Priniples of obstetrical referral to tertiary care centre

Dr Shumila yasir SR UNIT II OB_GYN Department Fatima Memorial Hospital

What is a Maternal Death?

The death of women while pregnant or within 42 days of termination of pregnancy, irrespective of duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.
World Health Organization

Scope of the problem

529,000 maternal deaths annually 99% in developing countries Stark inequity: A womans lifetime risk of dying a maternal death
1 in 61 in developing countries globally 1 in 2,800 in developed countries

4 Source: Millennium Project Overview Report, 2005

Maternal-child health Indicators

Maternal Mortality Ratio
>> 276 per 100,000 live births

Under 5 Mortality Rate

>>

94 per 1000 live births

Neonatal Mortality Rate

>>

54 per 1000 live births

Infant Mortality Rate

>>

78 per 1000 live births

Causes of maternal death

Indirect 25% Direct 75%

Direct causes of maternal death (75% of total)

Other 14% Infection 11% Obstruction 11% Abortion 19% Hemorrhage 28%

Eclampsia 17%

Indirect causes of maternal death (25% of total)

Malaria Anemia Hepatitis Rheumatic heart disease HIV and AIDS Other
8

Past and current approaches to addressing maternal mortality

Past approaches to addressing maternal mortality

Prediction and prevention Training of Traditional Birth Attendants

10

What are the implied strategies for prediction and prevention? Screen high risk women during ANC Predict those who will have complications and refer to tertiary care centres Prevent the complication

11

Evidence: Screening misses most complications

Type of labor, by obstetric history, Kasongo, Zaire, 1971-75 Type of Labor Bad Obstructed Not Obstructed 15 141 Obstetric History Good 36 3,422 Total 51 3,563

Total
Sensitivity = 15/51 = .29
False Positives = 141/156 = .90

156

3,458

3,614

Relative Risk = (15/156) / (36/3,458) = 9.2

12 Source: Maine, D et al. Options and Issues.

Which complications can be prevented?

Obstructed labor?

Infection?
Hypertensive diseases? Haemorrhage: antepartum, postpartum? Complications of abortion?
13

What is the implied strategy for training TBAs?

TBAs will conduct clean normal delivery

They will refer complications

TBA programs are inexpensive and easy

14

Why havent these past approaches worked to reduce maternal mortality? Once a woman is pregnant, most serious obstetric complications can not be predicted or prevented, but they can be treated.

15

Present approach: Central role of EmOC and skilled attendance at birth

16

Maternal deaths averted through access to services (World Bank, 2003)

17

EmOC program approach

18

The 3 Delays Model

1st Delay Deciding to seek EmOC

2nd Delay Reaching EmOC facility

3rd Delay Receiving care at EmOC facility

EmOC program start-up

19

EmOC Signal Functions

1. parenteral antibiotics Basic EmOC

Comprehensive EmOC

2. parenteral oxytocic drugs

3. parenteral anticonvulsants 4. manual removal of placenta 5. removal of retained products 6. assisted vaginal delivery 7. surgery (e.g. cesarean delivery) 8. blood transfusion
20

BASIC EmOC
A facility that had each of following functions at the time of survey was considered as provider of basic EmOC. i. Availability of Parenteral antibiotics. ii. Availability of Parenteral oxytoxic drugs. iii. Availability of Parenteral anticonvulsants for pregnancy induced convulsions. iv. Performance of manual removal of placenta v. Performance of removal of retained products of placenta (D&C) vi. Performance of assisted vaginal delivery (e.g., ventouse, forceps).
21

COMPREHENSIVE EmOC
A facility that provided the following functions in addition to the function defined under basic EmOC were said to be providing comprehensive EmOC: i. Performs surgery (e.g., Cesarean Section) ii. Performs blood transfusion; it was presumed that blood transfusion was being performed where C-section was conducted
22

EmOC is the foundation for all other efforts

Skilled Attendant Referral Semi-skilled Attendant Community Mobilization Antenatal Care Community Treatment TBAs

Emergency Obstetric Care

23

24

Essential service package to be provided by a 24-hour functional PHC

1. 2. 3. 1.

Essential Services :

24-hour delivery services, both normal and assisted Essential new born care Referral for emergencies Ante- natal care and routine immunization services for children and pregnant women ( besides fixed day services). Post-natal care. Early and safe abortion services (including MVA) Family planning services. Prevention and management of RTIs/STIs. Essential laboratory services.

Desirable Services :

2. 3. 4. 5. 6.
24

25

Selection of the PHC as 24 hour Delivery and New Born Care in RCH-II
A scoring system has been developed, which are being used to prioritize the PHCs. The PHC with maximum scoring is operationalized first. The criteria for scoring include : o Location and Accessibility o Presence of Staff and Staff Quarters o Labour Room o Number of deliveries conducted in one year o Referral services.
25

26

Scoring System
Category/Facility
1 2 A B C D 3 A B C 4 5 6 7 Name and Address Location and Accessibility Road Population Size Other health Facilities Market Place Staff Medical Officer Staff Nurse/ANMs Staff Quarters Labour Room Deliveries Referral Services Total Score

26

Scoring Criteria
A Location and Accessibility 3. If facility connected with an all weather road link 1. If facility connected by a kuccha road 0. If facility not connected by road 3. Population size catered to > 35,000 ( or > 25,000 in hilly/tribal areas) 2. If Population size catered to 25,000 - 35,000 (or 15,000-25,000 in hilly/tribal areas) 1. Population size catered to < 25,000 (or < 15,000 in hilly/tribal areas) 3. If no private/charitable/trust hospital/health facility in a radius of 15 Kms 2. If no private/charitable/trust hospital/health facility in a radius of 10 Kms 1. If no private/charitable/trust hospital/health facility in a radius of 5 Kms 0. If private/charitable/trust hospital/health facility present in a radius of 15 Kms
1. If a market place is present within 2 Kms radius of facility 0. If no market place is present within 2 Kms radius of facility 5. If 2 Medical Officers are posted and working at facility 3. If 1 Medical Officer is posted and working at facility 0. If no Medical Officer is working at facility 5. If > 3 Staff Nurses/ANMs are posted and working at facility 3. If 1-2 Staff Nurses/ANMs are posted and working at facility 0. If no Staff Nurse/ANM is working at facility Staff Quarters 5. Residential quarters for Doctors, Nursing Staff, and other paramedical staff 3. Residential quarters for only Doctors and Nursing Staff 1. Residential quarters for either Doctors OR Nursing Staff 0. No residential quarters
10. If the facility has a functional labour room with Electricity Supply (and power back-up) and 24 hour water supply 8. If the facility has a labour room in use, with either Electricity Supply (and power back up) or 24 hour water supply 5. If the facility has a labour room in use with no/intermittent electric supply and/or no/intermittent water supply 1. If facility has a space earmarked as the labour room, but not in use 0. If facility has no labour room 10. If > 500 deliveries conducted annually 8. If 100-499 deliveries conducted annually 5. If 50-99 deliveries conducted annually 2. If 20-49 deliveries conducted annually 0. If < 20 deliveries conducted annually 3. Established Referral Linkage with sub-centres, villages and FRU (Government or Private) 2. Established Referral Linkage with FRU (Government or Private) only 1. Established Referral Linkage with Sub-centres and/or villages only 0. No Referral Linkage with either the community or sub-centres nor the CHC or FRU (Government or Private)

27

B Presence of Staff and Staff Quarters C

LR

Deliver y

27

Referral Services

28

29

30

31

32