal and Newborn Care Learning Resource Package (MNC LRP) for Skilled Birth Attendants (SBAs) to
train and upgrade existing healthcare providers (namely auxiliary nurse midwives, staff nurses and medical
officers) in SBA skills as defined by the National Policy on Skilled Birth Attendants (2006).
To quickly start up this training, NHTC assessed a number of sites, provided some equipment and initiated training
in early 2007. NHTC wanted also to ensure the quality of the trainingfor example those sites conducting SBA-
related training using the MNC LRP were providing an interactive, competency-based training environment and a
clinical practice experience was consistent with the content defined in the LRP. NHTC and various stakeholders
felt this quality improvement process could be an ongoing process, which led to the development of this set of
tools. Derived from the LRP itself, these tools define the minimum standards for a range of service and training
activities. They help standardize and improve both the MNC services in participating facilities and the quality of
inservice training.
The standards-based tools were developed in July 2007 and field-tested in eight SBA inservice training sites in
Nepal. An orientation for training site staff was conducted on how to use the tools for self-assessment, monitoring
and quality improvement, followed by site visits to support staff through this process. This revised set presented
here was finalized in October 2007 based on training sites staff feedback. These tools will be used by all NHTC
SBA inservice training sites to improve and then maintain quality of SBA training.
NHTC would like to acknowledge those who contributed to the development of these tools in support of national
efforts to expand quality SBA training.
NHTC conducted several activities to develop these tools through a series of workshops in February, July and
August 2007. Participants in these activities included representatives from Family Health Division (FHD), National
Health Training Center (NHTC), Nepal Family Health Program (NFHP), World Health Organization (WHO),
Support to Safe Motherhood Programme (SSMP), Nick Simons Inc. (NSI), Maternity Hospital (MH), Lalitpur
Nursing Campus, Koshi Zonal Hospital, Bharatpur Hospital, Lumbini Zonal Hospital, Seti Zonal Hospital, AMDA
Hospital, Baglung District Hospital, Dhulikhel Hospital, Tribhuwan University Teaching Hospital (TUTH), Nepal
Nursing Council (NNC), United Nations Fund for Population Activities (UNFPA), Kathmandu Medical College
(KMC), Council for Educational and Vocational Training (CTEVT), United Mission to Nepal (UMN), United Nations
International Childrens Educational Fund (UNICEF) and JHPIEGO, Save the Children, US/ACCESS.
Notably, staffs from SBA inservice training sites were essential to the development and field-testing process.
Special thanks to all the staffs working to improve the quality of SBA training at the following sites: Seti Zonal
Hospital, Kailali District Hospital, Bharatpur Hospital, Maternity Hospital, Koshi Zonal Hospital, Dhulikhel Hospital,
Baglung Hospital, AMDA Hospital and Lumbini Zonal Hospital.
NHTC recognizes and appreciates the United States Agency for International Development (USAID) support to the
ACCESS Program. Also, recognized are the contributions of ACCESS staff and consultants who provided the
technical assistance in the development of these quality improvement toolsespecially by Sarala Adhikari, Lalit
Mani Dhakal, Anne Hyre and Geeta Sharma.
Arjun B. Singh
Director
National Health Training Center
INTRODUCTION TO SBA QUALITY TRAINING IMPROVEMENT TOOLS
ABOUT THE TOOLS

The quality improvement tools developed with input and support from training site staff, stakeholders and
government officials will be used to ensure and sustain high quality clinical and classroom training. This set
was derived from the Maternal and Newborn Care TOTAL
Learning Resource Package (MNC LRP) for Skilled TOOL AREA
STANDARDS
Birth Attendants (SBAs) used by NHTC of the Ministry Maternal and Newborn Care
of Health and Population (MoHP) to train healthcare 1 Infection Prevention 12
providers. The content in the tools is consistent with the 2 Focused Antenatal Care 18
LRP and is presented in table form as 12 individual 3 Complications during Pregnancy 15
tools: 4
Normal Delivery and Immediate Newborn
25
Care
Nine tools that support quality MNC service delivery 5 Postpartum Care 15
at a clinical practice siteand can also be used by 6 Newborn Care 11
any health facility providing MNC services 7 Complications during Labor and Childbirth 27
Three tools that support quality competency-based 8 Assessment of a Newborn with a Problem 5
clinical training 9 Family Planning 30
Quality Competency-Based SBA Training
For each of the 12 tools, a set of standards are detailed
10 SBA Classroom-Based Clinical Training 15
that define quality. For example, there are 18 standards
11 SBA Clinical Instruction and Practice 14
that define quality focused ANC (tool 2). For each
12 Training Site Management 14
standard listed in a tool, there are objectively verifiable
TOTAL 201
steps which can be used to observe and assess performance.
The tools have many uses such as:
Internally by inservice training site staff to assess clinical and training practices
Job aids at the sites to improve performance
To measure performance over time internally and externally
By all SBA inservice training sites for consistency and comparison
As site monitoring tools by NHTC and external monitors
To support national accreditation processes (as appropriate)
INSTRUCTIONS FOR USING THE TOOLS AT TRAINING SITES

The tools are meant to be used while observing actual services and training at a siteactively walking
through wards and training facilities. While observing, the user fills in the boxes for each activity/step s/he
observes. If all the criteria are observed, this standard has been achieved, and one point is awarded. If even
one of the listed criteria is missing or not performed correctly, the standard has not been achieved in its
entirety so no point is awarded. All of the steps must be met to achieve the standard. No partial credit is
given for completing some of most of the steps because only these are the minimum required.
The score then for all standards in a tool is summed. For example, of the 18 ANC standards, a site might
have only successfully met 9 of the 18resulting in a score of 50%. Site staff can then use the tools to
determine which steps and standards were not met. They can then develop an action plan as a team to
make improvements to meet all of the standards.
Over time, the tools can be used for internal monitoring on an ongoing basis by the staff. The tools can be
used as job aids for staff. Every foursix months, the site can use the tools to conduct an internal
assessment using all 12 tools to measure progress over time. Usually a team led by a designated focal
person conducts the assessment, monitor progress and revise action plans to make improvements. Sites
can share their progress with NHTC.
NHTC MONITORING AND CERTIFICATION OF SBA TRAINING SITE QUALITY

NHTC will use these tools to monitor and certify all SBA inservice training sites.
For those sites already conducting some MNC-related training and being upgraded to SBA inservice
training sites: NHTC staff conduct external assessments used its NHTC assessment tools and prepare
them to begin training. These quality improvement tools are then introduced to the site to assist them in the
internal process of strengthening the site and measuring quality of their training. While the tools are designed
will primarily be used internally at sites to improve SBA training quality, NHTC will also use the tools to
measure and ensure training quality across all sites. As many have already achieved the minimum score of
60% to begin SBA training, these sites will use the quality improvement tools to further improve to meet 80%
of the standards and be recognized by NHTC as a high-quality SBA training site. Each site will be given 18
months of support to achieve the standards. In spite of efforts, some sites may not achieve 80%. In such
cases, NHTC would continue to provide support to enable that site to achieve 80%. In the case that a
training site is unable to meet 80% of the standards in the given time, NHTC may decide to drop the site
from upgrading it to SBA training or continue to support the site after in-depth analysis of the situation. NHTC
will develop a process to recognize sites who achieve these standards and to halt training at sites which are
unable to achieve them.
For those new sites being developed SBA inservice training sites: NHTC staff conduct external
assessments used its NHTC assessment tools, select appropriate site and prepare them to begin training.
These quality improvement tools are then introduced to the site to assist them in the internal process of
strengthening the site and measuring quality of their training. The site first focuses on clinical site
standardization using the first nine tools. New training sites will need to score a minimum score of 60% on
Tools 19 as assessed by NHTC to begin SBA training site development. A new site then receives support
and uses Tools 1012 to improve training quality up to a minimum score of 60% on Tools 1012 as
assessed by NHTC to begin SBA training. To be recognized by NHTC as a high-quality SBA training site,
80% on all 12 tools would be required. Each site will be given 18 months of support to achieve the
standards. In spite of efforts, some sites may not achieve 80%. In such cases, NHTC would continue to
provide support to enable that site to achieve 80%. In the case that a training site is unable to meet 80% of
the standards in the given time, NHTC may decide to drop the site from upgrading it to SBA training or
continue to support the site after in-depth analysis of the situation. NHTC will develop a process to recognize
sites who achieve these standards and to halt training at sites which are unable to achieve them.
For certification sites must achieve 80% on each of the 12 tools in this set (as opposed to an average of all
tools equally 80%).
External monitoring would be done by NHTC (or assigned individuals or agencies). The external assessors
will visit once a year and use these same tools during their monitoring visit, or as needed to certify a training
site has met and/or maintain the standards.
QUALITY IMPROVEMENT TOOLS FOR SBA TRAINING SITES
SUMMARY FORM
TOTAL STANDARDS STANDARDS ACHIEVED
TOOL NO. TOOLS
BY TOOL NUMBER PERCENTAGE
1 Infection Prevention 12
2 Focused Antenatal Care 18
3 Complications during Pregnancy 15
4 Normal Delivery and Immediate Newborn Care 25
5 Postpartum Care 15
6 Newborn Care 11
7 Complications during Labor and Childbirth 27
8 Assessment of a Newborn with a Problem 5
9 Family Planning 30
10 SBA Classroom-Based Clining Training 15
11 SBA Clinical Instruction and Practice 14
12 Training Site Management 14
TOTAL 201
Nepal SBA Inservice Training Site Quality Improvement Tools for Site Strengthening
TOOL 1: INFECTION PREVENTION
Training site (name, place):

Date:
Individual observing:
PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

1. The hospital has available Observe if there is running water (sink or plastic bucket with faucet) in:
running water. Admission (emergency room)
First stage labor and labor room/delivery room
Neonatal unit
Operating room
Laboratory
Toilet
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 1 of 7
Tool 1: Infection Prevention

2. The hospital is clean. Check for the absence of dust, blood, trash and cobwebs in the following areas:
Admissions
Postnatal ward
Operating room
Neonatal unit
Patient toilets
3. The hospital has available Observe during the visit whether:
and properly uses sharps The containers are appropriate: cardboard box, hard plastic containers, cans,
containers. closed with only a small opening for disposing of syringes with needles
The collectors are located in:
Antenatal room
Postnatal ward
Neonatal unit
Emergency room
Operating room
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 2 of 7
4. Staff properly disposes of Syringes with needles are:
sharps in each room. Immediately placed in sharp container without recapping.
Containers are closed and disposed of when filled (3/4 full).
5. Antiseptics are properly Antiseptics are kept in small, closed and reusable containers for daily use.
prepared. Antiseptics are stored in cool and away from direct sunlight.
Gauze and cotton are stored in containers without antiseptics.
Reusable containers are washed with soap and water and dried before being
refilled with antiseptic solution.
Auxiliary instruments such as thermometers, probes and other materials are
stored in dried containers without antiseptic or disinfectant solutions.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 3 of 7

6. Instruments are properly Observe whether:
decontaminated. Concentration of the chlorine solution is 0.5%.
The chlorine solution is prepared daily or more frequently if cloudy.
The containers holding the 0.5% chlorine solution are located in appropriate
places:
Antenatal room
Delivery room
Blood bank
Laboratory
Neonatal unit
Operating room
The material/instruments remain in the solution for 10 minutes.
Then material (gloves)/instruments are transferred into soap and water
solution for cleaning.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 4 of 7
7. Instruments are properly Observe during the cleaning, whether the personnel responsible:
cleaned. Uses clean water, detergent (liquid or powder) and a soft brush.
Disassembles instruments with multiple parts.
Cleans instruments in soapy water with a soft brush until all blood and
organic material is gone (especially instruments with teeth, joints or screws).
Thoroughly rinses the instruments with clean water until all the detergent was
removed.
Dries the instruments with a clean towel or airdry.
8. Staff use personal protective Observe during cleaning of materials and instruments that the personnel
barriers during cleaning of responsible use the following protective barriers:
instruments. Utility gloves
Plastic apron
Closed shoes
Visor or protective goggles
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 5 of 7

9. The high-level disinfection Observe during the HLD cycle, when boiling:
(HLD) process is performed Cleaned, disassembled instruments are totally immersed in water.
according to the standards. Lid is closed.
Instruments are boiled for 20 minutes starting from the time of rolling boil
begins.
No additional instruments are added after timing begins.
After 20 minutes, instruments are removed with high-level disinfected or
sterile forceps or gloves, dried and stored in HLD containers.
10. The labor, postpartum and Observe if:
newborn wards have an Staff members use utility gloves when handling or transporting waste.
appropriate system for There is a container with plastic liner for contaminated waste in examining
collecting and disposing rooms, procedure areas and toilets.
waste.
There is a container with plastic liner for ordinary waste in the exam rooms,
procedure areas, reception area, waiting rooms and hallways.
11. The hospital promotes good Observe if:
practices for waste disposal. There are dustbins outside of the hospital (in the grounds) for general waste
to reduce littering.
The grounds (outside of the hospital) are free of litter and waste.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 1: Page 6 of 7
12. The IP practices during Observe if:
handling waste are Housekeeping personnel (e.g. ward attendant, sweeper) in labor, postpartum
performed according to the and newborn wards wear utility gloves when handling waste.
standards. Waste is transported to the interim storage area or for disposal in adequate
closed containers.
Housekeeping personnel (e.g. ward attendant, sweeper) wash hands after
handling waste and removing utility gloves.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total of standards 12
Total standards met
Percent achievement %
Tool 1: Page 7 of 7

TOOL 2: FOCUSED ANTENATAL CARE

Date:

1. The facility has a client- Observe if:
friendly waiting area. There is a designated waiting area.
Area is clean.
Safe drinking water is available.
There is good ventilation (e.g. window, fan) and warmth.
The area has good light.
The area is protected from sun and rain.
There are sufficient seats for sitting.
Educational materials are available (related to maternal and neonatal health).
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Page 1 of 10
Tool 2: Focused ANC

2. The facility has functioning Observe if the toilets:
toilets for clients and Are clean.
providers. Have doors that can be locked.
Have sinks with running water (taps or bucket with tap) and soap.
Have water and bucket to flush the toilet.
Contain rubbish bin.
3. The facility has a client- Observe if:
friendly counseling area. The counseling area provides privacy for the client:
Area is set up so that other people cannot hear what is being said.
There is a table.
There are chairs for:
Client
Companion
Provider
Educational materials on display:
Postersdanger signs, nutrition, immunization, postpartum family
planning, etc.
Birth preparedness package (BPP) flipchart
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
4. The facility has an adequate Observe if:
examination/procedure room The room is clean and well-maintained.
for antenatal care (ANC). The room is well ventilated.
The examination/procedure area provides privacy for the client:
Curtains or screens to prevent seeing the examination area from the
door.
Handwashing facilities inside or nearby.
5. The room has all necessary Observe that there are:
equipment to provide ANC. Examination table
Foot steps
Proper light source
Container with 0.5% chlorine solution for decontamination
Container with plastic bag for waste
Puncture-proof container for sharps
Speculum
Sphygmomanometer
Adult stethoscope
Fetoscope
Thermometer
Tape to measure fundal height
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Focused ANC

6. The room has sufficient Observe if the facility has the following supplies:
supplies to provide ANC. Cotton swabs
Examination gloves
Disposable needles and syringes
Iron folate tablets
Injection TT
Nefidipine
Paracetamol
Albendazole
7. The facility has laboratory Observe if the facility laboratory offers:
services. Hemoglobin test
Blood grouping
Urine test for protein (dipstick or boiling)
8. The ANC clinic has clinical Observe whether the clinic has available and uses the following:
records system in use. Antenatal register
PMTCT register
ANC/PNC cards
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Instructions: Observe the following standards (912) in sequence with two pregnant women that come for ANC.
First Second
9. The pregnant woman is Observe during care of two pregnant women whether the provider: Woman Woman
received and greeted Y N NA Y N NA
cordially and respectfully. Greets the woman and her companion (if present) in a cordial manner.
Allows the womans companion to remain in the room as her choice.
Explains to the woman and her companion what s/he is going to do and
encourages her to ask questions.
Responds to questions using easy-to-understand language for the client.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Focused ANC

First Second
10. The provider takes history Observe during the care of two pregnant women whether the provider: Woman Woman
and records. Y N NA Y N NA
Asks about and records danger signs that the woman may have or has had:
Vaginal bleeding
Respiratory difficulty
Severe headache, blurred vision
Severe abdominal pain
Convulsions/loss of consciousness
Asks about and records previous pregnancies and births (on first antenatal
visit only).
Asks about and records common discomforts of pregnancy and manages
accordingly.
Asks about and records surgical, medical and family history.
Asks about and records any general health problems.
Asks about and records:
Full or partial TT immunization
Current medications and/or herbal treatments
Malaria treatment (if applicable)
Calculates/confirms gestational age.
Calculates/confirms expected due date (EDD)first visit.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
First Second
11. The provider correctly Observe during care of two pregnant women whether the provider: Woman Woman
performs a physical Y N NA Y N NA
examination. Washes hands.

Explains each stage of the examination to the woman using easy-to-
understand language.
Measures pulse.
Measures blood pressure.
Checks conjunctiva and palms/nails for anemia.
Examines the womans breasts for inverted nipples, lumps and discharge.
Examines for thyroid and lymph nodes under arms.
First Second
12. The provider correctly Observe during care of two pregnant women whether the provider: Woman Woman
performs an obstetrical Y N NA Y N NA
exam. Inspects the abdomen.

Measures symphysiofundal height (SFH).
Determines fetal lie and presentation (after 36 weeks).
Listens to fetal heart rate (after 20 weeks).
Washes hands.
Records all findings on the ANC card.
Informs woman of key findings.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Focused ANC

13. The provider informs and Observe whether the provider (first visit):
refers to voluntary counseling Asks the woman if she has ever tested for HIV:
and testing (VCT) and/or If no, provides information about VCT including the process,
PMTCT. confidentiality, results and locally available service.
If yes and positive:
Explains about HIV/AIDS and the risks for the child.
Explains about nearest available of PMTCT services.
14. The provider requests and Observe during care of two pregnant women whether the provider requests or First Second
Woman Woman
provides laboratory tests. checks the following laboratory tests: Y N NA Y N NA
Hemoglobin
Blood grouping and Rh factor
Urinalysis to test albumin
15. The provider assists the Observe during care of two pregnant women whether the provider asks about or First Second
Woman Woman
woman and her companion describes: Y N NA Y N NA
to develop a birth plan. Skilled provider and place of birth

Signs and symptoms of labor and when she has to go to the hospital
Emergency transportation and funds
Items for clean and safe birth
Decision-making person in case complication occurs at home
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
16. The provider correctly Observe whether the provider describes:
describes danger signs and Vaginal bleeding
symptoms. Respiratory difficulty
Severe headache/blurred vision
Severe abdominal pain
Convulsions/loss of consciousness
17. The provider gives routine Observe whether the provider:
medications and counseling Provides sufficient iron tablets to be taken once daily until next visit.
to the woman. Counsels about eating nutritious food.
Gives TT based on womans need and according to protocol.
Provides albendazole 400 mgone tablet during second trimester.
Provides specific advice and counseling as needed (i.e., common
discomforts, rest, hygiene, breastfeeding).
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Focused ANC

18. The provider reviews/ Observe whether the provider:
evaluates care and Asks if she has any questions and responds.
schedules a return visit with Sets a date for the next visit based on GoNs SBA policy of four focused ANC
the pregnant woman. visits (second visit at 2228 weeks, third at 32 and fourth at 38).
Informs the woman that she must come anytime if she has danger signs and
symptoms.
Fills out the womans ANC card.
Thanks the woman for coming and requests her to come back in the next
visit.
Records all information in the antenatal register.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 2: Focused Antenatal Care

Total standards met
TOOL 3: COMPLICATIONS DURING PREGNANCY

Date:

Hypovolemic Shock: Interview a provider who is likely to manage a case of hypovolemic shock.
1. The provider describes signs Ask the provider What are the signs of shock?
of shock. Pulse weak and equal to or greater than 110 per minute
Systolic blood pressure less than 90 mm Hg
Pallor, sweating
Confusion or unconsciousness
Scanty urine output less than 30 ml
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 3: Complications during Pregnancy

2. The provider describes the Ask the provider What is the immediate treatment to be given?
management of shock. Ensures that the woman is in the trendelenburg position.
Maintains airway.
Administers oxygen 68 liter/minute by cannula or mask.
Starts two IV lines using a no. 16 or 18 IV cannula.
Takes a blood sample for performing hemoglobin, coagulation, blood group
and Rh (cross-matching).
Replaces fluids with saline or Ringers Lactate:
1 liter over a 1520 minute period (wide open rate).
Administers at least 2 additional liters of this solution during the first
hour.
Continues to replace volume intravenously in accordance with the loss
of blood.
Assesses womans need for transfusion.
Performs bladder catheterization and measures urine output.
Keeps the woman warm.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
3. The provider identifies the Ask the provider "How do you identify the cause of the shock?
specific cause of shock and Take history (patient or accompanying person).
describes the management Perform vaginal obstetric examination if needed.
according to the cause.
Propose diagnosis or identify cause of bleeding.
Ask the provider "What are the next steps?
Perform specific actions to stop the bleeding.
Perform blood transfusion as soon as possible, as needed.
Refer to speciality service (ICU, OR, ER etc.), if needed.
4. The facility has the Observe the availability of:
equipment and drugs for No. 16 or 18 IV cannula
management of shock. Container for taking blood sample
IV equipment
Saline or Ringers lactate
Oxygen cylinder or central supply source in working order
Nasal cannula and mask
Foley's catheter
Urine collection bag
Catheterization set
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Blood transfusion
5. Clinical records show that Determine whether the following information is recorded on the clinical records of First Second
Case Case
the provider followed the the two most recent transfusions for obstetric care: Y N NA Y N NA
recommended procedures Information prior to initiating transfusion:
BEFORE initiating a blood
General appearance
transfusion.
Temperature
Pulse
Respiration
Blood pressure (BP)
Liquid intake (IV and oral)
Diuresis
Hematocrit or hemoglobin
Womans blood group, type and volume of blood to be transfused
Confirmed donor code to be transfused is matching with womens blood
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
6. Clinical records show that Determine whether the following information is recorded on the womens clinical
the provider followed the records:
recommended procedures Information on the history of patient's condition 15 minutes subsequent to
DURING a blood transfusion. initiation of transfusion then hourly during transfusion:
General appearance
Temperature
Pulse
Respiration
BP
Liquid intake (IV and oral)
Amount of urine
7. Clinical records show that Determine whether the following information is recorded on the womens clinical
the provider followed and records:
recorded the recommended Information on the history upon completion of the transfusion:
procedures AFTER Duration (time of completion of transfusion)
completing a blood
Volume and type of products transfused
transfusion.
Donor code for product transfused
Whether there was an adverse reaction
Specific actions taken according to the adverse reaction if any
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Managing bleeding during pregnancy (observe PAC services)
8. The provider performs initial Observe whether the provider:
assessment of bleeding Greets woman respectfully and with kindness.
during pregnancy. Assesses patient for shock or complications.
9. The provider assesses the Takes a reproductive history and perform physical examination and
womans condition. laboratory tests.
Gives her information about her condition.
10. The provider prepares to Tells the woman (and her support person) what is going to be done, listens to
manage bleeding using MVA her and responds attentively to her questions and concerns.
(PAC). Provides continual emotional support and reassurance.
Gives paracetamol 500 mg by mouth to the woman 30 minutes before
procedure.
Determines that required sterile or HLD instruments and cannula are ready.
Checks MVA syringe and charges it (establishes vacuum). Ensures that
appropriate size cannula and adapters are available.
Checks that patient has recently emptied her bladder and washed her
perineal area.
Puts on plastic apron.
Washes hands thoroughly and put on HLD or sterile surgical gloves.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
11. The provider performs Performs bimanual examination.
procedural task of MVA. Inserts speculum.
Applies antiseptic to cervix and vagina two times.
Removes any products of conception (POC) hanging from os and check for
any cervical tears.
Puts tenaculum or volsellum forceps on lower lip (7 or 5 o'clock) of cervix.
Inserts the cannula gently through the cervix into the uterine cavity.
Attaches the prepared syringe to the cannula.
Evacuates contents of the uterus.
Ensures sign of completion (e.g. pink foam, grating sensation).
Removes forceps and tenaculum and speculum.
Performs bimanual examination.
Inserts speculum and checks for bleeding.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

12. The provider performs post Flushes MVA syringe and cannula with 0.5% chlorine solution and submerge
procedural task of MVA. in solution for decontamination.
Washes hands with gloves on in 0.5% chlorine solution, removes gloves and
discards them in a leak-poof container or plastic bag if disposing of; or
decontaminate them in 0.5% chlorine solution if reusing.
Washes hands thoroughly.
Checks for bleeding and ensure cramping has decreased before discharge.
Monitors vital signs.
Instructs patient regarding postabortion care.
Discusses reproductive goals and, as appropriate, provides family planning.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
1
Severe pre-eclampsia or eclampsia : Interview a provider who is likely to manage severe pre-eclampsia or eclampsia.
13. The provider correctly Ask the provider What are the signs and symptoms of severe pre-eclampsia and
describes the signs and eclampsia?
symptoms of severe pre- Severe pre-eclampsia:
eclampsia and eclampsia. Diastolic BP equal to or more than 110 mm Hg
20 weeks or more gestation
Proteinuria 3+
Eclampsia:
Convulsions
Diastolic BP equal to or more than 90 mm Hg
20 weeks or more gestation
Proteinuria 2+ or greater
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
1
Instructions to the assessors: Remember that severe pre-eclampsia and eclampsia are managed similarly except that birth must take place within 12 hours following a convulsive
episode and within 24 hours in the absence of a convulsion.

14. The provider describes the Ak the provider How would you manage severe pre-eclampsia and eclampsia?
correct management of Administer initial (loading) dose of magnesium sulphate:
severe pre-eclampsia and Administer 4 grams of 20% magnesium sulphate in solution (20 ml) IV
eclampsia. over a 5-minute period.
Administer 5 grams of 50% magnesium sulphate solution (20 ml) with 1
ml of 2% lidocaine IM deep in each buttock (total 10 grams).
In the event of a second convulsion after 15 minutes, administer 2 grams of
50% magnesium sulphate in solution (10 ml) IV over a 5-minute period.
Administer maintenance dose:
Administer 5 grams of 50% magnesium sulphate solution with 1 ml of
2% lidocaine deep IM alternately in each buttock every 4 hours,
providing there are no complications.
Continue with magnesium sulphate for 24 hours following birth or the
most recent convulsion (which ever occurs last).
Catheterize bladder.
Monitor Intake and output.
Monitor vital signs of women.
Monitor fetal heart rate (FHR).
If there were convulsions, birth must take place within 12 hours following the
convulsion or, in the absence of convulsions, within 24 hours.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider describes the Provide antihypertensive treatment (if diastolic BP is 110 mm Hg or more if
correct management of no convulsion; 90 mm Hg if convulsion):
severe pre-eclampsia and Plan 1: Hydralazine 5 mg IV slowly every 5 minutes or 12.5 mg IM every
eclampsia (continued) 2 hours, until diastolic BP stabilizes between 90 and 100 mm Hg OR
Plan 2: Nifedipine 5 mg sublingual, repeating the dose if the diastolic BP
is still >110 after 10 minutes
15. The provider correctly Ask the provider What is the correct follow up for woman with severe pre-
describes followup. eclampsia or eclampsia?
Monitor hourly:
BP
Pulse
Temperature
Patellar reflex
FHR
Intake and urine output
Signs and symptoms of pulmonary edema
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

The provider correctly Suspend or postpone use of magnesium sulphate if respiration <16/minute,
describes followup patellar reflexes absent or output <30ml/hour.
(continued) If urine output less than 30/hour, magnesium sulphate withheld and patient
infused with 1 L IV over 8 hours, with monitoring for pulmonary edema.
In the event of respiratory arrest:
Perform assisted ventilation.
Administer calcium gluconate 1 g (10 ml of a 10% solution) IV slowly
(over 10 mins) until calcium gluconate begins to antagonize the effects
of magnesium sulphate and respiration begins.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met
TOOL 4: NORMAL DELIVERY AND IMMEDIATE NEWBORN CARE

Date:

1. The area designated for first Observe if the area:
stage of labor and delivery Is well ventilated (open windows, fan) and warm.
room provides a safe and Is clean.
comfortable environment.
Has good light.
A chair available for women during the first stage of labor.
Sufficient chairs and space for one companion for each pregnant woman in
the first stage room.
Sufficient space for pregnant women in the first stage room to be able to walk
around.
A delivery table with pad and back that raises to allow for semi-seated
position.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 4: Normal Delivery and Immediate Newborn Care

The area designated for first Screens or curtains to ensure the privacy of women.
stage of labor and delivery Accessible, working bathrooms available for women during the first and
room provides a safe and second stage of labor.
comfortable environment
(continued) A sink with running water and soap.
2. The area designated for first Observe if the designated area is equipped with:
stage of labor and delivery Sphygmomanometer
room has equipment Stethoscope
appropriate for the provision Fetoscope or doppler
of care. Thermometer
Working oxygen tank
Delivery kits
Suture kit
Forceps or vacuum extractor
Ambu-bag
Neonatal mask size 0 and 1
DeLee Suction or foot or electric suction
Sterile clamp or thread to tie umbilical cord
Instrument table or stand
Scale for weighing the newborn
Wall clock
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
3. The area designated for first Observe if the area contains:
stage of labor and delivery Sterile gloves
room has appropriate Examination gloves
supplies for provision of
Suture materials
care.
Two clean baby wraps per newborn for warming and drying newborn
Sterile gauze for wiping face and mouth of newborn
Cotton swabs and antiseptic solution (povidine iodine) or boiled water for
cleaning perineum
Disposable syringes and needles
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

4. The area designated for first Observe if the area contains:
stage of labor and delivery Plastic aprons
room has appropriate Eye shields
infection prevention
Face masks
materials available.
Closed-toed rubber shoes or boots
Individual hand towels for drying hands for each staff member and training
participant.
Containers for 0.5% chlorine solution for gloves and instruments
Buckets for immersing dirty linens in water with detergent
Sharps containers
Waste bins with plastic liners
Spray bottle or basin containing 0.5% chlorine solution
Cloth for wiping tables with chlorine solution
Bucket with cover or plastic bag for placenta disposal
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
5. Appropriate medications are Observe in the labor room that there is:
available for provision of Oxytocin (stored in refrigerator)
routine care in the labor Ergometrine
room.
Lidocaine 1%
IV fluids and sets
Vitamin A
Antibiotic eye ointment for newborn
6. There is a designated Observe if there is a designated trolley with:
emergency trolley that is IV set
easily accessible. IV cannulae (16, 18 gauge)
IV fluid/normal saline
Oxytocin
Syringe 5ml, 10ml, 20 ml
Ergometrine
Magnesium sulphate
Calcium gluconate
Lignocaine 1%
Nefidipine
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

7. Equipment and supplies for Observe that there are prepared:
newborn resuscitation are Place for resuscitation: clean, dry, well-lit, flat surface covered with clean
prepared before every birth. cloth
Three cloths
2 cloths for delivery (1 to dry baby, 1 to wrap baby)
1 cloth for resuscitation to put under the babys shoulder
A clock or watch with a second switch/hand
Suction or cloth to wipe mouth
Bag and mask
Oxygen, if available
8. The maternity (postnatal) Observe if the maternity (postnatal) ward:
ward is adequate for Is well ventilated (open windows or fan) and warm.
providing postpartum care. Is clean and well-maintained.
Has good light.
Has sufficient space for the mother, the baby and a companion.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
9. Appropriate equipment is Observe if the postnatal ward is equipped with:
available in the postnatal Sphygmomanometer
ward for providing Stethoscope
postpartum care.
Clinical thermometers
IV stand
Working oxygen tank or central supply source in or near the area
Examination gloves
10. There are working toilets for Observe if there is a toilet for women that has:
provider and for women in A door that locks
the first stage labor, delivery An area is clean and well-maintained
and postpartum areas.
A working washbasin
Soap
Container with plastic liner for waste
Working toilet with flush
Shower with hot water
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Care during Labor and Delivery
Instructions (for standards 1125): Observe one or more providers giving care to two women in the labor and/or delivery rooms. The first column is for the first case (woman)
and the second column is for the second case (woman).
11. The provider receives the Observe two women in labor and determine whether the provider (in the labor First Second
Woman Woman
woman in labor in a cordial and delivery rooms): Y N NA Y N NA
manner. Greets the woman and her companion in a cordial manner.
Responds to questions using easy-to-understand language.
Responds to her immediate needs (thirst, hunger, cold/hot, need to urinate,
etc.).
12. The provider properly Observe two women in labor and determine whether the provider (in the labor First Second
Woman Woman
reviews and fills out the room): Y N NA Y N NA
clinical history of the woman Asks the woman the following information:
in labor.
Name
Age
Number of previous pregnancies/births
Any complications during labor and postpartum period
Previous births by cesarean section, forceps or vacuum
Other general medical problems
Use of medications
Estimated date of delivery (EDD) or last menstrual period
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider properly Asks the woman about her labor: First Second
Woman Woman
reviews and fills out the Y N NA Y N NA
clinical history of the woman When the painful regular contractions began
in labor (continued)
How frequently they are occurring
If her membranes rupture: when, what color and what smell it had
Whether she feels the babys movements
Records the information on clinical history chart.
13. The provider properly First Second
Determine whether the provider (in the labor and delivery rooms): Woman Woman
prepares for the physical Y N NA Y N NA
examination. Ensures privacy with a screen or curtain to separate the woman from others
at least during examination.
Explains to the woman and her companion what the provider is going to do
and encourages them to ask questions.
Asks the woman to empty the bladder and clean the perineum.
Helps the woman to climb up on to the bed or examining table.
Washes hands with running water and soap for 1015 seconds and dries
with an individual clean towel or allows hands to airdry.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

14. The provider properly Observe if the provider: First Second
Woman Woman
conducts the physical Y N NA Y N NA
examination. Explains each step of the examination to the woman.
Takes temperature.
Takes pulse.
Measures blood pressure.
Determines respiratory rate.
Measures symphysiofundal height (SFH).
Determines fetal lie and presentation.
Identifies degree of engagement by abdominal palpation (from five to zero
fingers above the pubis).
Evaluates uterine contractions (frequency and duration over a 10-minute
period).
Auscultates fetal heart rate (FHR).
Explains all findings to the woman and her companion.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
15. The provider properly First Second
Observe if the provider: Woman Woman
conducts a vaginal Y N NA Y N NA
examination. Explains to the woman what s/he is going to do.
Puts sterile gloves on both hands.
Cleanses the perineum with non-alcoholic antiseptic solution or boiled, warm
water.
Carefully inserts two fingers of the exam hand.
Assesses cervical dilatation, molding, station of presenting part and position.
Carefully withdraws her fingers once the examination has concluded.
Explains findings to the woman.
Gloves are removed after being immersed in 0.5% chlorine solution and
placed in a leak-proof container.
Records all information on the clinical records and partograph.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

16. The provider prepares and First Second
Observe two women in labor and determine if the provider: Woman Woman
implements a plan according Y N NA Y N NA
to the findings of the clinical Ensures the woman has a companion during first stage of labor and birth.

history and the physical,
Counsels the woman about the importance of:
obstetric and vaginal
examinations for providing Going to the bathroom often to empty her bladder.
care to the woman. Taking liquids and light foods whenever she needs to.
Walking and changing position according to desire and comfort.
17. The provider uses the Observe, based on the clinical history and partograph of two women in labor, if First Second
Woman Woman
partograph to monitor labor the provider: Y N NA Y N NA
and make adjustments to the Records patient information:
birth plan when the woman
Name
goes into active stage of
labor (4cm). Gravida, para
Hospital number (if applicable)
Date and time of admission
Time of ruptured membranes
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider uses the Records every 30 minutes: First Second
Woman Woman
partograph to monitor labor Y N NA Y N NA
and make adjustments to FHR
the birth plan when the
Uterine contractions (frequency and intensity over a 10-minute period)
woman goes into active
stage of labor (4cm) Maternal pulse
(continued) Amount of IV solution with oxytocin in drops per minute, medications
and other intravenous liquids, if used
Records temperature every four hours.
Records BP every 4 hours.
At every vaginal examination (every 4 hours or less according to progress of
labor):
Records the condition of the membranes and characteristics of the
amniotic fluid.
Graphs the degree of molding of the head.
Graphs cervical dilation.
Graphs the descent of the head or buttocks.
Records the amount of urine every time the woman urinates.
Records the time of the observations.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

The provider uses the Adjusts the labor plan according to the parameters encountered: First Second
Woman Woman
partograph to monitor labor Y N NA Y N NA
and make adjustments to the If parameters are normal, continues to implement the plan (walk about
birth plan when the woman freely, hydration, light food if desired, change positions, etc.) OR
goes into active stage of If parameters are not normal, identifies complications, records the
labor (4cm) (continued) diagnosis and makes adjustments to the birth plan
18. The IP practices during labor First Second
Observe in the labor room if the provider: Woman Woman
are performed according to Y N NA Y N NA
standards. Cleanse the vulva with an antiseptic solution or boiled water before
performing vaginal examination.
Uses HLD or sterile gloves when performing vaginal examination or when in
contact with body fluids.
Performs limited vaginal examination (e.g., every four hours or as indicated).
Performs limited bladder catheterization:
The bladder is kept empty by encouraging to go to the toilet during
labor.
Straight bladder catheterization is not a routine for normal delivery.
Uses limited IV solution:
Ingestion of liquids is encouraged during labor.
Use of IV solution is not a routine during labor and delivery.
Shaving of the perineal area is not performed.
Rupture of membranes is not performed routinely.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
19. The provider prepares to Observe two women in labor and determine whether the provider (in the labor or First Second
Woman Woman
assist the birth. delivery rooms): Y N NA Y N NA
Has delivery pack and other essential materials available and ready to assist
the delivery:
Sterile tray
Two hemostats (clamps)
One scissors for cutting the cord
One cord clamp or sterile tie
Four clean or sterile towels: one to receive baby; one to dry the baby;
one for under the woman; one for active management
Sterile gauze to clean babys mouth and nose
One syringe with 10 IU of oxytocin
Two pairs of sterile gloves
Ambu bag and mask ready for use.
Has one plastic container with 0.5% chlorine solution for decontamination.
Has one plastic container with lid and a plastic liner to dispose the placenta.
Has one plastic container with a plastic liner for medical waste (gauze, etc.).
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

The provider prepares to Has one sharp container at point of use to dispose of needle and syringe. First Second
Woman Woman
assist the birth (continued) Y N NA Y N NA
Has one leak-proof container to dispose of soiled linen.

Keeps the place where the woman is located clean.
Attends the birth in the position selected by the woman.
Ensures the privacy of the woman:
Separates the area with curtains, sheets or screens as appropriate.
Ensures that the minimum number of individuals are present during
birth (the provider attending the birth and a family memberthe
individual chosen by the woman).
Explains to the woman how to help herself and manage the bearing down
process (when and how).
Puts on a clean plastic or rubber apron.
Puts on face shield or mask and goggles.
Wears shoes that protect feet from blood spills, splashes or instruments.
Puts sterile gloves on both hands.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
20. The provider properly assists Observe two women during a delivery and determine whether the provider (in the First Second
Woman Woman
delivery of the head. labor or delivery rooms): Y N NA Y N NA
Cleanses the vulva with non-alcoholic antiseptic solution or boiled warm

water.
Allows the woman to bear down when she feels the desire (does not force
her to bear down).
Performs an episiotomy only if necessary (breech, shoulder dystocia,
forceps, vacuum, scarring from poorly healed third or fourth degree tear).
Asks to bear down gently along with the contractions while the head is
emerging.
Places the fingers of one hand against the babys head to keep it flexed and
to prevent abrupt expulsion.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

21. The provider properly assists Determine whether the provider: First Second
Woman Woman
with the delivery of the body. Y N NA Y N NA
After the emergence of the head, asks the woman to stop bearing down.
Cleans the babys mouth and nose using sterile gauze.
Palpates to determine if cord around neck.
Allows spontaneous external rotation without manipulation.
Carefully takes the babys head in both hands and applies downward
traction until the anterior shoulder has emerged (no neck holding).
Guides the babys head and chest upward until the posterior shoulder has
emerged.
Holds the baby by the trunk and places the baby on a clean dry towel on the
mothers abdomen.
Dries baby vigorously and changes wet towel for a clean dry one.
Cuts/clamps the umbilical cord using sterile scissors under gauze to prevent
blood spurting.
If the baby is breathing normally, passes the baby to mother for skin-to-skin
contact on breast.
If the baby does not begin breathing or is breathing with difficulty, initiates
resuscitation.
Notes time of birth.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
22. The provider properly Observe two women during a delivery and determine whether the provider (in the First Second
Woman Woman
performs active labor or delivery rooms): Y N NA Y N NA
management of the third Palpates the mothers abdomen to rule-out the presence of a second baby.
stage of labor.
Tells the woman that she will receive an injection and administers 10 IU of
oxytocin IM.
Places the other hand on the womans symphysis pubis (over the sterile
towel).
Maintains firm traction on the cord and waits for the uterus to contract.
Upon contraction, applies firm and sustained downward traction on the cord
with counter traction above the pubis to guard the uterus, until the placenta
is expelled.
If this maneuver does not provide immediate results, stops applying traction,
holding the cord and clamp until the next contraction.
Repeats controlled cord traction during contraction while simultaneously
applying counter traction above pubis to guard uterus.
With both hands, assists in the expulsion of the placenta by turning it over in
the hands without applying traction twisting the membranes.
Massages the uterus with one hand on a sterile cloth over the abdomen until
it contracts firmly.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Immediate Postpartum and Newborn Care
23. The provider adequately Observe two women during a delivery and determine whether the provider (in the First Second
Woman Woman
performs immediate labor or delivery rooms): Y N NA Y N NA
postpartum care. Checks to see whether the placenta is complete (maternal and fetal sides,
plus membranes).
Informs the woman what she is going to do before proceeding, then
carefully examines the vagina and perineum.
Sutures tears if necessary.
Covers the perineum with a clean sanitary pad.
Makes sure that the woman is comfortable (clean, hydrated and warmly
covered).
Ensures that the baby is well covered, is with the mother and has started
breastfeeding.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
24. The provider properly Observe whether the provider (in the labor or delivery rooms):
disposes of the used Before removing gloves:
instruments and medical Discards the placenta in a leak-proof container with a plastic liner.
waste after assisting the
birth. Disposes of medical waste (gauze, etc.) in a plastic container with a
plastic liner.
Puts the soiled linen in a leak-proof container.
Places all reusable instruments in a 0.5% chlorine solution for 10
minutes.
Disposes needle and syringe in a puncture-resistance container, without
removing, recapping or breaking the needle.
Gloves are removed after being immersed in 0.5% chlorine solution and
placed in a leak-proof container.
Washes hands with running water and soap for 1015 seconds and dries with
an individual clean towel or allows hands to airdry.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Immediate care provided to newborn and to the woman. Observe one or more providers giving care to two women in the labor and/or delivery rooms. The first column is for the
first case (woman) and the second column is for the second case (woman).
25. The provider closely Observe two women after the delivery and determine whether the provider: First Second
Woman Woman
monitors the woman and Y N NA Y N NA
newborn for at least six Monitors the woman every 15 minutes in the first two hours checking:
hours after the birth. Uterine contraction
Vaginal bleeding
Bladder distention
BP
Pulse
Consciousness
Babys breathing, condition and breastfeeding
Monitors the woman every 30 minutes in the third hour checking:
Uterine contraction
Vaginal bleeding
Bladder distention
BP
Pulse
Hydration
Consciousness
Babys breathing, condition and breastfeeding
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider closely Monitors the woman and newborn every hour for the next three hours. First Second
Woman Woman
monitors the woman and Y N NA Y N NA
newborn for at least six Assists the woman with breastfeeding.
hours after the birth
Asks the woman if she has urinated and encourages her to do so whenever
(continued) she wishes.
Records the information on the womans clinical record and reports any
abnormalities.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met

TOOL 5: POSTPARTUM CARE

Date:

1. The provider prepares for Observe if the provider:
postpartum assessment and Prepares the necessary equipment.
care. Greets woman respectfully and with kindness.
Tells the woman and her support person, what is going to be done, listens to
her attentively and responds to her questions and concern.
Provides continual emotional support and reassurance.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 1 of 7
Tool 5: Postpartum Care

2. The provider takes history of Observe whether the provider asks the following questions if the information is not
personal information (first available on the womens record:
visit). Name, age and the name of baby
Access to reliable transportation
Sources of income/financial support
Frequency of pregnancies and number of children
Number of children that are still living
Any particular problem at present
Care received from another caregivers
3. The provider takes history of Observe that the provider asks the mother if she is:
daily habits and lifestyle. Working outside the home
Long distance walking, carrying heavy loads or physical labor
Getting enough sleep/rest in a day
Normally eating in a day
Eating any substances such as dirt or clay
Smoking, drinking alcohol or using other possibly harmful substances
Ever prevented from seeing family or friends, stopped from leaving home or
any threats to life
Injured, hit or forced to have sex by someone
Frightened of anyone
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 2 of 7
4. The provider takes history of Observe if the provider asks the woman:
recent pregnancy and When woman delivered the baby
childbirth (first visit). Delivery place of the baby and who attended the birth
Whether woman had any vaginal bleeding during this pregnancy
Whether woman had any complications during this childbirth
Any complications with the baby
5. The provider takes history of Observe if the provider asks the woman:
present postpartum period About any heavy bleeding since women gave birth
(every visit). Color of vaginal discharge and frequency to change pad/cloth
Any problems with bowel or bladder function
Feels good about baby and ability to take care of the baby
How the family is adjusting to the baby
Feels that breastfeeding is going well
If she has had any complications following previous childbirth
6. The provider takes Observe if the provider asks the woman:
contraceptive history (first Number of children she plans to have
visit). If she has used any family planning method before
If she plans to use family planning in the future
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 3 of 7

7. The provider takes medical Observe the provider if s/he asks the woman if the woman:
history. Has any allergies
Has had anemia recently
Has been tested for HIV, syphilis
Has any chronic illness/conditionsuch as tuberculosis, hepatitis, heart
diseases, diabetes or any other chronic illness
Has history of hospitalization or surgery/an operation
Has taking any drugs\medicationsincluding traditional/local preparations,
herbal remedies, overthe-counter drugs, vitamins and dietary supplements
Complete series of five tetanus toxoid immunizations
Date of last booster of tetanus toxoid
Any problem at present
8. The provider takes interim Observe the provider if s/he asks the woman:
history (return visit). Any problems since last visit
Daily habits or lifestyle (workload, rest, dietary intake) changed since last visit
Care received from another caregiver since last visit
Have taken drugs/medications prescribed and followed the
advice/recommendations provided during the last visit
Any reactions to or side effects from immunizations or drugs/ medications
give at last visit
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 4 of 7
9. The provider performs Observe if the provider:
physical examination/ Asks the women to empty her bladder.
assessment of general well- Observes gait and movements, behavior and facial expressions.
being (every visit).
Observes general hygienenoting visible dirt and odor.
Checks skinnoting lesions and bruises.
Checks conjunctiva for pallor.
10. The provider performs Observe that the provider observes the women while seated and relaxed and
measurement of vital signs measures blood pressure, temperature and pulse.
(every visit).
11. The provider performs breast Observe if the provider:
examination (every visit). Explains the next steps in the physical examination to the women and obtains
her consent to proceed.
Washes hand thoroughly.
Asks the women to uncover her body from the waist up and examines her
breastsnoting any abnormalities.
abdominal examination Asks the women to uncover her stomach and lie on her back with her knees
(every visit). slightly bent.
Looks for old or new incisions on the abdomen and gently palpates abdomen
between umbilicus and symphysis pubisnoting size and firmness of uterus.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 5 of 7

13. The provider performs leg
Observe whether the provider examines the woman's legsnothing any calf pain.
examination (every visit).
genital examination (every Asks the woman to uncover her genital area and covers or drapes her to
visit). preserve privacy and modesty.
Washes hands thoroughly and puts on new examination or HLD gloves on
both hands.
Inspects/examines labia, clitoris and perineumnoting lochia, scars, bruising
and skin integrity.
Decontaminates gloves before removing them, then if disposing of them,
places in a plastic bag or leak-proof, covered container, if reusing them,
decontaminates them in 0.5% chlorine solution.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 5: Page 6 of 7
15. The provider provides Observe if the provider:
specialized care according to Provides HIV counseling (if the woman does not know her HIV status or has
the mothers needs. not been tested for HIV).
Provides information about breast-feeding and breast care, based on the
women's breastfeeding history.
Reviews the women complications readiness plan with her (or develop one if
she does not have one).
Introduces the concepts of birth spacing and family planning.
Provides advice and counseling about diet and nutrition.
Provides advice and counseling about self-care.
Gives TT based on woman's need.
Dispenses sufficient supply of iron/folate until next visit and counsels the
women about taking the pills.
Dispenses other medications (such as vitamin A) if not given immediately
after birth.
Schedules the next visit (second visit within 47 days; third visit within 42
days) or as needed in case of complications.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met
Tool 5: Page 7 of 7

TOOL 6: NEWBORN CARE

Date:

1. The provider properly Observe if the provider:
prepares for assessment of Prepares the necessary equipment.
newborn. Tells the mother what she is going to do, encourages her to ask questions
and listens to what she has to say.
2. The provider takes history of Observe whether the provider asks the following questions if the information is not
personal information (first available on the mothers/baby's record:
visit). Name and address
The name and sex of the baby
Date and time of birth of the baby
Sources of income/financial support
Frequency of pregnancy and number of children
Any particular problem at present
Care received from another caregivers
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 6: Page 1 of 6
Tool 6: Newborn Care

3. The provider takes birth Observe whether the provider asks the following questions if the information is not
history of the baby. available on the mothers/baby's record:
Place of baby born and who attended the birth
Any complications during the birth that may have caused injury to the baby
Did the baby needs resuscitation (help to breath) at birth
Babys weight at birth
Does the baby have a congenital malformation and/or deformity
Immunizations such as for polio, TB and hepatitis B given
4. The provider takes medical Observe whether the provider asks the following questions if the information is not
history of the mother (first available on the mothers/baby's record:
visit). History of any infectious diseases such as hepatitis B, HIV, syphilis or TB
5. The provider takes history of Observe whether the provider asks about the following:
newborn period (first and Feelings about the baby and ability to take care of her/him
every visit). Is family adjusting to the baby
Is breastfeeding is going well
Frequency of the babys feeding
The last time the baby passed stool and the color/consistency
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 6: Page 2 of 6
6. The provider takes interim Observe whether the provider asks about the following:
history (return visit). Any problem at present and any problem since the last visit
Care received from another caregiver since the last visit
Any changes in the babys condition or routine since the last visit
Any reactions or side effects from immunizations drugs/medications
7. The provider performs a Observe if the provider:
newborn examination (first Washes hands thoroughly for 1015 seconds with soap and water and dries
and every visit). them with a clean, dry cloth or allow them to airdry.
Places the baby on a clean warm surface or examine her/him in the mothers
arms.
Weighs the baby.
Measures respiratory rate and temperature.
Observes color, movements and posture, level of alertness and muscle tone,
and skinnoting any abnormalities.
Examines head, face and mouth, eyesnoting any abnormalities.
Examines chest, abdomen and cord, and external genitalianoting any
abnormalities.
Examines back and limbsnoting any abnormalities.
Washes hands.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 6: Page 3 of 6

8. The provider correctly Observeif the provider:
provides BCG vaccination to Prepares the necessary equipment.
the baby. Tells the mother what is going to be done and responds to her questions and
concerns.
Washes hands thoroughly for 1015 seconds with soap and water and dries
them with a clean, dry cloth or allow them to airdry.
Selects the deltoid site for injection.
Checks the expiry date on the vial of vaccine.
Draws vaccine into a BCG syringe.
Checks that vaccine and dose are correct.
Holds the syringe and needle almost parallel with skin, with the bevel of
needle facing up.
Pulls the skin taut with one hand, inserts the tip of needle barely under the
skin and advances the needle slowly until bevel of needle has fully entered
the skin.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 6: Page 4 of 6
The provider correctly Gently points the needle upward, without repiercing skin and injects the
provides BCG vaccination to vaccine with steady pressure for three to five seconds and look for blanching
the baby (continued) of skin.
Places any blood-contaminated items (cotton-wool balls) in a plastic bag or
leak-proof, covered waste container.
Disposes of needle and syringe in puncture-proof container.
Washes hands thoroughly with soap and water and dries with a clean, dry
cloth (or airdry).
9. The provider provides Observe if the provider:
education on breastfeeding. Includes family in discussion of breastfeeding, if possible.
Explains why it is important to breastfeed the baby.
10. The provider assesses Observe if the provider:
breastfeeding. Helps the mother into a comfortable position.
Assists the mother to position the baby:
Looks at how the baby is attached and sucking. Explains to mother how
she can tell if the baby is sucking well.
If the baby is not attached or sucking well, takes the baby off the breast
and tries again.
Lets baby suck as long as s/he wants or until s/he releases the breast.
After breastfeeding burps the baby.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 6: Page 5 of 6

11. The provider advises mother Observe if the provider explains to the mother to:
about feeding the baby and Give only breast milk in the first six months.
how to maintain her own Feed the baby on demand.
health during breastfeeding.
Use comfortable and different positions.
Get enough rest to ensure sufficient milk supply.
Eat one extra meal a day and drink extra fluids to ensure sufficient milk
supply.
Check for signs that the baby is getting enough milk:
Baby passes urine at least six times in 24 hours.
Baby gains weight over time (after the first week).
Continue to breastfeed a sick baby.
Breastfeed for at least two years.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met
Tool 6: Page 6 of 6
TOOL 7: COMPLICATIONS DURING LABOR AND CHILDBIRTH

Date:

Cord prolapse: Guided interview
1. The provider states the Ask the provider What is the management of cord prolapse?
correct management of Greet the woman and her companion cordially.
prolapsed cord. Provide continual emotional support and reassurance, as feasible.
Give oxygen 46 L/minute by face mask or nasal cannula.
Elevate the hips/trendelenberg position as feasible.
Place one gloved hand into the vagina and push the presenting part upward.
Hold the presenting part as high as possible out of the pelvic brim with the
abdominal hand until the woman has been prepared for cesarean section.
Breech delivery: Direct observation
2. The provider properly Observe whether the provider:
prepares for breech delivery. Prepares the necessary equipment.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 7: Complications during Labor and Childbirth

The provider properly Tells the woman (and her support person) what is going to be done, listens to
prepares for breech delivery her and responds attentively to her questions.
(continued) Provides continual emotional support and reassurance.
Ensures that the conditions for breech delivery are present.
Puts on personal protective barriers.
Washes hands thoroughly and put on HLD or sterile surgical gloves.
Cleans the vulva with antiseptic solution or boiled water.
Catheterize the bladder, if necessary.
3. The provider performs Observe the provider (for delivery of the buttocks and legs) if s/he:
correct delivery of buttocks Tells the woman, when the anterior and posterior buttocks are seen in the
and legs. vagina and the cervix is fully dilated, she can bear down with contractions if
she has the urge to push.
Performs an episiotomy, if necessary.
Lets the buttocks deliver until the lower back and shoulder blades are seen.
Gently holds the buttocks in one hand.
Covers the baby with a clean towel.
If the legs do not deliver spontaneously, delivers one leg at a time.
Holds the baby by the hips.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
4. The provider properly Observe the provider, if s/he:
manages delivery of the Allows arms to dis-engage spontaneously.
arms. If the arms are stretched above the head or folded around the neck, uses
Lovsets maneuver:
Holds the baby by the hips and turn half a circle, keeping the back
uppermost.
Applies downward traction at the same time so that the posterior arm
becomes anterior and deliver the arm under the pubic arch by placing
two fingers on the upper part of the arm.
Draws the arm down over the face as the elbow is flexed, with the hand
sweeping over the face.
To deliver the second arm, turns the baby back half a circle while
keeping the back uppermost and applying downward traction to deliver
the second arm in the same way under the pubic arch.
If the babys body cannot be turned to deliver the arm that is anterior first,
delivers the arm that is posterior.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

5. The provider manages to Observe the provider if s/he assists delivery of the head by modified Mauriceau
deliver head properly. Smellie Veit maneuver:
Lays baby face down with the length of its body over hand and arm.
Places first and third fingers of this hand on babys cheekbones and places
second finger on babys chin to flex head.
Uses the other hand to grasp the babys shoulders.
With two fingers of this hand, gently flexes the babys head toward chest,
while applying downward pressure on the jaw to bring the babys head down
until hairline is visible.
Pulls gently to deliver the head.
Raises the baby, still astride the arm, until the mouth and nose are free.
6. The provider performs the Observe if the provider:
post-procedure task properly. Disposes of waste materials in a leak-proof container or plastic bag before
removing gloves.
Places all instruments in 0.5% chlorine solution for decontamination.
Removes gloves and discard them in a leak-proof container or plastic bag if
disposing of or decontaminate them in 0.5% chlorine solution if reusing.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Shoulder dystocia: Guided interview
7. The provider states the Ask the provider What is the correct management of shoulder dystocia?
correct management of Provide continual emotional support and reassurance to the woman.
shoulder dystocia. Call for help.
Make an adequate episiotomy.
Ask the woman to flex both thighs, bringing her knees as far up as possible
towards her chest.
Ask an assistant to apply suprapubic pressure downwards to assist delivery.
Wearing HLD gloves, apply firm downwards pressure on the fetal head to
move shoulder that is anterior under symphisis pubis.
If the shoulder is still not delivered, insert a hand into vagina and apply
pressure to shoulder that is anterior to rotate shoulder and decrease shoulder
diameter.
If necessary, apply pressure to shoulder that is posterior in the direction of
sternum.
If the shoulder is not delivered, insert a hand into vagina and grasp the
humerus and sweep the arm across the chest.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Newborn resuscitation: Guided interview
8. The provider states the Ask the provider What are the correct steps in preparing for newborn
necessary steps required to resuscitation?"
perform newborn Prepare equipment and supplies for resuscitation before every birth.
resuscitation. Immediately after delivery, put the baby on the mothers abdomen. Rub the
babys whole body firmly with the covering cloth to dry and stimulate the
baby.
If the baby does not begin breathing spontaneously, cut cord and move baby
to resuscitation place.
Explain to the mother and family that the baby needs help.
Remove the wet cloth or towel.
Quickly wrap the baby in the clean, dry, warm cloth without covering the face.
Put the wrapped baby on its back with the rolled cloth under the shoulders to
slightly extend the head.
Suction the mouth first and then the nose.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
9. The provider states the Ask the provider What are the next steps to resuscitate the baby if the baby is not
correct technique for breathing after suctioning?
ventilating the baby. If baby still not breathing, place the mask over the babys mouth and nose
and ventilate two times.
If the chest does not rise:
Check head position.
Check that the mask position and seal are correct.
Check for fluid in the mouth. If there is fluid, suction.
Ventilate the baby 2030 times in 30 seconds. When the baby begins to
breathe, stop ventilation.
After every 30 seconds of ventilation, re-assess the babys breathing:
If the baby breathes spontaneously, stop resuscitation. Continue to give
supportive care.
If the baby is not breathing or is gasping and heart rate is <100 (evaluate
for 6 seconds), continue to ventilate 2030 times in 30 seconds and then
re-evaluate.
If the baby still is not breathing after 20 minutes of resuscitation, stop
resuscitating and provide emotional support to family.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

10. The provider states the Ask the provider How do you care for the newborn immediately after successful
correct care of the newborn resuscitation?
following resuscitation. Stimulate the baby gently to continue breathing as needed.
If babys breathing/color is good, give baby to the mother to keep warm and
initiate breastfeeding.
Keep baby warm and dry. Wait 24 hours for first bath.
If the baby shows danger signs, refer immediately for specialized care.
11. The provider states the Ask the provider What tasks must be performed immediately following
correct post-procedure tasks. resuscitation?
Soak suction catheters in 0.5% chlorine solution for 10 minutes for
decontamination.
Wipe exposed surfaces of the bag and mask with a gauze pad soaked in 60
90% alcohol or 0.5% chlorine solution and rinse immediately.
Wash hands thoroughly with soap and water and dry with a clean, dry cloth
(or airdry).
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider states the Record the resuscitation effort:
correct post-procedure tasks The newborns condition at birth
(continued) Time resuscitation started
Steps used (stimulation, ventilation)
Time baby breathed normally OR resuscitation stopped
Results of the resuscitation (successful, needed referral, baby died)
Bimanual compression of the uterus: Guided interview
12. The provider states the Ask the provider What are the steps of bimanual compression?
correct procedure for Provide continual emotional support and reassurance.
bimanual compression of If not wearing gloves already, put on HLD or sterile surgical gloves.
uterus.
Insert fist into anterior vaginal fornix and apply pressure against the anterior
wall of the uterus.
Place other hand on abdomen behind uterus, press the hand deeply into the
abdomen and apply pressure against the posterior wall of the uterus.
Maintain compression until bleeding is controlled and the uterus contracts.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

13. The provider states the Ask the provider What are the post-procedure steps following bimanual
correct post-procedure tasks.compression of the uterus?
Remove gloves and discard them in leak-proof container or plastic bag if
disposing of them or decontaminate them in 0.5% chlorine solution if reusing.
Wash hands thoroughly.
Monitor vaginal bleeding, take the womans vital signs and make sure that the
uterus is firmly contracted.
Compression of the abdominal aorta: Guided interview
compression procedure. Tells the woman what is going to be done, listens to her and responds
attentively to her questions and concerns.
15. The provider states correct Ask the provider What are the steps of compression of the abdominal aorta?
procedure for compression of Provide continual emotional support and reassurance.
the abdominal aorta. Tell the woman what is going to be done, listen to her and respond attentively
to her questions and concerns.
Place a closed fist just above the umbilicus and slightly to the left.
Apply downward pressure over the abdominal aorta directly through the
abdominal wall.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The provider states correct With the other hand, palpate the femoral pulse to check the adequacy of
procedure for compression of compression.
the abdominal aorta Maintain compression until bleeding is controlled.
(continued) Monitor vaginal bleeding, take the woman's vital signs and make sure that the
Vacuum extraction: Direct observation
vacuum extraction. Prepares the necessary equipment.
Tells the woman what is going to be done, listens to her and responds
Ensures that the conditions for vacuum extraction are present.
Makes sure an assistant is available.
Puts on personal protective barriers.
Washes hands thoroughly and puts on HLD or sterile surgical gloves.
Cleans the vulva with antiseptic solution or boiled water.
Catheterizes the bladder, if necessary.
Checks all connections on the vacuum extractor and test the vacuum.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

vacuum extraction. Assess the position of the fetal head and identify the posterior fontanelle.
Applies the largest cup that will fit.
Performs episiotomy if necessary for placement of the cup.
Checks the application and ensure that there is no maternal soft tissue within
the rim of the cup.
2
Have assistant create a vacuum of 0.2 kg/cm negative pressure and checks
the application of the cup.
2
Increases the vacuum to 0.8 kg/cm and then apply traction. Correct the tilt or
deflexion of the head.
With each contraction, applies traction in a line perpendicular to the plane of
the cup rim and assesses potential slippage and descent of the vertex.
Between each contraction, have assistant check fetal heart rate and
application of the cup.
Continues the guiding pulls for a maximum of 30 minutes if there is descent
and in the absence of fetal distress. Releases the vacuum when the head has
been delivered.
Checks the birth canal for tears following delivery and repair if necessary.
Repair the episiotomy, if one was performed.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
18. The provider performs post- Observe if the provider:
extraction tasks. Before removing gloves, disposes of waste materials in a leak-proof container
or plastic bag.
disposing of or decontaminates them in 0.5% chlorine solution if reusing.
Repair of cervical tears: Guided interview
19. The provider states the Ask the provider What steps are required to prepare for repair of cervical tears?
correct preparation for Prepare the necessary equipment.
cervical tear repair. Tell the woman what is going to be done, listen to her and respond attentively
Provide continual emotional support and reassurance.
Have the woman empty her bladder or insert a catheter.
Put on personal protective barriers.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

20. The provider states the Ask the provider What is the correct technique for repairing a cervical tear?
proper technique for Wearing HLD or sterile surgical gloves, clean the vagina and cervix with an
repairing cervical tears. antiseptic solution.
Grasp both sides of the cervix using ring or sponge forceps (one forceps for
each side of tear).
Place the first suture at the top of the tear and close it with a continuous
sutureincluding the whole thickness of the cervix each time the suture
needle is inserted.
If a long section of the rim of the cervix is tattered, under-run it with a
continuous suture.
Use ring forceps if the apex is difficult to reach and ligate.
21. The provider performs post- Ask the provider What tasks should be performed immediately following the
tear repair tasks. repair?
Before removing gloves, dispose of waste materials in a leak-proof container
or plastic bag.
Place all instruments in 0.5% chlorine solution for decontamination.
Remove gloves and discard them in a leak-proof container or plastic bag if
disposing of or decontaminate in 0.5% chlorine solution them if reusing.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Repair of first and second degree tears: Direct observations
repair of first or second Prepares the necessary equipment.
degree tears. Tells the woman what is going to be done, listens to her and responds
Asks about allergies to anesthetics.
Wears personal protective barriers.
23. The provider correctly repairs Observe if the provider:
first and second degree Washes hands thoroughly and put on HLD or sterile surgical gloves.
tears. Applies antiseptic solution to the areas around the tear.
Administers local anesthesia 0.5% lignocaine.
Places the first suture about 1 cm above the top of the vaginal tear.
Using a continuous suture, works down to the level of the vaginal opening
and brings together the torn edges of the vaginal opening.
Repairs the perineal muscle using interrupted sutures. Repairs the skin using
interrupted (or subcuticular) sutures starting at the vaginal opening.
Washes the perineum and puts a clean pad on the womans perineum.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

24. The provider correctly Observe if the provider:
performs post-tear repair Disposes of waste materials in a leak-proof container or plastic bag before
tasks. removing gloves.
Places syringe in puncture-proof container.
Manual removal of placenta: Guided interview
25. The provider correctly states Ask the provider What steps must be taken to prepare for manual removal of
the preparation for manual placenta?
removal of the placenta. Prepare the necessary equipment.
Tell the woman what is going to be done, listen to her and respond attentively
Provide continual emotional support and reassurance.
Ask the woman to empty her bladder or insert a catheter.
Give anesthesia (IV pethidine and diazepam or ketamine)
Give prophylactic antibiotics: ampicillin 2g IV PLUS metronidazole 500 mg IV
or cefazolin 1 g IV PLUS metronidazole 500 mg IV.
Put on personal protective barriers.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
26. The provider correctly Ask the provider What are the steps for performing manual of the placenta?
describes the procedure for Wash hands and forearms thoroughly and puts on HLD or sterile surgical
manual removal of the gloves (ensure elbow-length protection).
placenta. Hold the umbilical cord with a clamp and pull the cord gently.
Place the fingers of one hand into the uterine cavity and locate the low edge
placenta.
Provide support to the fundus.
Move the hand back and forth in a smooth lateral motion until the whole
placenta is separated from the uterine wall.
Withdraws the hand from the uterus, bringing the placenta with it while
continuing to provide counter-traction abdominally.
Give oxytocin in IV fluid.
Have an assistant massage the fundus to encourage uterine contraction.
If there is continued heavy bleeding, give ergometrine by IM injection or
prostaglandins.
Examine the uterine surface of the placenta to ensure that it is complete.
Examine the woman carefully and repair any tears to the cervix or vagina or
repair episiotomy.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

27. The provider correctly states Ask the provider What steps must be performed following removal of the
the steps to perform after placenta?
placenta removal. Remove gloves and discard them in a leak-proof container or plastic bag if
Monitor vaginal bleeding, take the womans vital signs and make sure that the
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 7: Complications During Labor and Childbirth

Total standards met
TOOL 8: ASSESSMENT OF THE NEWBORN WITH A PROBLEM

Date:

1. The provider properly Observe if the provider:
prepares for the assessment Prepares the necessary equipment. Tells the mother what is going to be done
of newborn with a problem. and encourages her to ask questions.
Listens to what she has to say.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 8: Page 1 of 4
Tool 8: Assessment of the Newborn with a Problem

2. The provider thoroughly Observe if the provider reviews referral notes or records, if available and asks the
reviews the newborn and following questions about the baby and mother:
maternal history. Personal information including name and address
What is the problem of the baby
Any care the baby has already had (including specific treatment)
Age and sex of the baby
Baby's weight at birth
Gestational age of the baby at birth
Place of birth
Who assisted the birth
Babys condition immediately after birth
When the problem first started
Whether the problem is getting worse
Any problems with feeding
3. The provider reviews the Observe if the provider asks about:
mothers history of Any complications during pregnancy and treatment received
pregnancy, labor and birth. Rupture of membranes for more than 18 hours before labor
Difficulties during labor or birth
Complications after the birth
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 8: Page 2 of 4
4. The provider performs a Observe if the provider:
thorough physical Washes hands thoroughly for 1015 seconds with soap and water and dries
examination of the baby. them with a clean, dry cloth or allow them to airdry.
Places baby on a clean, warm surface under a good light, with the mother or
family present.
Weighs the baby and records the weight.
Explains the findings to the mother during the exam and points out any
abnormalities.
Determines respiratory rate by counting the number of breaths taken in a full
minute.
Takes axillary temperature.
Checks color for pallor, jaundice and cyanosis.
Uses a stethoscope to determine the babys heart rate.
Observes posture and movements.
Checks muscle tone and level of alertness.
Examines the limbs.
Examines the skin.
Examines the umbilicus.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 8: Page 3 of 4

The provider performs a Examines the eyes.
thorough physical Examines the head and face.
examination of the baby Examines the mouth.
(continued)
Examines abdomen and back.
Washes hands again.
5. The provider correctly Observe if the provider:
performs immediate action Categorizes the findings from the examination and treats the priority findings
following examination and first.
next steps in the Reviews the findings with the mother and obtains informed consent before
management of the newborn performing any additional procedures.
with problems.
Continues any treatment started.
Determines what procedures and laboratory investigations are required.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met
Tool 8: Page 4 of 4
TOOL 9: FAMILY PLANNING

Date:

1. The facility has an area Observe if:
where family planning clients There is an area for client reception.
can wait comfortably. The waiting area is well ventilated.
The waiting area is well lit to allow viewing of educational materials.
The waiting area is protected from sun and rain.
2. The facility has counseling Observe if the area where counseling is conducted:
room. Is set up so that other waiting clients cannot hear what is being said OR
Has a door or partition that can be closed/drawn
Has a desk to put counseling kit and IEC materials
Has chairs for client and provider
Has samples of all FP methods in the room for counseling
COCs, IUCD, injectables, implants, condoms, emergency contraception
Has FP flipchart
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 9: Family Planning

3. Working toilets are available Observe if the toilets are:
near the waiting area for Clean
clients. Have:
Doors that can be locked
Sinks with running water (or bucket with taps)
Soap
Toilets with running water (flush or bucket)
Rubbish bin
4. The facility has an adequate Observe if the room where client examination is done has:
examination/procedure room A door or partition that can be closed/drawn for privacy during examination
for FP. Examination table
Rubber mackintosh
Light source
Drapes for covering clients abdomen
Covered container with 0.5% chlorine solution for decontamination
Container with plastic bag for contaminated waste
Functioning BP cuff
Functioning stethoscope
Weighing scale
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
5. The facility has all necessary Observe to verify if the clinic has a minimum of:
instruments and equipment One complete IUCD insertion/removal kit:
to provide family planning Speculum
services.
Tenaculum/volselum
Uterine sound
Sponge-holding forceps
Long scissors for cutting IUCD strings
Instrument container
Speculum for pelvic examination
A heat source and a pot for boiling instruments or autoclave
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

6. The facility has sufficient Observe that the following materials are available:
supplies and materials to Chlorine solution
provide FP services. Antiseptic (povidone iodine, 6090% alcohol)
Cotton balls or gauze
Examination gloves
HLD or sterile gloves
Clean sheet
Individual hand towels for staff
Sharps container
Utility gloves
0.5% chlorine solution for decontaminating exam table
Surgical drums for storing instruments with lids
Surgical tray for instruments
Plastic liners for waste baskets
Clinical record book
Followup cards
National Medical Standards, Volume 1
Essentials of Contraceptive Technology
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
7. There are sufficient Observe if there is:
1
contraceptive supplies in the Two weeks stock of the following contraceptive methods:
facility. Combined oral contraceptives (low-dose)/Lo-femanol
Progestin-only injectable contraceptives (Depo Provera)
Emergency contraceptives (EC)
IUCDs (Copper T 380 A)
Condoms (Dhal)
Simple stock maintenance register system
The register which shows that all methods were available in the last one
month
8. There are posters on family Observe in the area where clients are waiting if:
planning methods in the There are posters with general information on FP method
clinic. There is a poster on informed choice (Tiehart):
Posted information is visible.
Posted information is in Nepali, simple and with pictures.
Posted information is up to date with guidelines.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
1
Calculation of two weeks stock: (sum of total items dispensed over 1 month/2)

9. There are written routine Observe in the clinic the display of written routine protocols or instructions for the
protocols/instructions for the following areas:
delivery of FP services. Family planning services:
Oral contraceptive
Injectables
IUCD
Emergency contraceptives
Condoms
Infection prevention practices:
Handwashing
Instrument processing
Sharps disposal
General cleaning
10. The clinic has a simple FP Observe that:
client record system. The clinic uses a FP client record form/book to document clients history.
The forms/books are organized for easy retrieval on followup.
The entries are complete and regularly updated:
All relevant columns are completed.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
11. The FP client is greeted Observe if the provider:
cordially and respectfully, Greets client.
then asked about her FP Offers client a seat.
needs.
Asks clients name, calls her by name and introduces self.
Obtains or confirms personal information (name, address, etc).
Confirms purpose of the visit.
Assures client of confidentiality:
Says that the information disclosed during the visit will not be shared
with anyone.
Assures necessary privacy during the visit:
Keeps the door or partition closed.
Minimizes people coming in and out of the room during the visit.
Asks the client her reproductive goals and needs for contraception.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

12. Adequate interpersonal Observe if the provider:
communication skills are Encourages client to ask questions.
used during the entire visit. Addresses clients questions and concerns.
Uses active listening and questioning techniques (e.g. open-ended
questions).
Maintains eye contact.
Uses body language that shows interest and concern for the woman.
Uses simple language that client understands.
Uses open, friendly non-verbal communication (smiling, facing client directly,
etc.).
Uses visual-aids during the counseling including methods samples.
13. The FP client is given Observe if the provider:
information about the Asks if the client is interested in one specific contraceptive method.
contraceptive methods Tells the clients what are the other methods available and gives information
available in the facility and according to her interest.
confirms clients choice.
Confirms the contraceptive method that she wants to use or helps the client
to choose an appropriate method.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
14. Pregnancy is ruled out. Observe that the provider:
Explains to the client that it is important to check that she is not pregnant.
Checks that client is within seven days of onset menstrual period.
Rules out pregnancy if beyond day seven:
Abstinence since last menses OR
Using effective contraceptive method OR
Is within six weeks postpartum OR
Is within seven days post abortion OR
Less than six months postpartum, is exclusively breastfeeding and has
not had any menses
If client is more than six months postpartum and has not had any menses, it is
unlikely she is pregnant if she is:
Breastfeeding exclusively
Has no clinical signs or symptoms of pregnancy
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Method-specific counseling
15. Method-specific reproductive Observe that the provider:
and medical history are Takes a reproductive and basic medical history using the language she will
taken and recorded once the understand
woman has selected a Performs a physical assessment that is appropriate for the method chosen, if
method. indicated, refers the woman for evaluation.
Ensures there are no conditions that contraindicate the use of the chosen
method.
If necessary, helps the woman to find a more suitable method.
COC choosen method
16. COC-specific information is Observe that the provider:
shared with the woman Asks the woman what she knows about the pill (combined oral
about the method she has contraceptives) and corrects any misinformation.
chosen. Briefly, giving only the most important information, tells the woman about the
COC that she has chosen:
How it works
Effectiveness
Advantages and non-contraceptive benefits
Disadvantages
Contraindications
Common side effects and warning signs
Protection against STIs, HIV/AIDS
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
17. The woman is given Observe that the provider:
information on COC and its Provides the method of choice.
use. Gives the woman instructions about COC:
How to use the method of contraception
Side effects and what to do if the side effects occur
Problems or complications for which the woman should return to the
health facility
Educates the woman about prevention of STIs and HIV/AIDS:
If she is at risk:
If necessary provides her with condoms, instructs on how to use
them and where to obtain them.
Encourages the woman to repeat the instructions to be sure she understands.
Confirms medical eligibility.
Provides the woman with three cycles of COC.
Schedules a followup visit in three months to make sure that the woman is not
having any problems with the pill.
Records the relevant information in the womans record card.
Thanks the woman and politely says goodbye.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

18. The woman receives Observe if the provider:
folllowup counseling. Greets the woman with respect and kindness.
Asks the woman the purpose of her visit.
Reviews her record/chart.
Checks whether the woman is satisfied with her family planning method and
is still using it.
Reassures the woman about side effects she is having and treats them if
necessary.
Asks the woman if she has any questions. Listens to her attentively and
responds to her questions or concerns.
Performs any necessary physical assessment.
provides the woman with three cycles of COC.
Schedules return visit as necessary.
Records relevant information in the womans chart.
Thanks the woman, politely says goodbye and encourages her to return as
needed.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
DMPA (choosen as method of choice)
19. DPMA-specific information Observe that the provider:
given to the woman. Asks the woman what she already knows about DMPA and corrects any
misinformation.
Briefly, giving only the most important information, tells the woman about the
DMPA that she has chosen:
How it works
Effectiveness
Disadvantages
Contraindications
20. The woman is given Observe that the provider:
information on use of DMPA. Instructs the woman about injection schedule and menstrual bleeding
changes, and have the woman repeat the instructions to be sure she
understands.
Confirms eligibility for DMPA.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

21. The woman is given DMPA Observe if the provider:
injection followed by post- Washes hands thoroughly.
procedure counseling. Prepares Depo-Provera for injection.
Confirms that the medication and amount are correct.
Inserts needle deep into muscle (deltoid or gluteal).
Makes sure the needle is not in a vein, then injects Depo-Provera slowly and
removes needle.
Applies pressure to the injection site with clean cotton; does not rub site.
Places needle and syringe in puncture-proof container.
Disposes of waste materials.
Records all relevant details on the womans chart.
Instructs woman to return in 12 weeks for next injection. Gives her an
appointment date and time.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
followup counselling. Greets the woman with respect and kindness.
is still using it.
Reassures the woman about side effects she is having and treats them if
necessary.
Asks the woman if she has any questions. Listens to her attentively and
If necessary, provides the woman with her contraceptive method (e.g. the pill,
Depo-Provera, condoms, etc.).
needed.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

IUCD (choosen as method of choice)
23. The woman receives IUCD Observe if the provider:
pre-insertion counseling. Asks the woman what she already knows about the IUCD and corrects any
misinformation.
Briefly, giving only the most important information, tells the woman about the
IUCD that she has chosen:
How it works
Effectiveness
Disadvantages
Contraindications
Instructs the woman about when and how to check for strings and to return to
the clinic if she thinks the IUCD is not in place.
Encourages the woman to repeat the instructions to be sure she understands.
Describes how the IUCD will be inserted and what the woman should expect
during and after the procedure.
Answers any questions the woman has.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
24. A pre-insertion physical Observe if the provider:
examination is conducted. Prepares equipment and supplies (including a light source).
Asks the woman to wash and rinse her genital area with soap and water.
Ensures that she has emptied her bladder.
Helps the woman onto the examination table, positions her comfortably.
Makes sure that she is draped/covered throughout the examination.
Explains each step of the examination to the woman. Encourages her to ask
questions and responds to her questions and concerns.
Palpates the abdomen and checks for lower abdominal (especially
suprapubic) tenderness, masses or other abnormalities.
Washes hands thoroughly and puts on gloves.
Without contaminating them, arranges instruments and supplies on a HLD or
sterile tray.
Gently performs examination of external genitalia, urethral opening, Skenes
and Bartholins glands.
Gently performs speculum examination of vagina and cervix.
Gently removes speculum and sets it in a HLD or sterile kidney basin or
places in 0.5% chlorine solution for 10 minutes for decontamination if another
HLD or sterile speculum is available.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

A pre-insertion physical Performs a gentle bimanual examination:
examination is conducted Immerses both gloved hands in 0.5% chlorine solution. Remove gloves
(continued) by turning inside out.
If disposing of gloves, places in leak- proof container or plastic bag.
If reusing surgical gloves, submerges in 0.5% chlorine solution for 10
minutes for decontamination.
Based on findings of history and physical examination, confirms that the
IUCD is an appropriate method of contraception for the woman.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
25. The provider inserts the Observe if the provider:
IUCD properly. Tells the woman what is going to be done and encourages her to ask
questions.
Loads Copper T 380A in sterile package.
Puts new examination or HLD surgical gloves on both hands.
Gently inserts vaginal speculum to see the cervix and applies antiseptic
solution two times to the cervix and vagina.
Gently grasps cervix with tenaculum.
Sounds uterus using no-touch technique.
Inserts Copper T 380A IUCD using withdrawal technique.
Partially withdraws the inserter tube and cut IUCD strings to 34 cm length.
Removes inserter tube.
Gently removes the tenaculum and places it in 0.5% chlorine solution for 10
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

The provider inserts the Examines cervix; if there is bleeding at the tenaculum puncture site(s), places
IUCD properly (continued) cotton (or gauze) swab over bleeding and applies gentle pressure for 3060
seconds.
Gently removes speculum and places it in 0.5% chlorine solution for 10
Before removing gloves, places all instruments in 0.5% chlorine solution for
10 minutes for decontamination.
Disposes of waste materials in a leak-proof container or plastic bag.
Immerses both gloved hands in 0.5% chlorine solution. Removes gloves by
turning inside out:
If disposing of gloves, places in leak-proof container or plastic bag.
If reusing surgical gloves, submerges in 0.5% chlorine solution for 10
Checks to be sure woman is not having excessive cramping and answers any
questions.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
26. The woman receives post Observe if the provider:
IUCD insertion counseling. Observes the woman for at least 15 to 20 minutes before sending her home.
Reviews side effects and warning signs; reminds the woman to return to the
clinic if these occur.
Reviews how to check for strings.
Instructs the woman to return for followup. Gives her appointment date and
time.
Asks the woman to repeat the instructions to ensure that she understands.
Answers any questions the woman has.
Encourages the woman to return if she has any questions or concerns, for
followup, and if she wants to have the IUCD removed. Politely says goodbye.
Completes IUCD card and records all relevant details on womans
record/chart.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

27. The woman receives IUCD Observe if the provider:
pre-removal counseling and Greets the woman respectfully and with kindness.
examination. Confirms her name, address and other required information.
Asks the woman, her reason for removal and answers any questions.
Reviews the womans reproductive goals and need for protection against
STIs and HIV/AIDS.
Prepares equipment and supplies (including a light source).
Asks the woman to wash and rinse her genital area. Ensures that the woman
has emptied her bladder.
Helps the woman onto examination table, ensures her comfort and makes
sure that she is draped/covered appropriately throughout the procedure.
Describes the removal procedure and answer any questions.
Washes hands thoroughly and puts gloves on.
Without contaminating them, arranges instruments and supplies in HLD
container or sterile tray.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
28. The provider removes the Observe if the provider:
IUCD. Performs bimanual examination.
Gently inserts vaginal speculum to see cervix and IUCD strings, applies
antiseptic solution two times to the cervix, grasps strings close to the cervix
with hemostat or other narrow forceps and pulls on strings slowly but firmly to
remove IUCD.
Shows IUCD to woman.
Immerses IUCD in 0.5% chlorine solution for 10 minutes for decontamination.
Then disposes of it in a leak-proof container or plastic bag.
Gently removes speculum and places in 0.5% chlorine solution for 10 minutes
for decontamination.
Before removing gloves, places all instruments in 0.5% chlorine solution for
10 minutes for decontamination.
Disposes of waste materials in a leak-proof container or plastic bag.
Immerses both gloved hands in 0.5% chlorine solution. Removes gloves by
turning inside out.
If disposing of gloves, places in leak-proof container or plastic bag.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

The provider removes the If reusing surgical gloves, submerges in 0.5% chlorine solution for 10 minutes
IUCD (continued) for decontamination.
Checks to be sure woman is not having excessive cramping and answers any
questions.
Records IUCD removal on womans record/chart.
29. The provider provides post- Observe if the provider:
removal counseling to the Counsels woman regarding new family planning method if desired.
woman. Helps the woman obtain new contraceptive method or provide temporary
method (e.g. condoms) until method of choice can be started.
Encourages the woman to return whenever she has any questions or
concerns and politely says goodbye.
Followup counseling
followup counseling. Greets the woman with respect and kindness.
is still using it.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
The woman receives Reassures the woman about side effects she is having and treats them if
followup counseling necessary.
(continued) Asks the woman if she has any questions. Listens to her attentively and
If necessary, provides the woman with her contraceptive method (e.g. the pill,
Depo-Provera, condoms, etc.).
needed.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met

TOOL 10: SBA CLASSROOM-BASED CLINICAL TRAINING

Date:

1. The SBA training site has the Observe if the site has clean, functioning and well-maintained:
basic equipment and Computer in coordinator room
furniture to support training. Photocopy machine
Tables
At least 12 chairs
Blackboard or whiteboard
Overhead projector or LCD projector
Laptop computer
Screen
Pen (USB) drive
Rack for materials in training hall
Flipchart easel
Transparencies
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 10: SBA Classroom-Based Clinical Training

2. The SBA training site has the Observe if the site has:
basic materials, instruments MNC LRP Transparency Set
and models to support 3 Zoe anatomic models
training. 3 childbirth simulators
Delivery kit of instruments
3 delivery sets available for training on models
3 newborn resuscitation models
3 newborn resuscitation set
1 MVA
3 IUCD insertion sets
3 stethoscopes
3 fetoscopes
3 BP cuffs
3 buckets for 0.5% chlorine solution
3 waste bins with plastic liners
3 drapes for covering models
3 towels to put under models
6 towels for baby
Gloves
3 plastic aprons, 3 eye shields, 3 face masks
Individual hand towels
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

3. The SBA training site has all Observe if the site has:
necessary reference MNC LRP trainer set
materials to support the Managing Complications in Pregnancy and Childbirth: A Guide for Midwives
training. and Doctors (WHO)
Managing Newborn Problems (WHO)
Basic Maternal and Newborn Care (JHPIEGO)
Pregnancy, Childbirth, Postpartum and Newborn Care (WHO, UNICEF,
UNFPA (2006)
National Medical Standards Volume 1 (FP)
National Medical Standards Volume 2 (Other RH)
National Medical Standards Volume 3 (MNH)
National Policy on Skilled Birth Attendants (2006)
National Newborn Health Strategy (2004)
Newborn Care Trainers Guide for MBBS Program
Newborn Care Trainers Guide for PCLN Program
4. The training coordinator has Observe if the training coordinator has:
additional resource materials. National Safe Motherhood Long Term Plan
NHTC Need Assessment Tools
NHTC Accreditation Guidelines
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

5. SBA clinical trainers have the Review administrative records and/or discuss with training coordinator to find out if
required qualifications. all the trainers:
Are doctors or nurses.
At least 80% have completed SBA training and are certified SBAs.
Are currently clinically active in maternal and newborn care.
Have completed a CTS course and been certified as a SBA clinical trainer by
NHTC.
Have participated in a MNC LRP orientation.
6. SBA clinical trainers come to Observe or interview and review teaching plans and materials to see if the clinical
training prepared. trainer:
Is following the course outline including using relevant resource materials.
Has prepared notes.
Has prepared, or uses prepared, visual aids such as metacards or flipcharts
to use during the training.
7. SBA clinical trainers are During classroom instruction, observe if the clinical trainer:
training according to the Specifies which module is being taught.
curriculum and related Refers to the correct reference books for that module.
learning resource materials.
Uses the learning resource materials for that module.
Encourages participants to use the learning resources for that module.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

8. SBA clinical trainers During classroom instruction, observe if the clinical trainer:
introduce their sessions States the objectives for the session or module.
effectively. Relates this topic to content previously covered or related topics.
Introduces the topic in an engaging and informative manner.
9. SBA clinical trainers use During classroom observe if the clinical trainer:
effective presentation and Projects her/his voice clearly.
questioning techniques. Moves about the room.
Maintains eye contact with participants.
Uses visual aids during lecture segments.
Selects appropriate questions for topic from relevant clinical examples.
Provides respectful feedback and repeats correct responses.
Constructively handles questions that are partially or totally incorrect.
Uses at least one activity (e.g., role plays, case studies, group work,
exercises) during the classroom session.
10. SBA clinical trainers During classroom instruction, observe if the clinical trainer:
summarize before ending a Emphasizes the main points of the presentation, session or day.
presentation, session or day. Relates information to the objectives.
Provides an opportunity for participant questions.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

11. SBA clinical trainers Interview training records and interview clinical trainers to know if the pre-course
administer pre-course questionnaires are:
questionnaires properly. Administered at the beginning of training or module
Used from MNC LRP
Given with clear instructions and time limit
Clinical trainer moving around the room as needed to monitor the participants
The room is kept quiet
Matrix is used to record participants correct answers
Results are accurately recorded and shared
Graded/scored using the answer key
Results are posted in matrix anonymously
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

12. SBA clinical trainers Interview participants or trainers and review clinical training records to know if:
administer mid-course Participants are informed at least one week in advance of mid-course
questionnaires properly. questionnaires.
Mid-course questionnaires are used from the MNC LRP.
Instructions are clear.
Clinical trainer remains in the room and moves around the room as needed to
monitor the participants.
The room is kept quiet.
Through discussion or interview with at least two clinical trainers, observe if:
Participant questionnaires graded/scored consistently (e.g., using answer
key).
Participants who do not achieve 85% the first time are given another
opportunity to retake the mid-course questionnaire.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

13. SBA clinical trainers Verify through observation or by interviewing the clinical trainer:
effectively demonstrate Direct observation: Observe whether clinical trainer introduce new skills by:
clinical skills. Ensuring that all participants have the necessary learning materials (e.g.,
supplies, models, learning guides, etc.).
Describing the skill and why the skill is important.
Describing steps involved in the skill, using the relevant learning guide.
Demonstrating the skill as follows:
Simulates clinical setting as much as possible.
Proceeds in a step-by-step manner.
Demonstrates skill accurately.
Demonstrates skill from beginning to end, without skipping steps.
Interacts with participants, asking and answering questions.
Uses all the necessary supplies and equipment.
Demonstrates so that all participants can see.
Ensures that each student follows using a learning guide.
Summarizes and asks participants if they have questions.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

SBA clinical trainers OR Interview:
effectively demonstrate Ask the clinical trainer "Can you explain step-by-step how you introduce new skills
clinical skills (continued) to the participants using the learning lab?"
Ensure that all participants have the necessary learning materials.
Describe the skill and why the skill is important.
Describe the steps involved in the skill, using the relevant learning guide.
Demonstrate the new skill.
Ask the clinical trainer "Can you explain and show me how you demonstrate the
skills to the participants?"
Simulate clinical setting as much as possible.
Proceed in a step-by-step manner.
Demonstrate skill accurately.
Demonstrate skill from beginning to end, without skipping steps.
Ask the clinical trainer "Can you explain how you interact with the participants
during the demonstration?"
Interact with participants, asking and answering questions.
Use all the necessary supplies and equipment.
Demonstrate so that all participants can see.
Ensure that each student follows using a learning guide.
Summarize and asks participants if they have questions.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

14. SBA clinical trainers Verify through observation or by interviewing clinical trainer:
effectively facilitate student Direct observation: Observe whether clinical trainer facilitates practical learning by:
practice of clinical skills. Allowing participants to practice the skill in small groups, taking turns with
various roles (practicing, observing, giving feedback, simulating role of
patient)
Ensuring that there are no more than five participants per model
Observing participants practicing and providing feedback in a positive and
constructive manner
Questioning participants to check their knowledge and problem-solving skills
Summarizing the session before the end
OR Interview: Ask the clinical trainer to explain to you how s/he facilitates practical
learning:
Allowing participants to practice the skill in small groups, taking turns with
various roles (practicing, observing, giving feedback, simulating role of
patient)
Ensuring that there are no more than four participants per model
Observing participants practicing and providing feedback in a positive and
constructive manner
Questioning participants to check their knowledge and problem-solving skills
Summarizing the session before the end
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

15. SBA clinical trainers Verify through observation or by interviewing clinical trainer:
effectively assess participant Direct observation: Observe whether the clinical trainer assesses the achievement
achievement of clinical skill of clinical competence in desired skills in the following manner:
competence. Ensures participants are aware that they will be assessed for specific skill
competence using the skills checklist
Ensures that each participant has a copy of the skills checklist
Prepares assessment station with all necessary supplies and equipment
Conducts assessments in a fair and objective manner
Provides feedback at the conclusion of the assessment session, but not
during the assessment
Records results of the assessment session in the participants clinical
experience logbook
Records results of the assessment session in the participants performance
file
Provides opportunity for re-assessment if the participant does not achieve
competence during the session
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

SBA clinical trainers OR Interview: Ask the clinical trainer to explain to you how s/he assesses the
effectively assess participant achievement of clinical competence in the desired skill:
achievement of clinical skill Ensures participants are aware that they will be assessed for specific skill
competence (continued) competence using the skills checklist
Ensures that each participant has a copy of the skills checklist
Prepares assessment station with all necessary supplies and equipment
Conducts assessments in an objective and impartial manner
Provides feedback at the conclusion of the assessment session, but not
during the assessment
Records results of the assessment session in the participants clinical
experience logbook
Records results of the assessment session in the participants performance
file
Provides opportunity for re-assessment if the participant does not achieve
competence during the session
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met

TOOL 11: SBA CLINICAL INSTRUCTION AND PRACTICE

Date:
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N NA

1. The number of clinical Determine by interviewing clinical supervisors and visiting clinical practice areas
practice areas meets whether:
requirements of the SBA The number of areas/sites is sufficient so that no more than four participants
curriculum. are practicing in a particular service delivery area during one shift.
The number of areas/sites is sufficient so that no more than a total of six
preservice students and/or other inservice training participants are practicing
in a particular service delivery area during one shift.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 11: SBA Clinical Instruction and Practice

2. The variety of clinical Determine by interviewing SBA training coordinator and clinical trainers and
practice areas meets the reviewing administrative records whether:
requirements of the SBA Clinical practice areas/sites are available for:
curriculum. ANC/PNC clinic
Admission room
Labor (first stage) room
Delivery room
Postnatal room
PAC room
Post-op room
FP clinic
Neonatal ward
3. The infrastructure of the Observe in the hospital whether there is:
hospital clinical practice Sufficient space in each clinical area to accommodate four to six participants
areas is conducive to clinical working alongside staff
practice. Space where clinical trainers and participants can meet to review objectives
and discuss practice
4. Clinical volume (caseload) in Determine by reviewing statistical records whether there is sufficient clinical
the clinical practice areas is volume during the duration of clinical practice total caseload allows for at least:
adequate for participant Six competent deliveries per participant
learning. Six newborn cases per participant
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

5. There is a clinical Observe whether there is a:
demonstration room setup Room nearby the clinical practice areas
nearby to support clinical At least one childbirth model
coaching.
Neonatal resuscitation model
At least one zoe model
Equipment
Supplies
Learning materials (learning guides, checklists, etc.)
6. Schedules have been Verify with clinical trainers if a schedule for participants clinical practice:
developed to distribute Exists for every SBA training course.
participants across clinical Shared with all the clinical practice areas.
practice areas evenly.
Identifies the clinical trainer/coach responsible for each block of time a
participant group is in a unit.
7. Participants are provided Verify with participants and clinical trainers/coaches when participants are on a
meals while on clinical clinical practice shift for more than five hours:
practice duty. Meal breaks are given for a half-hour.
There is nutritious food available near the clinical practice areas.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

8. Clinical trainers/coaches Verify with the SBA training coordinator and clinical trainers/coaches through
have been appropriately interviews and review of documents if clinical trainers/coaches:
selected. Have completed SBA training and are certified SBAs.
Are currently clinically active in maternal and newborn care.
Each has completed a CTS course and has been certified as a Clinical trainer
by NHTC.
Each has participated in a MNC LRP orientation.
9. Participants are adequately Verify with the SBA training coordinator and clinical trainers/coaches by document
prepared for clinical practice. review and interviews if:
A clinical coach or trainer meets with participants prior to the beginning of
clinical practice.
Participants are oriented to the use of a personal clinical experience logbook.
Participants are oriented to site including:
Facility including laboratory and out-patient department
Explanations of admission and discharge procedures
Medication administration record
Patient emergency procedures and equipment
Made aware of safety and security concerns
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

10. Clinical trainers/coaches Observe whether the clinical trainers/coaches:
begin practice sessions by Present clearly the objectives from the MNC LRP modules for the clinical
providing clear instructions. practice session.
Describe the tasks to be performed by participants.
Demonstrate or reinforce clinical skills, if necessary.
Demonstrate skills on actual patients whenever possible, or use simulation if
necessary.
11. Participants and clinical Observe during clinical practice if:
trainers/coaches use Participants have their personal learning resources (learning guides,
appropriate learning and checklists, etc.).
assessment tools. Clinical trainers/coaches are recording observations, comments and
achievement of competence in participant learning guides and clinical
experience logbook.
Clinical trainers/coaches and participants are using the clinical experience
logbooks for recording the attainment of skills.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

12. Clinical trainers/coaches Observe whether the clinical trainers/coaches:
monitor participants' Protect patients rights by:
performance and give Introducing the participants to the patient and share the participants
feedback. experience and training.
Obtaining the patient's permission before participants observe, assist
with or perform any procedures.
Ensuring that a qualified clinical supervisor is always present
Respecting the right to bodily privacy whenever a patient is undergoing a
physical exam or procedure.
Assisting in care if the participant is incorrectly doing the procedure if
life-threatening or dangerous.
Supervise participants as they work and do not leave participants
unsupervised for extended periods of time (more than two hours).
Provide feedback to participants by:
Providing praise and positive reinforcement during and/or after practice
During care, be careful not to give negative feedback in front of patient
Correcting participant errors while maintaining their self-esteem
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

13. Clinical trainers/coaches Observe whether clinical trainers/coaches:
meet with participants at the Review the learning objectives
end of a clinical practice Discuss cases seen that day, particularly those that were interesting, unusual,
session. or difficult.
Provide opportunities for participants to ask questions.
14. Clinical trainers/coaches Verify with the training site administration, clinical trainers/coaches and participants
track, ensure and record by interviews and records review, if:
participants competency as Participants are provided information about the process to reduce their
SBAs. anxiety level.
Tracking of competency in all required SBA skills is routinely done in
participant clinical experience logbook.
Participant competency is recorded in participant profile for each participant.
Participants who meet NHTC SBA certification requirements are awarded a
certificate at the end of training.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met

TOOL 12: TRAINING SITE MANAGEMENT

Date:

1. The SBA training site has the Observe that the site has:
basic infrastructure to Training hall
support training. Toilet facilities near the training hall
Space for demonstration for clinical practice
Training site coordinator room near the training hall
Area for tea and lunch breaks
Drinking water available
2. Infrastructure is well- Observe that the site has clean, functioning, well-lit and well-maintained:
maintained, clean and Training hall
functional. Toilet facilities near the training hall
Space for demonstration for clinical practice
Training site coordinator room near the training hall
Area for tea and lunch breaks
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________
Tool 12: Training Site Management

3. The SBA training site is well Observe if there is:
coordinated and managed. A designated SBA inservice training coordinator.
Regular coordination meetings with SBA inservice training coordinator and
hospital management.
Regular coordination meetings with SBA inservice training coordinator and
trainers.
A hospital training management committee that regular meets.
4. There is sufficient space and Observe if there is:
support for the training site A designated work space for the SBA inservice training coordinator
coordinator. A computer and printer
Filing cabinets
5. The SBA training site has Observe if the site has:
good financial systems and A separate bank account set up to receive and manage SBA inservice
management. training funds
An established mechanism to resource/support training using available funds
Paid trainers and participants on time.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

6. The SBA training site has Discuss with the training site coordinator and observe the records to see if::
good record keeping There is a file for each training course/batch.
systems and management. Each file contains:
Participant list (photocopy)
Participant registration forms (photocopies)
Training report (photocopy)
Participant evaluation information (such as MCQ scores, matrix,
competencies)
All NHTC participant profiles for each course/batch also are filed.
7. The SBA training sites Discuss with the training site coordinator and observe in the records if:
submits training Participant list is sent to NHTC.
documentation to NHTC. Participant registration forms are sent to NHTC.
Training report is sent to NHTC and any sponsor
Participant evaluation information (such as MCQ scores, competencies) is
sent to NHTC and any sponsor.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

8. Site has a clear annual SBA Observe if the site has a written training calendar that:
training calendar. Shows all SBA batches to be conducted in a year for the site.
Includes start and end dates of the each course.
Includes approximate dates of holidays.
9. Participant composition Observe in the registry with record of participant data and discuss with training site
reflects NHTC SBA Inservice coordinator and trainers that participants:
Training Standard Have BEOC and/or MRT certificate.
Guidelines. Are currently medical officers, ANMs or Staff Nurses.
Clinically actively in MNC services.
10. Class size and support is Through review of site records, observe if:
consistent with NHTC SBA At least 3 trainers available during classroom and clinical practice.
Inservice Training Standard No batch has no more than 10 participants.
Guidelines.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

11. Trainer performance Interview the training coordinator and training staff and review administrative
evaluations are regularly documents, if:
conducted. Trainer performance is measured on a regular basis, at least once a year.
Evaluations of performance are performed using a standardized format.
The evaluations are documented in writing.
Staff participates in the process and sign written evaluations to show that they
agree to their content.
Feedback to staff includes participant evaluations.
Trainers periodically have refresher training (every 2 years).
12. Participant course Observe/review records for course performance standards exist and include:
completion requirements are 85% achievement on mid-course questionnaire
known by participants and Definition and assessment of competency
trainers.
Clears steps if a participant does not meet questionnaire and/or competency
requirements.
Through interviewing two trainers and two participants, observe if:
Trainers are aware of standards.
Participants are aware of standards.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

13. Course completion Through record reviews, observe that:
requirements are met before Course completion requirements are explicitly stated and participants
any participant can be informed of requirements.
certified. All participants who have received certificates during the last training have
met these requirements.
Participant who has not met SBA certification requirements is requested to
NHTC to extend until competent.
14. SBA clinical training is Through interviews with trainers and by review of administrative records, observe
routinely monitored for that clinical training is monitored for effectiveness:
effectiveness. Standardized course evaluation form is used.
Trainers and training coordinator meeting is conducted immediately after the
training course ends.
Course evaluation feedback is shared with trainers and training coordinator.
Course evaluation feedback that requires action is resolved by training
coordinator.
Comments: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Total standards met

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PREFACE

ABOUT THE TOOLS

INSTRUCTIONS FOR USING THE TOOLS AT TRAINING SITES

NHTC MONITORING AND CERTIFICATION OF SBA TRAINING SITE QUALITY

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 1: Infection Prevention

Tool 1: Infection Prevention

Tool 1: Infection Prevention

Tool 1: Infection Prevention

Tool 1: Infection Prevention

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 2: Focused ANC

Tool 2: Focused ANC

Tool 2: Focused ANC

examination. Washes hands.

exam. Inspects the abdomen.

Tool 2: Focused ANC

to develop a birth plan. Skilled provider and place of birth

Tool 2: Focused ANC

Tool 2: Focused Antenatal Care

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Tool 3: Complications during Pregnancy

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Has one leak-proof container to dispose of soiled linen.

Cleanses the vulva with non-alcoholic antiseptic solution or boiled warm

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Tool 4: Normal Delivery and Immediate Newborn Care

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 5: Postpartum Care

Tool 5: Postpartum Care

Tool 5: Postpartum Care

Tool 5: Postpartum Care

Tool 5: Postpartum Care

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 6: Newborn Care

Tool 6: Newborn Care

Tool 6: Newborn Care

Tool 6: Newborn Care

Training site (name, place):

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Tool 7: Complications during Labor and Childbirth