Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 1

SOP for Obstetrics & Gynaecology,

Ist Edition: August; 2016
Quality Assurance Cell
Delhi State Health Mission
Department of Health and Family Welfare
Government of NCT of Delhi

Compilation facilitated by : State QA Cell (Nodal Officer: Dr. Monika Rana , Consultant :
Ramesh Pandey , Communitization Officer : Arvind Mishra , Statistical Officer : Shahadat
Hussain ), ARC ( Maneesh and Md. Irshad Ansari).
Designed and Formatted by: Graphic Designer : Mansi Rana

Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 2
DETAILS OF THE DOCUMENT

-------------------------HOSPITAL

Address:

Document Name :

Document No. :

No. of Pages :

Date Created :

Designation :

Prepared By : Name :
Signature :

Designation :

Approved By : Name :

Signature :
Designation :

Responsibility of Updating : Name :

Signature :

Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 3
This Document is prepared by the expert committee comprising of:

Sl. Member Designation

No.
1. Dr. Anjali Tempe Director Professor & M.S. (MCH), Chairperson
MAMC & Lok Nayak Hospital
2. Dr. Amita Suneja Director Professor & HOD ,UCMS Member
and Guru Teg Bahadur Hospital
3. Dr. Mirnalini Mani Specialist & HOD ,Guru Gobind Member
Singh Govt. Hospital
4. Dr. Anshuman Kumar M.S. (MCH),Jag Pravesh Chandra Member
Hospital
5. Dr. Poonam Joon Specialist, Sanjay Gandhi Member
Memorial Hospital
6. Dr. Chetna Arvind Sethi Specialist ,Lok Nayak Hospital Member
7. Ms. Laxmi Narang Nursing Sister, Deen Dayal Member
Upadhayay Hospital

The SOP’s have been prepared by a committee of experts and are being circulated for customization
and adoption by all Hospitals. These are by no means exhaustive or prescriptive. An effort has been
made to document all dimensions / working aspects of common processes/ procedures being
implemented in provision of Healthcare in different departments. This document pertains to
department of Obstetrics and Gynecology. The individual Hospital departments may customize /
adapt/adopt the SOP’s relevant to their settings and approved by the Medical director/ Medical
Superintendent and issued by the Head of the concerned department. The stakeholders must be
trained and familiarize with the SOP’s and the existing relevant technical guidelines/ STG’s/Manuals
mentioned in the SOP’s must also be made available to the stakeholders.

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 INDEX

S. No. Particular Page No.

8-22
1 Obstetrics & Gynaecology- Outpatient Department
223-45
2 Obstetrics & Gynaecology- Inpatient Department

Labour Room
3 46-83
Maternity Ward
4 84-112

Family Planning
5 113-142

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 AMENDMENT SHEET

[Link]. Page Details of the amendment Reasons Signature of Signature

No. the of the
preparatory approval
authority authority

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CONTROL OF THE DOCUMENT

The holder of the copy of this manual is responsible for maintaining it in good and safe condition and
in a readily identifiable and retrievable.

The holder of the copy of this manual shall maintain it in current status by inserting latest
amendments as and when the amended versions are received.

The Manual is reviewed once a year and is updated as relevant to the Hospital policies and
procedures.

The Authority over control of this manual is as follow:

Prepared By Approved By Issued By

Quality – Nodal Officer
Name: Medical Superintendent
Designation : HOD /Dept. In charge Name: Name:

Signature: Signature: Signature:

The procedure Manual with Original Signature of the above on the Title page is considered as ”Master
Copy” , and the photocopies of the master copy for the distribution are considered as “Controlled
Copy’.

Distribution List of the Manual

Sr. No. Officials Signature of Officials receiving copy

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Out Patient Department GNCTD/………………/SOP/OBG/02

OBSTETRICS & GYNAECOLOGY-OUTPATIENT DEPARTMENT

1.1 Purpose:
Purpose of this SOP is to ensure that all patients Attending OPD are attended and provided
with quality care in an environment of minimal risk, covering every aspect of patient care from
the time patient walks in the registration counter, to consultation and examination room,
through diagnosis, treatment and follow-up of the patient in the Hospital.

1.2 Scope:
This SOP covers all the processes and guidelines to be followed by all doctors, nurses,
paramedical and other support staff involved in the management of the patient in the OPD. It
includes provision of preventive, diagnostic, curative and rehabilitative services to the patient
attending OPD. This also entails management of inventories, cleanliness, security, record
keeping and repair and maintenance of equipment.

1.3 Responsibility:
HOD, specialists, medical officers, senior residents, nursing sister OPD and respective security
and sanitation staff..

1.4 Procedure:
A. Assess, Assessment and continuity of care:

[Link]. ACTIVITY RESPONSIBILITY REFERENCE

1.4.1 Registration of patient

A.  Signage for OPD clinic and their timings MS / DMS
should be displayed prominently.
 Timings and days for special clinics to be
displayed in OPD.
 Timings for registration should also be
displayed prominently.
 Rules, regulations, patients rights,
responsibilities also be displayed prominently.
 NO smoking, signage in OPD should be
displayed prominently.
 There should be a help counter near the
entrance to guide and help needy patients.
Trolleys and wheel chairs for patients should Social workers
be available in adequate numbers at help
counter.
Registration of the patient: Any patient requiring
OPD services can get registered by one of the 2
methods.
a) By visiting the hospital and get registration
done in any OPD registration counter. An OPD
card is issued to her with assigned OPD room Registration counter
No. Clerk/ Patient
b) Recently Delhi Government has launched an herself
on-line OPD registration application, patient
can generate an online OPD card.

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Out Patient Department GNCTD/………………/SOP/OBG/02

1.4.2 Patient calling system in OPD

Patient Calling System And queue Management: Security Personnel, IPD
a) Patients should be provided with a token Nursing Orderly OR
preferably from the registration counter or it can Social Worker
also be provided by the Guard/ N.O outside the
consultation room. All the number may be put
directly on the OPD slip by the registration
counter.
b) Patients are called one by one to the
consultation room.
c) There should be preferably an electronic display
board for display of token number at every OPD.

1.4.3 Receiving of patient in OPD

A.  Patients are called by calling patient’s Attendant N
name/token number. Nursing Orderly
 Patient is asked to sit comfortably &
communicate with doctor.

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Out Patient Department GNCTD/………………/SOP/OBG/02

1.4.4 OPD Consultation

B.  A detail history and complete physical assessment Doctor on Duty
of the patient to be done in a designated
examination room / area in complete privacy
taking appropriate precautions and hygiene. (
respect the women’s dignity and right to privacy)
 The details of history and clinical examination,
allergies etc. shall be appropriately recorded in
the OPD slip.
 After history and evaluation try to make a
diagnosis /provisional diagnosis wherever feasible
and Plan treatment accordingly.
 Record the diagnosis and ICD-10 code on the
counter foil of OPD and keep the counterfoil for
records.
 Discuss the possible treatment options with the
patient and prescribe treatment accordingly.
 Prescribe and also communicate the patient
clearly about precautions, investigations and
follow-up visits wherever applicable.
 Referral: Patient seen in one OPD and referred to
other OPD should be seen preferably on priority
basis, and should be entertained on same OPD
card. However patient is instructed to make a
fresh card for the referred OPD on her next visit.
 If a patient visits OPD on a wrong day she should
not be returned but seen and treated and also
instructed to follow on her designed OPD days.
 Patients should be prescribed medicines as per
the essential drug list. Requisite SDF,
investigation slips to be issued by the doctor.
 Sick /patient requiring expert advise should be
referred to consultant / Senior Doctor whenever
required.
 Referral of patient to other department must be
done in consultation of the specialist / SR
depending on the case.
 When no definite diagnosis can be made patients
should not be shuttled from one OPD to other
OPD unnecessarily. Depending upon the
condition of the patient such patients should be
admitted if sick and proper references to be
obtained by the different departments (after
admission). Referral may be done by telephonic
consultation at OPD level also.

D. Referral : Doctor on Duty

 All patient requiring advice of different
specialty should be appropriately referred.
 Sick Patients requiring emergency/ labor room
should be referred and shifted immediately
from OPD, with staff and written advice.

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1.4.5 Investigations:
E.  Investigation/ Imaging should be prescribed to the Doctor on Duty, Annexure:2, FORM
patient as per the requirement, and referred to Staff Nurse, & NO –F
the OPD Lab.
 Appropriate investigation slips to be provided to
the patient duly filled and signed by the
prescribing doctor.
 Any precaution/ preparation required for the
investigation must be explained and recorded in
the OPD/ investigation slip.
 Patient should be clearly guided for day and date
for collection of reports.

1.4.6 Prescription and drug dispensing

A. The prescription : Doctor on Duty
 The prescription should always contain the
presenting complaint, brief history, family history,
physical examination, vitals recorded during
examination, a provisional diagnosis, investigation
and imaging prescribed, drug along with dose and
duration,.
 Medication orders should be clear, legible, with
date, sign and stamp.
 Appropriate doses and duration shall be clearly
mentioned in the prescription.
 Patient should be informed of possible serious
side effects and should be advised what needs to
be done if such situation arises.
 Possible drug/ food interactions should be
assessed while prescribing and advised /
prescribed appropriately.
Consult senior doctor / SR in OPD while prescribing a
high risk medication to the patient. The list of these
drugs should be available in the OPD.

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Out Patient Department GNCTD/………………/SOP/OBG/02

B Drug dispensing Pharmacist

 Pharmacy counters should be located in OPD.
 Opening, closing and lunch timing should be
prominently displayed in pharmacy.
 There should be a proper queue management
system for every pharmacy counter.
 There should be a sitting arrangement for patients
in the pharmacy along with an electronic display
system.
 Doctors prescription should be honored, and drug
dispensed as per the dose and duration
prescribed.
 If there is any discrepancy or ambiguity in the
prescription pharmacist must consult the doctor
on phone to clarify and patients should not be
shuttled .
 Patient should be instructed about the doses and
precautions as per the prescription.
 Pharmacy counters should not be closed before
finishing the queue toward the end of the day.
 Pharmacy in-charge must ensure that no patient
prescribed should be returned from the counter.
 There should be a complaint readdressal system
for pharmacy.

1.4.7 Nursing processes in OPD

 Maintenance of Cleanliness and sanitation in OPD I/C Nursing OPD.
area .
 Record keeping.
 Assistance to doctors.
 Maintenance of instrument and equipments.
 Counseling and addressing issues pertaining to
patient.
 Provision of healthy and conducive environment
in OPD.
 Management of injection room and minor OT.
 Bio-medical waste management.
 Ensuring adequate supplies of consumables.
 To supervise the quality of patient care and assist
in patient satisfaction survey.

1.4.8 Patient privacy and confidentiality.

 Confidentiality and privacy is one of the OPD team (All staff
fundamentals rights of the patient. It should not members)
be violated by any member of the OPD patient
care team.
 Care should be taken while examining a female
patient in OPD by a male doctor. It should
preferably be done in presence of staff nurse.
 No detail of medical condition of any patient
(written or verbal) should be divulged to any one.
 Medical record of patient to be handed over to
the patients only and in case of minor/ mentally
challenged patients records to be handed over to
the authorized attendant only.

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1.4.9 Conducting and analyzing patient satisfaction

survey
 PSS conducted at periodic intervals DMS Annexure 3 : OPD
 PSS shall be taken up every month and data Administration Patient
collected shall be analyzed. Satisfaction survey
 Sample Size: As per the Patient load. Statistically Form
correct sample can be referred from the Annexure
of General Admin SOP.
 There shall be one person designated to co- Detailed
ordinate satisfaction survey. information about
 Results of Patient satisfaction survey are recorded PSS methodology
and disseminated to concerned staff is present in
 Patient feedback form are available in General
Hindi/English language Administration.
 Department prepares the action plans for the
areas of low satisfaction

1.4.10 Equipment management and maintenance in OPD

 Nursing staff (OPD) should maintain a log register I/C Nursing SOP for Repair &
of all the major equipment installed in OPD and R&M Office of maintenance of
an inventory of all instrument in OPD. Hospital Medical
 Status of all equipment should be checked by equipment
staff nurse.
 There should be a schedule for cleaning and
preventive maintenance of all equipments.
 All vital and life saving equipment should be
covered under AMC/CAMC.
 There should be an arrangement for backup of all
vital equipments.
 Vendor/ Supplier/ R&M branch should be
informed immediately for any fault/ requisite
repair.
 All unused/surplus/ irreparable/ damaged/
equipment and instruments furniture and linen
items to be condemned and replaced.

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1.4.11 Administrative and Nonclinical work at OPD

 Maintenance of OPD; infrastructure/ equipments Sister I/C
/furniture’s/ signage’s etc.
 Continuous monitoring and evaluation of OPD
services with respect to its adequacy /efficacy
includes following:
 Statistics of new and repeat visits on
monthly and yearly basis.
 Percent changes in new and repeat visits MRD/ Admin
over years in relation to availability of'
doctors and registration staff.
 Fluctuation in visits by days of the week
(or month) calculating average, high, low.
 Determine adequacy and utilization of
clinics from clinic schedules of preceding
year to current year, to decide on
increasing or decreasing number of clinic
/days etc.
 Monitoring of staff posted in OPD on
regular basis.
 Monitoring and evaluation of pharmacy
services. Administration.
 Monitoring and evaluation of other
auxiliary services in OPD, such as minor Sister I/C
OT, Injection room, registration services.
 Arrangement of drinking water.
 Continuous collection of patient feedback
(Through patient satisfaction surveys) and its
analysis /evaluation and improvement.
 Repair and maintenance of facility, equipments
and instrument of OPD.
 Regular condemnation.
 Transfer of records to MRD and weeding of
records as per Record Retention Schedule (RRS).
 Maintenance of records, log books, inventory of
consumables and non-consumable items
efficiently.
 Maintenance of daily roster. Punctuality and
discipline among the staff posted in OPD and
display of roster in a prominent location.

1.4.12 No Smoking Policy in OPD

 The whole hospital is a non smoking zone; Hospital
Smoking is not permitted in any part of the Administration
Hospital.
 No smoking instruction should be displayed
prominently at multiple locations in OPD
including toilets/ parking areas.

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1.4.13 Duty roster, punctuality, dress code and Identity

for OPD staff
 All staff working in OPD should wear their Dress
or apron as prescribed by hospital administration
with a name plate of the staff.
 All OPDs should start attending to patients by
(9:00 AM) or as per schedule.
 All doctors should sign and stamp / write their
name in block letters in every prescription they
write in OPD.
 Registration counter should start at 8:30 AM
sharp.
 Registration counter of afternoon clinics should
start at 2:00 PM sharp.
 Department wise duty roster of doctor should be
available with I/C OPD before the start of week/
Month. The nameplate with the name of the
doctor, degree of the doctor and designation of
the doctor should be displayed in front of each
consultation room.
 All specialist/ resident/ nursing staff/
Paramedical staff/ security and sanitation staff
should be punctual in their duty and start their
work in time.

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FLOW CHART OPD

OPD

Registration at Registration Counter

Documentation of Personal Details

Assignment of Unit/Room/Doctor

Waiting area and entry in OPD as per patient calling system

ANC CLINIC GYNAE CLINIC

History taking & examination

B.P. & Weight History taking

Albumin
H.b, Urine Examination in privacy
Sugar
ANC Profile (Investigations) Investigations

Immunization Room Collection centre & dispersing of reports Minor O.T.

procedure

Counseling regarding follow up, management and contraception

Pharmacy for drug dispensing

Grievances to be addressed (at any stage)

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Out Patient Department GNCTD/………………/SOP/OBG/02

ANNEXURES

[Link] TRAY

Content Content Content

1. Inj. Oxytocin 10 IU 2. Cap. Ampicillin 500 3. T. Metronidazole 400
mg mg
4. T. Paracetamol 5. T. Ibuprofen 6. T. B-complex
7. T. Misoprostol 200 mcg 8. Inj. Gentamycin 9. Inj. Vit K
10. [Link] 11. Ringer lactate 12. Normal saline
13. Inj. Hydrazaline 14. Nifedipine 15. [Link]
16. Magnifying glass

EMERGENCY TRAY (ESSENTIAL TO KEEP AND UPDATED AND CHECKED DAILY)

Content Content Content
1. Inj. Oxytocin 10 IU 2. Inj. Magsulf 3. Inj. Calcium gluconate
50%,20% 10%
4. Inj. Dexamethasone 5. Inj. Ampicillin 6. Inj. Gentamycin
7. Inj. Metronidazole 8. Inj. Lignocaine 9. Inj. Adrenaline
2%
10. Inj. Hydrocortisone 11. Inj. Diazepam 12. Inj. Pheneramine
Succinate maleate
13. Inj. Carborost 14. Inj. Pentazocine 15. Inj. Phenergan
16. Ringer lactate 17. Normal saline 18. [Link]
19. Inj. Hydrazaline 20. Nefidepine 21. [Link]
22. IV sets with two 16-guage 23. Mouth gag 24. Vials for drug collection
needles
25. IV Canula 26. Inj. Ceftriaxone 27. Controlled suction
catheter

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EXAMINATION TRAY

S. NO CONTENTS
1. Sim’s speculum
2. Cuscos speculum
3. Anterior vaginal wall retractor
4. Sponge holding forceps
5. Allis / artery forceps

DRESSING / STITCH REMOVAL TRAY

S. NO CONTENTS
1. Scissors/ Blade
2. Antiseptic solution
3. Kidney tray
4. Swabs
5. Catheters
6. Forceps
7. Gloves
8. Sterile linen

MINOR PROCEDURE TRAY (colposcopy/Cryo/Pap’s smear)

[Link]. CONTENTS
1. Pap’s smear spatula
2. Antiseptic solution
3. Speculum. (insulated/non insulated)
4. Good Light source
5. Gynae sheet

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Out Patient Department GNCTD/………………/SOP/OBG/02

Annexure 2. FORM- F
[See Proviso to Section 4(3), Rule 9(4) and Rule 10(1A)]

FORM FOR MAINTENANCE OF RECORD IN RESPECT OF PREGNANT WOMAN BY GENETIC

CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE

1. Name and address of the Genetic Clinic/Ultrasound Clinic/Imaging Centre.

2. Registration No.
3. Patient’s name and her age
4. Number of children with sex of each child
5. Husband’s/Father’s name
6. Full address with Tel. No., if any
7. Referred by (full name and address of Doctor(s)/Genetic Counseling Centre (Referral note
to be preserved carefully with case papers)/self referral
8. Last menstrual period/weeks of pregnancy
9. History of genetic/medical disease in the family (specify)
Basis of diagnosis:(a) Clinical (b) Bio-chemical (c) Cytogenetic (d) Other (e.g. Radiological,
ultrasonography etc. specify)
10. Indication for pre-natal diagnosis
A. Previous child/children with:

Chromosomal disorders Metabolic disorders Congenital anomaly Single gene disorder

Mental retardation Haemoglobinopathy Sex linked disorders Any other (specify)

B. Advanced maternal age (35 years)

C. Mother/father/sibling has genetic disease (specify)
D. Other (specify)
11. Procedures carried out (with name and registration No. of
Gynaecologist/Radiologist/Registered Medical Practitioner) who performed it.
……………………………………………………………………………….. Non-Invasive
(i) Ultrasound ………………………………………………………………………………………………………….. (Specify
purpose for which ultrasound is to done during pregnancy)
[List of indications for ultrasonography of pregnant women are given in the important Notes]
Invasive
Amniocentesis Chorionic Villi aspiration Foetal biopsy

Cordocentesis Any other (specify)

12. Any complication of procedure – please specify

13. Laboratory tests recommended [Strike out whichever is not applicable or not necessary]
Chromosomal studies Biochemical studies
Molecular studies Preimplantation genetic diagnosis

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14. Result of
(a) Pre-natal diagnostic procedure (give
details)…………………………………………………………………….
(b) Ultrasonography Normal/Abnormal (Specify abnormality
detected, if any).
15. Date(s) on which procedures carried out.
16. Date on which consent obtained. (In case of invasive)
17. The result of pre-natal diagnostic procedure was conveyed to ….………………..….on
…………….………
18. Was MTP advised/conducted?
19. Date on which MTP carried out.
Date: Name, Signature and Registration number of the
Place Gynaecologist/Radiologist/Director of the Clinic

DECLARATION OF PREGNANT WOMAN

I, Ms. (name of the pregnant woman) declare that by undergoing

ultrasonography /image scanning etc. I do not want to know the sex of my foetus.

Signature/Thump impression of pregnant woman

DECLARATON OF DOCTOR/PERSON CONDUCTING ULTRASONOGRAPHY/IMAGE SCANNING

I, (name of the person conducting Ultrasonography/image scanning) declare

that while conducting ultrasonography/image scanning on Ms. (name of the pregnant
woman), I have neither detected nor disclosed the sex of her foetus to any body in any manner.

Name and signature of the person conducting Ultrasonography/image scanning/ Director or owner
of genetic clinic/ ultrasound clinic/imaging centre
Important Notes are given in back side P.T.O

Important Note:-

(i) Ultrasound is not indicated/advised/performed to determine the sex of foetus except for
diagnosis of sex-linked diseases such as Duchenne Muscular Dystrophy, Haemophilia A &
B etc.
(ii) During pregnancy Ultrasonography should only be performed when indicated. The
following is the representative list of indications for ultrasound during pregnancy.
(1) To diagnose intra-uterine and/or ectopic pregnancy and confirm viability.
(2) Estimation of gestational age (dating).
(3) Detection of number of fetuses and their chorionicity.
(4) Suspected pregnancy with IUCD in-situ or suspected pregnancy following
contraceptive failure/MTP failure.

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(5) Vaginal bleeding / leaking.

(6) Follow-up of cases of abortion.
(7) Assessment of cervical canal and diameter of internal os.
(8) Discrepancy between uterine size and period of amenorrhoea.
(9) Any suspected adenexal or uterine pathology / abnormality.
(10) Detection of chromosomal abnormalities, foetal structural defects and other
abnormalities and their follow-up.
(11) To evaluate foetal presentation and position.

(12) Assessment of liquor amnii.

(13) Preterm labour / preterm premature rupture of membranes.
(14) Evaluation of placental position, thickness, grading and abnormalities
(placenta praevia, retroplacental haemorrhage, abnormal adherence etc.).
(15) Evaluation of umbilical cord – presentation, insertion, nuchal encirclement,
number of vessels and presence of true knot.
(16) Evaluation of previous Caesarean Section scars.
(17) Evaluation of foetal growth parameters, foetal weight and foetal well being.
(18) Colour flow mapping and duplex Doppler studies.
(19) Ultrasound guided procedures such as medical termination of pregnancy,
external cephalic version etc. and their follow-up.
(20) Adjunct to diagnostic and therapeutic invasive interventions such as chorionic
villus sampling (CVS), amniocenteses, foetal blood sampling, foetal skin biopsy,
amnio- infusion, intrauterine infusion, placement of shunts etc.
(21) Observation of intra-partum events.
(22) Medical/surgical conditions complicating pregnancy.
(23) Research/scientific studies in recognized institutions.

Person conducting ultrasonography on pregnant women shall keep complete

record thereof in the clinic/centre in Form – F and any deficiency or
inaccuracy found therein shall amount to contravention of provisions of
section 5 or section 6 of the Act, unless contrary is proved by the person
conducting such ultrasonography.

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Annexure 3 .OPD FEEDBACK Form

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2. OBSTETRICS & GYNAECOLOGY- IN-PATIENT DEPARTMENT.

2.1 Purpose:
Purpose of this SOP is to ensure that all patients are provided with evidence based quality
care in an environment of minimal risk, covering every aspect of patient care from the time
patient is received in the gynecology ward through diagnosis, treatment, discharge of the
patient from the hospital and follow-up.

2.2 Scope:
This SOP covers all the processes and guidelines to be followed by all doctors, nurses,
paramedical and other support staff involved in the management of the patients in the
gynecology ward, and management of the ward including provision of requisite specific
care, medication, nutrition, care during pre and post-operative period, transfer, cross
referrals/ consultation/discharge/ and end of life care. Management of ward includes
inventories, cleanliness, record keeping, ward rounds, duty rosters, and security
management.

2.3 Responsibility:
The tasks are divided in a practical manner among the doctors and staff posted in the
gynecology ward (IPD).

2.4 Procedure:

[Link]. ACTIVITY RESPONSIBILITY REFERENCE

2.4.1 Receiving and initial assessment of the patient.

A. Receiving of the patient: Nursing Staff

Patient is received in ward after admission is
done at the patient admission counter of the
hospital. Patient is provided with a admission
slip bearing a centralized registration number
(C.R. No.)
B. Documentation and entry of personal details Nursing Staff IPD Admission
of the patient in Records. (IPD admission register
register).
C. Initial Assessment: Doctor on Duty
 A quick assessment of the patient is to be
done in a designated examination area in
complete privacy.
 A provisional diagnosis is made and the
patient is classified as low risk or high risk
category depending on the basis of
condition of the patient or expected
outcomes.

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D. Diagnosis: Depending on the facilities available Doctor on Duty

at the hospital (with respect to
equipments/competencies/ availability of
other requisite services,

I. High Risk Patient: is either shifted to:

 HDU/ICU/ward after counseling and
documentation of the prognosis,
wherever facilities are available.
 In case of unavailability of any of the
critical facilities required for the
management of patient, such patient
should be counseled and transferred to
higher center as per the transfer policy
of the hospital
II. Low Risk Patients: are patients who are
low risk for complications (as per the initial
assessment) & they are provided bed with
clean linen, diet.

2.4.2 Admission, shifting and referral of patients.

A. Patient Transfer Protocol:

 Every Hospital should have their own Staff nurse/doctor on
patient transfer protocol/ (SOP). duty
 There must be reasonable ground for
transfer of patient. (grounds must be
recorded in the transfer summary).
 No patient should be transferred without
transfer summary (referral slip For
ambulatory and stable patient)
 Patient’s relatives to be informed and
explained about the condition and reasons
of transfer as soon as the decision of
transfer has been taken.
 No hemodynamically unstable patients
should be transferred; every effort should
be made to stabilize the patient before
transferring.
 If it is not possible to stabilize the patient,
such patients are to be transferred in an
adequately equipped ambulance and
available trained staff.

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 It must be for the benefit of the patients.

 Consultant must be informed about
transferring the patient.
 There should be a hospital policy for
transferring the patient, with respect to
ambulance / doctor and paramedic to
accompany the patient.
 A record of all transfers to be

maintained at department level.(patient

transfer register)
 Transfer summary must contain:
o History, Clinical examination,
Investigation reports if any, ECG, X-Ray,
USG reports, treatment provided.
o Reasons for transfer.
o What is required, is not available in the
transferring hospital.
o Whether a formal call to the referral
hospital was made, if yes, it should also
be recorded in the summary.
o If for any reason, if it was not possible
to contact the referral hospital reasons
for the same should also be recorded.
o Transfer summary must contain legible
name and designation of the
transferring doctor.
 For EWS patient transfer the guidelines
issued by DHS are to be followed.
 In case a low risk / manageable patient or
their relative wants a transfer, against the
advice of doctor it should be recorded in
the case sheet and on the discharge
summary along with the signatures of the
patients / his/ her relatives.

2.4.3 Requisition of diagnosis and receiving of reports.

A.  Requisite laboratory investigations, ECG, Doctor on duty

USG, X-Ray are to be prescribed in the
patient’s case sheet and investigation Staff nurse/Doctor on
forms are to be duly filled. duty
 Sample is collected and labeled properly Nursing orderly
for lab investigations, and for imaging
investigation and ECG, patient may be
required to be taken to that department. Staff nurse
 Low risk patient is taken to radiology

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department along with N.O and for high

risk patients a bed side imaging/ ECG
should be arranged where feasible or
patient may be taken to the department
accompanied by a doctor.
 Reports are to be collected from the lab /
Radiology department and placed in the
patients file, and concerned doctor to be
informed about the receipt of the reports.
2.4.4 Preparation of patient for surgical procedure
A. Informed consent for surgical procedure:
 Informed consent for surgical procedure is Doctor on Duty/Staff
a process in which the patient is informed nurse
of the indications for the surgery, the
possible risks, the possible benefits, the
alternatives, and the possible
consequences of not getting the surgery
done.
 Informed consent may be obtained by a
doctor, a nurse, who is knowledgeable
about surgical procedure and the patient’s
condition so as to be able to explain the
elements of informed consent above.
 A written informed consent is taken, duly
signed by the patient and/or her
immediate relative and doctor.
B. Patient preparation:Patient is prepared as per Nursing staff
the orders of the surgeon and anesthetist, Doctor on Duty
including
 Pre-operative investigation: CBC,LFT, KFT,
BS –Fasting &PP,CXR, USG, ECG,
coagulation profile.
 Screening for HBV, HCV and HIV is also
desirable.
 Medication for optimal control of
underlying medical disorder.
 Bath one night prior to surgery.
 Grouping and arrangement of blood, pre-
op blood transfusion
 Nil P.O (4-6 hrs fasting)
 Site preparation/clippingEnema/bowel
preparation.
 Site marking
 Any special instruction of anesthetist
given at the time of pre anesthetic
checkup.
 Pre –operative medications/ including
antibiotic as prescribed.

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 Enlist the Patient for O.T. list and inform Nursing staff/ nursing
the concerned surgeon and anesthetist. orderly
 Enlisted patients are provided with OT
clothes on the day of surgery and shifted
to O.R on wheel chair or trolley at least
half an hour before scheduled surgery.
 The patient is handed over to the O.T
staff.
C. Post-Operative: Nursing staff + Doctor
 The patient is received in ward by nurse on Duty
on duty after the procedure.
 Nurse calls the doctor on duty to assess
the condition of the patient and to check
the completeness of post-operative notes
including medication.
D. Daily Ward Rounds:
 There should be at least two rounds in the Unit In-charge/
ward to be taken in the morning and Doctor on Duty/ Staff
evening. nurse
 Morning rounds to be taken by Unit In-
charge along with the IPD team and
evening round by DOD.
2.4.5 Transfusion of blood
A PRE-REQUISITE FOR B.T
 A doctor’s order on the patient case sheet
is must for transfusion.
 Quantity of blood/component and rate of
transfusion must also be prescribed in the
case sheet.
B. Informed consent for blood transfusion:
 The patient is informed of the medical
indications for the transfusion, the possible
risks, the possible benefits, the
alternatives, and the possible
consequences of not receiving the
transfusion.
 Consent should be obtained sufficiently in
advance of the transfusion that the patient
can truly understand what is said and have
sufficient time to make a choice, whenever
feasible.
 Consent should be documented duly
signed by patient/ relative/ doctor/nurse
 A single informed consent may cover many
transfusions if they are part of a single
course of treatment.
 It may be advisable, though, to obtain a
new consent when there is a significant

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change in the patient's care status, such as

a transfer for care to another service, an
inpatient admission, or an outpatient
transfusion.
 In emergency situations the physician
ordering the transfusion must make a
reasonable judgment that the patient
would accept the transfusion. Transfusion
should not be delayed in a life-threatening
situation if it is likely that the patient would
agree to transfusion. After the event, the
circumstances of the transfusion decision
should be documented in the case sheet of
the patient.

C  Blood sample of the patient is sent to the Annexure 1 of

blood bank for grouping and cross SOP Maternity
matching, along with blood requisition ward -
form (should clearly mention name of the Checklist for
required product and number of units Blood
required). (sample labels, blood requisition Requisition
form checked and matched with the Form
patients file)
 Availability of requisite product is to be
ascertained from blood bank.
 If blood is required later, blood bank
should be informed and asked to keep the
cross matched blood reserved for the
patient till such time.
 If it is urgent and life saving, it should be
clearly mentioned in the requisition form.
 A blood release form is sent to the blood
bank, one bag at a time, if no storage
facility is available in house, If there is a
facility for storage, (Blood bank refrigerator
is available) the total quantity of the
required blood is to be released from the
blood bank.
D. Receive the blood and verify that:
 Blood is designated for a patient for whom
requisition was sent.
 Release form bears all the details along
with the signature of blood bank staff.
 Name and CR number recorded on the
release form attached to the unit
correspond with that of the intended
Patient.
 Check, ABO Rh type, patient name/ CR No./
blood bag no and date of expiry of the

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blood or component.
 Unit has a normal appearance and is cold.
In case of any discrepancy inform the blood
bank immediately, do not transfuse till
everything has been clarified from the blood
bank.
 Record the date and time of receipt of
blood bag in the ward on the blood bank
release form.
 Check the patient case sheet for
transfusion order, type, volume and rate of
transfusion.
 Check if any pre medication is prescribed.
Medicate the patient accordingly.
 Verify the patient’s name & CR No, blood
bag for component type/ group/ expiry
date.

 Check, and record the patient's blood

pressure, pulse, respirations and
temperature in the chart or on the case
sheet with date and time of starting
transfusion.
 Immediately before transfusion, mix the
unit of blood thoroughly by gentle
inversion.

 If rapid and large volume transfusion is

required, a blood warmer can be used if
available.
E. Start transfusion if everything is in order: Annexure 2 of
 Initial flow rate should be slow not more SOP Maternity
than 1 ml/minute to allow for recognition Ward-
of an acute adverse reaction. Checklist for
Proportionately smaller volume for before starting
pediatric patients. Blood
 If no reaction occurs for first 15 minutes Transfussion
increase the rate to 4 ml / min. usual
transfusion time is 2-4 hours, and it should
not exceed 4 hours for any component.
 Platelets, plasma and cryoprecipitate: 10
mL per minute. The transfusion may be
administered as rapidly as the patient can
tolerate, usually 30 minutes.
 During transfusion, monitor the vitals of
the patient every 30 minutes (PR, BP, RR,
Spo2, Temp and any sign of urticaria)
 Access the flow rate; if unusually slow (less
than 3 ml/Min. consider the following to

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enhance the flow rate.

 repositioning the patient's arm,

 changing to a larger gauge needle,
 changing the filter and tubing,
 elevating the IV pole.
 Consider using a transfusion pump if
available
F. Signs of blood transfusion reaction: Annexure 3 of
 Hives and itching: are non serious Maternity SOP-
reactions generally controlled by Checklist in case
antihistaminic/ steroid and slow the rate of of Blood
infusion. Transfusion
 Isolated fever; Developing a fever after a Reaction
transfusion is not serious. A fever is body’s
response to the white blood cells in the
transfused blood. (slow the rate of
infusion.)
 However, it can be a sign of a serious
reaction if the patient is also experiencing
nausea vomiting, back or chest pain ,dark
colored urine
STOP TRANSFUSION IMMEDIATELY AND
INFORM THE BLOOD BANK AND TREATING
DOCTOR.
If a transfusion reaction is suspected
 Stop the transfusion
 Maintain the IV with normal saline.
 Save the bag and attached tubing, send it
to the blood bank for investigation.

In case of uncomplicated transfusion.

 Record date and time when transfusion
was stopped.
 volume of blood infused.
 Documenting the presence/absence of a
transfusion reaction in the patient case
sheet.
 Discard the blood bag and tubing as per
BMW guidelines.
 Outpatients or patients who will be leaving
the hospital within one week of transfusion
should be given written instructions
regarding delayed transfusion reactions
and asked to report immediately

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2.4.6 Maintenance of rights and dignity of the patient

 Maintenance of women’s rights, dignity,
privacy and confidentiality is responsibility
of every doctor and staff involved in the
care of the patient.
 Patient’s right and responsibilities should
be displayed in local language in all patient
waiting areas and wards.
 Social workers and nurses should also
educate the patients about their right and
responsibilities.
 All doctors and paramedical staff should be
made aware of the right and
responsibilities of the patients..
A. Patients rights:
A.1 Care:
 Patients have a right to receive
treatment irrespective of their
demographic profile.
 Right to be heard regarding her
concerns.
A.2 Confidentiality and Dignity:
 Right to personal dignity and to receive
care without any form of stigma and
discrimination.
 Privacy during examination and
treatment.
 Protection from physical abuse and
neglect.
 Accommodating and respecting their
special needs such as spiritual and
cultural preferences.
 Right to confidentiality about their
medical condition.
A.3 Information:
The information to be provided to patients is
meant to be preferably in a language of
patient’s preference and in a manner that is
effortless to understand.
 Patients and/ or their family members
have the right to receive complete
information on the medical problem,
prescription, treatment & procedure
details.
 A documented procedure for obtaining

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patient’s and / or their family’s

informed consent exists to enable them
to make an informed decision about
their care.
 Patients have to be educated on
 risks, benefits, expected treatment
outcomes and possible complications
to enable them to make informed
decisions, and involve them in the care
planning and delivery process.
 Patients or their authorized individuals
have the right of access and to get a
copy of their clinical records on their
written request.

A 4. Preferences:
 Patients have a right to seek a second
opinion on their medical condition.
 Right to information from the doctor to
provide the patient with treatment
options, so that the patient can select
what works best for her.
B. Patients responsibility:

B.1 Honesty in disclosure:

 Patients shall be honest with doctor &
disclose their complete family/ medical
history whenever asked.
B.2
Treatment compliance:
 Patients shall do their best to comply
with doctor’s treatment plan.
 Patients shall have realistic
expectations from the doctor and
his/her treatment.
 Inform and bring to the doctor’s notice
if it has been difficult to understand
any part of the treatment or of the
existences of challenges in complying
with the treatment.
B.3 Transparency and honesty:
 Patients shall make a sincere effort to
understand their therapies which
include the medicines prescribed and
their associated adverse effects and
other compliances for effective
treatment outcomes.
 If not happy, patient shall inform and
discuss with her doctor/

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administration.
 Patients shall report any fraud and
wrong doing by any staff member or
person in the hospital.
B.4 Conduct:
 Patients shall be respecting the doctors
and medical staff.
 Patients shall abide by the hospital /
facility rules.
2.4.7 Record maintenance including taking consent.
A. Record maintenance in ward:
 A record index should be available in
every ward and it should contain:
o List of all forms
o List of all registers
 Management of patient’s case sheet.
o A separate file is created for every
patient admitted to ward.
o The cover of the file must contain CR
No. / Name/Age / Sex/ and bed
number of the patient.
o Following forms and documents are to
be kept in patient’s file in chronological
order.
o Admission form/ registration forms of
the patient.
o Clinical notes/ treatment sheets/
progress notes.
o Investigation reports
o O.T notes
o Blood Transfusion notes
o Interdepartmental consultation/
referral records.
o Discharge/transfer/ death summary of
the patient.
 The completed records (case sheet of the
patient is transferred to MRD after
discharge death and transfer of the
patient.)
 While transferring the records to MRD,
nursing staff must verify the record is
complete in every respect and documents
are duly signed by respective doctor on
the front sheet.

Management of ward registers:

 All important registers such as admission

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register, birth/ death register, daily census

register etc. are to be transferred to MRD
after their completion.
 Rest of registers such as treatment book,
injection register, lab register etc to be
retained and weeded as per the record
retention schedule of the Hospital.

B. Taking informed consent of patient:

 Informed consent to be taken apart from

general form of authorization for medical
and surgical management.
 Informed concerned is taken for all surgical
procedure, blood transfusion, invasive
procedure, high risk medications etc.
 Process for taking informed consent.
o Before any of the above procedure,
patient and their relatives are informed
about the planned procedure in a
language they can understand easily.
o Preferably in presence of a staff nurse.
o They are explained in detail about the
procedure its benefits, risk and
available alternatives.
o Also explained the risks and
complications that may arise on
refusing the planned procedure.
o All queries of patient and their relatives
are to be answered to their need and
satisfaction.
o After the counseling is complete and
patient /and or their relative agree, the
informed consent is prepared, read
aloud to the patient and then get it
signed by patient, relative , Nurse and
doctor.

2.4.8 Counseling of the patient at the time of

discharge.
A Discharge of patient from ward:
As soon as decision of discharge is taken on
account of cure/ or improvement or patient
willfully wants to get discharged against
advise. Before a discharge summary is issued
to the patient leaving the ward:

A.1 A pre discharge counseling is done for every

patient to explain the :

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 Current condition and the prognosis. It is

to be done by senior staff nurse or
consultants.
 Instruction and what to do in a case of
emergency.
 Instruction for follow up visits, with days,
date/ room number.
 Medications and precautions if any.
 Do’s and don’t’s
 Referrals after discharge if required (such
as for management of other medical/
surgical disorder).
 Obtain a patient feedback regarding
quality of services.

B. Discharge summary must contain the

following:
 DOA & DOD
 Personal detail of the patient
 Diagnosis
Annexure 4 of
 Investigations with reports /results.
SOP Maternity
 Pre-op, Operative note and post-op notes.
ward - IPD
 Treatment/intervention/ medications
feedback form
provided during the stay.
in Hindi
 Advise on discharge: should also include, From
Medicines, precautions, any special
instruction
 Instructions for follow-up visits.(with day
date and timing.

C. Death of Patient in Ward:

 Doctor on duty should be present at the
bed side in case of dying patient along
with other paramedical staff.
 Doctor will pronounce the patient as
dead.
 Information must be given clearly to the
relatives of the patient by doctor or
nursing staff.
 Autopsy to be offered wherever indicated
 Death report to be given only after lapse
of an hour of pronouncing death
 Patient to be covered and cornered in a
dignified way , body should be cleaned,
chin should be tied, and eye should be
closed, and wrapped in mortuary sheet.
 Two tag one around neck and one around
wrist is tied in case body is to be kept in

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mortuary, bearing details of the patient

along with date and time of death.
 Body to be handed over to the relative
after all requisite documentation along
with a death summary stating the cause
of death.
 Nodal Officer MDRC(maternal death
review committee) to be informed
immediately.
 Facility based format as per maternal
death review to be filled up and
submitted to nodal officer.

2.4.9 Environment cleaning , infection control and

processing of equipment
These include the following:
A. Hand washing and antisepsis (hand
hygiene);
B. Use of personal protective equipment
when handling blood, body substances,
excretions and secretions;
C. Appropriate handling of patient care
equipment and soiled linen;
D. Prevention of needle stick/sharp injuries;
E. Environmental cleaning(cleaning of
surfaces) and spills-management; and
F. Appropriate handling of waste (as per
biomedical waste management handling
rules).

A.1 Wash or decontaminate hands:

 After handling any blood, body fluids,
secretions, excretions and contaminated
items;
 Between contact with different patients;
 Between tasks and procedures on the
same patient to prevent cross
contamination between different body
sites;
 Immediately after removing gloves.

A.2 Antimicrobial soap:

Used for hand washing as well as hand
antisepsis.
 If bar soaps are used, use small bars and
soap racks, which drain.
 Do not allow bar soap to sit in a pool of
water as it encourages the growth of some

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micro-organisms such as pseudomonas.

 Clean dispensers of liquid soap thoroughly
every day.
 When liquid soap containers are empty
they must be discarded, not refilled with
soap solution.
A.3
Specific antiseptics recommended for hand
antisepsis:
 2%-4% chlorhexidine,
 5%-7.5% povidone iodine,
 1% triclosan, or
 70% alcoholic hand rubs.
 Waterless, alcohol-based hand rubs: with
antiseptic and emollient gel and alcohol
swabs, which can be applied to clean
hands.
 Dispensers for hand rub should be placed
outside each patient room.

B. Use of personal protective equipment

 Health care workers who provide direct
care to patients and who work in situations
where they may have contact with blood,
body fluids, excretions or secretions;
 support staff including medical aides,
cleaners, and laundry staff in situations
where they may have contact with blood,
body fluids, secretions and excretions
 Personal protective equipment includes:
 Gloves
 Protective eye wear (goggles)
 Mask
 Apron
 Gown
 Boots/shoe covers
 Cap/hair cover.
 After use discard the used personal
protective equipment in appropriate
disposal bags, and dispose of as per the
BMW policy of the hospital.
 Do not share personal protective
equipment.
 Change personal protective equipment
completely and thoroughly wash hands
each time you leave a patient to attend to
another patient or another duty.

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C. Appropriate handling of patient care,

equipment handling and soiled linen.

C.1  Handle patient care equipment soiled with

blood, body fluids secretions or excretions
with care in order to prevent exposure to
skin and mucous membranes, clothing and
the environment.
 Ensure all reusable equipment is cleaned
and reprocessed appropriately before
being used on another patient.
 Mattresses with plastic covers should be
wiped over with a neutral detergent.
 Mattresses without plastic covers should
be steam cleaned if they have been
contaminated with body fluids.
 If this is not possible to decontaminate the
bedding it should be removed by manual
washing, ensuring adequate personnel and
environmental protection.

C.2 Linen Handling:

 Place used linen in appropriate bags at the
point of generation.
 Contain linen soiled with body substances
or other fluids within suitable impermeable
bags and close the bags securely for
transportation to avoid any spills or drips
of blood, body fluids, secretions or
excretions. to be stored and transported in
a leak proof container.
 Do not rinse or sort linen in patient care
areas (sort in appropriate areas).

 Handle all linen with minimum agitation to

avoid aerosolization of pathogenic micro-
organisms

 Separate clean from soiled linen and

transport/store them separately.

 Transport and process used linen, and linen

that is soiled with blood, body fluids,
secretions or excretions with care to
ensure that there is no leaking of fluid.

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D. Prevention of needle stick/sharps injuries

 Take care to prevent injuries when using

needles, scalpels and other sharp
instruments or equipment.

 Place used disposable syringes and

needles, scalpel blades and other sharp
items in a puncture-resistant container
with a lid that closes and is located close to
the area in which the item is used.

 Take extra care when cleaning sharp

reusable instruments or equipment.
 Never recap or bend needles.

 Sharps must be appropriately disinfected

and/or destroyed as per the national
standards or guidelines.

E. Environmental cleaning(cleaning of surfaces)

and spills-management:
 Ward along with all equipments and all
surfaces should be cleaned every morning.
 All toilets to be cleaned using surface
disinfectant at the start of every shift.
 The floor and sink should be cleaned with
detergent soap at the start of every shift.
 Mopping of floors (at the start of every
shift/ and sos for spillage). Procedure for
mopping described as under.
o Clean water is taken in three bucket
numbered 1, 2 and 3.
o Surface disinfectant is added in bucket
no-3,(so that 1st and 2nd bucket has
clean water and third bucket has
disinfectant).
o Cleaning of floor begins from inside to
outside. Towards the end all corner
and groves to be cleaned.
o After each sweep of the floor the mop
should be dipped first in bucket no. 1,
then in no.2 and lastly in no-3 and then
floor is mopped again. This process is
repeated till the whole area is cleaned.
o Water of the three containers to be
changed (depending on the size of the
ward) as the water in 3rd bucket gets

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dirty.
o Mops to be cleaned in dirty utility area
and put in a stand under sun with head
of the mop upward, and mops should
not be left wet in the ward or any
patient area.
o After mopping blood or body fluids the
mop should be treated as soiled linen
and discarded as per BMW guidelines.
o Mops should be visibly clean before
starting cleaning of a ward

 Handle patient care equipment soiled with

blood, body fluids secretions or excretions
with care in order to prevent exposure to
skin and mucous membranes, clothing and
the environment.

 Ensure all reusable equipment is cleaned

and reprocessed appropriately before
being used on another patient.

 Universal safety guideline to be followed

by all staff members working in the ward.
F. Handling of general and biomedical waste in
wards:

To be done as per the biomedical waste

management and handling rules.

2.4.10 Sorting and distribution of clean linen to the

patients.
A.  The clean bedding and clean clothes Nursing Staff
installs psychological confidence in the
patients and the public and enhances their
faith in the services rendered by the
hospital.
 Every effort should be made to provide
clean and tidy linen to the patients.
 Linen management in ward has following
components.
o Maintenance of Stock of clean linen.
o Sorting and distribution of clean linen.
o Handling of dirty linen
o Managing laundry services.
B. Maintenance of stock of clean linen. Nursing Staff
 Adequate stocks of clean linen to be
maintained in ward.

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 Quantity to be calculated on the basis of

daily requirement, laundry turn over time
and 20% of buffer stock to be added.
Calculated as under:
 STOCK= Daily requirement X Laundry
turnover days.
 Laundry turn over days is number of days
laundry takes to clean and return clothes
to the ward.
 Add 25% to above for buffer and rainy
days.
 EXAMPLE ( calculation for stock of bed
sheet to be kept in ward): for a 25 bedded
ward , where laundry takes 7 days to
return the clothes.
 Daily requirement = Number of bed (25) X
7= 175
 Add 25 % = 43.75 (round it to 44)
 Stock of bed sheet to be kept in a 25
bedded ward is approximately 219.
Similarly a stock of other linen items to be
calculated and kept in stock.
 Torn and stained clothes to be sorted and
condemned as per hospital policy or if
possible stitched time to time as per
requirement.
 Life of linen depends on the quality of
fabric, washing methods.
 Following quantity of linen is suggested for
wards in general.
o Bed sheets – 6 -8 per bed.
o Pillow cover – 4-6 per bed.
o Pillow 2 per bed
o Blanket - 3-4 per bed
o towel - 2 per bed
o draw sheet -6-8 per bed
o patient dress 4 pairs
o duster 20 per ward
o Mortuary sheet 6/ward
o Baby sheet 10 per bed.
o Mattress cover 2 per bed
Note: above requirement is indicative only,
requirement can very as per availability of
laundry in house, demand /stock to be
calculated for individually for every ward .
C. Sorting of laundry: Nursing Staff
Linen for laundry to be sorted and kept in
separate bags at the point of generation.

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 Soiled linen: are used by patient/ ordinary

dirty without urine etc. are collected at
source and send for washing (no sorting
at source required , minimal storage at
source)

 Infected linen: Linen soiled with pus

blood, body discharge, Minimum storage
at source, sluicing and soaking in
disinfectant solution to be done in
laundry.

 Foul linen: Faeces, excretions and blood

stained linen to be collected in leak proof
containers, and sluicing to be done before
washing.
D.  Clean linen is distributed daily during the Nursing Staff
first shift in the ward. (bed sheets, pillow
cover etc require daily change.

 Also change linen as and when soiled/

stained.

 Patients should be provided with clean and

unstained linen.

 Torn linen are repaired or discarded

immediately, should not be provided to the
patients.
2.4.11 End of life care
A. Recognizing when a person may be in the Nice guidelines
last days of life
B. Communication
C. Shared decision-making
D. Maintaining hydration
E. Pharmacological interventions
F. Anticipatory prescribing.
A. Recognizing when a person may be in the last
days of life:
 If it is thought that a person may be
entering the last days of life, gather and
document information on:
 The person's physiological, psychological,
social and spiritual needs
 Current clinical signs and symptoms
 Medical history and the clinical context,
including underlying diagnoses

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 The person's goals and wishes.

 The views of those important to the
person about future care.
B. Communication:
 Assess the mental and psychological
condition of the patient by talking to the
patient and their close relative.
 Identify the most appropriate person or
team to explain the dying person’s
prognosis to the patient or their close
relatives. Discuss about the available
alternatives for the condition.
 Try to find out the cultural, religious,
social and spiritual needs and preferences
of the patient and family, also whether
the dying person has understood and can
retain information given about their
prognosis.
 Provide accurate information about their
prognosis (unless they do not wish to be
informed) explain any uncertainty and
how this will be managed, avoid false
optimism, and record this in the patient’s
case sheet.
 Talk about the fears, anxieties and
concerns of the patient and or the family
members and provide them the required
information if any.
 Inform the patient and family how to
contact members of the care team when
required.
 Provide them information on home care
of the patient.
C. Shared decision making :
 The clinical care team should help the
patient and his family in making decisions
regarding care and other social, cultural,
religious or spiritual requirements/ needs.
 Try to provide individualized care to the
patient as per their need and wishes.
 Provide information about the care plan
of the patient discuss it the patient and
their relative and try to take a shared
decision on the care of the patient.
D. Hydration
 Support the dying person to drink if they
wish to and are able to without any risk of
aspiration.

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 Encourage / educate relatives of the dying

person to help with mouth and lip care or
giving drinks, if they wish to. Provide any
necessary aids and give them advice on
giving drinks safely.
 Assess, preferably daily, the dying
person's hydration status, and review the
possible need for starting clinically
assisted hydration, respecting the
person's wishes and preferences.
 Discuss the risks and benefits of clinically
assisted hydration with the dying person
and/ or their relatives.
 Consider a therapeutic trial of clinically
assisted hydration if the person has
distressing symptoms or signs that could
be associated with dehydration, such as
thirst or delirium, and oral hydration is
inadequate.
 For people being started on clinically
assisted hydration:
o Monitor at least every 12 hours for
changes in the symptoms or signs of
dehydration, and for any evidence of
benefit or harm.
o Continue with clinically assisted
hydration if there are signs of clinical
benefit.
o Reduce or stop clinically assisted
hydration if there are signs of possible
harm to the dying person, such as fluid
overload, or if they no longer want it.
 Review the risks and benefits of
continuing clinically assisted hydration
with the person and those important to
them.

E. Pharmacological interventions:
Providing appropriate non-pharmacological
methods of symptom management is an
important part of high quality care at the end
of life, for example, re-positioning to manage
pain or using fans to minimize the impact of
breathlessness. However drugs must be
provided to control or relieve the patient
from:
 Pain
 Nausea and vomiting

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 Breathlessness
 Anxiety, delirium and agitation.
 Noisy respiratory secretions.
F. Anticipatory medicines can also be prescribed
for control of any of the above symptoms
before they occur.

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3 - LABOUR ROOM

3.1 Purpose:
To ensure that all patients in labour room are provided with evidence based quality care in
an environment of minimal risk, covering every aspect of patient care from the time
patient is received to discharge of the patient.

3.2 Scope:
This SOP covers all the processes and guidelines to be followed by all doctors (Obstetrician
& Neonatologist), nurses, paramedical and other support staff involved in the management
of the patient in the LR, cross referrals/ consultation, transfer inclusive of essential
newborn care.

3.3 Responsibility:

There is a division of tasks and they are divided in a practical manner among the doctors
and staff posted in the LR (the labour room team). Individual hospital can divide the task
further among available staff depending upon skills and competencies.

3.3 Procedure:
Sr. Activity/Description Responsibility Ref. Doc./Record
No.
3.3.1 Receiving and Assessment of the Patient of Delivery

A. Receiving of the patient:

The patient is received in the LR after getting Nursing Staff
admitted from OPD, casualty or can be transferred
from the maternity ward.
B. Documentation and entry of personal details of Nursing Staff
the patient is done in LR records.
C. Initial Assessment: .
 A quick assessment of the patient is to be Doctor on Duty
done in a designated examination room /
area in complete privacy. (including
assessment of vitals- PR, RR, BP, Temp, SPo2
and PV examination)
 A provisional diagnosis is made as soon as
possible following admission in labour room
by abdominal palpation and vaginal
examination.
 Classify the case as ‘low risk’ or ‘high risk’ Nursing Staff
category depending upon the condition and Doctor on Duty
expected outcomes/ complications.

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 Document whether
- Not in labor
- Early Labor
- Active Labor >4cm
- Abortion
 Provide clean linen and bed.
 Take consents, counsel the relatives
regarding the present situation, and further
course of action.

3.3.2 Emergency Obstetric Care

All obstetric emergencies should be managed in Senior Resident, See patient
HDU/ ICU of labour room where available, a Consultant transfer
decision to transfer the patient must be taken if protocol.
facilities are not available and as per the transfer 4.10 B
protocol of the hospital.
A. Antepartum Haemorrhage(APH):
 Antepartum Haemorrhage (vaginal bleeding
after 20 weeks of pregnancy) is a life
threatening condition both for mother and the
foetus. It requires urgent action for optimal
feto-maternal outcome.
 History is taken along with the assessment of
the maternal vital parameters (pallor, pulse,
RR, BP, SpO2) and per abdomen examination
for uterine tone and foetal condition.
 Simultaneous resuscitation of patient
depending on her general condition is done.
Insert IV cannula, No. 16 .Blood samples are
taken for investigations: CBC, coagulation
profile, blood group and cross matching.
 Counseling of the patient and relatives done
regarding the seriousness of the condition,
need for caesarean section, blood
transfusions, and emergency hysterectomy.
Consent for the same is taken.
 Patient is monitored for vital parameters,
bleeding PV, urine output.
 USG is done to confirm the diagnosis.
 Placenta Previa- no PV is done. If bleeding PV
uncontrolled- emergency caesarean section is
done.
 Abruptio placentae -ARM & oxytocin or
caesarean section as per need. If patient is in
DIC- the cause is treated and blood
component therapy given.
B. Postpartum Hemorrhage (PPH):
Postpartum hemorrhage is defined as the blood

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loss after delivery of baby in excess of 500 ml after

vaginal birth, 1000 ml after cesarean section.
However, clinically any amount of bleeding from
the genital tract following the birth of the baby
which adversely affects the general condition of
the mother is termed as PPH.
 Call for help, alert nursing staff, obstetrician and
anesthetist
 Resuscitate, monitor and take measures to
arrest bleeding at the same time
 Resuscitate :
 Patient is kept warm and head end
lowered
 Oxygen given by mask.
 Two IV cannula (16 or 18 G) inserted
 Blood samples taken for: haemogram,
PT, APTT, blood grouping and cross
matching, electrolytes.
 Catheterization of bladder is done
 Crystalloids (up to 2 L) are rapidly
infused until blood arrives
If Bleeding continues........
Explore uterus to ensure it is empty
I. Atonic uterus
 Bimanual massage is done
 Oxytocin infusion is started (20 IU in 1000
ml of normal saline @ 60 drops per
minute).
 Once bleeding is controlled: Oxytocin
infusion is reduced to 40 drops per minute.
(maximum 3 liters of oxytocin infusion can
be given).
 Intravenous bolus of oxytocin should not
be given as it may lead to hypotension.
 Methyl-ergometrine- IM or IV slowly 0.2
mg is given, if required repeated after 15
minutes with maximum 5 doses, 0.2 mg
can be given IM every 4 hourly.
 Injection PGF 2 alpha- 0.25mg IM, given if

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required, repeated after 15 minutes with

maximum of 8 doses.
 Tab Misoprostol 1000 μg can be inserted
per rectum.
 Simultaneously: Continuous monitoring done
to check pulse, BP, SO2, and ABG. Fluid intake
and urine output recorded hourly.
If Bleeding still continues........
 Perform balloon tamponade to arrest
bleeding.
 Surgical intervention is done if required:
Exploratory laparotomy.
 Stepwise devascularization performed.
 Compression sutures applied.
 Ligation of anterior division of internal iliac
artery done if required.
 Hysterectomy is done as a last resort.

II. Uterus well contracted:

Bleeding likely due to trauma to genital
tract
 Exploration under sedation or
preferably GA is done.
 Examination of cervix and vaginal tract
for tears is done.
 Bimanual palpation for integrity of
uterus or presence of broad ligament
hematoma is done.
 Surgical intervention is done if required:
Exploratory Laparotomy.

C. Severe Preeclampsia and Eclampsia:

 Place in semi prone position.
 Call for HELP and inform consultant,
senior resident anesthesia.
 Aim of management: Maintain ABC,
prevention and control of seizures,
control of blood pressure and
obstetrical management.
Maintain ABC:

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 Airway: Ensure patent airway.

 Breathing: Ventilate as required.
 Circulation: Evaluate pulse & BP, secure
IV access safely as soon as possible with
large bore cannula. If pulse or breathing
is absent, initiate CPR and call
anesthetist.
 Urgent Investigations to be sent: Blood
grouping and cross-matching ,
haemogram with peripheral smear for
haemolysis, platelet count, coagulation
screen, KFT, LFT, ECG
 Monitoring: Pulse , BP, respiratory rate,
temperature, SpO2 , urine for protein,
hourly input- output charting.
Prevention and Treatment of Seizures:
 Drug of choice: Magnesium sulphate
 Second Line drug: Phenytion
 Loading dose MgSO4: 4gMgSO4 in 20%
solution IV over 10-15 minutes and 5
gm MgSO4 of 50% solution IM in each
buttock
 Maintenance dose MgSO4 : 5gm IM 4
hourly or 1 g per hour IV infusion
 If seizure continues / recur: MgSO4 2g if
<70 kg and 4 g if > 70kg IV as per
loading dose over 5-10 mins.
 If fails: Diazepam 10 ml IV or
Thiopentone 50 mg IV and IPPV.
 Monitor: Hourly urine output,
respiratory rate & patellar reflexes –
before every IM dose or every 10
minutes for first two hours and then
every 30 minutes.
 Stop infusion if:
Urine output < 100 ml in 4 hours,
Or if Patellar reflexes are absent,
Or if Respiratory rate <16
breaths/minute,
Or if Oxygen saturation < 90% .
Blood Pressure Control:
Drug of choice: Inj. Labetalol if blood

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pressure is more than 160/110 mmHg.

Obstetrical Management
 There is no place for continuation of
pregnancy if eclampsia ensues.
 Stabilization and delivery is the key.
 In eclampsia, delivery should occur within
12 hours of the onset of convulsions.
 Delivery is a team effort involving
obstetrician, anesthetist and
pediatrician.
 Termination of pregnancy to be done in
all cases of eclampsia irrespective of
period of gestation.
 In severe preeclampsia > 34- wks:
termination of pregnancy is to be done.
 In severe preeclampsia <34 wks:
expectant management is done.
D. Cord prolapse: Senior Resident
a) Cord presentation: with membranes intact,
cord is seen on USG lying between the
presenting part of the foetus and cervix.
b) Overt cord prolapse: the cord passes through
the cervix past the presenting part of the
foetus with ruptured membranes.

Step 1: Identify the risk factors such as

multiparity, previous cord prolapse,
malpresentation, polyhydramnios, multiple
gestation, prematurity, low birth weight, foetal
malformation, unengaged presenting part, low
lying placenta, etc., may be procedure related such
as ARM, external cephalic version, internal podalic
version, vaginal manipulation of foetus in the
presence of ruptured membranes.

Step 2: Call the obstetrician, pediatrician and

anesthetist.

Step-3: Reduce cord compression by bladder

filling: insert size 16 foley’s catheter fill it with 500
ml normal saline and clamp, and position the
mother in knee chest/ trendlenburg position.

Step-4: Assess foetal well being, determine

viability, confirm FHS prior to any procedure.

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If foetal heart is present, and cervix is fully dilated

consider ventouse delivery without delay,

And if cervix is not fully dilated LSCS should be

performed.

If foetal heart is not present, first confirm IUFD

with USG and await spontaneous delivery.
E. Rupture uterus: Senior Resident
Suspect rupture uterus when patient is in pain, Consultant
shock and there is a combination of following risk
factors and warning signs.

Risk Factors: Obesity, uterine scar, oxytocies in

multipara with H/O previous LSCS, grand
multiparity, diagnosed CPD, malpresentation,
placenta accreta, macrosomic foetus, uterine
anomaly, etc.

Warning signs: Scar pain and tenderness,

persistent pain between contractions, vaginal
bleeding, foetal distress, FHR deceleration.

Secure airway and give 100% oxygen 1.5

liter per minute.
 Access and secure IV line with two large
bore cannula.
 Send blood sample for grouping cross
matching and arrange at least 2 units of
blood
 Call seniors, anesthetist, and pediatrician.
 Inform the relatives about the condition of
the patient.
 Take the patient for laparotomy and
uterine repair/hysterectomy to be decided
by the size and site of rupture, degree of
bleeding and patient’s fertility status.
 Give prophylactic antibiotic postnatal and
thromboprophylaxis as per requirement.
F. Sudden Unexplained Maternal Collapse: Senior Resident
 Call for HELP (Immediately inform Consultant
consultant and call anesthetist)
 Institute basic life support if no signs of
life: (BLS guidelines)
 Maintain airway, check breathing, check
circulation.
 Commence CPR: if no pulse or breathing.
 If no response to CPR after 4 minutes,

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consider delivery/ perimortem caesarean

section.
 Initial supportive treatment:
o Assess BP, PR, RR , SpO2.
o Intubate early, may require IPPV.
o Establish IV access with 2 large bore
cannula.
o Arrange blood & blood components as
per requirement.
o Catheterize.
 Investigations to be done:
Haemogram/LFT/KFT
serum electrolytes, ABG, ECG , CXR USG
abdomen.
All these actions are to be performed concurrently
with the aim to initiate basic life support and
identify / treat the cause of the collapse.
Evaluate history and re-examine patient to
establish cause and manage accordingly.
 MRP in case of retained placenta
 Manage PPH as per protocol
 Replacement in case of uterine inversion
 Laparotomy in case of rupture uterus
 Higher antibiotics to be started in case of
septicemia
 Anti coagulation in case of pulmonary
embolism
 Blood component therapy in DIC
3. 3.3 Management of High Risk Pregnancy
 High risk pregnancy to be identified at the Doctor on duty Annexure-1
earliest, during antenatal visits or in early Identification of
labour. high risk
 Management is individualized according to pregnancy.
obstetrical and medical complications
 Transferred to obstetric HDU/ICU, or in Annexure–2
case of unavailability of any of the critical High risk cases
facilities required for the management of for HDU/ICU
patient, such patient should be counseled transfer
and transferred to higher center as per the
transfer policy of the hospital.
 If there is any sign of obstetric emergency Transfer
shift the patient to appropriate area in LR, /Referral
(HDU/ICU where available). protocol 2.10B
 Make necessary arrangements with respect
to equipment, instrument and
investigation.
 Call the emergency team (obstetrician,
anesthetist, pediatrician as per the

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requirement of the case)

3.3.4 Rapid Initial Assessment

 On first seeing a woman who is already in Doctor on duty
labour, a rapid assessment is done to assess Staff nurse
whether she requires urgent referral for
emergency care, or is her labour progressing
normally at this stage.
 Check the antenatal card for booked patient,
for un-booked patient take a detailed obstetric
history.
 Record the woman’s name, age, address,
gravidity and parity, last menstrual period,
when she first felt the foetus, movement and
how long since the first contraction.
 Perform a complete head to toe physical
examination.
 Record vitals : PR, BP, SPO2, temperature and
FHS.
 Prepare the equipment for attending labour
and delivery in advance.
 Inform the patient and her relatives about the
condition of the patient. Take necessary
consents.
 Use abdominal palpation to determine the
foetal presentation and position, and the
extent of engagement of the presenting part.
 Do vaginal examination of the woman in labour
to assess cervical dilatation, foetal
presentation and descent, the position of the
fetal skull, and adequacy & pelvis
 Ask about danger symptoms:
o Vaginal bleeding, headache,
convulsions,
o Breathing difficulties, fever,
o Severe abdominal pain ,
o Premature leakage of amniotic fluid.
 Try to make a diagnosis, consult seniors if
required and act accordingly

3.3.5 Requisition of Diagnosis and Receiving of Reports

 Requisite laboratory investigations, blood, Doctor on Duty

urine, USG, are to be prescribed in the
patient’s case sheet and investigation Nursing staff
forms are to be duly filled. Nursing Orderly
 Samples to be drawn, labeled properly and
sent to the lab along with requisition slip. Nursing staff

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 Reports to be collected from the lab on

specified time and placed in the patients
file.
 DOD to be informed about the receipt of
reports.
3.3.6 Intrapartum Care of Patient
A. Low Risk Woman:
General physical & systemic examination is
performed as under
[Link] stage
 Latent phase: painful contraction, cervical Nursing Staff & Annexure 3 –
dilatation up to 4 cm. Doctor on Duty Checklist for
 Established first stage: regular painful Nursing orderly functionality of
contractions (4-5 in 10 minutes and cervical Labor Room.
dilatation from 4cms).
 Abdominal examination is performed and Nursing staff Annexure 4-
documented for: lie, presentation and foetal Seven trays in
heart rate, uterine contractions and descent LR.
of presenting part. Doctor on duty /
 Per vaginal examination is performed and Consultant Annexure 5–
documented to assess: cervical dilatation & List of
effacement and progress of labour. Equipments &
 Investigations: Hb%, urine, blood group, Instruments
Integrated Counseling Test for rapid HIV,
USG as and when desired and reports are to Annexure 6 –
be collected. WHO
 Use of a partogram is recommended in Modified
active stage. partogram
 Supportive care provided: ambulation,
nutrition, personal hygiene, and breathing /
relaxation techniques.
 Positions: encouraged to move and adopt
whatever position they find most
comfortable.
 Eating and drinking: encouraged to drink
during labour and may take a light diet.
 Any abnormality in maternal or fetal
condition during first stage: termination by
caesarean section is indicated.
b. Second stage (Cervix fully dilated )
 Reassess: Foetal heart, fetal position,
station, uterine contractions and augment
with oxytocin if necessary.
 Monitoring: to be done for frequency of Nursing Staff
contractions and intermittent fetal heart Doctor on Duty
auscultation post contractions preferably
every 15 minutes/ or as under
o B.P- - hourly

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o Maternal pulse - every 15 minutes.

o FHR - every 15 minutes
o Temperature - four hourly
 Encourage active pushing during Doctor on Duty
contractions, only after an urge to bear Staff Nurse
down is present. If no urge to push and
normal fetal heart rate- expectant
management to be done.
 Distension of the perineum and presenting
part visible.
 Prepare for delivery- cleaning and draping
of perineum.
 Episiotomy only for maternal and fetal
indications. Mediolateral episiotomy to be
given after crowning & thinning of
perineum.
 Delivery is conducted using 5 Cs- clean
hands, clean surface, clean blade, clean
cord tie, clean cord stump.
 Delayed cord clamping 1-3 minutes after
delivery to prevent neonatal anemia.
 The baby is placed on mother’s abdomen.

c. Third stage of Labour

Active Management of Third stage of Labour
(ATMSL)
After delivery of the baby

 Uterotonics: Oxytocin 10 IU IM,

Syntometrine IM (0.2 mg ergometrine & 5
IU oxytocin) or Misoprostol 600 μgm oral or
sublingual.

 Delayed cord clamping for upto 1-3 minutes

is advisable if baby is normal. Early cord
clamping (< 1 minute after birth) is
recommended only if a neonate is
asphyxiated and needs to be moved
immediately for resuscitation.

 No uterine massage till expulsion of

placenta.
 Watchful waiting for 1-5mins for signs of
placental separation: Uterus feels hard and
globular, sudden gush of blood, suprapubic
bulge, permanent lengthening of cord
 Delivery of placenta by controlled cord
traction.
Left hand: Palmar surface of fingers placed

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above pubic symphysis and body of

uterus pushed upwards & backwards.
Right hand: Controlled cord traction in
downward & backward direction. Continued
till placenta reaches the introitus.
Placenta lifted away from introitus using
both hands and by rotating the placenta
about the insertion site or grasping
membranes with a clamp or artery.
 Inspect placenta and membranes for
completeness.

 Keep your hand on the abdomen for

assessment of uterine tonus – if atonic 
fundal massage.
 Stitch episiotomy in layers .
3.3.7 Immediate Postpartum Care
 One hour immediately after delivery is Staff Nurse
defined as the 4th stage of labour and Doctor on duty
patient is closely monitored for pulse, BP,
uterine contraction and vaginal bleeding.
 Postpartum complications are managed as
per guidelines
 Patient is monitored closely for 4 - 6 hrs in
LR.
 Patient is shifted to postnatal ward after she
passes urine and is hemodynamically stable.

3.3.8 Essential Newborn Care

 Call out time of birth and sex of the baby. Staff Nurse, Annexure 7-
 Deliver the baby onto the dry pre-warmed Paediatrician or Work
cloth draped over the mother’s abdomen. Doctor on duty Instructions for
 Start drying baby within 5 seconds after birth: ENBC
Wipe eyes, face, head, trunk, back, arms and Staff Nurse
legs thoroughly, check breathing while drying.
 Remove wet cloth to start skin-to-skin contact.
 Cover the baby with dry cloth.
 Routine suctioning should not be done.

If the baby is breathing properly:

 Continue skin-to-skin contact on mother’s
abdomen or chest.
 Do not separate the baby from the mother for Staff Nurse
at least 60 minutes, unless in respiratory
distress or with maternal emergency.
 Encourage breastfeeding when baby shows
feeding cues.

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 Do eye care (before 1 hour).

 Monitor the baby every 15 minutes.
 Postpone bathing until after baby is 24 hours
of age.
 After the baby is detached from the mother’s
breast, weigh the baby and document.
 Baby case sheet is prepared.
 Identification tag is tied.
 Baby is shown to the relatives.
 Provide preventive measures: Vitamin K, HBV
vaccine.

3.3.9 Neonatal Resuscitation

If baby is gasping or not breathing:
Resuscitation
 Call for help, Doctor on Duty Annexure 8 --
 Clamp/cut the cord using sterile scissors/ blade Paediatrician Neonatal
and gloves. resuscitation
 Transfer the baby to the newborn resuscitation
area (new born corner).
 Position head/neck.
 Only suction if the mouth/nose are blocked or
prior to bag/mask ventilation of a non-vigorous
meconium stained baby
 Start bag/mask ventilation with air.
 (Explain the situation to the relatives of the
patient.)At any time if baby starts breathing or
crying and has no severe chest in-drawing, stop
ventilation and observe to ensure that the
baby continues to breathe well.
 Check breathing and heart rate every 1 or 2
minutes of effective ventilation.
 If any of the following is present:
– heart rate < 100
– gasping or not breathing
– severe chest in-drawing
o Continue resuscitation, Take ventilation
corrective steps and continue ventilation.
Ensure proper seal and effective chest rise
for effective ventilation.
o If baby is breathing normally do routine
care and record the events.

3.3.10 Admission, Shifting and Referral of Patient

A.  Admission of the patient is done in the LR Staff Nurse
when it is prescribed by doctor on duty.
Admission can be through OPD, casualty or

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patient can be transferred from maternity

ward.
 Patients get admitted through computerized
admission system directly to labour room.
 Sick patients are to be shifted in transport
trolley or wheel chair to the LR.

B. Patient transfer protocol:

 Every hospital should have their own patient
transfer protocol/ SOP.
 There must be reasonable ground for transfer
of patient. (which must be recorded in the
transfer summary).
 No attended patient should be transferred
without transfer summary/referral slip (for
ambulatory and stable patient)
 Patient’s relatives to be informed and
explained about the condition and reasons for
transfer as soon as the decision of transfer has
been made.
 No hemodynamically unstable patient should
be transferred; every effort should be made to
stabilize the patient before transferring.
 If it is not possible to stabilize the patient,
transfer in an adequately equipped ambulance
and available trained staff.
 It must be for the benefit of the patient.
 A permission of consultant of the concerned
department is must before transferring the
patient. (written/ telephonic permission is
taken, which should be recorded and is to be
confirmed by the consultant on next working
day).
 There should be a hospital policy for
transferring the patient, with respect to
ambulance / doctor and paramedic to
accompany the patient.
 A record of all transfers to be maintained at
department level.(patient out-transfer
register)
 Transfer summary must contain:
o History, clinical examination, investigation
reports if any, ECG, X-Ray, USG reports,
treatment provided.
o Reasons for transfer.
o What exactly is required which is not
available in the transferring hospital.
o Whether a formal call to the referral

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hospital was made, if yes it should also be

recorded in the summary.
o If for any reason it was not possible to
contact the referral hospital reasons for the
same should also be recorded.
o Transfer summary must contain legible
name and designation of the transferring
doctor.
 For EWS patient transfer, the guidelines issued
by DHS to be followed.
 In case a low risk / manageable patient or their
relative wants a transfer, against the advice of
doctor it should be recorded in the case sheet
and on the discharge summary along with the
signatures of the patient / her relatives.

3.3.11 Arrangement for Interventions in Labour Room

A. Induction of Labour:
 It should be a decision of senior resident or Senior Resident
consultant. Consultant,
 There should be a valid indication for
induction.
 Patient is counselled about the need of
induction, method of induction and need for
caesarean section in case of emergency or
failure of induction.
 Informed written consent is taken.
 If CTG machine is available, NST is done,
should be reactive.
 Bishop score is assessed.
If Bishop score is unfavourable (<6): cervical
ripening is done by PGE2 intracervical gel or
mechanical means e.g. foley's catheter or
dilapan S, followed by oxytocin & ARM.
 Bishop score favourable (>6): induction with
oxytocin and ARM is done.
 Monitoring for maternal pulse, uterine
contractions and foetal heart is done.
 Labour monitoring is done as per partogram.

B. Instrumental delivery- Forceps or Ventouse:

 Instrumental delivery is to be performed by
senior resident or consultant. Senior Resident,
 Case is reviewed. Complete abdominal and Consultant
vaginal examination is performed to
determine the valid indication for

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instrumental delivery, whether

prerequisites are met and classified i.e. outlet
or low-mid cavity.
 Informed consent is taken from the patient.
Verbal consent is acceptable in labor ward,
but written consent should be obtained in
cases of trial of instrumental delivery in
operation theatre.
 Ensure presence of pediatrician trained in
neonatal resuscitation during the delivery.
 Appropriate technique in conducting the
delivery with the chosen instrument is
applied. Optimal uterine contractions
ensured and fetal heart rate is closely
monitoring during the procedure.

C. Emergency Caesarean Section:

 Decision for caesarean section shall be Senior Resident,
taken by doctor on duty and confirmed by Consultant
senior doctor (on call in emergency hours).
 IN CASE OF immediate threat to the life
of the woman or fetus decision-to-delivery
interval should be not more than 30
minutes
Category 1- e.g. cord prolapse, fetal distress, APH
with active bleeding etc.

Category 2 - Maternal or fetal compromise which

is not immediately life-threatening (decision-to-
delivery intervals 30 and 75 minutes e.g. cervical
dystocia.

Category 3 - No maternal or fetal compromise but

needs early delivery e.g. breech in early labour.

 Pregnant women with antepartum

haemorrhage, abruption, and placenta
praevia should have the cesarean section
carried out at a hospital with on site blood
transfusion services.
 Informed written consent is taken
 Investigations: Haemoglobin, grouping
cross-matching of blood, clotting screen
(optional) & preoperative ultrasound for

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localization of the placenta is (not needed

in low risk patients) done.
 The team is notified (including for
indication of cesarean section): sister
incharge OT, operating assistant,
anesthetist, and pediatrician.
 Antacids and drugs (eg. Inj. Ranitidine
50mg IV) to reduce aspiration pneumonitis,
antiemetics (eg. Inj. Perinorm 10mg IM)
to reduce nausea and vomiting given.
 Timing of antibiotic administration –
Administer prophylactic antibiotics (1st
generation cephalosporin) at cesarean
before skin incision. Choose antibiotics
effective against endometritis, urinary tract
and wound infections. Do not use co-
amoxiclav when giving antibiotics before
skin incision.
3.3.12 Transfusion of blood
A. Perquisites for blood transfusion:
 A doctor’s order on the patient case sheet Doctor on Duty
is must for transfusion.
 Quantity of blood/component and rate of
transfusion must also be prescribed in the
case sheet.
B. Informed consent for blood transfusion:

 The patient is informed about the medical

indications for the transfusion, the possible
risks, the possible benefits, the
alternatives, and the possible
consequences of not receiving the
transfusion.

 Consent is obtained sufficiently in advance

of the transfusion so that the patient can
truly understand what is said and has
sufficient time to make a choice, whenever
feasible.
 Consent is documented duly signed by
patient/ relative/ doctor/nurse
 A single informed consent may cover many
transfusions if they are part of a single
course of treatment.
 It may be advisable, though, to obtain a
new consent when there is a significant
change in the patient's care status, such as
a transfer for care to another service, an

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inpatient admission, or an outpatient

transfusion.
 In emergency situations the physician
ordering the transfusion must make a
reasonable judgment that the patient
would accept the transfusion. Transfusion
should not be delayed in a life-threatening
situation if it is likely that the patient would
agree to transfusion. After the event, the
circumstances of the transfusion decision
should be documented in the case sheet of
the patient.

C. Requisition of blood component:

 Blood sample of the patient is sent to the
blood bank for grouping and cross Annexure 1 of
matching, along with blood requisition SOP Maternity
form (should clearly mention name of the Ward -
required product and number of units Check list for
required). Requisition form
 Availability of requisite product is
ascertained from blood bank.
 If blood is required at a later time, blood
bank is informed and asked to keep the
cross matched blood reserved for the
patient till such time.
 If it is urgent and life saving, it is clearly
mentioned in the requisition form.
 A blood release form is sent to the blood
bank, one bag at a time if no storage facility
is available in house, If there is a facility for
storage (Blood bank refrigerator is
available) the total quantity is required to
be released from the blood bank.
D. Receive the blood and verify that: Annexure 2 of
 Blood is designated for a patient for whom SOP Maternity
requisition was sent. Ward -
 Release form bears all the details along Checklist- Before
with the signature of blood bank staff. starting blood
 Name and CR number recorded on the transfusion
release form attached to the unit
corresponds with that of the intended
patient.
 Check, ABO Rh type, patient name/ CR No./
blood bag no and date of expiry of the
blood component.
 Unit has a normal appearance and is cold.
 In case of any discrepancy inform the

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blood bank immediately, do not transfuse

till everything has been clarified from the
blood bank.
 Record the date and time of receipt of
blood bag in the ward on the blood bank
release form.
 Check the patient case sheet for
transfusion order, type, volume and rate of
transfusion.
 Check if any pre medication is prescribed.
Medicate the patient accordingly.
 Verify the patient’s name / CR No. blood
bag for component type/ group/ expiry
date.
 Check, and record the patient's blood
pressure, pulse, respiration and
temperature in the chart or on the case
sheet with date and time of starting
transfusion.

 Immediately before transfusion, mix the

unit of blood thoroughly by gentle
inversion.

 If rapid and large volume transfusion is

required a blood warmer can be used if
available.
E. Start transfusion if everything is in order:

 Initial flow rate should be slow not more

than 1 ml/minute to allow for recognition
of an acute adverse reaction.
Proportionately smaller volume for
pediatric patients.

 If no reaction occurs for first 15 minutes

increase the rate to 4 ml / min; usual
transfusion time is 2-4 hours, and it should
not exceed 4 hours for any component.
 Platelets, plasma and cryoprecipitate: 10
ml per minute. The transfusion may be
administered as rapidly as the patient can
tolerate, usually 30 minutes.
 During transfusion monitor the vitals of the
patient every 30 minutes (PR, BP, RR, SpO2,
temp and any sign of urticaria)
 Assess the flow rate, if unusually slow (less
than 3 ml/min.) consider the following to
enhance the flow rate.

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 Repositioning the patient's arm.

 Changing to a larger gauge needle.
 Changing the filter and tubing.
 Elevating the IV pole.
 Consider using a transfusion pump if
available.
F. Signs of blood transfusion reaction: Annexure 3 of
 Hives and itching: Are non serious reactions SOP Maternity
generally controlled by antihistaminic/ Ward -
steroid and slowing the rate of infusion. Checklist in case
 Isolated fever: Developing a fever after a of a blood
transfusion is not serious. Fever is body’s transfusion
response to the white blood cells in the reaction
transfused blood. (slow the rate of
infusion.)
 However, it can be a sign of a serious
reaction if the patient is also experiencing
nausea, vomiting, back or chest pain, dark
colored urine.
STOP TRANSFUSION IMMEDIATELY AND INFORM
THE BLOOD BANK AND TREATING DOCTOR.
If a transfusion reaction is suspected
 Stop the transfusion.
 Maintain IV with normal saline.
 Save the bag and attached tubing, send it to
the blood bank for investigation.

G. In case of uncomplicated transfusion.

 Record date and time when transfusion was
stopped.
 Record volume of blood infused.
 Document the presence/absence of a
transfusion reaction in the patient case
sheet.
 Discard the blood bag and tubing as per
BMW guidelines.
 Outpatients or patients who will be leaving
the hospital within one week of transfusion
should be given written instructions
regarding delayed transfusion reactions and
asked to report immediately.

3.3.13 Distinguishing Between Newborn Death and Still

Birth
 New born death or neonatal death is defined Obstetrician
as death of a newborn who has shown some Pediatrician
signs of life immediately after birth. It is called
as early neonatal death if the baby dies within Staff Nurse

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7 days of birth, and up to 28 days it is called

late neonatal death.
 A new born is declared as Still born when
there are no signs of life on delivery.
 Filling of forms :
Still birth from by obstetrician.
Neonatal death form by pediatrician.
 Body is handed over to go the relatives.

3.3.14 Environmental Cleaning and Processing of the

Equipment in LR
 Traffic in labor room is kept minimal.
 Only staff that is required for procedures is
allowed in labor room.
 External foot wears are not allowed in the
area.
 All health care providers involved in direct care
of patients MUST use personal protective
equipment.
 After every procedure all working surfaces are
disinfected.
Following practices to be followed in LR by all
staff:
 Hand washing and antisepsis (hand hygiene).
 Use of personal protective equipment when
handling blood, body substances, excretions
and secretions.
 Appropriate handling of patient care
equipment and soiled linen.
 Prevention of needle stick/sharp injuries.
 Environmental cleaning (cleaning of surfaces)
and spills-management.
 Appropriate handling of waste (as per
biomedical waste management handling
guidelines).

A. Wash or decontaminate hands: Annexure-9

 After handling any blood, body fluids, Pictorial chart for
secretions, excretions and contaminated items. steps of hand
 Between contact with different patients. washing
 Between tasks and procedures on the same
patient to prevent cross contamination
between different body sites.
 Immediately after removing gloves.

Antimicrobial soap: Used for hand washing as well

as hand antisepsis.
 If bar soaps are used, use small bars and soap

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racks which drain.

 Do not allow soap bar to sit in a pool of water
as it encourages the growth of micro-
organisms such as pseudomonas.
 Clean dispensers of liquid soap thoroughly
every day.
 When liquid soap containers are empty they
must be discarded, not refilled with soap
solution.

Specific antiseptics recommended for hand

antisepsis:
 2%-4% chlorhexidine.
 5%-7.5% povidone iodine.
 1% triclosan.
 70% alcoholic hand rubs.
 Waterless, alcohol-based hand rubs: with
antiseptic and emollient gel and alcohol swabs,
which can be applied to clean hands.
 Dispensers for hand rub should be placed near
all tables in LR.

B. Use of personal protective equipment:

 Health care workers who provide direct care to
patients and who work in situations where
they may have contact with blood, body fluids,
excretions or secretions.
 Support staff including medical aides, cleaners,
and laundry staff in situations where they may
have contact with blood, body fluids,
secretions and excretions.
 Personal protective equipment includes:
o Gloves
o Protective eye wear (goggles)
o Mask
o Apron
o Gown
o Boots/shoe covers
o Cap/hair cover
 After use discard the personal protective
equipment in appropriate disposal bags, and
dispose of as per the BMW policy of the
hospital.
 Do not share personal protective equipment.
 Change personal protective equipment
completely and thoroughly wash hands each
time you leave a patient to attend to another
patient or another duty.

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C. Appropriate handling of patient care, equipment

handling and soiled linen: Staff Nurse,
 Handle patient care equipment soiled with Nursing Orderly,
blood, body fluids secretions or excretions with Housekeeping
care in order to prevent exposure to skin and staff.
mucous membranes, clothing and the
environment.
 Ensure all reusable equipment is cleaned and
reprocessed and sterilized appropriately
before being used on another patient.
 Mattresses with plastic covers should be wiped
with a neutral detergent.
 Mattresses without plastic covers should be
steam cleaned if they have been contaminated
with body fluids.
 If this is not possible to decontaminate the
bedding it should be removed by manual
washing, ensuring adequate personnel and
environmental protection.
Linen handling:
 Place used linen in appropriate bags at the
point of generation.
 Contain linen soiled with body substances or
other fluids within suitable impermeable bags
and close the bags securely for transportation
to avoid any spills or drips of blood, body
fluids, secretions or excretions. Bags to be
stored and transported in a leak proof
container.
 Do not rinse or sort linen in patient care areas
(sort in appropriate areas).
 Handle all linen with minimum agitation to
avoid aerosolization of pathogenic micro-
organisms.
 Separate clean from soiled linen and
transport/store them separately.
 Transport and process used linen, and linen
that is soiled with blood, body fluids,
secretions or excretions in separate leak proof
bags with care to ensure that there is no
leaking of fluid.

D. Prevention of needle stick/sharps injuries:

 Take care to prevent injuries when using
needles, scalpels and other sharp instruments

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or equipment.
 Place used disposable syringes and needles,
scalpel blades and other sharp items in a
puncture-resistant container with a lid that
closes and is located close to the area in which
the item is used.
 Take extra care when cleaning sharp reusable
instruments or equipment.
 Never recap or bend needles.
 Sharps must be appropriately disinfected
and/or destroyed as per the national standards
or BMW guidelines.
E. Environmental cleaning(cleaning of surfaces) and
spills-management:
 Labour room along with all equipments and all Staff Nurse/
surfaces should be cleaned every morning. Housekeeping
 All toilets to be cleaned using surface staff
disinfectant at the start of every shift.
 The floor and sink should be cleaned with
detergent soap at the start of every shift.
 Mopping of floors (at the start of every shift/
and SOS for spillage). Procedure for mopping
described as under.
o Clean water is taken in three bucket
numbered 1, 2 and 3.
o Surface disinfectant is added in bucket no.3
(so that 1st and 2nd bucket has clean water
and third bucket has disinfectant).
o Cleaning of floor begins from inside to
outside. Towards the end all corner and
groves to be cleaned.
o After each sweep of the floor the mop
should be dipped first in bucket no. 1, then
in no.2 and lastly in no.3 and then floor is
mopped again. This process is repeated till
the whole area is cleaned.
o Water of the three containers to be
changed (depending on the size of the
ward) as the water in 3rd bucket gets dirty.
o Mops to be cleaned in dirty utility area and
put in a stand under sun with head of the
mop upward, and mops should not be left
wet in the ward or any patient area.
o After mopping blood or body fluids the mop
should be treated as soiled linen and
discarded as per BMW guidelines.
o Mops should be visibly clean before starting
cleaning of a ward

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 Handle patient care equipment soiled with

blood, body fluids secretions or excretions with
care in order to prevent exposure to skin and
mucous membranes, clothing and the
environment.
 Ensure all reusable equipment is cleaned and
reprocessed and sterilized appropriately
before being used on another patient.
 Universal safety guidelines to be followed by
all staff members working in the ward.

F. Handling of general and biomedical waste in LR:

To be done as per the biomedical waste
management and handling guidelines.

3.3.15 Maintenance of Rights and Dignity of the Patient

 Maintenance of women’s rights, dignity,
privacy and confidentiality is responsibility of
every doctor and staff involved in the care of
the patient.
 Patient’s right and responsibilities should be
displayed in local language in all patient
waiting areas and wards.
 Social workers and nurses should also educate
the patients about their right and
responsibilities.
 All Doctors and paramedical staff should be
made aware of the right and responsibilities of
the patients.
A. Patients rights:
a) Care:
 Patients have a right to receive treatment
irrespective of their demographic profile.
 Right to be heard regarding her concerns.
b) Confidentiality and Dignity:
 Right to personal dignity and to receive
care without any form of stigma and
discrimination.
 Privacy during examination and treatment.
 Protection from physical abuse and
neglect.
 Accommodating and respecting their
special needs such as spiritual and cultural
preferences.
 Right to confidentiality about their medical
condition.
c) Information: The information to be provided to

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patients is meant to be in a language of

patient’s preference and in a manner that is
effortless to understand.
 Patients and/ or their family members have
the right to receive complete information
on the medical problem, prescription,
treatment & procedure details.
 A documented procedure for obtaining
patient’s and / or their family’s informed
consent exists to enable them to make an
informed decision about their care.
 Patients have to be educated on risks,
benefits, expected treatment outcomes
and possible complications to enable them
to make informed decisions, and involve
them in the care planning and delivery
process.
 Patients or their authorized individuals
have the right of access and to get a copy
of their clinical records on their written
request.
d) Preferences:
 Patients have a right to seek a second
opinion on their medical condition.
 Right to information from the doctor to
provide the patient with treatment
options, so that the patient can select what
works best for her.

B. Patients responsibility:
a) Honesty in disclosure:
 Patients shall be honest with doctor &
disclose their complete family/ medical
history whenever asked.
b) Treatment compliance:
 Patients shall do their best to comply with
doctor’s treatment plan.
 Patients shall have realistic expectations
from the doctor and his/her treatment.
 Inform and bring to the doctor’s notice if it
has been difficult to understand any part of
the treatment or of the existences of
challenges in complying with the
treatment.
c) Transparency and honesty:
 Patients shall make a sincere effort to
understand their therapies which include
the medicines prescribed and their

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associated adverse effects and other

compliances for effective treatment
outcomes.
 If not happy, patient shall inform and
discuss with her doctor/ administration.
 Patients shall report any fraud and wrong
doing by any staff member or person in the
hospital.
d) Conduct:
 Patients shall be respecting the doctors and
medical staff.
 Patients shall abide by the hospital / facility
rules.

3.3.16 Record Maintenance including Taking Consent

A Record maintenance in Labour Room:
 A record index should be available in every
ward and it should contain:
o List of all forms
o List of all registers
 Management of patient’s case sheet:
o A separate file is created for every patient
admitted or transferred to LR
o The cover of the file must contain CR No. /
Name, Husbands Name/Age / Sex/ of the
patient.
o Following forms and documents are to be
kept in patient’s file in chronological
order.
o ANC card when available, clinical notes,
treatment sheets, progress notes.
o Investigation reports
o LR notes.
o Blood Transfusion notes.
o Interdepartmental consultation/ referral
records.
o Baby admission slip.
o Baby clinical notes and treatment notes.
o Birth form.
o Discharge /transfer/ death summary of
the patient.
 The completed records (case sheet of the
patient is transferred to MRD after discharge,
death and transfer of the patient along with
birth/ death form duly completed).
 While transferring the records to MRD nursing
staff must verify the record is complete in
every respect and documents are duly signed

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by respective doctors.
 Management of ward registers:
o All important registers such as admission
register, birth/ death register, daily census
register etc. are to be transferred to MRD
after their completion.
o Rest of registers such as treatment book,
injection register, lab register etc to be
retained and weeded as per the record
retention schedule of the hospital.
B. Doctor on Duty
Taking informed consent of patient: Staff Nurse
 Informed consent to be taken apart from
general form of authorization for medical and
surgical management.
 Is taken for all surgical procedures, blood
transfusion, invasive procedures, etc.
 Before any of the above procedure patient and
their relatives are informed about the planned
procedure in a language they can understand
easily.
 Preferably in presence of a staff nurse.
 They are explained in detail about the
procedure, its benefits, risk and available
alternatives.
 Also explained the risks and complications that
may arise on refusing the planned procedure.
 All queries of patient and their relatives are to
be answered to their need and satisfaction.
 After the counseling is complete and patient
/and or their relative agree, the informed
consent is prepared, read aloud to the patient
and signed by the patient and witnesses.

ANNEXURES

Annexure 1. HIGH RISK CASES

IDENTIFICATION OF HIGH RISK PREGNACY
( To be referred to secondary/ tertiary care centre as per facilities available in the health unit)

Personal/Past health factors Ongoing maternal and/or fetal problems

Age < 18 years or > 35 yrs Post dated
Short statured height <140 cm Preterm labor/Premature rupture of membranes/
PPROM
H/O consanguinity Maternal weight > 90 kg
excessive obesity or < 45 kg
Smoking, Alcoholism, Substance/ Drug IUGR/ Uteroplacental insufficiency

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Abuse
Parity > 5 Cephalopelvic disproportion/Obstructed labor
Treatment for infertility and use of Vaginal bleeding in early pregnancy, Molar
ovulatory drugs pregnancy, Ectopic pregnancy
Chronic medical disorders Third trimester vaginal bleeding-Placenta Previa,
Abruptio
Previous uterine surgery -cesarean section Oligoamnios,Hydramnios
myomectomy. cervical cerclage
Bad Obstetric History Malpresentation
Previous Rh isoimmunization/ Uncontrolled Hyperemesis gravidarum
hydrops fetalis
Multiple Pregnancy,
Severe Anemia Hb <= 7 gm%

Gestational Hypertension
Gestational Diabetes
Jaundice
HIV Positive/AIDS, Hepatitis B Positive

Annexure [Link] RISK CASES REQUIRING ADMISSION IN HDU/ICU

(To be referred to tertiary care centre)
obstetric ComplicationsObstetric Complications Pregn

OBSTETRIC COMPLICATIONS PREGNANCY WITH MEDICAL DISORDERS

Accidental Hemorrhage‐ Placental Pregnancy/Labor Pain with Severe
Abruption, Couvelaire Uterus Anemia (< 7 gm %) and its complications

PostPartum Hemorrhage Pregnancy with Gestational Diabetes

Placenta Previa Pregnancy with Diabetic Ketoacidosis

Adherent Placenta and other placental Pregnancy with Cardiac Diseases

abnormalities
HELLP Syndrome Pregnancy with Jaundice
Severe Pre‐eclampsia/Hypertensive Crisis Pregnancy with Thyrotoxicosis,Thyroid Storm
Eclampsia Pregnancy with DIC

Multiple Gestation with complications Pregnancy with Pheochromocytoma

Pregnancy with complications due to Pregnancy with Bleeding Disorders
Uterine Anomaly and Pathologies
Ruptured Ectopic Pregnancy with Dengue, Complicated Malaria
Hydatidiform Mole
Sepsis & Systemic Inflammatory
Response Syndrome (SIRS)
Obstetric Hysterectomy
Postoperative patients requiring
hemodynamic monitoring or intensive
nursing care

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Modified from : Guidelines on Obstetric HDU and ICU, March 2016, Department of Health and
Family Welfare, Govt. of India.

Annexure [Link] LR FUNCTIONALITY

Source: Department of H&FW, GOI

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Annexure 4 : .CONTENTS OF 7 TRAYS IN LABOUR ROOM

Source: Modified from “Guidelines for Standardization of Labor Rooms at Delivery Points”, Ministry
of H&FW, Govt. of India, March 2016.

Tray 1: Delivery Tray

SNo. Content SNo. Content

1. Gloves 2. Scissors

3. Artery forceps 4. Cord clamp

5. Sponge holding forceps 6. Urinary catheter &

Urobag
7. Bowl for antiseptic 8. Gauze pieces
lotion
9. Cotton swabs 10. Speculum

11. Sanitary pads 12. Kidney tray

13. Sterilized linen 14. Kelley’s pad

Tray 2: Episiotomy Tray

SNo. Content SNo. Content

1. 2% Inj. Xylocaine 2. 10 ml disposable syringe and needle
3. Episiotomy scissors 4. Kidney tray
5. Artery forceps 6. Allis forceps

7. Sponge holding forceps 8. Toothed forceps

9. Needle holder 10. Thumb forceps
11. Sim’s speculum 12. No. 0 Chromic catgut/ Polygalactin rapid no 0 or
20
13. Gauze pieces 14. Cotton swabs

15. Gloves 16. Antiseptic lotion

17. Sterilized linen/gynae
sheet

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Tray 3: Baby tray

SNo. Content SNo. Content

1. Pre-warmed 2.
Cotton swabs
towel/sheets
3. Mucus extractor 4. Bag and mask

5. Sterilized thread for cord 6. Nasogastric tube

or cord clamp
7. Gloves 8. In. Vit. K

9. Needle and syringe

Tray 4: Medicine tray

SNo. Content SNo. Content

1. Inj. Oxytocin 10 IU 2. T. Misoprostol 200 mcg

3. Inj. PG F2 alpha 4. Inj. Methylergometrine
5. Cap. Ampicillin 500 mg 6. T. Metronidazole 400 mg

7. T. Ibuprofen 8. T. B-complex
9. T. Paracetamol 10. Inj. Gentamycin

11. Inj Dexamethasone 12. Inj. Betamethasone

13. Ringer lactate 14. Normal saline
15. Inj. Hydralazine 16. Inj Labetolol

17. T. Methyldopa 18. Cap. Nifedipine

19. Inj. Vit K 20. Magnifying glass

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Tray 5: Emergency tray for Labor Room and Maternity Ward

SNo. Content SNo. Content
1. Inj. Adrenaline 2. Inj. Diazepam
3. Inj. Calcium gluconate 4. Inj. Atropine
10%
5. Inj. Soda bicarbonate 6. Inj. Hydrocortisone Succinate
7. Inj. Pheniramine maleate 8. Inj. Lignocaine 2%
9. Inj. Magsulf 50% 10. Inj. PG F2 alpha
11. Inj. Labetolol/Inj . 12. Ringer lactate
Hydralazine
13. Normal Saline 14. IV sets with two 16-guage needles
15. IV Cannula 16. Vials for drug collection
17. Controlled suction 18. Mouth gag
catheter
19. Foleys catheter 20. Urobag
21. Endotracheal tube 22. Ambu Bag and Mask
23. Laryngoscope 24. Defirillator AED device

Tray 6: Evacuation / D&E tray

SNo. Content SNo. Content

1. Gloves 2. Anterior vaginal wall retractor
3. Sim’s Speculum 4. Sponge holding forceps
5. Suction Cannula 6.
Stainless steel bowl
different sizes
7. Antiseptic lotion 8. Endometerial curette
9. Hegar’s cervical dilator 10. Sanitary pads
set
11. Cotton swabs or pads 12. Disposable syringe and needle
13. Sterilised gauze/pads 14. Urobag
15. Foley’s catheter 16. T . Misoprostol
17. Inj. Oxytocin 18. In. Methylergometrine
19. Sterilized linen 20.

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Tray 7: PPIUCD TRAY

SNo. Content SNo. Content

1. PPIUCD insertion forceps 2. Cu IUCD 380A or 375

3. Sim’s speculum 4. Sponge holding forceps

5. Stainless steel bowl 6. Sterilized linen

7. Antiseptic solution 8. Gloves

Annexure [Link] FACILITY HAS EQUIPMENT & INSTRUMENTS REQUIRED FOR ASSURED LIST OF
SERVICES.
S. No. ITEM
1. BP apparatus, stethoscope ,thermometer, foetosope/ docppler, baby
weighting scale, wall clock (tracers).
2. Scissor, rtery forceps, cord clamp, sponge holder, speculum, kocker’s forceps, kidney
tray,bowl for antiseptic lotion.
3. Episiotomy scissor, kidney tray, artery forceps, allis forceps, sponge holder, toothed
forceps, needle holder ,thumb forceps.
4. Two pre warmed towels/sheets for wrapping the baby, mucus extractor, bag and mask
(0 &1 no.), sterilized thread for cord/ cord clamp, nasogastric tube.
5. Speculum, anterior vaginal wall retractor, posterior wall retractor, sponge holding
forceps, MTP cannulas, small bowl of antiseptic lotion.
6. PPIUCD insertion forceps, Cu IUCD 380A/ Cu IUCD375 in sterile package.
7. Glucometer, Hand held fetal Doppler and HIV rapid diagnostic kit.
8. Oxygen, Suction machine/ mucus sucker ,radiant warmer, Laryngoscope adult and
neonatal.
9. Suction machine, oxygen, Adult and neonatal bag and mask, mouth gag.
10. Refrigerator, crash cart/ drug trolley, instrument trolley, dressing trolley,light source.
11. Buckets for mopping, separate mops for labour room and circulation area duster,
waste trolley, deck brush.
12. Boiler/Autoclave.
13. Hospital grade mattress, IV stand, Kelly’s pad, Support for delivery tables, macintosh,
foot step, bed pan.
14. Wall clock with second arm, lamps- wall mounted /side, electrical fixture for
equipments like radiant warmer, suction.

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Source: Assessors Guidebook for QA, GOI

Annexure 6 :MODIFIED WHO PARTOGRAM

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Annexure 7 WORK INSTRUCTIONS –ENBC (ESSENTIAL NEW BORN CARE)

Immediate Newborn Care

Assess by Checking

 Is the baby term gestation?

 Is the amniotic fluid clear?
 Is the baby breathing or crying?
 Does the baby have good muscle tone?

If yes, provide Routine Care

If no

 Place the baby on the mother’s abdomen.

 Dry the baby with a warm clean sheet. Do not wipe off vernix. Proceed for
resuscitation
 Wipe the mouth and nose with a clean cloth.
 Clamp the cord after 1-3 min. and cut with sterile instrument. Tie the
cord with a sterile tie.
 Examine the baby quickly for malformations/birth injury.
 Leave the baby between the mother’s breasts to start skin-to-skin
care.
 Support initiation of breastfeeding.
 Cover the baby’s head with a cloth. Cover the mother and baby with
warm cloth.
 Place an identity label on the baby.
 Give Ing. Vit K Img IM (0.5mg for preterm).
 Record the baby’s weight.
 Refer if birth weight <1500g, has major congenital malformation or
has severe respiratory distress.

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[Link]

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Annexure [Link] HAND WASHING INSTRUCTIONS

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4. MATERNITY WARD

4.1 Purpose:
Purpose of this SOP is to ensure that all antenatal & postnatal patient are provided with
evidence based quality care in an environment of minimal risk covering every aspect of
obstetric care from the time patient is received in antenatal / postnatal ward.

4.2 Scope:
This SOP covers all the processes and guidelines to be followed by all doctors, nurse,
paramedical & other support staff involved in the management of the patient in maternity
ward with an objective of good maternal & foetal outcome. Providing care during
antenatal/postnatal period including transfer/referral/discharge.

4.3 Responsibility:
Responsibility is divided among the doctors and staff posted in maternity ward.

4.4 Procedure:
Sr. Activity Responsibilit Reference
No. y

4.4.1 Receiving and assessment of the patient in maternity

ward.
A. Receiving of the patient: Nursing Staff
Patient is received in ward after admission of the
patient through OPD / ANC clinic or emergency.
B. Documentation of personal details of the patient in Nursing Staff
ward admission registers.
Complete workup for unbooked patient is to be done
immediately after admission
C. Initial assessment: Doctor on
 ANC card, all investigation reports of the booked duty
patient is asked for.
 A quick assessment of the patient is done by the
doctor on duty in a designated room with
complete privacy.
 Provisional diagnosis is made depending on the
findings of history examination and investigations.
 Patient is categorized as low risk and high risk.
D. Low risk patient: Nursing
Are provided bed with clean linen, diet, medication, Staff/Doctor
investigations as per diagnosis or plan of treatment. on duty
Patient is shifted to labour room if she goes in labour.
Trolley/wheelchair to be provided in the ward.

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E. High risk patient: Depending on the facilities available Doctor on Refer Annexure-
in hospital patient is either. duty 2 of OPD: FORM
A. Shifted to HDU/ICU/ward after counseling and -F
documentation of prognosis. For ANC patient
having medical/surgical disorder inter-
departmental referrals to be taken to provide
comprehensive care.
B. In case of unavailability of any of the critical
facilities required for the management patient
is counseled and transferred to higher centre
as per transfer policy of the hospital.
F. Diagnosis is made of pregnancy with any associated Doctor on
existing condition. Report sent from the ward to be duty
collected by the staff and attached in the file of the /Nursing
concerned patient. Staff
G. Daily monitoring of patient is performed regarding Doctor on
vitals, (Pulse, BP, Temperature, Respiration, Input/ duty
Output charting) control of medical disorder and /Nursing
foetal growth monitoring (fundal height and growth, Staff
FHS, daily foetal movement count, BPP/NST).

4.4.2 Admission, shifting and referral of pregnant mother.

A.  Expectant mother admitted to maternity ward may
require shifting to labour room or referral to
higher centre any time during their course of stay.
 Patient is shifted to labour room when she goes in
to labour, or shifted to O.T for CS as per
requirement and indication.
B. Patient admitted for surgical intervention:

 A written informed consent is must, duly signed by

the patient and attested by doctor on duty.
 PAC to be done
 Patient is prepared as per the pre-op orders.
 O.T. list sent - Anesthetist and O.T. staff informed.
C. Patient Transfer Protocol:

 Every Hospital should have their own patient Nursing

transfer protocol/ SOP for transferring pregnant Staff/ Doctor
patients. on duty
 Decision of transfer should be taken well in
advance in case of pregnant patients, when
facilities are inadequate and complications are
expected.
 There must be reasonable ground for transfer of
patient. (ground must be recorded in the transfer
summary).

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 No patient should be transferred without transfer

summary (referral slip for ambulatory and stable
patient)
 Patient’s relatives to be informed and explained
about the condition and reasons of transfer as
soon as the decision of transfer has been taken.
 No hemodynamically unstable patients should be
transferred; every effort should be made to
stabilize the patient before transferring.
 If it is not possible to stabilize the patient, such
patients are to be transferred in an adequately
equipped ambulance and available trained staff.
 It must be for the benefit of the patients.
 Consultant must be informed before transferring
the patient.
 There should be a hospital policy for transferring
the patient, with respect to ambulance / doctor
and paramedic to accompany the patient.
 A record of all transfers to be maintained at
department level.(Out referral register)
 Transfer summary must contain:
o History, clinical examination, investigation
reports if any, ECG, X Ray, USG reports,
treatment provided.
o Reasons for transfer.
o What is required, is not available in the
transferring hospital.
o Whether a formal call to the referral
hospital was made, if yes, it should also be
recorded in the summary.
o If for any reason if it was not possible to
contact the referral hospital reasons for the
same should also be recorded.
o Transfer summary must contain legible
name and designation of the transferring
doctor.
 For EWS patient transfer, the guidelines issued by
DHS to be followed.
 In case a low risk / manageable patient or their
relative wants a transfer, against the advice of
doctor it should be recorded in the case sheet and
on the discharge summary (DAMA) along with the
signatures of the patients / her relatives.

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4.4.3 Shifting of mother to labor room

 Expectant mother is admitted in maternity ward Doctor on
and monitored regularly for vitals (PR. BP, RR, FHS, duty
Foetal movements, etc).
 Patient should be immediately shifted to LR if
there is any sign of onset of labour, maternal or
foetal distress, bleeding or leaking.
 LR staff should be informed about the condition of
the patient, and patient shifted as per the advice
of the labour room consultant / SR.
 Patient should be shifted in wheel chair/trolley.
 Patient should be handed over to the staff of
labour room along with all relevant patient record.
4.4.4 Requisition of diagnostics and receiving of the reports.

 Requisition for diagnostics as prescribed by the Doctor on

doctor should be followed. duty/Staff
 Requisite Lab/USG/ECG form is filled for the nurse
patient.
Refer Annexure-
 Samples are drawn in appropriate containers, and
labeled properly. 2 of OPD: FORM
 Or patient is prepared for testing.(ECG/USG) -F
 Samples are sent to the lab for testing.
 Reports are collected from the lab.
 Reports are filed in the patient’s case sheet, and
doctor on duty is informed about the receipt of
report.
4.4.5 Preparation of patient for surgical procedure

A.  Intimate the staff nurse on duty regarding Doctor on

operation of the patient well in advance. duty
 Date, time and operation theatre number should
be clearly written on the patient case sheet. Staff nurse
 PAC if not done earlier, should be done prior to
surgery, (clearance for anesthesia is required).
 An informed consent of the patient or her
authorization is taken by the doctor and duly
signed by doctor and patient / her relative.
 Patient is prepared as per the orders of the
surgeon and anesthetist, including:
i. Pre-operative investigations (CBC, LFT, KFT,
BS –Fasting &PP, CXR, USG, ECG,
Coagulation profile).
ii. Screening for HBV, HCV and HIV is also
desirable.
iii. Medication for optimal control of
underlying medical disorder.

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iv. Bath one night prior to surgery.

v. Grouping and arrangement of blood, pre-
op blood transfusion if required.
vi. Nil P.O (4-6 hrs fasting).
vii. Site preparation/ clipping.
viii. Enema/bowel preparation.
ix. Site marking if indicated.
x. Any special instruction of anesthetist given
at the time of pre anesthetic checkup.
xi. Pre – operative medications/ including
antibiotic as prescribed.
xii. Collection of lab reports, ECG, X-Ray, USG
reports.
xiii. And completing the case record should be
done well before posting the patient for
operation.
 A tentative OT list is sent to the anesthetist a day
before the surgery so that he can reassess the
patients before surgery and give necessary
instructions.
 Patient is provided with O.T clothes, (gown / cap)
an hour before the surgery.
 Patient should be sent to the operation theatre on
receipt of message from OT; patients should not
be allowed to wait unnecessarily outside the
operation theatre.
 The case record of the patient should also be
 sent to the theatre, and returned to the ward
after operation.
 The case sheet must have operation notes, post
operative prescription/ instructions.
 Vitals of the patient to be monitored post
operatively.
 Special precaution to be taken in ward to prevent
any post operative infection.
4.4.6 Transfusion of blood
A Prerequisite for blood transfusion:

 A doctor’s order on the patient case sheet is must

for transfusion.
 Quantity of blood/component and rate of
transfusion must also be prescribed in the case
sheet.

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B. Informed consent for blood transfusion:

 The patient is informed of the medical indications

for the transfusion, the possible risks, the possible
benefits, the alternatives and the possible
consequences of not receiving the transfusion.
 Consent is obtained sufficiently in advance of the
transfusion so that the patient can truly
understand what is said and has sufficient time to
make a choice, whenever feasible.
 Consent is documented duly signed by patient/
relative/ doctor/nurse
 A single informed consent may cover many
transfusions if they are part of a single course of
treatment.
 It may be advisable, though, to obtain a new
consent when there is a significant change in the
patient's care status, such as a transfer for care to
another service, an inpatient admission, or an
outpatient transfusion.
 In emergency situations the physician ordering the
transfusion must make a reasonable judgment that
the patient would accept the transfusion.
Transfusion should not be delayed in a life-
threatening situation if it is likely that the patient
would agree to transfusion. After the event, the
circumstances of the transfusion decision should
be documented in the case sheet of the patient

C  Blood sample of the patient is sent to the blood

bank for grouping and cross matching along with
blood requisition form (should clearly mention Annexure 1-
name of the required product and number of units Checklist for
required, sample labels, blood requisition form filling Blood
checked and matched with the patients file). Requisition
 Availability of requisite product is ascertained Form
from blood bank.
 If blood is required at a later time, blood bank is
informed and asked to keep the cross matched
blood reserved for the patient till such time.
 If it is urgent and life saving, it is clearly mentioned
in the requisition form.
 A blood release form is sent to the blood bank,
one bag at a time if no storage facility is available
in house. If there is a facility for storage, (Blood
bank refrigerator is available) the total quantity of
the required blood is to be released from the
blood bank.

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D. Receive the blood and verify that:

 Blood is designated for a patient for whom Annexure 2-

requisition was sent.
 Release form bears all the details along with the Checklist for
signature of blood bank staff. before starting
 Name and CR number recorded on the release blood
form attached to the unit corresponds with that of transfusion
the intended patient.
 Check, ABO Rh type, patient name/ CR No./ blood
bag no and date of expiry of the blood component.
 Unit has a normal appearance and is cold.
 In case of any discrepancy inform the blood bank
immediately, do not transfuse till everything has
been clarified from the blood bank.
 Record the date and time of receipt of blood bag in
the ward on the blood bank release form.
 Check the patient case sheet for transfusion order,
type, volume and rate of transfusion.
 Check if any pre medication is prescribed.
Medicate the patient accordingly.
 Verify the patient’s name, CR No., blood bag for
component type/ group/ expiry date.
 Check, and record the patient's blood pressure,
pulse, respiration and temperature in the chart or
on the case sheet with date and time of starting
transfusion.
 Immediately before transfusion, mix the unit of
blood thoroughly by gentle inversion.
 If rapid and large volume transfusion is required a
blood warmer can be used if available.
E. Start transfusion if everything is in order:

 Initial flow rate should be slow not more than 1

ml/minute to allow for recognition of an acute
adverse reaction. Proportionately smaller volume
for pediatric patients.

 If no reaction occurs for first 15 minutes increase

the rate to 4 ml / min; usual transfusion time is 2-4
hours, and it should not exceed 4 hours for any
component.
 Platelets, plasma and cryoprecipitate: 10 ml per
minute. The transfusion may be administered as
rapidly as the patient can tolerate, usually 30
minutes.
 During transfusion monitor the vitals of the patient
every 30 minutes (PR, BP, RR, SpO2, temp and any

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sign of urticaria)
 Access the flow rate, if unusually slow (less than 3
ml/min.) consider the following to enhance the
flow rate.

 Repositioning the patient's arm.

 Changing to a larger gauge needle.
 Changing the filter and tubing.
 Elevating the IV pole.
 Consider using a transfusion pump, if
available.
F. Signs of blood transfusion reaction: Annexure 3:

 Hives and itching: Are non serious reactions Checklist in case

generally controlled by antihistaminic/ steroid and of a Blood
slowing the rate of infusion. Transfusion
 Isolated fever: Developing a fever after a
Reaction
transfusion is not serious. Fever is body’s response
to the white blood cells in the transfused blood.
(slow the rate of infusion.)
 However, it can be a sign of a serious reaction if
the patient is also experiencing nausea, vomiting,
back or chest pain, dark colored urine.
STOP TRANSFUSION IMMEDIATELY AND INFORM THE
BLOOD BANK AND TREATING DOCTOR.

If a transfusion reaction is suspected

 Stop the transfusion.

 Maintain IV with normal saline.
 Save the bag and attached tubing, send it to the
blood bank for investigation.

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G. In case of uncomplicated transfusion:

 Record date and time when transfusion was

stopped.
 Record volume of blood infused.
 Document the presence/absence of a transfusion
reaction in the patient case sheet.
 Discard the blood bag and tubing as per BMW
guidelines.
 Outpatients or patients who will be leaving the
hospital within one week of transfusion should be
given written instructions regarding delayed
transfusion reactions and asked to report
immediately.

4.4.7 Maintenance of rights and dignity of the patient

 Maintenance of women’s rights, dignity, privacy
and confidentiality is responsibility of every doctor
and staff involved in the care of the patient.
 Patient’s right and responsibilities should be
displayed in local language in all patient waiting
areas and wards.
 Social workers and nurses should also educate the
patients about their right and responsibilities.
 All doctors and paramedical staff should be made
aware of the right and responsibilities of the
patients.

A. Patients rights:

A.1 Care:

Patients have a right to receive treatment

irrespective of their demographic profile.
 Right to be heard regarding her concerns.
Confidentiality and Dignity:

 Right to personal dignity and to receive care

without any form of stigma and discrimination.
 Privacy during examination and treatment.
 Protection from physical abuse and neglect.
A.2  Accommodating and respecting their special
needs such as spiritual and cultural
preferences.

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Right to confidentiality about their medical

condition.
Information:

The information to be provided to patients is meant to

be in a language of patient’s preference and in a
manner that is effortless to understand.

 Patients and/ or their family members have the

right to receive complete information on the
medical problem, prescription, treatment &
procedure details.
 A documented procedure for obtaining
patient’s and / or their family’s informed
consent exists to enable them to make an
informed decision about their care.
 Patients have to be educated on risks, benefits,
expected treatment outcomes and possible
complications to enable them to make
informed decisions, and involve them in the
A.3 care planning and delivery process.
 Patients or their authorized individuals have
the right of access and to get a copy of their
clinical records on their written request.
Preferences:

Patients have a right to seek a second opinion on their

medical condition.

 Right to information from the doctor to

provide the patient with treatment options, so
that the patient can select what works best for
A.4 her.

B. Patients responsibility:
Honesty in disclosure:
B.1  Patients shall be honest with doctor & disclose
their complete family/ medical history
whenever asked.
B.2 Treatment compliance:
 Patients shall do their best to comply with
doctor’s treatment plan.
 Patients shall have realistic expectations from
the doctor and his/her treatment.
 Inform and bring to the doctor’s notice if it has
been difficult to understand any part of the
treatment or of the existance of challenges in
complying with the treatment.

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B.3 Transparency and honesty:

 Patients shall make a sincere effort to
understand their therapies which include the
medicines prescribed and their associated
adverse effects and other compliances for
effective treatment outcomes.
 If not happy, patient shall inform and discuss
with her doctor/ administration.
 Patients shall report any fraud and wrong
doing by any staff member or person in the
hospital.
B.4 Conduct:
 Patients shall be respecting the doctors and
medical staff.
 Patients shall abide by the hospital / facility
rules.
4.4.8 Record maintenance including taking consent.
A.1 Record maintenance in ward:

 A record index should be available in every

ward and it should contain:
o List of all forms
o List of all registers
 Management of patient’s case sheet.
o A separate file is created for every patient
admitted to ward.
o The cover of the file must contain CR No. /
Name/Age / Sex/ and bed number of the
patient.
o Following forms and documents are to be
kept in patient’s file in chronological order.
o Admission form/ registration forms of the
patient.
o Clinical notes/ treatment sheets/ progress
notes.
o Investigation reports
o O.T notes
o Blood Transfusion notes
o Interdepartmental consultation/ referral
records.
o Discharge/transfer/ death summary of the
patient.
 The completed records (case sheet of the
patient is transferred to MRD after discharge,
death and transfer of the patient.
 While transferring the records to MRD nursing
staff must verify the record is complete in

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every respect and documents are duly signed

by respective doctor.
A.2 Management of ward registers:

 All important registers such as admission

register, referral register, death register, daily
census register etc. are to be transferred to
MRD after their completion.
Rest of registers such as treatment book, injection
register, lab register etc. to be retained and weeded as
per the record retention schedule of the hospital.

B. Taking informed consent of patient:

 Informed consent to be taken apart from general

form of authorization for medical and surgical
management.
 Is taken for all surgical procedures, blood
transfusion, invasive procedures, etc.
 Before any of the above procedure patient and
their relatives are informed about the planned
procedure in a language they can understand
easily.
 Preferably in presence of a staff nurse.
 They are explained in detail about the procedure,
its benefits, risk and available alternatives.
 Also explained the risks and complications that
may arise on refusing the planned procedure.
 All queries of patient and their relatives are to be
answered to their need and satisfaction.
 After the counseling is complete and patient /and
or their relative agree, then only the informed
consent is prepared, read aloud to the patient and
signed by the patient and witnesses.

4.4.9 Discharge of patient from maternity ward

 All mothers and new borns should provided Doctor on
postnatal care in maternity ward for at least 48 duty
hours for uncomplicated deliveries before their
discharge from the maternity ward. Staff nurse
 If there is no complication and everything is
normal patients are prepared for discharge.
 Counseling of mother before discharge:
All women should be given information about the
physiological process of recovery after birth, and

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that some health problems are common, with

advice to report any health concerns to a health
care professional, in particular:

 Signs and symptoms of PPH: sudden and profuse

blood loss or persistent increased blood loss,
faintness, dizziness, palpitations/ tachycardia.
 Signs and symptoms of pre-eclampsia/ eclampsia:
headaches accompanied by one or more of the
symptoms of visual disturbances, nausea,
vomiting, epigastric or hypochondrial pain, feeling
faint, convulsions (in the first few days after birth).
 Signs and symptoms of infection: fever, shivering,
abdominal pain and/or offensive vaginal loss.
 Signs and symptoms of thromboembolism:
unilateral calf pain, redness or swelling of calves,
shortness of breath or chest pain.
 Women should be counseled on nutrition.
 Women should be counseled on hygiene,
especially hand washing.
 Women should be counseled on birth spacing and
family planning. Contraceptive options should be
discussed, and contraceptive methods should be
provided if requested.
 Women should be counselled on safer sex
including use of condoms.
 In malaria endemic areas and during dengue
outbreaks, mothers and babies should sleep under
insecticide impregnated bed nets.
 All women should be encouraged to mobilize as
soon as appropriate following the birth.
 They should be encouraged to take gentle exercise
and make time to rest during the postnatal period.
 Iron and calcium supplementation should be
provided for at least six month.
 On discharge all mothers are advised and
encouraged to visit OPD at least thrice after
discharge
 1st visit on day 3 (72 hrs after discharge)
 2nd visit between day 7 to 14.
 3rd visit six weeks after birth.

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4.4.10 Postnatal inpatient care of mother

 All mothers and new born should be provided with
postnatal care in maternity ward for at least 48
hours for uncomplicated deliveries.
 On postnatal care round mother to be assessed
and documented for the following:
o General condition including pallor.
o Pulse, BP and temperature should be recorded
immediately after birth and if normal 2nd
measurement to be taken within 6 hrs.
o Amount of vaginal bleeding.
o Uterine tenderness and tone.
o Lochia colour and odour.
o Condition of perineum.
o Calf tenderness.
o Condition of the breasts.
o Any other complaint (vomiting, fever, headache,
blurred vision, excessive abdominal/ perineal
pain).
o In case of any positive finding, patient to be
treated accordingly in the ward.

4.4.11 Postnatal in-patient care of the newborn.

The following signs should be Paediatrician

assessed during each postnatal care contact and the Staff nurse
newborn should be referred for further evaluation if
any of the signs is present:

 Stopped feeding well.

 History of convulsions.
 Fast breathing (breathing rate ≥60 per
minute).
 Severe chest in-drawing,
 No spontaneous movement.
 Fever (temperature ≥37.5 °C).
 Low body temperature (temperature
<35.5º C).
 Any jaundice in first 24 hours of life, or
yellow palms and soles at any age.
The family should be encouraged to seek health care
early if they identify any of the above danger signs in-
between postnatal care visits.

Breast feeding:

 All babies should be exclusively breastfed from

birth until 6 months of age.

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 Mothers should be counselled and encouraged

for exclusive breastfeeding at each postnatal
contact.
 Check and reinforce mother’s knowledge on
positioning and attachment.
 Ask whether baby is taking feeds every 2-3
hours
 Enquire about any difficulty in breastfeeding

 Clean and dry cord care is recommended for

newborns in health facilities and at home in low
neonatal mortality settings.
 Appropriate clothing of the baby for ambient
temperature is recommended. This means one to
two layers of clothes more than adults, and use of
hats/caps.
 The mother and baby should not be separated and
kangaroo care must be promoted.
 Communicating and playing with the newborn
should be encouraged.
 Immunization should be promoted
 Preterm and low-birth-weight babies should be
identified immediately after birth and should be
provided special care as per advise of the
pediatrician.

4.4.12 Payments and incentive of beneficiary.

 Entitlement and incentive schemes of the Family
government should be prominently displayed in welfare
concerned areas of the hospital. staff/ANM
 Patient and her relative should be informed about
all / any ongoing government incentives and
benefits.
 Patient/ relative should also be informed about
the codal formalities for availing the benefits of
the scheme, and whom to contact for the benefit.
 As all benefits are transferred through DBT online,
patient’s bank details must be accurately
documented.

4.4.13 Counseling of the patient at the time of discharge.

A. Discharge of patient from ward:

As soon as decision of discharge is taken on account of

fitness/ cure/ or improvement of mother and child:

A pre discharge counseling is done for every patient

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A.1 to explain the :

 Current condition and the prognosis. It is to be Doctor on Refer para 4.10

done by senior staff nurse or doctor. duty and 4.11 for
 Instruction and what to do in a case of counseling
emergency. Staff nurse
 Instruction for follow up visits, with days, date/
room number.
 Medications and precautions if any.
 Do’s and Don’ts.
 Referrals after discharge if required (such as
for management of other medical/ surgical
disorders).
 This opportunity can also be utilized for getting
the feedback of the patient regarding quality
of services.

A.2 Discharge summary must contain the following:

Date of admission and Date of discharge.

Personal details of the patient.
Diagnosis.
Investigations with reports/results.
Pre-op, operative and post-op notes if any.
Treatment /intervention/ medication provided
during the stay.
 Advise on discharge should also include
medicines, precautions or any special
instruction
 Instructions for follow-up visits (with day, date
and timing).
A.3 Death of Patient in Ward
For IPD patient
 Doctor on duty should be present at the bed
side in case of dying patient along with other satisfaction
paramedical staff. survey form
 Doctor will pronounce the patient as dead. Refer Annexure
 Information must be given clearly to the 4 of SOP
relatives of the patient buy doctor or nursing Maternity Ward
staff.
 Autopsy to be offered wherever indicated
 Death report to be given only after lapse of an
hour of pronouncing death
 Patient to be covered and cornered in a
dignified way, body should be cleaned, chin
should be tied, and eye should be closed, and
wrapped in mortuary sheet.
 Two tags, one around neck and one around

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wrist is tied in case body is to be kept in

mortuary, bearing details of the patient along
with date and time of death.
 Body to be handed over to the relative after all
requisite documentation along with a death
summary stating the cause of death.
 Nodal Officer MDRC (maternal death review
committee) to be informed immediately.
 Facility based format as per maternal death
review to be filled up and submitted to nodal
officer.

4.4.14 Environmental cleaning, infection control and

Processing of equipment
These include the following:

G. Hand washing and antisepsis (hand hygiene);

H. Use of personal protective equipment when
handling blood, body substances, excretions and
secretions;
I. Appropriate handling of patient care equipment
and soiled linen;
J. Prevention of needle stick/sharp injuries;
K. Environmental cleaning(cleaning of surfaces) and
spills-management; and
L. Appropriate handling of waste (as per biomedical
waste management handling rules).
A.1 Wash or decontaminate hands: Refer SOP Labor
room annexure
 after handling any blood, body fluids, secretions,
9-pictorial chart
excretions and contaminated items;
for hand
 between contact with different patients;
 between tasks and procedures on the same washing
patient to prevent cross contamination between
different body sites;
A.2  immediately after removing gloves.
Antimicrobial soap:

 Used for hand washing as well as hand antisepsis.

 If bar soaps are used, use small bars and soap
racks, which drain.
 Do not allow bar soap to sit in a pool of water as it
encourages the growth of some micro-organisms
such as pseudomonas.
 Clean dispensers of liquid soap thoroughly every
day.
 When liquid soap containers are empty they must
be discarded, not refilled with soap solution.

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A.3 Specific antiseptics recommended for hand

antisepsis:

 2%-4% chlorhexidine,
 5%-7.5% povidone iodine,
 1% triclosan, or
 70% alcoholic hand rubs.
 Waterless, alcohol-based hand rubs: with
antiseptic and emollient gel and alcohol swabs,
which can be applied to clean hands.
Dispensers for hand rub should be placed outside each
patient room.

B Use of personal protective equipment

 Health care workers who provide direct care to

patients and who work in situations where they
may have contact with blood, body fluids,
excretions or secretions;
 Support staff including medical aides, cleaners,
and laundry staff in situations where they may
have contact with blood, body fluids, secretions
and excretions
B.1 Personal protective equipment includes:

 Gloves
 Protective eye wear (goggles)
 Mask;
 Apron;
 Gown;
 Boots/shoe covers; and
 Cap/hair cover.
 After use discard the used personal protective
equipment in appropriate disposal bags, and
dispose of as per the BMW policy of the hospital.
 Do not share personal protective equipment.
 Change personal protective equipment completely
and thoroughly wash hands each time you leave a
patient to attend to another patient or another
duty.

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C Appropriate handling of patient care, equipment Staff Nurse,

handling and soiled linen. Nursing
orderly,
 Handle patient care equipment soiled with blood, House
body fluids secretions or excretions with care in
keeping staff.
order to prevent exposure to skin and mucous
membranes, clothing and the environment.
 Ensure all reusable equipment is cleaned and
reprocessed and sterilized appropriately before
being used on another patient.
 Mattresses with plastic covers should be wiped
over with a neutral detergent.
 Mattresses without plastic covers should be steam
cleaned if they have been contaminated with body
fluids.
 If this is not possible to decontaminate the
bedding it should be removed by manual washing,
ensuring adequate personnel and environmental
protection.
C.1
Linen Handling:

 Place used linen in appropriate bags at the point of

generation.
 Contain linen soiled with body substances or other
fluids within suitable impermeable bags and close
the bags securely for transportation to avoid any
spills or drips of blood, body fluids, secretions or
excretions. Bags to be stored and transported in a
leak proof container.
 Do not rinse or sort linen in patient care areas (sort
in appropriate areas).
 Handle all linen with minimum agitation to avoid
aerosolization of pathogenic micro-organisms.
 Separate clean from soiled linen and
transport/store them separately.
 Transport and process used linen, and linen that is
soiled with blood, body fluids, secretions or
excretions in separate leak proof bags with care to
ensure that there is no leaking of fluid.

D. Prevention of needle stick/sharps injuries:

 Take care to prevent injuries when using needles,

scalpels and other sharp instruments or
equipment.
 Place used disposable syringes and needles, scalpel

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blades and other sharp items in a puncture-

resistant container with a lid that closes and is
located close to the area in which the item is used.
 Take extra care when cleaning sharp reusable
instruments or equipment.
 Never recap or bend needles.
 Sharps must be appropriately disinfected and/or
destroyed as per the national standards or BMW
guidelines.
E. Environmental cleaning(cleaning of surfaces) and Staff Nurse/
spills-management: House
keeping staff
 Ward along with all equipments and all surfaces
should be cleaned every morning.
 All toilets to be cleaned using surface disinfectant
at the start of every shift.
 The floor and sink should be cleaned with
detergent soap at the start of every shift.
 Mopping of floors (at the start of every shift/ and
sos for spillage). Procedure for mopping described
as under.
o Clean water is taken in three bucket numbered
1, 2 and 3.
o Surface disinfectant is added in bucket no-3(so
that 1st and 2nd bucket has clean water and
third bucket has disinfectant).
o Cleaning of floor begins from inside to outside.
Towards the end all corner and groves to be
cleaned.
o After each sweep of the floor the mop should
be dipped first in bucket no. 1, then in no.2
and lastly in no-3 and then floor is mopped
again. This process is repeated till the whole
area is cleaned.
o Water of the three containers to be changed
(depending on the size of the ward) as the
water in 3rd bucket gets dirty.
o Mops to be cleaned in dirty utility area and put
in a stand under sun with head of the mop
upward, and mops should not be left wet in
the ward or any patient area.
o After mopping blood or body fluids the mop
should be treated as soiled linen and discarded

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o as per BMW guidelines.

o Mops should be visibly clean before starting
cleaning of a ward
 Handle patient care equipment soiled with blood,
body fluids secretions or excretions with care in
order to prevent exposure to skin and mucous
membranes, clothing and the environment.
 Ensure all reusable equipment is cleaned and
reprocessed appropriately before being used on
another patient.
 Universal safety guideline to be followed by all
staff members working in the ward.
F. Handling of general and biomedical waste in wards: Reference- SOP
To be done as per the biomedical waste management Housekeeping
and handling rules. and BMW
guidelines and
rules

4.4.15 Arrangement of intervention in maternity ward.

 There should be adequate arrangement of Trays in LR -

equipment and instruments in the maternity ward Refer to
to deal with any prenatal or postnatal emergent Annexure: 4 of
situation that may arise SOP Labour
 Following equipments and trays should be kept Room
ready in ward and daily checked for its working
status / completeness.
o Emergency tray.
o Delivery tray.
o Baby tray
o Medicine tray
o Emergency drug tray
o MVA/EVA tray.
o PPIUCD tray
4.4.16 Sorting and distribution of clean linen to the patients.
A.  Clean bedding and clean clothes install Nursing Staff
psychological confidence in the patients and the
public and enhances their faith in the services
rendered by the hospital.
 Every effort should be made to provide clean and
tidy linen to the patients.
 Linen management in ward has following
components.
o Maintenance of stock of clean linen.
o Sorting and distribution of clean linen.
o Handling of dirty linen.
o Managing laundry services.
B. Maintenance of stock of clean linen: Nursing Staff

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 Adequate stocks of clean linen to be maintained in

ward.
 Quantity to be calculated on the basis of daily
requirement, laundry turn over time and 20% of
buffer stock to be added. Calculated as under:
 (Stock) = Daily requirement X Laundry turnover
days.
 Laundry turn over days is number of days laundry
takes to clean and return clothes to the ward.
 Add 25% to above for buffer and rainy days.
 (Example) ( calculation for stock of bed sheet to be
kept in ward): for a 25 bedded ward , where
laundry takes 7 days to return the clothes.
 Daily requirement = Number of bed (25) X 7= 175
 Add 25 % = 43.75 (round it to 44)
 Stock of bed sheet to be kept in a 25 bedded ward
is approximately 219. Similarly a stock of other
linen items to be calculated and kept in stock.
 Torn and stained clothes to be sorted and
condemned as per hospital policy.
 Life of linen depends on the quality of fabric,
washing methods.
 Following quantity of linen is suggested for wards
in general.
o Bed sheets – 6 -8 per bed.
o Pillow cover – 4-6 per bed.
o Pillow 2 per bed
o Blanket - 3-4 per bed
o towel - 2 per bed
o draw sheet -6-8 per bed
o patient dress 4 pairs
o duster 20 per ward
o Mortuary sheet 6/ward
o Baby sheet 10 per bed.
o Mattress cover 2 per bed
Note: above requirement is indicative only,
requirement can very as per availability of laundry in
house, demand /stock to be calculated for
individually for every ward for pediatrics ward demand
is double.
C. Sorting of laundry: Nursing Staff

Linen for laundry to be sorted and kept in separate

bags at the point of generation.

 Soiled linen: are used by patient/ ordinary

dirty without urine etc. are collected at source
and send for washing (no sorting at source

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required , minimal storage at source)

 Infected linen: Linen soiled with pus blood,
body discharge, Minimum storage at source,
sluicing and soaking in disinfectant solution to
be done in laundry.
 Foul linen: Faeces, excretions and blood
stained linen to be collected in leak proof
containers, and sluicing to be done before
washing.
D. Distribution of linen: Nursing Staff

 Clean linen is distributed daily during the first shift

in the ward. (bed sheets, pillow cover etc require
daily change.
 Also change linen as and when soiled/ stained.
 Patients should be provided with clean and
unstained linen.
 Torn linen are repaired or discarded immediately,
should not be provided to the patients.
4.4.17 Providing free diet to the patient as per their
requirement.
 Food distribution timing should be displayed Refer SOP
prominently in wards. Auxillary
 Patients are to be provided free diet, as per the services:
advise of the dietician or treating doctor. dietetics
 Special diets such as diabetic diet, low salt diet,
high protein diet etc. should be advised in patient’s
case sheet and nursing staff should also be
informed.

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Annexures

Annexure 1. Checklist For Filling Blood Requistion Form

1. All details filled Legibly, in capitals, without any overwriting or cutting YES / NO
2. Form Signed by Senior resident YES / NO
3. Lifesaving forms signed by faculty/CMO with stamp YES / NO
4. Blood Group of patient clearly written on the form YES / NO
5. Haemoglobin written on the form YES / NO
6. Reason for blood transfusion mentioned YES / NO
7. Blood component required mentioned YES / NO
8. No of Units clearly mentioned ( in words) YES / NO
9. Patient correctly identified from case sheet before sample drawing YES / NO
10. Sample taken from a vein other than that of an IV line on flow YES / NO
11. Sample in plain vial and one EDTA vial(2cc each) YES / NO
12. Vial labeling confirmed by Senior Resident YES/NO

Checklist filled by (Name, Designation, Sign)--

BY S/N or DOD

Annexure 2. Checklist Before Starting Blood Transfusion

Date: Patient: CR NO:

Checklist Before Blood Transfusion

1. Availability of Emergency Tray and the Drugs ensured YES / NO

2. Working Oxygen connection YES / NO
3. Working Suction Apparatus at hand YES / NO
4. Written Consent obtained from patient or attendant YES / NO
5. Correct Patient Identified before transfusion YES / NO
6. Patients Name, CR No., Blood group confirmed from case sheet and YES / NO
tallied with that on the Form and the Blood Bag
7. Blood Bag No. Checked and tallied with that on the form YES / NO
8. Date of Collection and date of Expiry checked YES / NO
9. Checked whether Patient is in failure or not YES / NO
10. Pre Transfusion vital signs checked YES / NO
11. Inj. frusemide 20 mg given pre transfusion YES / NO

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Checklist filled by (Name, Designation, Sign)--

BY S/N S. No 1-3:

By DOD [Link].4-11:

3. Checklist In Case of A Blood Transfusion Reaction

Date: Patient: CR NO:

Checklist In Case of Blood Transfusion (Bt) Reaction

1. Doctor on Duty Informed YES / NO

2. Type of Reaction
3. Any Medication Given YES / NO
4. Attendents Informed about BT Reaction YES / NO
5. Time of Reaction from the start of BT
6. Amount of blood transfused since than ( in ml)
7. Immediate Post Transfusion Reaction blood sent to blood bank ( Plain YES / NO
vial + EDTA vial)
8. Blood Bag and BT set sent to Blood Bank YES / NO
9. First specimen of urine voided after reaction sent for microscopic YES / NO
haematuria to lab

Checklist filled by (Name, Designation, Sign)-

Source: Modified from WHO checklists for blood transfusion

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[Link] Patient Feedback Schedule

vkbZ0ih0Mh0 jksxh QhMcsd QkWeZ

lwpd fuEu lkekU; vPNk cgqr

Lrjh; vPNk

1 vLirky esa fofHkUu lsokvks@

a foHkkxksa rd igqWpus ds fy, lwpuk cksMZ dk
;Fkkfpr izn”kZ.k
2 iathdj.k djkus esa dqy le; 30 11&30 5&10 5 feuV
feuV feuV feuV es
ls
T;nk
3 jftLVsª”ku dkmaVj esa vLirky ds deZpkfj;ksa dk O;ogkj
4 fMLpktZ izfdz;k dk vuqHko ¼;fn lrq’V ugh rks uhps lq>ko ns½a
5 okMZ dh lkQ&lQkbZ dk vuqHko
6 “kkSpky; o Luku?kj dh lkQ&lQkbZ
7 pknj@csM rfd;k doj dh LoPNrk
8 vLirky ifjlj o ukfy;ksa dh lkQ&lQkbZ
9 MkWDVjksa }kjk fu;fer tkap o ns[kHkky
10 MkWDVjksa }kjk ejht ds izfr O;ogkj
11 tkap@ijke”kZ] lykg esa fn;s x;s le; ls larqf’V
12 lsok miyC/k djkus esa ulksZa dh “kh/kzrk o ltxrk
13 okWMZ esa 24 ?kaVs ulksZa dh miyC/krk
14 ulksZa }kjk ejht ds izfr O;ogkj
15 okWMZ ckW;@efgyk ¼deZpfj;ks½sa dh miyC/krk o mudk ejht ds lkFk
O;ogkj
16 vLirky esa nokbZ dh miyC/krk
17 vLirky esa ysc tkap] ,Dljs bR;fn dh miyC/krk
18 vLirky esa Hkkstu forj.k dh le;c)rk
19 vLirky esa fn;s x;s Hkkstu dh [Link]
20 vLirky esa fn;s x;s mipkj o lsokvksa ls larqf’V
1 bl vLirky o bldh lsokvksa esa lq?kkj ds fy, lq>ko

2 D;k vki bykt ds fy, bl vLirky dh lsokvksa dks iqu% izkIr djuk pkgsx
a s ;fn gkW rks D;ksa\

;fn ugh rks D;ksa\ fnukad% vk;q% fyax% iq:’k@efgyk vkbZ0ih0Mh0 uEcj%
Qksu u0

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5. Contents Of 7 Trays In Labour Room

Source: Modified from “Guidelines for Standardization of Labor Rooms at Delivery Points”, Ministry
of H&FW, Govt. of India, March 2016.

Tray 1: Delivery Tray

Content Content
1. Gloves 2. Scissors
3. Artery forceps 4. Cord clamp
5. Sponge holding forceps 6. Urinary catheter & Urobag
7. Bowl for antiseptic lotion 8. Gauze pieces
9. Cotton swabs 10. Speculum
11. Sanitary pads 12. Kidney tray
13. Sterilized linen 14. Kelley’s pad

Tray 2: Episiotomy Tray

Routine episiotomy is not recommended. However, it is desirable to keep the episiotomy tray
ready in case of need.

Content Content
1. 2% Inj. Xylocaine 2. 10 ml disposable syringe and needle
3. Episiotomy scissors 4. Kidney tray
5. Artery forceps 6. Allis forceps
7. Sponge holding forceps 8. Toothed forceps
9. Needle holder 10. Thumb forceps
11. Sim’s speculum 12. Round body and cutting needle
13. No. 0 Chromic catgut/ Polygalactin 14. Gauze pieces
rapid no 0 or 2 0
15. Cotton swabs 16. Gloves
17. Antiseptic lotion 17. Sterilized linen/gynae sheet

Tray 3: Baby tray

Content Content
1. Pre-warmed towel/sheets 2. Cotton swabs
3. Mucus extractor 4. Bag and mask
5. Sterilized thread for cord or cord 6. Nasogastric tube
clamp
7. Gloves 8. In. Vit. K
9. Needle and syringe 10. Pre-warmed receiving baby sheet

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Tray 4: Medicine tray

Content Content
1. Inj. Oxytocin 10 IU – pre loaded 2. T. Misoprostol 200 mcg
3. Inj. PG F2 alpha 4. Inj. Methylergometrine
5. Cap. Ampicillin 500 mg 6. T. Metronidazole 400 mg
7. T. Ibuprofen 8. T. B-complex
9. T. Paracetamol 10. Inj. Gentamycin
11. Inj Dexamethasone 12. Inj. Betamethasone
13. Ringer lactate 14. Normal saline
15. Inj. Hydralazine 16. Inj Labetolol
17. T. Methyldopa 18. Cap. Nifedipine
19. Inj. Vit K 20. Magnifying glass

Tray 5: Emergency tray for Labor Room and Maternity Ward

Content Content
1. Inj. Adrenaline 2. Inj. Diazepam
3. Inj. Calcium gluconate 10% 4. Inj. Atropine
5. Inj. Soda Bicarbonate 6. Inj. Hydrocortisone Succinate
7. Inj. Pheniramine maleate 8. Inj. Lignocaine 2%
9. Inj. Magsulf 50% 10. Inj. PG F2 alpha
11. Inj. Labetolol/Inj . Hydralazine 12. Ringer lactate
13. Normal Saline 14. IV sets with two 16-guage needles
15. IV Cannula 16. Vials for drug collection
17. Controlled suction catheter 18. Mouth gag
19. Foleys catheter 20. Urobag
21. Endotracheal tube 22. Ambu Bag and Mask
23. Laryngoscope 24. Defirillator AED device

Tray 6: Evacuation / D&E tray

Content Content
1. Gloves 2. Cusco’s Speculum
3. Anterior vaginal wall retractor 4. Sim’s Speculum
5. Sponge holding forceps 6. Suction Cannula different sizes
7. Stainless steel bowl 8. Antiseptic lotion
9. Endometerial curette 10. Hegar’s cervical dilator set
11. Sanitary pads 12. Cotton swabs or pads
13. Disposable syringe and needle 14. Sterilised gauze/pads
15. Urobag 16. Foley’s catheter
17. T . Misoprostol 18. Inj. Oxytocin
19. In. Methylergometrine 20. Sterilized linen

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Tray 7: PPIUCD TRAY

Content Content
1. PPIUCD insertion forceps 2. Cu IUCD 380A or 375
3. Sim’s speculum 4. Sponge holding forceps
5. Stainless steel bowl 6. Sterilized linen
7. Antiseptic solution 8. Gloves

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5. FAMILY PLANNING CLIENTS

5.1 Purpose:
To accomplish management of Family Planning (FP) client.

5.2 Scope:
Patient attending family planning OPD & requiring MTP/ temporary/ permanent method of
contraception/ emergency contraception.

5.3 Responsible Person:

Doctor on Duty/ Staff Nurse/ ANM.

5.4Procedure:
Sr. No. Activity Responsibility Reference

5.3.1 Registration

Registration Clerk
Separate registration of Family
Planning client.

5.3.2 Initial assessment of patient

 Patient goes to Family Planning Doctor on duty/

OPD where history taking is Nursing Staff/
followed by detailed general / ANM
systemic examination and services
required by patient established.
 Cafeteria choice offered &
necessary forms to be filled
accordingly.

5.3.3 Temporary method of contraception

Patient seeking temporary method of Doctor on duty/

contraception are managed on OPD Nursing Staff/
basis as per need. ANM
A. Condom:
 Counseling regarding correct
use.
 Preferable with spermicidal
jelly.
 Benefits & failure rate to be
explained.

B. Oral Contraceptive Pills: MEC criteria

[Link] Pills 2. Progesterone

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only pills 3. Emergency contraceptives

4. Others.
 Selection as per MEC criteria.
 Counselling to be done about
effectiveness & side effects.
 Regular intake of doses to be
emphasized and query
regarding
missed dose to be explained. MEC criteria see
C. Intrauterine contraceptive device: website:
 Assess suitability as per MEC [Link].in2016
criteria. GOI . IUCD
 Timings - Post menstrual reference manual
- Post abortal for medical officers,
- Post delivery
 Method of insertion as per GOI Annexures: 1,
guidelines. IUCD
 Follow up & counseling insertion/removal
(1 week – 4 week – 6 Month – 1 tray
year) Annexures:7 & 8 ,
 Index card to be given Consent forms:
insertion/removal
Annexures: 7 (a),
IUCD follow up card
5.3.4 Permanent method of contraception
A. Female Sterilization:
 Selection of patient to be done Empanelled GOI Guidelines:
 It can be done laparoscopic/ doctors/ANM Standards for
interval/ minilap/with Female and Male
caesarean section. Sterlization Services
 Admission in hospital.
 Preop Investigation: - Hb, blood
gp, urine test as per GOI Annexures:6,
guidelines. USG not mandatory.  Checklist for
Rest investigations tailored as sterilization
applicable. Annexures: 5,
 Consent and counseling.
 Anesthesia fitness.  Consent
 Procedure to be done by form for
empanelled doctor. male/femal
 OT notes to be signed by e
operating doctor. sterilization
 Discharge only after
assessment.
 Advise during discharge.
 Follow up 7 days, 14 days, 1
Month.

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Certificate to be collected from

family planning department.
 Incentive money as per GOI
policy.
B. Male Sterilization:
 Non scalpel vasectomy (NSV).
 Day care surgery.
 Consent and counseling. Empanelled
 To be done by empanelled doctors
doctor
 Certificate to be collected after
3 months after semen analysis
report.
Incentive money distribution as per
GOI policy.

5.3.5 Family planning indemnity

scheme(FPIS)
 In case of Family Planning Website for
failure/complication/death Incharge guidelines:
detailed document to be [Link]
forwarded to competent Quality Assurance
authority. Manual for
 Appoint a Nodal officer Sterilization
(preferably Family Planning Services
Incharge)
 Manual for FPIS to be kept in FP
department and with H.O.D
5.3.6 Medical Termination of Pregnancy
(MTP)
 Patient selection to be done. Empanelled MTP ACT, Medical
 Allot MTP number. Doctor/ Nursing Termination Of
 Confirm period of gestation. Staff/ ANM Pregnancy
 Assignment of method of MTP Regulations, 2003
after patient counseling. MH&FW ( DFW )
 Consent form should be duly
signed and attested.

A. Ist Trimester MTP:

A.1 Medical Method Abortion (MMA) Annexure:2,

 Baseline investigations to be Consent form for
done (Hb, urine test, USG MTP by MMA
desirable)
 Prescription of drugs as per GOI

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guidelines (Mifepristone +
Misoprost).
 Counseling of side effects & [Link]
follow up. CAC providers
 Day 14 USG. manual
 Post abortal contraception
A.2 counseling.
Surgical Method
 Baseline investigations to be
done.
 Date for surgery to be taken.
 Consent form to be filled (Form
C, Form I). Annexure:3,
 Pre procedural cervical ripening MTP: Consent Form
desirable (400 ugm misoprost C& I
2-4 hrs prior to procedure).
 Procedure – MVA/EVA
 Counseling done at discharge.
 Concurrent contraception to be
given (IUCD/Ligation).
B. IInd Trimester MTP:
Ministry of H&FW,
 Admit patient.
GOI.
 Certification by 2 doctors.
[Link]
 Choose the correct method.
CAC Providers
 Concurrent ligation (minilap) to Manual
be offered.
 Contraceptive follow up after
1wk/SOS.

5.3.7 Emergency Contraceptive

A.  Suitability to be assessed. Doctor / Nursing
 Works best when used within sister/ ANM
24hrs of unprotected intercourse
but prevents pregnancy even upto
5 days.
 Choice given-
- LNG (1.5 mg) drug of choice.
- IUCD
-Combined pill- estrogen+
progesterone (Yuzpe regimen)
 Antiprogestins-Mifepristone
/ulipristal.
 Follow up must after next period /
missed period.
 Counseling for regular
contraception.

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B. MTP Act, Guidelines of medical

abortion, manual for male and female
sterilization and manual for quality
assurance for sterilization to be kept in
family planning department.

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FLOW CHART PPU

FLOW CHART S.O.P. Family Planning OPD

Separate Registration of F.P. Patient

F.P. OPD

History taking

Examination by doctor on duty

Provisional diagnosis

Cafeteria Choices

Services required established

Consent & necessary forms to be filled

MTP CONTRACEPTION EMERGENCY METHODS

MTP no. given Temporary Permanent Prevents pregnancy upto 5 Days
(Managed on OPD basis) (admit in ward)
Record maintained LNG 1.5mg – Drug of choice

Confirmation of period of gestation Other options - IUCD

Male Female
Barrier Method (Condom)
Combined Pill (Estrogen + Progestrone)
Baseline Investigation Consent
IUCD Selection as per Empanelled
Antiprogestins – Mifepristone/Ulipristal
a) 1st trimester MTP- Medical (Mifepristone + Misoprost)
followed by day 14th USG. doctor
MEC criteria Tissue sent for HPE Follow up important
Surgical- MVA/EVA
OCP’s
b) 2nd Trimester MTP – Certification by 2 doctors.
Incentive Money
Concurrent Minilap to be offered.
Family Planning Indemnity Scheme to have Nodal Officer in case of
failure/complication/death

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Annexure

Annexure 1. IUCD Insertion/ Removal Tray

[Link]. CONTENTS [Link] CONTENTS

1. IUCD 380A 2. IUCD 375
3. Sim’s speculum 4. Anterior vaginal wall retractor
5. Volsellum 6. Uterine sound
7. Artery forceps 8. Suture cutting scissors
9. Stainless steel bowl 10. Cotton swabs
11. Antiseptic solution 11. Gloves

Annexure 2. Consent Forms For MTP by MMA

Source: Website for detailed information: [Link]
guidelines/[Link]

CONSENT FORM OF MTP BY MMA

I have been explained about the process of medical method of abortion, which is a method to
terminate pregnancy using a combination of two medicines. I understand that I will be require to
take the prescribe doses of Mefepristone on day 1 followed by Misoprostol on day 3. I also
understand that I will be required to come to the clinic for a follow a visit on day 15 to confirm the
completion of the procedure.

I understand that many women experience some side effects with medical method of abortion
such as nausea, vomiting, diarrhea, abdominal pain, cramping and bleeding. The bleeding may be
heavier than I usually experience during my menstruation.

My doctor / counselor has also explained that there are chances that the method may failed to
terminate the pregnancy. In such a situation, it will be necessary for me to undergo a surgical
abortion to complete the process. If I experience any symptoms identified by my doctor as danger
sign, or if I have any concern about the procedure during the course of 15 days, I may call my
doctor.

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I _________________________ D / W / o __________________ age about ____

Years, residing at (Address) ___________________________________________

Do hereby give my consent for termination of pregnancy at __________________

Place :
Date: SIGNATURE

I _________________________ D / W / o __________________ age about ____

Years, residing at (Address) ___________________________________________

Do hereby give my consent for termination of pregnancy of my ward at __________________

Place :
Date: Signature

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MMA Client Card

In case of emergency please contact Detail of patient

Doctor Name :

Ph. No. Ph. No.:

Hospital address : Residential address :

Date of first visit :

Date of Second visit :

Date of third Visit :

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Annexure 3. [A] MTP : Consent Form C & I

FORM C (See rule 9)

I _________________________ daughter / wife of ________________________________

aged about _________ years at present residing at _________________________________ (state

the permanent address) do hereby give my consent to termination of my pregnancy at

__________________________________________________ (state the name of place where

pregnancy is to be terminated )

Place________________
Date ________________

Signature / Thumb impression ____________________

(to be filled in by guardian where the woman is mentally ill person or minor)

I _____________________ son / daughter / wife of________________________________ aged

about ___________ years at present residing at (Permanent address) _____________
_________________________________________________________________________
do hereby give my consent to the termination of the pregnancy of my ward
__________________________________________ who is a minor / mentally ill person at
______________________________________________(place of termination of pregnancy)

Place _____________________
Date _____________________

Signature / Thumb impression ____________________

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FORM I [ See Regulation 3 ]

I_______________________________________________________________________
( Name and qualifications of the Registered Medical practitioner in block letters )
________________________________________________________________________
( Full address of the Registered Medical practitioner )
I_______________________________________________________________________
( Name and qualifications of the Registered Medical practitioner in block letters )
________________________________________________________________________
( Full address of the Registered Medical practitioner ) hereby certify that *I/We am/are of
opinion, formed in good faith, that it is necessary to terminate the pregnancy of
________________________________________________________________________
( Full name of pregnant women in block letters ) resident of
________________________________________________________________________
( Full address of pregnant women in block letters )
for the reasons given below**.

* I/We hereby give intimation that *I/We terminated the pregnancy of the woman referred to
above who bears the serial no. _______________ in the Admission Register of the
hospital/approved place.

Signature of the registered Medical Practitioner

Signature of the registered Medical Practitioners
Place :
Date :

*Strike out whichever is not applicable,

** of the reasons specified items
(i) to (v) write the one which is appropriate.

(i) in order to save the life of the pregnant women,

(ii) in order to prevent grave injury to the physical and mental health of the pregnant women,
(iii) in view of the substantial risk that if the child was born it would suffer from such physical or
mental abnormalities as to be seriously handicapped,
(iv) as the pregnancy is alleged by pregnant women to have been caused by rape,
(v) as the pregnancy has occurred as result of failure of any contraceptive device or methods used by
married woman or her husband for the purpose of limiting the number of children

Note : Account may be taken of the pregnant women’s actual or reasonably foreseeable
environment in determining whether the continuance of her pregnancy would involve a grave
injury to her physical or mental health.

Place :

Date :

Signature of the Registered Medical Practitioner

Signature of the Registered Medical Practitioners

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Annexure 4. [B] STERILIZATION :

a). Checklist
Source: Sterlization Checklist, Quality Assurance Manual for Sterlization Services, , Ministry of
H&FW, GOI, 2006,
b). Consent form
Informed consent form for Sterilization Operation /Resterlization. Annexure 4, Standards for
Female and Male Sterlization Services, Oct 2006

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Annexure 5. CONSENT FORM (Sample) FOR MALE/FEMALE STERLIZATION

ifjokj dY;k.k
fnYyh ljdkj

mikca/k &1

uycanh@ulcanh ds fy, vkosnu rFkk lwfpr fd;k x;k lgefr i=

LokLF; dsUnz dk uke ------------------------------------------------------- rkjh[k --------------------------------

ykHk xzkgh dh vLirky iathdj.k la[;k --------------------------------------------------------------------------------------------------------------------------
1- Lohd`fr drkZ dk uke Jh@Jherh --------------------------------------------------------------------------------------------------------------------------
2- ifr@iRuh dk uke Jh@Jherh --------------------------------------------------------------------------------------------------------------------------
3- irk --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
4- nwjHkk’k ua0------------------------------------------------------------------------- eksckbZy--------------------------------------------------------------------------
5- lHkh thfor] vfookfgr] vkfJr] cPpksa ds uke

i. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------

ii. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------
iii. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------
iv. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------
v. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------
vi. --------------------------------------------------------------------------- vk;q ---------------------------------------------------------------------------

6- ykHkxzkgh ds firk dk uke % Jh ---------------------------------------------------------------------------------------------------------------------------------

7- irk --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

8- /keZ@jk’Vªh;rk ------------------------------------------------------------------------------------------------------------------------------------------------------------------
9- tkfr ,l0lh0],l0Vh0]ch0lh0]tujy ----------------------------------------------------------------------------------------------------------------------
10- Lrj ,0ih0,y0@ch0ih0,y0 --------------------------------------------------------------------------------------------------------------------------------------
11- “kS{[Link] ;ksX;rk --------------------------------------------------------------------------------------------------------------------------------------------------------------
12- O;kikj@O;olk; --------------------------------------------------------------------------------------------------------------------------------------------------------------
13- “kY; dsUnz -------------------------------------------------------------------------------------------------------------------------------------------------------------------------

eSa] Jh@Jherh -------------------------------------------------------- ¼ykHkxzkgh dk uke½ vius uycanh@ulcanh djokus gsrq lgefr
nsrk@nsrh gw¡A eSa fookfgr@dHkh fookfgr gaAw esjh vk;q -------------------- gS rFkk esjs ifr@iRuh dh vk;q ----------------------- o’kZ gSA
gekjs ----------------------- thfor yM+ds rFkk -thfor yM+fd;ka gSaA esjs lcls NksVs thfor cPps dh vk;q ------------------------- o’kZ gSA
EkSusa ;g uycanh@ulcanh vkWisz”ku@iqu% uycanh@ulcanh fcuk fdlh ckgjh ncko] ykyp ;k tcjnLrh ds viuh LosPNk ls
djokus dk [Link]; fy;k gSA esjs ifr@iRuh us igys dksbZ ulcanh@uycanh vkWisz”ku ugha djok;kA ¼iqu % uycanh@ulcanh ds
fy, ykxw ugha½ ¼---------------½

1. eq>s irk gS fd xHkZ fujks/k ds vU; rjhds Hkh miyC/k gSaA eSa ;g tkurk@tkurh g¡w fd ;g ewyr% LFkk;h gSA
eq>s ;g Hkh irk gS fd ds vLkQy gksus ds Hkh dqN volj gks ldrs gSa ftlds fy, djus okyk

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MkWDVj@LokLF; lqfo/kk dks esjs lEcaf/k;ksa }kjk ;k esjs }kjk ;k fdlh Hkh vU; O;fDr] tks Hkh gks] }kjk mRrjnk;h ugha
Bgjk;k tk,xkA ¼---------------½

2. eq>s bl ckr dh tkudkjh gS fd eSusa tks djokuk gS mlds tksf[ke dk rRo gks ldrk gSA
i. ¼---------------½

3. eq>s ds fy, ik=rk ekinaM Li’V dj fn, x, gSa rFkk bl ckr dh iqf’V djrk@djrh ga¡w fd ekin.M ds
vuqlkj djkus dk@dh ik= ga¡wA ¼---------------½

4. eSa fdlh Hkh izdkj dh ,ulfFkfl;k ¼ ½ ds vUrxrZ vkWisz”ku djokus ds fy, lger gw¡ ¼ftls MkWDVj@LokLF;
lqfo/kk esjs fy, mfpr le>s½ rFkk tks MkWDVj@lEcaf/kr LokLF; lqfo/kk }kjk nh tkus okyh vU; nokbZ;k¡ mfpr le>h
tk,] xzg.k djus ds fy, lger gw¡A eSa fdlh Hkh lgk;d thou j{kd dk;[Link] ds fy, Hkh lger ga¡w ;fn vko”;d
gqvkA ¼---------------½

5. eSa vLIkrky@laLFkk@fpfdRld@LokLF; lqfo/kk dsUnz esa rRi”pkr~ tk¡p gsrq vkus ds fy, lger ga¡w]
vlQy jgus ij [Link]] ;fn dksbZ gks] ds fy, ftEesnkj jgax
w k@jgax
w h ¼---------------½

6. ;fn uycanh@ulcanh vkWisz”ku ds Ik”pkr~ esjs @esjh iRuh dk ekfld pdz le; ij ugha vkrk rks eSa MkWDVj@LokLF;
lqfo/kk dks nks LkIrkg ds vanj lwfpr d:axh@d:axk rFkk क xHkZikr dh lqfo/kk izkIr dj ldwx
a k@ldax
w hA eSa
[Link]] ;fn dksbZ gks] ds fy, ftEesnkj jgax
w kA ¼---------------½

7. eSa le>rk gw¡ fd iq:’k ulcanh rRdky ca/;kdj.k esa izHkkoh ugha gksrk gSA *EkSa ulcanh lTkZjhdh lQyrk dh iqf’V
¼,twLifeZ;k½ ds fy, “kY; fdz;k ds rhu eghus ds ckn oh;Z fo”ys’k.k ds fy, vkus dks lger gw¡ rFkk vkus esa vlQy
jgus ij [Link]] ;fn dksbZ gks] ds fy, Lo;a ftEesokj jgax w kA ¼*dsoy iq:’k ulcanh ds fy, ykxw½
¼---------------½

8. ;fn uycanh@ulcanh ds dkj.k dksbZ tfVyrk@vlQyrk vFkok e`R;q dh ?kVuk gksrh gS] ml
fLFkfr esa ljdkj dh “ifjokj fu;kstu {kfriwfrZ ;kstuk” ds varxrZ ftruh gtkZus ds :Ik esa ljdkj }kjk nh
tk,xh mijksDRk eq>s ifr@iRuh esjs vkfJr] vfookfgr larku dks [Link] vkSj vafre fuiVku ds :Ik esa Lohdk;Z
gksxhA ;fn eSa @esjh iRuh ulcanh dh foQyrk ds ~ xHkZorh gksrh gS rc esa bl lEca/k esa fdlh Hkh
vU; dkuwu dh vnkyr ds varxrZ ifjokj fu;kstu chek ;kstuk ds varxrZ eqvkots ls vfrfjDr ] vU; eqvkots
ds nkos ;k cPps dks ikyus ds fy, fdlh eqvkots dk nkok djus dk gdnkj ugha gw¡xk@gw¡xhA
¼---------------½

eSusa mijksDr tkudkjh i<+ yh gSA mijksDr lwpuk i<+ dj esjh esa Li’V :Ik ls le>k nh xbZ gS vkSj
bl izk:Ik dks dkuwuh nLrkost dk izkf/kdkj gSA

eq>s Kkr gS fd eSa fdlh Hkh le; uycanh@ulcanh djokus ls badkj dj ldrk@ldrh gw¡ vkSj blls eq>s
feyus okyh vU; iztuu lEca/kh lqfo/kkvksa ij dksbZ izHkko ugha iM+x
s kA

rkjh[k ------------------------------------------------- Lohd`fr drkZ ds gLrk{kj@vaxwBk

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xokg ¼ ykHk xzkgh dh rjQ ls½ ds gLrk{kj -----------------------------------------------------------------------------------

Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 129
Family Planning GNCTD/………………/SOP/OBG/02

iwjk uke ----------------------------------------------------------------------------------------------------------

iwjk irk -----------------------------------------------------------------------------------------------------------

eq>s irk gS fd ykHkxzkgh fookfgr gS@dHkh dh Fkh vkSj mldk ,d thfor cPpk ,d Z ls mij gSA

vk”kk@lykgdkj@izsjd ds gLrk{kj ----------------------------------------------------------

iwjk uke ---------------------------------------------------------------------------------------------------------------
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eSa [Link] djrk gw¡ fd EkSausa Lo;a dks bl ckr ls larq’V dj fy;k gS fd % &

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Family Planning GNCTD/………………/SOP/OBG/02

6. CHECK LIST FOR STERLIZATION

Medical Record & Checklist for Female and Male Sterilization.

This checklist is to be filled by the doctor before commencing the sterilization procedure for
ensuring the eligibility and fitness of the client for the sterilization.

Name of the Facility:

Beneficiary Registration No.:

Date:

A. Eligibility Checklist

Client is within eligible age Yes……………………..No………………………..

Client is ever married Yes……………………..No………………………..
Client has at least one child over one Yes……………………..No………………………..
year of age

Lab investigation (HB, urine) undertaken Yes……………………..No………………………..

are within normal limits (7.0 gms or
more)
Medical status as per clinical observation Yes……………………..No………………………..
is normal
Local examination done is normal Yes……………………..No………………………..
Informed consent given by the client Yes……………………..No………………………..
Explained to the client that consent form Yes……………………..No………………………..
has authority of a legal document
Infection prevention practices as per laid Yes……………………..No………………………..
down standards

B. Menstrual Hygiene (for female clients)

Cycles Days
Length
Regularity Regular…………………Irregular…………............
Date of LMP (DD/MM/YYYY) ……………../…………./………….

C. Obstetric History (for female clients)

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Number of spontaneous abortions

Number of induced abortions
Currently lactating Yes……………………..No………………………..
Amenorheic Yes……………………..No………………………..
Weather pregnant Yes……………………..No………………………..
If yes (no. of weeks pregnancy)…………………....
No. of children Total no…………………..
Date of Birth of Last Child (dd/mm/yyyy) ……………../…………./………….

D. Contraceptive History

Have you or your spouse ever used

Yes……………………..No………………………..
contraceptives?
Are you or your spouse currently using  None…………………………………
any contraception or have you or your  IUCD………………………………….
spouse used any contraception during  Condoms…………………………..
the last six months?  Oral Pills…………………………….
(√) Tick the option  Any other (specify)…………….

E. Medical History

Recent Medical illness Yes……………………..No………………………..

Previous surgery Yes……………………..No………………………..
Allergies to medication Yes……………………..No………………………..
Bleeding disorder Yes……………………..No………………………..
Anemia Yes……………………..No………………………..
Diabetes Yes……………………..No………………………..
Jaundice or liver disorder Yes……………………..No………………………..
RTI/STI/PID Yes……………………..No………………………..
Convulsive disorder Yes……………………..No………………………..
Tuberculosis Yes……………………..No………………………..
Malaria Yes……………………..No………………………..
Asthma Yes……………………..No………………………..
Heart disease Yes……………………..No………………………..
Hypertension Yes……………………..No………………………..
Mental Illness Yes……………………..No………………………..
Sexual Problems Yes……………………..No………………………..
Prostatitis (Male sterilization) Yes……………………..No………………………..

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Epididymitis (Male sterilization) Yes……………………..No………………………..

H/O Blood Transfusion Yes……………………..No………………………..
Gynecological problems (Female
Yes……………………..No………………………..
Sterilization)
Currently on medication (female
Yes……………………..No………………………..
sterilization)
Comments:…………………………………………………………........................................................………………
………………………………………………………………….
..............................................................…………………………………………………….………………………………
…………………………………………………………………………………………………………………………………………………
……………………………………………………………………….......................................................

F. Physical Examination:

BP………………………Pulse…………………….. Temperature…………………………………………………

Lungs Normal………………………Abnormal…………………..
Heart Normal………………………Abnormal…………………..
Abdomen Normal………………………Abnormal…………………..
Physical Examination:
1. Male Sterilization

Skin of Scrotum Normal………………………Abnormal…………………..

Testis Normal………………………Abnormal…………………..
Dpididymis Normal………………………Abnormal…………………..
Hydrocele Yes……………………..No………………………..
Varicocele Yes……………………..No………………………..
Hernia Yes……………………..No………………………..
Vas Defrenes Yes……………………..No………………………..
Both Vas Palpable Yes……………………..No………………………..

2. Female Sterilization:

External Genitalia Normal………………………Abnormal…………………..

PS Examination Normal………………………Abnormal…………………..
PV Examination Normal………………………Abnormal…………………..
Uterus Position A/V……………………………….R/V……………………..
Mid Position………………..Not determined………….
Uterus size Normal………………………Abnormal…………………..
Uterus Mobility Yes……………………..No………………(Restricted/Fixed)
Cervical Erosion Yes……………………..No………………………..

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Adnexia Normal………………………Abnormal…………………..

Comments…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
………………........................................................................................................................................
...........................................................................................................................

G. Laboratory Investigations

Hemoglobin Level …………………………………………gms%

Urine: Albumin Yes……………………..No……………….
Urine- Sugar Present………………Absent…………..
Urine test for Pregnancy Positive………………Negative…………
Any other (specify) …………………………………………………..

Name………………………………… Signature of the examining doctor

Date……………................................. HOSPITAL SEAL

H. Preoperative preparation

Fasting Yes………………………………… duration………….hrs

No…………………….
Passed urine Yes……………………..No………………
Any other (specify)

Anesthesia/Analgesia

Type of anesthesia given. (√) Tick  Local only

the option  Local and analgesia
 General, no intubation
 Any other (specify)
Time ……………………………………………………………

Drug name ……………………………………………………………

Dosage ……………………………………………………………

Route ……………………………………………………………

Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 134
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Signature of anaesthetist in case or regional or general anaesthesia

I. Surgical Approach ( Strike out which ever is not applicable) Male Sterilization.
Lignocaine 2%...............................cc
Local Anasthesia
Other
Technique Conventional……………………..NSV……………………
Types of incision Single vertical……………….Double vertical………….....
Conventional/NSV Single puncture
Material for occlusion vas 2-0 Silk…………………..2-0 Catgut……………………...
Yes……………………..No………………
If no, give reasons…………………………………………
Facial interposition ………………………………………………………..........
.............................................................................................
.
Length of vas resected ……………………………………………………… .Cm
Suture of skin for
Silk…………………………..Other………………………
conventional vasectomy
Surgical notes
Any other surgery done at Yes…………………………….No………………………..
time of sterilization? If yes, give details
Specify details of
complications and
management

Name…………………….... Signature of the operating surgeon

Date………………………..

Female Sterilization

Local Anasthesia Lignocaine………….%

Other
Timing of procedure. (√) Tick  Within 7 days post partum………….
the option used  Interval (42 days or more after delivery or abortion)
 With abortion, induced or spontaneous
 Less than 12 weeks……..
 More than 12 weeks………..
 Any other (specify)

Technique (√) Tick the option  Minilap Tubectomy

 With C section
 With other survey………..

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 Laparoscopy Tubal Occulsion

 SPL/DPL………………..
Methods of occulasion of  Modified Pomeroy Laproscopy
fallopian tubes. (√) Tick the  Ring
option used  Clip
Details of gas insufflations Yes…………………………….No………………………..
pneumoperitoneum created
(CO2/Air)
Insufflator used Yes…………………………….No………………………..

Specify details of complications

and management

Name…………………………………… Signature of the operative surgeon

Date………………………………..

J. Vital Signs: Monitoring Chart ( For Female Sterilizations)

“Sedation 0 – Alert 1 – Drowsy 2, - Sleeping/arousable 3 – Not Arousable

Event Time Sedation Pulse Blood Respiratory Bleeding Comments

Pressure (Treatment)
Preoperative
(Every 15 min
after
premedication
Intra operative
(continuous)
Post Operative
1. Every 15 min 15min
for first hour 30 min
and loger if 45 min
the patient is
not
stable/awake

1 hr
2hrs
2. Every 1 hour 3hrs
until 4 hours

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after surgery 4 hrs

Name ……………………….. Signature of the attending staffs

Date………………………......

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K. Post-Operative Information

Passed time Yes…………………………….No………………………..

Abdominal distension Yes…………………………….No………………………..
Patient feeling well Yes…………………………….No………………………..
If no, please specify Yes…………………………….No………………………..

L. Instructions for discharge

Male sterilization client observed for

Yes…………………….No………………………..
half an hour after surgery
Female sterilization client observed for
Yes…………………….No………………………..
four hours after surgery
Post operative instructions given
Yes…………………….No………………………..
verbally
Post Operative instructions given
Yes…………………….No………………………..
verbally
Post operative instructions given in
Yes…………………….No………………………..
writing
Patient counseled for postoperative
Yes…………………….No………………………..
instructions
Comments

Name………………………… Signature of the discharging doctor.

7. [C] IUCD
Source: Annexure 11 IUCD Reference Manual for Medical Officers,Ministry of H&FW,GOI

a) IUCD follow up card

IUCD (380 A) follow up card

Name of Centre ______________ S. No.__________

Name: Age (years):

Husband’s name:

Address:

Contact no.(if any):

Obstetric status: LMP________ LCB ___________

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Date of insertion:

S No. Date Remarks

Name/Signature of staff

1ST visit

10

Date of removal:

Reason for removal: desire for pregnancy/ pain/ bleeding/ others

b) IUCD Insertion Consent Form (may consider using insertion and removal consent forms)

c) IUCD Removal Consent Form

Delhi State Health Mission, Department of Health & Family Welfare, GNCTD Page 139
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8. CONSENT FORM FOR IUCD INSERTION

I have requested and received information, in the language that I understand, on the Intrauterine
Device (IUD) and have chosen to use this method of contraception. I have been counseled on the
advantages and disadvantages of the IUD method. I also understand that the IUD does not protect
me from HIV or any sexually transmitted infection and have been advised to use condoms to
decrease the risk of infections. It is my responsibility to report any danger signs to my physician
and come for follow up as advised.

Benefits/Advantages Risks/Disadvantages
1. Very effective in preventing pregnancy 1. May cause increase bleeding
2. Easily reversible 2. May cause increase cramps
3. Offers contraceptive “privacy” 3. Must come for follow up as advised
4. Can be used by women who cannot use 4. Cannot be used by women at risk for
estrogen due to medical problems pelvic infections
5. Offers no protection against HIV or STI i
6. Insertion may be uncomfortable

I hereby consent to the insertion of the ________________ IUD and understand that it is effective
until ________ at which time I must have it removed.

___________________________ ________________ __________________________

Patient Signature Today’s Date Professional Obtaining Consent

[Link] FOR THE REMOVAL OF THE IUD

I have asked to have my IUD removed. I am aware that once the IUD is removed, I will need
another method of contraception unless I am planning a pregnancy.

I have had an opportunity to discuss my questions and concerns and after doing so give my
consent for the IUD removal.

___________________________ ________________ __________________________

Patient Signature Date Doctor Obtaining Consent

10. IUCD Card (Sample)

Govt. Hospital
IUCD CARD
Name of the Facility Govt. Hospital ID/S. NO. ...............................................
Client’s Name ............................................. Husband’s Name.................................................

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Address...................................................................................................Tel No.........................
Age........................................................................Date of Incretion............... Type of IUCD – Cu IUCD 380/Cu IUCD 375
Timing of incretion interval/Post-placental/Intra-caesarian/Postparturn (within 48 hours)

Party.....................................................................Provider: Gynae Specialist/Medical Officer/SR/Staff Nurse/LHV/ANM

Name of the Provider.............................................................................................................
Date of Last Child birth/obortion...................... Signature................................................................................................................................

LMP.......................................................................
Purpose of Visit
Visits Date Complains (if Findings/Advice Given
Routine
any)
1st Follow-up
2nd Follow-up
3rd Follow-up
Additional Visit
IUCD Removed on.............................. Reason for
Removal .........................................................................
Alternative contraceptive provided:
OCPs/Condoms/IUCD380A/IUCD375NSV/Tubectomy....................................................
Client ID/S No. ................................................................................
Date of Incretion.......................................... Type of IUCD – Cu IUCD 380/Cu IUCD 375

Timing of incretion interval/Post-placental/Intra-caesarian/Postparturn (within 48 hours)

Name of the Facility .......................................................................
Provider: Gynae Specialist/Medical Officer/SR/Staff Nurse/LHV/ANM

Name of the Client ..........................................................................

Name of the Provider.............................................................................................................

Signature................................................................................................................................
Husband’s Name ............................................................................
Age ................... Parity..................................................................
Purpose of Visit
isites Date Complains (if Findings/Advice Given
Routine
any)
1st Follow-up
2nd Follow-up
3rd Follow-up
Additional Visit

“Swasthya, Suraksha aur Aazadi; khushiyan Laaye IUCD’’

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