1. Improving Quality of MNH Services at RSUD Serang and PKM September-December 2011 Kathleen H. Jeffers, RN, CNM, MBA, PhD

2. MCHIP in Serang  Strengthening quality of MNH services in 1 hospital and 5 puskesmas  RSUD Serang  PKM Tirtayasa  PKM Kramat Watu  PKM Petir  PKM Padarincang  PKM Pamarayan

3. Interventions to Date  Implementing use of standards to improve and monitor quality  Onsite training in infection prevention  Onsite training in kangaroo mother care  Training for ER staff  On the job mentoring by midwife volunteer (Sharon Ryan) and Indonesian midwives

4. Purpose of Visit  Provide on the job mentoring for hospital and PKM staff as a follow up to prior interventions  Particular focus on MgSO4 use, kangaroo mother care, infection prevention, labor support, and documentation  Conduct technical updates for hospital and PKM staff  Document changes in practice

5. Gave MgSO4 presentation In 5 MCHIP Puskesmas

6. PE/E Referral from Puskesmas

7. Reinforcing use of infusion pumps  IV pump refresher conducted because pumps had not been used for several months  Facilitated problem solving for obtaining correct tubing  Use of infusion pump with IV tubing currently available.

8. INFUSION PUMP REFRESHER

9. DECREASED USE OF RESTRAINTS IN ECLAMPSIA Use of restraints should decline further with new building

10. Rooming-in in 2011 Midwife volunteer in Serang from Feb-April and from September- December

11. Use of Kangaroo Mother Care

12. Barriers to KMC  Lower educational level  Cost  Distance from hospital KMC - OUTCOME -October 2011 -November 2011

13. KANGAROO MOTHER CARE Patient discharge Nursery Nurses DHO Call PKM & Village MW Continue KMC at home

14. Infection Prevention  Follow Up to Training  Provided refresher for MW  Procured additional self protective clothes  Participated in ward cleaning  Initiated meeting with Pediatrician & Obgyn to discuss TB cases

15. Midwife and medical students wearing self protective clothing for delivery Infection Prevention Meeting with ObGyn, Pediatrician, heads of L&D, Nursery, Post- partum Units, RSUD Serang Administration, and MCHIP Volunteer

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17. Labor Support  Modeled labor support  Assisted midwives and students to implement labor support and alternative positions  Provided clip boards to encourage midwives and students to assume responsibility for designated patients

18. LABOR SUPPORT

19. ALTERNATIVE POSITION FOR DELIVERY CLIP BOARD

20. Eliminating Delays in Early Initiation of Breastfeeding Achieved agreement from staff on importance of early initiation of breastfeeding for all infants. Senior nurse will identify factors that cause non- compliance

21. EARLY INITIATION OF BREASTFEEDING

22. Improved Documentation  Provided written partograph guidelines for students.  Established documenting Intake & Output in cc  Gained consensus that infant data will be recorded by L&D midwife for mothers that remain in L&D during post-partum period.

23. BEFORE AFTER

24. Include signature for every documentation on patient record. Midwife teaches medical student how to complete partograph.

25. Monitoring Fetal Heart Rate During Second Stage  Emphasized that midwife is responsible to check FHTs in second stage after every contraction. Midwives agreed to delegate task to student and confirm action.

26. VE By PKM Staff Resuscitation By PKM Staff Rooming In In Labor & Delivery Breastfeeding Room Poster Rooming In

27. TYPE OF DELIVERY PE/E 2011

28. TYPE OF DELIVERY * OUTCOME JULY 2011 BABY OUTCOMETOTAL Spontaneous cry Not Cry TYPE OF DELIVERY PE/E – NORMAL DELIVERY 28937 PE/E – VACUUM 41216 TOTAL 322153 P value : 0.001 OR: 9.333 CI: 2.400 – 36.296- 36.296

29. Neonatal Resuscitation Refresher

30. Overall Achievements: Sept-Dec 2011  Increased referrals with MgSO4 prior to transport  Increased use of infusion pumps for MgSO4 and oxytocin  Increased numbers of women choosing rooming-in  Improved processes for KMC  Decreased use of restraints for eclamptic patients  Improved labor support 30

31. Thank you and goodbye!