Operational Guidelines For Midwifery Units in Gujarat

Operational
Guidelines for
Midwifery Units in Gujarat
“We are the only species of mammal that doubts our ability to give birth”
-Ina May Gaskin

Department of Health & Family Welfare

Government of Gujarat
No. : H.&F.W./M.E.A/V.R.^/v. S t 7O1- / TAVL nO A-,--
RUSHIKESH PATEL
Minister,
Health and Family Welfare,
Medical Education, Water Resources and
Water Supply
2ndfloor, Swarnim Sankul-1, Sardar Bhavan,
Sachivalaya, Gandhinagar-382 01 0.
Date: g-P^ ?,oRR
Preface
Gujarat has been at the forefront of development in the health sector, pioneering
many important programs and schemes to improve maternal and child health services.
Some of the notable examples are Mamta Abhiyan, Mission BalamSukham, BalsakhaYojna,
Chiranjeevi Yojna, and 108 GVK EMRI referral transport services that has immensely
contributed to transform health care system in Gujarat. These interventions along with
efforts made by National Health Mission have helped in taking health services closer to the
people, even in most remote areas, significantly contributing toreduction of maternal and
infant mortality. However, we envision health care services with utmost respect, dignity
and compassion to every newborn and every mother. One such wonderful step is
midwifery initiative to promote natural birth ensuring bio-psycho-social need of women
and family.
I am happy to see that Gujarat has been pioneer in implementation of midwifery

program since last one decade. We have already made huge efforts in this direction by
creating cadre of nurse practitioner midwifes and established special Midwifery Units in
many facilities to provide care to women in natural atmosphere. I must congratulate
Department of Health and Family Welfare for these people centric approaches for
enhancing the quality of care. However, we need much more efforts to accelerate progress
giving attention to continuum of care and incorporating evidence based and high impact
interventions.We want to promote natural childbirth for every mother in calm and homely
atmosphere of hospital, where women have control over all decisions regarding childbirth
including controlling colors and brightness of light. We also want to ensure; all women can
have childbirth in position of her choice with support of specially trained and competent
midwives. We are committed towards smooth integration of midwifes into current health
care system by ensuring regular training, recruitment and mentoring of midwives.
Current operational guidelines is much needed step, when we are witnessing

paradigm shift from increasing institution delivery to having childbirth with utmost
privacy, dignity, respect, and compassionate care to provide positive birthing experience.
We are committed to establish Midwifery Led Care Units and Midwifery Led Antenatal Unit
by ensuring necessary support and supplies to facility. I am grateful to Department of
Health & Family Welfare, UNICEF, and other partner for this wonderful effort.
Let us make our best efforts to ensure that every woman, every child in Gujarat
aretreated with equity, dignity, and respect and contribute for building a
Patel)
Resi. : Minister's Bunglows No.21, Sector-20, Gandhinagar -38202Q, Ph. : 23257431,23257 432
Office ; 079-23250236,23250224, 23250218, Fax : 079-23250264, E-Mail : min-health@gujarat.gov.in
No.R CS/HFWS /PS-o 6/2022
Manoj Agganral, r.r.s. Health & Family Welfare Department
Additional Chief Secretary Government of Gujarat
7 17, Sardar Bhavan, Sachivalaya,
Gandhinagar-382O10.
Date : og / O 2/ zo 22.
Message
Gujarat has made remarkable progress in reducing Maternal Mortality Ratio by
improving quality of health care services. As maternal mortality is coming down, we
need more focus on providing good quality care as well as positive birthing experience
for every woman. There is a growing concern over increasing rates of cesarean section
and other medical procedures during childbirth process, negatively affecting women's
childbirth experience. Further, there is congestion oftertiary care hospitals, as a greater
number of women are delivering at higher level facilities. Midwifery initiative seems to
be best fit in the quest to find solution to these issues. As per International
Confederation of Midwifes, competent midwife can take care of >B5o/o of deliveries.
Midwifery care is based on the ethical principles of justice, equity and respect for
human dignity.
Gujarat has already taken step in the right direction by introducing Midwifery
practices since 2008. I am happy to see that we have already developed Midwifery Led
Care Units in many facilities where women are offered position of choice during
childbirth, intra partum exercise, and humanized care with complete privacy to ensure
physiological birth. There have been long strides in the last decades to achieve this feat
including establishment of NPM training centers, creation of NPM cadres, trainings,
special sanction of budgets and establishment of MLCUs. We have mainstreamed
midwifery practices into current system of maternity care. However, lack of uniform
standards Ied to varied practices at different level. So, there was a need to develop
Operational Guidelines to ensure uniform practices at all levels, while we scale up these
interventions across the state.
I must congratulate my Health Team for developing these wonderful guidelines,
that defines detailed standards to establish Midwifery Led Care Unit and Midwifery Led
Antenatal Unit. Not only that, but it has also covered other aspects like administrative
structure, scope ofpractices, standard reports and registers and assessment checklists. I
am thankful to UNICEF and other partners for their technical support during
development of these guidelines and for supporting midwifery initiative.
Iam confident that these guidelines will help facility managers and other
stakeholders in strengthening midwifery units in the facilities. I am sure that this is
much needed step towards promoting physiological birth and ensuring birthing
experience for women of Gujarat.
Manoj
Additional Secretary
Department of Health & Family Welfare, Gujarat
o Phone : (079) 232 5L4O3,232 5t40L o Fax : 1079l'232 54653 o Email : sechfwd@gujarat.gov.in
Commissionerate of Health, Medical
Services. Medical Education & Research
5/1, Dr. Jivraj Mehta Bhavan,
sar*a ad Candhinagar - 382010
(;o!'t.RNItEfi t 0l ctiJARAT
Jai Prakash Shivahtr€, r,rs

('ommissioner
Foreword
Improving the quality of care has dominated maternal health strategies in the
Iast decade, and is motivated by the desire to offer care that not only leads to improved
outcomes, but also offers a good experience for women and their families. However,
care should also be provided by competent, respectful practitioners, who are not only
able to carry out specific tasks, but who also have the knowledge to support their
practices.Midwifery is one such age old practices where natural birth is promoted
keeping in mind Bio Psycho Social needs of woman in order to ensure positive birthing
experience.
Government of Gujarat has recognized importance of Midwifery Practices to

provide access to good quality of maternal and new-born health services and promote
respectful maternity care throughout pregnancy and natural child birthing, Midwifery
practices has evolved to a great extent in Gujarat since learning visit to Sweden in 2008.
Further, as per Guidelines on Midwifery care by Government of India, we have ensured
recruitment of specially trained Nurse Practitioner Midwifes, modification of
infrastructure as per midwifery philosophy, special approval of budget in NHM and
state and capacity building. These has led to successful implementation of midwifery
practices in more than 70 facilities in the state with development of midwifery led care
units. However, there was need to develop evidence based standard operational
guidelines to define standards of midwifery units in order to ensure uniform
implementation.
These guidelines have been developed with numerous consultation with experts
in the field of maternity care and public health. The purpose of these guidelines is to
provide standard guidance to facility managers and other stakeholders to
operationalize midwifery units. I thank my team, UNICEF and other partners for their
valuable inputs during development of these guidelines.
I
strongly believe these guidelines will help all the facilities to establish
midwifery units as per standard norms. I urge all the stakeholders to implement it in
true spirit, I am sure, these is the giant leap towards g positive birthing
experience to all women and new-borns of Gujarat.
Jai Prakash vahare

Commissioner of Health, Gandhinagar
Phone : +91 79 23253271lFax :91 79 23256430 | Enrail : cohcalth(agujarat.gov.in

United Nations Children’s Fund | Gujarat State Office
Plot # 145, Sector 20, Gandhinagar 382 021
Telephone: (+91) 79-23225366/ 23227034 | Facsimile: (+91) 79-23225364 | gandhinagar@unicef.org | www.unicef.in
The past 10 years have seen remarkable progress in child survival and newborn
health in Gujarat and in India. Yet, the fact remains, the risk of newborn deaths
is highest at the time of birth and in the first month of a child’s life. Every
Newborn Action Plan (ENAP) 2019 developed by WHO and UNICEF estimates
that 3 million lives – mothers, newborns, and stillbirths - could be saved each
year with universal coverage of quality maternal and newborn care in the
world. We at UNICEF are committed towards ensuring the health, survival and
development of every mother and every child. This requires evidence-based
strategies and women centric care to ensure positive birthing experience for
every mother.
Midwifery promotes, protects, and supports women’s sexual and reproductive rights. Research suggests
that midwife led care is associated with fewer instrumental birth and increased chances of spontaneous
birth and breast feeding.
UNICEF is supporting the midwifery initiative in Gujarat in close collaboration with the Department of
Health and Family Welfare, nursing colleges and other partners. This initiative is helping create a new cadre
of “Nurse Practitioner in Midwifery” (NPM) who are skilled in accordance with International Confederation
of Midwives (ICM) competencies in providing skilled, compassionate, respectful and women centered care.
We will continue to work with the Government and partners in developing operation plan for
demonstrating and scaling up dedicated Midwife Led Care Units (MLCUs), antenatal OPD managed by
midwives and broadening the scope of work to improve early initiation of breast feeding, Kangaroo Mother
Care, post-natal care for mothers and newborns and enhancing the capacity of Midwifery Training
Institutions in the State.
This new guideline has come at an opportune moment when we are seeing a momentous shift towards
ensuring health care with quality, respect, dignity, and equity for all. The standards defined for developing
midwifery unit in these Operational Guidelines will be of great help to hospitals in planning and
reorganizing perinatal care services as per the midwifery philosophy and the 1000 days strategy for
promoting early childhood development.
UNICEF as the lead development partner for the RMNCH+A programme in Gujarat, will continue to provide
technical assistance to the Department of Health and Family Welfare, to accelerate implementation of all
evidence-based interventions to ensure safer pregnancies and deliveries for every mother and child. We
look forward to our collaboration with the Government of Gujarat to help children survive and lead healthy
lives.
Prasanta Dash
Chief Field Office, UNICEF Gujarat
Contents
Abbreviations ........................................................................................................................... 1
Executive Summary ................................................................................................................. 2
Background and Introduction ................................................................................................ 5
Introduction ............................................................................................................................ 6
Midwifery care ....................................................................................................................... 6
Journey of Midwifery Program in Gujarat ............................................................................. 7
Rationale for the present guidelines ....................................................................................... 8
Objectives ............................................................................................................................... 9
Integrating Midwifery into Health System .......................................................................... 10
Strategic Framework for Midwifery Initiative ..................................................................... 11
Definitions of Midwifery Units ............................................................................................ 11
Recommendations of Midwifery Units in Facilities ............................................................ 12
Scope of Practices ................................................................................................................ 13
Staffing Pattern of Midwifery Units..................................................................................... 14
Administrative Structure ...................................................................................................... 15
Functional Structure of Midwifery Units ............................................................................. 16
Role and Responsibilities ..................................................................................................... 18
Criteria for Admission and Management in Midwifery Unit ............................................... 20
Referral Services .................................................................................................................. 20
Standards for Midwifery Units ............................................................................................. 21
Organizing Midwifery services in Maternity care areas ...................................................... 22
Standards for Establishing Midwifery Units (Intra-partum Care) .................................. 25
Requirements of Beds .......................................................................................................... 25
Components of Midwifery Unit ........................................................................................... 26
Space Requirement ............................................................................................................... 27
Infrastructure Design of MLCU ........................................................................................... 28
Specification of MLCU and Hybrid Midwifery Units ......................................................... 32
Equipment for Midwifery Unit ............................................................................................ 43
Standards for Establishing Midwifery Led Antenatal Units ............................................. 45
Layout of Midwifery Led Antenatal Unit ............................................................................ 46
Component wise Specifications of MLAU .......................................................................... 47
Other Important Components of Midwifery Unit .............................................................. 52
Childbirth in Alternative Birthing Positions ........................................................................ 53
Physiological Cord Clamping and Zero Separation .......................................................... 56
Registers and Reports ........................................................................................................... 58
Behavior and Attitude .......................................................................................................... 59
Continuous skill enhancement ............................................................................................. 60
Digitalization of processes ................................................................................................... 61
Research and Innovations..................................................................................................... 62
Funding ................................................................................................................................ 63
Midwifery Unit Performance Indicators .............................................................................. 65
List of Annexures ................................................................................................................... 66
Annexure 1:Criterias for Admission to Midwifery Unit ...................................................... 67
Annexure 2: Criteria for referral of women from Midwifery Care to Obstetric Care ......... 68
Annexure 3: Midwifery Unit Equipment ............................................................................. 69
Annexure 4 : Midwifery Unit Monthly Reporting Format .................................................. 72
Annexure 5: BUDSET tool : Assessment of Midwifery Units ............................................ 73
Annexure 6: Mother’s feedback form (listening to mothers) ............................................... 84
List of Contributors ............................................................................................................... 87
References:.............................................................................................................................. 89

Abbreviations
CHC : Community Health Center
U-CHC : Urban Community Health Center
SDH : Sub District Hospital
DH : District Hospital
MCH : Medical College Hospital
MLCU : Midwife Led Care Unit
MLAU : Midwife Led Antenatal Unit
NPM : Nurse Practitioner Midwife
NHM : National Health Mission
GSEDS : Gujarat Socio Economic Development Society
RMC : Respectful Maternity Care
ABP : Alternative Birthing Position
LR : Labor Room
ANC : Antenatal Care
PNC : Postnatal Care
HOD : Head of Department
PIP : Project Implementation Plan
ICU : Intensive Care Unit
HDU : High Dependency Unit
USG : Ultra-Sonography
NBCC : Newborn Care Corner
CUB : Comfortable Upright Birth
OPD : Outpatient Department
IEC : Information Education Communication
OGTT : Oral Glucose Tolerance Test
ICTC : Integrated Counselling and Testing Center
IFA : Iron Folic Acid
PCC : Physiological Cord Clamping
NRP : Newborn Resuscitation Protocol
GDM : Gestational Diabetes Mellitus
CS : Cesarean Section
PROM : Premature Rupture of Membrane
FHR : Fetal Heart Rate
PPH : Post-Partum Hemorrhage
NICU : Neonatal Intensive Care Unit
BUDSET : Birthing Unit Design Spatial Evaluation Tool

1
Executive Summary
• Childbirth is the key life event for mother, baby, and family. Women and child
should be center of care provision in Midwifery Unit. Respect their dignity,
autonomy, and privacy all the time.
• Ensure practices that facilitate physiological pregnancy, and childbirth.
• Offer personalized and supportive care that promotes physical and psychological
wellbeing. Provide women centric care keeping in mind socio cultural aspects.
• Family is integral part of childbirth process. They must be involved at all stages
of childbirth.
• Midwifery unit should have philosophy of providing information as early as
possible and keeping decision open. Provide clear-cut information in language
women and family can understand.
• Relationship between midwifery unit and obstetric unit is crucial for ensuring
positive childbirth experience. Obstetric unit and midwifery unit should develop
shared vision of providing best quality care to mother and child.
• There should be shared written commitment of mutual respect and cross
boundary working between midwifery and obstetric units. Facility level
guidelines should be develop and agreed upon by multidisciplinary team
including obstetric units. Obstetric units need to groom midwifery units till they
become self-reliant.
• Designated Senior Midwifery Officer in midwifery unit should be a link between
nodal officer in obstetric unit and pediatric unit to provide best collaborative
care.
• There should be clear policies and procedures for transfer to obstetric unit or
nearby higher-level facility. Linked tertiary care facility should support DH, SDH
and CHC level midwifery units to develop common understanding, policies, and
procedures for transfer.
• Spontaneous child births are more likely to occur between 1:00 AM to 7:00 AM
with peak around 4:00 AM13. Staffing pattern of midwifery unit should follow
this pattern and ensure more staff at night-time than daytime.
2
• Appropriate number of support staff (staff nurses, aaya, peon, cleaning persons)
should be provided to midwifery units for proper functioning.
• Most Midwifery trainings are still based in obstetric units. Sufficient liberty
should be provided to midwifery to adopt and practice midwifery philosophy of
care.
• Continuous professional development should be norms in all midwifery units. All
midwives should undergo regular training to upgrade knowledge, skills, and
practices.
• Daily learning sessions and monthly review should be part of regular schedule of
midwifery units.
• Whole inter-disciplinary team including obstetrics, pediatrics, laboratory,
radiology, ambulances, support staff should be oriented in “the first 1000 days
approach” and midwifery philosophy of care.
• All efforts must be made to spread midwifery philosophy across all fraternity. All
types of students and professionals should be exposed to natural birthing
process, physiological cord clamping, respectful care with dignity and privacy,
ensuring autonomy of women etc…
• It is envisioned that, gradually all healthy pregnant women will be diverted to
midwifery unit and complicated ones will go to obstetric led care.
• Gradually all obstetric residents, medical officer and staff nurse will be trained to
support women to deliver through natural birth.
• Under no circumstances, oxytocin will be given for induction or augmentation of
labour without medical indication.
• Physical environment should speak midwifery philosophy. Ensure design and
environment of midwifery unit that gives homely feelings, calm, and relaxing
environment. Environment should have optimal natural feel with minimal
clinical appearance.
• Midwifery unit should thrive for continues improvement drawing on clinical
outcome and user experience.

4
Background and Introduction

“Babies are bits of stardust, blown from the hand of God. Lucky the woman who knows the
pangs of birth, for she has held a star.”
- Larry Barratto

5
Operational Guidelines for Midwifery Units in Gujarat
Introduction
Maternal Health care services in Gujarat has shown remarkable progress in the last
decade. Maternal Mortality Ratio has improved from 160 per one lakh live births in 2004 -
06 to 75 per one lakh live births in 2016-18. These has resulted from tremendous increase
in institutional deliveries apart from strengthening antenatal care and referral care
services. Institutional deliveries have reached to 94.3% in the state with share of its
public health facilities to 43.3%(NFHS-5). Improved institutional deliveries has brought
its own sets of challenges, such as increasing rates of caesarean sections, increasing
medicalization and instrumentation, affecting quality of care. Further, there is an ever
increasing need for providing respectful maternity care and positive birthing experience
to mother. These holds true, not only for Gujarat, but also for other states of India.

WHO in its guidelines on “Intrapartum Care for Positive Birthing Experience” states that
increasing medicalization of childbirth processes tends to undermine the woman’s own
capability to give birth and negatively impacts her childbirth experience18. International
Confederation of Midwifes (ICM) states that midwife led care results in fewer episiotomies
and instrumental births, increased spontaneous vaginal births and increased breast
feeding rates19. Government of India released guidelines on Midwifery Services in India in
2018 highlighting commitment to roll out midwifery services across country. Based on
these, Government of Gujarat implemented Midwifery Initiative to establish midwifery
practices in the state to ensure positive birthing experience and respectful maternity care
to mother and new-borns.
Midwifery care
Midwifery services is maternity care service where Nurse Practitioner Midwife provide
antenatal, intrapartum and post-partum services as per “Scope of practices for midwifery
educator and Nurse Practitioner Midwifes” by Government of India in order to promote
respectful care and natural birth.

Midwifery services will adopt and promote a bio-psycho-social model of care that
addresses physical, psychological and social needs of women and family16. Midwifery
services are organised around the social needs of women and families, aiming to provide
6
a comfortable, homely atmosphere, rather than a clinical environment, which may seem
impersonal. It promotes equality between women and their carers, bodily autonomy and
informed decision making17.

Whole philosophy of allowing natural birth revolve around avoiding stressful atmosphere
that produces adrenaline and promoting relaxing atmosphere, that produces oxytocin.
These are amenable to modification by ensuring necessary changes in infrastructure,
environment, equipment, and trainings.

What matters to women during child birth is 1. access to specific facilities such as an en
suite toilet, a clean room or space to move around freely, and, 2. control over aspects of
the environment, such as who could see and hear them, who entered the room, and the
temperature and lighting.
Journey of Midwifery Program in Gujarat

History of Midwifery in Gujarat goes back to 2008 when team of eminent experts and
administrator visited Sweden. Visit instilled enthusiasm to start “Inter-Institutional
Collaboration between Institutions in Gujarat and Sweden for Improving Midwifery and
Figure 1: Journey of Midwifery Initiative in Gujarat
2020-21
Scaling up of
• Training
• Recruitment
• Operationalizing
2019 MLCUs
• MLCU Operational
guidelines
2018 • Operationalizing • Approval of NPM
MLCUs in Urban Posts in State
2014 and rural areas budget
• Scaling up • Approval of NHM
2009 Establishment training from 60
of MLCUs in Budget for MLCU
Recruitment of to 132 per year
2008 NPMs through
MCHs
Starting of GSEDS
Learning NPM training
visit to
Sweden
7
Emergency Obstetric Care (EmOC) Services”. These resulted in establishment of three

Centres for Advanced Midwifery Trainings (CAMT) with advance skills laboratories,
training equipment, mannequins, audio-visual teaching aids and well-equipped libraries.
Further, state initiated process for developing model for midwifery led care, policy
changes and networking.

This was followed by demonstrating scalable MLCU models in select high case load
tertiary care public health facilities with the approval of human resources and
infrastructure modification. Implementation of Midwifery initiative was accelerated in
huge way in year 2020-21. Midwifery roll out plan was developed with ambitious target of
starting midwifery services at all high case load facilities. State Midwifery Training
Institutes were increased from three to six increasing annual intake of NPM graduates
from 60 to 132. Dedicated Midwifery Led Care Units (MLCUs) were demonstrated at
several high case load facilities. Special budget was approved in NHM and state budget for
infrastructure, equipment and HR.
Rationale for the present guidelines

Based on learning from Gujarat and Telangana, Government of India is now planning to
scale up Midwifery Initiative. As a first step towards it, Government of India has revised
scope of midwifery practices for Midwifery Educators and Nurse Practitioner Midwifes.
Based on revised scope of practices and experience of our state, need was felt to develop
operational guidelines for midwifery practices in Gujarat to guide facilities on various
aspects of midwifery services. Furthermore, growing body of evidences suggest that
modification in birth space environment may feel calming and safe to mother, supporting
natural birth. Thus, reducing need for interventions, leading to good clinical outcome and
positive birthing experience. So there was need to develop evidence-based standards for
establishing midwifery units to ensure uniform implementation,

These guidelines is developed based on numerous consultations with experts from
Obstetrics, Nursing, Midwifery, Arts, Designing from Government and Development
Partners.
8
Objectives
• To provide guidance to facility staff for implementation of midwifery services
in facility.
• To provide evidence based guidance to facility heads and other stake holders
on establishing Midwifery Units.
• To provide guidance to program managers on smooth functioning and

integration of midwifery units in current system of maternity care.
These guidelines are developed as per current contexts. It will be revised as per need and
after release of operational guidelines from government of India.
9
Integrating Midwifery into

Health System
“Midwifery is a balancing act between art, science and care.”

- Marie Batley
10
Strategic Framework for Midwifery Initiative
Figure 2 : Strategic framework of midwifery initiative in Gujarat

Establish
Midwifery
Units
Health
Inclusion
System of RMC &
Strengthe ABP
ning
Midwifery
Philosophy
First
Capacity 1000
Building days
approach
Research
&
Innovation
Definitions of Midwifery Units

Midwifery Unit is the unit that provide maternity care to healthy pregnant women without
complications where Nurse Practitioner Midwifes or personnel trained or skilled for the
purpose takes primary professional responsibility in order to promote respectful care and
natural birth. Following paragraph describes midwifery units for intra partum and ante
natal services.

Recommendation of Midwifery Unit for Intrapartum Care
o Midwifery Led Care Units (MLCU)- these are dedicated Midwife led care unit
located adjacent to obstetrician led care units(LR) and run only by Nurse
Practitioner Midwifes(NPMs) to provide intrapartum care.
o Hybrid Midwifery Units – these are Midwifery Units where existing obstetric LR is
modified for midwifery services and obstetric team and midwifery team work along
each other. It can be developed in facility where dedicated MLCU is not possible.

11
Facility should aim for developing dedicated MLCU in long term
Recommendation of Midwifery Units for Antenatal Care

Midwife Led Antenatal Unit (MLAU) : Midwife Led Antenatal Unit is unit located
adjacent to obstetric antenatal care area where primary professional responsibility
is assumed by Nurse Practitioner Midwifes in order to promote respectful antenatal
services. NPM should work in obstetric Antenatal OPD alongside obstetric team,
where dedicated MLAU is not feasible.
Recommendations of Midwifery Units in Facilities
Table 1: Recommendation of Midwifery Units in Facilities

Facilities Types of Units Remarks

Medical College Hospitals MLCU & MLAU

District Hospitals MLCU* & MLAU
MLCU or Hybrid Midwifery Units, First priority should be

Sub-district hospitals
MLAU as per feasibility to develop MLCU
Community Health
First priority should be
Centres MLCU or Hybrid Midwifery Units
to develop MLCU
(Urban & Rural)
Primary Health Centres
Hybrid Midwifery Units
(Urban & Rural)
* In exceptional circumstances, hybrid unit may be developed at DH. However, all
facility must aim for dedicated MLCU.

These are proposed Units. Facility may decide upon appropriate units based on current
set up of maternity area. Vision should be to establish dedicated MLCU in long term.

12
Scope of Practices
Midwifery philosophy revolve around care with privacy, respect, and dignity to promote
natural birth and positive birthing experience to mother and baby. Scope of practices for
midwifery unit/NPMs should be as per Guidelines on “Scope of Practices for Midwifery
Educators and Nurse Practitioner Midwife” by Ministry of Health & Family Welfare,
Government of India, June 2021.
However, following are non-negotiable components for midwifery units, while caring for
mother and baby.
• Care with privacy, respect, and dignity
• Inform, educate, and encourage for position of choice during birth
• Allow and involve birth companion of choice in care of mother
• Allow and encourage for mobility and exercise during labor
• Encourage for emptying bladder, whenever mother feels urge
• Ensure relaxing and calm atmosphere
• Provide appropriate nutrition of choice during labor
• Ensure non-pharmacological methods of pain relief
• Ensure continuous motivation and support
• Intervene only, if necessary
• Light and music of mother’s choice, if possible
• Practice physiological cord clamping (Cut umbilical cord only after delivery of
placenta)
• Ensure immediate skin to skin care and immediate breast feeding
• Ensure continuum of care from ANC to childbirth to PNC
• Inform, educate, and counsel during antenatal visits about different birthing
positions, mobility, and antenatal and intrapartum exercises
State envision midwifes to provide continuum of care from ANC to intrapartum

to PNC. However, required number of midwifes are not available as of now. So,
state recommend posting of NPMs in Midwifery Units/LR first. This is to be
followed by posting in ANC clinic, if more midwifes are available. This is to be
followed by posting in PNC, if more midwifes are available.
.
13
Staffing Pattern of Midwifery Units

We intend to develop type of midwifery units, where NPMs assumes responsibilities of
conducting normal delivery as per their specialization. So, they will not be able to carry
out several routine nursing tasks. They will need support of staff nurses, housekeeping
and data entry operator.
State recommends following team for midwifery units. Facility superintendent must make
all the efforts for formation of team.
Team Composition of Midwifery Unit

• Senior Midwifery Officer -1
• NPM – as per Midwifery Guidelines by GOI
o Medical Colleges: Minimum of 16 -18 midwives
o District Hospital: Minimum of 6-8 midwives
o Sub District Hospital - Minimum 4 midwives
o Community Health Centre (Urban & Rural) - Minimum 4
midwives
o PHCs(Urban & Rural) – Minimum 4 midwifes
• Staff Nurse – at least 10 in Medical College Hospitals, 4 in DH, SDH
and CHC
• Data Entry Operator – 1
• Housekeeping Staff – at least 10 in Medical College Hospitals, 4 in
DH, SDH and CHC
• NPM students – as per rotation in teaching facilities
• Midwifery Educators – Minimum one between 9 AM to 5 PM in
teaching hospitals
14
Facility head should ensure availability of this staff in midwifery units. Required staff may
be proposed in NHM PIP or state budget as per need.
Many people have completed NPM course in the past but joined as a regular staff nurse.
Facility should identify such people and post them to Midwifery Units on priority basis.

Administrative Structure
Our long-term vision is to develop administrative structure to ensure stability and
leadership in midwifery units along with integration into current system of maternity
care.
Figure 3: Recommended Administrative Structure

Head Of Department - Obstetrics & Gynecology in
Medical College Hospitals.
Obstetricians in other facilities.
Superintendent / facility in charge,
if obstetrician is not available
Senior Midwifery Officer
NPM / Midwifery Unit

Currently Recommended Administrative Structure
One senior NPM will be designated as Senior Midwifery Officer, who will supervise NPM
work. Senior Midwifery Officer will report to Head of Dept. Obstetrics and Gynecology or
obstetrician in facility. In facilities, where obstetrician is not there, senior midwifery
officer will directly report to superintendent or facility in charge.

15
Each facility must designate senior midwifery officer from experienced midwifes. This
person is responsible for the philosophy of the unit, staffing, quality, and safety, as well as
overall smooth running of midwifery unit. Role of senior midwifery officer is defined
separately in this document.
Functional Structure of Midwifery Units

• State envision to have collaborative model between obstetric unit and midwifery
unit. A model of mutual collaboration where midwifery unit takes care of normal
delivery and obstetric unit takes care of complicated delivery.

Figure 4: Model of Collaborative Care between Midwifery & Obstetric Unit

Obstetric Unit
Midwifery Unit
(Complicated
(Normal Delivery)
Delivery

• Pregnant women will be seen by both, obstetrician/medical officer and midwifes in

triage area. Women identified as being without complications will have access to
midwifery-led care. All other women will go to Obstetrician/Medical Officer led
care.
• Basic Idea is task shifting from doctors to midwives in relation to promotion and
conduction of physiological normal births, and reduces unnecessary interventions
including caesarean sections.
• If pregnant woman develops complications at any point of time in Midwifery Unit.
Her care will be taken over by Obstetrician / Medical personnel on duty in Labor-
delivery Room.

16
• Institute head, obstetric HOD and in charge of midwifery unit should ensure all
efforts to maintain cordial relationship between Midwifery and obstetric units.
Midwifery Unit and Obstetric Units must work as a collaborative unit.
• Relationship between midwifery unit and obstetric unit is crucial for ensuring
positive childbirth experience. Obstetric unit and midwifery unit should develop
shared vision of providing best quality care to mother and child.
• There should be shared written commitment of mutual respect and cross boundary
working between midwifery and obstetric units. Facility level guidelines should be
developed and agreed upon by multidisciplinary team including obstetric units.
• There should be clear policies and procedures for transfer to obstetric unit or
nearby higher-level facility. Linked tertiary care facility should support DH, SDH
and CHC level midwifery units to develop common understanding, policies, and
procedures for transfer.

Figure 5: Flow of Client in Maternity Care areas having Midwifery Units
Flow in Maternity Care having Midwifery Unit

woman is admitted
Assessment and Woman with
Woman came in labor room led by
Examination by complication
with labor pains Obstetrician
in Labor room Resident, doctor /
NPM
Woman Without woman is
complication admitted in
Midwifery Unit
Woman is referred • Respectful Maternity

If any
in labor room led care
complication
by Obstetrician • Promote physiological
labor and birth
Ongoing care of • Assessment and
No progression of labor
women and complication
Newborn by NPM

• Nurture positive multidisciplinary communication between obstetric and
midwifery units. Hold regular co-reviews and learning sessions.

17
• For success of this model, it is necessary that pregnant women come in contact
with NPM during their antenatal care in antenatal clinics and also in postnatal care
in post-natal wards/ postnatal follow up clinics. NPMs to be posted in ANC and PNC
OPD as per availability.
• Designated Senior Midwifery Officer in Midwifery unit should be a link between
nodal officer in obstetric unit and pediatric unit to provide best collaborative care.

NPMs should only be engaged in providing maternity care services as
per Guidelines on “Scope of Practices for Midwifery Educators and
Nurse Practitioner Midwife” by the Government of India. No other
work should be allotted to NPMs.

Role and Responsibilities

Role of Head of Dept. – Obstetrics, Obstetricians, Medical Superintendents, Facility
in charge.
• Groom midwifery unit to ensure it works independently and in collaboration with
obstetric unit and other departments.
• Orient all staff of hospital about midwifery unit and its roles in care of pregnant
women
• Nurture and allow midwifery philosophy to grow.
• To ensure midwifery unit gets required support staff
• To ensure midwifery unit gets all logistics and supplies regularly
• Solution of inter and intra departmental issues
• Monitoring and review of midwifery units
• To ensure continuous learning for midwifery staff
• To ensure all budgetary requirement goes to NHM PIP or state budget

18

Role of Senior Midwifery Officer.
• Arrangement of duties and leaves of NPM
• Coordination with labour room in charge for ensuring supplies and logistics in
midwifery units
• Coordination with HOD – Obstetrics, Obstetricians, Superintendent, Facility in
charge for smooth running of midwifery unit.
• Ensure all NPM practices alternative birthing positions, physiological cord
clamping, respectful care, and all other aspects of midwifery philosophy.
• Ensure evidence-based practices in midwifery units
• Continue clinical work
• Monitor day to day activities of Midwifery Units
• Conflict resolution and smooth internal coordination
Role of Medical Officer in maternity services
• This will be applicable to peripheral facilities (SDHs, CHCs (Urban & Rural), & PHCs
(Urban & Rural) where obstetricians are not available.
• Consider NPM as your colleague.
• Nurture and respect midwifery philosophy in all aspects of maternity care.
• Support midwifes in all possible ways.
• Manage mother with complications referred from midwifery unit as per clinical
skills.
Role of Staff Nurses
Role of staff nurse in midwifery unit will be same as her/his current job description
while her/his posting in labour room.
19
Criteria for Admission and Management in

Midwifery Unit
The midwife and Obstetric resident / Obstetrician / Medial Officer on duty together will
take history of the expectant mother, review the clinical records and undertake a physical
examination. They will complete exclusion criteria checklist and decide that the expectant
mother is suitable to be cared for in the MLCU or should be transferred to the obstetrician
led care unit.

Admission checklist for Midwifery Unit is attached at Annexure -1
Referral Services
As described in figure 5, any women developing complications during care in midwifery
unit should be transferred to obstetric care immediately.

Midwifery unit and obstetric unit should have common understanding on criteria for
referral. Wherever required, women should not be transferred from midwifery unit to
obstetric unit, but obstetrician should care for women in midwifery unit itself. Facilities
below District Hospital level should identify places of referral as per condition and ensure
appropriate and informed referral in timely manner. Smooth coordination between
referring facility and referral facility need to be established by regularly organizing
monthly meetings and referral audits.

Criteria for referral from midwifery care to obstetric care is attached at Annexure -2
20
Standards for Midwifery Units
“If women lose the right to say where and how they birth their children, then they will
have lost something that’s as dear to life as breathing.”
- Ami McKay, The Birth House
21
Organizing Midwifery services in Maternity care

areas
For many women, hospital environment is unknown and provoke feeling of anxiety. This can
interrupt hormonal balance that drives natural birth, making intervention more likely20,21.
Minimizing anxiety by providing feeling of privacy, safety, and security to mother from the
time she enters the hospital supports natural physiological birth. That is, facility must thrive to
make environment women and family centric not only in LR / Midwifery unit, but also at other
service areas such as triage, ambulance drop off etc..
This section discusses organizing maternity service areas to make environment women centric.
It includes following components.
• Layout of Maternity Service areas
• Ambulance drop off areas
• Reception / Registration and
• Triage area
Figure 6: Layout of Maternity Service Area (Not up to the scale)
Ambulance Drop Off Area

with Shades
Stretcher Ramp
Bay
Exit Entry
LR Toilet Triage Room Store
Room
Curtain or Nursing Sample MLCU

non-transparent door Station Collection Toilet
Registration room MLCU
Desk ANC Ward
MLCU
Toilet
MLCU
Obstetric Obstetric LR
ICUs and with
HDUs attached
Other Service Areas in the Hospital toilets
PNC ward
22
Figure 6 depicts layout of maternity service area after inclusion of midwifery services in
Medical College Hospitals. At District Hospital, Sub-district Hospitals, CHCs and other lower-
level, facility should ensure maximum modifications to include midwifery services. Basic idea
is to ensure privacy, dignity, and respectful care at all places all the time.
Feeling of safety and privacy is the Key
Ambulance Drop Off Area

• Dedicated entrance for birthing women ensures privacy and safety. Facility should
develop dedicated entrance for birthing women near to triage room / labour room.
Demarcated ambulance drop off area should be developed close to entrance.
• It should be well labelled and directions and sign boards should be displayed at all
necessary places, including main entry gate of campus.
• Ambulance drop of area should be well lit, clean and uncluttered with shed to protect
birthing women from rain or heat. It should have ramp as per need with sufficient
numbers of stretcher with adjustable height and wheel chair.

Figure 7: Stretcher Bay at Ambulance drop off area in Maternity unit
23
• Distance between ambulance drop off area and Triage room / LR / Midwifery Unit
should be short. Corridor and gates should be sufficiently wide to allow easy
movement of stretcher.
• Ensure availability of person to handle stretcher along with support staff.
Reception/Registration
• Women in labour pain should go directly to triage room from ambulance drop off area
and her relative should manage registration process. So reception/registration area
should be established near triage area to facilitate this process.
• Reception area should be clearly identified, clean and uncluttered.
• Environment of reception area should be pleasant with indoor plants, flowers and
soothing instrumental music.
• Height of reception desk/counter should be low enough to ensure clear line of sight
with women.
• Facility for drinking water and rest is to be provided in the area.
• Registration desk may be considered.
Triage area
• Triage area should be close to ambulance drop off area. It should have triage room with
adequate number of beds to take care of all pregnant women coming to facility.
• Triage area should have one labour room with attached toilet to take care of delivery in
triage area.
• Entire walkway to triage area should be covered or closed for entry for common people
to ensure privacy.
• Labour room register should be available for women delivering in this area.
• Triage room must have three essential equipment 1. USG, 2. Multipara and 3. Doppler
apart from other routine equipment.
• It should have lab sample collection area with availability of three essential equipments
for 1. Blood gas analysis 2. Electrolytes measurement and 3. Three part cell counter
apart from other routine equipment
• Obstetric resident/Doctor and NPM should work together in triage area to ensure
primary screening of women.
All women in labour pain must go to triage area first.
24
Standards for Establishing Midwifery

Units (Intra-partum Care)
Facility should include midwifery unit from planning phase, while constructing new
building. If new construction is not possible, every efforts should be made to re-organize
existing labour room as per these standards. As mentioned earlier, first priority for each
facility should be to develop MLCU. Where MLCU is not possible, develop Hybrid
Midwifery Unit, as per these standards
Requirements of Beds
Figure 8 shows facility wise recommended number of beds for establishing midwifery
units. However, facility may calculate bed requirement as shown in below formula as per
workload and available HR.
Figure 8: Recommendation of beds for establishing Midwifery Units
Medical College Hospitals 3 to 4 beds
District Hospitals 2 to 3 beds
Sub District Hospitals 1 to 2 beds
Community Health Centres

1 to 2 beds
(Rural & Urban)
Primary Health Centers

1 bed
(Rural & Urban)

Calculation of beds for MLCUs and Hybrid Midwifery Units for providing intrapartum care
is to be done as below. This guidance is adopted from Guidelines by Government of India
on Standardization of Labour rooms at Delivery Points.

25
Formula to calculate the number of beds: = [(Projected No of normal delivery

events in a year)*(Average length of stay)]/ [(365)* (Occupancy rate)]
• Step 1: Determine the number of vaginal birth events in a year

• Step 2: Take 0.67 days or 16 hours (12 hours for labor and delivery, 4 hours
recovery, including the room clean-up) as the average length of stay.
• Step 3: 75% or 0.75 is the recommended occupancy rate for health facilities.
• Step 4: Insert the numbers attained in the above steps, in the formula, and calculate
the number of beds
For Example, bed requirement for a hospital with 2000 projected normal
deliveries can be calculated as follows:
No. of beds = (2000* 0.67)/ (365*0.75) = 5 beds
Components of Midwifery Unit

Each midwifery unit should have main birthing area, area for ambulation and exercise,
bathroom with facility for shower, working area including newborn care corner.
Main Caring Area for mother
• Main caring area should include birthing bed, sofa, chair, and stool for relatives.
• Privacy should be provided to mother through partition or curtain
• Facility should be provided to mother to personalize this area.
Area for ambulation and exercise
• These area should have yoga mat, gym ball, rebozo or rope ladder, kitchen height
platform, railing for support etc..
• Area should be protected from outside view through curtain at main door.
• Install TV for informational videos
Bathroom with shower
• This area should have toilet, facility for shower, wash basin, geyser for hot water.
• There should be railing on both side of toilet for support.
• Install celling fan to dry bathroom after use.
Working Area for staff
• This includes working platform with under storage in cabinets
• There should be closet for mother and family to store personal belongings

26
• Cupboard for staff to store documents

• This area should be covered with curtain from main midwifery unit area.
Hand Washing area
• Hand washing area should have steel sink of dimension 28”X18”X8”.
• Elbow-operated taps with 24x7 running water supply.
• A geyser for hot water
• Soap dispenser.
• Hand washing protocol should be mounted on the wall above the hand washing
area.
Newborn Care Corner (NBCC)
• Each midwifery unit should have newborn care corner with necessary equipment
for resuscitation as per operational guideline on facility based newborn care 2014
by Government of India.
Space Requirement
These are suggested space requirement for establishing midwifery units. However, facility
may develop unit as per local context as per these standards, keeping in mind philosophy
of midwifery care.

Table 2: Estimated space requirement for establishing Midwifery Units

sr Areas Space requirement
1 Total space requirement for one bedded unit 200 sq ft
2 Total space requirement for two bedded unit 320 sq ft
Space requirement for individual components
3 Main caring area with birthing bed 64 sq ft (8’ X 8’)
4 Area for ambulation and exercise 30 to 50 sq ft per mother
5 Bathroom with shower and wash basin 30 to 40 sq ft

Working area including nursing station and
6 30 to 60 sq ft
Newborn Care corner
27

16 ft
6 ft 5 ft 5 ft
Birthing bed Railing for support T

V
Geyser
Rebozo
Or
Rope Toilet with 6 ft
Ladder
Door
Shower
Mat
5’ X 6’
Yoga
28
12 ft
Window
Working Platform
Sink
Infrastructure Design of MLCU
Chair Gym Ball Working Area
Sofa
5’ X 6’
6 ft
Closet for NBCC

Platform for mother
Mother Door
Figure 9: MLCU design option 1 : 16 feet X 12 feet

29
20 ft
8 ft 6 ft 6 ft
Birthing bed Platform for mother
Geyser
Door
8 ft Rebozo 6 ft
Yoga Mat Or Toilet with
Rope Shower
Window
Ladder T 6’ X 6’
Chair V
Sofa
16 ft
Partition Closet for
Mother
Sofa
Gym Ball Working 10 ft
8 ft Area
Under storage
Yoga Mat Chair
Window
6’ X 10’
Platform Platform &
Birthing bed
Railing for support
Door NBCC

20 ft
8 ft 4 ft 8 ft
Window Window
Closet for Closet for
Mother NBCC Mother
Sofa Sofa
6 ft
Birthing bed
Birthing bed
Curtain
Chair Gym Ball Door
Chair
T 16 ft
T
30
V V Rebozo
Rebozo
Or Or
Rope Rope
Geyser Ladder 10 ft
Ladder
Yoga Mat
Railing
Yoga Mat
Railing
Shower
Toilet
Platform Platform
Door Door

20 ft
2 ft 4 ft 8 ft 4 ft 2 ft
NBCC NBCC
Closet Closet
for Geyser for 5 ft
Door
mother mother
Door
Toilet with
Door Shower Door
T T
V Sofa Sofa V
16 ft
Chair
Chair
Birthing bed
Birthing bed
Rebozo
Rebozo Or
31
11 ft
Or Gym Ball Rope
Rope Gym Ball Ladder
Window
Ladder
Window
Railing for support
Railing for support

Yoga Mat Yoga Mat
Door Platform for mother Platform for mother Door

10 ft 10 ft

Specification of MLCU and Hybrid Midwifery Units
These specifications are developed as per midwifery philosophy to provide

women centric care. Some of the components will differ from LaQshya
guidelines. These need to be considered during LaQshya assessment.
Privacy
• Feeling of being observed is associated with increased cortical activities leading to
increased release of adrenaline and decreased release of oxytocin during child
birth22, 23, 24. Thus, affecting progression of labour. Privacy is very important factor
responsible for release of oxytocin to promote natural child birth.
• Facility should opt for MLCU to ensure privacy. In existing facilities and where MLCU
is not possible, adequate privacy must be ensured by curtain or cubicles.
• External doors of main lobby should not open directly into the labour room.
Secondary curtains or screens should be used to create a visible barrier, protecting
the privacy of the birthing women even when the door is open.
• Windows of Midwifery Unit should allow natural light in, but protect the privacy of
the pregnant woman. This could be achieved with internal blind or frosted glasses.
• Direct entry of common public should be restricted in labour room.
• Front open cotton gown and chappals should be provided to mother.
Beds

Please see section on “Childbirth in Alternative Birthing Positions” to read about description
of different birthing positions.
• Midwifery Unit should have facility to support position of women’s choice. Common
alternative birthing positions are standing, squatting, semi squatting, side lying,
kneeling and all fours.
• Required furniture for these purpose are birthing bed with facility to support
various birthing positions, Gym ball, birthing stool, rebozo, hanging rope ladder,
armless chair, still railing on the wall, kitchen height platform etc..
• Detailed list of furniture and equipment is given in section for equipment

32
Figure 13: Birthing Stool Figure 14: Modified bed with support
for sitting position

Use birthing bed in place of
labour table. Place it on the
side of room, close to wall.

• Kitchen height platform helps women lean against during bearing down efforts.
• Wall attached railing for support to mother helps during walking and bearing down
efforts. Pillows and towels should be provided for comfort and support to mother to
assume position of her choice.

Figure 15: Railing support during bearing down efforts

33
Lighting
• Generally people prefer different intensity and colour of light at different time.
Colour and intensity of light convey certain emotions.
• Visible light with wave lengths of 446–477 nm known as High Energy Visible light
or Blue light affects secretion of melatonin through receptor melanopsin, a
photosensitive retinal ganglion receptor in the eye 26,27,28,45. Two hour exposure to
blue wavelength light from self-luminous devices decreases melatonin secretion by
38%46. Melatonin synergistically enhance Oxytocin induced contractility of uterine
muscles via the MT2R receptor, which is coupled to a protein kinase C-dependent
increase in phosphorylation of the myosin light chain protein. MT2R expression
appears to be markedly elevated in samples from pregnant women who had
entered labor, as compared to matched nonlaboring pregnant women 29,44.
• White LEDs emits more blue (High Energy Visible Light) light than traditional light
sources(Incandescent) , affecting secretion of melatonin at night time. Further,
bright, artificial light stimulate adrenaline releases and affect physiology of birth9.
• Red light does not affect melatonin level52. Some studies also suggest increase in
melatonin after exposure to red light53. Likewise, another study shows that, a large
amount of melatonin was secreted after irradiation due to the biological response
of human to yellow light54.
• Warming lighting such as yellows, oranges and reds have a positive effect on labour
progression as they are the colours of our primal brain associates with fire and
warmth51
• Low light settings promote sequence of emotions that helps physiology of labour.
Environment with regular bright lights suffers interference in the sequential
appearance of emotions disrupting physiological process of labour50.
• Natural light connects women with the nature and allow her to be calm and relax.
Natural light and views by means of a window is essential and should be available
in all Midwifery Units.
• The risk of a caesarean delivery and use of oxytocin infusion was significantly
decreased when giving birth in a sensory room compared with a standard delivery
room 43
• Ability of women to control light can give sense of control over the environment,
making her confident to birth naturally9.

34
Recommendations for use of lights in Midwifery Units

• Situation and labour phase specific circadian light that mimics natural light should
be used.
• Use dim lights during day time by switching off few lights. Allow light from
windows in controlled manner through curtain or frosted glasses to mimic natural
home lights.
• Do not use artificial bright LED light or blue light after dark during evening or at
night time.
• Use dim red, yellow or orange lights at night times. These light are less likely to
shift circadian rhythm and suppress melatonin. Mobile spot light (bright white
light) should be made available to perform procedure without affecting visibility.
• Do not use “One Size Fits all” approach. Women should be allowed to choose color
and brightness of light as per her wish. Install regulator to dim brightness of light.
• Use situation and phase specific light as shown in this figure 16 as per mother’s
comfort.
Figure 16: Situation and Labour phase specific lighting
(courtesy chromoviso health promoting lighting)

• Transition from one light to another should be gradual.
• Many electronic, low costs smart home solutions are available in the market for
light automation, that is, to control light. These are usually retrofitting solutions,
where modules is fitted with existing switch board to control light remotely.

35
• Some of these retrofitting modules should be installed in Midwifery units to ensure

control over lights. These are usually voice enabled or operated from mobile
through wifi network. Facility for wifi network should be made available for this
purpose.
• Ensure such types of retrofitting of light or some other system to provide control of
light to women.
• These types of lighting are part of midwifery philosophy and need to be considered
during laQshya assessment.
Figure 17: Use of Colored Light in Midwifery Unit at SSG Hospital Vadodara

Windows
• Natural light support physiological birthing process. Labour room should have
windows to allow natural light while protecting privacy of women.
• Windows should be large enough to allow natural indirect light to fill the room,
while minimizing glare.
• Adjustable window coverings, blinds or curtains should be provided to preserve
privacy and control light levels.
• Window should be positioned to allow visual view of natural surroundings.
36
• Alternative methods of window placement as shown in photograph may help in

bringing natural light in while protecting privacy.

Figure 18: Innovative ways of window placement to bring sunlight in midwifery unit

Colour
• Color of the birth room can shape the mood31. Bright colors such as white, cream or
yellow may be useful in clinical settings. However, it gives clinical feel to birthing
environment. Further, it stimulate cortical activities releasing adrenaline4. Thus,
affecting physiology of birth.
• Soothing and non-reflective colors such as light green or light purple or light pink
should be used in Midwifery Unit11.
Noise Reduction
• High level of noise can create stress for Figure 19: signboard to Maintain
beneficiaries as well as staff. It can Silence in Maternity area
deceases concentration and alertness9.
• Women need to feel comfortable enough
to make noise during labour without the
fear of being overheard, nor should they
be worried by overhearing the sounds of
other women. Soundproofing of birth rooms also contributes to privacy.

37
• Wherever possible, birth room should be located away from main road or noisy
areas. This should be taken into consideration while planning for new building.
• Midwifery unit may consider rubber flooring to reduce unnecessary noises. Further,
ensure sound proofing of room to reduce external noise.
• Demarcate Maternity Complex as a “silence zone”. Only minimum required
conversation should be allowed. Mobile phone should be in silent mode. Only
emergency phone calls may be allowed.
• Instrument and trolleys making unnecessary noise should be modified or repaired
immediately.
• Staff to be sensitized to make no or minimum sound inside midwifery unit.
• Sign language may be developed to reduce loud conversation.
Music Therapy:
• Music therapy helps to decrease sensation of pain and anxiety in birthing women. It
also reduces need of post-partum analgesia32,33.
• Music evoke powerful emotions based on past experience with the music. People
relates well with music that they have enjoyed in the past. So, concept of universal
music does not usually work well in birthing room.
• All efforts must be made to provide personalized music to individual birthing
women. Facility may provide headphone to individual women in conventional
labour room or hybrid midwifery room.
• If personalized music is not possible, natural sound (sea, rain, mountain) classical or
instrumental music may be played.
• Ideally, women should be requested to develop collection of music of her choice and
keep listening to it during antenatal period. She should bring same collection to
midwifery unit during childbirth.
• Voice enabled, wifi operated digital smart home solutions are available in the
market. Some of these may be used for music therapy.
38
Visual Focal Points:

• Visual focal points can provide positive distraction from the pain to the women34.
• Cheerful images/posters of mother and child, artwork depicting mother with baby,
natural scenes may be used for this purpose.

Figure 20: Picture of Mother and Baby for Visual Focal Points in Midwifery Units

• Effort can be made to include nature such as plastic saplings, natural arts in the
midwifery unit.
Toilet and Shower:
• Easy access to ensuite toilet have clinical significance apart from providing privacy.
Acute bladder distention due to infrequent voiding or inability to void can have
negative short term and long term outcomes. It can interfere with descent of head
during delivery. It can affect contraction of uterus leading to increased chances of
bleeding after delivery. Further, it can lead to pelvic pain and voiding dysfunction in
long term35,36,37.
39
• Many women give importance to shower as it releases oxytocin through sensory

stimulation. Further it gives feeling of secluded environment38.
• Midwifery unit should have attached toilet with facility for shower and geyser.
• Bathroom should be wide enough to allow entry of emergency equipment and
support person. It should have non-slippery surface.
• A handrail should be fixed on both side of wall to assist women.
• There should be facility for shower with provision of hot water through geyser.
• Install ceiling fan in bathroom to dry it after use.
Décor and Furniture

• Décor should have a domestic feel rather than institutional feel. Ensure
contextualization as per local culture.
• Fixed furniture hinders movement of women. That is why, facility should make all
efforts to minimize fixed furniture and ensure availability of movable furniture. All
furniture should have rounded corner and edges.
• Sight of medical equipment may make woman believe that they are placed in the
room with the purpose and will be use during child birth on her. Keeping it in
enclosed spaces, away from woman’s sight help her relax and focus on child birth. All
medical equipment should be placed in cupboard or cabinets under platform.
Creating homely midwifery unit supports physiological birth.
• Protocols posters and other clinically important displayed material as per LaQshya
guidelines may be filed and placed in cabinets in easily accessible location for use
during emergency situations.
• Above points need to be considered as a part of midwifery philosophy during
laQshya assessment.
• Ability to personalize birthing room helps women to relax and feel safe. She should
be allowed to bring her belongings to birthing unit and place it as per her wish.
• Room should be clean without evidence of previous use.
40
Space for Movement and exercise

• Physical movements like walking and exercise during labour will help pregnant
women to cope with strong and painful contractions and at the same time facilitate
gentle passage of baby through the birth canal12.
• Research supports that walking, movement, and changing positions may shorten
labour, and are effective forms of pain relief and assures the newborns safety.
• Birthing rooms should be large enough to allow the woman to walk around and
adopt different positions. It should accommodate necessary equipment and furniture
for exercise.
• Wireless equipment should be made available for continuous monitoring of the
foetal heart rate and uterine contractions. Patches or belt are available in the market
that transfer data wirelessly to computer. Facility should consider such devices to
allow grater movement.
Figure 21: Midwife Assisting Women during Exercise on Gym ball

• Wherever possible, outside space (small gardens in the backyards) should be made
available to women. decorate this space with plants, pots, flowers and other natural
objects.
41
Figure 22: Midwife doing Back Message to Birthing Women in Midwifery Unit
Figure 23: Midwife Teaching Exercise to Birthing Women in Midwifery Unit while her
mother watches it
Facility may adopt other forms of non-pharmacological methods of pain relief.

However, it should have clear cut evidence of benefit and should not harm mother or
baby.
42
Equipment for Midwifery Unit

Following list suggest minimum requirement for two bedded unit. Facility have liberty to
decide for number of equipment as per local context and need.
Table 3: List of Equipment for Two (2) bedded Midwifery Unit
Name of equipment Quantity

Birthing bed with facility to support various birthing
2
positions
Gym ball 2
Yoga mat 2
Rebozo (chunni – mul mul cloth) – 2 ½ meter length /
2
Rope ladder with ceiling hook
Birthing stool 2
Armless chair 2
Rolling pin 2
Soft pillows with pillow cover 4-6
Hot water bag 2
Cold pack with ice cube 2
Large basin bowl 2
Foetal doppler / Wireless foetal monitor 2
Sphygmomanometer 2
Delivery tray 4
Episiotomy tray 2
Emergency trug tray 2
Neonatal resuscitation kit 2
Baby weighing scale 2
Mobile spot light 2
Stethoscope 2
Pulse oxymeter 2
Thermometer 2
Glucometer 2
Wall cock with second hand 2

43
List of other essentials and Furniture for Midwifery Units
Name of furniture/items Quantity

Closet for mother 2
Sofa 2
Computer (desktop or laptop or tablet) 1-2
Music system 1-2
Television set 1-2
Retrofitting module for controlling light and music 1-2
Wireless internet 1
44
Standards for Establishing Midwifery

Led Antenatal Units
State promotes continuum of care by midwifes from ante-natal to intra-natal to post-natal
care. Facility should post midwifes in antenatal OPD also as per availability. Midwife Led
Antenatal Unit (MLAU) should be developed to support midwifery practices in this area.
This section talks about standards for establishing midwifery led antenatal unit (MLAU).
MLAU is still evolving concept. However, this guidance is prepared based on available
information and evidence. It will be modified in future as new information is made
available.
MLAU should be established in area adjoining to obstetric OPD area. Facility should
include MLAU from the planning phase, while constructing new building. If new
construction is not possible, every efforts should be made to re-organize existing OPD area
as per these standards.
This section talks about following

• Layout of midwifery led antenatal unit (MLAU)
• Components wise specification of MLAU
45
Layout of Midwifery Led Antenatal Unit

Following figure shows general layout of Antenatal OPD area after incorporating
MLAU. This is prescriptive layout. Facility can modify its structure as per existing
infrastructure. Basic ideas is to practice midwifery philosophy.
Figure 24: Layout of Maternity OPD with inclusion of Midwife Led Antenatal Unit
(Not Up to the Scale)

Entry
Reception
Counselling Room for Sample
Dental USG
and Exercise conducting Collection
Clinic Room
Room OGTT Room
Exit
Waiting Area
Midwife Midwife Obstetric High Risk

Obstetric Drug
Led ANC Led ANC ANC Exam
ANC room dispensing
room room room Room
Figure 25: MLAU adjacent to Obstetric Antenatal OPD

46
Component wise Specifications of MLAU

Reception
• Reception cum information desk should be available to guide pregnant
woman and her relatives at the entrance.
• Purpose is welcoming women and family members, allotting token and
obtaining primary information to segregate women as per risk categories.
• Help of nursing student should be taken to manage this area.
• Area should be clean with availability of water.
• Wherever possible, computerized system should be used to record this
information.
Antenatal examination room

• ANC room should have chairs and table for consultation and examination
table with privacy.
• Only one pregnant woman should be allowed at a time in ANC room.
• Mamta Sakhi should be allowed with pregnant woman.
• All women should be seen first by midwifes. Midwife should manage or refer
high risk cases to obstetrician as per scope of practices.
Figure 26: Support by Mamta Sakhi while Midwife Examine Mother in
MALU

47
Waiting Area
• Facility should establish waiting area for pregnant women in MLAU.

• It should have adequate number of chairs. To count number of chairs
required, find out number of pregnant women at maximum OPD hours and
multiply it by 2.5. If this is not possible, ensure that pregnant women and their
relatives can sit comfortably. Avoid cluttering as it prevents free movement.
Consider alternative arrangement, if space is small.
• It should have wall mounted TV in a way that maximum number of people can
see it. TV should continuously show IEC and messages related to the first
1000 days approach and midwifery.
Figure 27: Waiting area in MLAU

48
• Filtered water should be available. It should be at room temperature. It should

be placed in a way that it is easily accessible to all. Arrangement should be
made for adequate number of paper glasses. If stainless still glass is used, it
should be cleaned properly every day. Quality of water should be ensured as
per standard norms.
• The room should have adequate number of windows for cross ventilation and
lights. Windows should have mosquito nets installed.
• Sitting arrangement should be made as per risk categorization with high risk
women getting priority.
Counselling and Exercise room.

• Facility should develop counselling and exercise room to teach women
different antenatal exercise and yoga during pregnancy.
• It should have sufficient space for pregnant women to sit and learn exercises.
• Facility for rope ladder / rebozo, gym ball, yoga mat should be made available.
• Relevant educational material should be available in Guajarati as well as
English language.
Figure 28: Counselling & Exercise room in MLAU

49
• NPM should counsel and teach mother on different types of antenatal

exercises, birthing positions, importance of specific activities as per first 1000
days approach.
• Install music system and play soft instrumental music in the room.
• Room should have attached bathroom, wherever possible.

Figure 29: Midwife Teaching Antenatal Exercise and Yoga in MLAU

50
High Risk counselling room Figure 30: High Risk Counselling Room
Pregnant women with
gestational diabetes mellitus,
pregnancy induced
hypertension, moderate to
severe anemia, malnutrition
needs special counselling.
Separate room with adequate
privacy should be available to
provide counselling for these
conditions. Adequate resource material and IEC material should be available in the
room.
One Stop All ANC Services
• Concept of “One Stop All ANC Services” should be followed. That means all
ANC services must be provided at one place or else with minimum difficulties
to pregnant women. Facility should thrive to achieve this objective with
following options.
• Option 1: Registration window, waiting room, ANC clinic, Immunization
Clinic, Laboratory, ICTC clinic and Radiology room should be in in one area.
This should be mandatory in newly planned structure.
• Option 2: Where structural modification is not possible, facility should be
made available to collect blood sample and report distribution from ANC
clinic itself. Separate sample collection room should be established for this
purpose. Sample collection room/laboratory must ensure minimum needle
prick (usually one prick) to draw blood for all necessary tests including HIV.
• Option 3: Where option 1 and 2 is not possible, policy to give preference to
pregnant women in all service areas should be adopted. Appropriate signage
should be displayed.
• If these services are located on different floors, facilities for elevator and
ramps with handrails should be provided.
• Micronutrient supplements such as Folic Acid, IFA, and Calcium should be
provided in ANC clinic.
51
Other Important Components of

Midwifery Unit
"If I don’t know my options, I don’t have any.”

— Diana Korte
52
Childbirth in Alternative Birthing Positions

Alternative birthing positions favors childbirth by creating more space in birth canal.
Movements of sacrum, ilium, and femur are essential to create this extra space.

Figure 31: Counternutation increases size of pelvic inlet (Courtesy University of Lyon, France)

Figure 32: Nutation increases size of pelvic outlet (Courtesy University of Lyon, France)

As shown in above photograph, counternutation (posterior tilt) of sacrum along with
outward tilting of lilium creates more space in pelvic inlet. Opposite movement or
nutation of sacrum (anterior tilt) along with inward tilting of ilium creates more space in
pelvic outlet.

Flexible Sacrum Position: Flexible sacrum position or birthing position where sacrum
has space to move, increases pelvic inlet and outlet, creating more space. These are
standing, squatting, semi squatting, side lying, kneeling and all fours. Sacrum is not flexible
in Lithotomy(supine) and sitting positions.

53
Figure 33: External femoral rotation tenses Figure 34: Internal femoral rotation
muscles and ligaments located above hip tenses muscles and ligaments located
increases pelvic inlet below hip increases pelvic outlet
(Courtesy University of Lyon, France) (Courtesy University of Lyon, France)

Video link for scientific explanation of movement of pelvic bones to facilitate birthing
process: https://www.youtube.com/watch?v=-ZKgzMvWXVM&t=55s

As pelvis moves up and down and sideways during walking, exercise, and rocking
movement, baby’s head negotiate its way through narrow birth canal, making birth
easy.

What is the Ideal Birthing Position ??

There is no one "right" position for laboring or pushing out a baby. All positions
have pros and cons. Care providers should encourage women to experiment with
different positions and then trust that the woman's body will tell her the right
position for her needs. If a woman is not making progress with a certain position,
encourage her to try other positions, as these may help the baby move down or
turn to help labor progress, but in the end it is the mother who should have the
ultimate say in her position.
•

Evidence:
• From physiological perspective, the ideal position in which humans should give birth
is an upright or squatting position. Squatting is known to be beneficial in reducing
back pain, supporting foetal oxygenation and can facilitate the rotation of the baby
through the birth canal1,2.
54
• Upright birthing positions increases pelvic bony dimension to promote natural birth.
It is also associated with a lower rates of instrumentation such as forceps or vacuum
and lower rates of episiotomy1,2,3,25,49. Upright birthing position is associated with
reduction in duration of second stage of labour47,48,49. Upright birthing position is
associated with fewer cases of abnormal foetal heart rate and lower rate of NICU
admission47. Upright birthing position is associated with fewer episiotomies49
• Forward leaning position while standing and sitting helps to soothe back pain and
facilitate foetal head flexion and rotation as well as increases urge to push6
Figure 35: Different Birthing Positions

. Women should be allowed to birth in position of her choice. All midwifes are trained for
supporting mother in position of her choice. Mother should be informed and encouraged
to assume position of her choice.

55

Figure 36: Midwife Assisting women in Alternative birthing Position

Physiological Cord Clamping and Zero Separation

During foetal life, umbilical arteries carry deoxygenated blood from body to placenta,
which gets oxygenated in placenta and transferred back to body via umbilical vein.
Immediate cord cutting reduces blood flow from umbilical vein to heart, reducing preload.
On the other side, blocked umbilical arteries increase vascular resistance, increasing
afterload. This lead to decreased cardiac output. Thus, leading to hemodynamic instability
for brief period. Studies have shown that umbilical cord blood flow continues for 4 to 5
minutes after birth. This extra time helps to transfer much needed oxygen to newborn
during transition from intrauterine to extrauterine life.
All midwifery unit should practice Physiological Cord Clamping (PCC) where cord is
clamped and cut only after delivery of placenta.
Following guidance is taken from advisory of physiological cord clamping by Government

of India (Ref Letter from Offices of AS & MD, NHM, MOHFW, DO. No: M. 12015/40/219
MCH dated 6th November 2019.). It should be integral part of midwifery practice.
• In all uncomplicated pregnancy, prophylactic oxytocin (Uterotonics) should not be
administered immediately after birth or with presentation of anterior shoulder at
birth, but only after delivery of placenta.
56
• Upon delivery, newborn is received by a NPM/Nurse/doctor with a worm towel and

is transferred to mother’s breast immediately and establish skin to skin contact
while the umbilical cord is still intact.
• Time of baby’s delivery is noted.
• After immediate care and assessment, if the newborn is vigorously active and crying,
the baby is to be kept over mother’s chest for skin to skin contact and put to nipple.
• Rapid evaluation of the newborn is done.
• The routine essential newborn care and resuscitation steps, as per the current NRP
guidelines with early skin to skin contact are performed, while the baby is on
mother’s chest.
• The placenta will be allowed
Figure 37: Practice of Physiological Cord Clamping
to deliver physiologically in Midwifery Unit
without any cord traction or
cord pull; encouraging
mother’s own uterine
contraction and taking help of
gravity.
• Prophylactic oxytocin is given
to mother intramuscularly
only after placental delivery.
• The umbilical cord is
clamped and cut only after
delivery of placenta.
• Time of placental delivery is
also noted. After the cord is
cut, the newborn continue to
be on mother’s chest for at
least one hour. Support for
breast feeding is given.
• If placenta is not delivered within 15 minutes of newborn delivery or any signs of
increased bleeding is noted, decision for manual separation of placenta and further
management shall be taken by Medical Officer/Obstetrician.

57
• The physiological cord clamping may be replaced by immediate cord clamping, if

newborn heart rate is less than 60 beats/minutes and is not improving or getting
any faster or any major malformation that require immediate care or any other
major complications to newborn that require immediate resuscitation. In such cases,
umbilical cord is clamped and cut and appropriate care, as required is provided.
Registers and Reports

All midwifery unit will have to maintain registers and reports as per currently used
standard labour room registers. However, following additional components on midwifery
practices to be captured in case sheet and registers.

Table 4: List of Additional Midwifery Components to be captured in Registers
and Reports
• Ambulation • Breast crawl

• Intrapartum exercise • Placement on abdomen
• Music therapy • Physiological cord clamping
• Voiding of bladder • Oxytocin before or after delivery of
• Diet offered placenta
• Nonpharmacological method of • Duration of third stage of labour
pain relief • Amount of blood loss (actual blood
• Breathing exercise loss to be measured)
• Birthing positions • Zero separation

Midwifery Unit reporting Format
State has developed monthly reporting format as attached at annexure 4. Midwifery unit to
share this reporting on monthly basis with state.

58
Behavior and Attitude

Pregnancy and childbirth are key events in the life of mother, child, and family. It must be
enjoyed to its fullest. These are also very sensitive period, when exposure to excess stress
has the potential to impact the fetus and placental functioning with adverse consequences
for pregnancy course, birth outcomes, and subsequent newborn, infant, and child’s
neurodevelopmental and physical health trajectories14. Stress during pregnancy accounts
for 30% of pre-term births15.

Everything in the hospitals including Labour room, color of wall, equipment, staff,
behavior is unknown to mother and may lead to stress. Behavior is the single most
significant factor among these to assure mother about her appropriate care. Sometimes,
all it takes is just a smile. So, midwifery unit should ensure following protocols.
• Midwifery unit should have philosophy of providing information as early as possible
and keeping decision open. Provide clear-cut information in language women and
family can understands. All
Figure 38: Compassionate Care by Midwife
members of maternity areas
(obstetric and midwifery)
should provide unbiased,
consistent, and evidence-based
information.
• Try to comfort mother from
the point of entry into hospital
till she leaves the hospital.
Nursing students may be given
duty to guide or accompany
mother to appropriate places
in the hospitals.
• Greet mother and family with
smile and ask her wellbeing.
• No tolerance policy should be followed for any type of verbal or physical abuse or
violence. Never ever shout on mother or make any gesture that is not comforting to
mother.

59
• Do not use mobile phone in the labour room.

• Do not take photo or video of mother or family without their due consent.
• Make minimal noise in the labour room. Do not talk loud.
• Involve birth companion in the care of mother.
• Provide light and music of mother’s comfort.
• Ensure delivery in position of choice of mother.
• Don’t perform any procedure without explaining it to mother.
Continuous skill enhancement

• Most Midwifery trainings are still based in obstetric units, sufficient liberty should
be provided to midwifery to adopt and practice midwifery philosophy of care.
• Continuous professional development should be norms in all midwifery units. All
midwives should undergo regular training to upgrade knowledge, skills, and
practices.
• Daily learning sessions and monthly review should be part of regular schedule of
midwifery units.
• Midwife should get refresher training every year for alternative birthing positions
and respectful maternity care and other components of midwifery care.
• Stringent criteria should be implemented for obtaining skills during pre-service
education and internship

Nursing colleges should develop midwifery units in skills lab as per these
guidelines to strengthen pre-service education. Budget for the same may be
proposed in NHM/State budget

60
Digitalization of processes
Each midwifery unit should thrive for paperless working environment. State recommend
digitalization of process to
Figure 39: Wireless device for monitoring of
reduce paper work. Appropriate contractions & FHR

software must be adopted for
this purpose. Wireless foetal
monitoring through belt or
patches are available that can be
applied to mother’s abdomen for
continuation monitoring of FHR
and uterine contractions. This
types of devices should be
adopted to provide greater
mobility to mother.

Figure 40: Use of Wireless device for monitoring of uterine contractions &
FHR providing mobility to birthing women

61
Research and Innovations

Evidence based practices are the crux of midwifery practices. Special emphasis is given on
research and innovation in midwifery practices. Interested NPM candidates will be
promoted to conduct research in the areas of midwifery care. Funding support for
research will be provided through NHM PIP or state budget. Research oriented cadre will
be established in future to promote research.
Following areas are suggested for study by Midwifes in collaboration with Preventive and
Social Medicine or any other appropriate department/institutes.
• What women want? This is qualitative study which need to be conducted every
year by all institute to ensure continues improvement in provision of quality of
care.
• Preference of women for different birthing positions
• Factors affecting respectful maternity care and behavior of service providers.
• Physiological cord clamping (Clamping and cutting umbilical cord after delivery of
placenta) and its effect on mother and newborn
• Effect of different types of light on mother and newborn
• Effect of music on mother and newborn
• Newborn resuscitation in cases of birth asphyxia with intact umbilical cord
• Any other areas deemed appropriate by facility

62
Funding
Following budgetary estimates are provided for developing midwifery unit. These are just
suggestive guidance. Actual estimate to be prepared in consultation with Project
Implementation Unit (PIU).

Table 5: Budget estimates for Establishing Midwifery Units
Estimated
Sr Component Justification
Amount
1 Strengthening Infrastructure renovation to support 20 - 25 lakhs
infrastructure of midwifery practices. This includes renovation,
MLCU, Hybrid partition, privacy through curtain, cabinets
Midwifery unit, for patients and relatives, establishing
MLAU facilities for shower, changing floor surface of
bathroom, adding frosted glasses to windows
etc… Any other renovation aspects should
also be considered as per standard prescribed
in these guideline. Further, this include
budget for innovative ways to bring sunlight
in through windows or tunnels.
2 Electrification of This includes procurement of electrical 2 - 3 lakhs
MLCU, Hybrid equipment, light, music system, router, etc.. It
Midwifery unit, also include installation of retrofitting
MLAU modules for lights, music system etc..

3 Digitalization of This includes developing facility to assist 2 - 3 lakhs
MLCU, Hybrid unrestricted movement of mother and
Midwifery unit, capturing data in digital format. This includes
MLAU procurement of computer, laptop, laptop
stands, tablets, equipment for wireless data
transfer(Belts, patches that can be applied to
abdomen), software etc..

63
4 Equipment of This include procurement of equipment for 5 - 6 lakhs

MLCU, Hybrid per list mentioned in equipment section.
Midwifery unit,
MLAU
5 Furniture for This include procurement of furniture and 3 – 4 lakhs
MLCU, Hybrid other logistics such as sofa, chair, benches,
Midwifery unit, curtains etc..
MLAU
6 Miscellaneous Miscellaneous expenditure in midwifery unit 50000
64
Midwifery Unit Performance Indicators
Table 6: Midwifery Unit Performance Indicators

• % of total deliveries conducted in
• % of babies admitted to NICU
Midwifery unit
• % of episiotomies
• % of deliveries conducted at night
• % of perineal tear
time
• % of still births
• % of referrals to obstetric unit
• % of baby ensured immediate skin
• % of babies requiring neonatal
to skin care
resuscitation measures
• % of cases receiving prophylactic
• % of Physiological cord clamping
oxytocin after delivery of placenta
• % of delivery in alternative
• % of cases with established breast
birthing positions
feeding within 1hr of birth
• % of complications to mother
• % cases with PPH
65
List of Annexures
66
Annexure 1:Criterias for Admission to Midwifery Unit

Name of Mother: Date & Time:
Name of Midwife doing assessment :
Name of Resident/Obstetrician / Doctor doing assessment :
Gravida / Parity: Blood Group
If None of the following criteria is present , women can be admitted to
Midwifery Unit
Maternal Characteristics Current Antenatal Problems
Maternal Age <17 or >40 years Anaemia < 9 gm/dl
Height <145 cm Urine Albumin > +1
Weight on admission >70 Kg Glycosuria, GDM
Parity 5 or Above Breach or Any other mal presentation
Past Obstetric History Multifetal pregnancy
PPH Hypertension in pregnancy (>140/90)
Difficult Delivery Antepartum Haemorrhage
Neonatal death or still birth Estimated foetal weight <2.2 kg or >3.5 kg
History of previous CS PROM
History of eclampsia Post-dated pregnancy >40 weeks
Manual removal of placenta Pre-term labour confirmed
History of repair of complete Presenting with diminished or loss of foetal
perineal Tear movement
Current Medical Problems Temperature >100 F
Hypertension Hyperthyroidism
Diabetes Rh -ve
Cardiac diseases Problem Detected in Labour
Connective tissue diseases Meconium stained liquor
Liver diseases FHR <110, >160
Pulmonary diseases Maternal Heart Rate >120
Thyrotoxicosis Blood stained liquor
Neurological disease Unengaged head >6 hrs duration
Gastrointestinal disease Poor progress in active labour
Haematological diseases Epidural
Past Surgical History Pyrexia
Myomectomy Induction of labour
Laparotomy Non engaged foetal head in primi at term
Pelvic Floor Repair (OASI) Cephalo pelvic disproportion (CPD)
Uterine Repair
Heart Surgery
Signature of NPM Signature of Resident/Obstetrician/MO

67
Annexure 2: Criteria for referral of women from

Midwifery Care to Obstetric Care
Criteria for transfer of women from Midwifery Care to Obstetric Care
Name of Mother :
Date and Time of transfer :
Name of NPM:
If women meets any one of the below criteria during care in Midwifery Unit, She
should be referred to Obstetric Care
Maternal Indications
Pulse >110
A single reading of either raised diastolic blood pressure of 90 mmHg or more or raised
systolic blood pressure of 140 mmHg or more
A reading of 2+ of protein on urinalysis
Temperature of above 100 F
Any heavy vaginal blood loss other than a show before delivery of baby
Suspected post-partum haemorrhage

Pain reported by the woman that differs from the pain normally associated with
contractions
Foetal Indications
Foetal heart rate below 110 or above 160 beats/minute; or any suspected foetal heart
abnormality heard or suspected on intermittent auscultation
Labour Related Transfer Conditions

Delay in labour: Delay in progress of labour in monitoring of descent, cervical dilation
or uterine contraction, caput and moulding as noted on partograph
Duration of second stage >half an hour
Uterine inertia in second stage of labour
Meconium stained liquor
Third-degree or fourth-degree perineal tear
Retained placenta > 30 mins after active management of third stage
68
Annexure 3: Midwifery Unit Equipment
S. Name and picture of the item

No. Utility
1 Birthing Bed with facility

to support various
birthing positions
To provide support during
alternative birthing positions
2 Floor Mats / Yoga Mats

Antenatal and intrapartum exercise

and yoga
3 Gym Ball

4 Armless chair

Support during bearing down in
seating position
69

No. Utility
5 Birthing
Stool

Support during sitting birthing
position
6 Rebozo or Rope ladder

and support during birthing
positioins
7 Soft cotton chunny
Support and pain relief during

birthing positions and exercise
8 Wooden Rolling Pin (Velan)

Back message for non-
pharmacological methods of pain
relief

9 One pair of socks with two tennis balls

Back message for non-
pharmacological methods of pain
relief

70

No. Utility
10 Soft pillows Two

For support during various birthing
positions
11 Hot Water Bag

For pain Relief
12 Cold pack bag

For Pain relief
13 Basin bowl

Collecting hot water
13 CUB Support

Support during sitting birthing
position
71
Annexure 4 : Midwifery Unit Monthly Reporting Format
Midwifery Unit monthly reporting format

To be filled by MLCU and Hybrid Midwifery Units
Name of Facility
Reporting Month
Type of Unit MLCU Hybrid Midwifery Unit
Sr Parameters Numbers
1 Number of total deliveries in entire facility
2 Number of C section in entire facility
3 Number of vaginal deliveries in entire facility
4 Number of instrumental deliveries in entire facility (Forceps and
vacuum)
5 Number of deliveries conducted in midwifery unit / by NPM
6 Number of women encouraged & allowed for ambulation
7 Number of women who had intrapartum exercise
8 Number of women received music of their choice
9 Number of women allowed to void bladder on urge
10 Number of women received any form of non-pharmacological pain
relief
11 Number of women received diet (Liquid, juice, raab etc..)
12 Number of women allowed birth companion
13 Number of women delivered Supine positions
14 Standing Position
15 Sitting Position
16 squatting position
17 Kneeling Position
18 All Four Positions
19 Side lying positions
20 Any other alternative positions
21 Number of newborns ensured immediate skin to skin care
22 Number of newborns ensured zero separation
23 Number of newborns ensured physiological cord clamping
24 Number of women received oxytocin before delivery of placenta
(AMTSL)
25 Number of women received oxytocin after delivery of placenta
(AMTSL)
26 Number of newborns developed birth asphyxia
27 Number of newborns referred to NICU due to any complications
28 Number of women needed episiotomy
29 Number of women developed second degree or more perineal tear
30 Number of women referred to obstetric care
31 Number of women developed PPH (Blood loss >500 ml)
32 Number of women needed blood transfusion
72
Annexure 5: BUDSET tool : Assessment of Midwifery Units

BUDSET tool is Birthing Unit Design Spatial Evaluation Tool. It is developed and designed
by Centre for Midwifery, Child and Family Health, the Group for Health Architecture and
Planning and the Centre for Contemporary Design Practices - University of Technology,
Sydney, NSW.
The BUDSET is based on 18 design principles and is divided into four domains (Fear
Cascade; Facility; Aesthetics; Support) with three to eight assessable items in each. Birth
units must be designed so that they facilitate and support the physiology of normal
childbirth. Studies suggest usefulness of The BUDSET to assess the optimality of birth
units and determine which domain areas may need to be improved39.
State recommend use of BUDSET tool for
• Assessment during planning phase

• Assessment of functional midwifery units to initiate corrective actions
• Certification of midwifery units
• Rating and comparisons of midwifery units.
Birthing Unit Design Spatial Evaluation Tool (The BUDSET tool)

Name of Centre
Name of Evaluators

Date of evaluation
Note : Item is present
0 = No
1= Yes
73
100 Fear Cascade
Number Fear Cascade Characteristic Score
N100 Space - Arrival (6

points)
A. Maternity drop-off area is directionally well labelled 0 1
0 1
B. Drop-off area is well lit
C. Drop-off area has temporary parking places 0 1
D. Drop off area is clean and uncluttered 0 1

E. Birth unit has a dedicated entrance 0 1
separate from main hospital entrance
F. The distance from the drop off area to the birth unit 0 1
is short and route logical
Overall
Comments
N101 Space - Reception (5

points)
A. Reception space is clearly identified 0 1
B. Reception desk is open and inviting (includes low

counter to ensure clear line of sight with the woman) 0 1
C. Area around reception is clean and uncluttered 0 1

D. Reception has indoor plants, flowers 0 1
E. Reception area and corridor is free from medical
equipment or clinical signage 0 1
Overall
Comments
74

Space - Birthing Rooms (5
N102 points)
A. Internal birth room is shielded from exposure to the

main corridor area (eg using an ante room, short 0 1
corridor, curtain, screen, partition)
B. There is sufficient space within the room for the woman 0 1
to freely move around
C. The bed occupies less than 1/3rd of the space within the 0 1
room

D. The bed is not the first object seen on entering the room 0 1
E. The bed is able to be moved out of the way to enable the 0 1

woman to choose a range of support options
Overall
Comments
N103 Space - Outside (5

points)
0 1
A. A window is present

B. Outside views include nature 0 1
C. Outside space is accessible with places to sit 0 1
D. Outside space provides positive distractions

plants, flowers, water features 0 1
E. Outside space minimizes intrusions

urban noise, smoke, artificial lighting 0 1
Overall
Comments
75

Sense of Domesticity (5
N104 points)
A. Décor has a domestic rather than institutional feel 0 1
B. Room is clean without evidence of previous use 0 1
C. Medical gasses available and obscured from view 0 1
D. Trolleys and Emergency equipment obscured from view 0 1

E. Linen hampers and waste bins obscured from view 0 1
Overall
Comments
N105 Privacy (6
points)
A. Rooms contain interior lockable doors to control who 0 1
enters the room

B. A 'Knock Before Entering' policy used and enforced by 0 1
staff
C. Perception of not being able to be seen from outside the 0 1
window
D. Secure and lockable places for women's belongings when
leaving the room 0 1

E. Entry door screened so women cannot be observed from
the doorway 0 1

F. Window-less doors for entry to birth room
Overall
Comments
76

Noise Control (5
N106 points)
A. Loudspeaker paging system and/or common music not 0 1
audible in birth room
B. Confidentiality
1 Marginal/Poor to No Privacy - most to all
conversation and birthing sounds can be 0 1
overheard and intelligible to unintended listeners
2 Normal - conversations and birthing sounds may 2 3

be overheard but are only partially intelligible
3 Confidential - conversations and birthing sounds
are not overheard outside the confines of the spac
C. Music can be selected and controlled by woman within the 0 1
rooms
Overall
Comments
N107 (5
Universal Precautions and communication points)
A. Scrub basin in room with soap and glove dispenser 0 1

available but not directly visible to the woman
B. Sharps disposal box located within room but not directly
visible to the woman 0 1
C. Staff assist systems installed in room 0 1
D. Presence of telephone or intercom in room

0 1
E. Anti-slip devices present around water usage areas to
prevent slipping of woman and/or staff 0 1
Overall
Comments
77
200 Facility
Number Facility Characteristics Score

Physical Support (5
N200 points)
A. Availability of birth assistance material in the actual room 0 1

B. Presence of bars on walls at various heights 0 1
C. Presence of mantelpiece or bench on which to lean 0 1
D. Presence of comfortable chair for breastfeeding 0 1
E. Furniture (eg bed) able to be moved to the corner or 0 1

side of the room
Overall
Comments

N201 Birthing Bath (considering current contexts, please (9

ignore this section) points)
A. Birthing bath present 0 1
B. Access to bath is directly connected with birth room
0 1
C. Bath is deep and wide enough allowing woman’s 0 1

back/buttocks/perineum to be totally immersed when on
hands and knees
D. The woman has access to hand rails to assist

position change 0 1
E. Two-sided access to the bath
0 1
F. Short wide bore taps to enable quick filling of bath

0 1
G. Wide bore drain for quick emptying of the bath

0 1
H. Thermostatically controlled bath water

0 1
I. Access to a shower hose over the bath

0 1
Overall
Comments
78

En suite bathroom facilities (5
N202 points)
A. Toilet and shower in en suite available 0 1
B. There is adequate space within toilet and shower room 0 1

for the woman to labour and birth
C. Drainage is off set under the shower to allow free 0 1

drainage if the woman is sitting on a birth ball
D. Décor has a domestic rather than institutional feel 0 1

E. The woman has access to hand rails to assist 0 1

position change
Overall
Comments
300 Aesthetics
Number Aesthetic Characteristic Score
N300 Light (7
points)
A. Presence of natural light through windows and/or 0 1
skylights
B. Windows low enough to see through when lying in

bed 0 1
C, Window dressings (blinds, curtains are present and 0 1

functional)

D. Ability to control lighting 0 1
E. Multiple lighting options in all areas (eg. Bedside lamp)

0 1
F Absence of fixed ceiling operating theatre lighting
G Ability to create a "cave-like" space

dark and protective
Overall
Comments
79

Colour (5
N301 points)
0 1
A. Contemporary combination of colours are used
B. Colour has a domestic rather than institutional feel 0 1
C. Floor finish is matt 0 1
D. Minimal use of white and/or yellow 0 1

E. Minimal use of highly reflective (gloss/semi gloss) 0 1

paint
Overall
Comments
N302 Texture (5
points)
0 1
A. Presence of textural variety in the birth room
B, Some furnishings are soft/yielding
0 1
C. Some furnishings provide firm support 0 1
D. Use of natural materials

0 1
E. Minimal use of metallic materials on surfaces or the
presence of metal/industrial/trolleys 0 1
Overall
Comments
80

Indoor Environment (6
N303 points)
A. Adjustable temperature to enable woman to be naked in 0 1
comfort
B. Additional heating for mother and baby available 0 1
C. Blanket warming cupboard or system available 0 1
D. Hot pack heating facility available 0 1

E. Windows open for fresh air 0 1
F. Ability to use aromatherapy or oil burner 0 1
Overall
Comments
N304 Femininity (5
points)
0 1
A. Images of mothers and babies and/or views of nature in
artworks within common areas
B. Rounded corners and edges to walls and furniture
0 1
C. Presence of appropriate flowers/ potted plants within 0 1
birthing room
D. Sense of calm and peacefulness within common areas
0 1
E. References made to multiple cultures in artworks
0 1
Overall
Comments
81
400 Support
Number Support Characteristic Score

N400 Food and Drink for the Woman (6
points)
A. Food and drink available 24 hours 0 1
B. Microwave for heating foods available and 0 1

accessible
C. Toaster available or accessible through staff 0 1
D. Hot water available and accessible 0 1

E. Refrigerator with ice available 0 1
F. Refrigerator in the birth room
Overall
Comments
N401 Accommodation for Companions and Birth Attendants (6

points)
A. Companions are made to feel welcome outside of 0 1

birthing room without feeling a sense of intrusiveness
eg able to access toilets, food, water, etc
B. Access to food/drink vending machines nearby
0 1
C. Access to telephones or place to use mobile phone 0 1
D. Access to toilet & shower not in birth room

0 1
E Presence of play room and/or provisions for the
entertainment/distraction of children/siblings 0 1
F. Comfortable place for supporters to rest or lie down
inside and outside the birthing room
0 1
Overall
Comments
82
FINAL SCORES

Number Characteristic Audit Weight Final Ideal
Series Score Score Score
N100 Space arrival 1
N101 Space - outside 1
N102 Space - Reception 1
N103 Space - Birthing Rooms 1
N104 Sense of Domesticity 1
N105 Privacy 1
N106 Noise Control 1
N107 Universal Precautions 1
Series Sub - Total 1
N200 Physical Support 2
N201 Birthing Bath 2
N202 En Suite Facilities 2
N300 Light 1
N301 Colour 1
N302 Texture 1
N303 Indoor Environment 1
N304 Femininy 1
Series Sub - Total
N400 Food and Drink for Women 2
N401 Accommodation for 2
Companions

TOTAL WEIGHTED SCORE
83
Annexure 6: Mother’s feedback form (listening to

mothers)
It is paramount important that facility provide midwifery services as per wish of

mother. That is why, it is critical to receive mother’s opinion on their experience of
midwifery unit and recommendations to improve environment and staff behaviors.
Facility must take regular feedback from mother before she is discharged. Further
facility may take help of research team from community medicine or other relevant
organizations to conduct research.
Mother’s feedback form (listening to mothers)

sr Particulars Response
1 Name of Mother
2 Date of Delivery

3 Do you think birthing room Yes No
environment(physical and behavioural )
can affect how easy or difficult birth is?
4 Why do you think so?

Infrastructure and supporting furniture
Please select importance of individual Very Important Not
components in birthing room during your child Important Importa
birth nt
5 Individual room for child birth
6 Privacy is protected through doors,
curtains, frosted window glasses etc..
7 Not overlooked by others
8 Nice space to walk around
9 Ability to walk around
10 Attached bathroom
11 Bathroom has facility for shower
12 Bathroom has functional geyser
13 Bathroom has bar handle for support
14 Ability to control brightness & color of
light
15 Ability to control temperature
16 Ability to control music

84

17 Room has window that allows natural light in
18 Bed on the side of the room
19 Flexible bed supporting various positions
during child birth
20 Sofa for me and my partner
21 Various equipment for support during
walking and exercise (Gym ball, rope, yoga
mat etc..)
22 Ability to control who comes inside birthing
room
23 Not hearing voices of other women giving
birth
24 My voice not heard by other women giving
birth
25 Quiet and homely atmosphere
26 Clean room as per your perspective
27 Ability to move furniture
28 Nice photos/artwork of mother and baby in
birthing room
29 Working TV in birthing room
Behaviour Components
Please select importance of individual Very Important Not
components in birthing room during your child Important Important
birth
30 Staff comes when called
31 Staff answers questions and doubts
32 Staff’s polite behaviour
33 Advise by staff on exercise, walking,
birthing positions etc..
34 Birth companion allowed to stay inside
the birthing room during delivery
35 Staff greets and smiles
36 Staff advised birth companion on how to
support and care for me
37 Getting diet (juice, raab etc..) & Water as
per need

85
If you want to design a birthing room, what would you include that helps in types of
childbirth your wants

List out factors you think helpful for type of childbirth you want

List out factors you think are unhelpful for types of childbirth you want

List out any other factors important for you apart from mentioned above

86
List of Contributors
Department of Health & Family Welfare, Government of Gujarat
• Shri Manoj Aggarwal, IAS, Additional Chief Secretary (Medical Services & Medical
Education), Health & Family Welfare Department, Gujarat
• Shri Jay Prakash Shivahare, IAS, Commissioner of Health, Medical Services and
Medical Education and Secretary (Public Health & Family Welfare), Gujarat
• Mrs Remya Mohan, IAS, Mission Director, NHM, Gujarat
• Dr H. K. Bhavsar, Additional Director, Medical Services, Gujarat
• Dr R. Dixit, Additional Director, Medical Education, Gujarat
• Dr Nilam Patel, Additional Director, Public Health, Gujarat
• Dr N. P Jani, Additional Director, Family Welfare, Gujarat
• Dr A. M. Kadri, Executive Director, SHSRC, Gujarat
• Dr Trupti Desai, Deputy Director, Nursing, Gujarat
• Dr Rakesh Vaidya, Deputy Director, MCH, Gujarat
• Mr Mayurbhai Damor, Assistant Director, Nursing, Gujarat,
• Dr Ragini Verma, HOD, Dept. of Obstetrics and Gynecology, New Civil Hospital,
Surat
• Dr Ashish Gokhle, HOD, Dept. of Obstetrics and Gynecology, SSG Hospital,
Vadodara
• Dr A U Mehta, HOD, Dept. of Obstetrics and Gynecology, Civil Hospital,
Ahmedabad
• Dr Bipin Nayak, HOD, Dept. of Obstetrics and Gynecology, GMERS Hospital,
Gandhiangar
• Dr Kamal Goswami, HOD, Dept. of Obstetrics and Gynecology, PDU Hospital,
Rajkot
• Pragnaben Dabhi, Registrar, Gujarat Nursing Council
• Dr Sonali Agarwal, Associate Professor, Dept. of Obstetrics and Gynecology, SSG
Hospital, Vadodara
• Dr Mehul Parmar, Associate professor, Dept. of Obstetrics and Gynecology, PDU
Hospital Rajkot
• Dr Lipy Shukla, SIHFW, Vadodara
87
• Dr Kedar Trivedi, Assistant Professor, Dept. of Obstetrics and Gynecology, New

Civil Hospital, Surat
• Mr Harisinh Chaudhary, Principal, Government Nursing College, Ahmedabad
• Mrs Bhartiben Sanadiya, Principal, Government Nursing College, Vadodara
• Dr Indravati Rao, Principal, Government Nursing College, Surat
• Mr A. H. Mandaliya, Principal, Government Nursing College, Bhavnagar
• Mr Pravin Prajapati, Principal, Government Nursing College, Jamnagar
• Mrs J. C. Chudasama, Principal, Government Nursing College, Rajkot
• Mrs Ektaben Das, Staff Nurse, Civil Hospital, Ahmedabad
• Mrs Bhanuben Gheewala, Head Nurse(NPM), SSG Hospital, Vadodara

Partners, Organizations & Agencies
• Mr Prasanta Das, Chief, Field Office, UNICEF, Gujarat
• Dr Narayan Gaonkar, Health Specialist, UNICEF, Gujarat
• Dr Arun K Singh, National Advisor, RBSK, MOHFW, New Delhi
• Dr Dinesh Baswal, Ex Joint Commissioner, Maternal Health, MOHFW, New Delhi
• Dr Evita Fernandez, Fernandez Foundation, Hyderabad
• Ms Inderjeet Kaur, Fernandez Foundation, Hyderabad
• Dr Bharti Sharma, Associate Professor, IIPH Gandhinagar
• Dr Sravan Chenji, Health Officer, UNICEF, Gujarat
• Dr Suraj Kuriya, Capacity Building Consultant, UNICEF, Gujarat
• Dr Hariprakash Hadial, Newoborn Care Cosultant, UNICEF, Gujarat
• Dr Apurva Ratnu, Managing Director, Niramay Charitable Trust, Gandhinagar
• Dr Saurabh Parmar, JHPIEGO, Gujarat
• Mr Jagdish Chhimpa, DCSO, UNICEF, Narmada
• Ms Khyati Chauhan, Intern, IIPH Gandhinagar
Proof Reading support

• Ms Dwija Modi, Mass Communication, Ahmedabad

88
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Expression of oxytocin receptor in human pregnant myometrium. Endocrinology.
(1996) 137:780–5. doi: 10.1210/endo.137.2.8593830
30. Stenglin, M. and M. Foureur, Designing out the Fear Cascade to increase the
likelihood of normal birth. Midwifery, 2013. 29(8): p. 819-825.
31. Foureur, M., Developing the Birth Unit Design Spatial Evaluation Tool (BUDSET) in
Australia: A qualitative study. Health Environments Research Design Journal,
2010. 3(4): p. 43-57.
32. Simavli S, Gumus I, Kaygusuz I, Yildirim M, Usluogullari B, Kafali H: Effect of Music
on Labor Pain Relief, Anxiety Level and Postpartum Analgesic Requirement: A
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MSc, DMid, Deborah L. Davis, RM, BN, MNS, PhD, Ian F. Forbes, BArch, MSc,
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Sollomon Mekonnen3 and Mulat Adefris4
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Polytechnic Institute, 21 Union Street, 3rd Floor, Troy, New York, NY 12180, USA,
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Effects of Red and Blue Lights on Circadian Variations in Cortisol, Alpha Amylase,
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MS‡ *Sport Biological Center, China Institute of Sport Science, Beijing, China;
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Notes :

93

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Operational Guidelines For Midwifery Units in Gujarat

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Operational

Department of Health & Family Welfare

I am happy to see that Gujarat has been pioneer in implementation of midwifery

Current operational guidelines is much needed step, when we are witnessing

Jai Prakash Shivahtr€, r,rs

Government of Gujarat has recognized importance of Midwifery Practices to

Jai Prakash vahare

Phone : +91 79 23253271lFax :91 79 23256430 | Enrail : cohcalth(agujarat.gov.in

Journey of Midwifery Program in Gujarat

Figure 1: Journey of Midwifery Initiative in Gujarat

Emergency Obstetric Care (EmOC) Services”. These resulted in establishment of three

Rationale for the present guidelines

• To provide guidance to program managers on smooth functioning and

Integrating Midwifery into

“Midwifery is a balancing act between art, science and care.”

Strategic Framework for Midwifery Initiative

Figure 2 : Strategic framework of midwifery initiative in Gujarat

Definitions of Midwifery Units

Facility should aim for developing dedicated MLCU in long term

Recommendation of Midwifery Units for Antenatal Care

Recommendations of Midwifery Units in Facilities

Table 1: Recommendation of Midwifery Units in Facilities

Facilities Types of Units Remarks

MLCU or Hybrid Midwifery Units, First priority should be

State envision midwifes to provide continuum of care from ANC to intrapartum

Staffing Pattern of Midwifery Units

Team Composition of Midwifery Unit

Figure 3: Recommended Administrative Structure

Senior Midwifery Officer

NPM / Midwifery Unit

Functional Structure of Midwifery Units

• Pregnant women will be seen by both, obstetrician/medical officer and midwifes in

Flow in Maternity Care having Midwifery Unit

Woman is referred • Respectful Maternity

Role and Responsibilities

Criteria for Admission and Management in

Standards for Midwifery Units

Organizing Midwifery services in Maternity care

Ambulance Drop Off Area

Curtain or Nursing Sample MLCU

Feeling of safety and privacy is the Key

Ambulance Drop Off Area

All women in labour pain must go to triage area first.

Standards for Establishing Midwifery

Figure 8: Recommendation of beds for establishing Midwifery Units

Medical College Hospitals 3 to 4 beds

District Hospitals 2 to 3 beds

Sub District Hospitals 1 to 2 beds

Community Health Centres

Primary Health Centers

Formula to calculate the number of beds: = [(Projected No of normal delivery

• Step 1: Determine the number of vaginal birth events in a year

Components of Midwifery Unit

• Cupboard for staff to store documents

1 Total space requirement for one bedded unit 200 sq ft

2 Total space requirement for two bedded unit 320 sq ft

Space requirement for individual components

3 Main caring area with birthing bed 64 sq ft (8’ X 8’)

4 Area for ambulation and exercise 30 to 50 sq ft per mother

5 Bathroom with shower and wash basin 30 to 40 sq ft

Birthing bed Railing for support T

Chair Gym Ball Working Area

Closet for NBCC