Guideline 1
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Welcoming in |
Health professionals introduce themselves to patients |
Do the health professionals in this facility introduce themselves to patients informing their name and function? Most or all professionals |
0.1 |
0.4 |
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How many health professionals have introduced themselves, informing their name and function since you arrived in this maternity facility? Most or all professionals |
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1.0 |
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Addressing patients by name |
Do health professionals address pregnant and puerperal women by name? Most or all professionals |
0.1 |
0.4 |
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How many health professionals are addressing you by your name since you arrived in this maternity facility? Most or all professionals |
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1.0 |
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Active listening to patients'/companions' complaints, fears and expectations |
How often do you feel welcomed, well treated and respected during your stay in this maternity facility? Most of the time or always |
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1.5 |
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Effective communication |
Do health professionals provide pregnant and puerperal women information about their health status? Most or all professionals |
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0.3 |
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Do the health professionals use in keeping with the patient and moment? Most or all professionals |
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0.3 |
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How often do you understand the information that you receive during your stay in this maternity facility? Most of the time or alway |
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1.2 |
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How often do you feel that the health staff in this maternity facility seek to give answers and answer your doubts/requests? Most of the time or always |
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1.2 |
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Risk Rating Assessment |
Risk rating by health professional/team from the area 24 hours a day |
Does this maternity use obstetric risk rating when receiving patients? Yes |
1.0 |
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Is risk obstetric risk rating done 24 hours a day? Yes |
0.5 |
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Is obstetric risk rating done 7 days a weeks? Yes |
0.5 |
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Provision of Information/explanation to pregnant women regarding WRA |
Are there welcoming and risk rating signs (WRA) showing the colors and waiting times? Yes |
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1.5 |
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After the were you advised of the waiting time to see a doctor or nurse? Yes |
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1.5 |
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Network obstetric care |
Registration of pregnant women with the referral maternity facility guaranteed |
Were the pregnant women who use this maternity facility as their delivery referral facility able to visit facility during antenatal care? Yes
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0.3 |
0.7 |
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Counter-referral from the maternity facility to primary care guaranteed |
Does the maternity facility communicate with primary care services to guarantee counter-referral? Yes |
0.6 |
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Does the maternity facility communicate with primary care services to guarantee counter-referral? Yes |
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1.4 |
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Hospital bed always available |
When admission is indicated, but there are no available beds in this maternity facility, what arrangements are made? Patient is welcomed, risk rating is performed and the transfer regulation center is advised or Patient is welcomed, risk is performed and the patient is transferred directly to another service by the maternity facility or Patient is welcomed, risk is performed and the patient is admitted to the facility |
1.0 |
2.0 |
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Guideline 2
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Right to a Companion of Choice |
Inclusion of a companion of choice |
Does the maternity facility guarantee pregnant women the right to a companion of choice during her whole stay for delivery in this maternity facility? |
0.5 |
1.0 |
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Did you have a companion during your stay? Yes |
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2.0 |
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Did the maternity facility allow your companion to stay with you the whole time? Yes |
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0.5 |
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Newborn's mother and father have free 24-hr access to and can stay in the neonatal unit |
Does this maternity facility allow the mother/father free 24-hour access to and to stay in the neonatal unit? Mother and father at the same time |
0.75 |
1.4 |
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Availability of chairs for companions during labor and birth |
Does this maternity facility have the space for companions to be present during labor? Yes |
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1.0 |
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Does this maternity facility have the area and layout that allow companions to stay in rooming-in? Yes |
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1.0 |
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Meals provided to companions |
Does the maternity facility provide meals to companions? To all companions |
0.1 |
0.1 |
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Did the maternity facility provide meals to your companions? Yes |
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0.6 |
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Best Practices in Childbirth, Birth and Postpartum Care |
Obstetric nurses/midwives participate in low-risk vaginal deliveries |
"Which professionals perform normal births without dystocia? Obstetrician and/or obstetric nurse; midwife " |
0.75 |
1.0 |
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Partogram filled in |
How often is the partogram used to monitor the progression of labor, guiding obstetric conduct? Always |
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0.1 |
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Is the partogram filled in the mother's medical records? Yes |
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2.0 |
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Drinks and food offered to normal low -risk pregnant women during labor |
Fluids, water, juice, soup or other food were offered to the mother during labor? Yes |
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0.5 |
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Did you request some type of fluid or food during labor? Yes, and I was given it |
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0.2 |
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What type of diet was prescribed during labor? Liquid or other type of diet |
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1.3 |
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Best Practices in Childbirth, Birth and Postpartum Care |
Non-pharmacological pain relief methods offered during labor |
Does the maternity facility have non-pharmacological pain relief equipment/materials? At least one |
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0.4 |
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How often does the maternity facility offer pregnant women non-pharmacological pain relief methods during labor? Often or always |
0.1 |
0.1 |
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How often were you offered a massage? Often or always |
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0.03 |
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How often were you offered a birthing ball? Often or always |
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0.03 |
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How often were you offered a birthing stool? Often or always |
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0.03 |
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How often were you offered a stool? Often or always |
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0.03 |
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Does the maternity facility offer other non-pharmacological pain relief methods? Often or always |
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0.03 |
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Did you use any of the following pain relief methods during labor? Massage (Yes or didn't want to) |
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0.16 |
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Did you use any of the following pain relief methods during labor? Ball (Yes or Didn't want to) |
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0.16 |
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Did you use any of the following pain relief methods during labor? Birthing stool (Yes or Didn't want to) |
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0.16 |
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Did you use any of the following pain relief methods during labor? Stool for squatting position (Yes or Didn't want to) |
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0.16 |
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Did you use any of the following pain relief methods during labor? Other? (Yes or Didn't want to) |
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0.11 |
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Encouragement of walking around during Good practice in childbirth care |
Pregnant women are encouraged to walk around during labor? Always |
0.1 |
0.2 |
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Were you allowed to get out of bed and walk around during labor? Yes |
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1.0 |
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Encouragement of non-supine birth positions |
Does the maternity facility provide conditions non-supine birth positions? Yes |
0.1 |
0.15 |
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How often are deliveries performed in non-supine positions? Often or always |
0.1 |
0.15 |
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What position were you in when you had your baby? In bed lying on my side or laid back or in a vertical position; sitting or vertical position; squatting or vertical position, standing up or on all fours |
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1.0 |
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Unnecessary Maternal Care Interventions |
Amniotomy |
Do the professionals in this maternity facility perform routine amniotomy ? No |
0.1 |
0.2 |
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Did they break your waters ( waters break) after you arrived in the hospital? No, they broke before admission or no, they broke by themselves during my stay or Yes, they broke during the cesarean |
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0.5 |
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Is amniotomy recorded in the mother's medical records? Yes, there is a record of what was not done |
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1.2 |
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Use of an venous catheter during labor |
Is routine use of the venous catheter made in this maternity facility for parturient women? No |
0.1 |
0.2 |
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Did you have IV during labor? No |
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1.0 |
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Is the use of IV during labor recorded in the mother's medical records? No |
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1.2 |
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Administration of uterotonic drugs during labor |
Do the health professionals in this maternity facility administer oxytocin during labor? No or selectively |
0.1 |
0.2 |
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Is the use of oxytocin to induce or accelerate labor recorded in the mother's medical records? No |
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1.3 |
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Is the use of misoprostol to induce labor recorded in the mother's medical records? No |
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1.3 |
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Kristeller maneuver |
Is the Kristeller maneuver performed in the maternity facility? No |
0.1 |
0.2 |
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Did someone press or put their weight on your tummy to help the baby come out? No |
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1.0 |
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Episiotomy |
Do the health professionals in this maternity facility perform episiotomy? No or selectively |
0.1 |
0.2 |
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Did they make a cut in your perineum (vagina) during birth? No |
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1.0 |
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Did you feel pain during suturing (stitching) of the perineum? No |
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0.3 |
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Is episiotomy recorded in the mother's medical records? Yes, there is a record of what was not done |
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1.5 |
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Guideline 3
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Availability of Childbirth Care Indicators |
Bed occupancy rate in rooming-in and neona+A19+B19: C2+B19:C35 |
Bed occupancy rate in rooming-in |
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0.25 |
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Bed occupancy rate in the neonatal unit |
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0.25 |
Average length of stay in rooming-in and neonatal unit |
Average length of stay in rooming-in |
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0.25 |
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Average length of stay in the neonatal unit |
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0.25 |
Monitoring of the proportion of cesarean sections |
Proportion of cesarean sections |
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0.5 |
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What indicators are monitoed? % of cesarean sections; % cesarean sections in high-risk women; % cesarean sections by age group; % cesarean sections by main indications; % normal births in women who have had a cesarean section; % skin-to-skin contact in cesarean sections; % optimal umbilical cord clamping in cesarean sections; % cesarean sections in womene who have had a previous delivery; Robson classification; % adolescent deliveries. At least one |
0.2 |
0.3 |
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Presence of companion during hospital stay for delivery |
Percentage of cesareans with companion |
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0.25 |
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Percentage of companions during labor |
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0.25 |
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Percentage of companion during birth |
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0.25 |
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Percentage of companions during postpartum |
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0.25 |
Risk rating in the maternity facility |
Average waiting time for risk rating |
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0.275 |
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Average waiting time to be seen according to risk assessment color bands |
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0.275 |
Maternity facility develops strategies to reduce the number of cesarean sections |
What indicators are monitoed?Average waiting time for risk assessment; Average waiting time between risk assessment and consultation by color; % patients classified referred to primary care; % women by classification; Percentage of admissions by diagnosis. At least one |
0.15 |
0.3 |
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Action plan in place to reduce rate of cesarean sections? Yes, % of cesarean sections lower than 35% in HIS for high-risk maternity facilities |
0.1 |
0.15 |
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0.25 |
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Planning and analysis of indications for cesarean sections performed periodically? Yes |
0.1 |
0.15 |
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Management or coordinator of obstetrics or staff hold periodic meetings with teams to discuss cesarean percentages and indications? Yes |
0.1 |
0.15 |
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Percentage of episiotomies in normal births |
Availability of indicators of episiotomies in normal births |
0.2 |
0.4 |
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0.4 |
Availability of Maternal, Neonatal and Fetal Mortality Indicators |
Number of maternal, infant and fetal deaths |
Availability of number of fetal deaths |
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0.5 |
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Availability of number of neonatal deaths |
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0.5 |
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Availability of number of maternal deaths |
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0.5 |
Death analysis |
How often is an analysis of maternal deaths peformed? Weekly; two-weekly; monthly; two-monthly; quarterly; only with unusual situations |
0.2 |
0.3 |
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Is there a maternal and neonatal death committee? Yes, is the facility performs over 1000 chilbirth per year |
1.0 |
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Publication of morbidity and mortality indicators |
Does the management provide/disclose data on morbidity and mortality indicators to health staff? Yes |
0.3 |
0.7 |
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Guideline 4
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Existence of a Collegial Management Body and/or other Collegial Management Mecanism |
Existence of a collegial management body or other collegial management mechanism |
What strategies are in place in the maternity facility? Collegial management body or similar (spaces for shared management) or wide-scale participatory management |
0.3 |
0.7 |
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Participation of professionals performing different roles in collegial management bodies |
Who participates in shared management spaces? Health staff in management positions and/or professionasl with degrees who work in care and/or technicianswho work in care and/or administrative staff |
0.4 |
0.6 |
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Staff participation in decision making about work processes |
Do staff from different sectors in this maternity facility regularly attend meetings where decisions are made about work processes? Yes |
0.3 |
0.7 |
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Promotion of debates on labor and best childbirth and birth care practices with with professional staff |
How often were debates promoted with maternity staff over the last year (seminars, study circles, rclincial meetings) about best practice in childbirth care and birth care practices? Weekly; two-weekly; monthly; two-monthly; quarterly |
1.0 |
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Regular meetings with staff to ensure the functioning of collegial management mechanisms |
If there are shared-managements spaces, how often are meetings held? Weekly or two-weekly or two-monthly or quarterly |
0.3 |
0.7 |
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Patient, Companion and Worker Information and Listening mechanism |
SUS patient access to the ombudsman with guaranteed response |
Does the maternity facility have na ombudsman service? Yes |
0.2 |
0.3 |
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"Does the maternity facility have a routine for answering suggestions, compliments, denouncements or complaints? Yes" |
0.4 |
0.6 |
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Were you told about/aware that there is na ombudsman for making suggestions, compliments, denouncements and complaints about the care you recevive in this maternity facility? Yes |
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1.5 |
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Changes in work processes and decision making from listening to patients |
Are professionals informed about the reports sent to the ombudsman? Yes |
0.5 |
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Is the information from the ombudsman used in the maternity facility's decision making processes? Yes |
0.5 |
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Are professionals informed about the reports sent to the ombudsman? Yes |
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1.0 |
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Guideline 5
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Environment Suitable for Good Front Door Practices |
Suitable and comfortable environment for welcoming women and their companions |
Is the space private? Yes |
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0.4 |
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Does the area have the space for companions to be present during classification? Sim |
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0.3 |
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Are there enough seats/chairs for the mother and companion? Yes |
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0.3 |
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Comfort and privacy assured in the clinical examiation room and admission of the parturient woman |
Is the room individual?Yes |
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1.0 |
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Environment Suitable for Good practice in childbirth care OU Birthing rooms |
Adequacy of the supply of rooms |
Adequacy of the provision of LDP rooms in relation to total number of labor beds |
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3.0 |
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Adequacy of the structure of the rooms |
Are women in labor admitted to a LDP room with private en-suite bathroom with hot and cold water |
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3.0 |
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Environment Suitable for Rooming-in |
Adequate level of comfort in rooming-in |
Does rooming-in have em-suite bathroom? Yes |
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1.0 |
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Does it have a recliner chair for the companion? Yes |
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1.0 |
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Does it have a bathing area for the newborn? Yes |
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1.0 |
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Suitable Environment in the Neonatal unit |
Accommodation provided for mothers of babies admitted to the neonatal unit |
Is there accommodation in the hospital for mothers of babies admitted to the neonatal unit? Yes |
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3.0 |
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Noise, brightness and temperature control in the NICU and CICU |
Does the NICU have comfortable lighting levels? Yes |
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0.4 |
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Does the NICU have comfortable temperature levels? Yes, with controlled air-conditioning |
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0.2 |
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Does the NICU have comfortable noise levels? Yes |
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0.4 |
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Does the CICU have comfortable lighting levels? Yes |
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0.4 |
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Does the CICU have comfortable temperature levels? Yes, with controlled air-conditioning |
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0.2 |
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Does the CICU have comfortable noise levels? Yes |
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0.4 |
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Chairs and easy chairs in the NICU and CICU |
Is there a place for companions in all beds in the NICU? Yes |
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0.8 |
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Are the chairs for companions the NICU recliners? Yes |
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0.2 |
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Is there a place for companions in all beds in the CICU? Yes |
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0.8 |
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Are the chairs for companions the CICU recliners? Yes |
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0.2 |
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Accessible environment |
Access for disabled pregnant women/companions |
Does the reception have disabled access? Ramps with rails or lift and/or wheelchair accessible bathrooms with grab bars |
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1.0 |
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Does the welcoming and risk rating area have disabled access, ramps with rails or lift and/or wheelchair accessible bathrooms with grab bars |
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1.0 |
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