Labour Room Quality Improvement Initiative

After launch of the National Health Mission (NHM), there has been substantial increase in the number of institutional deliveries. However, this increase in the numbers has not resulted into commensurate improvements in the key maternal and new-born health indicators. It is estimated that approximately 46% maternal deaths, over 40% stillbirths and 40% newborn deaths take place on the day of the delivery.

A transformational change in the processes related to the care during the delivery, which essentially relates to intrapartum and immediate postpartum care, is required to achieve tangible results within short period of time.

‘LaQshya’ programme of the Ministry of Health and Family Welfare aims at improving quality of care in labour room and maternity Operation Theatre (OT).

Goal

Reduce preventable maternal and newborn mortality, morbidity and stillbirths associated with the care around delivery in Labour room and Maternity OT and ensure respectful maternity care.

Objectives

• To reduce maternal and newborn mortality & morbidity due to APH, PPH, retained placenta, preterm, preeclampsia & eclampsia, obstructed labour, puerperal sepsis, newborn asphyxia, and sepsis, etc.
• To improve Quality of care during the delivery and immediate post-partum care, stabilization of complications and ensure timely referrals, and enable an effective two-way follow-up system.
• To enhance satisfaction of beneficiaries visiting the health facilities and provide Respectful Maternity Care (RMC) to all pregnant women attending the public health facility.

Strategies

• Reorganizing/aligning Labour room & Maternity Operation Theatre layout and workflow as per ‘Labour Room Standardization Guidelines’ and ‘Maternal & Newborn Health Toolkit’ issued by the Ministry of Health & Family Welfare, Government of India.
• Ensuring that at least all government medical college hospitals and high case- load district hospitals have dedicated obstetric HDUs as per GoI MOHFW Guidelines, for managing complicated pregnancies that require life-saving critical care.
• Ensuring strict adherence to clinical protocols for management and stabilization of the complications before referral to higher centres.

Scope

Following facilities would be taken under LaQshya initiative on priority:

• All government medical college hospitals.
• All District Hospitals & equivalent healthy facilities.
• All designated FRUs and high case load CHCs with over 100 deliveries/60 (per month) in hills and desert areas.

Institutional Arrangement

Under the National Health Mission, the States have been supported in creating Institutional framework for the Quality Assurance - State Quality Assurance Committee (SQAC), District Quality Assurance Committee (DQAC), and Quality Team at the facility level. These committees will also support implementation of LaQshya interventions. For specific technical activities and program management, special purpose groups have been suggested, and these groups will be working towards achievement of specific targets and program milestones in close coordination with relevant structure.

Targets

Immediate (0-4 Months)

• 80% of the selected Labour rooms & Maternity OTs assess their quality and staff competence using defined NQAS checklists and OSCE.
• 80% of Labour rooms & Maternity OTs have setup functional quality circles and facility level quality tea ms.

Short Term (up to 8 Months)

• 80% of Labour Room and OT Quality Circles are oriented to latest labour room protocols, quality improvement processes and respectful maternity care (RMC).
• 50% of deliveries take place in presence of the Birth Companions.
• 60% of deliveries conducted using safe birth checklist and Safe Surgery Checklist in Labour Room & Maternity OT respectively.
• 60% of the deliveries are conducted using real-time par to graph.
• 30% increase in Breast Feeding within one hour of delivery
• 80% labour rooms and Maternity OTs take microbiological samples from defined areas every month.
• 30% reduction in surgical site infection ratein r/o planned surgery in the Maternity OT.

Intermediate Term (Up to 12 Months)

• 30% in crease in antenatal corticosteroid administration in case of preterm labour.
• 30% reduction in pre-eclampsia, eclampsia& PIH related mortality.
• 30% reduction in APH/PPH related mortality.
• 20% reduction in new-born asphyxia related admissions in SNCUs for inborn deliveries.
• 20% reduction in newborn sepsis rate in SNCUs for inborn deliveries.
• 20% reduction in Stillbirth rate.
• 80% of all beneficiaries are either satisfied or highly satisfied
• 60% of the labour rooms are reorganized as per 'Guidelines for Standardisation of Labour Rooms at Delivery Points'.
• 80% of lab our rooms have staffing as per defined norms.
• 100% compliance to administration of Oxytocin, immediately after birth.
• 30% improvement in OSCE scores of labour room staff.
• 100% Maternal death, Neonatal Death audit and clinical discussion on near miss/maternal and neonatal complications
• 80% Labour Room and OTs are reporting zero stock-outs of drugs and consumables.

Long Term (up to 18 Months)

• 60% of labour rooms achieve quality certification against the NQAS.
• 50% of labour rooms are linked to Obstetrics HDU/ICU.
• 15% improvement in short term & Intermediate targets.

After 18 months, this initiative would be continued through sustained mentoring.

Interventions

• Ensuring availability of optimal and skilled human resources as per case-load and prevalent norms through rational deployment and skill upgradation.
• Ensuring skill assessment of all staff of LR & Maternal OT through OSCE (Objective Structured Clinical Examination) testing as per Dakshata guidelines for delivery of ‘zero-defect’ quality obstetric and newborn care. Enhance proficiency of labour room and operation theatre staff for management of the complications through skill-lab training, simulations and drills. Ensuring that staff working in the labour room and maternity OT are not shifted from maternity duty to other departments/ wards frequently.
• Sensitising care-providers for delivery of respectful maternity care and close monitoring of language, behaviour and conduct of the labour room, OT & HDU Staff.
• Creating an enabling environment for natural birthing process.
• Implementation of Clinical Guidelines, Labour Room Clinical Pathways, Referral Protocols, safe birth checklist (in labour room and Obstetric OT) and surgical safety check-list.
• Ensuring round the clock availability of Blood transfusion services, diagnostic services, drugs & consumables.
• Ensuring availability of triage area and functional newborn care area.
• Ensuring systematic facility-level audit of all cases of maternal/neonatal deaths, stillbirth, and maternal near miss etc. including with their mentor teams through clinical discussions, peer reviews in teaching institutes, Videoconference, or other distance mode mechanisms for continuous improvement and learning.
• Operationalisation of ‘C’ Section audit and corrective & preventive actions for ensuring that ‘C’ Sections are undertaken judiciously in those cases having robust clinical indications.
• Instituting an ongoing system of capturing of beneficiaries’ independent feedback through mechanism ‘Mera- Aspataal’ or manual recording, or Grievance Redressal Help Desk and take action to address concerns, for continual enhancement in their satisfaction.
• Ensuring availability of essential support services such as 24x7 running water, electricity, housekeeping, linen and laundry, security, equipment maintenance, laboratory services, dietary services, BMW management, etc.
• Use of digital technology for record keeping & monitoring for maternity wing (MIS), including use of E partograph. Piloting of technology for managing care, such as Computer on Wheel, Computerised Physician Order Entry.
• Use aggressive IEC, user friendly training material and IT-enabled tools. Facilitating branding of all high case load facilities meeting quality standards to improve visibility and awareness.
• Using Quality tools for prioritisation, and gap closure such as Plan Do Check Act (PDCA), Root Cause Analysis, Run Charts, Pareto chart and Mistake Proofing for achieving desired targets.
• Rapid Improvement Events - Six cycles of two months each as defined below will need to be rigorously supervised and ensured. This will enable competency in all critical skills needed. For each area, a targeted campaign would be launched for a two month duration, with the first month for the roll-out, followed by sustaining such efforts during the subsequent month (Period for one event – 2 months). Suggested list of the themes for campaigns is given below :
• Cycle 1: Real-time Partograph generation including shift to electronic partograph & usage of safe birth check-list & surgical safety check-list and strengthening documentation practices for generating robust data for driving improvement.
• Cycle 2: Presence of Birth companion during delivery, respectful maternity care and enhancement of patients’ satisfaction.
• Cycle 3: Assessment, Triage and timely management of complications including strengthening of referral protocols.
• Cycle 4: Management of Labour as per protocols including AMTSL & rational use of Oxytocin.
• Cycle 5: Essential and emergency care of Newborn & Pre-term babies including management of birth asphyxia and timely initiation of breast feeding as well as KMC for preterm newborn.
• Cycle 6: Infection Prevention including Biomedical Waste Management.

Incentives

The Quality Improvement in labour room and maternity OT will be assessed through NQAS (National Quality Assurance Standards). Every facility achieving 70% score on NQAS will be certified as LaQshya certified facility. Furthermore, branding of LaQshya certified facilities will be done as per the NQAS score. Facilities scoring more than 90%, 80% and 70% will be given Platinum, Gold and Silver badge accordingly. Facilities achieving NQAS certification, defined quality indicators and 80% satisfied beneficiaries will be provided incentive of Rs 6 lakh, Rs 3 lakh and Rs 2 lakh for Medical College Hospital, District Hospital and FRUs respectively.

To access the full programme document, click here.

Source : National Health Mission

Related resources

1. Operational Guidelines for Obstetric HDU and ICU