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Performance Standards for Maternal and Neonatal Health
NORMAL LABOR AND DELIVERY (NLD)
Facility Name: __________________________ District: _________________________ Province: _________________________
Date of Assessment: ____________________ (day/month/year)
Assessor(s) Name(s):
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
Contacted People Names:
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
STANDARD
N°
VERIFICATION CRITERIA
NLD-01
01
The provider in charge
prepares equipment,
supplies and the
environment to conduct
clean and safe deliveries
02
Ensures that the delivery room is clean. (DETAILS IN FOLLOWING PAGE)
Ensures that the supplies and equipment to perform normal deliveries are available.
(DETAILS IN FOLLOWING PAGE)
Ensures that the supplies and equipment to manage the normal newborn including
appropriate room temperature are available. (DETAILS IN FOLLOWING PAGE)
Ensures that the supplies and equipment to manage any maternal or newborn complication
are available. (DETAILS IN FOLLOWING PAGE)
03
04
05
Ensures that the supplies and materials for infection prevention are available.
06
Ensures that the clerking notes, partograph, and all necessary registers are available.
02
Observe when pregnant women arrive at the facility to check if the provider:
Assesses for all emergency and priority signs immediately. (DETAILS IN THE FOLLOWING
PAGE).
If emergency or priority signs are present, initiates the designated emergency response
procedures and begins appropriate treatment and/or referral (see performance standards
for EmOC)
Makes an immediate assessment of whether delivery is imminent (pushing, grunting,
bulging thin perineum, or vagina gaping and head visible):
If birth is imminent, prepares for birth / If birth is not imminent, continues with care as
follows
The provider ensures that she/he speaks the language spoken by the woman or seeks
someone who can assist in this regard
Makes sure that the woman’s bodily privacy is protected (curtains, doors that close, cloths
to cover the woman, etc.)
Greets the woman and her husband or companion in a cordial manner
03
Introduces her/himself
04
07
Explains care before any examination or procedures
Discreetly asks woman if she would like someone to remain with her during the
examination, labor and delivery
Facilitates the presence of the support person of the woman’s choice, as appropriate (if the
setting allows) / Ensures that ONLY the people the woman desires are present
Responds to questions using easy-to-understand language
08
Responds to her immediate needs (thirst, hunger, cold/hot, need to urinate, etc.)
NLD – 02
The provider performs a
rapid initial assessment of
the pregnant women in
labor to identify
complications and
prioritize admissions.
01
02
NLD-03
The provider treats the
pregnant woman in labor
in a cordial manner.
01
05
06
OBSERVATION
(YES, NO, N.A.)
COMMENTS
2
MNH Performance Standards – Normal Labor and Delivery
Status of the delivery room
Verify the cleanliness and absence of dust,
blood, trash on the following:
 Floors.
 Walls
 Top of doors
 Chairs and tables
 Lamps, tabletops, lights
 Exam and delivery table
 Counters
 Non-critical equipment (e.g. stethoscope
and blood pressure cuffs)
Warm and clean room
Supplies
 Delivery bed: a bed that supports the woman in a
semi-sitting or lying in a lateral position, with
removable stirrups (only for repairing the perineum or
instrumental delivery)
 Clean bed linen
 Curtains if more than one bed
 Clean surface (for alternative delivery position)
 Work surface for resuscitation of newborn near
delivery beds
 Light source
 Heat source
 Room thermometer
 Gloves: utility, sterile or highly disinfected, long sterile
for manual removal of placenta, long plastic apron
 Urinary catheter
 Syringes and needles
 IV tubing
 Suture material for tear or episiotomy repair
 Antiseptic solution (iodophors or chlorhexidine)
 Spirit (70% alcohol)
 Swabs
 Bleach (chlorine-base compound)
 Clean (plastic) sheet to place under mother
 Sanitary pads
 Clean towels for drying and wrapping the baby
 Cord ties (sterile)
 Blanket and cap for the baby
Hand washing







Danger symptoms/signs of labor/
complications
Vaginal bleeding
Convulsions
Severe headache and blurred vision
Severe abdominal pain
Fever
Respiratory difficulty
Rupture of membranes (premature,
preterm, prolonged




Clean water supply
Soap
Nail brush or stick
Clean towels
Waste




Container for sharps disposal
Receptacle for soiled linens
Bucket for soiled pads and swabs
Bowl and plastic bag for placenta
Miscellaneous
Delivery instruments (sterile)







Scissors
Needle holder
Artery forceps or clamp
Dissecting forceps
Sponge forceps
Vaginal speculum
Episiotomy pack
MNH Performance Standards – Normal Labor and Delivery




Wall clock with second hand
Torch with extra batteries and bulb
Log books / Registers
Blank partographs
Equipment






Blood pressure machine and stethoscope
Body thermometer
Fetal stethoscope
Baby scale
Self inflating bag and mask - neonatal size / adult size
Mucus extractor with suction tube
Drugs
 Uterotonic drugs: Oxytocin, Ergometrine
 Anti-convulsives: Magnesium sulphate, Calcium
gluconate, Diazepam
 Anti-hypertensives: Hydralazine, Nifedipine
 Lignocaine
 Antibiotics: Ampicillin, Gentamicin, Metronidazole,
Benzathine penicillin
 Adrenaline
 IV solutions: Ringer lactate, Normal saline 0.9%, D5W
 Water for injection
 Eye antimicrobial: 1% silver nitrate or 2.5% povidone
iodine or Tetracycline 1% eye ointment
 Vitamin A
 ARV drugs: Nevirapine (adult, infant), Zidovudine (AZT)
(adult, infant), Lamivudine (3TC)
 Vaccines: BCG, OPV, Hepatitis B
Tests
 HIV testing kits (2 types)
 Hemoglobin testing kit
3
STANDARD
NLD-04
The provider properly
reviews and fills out the
clinical history of the
woman in labor.
N°
06
07
Asks the woman about her current labor. DETAILS IN THE FOLLOWING
PAGE.
Checks the woman’s antenatal record or asks for information about the
pregnancy
Checks the woman’s record or asks about medical and surgical history
Checks the woman’s antenatal record or asks about HIV status
if HIV status is known to be positive – looks at antenatal record and asks
about ARV drugs, most recent CD4 count, and any documents related to her
HIV care
Asks the woman how she plans to feed her baby.
Reviews the woman’s individualized birth plan with her
08
Avoids asking questions during contractions
09
Records the information in the client’s notes
01
02
03
04
05
NLD-05
The provider properly
conducts a physical
examination between
contractions.
VERIFICATION CRITERIA
04
Ensures privacy during the entire process of the provision of care or at least
during examination. DETAILS IN THE FOLLOWING PAGE.
Explains to the woman and her husband/companion what the provider is
going to do and encourages her to ask questions
Asks the woman to urinate and the provider tests the urine for albumin,
glucose and ketones.
Performs hand hygiene. DETAILS IN THE FOLLOWING PAGE.
05
Observes the woman’s emotional response
06
Observes the woman’s response to contractions
01
02
03
07
08
09
OBSERVATION
(YES, NO, N.A.)
COMMENTS
Takes vital signs or delegates the task to an assistant: DETAILS IN THE
FOLLOWING PAGE.
Checks the conjunctiva and palms of hands for pallor (clinical anemia)
If suspicious of anemia, sends blood for hemoglobin test or /does a
hemoglobinometer test.
4
MNH Performance Standards – Normal Labor and Delivery
Questions about current labour
Danger symptoms/signs of labor complications
-
Vaginal bleeding
Convulsions
Severe headache and blurred vision
Severe abdominal pain
Persistent strong contractions
Respiratory difficulty
Fever
Rupture of membranes (preterm, premature or
prolonged)
Antenatal card information
-
-
-
Obstetric history
General medical problems
Use of medications or herbs
Background of the woman and her partner with
regard to sexually transmitted infections (STIs), HIV
and tuberculosis (TB) and medical/surgical
conditions that render delivery high risk.
Gestational age, last menstrual period (LMP), and
estimated date of childbirth (EDC) for current
pregnancy
Complications detected during current pregnancy
and their management
Fetal growth and development
Hemoglobin at last antenatal visit
Syphilis (RPR) status
STI identification during pregnancy and treatment
Tetanus immunization status
HIV status
ARV prophylaxis – MER including HAART (National
Guidelines)
-
When the painful regular contractions began
How frequently they are occurring
If her “bag of waters” broke: when, what colour, and
what smell it had, any cord prolapse
Whether she feels the baby’s movements
Whether she has taken any drugs or traditional
medicine
If she has any concerns
Vital signs
-
Privacy measures
-
Woman remains covered with a sheet
Area is separated with curtains, sheets, or screens,
as appropriate
The minimum number of individuals are present
during examinations and delivery (the provider
attending the delivery and a family member—the
individual chosen by the woman)
Hands hygiene
 Washes their hands with water and soap for 10-15
seconds, paying attention to areas under the finger
nails and between the fingers
 Dries hands with an individual clean towel or air dries
them
-
Temperature.
Pulse
Blood pressure (BP)
- Checks that the needle is at the zero mark at the
start and the end of the measurement
- Checks to see that the screw valve on the ball
works properly before using the BP machine
- Pumps up the bladder and watches for any air
leaks before checking BP
- Chooses the correct cuff size
- Removes all tight clothes from around the arm
- Does not check BP during a contraction
- Makes sure that the woman is as relaxed and
comfortable as possible
- If diastolic BP is 90 mmHg or more, checks urine
for protein
- If diastolic BP is 90 mmHg or more and the
woman has proteinuria, checks biceps or patellar
reflexes
- If diastolic BP is 110 mmHg or more with
proteinuria, manages as severe pre-eclampsia
Respiratory rate
OR
 Rub both hands with approximately 5 ml of alcohol gel
70%, paying attention below to the areas the under
the finger nails and between the fingers, until dry
5
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-06
The provider properly
conducts the obstetric
examination between
contractions if time
allows.
N°
VERIFICATION CRITERIA
01
Observes the shape and size of the abdomen and checks for the presence
of scars and other skin lesions
02
Avoids examining the woman during a contraction
03
Measures fundal height
04
05
06
07
Records the results of the obstetric examination on
09
Explains her findings to the woman and her husband/companion
01
The provider properly
conducts a vaginal
examination.
02
03
04
05
08
09
Performs hand hygiene after removing gloves
10
Explains to the woman the findings and what they mean.
11
Registers findings
07
COMMENTS
Explains to the woman in easy-to-understand language what she is going
to do
Performs hand hygiene after removing gloves
Puts on surgical sterile or high-level disinfected (HLD) gloves on both
hands
Examines the vulva (ulcers, blood, liquid, secretion)
Cleans the vulva with an antiseptic
If the membranes are ruptured, then conducts a vaginal cleansing with
chlorhexidine prior to vaginal examinations
Assesses cervical dilatation, molding, and level of presenting part, Caput,
State of the MRS, if ruptured the color of liquor
Properly disposes of gloves
06
(YES, NO, N.A.)
Determines presentation, fetal lie and degree of engagement by
abdominal palpation
Evaluates and grades uterine contractions (frequency and duration over a
10 minute period)
Asks if the baby is moving regularly and observes for fetal movement
during the examination
Auscultates fetal heart rate (FHR) over a 10 minute period (fetal heart
rate and changes before, during, and after a contraction)
08
NLD-07
OBSERVATION
6
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-08
Health care provider
decides on stage and
phase in labor and
develops a plan of care
N°
01
02
03
VERIFICATION CRITERIA
05
06
07
Calculates gestational age
Order s the appropriate laboratory exams. DETAILS ARE ON THE PAGE BELOW
Makes a plan of care based on stage of labor and findings on examination.
Records all findings – if cervix is 4 cm or more dilated, records on the partograph; if
the cervix is less than 4 cm, records on the woman’s chart
Discusses the care decisions with the woman and her husband/companion if possible
Provides information to the woman and support person on the plan of care
Provides supportive car. (DETAILS IN THE FOLLOWING PAGE).
08
Provides information to companion on danger signs and how to support the woman in
labor, including breathing exercises, massage, bathing, etc.
09
Helps the woman take a bath to ensure cleanliness
NLD-09
Health care provider
provides counseling and
testing for woman in labor
with unknown HIV status.
01
02
NLD-10
If the woman’s HIV status
is positive, the healthcare
provider gives her
appropriate antiretroviral
prophylaxis
01
02
Offers HIV testing and counseling
Provides counseling for negative or positive test results
If results were positive, discusses mother-to-child transmission of HIV, and tells the
woman that she will get medicines (ARVs) right away to reduce the risk of transmitting
infection to her baby (if early labor and time allows) and that the baby will also receive
ARVs after delivery
Checks if the woman is on HAART or received ARV prophylaxis during the ANC
Makes sure woman is in true labor
If woman is not on HAART and/or did not receive ARV Prophylaxis and is in labor:
 Explains the importance of ARV Prophylaxis to prevent mother-to-child
transmission
 Administers ARVs for prophylaxis immediately according to national PMTCT
guidelines or advises the mother to continue with HAART
 Informs /reminds the woman that the baby should receive ARV Prophylaxis after
birth
04
03
03
04
OBSERVATION
(YES, NO, N.A.)
COMMENTS
7
MNH Performance Standards – Normal Labor and Delivery
Possible additional exams
If pallor, check haemoglobin
If diastolic BP ≥90 mmHg, check urine for protein
If diastolic BP ≥90 mmHg with proteinuria, check reflexes
If signs of dehydration, check urine for ketones
If HIV status is unknown or if HIV-negative and HIV test was
>6 weeks previous, offer voluntary counselling for rapid
testing for HIV
 HIV status is positive, consider checking CD4 count if recent
CD4 count is not available
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Monitoring during latent phase of labor (<4 cm cervical
dilatation)
At every observation
 Asks the woman how she is feeling.
 Assesses for all emergency and priority signs/symptoms
immediately and, if present, initiates the designated
emergency response procedures and begins appropriate
treatment and/or referral.
 Makes an immediate assessment of whether delivery is
imminent (pushing, grunting, bulging thin perineum, or
vagina gaping and head visible): If so, prepared for birth; If
not, continued as follows
 Observes the woman’s emotional response
 Observes the woman’s response to contractions
 Observes the woman’s eyes, mouth and skin to check for
signs of dehydration
 Asks the woman if she needs to empty her bladder (Saves
urine for testing, if necessary)
Monitors the following:

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Blood pressure (every 2 hours)
Pulse (hourly)
Temperature (every 4 hours unless elevated)
The number and duration of contractions in a 10-minute
period (hourly)
 Fetal heart rate (hourly)
 Fetal descent abdominally (before cervical exam)
 Cervical dilatation (4-hourly)
8
MNH Performance Standards – Normal Labor and Delivery
Supportive care during labor
Supportive care during labor
Communication
Breathing technique

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 Teaches her to notice her normal breathing.
 Encourages her to breathe out more slowly, making a sighing noise, and to
relax with each breath.
 If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face,
hands and feet, encourages her to breathe more slowly.
 To prevent pushing at the end of first stage of labor, teaches her to pant, to
breathe with an open mouth, to take in 2 short breaths followed by a long
breath out.
 During delivery of the head, asks her not to push but to breathe steadily or to
pant.
Explains all procedures, seek permission, and discuss findings with the woman
Keeps her informed about the progress of labor
Praises her, encourages and reassures her that things are going well
Ensures and respects privacy during examinations and discussions
If known HIV positive, finds out what she has told the companion. Respects her
wishes
Cleanliness
 Encourages the woman to bathe or shower or wash herself and genitals at the onset
of labor
 Washes the vulva and perineal areas before each examination
 Washes hands with soap before and after each examination
 Ensures cleanliness of labor and birthing area(s)
 Clean sup spills immediately
 DOES NOT give enema
Pain and discomfort relief
 Encourages the woman to walk around freely during the first stage of labor
 Supports the woman’s choice of position (left lateral, squatting, kneeling, standing
supported by the companion) for each stage of labor and deliver
 Suggests change of position
 Encourages mobility, as comfortable for her
 Encourages companion to:
- massage the woman’s back if she finds this helpful
- hold the woman’s hand and sponge her face between contractions
 Encourages her to use the breathing technique
 Encourages warm bath or shower, if available
 If woman is distressed or anxious, investigates the cause
Urination
Asks the woman and birth companion to call for help if:
 Encourages the woman to empty her bladder frequently
 Reminds her every 2 hours
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Mobility
Eating, drinking
 Encourages the woman to eat and drink as she wishes throughout labor.
 If the woman has visible severe wasting or tires during labor, makes sure she eats
and drinks
The woman is bearing down with contractions.
There is vaginal bleeding.
She is suddenly in much more pain.
She loses consciousness or has fits.
 There is any other concern.
9
MNH Performance Standards – Normal Labor and Delivery
STANDARD
N°
VERIFICATION CRITERIA
NLD-11
01
If the woman has not chosen an infant feeding option, provides counseling for
choosing an infant feeding method
The healthcare provider
informs or reinforces
information about infant
feeding-emphasizing
Breastfeeding
COMMENTS
For women with no HIV infection and unknown status, informs or reinforces about:
02
03
04
Avoiding pre-lacteal feeds
Initiating breastfeeding within 1 hour of delivery to maximize colostrum intake
Importance of exclusive breastfeeding for the first 6 months and continued feeding for
12 months and beyond, avoiding bottle feeding
For women in early labor:
05
How to establish good breastfeeding skills, practicing frequent and on demand feeding
If labor advanced
postpone till after delivery
06
Where to go when she gets breastfeeding problems e.g FHS
For women living with HIV:
07
All of the above PLUS:
Explains the risks of mixed feeding
08
Explains continued infant ARV prophylaxis during breastfeeding
09
Asks the woman to repeat the message
NLD-12
The healthcare provider
informs or reinforces
information about Post
Partum Family Planning
(PPFP).
OBSERVATION
(YES, NO, N.A.)
Postpartum family planning:
01
02
Provides information for the women on family planning methods available that can be
used during postpartum.
Discusses the importance of using a condom while breastfeeding
For women in early labor:
If labor advanced
postpone till after delivery
10
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-13
The provider uses the
partograph to monitor
labor and make
adjustments to care when
necessary
N°
VERIFICATION CRITERIA
01
Records patient information on a partograph. DETAILS IN THE FOLLOWING
PAGE.
02
Evaluates fetal heart rate, maternal pulse, and frequency/duration of
contractions in a 10-minute period every half hour. DETAILS IN THE FOLLOWING
PAGE.
03
If membranes are ruptured, evaluates color and odor of liquor every half hour
04
Evaluates blood pressure every two hours ( DETAILS IN THE FOLLOWING PAGE)
05
Evaluates temperature every four hours
06
Evaluates cervical dilatation and fetal descent every four hours
07
Performs hands hygiene before and after every vaginal examination
08
If the membranes are ruptured, then conducts a vaginal cleansing with
chlorhexidine prior to vaginal examinations
09
Wears sterile gloves for each vaginal examination and disposes them properly
10
Records required partograph information after every evaluation). DETAILS IN
THE FOLLOWING PAGE.
11
If membranes rupture, record time of rupture and color / character of liquor
12
Records the amount of urine output each time the woman empties the bladder
13
Records protein and acetone in urine each time they are tested
14
Records IV fluids and medications administered immediately after they are
given
15
Records the time of the above observations
16
Adjusts care according to the parameters encountered:
- If parameters are normal, continues care as planned (walk about freely,
hydration, light food if desired, change positions, etc.) OR
- If parameters are not normal, identifies complications, records the
diagnosis and makes adjustments to care.
OBSERVATION
(YES, NO, N.A.)
COMMENTS
11
MNH Performance Standards – Normal Labor and Delivery
Partograph details:
Patient information:
- Name
- Gravida, Parity
- Hospital number
- Date and time of admission
- Time of ruptured membranes
- Time of onset of labour
Information to be recorded every half hour
Fetal heart rate
Uterine contractions- frequency and duration
Maternal pulse a
Amount of IV solution with Oxytocin in
drops/minute if the woman was commenced on
Oxytocin
Information to be recorded every two hours
Maternal blood pressure
Descent by abdominal examination
Information to be recorded every four hours
Cervical dilatation
Descent
Temperature
Documentation at every vaginal examination:
- Records the condition of the membranes and
characteristics of the amniotic fluid
- Records the degree of molding of the presentation
- Graphs cervical dilation
- Graphs the descent of the head or buttocks
Information to be recorded as it occurs
- Urine – amount, presence of protein or ketones
- Administration of any medications
- Administration of IV fluids
12
MNH Performance Standards – Normal Labor and Delivery
STANDARD
N°
VERIFICATION CRITERIA
NLD-13
01
The provider prepares to
assist the delivery/ birth.
Provider prepares delivery pack and other essential materials
according to National Guidelines.
02
Allows the woman to give birth in the position she wants and in the
same bed where she has labored (if possible)
03
Ensures privacy of the woman.
- Woman remains covered with a sheet
- Area is separated with curtains, sheets, or screens, as
appropriate
- The minimum number of individuals present during birth
(including the individual chosen by the woman)
Explains to the woman how to help herself and manage the bearing
down process (when and how)
Encourages and speaks kindly to the woman during labor
04
05
07
Encourages the woman to ask questions and responds in easy-tounderstand language
Makes sure the woman’s bladder is empty
08
Makes sure the woman is clean
09
Registers procedures in clinical record
06
OBSERVATION
(YES, NO, N.A.)
COMMENTS
13
MNH Performance Standards – Normal Labor and Delivery
STANDARD
N°
NLD-14
The provider assists the
woman to have a safe and
clean delivery/birth.
01
Monitors, or has assistant monitoring Fetal Heart Rate every 5 minutes during
second stage (DETAILS ARE ON FOLLOWING PAGE)
02
Puts on personal protective clothing and equipment
03
Washes hands with soap and water and dries them, or applies alcohol gel and
rub their hands until dry
04
Puts sterile or HLD gloves on both hands
05
Cleanses the perineum with antiseptic solution
06
Gives Supportive care and never leaves the woman alone.
07
08
09
VERIFICATION CRITERIA
Allows the head to spontaneously crown while guarding the perineum
11
After the emergence of the head, asks the woman to briefly refrain from
bearing down (open mouth breathing- panting)
12
Wipes the baby’s mouth and nose using a sterile gauze if meconium present
13
Assists in delivering the baby. DETAILS ON THE FOLLOWING PAGE.
14
Provides immediate newborn care. DETAILS ON THE FOLLOWING PAGE.
16
17
18
(YES, NO, N.A.)
COMMENTS
Allows the woman to bear down when she feels the desire or with contractions
(does not force her to bear down)
Artificial rupture of membranes is avoided (especially important for women
living with HIV in order to reduce MTCT of HIV)
Performs an episiotomy only if necessary (breech, shoulder dystocia, forceps,
vacuum, poorly healed 3rd or 4th degree tear, or fetal distress)
10
15
OBSERVATION
Enthusiastically informs mother of the sex of her child (with same enthusiasm if
male or female) and shows sex of baby to mother
If the newborn is well, keeps the covered baby with the mother in skin-to-skin
contact to keep warm and to initiate breastfeeding
Instructs assistant to put name tag onto the baby with mother’s name written
on it.
Registers time of delivery and sex of the baby on the clinical record
14
MNH Performance Standards – Normal Labor and Delivery
 MONITOR Every 5 minutes :
o For emergency signs, using rapid
assessment
o Frequency, intensity and duration of
contractions
o Fetal heart rate
o Perineum thinning and bulging
o Visible descent of fetal head or during
contraction
o Mood and behaviour (distressed,
anxious)
 Records findings regularly in Labour
record and Partograph
Delivering the baby; steps during the second
stage
 Quickly palpates to determine nuchal
cord; if it is loose, slide it over the baby’s
head; if it is very tight, clamp it in two
places and cut it before unraveling it from
around the baby’s neck
 Allows spontaneous external rotation
without manipulation if it happens quickly
 Carefully takes the baby’s head in both
hands and applies downward traction
until the anterior shoulder has emerged
(no neck holding)
 Guides the baby’s head and chest upward
until the posterior shoulder has emerged
 Holds the baby by the trunk and places it
on a dry towel on the mother’s abdomen
 Dries baby gently, assesses the baby's
breathing , removes wet towel
 Covers both the mother and infant with a
dry, warm cloth or towel to prevent heat
loss
 Covers the baby’s head with a cloth or, if
available, a cap
Immediate newborn care








When the baby is born, receives her in a clean, dry cloth.
Places the baby on the mother’s abdomen.
Thoroughly dries the baby and wipes each eye with a clean
part of cloth.
Removes the wet cloth
Places the baby in skin-to-skin contact with the mother to
maintain warmth
Covers the baby—including the head—with a clean, dry cloth
while keeping the face unobstructed
Assesses the baby’s breathing while drying the baby
o If the baby is not crying or breathing at least 30 times per
minute within 30 seconds of birth, calls for help and
begins resuscitation
o If the baby is breathing normally, continues with
immediate care of the newborn
If the mother is not able to hold the baby, asks her
companion or an assistant to care for the baby. Otherwise,
the baby should remain with the mother
15
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-15
The provider adequately
performs active
management of the third
stage of labor (AMTSL)
N°
VERIFICATION CRITERIA
01
Palpates the mother’s abdomen to rule out the presence of a second
baby (without stimulating contractions)
02
Tells the woman that she will receive an injection of oxytocin
03
04
OBSERVATION
(YES, NO, N.A.)
COMMENTS
If there is not another twin, administers 10 IU of oxytocin IM (If the
health care facility does not have oxytocin, injects ergometrine 0.2 mg
IM or Syntometrine 1 mL IM or administers misoprostol 600 mcg by
mouth)
Waits to clamp and cut the cord until the cord ceases to pulsate or 2–3
minutes after the baby’s birth, whichever comes first
05
Performs controlled cord traction. DETAILS IN THE FOLLOWING PAGE.
06
Delivers the placenta
07
Informs the woman that uterine massage will be performed
08
After expulsion of the placenta, massages the uterus with one hand on a
sterile cloth over the abdomen, until the uterus contracts firmly
09
Instructs the woman on how the uterus should feel and how to perform
uterine massage
10
Inspects the perineum and vagina for lacerations
11
Examines the placenta and membranes to see if complete
12
Measures the blood lost and if the condition of the woman is affected by
the blood lost then decides immediate action
16
MNH Performance Standards – Normal Labor and Delivery
Clamp and cut the cord
Controlled cord traction (CCT)
 Wait to clamp and cut the cord until the
cord ceases to pulsate or 2–3 minutes
after the baby’s birth, whichever comes
first
 Place the clamp close to the woman’s perineum to
make CCT easier.
 Keep slight tension on the cord and await a
strong uterine contraction (2–3 minutes).
 When there is a uterine contraction, apply
countertraction to the uterus with the hand above
the pubic bone (apply pressure on the uterus in an
upward direction—towards the woman’s head).
 While applying countertraction to the uterus, apply
firm, steady traction to the cord, pulling downward
on the cord following the direction of the birth
canal.
 If the placenta does not descend during 30 to 40
seconds of controlled cord traction and there are
no signs of placental separation), stop controlled
cord traction.
 Gently hold the cord and wait until the uterus is
well contracted again. If necessary, clamp the cord
closer to the perineum as it lengthens.
 When there is another contraction, repeat steps 1
through 5
NOTE: Refer to national protocols for cord
cutting if the woman is infected with HIV
NOTE: Clamp and cut the cord
immediately if the baby is not breathing
 Place one clamp 4 cm from the baby’s
abdomen.
 Gently milk the cord towards the woman’s
perineum and place a second clamp on the
cord approximately 1 cm from the first
clamp.
 Cut the cord using sterile scissors, covering
the scissors with gauze to prevent blood
spurts. Do NOT use the same scissors used
for episiotomy.
 Tie the cord only after the provider
performs AMTSL and completes initial care
of the mother and baby
Delivery of the placenta
 As the placenta delivers, hold it in both hands and
gently turn it until the membranes are twisted.
 Slowly and gently pull to complete the delivery.
Move membranes up and down until they deliver.
 Place the placenta in the receptacle provided (for
later examination)
17
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-16
The provider adequately
performs immediate
postpartum care.
NLD-17
The provider properly
monitors the newborn and
provides essential initial
newborn care, and
subsequent care.
N°
VERIFICATION CRITERIA
01
Informs the woman what she is going to do before proceeding, then
carefully examines the vagina and perineum
02
Gently cleanses the vulva and perineum with clean, warm water or a
nonalcoholic antiseptic solution
03
Sutures tears, if necessary
04
Covers the perineum with a clean sanitary pad
05
Makes sure that the woman is comfortable (clean, hydrated and warmly
covered)
06
Assist woman to empty her bladder
07
Keeps the woman in the delivery room for at least 1 hour after
childbirth; and does not discharge the woman and her newborn until at
least 12 hours after childbirth
08
Informs woman of findings
09
Registers information in clinical record
01
Keeps the woman and her newborn together and never leaves them
alone
02
Ensures that the baby is well covered, is with the mother and has began
to suckle within one hour of birth
03
Provides routine essential care of the newborn. DETAILS IN THE
FOLLOWING PAGE.
04
Ensures Baby is warm at all times. DETAILS IN THE FOLLOWING PAGE.
05
Monitors the baby closely during at least the first six hours after birth (at
the same time as the postpartum woman is monitored) DETAILS IN THE
FOLLOWING PAGE.
06
Supervises breastfeeding - baby attachment to breast
07
Assesses baby for any jaundice
08
Monitors and records passage of meconium and urine
09
Informs parents of findings
10
Gives the baby the appropriate immunizations and issues the
appropriate under-five card
OBSERVATION
(YES, NO, N.A.)
COMMENTS
18
MNH Performance Standards – Normal Labor and Delivery
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Essential Newborn Care
Cleanliness: Prevention of newborn infections
o Assures a clean delivery
o Assures clean cord care
o Assures clean hands (providers, mother, family
members)
o Verifies maternal tetanus toxoid status
Thermal protection
o Warms room for delivery
o Immediately dries the baby after birth
o Avoids separating baby from mother whenever
possible
o Facilitates skin-to-skin contact
Early and exclusive breastfeeding
o Facilitates initiation within one hour after birth
o Counsels the mother about on demand feeding
o Counsels the mother to avoid prelacteal feeds or other
fluids/food
Initiation of breathing, resuscitation
o Promptly recognizes and manages birth asphyxia
Eye care
o Cleans the eyes immediately after birth
o Applies silver nitrate drops or antibiotic ointment
within the first hour of birth
o Promptly diagnoses and manages ophthalmia
Provides the following immunizations at birth:
o OPV
o BCG
o Hepatitis B
Administers Vitamin K
Prevention of maternal-to-child transmission of HIV
o Gives ARV drugs for prophylaxis to infant
o Explains administration of ARV drugs to the mother and
family
o Advises on early and exclusive breastfeeding
o Counsels on use of condoms while breastfeeding
Performs a comprehensive exam at 6 hours and before
discharge
Monitoring the newborn
Assess the baby in general when the mother is assessed:
 immediately after birth then
 every 15 minutes for 2 hours, then
 every 30 minutes for 1 hour, then
 every hour for the next 3 hours
o Respiration
o Color
o Temperature - touch the baby’s hands and feet
and check axillary temperature if they are cold
o Umbilical cord for bleeding
o Presence of other danger signs
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Procedure for warming up the baby
Verifies body temperature by checking
axillary temperature
Makes sure that baby is kept warm by
maintaining skin-to-skin contact
If skin-to-skin contact is not possible, rewraps the baby, including the head and
places the baby under a heat source or
incubator
Continues to monitor temperature on an
hourly basis or until temperature stabilizes
Danger signs in the newborn
Rapid respirations (more than 60 respirations per
minute)
Slow respirations (less than 30 respirations per
minute)
Flaring of the nostrils
Grunting
Severe subcostal retractions
Poor sucking/not sucking
Cyanosis, especially of the lips and tongue (Cyanosis of
the hands and feet may also be due to hypothermia
for which the baby needs to be warmed)
Hypothermia: body feeling cold (temperature <36.5
°C)
Fever: usually later in the postnatal period
(temperature >37.5 °C)
Convulsions
Umbilical cord bleeding usually in the first day or two;
needs retying of the cord; referral not required if that
is the only sign
19
MNH Performance Standards – Normal Labor and Delivery
STANDARD
NLD-18
The provider properly
disposes of the used
instruments and medical
waste after assisting the
birth.
N°
01
02
03
04
05
06
07
NLD-19
The provider properly
monitors the woman and
provides essential initial
and subsequent
postpartum care.
NLD - 20
The HF provides Family
Planning care at the
maternity ward during the
immediate postpartum
period.
VERIFICATION CRITERIA
OBSERVATION
(YES, NO, N.A.)
COMMENTS
Puts on gloves while disposing of used instruments and medical
waste
Discards the placenta in a leak-proof container with a plastic liner
Disposes of medical waste (gauze, etc.) in a plastic container with a
plastic liner.
Puts the soiled linen in a leak-proof container
Opens (un-hinges) all instruments and immerses them in a 0.5%
chlorine solution for 10 minutes
Disposes of all sharps and syringes per national Infection Prevention
guidelines. the sharps container
Removes and disposes of gloves and Performs hand hygiene after
removing gloves according to Infection Prevention guidelines
01
Keeps the woman in the maternity ward to be closely monitored for
at least two hours after the birth
02
Monitors specific indicators in the woman during at least the first six
hours postpartum. DETAILS IN THE FOLLOWING PAGE.
03
Provides care and counsel for the woman after delivery and before
discharge. DETAILS IN THE FOLLOWING PAGE.
05
Responds immediately if there are complications (see performance
standards for EmOC)
06
Informs the woman of all findings
07
Records the information on the woman’s clinical record
01
Provides information for the women after delivery on family
planning methods available that can be used during postpartum.
02
Support woman to choose a contraceptive method according her
preference and clinical condition.
03
Provides specifics information related to the contraceptive method
chosen.
04
Encourages client to ask questions and addresses them with an easyto-understand language
05
Provides method of choice as appropriate
20
MNH Performance Standards – Normal Labor and Delivery
Monitoring the postpartum woman
Assess the woman in general when the baby is
assessed:
Immediately after birth then every 15 minutes
for 2 hours, then every 30 minutes for 1 hour,
then every hour for the next 3 hours
 Vital signs:
o blood pressure
o pulse
 Vaginal bleeding
 Uterine hardness
Every 4 hours
 Temperature
 Respiration
Every hour
 Bladder (help the woman empty her bladder
if it is distended)
 Breastfeeding
 Psychological reaction
Danger signs in the postpartum woman
 Systolic BP ≤90; Diastolic BP ≤60
 vaginal bleeding:
o more than 2 or 3 pads soaked in
20-30 minutes after delivery OR
o bleeding increases rather than
decreases after delivery.
 Convulsions
 fast or difficult breathing
 fever
 too weak to get out of bed
 abdominal pain
 feels ill
 urine dribbling or pain on micturition
 pain in the perineum or draining pus
 foul-smelling lochia

Additional care for postpartum women living with HIV
Determines how much the woman has told her partner and family and respects this
confidentiality.
Is sensitive to her special concerns and fears. Gives her additional support
Advises on the importance of good nutrition
Advises her that she is more prone to infections and should seek medical help as soon as
possible if she has signs / symptoms of an infection
Tells her that lochia can cause infection in other people and therefore she should dispose of
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blood stained sanitary pads safely (list local options).
Counsels her on family planning
Counsels on ARV drug regimen
Explains the risks of HIV transmission during breastfeeding / mixed feeding
Counsels on importance of always using condoms
Advises her to visit HIV services 2 weeks after delivery for further assessment
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Care for the Woman after delivery of the placenta
 Ensures the woman has sanitary napkins or clean material to
collect vaginal blood.
 Encourages the woman to eat, drink, and rest.
 Encourages the woman to empty her bladder and ensure that she
has passed urine.
 Asks the woman’s companion to watch her and call for help if
bleeding or pain increases, if the woman feels dizzy or has severe
headaches, visual disturbance, or epigastric distress.
 Keeps the mother and baby together
 Never leaves the woman and newborn alone.
 Performs a comprehensive exam at 6 hours and before discharge
 Counsels the woman on:
o Complication readiness plan (danger signs and how to
respond)
o Hygiene
o Breast care
o Rest
o Responsibilities when caring for a baby
o Exercise
o Nutrition
o Resumption of sexual activity
o Safer sexual practices (HIV positive and negative prevention)
o Birth spacing
o Postpartum contraception
o Information on findings and plan of care
o Routine care visits
 Provides preventive measures:
o Iron-folate tablets
o Vitamin A
o Tetanus toxoid vaccination, if due
o Mebendazole, if due
o Paracetamol
 Provides counseling on LAM or provides the family planning
method of the woman’s choice if not breastfeeding
 Documents all findings and care provided.
21
MNH Performance Standards – Normal Labor and Delivery
TOTAL STANDARDS FOR NLD:
20
A. TOTAL STANDARDS OBSERVED:
B. TOTAL STANDARDS ACHIEVED:
C. PERCENTAGE OF ACHIEVEMENT: (
B  100
)
A
22
MNH Performance Standards – Normal Labor and Delivery