1. Aspects of Quality of Clinical
Care in Labor & Delivery
Stephan Brenner

2. Rationale
• Obstetric complications  intra- & postpartum
phase.
• Timely initiation & organization of EmOC  ability
of SBAs to detect high-risk pregnancies.
• early identification & prevention of obstetric
complications  routinely in every pregnancy.
Quality of Care Focus:
• Evidence-based routine care processes in L&D
1.
2.
3.
Screening for early signs of complications.
Monitoring for signs of complications.
Preparedness to timely intervene once complications
occur.

3. Objectives
1) Early Identification of emergencies:
– Screening processes  Danger Signs, risk factor
assessments, APGAR, etc.
– Monitoring processes  partograph, early
postpartum observation
2) Prevention of emergencies:
– Infection  maternal/neonatal sepsis
– Hemorrhage  AMSTL
3) Preparedness in emergencies:
– Anticipation of need for neonatal resuscitation

4. Methods
• Observational checklists:
– Routine processes performed by providers
during labor & delivery care
– Basic equipment, supplies related routine
labor & delivery care
– Information on facility type
• Sampling:
– Convenience samples
• Analysis:
– Descriptive summary of frequencies of
performed routine processes
– Composed scores

5. Distribution of Observations
Facility
level
Balaka
District
Dedza Mchinji Ntcheu
Total
BEmOC
11
10
14
10
45
CEmOC
10
8
5
14
37
21
18
19
24
82
Total

6. Screening:
Initial assessment Danger Signs & risk factors (Hx)
BEmOC
35
(n = 33)
30
32.5
25
27.5
24.24
21.21
21.21
15
20
20
10
12.12
9.091
7.5
6.061
5
6.061
5
2.5
0
______________________________
Max score: 8
CEmOC
(n = 40)
5
Percent
Score components:
• Vaginal bleeding
• Abdominal pain
• Breathing
difficulties
• Fever
• Headache
• Convulsions
• HTN
• Diabetes
0
1
2
3
4
5
6
7
8
0
1
2
3
4
5
6
7
8
ScreenScore4
Graphs by facility type
• Only approx. 7% of cases assessed for all 8 medical history components.
• About 1/4 of cases no history on risk factors or Danger Signs was obtained.
• Most commonly asssessed risk factors: „vaginal bleeding“ (62%) and „abd. pain“ (51%).

7. Screening:
Initial assessment vital signs (PE)
35
BEmOC
CEmOC
(n = 35)
(n = 31)
32.26
30
31.43
25
25.71
22.58
20
19.35
17.14
15
Percent
Score components:
• Pulse
• BP
• RR
• Temp
• FHR
16.13
14.29
Max score: 5
10
______________________________
6.452
5.714
5
5.714
0
3.226
0
1
2
3
4
5
0
1
2
3
4
ScreenScore1
Graphs by facility type
•
•
•
•
In about 5% of all cases no vital signs taken during initial assessment.
In only about 18% of cases all 5 vital sign parameters were assessed.
Most commonly performed assessment was “fetal heart rate” (94%)
least commonly performed assessment was “respiratory rate” (27%)
5

8. Screening:
Focused assessment of Newborn (PE)
90
(n = 40)
(n = 35)
80
CEmOC
85.71
50
60
70
75.61
10
20
30
Max score: 4
BEmOC
40
______________________________
Percent
Score components:
• APGAR 1 min
• APGAR 5 min
• Temp
• weight
7.317
8.571
5.714
4.878
0
2.439
9.756
0
1
2
3
4
0
1
2
3
4
ScreenScore7
Graphs by facility type
• Only 10% / 6% of cases assessed for all 4 components.
• Approx. 80% of cases assessed for 3 components  most commonly omitted
assessment was “Temperature check” (8%)

9. Vital signs vs. Equipment availability
Blood Pressure:
• In 58% cases without initial BP check a functional BPcuff and stethoscope available.
Heart and Respiratory Rates:
• In 89% cases without initial pulse check, and
• in 93% cases without initial respiratory rate check a
functional clock/watch available.
Body temperature:
• In 90% maternal (93% neonatal) cases without initial
temperature check a functional thermometer
available.

10. Prevention: Partograph documentation (S1L)
Partograph used in only 67% / 76% of cases
60
CEmOC
(n = 30)
(n = 28)
50
53.57
30
40
43.33
20
20
16.67
14.29
13.33
10
______________________________
BEmOC
Percent
Score components:
• FHR Q 30 min
• Contractions Q
60 min
• Heart rate Q 60
min
• BP Q 60 min
• Fetal descent Q
60 min
• Temp Q 4 hrs
7.143 7.143 7.143
3.571
3.333 3.333
0
Max score: 6
7.143
0
1
2
3
4
5
6
0
1
2
3
4
5
MonitorScore2
Graphs by facility type
• Only approx. 12% of cases complete stage 1 monitoring documented.
• In 43% / 54% of cases no documentation of stage 1 monitoring.
• Most frequently documented parameter “FHR Q 30 min” (41%).
6

11. Monitoring: maternal 1st hour postpartum
2-hr postpartum observation in only 68% / 69% of cases
______________________________
CEmOC
(n = 40)
50
BEmOC
(n = 36)
40
44.44
30
35
25
22.22
20
20
16.67
13.89
12.5
10
Percent
Score components:
• Uterus tone Q 15
min (4x)
• Vaginal bleeding
Q 15 min (4x)
• BP Q 15 min (4x)
• Heart rate Q 15
min (4x)
Max score: 16
2.5
2.778
2.5
0
2.5
0 1 2 3 4 5 6 7 8 9 10111213141516
0 1 2 3 4 5 6 7 8 9 10111213141516
MonitorScore5
Graphs by facility type
• No case with recommended minimum monitoring checks.
• 35% / 44% of cases were not monitored during the 1st hour postpartum.
• Approx . ½ of cases had “vaginal bleeding” and “BP” checked only once within
the 1st hour postpartum.

12. Monitoring: neonatal 1st hour postpartum
2-hr postpartum observation in only 68% / 69% of cases
90
83.33
30
40
50
60
70
80
82.5
12.5
11.11
2.778
2.778
2.52.5
0
Max score: 16
CEmOC
(n = 36)
20
______________________________
BEmOC
(n = 40)
10
Percent
Score components:
• Respiratory rate Q
15 min (4x)
• Heart rate Q 15
min (4x)
• Responsiveness Q
15 min (4x)
• Temp Q 15 min
(4x)
0 1 2 3 4 5 6 7 8 9 10111213141516
0 1 2 3 4 5 6 7 8 9 10111213141516
MonitorScore7
Graphs by facility type
• None of the cases received the recommended minimum monitoring checks.
• 83% of cases were not monitored during the 1st hour of life.
• “responsiveness” was the most common parameter monitored within 1st hour
of life (17%).

13. Monitoring vs. Equipment availability
Stage 1 Labor Monitoring:
• In 84% cases without partograph use
partograph forms available.
Postpartum Monitoring:
• In 67% of cases without early postpartum
monitoring at least one dedicated recovery
bed available in maternity unit.

14. Prevention:
Infection prevention during assessment and delivery
______________________________
CEmOC
(n = 31)
35
BEmOC
(n = 30)
30
30
25
25.81
23.33
22.58
20
20
15
16.13
16.13
13.33
10
12.9
6.667
5
Percent
Score components:
• Hand hygiene
physical exam
• Hand hygiene S2L
• Sterile gloves
vaginal exam
• Sterile gloves S2L
• Perineal cleansing
vaginal exam
• Perineal cleansing
S2L
3.333 3.333
3.226 3.226
0
Max score: 6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
PrevScore1
Graphs by facility type
• Most commonly omitted processes were “hand hygiene vaginal exam” (61%)
and “hand hygiene” ( 55%).
• Most frequently performed processes were the use of sterile gloves for vaginal
exam (79%) and stage 2 labor (83%).

15. Prevention: Hemorrhage (use of oxytocin)
Max score: 4
CEmOC
60
(n = 39)
(n = 36)
55.56
40
50
53.85
38.46
20
30
30.56
10
11.11
7.692
2.778
0
______________________________
BEmOC
Percent
Score components:
• Setting up
oxytocin
• Rule out twin
pregnancy
• Inform patient
• Oxytocin
administration
0
1
2
3
4
0
1
2
3
4
PrevScore4
Graphs by facility type
• 97% of all cases received oxytocin.
• In only about ½ of all cases oxytocin was given according to the recommended
standard actions.
• Ruling out twin pregnancy prior to oxytocin administration was the most
omitted action.

16. Prevention: Hemorrhage (delivery of placenta)
______________________________
CEmOC
70
(n = 36)
50
60
61.11
40
45
30
37.5
20
19.44
16.67
10
2.5
2.5
3
4
2.778
2.5
0
Max score: 6
BEmOC
(n = 40)
10
Percent
Score components:
• Place cord-clamp
proximally
• Transabdominal
pressure on uterus
• Downward cord
traction during
contraction
• Ensure completeness
of placenta
• Massage uterus
• Estimate blood loss
0
1
2
5
6
0
1
2
3
4
5
PrevScore5
Graphs by facility type
• Overall, in about 82% of all cases all or 5 actions were performed.
• Most frequently omitted action was “estimation of total blood loss”
6

17. Infection prevention vs. Supplies
Hand Hygiene:
• In 92% of cases during physical exam and
• In 85% of cases during newborn delivery without
provider performing some form of hand hygiene
some source of water plus soap available.
• In 19% of cases during physical exam and
• In 86% of cases during newborn delivery without
provider performing some form of hand hygiene
hand desinfectant available.

18. Preparedness: neonatal complications
BEmOC
CEmOC
50
(n = 36)
(n = 36)
40
44.44
30.56
30
30.56
25
25
20
Percent
Score components:
• Resuscitaire
• Ambu-bag
• Suction device
• Oxygen source
• Oxygen delivery
system
______________________________
13.89
10
Max score: 5
8.333
8.333
5.556
2.778
3
4
2.778
0
2.778
0
1
2
5
0
1
2
3
4
PrepScore1
Graphs by facility type
• Overall, in about 31% of all cases all or 5 devices were set up prior to delivery.
• “oxygen source” and “oxygen delivery system” were not prepared in 2/3 of
cases.
5

19. Preparedness vs. Equipment
• In 32% of cases without oxygen set-up
prior to delivery oxygen source and
delivery system available.

20. Steps ahead…
• Analysis of ANC observation data.
• Analysis of provider knowledge
assessment data.