Adaptation and validation of the World Health Organization’s on Safe Childbirth Checklist for the Brazilian context

Carvalho, Isis Cristiane Bezerra de Melo; Rosendo, Tatyana Maria Silva de Souza; Freitas, Marise Reis de; Silva, Edna Marta Mendes da; Medeiros, Wilton Rodrigues; Moutinho, Nathanny Ferreira; Pimenta, Isac Davidson Santiago Fernandes; Gama, Zenewton André da Silva

doi:10.1590/1806-93042018000200009

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Revista Brasileira de Saúde Materno Infantil

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ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 18 (2) • Apr-Jun 2018 • https://doi.org/10.1590/1806-93042018000200009 copy

Adaptation and validation of the World Health Organization’s on Safe Childbirth Checklist for the Brazilian context

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives:

to culturally adapt and validate the WHO Safe Childbirth Checklist (SCC) in Brazilian hospitals.

Methods:

a methodological study was carried out with consensus techniques and cross-cultural adaptation stages. The original SCC underwent three adaptation and validation stages: 1- nominal group with a panel of experts; 2- consensus conference at two maternity schools, in meetings with professionals who would use the list; 3- pre-test with a structured questionnaire for health professionals from both maternities (n=40) after 30 days of using the checklist. Validation criteria contemplated the content validity, adequated to Brazilian protocols, terminology and feasibility for local context.

Results:

the adapted SCC in Brazil was called the Lista de Verificação para o Parto Seguro - Brasil (LVPS-BR) (Checklist for Safe Childbirth -Brazil) and included 49 items. In the first stage, the 29 items of the original SCC were approved with some adaptations (e.g. CD4 was replaced by the Rapid HIV Test). In the second stage, some of the 29 items were adjusted and added 24 items more. In the third stage, three items were excluded, two were grouped and one more was added.

Conclusions:

the validation process provided a potentially useful LVPS for the Brazilian context, presenting validity and feasibility evidences for the Brazilian context.

Key words
Healthcare quality; Patient’s safety; Maternal-child health services; Checklist

LVPS assessed questions during the consensus phases
At the moment of admission
1. Does the pregnant woman need to be referred?	Stage 1: The term pregnant woman was changed to parturient. Stage 3: Added: referred to another hospital.
2. Was the partogram initiated?	Stage 1: The temperature registered was every 4 hours rather than every 2 hours. Stage 2: Does not apply was added to the check and register the temperature every 6 hours and register the blood pressure every 2 hours when Magnesium Sulfate was taken.
3. Does the pregnant woman need to take an antibiotic?	Stage 1: Administrate antibiotic when fever is unexplained. Stage 2: Left only membrane rupture > 18 hours and added another reason in the checklist, the item "no need for clinical and/or laboratorial reassessment" was added.
4. Does the pregnant woman need to take magnesium sulfate?	Stage 2: The reasons to administrate were: severe, pure or pre-eclampsia in conjunction with hypertension; DBP ≥110mmHg and/or clinical symptoms; headache, visual disorders and altered awareness level; epigastric pain, right upper quadrant pain ; nausea and vomiting and exalted patellar reflexes (increased amplitude and/or area obtained).
5. Does the pregnant woman need to take antiretroviral ?	Stage 1 : Unknown diagnosis was removed from the checklist and the parameters to check were changed from CD4 cell counts to confirmed seropositivity in the prenatal or after the rapid test. Stage 2: Does not apply to check was added. Stage 3: Does not apply was removed and the retroviral administration criterion became only seropositivity confirmed.
6. Were there hand-washing material and gloves for each vaginal examination?	Stage 1: Yes and no were added to be checked. Stage 2: Does not apply was added and modified the term hand washing was replaced by hand sanitation. Stage 3: Does not apply was replaced by material to check (water, soap, paper towel, alcohol solution and gloves).
7. Was the presence of a companion during delivery encouraged?	No changes were made.
8. Will the pregnant woman or companion ask for help during labor, if necessary? A. Did the woman bring her prenatal card? B. Does the parturient need to take an antihypertensive?	Stage 3: Added the alert signal decreasing fetal movements. Stage 2: Added. Stage 2: Added.
Before the vaginal delivery
9. Does the pregnant woman need to take an antibiotic?	Stage 1: In considering antibiotic administration mother's temperature ≥38oC was replaced by unexplained fever during labor. Stage 2: Left only membrane rupture >18hours and other reason was added. The item does not need clinical and/or laboratorial reassessment was added.
10. Does the pregnant woman need to take magnesium sulfate?	Stage 2: The reasons to administrate were: severe, pure or pre-eclampsia in conjunction with hypertension; DBP ≥110mmHg and/or clinical symptoms; headache, visual disorders and altered awareness level; epigastric pain, right upper quadrant pain; nausea and vomiting and exalted patellar reflexes (increased amplitude and/or area obtained).
11. Was there essential material near the bed and preparation for the delivery. For the pregnant woman	Stage 2: Two Kelly forceps were added to check.
12. Was there essential material near the bed and preparation for the delivery. For the newborn	Stage 1: The items to check were clean towels, sterile blade to cut the umbilical cord, suction device as well as a pediatric balloon and mask. Stage 2: Number 6, 8 and 10 tracheal probe and number 6 and 8 short gastric probes; meconium aspiration device; vacuum aspiration and gauge; manual neonatal resuscitator/self-inflating balloon; 00, 0 and 1 ventilation masks; wrist pulse oximeter; laryngoscope with straight blades number 00, 0 and 1; tracheal intubation tubes number 2.5/3/3.5/4; adrenalin; volume expander (0.9% saline solution or Ringer lactate); sterile fields; number 6 or 8 tracheal probe or 5F or 8F umbilical catheter; gloves and glasses, sterile blade to cut the umbilical cord; umbilical cord clamp; sources of oxygen/compressed air; radiant heat source; and a clock.
13. Was the assistant identified and ready to help during the delivery if necessary? C. Does the parturient need to have a cesarean? D. Does the parturient need to take an antihypertensive? E. Does the professional have recent updated neonatal resuscitation qualifications (maximum 2 years)? F. Does the parturient need to have an episiotomy?	Stage 1 : The question was changed to was the professional assistant identified and informed to be ready to provide delivery assistance if necessary?" and no and yes were added to be checked. Stage 3: Was a second professional identified and informed to assist with the delivery, if necessary? Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 3: Added.
After the delivery
14. Is the mother bleeding more than expected?	Stage 2: In the instructions was added: rectal misoprostol and call into action the rapid response team for obstetric emergencies.
15. Does the mother need to initiate antibiotics?	Stage 2: The administration criteria were changed to excessive manipulation in the delivery, forceps and other reasons. An item to the checklist was added: no, clinical and/or laboratory reassessment needed. Stage 3: Cesarean.
16. Does the mother need to initiate magnesium sulfate?	Stage 2: The reasons to administrate were changed to: Severe, pure or pre-eclampsia in conjunction with hypertension; DBP ≥110mmHg and/or clinical symptoms; headache, visual disorders and altered awareness level; epigastric pain, right upper quadrant pain; nausea and vomiting and exalted patellar reflexes (increased amplitude and/or area obtained).
17. Does the newborn need to be referred?	Stage 2: The question was changed to: does the newborn need to be referred to a special care unit? and the items in the checklist were no, yes, at the own institution or yes, to another institution". Stage 3: The question was changed to: does the newborn need to be referred to another hospital and the items in the checklist was no or yes, is/was provided.
18. Does the newborn need to take antibiotics?	Stage 2: In the administration criteria membrane rupture > 18 hours" and other reasons were added. And in the checklist another item was added no, clinical and/or laboratory reassessment needed.
19. Does the newborn need special care/monitoring?	Stage 2: The question was changed to special care or surveillance? And the criteria added were need to take antibiotic, needed resuscitation and other reasons.
20. Does the newborn need to initiate antiretroviral therapy?	Stage 2: Antiretroviral prophylaxis criterion changed from 12 hours after birth to 4 hours after birth.
21.1 Was there skin-to-skin contact (if the mother and the newborn are well)?	Stage 2: Item was divided.
21.2 Was breastfeeding initiated in the first hour (if the mother and the newborn are well)?	Stage 2: Item was divided.
22. Will the mother/companion ask for help if there are any signs of danger? G. Does the parturient need to take an antihypertensive? H. Was the cord clamped between 1 and 3 minutes? I. Was vitamin K administrated? J. Was prophylaxis for neonatal conjunctivitis performed?	Stage 2: There was less than normal in signs of danger activity. And the term signs of danger was replaced for signs of warning. Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 3: Was not approved.
K. Did the NB have an identification bracelet on?	Stage 2: Added.
Before hospital discharge
23. Is the mother's bleeding controlled?	Was not modified.
24. Does the mother need to take an antibiotic?	Stage 2: In the administration criteria chills and foul smelling discharge were replaced by suspected endometritis and other reason. And the checklist an item was added no, need clinical and/or laboratorial reassessment.
25. Does the newborn need to take an antibiotic?	Stage 2: The question was modified to: if the newborn was taking antibiotics, was the treatment concluded?
26. Does the baby breastfeed correctly?	Stage 2: Good teaching practice on breastfeeding and postpone hospital discharge were not added to the checklist.
27. If the mother is seropositive, did the mother and the newborn receive sufficient amount of antiretrovirals (ARV) for the period of 6 weeks?	Stage 2: The checklist items were: - Yes, for the baby; - Yes, for the mother; - Yes, for the mother and the baby. Stage 3: Does not apply was added to the checklist.
28. Were family planning options discussed and presented to the mother?	Stage 3: Was not approved.
29.1 Was the follow-up organized and was it confirmed that the mother and/or companion will seek help if there are signs of danger for the mother?	Stage 2: It was divided in two questions: was the mother's follow-up organized and agreed to and was it confirmed that the mother and/or companion were informed of the signs of danger? The term signs of danger was replaced for signs of warning. Stage 3: The item was combined.
29.2 Was the follow-up organized and was it confirmed that the mother and/or companion will seek help if there are any signs of danger for the newborn?	Stage 2: It was divided in two questions: was the newborn's follow-up organized and agreed to and was it confirmed that the mother and/or companion were informed of the signs of danger? The term sings of danger was replaced for signs of warning. Stage 3: The item was combined.
L. Did the NB present signs of jaundice? M. Did the newborn perform blood group and RH factor tests?	Stage 2: Added. Stage 2: Added.
N. Did the newborn take BCG vaccine? O. Did the newborn take the hepatitis B vaccine? P.Was the neonatal heel prick test performed? Q. Was the newborn hearing screening performed? R. Was the red reflex examination performed? S. Was the tongue screening test performed? T. Was the screening for critical congenital heart defects test performed?	Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 2: Added. Stage 2: Added.

Initial proposals of assessed questions during the consensus phases	Staqes			Final
	1	2	3	Final
At the moment of admission
1. Does the pregnant woman need to be referred?	T		T	WHO
2. Was the partogram initiated?	≅	≅		≅ WHO
3. Does the pregnant woman need to take an antibiotic?	≅	≅		≅ WHO
4. Does the pregnant woman need to take magnesium sulfate?		≅		≅ WHO
5. Does the pregnant woman need to take an antiretroviral ?	≅	≅	≅	≅ WHO
6. Were there availability of hand-washing material and gloves for each vaginal examination?	≅	≅	≅	≅ WHO
7. Was the presence of a companion during the delivery encouraged?	≅			WHO
8. Will the pregnant woman or companion ask for help during labor if necessary?		≅		≅ WHO
A. Did the woman bring her prenatal card?		+		BR
B. Does the pregnant woman need to take an antihypertensive?		+		BR
Before the vaginal delivery
9. Does the pregnant woman need to take an antibiotic?	≅	≅		≅ WHO
10. Does the parturient need to take magnesium sulfate?		≅		≅ WHO
11. Was there essential material near the bed and preparation for the delivery confirmed. For the pregnant woman		≅		WHO
12. Was there essential material near the bed and preparation for the delivery confirmed. For the newborn		≅	≅	≅ WHO
13. Was the assistant identified and ready to help during the delivery if necessary?	T	T	T	WHO
C. Does the parturient show signs to have a cesarean?		+	≅	BR
D. Does the parturient need to take an antihypertensive?		+		BR
E. Is the current professional with recent updated neonatal resuscitation qualifications (maximum 2 years)?		+		BR
F. Does the parturient show signs to have an episiotomy?			+	BR
After childbirth
14. Is the mother bleeding more than expected?	T	≅		≅ WHO
15. Does the mother need to initiate antibiotics?	T	≅	≅	≅ WHO
16. Does the mother need to initiate magnesium sulfate?		≅		≅ WHO
17. Does the newborn need to be referred?	T	T	T	WHO
18. Does the newborn need antibiotics?		≅	≅	≅ WHO
19. Does the newborn need special care/monitoring?		≅	≅	≅ WHO
20. Does the newborn need to initiate antiretroviral therapy?		≅		≅ WHO
21.1 Was there skin-to-skin contact (if the mother and the newborn are well)?		≅		≅ WHO
21.2 Was breastfeeding initiated in the first hour (if the mother and the newborn are well)?		≅		≅ WHO
22. Will the mother/companion ask for help if there are any signs of danger?		≅	≅	≅ WHO
G. Does the parturient need to take an antihypertensive?		+		BR
H. Was the cord clamped between 1 and 3 minutes?		+		BR
I. Was vitamin K administrated?		+		BR
J. Was prophylaxis for neonatal conjunctivitis performed?		+	X	-
K. Did the NB have an identification bracelet on?		+		BR
L. Did the mother receive immediate care after childbirth?		+	X	BR
Before hospital discharge
23. Is the mother's bleeding controlled?				WHO
24. Does the mother need to take an antibiotic?		≅		≅ WHO
25. Does the newborn need to take an antibiotic?		≅	≅	≅ WHO
26. Does the baby breastfeed correctly?		≅		WHO
27. If the mother is seropositive, did the mother and the newborn receive sufficient amount of antiretrovirals (ARV) for a period of 6 weeks?		≅	≅	≅ WHO
28. Were family planning options discussed with the mother?			X	-
29.1 Was follow-up organized and confirmed that the mother and/or companion will seek help if there are signs of danger for the mother?		≅		≅ WHO
29.2 Was the mother's follow-up organized and agreed to?		+	X
29.3 Was the follow-up organized and confirmed that the mother and/or companion will seek help if there are any signs of danger for the newborn?		≅		≅ WHO
29.4 Was the newborn's follow-up organized and agreed to?		+	X
M. Did the NB show any signs of jaundice?		+		BR
N. Did the newborn perform blood group and RH factor tests?		+		BR
O. Did the newborn receive BCG vaccine?		+		BR
P. Did the newborn receive hepatitis B vaccine?		+		BR
Q. Was the neonatal heel prick test performed?		+		BR
R. Was the newborn hearing screening performed?		+		BR
S. Was the red reflex examination performed?		+		BR
T. Was the tongue screening test performed?		+		BR
U. Was the screening for critical congenital heart defects performed?		+		BR

Item	10^th percentile (n=40)					Validity index P10	20^th percentile (n=40)					Validity index P20	Final decision
Item	C1	C2	C3	C4	C5	Validity index P10	C1	C2	C3	C4	C5	Validity index P20	Final decision
At the moment of admission
1	3	4	3	3	3	3	4	4	4	4	4	4	Included
2	4	4	3	4	4	4							Included
3	4	4	4	4	4	4							Included
4	4	4	4	4	4	4							Included
5	4	4	4	4	4	4							Included
6	2	3	3	3	3	3	4	4	4	4	4	4	Included
7	2	2	2	3	3	2	4	3	3	3	4	3^* * Despite obtaining IV 3, the item was included after the researchers' analyzed qualitatively	Included
8	4	3	3	3	3	3	4	4	4	4	4	4	Included
A	4	4	4	4	4	4							Included
B	4	4	4	4	4	4							Included
Immediately before the vaginal delivery (or cesarean)
9	4	4	3	4	4	4							Included
10	4	4	4	4	4	4							Included
11	4	4	4	4	4	4							Included
12	4	4	4	4	4	4							Included
13	2	2	2	2	2	2	4	4	4	4	4	4	Included
C	3	3	3	3	3	3	4	4	4	4	4	4	Included
D	4	4	3	4	3	4							Included
E	4	4	4	4	4	4							Included
F													NA
Immediately after the delivery
14	4	4	4	4	4	4							Included
15	4	4	4	4	4	4							Included
16	4	4	4	4	4	4							Included
17	3	3	3	3	3	3	4	4	4	4	4	4	Included
18	4	4	3	4	4	4							Included
19	4	4	4	4	4	4							Included
20	4	4	4	4	4	4							Included
21.1	3	3	3	3	3	3	4	4	4	4	4	4	Included
21.2	3	3	3	3	3	3	4	4	4	4	4	4	Included
22	4	4	4	4	4	4							Included
G	4	4	4	4	4	4							Included
H	4	4	4	4	4	4							Included
I	4	4	4	4	4	4							Included
J	2	2	1	2	3	2	3	3	2	3	3	3	Excluded
K	4	4	4	4	4	4							Included
L	4	3	3	3	3	3	4	4	3	3	3	3	Excluded
Before hospital discharge
23	4	4	4	4	4	4							Included
24	4	4	4	4	4	4							Included
25	4	4	4	4	4	4							Included
26	4	4	4	4	4	4							Included
27	4	4	4	4	4	4							Included
28	3	2	2	3	2	2	4	3	3	3	4	3	Excluded
29.1	4	4	4	4	4	4							Included
29.2	4	4	2	4	4	4							Included
29.3	4	4	4	4	3	4							Included
29.4	4	3	4	3	4	4							Included
M	4	4	4	4	4	4							Included
N	4	4	4	4	4	4							Included
O	4	4	4	4	4	4							Included
P	4	4	4	4	4	4							Included
Q	4	4	4	4	4	4							Included
R	4	4	4	4	4	4							Included
S	4	4	4	4	4	4							Included
T	4	4	3	4	4	4							Included
U	4	4	3	4	4	4							Included

Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[TFN1] - Items indicated by cardinal numbers (1,2,3 ...) are those present on the original Safe Childbirth Checklist and items in letter order (A, B, C...) are those added in the adapted Safe Childbirth Checklist.

- Items with unmodified content are indicated in the "final" column as WHO, those content that had adaptations are WHO and the original items on the Brazilian list are as BR.