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Sample records for improve emergency obstetric

  1. Emergency obstetric care in Punjab, Pakistan: improvement needed.

    PubMed

    Ali, Moazzam; Ahmed, Khawaja Masuood; Kuroiwa, Chushi

    2008-06-01

    This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services. In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis. No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality. The study may be taken as a baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications.

  2. Obstetric emergencies.

    PubMed

    Crochetière, Chantal

    2003-03-01

    Obstetric hemorrhage is still a significant cause of maternal morbidity and mortality. Prevention, early recognition, and prompt intervention are the keys to minimizing complications. Resuscitation can be inadequate because of under-estimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs. All members of the obstetric team should know how to manage hemorrhage because timing is of the essence. Good communication with the blood bank ensures timely release of appropriate blood products. A well-coordinated team is one of the most important elements in the care of a compromised fetus. If fetal anoxia is presumed, there is less than 10 minutes to permanent fetal brain damage. Antepartum anesthesia consultation should be encouraged in parturients with medical problems.

  3. Using emergency obstetric drills in maternity units as a performance improvement tool.

    PubMed

    Osman, Hibah; Campbell, Oona M R; Nassar, Anwar H

    2009-03-01

    Obstetric drills are being used increasingly to test, improve, and maintain knowledge and skills related to obstetric emergencies as a means to improve proficiency and efficiency of practitioners. The purpose of this study was to assess the feasibility and usefulness of conducting drills to evaluate the response to obstetric emergencies using a holistic approach that tested the hospital system. A prospective trial was conducted at three hospitals (two tertiary referral centers and one small community hospital) in Beirut, Lebanon. Two different emergency obstetric drills at two points in time were conducted between April and May 2006 either in the emergency room or on the labor floor. The drills included medical and paramedical staff, a female actor (simulating a pregnant woman), a research assistant (acting as her companion), and a physician trained in obstetrics (the drill leader). Responses were recorded and critically analyzed. Although overall quality of care was within standards of care, problems were identified related to hospital policies, supplies and equipment, communication, and clinical management. Some technical problems related to administration of the drills were identified. Most drill participants appreciated the exercise and found it beneficial. Obstetric drills provide a useful tool to identify and address deficiencies in the hospital system. This finding could have implications on improving quality of care provided to obstetric patients.

  4. A hospital-centered approach to improve emergency obstetric care in South Sudan.

    PubMed

    Groppi, Lavinia; Somigliana, Edgardo; Pisani, Vincenzo; Ika, Michelina; Mabor, Joseph L; Akec, Henry N; Nhial, John A; Mading, Michel S; Scanagatta, Chiara; Manenti, Fabio; Putoto, Giovanni

    2015-01-01

    To assess provision of emergency obstetric care (EmOC) in Greater Yirol, South Sudan, after implementation of a hospital-centered intervention with an ambulance referral system. In a descriptive study, data were prospectively recorded for all women referred to Yirol County Hospital for delivery in 2012. An ambulance referral system had been implemented in October 2011. Access to the hospital and ambulance use were free of charge. The number of deliveries at Yirol County Hospital increased in 2012 to 1089, corresponding to 13.3% of the 8213 deliveries expected to have occurred in the catchment area. Cesareans were performed for 53 (4.9%) deliveries, corresponding to 0.6% of the expected number of deliveries in the catchment area. Among 950 women who delivered a newborn weighing at least 2500 g at the hospital, 6 (0.6%) intrapartum or very early neonatal deaths occurred. Of 1232 women expected to have major obstetric complications in 2012 in the catchment area, 472 (38.3%) received EmOC at the hospital. Of 115 expected absolute obstetric indications, 114 (99.1%) were treated in the hospital. A hospital-centered approach with an ambulance referral system effectively improves the availability of EmOC in underprivileged remote settings. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  5. Emergency preparedness in obstetrics.

    PubMed

    Haeri, Sina; Marcozzi, David

    2015-04-01

    During and after disasters, focus is directed toward meeting the immediate needs of the general population. As a result, the routine health care and the special needs of some vulnerable populations such as pregnant and postpartum women may be overlooked within a resource-limited setting. In the event of hazards such as natural disasters, manmade disasters, and terrorism, knowledge of emergency preparedness strategies is imperative for the pregnant woman and her family, obstetric providers, and hospitals. Individualized plans for the pregnant woman and her family should include knowledge of shelter in place, birth at home, and evacuation. Obstetric providers need to have a personal disaster plan in place that accounts for work responsibilities in case of an emergency and business continuity strategies to continue to provide care to their communities. Hospitals should have a comprehensive emergency preparedness program utilizing an "all hazards" approach to meet the needs of pregnant and postpartum women and other vulnerable populations during disasters. With lessons learned in recent tragedies such as Hurricane Katrina in mind, we hope this review will stimulate emergency preparedness discussions and actions among obstetric providers and attenuate adverse outcomes related to catastrophes in the future.

  6. Improving the availability of emergency obstetric care in conflict-affected settings.

    PubMed

    Krause, S K; Meyers, J L; Friedlander, E

    2006-01-01

    This paper describes an emergency obstetric care (EmOC) project implemented by the Reproductive Health Response in Conflict (RHRC) Consortium in 12 conflict-affected settings in nine countries from 2000-2005 with funding and technical support from Columbia University's Mailman School of Public Health Averting Maternal Death and Disability (AMDD) programme. The overall goal of the project was to reduce maternal morbidity and mortality in select conflict-affected settings by improving the availability of EmOC. Another aim of the project was to institutionalize EmOC within RHRC Consortium agencies by modelling how to improve the availability of basic and comprehensive EmOC at clinics and hospitals. The specific project purpose was to increase the availability of EmOC in select conflict-affected settings. The project demonstrated that a great deal more can and should be done by humanitarian workers to improve the availability of basic and comprehensive emergency obstetric services in conflict-affected settings.

  7. Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North district, Ghana

    PubMed Central

    Afari, Henrietta; Hirschhorn, Lisa R; Michaelis, Annie; Barker, Pierre; Sodzi-Tettey, Sodzi

    2014-01-01

    Objective To describe healthcare worker (HCW)-identified system-based bottlenecks and the value of local engagement in designing strategies to improve referral processes related to emergency obstetric care in rural Ghana. Design Qualitative study using semistructured interviews of participants to obtain provider narratives. Setting Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included one district hospital, six health centres and four local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays. Participants 18 HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 emergency room nurses, 1 doctor) at different facility levels within the district. Results We identified important gaps in referral processes in Assin North, with the most commonly noted including recognising danger signs, alerting receiving units, accompanying critically ill patients, documenting referral cases and giving and obtaining feedback on referred cases. Main root causes identified by providers were in four domains: (1) transportation, (2) communication, (3) clinical skills and management and (4) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district. Conclusions Providers are an important source of information on local referral delays and in the development of approaches to improvement responsive to these gaps. Better engagement of HCWs can help to identify and evaluate high-impact holistic interventions to address faulty referral systems which result in poor maternal outcomes in resource-poor settings. These perspectives need to be integrated with patient and community perspectives. PMID:24833695

  8. The challenges of improving emergency obstetric care in two rural districts in Mali.

    PubMed

    Otchere, S A; Kayo, A

    2007-11-01

    We describe a collaboration between Save the Children USA, the Averting Maternal Death and Disability (AMDD) program and the Ministry of Health of Mali, to improve the availability, quality and utilization of emergency obstetric care (EmOC) in Yanfolila and Bougouni rural districts in Sikasso Region of Mali. Project planning, interventions and strategies between 2001 and 2004 were aimed at improving the capacity of 2 district hospitals to provide quality EmOC, sensitizing the community as partners to use services and to influence changes in policy at a national level through advocacy efforts. By the end of 2004, despite many health systems' challenges, the 2 hospitals were providing comprehensive EmOC. Providing 24-hour service proved difficult and, though not effectively institutionalized in the 2 hospitals, the UN Process Indicators showed modest improvements in quality and utilization of EmOC. Met need for EmOC increased from 9% in 2001 to 15% in 2004 in Bougouni and from 6% in 2001 to 15% in 2004 in Yanfolila. Case fatality rates declined by 69% (from 7% in 2001 to 2% in 2004) and by 38% (from 8% in 2001 to 5% in 2004) in Bougouni and Yanfolila, respectively. Although useful policy changes were achieved at the national level, more are needed if UN Guidelines are to be met. Availability of more obstetric functions at the community level, and fewer staff transfers are among policy changes needed. Save the Children's project experience showed that it is possible to improve the quality and use of EmOC in hospitals despite challenges; we drew national attention to EmOC as a key strategy in maternal mortality reduction, and raised awareness of the need for improved EmOC services at clinics that are more accessible to the community.

  9. Reducing maternal mortality: better monitoring, indicators and benchmarks needed to improve emergency obstetric care. Research summary for policymakers.

    PubMed

    Collender, Guy; Gabrysch, Sabine; Campbell, Oona M R

    2012-06-01

    Several limitations of emergency obstetric care (EmOC) indicators and benchmarks are analysed in this short paper, which synthesises recent research on this topic. A comparison between Sri Lanka and Zambia is used to highlight the inconsistencies and shortcomings in current methods of monitoring EmOC. Recommendations are made to improve the usefulness and accuracy of EmOC indicators and benchmarks in the future.

  10. Can mHealth improve access to safe blood for transfusion during obstetric emergency?

    PubMed Central

    Rahman, Aminur; Akhter, Sadika; Nisha, Monjura Khatun; Islam, Syed Shariful; Ashraf, Fatema; Rahman, Monjur; Begum, Nazneen; Chowdhury, Mahbub Elahi; Austin, Anne; Anwar, Iqbal

    2017-01-01

    Purpose Of the 99% maternal deaths that take place in developing countries, one-fourth is due to postpartum hemorrhage (PPH). PPH accounts for one-third of all blood transfusions in Bangladesh where the transfusion process is lengthy as most facilities do not have in-house blood bank facilities. In this context, the location where blood is obtained and the processes of obtaining blood products are not standardized, leading to preventable delays in collecting blood, when it is needed. This study evaluated the effectiveness of an online Blood Information Management Application (BIMA) system for reducing lag time in the blood transfusion process. Patients and methods The study was conducted in a public medical college hospital in Dhaka, Bangladesh, and in two proximate, licensed blood banks between January 2014 and March 2015, using a before after design. A total of 310 women (143 before and 177 after), who needed emergency blood transfusion during their perinatal period, as determined by a medical professional, were included in the study. A median linear regression model was employed to assess the adjusted effect of BIMA on transfusion time. Results After the introduction of BIMA, the median duration between the identified need for blood and blood transfusion reduced from 152 to 122 minutes (P<0.05). For PPH specifically, the reduction was from 175 to 113 minutes (P<0.05). After introducing BIMA and after adjusting for criteria such as maternal age, education, parity, duty roster of providers, and reasons for blood transfusion, a 24 minute reduction in the time was observed between the identified need for blood and transfusion (P<0.001). Conclusion BIMA was effective in reducing delays in blood transfusion for emergency obstetric patients. This pilot study suggests that implementing BIMA is one mechanism that has the potential to streamline blood transfusion systems in Bangladesh. PMID:28461767

  11. Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals.

    PubMed

    Guise, Jeanne-Marie; Lowe, Nancy K; Deering, Shad; Lewis, Patricia O; O'Haire, Christen; Irwin, Lori K; Blaser, Molly; Wood, Laurie S; Kanki, Barbara G

    2010-10-01

    Evidence from other high-risk industries has demonstrated that teamwork skills can be taught and effective teamwork may improve safety. Increasingly, health care providers, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve quality and patient safety. A mobile obstetric emergency simulation and team training program was created to bring simulation technology and teamwork training used routinely in other high reliability fields directly to health care institutions. A mobile unit constituted a practical approach, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites. Between 2007 and 2009, in situ simulation of obstetric emergencies and teamwork training was tested with more than 150 health care professionals in labor and delivery units across four rural and two community hospitals in Oregon. HOW DO ORGANIZATIONS DETERMINE WHICH TYPE OF SIMULATION IS BEST FOR THEM? Because simulation technologies are relatively costly to start and maintain, it can be challenging for hospitals and health care professionals to determine which format (send staff to a simulation center, develop in-house simulation program, develop a consortium of hospitals that run a simulation program, or use a mobile simulation program) is best for them. In situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting.

  12. [Shoulder dystocia: an obstetrical emergency].

    PubMed

    Marques, Joana Borges; Reynolds, Ana

    2011-01-01

    Shoulder dystocia is one of the most feared obstetric emergencies due to related maternal and neonatal complications and therefore, the growing of medico-legal litigation that it entails. Although associated with risk factors such as fetal macrossomia, gestacional diabetes and instrumented delivery, the majority of cases are unpredictable. The lack of a consensus on shoulder dystocia diagnosis causes variations on its incidence and hampers a more comprehensive analysis. Management guidelines described for its resolution include several manoeuvres but the ideal sequence of procedures is not clearly defined in more severe cases. Hands-on and team training, through simulation-based techniques applied to medicine, seems to be a promising method to learn how to deal with shoulder dystocia having in mind a reduction in related maternal or neonatal morbidity and mortality. The main goal of this paper is to provide a comprehensive revision of shoulder dystocia highlighting its relevance as an obstetric emergency. A reflection on the management is presented emphasising the importance of simulation-based training.

  13. Improvement and retention of emergency obstetrics and neonatal care knowledge and skills in a hospital mentorship program in Lilongwe, Malawi.

    PubMed

    Tang, Jennifer H; Kaliti, Charlotte; Bengtson, Angela; Hayat, Sumera; Chimala, Eveles; MacLeod, Rachel; Kaliti, Stephen; Sisya, Fanny; Mwale, Mwawi; Wilkinson, Jeffrey

    2016-02-01

    To evaluate whether a hospital-based mentoring program could significantly increase short- and longer-term emergency obstetrics and neonatal care (EmONC) knowledge and skills among health providers. In a prospective before-and-after study, 20 mentors were trained using a specially-created EmONC mentoring and training program at Bwaila Hospital in Lilongwe, Malawi. The mentors then trained an additional 114 providers as mentees in the curriculum. Mentors and mentees were asked to complete a test before initiation of the training (Pre-Test), immediately after training (Post-Test 1), and at least 6 months after training (Post-Test 2) to assess written and practical EmONC knowledge and skills. Mean scores were then compared. Scores increased significantly between the Pre-Test and Post-Test 1 for both written (n=134; difference 22.9%, P<0.001) and practical (n=125; difference 29.5%, P<0.001) tests. Scores were still significantly higher in Post-Test 2 than in the Pre-Test for written (n=111; difference 21.0%, P<0.001) and practical (n=103; difference 29.3%, P<0.001) tests. A hospital-based mentoring program can result in both short- and longer-term improvement in EmONC knowledge and skills. Further research is required to assess whether this leads to behavioral changes that improve maternal and neonatal outcomes. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  14. [Simulation' benefits in obstetrical emergency: Which proof level?

    PubMed

    Raynal, P

    2016-10-01

    Simulation in obstetrical emergency is in expansion. The important economic and human cost in simulation needs a real evaluation about enhancement in technical and non-technical skills, maternal and neonatal morbidity and mortality. We present a literature review of the results published on the subject in shoulder dystocia, post-partum haemorrhage, eclampsia and cord prolaps with a selection of publications with high evidence level or positive impact of training on obstetrical emergencies. There are few publications with a positive impact of training on obstetrical emergencies. Some publications from 10years by the same obstetrical team for training and shoulder dystocia reveal a 75% reduction in brachial plexus injury after 4years of training, and 100% reduction in permanent injury after a decade of training. Only one publication is in accordance with a reduction of severe post-partum haemorrhage with training. For all obstetrical emergencies, crew resource management (communication, self-confidence…) and team training are improved.

  15. Improvement and retention of emergency obstetrics and neonatal care knowledge and skills in a hospital mentorship program in Lilongwe, Malawi☆

    PubMed Central

    Tang, Jennifer H.; Kaliti, Charlotte; Bengtson, Angela; Hayat, Sumera; Chimala, Eveles; MacLeod, Rachel; Kaliti, Stephen; Sisya, Fanny; Mwale, Mwawi; Wilkinson, Jeffrey

    2015-01-01

    Objective To evaluate whether a hospital-based mentoring program could significantly increase short- and longer-term emergency obstetrics and neonatal care (EmONC) knowledge and skills among health providers. Methods In a prospective before-and-after study, 20 mentors were trained using a specially-created EmONC mentoring and training program at Bwaila Hospital in Lilongwe, Malawi. The mentors then trained an additional 114 providers as mentees in the curriculum. Mentors and mentees were asked to complete a test before initiation of the training (Pre-Test), immediately after training (Post-Test 1), and at least 6 months after training (Post-Test 2) to assess written and practical EmONC knowledge and skills. Mean scores were then compared. Results Scores increased significantly between the Pre-Test and Post-Test 1 for both written (n=134; difference 22.9%, P<0.001) and practical (n=125; difference 29.5%, P<0.001) tests. Scores were still significantly higher in Post-Test 2 than in the Pre-Test for written (n=111; difference 21.0%, P<0.001) and practical (n=103; difference 29.3%, P<0.001) tests. Conclusion A hospital-based mentoring program can result in both short- and longer-term improvement in EmONC knowledge and skills. Further research is required to assess whether this leads to behavioral changes that improve maternal and neonatal outcomes. PMID:26658095

  16. Hepatitis C in haemorrhagic obstetrical emergencies.

    PubMed

    Khaskheli, Meharunnisa; Baloch, Shahla; Farooq, Sumiya

    2014-03-01

    To determine the maternal health and fetal outcome in hepatitis C with obstetrical haemorrhagic emergencies. An observational study. Department of Obstetrics and Gynaecology Unit-I, Liaquat University of Medical and Health Sciences Hospital, Hyderabad, Sindh, from January 2009 to December 2010. All the women admitted during the study period with different obstetrical haemorrhagic emergencies were included. On virology screening, hepatitis C screening was done on all. The women with non-haemorrhagic obstetrical emergencies were excluded. Studied variables included demographic characteristics, the nature of obstetrical emergency, haemorrhagic conditions and maternal and fetal morbidity and mortality. The data was analyzed on SPSS version 20. More frequent obstetrical haemorrhagic emergencies were observed with hepatitis C positive in comparison with hepatitis C negative cases including post-partum haemorrhage in 292 (80.88%) and ante-partum haemorrhage in 69 (19.11%) cases. Associated morbidities seen were disseminated intravascular coagulation in 43 (11.91%) and shock in 29 (8.03%) cases with hepatitis C positive. Fetal still birth rate was 37 (10.24%) in hepatitis C positive cases. Frequency of maternal morbidity and mortality and perinatal mortality was high in obstetrical haemorrhagic emergencies with hepatitis C positive cases.

  17. Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study

    PubMed Central

    Varghese, Beena; Krishnamurthy, Jayanna; Correia, Blaze; Panigrahi, Ruchika; Washington, Maryann; Ponnuswamy, Vinotha; Mony, Prem

    2016-01-01

    ABSTRACT Objective: The majority of the maternal and perinatal deaths are preventable through improved emergency obstetric and newborn care at facilities. However, the quality of such care in India has significant gaps in terms of provider skills and in their preparedness to handle emergencies. We tested the feasibility, acceptability, and effectiveness of a “skills and drills” intervention, implemented between July 2013 and September 2014, to improve emergency obstetric and newborn care in the state of Karnataka, India. Methods: Emergency drills through role play, conducted every 2 months, combined with supportive supervision and a 2-day skills refresher session were delivered across 4 sub-district, secondary-level government facilities by an external team of obstetric and pediatric specialists and nurses. We evaluated the intervention through a quasi-experimental design with 4 intervention and 4 comparison facilities, using delivery case sheet reviews, pre- and post-knowledge tests among providers, objective structured clinical examinations (OSCEs), and qualitative in-depth interviews. Primary outcomes consisted of improved diagnosis and management of selected maternal and newborn complications (postpartum hemorrhage, pregnancy-induced hypertension, and birth asphyxia). Secondary outcomes included knowledge and skill levels of providers and acceptability and feasibility of the intervention. Results: Knowledge scores among providers improved significantly in the intervention facilities; in obstetrics, average scores between the pre- and post-test increased from 49% to 57% (P=.006) and in newborn care, scores increased from 48% to 56% (P=.03). Knowledge scores in the comparison facilities were similar but did not improve significantly over time. Skill levels were significantly higher among providers in intervention facilities than comparison facilities (mean objective structured clinical examination scores for obstetric skills: 55% vs. 46%, respectively; for

  18. Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study.

    PubMed

    Varghese, Beena; Krishnamurthy, Jayanna; Correia, Blaze; Panigrahi, Ruchika; Washington, Maryann; Ponnuswamy, Vinotha; Mony, Prem

    2016-12-23

    The majority of the maternal and perinatal deaths are preventable through improved emergency obstetric and newborn care at facilities. However, the quality of such care in India has significant gaps in terms of provider skills and in their preparedness to handle emergencies. We tested the feasibility, acceptability, and effectiveness of a "skills and drills" intervention, implemented between July 2013 and September 2014, to improve emergency obstetric and newborn care in the state of Karnataka, India. Emergency drills through role play, conducted every 2 months, combined with supportive supervision and a 2-day skills refresher session were delivered across 4 sub-district, secondary-level government facilities by an external team of obstetric and pediatric specialists and nurses. We evaluated the intervention through a quasi-experimental design with 4 intervention and 4 comparison facilities, using delivery case sheet reviews, pre- and post-knowledge tests among providers, objective structured clinical examinations (OSCEs), and qualitative in-depth interviews. Primary outcomes consisted of improved diagnosis and management of selected maternal and newborn complications (postpartum hemorrhage, pregnancy-induced hypertension, and birth asphyxia). Secondary outcomes included knowledge and skill levels of providers and acceptability and feasibility of the intervention. Knowledge scores among providers improved significantly in the intervention facilities; in obstetrics, average scores between the pre- and post-test increased from 49% to 57% (P=.006) and in newborn care, scores increased from 48% to 56% (P=.03). Knowledge scores in the comparison facilities were similar but did not improve significantly over time. Skill levels were significantly higher among providers in intervention facilities than comparison facilities (mean objective structured clinical examination scores for obstetric skills: 55% vs. 46%, respectively; for newborn skills: 58% vs. 48%, respectively; P

  19. Effects of improved access to transportation on emergency obstetric care outcomes in Uganda.

    PubMed

    Mucunguzi, Stephen; Wamani, Henry; Lochoro, Peter; Tylleskar, Thorkild

    2014-09-01

    Reduction in maternal mortality has not been appreciable in most low-income countries. Improved access to transport for mothers is one way to improve maternal health. This study evaluated a free-of-charge 24-hour ambulance and communication services intervention in Oyam district using 'Caesarean section rate' (CSR) and compared with the neighbouring non-intervention district. Ecological data were collected retrospectively from maternity/theatre registers in October 2010 for 3 years pre and 3 years intervention period. The average CSR in the intervention district increased from 0.57% before the intervention to 1.21% (p = 0.022) during the intervention, while there was no change in the neighbouring district (0.51% to 0.58%, p = 0.512). Hospital deliveries increased by over 50% per year with a slight reduction in the average hospital stillbirths per 1000 hospital births in the intervention district (46.6 to 37.5, p = 0.253). Reliable communication and transport services increased access to and utilization of maternal health services, particularly caesarean delivery services.

  20. Obstetric Emergencies: Shoulder Dystocia and Postpartum Hemorrhage.

    PubMed

    Dahlke, Joshua D; Bhalwal, Asha; Chauhan, Suneet P

    2017-06-01

    Shoulder dystocia and postpartum hemorrhage represent two of the most common emergencies faced in obstetric clinical practice, both requiring prompt recognition and management to avoid significant morbidity or mortality. Shoulder dystocia is an uncommon, unpredictable, and unpreventable obstetric emergency and can be managed with appropriate intervention. Postpartum hemorrhage occurs more commonly and carries significant risk of maternal morbidity. Institutional protocols and algorithms for the prevention and management of shoulder dystocia and postpartum hemorrhage have become mainstays for clinicians. The goal of this review is to summarize the diagnosis, incidence, risk factors, and management of shoulder dystocia and postpartum hemorrhage. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance.

    PubMed

    Lipman, S S; Carvalho, B; Cohen, S E; Druzin, M L; Daniels, K

    2013-04-01

    We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean. Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision. The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s). In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.

  2. QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali

    PubMed Central

    Dumont, Alexandre; Fournier, Pierre; Fraser, William; Haddad, Slim; Traore, Mamadou; Diop, Idrissa; Gueye, Mouhamadou; Gaye, Alioune; Couturier, François; Pasquier, Jean-Charles; Beaudoin, François; Lalonde, André; Hatem, Marie; Abrahamowicz, Michal

    2009-01-01

    Background Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel. Methods/Design This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews. The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along

  3. Developing protocols for obstetric emergencies.

    PubMed

    Roth, Cheryl K; Parfitt, Sheryl E; Hering, Sandra L; Dent, Sarah A

    2014-01-01

    There is potential for important steps to be missed in emergency situations, even in the presence of many health care team members. Developing a clear plan of response for common emergencies can ensure that no tasks are redundant or omitted, and can create a more controlled environment that promotes positive health outcomes. A multidisciplinary team was assembled in a large community hospital to create protocols that would help ensure optimum care and continuity of practice in cases of postpartum hemorrhage, shoulder dystocia, emergency cesarean surgical birth, eclamptic seizure and maternal code. Assignment of team roles and responsibilities led to the evolution of standardized protocols for each emergency situation.

  4. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES): Promoting Patient Safety in Obstetrics with Teamwork-Focused Interprofessional Simulations

    ERIC Educational Resources Information Center

    Freeth, Della; Ayida, Gubby; Berridge, Emma Jane; Mackintosh, Nicola; Norris, Beverley; Sadler, Chris; Strachan, Alasdair

    2009-01-01

    Introduction: We describe an example of simulation-based interprofessional continuing education, the multidisciplinary obstetric simulated emergency scenarios (MOSES) course, which was designed to enhance nontechnical skills among obstetric teams and, hence, improve patient safety. Participants' perceptions of MOSES courses, their learning, and…

  5. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES): Promoting Patient Safety in Obstetrics with Teamwork-Focused Interprofessional Simulations

    ERIC Educational Resources Information Center

    Freeth, Della; Ayida, Gubby; Berridge, Emma Jane; Mackintosh, Nicola; Norris, Beverley; Sadler, Chris; Strachan, Alasdair

    2009-01-01

    Introduction: We describe an example of simulation-based interprofessional continuing education, the multidisciplinary obstetric simulated emergency scenarios (MOSES) course, which was designed to enhance nontechnical skills among obstetric teams and, hence, improve patient safety. Participants' perceptions of MOSES courses, their learning, and…

  6. Strengthening emergency obstetric care in Ayacucho, Peru.

    PubMed

    Kayongo, M; Esquiche, E; Luna, M R; Frias, G; Vega-Centeno, L; Bailey, P

    2006-03-01

    With support from the Averting Maternal Death and Disability (AMDD) Program, CARE began the FEMME Project in 2000 to increase access and utilization of emergency obstetric care (EmOC) services for the approximately 48,000 pregnant women in the northern provinces of Ayacucho. The project targeted 5 facilities with a comprehensive package of interventions designed to improve capacity to provide quality EmOC services and to promote a human rights approach in health care. Key program activities included improvements in infrastructure, human resources capacity development, development of service standards and protocols, quality improvement activities, and promoting a rights-based approach to health. By the end of the project, northern Ayacucho had 6 functioning EmOC facilities: 3 comprehensive (including a non-FEMME project facility) and 3 basic. This exceeds the UN minimum recommendation of 5 EmOC facilities per 500,000 population. Other changes in the UN process indicators indicate an increase in quality and utilization of EmOC services. Met need for EmOC increased significantly from 30% in 2000 to a high of 84% in 2004. Case fatality rates declined and the number of maternal deaths in the entire region declined. CARE's work in Ayacucho made an impact on policies and programs related to EmOC throughout the region. Within CARE, project experiences have supported maternal health programs particularly in the Latin American/Caribbean region.

  7. Emergency obstetric care in Pakistan: potential for reduced maternal mortality through improved basic EmOC facilities, services, and access.

    PubMed

    Ali, M; Hotta, M; Kuroiwa, C; Ushijima, H

    2005-10-01

    To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces. Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts (n=19); were randomly selected; all public health facilities providing EmOC services (n=170) were included. The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab. Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality.

  8. An obstetric emergency called peripartum cardiomyopathy!

    PubMed

    Shaikh, Nissar

    2010-01-01

    Peripartum cardiomyopathy (PPCM) is a rare obstetric emergency affecting women in late pregnancy or up to five months of postpartum period. The etiology of PPCM is still not known. It has potentially devastating effects on mother and fetus if not treated early. The signs, symptoms and treatment of PPCM are similar to that of heart failure. Early diagnosis and proper management is the corner stone for better outcome of these patients. The only way to prevent PPCM is to avoid further pregnancies.

  9. Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system.

    PubMed

    Deering, Shad; Rosen, Michael A; Salas, Eduardo; King, Heidi B

    2009-01-01

    The infrequent and high-stakes nature of obstetric emergencies requires staff members to respond quickly and proficiently to a complex and high-stress situation, a situation they have likely had little opportunity to experience. This situation requires a systematic approach to preparing personnel to manage these situations. Therefore, this article seeks to contribute to the growing literature on training programs for obstetric emergencies by documenting the development and implementation of the Mobile Obstetric Emergencies Simulator (MOES) system. MOES is a comprehensive package of simulation technology, standardized curriculum, and instructional features that combines traditional classroom learning activities and simulation-based training on the actual labor and delivery (L&D) ward. Specifically, the MOES system leverages the TeamSTEPPS teamwork training being implemented throughout the US military healthcare system with opportunities to practice teamwork and technical skills using mannequin-based patient simulation embedded within L&D units. The primary goals of this article are twofold. First, this article explicitly identifies the unique training needs for preparing staff for obstetric emergencies through a comprehensive review and synthesis of the literature. Second, this article documents the approach taken in MOES to meet these needs.

  10. The impact of emergency obstetric care training in Somaliland, Somalia.

    PubMed

    Ameh, Charles; Adegoke, Adetoro; Hofman, Jan; Ismail, Fouzia M; Ahmed, Fatuma M; van den Broek, Nynke

    2012-06-01

    To provide and evaluate in-service training in "Life Saving Skills - Emergency Obstetric and Newborn Care" in order to improve the availability of emergency obstetric care (EmOC) in Somaliland. In total, 222 healthcare providers (HCPs) were trained between January 2007 and December 2009. A before-after study was conducted using quantitative and qualitative methods to evaluate trainee reaction and change in knowledge, skills, and behavior, in addition to functionality of healthcare facilities, during and immediately after training, and at 3 and 6 months post-training. The HCPs reacted positively to the training, with a significant improvement in 50% of knowledge and 100% of skills modules assessed. The HCPs reported improved confidence in providing EmOC. Basic and comprehensive EmOC healthcare facilities provided 100% of expected signal functions-compared with 43% and 56%, respectively, at baseline-with trained midwives performing skills usually performed by medical doctors. Lack of drugs, supplies, medical equipment, and supportive policy were identified as barriers that could contribute to nonuse of new skills and knowledge acquired. The training impacted positively on the availability and quality of EmOC and resulted in "up-skilling" of midwives. Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  11. Uterine Artery Embolization: Exploring New Dimensions in Obstetric Emergencies

    PubMed Central

    Singhal, Seema; Singh, Abha; Raghunandan, Chitra; Gupta, Usha; Dutt, Seema

    2014-01-01

    The role of transcatheter arterial embolization in the management of obstetric emergencies is relatively new and not so commonly used. In the following series, the efficacy of this technique in situations such as scar site ectopic pregnancy, antepartum and postpartum obstetric hemorrhage, especially in the presence of coagulation derangement is presented. PMID:24936273

  12. Identifying obstetrical emergencies at Kintampo Municipal Hospital: a perspective from pregnant women and nursing midwives.

    PubMed

    Oiyemhonlan, Brenda; Udofia, Emilia; Punguyire, Damien

    2013-06-01

    A hospital based cross-sectional qualitative study was conducted at Kintampo Municipal Hospital in Northern Ghana, to identify obstetric emergencies and barriers to emergency care seeking; examine the perspective of midwives regarding their role in maternity care and management of obstetric emergencies, and explore women's knowledge and response to obstetric emergencies. Study subjects comprised of 2 emergency obstetric cases, 29 antenatal focus group discussants and 5 midwives at the maternity unit. Data was collected from 23rd March to 9th April, 2012 using in-depth interviews, focus group discussions and record reviews. The most common obstetric emergencies were hemorrhage, eclampsia and anemia. Potential obstetric complications were poorly understood by antenatal women and known barriers limited access to emergency obstetric care. Service challenges included insufficient staffing and well as inadequate equipment and physical space in the maternity ward. Local community efforts can address communication and service access gaps. Government intervention is required to address service provision gaps for improved maternity care in Kintampo.

  13. Obstetric training in Emergency Medicine: a needs assessment.

    PubMed

    Janicki, Adam James; MacKuen, Courteney; Hauspurg, Alisse; Cohn, Jamieson

    2016-01-01

    Identification and management of obstetric emergencies is essential in emergency medicine (EM), but exposure to pregnant patients during EM residency training is frequently limited. To date, there is little data describing effective ways to teach residents this material. Current guidelines require completion of 2 weeks of obstetrics or 10 vaginal deliveries, but it is unclear whether this instills competency. We created a 15-item survey evaluating resident confidence and knowledge related to obstetric emergencies. To assess confidence, we asked residents about their exposure and comfort level regarding obstetric emergencies and eight common presentations and procedures. We assessed knowledge via multiple-choice questions addressing common obstetric presentations, pelvic ultrasound image, and cardiotocography interpretation. The survey was distributed to residency programs utilizing the Council of Emergency Medicine Residency Directors (CORD) listserv. The survey was completed by 212 residents, representing 55 of 204 (27%) programs belonging to CORD and 11.2% of 1,896 eligible residents. Fifty-six percent felt they had adequate exposure to obstetric emergencies. The overall comfort level was 2.99 (1-5 scale) and comfort levels of specific presentations and procedures ranged from 2.58 to 3.97; all increased moderately with postgraduate year (PGY) level. Mean overall percentage of items answered correctly on the multiple-choice questions was 58% with no statistical difference by PGY level. Performance on individual questions did not differ by PGY level. The identification and management of obstetric emergencies is the cornerstone of EM. We found preliminary evidence of a concerning lack of resident comfort regarding obstetric conditions and knowledge deficits on core obstetrics topics. EM residents may benefit from educational interventions to increase exposure to these topics.

  14. Improved accessibility of emergency obstetrics and newborn care(EmONC) services for maternal and newborn health: a community based project

    PubMed Central

    2013-01-01

    Background Every year an estimated three million neonates die globally and two hundred thousand of these deaths occur in Pakistan. Majority of these neonates die in rural areas of underdeveloped countries from preventable causes (infections, complications related to low birth weight and prematurity). Similarly about three hundred thousand mother died in 2010 and Pakistan is among ten countries where sixty percent burden of these deaths is concentrated. Maternal and neonatal mortality remain to be unacceptably high in Pakistan especially in rural areas where more than half of births occur. Method/Design This community based cluster randomized controlled trial will evaluate the impact of an Emergency Obstetric and Newborn Care (EmONC) package in the intervention arm compared to standard of care in control arm. Perinatal and neonatal mortality are primary outcome measure for this trial. The trial will be implemented in 20 clusters (Union councils) of District Rahimyar Khan, Pakistan. The EmONC package consists of provision of maternal and neonatal health pack (clean delivery kit, emollient, chlorhexidine) for safe motherhood and newborn wellbeing and training of community level and facility based health care providers with emphasis on referral of complicated cases to nearest public health facilities and community mobilization. Discussion Even though there is substantial evidence in support of effectiveness of various health interventions for improving maternal, neonatal and child health. Reduction in perinatal and neonatal mortality remains a big challenge in resource constrained and diverse countries like Pakistan and achieving MDG 4 and 5 appears to be a distant reality. A comprehensive package of community based low cost interventions along the continuum of care tailored according to the socio cultural environment coupled with existing health force capacity building may result in improving the maternal and neonatal outcomes. The findings of this proposed community

  15. [The emergence of obstetrical mechanism: From Lucy to Homo sapiens].

    PubMed

    Frémondière, P; Thollon, L; Marchal, F

    2017-03-01

    The evolutionary history of modern birth mechanism is now a renewed interest in obstetrical papers. The purpose of this work is to review the literature in paleo-obstetrical field. Our analysis focuses on paleo-obstetrical hypothesis, from 1960 to the present day, based on the reconstruction of fossil pelvis. Indeed, these pelvic reconstructions usually provide an opportunity to make an obstetrical assumption in our ancestors. In this analysis, we show that modern birth mechanism takes place during the emergence of our genus 2 million years ago. References are made to human specificities related to obstetrical mechanism: exclusive bipedalism, increase of brain size at birth, metabolic cost of the pregnancy and deep trophoblastic implantation. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  16. The state of routine and emergency obstetric and neonatal care in Southern Province, Zambia.

    PubMed

    Owens, Lauren; Semrau, Katherine; Mbewe, Reuben; Musokotwane, Kebby; Grogan, Caroline; Maine, Deborah; Hamer, Davidson H

    2015-01-01

    To evaluate the capacity of health facilities in Southern Province, Zambia, to perform routine obstetric care and emergency obstetric and neonatal care (EmONC). Surveys were completed at 90 health centers and 10 hospitals between September 1, 2011, and February 28, 2012. An expanded set of signal functions for routine care and EmONC was used to assess the facilities' capacity to provide obstetric and neonatal care. Interviews were completed with 172 health workers. Comprehensive EmONC was available in only six of 10 hospitals; the remaining four hospitals did not perform all basic EmONC signal functions. None of the 90 health centers performed the basic set of EmONC signal functions. Performance of routine obstetric care functions, health worker EmONC training, and facility infrastructure and staffing varied. Assessment of the indicators for routine care revealed that several low-cost interventions are currently underused in Southern Province. There is substantial room for improvement in emergency and routine obstetric and neonatal care at the surveyed facilities. Efforts should focus on improving infrastructure and supplies, EmONC training, and adherence to the UN guidelines for routine and emergency obstetric care. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  17. Emergency obstetric care: Making the impossible possible through task shifting.

    PubMed

    Schneeberger, Caroline; Mathai, Matthews

    2015-10-01

    Task shifting-moving tasks to healthcare workers with a shorter training-for emergency obstetric care (EmOC) can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without significant increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC and the role of this approach in improving maternal and newborn health in the short and long term.

  18. Improved obstetric safety through programmatic collaboration.

    PubMed

    Goffman, Dena; Brodman, Michael; Friedman, Arnold J; Minkoff, Howard; Merkatz, Irwin R

    2014-01-01

    Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

  19. Emergency obstetric surgery by non-physician clinicians in Tanzania.

    PubMed

    Pereira, Caetano; Mbaruku, Godfrey; Nzabuhakwa, Calist; Bergström, Staffan; McCord, Colin

    2011-08-01

    To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC. All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined. Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma. AMOs carried most of the burden of life-saving EmOC-particularly cesarean deliveries-in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  20. Global patterns in availability of emergency obstetric care.

    PubMed

    Paxton, A; Bailey, P; Lobis, S; Fry, D

    2006-06-01

    This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.

  1. Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial.

    PubMed

    Bajaj, Komal; Rivera-Chiauzzi, Enid Y; Lee, Colleen; Shepard, Cynthia; Bernstein, Peter S; Moore-Murray, Tanya; Smith, Heather; Nathan, Lisa; Walker, Katie; Chazotte, Cynthia; Goffman, Dena

    2016-10-01

    Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.

  2. Community involvement in obstetric emergency management in rural areas: a case of Rukungiri district, Western Uganda

    PubMed Central

    2012-01-01

    Background Maternal mortality is a major public health problem worldwide especially in low income countries. Most causes of maternal deaths are due to direct obstetric complications. Maternal mortality ratio remains high in Rukungiri district, western Uganda estimated at 475 per 100,000 live births. The objectives were to identify types of community involvement and examine factors influencing the level of community involvement in the management of obstetric emergencies. Methods We conducted a descriptive study during 2nd to 28th February 2009 in rural Rukungiri district, western Uganda. A total of 448 heads of households, randomly selected from 6/11 (54.5%) of sub-counties, 21/42 (50.0%) parishes and 32/212 (15.1%) villages (clusters), were interviewed. Data were analysed using STATA version 10.0. Results Community pre-emergency support interventions available included community awareness creation (sensitization) while interventions undertaken when emergency had occurred included transportation and referring women to health facility. Community support programmes towards health care (obstetric emergencies) included establishment of community savings and credit schemes, and insurance schemes. The factors associated with community involvement in obstetric emergency management were community members being employed (AOR = 1.91, 95% CI: 1.02 - 3.54) and rating the quality of maternal health care as good (AOR = 2.22, 95% CI: 1.19 - 4.14). Conclusions Types of community involvement in obstetric emergency management include practices and support programmes. Community involvement in obstetric emergency management is influenced by employment status and perceived quality of health care services. Policies to promote community networks and resource mobilization strategies for health care should be implemented. There is need for promotion of community support initiatives including health insurance schemes and self help associations; further community sensitization by empowered

  3. Ambulance referral for emergency obstetric care in remote settings.

    PubMed

    Tsegaye, Ademe; Somigliana, Edgardo; Alemayehu, Tadesse; Calia, Federico; Maroli, Massimo; Barban, Paola; Manenti, Fabio; Putoto, Giovanni; Accorsi, Sandro

    2016-06-01

    To evaluate the functionality of an ambulance service dedicated to emergency obstetric care (EmOC) that referred pregnant women to health centers for delivery assistance or to a hospital for the management of obstetric complications. A retrospective study investigated an ambulance referral system for EmOC in a rural area of Ethiopia between July 1 and December 31, 2013. The service was available 24h a day and was free of charge. Women requesting referral were transported to nearby health centers. Assistance was provided locally for uncomplicated deliveries. Women with obstetric complications were referred from health centers to a hospital. A total of 528 ambulance referrals were recorded. The majority of patients (314 [59.5%]) were transported from villages to health centers. The remaining individuals were brought to a hospital, having been referred from health centers (179 [33.9%]) or were referred directly from villages owing to hospital proximity (35 [6.6%]). Of the 179 patients referred to the hospital from health centers, 84 (46.9%) were diagnosed with major direct obstetric complications. No maternal deaths were recorded among patients using the ambulance service. The cost of the ambulance service was US$ 18.47 per referred patient. An ambulance service dedicated to EmOC that interconnected health centers and a hospital facilitated referrals and better utilized local resources. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  4. The unmet need for Emergency Obstetric Care in Tanga Region, Tanzania

    PubMed Central

    Prytherch, Helen; Massawe, Siriel; Kuelker, Rainer; Hunger, Claudia; Mtatifikolo, Ferdinand; Jahn, Albrecht

    2007-01-01

    Background Improving maternal health by reducing maternal mortality constitutes the fifth Millennium Development Goal and represents a key public health challenge in the United Republic of Tanzania. In response to the need to evaluate and monitor safe motherhood interventions, this study aims at assessing the coverage of obstetric care according to the Unmet Obstetric Need (UON) concept by obtaining information on indications for, and outcomes of, major obstetric interventions. Furthermore, we explore whether this concept can be operationalised at district level. Methods A two year study using the Unmet Obstetric Need concept was carried out in three districts in Tanga Region, Tanzania. Data was collected prospectively at all four hospitals in the region for every woman undergoing a major obstetric intervention, including indication and outcome. The concept was adapted to address differentials in access to emergency obstetric care between districts and between rural and urban areas. Based upon literature and expert consensus, a threshold of 2% of all deliveries was used to define the expected minimum requirement of major obstetric interventions performed for absolute maternal indications. Results Protocols covering 1,260 complicated deliveries were analysed. The percentage of major obstetric interventions carried out in response to an absolute maternal indication was only 71%; most major obstetric interventions (97%) were caesarean sections. The most frequent indication was cephalo-pelvic-disproportion (51%). The proportion of major obstetric interventions for absolute maternal indications performed amongst women living in urban areas was 1.8% of all deliveries, while in rural areas it was only 0.7%. The high proportion (8.3%) of negative maternal outcomes in terms of morbidity and mortality, as well as the high perinatal mortality of 9.1% (still birth 6.9%, dying within 24 hours 1.7%, dying after 24 hours 0.5%) raise concern about the quality of care being

  5. Design of a Serious Game for Handling Obstetrical Emergencies

    PubMed Central

    Bot-Robin, Virginie; Libessart, Aurélien; Doucède, Guillaume; Cosson, Michel; Rubod, Chrystèle

    2016-01-01

    Background The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game. Objective Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations. Methods A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative. Results Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested. Conclusions Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development. PMID

  6. Design of a Serious Game for Handling Obstetrical Emergencies.

    PubMed

    Jean Dit Gautier, Estelle; Bot-Robin, Virginie; Libessart, Aurélien; Doucède, Guillaume; Cosson, Michel; Rubod, Chrystèle

    2016-12-21

    The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game. Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations. A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative. Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested. Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development.

  7. Emergency obstetric care: how do we stand in Malawi?

    PubMed

    Leigh, Bailah; Mwale, Theresa Gloria; Lazaro, Dorothy; Lunguzi, Juliana

    2008-04-01

    To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.

  8. Challenges to the provision of emergency obstetric care in Iraq.

    PubMed

    Ameh, Charles A; Bishop, Sophie; Kongnyuy, Eugene; Grady, Kate; Van den Broek, Nynke

    2011-01-01

    To assess the availability of, and challenges to the provision of emergency obstetric care in order to raise awareness and assist policy-makers and development partners in making appropriate decisions to help pregnant women in Iraq. Descriptive and exploratory study based on self-administered questionnaires, an in-depth interview and a Focus Group Discussion. The setting was 19 major hospitals in 8 out of the 18 Governorates and the participants were 31 Iraqi doctors and 1 midwife. The outcome measures were availability of emergency obstetric care (EOC) in hospitals and challenges to the provision of EOC. Only 26.3% (5/19) of hospitals had been able to provide all the 8 signal functions of comprehensive emergency obstetric care in the previous 3 months. All the 19 hospitals provided parenteral antibiotics and uterine evacuation, 94.7% (18/19) were able to provide parenteral oxytocics and perform manual removal of retained placenta, magnesium sulphate for eclampsia was available in 47.4% (9/19) of hospitals, 42.1% (8/19) provided assisted vaginal delivery, 26.5% (5/19) provided blood transfusion and 89.5% (17/19) offered Caesarean section. The identified challenges for health care providers include difficulties travelling to work due to frequent checkpoints and insecurity, high level of insecurity for patients referred or admitted to hospitals, inadequate staffing due mainly to external migration and premature deaths as a result of the war, lack of drugs, supplies and equipment (including blood for transfusion), and falling standards of training and regulation. Most women and their families do not currently have access to comprehensive emergency obstetric care. Health care providers recommend reconstruction and strengthening of all components of the Iraqi health system which may only be achieved if security returns to the country.

  9. Implementation of emergency obstetric care training in Bangladesh: lessons learned.

    PubMed

    Islam, Mohammad Tajul; Haque, Yasmin Ali; Waxman, Rachel; Bhuiyan, Abdul Bayes

    2006-05-01

    The Women's Right to Life and Health project aimed to reduce maternal morbidity and mortality in Bangladesh through provision of comprehensive emergency obstetric care (EmOC) in the country's district and sub-district hospitals. Human resources development was one of the project's major activities. This paper describes the project in 2000-2004 and lessons learned. Project documents, the training database, reports and training protocols were reviewed. Medical officers, nurses, facility managers and laboratory technicians received training in the country's eight medical college hospitals, using nationally accepted curricula. A 17-week competency-based training course for teams of medical officers and nurses was introduced in 2003. At baseline in 1999, only three sub-district hospitals were providing comprehensive EmOC and 33 basic EmOC, mostly due to lack of trained staff and necessary equipment. In 2004, 105 of the 120 sub-district hospitals had become functional for EmOC, 70 with comprehensive EmOC and 35 with basic EmOC, while 53 of 59 of the district hospitals were providing comprehensive EmOC compared to 35 in 1999. The scaling up of competency-based training, innovative incentives to retain trained staff, evidence-based protocols to standardise practice and improve quality of care and the continuing involvement of key stakeholders, especially trainers, will all be needed to reach training targets in future.

  10. [Simulation training in the management of obstetric emergencies. A review of the literature].

    PubMed

    Bogne, V; Kirkpatrick, C; Englert, Y

    2014-01-01

    To assess the value of simulation based training in the management of obstetric emergencies. A search by keywords: obstetrics, gynecology, simulation, drills, emergency training restricted to randomized trials led to a selection of eight articles. Shoulder dystocia simulation unmasked deficiencies in performing Mc Robert maneuver in nearly 20% of doctors in training as well as ineffective and potentially harmful maneuver such as pressure on the uterine fundus. Delivery of the impacted shoulder improved from 42.9% to 83.3% after simulation training leading to a shorter head to body delivery interval. In postpartum haemorrhage simulation, lack of knowledge on prostaglandins and alkaloids of ergot, delay to transfer the patient to the operating room (82% of cases) and a poor communication between different professionals were identified. Post simulation improvement was seen in knowledge, technical skills, team spirit and structured communication. In severe preeclampsia simulation, mistakes such as injection of undiluted magnesium sulphate, caesarean section on an unstable patient were identified and reduced by 75%. Management of magnesium sulphate toxicity was also improved after simulation training. This review confirms the potential of simulation in training health professionals on management of obstetrics emergencies. Although the integration of this training modality into the curriculum of health care professionals in obstetrics and gynaecology seems beneficial, questions on the cost, the minimum standard of facilities, type of mannequins, human resources and frequency of drills required to achieve the learning objectives remain unanswered.

  11. The cost of local, multi-professional obstetric emergencies training.

    PubMed

    Yau, Christopher W H; Pizzo, Elena; Morris, Steve; Odd, David E; Winter, Cathy; Draycott, Timothy J

    2016-10-01

    We aim to outline the annual cost of setting up and running a standard, local, multi-professional obstetric emergencies training course, PROMPT (PRactical Obstetric Multi-Professional Training), at Southmead Hospital, Bristol, UK - a unit caring for approximately 6500 births per year. A retrospective, micro-costing analysis was performed. Start-up costs included purchasing training mannequins and teaching props, printing of training materials and assembly of emergency boxes (real and training). The variable costs included administration time, room hire, additional printing and the cost of releasing all maternity staff in the unit, either as attendees or trainers. Potential, extra start-up costs for maternity units without established training were also included. The start-up costs were €5574 and the variable costs for 1 year were €143 232. The total cost of establishing and running training at Southmead for 1 year was €148 806. Releasing staff as attendees or trainers accounted for 89% of the total first year costs, and 92% of the variable costs. The cost of running training in a maternity unit with around 6500 births per year was approximately €23 000 per 1000 births for the first year and around €22 000 per 1000 births in subsequent years. The cost of local, multi-professional obstetric emergencies training is not cheap, with staff costs potentially representing over 90% of the total expenditure. It is therefore vital that organizations consider the clinical effectiveness of local training packages before implementing them, to ensure the optimal allocation of finite healthcare budgets. © 2016 Nordic Federation of Societies of Obstetrics and Gynecology.

  12. Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations.

    PubMed

    Freeth, Della; Ayida, Gubby; Berridge, Emma Jane; Mackintosh, Nicola; Norris, Beverley; Sadler, Chris; Strachan, Alasdair

    2009-01-01

    We describe an example of simulation-based interprofessional continuing education, the multidisciplinary obstetric simulated emergency scenarios (MOSES) course, which was designed to enhance nontechnical skills among obstetric teams and, hence, improve patient safety. Participants' perceptions of MOSES courses, their learning, and the transfer of learning to clinical practice were examined. Participants included senior midwives, obstetricians, and obstetric anesthetists, including course faculty from 4 purposively selected delivery suites in England. Telephone or e-mail interviews with MOSES course participants and facilitators were conducted, and video-recorded debriefings that formed integral parts of this 1-day course were analyzed. The team training was well received. Participants were able to check out assumptions and expectations of others and develop respect for different roles within the delivery suite (DS) team. Skillful facilitation of debriefing after each scenario was central to learning. Participants reported acquiring new knowledge or insights, particularly concerning the role of communication and leadership in crisis situations, and they rehearsed unfamiliar skills. Observing peers working in the simulations increased participants' learning by highlighting alternative strategies. The learning achieved by individuals and groups was noticeably dependent on their starting points. Some participants identified limited changes in their behavior in the workplace following the MOSES course. Mechanisms to manage the transfer of learning to the wider team were weakly developed, although 2 DS teams made changes to their regular update training. Interprofessional, team-based simulations promote new learning.

  13. Reducing maternal mortality on a countrywide scale: The role of emergency obstetric training.

    PubMed

    Moran, Neil F; Naidoo, Mergan; Moodley, Jagidesa

    2015-11-01

    Training programmes to improve health worker skills in managing obstetric emergencies have been introduced in various countries with the aim of reducing maternal mortality through these interventions. In South Africa, based on an ongoing confidential enquiry system started in 1997, detailed information about maternal deaths is published in the form of regular 'Saving Mothers' reports. This article tracks the recommendations made in successive Saving Mothers reports with regard to emergency obstetric training, and it assesses the impact of these recommendations on reducing maternal mortality. Since 2009, South Africa has had its own training package, Essential Steps in the Management of Obstetric Emergencies (ESMOE), which the last three Saving Mothers reports have specifically recommended for all doctors and midwives working in maternity units. A special emphasis has been placed on the need for the simulation training component of ESMOE, also called obstetric 'fire drills', to be integrated into the clinical routines of all maternity units. The latest Saving Mothers report (2011-2013) suggests there has been little progress so far in improving emergency obstetric skills, indicating a need for further scale-up of ESMOE training in the country. The example of the KwaZulu-Natal province of South Africa is used to illustrate the process of scale-up and factors likely to facilitate that scale-up, including the introduction of ESMOE into the undergraduate medical training curriculum. Additional factors in the health system that are required to convert improved skills levels into improved quality of care and a reduction in maternal mortality are discussed. These include intelligent government health policies, formulated with input from clinical experts; strong clinical leadership to ensure that doctors and nurses apply the skills they have learnt appropriately, and work professionally and ethically; and a culture of clinical governance. Copyright © 2015 Elsevier Ltd. All

  14. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module XI. Obstetric/Gynecologic Emergencies.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on obstetric/gynecologic emergencies is one of fifteen modules designed for use in the training of emergency medical technicians (paramedics). Six units of study are presented: (1) anatomy and physiology of the female reproductive system; (2) patient assessment; (3) pathophysiology and management of gynecologic…

  15. Measuring access to emergency obstetric care in rural Zambia.

    PubMed

    Levine, Adam C; Marsh, Regan H; Nelson, Sara W; Tyer-Viola, Lynda; Burke, Thomas F

    2008-06-01

    Global health experts identify emergency obstetric care (EmOC) as the most important intervention to improve maternal survival in low- and middle-income countries. In Zambia, 1 in 27 women will die of maternal causes, yet the level of availability of EmOC is not known at the provincial level. Our goal was to develop a tool to measure the availability of EmOC in rural Zambia in order to estimate pregnant women's access to this life-saving intervention. We created an instrument for determining the availability of EmOC based on the supplies and medicines in stock at health facilities as well as the skill level of health workers. We then surveyed a random sample of 35 health centres in the Central Province of Zambia using our novel instrument. We graded health centres based on their ability to provide the six basic functions of EmOC: administering parenteral antibiotics, administering parenteral oxytocics, administering parenteral anticonvulsants, performing manual removal of the placenta, removing retained products of conception and performing assisted vaginal delivery. Of the 29 health centres providing delivery care, 65% (19) were graded as level 1 or 2, 28% (8) as level 3 or 4 and 7% (2) as level 5. No health centre received a grade of level 6. The availability of EmOC in the Central Province of Zambia is extremely limited; the majority of health centres provide only one or two basic functions of EmOC, and no health centres perform all six functions. Our grading system allows for inter- and intra-country comparisons by providing a systematic process for monitoring access to EmOC in rural, low-income countries similar to Zambia.

  16. Complicated deliveries, critical care and quality in emergency obstetric care in Northern Tanzania.

    PubMed

    Olsen, Ø E; Ndeki, S; Norheim, O F

    2004-10-01

    Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

  17. Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology.

    PubMed

    Benacerraf, Beryl R; Minton, Katherine K; Benson, Carol B; Bromley, Bryann S; Coley, Brian D; Doubilet, Peter M; Lee, Wesley; Maslak, Samuel H; Pellerito, John S; Perez, James J; Savitsky, Eric; Scarborough, Norman A; Wax, Joseph; Abuhamad, Alfred Z

    2017-07-06

    The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Views of senior health personnel about quality of emergency obstetric care: A qualitative study in Nigeria

    PubMed Central

    Okonofua, Friday; Agholor, Kingsley; Okike, Ola; Abdus-salam, Rukayat Adeola; Gana, Mohammed; Abe, Eghe; Durodola, Adetoye; Galadanci, Hadiza

    2017-01-01

    Background Late arrival in hospital by women experiencing pregnancy complications is an important background factor leading to maternal mortality in Nigeria. The use of effective and timely emergency obstetric care determines whether women survive or die, or become near-miss cases. Healthcare managers have the responsibility to deploy resources for implementing emergency obstetric care. Objectives To determine the nature of institutional policies and frameworks for managing obstetric complications and reducing maternal deaths in Nigeria. Methods Thirty-six hospital managers, heads of obstetrics department and senior midwives were interviewed about hospital infrastructure, resources, policies and processes relating to emergency obstetric care, whilst allowing informants to discuss their thoughts and feelings. The interviews were audiotaped, transcribed and analyzed using Atlas ti 6.2software. Results Hospital managers are aware of the seriousness of maternal mortality and the steps to improve maternal healthcare. Many reported the lack of policies and specific action-plans for maternal mortality prevention, and many did not purposely disburse budgets or resources to address the problem. Although some reported that maternal/perinatal audit take place in their hospitals, there was no substantive evidence and no records of maternal/perinatal audits were made available. Respondents decried the lack of appropriate data collection system in the hospitals for accurate monitoring of maternal mortality and identification of appropriate remediating actions. Conclusion Healthcare managers are handicapped to properly manage the healthcare system for maternal mortality prevention. Relevant training of healthcare managers would be crucial to enable the development of strategic implementation plans for the prevention of maternal mortality. PMID:28346519

  19. Intelligent navigation to improve obstetrical sonography.

    PubMed

    Yeo, Lami; Romero, Roberto

    2016-04-01

    use of software to perform manual navigation of volume datasets. Diagnostic planes and VIS-Assistance videoclips can be transmitted by telemedicine so that expert consultants can evaluate the images to provide an opinion. The end result is a user-friendly, simple, fast and consistent method of obtaining sonographic images with decreased operator dependency. Intelligent navigation is one approach to improve obstetrical sonography. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

  20. Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe.

    PubMed

    Crofts, Joanna F; Mukuli, Teclar; Murove, Bobb T; Ngwenya, Solwayo; Mhlanga, Sma; Dube, Meluleki; Sengurayi, Elton; Winter, Cathy; Jordan, Sharon; Barnfield, Sonia; Wilcox, Heather; Merriel, Abi; Ndlovu, Sabelo; Sibanda, Zedekiah; Moyo, Sikangezile; Ndebele, Wedu; Draycott, Tim J; Sibanda, Thabani

    2015-05-01

    In Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths. We established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital. Maternal mortality in Zimbabwe has increased from 555 to 960 per 100,000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff. Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014. Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.

  1. Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe

    PubMed Central

    Mukuli, Teclar; Murove, Bobb T; Ngwenya, Solwayo; Mhlanga, Sma; Dube, Meluleki; Sengurayi, Elton; Winter, Cathy; Jordan, Sharon; Barnfield, Sonia; Wilcox, Heather; Merriel, Abi; Ndlovu, Sabelo; Sibanda, Zedekiah; Moyo, Sikangezile; Ndebele, Wedu; Draycott, Tim J; Sibanda, Thabani

    2015-01-01

    Abstract Problem In Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths. Approach We established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital. Local setting Maternal mortality in Zimbabwe has increased from 555 to 960 per 100 000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff. Relevant changes Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014. Lessons learnt Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required. PMID:26229206

  2. Public private partnerships for emergency obstetric care: lessons from maharashtra.

    PubMed

    Chaturvedi, Sarika; Randive, Bharat

    2011-01-01

    The National Rural Health Mission of India advocates public private partnerships (PPPs) to meet its "service guarantee" of Emergency obstetric care (EmOC) provision. The Janani Suraksha Yojana (JSY) has a provision of Rs. 1500 for contracting in obstetric specialists. The study aimed to understand the issues in the design and implementation of the PPPs for EmOC under the JSY in Maharashtra and how they affect the availability of EmOC services to women. A cross-sectional study using the rapid assessment approach was conducted in Ahmednagar district of Maharashtra spanning 1-year duration ending in June 2009. Primary data were obtained through interviews with women, providers, and administrators at various levels. Data were analyzed thematically. The PPP scheme for EmOC is restricted to deliveries by Caesarean section.The administrators prefer subsidization of costs for services in private facilities to contracting in. There are no PPPs executed in the study district. This study identifies barriers to women in accessing the benefit and the difficulties faced by administrators in implementing the scheme. The PPPs for EmOC under the JSY have minimally influenced the out-of-pocket payments for EmOC. Infrastructural inadequacies and passive support of the implementers are major barriers to the implementation of contracting-in model of PPPs. Capacities in the public health system are inadequate to design and manage PPPs.

  3. Public Private Partnerships for Emergency Obstetric Care: Lessons from Maharashtra

    PubMed Central

    Chaturvedi, Sarika; Randive, Bharat

    2011-01-01

    Background: The National Rural Health Mission of India advocates public private partnerships (PPPs) to meet its “service guarantee” of Emergency obstetric care (EmOC) provision. The Janani Suraksha Yojana (JSY) has a provision of Rs. 1500 for contracting in obstetric specialists. Objectives: The study aimed to understand the issues in the design and implementation of the PPPs for EmOC under the JSY in Maharashtra and how they affect the availability of EmOC services to women. Materials and Methods: A cross-sectional study using the rapid assessment approach was conducted in Ahmednagar district of Maharashtra spanning 1-year duration ending in June 2009. Primary data were obtained through interviews with women, providers, and administrators at various levels. Data were analyzed thematically. Results: The PPP scheme for EmOC is restricted to deliveries by Caesarean section.The administrators prefer subsidization of costs for services in private facilities to contracting in. There are no PPPs executed in the study district. This study identifies barriers to women in accessing the benefit and the difficulties faced by administrators in implementing the scheme. Conclusion: The PPPs for EmOC under the JSY have minimally influenced the out-of-pocket payments for EmOC. Infrastructural inadequacies and passive support of the implementers are major barriers to the implementation of contracting-in model of PPPs. Capacities in the public health system are inadequate to design and manage PPPs. PMID:21687376

  4. Emergency hysterectomy in obstetrics--a review of 117 cases.

    PubMed

    Al-Sibai, M H; Rahman, J; Rahman, M S; Butalack, F

    1987-08-01

    A series of 117 cases of emergency obstetric hysterectomy performed between 1976 and 1985 is reviewed. The indications included ruptured uterus (53.8%), intractable postpartum haemorrhage (20.5%), placenta accreta (7.7%), major degree of placenta praevia (7.7%), haemorrhage at Caesarean section (4.5%), couvelaire uterus (3.4%) and abdominal pregnancy (2.6%). Despite a general aversion to hysterectomy by the women in our society, these procedures were undertaken in a desperate attempt to save life. There were 6 (5.1%) maternal deaths, all due to the severity of the indication for the hysterectomy. Presence of an experienced obstetrician is important to make an early decision to operate before the patient's condition is extreme and to provide the technical skills required to minimize morbidity and mortality.

  5. Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District

    PubMed Central

    Ng’anjo Phiri, Selia; Fylkesnes, Knut; Moland, Karen Marie; Byskov, Jens; Kiserud, Torvid

    2016-01-01

    Background Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. Method A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. Results A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76). Conclusions Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths. PMID:26824599

  6. [Obstetric emergency and non-emergency transfers to the university teaching hospital Yalgado ouedraogo of Ouagadougou: A 3-year study of their epidemiologic, clinical, and prognostic aspects].

    PubMed

    Ouattara, A; Ouedraogo, C M; Ouedraogo, A; Lankoande, J

    2015-01-01

    to describe the epidemiologic, clinical, and prognostic aspects of the emergency and non-emergency transfers of obstetric patients to Yalgado Ouédraogo University Hospital Center (UHC-YO) in Ouagadougou. this retrospective descriptive study looked at the outcomes of women transferred, on an emergency basis or not, to the obstetrics department of the UHC-YO. The study population comprised all women transferred to the department during 2010, 2011, and 2012. during the study period, there were 9,806 admissions for obstetric disorders: 43% were transfers. The patients' mean age was 26.11 years [(13-49]. Women transferred from health care facilities within the city of Ouagadougou accounted for 96% of the sample. The leading reason for these transfers - emergency or not - was preeclampsia and eclampsia (24.57%). We recorded a total of 161 maternal deaths, for a mortality rate of 3.9%. Approximately 26.55% of the newborns received immediate intensive care and were then transferred to the neonatology department. maternal and neonatal prognosis is always poor in cases transferred to UHC-YO, despite increased funding for emergency obstetric and neonatal care. Increased population awareness of the importance of prenatal consultation and adequate funding for health care facilities to provide equipment for emergency transfers and staff training in the management of obstetric and neonatal emergencies would probably improve these mortality and morbidity rates.

  7. Barriers to emergency obstetric care services: accounts of survivors of life threatening obstetric complications in Malindi District, Kenya.

    PubMed

    Echoka, Elizabeth; Makokha, Anselimo; Dubourg, Dominique; Kombe, Yeri; Nyandieka, Lillian; Byskov, Jens

    2014-01-01

    Pregnancy-related mortality and morbidity in most low and middle income countries can be reduced through early recognition of complications, prompt access to care and appropriate medical interventions following obstetric emergencies. We used the three delays framework to explore barriers to emergency obstetric care (EmOC) services by women who experienced life threatening obstetric complications in Malindi District, Kenya. A facility-based qualitative study was conducted between November and December 2010. In-depth interviews were conducted with 30 women who experienced obstetric "near miss" at the only public hospital with capacity to provide comprehensive EmOC services in the district. Findings indicate that pregnant women experienced delays in making decision to seek care and in reaching an appropriate care facility. The "first" delay was due to lack of birth preparedness, including failure to identify a health facility for delivery services regardless of antenatal care and to seek care promptly despite recognition of danger signs. The "second" delay was influenced by long distance and inconvenient transport to hospital. These two delays resulted in some women arriving at the hospital too late to save the life of the unborn baby. Delays in making the decision to seek care when obstetric complications occur, combined with delays in reaching the hospital, contribute to ineffective treatment upon arrival at the hospital. Interventions to reduce maternal mortality and morbidity must adequately consider the pre-hospital challenges faced by pregnant women in order to influence decision making towards addressing the three delays.

  8. The state of emergency obstetric care services in Nairobi informal settlements and environs: Results from a maternity health facility survey

    PubMed Central

    Ziraba, Abdhalah K; Mills, Samuel; Madise, Nyovani; Saliku, Teresa; Fotso, Jean-Christophe

    2009-01-01

    mortality was a challenge due to poor and incomplete medical records. Conclusion The quality of emergency obstetric care services in Nairobi slums is poor and needs improvement. Specific areas that require attention include supervision, regulation of maternity facilities; and ensuring that basic equipment, supplies, and trained personnel are available in order to handle obstetric complications in both public and private facilities. PMID:19284626

  9. Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda.

    PubMed

    Mbonye, A K; Asimwe, J B; Kabarangira, J; Nanda, G; Orinda, V

    2007-03-01

    We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.

  10. Delivering quality care: what can emergency gynaecology learn from acute obstetrics?

    PubMed

    Bika, O H; Edozien, L C

    2014-08-01

    Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.

  11. The cost of emergency obstetric care: concepts and issues.

    PubMed

    Desai, J

    2003-04-01

    Emergency obstetric care (EmOC), like any health intervention, requires resources, and resources are almost always limited. This forces decision makers to take into account the costs (and effectiveness) of EmOC provision and compare them with the costs (and effectiveness) of other health interventions. This is not inordinately complicated, but it does require paying attention to the fact that EmOC services require different types of inputs and are produced in facilities that also provide other health care services. This paper discusses the basic concepts underlying the costing of EmOC services, and the essential issues one must take into account while assessing the cost-effectiveness of EmOC interventions. A definition of EmOC provision cost is offered and then explained by progressively refining a simple measure of expenditures on all that is used to provide EmOC services. Thereupon the process of collecting cost data and calculating costs is outlined using a simple spreadsheet format, and issues related to the analysis of costs and cost-effectiveness are discussed.

  12. A behavioral intervention to improve obstetrical care.

    PubMed

    Althabe, Fernando; Buekens, Pierre; Bergel, Eduardo; Belizán, José M; Campbell, Marci K; Moss, Nancy; Hartwell, Tyler; Wright, Linda L

    2008-05-01

    Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed. We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention. The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the

  13. Patient perspectives on improving the depression referral processes in obstetrics settings: A qualitative study

    PubMed Central

    Flynn, Heather A.; Henshaw, Erin; O’Mahen, Heather; Forman, Jane

    2009-01-01

    Objectives Although depression screening in obstetrics settings has been recommended, little research exists to guide strategies for screening follow up and depression referral. The purpose of this qualitative study was to inform recommendations for depression screening follow up and referral in obstetrics settings based on responses from a key sample of women about influences on depression treatment use and engagement. Methods A stratified purposeful sampling based on pregnancy, socioeconomic status, and depression severity was used to identify 23 women who completed semi-structured interviews that centered on their beliefs about what would prevent or facilitate entry into depression treatment in the context of obstetrical care. We conducted a thematic analysis through an iterative process of expert transcript review, creation of and refining codes, and identifying themes. Results Two broad themes influencing depression treatment usage emerged including practical and psychological factors. Among practical factors, women reported a strong preference for treatment provided in the obstetric clinic or in the home with a desire for a proactive referral process and flexible options for receiving treatment. Psychological factors included differing conceptualizations of depression, knowledge about severity and treatment, and issues of stigma. Conclusions This study suggests that the current standard practice of depression screening and referral to specialty treatment does not match with perceived influences on treatment use among our sample of perinatal women. Recommendations derived from the results for improving follow up with screening and depression referral in obstetrics settings are provided as a platform for further research. PMID:20114123

  14. Barriers to emergency obstetric care services: accounts of survivors of life threatening obstetric complications in Malindi District, Kenya

    PubMed Central

    Echoka, Elizabeth; Makokha, Anselimo; Dubourg, Dominique; Kombe, Yeri; Nyandieka, Lillian; Byskov, Jens

    2014-01-01

    Introduction Pregnancy-related mortality and morbidity in most low and middle income countries can be reduced through early recognition of complications, prompt access to care and appropriate medical interventions following obstetric emergencies. We used the three delays framework to explore barriers to emergency obstetric care (EmOC) services by women who experienced life threatening obstetric complications in Malindi District, Kenya. Methods A facility-based qualitative study was conducted between November and December 2010. In-depth interviews were conducted with 30 women who experienced obstetric “near miss” at the only public hospital with capacity to provide comprehensive EmOC services in the district. Resuls Findings indicate that pregnant women experienced delays in making decision to seek care and in reaching an appropriate care facility. The “first” delay was due to lack of birth preparedness, including failure to identify a health facility for delivery services regardless of antenatal care and to seek care promptly despite recognition of danger signs. The “second” delay was influenced by long distance and inconvenient transport to hospital. These two delays resulted in some women arriving at the hospital too late to save the life of the unborn baby. Conclusion Delays in making the decision to seek care when obstetric complications occur, combined with delays in reaching the hospital, contribute to ineffective treatment upon arrival at the hospital. Interventions to reduce maternal mortality and morbidity must adequately consider the pre-hospital challenges faced by pregnant women in order to influence decision making towards addressing the three delays. PMID:24643142

  15. Effects of changes in copayment for obstetric emergency room visits on the utilization of obstetric emergency rooms.

    PubMed

    Raz, Iris; Novack, Lena; Yitshak-Sade, Maayan; Shahar, Yemima; Wiznitzer, Arnon; Sergienko, Ruslan; Warshawsky-Livne, Lora

    2015-10-01

    In view of the growing proportion of "non-urgent" admissions to obstetric emergency rooms (OERs) and recent changes in copayment policies for OER visits in Israel, we assessed factors contributing to OER overcrowding. The changes investigated were (a) exemption from copayment for women with birth contractions, (b) allowing phone referrals to the OER and (c) exemption from copayment during primary care clinic closing hours. We analyzed data of a large tertiary hospital with 37 deliveries per day. Counts of women discharged to home from the OER were an indicator of "non-urgent" visits. The annual number of non-urgent visits increased at a higher rate (3.4%) than the natural increase in deliveries (2.1%). Exemption from copayment for visits during non-working hours of primary care clinics was associated with increases in OER admissions (IRR=1.22) and in non-urgent OER visits (IRR=1.54). Younger and first-time mothers with medically unjustified complaints were more likely to be discharged to home. We showed that the changes in the policy for OER copayment meant to attract new clients to the HMO had an independent impact on OER utilization, and hence, added to the workload of medical personnel. The change in HMO policy regulating OER availability requires rigorous assessment of possible health system implications. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  16. Strengthening emergency obstetric care in Nepal: The Women's Right to Life and Health Project (WRLHP).

    PubMed

    Rana, T G; Chataut, B D; Shakya, G; Nanda, G; Pratt, A; Sakai, S

    2007-09-01

    The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women.

  17. Educational needs of Australian rural and remote doctors for intermediate obstetric ultrasound and emergency medicine ultrasound.

    PubMed

    Glazebrook, Roz; Manahan, Dan; Chater, A Bruce

    2006-01-01

    The aim of this research was to determine the educational needs of Australian rural and remote doctors for intermediate obstetric ultrasound and emergency medicine ultrasound. The main research questions were: what educational topics would rural and remote doctors prefer to learn about in intermediate obstetric ultrasound and emergency medicine ultrasound, and what were those doctors' preferred methods of delivery for an ultrasound education program. A self-administered postal questionnaire containing a pre-paid return envelope was mailed to 344 Australian rural and remote doctors in December 2003. 107 completed questionnaires were returned, giving a response rate of 32.7%. This was after the denominator was adjusted for the 17 doctors whose letters were returned to sender. The respondents included 23 (21.5%) female and 84 (78.5%) male doctors. Eighty doctors (74.8%) stated that they used ultrasound, and 27 (25.2%) said they did not. Seventy-seven (72%) indicated they had previously participated in some ultrasound education and training. The respondents stated that their main areas of educational need in intermediate obstetric ultrasound were ectopic pregnancy (76.6%), miscarriage (72%), intrauterine growth restriction (65.4%), transvaginal scanning (47.7%), detecting fetal abnormalities (47.7%) and morphology scanning at 18-20 weeks (41.1%). The main areas of educational need in emergency medicine ultrasound were focused abdominal sonography in trauma (63.5%), detecting foreign bodies (40.2%), gynecological ultrasound (39.2%), gall bladder and biliary tract (37.4%), abdominal aortic aneurysm (32.7%) and trauma bleeding (31.7%). Australian rural and remote doctors are using ultrasound technology to improve the clinical investigation and diagnosis of a large variety of clinical conditions in their family medical practices. This paper describes the results of research into the educational needs of this target group of doctors.

  18. Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households

    PubMed Central

    Fournier, Pierre; Philibert, Aline; Sissoko, Koman; Coulibaly, Aliou; Tourigny, Caroline; Traoré, Mamadou; Dumont, Alexandre

    2013-01-01

    Abstract Objective To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali. Methods Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008–2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them. Findings Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system’s inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits. Conclusion The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies. PMID:23476093

  19. Barriers to Emergency Obstetric Care Services in Perinatal Deaths in Rural Gambia: A Qualitative In-Depth Interview Study

    PubMed Central

    Jammeh, Abdou; Sundby, Johanne; Vangen, Siri

    2011-01-01

    Objective. The Gambia has one of the world's highest perinatal mortality rates. We explored barriers of timely access to emergency obstetric care services resulting in perinatal deaths and in survivors of severe obstetric complications in rural Gambia. Method. We applied the “three delays” model as a framework for assessing contributing factors to perinatal deaths and obstetric complications. Qualitative in-depth interviews were conducted with 20 survivors of severe obstetric complications at home settings within three to four weeks after hospital discharge. Family members and traditional birth attendants were also interviewed. The interviews were translated into English and transcribed verbatim. We used content analysis to identify barriers of care. Results. Transport/cost-related delays are the major contributors of perinatal deaths in this study. A delay in recognising danger signs of pregnancy/labour or decision to seek care outside the home was the second important contributor of perinatal deaths. Decision to seek care may be timely, but impaired access precluded utilization of EmOC services. Obtaining blood for transfusion was also identified as a deterrent to appropriate care. Conclusion. Delays in accessing EmOC are critical in perinatal deaths. Thus, timely availability of emergency transport services and prompt decision-making are warranted for improved perinatal outcomes in rural Gambia. PMID:21766039

  20. Barriers to emergency obstetric care services in perinatal deaths in rural gambia: a qualitative in-depth interview study.

    PubMed

    Jammeh, Abdou; Sundby, Johanne; Vangen, Siri

    2011-01-01

    Objective. The Gambia has one of the world's highest perinatal mortality rates. We explored barriers of timely access to emergency obstetric care services resulting in perinatal deaths and in survivors of severe obstetric complications in rural Gambia. Method. We applied the "three delays" model as a framework for assessing contributing factors to perinatal deaths and obstetric complications. Qualitative in-depth interviews were conducted with 20 survivors of severe obstetric complications at home settings within three to four weeks after hospital discharge. Family members and traditional birth attendants were also interviewed. The interviews were translated into English and transcribed verbatim. We used content analysis to identify barriers of care. Results. Transport/cost-related delays are the major contributors of perinatal deaths in this study. A delay in recognising danger signs of pregnancy/labour or decision to seek care outside the home was the second important contributor of perinatal deaths. Decision to seek care may be timely, but impaired access precluded utilization of EmOC services. Obtaining blood for transfusion was also identified as a deterrent to appropriate care. Conclusion. Delays in accessing EmOC are critical in perinatal deaths. Thus, timely availability of emergency transport services and prompt decision-making are warranted for improved perinatal outcomes in rural Gambia.

  1. Perianesthesia care following obstetric emergencies at risk for multisystem organ dysfunction.

    PubMed

    Curran, Carol A

    2005-06-01

    Perianesthesia care provided to obstetric patients is on the rise due to current obstetric practice habits, changes in the maternal population, and the increased desire for scheduled childbirth. Both scheduled and emergent cesarean deliveries create risk, yet the use of general anesthesia increases maternal morbidity and mortality significantly. Obstetric emergencies make up the majority of emergent cesarean deliveries. Detrimental events during pregnancy and childbirth may be categorized into hemorrhagic, septic, or anaphylactic shock. Excessive loss of circulating volume with subsequent loss in oxygenation creates an environment for multisystem organ dysfunction syndrome (MODS). Both MODS and pregnancy are hyperdynamic and hypermetabolic states. Close monitoring is needed to differentiate pregnancy for the progression of organ dysfunction. Caring for pregnant women with the intent that pregnancy is a normal, physiologic state can lead to complacency and the risk of misdiagnosis. The purpose of this article is to review current obstetric emergencies that place the obstetric population at risk for MODS and offer management options to perianesthesia providers.

  2. Availability and quality of emergency obstetric care in Shanxi Province, China.

    PubMed

    Gao, Yu; Barclay, Lesley

    2010-08-01

    To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province. The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care. The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%-40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor. Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement. Copyright 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  3. Rate of cesarean delivery at hospitals providing emergency obstetric care in Bangladesh.

    PubMed

    Islam, Mohammad T; Yoshimura, Yukie

    2015-01-01

    To assess the rate of cesarean delivery and its indications at public emergency obstetric care (EmOC) hospitals in a district in Bangladesh. In a retrospective, cross-sectional study, data were extracted from the Safe Motherhood Promotion Project database and operation theater registers for cesarean deliveries at three district and three subdistrict EmOC hospitals in Narsingdi between January 1 and December 31, 2008. Information on cesarean deliveries and their indications, and maternal and neonatal outcomes were analyzed descriptively. Among 3329 deliveries, 1075 (32.3%) occurred by cesarean. The frequency of cesarean delivery ranged from 17.8% (147 of 824 deliveries) to 56.3% (174 of 309) among the six hospitals. Information on indications was available for 1043 cesarean deliveries. The main indications were previous cesarean delivery (251 deliveries, 24.1%), fetal distress (228, 21.9%), and prolonged or obstructed labor (214, 20.5%). There were no maternal deaths, but 10 (1.0%) cesarean deliveries resulted in stillbirth. The overall rate of cesarean delivery was high at EmOC hospitals. Interventions to improve decision making and limit possible unnecessary cesarean operations are needed. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  4. Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training

    PubMed Central

    Walker, Dilys M.; Cohen, Susanna R.; Fritz, Jimena; Olvera-García, Marisela; Zelek, Sarah T.; Fahey, Jenifer O.; Romero-Martínez, Martín; Montoya-Rodríguez, Alejandra; Lamadrid-Figueroa, Héctor

    2016-01-01

    Introduction Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. Methods We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. Results There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months’ (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. Conclusions PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes. PMID:26312613

  5. Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training.

    PubMed

    Walker, Dilys M; Cohen, Susanna R; Fritz, Jimena; Olvera-García, Marisela; Zelek, Sarah T; Fahey, Jenifer O; Romero-Martínez, Martín; Montoya-Rodríguez, Alejandra; Lamadrid-Figueroa, Héctor

    2016-02-01

    Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months' (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes.

  6. A sector-wide approach to emergency obstetric care in Uganda.

    PubMed

    Orinda, V; Kakande, H; Kabarangira, J; Nanda, G; Mbonye, A K

    2005-12-01

    To establish a baseline for the availability, utilization, and quality of EmOC, and to help develop an operational strategy based on the findings. A needs assessment of emergency obstetric care (EmOC) was carried out in 197 health facilities in 19 out of 56 districts in Uganda, covering 38% of the total population. There were a large number of missing signal functions at health facilities and an urgent need to improve the availability of EmOC. By using the data from the assessment, it was possible to influence national policy through the health sector-wide approach (SWAp) and place EmOC high on the national agenda. A national strategy and roll out plan to strengthen EmOC is now in place.

  7. Reducing neonatal mortality in India: critical role of access to emergency obstetric care.

    PubMed

    Rammohan, Anu; Iqbal, Kazi; Awofeso, Niyi

    2013-01-01

    Neonatal mortality currently accounts for 41% of all global deaths among children below five years. Despite recording a 33% decline in neonatal deaths between 2000 and 2009, about 900,000 neonates died in India in 2009. The decline in neonatal mortality is slower than in the post-neonatal period, and neonatal mortality rates have increased as a proportion of under-five mortality rates. Neonatal mortality rates are higher among rural dwellers of India, who make up at least two-thirds of India's population. Identifying the factors influencing neonatal mortality will significantly improve child survival outcomes in India. Our analysis is based on household data from the nationally representative 2008 Indian District Level Household Survey (DLHS-3). We use probit regression techniques to analyse the links between neonatal mortality at the household level and households' access to health facilities. The probability of the child dying in the first month of birth is our dependent variable. We found that 80% of neonatal deaths occurred within the first week of birth, and that the probability of neonatal mortality is significantly lower when the child's village is closer to the district hospital (DH), suggesting the critical importance of specialist hospital care in the prevention of newborn deaths. Neonatal deaths were lower in regions where emergency obstetric care was available at the District Hospitals. We also found that parental schooling and household wealth status improved neonatal survival outcomes. Addressing the main causes of neonatal deaths in India--preterm deliveries, asphyxia, and sepsis--requires adequacy of specialised workforce and facilities for delivery and neonatal intensive care and easy access by mothers and neonates. The slow decline in neonatal death rates reflects a limited attention to factors which contribute to neonatal deaths. The suboptimal quality and coverage of Emergency Obstetric Care facilities in India require urgent attention.

  8. Survey of Emergency and Essential Surgical, Obstetric and Anaesthetic Services Available in Bangladeshi Government Health Facilities.

    PubMed

    Loveday, Jonathan; Sachdev, Sonal P; Cherian, Meena N; Katayama, Francisco; Akhtaruzzaman, A K M; Thomas, Joe; Huda, N; Faragher, E Brian; Johnson, Walter D

    2017-07-01

    Evaluate the capacity of government-run hospitals in Bangladesh to provide emergency and essential surgical, obstetric and anaesthetic services. Cross-sectional survey of 240 Bangladeshi Government healthcare facilities using the World Health Organisation Situational Analysis Tool to Assess Emergency and Essential Surgical Care (SAT). This tool evaluates the ability of a healthcare facility to provide basic surgical, obstetric and anaesthetic care based on 108 queries that detail the infrastructure and population demographics, human resources, surgical interventions and reason for referral, and available surgical equipment and supplies. For this survey, the Bangladeshi Ministry of Health sent the SAT to sub-district, district/general and teaching hospitals throughout the country in April 2013. Responses were received from 240 healthcare facilities (49.5% response rate): 218 sub-district and 22 district/general hospitals. At the sub-district level, caesarean section was offered by 55% of facilities, laparotomy by 7% and open fracture repair by 8%. At the district/general hospital level, 95% offered caesarean section, 86% offered laparotomy and 77% offered open fracture treatment. Availability of anaesthesia services, general equipment and supplies reflected this trend, where district/general hospitals were better equipped than sub-district hospitals, though equipment and infrastructure shortages persist. There has been overall impressive progress by the Bangladeshi Government in providing essential surgical services. Areas for improvement remain across all key areas, including infrastructure, human resources, surgical interventions offered and available equipment. Investment in surgical services offers a cost-effective opportunity to continue to improve the health of the Bangladeshi population and move the country towards universal healthcare coverage.

  9. Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi.

    PubMed

    Kongnyuy, E J; Leigh, B; van den Broek, N

    2008-12-01

    Facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts in Malawi in 2006. Can audit and feedback improve the availability, utilisation and quality of emergency obstetric care (EmOC)? Observational study in which emergency obstetric care offered to women who gave birth in 73 health facilities (13 hospitals and 60 health centres) in three districts in Malawi in 2005 (baseline, 41,637 women) was compared to 2006 (43,729 women) and 2007 (51,085 women). The number of comprehensive and basic EmOC facilities did not change over the 3-year period (p for trend=1.000). Although institutional delivery rate decreased in 2006, overall it increased over 3 years (p for trend<0.001) - 31.8% (2005), 31.1% (2006) and 34.7% (2007), and Caesarean section rate was low and did not change (p for trend=0.257) - 1.7% (2005), 1.6% (2006) and 1.5% (2007). There was a significant increase in the met need for EmOC (p for trend<0.001) - 15.2% for 2005, 17.0% for 2006 and 18.8% for 2007. Maternal mortality decreased significantly from 250 per 100,000 women in 2005 to 222 in 2006 and 182 in 2007 (p for trend<0.001). Similarly, the case fatality rate decreased monotonically (p for trend<0.001) - 3.7% (2005), 3.0% (2006) and 1.5% (2007). Audit and feedback can improve availability, utilisation and quality of emergency obstetric care in countries with limited resources. There is need to increase availability of emergency obstetric care by upgrading some health centres to EmOC level through training of staff and provision of equipment and supplies.

  10. Chikungunya Fever: Obstetric Considerations on an Emerging Virus.

    PubMed

    Dotters-Katz, Sarah K; Grace, Matthew R; Strauss, Robert A; Chescheir, Nancy; Kuller, Jeffrey A

    2015-07-01

    Chikungunya fever is an increasingly common viral infection transmitted to humans by species of the Aedes mosquitoes. Characterized by fevers, myalgias, arthralgias, headache, and rash, the infection is endemic to tropical areas. However, identification of disease vectors to Europe and the Americas has raised concern for possible spread of chikungunya to these areas. More recently, these concerns have become a reality; with more than 500,000 new cases in the Western hemisphere in the last 2 years, questions have arisen about the implications of infection during pregnancy and delivery. A literature review was performed using MEDLINE in order to gather information regarding the obstetric implications of this infection. It appears that although this virus can cross the placenta in the first and second trimester leading to fetal infection and miscarriage, this is a very rare occurrence. In contrast, active maternal infection within 4 days of delivery conveys a high risk of vertical transmission. Maternal infection during pregnancy does not appear to be more severe than infection on the nonpregnant female. Given the increasing incidence of chikungunya, obstetric providers should be aware of the disease and its implication for the gravid female.

  11. Obstetric emergencies at the United States–Mexico border crossings in El Paso, Texas

    PubMed Central

    McDonald, Jill A.; Rishel, Karen; Escobedo, Miguel A.; Arellano, Danielle E.; Cunningham, Timothy J.

    2015-01-01

    Objective To describe the frequency, characteristics, and patient outcomes for women who accessed Emergency Medical Services (EMS) for obstetric emergencies at the ports of entry (POE) between El Paso, Texas, United States of America, and Ciudad Juárez, Chihuahua, Mexico. Methods A descriptive study of women 12–49 years of age for whom an EMS ambulance was called to an El Paso POE location from December 2008–April 2011 was conducted. Women were identified through surveillance of EMS records. EMS and emergency department (ED) records were abstracted for all women through December 2009 and for women with an obstetric emergency through April 2011. For obstetric patients admitted to the hospital, additional prenatal and birth characteristics were collected. Frequencies and proportions were estimated for each variable; differences between residents of the United States and Mexico were tested. Results During December 2008–December 2009, 47.6% (68/143) of women receiving EMS assistance at an El Paso POE had an obstetric emergency, nearly 20 times the proportion for Texas overall. During December 2008–April 2011, 60.1% (66/109) of obstetric patients with ED records were admitted to hospital and 52 gave birth before discharge. Preterm birth (23.1%; No. = 12), low birth weight (9.6%; No. = 5), birth in transit (7.7%; No. = 4), and postpartum hemorrhage (5.8%; No. = 3) were common; fewer than one-half the women (46.2%; No. = 24) had evidence of prenatal care. Conclusions The high proportion of obstetric EMS transports and high prevalence of complications in this population suggest a need for binational risk reduction efforts. PMID:25915011

  12. Obstetric emergencies at the United States-Mexico border crossings in El Paso, Texas.

    PubMed

    McDonald, Jill A; Rishel, Karen; Escobedo, Miguel A; Arellano, Danielle E; Cunningham, Timothy J

    2015-02-01

    To describe the frequency, characteristics, and patient outcomes for women who accessed Emergency Medical Services (EMS) for obstetric emergencies at the ports of entry (POE) between El Paso, Texas, United States of America, and Ciudad Juárez, Chihuahua, Mexico. A descriptive study of women 12-49 years of age for whom an EMS ambulance was called to an El Paso POE location from December 2008-April 2011 was conducted. Women were identified through surveillance of EMS records. EMS and emergency department (ED) records were abstracted for all women through December 2009 and for women with an obstetric emergency through April 2011. For obstetric patients admitted to the hospital, additional prenatal and birth characteristics were collected. Frequencies and proportions were estimated for each variable; differences between residents of the United States and Mexico were tested. During December 2008-December 2009, 47.6% (68/143) of women receiving EMS assistance at an El Paso POE had an obstetric emergency, nearly 20 times the proportion for Texas overall. During December 2008-April 2011, 60.1% (66/109) of obstetric patients with ED records were admitted to hospital and 52 gave birth before discharge. Preterm birth (23.1%; No. = 12), low birth weight (9.6%; No. = 5), birth in transit (7.7%; No. = 4), and postpartum hemorrhage (5.8%; No. = 3) were common; fewer than one-half the women (46.2%; No. = 24) had evidence of prenatal care. The high proportion of obstetric EMS transports and high prevalence of complications in this population suggest a need for binational risk reduction efforts.

  13. Myths and realities of training in obstetric emergencies.

    PubMed

    Draycott, Timothy J; Collins, Katherine J; Crofts, Joanna F; Siassakos, Dimitrios; Winter, Cathy; Weiner, Carl P; Donald, Fiona

    2015-11-01

    Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting. Copyright © 2015 Elsevier Ltd. All rights reserved.

  14. A pilot structured resident orientation curriculum improves the confidence of incoming first-year obstetrics and gynecology residents.

    PubMed

    Hiraoka, Mark; Kamikawa, Ginny; McCartin, Richard; Kaneshiro, Bliss

    2013-11-01

    A prospective, observational study was performed to evaluate a pilot orientation curriculum which involved all 7 incoming obstetrics and gynecology residents in June 2012. The objective of this study was to assess how a structured orientation curriculum, which employs an evaluation of baseline competency, affects the confidence of incoming first-year obstetrics and gynecology residents. The curriculum included didactic lectures, online modules, simulation, and mock clinical scenarios. Pre- and post-course surveys were conducted online via SurveyMonkey™ and were sent to all incoming obstetrics and gynecology residents. All seven incoming obstetrics and gynecology residents completed the orientation curriculum which included evaluations at the end of the orientation to assess baseline competency prior to taking part in clinical care. Confidence levels improved in all 27 elements assessed. Statistically significant improvement in confidence levels occurred in cognitive skills such as obstetric emergency management (2.9 vs 3.9, P< .05) and technical skills such as knot tying (3.9 vs. 4.6, P< .05). Certain teaching skills also demonstrated statistically significant improvements. A structured orientation program which improves resident self-confidence levels and demonstrates baseline competencies in certain clinical areas can be valuable for many residency training programs.

  15. A Pilot Structured Resident Orientation Curriculum Improves the Confidence of Incoming First-Year Obstetrics and Gynecology Residents

    PubMed Central

    Kamikawa, Ginny; McCartin, Richard; Kaneshiro, Bliss

    2013-01-01

    A prospective, observational study was performed to evaluate a pilot orientation curriculum which involved all 7 incoming obstetrics and gynecology residents in June 2012. The objective of this study was to assess how a structured orientation curriculum, which employs an evaluation of baseline competency, affects the confidence of incoming first-year obstetrics and gynecology residents. The curriculum included didactic lectures, online modules, simulation, and mock clinical scenarios. Pre- and post-course surveys were conducted online via SurveyMonkey™ and were sent to all incoming obstetrics and gynecology residents. All seven incoming obstetrics and gynecology residents completed the orientation curriculum which included evaluations at the end of the orientation to assess baseline competency prior to taking part in clinical care. Confidence levels improved in all 27 elements assessed. Statistically significant improvement in confidence levels occurred in cognitive skills such as obstetric emergency management (2.9 vs 3.9, P< .05) and technical skills such as knot tying (3.9 vs. 4.6, P< .05). Certain teaching skills also demonstrated statistically significant improvements. A structured orientation program which improves resident self-confidence levels and demonstrates baseline competencies in certain clinical areas can be valuable for many residency training programs. PMID:24251084

  16. Optimization of competency in obstetrical emergencies: a role for simulation training.

    PubMed

    Monod, Cécile; Voekt, Cora A; Gisin, Martina; Gisin, Stefan; Hoesli, Irene M

    2014-04-01

    In obstetrical emergency situations, optimal management requires the immediate coordinated actions of a multi-disciplinary and multi-professional team. This study investigated the influence of simulation training on four specific skills: self-confidence, handling of emergency situation, knowledge of algorithms and team communication. Clinical algorithms were first presented to the participants. Training for six emergency situations (shoulder dystocia, postpartum haemorrhage, pre-eclampsia, maternal basic life support, neonatal resuscitation and operative vaginal birth) was performed using high- and low-fidelity simulation mannequins. General impression of the simulation training and the four above-mentioned skills were evaluated anonymously through a self-assessment questionnaire with a five-point Likert scale immediately after the training and 3 months later. From November 2010 to March 2012, 168 participants, distributed over six one-day courses, took part in the training. 156 participants returned the questionnaire directly after the course (92.9 %). The questionnaire return rate after 3 months was 36.3 %. The participants gave higher Likert scale answers for the questions on the four specific skills after 3 months compared to immediately after the course. The improvement was statistically significant (p ≤ 0.05) except for the question regarding team communication. Implementation of simulation training strengthens the professional competency.

  17. [Improving emergency department organisation].

    PubMed

    Yordanov, Youri; Beltramini, Alexandra; Debuc, Erwan; Pateron, Dominique

    2015-01-01

    Emergency departments use has been constantly increasing over the world. Overcrowding is defined as a situation which compromises patient safety because of delayed cares. This situation is often reached. Emergency departments have to continuously improve their organization to be able to ensure the same quality of care to a higher number of patients. Thus a good organization is essential: it doesn't always avoid overcrowding. The rest of the hospital has to be involved in this process to ensure efficiency. We examine the various interventions and procedures that can be found in medical literature for improving patients flow and management in emergency departments.

  18. Making It Happen: Training health-care providers in emergency obstetric and newborn care.

    PubMed

    Ameh, Charles A; van den Broek, Nynke

    2015-11-01

    An estimated 289,000 maternal deaths, 2.6 million stillbirths and 2.4 million newborn deaths occur globally each year, with the majority occurring around the time of childbirth. The medical and surgical interventions to prevent this loss of life are known, and most maternal and newborn deaths are in principle preventable. There is a need to build the capacity of health-care providers to recognize and manage complications during pregnancy, childbirth and the post-partum period. Skills-and-drills competency-based training in skilled birth attendance, emergency obstetric care and early newborn care (EmONC) is an approach that is successful in improving knowledge and skills. There is emerging evidence of this resulting in improved availability and quality of care. To evaluate the effectiveness of EmONC training, operational research using an adapted Kirkpatrick framework and a theory of change approach is needed. The Making It Happen programme is an example of this. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

  19. Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers' perspectives on training, referrals and supervision, a mixed methods study.

    PubMed

    Austin, Anne; Gulema, Hanna; Belizan, Maria; Colaci, Daniela S; Kendall, Tamil; Tebeka, Mahlet; Hailemariam, Mengistu; Bekele, Delayehu; Tadesse, Lia; Berhane, Yemane; Langer, Ana

    2015-03-29

    Increasing women's access to and use of facilities for childbirth is a critical national strategy to improve maternal health outcomes in Ethiopia; however coverage alone is not enough as the quality of emergency obstetric services affects maternal mortality and morbidity. Addis Ababa has a much higher proportion of facility-based births (82%) than the national average (11%), but timely provision of quality emergency obstetric care remains a significant challenge for reducing maternal mortality and improving maternal health. The purpose of this study was to assess barriers to the provision of emergency obstetric care in Addis Ababa from the perspective of healthcare providers by analyzing three factors: implementation of national referral guidelines, staff training, and staff supervision. A mixed methods approach was used to assess barriers to quality emergency obstetric care. Qualitative analyses included twenty-nine, semi-structured, key informant interviews with providers from an urban referral network consisting of a hospital and seven health centers. Quantitative survey data were collected from 111 providers, 80% (111/138) of those providing maternal health services in the same referral network. Respondents identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision as key barriers to provision of quality emergency obstetric care. Dedicated transportation and communication infrastructure, improvements in pre-service and in-service training, and supportive supervision are needed to maximize the effective use of existing human resources and infrastructure, thus increasing access to and the provision of timely, high quality emergency obstetric care in Addis Ababa, Ethiopia.

  20. Program note: applying the UN process indicators for emergency obstetric care to the United States.

    PubMed

    Lobis, S; Fry, D; Paxton, A

    2005-02-01

    The United Nations Process Indicators for emergency obstetric care (EmOC) have been used extensively in countries with high maternal mortality ratios (MMR) to assess the availability, utilization and quality of EmOC services. To compare the situation in high MMR countries to that of a low MMR country, data from the United States were used to determine EmOC service availability, utilization and quality. As was expected, the United States was found to have an adequate amount of good-quality EmOC services that are used by the majority of women with life-threatening obstetric complications.

  1. Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi.

    PubMed

    Kongnyuy, Eugene J; Hofman, Jan; Mlava, Grace; Mhango, Chisale; van den Broek, Nynke

    2009-09-01

    To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.

  2. Strengthening emergency obstetric care in Thanh Hoa and Quang Tri provinces in Vietnam.

    PubMed

    Otchere, S A; Binh, H T

    2007-11-01

    Save the Children/USA and the Ministry of Health of Vietnam undertook a project between 2001 and 2004 to improve the availability of, access to, quality and utilization of emergency obstetric care (EmOC) services at district and provincial hospitals in two provinces in Vietnam. The project improved the functional capacity of 3 provincial and 1 district hospitals providing comprehensive EmOC services, and upgraded 1 district hospital providing basic EmOC into a comprehensive EmOC facility through training, infrastructure and quality improvement. Data presented in this paper focus on only the 2 district hospitals even though the UN process indicators showed increases in utilization of EmOC in all 5 hospitals. In the case of Hai Lang, the proportion of births increased from 13% at baseline to 31% at the end of 2004, and met need increased significantly from 16% to 87% largely due to increased capacity of the hospital and staff. Met need in Hoang Hoa hospital more than doubled (17% at baseline versus 54% in 2004) and the proportion of births increased slightly from 19% in 2001 to 22% in 2004. Case fatality rates for the two hospitals remarkably remained at zero. Lessons from this project have been incorporated into national policy and guidelines. Improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth can be realized in a relatively short period of time and is an essential element in reducing maternal mortality.

  3. Availability, utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria.

    PubMed

    Abegunde, Dele; Kabo, Ibrahim A; Sambisa, William; Akomolafe, Toyin; Orobaton, Nosa; Abdulkarim, Masduk; Sadauki, Habib

    2015-03-01

    To report the availability, utilization, and quality of emergency obstetric care (EmOC) services in Bauchi State, Nigeria. Between June and July 2012, a cross-sectional survey of health facilities was conducted. Data on the performance of EmOC services between June 2011 and May 2012 were obtained from records of 20 general hospitals and 39 primary healthcare centers providing delivery services. Additionally, structured interviews with facility managers were conducted. Only 6 (10.2%) of the 59 facilities met the UN requirements for EmOC centers. None of the three senatorial zones in Bauchi State had the minimum acceptable number of five EmOC facilities per 500 000 population. Overall, 10 517 (4.4%) of the estimated 239 930 annual births took place in EmOC facilities. Cesarean delivery accounted for 3.6% (n=380) of the 10 517 births occurring in EmOC facilities and 0.2% of the 239 930 expected live births. Only 1416 (3.9%) of the expected 35 990 obstetric complications were managed in EmOC facilities. Overall, 45 (3.2%) of 1416 women with major direct obstetric complications treated at EmOC facilities died. Among 379 maternal deaths, 317 (83.6%) were attributable to major direct obstetric complications. Availability, utilization, and quality of EmOC services in Bauchi State, Nigeria, are suboptimal. The health system's capacity to manage emergency obstetric complications needs to be strengthened. Copyright © 2014 International Federation of Gynecology and Obstetrics. All rights reserved.

  4. Availability and use of emergency obstetric care services in four districts of West Bengal, India.

    PubMed

    Biswas, Akhil Bandhu; Das, Dilip Kumar; Misra, Raghunath; Roy, Rabindra Nath; Ghosh, Debdatta; Mitra, Kaninika

    2005-09-01

    Process indicators have been recommended for monitoring the availability and use of emergency obstetric care (EmOC) services. A health facility-based study was carried out in 2002 in four districts of West Bengal, India, to analyze these process indicators. Relevant records and registers for 2001 of all studied facilities in the districts were reviewed to collect data using a pre-designed schedule. The numbers of basic and comprehensive EmOC facilities were inadequate in all the four districts compared to the minimum acceptable level. Overall, 26.2% of estimated annual births took place in the EmOC facilities (ranged from 16.2% to 45.8% in 4 districts) against the required minimum of 15%. The rate of caesarean section calculated for all expected births in the population varied from 3.5% to 4.4% in the four districts with an overall rate of 4%, which is less than the minimum target of 5%. Only 29.9% of the estimated number of complications (which is 15% of all births) was managed in the EmOC facilities. The combined case-fatality rate in the basic/comprehensive EmOC facilities was 1.7%. Major obstetric complications contributed to 85.7% of maternal deaths, and pre-eclampsia/eclampsia was the most common cause. It can be concluded that all the process indicators, except proportion of deliveries in the EmOC facilities, were below the acceptable level. Certain priority measures, such as making facilities fully functional, effective referral and monitoring system, skill-based training, etc., are to be emphasized to improve the situation.

  5. Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda.

    PubMed

    Pearson, L; Shoo, R

    2005-02-01

    The article summarises the baseline assessments of emergency obstetric care (EmOC) carried out in Uganda, Kenya, Southern Sudan, and Rwanda in 2003 and 2004. Our objectives were to: (1) set up program baselines on the availability and utilization of EmOC services in these countries; (2) identify gaps and obstacles in providing EmOC services; and (3) make recommendations to governments based on evidence generated. Data were collected from clinical record reviews, provider and client interviews, observations, and focus group discussions. Either random or universal sampling was applied in the selection of health facilities assessed. Local nurses and midwives participated in the data collection and, to some extent, data processing and analysis. The coverage of basic EmOC services ranged 0-1.1/500,000 population compared to the UN-recommended level of 4/500,000. The coverage of comprehensive EmOC services ranged 0.5-4.3/500,000 compared to the recommended level of 1/500,000. Between 0.6% and 8.8% of all births took place in EmOC facilities, and 2.1% and 18.5% of all expected direct obstetric complications were treated. Cesarean section as a proportion of all births was between 0.1% and 1%. Shortage of trained staff especially mid-level providers, poor basic infrastructure such as lack of electricity and water supplies, inadequate supply of drugs and essential equipment, poor working conditions and staff morale, lack of communication and referral facilities, cost of treatment, and lack of accountability and proper management were identified as the main obstacles in providing 24-h quality EmOC services especially in remote and rural areas. Lack of basic EmOC services limits women's access to life-saving services during obstetric complications. To reduce maternal mortality ratio the states and development partners need to focus their effort to improve the coverage, quality, and utilization of EmOC services through supportive national policy, effective program strategies

  6. Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality?

    PubMed Central

    Olsen, Øystein Evjen; Ndeki, Sidney; Norheim, Ole Frithjof

    2005-01-01

    Background Health care agencies report that the major limiting factor for implementing effective health policies and reforms worldwide is a lack of qualified human resources. Although many agencies have adopted policy development and clinical practice guidelines, the human resources necessary to carry out these policies towards actual reform are not yet in place. Objectives The goal of this article is to evaluate the current status of human resources quality, availability and distribution in Northern Tanzania in order to provide emergency obstetric care services to specific districts in this area. The article also discusses the usefulness of distribution indicators for describing equity in the decision-making process. Methods We conducted a quantitative facility survey in six districts of Northern Tanzania. We collected data from all 129 facilities that provide delivery services in the study area. The data includes information on the emergency obstetric care indicators, as described by the WHO/UNICEF/UFPA guidelines for monitoring the provision of obstetric care. The inventory also includes information on the numbers of qualified health personnel at the basic and comprehensive emergency obstetric care level. We analysed the distribution and workload of the available human resources in a wider policy context with a particular focus on equity, use and quality, by means of descriptive statistics and the Spearman's correlation test. Results We determined that there are adequate human resources allocated for health care provision in Tanzania, according to national standards. Compared to similar countries however, Tanzania has a very low availability of health care staff. Most qualified staff are concentrated in a few centralized locations, while those remaining are inequitably and inefficiently distributed in rural areas and lower-level services. Rural districts have restricted access to government-run health care, because these facilities are understaffed. In fact

  7. Opinion of women on emergency obstetric care provided in public facilities in Lagos, Nigeria: A qualitative study.

    PubMed

    Wright, Kikelomo; Banke-Thomas, Aduragbemi; Sonoiki, Olatunji; Ajayi, Babatunde; Ilozumba, Onaedo; Akinola, Oluwarotimi

    2017-06-01

    Limited attention has been given to opinions of women receiving emergency obstetric care (EmOC) in developing countries. We organized focus groups with 39 women who received this care from Lagos public facilities. Availability of competent personnel and equipment were two positive opinions highlighted. Contrarily, women expressed concerns regarding the seeming unresponsiveness of the service to nonmedical aspects of care, associated stress of service utilization, and high treatment costs. There is a need to leverage the positive perception of women regarding the available technical resources while improving institutional care components like administrative processes, basic amenities, and costs toward increasing utilization and preventing complications.

  8. [Preeclampsia and HELLP syndrome as an obstetric emergency].

    PubMed

    Tallarek, A-C; Stepan, H

    2012-03-01

    Preeclampsia and HELLP syndrome are multisystemic hypertensive disorders in pregnancy. A causative treatment is not yet available. The obstetrician has to choose between the risk of prolongation of pregnancy for mother and fetus on the one hand and the hazard of prematurity on the other, when iatrogenic delivery is considered. As the clinical severity and progression of both diseases is very difficult to predict, an emergency situation can develop rapidly and unexpectedly. In this scenario a good interdisciplinary cooperation between obstetricians and intensive care physicians ensures an optimal outcome for the pregnant woman. This article gives an insight into both diseases and the clinical management.

  9. Medication errors in the obstetrics emergency ward in a low resource setting.

    PubMed

    Kandil, Mohamed; Sayyed, Tarek; Emarh, Mohamed; Ellakwa, Hamed; Masood, Alaa

    2012-08-01

    To investigate the patterns of medication errors in the obstetric emergency ward in a low resource setting. This prospective observational study included 10,000 women who presented at the obstetric emergency ward, department of Obstetrics and Gynecology, Menofyia University Hospital, Egypt between March and December 2010. All medications prescribed in the emergency ward were monitored for different types of errors. The head nurse in each shift was asked to monitor each pharmacologic order from the moment of prescribing till its administration. Retrospective review of the patients' charts and nurses' notes was carried out by the authors of this paper. Results were tabulated and statistically analyzed. A total of 1976 medication errors were detected. Administration errors were the commonest error reported. Omitted errors ranked second followed by unauthorized and prescription errors. Three administration errors resulted in three Cesareans were performed for fetal distress because of wrong doses of oxytocin infusion. The rest of errors did not cause patients harm but may have lead to an increase in monitoring. Most errors occurred during night shifts. The availability of automated infusion pumps will probably decrease administration errors significantly. There is a need for more obstetricians and nurses during the nightshifts to minimize errors resulting from working under stressful conditions.

  10. Emergency obstetric care availability, accessibility and utilization in eight districts in Pakistan's North West Frontier Province.

    PubMed

    Ali, Moazzam; Ayaz, Mohammad; Rizwan, Humayun; Hashim, Saima; Kuroiwa, Chushi

    2006-01-01

    Reducing maternal mortality is a critical issue in Pakistan. Do public health care centers in Pakistan's North West Frontier Province (NWFP) comply with minimum UN recommendations for availability, use, and quality of basic and comprehensive Emergency Obstetric Care (EmOC) as measured by UN process indicators? All public health facilities providing EmOC (n = 50) in 30% of districts in NWFP province (n = 8 districts) sampled randomly in September 2003 were included in a cross-sectional study. Data came from health facility records. Almost all indicators were below minimum recommended UN levels. The number of facilities providing basic EmOC services was much too low to be called providing comprehensive coverage. A low percentage of births took place in hospital and few women with complications reached EmOC facilities. Caesarean section was either underutilized or unavailable. The case fatality rate was low, perhaps due to poor record-keeping. The findings of this first needs assessment in NWFP province can serve as a benchmark for monitoring future progress. In resource-poor countries like Pakistan, it is important to upgrade existing facilities, giving special emphasis to facilities that provide basic EmOC services, since many problems can be resolved at the most basic level. Health policy makers and planners need to take immediate, appropriate rectifying measures to, inter alia, improve staffing in rural areas, enhance staff skills through training, upgrade management and supervision, ensure medical supply availability, mandate proper record-keeping, and observe progress by monitoring process indicators regularly.

  11. Maternal and fetal outcome of obstetric emergencies in a tertiary health institution in South-Western Nigeria.

    PubMed

    Mustafa Adelaja, Lamina; Olufemi Taiwo, Oladapo

    2011-01-01

    Objective. This study was carried out to determine the pattern of obstetric emergencies and its influence on maternal and perinatal outcome of obstetric emergencies at the Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria. Method. A retrospective study of obstetric emergencies managed over a three-year period at Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria was conducted. Results. There were 262 obstetric emergencies accounting for 18.5% of the 1420 total deliveries during the period. Unbooked patients formed the bulk of the cases (60.3%). The most common emergencies were prolonged/obstructed labour, postpartum haemorrhage, fetal distress, severe pregnancy-induced hypertension/eclampsia, and antepartum haemorrhage. Obstetric emergencies were responsible for 70.6% of the maternal mortality and 86% of the perinatal mortality within the period. Conclusion. Prevention/effective management of obstetric emergencies will help to reduce maternal and perinatal mortality in our environment. This can be achieved through the utilization of antenatal care services, making budget for pregnancies and childbirth at family level (pending the time every family participates in National Health Insurance Scheme), adequate funding of social welfare services to assist indigent patients, liberal blood donation, and regular training of doctors and nurses on this subject.

  12. Modification of Obstetric Emergency Simulation Scenarios for Realism in a Home-Birth Setting.

    PubMed

    Komorowski, Janelle; Andrighetti, Tia; Benton, Melissa

    2017-01-01

    Clinical competency and clear communication are essential for intrapartum care providers who encounter high-stakes, low-frequency emergencies. The challenge for these providers is to maintain infrequently used skills. The challenge is even more significant for midwives who manage births at home and who, due to low practice volume and low-risk clientele, may rarely encounter an emergency. In addition, access to team simulation may be limited for home-birth midwives. This project modified existing validated obstetric simulation scenarios for a home-birth setting. Twelve certified professional midwives (CPMs) in active home-birth practice participated in shoulder dystocia and postpartum hemorrhage simulations. The simulations were staged to resemble home-birth settings, supplies, and personnel. Fidelity (realism) of the simulations was assessed with the Simulation Design Scale, and satisfaction and self-confidence were assessed with the Student Satisfaction and Self-Confidence in Learning Scale. Both utilized a 5-point Likert scale, with higher scores suggesting greater levels of fidelity, participant satisfaction, and self-confidence. Simulation Design Scale scores indicated participants agreed fidelity was achieved for the home-birth setting, while scores on the Student Satisfaction and Self-Confidence in Learning indicated high levels of participant satisfaction and self-confidence. If offered without modification, simulation scenarios designed for use in hospitals may lose fidelity for home-birth midwives, particularly in the environmental and psychological components. Simulation is standard of care in most settings, an excellent vehicle for maintaining skills, and some evidence suggests it results in improved perinatal outcomes. Additional study is needed in this area to support home-birth providers in maintaining skills. This pilot study suggests that simulation scenarios intended for hospital use can be successfully adapted to the home-birth setting. © 2016 by

  13. Contemporary Obstetric Triage.

    PubMed

    Sandy, Edward Allen; Kaminski, Robert; Simhan, Hygriv; Beigi, Richard

    2016-03-01

    The role of obstetric triage in the care of pregnant women has expanded significantly. Factors driving this change include the Emergency Medical Treatment and Active Labor Act, improved methods of testing for fetal well-being, increasing litigation risk, and changes in resident duty hour guidelines. The contemporary obstetric triage facility must have processes in place to provide a medical screening examination that complies with regulatory statues while considering both the facility's maternal level of care and available resources. This review examines the history of the development of obstetric triage, current considerations in a contemporary obstetric triage paradigm, and future areas for consideration. An example of a contemporary obstetric triage program at an academic medical center is presented. A successful contemporary obstetric triage paradigm is one that addresses the questions of "sick or not sick" and "labor or no labor," for every obstetric patient that presents for care. Failure to do so risks poor patient outcome, poor patient satisfaction, adverse litigation outcome, regulatory scrutiny, and exclusion from federal payment programs. Understanding the role of contemporary obstetric triage in the current health care environment is important for both providers and health care leadership. This study is for obstetricians and gynecologists as well as family physicians. After completing this activity, the learner should be better able to understand the scope of a medical screening examination within the context of contemporary obstetric triage; understand how a facility's level of maternal care influences clinical decision making in a contemporary obstetric triage setting; and understand the considerations necessary for the systematic evaluation of the 2 basic contemporary obstetric questions, "sick or not sick?" and "labor or no labor?"

  14. Emergency peripartum hysterectomy in a tertiary obstetric center: nine years evaluation.

    PubMed

    Demirci, Oya; Tuğrul, Ahmet S; Yilmaz, Ertuğrul; Tosun, Özgür; Demirci, Elif; Eren, Yadigar S

    2011-08-01

    The aim of this study was to estimate the incidence, indications, risk factors, complications, and maternal morbidity and mortality associated with obstetric hysterectomy performed at the Zeynep Kamil Gynecologic and Pediatric Training and Research Hospital between January 2000 and January 2008. A retrospective study of patients requiring an emergency peripartum hysterectomy (EPH) over a 9-year period was conducted. Emergent peripartum hysterectomy was defined as an operation performed in cases whose bleeding was not prevented by other approaches for 24 h after delivery. Thirty-nine cases of emergency peripartum hysterectomy were performed. The incidence of emergency peripartum hysterectomy was 0.37 per 1000 deliveries. Thirty-four cases of hysterectomy were performed after cesarean section (CS). The main indication for EPH was placenta accreta (53.8%), followed by uterine atony (25.6%). There were six maternal deaths (15.4%). Severe maternal morbidity included: bladder injury (15.4%), relaparotomy (35.4%), and transfusion >10 unit's red blood cells (15.6%). Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta; the relative ratio increased from 3.6 for one previous CS to 37 for three or more previous CS. Emergency peripartum hysterectomy is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform peripartum hysterectomy. EPH is associated with a high incidence of maternal morbidity and mortality. © 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.

  15. Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature.

    PubMed

    Dogba, Maman; Fournier, Pierre

    2009-02-06

    This paper reports on a systematic literature review exploring the importance of human resources in the quality of emergency obstetric care and thus in the reduction of maternal deaths. A systematic search of two electronic databases (ISI Web of Science and MEDLINE) was conducted, based on the following key words "quality obstetric* care" OR "pregnancy complications OR emergency obstetric* care OR maternal mortality" AND "quality health care OR quality care" AND "developing countries. Relevant papers were analysed according to three customary components of emergency obstetric care: structure, process and results. This review leads to three main conclusions: (1) staff shortages are a major obstacle to providing good quality EmOC; (2) women are often dissatisfied with the care they receive during childbirth; and (3) the technical quality of EmOC has not been adequately studied. The first two conclusions provide lessons to consider when formulating EmOC policies, while the third point is an area where more knowledge is needed.

  16. A State-Wide Obstetric Hemorrhage Quality Improvement Initiative

    PubMed Central

    Bingham, Debra; Lyndon, Audrey; Lagrew, David; Main, Elliott K.

    2011-01-01

    Purpose The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and promote equitable maternity care in California. This article describes CMQCC’s statewide multi-stakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project Design and Approach In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multi-disciplinary, multi-stakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project Description The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multi-level strategy to disseminate the guideline, including an open access toolkit, a minimal support mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical Implications In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 or greater hemorrhage, hosting skills stations for measuring blood loss, and running OB hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the state-wide initiative where nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a

  17. Low cost, high yield: simulation of obstetric emergencies for family medicine training.

    PubMed

    Magee, Susanna R; Shields, Robin; Nothnagle, Melissa

    2013-01-01

    Simulation is now the educational standard for emergency training in residency and is particularly useful on a labor and delivery unit, which is often a stressful environment for learners given the frequency of emergencies. However, simulation can be costly. This study aimed to assess the feasibility and effectiveness of low-cost simulated obstetrical emergencies in training family medicine residents. The study took place in a community hospital in an urban underserved setting in the northeast United States. Low-cost simulations were developed for postpartum hemorrhage (PPH) and preeclampsia/eclampsia (PEC). Twenty residents were randomly assigned to the intervention (simulated PPH or PEC followed by debriefing) or control (lecture on PPH or PEC) group, and equal numbers of residents were assigned to each scenario. All participants completed a written test at baseline and an oral exam 6 months later on the respective scenario to which they were assigned. The participants provided written feedback on their respective teaching interventions. We compared performance on pretests and posttests by group using Wilcoxon Rank Sum. Twenty residents completed the study. Both groups performed similarly on baseline tests for both scenarios. Compared to controls, intervention residents scored significantly higher on the examination on the management of PPH but not for PEC. All intervention group participants reported that the simulation training was "extremely useful," and most found it "enjoyable." We demonstrated the feasibility and acceptability of two low-cost obstetric emergency simulations and found that they may result in persistent increases in trainee knowledge.

  18. Affordability of emergency obstetric and neonatal care at public hospitals in Madagascar.

    PubMed

    Honda, Ayako; Randaoharison, Pierana Gabriel; Matsui, Mitsuaki

    2011-05-01

    Timely access to emergency obstetric care is necessary to save the lives of women experiencing complications at delivery, and for newborn babies. Out-of-pocket costs are one of the critical factors hindering access to such services in low- and middle-income countries. This study measured out-of-pocket costs for caesarean section and neonatal care at an urban tertiary public hospital in Madagascar, assessed affordability in relation to household expenditure and investigated where families found the money to cover these costs. Data were collected for 103 women and 73 newborns at the Centre Hospitalier Universitaire de Mahajanga in the Boeny region of Madagascar between September 2007 and January 2008. Out-of-pocket costs for caesarean section were catastrophic for middle and lower socio-economic households, and treatment for neonatal complications also created a big financial burden, with geographical and other financial barriers further limiting access to hospital care. This study identified 12 possible cases where the mother required an emergency caesarean section and her newborn required emergency care, placing a double burden on the household. In an effort to make emergency obstetric and neonatal care affordable and available to all, including those living in rural areas and those of medium and lower socio-economic status, well-designed financial risk protection mechanisms and a strong commitment by the government to mobilise resources to finance the country's health system are necessary.

  19. Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

    PubMed Central

    Zachariah, R.; Kumar, A. M. V.; Trelles, M.; Caluwaerts, S.; van den Boogaard, W.; Manirampa, J.; Tayler-Smith, K.; Manzi, M.; Nanan-N’zeth, K.; Duchenne, B.; Ndelema, B.; Etienne, W.; Alders, P.; Veerman, R.; Van den Bergh, R.

    2017-01-01

    Objectives In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. Methods A retrospective analysis of EmOC data (2011 and 2012). Results A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by ‘general practitioners with surgical skills’ and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Conclusion Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa. PMID:28170398

  20. Multidisciplinary Delphi Development of a Scale to Evaluate Team Function in Obstetric Emergencies: The PETRA Scale.

    PubMed

    Balki, Mrinalini; Hoppe, David; Monks, David; Cooke, Mary Ellen; Sharples, Lynn; Windrim, Rory

    2017-06-01

    The objective of this study was to develop a new interdisciplinary teamwork scale, the Perinatal Emergency: Team Response Assessment (PETRA), for the management of obstetric crises, through consensus agreement of obstetric caregivers. This prospective study was performed using expert consensus, based on a Delphi method. The study investigators developed a new PETRA tool, specifically related to obstetric crisis management, based on the existing literature and discussions among themselves. The scale was distributed to a selected panel of experts in the field for the Delphi process. After each round of Delphi, every component of the scale was analyzed quantitatively by the percentage of agreement ratings and each comment reviewed by the blinded investigators. The assessment scale was then modified, with components of less than 80% agreement removed from the scale. The process was repeated on three occasions to reach a consensus and final PETRA scale. Fourteen of 24 invited experts participated in the Delphi process. The original PETRA scale included six categories and 48 items, one global scale item, and a 3-point rubric for rating. The overall percentage agreement by experts in the first, second, and third rounds was 95.0%, 93.2%, and 98.5%, respectively. The final scale after the third round of Delphi consisted of the following seven categories: shared mental model, communication, situational awareness, leadership, followership, workload management, and positive/effective behaviours and attitudes. There were 34 individual items within these categories, each with a 5-point rating rubric (1 = unacceptable to 5 = perfect). Using a structured Delphi method, we established the face and content validity of this assessment scale that focuses on important aspects of interdisciplinary teamwork in the management of obstetric crises. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada

  1. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals.

    PubMed

    Filippi, Veronique; Ronsmans, Carine; Gohou, Valerie; Goufodji, Sourou; Lardi, Mohamed; Sahel, Amina; Saizonou, Jacques; De Brouwere, Vincent

    2005-01-01

    This study examines near-miss obstetric events in African hospitals as to the frequency, nature, and ratio of near miss to death and considers whether these could become useful indicators for monitoring the performance of obstetric services in Africa. Prospective or retrospective reviews of medical records were conducted in nine referral hospitals in three countries (Benin, Côte d'Ivoire, and Morocco). We calculated the incidence of near-miss obstetric events, near-miss cases, and maternal deaths related to hemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia and analyzed these according to hospital and timing relative to admission. The incidence of near-miss cases was varied, and in some hospitals extremely large: from 1% to almost a quarter of all deliveries were near misses. Near-miss cases were 15 times more common than deaths (ranging from a ratio of 9:1-108:1). Most of the women with near-miss events (NMEs) (83%) were already in a critical condition on arrival at the hospital (range 54-90%), and two in three were referred from another facility. The most frequent types of NMEs were hemorrhage and hypertensive diseases of pregnancy, but anemia was the leading cause in three first referral level hospitals in Benin and Côte d'Ivoire. Near-miss events due to infections were rare. Near-miss events are extremely common in some African hospitals, with a high proportion arriving in critical conditions. Near-miss events must be estimated separately for those already in a critical condition on arrival and those developing after admission; the first as a good indicator of the effectiveness of emergency referrals and the second as a potential tool for monitoring the performance of obstetric services.

  2. Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

    PubMed

    De Plecker, E; Zachariah, R; Kumar, A M V; Trelles, M; Caluwaerts, S; van den Boogaard, W; Manirampa, J; Tayler-Smith, K; Manzi, M; Nanan-N'zeth, K; Duchenne, B; Ndelema, B; Etienne, W; Alders, P; Veerman, R; Van den Bergh, R

    2017-01-01

    In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. A retrospective analysis of EmOC data (2011 and 2012). A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.

  3. Implementation of a modified obstetric early warning system to improve the quality of obstetric care in Zimbabwe.

    PubMed

    Merriel, Abi; Murove, Bobb T; Merriel, Samuel W D; Sibanda, Thabani; Moyo, Sikangezile; Crofts, Joanna

    2017-02-01

    To implement a modified obstetric early warning system (MOEWS) to promote identification and stabilization of unwell women. A before-and-after study of MOEWS implementation took place between April 2013 and January 2014 in a government referral hospital in Bulawayo, Zimbabwe. After piloting MOEWS, cesarean case files were retrospectively assessed to compare preoperative stabilization. A longitudinal "spot-check" study measured use of MOEWS and action taken on abnormal results. A quality indicator was introduced to assess ongoing implementation. Analysis of women undergoing cesarean before (n=79) and after (n=85) MOEWS implementation showed that preoperative stabilization improved significantly post-intervention (odds ratio 2.78, 95% confidence interval 1.39-5.54). The longitudinal analysis of women at baseline (n=43) and after (n=85) MOEWS implementation also showed a significant improvement in action taken (1/24 [4%] vs 28/45 [62%]; P=0.001). The 6-month aggregated quality indicator revealed that 78 (62%) of 125 patients had a completed MOEWS chart, with appropriate stabilization of 65 (93%) of 70 women. Implementation of MOEWS improved women's care through action being taken on abnormal observations. Before whole-scale adoption of MOEWS in low-resource settings, the study should be scaled up and repeated to ensure replicable findings. © 2016 International Federation of Gynecology and Obstetrics.

  4. Distance to emergency obstetric services and early neonatal mortality in Ethiopia.

    PubMed

    McKinnon, Britt; Harper, Sam; Kaufman, Jay S; Abdullah, Muna

    2014-07-01

    To assess the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality in rural Ethiopia and examine whether proximity to services contributes to socio-economic inequalities in early neonatal mortality. We linked data from the 2011 Ethiopian Demographic and Health Survey with facility data from the 2008 Ethiopian National EmONC Needs Assessment based on geographical coordinates collected in both surveys. Health facilities were classified based on the performance of nine EmONC signal functions (e.g. neonatal resuscitation, Caesarean section). We used multivariable logistic regression to assess the relationship between distance to services and early neonatal mortality. A decomposition approach was used to quantify the relative contributions of distance to EmONC services and other determinants to overall and socio-economic inequality in early neonatal mortality. In general, closer proximity to EmONC services and higher level of care were associated with lower early neonatal mortality. Living more than 80 km from the nearest comprehensive EmONC facility able to perform all nine signal functions compared to living within 10 km was associated with an increase of 14.4 early neonatal deaths per 1000 live births (95% CI: 0.1, 28.7). Closer proximity to a substandard EmONC facility compared with no facility was not associated with lower early neonatal mortality. Distance to EmONC services was an important determinant of early neonatal mortality, although it did not make a significant contribution to explaining socio-economic inequality. Our results suggest that recent initiatives by the Ethiopian government to improve geographical access to EmONC services have the potential to reduce early neonatal mortality but may not affect inequalities. © 2014 John Wiley & Sons Ltd.

  5. The global met need for emergency obstetric care: a systematic review.

    PubMed

    Holmer, H; Oyerinde, K; Meara, J G; Gillies, R; Liljestrand, J; Hagander, L

    2015-01-01

    Of the 287,000 maternal deaths every year, 99% happen in low- and middle-income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as 'Met need for EmOC'. To estimate the global met need for EmOC and to examine the correlation between met need, maternal mortality ratio and other indicators. A systematic review was performed according to the PRISMA guidelines. Searches were made in PubMed, EMBASE and Google Scholar. Studies containing data on met need in EmOC were selected. Analysis was performed with data extracted from 62 studies representing 51 countries. World Bank data were used for univariate and multiple linear regression. Global met need for EmOC was 45% (IQR: 28-57%), with significant disparity between low- (21% [12-31%]), middle- (32% [15-56%]), and high-income countries (99% [99-99%]), (P = 0.041). This corresponds to 11.4 million (8.8-14.8) untreated complications yearly and 951 million (645-1174 million) women without access to EmOC. We found an inverse correlation between met need and maternal mortality ratio (r = -0.42, P < 0.001). Met need was significantly correlated with the proportion of births attended by skilled birth attendants (β = 0.53 [95% CI 0.41-0.65], P < 0.001). The results suggest a considerable inadequacy in global met need for EmOC, with vast disparities between countries of different income levels. Met need is a powerful indicator of the response to maternal mortality and strategies to improve EmOC act in synergy with the expansion of skilled birth attendance. © 2014 Royal College of Obstetricians and Gynaecologists.

  6. Recommendations for renovating an operating theater at an emergency obstetric care facility.

    PubMed

    Abreu, E; Potter, D

    2001-12-01

    The importance of emergency obstetric care (EmOC) in reducing maternal mortality has focused attention on both the skills of the clinicians to provide high quality care and on the health facilities in which the care is provided. Essential elements of EmOC include the capacity to perform cesarean sections for which an operating theater is needed. This article focuses on renovation of existing operating theaters to meet the necessary standards. While building, adding to, or renovating operating theaters can be expensive, this article emphasizes appropriate materials that are likely to be locally available and relatively inexpensive. The importance of proper maintenance is discussed.

  7. Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care.

    PubMed

    Hussein, Julia; Hirose, Atsumi; Owolabi, Oluwatoyin; Imamura, Mari; Kanguru, Lovney; Okonofua, Friday

    2016-04-22

    Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria's high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care. We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000-2014. A 'best-fit' framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score. Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services. Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

  8. Status of Emergency Obstetric Care in Six Developing Countries Five Years before the MDG Targets for Maternal and Newborn Health

    PubMed Central

    Ameh, Charles; Msuya, Sia; Hofman, Jan; Raven, Joanna; Mathai, Matthews; van den Broek, Nynke

    2012-01-01

    Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline. PMID:23236357

  9. Emergency obstetric care availability: a critical assessment of the current indicator.

    PubMed

    Gabrysch, Sabine; Zanger, Philipp; Campbell, Oona M R

    2012-01-01

    Monitoring progress in reducing maternal and perinatal mortality requires suitable indicators. The density of emergency obstetric care (EmOC) facilities has been proposed as a potentially useful indicator, but different UN documents make inconsistent recommendations, and its current formulation is not associated with maternal mortality. We compiled recently published indicator benchmarks and distinguished three sources of inconsistency: (i) use of different denominator metrics (per birth and per population), (ii) different assumptions on need for EmOC and for EmOC facilities and (iii) failure to specify facility capacity (birth load). The UN guidelines and handbook require fewer EmOC facilities than the World Health Report 2005 and do not specify capacity for deliveries or staffing levels. We recommend (i) always using births as the denominator for EmOC facility density, (ii) clearly stating assumptions on the proportion of deliveries needing basic and comprehensive emergency obstetric care and the desired proportion of deliveries in EmOC facilities and (iii) specifying facility capacity and staffing and adapting benchmarks for settings with different population density to ensure geographical accessibility.

  10. What is needed for taking emergency obstetric and neonatal programmes to scale?

    PubMed

    Bergh, Anne-Marie; Allanson, Emma; Pattinson, Robert C

    2015-11-01

    Scaling up an emergency obstetric and neonatal care (EmONC) programme entails reaching a larger number of people in a potentially broader geographical area. Multiple strategies requiring simultaneous attention should be deployed. This paper provides a framework for understanding the implementation, scale-up and sustainability of such programmes. We reviewed the existing literature and drew on our experience in scaling up the Essential Steps in the Management of Obstetric Emergencies (ESMOE) programme in South Africa. We explore the non-linear change process and conditions to be met for taking an existing EmONC programme to scale. Important concepts cutting across all components of a programme are equity, quality and leadership. Conditions to be met include appropriate awareness across the board and a policy environment that leads to the following: commitment, health systems-strengthening actions, allocation of resources (human, financial and capital/material), dissemination and training, supportive supervision and monitoring and evaluation. Copyright © 2015 Elsevier Ltd. All rights reserved.

  11. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care.

    PubMed

    McCord, C; Chowdhury, Q

    2003-04-01

    home treatment, or 2 for tetanus immunization of pregnant women. Sixty-two percent of the DALYS saved came from emergency obstetric care (EmOC) related activities. We conclude that cost effective basic hospital service can be added to immunization, family planning and other basic health services now available in countries like Bangladesh with a very low increase in total cost and that the benefits which would accrue, particularly for maternal and perinatal mortality, would be great.

  12. Governing the implementation of emergency obstetric care: experiences of rural district health managers, Tanzania.

    PubMed

    Mkoka, Dickson Ally; Kiwara, Angwara; Goicolea, Isabel; Hurtig, Anna-Karin

    2014-08-03

    Many health policies developed internationally often become adopted at the national level and are implemented locally at the district level. A decentralized district health system led by a district health management team becomes responsible for implementing such policies. This study aimed at exploring the experiences of a district health management team in implementing Emergency Obstetric Care (EmOC) related policies and identifying emerging governance aspects. The study used a qualitative approach in which data was obtained from thirteen individual interviews and one focus group discussion (FGD). Interviews were conducted with members of the district health management team, district health service boards and NGO representatives. The FGD included key informants who were directly involved in the work of implementing EmOC services in the district. Documentary reviews and observation were done to supplement the data. All the materials were analysed using a qualitative content analysis approach. Implementation of EmOC was considered to be a process accompanied by achievements and challenges. Achievements included increased institutional delivery, increased number of ambulances, training service providers in emergency obstetric care and building a new rural health centre that provides comprehensive emergency obstetric care. These achievements were associated with good leadership skills of the team together with partnerships that existed between different actors such as the Non-Governmental Organization (NGO), development partners, local politicians and Traditional Birth Attendants (TBAs). Most challenges faced during the implementation of EmOC were related to governance issues at different levels and included delays in disbursement of funds from the central government, shortages of health workers, unclear mechanisms for accountability, lack of incentives to motivate overburdened staffs and lack of guidelines for partnership development. The study revealed that

  13. Governing the implementation of Emergency Obstetric Care: experiences of Rural District Health Managers, Tanzania

    PubMed Central

    2014-01-01

    Background Many health policies developed internationally often become adopted at the national level and are implemented locally at the district level. A decentralized district health system led by a district health management team becomes responsible for implementing such policies. This study aimed at exploring the experiences of a district health management team in implementing Emergency Obstetric Care (EmOC) related policies and identifying emerging governance aspects. Methods The study used a qualitative approach in which data was obtained from thirteen individual interviews and one focus group discussion (FGD). Interviews were conducted with members of the district health management team, district health service boards and NGO representatives. The FGD included key informants who were directly involved in the work of implementing EmOC services in the district. Documentary reviews and observation were done to supplement the data. All the materials were analysed using a qualitative content analysis approach. Results Implementation of EmOC was considered to be a process accompanied by achievements and challenges. Achievements included increased institutional delivery, increased number of ambulances, training service providers in emergency obstetric care and building a new rural health centre that provides comprehensive emergency obstetric care. These achievements were associated with good leadership skills of the team together with partnerships that existed between different actors such as the Non-Governmental Organization (NGO), development partners, local politicians and Traditional Birth Attendants (TBAs). Most challenges faced during the implementation of EmOC were related to governance issues at different levels and included delays in disbursement of funds from the central government, shortages of health workers, unclear mechanisms for accountability, lack of incentives to motivate overburdened staffs and lack of guidelines for partnership development

  14. Emergency Obstetric Care in a Rural Hospital: On-call Specialists Can Manage C-sections.

    PubMed

    Ashtekar, Shyam V; Kulkarni, Madhav B; Ashtekar, Ratna S; Sadavarte, Vaishali S

    2012-07-01

    Institutional birth and Emergency Obstetric Care (EmOC) are important strategies of the National Rural Health Mission (NRHM). While the Community Health Center (CHC) is expected to serve EmOC needs in NRHM, the CHCs are hamstrung due to chronic shortage of specialist doctors. Alternative strategies are therefore needed for ensuring EmOC. This study aims to estimate the EmOC needs in a private rural hospital from case records and find some useful predictors for caesarian section (C-section) and to assess C-section needs in the context of on-call specialist support. We analyzed a two-decade series of 2587 obstetric cases in a private rural hospital for normal deliveries and EmOC including C-section. About 80% of the obstetric cases were normal deliveries. Of the remaining 20% cases that required EmOC, nearly one-third required C-section. In the series, two maternal deaths occurred due to hemorrhage. About 13% case records showed past abortion, which adds to EmOC workload. Primipararous mothers with higher age had a greater incidence (23%) of C-section. The C-section rate shows a steady rise from 3% to above 10% in the series. This rural hospital required C-section in 6.4% cases. This C-section workload was managed with the help of on-call specialists. The local hospital team could manage 93.6% of the cases and abortions with only two maternal deaths. This strategy of an on-call specialist team can be an option for CHCs till resident specialists are adequately available.

  15. Availability of emergency obstetric care (EmOC) among public and private health facilities in rural northwest Bangladesh.

    PubMed

    Sikder, Shegufta S; Labrique, Alain B; Ali, Hasmot; Hanif, Abu A M; Klemm, Rolf D W; Mehra, Sucheta; West, Keith P; Christian, Parul

    2015-01-31

    Although safe motherhood strategies recommend that women seek timely care from health facilities for obstetric complications, few studies have described facility availability of emergency obstetric care (EmOC). We sought to describe and compare availability and readiness to provide EmOC among public and private health facilities commonly visited for pregnancy-related complications in two districts of northwest Bangladesh. We also described aspects of financial and geographic access to healthcare and key constraints to EmOC provision. Using data from a large population-based community trial, we identified and surveyed the 14 health facilities (7 public, 7 private) most frequently visited for obstetric complications and near misses as reported by women. Availability of EmOC was based on provision of medical services, assessed through clinician interviews and record review. Levels of EmOC availability were defined as basic or comprehensive. Readiness for EmOC provision was based on scores in four categories: staffing, equipment, laboratory capacity, and medicines. Readiness scores were calculated using unweighted averages. Costs of C-section procedures and geographic locations of facilities were described. Textual analysis was used to identify key constraints. The seven surveyed private facilities offered comprehensive EmOC compared to four of the seven public facilities. With 100% representing full readiness, mean EmOC readiness was 81% (range: 63%-91%) among surveyed private facilities compared to 67% (range: 48%-91%) in public facilities (p = 0.040). Surveyed public clinics had low scores on staffing and laboratory capacity (69%; 50%). The mean cost of the C-section procedure in private clinics was $77 (standard deviation: $16) and free in public facilities. The public sub-district facilities were the only facilities located in rural areas, with none providing comprehensive EmOC. Shortages in specialized staff were listed as the main barrier to EmOC provision in

  16. Emergency Response Improvement Act

    THOMAS, 113th Congress

    Rep. Andrews, Robert E. [D-NJ-1

    2013-11-20

    11/21/2013 Referred to the Subcommittee on Economic Development, Public Buildings and Emergency Management. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  17. Emergency Response Improvement Act

    THOMAS, 113th Congress

    Rep. Andrews, Robert E. [D-NJ-1

    2013-11-20

    11/21/2013 Referred to the Subcommittee on Economic Development, Public Buildings and Emergency Management. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  18. Availability and distribution of, and geographic access to emergency obstetric care in Zambia.

    PubMed

    Gabrysch, Sabine; Simushi, Virginia; Campbell, Oona M R

    2011-08-01

    To assess the availability and coverage of emergency obstetric care (EmOC) services in Zambia. Reported provision of EmOC signal functions in the Zambian Health Facility Census and additional criteria on staffing, opening hours, and referral capacity were used to classify all Zambian health facilities as providing comprehensive EmOC, basic EmOC, or more limited care. Geographic accessibility of EmOC services was estimated by linking health facility data with data from the Zambian population census. Few Zambian health facilities provided all basic EmOC signal functions and had qualified health professionals available on a 24-hour basis. Of the 1131 Zambian delivery facilities, 135 (12%) were classified as providing EmOC. Zambia nearly met the UN EmOC density benchmarks nationally, but EmOC facilities and health professionals were unevenly distributed between provinces. Geographic access to EmOC services in rural areas was low; in most provinces, less than 25% of the population lived within 15 km of an EmOC facility. A national Health Facility Census with geographic information is a valuable tool for assessing service availability and coverage at national and subnational levels. Simultaneously assessing health worker density and geographic access adds crucial information. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  19. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome?

    PubMed

    Mekinian, Arsene; Costedoat-Chalumeau, Nathalie; Masseau, Agathe; Tincani, Angela; De Caroli, Sara; Alijotas-Reig, Jaume; Ruffatti, Amelia; Ambrozic, Ales; Botta, Angela; Le Guern, Véronique; Fritsch-Stork, Ruth; Nicaise-Roland, Pascale; Carbonne, Bruno; Carbillon, Lionel; Fain, Olivier

    2015-01-01

    The use of the conventional APS treatment (the combination of low-dose aspirin and LMWH) dramatically improved the obstetrical prognosis in primary obstetrical APS (OAPS). The persistence of adverse pregnancy outcome raises the need to find other drugs to improve obstetrical outcome. Hydroxychloroquine is widely used in patients with various autoimmune diseases, particularly SLE. Antimalarials have many anti-inflammatory, anti-aggregant and immune-regulatory properties: they inhibit phospholipase activity, stabilize lysosomal membranes, block the production of several pro-inflammatory cytokines and, in addition, impair complement-dependent antigen-antibody reactions. There is ample evidence of protective effects of hydroxychloroquine in OAPS similar to the situation in SLE arising from in vitro studies of pathophysiological working mechanism of hydroxychloroquine. However, the clinical data on the use of hydroxychloroquine in primary APS are lacking and prospective studies are necessary. Copyright © 2014 Elsevier B.V. All rights reserved.

  20. Where there is no anesthetist--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors.

    PubMed

    Mavalankar, Dileep; Callahan, Katie; Sriram, Veena; Singh, Prabal; Desai, Ajesh

    2009-12-01

    The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance. The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected. Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures. Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.

  1. Effect of high-fidelity shoulder dystocia simulation on emergency obstetric skills and crew resource management skills among residents.

    PubMed

    Mannella, Paolo; Palla, Giulia; Cuttano, Armando; Boldrini, Antonio; Simoncini, Tommaso

    2016-12-01

    To determine the effect of a simulation training program for residents in obstetrics and gynecology in terms of technical and nontechnical skills for the management of shoulder dystocia. A prospective study was performed at a center in Italy in April-May 2015. Thirty-two obstetrics and gynecology residents were divided into two groups. Residents in the control group were immediately exposed to an emergency shoulder dystocia scenario, whereas those in the simulation group completed a 2-hour training session with the simulator before being exposed to the scenario. After 8weeks, the residents were again exposed to the shoulder dystocia scenario and reassessed. Participants were scored on their demonstration of technical and nontechnical skills. In the first set of scenarios, the mean score was higher in the simulation group than the control group in terms of both technical skills (P=0.008) and nontechnical skills (P<0.001). This difference was retained after 8weeks. High-fidelity simulation programs could be used for the training of residents in obstetrics and gynecology to diagnose and manage obstetric emergencies such as shoulder dystocia. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  2. Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India?

    PubMed Central

    Vora, Kranti Suresh; Yasobant, Sandul; Patel, Amit; Upadhyay, Ashish; Mavalankar, Dileep V.

    2015-01-01

    Background The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Methods Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Results Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the

  3. Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India?

    PubMed

    Vora, Kranti Suresh; Yasobant, Sandul; Patel, Amit; Upadhyay, Ashish; Mavalankar, Dileep V

    2015-01-01

    Background The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public-private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Methods Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Results Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the

  4. Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India?

    PubMed

    Vora, Kranti Suresh; Yasobant, Sandul; Patel, Amit; Upadhyay, Ashish; Mavalankar, Dileep V

    2015-01-01

    The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public-private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services

  5. Crew Resource Management for Obstetric and Neonatal Teams to Improve Communication During Cesarean Births.

    PubMed

    Mancuso, Mary P; Dziadkowiec, Oliwier; Kleiner, Catherine; Halverson-Carpenter, Katherine; Link, Terri; Barry, James

    2016-01-01

    To assess the effectiveness of crew resource management training and interventions on the quality and quantity of communication during cesarean births in a tertiary academic hospital's labor and birthing services. A prospective pre-post crew resource management training intervention. Tertiary academic hospital in the Western United States. All members of obstetric and neonatal teams that participated in cesarean births. Over a 5-month time period, all obstetric and neonatal staff were required to participate in team training in crew resource management critical language, communication, and team structure. Trained observers collected baseline data (n = 52) for 3 months on the quantity and quality of communications that occurred during cesarean births. Postintervention data (n = 50) were gathered for 3 months after team training. Analysis approach included use of Fisher's exact test, independent-samples t test, and multilevel generalized linear regression models with Poisson distribution. There was a statistically significant increase in quantity and quality of communication from pre- to postintervention assessment for obstetric and neonatal staff. Although the increase in quality was similarly great between both types of teams, increase in quantity was more substantial in obstetric staff. Principles of team communication training shown to be effective in increasing communication among team members in a variety of clinical areas were also effective in improving communication in the labor and birth setting during cesarean births. Copyright © 2016 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

  6. BE-SAFE: Bedside sonography for assessment of the fetus in emergencies: educational intervention for late-pregnancy obstetric ultrasound.

    PubMed

    Shah, Sachita; Adedipe, Adeyinka; Ruffatto, Benjamin; Backlund, Brandon H; Sajed, Dana; Rood, Kari; Fernandez, Rosemarie

    2014-09-01

    Late obstetric emergencies are time critical presentations in the emergency department. Evaluation to ensure the safety of mother and child includes rapid assessment of fetal viability, fetal heart rate (FHR), fetal lie, and estimated gestational age (EGA). Point-of-care (POC) obstetric ultrasound (OBUS) offers the advantage of being able to provide all these measurements. We studied the impact of POC OBUS training on emergency physician (EP) confidence, knowledge, and OBUS skill performance on a live model. This is a prospective observational study evaluating an educational intervention we designed, called the BE-SAFE curriculum (BEdside Sonography for the Assessment of the Fetus in Emergencies). Subjects were a convenience sample of EP attendings (N=17) and residents (N=14). Prior to the educational intervention, participants completed a self-assessment survey on their confidence regarding OBUS, and took a pre-test to assess their baseline knowledge of OBUS. They then completed a 3-hour training session consisting of didactic and hands-on education in OBUS. After training, each subject's time and accuracy of performance of FHR, EGA, and fetal lie was recorded. Post-intervention knowledge tests and confidence surveys were administered. Results were compared with non-parametric t-tests. Pre- and post-test knowledge assessment scores for previously untrained EPs improved from 65.7% [SD=20.8] to 90% [SD=8.2] (p<0.0007). Self-confidence on a scale of 1-6 improved significantly for identification of FHR, fetal lie, and EGA. After training, the average times for completion of OBUS critical skills were as follows: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), and EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w6d) for the model's true gestational age of 27w0d. After a focused POC OBUS training intervention, the BE-SAFE educational intervention, EPs can accurately and rapidly use ultrasound to determine FHR, fetal lie, and estimate gestational age in mid

  7. [Non elective cesarean section: use of a color code to optimize management of obstetric emergencies].

    PubMed

    Rudigoz, René-Charles; Huissoud, Cyril; Delecour, Lisa; Thevenet, Simone; Dupont, Corinne

    2014-06-01

    The medical team of the Croix Rousse teaching hospital maternity unit has developed, over the last ten years, a set of procedures designed to respond to various emergency situations necessitating Caesarean section. Using the Lucas classification, we have defined as precisely as possible the degree of urgency of Caesarian sections. We have established specific protocols for the implementation of urgent and very urgent Caesarean section and have chosen a simple means to convey the degree of urgency to all team members, namely a color code system (red, orange and green). We have set time goals from decision to delivery: 15 minutes for the red code and 30 minutes for the orange code. The results seem very positive: The frequency of urgent and very urgent Caesareans has fallen over time, from 6.1 % to 1.6% in 2013. The average time from decision to delivery is 11 minutes for code red Caesareans and 21 minutes for code orange Caesareans. These time goals are now achieved in 95% of cases. Organizational and anesthetic difficulties are the main causes of delays. The indications for red and orange code Caesarians are appropriate more than two times out of three. Perinatal outcomes are generally favorable, code red Caesarians being life-saving in 15% of cases. No increase in maternal complications has been observed. In sum: Each obstetric department should have its own protocols for handling urgent and very urgent Caesarean sections. Continuous monitoring of their implementation, relevance and results should be conducted Management of extreme urgency must be integrated into the management of patients with identified risks (scarred uterus and twin pregnancies for example), and also in structures without medical facilities (birthing centers). Obstetric teams must keep in mind that implementation of these protocols in no way dispenses with close monitoring of labour.

  8. Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature

    PubMed Central

    Dogba, Maman; Fournier, Pierre

    2009-01-01

    Background This paper reports on a systematic literature review exploring the importance of human resources in the quality of emergency obstetric care and thus in the reduction of maternal deaths. Methods A systematic search of two electronic databases (ISI Web of Science and MEDLINE) was conducted, based on the following key words "quality obstetric* care" OR "pregnancy complications OR emergency obstetric* care OR maternal mortality" AND "quality health care OR quality care" AND "developing countries. Relevant papers were analysed according to three customary components of emergency obstetric care: structure, process and results. Results This review leads to three main conclusions: (1) staff shortages are a major obstacle to providing good quality EmOC; (2) women are often dissatisfied with the care they receive during childbirth; and (3) the technical quality of EmOC has not been adequately studied. The first two conclusions provide lessons to consider when formulating EmOC policies, while the third point is an area where more knowledge is needed. PMID:19200353

  9. Contracting in specialists for emergency obstetric care- does it work in rural India?

    PubMed Central

    2012-01-01

    Background Contracting in private sector is promoted in developing countries facing human resources shortages as a challenge to reduce maternal mortality. This study explored provision, practice, performance, barriers to execution and views about contracting in specialists for emergency obstetric care (EmOC) in rural India. Methods Facility survey was conducted in all secondary and tertiary public health facilities (44) in three heterogeneous districts in Maharashtra state of India. Interviews (42) were conducted with programme managers and district and block level officials and with public and private EmOC specialists. Locations of private obstetricians in the study districts were identified and mapped. Results Two schemes, namely Janani Suraksha Yojana and Indian Public Health standards (IPHS) provided for contracting in EmOC specialists. The IPHS provision was chosen for use mainly due to greater sum for contracting in (US $ 30/service episode vs.300 US$/month). The positions of EmOC specialists were vacant in 83% of all facilities that hence had a potential for contracting in EmOC specialists. Private specialists were contracted in at 20% such facilities. The contracting in of specialists did not greatly increase EmOC service outputs at facilities, except in facilities with determined leadership. Contracting in specialists was useful for non emergency conditions, but not for obstetric emergencies. The contracts were more of a relational nature with poor monitoring structures. Inadequate infrastructure, longer distance to private specialists, insufficient financial provision for contracting in, and poor management capacities were barriers to effective implementation of contracting in. Dependency on the private sector was a concern among public partners while the private partners viewed contracting in as an opportunity to gain experience and credibility. Conclusions Density and geographic distribution of private specialists are important influencing factors in

  10. Contracting in specialists for emergency obstetric care- does it work in rural India?

    PubMed

    Randive, Bharat; Chaturvedi, Sarika; Mistry, Nerges

    2012-12-31

    Contracting in private sector is promoted in developing countries facing human resources shortages as a challenge to reduce maternal mortality. This study explored provision, practice, performance, barriers to execution and views about contracting in specialists for emergency obstetric care (EmOC) in rural India. Facility survey was conducted in all secondary and tertiary public health facilities (44) in three heterogeneous districts in Maharashtra state of India. Interviews (42) were conducted with programme managers and district and block level officials and with public and private EmOC specialists. Locations of private obstetricians in the study districts were identified and mapped. Two schemes, namely Janani Suraksha Yojana and Indian Public Health standards (IPHS) provided for contracting in EmOC specialists. The IPHS provision was chosen for use mainly due to greater sum for contracting in (US $ 30/service episode vs.300 US$/month). The positions of EmOC specialists were vacant in 83% of all facilities that hence had a potential for contracting in EmOC specialists. Private specialists were contracted in at 20% such facilities. The contracting in of specialists did not greatly increase EmOC service outputs at facilities, except in facilities with determined leadership. Contracting in specialists was useful for non emergency conditions, but not for obstetric emergencies. The contracts were more of a relational nature with poor monitoring structures. Inadequate infrastructure, longer distance to private specialists, insufficient financial provision for contracting in, and poor management capacities were barriers to effective implementation of contracting in. Dependency on the private sector was a concern among public partners while the private partners viewed contracting in as an opportunity to gain experience and credibility. Density and geographic distribution of private specialists are important influencing factors in determining feasibility and use of

  11. Availability and Quality of Emergency Obstetric and Newborn Care in Bangladesh.

    PubMed

    Wichaidit, Wit; Alam, Mahbub-Ul; Halder, Amal K; Unicomb, Leanne; Hamer, Davidson H; Ram, Pavani K

    2016-08-03

    Bangladesh's maternal mortality and neonatal mortality remain unacceptably high. We assessed the availability and quality of emergency obstetric care (EmOC) and emergency newborn care (EmNC) services at health facilities in Bangladesh. We randomly sampled 50 rural villages and 50 urban neighborhoods throughout Bangladesh and interviewed the director of eight and nine health facilities nearest to each sampled area. We categorized health facilities into different quality levels (high, moderate, low, and substandard) based on staffing, availability of a phone or ambulance, and signal functions (six categories for EmOC and four categories for EmNC). We interviewed the directors of 875 health facilities. Approximately 28% of health facilities did not have a skilled birth attendant on call 24 hours per day. The least commonly performed EmOC signal function was administration of anticonvulsants (67%). The quality of EmOC services was high in 33% and moderate in 52% of the health facilities. The least common EmNC signal function was kangaroo mother care (7%). The quality of EmNC was high in 2% and moderate in 33% of the health facilities. Approximately one-third of health facilities lack 24-hour availability of skilled birth attendants, increasing the risk of peripartum complications. Most health facilities offered moderate to high quality services for EmOC and low to substandard quality for EmNC.

  12. Availability and Quality of Emergency Obstetric and Newborn Care in Bangladesh

    PubMed Central

    Wichaidit, Wit; Alam, Mahbub-Ul; Halder, Amal K.; Unicomb, Leanne; Hamer, Davidson H.; Ram, Pavani K.

    2016-01-01

    Bangladesh's maternal mortality and neonatal mortality remain unacceptably high. We assessed the availability and quality of emergency obstetric care (EmOC) and emergency newborn care (EmNC) services at health facilities in Bangladesh. We randomly sampled 50 rural villages and 50 urban neighborhoods throughout Bangladesh and interviewed the director of eight and nine health facilities nearest to each sampled area. We categorized health facilities into different quality levels (high, moderate, low, and substandard) based on staffing, availability of a phone or ambulance, and signal functions (six categories for EmOC and four categories for EmNC). We interviewed the directors of 875 health facilities. Approximately 28% of health facilities did not have a skilled birth attendant on call 24 hours per day. The least commonly performed EmOC signal function was administration of anticonvulsants (67%). The quality of EmOC services was high in 33% and moderate in 52% of the health facilities. The least common EmNC signal function was kangaroo mother care (7%). The quality of EmNC was high in 2% and moderate in 33% of the health facilities. Approximately one-third of health facilities lack 24-hour availability of skilled birth attendants, increasing the risk of peripartum complications. Most health facilities offered moderate to high quality services for EmOC and low to substandard quality for EmNC. PMID:27273640

  13. Obstetric audit in resource-poor settings: lessons from a multi-country project auditing 'near miss' obstetrical emergencies.

    PubMed

    Filippi, Veronique; Brugha, Ruairi; Browne, Edmund; Gohou, Valerie; Bacci, Alberta; De Brouwere, Vincent; Sahel, Amina; Goufodji, Sourou; Alihonou, Eusebe; Ronsmans, Carine

    2004-01-01

    This paper outlines the practical steps involved in setting up and running multi-professional, in-depth case reviews of 'near miss' obstetrical complications. It draws on lessons learned in 12 referral hospitals in Benin, Côte d'Ivoire, Ghana and Morocco. A range of feasibility indicators are presented which measured the implementation and frequency of audit activities, the quality of participation, adherence to the planned protocol for the near-miss audits, the quality of audit discussions and the sustainability of the project. Although the principles of the audit approach were well accepted and implemented everywhere, near-miss audits appeared most successful in first referral level hospitals. Contextual factors that determine the successful implementation of near-miss audit include staff finding adequate time for audit activities, financial incentives to groups rather than individuals, involvement of senior staff and hospital managers, the ease of communication in smaller units, the employment of social workers for the incorporation of women's views at audits, and the strength of external support provided by the research team. The poor quality of information recorded in case notes was recognized everywhere as a deficiency, but did not present a major obstacle to effective case reviews. Ownership and leadership within the hospital, more easily achieved in the first-level referral hospitals, were probably the most important determinants of successful implementation. Sustainability requires a commitment to audit from policy makers and managers at higher levels of the health system and some devolution of resources for implementing recommendations.

  14. The emergence of a global right to health norm – the unresolved case of universal access to quality emergency obstetric care

    PubMed Central

    2014-01-01

    Background The global response to HIV suggests the potential of an emergent global right to health norm, embracing shared global responsibility for health, to assist policy communities in framing the obligations of the domestic state and the international community. Our research explores the extent to which this global right to health norm has influenced the global policy process around maternal health rights, with a focus on universal access to emergency obstetric care. Methods In examining the extent to which arguments stemming from a global right to health norm have been successful in advancing international policy on universal access to emergency obstetric care, we looked at the period from 1985 to 2013 period. We adopted a qualitative case study approach applying a process-tracing methodology using multiple data sources, including an extensive literature review and limited key informant interviews to analyse the international policy agenda setting process surrounding maternal health rights, focusing on emergency obstetric care. We applied John Kingdon's public policy agenda setting streams model to analyse our data. Results Kingdon’s model suggests that to succeed as a mobilising norm, the right to health could work if it can help bring the problem, policy and political streams together, as it did with access to AIDS treatment. Our analysis suggests that despite a normative grounding in the right to health, prioritisation of the specific maternal health entitlements remains fragmented. Conclusions Despite United Nations recognition of maternal mortality as a human rights issue, the relevant policy communities have not yet managed to shift the policy agenda to prioritise the global right to health norm of shared responsibility for realising access to emergency obstetric care. The experience of HIV advocates in pushing for global solutions based on right to health principles, including participation, solidarity and accountability; suggest potential avenues for

  15. Responsiveness of emergency obstetric care systems in low- and middle-income countries: a critical review of the "third delay".

    PubMed

    Cavallaro, Francesca L; Marchant, Tanya J

    2013-05-01

    We reviewed the evidence on the duration, causes and effects of delays in providing emergency obstetric care to women attending health facilities (the third delay) in low- and middle-income countries. We performed a critical literature review using terms related to obstetric care, birth outcome, delays and developing countries. A manual search of reference lists of key articles was also performed. 69 studies met the inclusion criteria. Most studies reported long delays in providing care, and the mean waiting time for women admitted with complications was as much as 24 h before treatment. The three most cited barriers to providing timely care were shortage of treatment materials, surgery facilities and qualified staff. Existing evidence is insufficient to estimate the effect of delays on birth outcomes. Delays in providing emergency obstetric care seem common in resource-constrained settings but further research is necessary to determine the effect of the third delay on birth outcomes. © 2013 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

  16. Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia.

    PubMed

    Girma, Meseret; Yaya, Yaliso; Gebrehanna, Ewenat; Berhane, Yemane; Lindtjørn, Bernt

    2013-11-04

    Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (Em

  17. Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia

    PubMed Central

    2013-01-01

    Background Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. Methods We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. Results There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). Conclusion Based on a population of 1.7 million people, there should be 14 basic and four

  18. Status of emergency obstetric care in a local government area in south-south Nigeria.

    PubMed

    Mezie-Okoye, Margaret M; Adeniji, Foluke O; Tobin-West, Charles I; Babatunde, Seye

    2012-09-01

    This study assessed the status of the availability and performance of emergency obstetric care (EmOC) in 12 functional public health facilities out of the existing 19 in Gokana Local Government Area of Rivers State in south-south Nigeria, prior to the midwives service scheme (MSS) launch in 2009. No facility qualified as basic EmOC, while one had comprehensive EmOC status. Signal functions that required supply of medical consumables were performed by more facilities than services that required special training, equipment and maintenance. Only two facilities (16.67%) had the minimum requirement of > or =4 midwives for 24-hour EmOC service; while only 2.2% of expected births occurred at the facilities. The poor state of maternal health resources in the study area requires urgent interventions by Local and State Governments for infrastructure upgrade and deployment and training of staff towards attainment of MDG-5. A follow-up evaluation would be required since the commencement of the MSS.

  19. Characteristics and mortality of neonates in an emergency obstetric and neonatal care facility, rural Burundi

    PubMed Central

    Van den Bergh, R.; Ndelema, B.; Bulckaert, D.; Manzi, M.; Lambert, V.; Zachariah, R.; Reid, A. J.; Harries, A. D.

    2013-01-01

    Setting: A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi. Objective: To describe the characteristics and in-facility mortality rates of neonates born in 2011. Design: Descriptive study involving a retrospective review of routinely collected facility data. Results: Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia. Conclusion: Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates. PMID:26393046

  20. Magnetic resonance imaging - A troubleshooter in obstetric emergencies: A pictorial review.

    PubMed

    Gupta, Rohini; Bajaj, Sunil Kumar; Kumar, Nishith; Chandra, Ranjan; Misra, Ritu Nair; Malik, Amita; Thukral, Brij Bhushan

    2016-01-01

    The application of magnetic resonance imaging (MRI) in pregnancy faced initial skepticism of physicians because of fetal safety concerns. The perceived fetal risk has been found to be unwarranted and of late, the modality has attained acceptability. Its role in diagnosing fetal anomalies is well recognized and following its safety certification in pregnancy, it is finding increasing utilization during pregnancy and puerperium. However, the use of MRI in maternal emergency obstetric conditions is relatively limited as it is still evolving. In early gestation, ectopic implantation is one of the major life-threatening conditions that are frequently encountered. Although ultrasound (USG) is the accepted mainstay modality, the diagnostic predicament persists in many cases. MRI has a role where USG is indeterminate, particularly in the extratubal ectopic pregnancy. Later in gestation, MRI can be a useful adjunct in placental disorders like previa, abruption, and adhesion. It is a good problem-solving tool in adnexal masses such as ovarian torsion and degenerated fibroid, which have a higher incidence during pregnancy. Catastrophic conditions like uterine rupture can also be preoperatively and timely diagnosed. MRI has a definite role to play in postpartum and post-abortion life-threatening conditions, e.g., retained products of conception, and gestational trophoblastic disease, especially when USG is inconclusive or inadequate.

  1. What is the impact of multi-professional emergency obstetric and neonatal care training?

    PubMed

    Bergh, Anne-Marie; Baloyi, Shisana; Pattinson, Robert C

    2015-11-01

    This paper reviews evidence regarding change in health-care provider behaviour and maternal and neonatal outcomes as a result of emergency obstetric and neonatal care (EmONC) training. A refined version of the Kirkpatrick classification for programme evaluation was used to focus on change in efficiency and impact of training (levels 3 and 4). Twenty-three studies were reviewed - five randomised controlled trials, two quasi-experimental studies and 16 before-and-after observational studies. Training programmes had all been developed in high-income countries and adapted for use in low- and middle-income countries. Nine studies reported on behaviour change and 13 on process and patient outcomes. Most showed positive results. Every maternity unit should provide EmONC teamwork training, mandatory for all health-care providers. The challenges are as follows: scaling up such training to all institutions, sustaining regular in-service training, integrating training into institutional and health-system patient safety initiatives and 'thinking out of the box' in evaluation research.

  2. Alternative measures of spatial distribution and availability of health facilities for the delivery of emergency obstetric services in island communities.

    PubMed

    Oyerinde, Koyejo; Baravilala, Wame

    2014-12-01

    International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.

  3. An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh.

    PubMed

    Khan, Rasheda; Blum, Lauren S; Sultana, Marzia; Bilkis, Sayeda; Koblinsky, Marge

    2012-06-01

    Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008-August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems

  4. An Examination of Women Experiencing Obstetric Complications Requiring Emergency Care: Perceptions and Sociocultural Consequences of Caesarean Sections in Bangladesh

    PubMed Central

    Khan, Rasheda; Sultana, Marzia; Bilkis, Sayeda; Koblinsky, Marge

    2012-01-01

    Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008–August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health

  5. [Evolution of waiting time and length of stay between 2005 and 2012 in an obstetric and gynaecologic emergency unit in a French teaching hospital].

    PubMed

    Coutin, A-S; Vaucel, E

    2014-05-01

    To compare and analyze waiting time and length of stay between 2005 and 2012 in the obstetric and gynaecologic emergency unit of Nantes teaching hospital, new unit opened in 2004. Descriptive study from the registers over 2months' periods in 2005 and 2012. Despite an increase of the daily average number of visits from 28 to 39 (P<0.0001), the waiting time increased in obstetrics from 15minutes to 18 in 2012, P<0.03. In gynaecology, waiting time decreased in 2012 on daytime weekdays (37minutes versus 44) and increased on weekend (41minutes versus 28) and at night (37minutes versus 23) P<0.01. The length of stay was similar in obstetrics (108minutes versus 104) but reduced on daytime weekdays (124minutes in 2005, 109 in 2012, P<0.05). In gynaecology duration was similar (108minutes versus 105), but decreased on daytime weekdays (110minutes in 2005, 101 in 2012) and increased on overnight weekend (94minutes in 2005, 121 in 2012) (P<0.05). Our organization enabled to improve some lengths of time despite an increased activity. Those lengths of time should be monitored as they reflect our organizations and are indicators of efficiency. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

  6. The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India.

    PubMed

    Sabde, Yogesh; Diwan, Vishal; Randive, Bharat; Chaturvedi, Sarika; Sidney, Kristi; Salazar, Mariano; De Costa, Ayesha

    2016-05-18

    Since 2005, India has implemented a national cash transfer programme, the Janani Suraksha Yojana (JSY), which provides women a cash transfer upon giving birth in an existing public facility. This has resulted in a steep rise in facility births across the country. The early years of the programme saw efforts being made to strengthen the ability of facilities to provide obstetric care. Given that the JSY has been able to draw millions of women into facilities to give birth (there have been more than 50 million beneficiaries thus far), it is important to study the ability of these facilities to provide emergency obstetric care (EmOC), as the functionality of these facilities is critical to improved maternal and neonatal outcomes. We studied the availability and level of provision of EmOC signal functions in public facilities implementing the JSY programme in three districts of Madhya Pradesh (MP) state, central India. These are measured against the World Health Report (WHR) 2005benchmarks. As a comparison, we also study the functionality and contribution of private sector facilities to the provision of EmOC in these districts. A cross-sectional survey of all healthcare facilities offering intrapartum care was conducted between February 2012 and April 2013. The EmOC signal functions performed in each facility were recorded, as were human resource data and birth numbers for each facility. A total of 152 facilities were surveyed of which 118 were JSY programme facilities. Eighty-six percent of childbirths occurred at programme facilities, two thirds of which occurred at facilities that did not meet standards for the provision basic emergency obstetric care. Of the 29 facilities that could perform caesareans, none could perform all the basic EmOC functions. Programme facilities provided few EmOC signal functions apart from parenteral antibiotic or oxytocic administration. Complicated EmOC provision was found predominantly in non-programme (private) facilities; only one of

  7. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness.

    PubMed

    Dennis, A T

    2011-04-01

    Transthoracic echocardiography (TTE) is a powerful non-invasive diagnostic, monitoring and measurement device in medicine. In addition to cardiologists, many other specialised groups, including emergency and critical care physicians and cardiac anaesthetists, have recognised its ability to provide high quality information and utilise TTE in the care of their patients. In obstetric anaesthesia and management of obstetric critical illness, the favourable characteristics of pregnant women facilitate TTE examination. These include anterior and left lateral displacement of the heart, frequent employment of the left lateral tilted position to avoid aortocaval compression, spontaneous ventilation and wide acceptance of ultrasound technology by women. Of relevance to obstetric anaesthetists is that maternal morbidity and mortality due to cardiovascular disease is significant worldwide. This makes TTE an appropriate, important and applicable device in pregnant women. Clinician-performed TTE enables differentiation between the life-threatening causes of hypotension. In the critically ill woman this improves diagnostic accuracy and allows treatment interventions to be instituted and monitored at the point of patient care. This article outlines the application of TTE in the specialty of obstetric anaesthesia and in the management of obstetric critical illness. It describes the importance of TTE education, quality assurance and outcome recording. It also discusses how barriers to the routine implementation of TTE in obstetric anaesthesia and management of obstetric critical illness can be overcome.

  8. Kaqchikel midwives, home births, and emergency obstetric referrals in Guatemala: contextualizing the choice to stay at home.

    PubMed

    Berry, Nicole S

    2006-04-01

    Maternal mortality is highest in those countries whose health budgets are restricted. Practical strategies employed in the International Safe Motherhood Initiative, therefore, must be both effective and economical. Investing in emergency obstetric care resources has been touted as one such strategy. This investment aims to insure significant improvements are made in regional health centers, and a chain of referral is put into place so that only problem cases are attended by the most skilled health workers. This article examines how this model of referral functions in Sololá, Guatemala, where most Kaqchikel Mayan women give birth at home with a traditional midwife, and no skilled biomedical attendant is available at the birth to make a referral. Ethnographic data is used to explore reasons why women do not go to the hospital at the first sign of difficulty. I argue that the problem frequently is not that Mayan midwives, their clients and families fail to understand the biomedical information about dangers in birth, but rather that this information fails to fit into an already existing social system of understanding birth and birth-related knowledge.

  9. Promoting cultural humility during labor and birth: putting theory into action during PRONTO obstetric and neonatal emergency training.

    PubMed

    Fahey, Jenifer O; Cohen, Susanna R; Holme, Francesca; Buttrick, Elizabeth S; Dettinger, Julia C; Kestler, Edgar; Walker, Dilys M

    2013-01-01

    Maternal and neonatal mortality in Northern Guatemala, a region with a high percentage of indigenous people, is disproportionately high. Initiatives to improve quality of care at local health facilities equipped for births, and increasing the number of births attended at these facilities will help address this problem. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a low-tech, high-fidelity, simulation-based, provider-to-provider training in the management of obstetric and neonatal emergencies. This program has been successfully tested and implemented in Mexico. PRONTO will now be implemented in Guatemala as part of an initiative to decrease maternal and perinatal mortality. Guatemalan health authorities have requested that the training include training on cultural humility and humanized birth. This article describes the process of curricular adaptation to satisfy this request. The PRONTO team adapted the existing program through 4 steps: (a) analysis of the problem and context through a review of qualitative data and stakeholder interviews, (b) literature review and adoption of a theoretical framework regarding cultural humility and adult learning, (c) adaptation of the curriculum and design of new activities and simulations, and (d) implementation of adapted and expanded curriculum and further refinement in response to participant response.

  10. The effect of a multidisciplinary obstetric emergency team training program, the In Time course, on diagnosis to delivery interval following umbilical cord prolapse - A retrospective cohort study.

    PubMed

    Copson, Sean; Calvert, Katrina; Raman, Puvaneswary; Nathan, Elizabeth; Epee, Mathias

    2017-06-01

    Cord prolapse is an uncommon obstetric emergency, with potentially fatal consequences for the baby if prompt action is not taken. Simulation training provides a means by which uncommon emergencies can be practised, with the aim of improving teamwork and clinical outcomes. This study aimed to determine if the introduction of a simulation-based training course was associated with an improvement in the management of cord prolapse, in particular the diagnosis to delivery interval. We also aimed to investigate if an improvement in perinatal outcomes could be demonstrated. A retrospective cohort study was performed. All cases of cord prolapse in the designated time period were identified and reviewed and a comparison of outcome measures pre- and post-training was undertaken. Thirty-one cases were identified in the pre-training period, and compared to 64 cases post-training. Documentation improved significantly post-training. There were non-significant improvements in use of spinal anaesthetic, and in the length of stay in the special care neonatal unit. There was a significant increase in the number of babies with Apgar scores less than seven at 5 min. There were no differences in the diagnosis to delivery interval, or in perinatal mortality rates. Obstetric emergency training was associated with improved teamwork, as evidenced by the improved documentation post-training in this study, but not with improved diagnosis to delivery interval. Long-term follow-up studies are required to ascertain whether training has an impact on longer-term paediatric outcomes, such as cerebral palsy rates. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

  11. Geographic Access Modeling of Emergency Obstetric and Neonatal Care in Kigoma Region, Tanzania: Transportation Schemes and Programmatic Implications

    PubMed Central

    Chen, Yi No; Schmitz, Michelle M; Serbanescu, Florina; Dynes, Michelle M; Maro, Godson; Kramer, Michael R

    2017-01-01

    ABSTRACT Background: Access to transportation is vital to reducing the travel time to emergency obstetric and neonatal care (EmONC) for managing complications and preventing adverse maternal and neonatal outcomes. This study examines the distribution of travel times to EmONC in Kigoma Region, Tanzania, using various transportation schemes, to estimate the proportion of live births (a proxy indicator of women needing delivery care) with poor geographic access to EmONC services. Methods: The 2014 Reproductive Health Survey of Kigoma Region identified 4 primary means of transportation used to travel to health facilities: walking, cycling, motorcycle, and 4-wheeled motor vehicle. A raster-based travel time model was used to map the 2-hour travel time catchment for each mode of transportation. Live birth density distributions were aggregated by travel time catchments, and by administrative council, to estimate the proportion of births with poor access. Results: Of all live births in Kigoma Region, 13% occurred in areas where women can reach EmONC facilities within 2 hours on foot, 33% in areas that can be reached within 2 hours only by motorized vehicles, and 32% where it is impossible to reach EmONC facilities within 2 hours. Over 50% of births in 3 of the 8 administrative councils had poor estimated access. In half the councils, births with poor access could be reduced to no higher than 12% if all female residents had access to motorized vehicles. Conclusion: Significant differences in geographic access to EmONC in Kigoma Region, Tanzania, were observed both by location and by primary transportation type. As most of the population may only have good EmONC access when using mechanized or motorized vehicles, bicycles and motorcycles should be incorporated into the health transportation strategy. Collaboration between private transportation sectors and obstetric service providers could improve access to EmONC services among most populations. In areas where residents may

  12. Geographic Access Modeling of Emergency Obstetric and Neonatal Care in Kigoma Region, Tanzania: Transportation Schemes and Programmatic Implications.

    PubMed

    Chen, Yi No; Schmitz, Michelle M; Serbanescu, Florina; Dynes, Michelle M; Maro, Godson; Kramer, Michael R

    2017-09-27

    Access to transportation is vital to reducing the travel time to emergency obstetric and neonatal care (EmONC) for managing complications and preventing adverse maternal and neonatal outcomes. This study examines the distribution of travel times to EmONC in Kigoma Region, Tanzania, using various transportation schemes, to estimate the proportion of live births (a proxy indicator of women needing delivery care) with poor geographic access to EmONC services. The 2014 Reproductive Health Survey of Kigoma Region identified 4 primary means of transportation used to travel to health facilities: walking, cycling, motorcycle, and 4-wheeled motor vehicle. A raster-based travel time model was used to map the 2-hour travel time catchment for each mode of transportation. Live birth density distributions were aggregated by travel time catchments, and by administrative council, to estimate the proportion of births with poor access. Of all live births in Kigoma Region, 13% occurred in areas where women can reach EmONC facilities within 2 hours on foot, 33% in areas that can be reached within 2 hours only by motorized vehicles, and 32% where it is impossible to reach EmONC facilities within 2 hours. Over 50% of births in 3 of the 8 administrative councils had poor estimated access. In half the councils, births with poor access could be reduced to no higher than 12% if all female residents had access to motorized vehicles. Significant differences in geographic access to EmONC in Kigoma Region, Tanzania, were observed both by location and by primary transportation type. As most of the population may only have good EmONC access when using mechanized or motorized vehicles, bicycles and motorcycles should be incorporated into the health transportation strategy. Collaboration between private transportation sectors and obstetric service providers could improve access to EmONC services among most populations. In areas where residents may not access EmONC facilities within 2 hours

  13. Referrals between Public Sector Health Institutions for Women with Obstetric High Risk, Complications, or Emergencies in India - A Systematic Review.

    PubMed

    Singh, Samiksha; Doyle, Pat; Campbell, Oona M; Mathew, Manu; Murthy, G V S

    2016-01-01

    Emergency obstetric care (EmOC) within primary health care systems requires a linked referral system to be effective in reducing maternal death. This systematic review aimed to summarize evidence on the proportion of referrals between institutions during pregnancy and delivery, and the factors affecting referrals, in India. We searched 6 electronic databases, reviewed four regional databases and repositories, and relevant program reports from India published between 1994 and 2013. All types of study or reports (except editorials, comments and letters) which reported on institution-referrals (out-referral or in-referral) for obstetric care were included. Results were synthesized on the proportion and the reasons for referral, and factors affecting referrals. Of the 11,346 articles identified by the search, we included 232 articles in the full text review and extracted data from 16 studies that met our inclusion criteria Of the 16, one was RCT, seven intervention cohort (without controls), six cross-sectional, and three qualitative studies. Bias and quality of studies were reported. Between 25% and 52% of all pregnancies were referred from Sub-centres for antenatal high-risk, 14% to 36% from nurse run delivery or basic EmOC centres for complications or emergencies, and 2 to 7% were referred from doctor run basic EmOC centres for specialist care at comprehensive EmOC centres. Problems identified with referrals from peripheral health centres included low skills and confidence of staff, reluctance to induce labour, confusion over the clinical criteria for referral, non-uniform standards of care at referral institutions, a tendency to by-pass middle level institutions, a lack of referral communication and supervision, and poor compliance. The high proportion of referrals from peripheral health centers reflects the lack of appropriate clinical guidelines, processes, and skills for obstetric care and referral in India. This, combined with inadequate referral communication

  14. Obstetric Transport.

    PubMed

    Scott, Julie

    2016-12-01

    Obstetric transport is a specialized medical transport for maternal, fetal, and neonatal concerns. Perinatal regionalization of care provides a broader geographic availability of obstetric services with defined levels of maternal and neonatal care so that women can be transported to centers with increased resources and capabilities to reduce morbidity and mortality. The Emergency Medical Treatment and Active Labor Act provides regulatory guidance for care of laboring women who require transfer to a higher level of care. The Situation, Background, Assessment, and Recommendation communication can identify key pieces of medical information with recommendations given for mutual expectations of next steps. Copyright © 2016 Elsevier Inc. All rights reserved.

  15. Coverage of emergency obstetric care and availability of services in public and private health facilities in Bangladesh.

    PubMed

    Alam, Badrul; Mridha, Malay K; Biswas, Taposh K; Roy, Lumbini; Rahman, Maksudur; Chowdhury, Mahbub E

    2015-10-01

    To assess the coverage of emergency obstetric care (EmOC) and the availability of obstetric services in Bangladesh. In a national health facility assessment performed between November 2007 and July 2008, all public EmOC facilities and private facilities providing obstetric services in the 64 districts of Bangladesh were mapped. The performance of EmOC services in these facilities during the preceding month was investigated using a semi-structured questionnaire completed through interviews of managers and service providers, and record review. In total, 8.6 (2.1 public and 6.5 private) facilities per 500000 population offered obstetric care services. Population coverage by obstetric care facilities varied by region. Among 281 public facilities designated for comprehensive EmOC, cesarean delivery was available in only 215 (76.5%) and blood transfusion services in 198 (70.5%). In the private sector (for profit and not for profit), these services were available in more than 80% of facilities. In all facility types, performance of assisted vaginal delivery (range 12.2%-48.4%) and use of parenteral anticonvulsants to treat pre-eclampsia/eclampsia (range 48.6%-80.8%) were low. The main reason for non-availability of EmOC services was a lack of specialist/trained providers. Bangladesh needs to increase the availability of EmOC services through innovative public-private partnerships. In the public sector, additional trained manpower supported by an incentivized package should be deployed. Copyright © 2015. Published by Elsevier Ireland Ltd.

  16. Knowledge and Skills of Healthcare Providers in Sub-Saharan Africa and Asia before and after Competency-Based Training in Emergency Obstetric and Early Newborn Care

    PubMed Central

    Ameh, Charles A.; Kerr, Robert; Madaj, Barbara; Mdegela, Mselenge; Kana, Terry; Jones, Susan; Lambert, Jaki; Dickinson, Fiona; White, Sarah; van den Broek, Nynke

    2016-01-01

    Background Healthcare provider training in Emergency Obstetric and Newborn Care (EmOC&NC) is a component of 65% of intervention programs aimed at reducing maternal and newborn mortality and morbidity. It is important to evaluate the effectiveness of this. Methods We evaluated knowledge and skills among 5,939 healthcare providers before and after 3–5 days ‘skills and drills’ training in emergency obstetric and newborn care (EmOC&NC) conducted in 7 sub-Saharan Africa countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Zimbabwe) and 2 Asian countries (Bangladesh, Pakistan). Standardised assessments using multiple choice questions and objective structured clinical examination (OSCE) were used to measure change in knowledge and skills and the Improvement Ratio (IR) by cadre and by country. Linear regression was performed to identify variables associated with pre-training score and IR. Results 99.7% of healthcare providers improved their overall score with a median (IQR) increase of 10.0% (5.0% - 15.0%) for knowledge and 28.8% (23.1% - 35.1%) for skill. There were significant improvements in knowledge and skills for each cadre of healthcare provider and for each country (p<0.05). The mean IR was 56% for doctors, 50% for mid-level staff and nurse-midwives and 38% for nursing-aides. A teaching job, previous in-service training, and higher percentage of work-time spent providing maternity care were each associated with a higher pre-training score. Those with more than 11 years of experience in obstetrics had the lowest scores prior to training, with mean IRs 1.4% lower than for those with no more than 2 years of experience. The largest IR was for recognition and management of obstetric haemorrhage (49–70%) and the smallest for recognition and management of obstructed labour and use of the partograph (6–15%). Conclusions Short in-service EmOC&NC training was associated with improved knowledge and skills for all cadres of healthcare providers working

  17. Knowledge and Skills of Healthcare Providers in Sub-Saharan Africa and Asia before and after Competency-Based Training in Emergency Obstetric and Early Newborn Care.

    PubMed

    Ameh, Charles A; Kerr, Robert; Madaj, Barbara; Mdegela, Mselenge; Kana, Terry; Jones, Susan; Lambert, Jaki; Dickinson, Fiona; White, Sarah; van den Broek, Nynke

    2016-01-01

    Healthcare provider training in Emergency Obstetric and Newborn Care (EmOC&NC) is a component of 65% of intervention programs aimed at reducing maternal and newborn mortality and morbidity. It is important to evaluate the effectiveness of this. We evaluated knowledge and skills among 5,939 healthcare providers before and after 3-5 days 'skills and drills' training in emergency obstetric and newborn care (EmOC&NC) conducted in 7 sub-Saharan Africa countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Zimbabwe) and 2 Asian countries (Bangladesh, Pakistan). Standardised assessments using multiple choice questions and objective structured clinical examination (OSCE) were used to measure change in knowledge and skills and the Improvement Ratio (IR) by cadre and by country. Linear regression was performed to identify variables associated with pre-training score and IR. 99.7% of healthcare providers improved their overall score with a median (IQR) increase of 10.0% (5.0% - 15.0%) for knowledge and 28.8% (23.1% - 35.1%) for skill. There were significant improvements in knowledge and skills for each cadre of healthcare provider and for each country (p<0.05). The mean IR was 56% for doctors, 50% for mid-level staff and nurse-midwives and 38% for nursing-aides. A teaching job, previous in-service training, and higher percentage of work-time spent providing maternity care were each associated with a higher pre-training score. Those with more than 11 years of experience in obstetrics had the lowest scores prior to training, with mean IRs 1.4% lower than for those with no more than 2 years of experience. The largest IR was for recognition and management of obstetric haemorrhage (49-70%) and the smallest for recognition and management of obstructed labour and use of the partograph (6-15%). Short in-service EmOC&NC training was associated with improved knowledge and skills for all cadres of healthcare providers working in maternity wards in both sub-Saharan Africa and

  18. Health issues and the environment--an emerging paradigm for providers of obstetrical and gynaecological health care.

    PubMed

    Genuis, Stephen J

    2006-09-01

    Although ongoing study is required to winnow environmental ideology from scientific fact, existing evidence from recent research demonstrates a definitive link between chemical toxicants and potential health sequelae, including congenital affliction and gynaecological disorders. Amid media clamour of health risk and biological peril associated with various environmental toxicants, a spectrum of responses has emerged: some have embraced the environmental cause, some have summarily dismissed it as piffle and perhaps the majority has remained disinterested. Although journals devoted to toxicological and environmental health concerns have become prominent in academia with voluminous numbers of scientific reports being published, there has been limited exploration of the relationship between contemporary chemical exposure and reproductive medical issues in mainstream obstetrics and gynaecology literature. Providers of obstetrical and gynaecological health care need to acquire knowledge of taking an exposure history, instruction in details of precautionary avoidance, skills to provide preconception care and necessary tools to investigate and manage patients with toxicant exposure.

  19. Skilled birth attendants in Tanzania: a descriptive study of cadres and emergency obstetric care signal functions performed.

    PubMed

    Ueno, Etsuko; Adegoke, Adetoro A; Masenga, Gileard; Fimbo, Janeth; Msuya, Sia E

    2015-01-01

    Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all

  20. Quality of obstetric care in public-sector facilities and constraints to implementing emergency obstetric care services: evidence from high- and low-performing districts of Bangladesh.

    PubMed

    Anwar, Iqbal; Kalim, Nahid; Koblinsky, Marge

    2009-04-01

    This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. 'Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low

  1. Quality of Obstetric Care in Public-sector Facilities and Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and Low-performing Districts of Bangladesh

    PubMed Central

    Kalim, Nahid; Koblinsky, Marge

    2009-01-01

    This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. ‘Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low

  2. Obstetric Safety and Quality.

    PubMed

    Pettker, Christian M; Grobman, William A

    2015-07-01

    Obstetric safety and quality is an emerging and important topic not only as a result of the pressures of patient and regulatory expectations, but also because of the genuine interest of caregivers to reduce harm, improve outcomes, and optimize care. Although each seeks to improve care by using scientific approaches beyond human physiology and pathophysiology, patient safety methodologies seek to avoid preventable adverse events, whereas health care quality projects aim to achieve the best possible outcomes. It is well-documented that an increasingly complex medical system controlled by human workers is a circumstance subject to recurrent failure. A safety culture encourages a proactive approach to mitigate failure before, during, and after it occurs. This article highlights the key concepts in health care safety and quality and reviews the background of the quality improvement sciences with particular emphasis on obstetric outcomes and quality measures.

  3. Availability and use of emergency obstetric care services in public hospitals in Laos PDR: a systems analysis.

    PubMed

    Douangphachanh, Xaysomphou; Ali, Moazzam; Outavong, Phathammavong; Alongkon, Phengsavanh; Sing, Menorath; Chushi, Kuroiwa

    2010-12-01

    The maternal mortality ratio in Laos in 2005 was 660 per 100,000 lives birth which was the third highest in Asia-Pacific Region. The objective was to determine the availability and use of emergency obstetric care (EmOC) in provincial and district hospitals in Borikhamxay, Khammouane, and Savannakhet provinces using UN guidelines. A hospital-based cross sectional survey was conducted from January to March 2008. All district (30) and provincial hospitals (3) from three provinces were included. Analysis was based on hospital records reflecting 12 months of facility data. Data indicates that only 14 hospitals (42.4%) were providing EmOC services, i.e., 9 basic, 5 comprehensive services. The proportion of births in EmOC facilities was only 11.2%, the met need was a very low 14.5%, and the cesarean section rate was only 0.9%. The case fatality rate in Borikhanxay province was 2.8%; in Khammouane and in Savannakhet provinces it was less than 1%. Record keeping at hospitals was poor. Signal functions provided in the last three months showed only 48.5% of the facilities performed assisted vaginal delivery. This is the first study in Lao PDR to assess EmOC services. Almost all the indicators were below the UN recommendations. Health planners must take evidence-based decisions to rectify and improve the situation in the hospitals regarding EmOC services. These data can therefore help government to assign and allocate budgets appropriately, and help policymakers and planners to identify systemic bottlenecks and prioritize solutions and will help in improving maternal health.

  4. Revisiting the obstetric flying squad.

    PubMed

    Ravindran, J; Parampalam, S D

    2000-06-01

    The obstetric flying squad has been used in obstetric practice since 1933 to manage obstetric emergencies occurring in domicilliary practice. It has often been criticised in such situations as only delaying effective treatment to the patient. We have introduced the obstetric flying squad in an urban setting to cater for obstetric emergencies occurring in private practice. This service has been used on ten occasions since its inception without any maternal deaths being recorded or any delay in the provision of emergency care. The flying squad has led to closer cooperation between the government and private sectors in providing obstetric care.

  5. Standard basic emergency obstetric and neonatal care training in Addis Ababa; trainees reaction and knowledge acquisition.

    PubMed

    Mirkuzie, Alemnesh H; Sisay, Mitike Molla; Bedane, Mulu Muleta

    2014-09-24

    In 2010, the Federal Ministry of Health of Ethiopia (FMOH) has developed standard Basic Emergency Obstetric and Neonatal Care (BEmONC) in-service training curricula to respond to the high demand for competency in EmONC. However, the effectiveness of the training curricula has not been well documented. A collaborative intervention project in Addis Ababa has trained providers using the standard BEmONC curricula where this paper presents Krikpartick level 1 and level 2 evaluation of the training. The project has been conducted in 10 randomly selected public health centers (HC) in Addis Ababa. Providers working in the labour wards of the selected HCs have received the standard BEmONC training between May and July 2013. Using standard tools, trainees' reaction to the course and factual knowledge during the immediate post-course and six months after the training were assessed. Descriptive statistics and t-tests were done. Of the total 82 providers who received the training, 30 (36.6%) were male, 61 (74.4%) were midwives. Providers' work experiences ranged from 1 month to 37 years. Seventy-four (89%) providers reported that the training was appropriate for their work, 95% reported that the training have updated their knowledge & skills, while 27 (32.9%) reported that the training facilities & arrangements were unsatisfactory. The mean immediate post-course knowledge score was 83.5% and 33 (40%) providers did not achieve knowledge-based mastery in their first attempt. The midwives were more likely to achieve knowledge-based mastery than the nurses (p < 0.05). The mean knowledge score six-months post-training was 80.2% and 40% have scored knowledge based mastery. Being one of the first papers reporting the implementation of the standard in-service BEmONC training curriculum, we have identified an important limitation on the course evaluations of the curriculum, which need urgent consideration. The majority of the trainees has reported favourable reaction to the training

  6. Understanding the Dreyfus model of skill acquisition to improve ultrasound training for obstetrics and gynaecology trainees.

    PubMed

    Field, Alexander

    2014-05-01

    There have been significant problems in ultrasound training since the introduction of the new postgraduate curriculum for obstetrics and gynaecology. It is therefore important to understand how the skill of ultrasound is acquired in order to be able to improve the training program. Here, the potential application of the Dreyfus model of skill acquisition has been analysed to map the progression from novice to master and the progressions between each stage analysed. Although the Dreyfus model is not a perfect match for ultrasound scanning, it provides us with a theoretical framework on which to underpin educational practice in this field.

  7. Cost-effectiveness of simulation-based team training in obstetric emergencies (TOSTI study).

    PubMed

    van de Ven, J; van Baaren, G J; Fransen, A F; van Runnard Heimel, P J; Mol, B W; Oei, S G

    2017-09-01

    Team training is frequently applied in obstetrics. We aimed to evaluate the cost-effectiveness of obstetric multi-professional team training in a medical simulation centre. We performed a model-based cost-effectiveness analysis to evaluate four strategies for obstetric team training from a hospital perspective (no training, training without on-site repetition and training with 6 month or 3-6-9 month repetition). Data were retrieved from the TOSTI study, a randomised controlled trial evaluating team training in a medical simulation centre. We calculated the incremental cost-effectiveness ratio (ICER), which represent the costs to prevent the adverse outcome, here (1) the composite outcome of obstetric complications and (2) specifically neonatal trauma due to shoulder dystocia. Mean costs of a one-day multi-professional team training in a medical simulation centre were €25,546 to train all personnel of one hospital. A single training in a medical simulation centre was less effective and more costly compared to strategies that included repetition training. Compared to no training, the ICERs to prevent a composite outcome of obstetric complications were €3432 for a single repetition training course on-site six months after the initial training and €5115 for a three monthly repetition training course on-site after the initial training during one year. When we considered neonatal trauma due to shoulder dystocia, a three monthly repetition training course on-site after the initial training had an ICER of €22,878. Multi-professional team training in a medical simulation centre is cost-effective in a scenario where repetition training sessions are performed on-site. Copyright © 2017 Elsevier B.V. All rights reserved.

  8. Can we perform a prenatal diagnosis of vasa previa to improve its obstetrical and neonatal outcomes?

    PubMed

    Nohuz, E; Boulay, E; Gallot, D; Lemery, D; Vendittelli, F

    2017-04-01

    Vasa previa (VP) is defined as a condition in which the fetal blood vessels, unsupported by the placenta or the umbilical cord, run through the membranes of the lower uterine segment. It is associated with a high risk of stillbirth by exsanguination. This study aimed to assess the clinical context of diagnosis of VP in order to elaborate a strategy for its prenatal diagnosis and to improve its obstetrical and neonatal outcomes. This historical cohort study covered the period from January 1, 2011 to December 31, 2015. All women who gave birth at our obstetrics and gynecology department (level 3 university hospital) and who had a VP were included. Eight cases of VP among 18,152 deliveries were observed (0.04%). Transvaginal sonography (TVS) with color Doppler allowed a prenatal diagnosis of VP in all cases. The mean gestational age at diagnosis was 26 weeks. Placental abnormalities were noted in 7 cases (87.5%) as bipartita or low-lying placenta. In one case (12.5%), the placenta appeared normal while umbilical cord insertion was velamentous. In 2 cases (25%), concomitant placental and cord abnormalities were objectified. The mean gestational age at delivery was 37±2.1 weeks. Seven deliveries (87.5%) had been by caesarean sections, except one, which occurred by vaginal route at 33 weeks of gestation (twin pregnancy). No case of perinatal death was observed. Prenatal diagnosis of VP during screening ultrasounds appears easy to perform and can improve obstetrical and neonatal outcomes. For this purpose, TVS with color and pulsed Doppler remains essential, particularly when an anomaly of the umbilical cord insertion and/or placental location is diagnosed. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  9. Perinatal mortality associated with use of uterotonics outside of Comprehensive Emergency Obstetric and Neonatal Care: a cross-sectional study.

    PubMed

    Day, Louise T; Hruschka, Daniel; Mussell, Felicity; Jeffers, Eva; Saha, Stacy L; Alam, Shafiul

    2016-10-06

    Prior studies have shown that using uterotonics to augment or induce labor before arrival at comprehensive Emergency Obstetric and Neonatal Care (CEmONC) settings (henceforth, "outside uterotonics") may contribute to perinatal mortality in low- and middle-income countries. We estimate its effect on perinatal mortality in rural Bangladesh. Using hospital records (23986 singleton term births, Jan 1, 2009-Dec 31, 2015) from rural Bangladesh, we use a logistic regression model to estimate the increased risk of perinatal death from uterotonics administered outside a CEmONC facility. Among term births (≥37 weeks gestation), the risk of perinatal death adjusted for key confounders is significantly increased among women reporting uterotonic use outside of CEmONC (OR = 3 · 0, 95 % CI = 2 · 4,3 · 7). This increased risk is particularly high for fresh stillbirths (OR = 4 · 0, 95 % CI = 3 · 0,5 · 3) and intrapartum-related causes of early neonatal deaths (birth asphyxia) (OR = 3 · 1, 95 % CI = 2 · 2,4 · 5). In this sample, outside uterotonic use was associated with substantially increased risk of fresh stillbirths, deaths due to birth asphyxia, and all perinatal deaths. In settings of high uterotonic use outside of controlled settings, substantial improvement in both stillbirth and early neonatal mortality may be made by reducing such use.

  10. Measuring equity in utilization of emergency obstetric care at Wolisso Hospital in Oromiya, Ethiopia: a cross sectional study

    PubMed Central

    2013-01-01

    Introduction Improving equity in access to services for the treatment of complications that arise during pregnancy and childbirth, namely Emergency Obstetric Care (EmOC), is fundamental if maternal and neonatal mortality are to be reduced. Consequently, there is a growing need to monitor equity in access to EmOC. The objective of this study was to develop a simple questionnaire to measure equity in utilization of EmOC at Wolisso Hospital, Ethiopia and compare the wealth status of EmOC users with women in the general population. Methods Women in the Ethiopia 2005 Demographic and Health Survey (DHS) constituted our reference population. We cross-tabulated DHS wealth variables against wealth quintiles. Five variables that differentiated well across quintiles were selected to create a questionnaire that was administered to women at discharge from the maternity from January to August 2010. This was used to identify inequities in utilization of EmOC by comparison with the reference population. Results 760 women were surveyed. An a posteriori comparison of these 2010 data to the 2011 DHS dataset, indicated that women using EmOC were wealthier and more likely to be urban dwellers. On a scale from 0 (poorest) to 15 (wealthiest), 31% of women in the 2011 DHS sample scored less than 1 compared with 0.7% in the study population. 70% of women accessing EmOC belonged to the richest quintile with only 4% belonging to the poorest two quintiles. Transportation costs seem to play an important role. Conclusions We found inequity in utilization of EmOC in favour of the wealthiest. Assessing and monitoring equitable utilization of maternity services is feasible using this simple tool. PMID:23607604

  11. Measuring equity in utilization of emergency obstetric care at Wolisso Hospital in Oromiya, Ethiopia: a cross sectional study.

    PubMed

    Wilunda, Calistus; Putoto, Giovanni; Manenti, Fabio; Castiglioni, Maria; Azzimonti, Gaetano; Edessa, Wagari; Atzori, Andrea; Merialdi, Mario; Betrán, Ana Pilar; Vogel, Joshua; Criel, Bart

    2013-04-22

    Improving equity in access to services for the treatment of complications that arise during pregnancy and childbirth, namely Emergency Obstetric Care (EmOC), is fundamental if maternal and neonatal mortality are to be reduced. Consequently, there is a growing need to monitor equity in access to EmOC. The objective of this study was to develop a simple questionnaire to measure equity in utilization of EmOC at Wolisso Hospital, Ethiopia and compare the wealth status of EmOC users with women in the general population. Women in the Ethiopia 2005 Demographic and Health Survey (DHS) constituted our reference population. We cross-tabulated DHS wealth variables against wealth quintiles. Five variables that differentiated well across quintiles were selected to create a questionnaire that was administered to women at discharge from the maternity from January to August 2010. This was used to identify inequities in utilization of EmOC by comparison with the reference population. 760 women were surveyed. An a posteriori comparison of these 2010 data to the 2011 DHS dataset, indicated that women using EmOC were wealthier and more likely to be urban dwellers. On a scale from 0 (poorest) to 15 (wealthiest), 31% of women in the 2011 DHS sample scored less than 1 compared with 0.7% in the study population. 70% of women accessing EmOC belonged to the richest quintile with only 4% belonging to the poorest two quintiles. Transportation costs seem to play an important role. We found inequity in utilization of EmOC in favour of the wealthiest. Assessing and monitoring equitable utilization of maternity services is feasible using this simple tool.

  12. Maternal mortality and its relationship to emergency obstetric care (EmOC) in a tertiary care hospital in South India

    PubMed Central

    2015-01-01

    Objective: To determine the trends in maternal mortality ratio over 5 years at JIPMER Hospital and to find out the proportion of maternal deaths in relation to emergency admissions. Methods: A retrospective analysis of maternal deaths from 2008 to 2012 with respect to type of admission, referral and ICU care and cause of death according to WHO classification of maternal deaths. Results: Of the 104 maternal deaths 90% were emergency admissions and 59% of them were referrals. Thirty two percent of them died within 24 hours of admission. Forty four percent could be admitted to ICU and few patients could not get ICU bed. The trend in cause of death was increasing proportion of indirect causes from 2008 to 2012. Conclusion: The trend in MMR was increasing proportion of indirect deaths. Ninety percent of maternal deaths were emergency admissions with complications requiring ICU care. Hence comprehensive EmOC facilities should incorporate Obstetric ICU care. PMID:27512460

  13. Maternal mortality and its relationship to emergency obstetric care (EmOC) in a tertiary care hospital in South India.

    PubMed

    Dasari, Papa

    2015-06-01

    To determine the trends in maternal mortality ratio over 5 years at JIPMER Hospital and to find out the proportion of maternal deaths in relation to emergency admissions. A retrospective analysis of maternal deaths from 2008 to 2012 with respect to type of admission, referral and ICU care and cause of death according to WHO classification of maternal deaths. Of the 104 maternal deaths 90% were emergency admissions and 59% of them were referrals. Thirty two percent of them died within 24 hours of admission. Forty four percent could be admitted to ICU and few patients could not get ICU bed. The trend in cause of death was increasing proportion of indirect causes from 2008 to 2012. The trend in MMR was increasing proportion of indirect deaths. Ninety percent of maternal deaths were emergency admissions with complications requiring ICU care. Hence comprehensive EmOC facilities should incorporate Obstetric ICU care.

  14. [Maternal mortality in developing countries: statistical data and improvement in obstetrical care].

    PubMed

    Bouvier-Colle, M H

    2003-01-01

    Since launching of the safe motherhood initiative in 1987, much work has been undertaken, understanding of the situation in developing countries has improved, and numerous health programs have been designed. However the end result of action has been considered disappointing more often than encouraging especially in Sub Saharan Africa. What is the true picture? The purpose of this article is to review the means available for studying all facets of maternal mortality and methodological precautions that must be applied in the interpretation of statistical data. Perusal of recent reports on maternal mortality reveals that estimated incidences in different populations vary widely from 85 to 1000 per 100,000 live births, that rural zones are more affected than urban areas, that reductions have been achieved in the major cities, that the most common direct obstetrical causes are postpartum hemorrhage, dystocia with uterine rupture, eclampsia, and sepsis, and that 70% of deaths are avoidable, i.e., due to absent or insufficient care. Although currently underused, qualitative study methods are gradually being implemented and will identify the health care sectors requiring priority improvement. Based on previous experience, it is unlikely that technical or obstetrical measures and action on the part of medical professionals alone will achieve any reduction in maternal mortality without the commitment of political authorities.

  15. Women's perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania.

    PubMed

    Stal, Karen Berit; Pallangyo, Pedro; van Elteren, Marianne; van den Akker, Thomas; van Roosmalen, Jos; Nyamtema, Angelo

    2015-07-01

    To assess perceptions of the quality of obstetric care of women who delivered in a rural Tanzanian referral hospital. A descriptive-exploratory qualitative study, using semistructured in-depth interviews and participatory observation. Nineteen recently delivered women and 3 health workers were interviewed. Although most women held positive views about the care they received in hospital, several participants expressed major concerns about negative attitudes of healthcare workers. Lack of medical communication given by care providers constituted a major complaint. A more positive attitude by health workers and the provision of adequate medical information may promote a more positive hospital experience of women in need of obstetric care and enhance attendance. © 2015 John Wiley & Sons Ltd.

  16. Difficulties leaving home: a cross-sectional study of delays in seeking emergency obstetric care in Herat, Afghanistan.

    PubMed

    Hirose, Atsumi; Borchert, Matthias; Niksear, Homa; Alkozai, Ahmad Shah; Cox, Jonathan; Gardiner, Julian; Osmani, Khadija Ruina; Filippi, Véronique

    2011-10-01

    This study used an analytical cross-sectional design to identify risk factors associated with delays in care-seeking among women admitted in life-threatening conditions to a maternity hospital in Herat, Afghanistan, from February 2007 to January 2008. Disease-specific criteria of 'near-miss' were used to identify women in life-threatening conditions. Among 472 eligible women and their husbands, 411 paired interviews were conducted, and information on socio-demographic factors; the woman's status and social resources; the husband's social networks; health care accessibility and utilisation; care-seeking costs; and community characteristics were obtained. Decision and departure delays were assessed quantitatively from reported timings of symptom recognition, care-seeking decision, and departure for health facilities. Censored normal regression analyses suggest that although determinants of decision delay were influenced by the nature and symptoms of complications, uptake of antenatal care (ANC) and the birth plan reduced decision delay at the time of the obstetric emergency. Access to care and social networks reduced departure delay. Programmatic efforts may be directed towards exploiting the roles of ANC and social resources in facilitating access to emergency obstetric care.

  17. Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.

    PubMed

    Pitchforth, E; van Teijlingen, E; Graham, W; Dixon-Woods, M; Chowdhury, M

    2006-06-01

    To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. Mixed methods qualitative study. Large government medical college hospital in Bangladesh. Providers and users of EmOC. Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund" system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications" of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see" policy that meant women's condition could deteriorate before help was provided. Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.

  18. Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh

    PubMed Central

    Pitchforth, E; van Teijlingen, E; Graham, W; Dixon‐Woods, M; Chowdhury, M

    2006-01-01

    Objective To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. Design Mixed methods qualitative study. Setting Large government medical college hospital in Bangladesh. Sample Providers and users of EmOC. Methods Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. Results Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal “poor fund” system to help the poorest women. There was no formal assessment of poverty; rather, doctors made “adjudications” of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a “wait and see” policy that meant women's condition could deteriorate before help was provided. Conclusions Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity. PMID:16751473

  19. Invisible seams: Preventing childhood obesity through an improved obstetrics-pediatrics care continuum.

    PubMed

    Moscetti, Craig W; Pronk, Nicolaas P

    2017-03-01

    Progress in altering the current obesity epidemic among children and adolescents remains elusive. Evidence continues to underscore the challenges of altering weight status as children age. Further, weight loss interventions among children and adults alike tend to demonstrate efficacy in the short-term, however individuals tend to slowly revert back to their original weight status over time. New understanding of obesity's early origins suggests the need to rethink current approaches, particularly within healthcare. Instead of a predominant focus on "mid-flight course corrections," healthcare should consider the "take-off" time period for health trajectories. This means improved support and promotion of healthy behaviors before and after birth, and with both the mother and infant. To meet the challenge, greater continuity will be required across obstetrics and pediatrics, which often operate independently, focused on different clinical outcomes. Likewise, there is an urgent need to remedy a significant skills gap within both practices. Through its connection with almost every new mother, healthcare plays a unique and vital role in maternal and child health outcomes. A more seamless obstetrics-pediatrics care continuum could better address the early origins of obesity, factors that we are coming to learn have life-long consequences.

  20. Improving interprofessional coordination in Dutch midwifery and obstetrics: a qualitative study

    PubMed Central

    2014-01-01

    Background Coordination between the autonomous professional groups in midwifery and obstetrics is a key debate in the Netherlands. At the same time, it remains unclear what the current coordination challenges are. Methods To examine coordination challenges that might present a barrier to delivering optimal care, we conducted a qualitative field study focusing on midwifery and obstetric professional’s perception of coordination and on their routines. We undertook 40 interviews with 13 community midwives, 8 hospital-based midwives and 19 obstetricians (including two resident obstetricians), and conducted non-participatory observations at the worksite of these professional groups. Results We identified challenges in terms of fragmented organizational structures, different perspectives on antenatal health and inadequate interprofessional communication. These challenges limited professionals' coordinating capacity and thereby decreased their ability to provide optimal care. We also found that pregnant women needed to compensate for suboptimal coordination between community midwives and secondary caregivers by taking on an active role in facilitating communication between these professionals. Conclusions The communicative role that pregnant women play within coordination processes underlines the urgency to improve coordination. We recommend increasing multidisciplinary meetings and training, revising the financial reimbursement system, implementing a shared maternity notes system and decreasing the expertise gap between providers and clients. In the literature, communication by clients in support of coordination has been largely ignored. We suggest that studies include client communication as part of the coordination process. PMID:24731478

  1. Improving emergency department patient flow

    PubMed Central

    Jarvis, Paul Richard Edwin

    2016-01-01

    Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED. PMID:27752619

  2. Improving emergency department patient flow.

    PubMed

    Jarvis, Paul Richard Edwin

    2016-06-01

    Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.

  3. Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala.

    PubMed

    Walton, Anna; Kestler, Edgar; Dettinger, Julia C; Zelek, Sarah; Holme, Francesca; Walker, Dilys

    2016-03-01

    To assess the effect of a low-technology simulation-based training scheme for obstetric and perinatal emergency management (PRONTO; Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) on non-emergency delivery practices at primary level clinics in Guatemala. A paired cross-sectional birth observation study was conducted with a convenience sample of 18 clinics (nine pairs of intervention and control clinics) from June 28 to August 7, 2013. Outcomes included implementation of practices known to decrease maternal and/or neonatal mortality and improve patient care. Overall, 25 and 17 births occurred in intervention and control clinics, respectively. Active management of the third stage of labor was appropriately performed by 20 (83%) of 24 intervention teams versus 7 (50%) of 14 control teams (P=0.015). Intervention teams implemented more practices to decrease neonatal mortality than did control teams (P<0.001). Intervention teams ensured patient privacy in 23 (92%) of 25 births versus 11 (65%) of 17 births for control teams (P=0.014). All 15 applicable intervention teams kept patients informed versus 6 (55%) of 11 control teams (P=0.001). Differences were also noted in teamwork; in particular, skill-based tools were used more often at intervention sites than control sites (P=0.012). Use of PRONTO enhanced non-emergency delivery care by increasing evidence-based practice, patient-centered care, and teamwork. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  4. Current evidence on basic emergency obstetric and newborn care services in Addis Ababa, Ethiopia; a cross sectional study.

    PubMed

    Mirkuzie, Alemnesh H; Sisay, Mitike Molla; Reta, Alemnesh Tekelebirhan; Bedane, Mulu Muleta

    2014-10-10

    Emergency obstetric and neonatal care (EmONC) is a high impact priority intervention highly recommended for improving maternal and neonatal health outcomes. In 2008, Ethiopia conducted a national EmONC survey that revealed implementation gaps, mainly due to resource constraints and poor competence among providers. As part of an ongoing project, this paper examined progress in the implementation of the basic EmONC (BEmONC) in Addis Ababa and compared with the 2008 survey. A facility based intervention project was conducted in 10 randomly selected public health centers (HCs) in Addis Ababa and baseline data collected on BEmONC status from January to March 2013. Retrospective routine record reviews and facility observations were done in 29 HCs in 2008 and in10 HCs in 2013. Twenty-five providers in 2008 and 24 in 2013 participated in BEmONC knowledge and skills assessment. All the data were collected using standard tools. Descriptive statistics and t-tests were used. In 2013, all the surveyed HCs had continuous water supply, reliable access to telephone, logbooks & phartograph. Fifty precent of the HCs in 2013 and 34% in 2008 had access to 24 hours ambulance services. The ratio of midwives to 100 expected births were 0.26 in 2008 and 10.3 in 2013. In 2008, 67% of the HCs had a formal fee waiver system while all the surveyed HCs had it in 2013. HCs reporting a consistent supply of uterotonic drugs were 85% in 2008 and 100% in 2013. The majority of the providers who participated in both surveys reported to have insufficient knowledge in diagnosing postpartum haemorrhage (PPH) and birth asphyxia as well as poor skills in neonatal resuscitation. Comparing with the 2008 survey, no significant improvements were observed in providers' knowledge and competence in 2013 on PPH management and essential newborn care (p > 0.05). There are advances in infrastructure, medical supplies and personnel for EmONC provision, yet poor providers' competences have persisted contributing to

  5. Pravastatin improves pregnancy outcomes in obstetric antiphospholipid syndrome refractory to antithrombotic therapy

    PubMed Central

    Lefkou, Eleftheria; Mamopoulos, Apostolos; Dagklis, Themistoklis; Vosnakis, Christos; Rousso, David

    2016-01-01

    BACKGROUND. Administration of conventional antithrombotic treatment (low-dose aspirin plus low–molecular weight heparin [LDA+LMWH]) for obstetric antiphospholipid syndrome (APS) does not prevent life-threatening placenta insufficiency–associated complications such as preeclampsia (PE) and intrauterine growth restriction (IUGR) in 20% of patients. Statins have been linked to improved pregnancy outcomes in mouse models of PE and APS, possibly due to their protective effects on endothelium. Here, we investigated the use of pravastatin in LDA+LMWH-refractory APS in patients at an increased risk of adverse pregnancy outcomes. METHODS. We studied 21 pregnant women with APS who developed PE and/or IUGR during treatment with LDA+LMWH. A control group of 10 patients received only LDA+LMWH. Eleven patients received pravastatin (20 mg/d) in addition to LDA+LMWH at the onset of PE and/or IUGR. Uteroplacental blood hemodynamics, progression of PE features (hypertension and proteinuria), and fetal/neonatal outcomes were evaluated. RESULTS. In the control group, all deliveries occurred preterm and only 6 of 11 neonates survived. Of the 6 surviving neonates, 3 showed abnormal development. Patients who received both pravastatin and LDA+LMWH exhibited increased placental blood flow and improvements in PE features. These beneficial effects were observed as early as 10 days after pravastatin treatment onset. Pravastatin treatment combined with LDA+LMWH was also associated with live births that occurred close to full term in all patients. CONCLUSION. The present study suggests that pravastatin may improve pregnancy outcomes in women with refractory obstetric APS when taken at the onset of PE or IUGR until the end of pregnancy. PMID:27454295

  6. Expected to deliver: alignment of regulation, training, and actual performance of emergency obstetric care providers in Malawi and Tanzania.

    PubMed

    Lobis, Samantha; Mbaruku, Godfrey; Kamwendo, Francis; McAuliffe, Eilish; Austin, Judy; de Pinho, Helen

    2011-12-01

    Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania. A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities. A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery. Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  7. Use of a geographic information system to assess accessibility to health facilities providing emergency obstetric and newborn care in Bangladesh.

    PubMed

    Chowdhury, Mahbub E; Biswas, Taposh K; Rahman, Monjur; Pasha, Kamal; Hossain, Mollah A

    2017-08-01

    To use a geographic information system (GIS) to determine accessibility to health facilities for emergency obstetric and newborn care (EmONC) and compare coverage with that stipulated by UN guidelines (5 EmONC facilities per 500 000 individuals, ≥1 comprehensive). A cross-sectional study was undertaken of all public facilities providing EmONC in 24 districts of Bangladesh from March to October 2012. Accessibility to each facility was assessed by applying GIS to estimate the proportion of catchment population (comprehensive 500 000; basic 100 000) able to reach the nearest facility within 2 hours and 1 hour of travel time, respectively, by existing road networks. The minimum number of public facilities providing comprehensive and basic EmONC services (1 and 5 per 500 000 individuals, respectively) was reached in 16 and 3 districts, respectively. However, after applying GIS, in no district did 100% of the catchment population have access to these services. A minimum of 75% and 50% of the population had accessibility to comprehensive services in 11 and 5 districts, respectively. For basic services, accessibility was much lower. Assessing only the number of EmONC facilities does not ensure universal coverage; accessibility should be assessed when planning health systems. © 2017 International Federation of Gynecology and Obstetrics.

  8. New paradigm old thinking: The case for emergency obstetric care in the prevention of maternal mortality in Nigeria.

    PubMed

    Ijadunola, Kayode T; Ijadunola, Macellina Y; Esimai, Olapeju A; Abiona, Titilayo C

    2010-02-17

    The continuing burden of maternal mortality, especially in developing countries has prompted a shift in paradigm from the traditional risk assessment approach to the provision of access to emergency obstetric care services for all women who are pregnant. This study assessed the knowledge of maternity unit operatives at the primary and secondary levels of care about the concept of emergency obstetric care (EmOC) and investigated the contents of antenatal care (ANC) counseling services they delivered to clients. It also described the operatives' preferred strategies and practices for promoting safe motherhood and averting maternal mortality in South-west Nigeria. The study population included all the 152 health workers (doctors, midwives, nurses and community health extension workers) employed in the maternity units of all the public health facilities (n = 22) offering maternity care in five cities of 2 states. Data were collected with the aid of a self-administered, semi-structured questionnaire and non-participant observation checklist. Results were presented using descriptive statistics. Ninety one percent of the maternity unit staff had poor knowledge concerning the concept of EmOC, with no difference in knowledge of respondents across age groups. While consistently more than 60% of staff reported the inclusion of specific client-centered messages such as birth preparedness and warning/danger signs of pregnancy and delivery in the (ANC) delivered to clients, structured observations revealed that less than a quarter of staff actually did this. Furthermore, only 40% of staff reported counseling clients on complication readiness, but structured observations revealed that no staff did. Only 9% of staff had ever been trained in lifesaving skills (LSS). Concerning strategies for averting maternal deaths, 70% of respondents still preferred the strengthening of routine ANC services in the health facilities to the provision of access to EmOC services for all pregnant

  9. Availability and distribution of emergency obstetric care services in Karnataka State, South India: access and equity considerations.

    PubMed

    Mony, Prem K; Krishnamurthy, Jayanna; Thomas, Annamma; Sankar, Kiruba; Ramesh, B M; Moses, Stephen; Blanchard, James; Avery, Lisa

    2013-01-01

    As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the 'non-headquarter' taluks and 'backward' taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in

  10. New paradigm old thinking: the case for emergency obstetric care in the prevention of maternal mortality in Nigeria

    PubMed Central

    2010-01-01

    Background The continuing burden of maternal mortality, especially in developing countries has prompted a shift in paradigm from the traditional risk assessment approach to the provision of access to emergency obstetric care services for all women who are pregnant. This study assessed the knowledge of maternity unit operatives at the primary and secondary levels of care about the concept of emergency obstetric care (EmOC) and investigated the contents of antenatal care (ANC) counseling services they delivered to clients. It also described the operatives' preferred strategies and practices for promoting safe motherhood and averting maternal mortality in South-west Nigeria. Methods The study population included all the 152 health workers (doctors, midwives, nurses and community health extension workers) employed in the maternity units of all the public health facilities (n = 22) offering maternity care in five cities of 2 states. Data were collected with the aid of a self-administered, semi-structured questionnaire and non-participant observation checklist. Results were presented using descriptive statistics. Results Ninety one percent of the maternity unit staff had poor knowledge concerning the concept of EmOC, with no difference in knowledge of respondents across age groups. While consistently more than 60% of staff reported the inclusion of specific client-centered messages such as birth preparedness and warning/danger signs of pregnancy and delivery in the (ANC) delivered to clients, structured observations revealed that less than a quarter of staff actually did this. Furthermore, only 40% of staff reported counseling clients on complication readiness, but structured observations revealed that no staff did. Only 9% of staff had ever been trained in lifesaving skills (LSS). Concerning strategies for averting maternal deaths, 70% of respondents still preferred the strengthening of routine ANC services in the health facilities to the provision of access to Em

  11. Availability and Distribution of Emergency Obstetric Care Services in Karnataka State, South India: Access and Equity Considerations

    PubMed Central

    Mony, Prem K.; Krishnamurthy, Jayanna; Thomas, Annamma; Sankar, Kiruba; Ramesh, B. M.; Moses, Stephen; Blanchard, James; Avery, Lisa

    2013-01-01

    Background As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. Methods & Findings We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the ‘non-headquarter’ taluks and ‘backward’ taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. Conclusions In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater

  12. Existence and functionality of emergency obstetric care services at district level in Kenya: theoretical coverage versus reality.

    PubMed

    Echoka, Elizabeth; Kombe, Yeri; Dubourg, Dominique; Makokha, Anselimo; Evjen-Olsen, Bjørg; Mwangi, Moses; Byskov, Jens; Olsen, Øystein Evjen; Mutisya, Richard

    2013-03-25

    The knowledge on emergency obstetric care (EmOC) is limited in Kenya, where only partial data from sub-national studies exist. The EmOC process indicators have also not been integrated into routine health management information system to monitor progress in safe motherhood interventions both at national and lower levels of the health system. In a country with a high maternal mortality burden, the implication is that decision makers are unaware of the extent of need for life-saving care and, therefore, where to intervene. The objective of the study was to assess the actual existence and functionality of EmOC services at district level. This was a facility-based cross-sectional study. Data were collected from 40 health facilities offering delivery services in Malindi District, Kenya. Data presented are part of the "Response to accountable priority setting for trust in health systems" (REACT) study, in which EmOC was one of the service areas selected to assess fairness and legitimacy of priority setting in health care. The main outcome measures in this study were the number of facilities providing EmOC, their geographical distribution, and caesarean section rates in relation to World Health Organization (WHO) recommendations. Among the 40 facilities assessed, 29 were government owned, seven were private and four were voluntary organisations. The ratio of EmOC facilities to population size was met (6.2/500,000), compared to the recommended 5/500,000. However, using the strict WHO definition, none of the facilities met the EmOC requirements, since assisted delivery, by vacuum or forceps was not provided in any facility. Rural-urban inequities in geographical distribution of facilities were observed. The facilities were not providing sufficient life-saving care as measured by caesarean section rates, which were below recommended levels (3.7% in 2008 and 4.5% in 2009). The rates were lower in the rural than in urban areas (2.1% vs. 6.8%; p < 0.001 ) in 2008 and (2.7% vs

  13. Existence and functionality of emergency obstetric care services at district level in Kenya: theoretical coverage versus reality

    PubMed Central

    2013-01-01

    Background The knowledge on emergency obstetric care (EmOC) is limited in Kenya, where only partial data from sub-national studies exist. The EmOC process indicators have also not been integrated into routine health management information system to monitor progress in safe motherhood interventions both at national and lower levels of the health system. In a country with a high maternal mortality burden, the implication is that decision makers are unaware of the extent of need for life-saving care and, therefore, where to intervene. The objective of the study was to assess the actual existence and functionality of EmOC services at district level. Methods This was a facility-based cross-sectional study. Data were collected from 40 health facilities offering delivery services in Malindi District, Kenya. Data presented are part of the “Response to accountable priority setting for trust in health systems” (REACT) study, in which EmOC was one of the service areas selected to assess fairness and legitimacy of priority setting in health care. The main outcome measures in this study were the number of facilities providing EmOC, their geographical distribution, and caesarean section rates in relation to World Health Organization (WHO) recommendations. Results Among the 40 facilities assessed, 29 were government owned, seven were private and four were voluntary organisations. The ratio of EmOC facilities to population size was met (6.2/500,000), compared to the recommended 5/500,000. However, using the strict WHO definition, none of the facilities met the EmOC requirements, since assisted delivery, by vacuum or forceps was not provided in any facility. Rural–urban inequities in geographical distribution of facilities were observed. The facilities were not providing sufficient life-saving care as measured by caesarean section rates, which were below recommended levels (3.7% in 2008 and 4.5% in 2009). The rates were lower in the rural than in urban areas (2.1% vs. 6

  14. Improved obstetrical outcomes for adolescents in a community-based outreach program: a matched cohort study.

    PubMed

    Fleming, Nathalie A; Tu, Xiaowen; Black, Amanda Y

    2012-12-01

    Adolescent pregnancies are higher-risk pregnancies, and standard obstetrical care environments may not meet their needs. The objective of this study was to determine if adolescents followed in a community-based adolescent outreach obstetrical program had improved perinatal outcomes compared with provincial control subjects. We conducted a matched cohort study. Adolescent women who received prenatal care in the outreach program between 2004 and 2010 (intervention group, n = 206) were identified and matched 1:4 to adolescent control subjects in the provincial perinatal database (n = 831). Chi-square and Student t tests were performed for categorical and continuous variables. Regression models assessed the association between the intervention and pregnancy/perinatal outcomes. The intervention cohort had significantly higher rates of smoking, drug use, and alcohol use than control subjects P < 0.001); however, rates of first trimester visits (76.7% vs. 64%, P = 0.009), prenatal class attendance (52.8% vs. 30.3%; P < 0.001), and group B streptococcus screening (P = 0.01) were also higher. Although the intervention cohort had higher risk behaviours than control subjects, there were no significant differences between the groups in the proportion of preterm or very preterm births, low birth weight or very low birth weight infants, or intrauterine growth restricted/small for gestational age infants. The intervention cohort had a significantly higher mean gestational age at delivery (P = 0.005) and higher mean birth weight (P = 0.002) than control subjects. The adjusted relative risk of low birth weight was significantly lower in the intervention group (RR 0.41; 95% CI 0.18 to 0.95) and a decreased risk of preterm delivery was seen (RR 0.47; 95% CI 0.22 to 1.00). Pregnant adolescents may engage in higher-risk behaviours that can affect perinatal outcomes. Early prenatal care and education in adolescent-friendly programs may mitigate the effect of these behaviours on

  15. [The importance of simulation in team training on obstetric emergencies: results of the first phase of the national plan for continuous medical training].

    PubMed

    Maio Matos, Francisco; Sousa Gomes, Andrea; Costa, Fernando Jorge; Santos Silva, Isabel; Carvalhas, Joana

    2012-01-01

    Obstetric emergencies are unexpected and random. The traditional model for medical training of these acute events has included lectures combined with sporadic clinical experiences, but this educational method has inherent limitations. Given the variety of manual skills that must be learned and high-risk environment, Obstetrics is uniquely suited for simulation. New technological educational tools provide an opportunity to learn and master technical skills needed in emergent situations as well as the opportunity to rehearse and learn from mistakes without risks to patients. The goals of this study are to assess which are the factors that trainees associate to human fallibility before and after clinical simulation based training; to compare the confidence level to solve emergent obstetric situations between interns and experts with up to 5 years of experience before and after training, and to determine the value that trainees give to simulation as a teaching tool on emergent events. 31 physicians participated at this course sessions. After the course, we verified changes in the factores that trainees associate to human fallibility, an increase in confidence level to solve emergent obstetric and an increase in the value that trainees give to simulation as a teaching tool.

  16. Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania

    PubMed Central

    2014-01-01

    Background Provision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC). Methods In-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach. Results Participants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation. Conclusion The unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds. PMID

  17. Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania.

    PubMed

    Mkoka, Dickson Ally; Goicolea, Isabel; Kiwara, Angwara; Mwangu, Mughwira; Hurtig, Anna-Karin

    2014-03-19

    Provision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC). In-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach. Participants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation. The unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

  18. [Validity of the modern fetal monitoring methods in the decision of emergency obstetric operations].

    PubMed

    Issel, E P; Bollmann, R; Prenzlau, P

    1975-01-01

    The validity of the modern methods of fetal monitoring to decide for the indication of urgent obstetric operations. The reliability of the modern supervision of the fetus is studied in cases of doubtful fetal heart action. Up to the present day we have no method for the exact estimation of the degree of a damage to the fetus. In such a precarious situation we should use all available methods for the diagnosis of the fetal condition, because the results of only one of the methods offer insufficient evidence. By means of the literature the alterations in the ECG of the dying fetus are interpreted in comparison to artefacts. In cases of doubtful fetal heart action we recommend in addition to the clinical findings to record the fetal ECG, to controll the actual fetal pH and attempt an investigation by ultrasonic.

  19. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy.

    PubMed

    Chuang, David Chwei-Chin; Hattori, Yasunori; Ma And, Hae-Shya; Chen, Hung-Chi

    2002-01-01

    Children with previously untreated obstetric brachial plexus palsy frequently have abnormal elbow function because of motor recovery with aberrant reinnervation, or because of paresis or paralysis. From 1988 to 1997 (9-year period), 62 children with obstetric brachial plexus palsy with resulting elbow deformity underwent various methods of palliative reconstruction to improve elbow function. For motor recovery with aberrant reinnervation, release of aberrantly reinnervated antagonistic muscles and augmentation of paretic muscles form the basis of surgical intervention. The surgical procedures included triceps-to-biceps transfer, biceps-to-triceps transfer, brachialis-to-triceps transfer, or combined biceps- and brachialis-to-triceps transfer. Choice of procedures was individualized and randomly determined on the basis of the degree and pattern of aberrant reinnervation between elbow flexors and extensors. In patients' motor recovery with paresis or paralysis, persistently weak elbow flexion was salvaged with a functioning free muscle transplantation or Steindler's flexorplasty, or regional shoulder muscle transfer. In addition, patients with aberrant reinnervation between shoulder abductors and elbow flexors underwent anterior deltoid-to-biceps transfer with a fascia lata graft. All patients had a minimum follow-up of 2 years. Results are assessed and discussed and a reconstructive algorithm is recommended. In general, reconstruction of elbow extension should precede that of elbow flexion. Biceps-to-triceps transfer with preservation of an intact brachialis muscle, or brachialis-to-triceps transfer with preservation of an intact biceps, allows 50 percent of these patients to achieve acceptable elbow flexion and extension in a single-stage procedure.

  20. An assessment of priority setting process and its implication on availability of emergency obstetric care services in Malindi District, Kenya

    PubMed Central

    Nyandieka, Lilian Nyamusi; Kombe, Yeri; Ng'ang'a, Zipporah; Byskov, Jens; Njeru, Mercy Karimi

    2015-01-01

    Introduction In spite of the critical role of Emergency Obstetric Care in treating complications arising from pregnancy and childbirth, very few facilities are equipped in Kenya to offer this service. In Malindi, availability of EmOC services does not meet the UN recommended levels of at least one comprehensive and four basic EmOC facilities per 500,000 populations. This study was conducted to assess priority setting process and its implication on availability, access and use of EmOC services at the district level. Methods A qualitative study was conducted both at health facility and community levels. Triangulation of data sources and methods was employed, where document reviews, in-depth interviews and focus group discussions were conducted with health personnel, facility committee members, stakeholders who offer and/ or support maternal health services and programmes; and the community members as end users. Data was thematically analysed. Results Limitations in the extent to which priorities in regard to maternal health services can be set at the district level were observed. The priority setting process was greatly restricted by guidelines and limited resources from the national level. Relevant stakeholders including community members are not involved in the priority setting process, thereby denying them the opportunity to contribute in the process. Conclusion The findings illuminate that consideration of all local plans in national planning and budgeting as well as the involvement of all relevant stakeholders in the priority setting exercise is essential in order to achieve a consensus on the provision of emergency obstetric care services among other health service priorities. PMID:26889337

  1. Successes and Challenges of Interprofessional Physiologic Birth and Obstetric Emergency Simulations in a Nurse-Midwifery Education Program.

    PubMed

    Shaw-Battista, Jenna; Belew, Cynthia; Anderson, Deborah; van Schaik, Sandrijn

    2015-01-01

    This article describes childbirth simulation design and implementation within the nurse-midwifery education program at the University of California, San Francisco. Nurse-midwife and obstetrician faculty coordinators were supported by faculty from multiple professions and specialties in curriculum review and simulation development and implementation. The primary goal of the resulting technology-enhanced simulations of normal physiologic birth and obstetric emergencies was to assist learners' development of interprofessional competencies related to communication, teamwork, and patient-centered care. Trainees included nurse-midwifery students; residents in obstetrics, pediatrics, and family medicine; medical students; and advanced practice nursing students in pediatrics. The diversity of participant types and learning levels provided benefits and presented challenges to effective scenario-based simulation design among numerous other theoretical and logistical considerations. This project revealed practical solutions informed by emerging health sciences and education research literature, faculty experience, and formal course evaluations by learners. Best practices in simulation development and implementation were incorporated, including curriculum revision grounded in needs assessment, case- and event-based clinical scenarios, optimization of fidelity, and ample time for participant debriefing. Adequate preparation and attention to detail increased the immersive experience and benefits of simulation. Suggestions for fidelity enhancement are provided with examples of simulation scenarios, a timeline for preparations, and discussion topics to facilitate meaningful learning by maternity and newborn care providers and trainees in clinical and academic settings. Pre- and postsimulation measurements of knowledge, skills, and attitudes are ongoing and not reported. This article is part of a special series of articles that address midwifery innovations in clinical practice

  2. An assessment of priority setting process and its implication on availability of emergency obstetric care services in Malindi District, Kenya.

    PubMed

    Nyandieka, Lilian Nyamusi; Kombe, Yeri; Ng'ang'a, Zipporah; Byskov, Jens; Njeru, Mercy Karimi

    2015-01-01

    In spite of the critical role of Emergency Obstetric Care in treating complications arising from pregnancy and childbirth, very few facilities are equipped in Kenya to offer this service. In Malindi, availability of EmOC services does not meet the UN recommended levels of at least one comprehensive and four basic EmOC facilities per 500,000 populations. This study was conducted to assess priority setting process and its implication on availability, access and use of EmOC services at the district level. A qualitative study was conducted both at health facility and community levels. Triangulation of data sources and methods was employed, where document reviews, in-depth interviews and focus group discussions were conducted with health personnel, facility committee members, stakeholders who offer and/ or support maternal health services and programmes; and the community members as end users. Data was thematically analysed. Limitations in the extent to which priorities in regard to maternal health services can be set at the district level were observed. The priority setting process was greatly restricted by guidelines and limited resources from the national level. Relevant stakeholders including community members are not involved in the priority setting process, thereby denying them the opportunity to contribute in the process. The findings illuminate that consideration of all local plans in national planning and budgeting as well as the involvement of all relevant stakeholders in the priority setting exercise is essential in order to achieve a consensus on the provision of emergency obstetric care services among other health service priorities.

  3. Improvements in Cesarean Section Techniques: Arad's Obstetrics Department Experience on Adapting the Vejnovic Cesarean Section Technique.

    PubMed

    Furau, Cristian; Furau, Gheorghe; Dascau, Voicu; Ciobanu, Gheorghe; Onel, Cristina; Stanescu, Casiana

    2013-09-01

    Cesarean section has become recently the first choice for delivery in many clinics in Romania and worldwide. The purpose of our study is to assess the benefits of introducing the adapted Vejnovic uterine suture technique into daily practice. A total of 1703 out of the 1776 cesarean section performed in the period January, 2012 - March, 2013 in the Obstetric Department of the Emergency Clinical County Hospital of Arad were retrospectively analyzed based on the cesarean section registries, birth registries and patient's personal medical records. We compared results between the group of patients undergoing adapted Vejnovic cesarean section technique and the group of patients operated in a classic manner. The cesarean section rate in the studied period was 56.48%. Adapted Vejnovic cesarean section technique was performed in 548 cases (30.86% of the cases), furthermore in the last 3 months studied it reached 57.27%. Mean APGAR score was better in the adapted Vejnovic cesarean section group (8.43) compared with the reference group (8.34). No significant differences were seen between the two groups regarding maternal age, gestation, weeks of gestation, newborn weight, anesthesia and indications for cesarean section. Exteriorizing the uterus helped the incidental diagnosis of 35 uterine myoma, 22 adnexal masses and 13 uterine malformations. In a society with a constant growth of cesarean rate, the adapted Vejnovic cesarean section technique is becoming popular amongst clinicians for its advantages, but further studies need to be developed for its standardization.

  4. Obstetric team simulation program challenges.

    PubMed

    Bullough, A S; Wagner, S; Boland, T; Waters, T P; Kim, K; Adams, W

    2016-12-01

    To describe the challenges associated with the development and assessment of an obstetric emergency team simulation program. The goal was to develop a hybrid, in-situ and high fidelity obstetric emergency team simulation program that incorporated weekly simulation sessions on the labor and delivery unit, and quarterly, education protected sessions in the simulation center. All simulation sessions were video-recorded and reviewed. Labor and delivery unit and simulation center. Medical staff covering labor and delivery, anesthesiology and obstetric residents and obstetric nurses. Assessments included an on-line knowledge multiple-choice questionnaire about the simulation scenarios. This was completed prior to the initial in-situ simulation session and repeated 3 months later, the Clinical Teamwork Scale with inter-rater reliability, participant confidence surveys and subjective participant satisfaction. A web-based curriculum comprising modules on communication skills, team challenges, and team obstetric emergency scenarios was also developed. Over 4 months, only 6 labor and delivery unit in-situ sessions out of a possible 14 sessions were carried out. Four high-fidelity sessions were performed in 2 quarterly education protected meetings in the simulation center. Information technology difficulties led to the completion of only 18 pre/post web-based multiple-choice questionnaires. These test results showed no significant improvement in raw score performance from pre-test to post-test (P=.27). During Clinical Teamwork Scale live and video assessment, trained raters and program faculty were in agreement only 31% and 28% of the time, respectively (Kendall's W=.31, P<.001 and W=.28, P<.001). Participant confidence surveys overall revealed confidence significantly increased (P<.05), from pre-scenario briefing to after post-scenario debriefing. Program feedback indicates a high level of participant satisfaction and improved confidence yet further program refinement is

  5. Tanzanian lessons in using non-physician clinicians to scale up comprehensive emergency obstetric care in remote and rural areas

    PubMed Central

    2011-01-01

    Background With 15-30% met need for comprehensive emergency obstetrical care (CEmOC) and a 3% caesarean section rate, Tanzania needs to expand the number of facilities providing these services in more remote areas. Considering severe shortage of human resources for health in the country, currently operating at 32% of the required skilled workforce, an intensive three-month course was developed to train non-physician clinicians for remote health centres. Methods Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara, Tanzania. The required key competencies were identified, taught and objectively assessed. The training involved hands-on sessions, lectures and discussions. Participants were purposely selected in teams from remote health centres where CEmOC services were planned. Monthly supportive supervision after graduation was carried out in the upgraded health centres Results A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and 2 from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. During training, participants performed 278 major obstetric surgeries, 141 manual removal of placenta and evacuation of incomplete and septic abortions, and 1161 anaesthetic procedures under supervision. The first 8 months after introduction of CEmOC services in 3 health centres resulted in 179 caesarean sections, a remarkable increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate (OR: 0.4; 95% CI: 0.1-1.7) and reduced obstetric referrals (OR: 0.2; 95% CI: 0.1-0.4)). There were two maternal deaths, both arriving in a moribund condition. Conclusions Tanzanian AMOs, clinical officers, and nurse-midwives can be trained as a team, in a three

  6. The dominance of the private sector in the provision of emergency obstetric care: studies from Gujarat, India.

    PubMed

    Salazar, Mariano; Vora, Kranti; De Costa, Ayesha

    2016-07-07

    India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005). A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed. EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector. The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector.

  7. Essential basic and emergency obstetric and newborn care: from education and training to service delivery and quality of care.

    PubMed

    Otolorin, Emmanuel; Gomez, Patricia; Currie, Sheena; Thapa, Kusum; Dao, Blami

    2015-06-01

    Approximately 15% of expected births worldwide will result in life-threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource-poor settings. Providers have been educated to deliver high-impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiego's programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high-quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency-based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale-up of high impact evidence-based maternal and newborn interventions in low-resource settings.

  8. Signal functions for emergency obstetric care as an intervention for reducing maternal mortality: a survey of public and private health facilities in Lusaka District, Zambia.

    PubMed

    Tembo, Tannia; Chongwe, Gershom; Vwalika, Bellington; Sitali, Lungowe

    2017-09-06

    Zambia's maternal mortality ratio was estimated at 398/100,000 live births in 2014. Successful aversion of deaths is dependent on availability and usability of signal functions for emergency obstetric and neonatal care. Evidence of availability, usability and quality of signal functions in urban settings in Zambia is minimal as previous research has evaluated their distribution in rural settings. This survey evaluated the availability and usability of signal functions in private and public health facilities in Lusaka District of Zambia. A descriptive cross sectional study was conducted between November 2014 and February 2015 at 35 public and private health facilities. The Service Availability and Readiness Assessment tool was adapted and administered to overall in-charges, hospital administrators or maternity ward supervisors at health facilities providing maternal and newborn health services. The survey quantified infrastructure, human resources, equipment, essential drugs and supplies and used the UN process indicators to determine availability, accessibility and quality of signal functions. Data on deliveries and complications were collected from registers for periods between June 2013 and May 2014. Of the 35 (25.7% private and 74.2% public) health facilities assessed, only 22 (62.8%) were staffed 24 h a day, 7 days a week and had provided obstetric care 3 months prior to the survey. Pre-eclampsia/ eclampsia and obstructed labor accounted for most direct complications while postpartum hemorrhage was the leading cause of maternal deaths. Overall, 3 (8.6%) and 5 (14.3%) of the health facilities had provided Basic and Comprehensive EmONC services, respectively. All facilities obtained blood products from the only blood bank at a government referral hospital. The UN process indicators can be adequately used to monitor progress towards maternal mortality reduction. Lusaka district had an unmet need for BEmONC as health facilities fell below the minimum UN standard

  9. Maternity care calendar wheel. Improved obstetric wheel developed in British Columbia.

    PubMed Central

    Grzybowski, S.; Nout, R.; Kirkham, M.

    1999-01-01

    PROBLEM BEING ADDRESSED: Gestational calendar "wheels" are not well designed for routine prenatal care or for presenting the uncertainties of predicting date of delivery. OBJECTIVE OF PROGRAM: To design and pilot-test a new gestational calendar wheel that predicts the range of normal due dates in a way that reflects the biological realities of pregnancy. The calendar has prompts that could facilitate provision of antenatal care, support prenatal education, and guide the timing of induction for pregnancies past their due dates. MAIN COMPONENTS OF PROGRAM: The calendar sets out the key issues to be addressed with patients during pregnancy. It is designed to be photocopied while set to patients' dates: patients keep one copy; another is placed in their charts. The probability of delivering on a given date is presented graphically and as a percentage likelihood of giving birth during specified intervals. Twelve practising physicians, 12 residents, and 10 pregnant women pilot-tested and evaluated the wheel. Their responses were favourable. CONCLUSIONS: The Maternity Care Calendar wheel is a substantial advance on existing obstetric calendar wheels. It incorporates evidence-based information that should facilitate prenatal care, promote prenatal education, and foster realistic expectations about the likely timing of delivery. Early in the pregnancy, it can help establish the timing of induction for pregnancies past their due dates. Further testing of the calendar's effectiveness in improving patient outcomes is needed. PMID:10099805

  10. Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy.

    PubMed

    Nath, Rahul K; Somasundaram, Chandra

    2016-11-18

    To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions. We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations. Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon's surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively. We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.

  11. Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy

    PubMed Central

    Nath, Rahul K; Somasundaram, Chandra

    2016-01-01

    AIM To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions. METHODS We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations. RESULTS Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon’s surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively. CONCLUSION We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment. PMID:27900273

  12. Obstetrical Ultrasound

    MedlinePlus

    ... Index A-Z Obstetric Ultrasound Obstetric ultrasound uses sound waves to produce pictures of a baby (embryo ... pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or ...

  13. SYMPTEK homemade foam models for client education and emergency obstetric care skills training in low-resource settings.

    PubMed

    Deganus, Sylvia A

    2009-10-01

    Clinical training for health care workers using anatomical models and simulation has become an established norm. A major requirement for this approach is the availability of lifelike training models or simulators for skills practice. Manufactured sophisticated human models such as the resuscitation neonatal dolls, the Zoë gynaecologic simulator, and other pelvic models are very expensive, and are beyond the budgets of many training programs or activities in low-resource countries. Clinical training programs in many low-resource countries suffer greatly because of this cost limitation. Yet it is also in these same poor countries that the need for skilled human resources in reproductive health is greatest. The SYMPTEK homemade models were developed in response to the need for cheaper, more readily available humanistic models for training in emergency obstetric skills and also for client education. With minimal training, a variety of cheap SYMPTEK models can easily be made, by both trainees and facilitators, from high-density latex foam material commonly used for furnishings. The models are reusable, durable, portable, and easily maintained. The uses, advantages, disadvantages, and development of the SYMPTEK foam models are described in this article.

  14. Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines.

    PubMed

    Banke-Thomas, Aduragbemi; Wright, Kikelomo; Sonoiki, Olatunji; Banke-Thomas, Oluwasola; Ajayi, Babatunde; Ilozumba, Onaedo; Akinola, Oluwarotimi

    2016-01-01

    Background Lack of timely and quality emergency obstetric care (EmOC) has contributed significantly to maternal morbidity and mortality, particularly in low- and middle-income countries (LMICs). Since 2009, the global guideline, referred to as the 'handbook', has been used to monitor availability, utilization, and quality of EmOC. Objective To assess application and explore experiences of researchers in LMICs in assessing EmOC. Design Multiple databases of peer-reviewed literature were systematically reviewed on EmOC assessments in LMICs, since 2009. Following set criteria, we included articles, assessed for quality based on a newly developed checklist, and extracted data using a pre-designed extraction tool. We used thematic summaries to condense our findings and mapped patterns that we observed. To analyze experiences and recommendations for improved EmOC assessments, we took a deductive approach for the framework synthesis. Results Twenty-seven studies met our inclusion criteria, with 17 judged as high quality. The highest publication frequency was observed in 2015. Most assessments were conducted in Nigeria and Tanzania (four studies each) and Bangladesh and Ghana (three each). Most studies (17) were done at subnational levels with 23 studies using the 'handbook' alone, whereas the others combined the 'handbook' with other frameworks. Seventeen studies conducted facility-based surveys, whereas others used mixed methods. For different reasons, intrapartum and very early neonatal death rate and proportion of deaths due to indirect causes in EmOC facilities were the least reported indicators. Key emerging themes indicate that data quality for EmOC assessments can be improved, indicators should be refined, a holistic approach is required for EmOC assessments, and assessments should be conducted as routine processes. Conclusions There is clear justification to review how EmOC assessments are being conducted. Synergy between researchers, EmOC program managers, and

  15. Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines.

    PubMed

    Banke-Thomas, Aduragbemi; Wright, Kikelomo; Sonoiki, Olatunji; Banke-Thomas, Oluwasola; Ajayi, Babatunde; Ilozumba, Onaedo; Akinola, Oluwarotimi

    2016-01-01

    Lack of timely and quality emergency obstetric care (EmOC) has contributed significantly to maternal morbidity and mortality, particularly in low- and middle-income countries (LMICs). Since 2009, the global guideline, referred to as the 'handbook', has been used to monitor availability, utilization, and quality of EmOC. To assess application and explore experiences of researchers in LMICs in assessing EmOC. Multiple databases of peer-reviewed literature were systematically reviewed on EmOC assessments in LMICs, since 2009. Following set criteria, we included articles, assessed for quality based on a newly developed checklist, and extracted data using a pre-designed extraction tool. We used thematic summaries to condense our findings and mapped patterns that we observed. To analyze experiences and recommendations for improved EmOC assessments, we took a deductive approach for the framework synthesis. Twenty-seven studies met our inclusion criteria, with 17 judged as high quality. The highest publication frequency was observed in 2015. Most assessments were conducted in Nigeria and Tanzania (four studies each) and Bangladesh and Ghana (three each). Most studies (17) were done at subnational levels with 23 studies using the 'handbook' alone, whereas the others combined the 'handbook' with other frameworks. Seventeen studies conducted facility-based surveys, whereas others used mixed methods. For different reasons, intrapartum and very early neonatal death rate and proportion of deaths due to indirect causes in EmOC facilities were the least reported indicators. Key emerging themes indicate that data quality for EmOC assessments can be improved, indicators should be refined, a holistic approach is required for EmOC assessments, and assessments should be conducted as routine processes. There is clear justification to review how EmOC assessments are being conducted. Synergy between researchers, EmOC program managers, and other key stakeholders would be critical for

  16. Improving Care for Depression in Obstetrics and Gynecology: A Randomized Controlled Trial

    PubMed Central

    Melville, Jennifer L.; Reed, Susan D.; Russo, Joan; Croicu, Carmen A.; Ludman, Evette; LaRocco-Cockburn, Anna; Katon, Wayne

    2014-01-01

    OBJECTIVE To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care. METHODS Two-site randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 of at least 10) who then met criteria for major depression, dysthymia or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12-months of collaborative depression management or usual care; 6, 12 and 18-month outcomes were compared. The primary outcomes were change from baseline to 12-months on depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care. RESULTS Participants were on average 39 years old, 44% were non-white and 56% had posttraumatic stress disorder. Intervention (n= 102) compared to usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P< .001) and 18 months (P=.004). The intervention group compared with usual care had improved functioning over 18 months (P< .05), were more likely to have an at least 50% decrease in depressive symptoms at 12 months (relative risk [RR]=1.74, 95% confidence interval [CI] 1.11–2.73), greater likelihood of at least 4 specialty mental health visits (6 month RR=2.70, 95% CI1.73–4.20; 12 month RR=2.53, 95% CI 1.63–3.94), adequate dose of antidepressant (6-month RR=1.64, 95% CI 1.03–2.60; 12-month RR=1.71, 95%CI 1.08 2.73), and greater satisfaction with care (6-month RR=1.70, 95% CI 1.19–2.44; 12-month RR=2.26, 95% CI 1.52–3.36). CONCLUSION Collaborative depression care adapted to women’s health settings improved depressive and functional outcomes and quality of depression care. PMID:24807320

  17. Examining the Use of Magnesium Sulfate to Treat Pregnant Women with Preeclampsia and Eclampsia: Results of a Program Assessment of Emergency Obstetric Care (EmOC) Training in India.

    PubMed

    Budhwani, Henna; Shivkumar, Poonam; Purandare, Chittaranjan Narhari; Cataldo, Nicholas A; Desai, Sadhana; Bhatt, Prakash; Baswal, Dinesh; Bhardwaj, Ajey

    2017-10-01

    The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia-eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings. Trainees' curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia-eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states. Of 1320 cases of preeclampsia-eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia-eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia-eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity. To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia-eclampsia could lead to notable improvements in maternal and infant mortality.

  18. Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala

    PubMed Central

    Walton, Anna; Kestler, Edgar; Dettinger, Julia C.; Zelek, Sarah; Holme, Francesca; Walker, Dilys

    2016-01-01

    Objective To assess the effect of a low-technology simulation-based training scheme for obstetric and perinatal emergency management (PRONTO; Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) on non-emergency delivery practices at primary level clinics in Guatemala. Methods A paired cross-sectional birth observation study was conducted with a convenience sample of 18 clinics (nine pairs of intervention and control clinics) from June 28 to August 7, 2013. Outcomes included implementation of practices known to decrease maternal and/or neonatal mortality and improve patient care. Results Overall, 25 and 17 births occurred in intervention and control clinics, respectively. Active management of the third stage of labor was appropriately performed by 20 (83%) of 24 intervention teams versus 7 (50%) of 14 control teams (P = 0.015). Intervention teams implemented more practices to decrease neonatal mortality than did control teams (P < 0.001). Intervention teams ensured patient privacy in 23 (92%) of 25 births versus 11 (65%) of 17 births for control teams (P = 0.014). All 15 applicable intervention teams kept patients informed versus 6 (55%) of 11 control teams (P = 0.001). Differences were also noted in teamwork; in particular, skill-based tools were used more often at intervention sites than control sites (P = 0.012). Conclusion Use of PRONTO enhanced non-emergency delivery care by increasing evidence-based practice, patient-centered care, and teamwork. PMID:26797198

  19. Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?

    PubMed Central

    Bailit, Jennifer L.; Grobman, William; McGee, Paula; Reddy, Uma M.; Wapner, Ronald J.; Varner, Michael W.; Thorp, John M.; Leveno, Kenneth J.; Iams, Jay D.; Tita, Alan T. N.; Saade, George; Sorokin, Yoram; Rouse, Dwight J.; Blackwell, Sean C.

    2015-01-01

    Objective To evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes. Study Design Cohort study of a random sample of deliveries performed at 25 hospitals over three years. Condition-specific protocols were collected from all hospitals and categorized independently by two authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery. Results Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of EBL >1000cc. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer ICU admissions (OR 0.28, 95% CI 0.18–0.44) and fewer cases of severe maternal hypertension (OR 0.86, 95% CI 0.77–0.96). Conclusion The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful. PMID:25659468

  20. Multifaceted intervention to improve obstetric practices: The OPERA cluster-randomized controlled trial.

    PubMed

    Dupont, Corinne; Winer, Norbert; Rabilloud, Muriel; Touzet, Sandrine; Branger, Bernard; Lansac, Jacques; Gaucher, Laurent; Duclos, Antoine; Huissoud, Cyril; Boutitie, Florent; Rudigoz, René-Charles; Colin, Cyrille

    2017-08-01

    Suboptimal care contributes to perinatal morbidity and mortality. We investigated the effects of a multifaceted program designed to improve obstetric practices and outcomes. A cluster-randomized trial was conducted from October 2008 to November 2010 in 95 French maternity units randomized either to receive an information intervention about published guidelines or left to apply them freely. The intervention combined an outreach visit with a morbidity/mortality conference (MMC) to review perinatal morbidity/mortality cases. Within the intervention group, the units were randomized to have MMCs with or without clinical psychologists. The primary outcome was the rate of suboptimal care among perinatal morbidity/mortality cases. The secondary outcomes included the rate of suboptimal care among cases of morbidity, the rate of suboptimal care among cases of mortality, the rate of avoidable morbidity and/or mortality cases, and the incidence of, morbidity and/or mortality. A mixed logistic regression model with random intercept was used to quantify the effect of the intervention on the main outcome. The study reviewed 2459 cases of morbidity or mortality among 165,353 births. The rate of suboptimal care among morbidity plus mortality cases was not significantly lower in the intervention than in the control group (8.1% vs. 10.6%, OR [95% CI]: 0.75 [0.50-1.12], p=0.15. However, the cases of suboptimal care among morbidity cases were significantly lower in the intervention group (7.6% vs. 11.5%, 0.62 [0.40-0.94], p=0.02); the incidence of perinatal morbidity was also lower (7.0 vs. 8.1‰, p=0.01). No differences were found between psychologist-backed and the other units. The intervention reduced the rate of suboptimal care mainly in morbidity cases and the incidence of morbidity but did not succeed in improving morbidity plus mortality combined. More clear-cut results regarding mortality require a longer study period and the inclusion of structures that intervene before and

  1. Where there is no obstetrician--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors.

    PubMed

    Evans, Cherrie Lynn; Maine, Deborah; McCloskey, Lois; Feeley, Frank G; Sanghvi, Harshad

    2009-12-01

    Maternal mortality continues to be high in rural India. Chief among the reasons for this is a severe shortage of obstetricians to perform cesarean delivery and other skills required for emergency obstetric care (EmOC). In 2006, the Government of India and the Federation of Obstetric and Gynecological Societies of India (FOGSI) with technical assistance from Jhpiego, instituted a nationwide, 16-week comprehensive EmOC (CEmOC) training program for general medical officers (MOs). This program is based on an earlier pilot project (2004-2006). To evaluate the pilot project, and identify lessons learned to inform the nationwide scale-up. The lead author (CE) visited trainees and their facilities to evaluate the project. Eight data collection tools were created, which included interviews with informants (program/government staff, regional/international experts, trainees and trainers), facility observation, and facility-based data collection of births and maternal/newborn deaths during the study period. More trainees performed each of the basic EmOC skills after the training than before. After training, 10 of 15 facilities to which trainees returned could provide all signal functions for basic EmOC whereas only 2 could do so before. For comprehensive EmOC, 2 facilities with obstetricians were providing all functions before and 2 were doing so after, even though the specialists had left those facilities and services were being provided by CEmOC trainees. Barriers to providing, or continuing to provide, EmOC for some trainees included insufficient training for cesarean delivery, lack of anesthetists, equipment and infrastructure (operating theater, blood services, forceps/vacuum, manual vacuum aspiration syringes). Although MOs can be trained to provide CEmOC (including cesarean delivery), without proper selection of facilities and trainees, adequate training, and support, this strategy will not substantially improve the availability of comprehensive EmOC in India. To

  2. Referrals between Public Sector Health Institutions for Women with Obstetric High Risk, Complications, or Emergencies in India – A Systematic Review

    PubMed Central

    Singh, Samiksha; Doyle, Pat; Campbell, Oona M.; Mathew, Manu; Murthy, G. V. S.

    2016-01-01

    Emergency obstetric care (EmOC) within primary health care systems requires a linked referral system to be effective in reducing maternal death. This systematic review aimed to summarize evidence on the proportion of referrals between institutions during pregnancy and delivery, and the factors affecting referrals, in India. We searched 6 electronic databases, reviewed four regional databases and repositories, and relevant program reports from India published between 1994 and 2013. All types of study or reports (except editorials, comments and letters) which reported on institution-referrals (out-referral or in-referral) for obstetric care were included. Results were synthesized on the proportion and the reasons for referral, and factors affecting referrals. Of the 11,346 articles identified by the search, we included 232 articles in the full text review and extracted data from 16 studies that met our inclusion criteria Of the 16, one was RCT, seven intervention cohort (without controls), six cross-sectional, and three qualitative studies. Bias and quality of studies were reported. Between 25% and 52% of all pregnancies were referred from Sub-centres for antenatal high-risk, 14% to 36% from nurse run delivery or basic EmOC centres for complications or emergencies, and 2 to 7% were referred from doctor run basic EmOC centres for specialist care at comprehensive EmOC centres. Problems identified with referrals from peripheral health centres included low skills and confidence of staff, reluctance to induce labour, confusion over the clinical criteria for referral, non-uniform standards of care at referral institutions, a tendency to by-pass middle level institutions, a lack of referral communication and supervision, and poor compliance. The high proportion of referrals from peripheral health centers reflects the lack of appropriate clinical guidelines, processes, and skills for obstetric care and referral in India. This, combined with inadequate referral communication

  3. Closing emergency operating rooms improves efficiency.

    PubMed

    Wullink, Gerhard; Van Houdenhoven, Mark; Hans, Erwin W; van Oostrum, Jeroen M; van der Lans, Marieke; Kazemier, Geert

    2007-12-01

    Long waiting times for emergency operations increase a patient's risk of postoperative complications and morbidity. Reserving Operating Room (OR) capacity is a common technique to maximize the responsiveness of an OR in case of arrival of an emergency patient. This study determines the best way to reserve OR time for emergency surgery. In this study two approaches of reserving capacity were compared: (1) concentrating all reserved OR capacity in dedicated emergency ORs, and (2) evenly reserving capacity in all elective ORs. By using a discrete event simulation model the real situation was modelled. Main outcome measures were: (1) waiting time, (2) staff overtime, and (3) OR utilisation were evaluated for the two approaches. Results indicated that the policy of reserving capacity for emergency surgery in all elective ORs led to an improvement in waiting times for emergency surgery from 74 (+/-4.4) minutes to 8 (+/-0.5) min. Working in overtime was reduced by 20%, and overall OR utilisation can increase by around 3%. Emergency patients are operated upon more efficiently on elective Operating Rooms instead of a dedicated Emergency OR. The results of this study led to closing of the Emergency OR in the Erasmus MC (Rotterdam, The Netherlands).

  4. Emergency obstetrics care services in District Neelum, Azad Jammu and Kashmir.

    PubMed

    Mateen, Abdul; Shaikh, Babar Tasneem; Kumar, Ramesh

    2013-01-01

    Globally 529,000 women die annually due to pregnancy related problems and in Pakistan alone this toll is about 35,000 deaths per annum. This situation is even more critical in the rural remote areas of Azad Jammu & Kashmir (AJK). The whole phenomenon needs a contextual assessment to ascertain the geographical, financial and socio culturaI accessibility, and availability of EmOC services in order to generate fresh evidence for the decision makers and concerned stakeholders for improving these services. A cross-sectional study was conducted using a structured questionnaire with the women delivered in the last 15 days, whereas the geographical accessibility and availability of EmOC services were assessed by visiting EmOC facilities in the district Neelum of AJK. Over a hundred women delivered in the last 15 days, participated in the study. Geographically, a central EmOC facility is far away and the terrain is hilly and dangerous. Women's social status, education, husband's employment and household income were found to have a significant association with the use of EmOC services. The health facilities audit showed that around 90% centres do not have a female medical officer appointed. Moreover, the state of the equipment, medicines and the basic utilities such as water, sanitation, and electricity are not satisfactory. Accessibility of EmOC services is poor in the district Neelum. Evidence on ground calls for organisational reforms at EmOC service delivery level as well as for long term planning in other sectors for improving socioeconomic and education status of the women in Azad Jammu & Kashmir.

  5. Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana

    PubMed Central

    Lohela, Terhi Johanna; Nesbitt, Robin Clark; Manu, Alexander; Vesel, Linda; Okyere, Eunice; Kirkwood, Betty; Gabrysch, Sabine

    2016-01-01

    Objectives To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. Design Cross-sectional Health Facility Assessment linked to population-based surveillance data. Setting 7 districts in Brong Ahafo region, Ghana. Participants Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. Primary outcome measures Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. Results Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. Conclusions Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. Trial registration number NCT00623337

  6. The influence of travel time on emergency obstetric care seeking behavior in the urban poor of Bangladesh: a GIS study.

    PubMed

    Panciera, Rocco; Khan, Akib; Rizvi, Syed Jafar Raza; Ahmed, Shakil; Ahmed, Tanvir; Islam, Rubana; Adams, Alayne M

    2016-08-22

    Availability of Emergency Obstetric Care (EmOC) is crucial to avert maternal death due to life-threatening complications potentially arising during delivery. Research on the determinants of utilization of EmOC has neglected urban settings, where traffic congestion can pose a significant barrier to the access of EmOC facilities, particularly for the urban poor due to costly and limited transportation options. This study investigates the impact of travel time to EmOC facilities on the utilization of facility-based delivery services among mothers living in urban poor settlements in Sylhet, Bangladesh. A cross-sectional EmOC health-seeking behavior survey from 39 poor urban clusters was geo-spatially linked to a comprehensive geo-referenced dataset of EmOC facility locations. Geo-spatial techniques and logistic regression were then applied to quantify the impact of travel time on place of delivery (EmOC facility or home), while controlling for confounding socio-cultural and economic factors. Increasing travel time to the nearest EmOC facility is found to act as a strong deterrent to seeking care for the urban poor in Sylhet. Logistic regression results indicate that a 5-min increase in travel time to the nearest EmOC facility is associated with a 30 % decrease (0.655 odds ratio, 95 % CI: 0.529-0.811) in the likelihood of delivery at an EmOC facility rather than at home. Moreover, the impact of travel time varies substantially between public, NGO and private facilities. A 5-min increase in travel time from a private EmOC facility is associated with a 32.9 % decrease in the likelihood of delivering at a private facility, while for public and Non-Government Organizations (NGO) EmOC facilities, the impact is lower (28.2 and 28.6 % decrease respectively). Other strong determinants of delivery at an EmOC facility are the use of antenatal care and mother's formal education, while Muslim mothers are found to be more likely to deliver at home. Geospatial evidence points to

  7. Neonatal outcomes after the obstetric near-miss events uterine rupture, abnormally invasive placenta and emergency peripartum hysterectomy - prospective data from the 2009-2011 Finnish NOSS study.

    PubMed

    Jakobsson, Maija; Tapper, Anna-Maija; Palomäki, Outi; Ojala, Kati; Pallasmaa, Nanneli; Ordén, Maija-Riitta; Gissler, Mika

    2015-12-01

    Neonatal outcomes after the maternal obstetric near-miss complications of uterine rupture, abnormally invasive placenta, and emergency peripartum hysterectomy were assessed. This case-control study was conducted as part of the Nordic Obstetric Surveillance Study (NOSS). Data on 211 newborns from 197 deliveries in which an obstetric near-miss complication was involved, were collected prospectively from April 2009 to August 2011 from all Finnish delivery units via questionnaires. Missing cases were obtained from national health registers and confirmed by the clinics. Control populations consisted of all other children born during the same period of time in the Finnish Medical Birth Register (n = 147 551). The number of stillbirths in this cohort was high [n = 8, 3.8% vs. 0.3% among controls, odds ratio (OR) 12.5, 95% confidence interval (CI) 6.32-24.9]. In addition, there were two neonatal deaths. The majority of cases (n = 8, 80%) were connected to uterine rupture. The risk of severe birth asphyxia diagnosis was increased compared with controls (n = 17, 8.1% vs. 0.1%, OR 137, 95% CI 82.7-226). A low umbilical artery pH (<7.05) was also observed among these neonates (28.8% vs. 1.0%, OR 28.7, 95% CI 21.5-38.2). Post-term pregnancies were relatively common among the uterine rupture cases. Adverse neonatal outcomes in the AIP and emergency peripartum hysterectomy cases were associated with preterm deliveries. The prospective data collected from clinicians, combined with the information gathered from national health registers, provided valuable insights into rare maternal near-miss cases. These complications also predisposed stillbirth and neonatal death. In this study, 75% of fetal losses were associated with uterine rupture. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

  8. Teamwork improvement in emergency trauma departments

    PubMed Central

    Khademian, Zahra; Sharif, Farkhondeh; Tabei, Seyed Ziaadin; Bolandparvaz, Shahram; Abbaszadeh, Abbas; Abbasi, Hamid Reza

    2013-01-01

    Background: Interprofessional teamwork is considered as the key to improve the quality of patient management in critical settings such as trauma emergency departments, but it is not fully conceptualized in these areas to guide practice. The aim of this article is to explore interprofessional teamwork and its improvement strategies in trauma emergency departments. Materials and Methods: Participants of this qualitative study consisted of 11 nurses and 6 supervisors recruited from the emergency departments of a newly established trauma center using purposive sampling. Data were generated using two focus group and six in-depth individual interviews, and analyzed using qualitative content analysis. Results: Interprofessional teamwork attributes and improvement strategies were emerged in three main themes related to team, context, and goal. These were categorized as the effective presence of team members, role definition in team framework, managerial and physical context, effective patient management, and overcoming competing goals Conclusions: Interprofessional teamwork in trauma emergency departments is explained as interdependence of team, context, and goal; so, it may be improved by strengthening these themes. The findings also provide a basis to evaluate, teach, and do research on teamwork. PMID:24403932

  9. Improving European Wildfire Emergency Information Services

    NASA Astrophysics Data System (ADS)

    Bielski, Conrad; Whitmore, Ceri; O'Brien, Victoria; Zeug, Gunter; Kalas, Milan; Porras, Ignasi; Solé, Josep Maria; Gálvez, Pedro; Navarro, Maria; Nurmi, Pertti; Kilpinen, Juha; Ylinen, Kaisa; Furllanelo, Cesare; Maggio, Valerio; Alikadic, Azra; Dolci, Claudia

    2017-04-01

    European wildfires are a seasonal natural hazard that many regions must battle regularly. However, as European urbanization continues to encroach on natural areas and the climate changes it is likely that the frequency of wildfires will increase likewise the number of areas prone to wildfires. It is therefore paramount not only to increase public awareness of this natural hazard but also to be prepared by improving wildfire hazard forecasting, monitoring, and mapping. As part of the H2020 funded project entitled Improving Resilience to Emergencies through Advanced Cyber Technologies: I-REACT (Grant Agreement #700256) , there is a task with the goal to develop models and implement technologies to improve the support around the entire emergency management cycle with respect to wildfire hazards. Based on operational weather forecasts, pan-European geospatial data as well as regularly acquired Earth Observation imagery through the Copernicus program, and other sources of information such as social media channels a European wildfire service is being developed. This will be achieved by improving on the successes of the European Forest Fire Information Service (EFFIS) and the guidance of emergency managers experienced in wildfire hazards. Part of the research will be to reduce the number of false alarms. However, once a wildfire has been identified, the system focuses on the disaster region to provide situational information to the decision makers applying state-of-the-art approaches to improve disaster response. Post-wildfire information will continue to be produced for damage and recovery assessments. Ultimately, I-REACT expects to reduce wildfire costs to life, property and livelihood. This work will improve wildfire disaster emergency management through the development and integration of new data and technologies respectively as well as the knowledge from emergency managers who not only understand the hazard itself but also can provide insights into the information

  10. Obstetric retrospect

    PubMed Central

    Wood, Louis A. C.

    1981-01-01

    A series of 818 consecutive obstetric patients in a general practice between 1946 and 1970 is analysed in detail. The findings are discussed in relation to other studies from general practice and to current obstetric hospital practice. ImagesFigure 1.Figure 2.Figure 3. PMID:6973630

  11. Obstetric life support.

    PubMed

    Puck, Andrea Lorraine; Oakeson, Ann Marie; Morales-Clark, Ana; Druzin, Maurice

    2012-01-01

    The death of a woman during pregnancy is devastating. Although the incidence of maternal cardiac arrest is increasing, it continues to be a comparatively rare event. Obstetric healthcare providers may go through their entire career without participating in a maternal cardiac resuscitation. Concern has been raised that when an arrest does occur in the obstetric unit, providers who are trained in life support skills at 2-year intervals are ill equipped to provide the best possible care. The quality of resuscitation skills provided during cardiopulmonary arrest of inpatients often may be poor, and knowledge of critical steps to be followed during resuscitation may not be retained after life support training. The Obstetric Life Support (ObLS) training program is a method of obstetric nursing and medical staff training that is relevant, comprehensive, and cost-effective. It takes into consideration both the care needs of the obstetric patient and the adult learning needs of providers. The ObLS program brings obstetric nurses, obstetricians, and anesthesiologists together in multidisciplinary team training that is crucial to developing efficient emergency response.

  12. Improved Perinatal Depression Screening, Treatment, and Outcomes With a Universal Obstetric Program.

    PubMed

    Avalos, Lyndsay A; Raine-Bennett, Tina; Chen, Hong; Adams, Alyce S; Flanagan, Tracy

    2016-05-01

    To evaluate whether universal prenatal and early postnatal screening for depression leads to increased detection, subsequent intervention, and improved depressive symptom outcomes. We conducted a population-based retrospective cohort study of 97,678 pregnant Kaiser Permanente Northern California members during three phases of the Universal Perinatal Depression Screening Program (preimplementation, rollout, fully implemented) from 2007 through 2014. Depression screening scores (Patient Health Questionnaire-9), depression diagnoses, individual counseling visits, demographic characteristics, and medication dispensings were extracted from electronic health records and pharmacy databases. The percentage of women screened, new depression diagnoses, and women receiving treatment were compared among the three phases (tests of trend). Changes in depressive symptom scores up to 6 months postpartum were assessed (rollout and fully implemented phases). A significant increase emerged in the percentage of women screened over the three phases ranging from less than 1% (n=122) (preimplementation) to 98% (n=41,124) (fully implemented) (P<.001). Identification of a new depression diagnosis increased from 8.2% (n=1,341) (preimplementation) to 11.5% (n=4,943) (fully implemented) (P<.001). Although the observed percentage of women receiving treatment decreased (60.9% [preimplementation] to 47.1% [fully implemented]), significant increases in the expected percentage of women receiving treatment emerged (42.6% [preimplementation] to 47.1% [fully implemented]; P<.05). Similar trends were noted for women with Patient Health Questionnaire-9 scores of 15 or greater (greater severity), highlighting an increase in expected percentage of women receiving treatment (5.9% [preimplementation] to 81.9% [fully implemented]; P<.05). In the fully implemented phase, improvements in depressive symptoms up to 6 months postpartum were noted. These data provide evidence of benefit for universal perinatal

  13. Reducing the incidence of Obstetric Sphincter Injuries using a hands-on technique: an interventional quality improvement project

    PubMed Central

    Rasmussen, Ole Bredahl; Yding, Annika; Anh Ø, Jacob; Sander Andersen, Charlotte; Boris, Jane

    2016-01-01

    A main concern for women giving birth is the risk of obstetric anal sphincter injuries. In our department the incidence of sphincter injuries was around 8 % among vaginally delivering first time mothers. We aimed to halve the incidence to 4 % or less. A prospective interventional program was instituted. We implemented a hands-on technique with four elements in a bundle of care together with a certification process for all staff on the delivery ward. The incidence of episiotomies served as a balancing indicator. The adherence to three of the four elements of the care bundle rose significantly while the all-or-nothing indicator leveled around 80 %. The median number of deliveries between cases with a sphincter injury increased from 9.5 in the baseline period to 20 during the intervention period. This corresponded with a reduction in the incidence from 7.0 % to 3.4 %. The rate of episiotomy remained low at 8.4 % in this group. By implementing the hands-on technique, we halved the risk of obstetric anal sphincter injuries. Our data suggest that further improvement may be anticipated. The study has demonstrated how implementation of a hands-on technique can be carried out within a quality improvement framework with rapid and sustainable results. PMID:28074131

  14. Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines

    PubMed Central

    Banke-Thomas, Aduragbemi; Wright, Kikelomo; Sonoiki, Olatunji; Banke-Thomas, Oluwasola; Ajayi, Babatunde; Ilozumba, Onaedo; Akinola, Oluwarotimi

    2016-01-01

    Background Lack of timely and quality emergency obstetric care (EmOC) has contributed significantly to maternal morbidity and mortality, particularly in low- and middle-income countries (LMICs). Since 2009, the global guideline, referred to as the ‘handbook’, has been used to monitor availability, utilization, and quality of EmOC. Objective To assess application and explore experiences of researchers in LMICs in assessing EmOC. Design Multiple databases of peer-reviewed literature were systematically reviewed on EmOC assessments in LMICs, since 2009. Following set criteria, we included articles, assessed for quality based on a newly developed checklist, and extracted data using a pre-designed extraction tool. We used thematic summaries to condense our findings and mapped patterns that we observed. To analyze experiences and recommendations for improved EmOC assessments, we took a deductive approach for the framework synthesis. Results Twenty-seven studies met our inclusion criteria, with 17 judged as high quality. The highest publication frequency was observed in 2015. Most assessments were conducted in Nigeria and Tanzania (four studies each) and Bangladesh and Ghana (three each). Most studies (17) were done at subnational levels with 23 studies using the ‘handbook’ alone, whereas the others combined the ‘handbook’ with other frameworks. Seventeen studies conducted facility-based surveys, whereas others used mixed methods. For different reasons, intrapartum and very early neonatal death rate and proportion of deaths due to indirect causes in EmOC facilities were the least reported indicators. Key emerging themes indicate that data quality for EmOC assessments can be improved, indicators should be refined, a holistic approach is required for EmOC assessments, and assessments should be conducted as routine processes. Conclusions There is clear justification to review how EmOC assessments are being conducted. Synergy between researchers, EmOC program

  15. Development of an intervention to improve mental health for obstetric fistula patients in Tanzania

    PubMed Central

    Watt, Melissa H.; Wilson, Sarah M.; Sikkema, Kathleen J.; Velloza, Jennifer; Mosha, Mary V.; Masenga, Gileard G.; Bangser, Margaret; Browning, Andrew; Nyindo, Pilli M.

    2015-01-01

    Obstetric fistula is a debilitating childbirth injury that has been associated with high rates of psychological distress. Global efforts have helped to link women to surgical repair, but thus far no evidence-based interventions exist to address the psychological needs of these women during the hospital stay. In this paper, we describe the development of a psychological intervention for women in Tanzania who are receiving surgical care for an obstetric fistula. The intervention was developed based on theories of cognitive behavioral therapy and coping models. Content and delivery were informed by qualitative data collection with a range of stakeholders including women with fistula, and input from a study advisory board. The resulting intervention was six individual sessions, delivered by a trained community health nurse. The session topics were: 1) recounting the fistula story; 2) creating a new story about the fistula; 3) loss, grief and shame; 4) specific strategies for coping; 5) social relationships; and 6) planning for the future. A trial run of the intervention revealed that the intervention could be delivered with fidelity and was acceptable to patients. A future randomized control trial will evaluate the efficacy of this intervention to address the mental health symptoms of this population. PMID:25710896

  16. Competence of birth attendants at providing emergency obstetric care under India's JSY conditional cash transfer program for institutional delivery: an assessment using case vignettes in Madhya Pradesh province.

    PubMed

    Chaturvedi, Sarika; Upadhyay, Sourabh; De Costa, Ayesha

    2014-05-24

    Access to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications. A facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored. The mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care. Birth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are required to effectively increase the

  17. Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda

    PubMed Central

    Chi, Primus Che; Bulage, Patience; Urdal, Henrik; Sundby, Johanne

    2015-01-01

    Objectives Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services. Methods This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach. Results The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of Em

  18. Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda.

    PubMed

    Chi, Primus Che; Bulage, Patience; Urdal, Henrik; Sundby, Johanne

    2015-01-01

    Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services. This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach. The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve

  19. Improvement in abduction of the shoulder after reconstructive soft-tissue procedures in obstetric brachial plexus palsy.

    PubMed

    Nath, R K; Paizi, M

    2007-05-01

    Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45 degrees (20 degrees to 90 degrees ). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162 degrees (100 degrees to 180 degrees ) while 77 (78.6%) of the patients had active abduction of 160 degrees or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

  20. Improved robotic equipment for radiological emergencies

    SciTech Connect

    Chester, C.V.

    1984-09-01

    A study has been made of the requirements for an improved mobile manipulator for use by the US Department of Energy (DOE) in radiological emergencies. Emergency personnel with experience in past or present (Three Mile Island) radiological emergencies were interviewed to determine the shortcomings of present equipment and features most desired in future equipment. The present technology of mobile manipulators was reviewed. The existing DOE remotely controlled mobile manipulators are single-arm, nonforce-reflecting and have inherent limitations to their mobility and ease of operation. A survey of past radiological emergencies and routine operations at DOE facilities and two commercial power reactors, including TMI, indicates that great improvements in mobility and manipulator dexterity will be required if mobile manipulators are to be more useful in reducing radiation exposure to operating and emergency personnel. In particular, the ability to climb stairs and climb over airlock thresholds is required. Bilateral, force-feedback manipulators would greatly increase the speed, reliability, and safety of manipulator operations. In recent years dramatic advances have been made in manipulator technology with the development of digital control and force feedback. The development of a six-legged, computer-controlled walker by the Odetic Corporation is a quantum improvement in mobility. Unfortunately the Odex walker will likely require another $1 million in development funds before it will be ready for commercial production. The cost of the first-advanced capability, walker-mounted mobile manipulator will likely be between $1 and $2 million dollars but holds the promise of removing the need for men in a variety of hazardous environments. In 1984 NTG Nukleartechnik of West Germany offered a bilateral, force-reflecting master/slave-controlled manipulator mounted on a variable-geometry crawler for only $250,000.

  1. Web-Based Quality Assurance Process Drives Improvements in Obstetric Ultrasound in 5 Low- and Middle-Income Countries

    PubMed Central

    Swanson, Jonathan O; Plotner, David; Franklin, Holly L; Swanson, David L; Lokomba Bolamba, Victor; Lokangaka, Adrien; Sayury Pineda, Irma; Figueroa, Lester; Garces, Ana; Muyodi, David; Esamai, Fabian; Kanaiza, Nancy; Mirza, Waseem; Naqvi, Farnaz; Saleem, Sarah; Mwenechanya, Musaku; Chiwila, Melody; Hamsumonde, Dorothy; McClure, Elizabeth M; Goldenberg, Robert L; Nathan, Robert O

    2016-01-01

    ABSTRACT High quality is important in medical imaging, yet in many geographic areas, highly skilled sonographers are in short supply. Advances in Internet capacity along with the development of reliable portable ultrasounds have created an opportunity to provide centralized remote quality assurance (QA) for ultrasound exams performed at rural sites worldwide. We sought to harness these advances by developing a web-based tool to facilitate QA activities for newly trained sonographers who were taking part in a cluster randomized trial investigating the role of limited obstetric ultrasound to improve pregnancy outcomes in 5 low- and middle-income countries. We were challenged by connectivity issues, by country-specific needs for website usability, and by the overall need for a high-throughput system. After systematically addressing these needs, the resulting QA website helped drive ultrasound quality improvement across all 5 countries. It now offers the potential for adoption by future ultrasound- or imaging-based global health initiatives. PMID:28031304

  2. Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care.

    PubMed

    van der Nelson, Helen Anne; Siassakos, Dimitrios; Bennett, Joanne; Godfrey, Mandy; Spray, Liz; Draycott, Tim; Donald, Fiona

    2014-01-01

    This interrupted time-series study evaluated the impact of multiprofessional scenario-based training on the safety culture and teamwork climate of 3 surgical wards during a time of reduced financial resources. The authors ran 22 team training sessions for teams of 4 to 5 medical and nursing staff over a 4-month period on 3 surgical wards, using 2 scenarios based on a previously successful obstetric training program. Safety culture was measured before and after training using a validated psychometric questionnaire. After training there was a statistically significant improvement in safety culture (P = .036) on the wards. Teamwork climate improved, but the evidence was not as strong (P = .052). Perceptions of hospital management and adequacy of staffing levels showed significant deterioration. Simple, low-resource interventions can have a significant positive impact on safety culture and possibly teamwork climate on surgical wards. This could be of great value in maintaining patient safety at times of financial constraint.

  3. Web-Based Quality Assurance Process Drives Improvements in Obstetric Ultrasound in 5 Low- and Middle-Income Countries.

    PubMed

    Swanson, Jonathan O; Plotner, David; Franklin, Holly L; Swanson, David L; Lokomba Bolamba, Victor; Lokangaka, Adrien; Sayury Pineda, Irma; Figueroa, Lester; Garces, Ana; Muyodi, David; Esamai, Fabian; Kanaiza, Nancy; Mirza, Waseem; Naqvi, Farnaz; Saleem, Sarah; Mwenechanya, Musaku; Chiwila, Melody; Hamsumonde, Dorothy; McClure, Elizabeth M; Goldenberg, Robert L; Nathan, Robert O

    2016-12-23

    High quality is important in medical imaging, yet in many geographic areas, highly skilled sonographers are in short supply. Advances in Internet capacity along with the development of reliable portable ultrasounds have created an opportunity to provide centralized remote quality assurance (QA) for ultrasound exams performed at rural sites worldwide. We sought to harness these advances by developing a web-based tool to facilitate QA activities for newly trained sonographers who were taking part in a cluster randomized trial investigating the role of limited obstetric ultrasound to improve pregnancy outcomes in 5 low- and middle-income countries. We were challenged by connectivity issues, by country-specific needs for website usability, and by the overall need for a high-throughput system. After systematically addressing these needs, the resulting QA website helped drive ultrasound quality improvement across all 5 countries. It now offers the potential for adoption by future ultrasound- or imaging-based global health initiatives. © Swanson et al.

  4. 'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial

    PubMed Central

    2013-01-01

    Background Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose. Methods and design The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams. The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the

  5. 'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial.

    PubMed

    Sørensen, Jette Led; Van der Vleuten, Cees; Lindschou, Jane; Gluud, Christian; Østergaard, Doris; LeBlanc, Vicki; Johansen, Marianne; Ekelund, Kim; Albrechtsen, Charlotte Krebs; Pedersen, Berit Woetman; Kjærgaard, Hanne; Weikop, Pia; Ottesen, Bent

    2013-07-17

    Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose. The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video

  6. Quality of Care and Disparities in Obstetrics.

    PubMed

    Howell, Elizabeth A; Zeitlin, Jennifer

    2017-03-01

    Growing attention is being paid to obstetric quality of care as patients are pressing the health care system to measure and improve quality. There is also an increasing recognition of persistent racial and ethnic disparities prevalent in obstetric outcomes. Yet few studies have linked obstetric quality of care with racial and ethnic disparities. This article reviews definitions of quality of care, health disparities, and health equity as they relate to obstetric care and outcomes; describes current efforts and challenges in obstetric quality measurement; and proposes 3 steps in an effort to develop, track, and improve quality and reduce disparities in obstetrics.

  7. Improved satellite-based emergency alerting system

    NASA Astrophysics Data System (ADS)

    Bernard, E. N.; Milburn, H. B.

    1991-12-01

    Rapid-onset natural hazards have claimed more than 2.8 million lives worldwide in the past 20 years. This category includes such events as earthquakes, landslides, hurricanes, tornadoes, floods, volcanic eruptions, wildfires, and tsunamis. Effective hazard mitigation is particularly difficult in such cases, since the time available to issue warnings can be very short or even nonexistent. A general approach to mitigate the effects of these disasters was demonstrated in 1988 that included preevent emergency planning, real-time hazard assessment, and rapid warning via satellite communication links. This article reports on improvements in this satellite-based emergency alerting communication system that have reduced the response time from 87 to 17 sec and expanded the broadcast coverage from 40 percent to 62 percent of the earth's surface.

  8. Directional Navigation Improves Opportunistic Communication for Emergencies

    PubMed Central

    Kokuti, Andras.; Gelenbe, Erol.

    2014-01-01

    We present a novel direction based shortest path search algorithm to guide evacuees during an emergency. It uses opportunistic communications (oppcomms) with low-cost wearable mobile nodes that can exchange packets at close range of a few to some tens of meters without help of an infrastructure. The algorithm seeks the shortest path to exits which are safest with regard to a hazard, and is integrated into an autonomous Emergency Support System (ESS) to guide evacuees in a built environment. The algorithm proposed that ESSs are evaluated with the DBES (Distributed Building Evacuation Simulator) by simulating a shopping centre where fire is spreading. The results show that the directional path finding algorithm can offer significant improvements for the evacuees. PMID:25140633

  9. Improving handoffs in the emergency department.

    PubMed

    Cheung, Dickson S; Kelly, John J; Beach, Christopher; Berkeley, Ross P; Bitterman, Robert A; Broida, Robert I; Dalsey, William C; Farley, Heather L; Fuller, Drew C; Garvey, David J; Klauer, Kevin M; McCullough, Lynne B; Patterson, Emily S; Pham, Julius C; Phelan, Michael P; Pines, Jesse M; Schenkel, Stephen M; Tomolo, Anne; Turbiak, Thomas W; Vozenilek, John A; Wears, Robert L; White, Marjorie L

    2010-02-01

    Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area. Copyright (c) 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

  10. Private health care coverage and increased risk of obstetric intervention

    PubMed Central

    2014-01-01

    Background When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Methods Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. Results 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Conclusions Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques. PMID:24418254

  11. Private health care coverage and increased risk of obstetric intervention.

    PubMed

    Lutomski, Jennifer E; Murphy, Michael; Devane, Declan; Meaney, Sarah; Greene, Richard A

    2014-01-13

    When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.

  12. Emergency cervical cerclage after miscarriage of the first fetus in dichorionic twin pregnancies: obstetric and neonatal outcomes of delayed delivery interval.

    PubMed

    Petousis, Stamatios; Goutzioulis, Antonios; Margioula-Siarkou, Chrysoula; Katsamagkas, Taxiarchis; Kalogiannidis, Ioannis; Agorastos, Theodoros

    2012-09-01

    To study the effectiveness of emergency cervical cerclage in order to delay the delivery interval after miscarriage of the first fetus in dichorionic twin pregnancies. Dichorionic twin pregnancies after miscarriage of the first fetus (<24 weeks) were exclusively included in the present analysis. Prolongation of delivery interval was managed with additional emergency cervical cerclage in the already initiated tocolytic therapy. Obstetric outcomes (cervical dilatation, gestational age at delivery of the first twin, interval between miscarriage and delivery of the second fetus) and neonatal outcomes [neonatal birth weight, Apgar score in the first and fifth minute, admission to Neonatal Intensive Care Unit (NICU)] of the second twin were analyzed. Five cases of dichorionic twin pregnancies were included in our study. Cervical dilatation (mean ± SD) at admission time was 3.7 ± 1.4 cm. The gestational week at delivery of the first twin was 20.6 ± 2.6. The median delivery interval was 72 days and the maximum 121 days. Mean gestational age at delivery of the second twin was 28.8 ± 7.2 weeks and mean birth weight 1,772.5 ± 742 g. The rate of live birth was 80 %, while NICU admission was demanded in 75 % of the live births. All neonates discharged from NICU remained alive after 1 month of life. The present study demonstrated beneficial effect concerning obstetric and neonatal outcomes of the second twin after performing emergency cervical cerclage to postpone the delivery interval in premature dichorionic twin pregnancies.

  13. Emergency in the clinic: A simulation curriculum to improve outpatient safety.

    PubMed

    Espey, Eve; Baty, Gillian; Rask, John; Chungtuyco, Michelle; Pereda, Brenda; Leeman, Lawrence

    2017-09-14

    Emergency response skills are essential when events such as seizure, anaphylaxis or hemorrhage occur in the outpatient setting. As services and procedures increasingly move outside the hospital, training to manage complications may improve outcomes. The objective of this study was to evaluate a simulation-based curriculum in outpatient emergency management skills with the outcome measures of graded objective performance and learner self-efficacy. This pre-post curriculum study enrolled residents and fellows in Obstetrics and Gynecology and Family Medicine in a simulation-based, outpatient emergency management curriculum. Learners completed self-efficacy questionnaires and were videotaped managing three medical emergency scenarios (seizure, over-sedation/cardiopulmonary arrest and hemorrhage) in the simulation lab both before and after completing the curriculum. Evaluators, blinded to training level, scored the simulation performance videotapes using a graded rubric with critical action checklists. Scenario scores were assigned in five domains and globally. Paired t-tests were used to determine differences pre- and post- curriculum. Thirty residents completed the curriculum and pre- and post-curriculum testing. Subjects' objective performance scores improved in all five domains (p < .05) in all scenarios. When stratified by level of training, all participants demonstrated global improvement. When stratified by prior outpatient simulation experience, subjects with prior experience improved in all but management of excess sedation. Pre- and post-curriculum self-efficacy evaluations demonstrated improvement in seven of eight measured areas: confidence, use of appropriate resources, communication skills, complex airway management, bag mask ventilation, resuscitation, and hemorrhage management. Self-efficacy assessment showed improvement in confidence managing outpatient emergencies (p=0.001) and ability to communicate well in emergency situations (p<0.001). A simulation

  14. [Airway management in obstetrics].

    PubMed

    Boutonnet, M; Faitot, V; Keïta, H

    2011-09-01

    Reviewing problems related to the airway management in obstetrics, taking into account the recent evolutions of the anaesthetic practices in obstetrics. A review of the literature in English and French was performed in the Pumed database in April 2010. The first research used the following MeshTerms: "Anesthesia, Obstetrical" [Mesh] AND "Intubation, Intratracheal" [Mesh]. Complementary research used alone or in combination the following keywords: difficult tracheal intubation; failed tracheal intubation; airway; prediction of difficult tracheal intubation; maternal mortality; maternal morbidity; liability; aspiration pneumonia and obstetrical anesthesia. All the publications were retained excluding the correspondence. Data analysis for the airway management in obstetrics, the prediction of difficult intubation, the prevention of pulmonary inhalation of gastric fluid, but also on maternal morbi-mortality in link with general anesthesia in obstetrics. Airway management in obstetrics remains a true challenge for various reasons. The physiological and anatomical modifications related to pregnancy are responsible for a faster hypoxemia, a reduction of the diameter of the pharyngolaryngal tract, as well as an increase of the risk of inhalation of gastric contents after 16 weeks of amenorrhea. The emergency or extreme emergency context and the presence of diseases like obesity or preeclampsia raise the risks of difficulties with airway management. The logical evolution of the practices, with the considerable rise of the regional anesthesia/analgesia limits the training and the maintenance of competences for intratracheal intubation in obstetrics. The training per simulation appears particularly interesting on the subject and this approach needs to be developed. The literature indicates that the incidence of difficult intubation is of one per 30. The impossible intubation is one per 280 in obstetrics, eight times greater than in the general population. No criterion of

  15. Haemorrhagia post partum; an implementation study on the evidence-based guideline of the Dutch Society of Obstetrics and Gynaecology (NVOG) and the MOET (Managing Obstetric Emergencies and Trauma-course) instructions; the Fluxim study

    PubMed Central

    2010-01-01

    Background One of the most important causes of maternal mortality and severe morbidity worldwide is post partum haemorrhage (PPH). Factors as substandard care are frequently reported in the international literature and there are similar reports in the Netherlands. The incidence of PPH in the Dutch population is 5% containing 10.000 women a year. The introduction of an evidence-based guideline on PPH by the Dutch society of Obstetrics and Gynaecology (NVOG) and the initiation of the MOET course (Managing Obstetrics Emergencies and Trauma) did not lead to a reduction of PPH. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions. Therefore, the aim of this study is to develop and test a tailored strategy to implement both the NVOG guideline and MOET-instructions Methods/Design One step in the development procedure is to evaluate the implementation of the guideline and MOET-instructions in the current care. Therefore measurement of the actual care will be performed in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labour of 320 women with a high risk of PPH using quality indicators extracted from the NVOG guideline and MOET instructions. In the next step barriers and facilitators for guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients, followed by a questionnaire study among all Dutch gynaecologists and midwives to quantify the barriers mentioned. Based on the outcomes, a tailored strategy to implement the NVOG guideline and MOET-instructions will be developed and tested in a feasibility study in 4 hospitals, including effect-, process- and cost evaluation. Discussion This study will provide insight into current Dutch practice, in particular to what extent the PPH guidelines of the NVOG and the MOET-instructions have been implemented in the actual care, and into the barriers and

  16. Developing obstetric medicine training in Latin America.

    PubMed

    Rojas-Suarez, José; Suarez, Niza; Ateka-Barrutia, Oier

    2017-03-01

    Maternal mortality is an important indicator of health in populations around the world. The distribution of maternal mortality ratio globally shows that middle- and low-income countries have ∼99% of the mortality burden. Most countries of Latin America are considered to be middle- or low-income countries, as well as areas of major inequities among the different social classes. Medical problems in pregnancy remain an important cause of morbidity and mortality in this region. Previous data indicate the need for a call to action for adequate diagnosis and care of medical diseases in obstetric care. The impact of nonobstetric and medical pathologies on maternal mortality in Latin America is largely unknown. In Latin America, two educational initiatives have been proposed to improve skills in maternity care. The Advanced Life Support in Obstetrics (ALSO®) was first started to address obstetric emergencies, and subsequently adapted for low-middle-income country settings as the Global ALSO®. In parallel, the Latin American obstetric anesthesia community has progressively focused on improvement of several intrapartum/intraoperative issues, which has secondarily taken them to embrace the obstetric medicine area on interest and join the former initiatives. In the present review, we summarize the available data regarding medical morbidity and mortality in pregnancy in Latin America, as well as the challenges, achievements, issues, initiatives, and future directions encouraging maternal health educators, health care trainers, and physicians in middle- and low-income countries, such as many Latin American ones, to improve and/or change attitudes, if needed, on current clinical practice.

  17. Quality of care for obstetric emergencies in 4 general hospitals in Egypt: an observational study of delays in receiving care and blood bank services.

    PubMed

    Nada, K H; Barakat, A A; Gipson, R

    2011-01-01

    A lack of available blood contributes to 16% of all maternal deaths in Egypt. This study aimed to assess the quality of care for obstetric emergencies in 4 general hospitals in Egypt over a 6-month period with the focus on delays in receiving care and blood bank services. Observations were made of the processes and delays in the clinical setting, from the start of each patient's complaint until discharge, and the receipt and filling of orders for blood at the blood bank. Patients failed to recognize danger signs. Lack of transportation, incorrect choice of provider or facility and unclear referral systems added further delays. Delays occurred in hospital admission, assessment of patients, initiation of resuscitation, initiation of medical or surgical interventions, ordering blood, J receipt of blood and administration of blood to patients. The blood ordering procedures were substandard. Lack of blood availability had multidisciplinary causes.

  18. Multi-professional training for obstetric emergencies in a U.S. hospital over a 7-year interval: an observational study.

    PubMed

    Weiner, C P; Collins, L; Bentley, S; Dong, Y; Satterwhite, C L

    2016-01-01

    Birth is less safe than it can be. We adapted the UK-developed PROMPT (PRactical Obstetric Multi-Professional Training) course to local practices and initiated annual training. This observational study used quality assurance data from University of Kansas Hospital 2 years before and 7 years after intervention encompassing 14,309 consecutive deliveries from January 2006 through December 2014. An events/trials approach was applied to changes in proportions over time. PROMPT was associated with progressive decreases in rates (P<0.05) of brachial plexus injury and umbilical artery pH <7.00 exclusive of catastrophic events. Reduced rates (P<0.05) of cesarean section, episiotomy and higher perception of nurse/physician communication were documented. Hypoxic ischemic encephalopathy (HIE) rates declined progressively by >50% (P=NS). These improvements occurred despite younger faculty and higher rates of complicated pregnancies (P<0.05). Estimated health-care costs avoided exceeded annual training costs. Local annual multi-professional training as provided by PROMPT was temporally associated with improved obstetric outcomes.

  19. 'Maybe it was her fate and maybe she ran out of blood': final caregivers' perspectives on access to care in obstetric emergencies in rural Indonesia.

    PubMed

    D'Ambruoso, Lucia; Byass, Peter; Qomariyah, Siti Nurul

    2010-03-01

    Maternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect information on the exclusory mechanisms of health systems

  20. Exploring strategies to improve emergency department intake.

    PubMed

    Welch, Shari; Savitz, Lucy

    2012-07-01

    The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician. To study intake processes and identify new strategies for improving patient intake. A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an "improvement competition." Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference. Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes. The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented. Copyright © 2012 Elsevier Inc. All rights reserved.

  1. Obstetric skills drills: evaluation of teaching methods.

    PubMed

    Birch, L; Jones, N; Doyle, P M; Green, P; McLaughlin, A; Champney, C; Williams, D; Gibbon, K; Taylor, K

    2007-11-01

    To determine the most effective method of delivering training to staff on the management of an obstetric emergency. The research was conducted in a District General Hospital in the UK, delivering approximately 3500 women per year. Thirty-six staff, comprising of junior and senior medical and midwifery staff were included as research subjects. Each of the staff members were put into one of six multi-professional teams. Effectively, this gave six teams, each comprising of six members. Three teaching methods were employed. Lecture based teaching (LBT), simulation based teaching (SBT) or a combination of these two (LAS). Each team of staff were randomly allocated to undertake a full day of training in the management of Post Partum Haemorrhage utilising one of these three teaching methods. Team knowledge and performance were assessed pre-training, post training and at three months later. In addition to this assessment of knowledge and performance, qualitative semi-structured interviews were carried out with 50% of the original cohort one year after the training, to explore anxiety, confidence, communication, knowledge retention, enjoyment and transferable skills. All teams improved in their performance and knowledge. The teams taught using simulation only (SBT) were the only group to demonstrate sustained improvement in clinical management of the case, confidence, communication skills and knowledge. However, the study did not have enough power to reach statistical significance. The SBT group reported transferable skills and less anxiety in subsequent emergencies. SBT and LAS reported improved multidisciplinary communication. Although tiring, the SBT was enjoyed the most. Obstetrics is a high risk speciality, in which emergencies are to some extent, inevitable. Training staff to manage these emergencies is a fundamental principal of risk management. Traditional risk management strategies based on incident reporting and event analysis are reactive and not always effective

  2. Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury

    PubMed Central

    2013-01-01

    Background Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries. To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients. Methods All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements. Results The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients. Conclusion Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve. PMID:23714699

  3. Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury.

    PubMed

    Nath, Rahul K; Kumar, Nirupuma; Somasundaram, Chandra

    2013-01-01

    Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries. To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients. All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements. The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients. Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve.

  4. Cost-effectiveness of a quality improvement collaborative for obstetric and newborn care in Niger.

    PubMed

    Broughton, Edward; Saley, Zakari; Boucar, Maina; Alagane, Dondi; Hill, Kathleen; Marafa, Aicha; Asma, Yaroh; Sani, Karimou

    2013-01-01

    The purpose of this paper is to describe a quality improvement collaborative conducted in 33 Nigerian facilities to improve maternal and newborn care outcomes by increasing compliance with high-impact, evidence-based care standards. Intervention costs and cost-effectiveness were examined and costs to the Niger Health Ministry (MoH) were estimated if they were to scale-up the intervention to additional sites. Facility-based maternal care outcomes and costs from pre-quality improvement collaborative baseline monitoring data in participating facilities from January to May 2006 were compared with outcomes and costs from the same facilities from June 2008 to September 2008. Cost data were collected from project accounting records. The MoH costs were determined from interviews with clinic managers and quality improvement teams. Effectiveness data were obtained from facilities' records. The average delivery-cost decreased from $35 before to $28 after the collaborative. The USAID/HCI project's incremental cost was $2.43/delivery. The collaborative incremental cost-effectiveness was $147/disability-adjusted life year averted. If the MoH spread the intervention to other facilities, substantive cost-savings and improved health outcomes can be predicted. The intervention achieved significant positive health benefits for a low cost. The Niger MoH can expect approximately 50 per cent return on its investment if it implements the collaborative in new facilities. The improvement collaborative approach can improve health and save health care resources. This is one of the first studies known to examine collaborative quality improvement and economic efficiency in a developing country.

  5. Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study

    PubMed Central

    2011-01-01

    Background Recognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC. Methods This cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. Pearson's chi-square test, t-test and Mann-Whitney test were performed. Results The median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in

  6. Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study.

    PubMed

    Nahar, Shamsun; Banu, Morsheda; Nasreen, Hashima E

    2011-01-30

    Recognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC. This cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. Pearson's chi-square test, t-test and Mann-Whitney test were performed. The median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in income-generating activities

  7. Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery

    PubMed Central

    Karicherla, Priyanka; Mahmooduddin, Faiz

    2010-01-01

    Purpose Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals. Methods This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5–T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75–12) years were followed up clinically for more than 2 years. Results The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years. Conclusions The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery. PMID:20473676

  8. Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery.

    PubMed

    Nath, Rahul K; Karicherla, Priyanka; Mahmooduddin, Faiz

    2010-08-01

    Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals. This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5-T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75-12) years were followed up clinically for more than 2 years. The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years. The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery.

  9. Availability and provision of emergency obstetric care under a public–private partnership in three districts of Gujarat, India: lessons for Universal Health Coverage

    PubMed Central

    Sidney, K; Mehta, R; Mavalankar, D

    2016-01-01

    Objective The state of Gujarat in India (population 60 million) has implemented a public–private partnership (PPP) with private obstetricians called the Chiranjeevi Yojana (CY) since 2006. This study investigated the adequacy of basic and comprehensive emergency obstetric care (BEmOC and CEmOC) services through the public and private sectors with reference to the United Nations (UN) guidelines. Design A cross-sectional facility survey was conducted in three districts. Results A total of 300 facilities, 151 public and 149 private, had provided obstetric services to a total of 53 896 births in the past 6 months. Nearly half, 135 facilities (104 public and 31 private), individually reported <10 births per month (low load), and, as a group, reported only 4% of all births in the past 6 months. The remaining 165 high-load facilities consisted of 23 (3 public; 20 private) full CEmOC, 66 (1; 65) ‘potential’ CEmOC, 12 (3; 9) BEmOC and 57 (40; 17) non-EmOC facilities. All the three districts exceeded the UN recommendation for EmOC availability by 3.3 to 11.3 times. Free provision, through both public and PPP facilities, ranged from 1.42 to 3.43. The actual performance was nearly double the recommendation for CEmOC but inadequate for BEmOC. Conclusions Public sector EmOC availability and provision is negligible. Private sector availability is well beyond the recommended UN norms. The CY programme has resulted in increased availability and provision of EmOC services. However, the overall provision of EmOC is compromised due to the poor performance of BEmOC functions and clustering of private facilities in towns. PMID:28588914

  10. Availability and provision of emergency obstetric care under a public-private partnership in three districts of Gujarat, India: lessons for Universal Health Coverage.

    PubMed

    Iyer, V; Sidney, K; Mehta, R; Mavalankar, D

    2016-01-01

    The state of Gujarat in India (population 60 million) has implemented a public-private partnership (PPP) with private obstetricians called the Chiranjeevi Yojana (CY) since 2006. This study investigated the adequacy of basic and comprehensive emergency obstetric care (BEmOC and CEmOC) services through the public and private sectors with reference to the United Nations (UN) guidelines. A cross-sectional facility survey was conducted in three districts. A total of 300 facilities, 151 public and 149 private, had provided obstetric services to a total of 53 896 births in the past 6 months. Nearly half, 135 facilities (104 public and 31 private), individually reported <10 births per month (low load), and, as a group, reported only 4% of all births in the past 6 months. The remaining 165 high-load facilities consisted of 23 (3 public; 20 private) full CEmOC, 66 (1; 65) 'potential' CEmOC, 12 (3; 9) BEmOC and 57 (40; 17) non-EmOC facilities. All the three districts exceeded the UN recommendation for EmOC availability by 3.3 to 11.3 times. Free provision, through both public and PPP facilities, ranged from 1.42 to 3.43. The actual performance was nearly double the recommendation for CEmOC but inadequate for BEmOC. Public sector EmOC availability and provision is negligible. Private sector availability is well beyond the recommended UN norms. The CY programme has resulted in increased availability and provision of EmOC services. However, the overall provision of EmOC is compromised due to the poor performance of BEmOC functions and clustering of private facilities in towns.

  11. Accounts of severe acute obstetric complications in Rural Bangladesh

    PubMed Central

    2011-01-01

    Background As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh. Methods Using the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model. Results Women attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors. Conclusions Strategies to increase timely and appropriate care seeking

  12. Definitions of Obstetric and Gynecologic Hospitalists.

    PubMed

    McCue, Brigid; Fagnant, Robert; Townsend, Arthur; Morgan, Meredith; Gandhi-List, Shefali; Colegrove, Tanner; Stosur, Harriet; Olson, Rob; Meyer, Karenmarie; Lin, Andrew; Tessmer-Tuck, Jennifer

    2016-02-01

    The obstetric hospitalist and the obstetric and gynecologic hospitalist evolved in response to diverse forces in medicine, including the need for leadership on labor and delivery units, an increasing emphasis on quality and safety in obstetrics and gynecology, the changing demographics of the obstetric and gynecologic workforce, and rising liability costs. Current (although limited) research suggests that obstetric and obstetric and gynecologic hospitalists may improve the quality and safety of obstetric care, including lower cesarean delivery rates and higher vaginal birth after cesarean delivery rates as well as lower liability costs and fewer liability events. This research is currently hampered by the use of varied terminology. The leadership of the Society of Obstetric and Gynecologic Hospitalists proposes standardized definitions of an obstetric hospitalist, an obstetric and gynecologic hospitalist, and obstetric and gynecologic hospital medicine practices to standardize communication and facilitate program implementation and research. Clinical investigations regarding obstetric and gynecologic practices (including hospitalist practices) should define inpatient coverage arrangements using these standardized definitions to allow for fair conclusions and comparisons between practices.

  13. Patient safety series: obstetric safety improvement and its reflection in reserved claims.

    PubMed

    Iverson, Ronald E; Heffner, Linda J

    2011-11-01

    In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.

  14. A radio-education intervention to improve maternal knowledge of obstetric danger signs.

    PubMed

    Radoff, Kari A; Levi, Amy J; Thompson, Lisa M

    2013-10-01

    To examine whether a radio-education intervention (REI) is associated with improved maternal knowledge of pregnancy danger signs (PDS) in Nicaragua. This cross-sectional pilot study used pretests and posttests to evaluate whether an REI was associated with improved knowledge of PDS among 77 pregnant and postpartum women in Nicaragua. The total number of PDS identified by study participants increased from 130 before the intervention to 200 after the intervention, an increase of 53.8% (Wilcoxon signed-rank test (z) = -4.18; P < 0.00001). The three PDS for which participant knowledge increased significantly after the intervention were 1) swelling of the face and hands, 2) convulsions, and 3) vaginal bleeding. Participants who 1) reported having a sister who had experienced a pregnancy complication, 2) lived in an urban setting, and 3) had more than a sixth-grade education were significantly more likely to score higher on posttests related to knowledge of PDS than those without those attributes (90.9% versus 56.9% [Χ² (degrees of freedom) = 4.60 (1); P = 0.043; n = 76]; 75% versus 45.9% [Χ² = 6.8 (1); P = 0.009; n = 77]; and 62.5% (12+ years education) versus 79.3% (6-12 years) versus 50.0% (0-6 years education) versus 25.0% (no education) [Χ² = 8.11 (1); P = 0.044; n = 77] respectively). Exposure to the REI was associated with a significant increase in the ability to identify PDS. Further studies should establish whether this increase in knowledge of PDS is associated with increases in use of maternity care services and decreases in delays in seeking care.

  15. Does Screening with the MDQ and EPDS Improve Identification of Bipolar Disorder in an Obstetrical Sample?

    PubMed Central

    Clark, Crystal T.; Sit, Dorothy K.Y.; Driscoll, Kara; Eng, Heather F.; Confer, Andrea L.; Luther, James F.; Wisniewski, Stephen R.; Wisner, Katherine L.

    2015-01-01

    Background Women with Bipolar Disorder (BD) are at high risk for postpartum affective episodes and psychosis. Although validated screening tools are available for postpartum unipolar depression, few screening tools for hypomania/mania exist. Screening tools for BD in the postpartum period are essential for improving detection and planning appropriate treatment. We evaluated whether adding the Mood Disorders Questionnaire (MDQ) to the Edinburgh Postnatal Depression Scale (EPDS) increased the identification of BD in the early postpartum period. Methods Women (N=1279) who delivered a live infant and screened positive on the EPDS and/or MDQ at 4–6 weeks post-birth were invited to undergo an in-home Structured Clinical Interview for DSM-IV (SCID). Results Positive EPDS and/or MDQ screens occurred in 12% of the sample (n=155). In home SCID diagnostic interviews were completed in 93 (60%) of the mothers with positive screens. BD was the primary diagnosis in 37% (n=34). Women with BD screened positive on the EPDS and/or MDQ as follows: EPDS+/MDQ+ (n=14), EPDS+/MDQ− (n=17), and EPDS−/MDQ+ (n=3). The MDQ identified 50% (17/34) of the women with BD and 6 additional cases of BD when the MDQ question regarding how impaired the mother perceived herself was excluded from the screen criterion. Conclusion Addition of the MDQ to the EPDS improved the distinction of unipolar depression from bipolar depression at the level of screening in 50% of women with traditional MDQ scoring and by nearly 70% when the MDQ was scored without the impairment criterion. PMID:26059839

  16. Improving vaccine trials in infectious disease emergencies.

    PubMed

    Lipsitch, Marc; Eyal, Nir

    2017-07-14

    Unprecedented global effort is under way to facilitate the testing of countermeasures in infectious disease emergencies. Better understanding of the various options for trial design is needed in advance of outbreaks, as is preliminary global agreement on the most suitable designs for the various scenarios. What would enhance the speed, validity, and ethics of clinical studies of such countermeasures? Focusing on studies of vaccine efficacy and effectiveness in emergencies, we highlight three needs: for formal randomized trials-even in most emergencies; for individually randomized trials-even in many emergencies; and for six areas of innovation in trial methodology. These needs should inform current updates of protocols and roadmaps. Copyright © 2017, American Association for the Advancement of Science.

  17. Emergency Information Improvement Act of 2013

    THOMAS, 113th Congress

    Rep. Higgins, Brian [D-NY-26

    2013-07-10

    07/11/2013 Referred to the Subcommittee on Economic Development, Public Buildings and Emergency Management. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  18. Emergency Information Improvement Act of 2013

    THOMAS, 113th Congress

    Rep. Higgins, Brian [D-NY-26

    2013-07-10

    07/11/2013 Referred to the Subcommittee on Economic Development, Public Buildings and Emergency Management. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  19. Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix.

    PubMed

    Wall, L Lewis

    2012-02-01

    An obstetric fistula is classically regarded as an "accident of childbirth" in which prolonged obstructed labor leads to destruction of the vesicovaginal/rectovaginal septum with consequent loss of urinary and/or fecal control. Obstetric fistula is highly stigmatizing and afflicted women often become social outcasts. Although obstetric fistula has been eliminated from advanced industrialized nations, it remains a major public health problem in the world's poorest countries. Several million cases of obstetric fistula are currently thought to exist in sub-Saharan Africa and south Asia. Although techniques for the surgical repair of such injuries are well known, it is less clear which strategies effectively prevent fistulas, largely because of the complex interactions among medical, social, economic, and environmental factors present in those countries where fistulas are prevalent. This article uses the Haddon matrix, a standard tool for injury analysis, to examine the factors influencing obstetric fistula formation in low-resource countries. Construction of a Haddon matrix provides a "wide angle" overview of this tragic clinical problem. The resulting analysis suggests that the most effective short-term strategies for obstetric fistula prevention will involve enhanced surveillance of labor, improved access to emergency obstetric services (particularly cesarean delivery), competent medical care for women both during and after obstructed labor, and the development of specialist fistula centers to treat injured women where fistula prevalence is high. The long-term strategies to eradicate obstetric fistula must include universal access to emergency obstetric care, improved access to family planning services, increased education for girls and women, community economic development, and enhanced gender equity. Successful eradication of the obstetric fistula will require the mobilization of sufficient political will at both the international and individual country levels to

  20. Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling.

    PubMed

    Hirose, Atsumi; Borchert, Matthias; Cox, Jonathan; Alkozai, Ahmad Shah; Filippi, Veronique

    2015-02-05

    Women's delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman's travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times. A cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay. Amongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the "one-referral" group to the "self-referral" group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to "no difficulty"; 95% CI: 1.5-3.1]. A husband's very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9]. Delays were mostly explained by the number of health facilities visited. A husband's large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to

  1. Improving communication between emergency department staff.

    PubMed

    Moore, Kate

    2014-05-01

    During redevelopment of the emergency department at the Royal Sussex County Hospital, Brighton, it was deemed vital that its internal communication system should be as effective as possible. An audit of staff perceptions of the existing communication system and a relevant literature review were undertaken, therefore, to inform a proposal for the development of a new online system. This article describes the development and implementation of the system.

  2. Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit.

    PubMed

    Kayiga, Herbert; Ajeani, Judith; Kiondo, Paul; Kaye, Dan K

    2016-07-11

    Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda. Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results. There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to

  3. Vascular endothelial growth factor gene therapy improves nerve regeneration in a model of obstetric brachial plexus palsy.

    PubMed

    Hillenbrand, Matthias; Holzbach, Thomas; Matiasek, Kaspar; Schlegel, Jürgen; Giunta, Riccardo E

    2015-03-01

    The treatment of obstetric brachial plexus palsy has been limited to conservative therapies and surgical reconstruction of peripheral nerves. In addition to the damage of the brachial plexus itself, it also leads to a loss of the corresponding motoneurons in the spinal cord, which raises the need for supportive strategies that take the participation of the central nervous system into account. Based on the protective and regenerative effects of VEGF on neural tissue, our aim was to analyse the effect on nerve regeneration by adenoviral gene transfer of vascular endothelial growth factor (VEGF) in postpartum nerve injury of the brachial plexus in rats. In the present study, we induced a selective crush injury to the left spinal roots C5 and C6 in 18 rats within 24 hours after birth and examined the effect of VEGF-gene therapy on nerve regeneration. For gene transduction an adenoviral vector encoding for VEGF165 (AdCMV.VEGF165) was used. In a period of 11 weeks, starting 3 weeks post-operatively, functional regeneration was assessed weekly by behavioural analysis and force measurement of the upper limb. Morphometric evaluation was carried out 8 months post-operatively and consisted of a histological examination of the deltoid muscle and the brachial plexus according to defined criteria of degeneration. In addition, atrophy of the deltoid muscle was evaluated by weight determination comparing the left with the right side. VEGF expression in the brachial plexus was quantified by an enzyme-linked immunosorbent assay (ELISA). Furthermore the motoneurons of the spinal cord segment C5 were counted comparing the left with the right side. On the functional level, VEGF-treated animals showed faster nerve regeneration. It was found less degeneration and smaller mass reduction of the deltoid muscle in VEGF-treated animals. We observed significantly less degeneration of the brachial plexus and a greater number of surviving motoneurons (P < 0·05) in the VEGF group. The results of

  4. Preprocedural ultrasound assessment does not improve trainee performance of spinal anesthesia for obstetrical patients: a randomized controlled trial.

    PubMed

    Turkstra, Timothy P; Marmai, Kristine L; Armstrong, Kevin P; Kumar, Kamal; Singh, S Indu

    2017-02-01

    This randomized controlled trial was designed to evaluate the efficacy of additional information from preprocedure ultrasound examination to aid anesthesiology trainees performing spinal anesthesia for obstetric patients. Trainee residents were randomly allocated to landmark technique and anatomy demonstration via ultrasound examination or landmark technique only for spinal anesthetic placement. Obstetric delivery suite. Eighty healthy obstetric patients undergoing elective cesarean delivery. Ultrasound examination prior to spinal anesthetic placement. The primary outcome was the number of attempts for the spinal anesthetic. Secondary outcomes included placement duration; block height; and the incidence of need for staff intervention, paresthesia, and bloody tap. Subjective ease of placement was rated on a 100-mm visual analog scale. Baseline demographic data were similar between the patient groups. The median number of attempts with preprocedure ultrasound and landmark was 3 (interquartile range, 2-7). This was not significantly different from the number of attempts with landmark technique only of 3 (1-60) (P=.69). The median duration of spinal placement with ultrasound and landmark was 92 (51-140) seconds vs 75 (53-126) seconds with landmark only (P=.57). There was no statistical difference between the groups in spinal placement duration, need for staff intervention, paresthesia, bloody tap, lumbar interspace, or block height. There was no difference in subjective ease of spinal placement by the resident. In this study of junior anesthesia trainees performing obstetrical spinal anesthesia with preprocedure ultrasound and landmark technique or landmark technique only, no significant difference was observed in the number of attempts, duration of spinal placement, subjective ease of spinal placement, or any other measured secondary outcome. Copyright © 2016 Elsevier Inc. All rights reserved.

  5. Simulation-based crisis team training for multidisciplinary obstetric providers.

    PubMed

    Robertson, Bethany; Schumacher, Lori; Gosman, Gabriella; Kanfer, Ruth; Kelley, Maureen; DeVita, Michael

    2009-01-01

    The use of team training programs is promising with regards to their ability to impact knowledge, attitudes, and behavior about team skills. The purpose of this study was to evaluate a simulation-based team training program called Obstetric Crisis Team Training Program (OBCTT) (based on the original training program of Crisis Team Training) framed within a multilevel team theoretical model. We hypothesized that participation in OBCTT would positively impact 10 variables: individual's knowledge (about team process and obstetric emergency care); confidence and competence in handling obstetric emergencies; and participant attitudes (toward the utility of a rapid response team, simulation technology as a teaching methodology, the utility of team skills in the workplace, comfort in assuming team roles; and individual and team performance). Improvement of objectively measured team performance in a simulated environment was also assessed. Twenty-two perinatal health care professionals (attending physicians, nurses, resident, and nurse midwives) volunteered to participate in this pretest-posttest study design. All participants were given an online module to study before attending a 4-hour training session. Training consisted of participation in four standardized, simulated crisis scenarios with a female birthing simulator mannequin. Team simulations were video recorded. Debriefings were conducted after each simulation by having team members review the video and discuss team behaviors and member skills. Self-report measures of perinatal and team knowledge as well as several attitude surveys were given at the beginning and again at the end of the training session. A postsimulation attitude survey was administered immediately after the first and last simulation, and a course reaction survey was administered at the end of the training program. Objective task completion scores were computed after each simulation to assess performance. There were significant (P<0

  6. Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial.

    PubMed

    van de Ven, J; Fransen, A F; Schuit, E; van Runnard Heimel, P J; Mol, B W; Oei, S G

    2017-09-01

    Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei OBJECTIVE: To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time. Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy. During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5-147), and not thereafter. The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or

  7. [Obstetrical ultrasound simulator as a tool for improving teaching strategies for beginners: Pilot study and review of the literature].

    PubMed

    Chalouhi, G E; Quibel, T; Lamourdedieu, C; Hajal, N J; Gueneuc, A; Benzina, N; Bernardi, V; Ville, Y

    2016-11-01

    The aim of this study was to evaluate the obstetrical ultrasound simulator as an initiation tool for teaching obstetrical ultrasound scanning for beginners. Twenty medical students with no experience in ultrasound scan (US) received a basic theoretical ultrasonography course on US principles and 2nd trimester biometrical measurements. The participants were then divided into 2 groups (A, B). Only group A received a practical 2nd trimester scan training session on the simulator where they were asked to determine fetal and placental position, and to take the 3 biometrical standardized measurements. Group B had the same training session but with a real ultrasound machine and a pregnant volunteer. The 2 groups were then asked to perform an US session on real patients (22 weeks) during which they had to do the same US study. The time needed to complete the whole scan was analyzed. The quality of the measurements was compared based on the previously published Objective Quality Criteria scoring. The mean total score was significantly (P=0.001) better for group A (14.3±1.4) compared to group B 10.3 (±2.75) for group A and B respectively. The time needed to accomplish the whole exam tended to be longer for group A (569±174s) compared to group A (479±104s) (P=0.18). The simulator might be a useful initiation tool to obstetric ultrasound for those who never practiced. It might prove a time sparing procedure in the training process and allow trainees to reach a basic practice level before performing examinations on actual patients. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  8. Focused review: simulation in obstetric anesthesia.

    PubMed

    Pratt, Stephen D

    2012-01-01

    Simulation can be used to teach technical skills, to evaluate clinician performance, to help assess the safety of the environment of care, and to improve teamwork. Each of these has been successfully demonstrated in obstetric anesthesia simulation. Task simulators for epidural placement, failed intubation, and blood loss estimation seem to improve performance. Resident performance in an emergency cesarean delivery can be measured and assessed against his/her peers. Running simulated crises on a labor and delivery unit (in situ drills) can help to identify and correct potential safety concerns (latent errors) without exposing patients to the risks associated with these concerns. Finally, simulation can effectively assess and teach teamwork tools and behaviors. It is unclear, however, how well the lessons learned in the simulated environment translate into improved behaviors or better care in the clinical setting, or whether simulation improves patient outcomes. More research is needed to help answer these questions.

  9. Improving Quality of Emergency Care Through Integration of Mental Health.

    PubMed

    Okafor, Martha; Wrenn, Glenda; Ede, Victor; Wilson, Nana; Custer, William; Risby, Emile; Claeys, Michael; Shelp, Frank E; Atallah, Hany; Mattox, Gail; Satcher, David

    2016-04-01

    The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

  10. Significant improvement in nerve conduction, arm length, and upper extremity function after intraoperative electrical stimulation, neurolysis, and biceps tendon lengthening in obstetric brachial plexus patients.

    PubMed

    Nath, Rahul K; Somasundaram, Chandra

    2015-04-19

    Progressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity. We have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses. Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7-14.2 years) were included in this report. Mean follow-up time was 7.4 months (4-11 months). All the patients in this report had the elbow flexion contractures greater than 30°. Mean flexion contracture was 35° (30°-45°) preoperatively, which was improved to 0°-10° postoperatively with an average follow-up of 7 (4-11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant. Statistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.

  11. Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District

    PubMed Central

    2013-01-01

    Introduction Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. Objectives This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. Methods 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. Findings Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. Conclusion TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs’ inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about

  12. Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District.

    PubMed

    Vyagusa, Dismas B; Mubyazi, Godfrey M; Masatu, Melchiory

    2013-10-14

    Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal

  13. [A look into the past: improves in obstetrical and neonatal outcome in maternity since the 19th century].

    PubMed

    Ricard, E; Carcopino, X; Lalys, L; Bertrand, J; Le Du, R; Mancini, J; Boubli, L; Signoli, M; Panuel, M; Adalian, P

    2011-10-01

    Evaluate changes in obstetrical and neonatal outcome of women who delivered in maternity hospital since the 19(th) century. Data from a historic cohort of 1022 women who delivered between 1871 and 1874 in the hôtel Dieu hospital of Marseille were compared to those from 1159 women who delivered from 2005 to 2006 in the level 3 maternity of Nord hospital of Marseille (contemporary cohort). Deliveries that had occured before 22 weeks and/or with a foetal birth weight of less than 500 g were excluded. A total of 2131 pregnancies were included: 1011 and 1120 in historic and contemporary cohort, respectively. Despite comparable mean term of delivery, mean birth weight of neonates from historic cohort were significantly lower: 2971 g (550-4900 g) vs 3250 g (500-5375 g), respectively (p<0.001). Stillbirths were reported in 72 (7.1%) cases in historic cohort compared to nine (0.8%) in contemporary cohort (p<0.001). Neonatal mortality was 3.7% in historic cohort and 1.9% in contemporary cohort (p=0.012). A total of 99 (9.8%) maternal deaths were reported in historic cohort, while none in contemporary cohort (p<0.001). A wide majority of maternal deaths were caused by maternal infection (72.9%); 5.2% were caused by postpartum haemorrhage. Our results illustrate the tremendous impact on maternal and neonatal outcome of advances in obstetrical management. The significant increase in the median foetal birth weight is likely to be related to wide changes in environmental conditions and behaviour. Copyright © 2011. Published by Elsevier Masson SAS.

  14. Competence of birth attendants at providing emergency obstetric care under India’s JSY conditional cash transfer program for institutional delivery: an assessment using case vignettes in Madhya Pradesh province

    PubMed Central

    2014-01-01

    Background Access to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications. Methods A facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored. Results The mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care. Conclusions Birth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are

  15. Tocolytic Drugs for Use in Veterinary Obstetrics

    PubMed Central

    Ménard, L.

    1984-01-01

    The author presents a literature review of two tocolytic agents used in veterinary obstetrics: isoxsuprine and clenbuterol. The medical background from which these drugs emerged for human use and to which is linked their application in animal medicine is described. Each drug is reviewed according to its pharmacology, basic considerations for its clinical use and the reports on its application in the treatment and management of obstetrical disorders in veterinary medicine. PMID:17422462

  16. [Obstetric hysterectomy in the General Hospital Dr. Aurelio Valdivieso: three-year review].

    PubMed

    Calvo-Aguilar, O; Vásquez-Martínez J; Hernández-Cuevas, P

    2016-02-01

    Post-cesarean hysterectomy is the most extensive procedure used during the postpartum stage. This is an indicator of quality substantially associated with extreme obstetric morbidity. To determine the incidence, indications, and complications associated with obstetric hysterectomy in a hospital, after three years to implement the program of prevention and management of massive obstetric hemorrhage. Observational, transversal, retrospective and descriptive study conducted from January 2011 to November 2013. We records patients who underwent obstetric hysterectomy, of any age and at any time during pregnancy were reviewed. The results are expressed as frequencies, percentages and central tendency measures. 38 patients were recorded with obstetric hysterectomy. We found prevalence of 18.4 per 10,000, and incidence per year of 1.7, 1.4 and 2.6 per 1,000 births for 2011, 2012 and 2013. The prevalence of post-cesarean hysterectomy was 63.05 per 10,000 while postpartum was 9.05 per 10,000 births. The only difference between scheduled and emergency surgery was operating time. The procedure is associated with anemia in postpartum 13 times and the main indications for the procedures were hypo/atony and placenta accrete. The prenatal diagnoses of placenta accrete and improvement in the use of blood products and surgical technique has eliminated maternal mortality by massive obstetric hemorrhage in the last three years at the General Hospital "Dr. Aurelio Valdivieso".

  17. Challenges of major obstetric haemorrhage.

    PubMed

    Wise, Arlene; Clark, Vicki

    2010-06-01

    Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric haemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world while resource-rich countries have a rising caesarean section rate with its consequential effect on the incidence of abnormal placentation and its link with peripartum hysterectomy. Management of obstetric haemorrhage involves early recognition, assessment and resuscitation. Various methods are available to try to stop the bleeding - from pharmacological methods to aid uterine contraction (e.g., oxytocinon, ergometrine and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures or arterial ligation). Interventional radiology can be used if placenta accreta is suspected. Cell salvage has been introduced into obstetrics relatively recently in an attempt to reduce allogeneic transfusion. 2009 Elsevier Ltd. All rights reserved.

  18. Obstetric deaths in Bangladesh, 1996-1997.

    PubMed

    Rahman, M H; Akhter, H H; Khan Chowdhury, M-E-E; Yusuf, H R; Rochat, R W

    2002-05-01

    The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. We obtained case reports of 28998 deaths of women aged 10-50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100,000 women. Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

  19. Seed Mucilage Improves Seedling Emergence of a Sand Desert Shrub

    PubMed Central

    Yang, Xuejun; Baskin, Carol C.; Baskin, Jerry M.; Liu, Guangzheng; Huang, Zhenying

    2012-01-01

    The success of seedling establishment of desert plants is determined by seedling emergence response to an unpredictable precipitation regime. Sand burial is a crucial and frequent environmental stress that impacts seedling establishment on sand dunes. However, little is known about the ecological role of seed mucilage in seedling emergence in arid sandy environments. We hypothesized that seed mucilage enhances seedling emergence in a low precipitation regime and under conditions of sand burial. In a greenhouse experiment, two types of Artemisia sphaerocephala achenes (intact and demucilaged) were exposed to different combinations of burial depth (0, 5, 10, 20, 40 and 60 mm) and irrigation regimes (low, medium and high, which simulated the precipitation amount and frequency in May, June and July in the natural habitat, respectively). Seedling emergence increased with increasing irrigation. It was highest at 5 mm sand burial depth and ceased at burial depths greater than 20 mm in all irrigation regimes. Mucilage significantly enhanced seedling emergence at 0, 5 and 10 mm burial depths in low irrigation, at 0 and 5 mm burial depths in medium irrigation and at 0 and 10 mm burial depths in high irrigation. Seed mucilage also reduced seedling mortality at the shallow sand burial depths. Moreover, mucilage significantly affected seedling emergence time and quiescence and dormancy percentages. Our findings suggest that seed mucilage plays an ecologically important role in successful seedling establishment of A. sphaerocephala by improving seedling emergence and reducing seedling mortality in stressful habitats of the sandy desert environment. PMID:22511952

  20. A New Approach to Teaching Obstetric Anaesthesia in Low-Resource Areas.

    PubMed

    Enright, Angela; Grady, Kate; Evans, Faye

    2015-10-01

    Maternal mortality is high in many low- and middle-income countries. Unsafe anaesthesia contributes to this, especially for women requiring Caesarean section. Anaesthesia providers with limited skills and poor resources are often faced with complicated obstetric patients. A new course called SAFE-OB teaches a systematic approach to anticipating, preparing for, and dealing with obstetric anaesthetic emergencies. The course has now been taught in many African, Asian, and Latin countries. Initial follow-up suggests improvement in skills and knowledge, and effective translation of these to the workplace. Efforts are made to make the course locally owned and sustainable. We feel that SAFE-OB is an effective method of improving obstetric anaesthesia care.

  1. Planning a collaborative conference to provide interdisciplinary education with a focus on patient safety in obstetrics.

    PubMed

    Doyle, Jennifer; Newhouse, Linda; Flora, Robert; Burkett, Amy

    2014-01-01

    Collaboration is an important component of evidence-based practice in modern health care. A number of publications have touted the benefits of "team training" to improve obstetric outcomes during emergent situations. In August 2011, the Ohio sections of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the American Congress of Obstetricians and Gynecologists (ACOG) held a joint conference that focused on interdisciplinary education to promote patient safety. This joint venture drew more than 120 attendees, 12 exhibitors and 17 poster displays. Evaluations were positive and attendees cited planned practice changes for themselves as well as for their respective institutions.

  2. Retrospective cohort study of PAMG-1 and fetal fibronectin test performance in assessing spontaneous preterm birth risk in symptomatic women attending an emergency obstetrical unit.

    PubMed

    Melchor, J C; Navas, H; Marcos, M; Iza, A; de Diego, M; Rando, D; Melchor, I; Burgos, J

    2017-08-29

    To assess the performance of the PAMG-1 and fFN tests using real-world data for the prediction of spontaneous preterm delivery (sPTD) in patients presenting to an emergency obstetrical unit with threatened preterm labour (PTL) by conducting a retrospective audit of patient medical records over two different one-year time periods during which either fFN or PAMG-1 was used as the standard of care biochemical test. A retrospective cohort study chart review of women with threatened PTL electronic medical records (EMR) from a Level III maternity hospital was conducted for two periods of one year each: (1) the "Baseline" time period, during which the qualitative fFN test with a cutoff of 50 ng/ml was used as standard of care biochemical test for the risk assessment of preterm delivery, and (2) the "Comparative" time period, during which the PAMG-1 test with a cutoff of 1 ng/mL was used as the standard of care biomarker test. Patients with singleton gestations between 24(+0) to 34(+6) weeks of gestation with symptoms of early preterm labour, clinically intact membranes, and cervical dilation <3 cm, who did not have a medically-indicated preterm delivery within 14 days of testing were selected for chart review and included in the analysis. Key parameters used for analysis were biochemical test results, time of testing, and time of delivery. Positive predictive value (PPV), negative predictive value (NPV), sensitivity (SN), specificity (SP), and likelihood ratios (LR+ and LR-) for the prediction of sPTD ≤7 and ≤14 days were calculated for PAMG-1 and fFN. 420 patients were identified in the EMR as having presented with threatened PTL during the Baseline period. 90.0% (378/420) subjects met eligibility criteria, 10.1% (38/378) of which were fFN positive and 2.6% (10/378) of which had a sPTD ≤7 days. fFN PPV and NPV were 7.9% and 97.9% for sPTD ≤7 days, respectively. fFN LR+ and LR- were 3.15 and 0.77, respectively. 410 patients were identified in the EMR

  3. Provision for major obstetric haemorrhage: an Australian and New Zealand survey and review.

    PubMed

    Fowler, S J

    2005-12-01

    Obstetric haemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome. The aim of this study was to assess facilities relevant to major obstetric haemorrhage management in all units in Australia and New Zealand that offer operative obstetric services. The questionnaire was divided into ten sections: demographics, facilities, staffing, policies and guidelines, drugs, procedures, equipment, point of care testing, availability of O negative blood and free comments. Responses were received from 240 (76.4%) of the 314 hospitals surveyed (187 public and 53 private). One hundred and nine units (45%) had fewer than 500 deliveries per year Distances to referral facilities were frequently very large. Of the 90 hospitals (38.1%) without an onsite blood bank, 12 did not have a supply of blood for emergencies. Half of all units (n=121) had on-site intensive care or high dependency facilities and 72.9% (n=175) had an on-site cardiac arrest team. Only 58.8% of units (n=141) had a written haemorrhage protocol. Findings are presented in the context of other literature, including evidence-based guidelines. Haemorrhage responds well to appropriate treatment, although careful preparation and anticipation of problems is required. In our region geographical factors and different systems of healthcare complicate provision of obstetric services. Where facilities are limited, women should be offered antenatal transfer to a larger centre.

  4. A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia.

    PubMed

    Gebresilase, Yenenesh Tadesse

    2014-01-01

    Research on obstetric fistula has paid limited attention to the lived experiences of survivors. This qualitative study explored the evolution of survivors' perceptions of their social relationships and health since developing this obstetric complication. In-depth interviews were conducted with eight survivors who were selected based on purposive and snowball sampling techniques. Thematic categorization and content analysis was used to analyze the data. The resultant themes included participants' understanding of factors predisposing to fistula, challenges they encounter, their coping responses, and the meaning of their experiences. First, the participants had a common understanding of the factors that predisposed them to obstetric fistula. They mentioned poor knowledge about pregnancy, early marriage, cultural practices, and a delay in or lack of access to emergency obstetric care. Second, the participants suffered from powerlessness experienced during their childhood and married lives. They also faced prolonged obstructed labor, physical injury, emotional breakdown, depression, erosion of social capital, and loss of healthy years. Third, to control their negative emotions, participants reported isolating themselves, having suicidal thoughts, positive interpretation about the future, and avoidance. To obtain relief from their disease, the women used their family support, sold their properties, and oriented to reality. Fourth, the participants were struggling to keep going, to accept their changed reality, and to change their perspectives on life. In conclusion, obstetric fistula has significant physical, psychosocial, and emotional consequences. The study participants were not passive victims but rather active survivors of these challenges. Adequate support was not provided by their formal or informal support systems. To prevent and manage obstetric fistula successfully, there should be family-based interventions that improve access to and provision of emergency

  5. A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia

    PubMed Central

    Gebresilase, Yenenesh Tadesse

    2014-01-01

    Research on obstetric fistula has paid limited attention to the lived experiences of survivors. This qualitative study explored the evolution of survivors’ perceptions of their social relationships and health since developing this obstetric complication. In-depth interviews were conducted with eight survivors who were selected based on purposive and snowball sampling techniques. Thematic categorization and content analysis was used to analyze the data. The resultant themes included participants’ understanding of factors predisposing to fistula, challenges they encounter, their coping responses, and the meaning of their experiences. First, the participants had a common understanding of the factors that predisposed them to obstetric fistula. They mentioned poor knowledge about pregnancy, early marriage, cultural practices, and a delay in or lack of access to emergency obstetric care. Second, the participants suffered from powerlessness experienced during their childhood and married lives. They also faced prolonged obstructed labor, physical injury, emotional breakdown, depression, erosion of social capital, and loss of healthy years. Third, to control their negative emotions, participants reported isolating themselves, having suicidal thoughts, positive interpretation about the future, and avoidance. To obtain relief from their disease, the women used their family support, sold their properties, and oriented to reality. Fourth, the participants were struggling to keep going, to accept their changed reality, and to change their perspectives on life. In conclusion, obstetric fistula has significant physical, psychosocial, and emotional consequences. The study participants were not passive victims but rather active survivors of these challenges. Adequate support was not provided by their formal or informal support systems. To prevent and manage obstetric fistula successfully, there should be family-based interventions that improve access to and provision of

  6. Dedicated operating room for emergency surgery improves access and efficiency

    PubMed Central

    Heng, Marilyn; Wright, James G.

    2013-01-01

    Background Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children’s hospital. Methods We compared a 6-month period (January 2009 to June 2009) preimplementation with a 6-month period (January 2010 to June 2010) postimplementation of a dedicated OR. We evaluated OR use, wait times, percentage of cases done within and outside of access targets, off-hours surgery, cancellations, overruns and length of stay. Results Preimplementation, 1069 of the 5500 surgeries performed were emergency cases. Postimplementation, 1084 of the 5358 surgeries performed were emergency cases. Overall use of the dedicated OR was 53% (standard deviation 25%) postimplementation. Excluding outliers, the average wait time for priority 3 emergency patients decreased from 11 hours 8 minutes to 10 hours 5 minutes (p = 0.004). An increased proportion of priority 3 patients, from 52% to 58%, received surgery within 12 hours (p = 0.020). There was a 9% decrease in the proportion of priority 3 cases completed during the evening and night (p < 0.001). The elective surgical schedule benefited from the dedicated OR, with a significant decrease in cancellations (1.5% v. 0.7%, p < 0.001) and an accumulated decrease of 5211 minutes in overrun minutes in elective rooms. The average hospital stay after emergency surgery decreased from 16.0 days to 14.7 days (p = 0.12) following implementation of the dedicated OR. Conclusion A dedicated OR for emergency cases improved quality of care by decreasing cancellations and overruns in elective rooms and increasing the proportion of priority 3 patients who accessed care within the targeted time. PMID:23706847

  7. Obstetric antiphospholipid syndrome.

    PubMed

    Esteve-Valverde, E; Ferrer-Oliveras, R; Alijotas-Reig, J

    2016-04-01

    Obstetric antiphospholipid syndrome is an acquired autoimmune disorder that is associated with various obstetric complications and, in the absence of prior history of thrombosis, with the presence of antiphospholipid antibodies directed against other phospholipids, proteins called cofactors or PL-cofactor complexes. Although the obstetric complications have been related to the procoagulant properties of antiphospholipid antibodies, pathological studies of human placenta have shown the proinflammatory capacity of antiphospholipid antibodies via the complement system and proinflammatory cytokines. There is no general agreement on which antiphospholipid antibodies profile (laboratory) confers the greatest obstetric risk, but the best candidates are categories I and IIa. Combined treatment with low doses of aspirin and heparin achieves good obstetric and maternal outcomes. In this study, we also review the therapeutic possibilities in refractory cases, although the likelihood of progressing to other autoimmune diseases is low. We briefly comment on incomplete obstetric antiphospholipid syndrome, also known as antiphospholipid antibody-mediated pregnancy morbidity syndrome.

  8. [Childbirth preparation courses: obstetrical and neonatal evaluation].

    PubMed

    Grignaffini, A; Soncini, E; Riccò, R; Vadora, E

    2000-01-01

    From 1997, R.A.T. (Respiratory Autogenous Training) and "Stretching" training have been performed into the Department of Obstetrics and Gynecology University of Parma, for childbirth preparation. The aim of this study is to evaluate the obstetric characteristics of these women during labor and delivery. We compared the labour and delivery characteristics of 200 women who have completed antepartum R.A.T. and stretching training with 100 matched controls who have not. Preparation is significantly related to reduction in dystocic deliveries (operative vaginal delivery and cesarean section) and emergency cesarean section. Epidural analgesia (an obstetric procedure that is not routinely offered in the department of Parma) is more frequently performed in women prepared with ante-partum training. The neonatal outcome is good in all the three groups. "Prepared-childbirth" courses offer measurable clinical, obstetrical and neonatal advantages and psychological support, providing a useful link between prenatal ambulatory care and hospital labor and delivery care.

  9. Production layout improvement in emergency services: a participatory approach.

    PubMed

    Zanatta, Mateus; Amaral, Fernando Gonçalves

    2012-01-01

    Volunteer fire department is a service that responds emergency situations in places where there are no military emergency services. These services need to respond quickly, because time is often responsible for the operation success besides work environment and setup time interfere with the prompt response to these calls and care efficiency. The layout design is one factor that interferes with the quick setup. In this case, the spaces arrangement can result in excessive or unnecessary movements; also the equipment provision may hinder the selection and collection of these or even create movement barriers for the workers. This work created a new layout for the emergency assistance service, considering the human factors related to work through the task analysis and workers participation on the alternatives of improvement. The results showed an alternate layout with corridors and minimization of unusable sites, allowing greater flexibility and new possibilities of requirements.

  10. Utilizing Health Analytics in Improving Emergency Room Performance.

    PubMed

    Khalifa, Mohamed

    2016-01-01

    Emergency room performance improvement has been a major concern for healthcare professionals and researchers. ER patients' length of stay and percentage of patients leaving without treatment are two of the most important indicators for performance monitoring and improvement. The main objective of this study is to utilize health analytics methods in identifying areas of deficiency, potential improvements and recommending effective solutions to enhance ER performance. ER data of 2014 were retrospectively retrieved in January 2015 and analyzed for significant variables affecting inpatient admission rates. Patient Acuity Level was the significant variable on which the recommendations were based. A Fast-Track area was redesigned and dedicated for managing lower acuity level patients; CTAS levels 4 and 5. The performance of the ER has been monitored for the first six months of 2015 and compared to 2014. 29% improvement was achieved on shortening the total ER LOS and 30% improvement was achieved on the percentage of patients leaving ER without treatment.

  11. Improving Emergency Preparedness System Readiness through Simulation and Interprofessional Education

    PubMed Central

    Rambeck, Joan H.; Snyder, Annamay

    2014-01-01

    We applied emerging evidence in simulation science to create a curriculum in emergency response for health science students and professionals. Our research project was designed to (1) test the effectiveness of specific immersive simulations, (2) create reliable assessment tools for emergency response and team communication skills, and (3) assess participants' retention and transfer of skills over time. We collected both quantitative and qualitative data about individual and team knowledge, skills, and attitudes. Content experts designed and pilot-tested scaled quantitative tools. Qualitative evaluations administered immediately after simulations and longitudinal surveys administered 6–12 months later measured student participants' individual perceptions of their confidence, readiness for emergency response, and transfer of skills to their day-to-day experience. Results from 312 participants enrolled in nine workshops during a 24-month period indicated that the 10-hour curriculum is efficient (compared with larger-scale or longer training programs) and effective in improving skills. The curriculum may be useful for public health practitioners interested in addressing public health emergency preparedness competencies and Institute of Medicine research priority areas. PMID:25355984

  12. Using LEAN to improve a segment of emergency department flow.

    PubMed

    Vose, Courtney; Reichard, Christine; Pool, Susan; Snyder, Megan; Burmeister, David

    2014-11-01

    Emergency department (ED) overcrowding is an organizational concern. This article describes how Toyota LEAN methods were used as a performance improvement framework to address ED overcrowding. This initiative also impacted "bolus of patients" or "batching" concerns, which occur when inpatient units receive an influx of patients from EDs and other areas at the same time. In addition to decreased incidence of overcrowding, the organization realized increased interprofessional collaboration.

  13. Improving Emergency Department Door to Doctor Time and Process Reliability

    PubMed Central

    El Sayed, Mazen J.; El-Eid, Ghada R.; Saliba, Miriam; Jabbour, Rima; Hitti, Eveline A.

    2015-01-01

    Abstract The aim of this study is to determine the effectiveness of using lean management methods on improving emergency department door to doctor times at a tertiary care hospital. We performed a before and after study at an academic urban emergency department with 49,000 annual visits after implementing a series of lean driven interventions over a 20 month period. The primary outcome was mean door to doctor time and the secondary outcome was length of stay of both admitted and discharged patients. A convenience sample from the preintervention phase (February 2012) was compared to another from the postintervention phase (mid-October to mid-November 2013). Individual control charts were used to assess process stability. Postintervention there was a statistically significant decrease in the mean door to doctor time measure (40.0 minutes ± 53.44 vs 25.3 minutes ± 15.93 P < 0.001). The postintervention process was more statistically in control with a drop in the upper control limits from 148.8 to 72.9 minutes. Length of stay of both admitted and discharged patients dropped from 2.6 to 2.0 hours and 9.0 to 5.5 hours, respectively. All other variables including emergency department visit daily volumes, hospital occupancy, and left without being seen rates were comparable. Using lean change management techniques can be effective in reducing door to doctor time in the Emergency Department and improving process reliability. PMID:26496278

  14. Ontario's emergency department process improvement program: the experience of implementation.

    PubMed

    Rotteau, Leahora; Webster, Fiona; Salkeld, Erin; Hellings, Chelsea; Guttmann, Astrid; Vermeulen, Marian J; Bell, Robert S; Zwarenstein, Merrick; Rowe, Brian H; Nigam, Amit; Schull, Michael J

    2015-06-01

    In recent years, Lean manufacturing principles have been applied to health care quality improvement efforts to improve wait times. In Ontario, an emergency department (ED) process improvement program based on Lean principles was introduced by the Ministry of Health and Long-Term Care as part of a strategy to reduce ED length of stay (LOS) and to improve patient flow. This article aims to describe the hospital-based teams' experiences during the ED process improvement program implementation and the teams' perceptions of the key factors that influenced the program's success or failure. A qualitative evaluation was conducted based on semistructured interviews with hospital implementation team members, such as team leads, medical leads, and executive sponsors, at 10 purposively selected hospitals in Ontario, Canada. Sites were selected based, in part, on their changes in median ED LOS following the implementation period. A thematic framework approach as used for interviews, and a standard thematic coding framework was developed. Twenty-four interviews were coded and analyzed. The results are organized according to participants' experience and are grouped into four themes that were identified as significantly affecting the implementation experience: local contextual factors, relationship between improvement team and support players, staff engagement, and success and sustainability. The results demonstrate the importance of the context of implementation, establishing strong relationships and communication strategies, and preparing for implementation and sustainability prior to the start of the project. Several key factors were identified as important to the success of the program, such as preparing for implementation, ensuring strong executive support, creation of implementation teams based on the tasks and outcomes of the initiative, and using multiple communication strategies throughout the implementation process. Explicit incorporation of these factors into the

  15. Kaizen: a method of process improvement in the emergency department.

    PubMed

    Jacobson, Gregory H; McCoin, Nicole Streiff; Lescallette, Richard; Russ, Stephan; Slovis, Corey M

    2009-12-01

    Recent position statements from health care organizations have placed a strong emphasis on continuous quality improvement (CQI). CQI finds many of its roots in kaizen, which emphasizes small, low-cost, low-risk improvements. Based on the successful Kaizen Programs at organizations such as Toyota, the authors thought the emergency department (ED) would be an ideal environment to benefit from such a program. The authors sought to create a CQI program using a suggestion-based model that did not require a large time commitment, was easy to implement, and had the potential to empower all physicians in the department. It would not take the place of other improvement efforts, but instead augment them. The hypothesis was that such a program would foster sustainable engagement of emergency physicians in system improvement efforts and lead to a continuous stream of low-cost implementable system improvement interventions. A CQI program was created for the physician staff of the Department of Emergency Medicine at Vanderbilt University Medical Center, focusing on a suggestion-based model using kaizen philosophy. Lectures teaching kaizen philosophy were presented. Over the past 4 years, a methodology was developed utilizing a Web-based application, the Kaizen Tracker, which aids in the submission and implementation of suggestions that are called kaizen initiatives (KIs). The characteristics of the KIs submitted, details regarding resident and faculty participation, and the effectiveness of the Kaizen Tracker were retrospectively reviewed. There were 169, 105, and 101 KIs placed in the postimplementation calendar years 2006, 2007, and 2008, respectively. Seventy-six percent of KIs submitted thus far have identified a "process problem." Fifty-three percent of KIs submitted have led to operational changes within the ED. Ninety-three percent of the resident physicians entered at least one KI, and 73% of these residents submitted more than one KI. Sixty-nine percent of the

  16. 'The clock keeps ticking'--the role of a community-based intervention in reducing delays in seeking emergency obstetric care in rural Bangladesh: a quasi-experimental study.

    PubMed

    Banu, M; Akter, M; Begum, K; Choudhury, R H; Nasreen, H E

    2014-04-01

    To explore the role of a community-based intervention in reducing delays in accessing emergency obstetric care (EmOC) in rural Bangladesh, and the factors associated with delayed decision making, reaching the health facility and receiving treatment. Quasi-experimental study. Multistage random sampling was used to select 540 villages, from which 1200 women who reported obstetric complications in March-April 2010 were interviewed. The median time taken to make the decision to access health care was significantly lower in the intervention areas compared with the control areas (80 vs 90 min). In addition, the median time taken to reach the health facility was significantly lower in the intervention areas compared with the control areas (110 vs 135 min). However, no difference was found in the median time taken to receive treatment. Multiple linear regressions demonstrated that the community intervention significantly reduced decision making and time taken to reach the health facility when accessing EmOC in rural Bangladesh. However, for women experiencing haemorrhage, the delays were longer in the intervention areas. Protective factors against delayed decision making included access to television, previous medical exposure, knowledge, life-threatening complications during childbirth and use of a primary health facility. Financial constraints and traditional perceptions were associated with delayed decision making. Complications during labour, use of a motorized vehicle and use of a primary health facility were associated with faster access to EmOC, and poverty, distance, transportation difficulties and decision made by male guardian were associated with slower access to EmOC. The intervention appeared to reduce the time taken to make the decision to access health care and the time taken to reach the health facility when accessing EmOC. This study provides support for a focus on emergency preparedness for timely referral from the community. Copyright © 2014 The Royal

  17. Improving Emergency Response and Human-Robotic Performance

    SciTech Connect

    David I. Gertman; David J. Bruemmer; R. Scott Hartley

    2007-08-01

    Preparedness for chemical, biological, and radiological/nuclear incidents at nuclear power plants (NPPs) includes the deployment of well trained emergency response teams. While teams are expected to do well, data from other domains suggests that the timeliness and accuracy associated with incident response can be improved through collaborative human-robotic interaction. Many incident response scenarios call for multiple, complex procedure-based activities performed by personnel wearing cumbersome personal protective equipment (PPE) and operating under high levels of stress and workload. While robotic assistance is postulated to reduce workload and exposure, limitations associated with communications and the robot’s ability to act independently have served to limit reliability and reduce our potential to exploit human –robotic interaction and efficacy of response. Recent work at the Idaho National Laboratory (INL) on expanding robot capability has the potential to improve human-system response during disaster management and recovery. Specifically, increasing the range of higher level robot behaviors such as autonomous navigation and mapping, evolving new abstractions for sensor and control data, and developing metaphors for operator control have the potential to improve state-of-the-art in incident response. This paper discusses these issues and reports on experiments underway intelligence residing on the robot to enhance emergency response.

  18. Improving Emergency Providers’ Attitudes Towards Sickle Cell Patients in Pain

    PubMed Central

    Puri, Aditi; Haywood, Carlton; Beach, Mary Catherine; Guidera, Mark; Lanzkron, Sophie; Valenzuela-Araujo, Doris; Rothman, Richard E.; Dugas, Andrea Freyer

    2015-01-01

    Background Provider biases and negative attitudes are recognized barriers to optimal pain management in sickle cell disease, particularly in the emergency department (ED). Measures This prospective cohort measures pre- and post-intervention provider attitudes towards patients with sickle pain crises using a validated survey instrument. Intervention ED providers viewed an eight-minute online video that illustrated challenges in sickle cell pain management, perspectives of patients and providers as well as misconceptions and stereotypes of which to be wary. Outcomes Ninety-six ED providers were enrolled. Negative attitude scoring decreased, with a mean difference -11.5 from baseline, and positive attitudes improved, with a mean difference +10. Endorsement of red-flag behaviors similarly decreased (mean difference -12.8). Results were statistically significant and sustained on repeat testing three months post-intervention. Conclusions/Lessons Learned Brief video-based educational interventions can improve emergency provider attitudes towards patients with sickle pain crises, potentially curtailing pain crises early, improving health outcomes and patient satisfaction scores. PMID:26596878

  19. Teaching primary care obstetrics

    PubMed Central

    Koppula, Sudha; Brown, Judith B.; Jordan, John M.

    2014-01-01

    Abstract Objective To explore the experiences and recommendations for recruitment of family physicians who practise and teach primary care obstetrics. Design Qualitative study using in-depth interviews. Setting Six primary care obstetrics groups in Edmonton, Alta, that were involved in teaching family medicine residents in the Department of Family Medicine at the University of Alberta. Participants Twelve family physicians who practised obstetrics in groups. All participants were women, which was reasonably representative of primary care obstetrics providers in Edmonton. Methods Each participant underwent an in-depth interview. The interviews were audiotaped and transcribed verbatim. The investigators independently reviewed the transcripts and then analyzed the transcripts together in an iterative and interpretive manner. Main findings Themes identified in this study include lack of confidence in teaching, challenges of having learners, benefits of having learners, and recommendations for recruiting learners to primary care obstetrics. While participants described insecurity and challenges related to teaching, they also identified positive aspects, and offered suggestions for recruiting learners to primary care obstetrics. Conclusion Despite describing poor confidence as teachers and having challenges with learners, the participants identified positive experiences that sustained their interest in teaching. Supporting these teachers and recruiting more such role models is important to encourage family medicine learners to enter careers such as primary care obstetrics. PMID:24627402

  20. Improved Emergency Egress Lighting System for the ISS

    NASA Technical Reports Server (NTRS)

    Eaton, Leslie L.; Barr, Don A.

    2005-01-01

    Emergency lights provide illumination in corridors, stairwells, ramps, escalators, aisles, and exit passageways during power failures. Safety and visibility are critical during a power outage. If emergency lights fail to operate properly, the building occupants can become disoriented. Four documents in a collection discuss different topics relating to a proposed improved emergency egress lighting system (EELS) for the International Space Station (ISS). While the present EELS is designed around rows of green-light-emitting diodes, the proposed system contains strips of electroluminescent tape using different colors for each egress path. The proposed EELS can be powered by the same battery currently used by the present EELS, but would require an inverter because electroluminescent devices require AC. Electroluminescent devices also require significantly less current and, depending on the color, would emit 3 to 8 times the light of the present EELS. In addition, they could operate for up to 75 hours (versus .20 minutes for the present system). The first document contains a one-page summary of the proposal and an evaluation of technical merit. The second document summarizes the motivation for, and the design of, the proposed EELS. The third document addresses relevant aspects of the measurement of spectral sensitivity and the psychophysics of perception of light. The fourth document presents additional background information and technical specifications for the electroluminescent tapes.

  1. Telemedicine in obstetrics.

    PubMed

    Odibo, Imelda N; Wendel, Paul J; Magann, Everett F

    2013-09-01

    Telemedicine lends itself to several obstetric applications and is of growing interest in developed and developing nations worldwide. In this article we review current trends and applications within obstetrics practice. We searched electronic databases, March 2010 to September 2012, for telemedicine use studies related to obstetrics. Thirty-four of 101 identified studies are the main focus of review. Other relevant studies published before March 2010 are included. Telemedicine plays an important role as an adjunct to delivery of health care to remote patients with inadequate medical access in this era of limited resources and emphasis on efficient use of those available resources.

  2. [Obstetric analgesia in Norwegian hospitals].

    PubMed

    Barratt-Due, Andreas; Hagen, Inger; Dahl, Vegard

    2005-09-22

    Experience from our hospital has shown a significant increase in the use of epidural analgesia during labour. We wanted to see if this was a general trend in Norway, and wanted to find out for what kind of labour analgesia was offered in the different labour wards. A questionnaire concerning obstetric analgesia and anaesthetic methods for caesarean section was sent to chief anaesthetists and head midwives in Norwegian hospitals. The information was compared to an identical questionnaire from 1996. In addition, data concerning obstetric analgesia was collected from the Norwegian Medical Birth Register. 77% of the anaesthetic departments and 88% of the labour wards responded to the questionnaire. The use of epidural analgesia was on an average 20.6% (range 0-40.5%), which is twice as much as in 1996. 75% answered that the parturients' wish for epidural analgesia was reason enough to give an epidural. 84% of caesarean sections were performed in regional anaesthesia and 16% were done in general anaesthesia. This represents a significant reduction in the use of general anaesthesia. 85% of the labour wards offered acupuncture, which is a tremendous increase compared to 1996. Systemic opioids are still widely used, and pethidine is still the most frequently used opioid. Pethidine's negative side effect profile has been widely focused on during the past decade. The hospital's information on the various analgesic methods available for labour analgesi, is clearly improved since 1996. Obstetric analgesia in Norwegian hospitals has improved substantially since the last survey.

  3. Is antacid treatment necessary in obstetric anesthesia?

    PubMed

    Al Mazrooa, A A; Alyafi, W A; Marzouki, S A

    1995-10-01

    All the obstetric units in Jeddah were surveyed regarding the use of antacid prophylaxis and the methods of anesthesia used for emergency and elective cesarian section. The results were compared with the Western practice where marked variation was found but this apparently did not influence mortality from acid aspiration.

  4. Arachnoid cyst masquerading as obstetric brachial plexus palsy.

    PubMed

    Muthukumar, Natarajan; Santhanakrishnan, Alwar Govindan; Sivakumar, Krishnaswamy

    2012-07-01

    Obstetric brachial plexus palsy is not uncommon. However, lesions masquerading as obstetric brachial plexus palsy are rare. A child with a cervicothoracic arachnoid cyst masquerading as obstetric brachial plexus palsy is presented, and the relevant literature is reviewed. A girl born by vaginal delivery at full term without any antecedent risk factors for obstetric brachial plexus palsy was noted to have decreased movements of the right upper extremity. After 7 months, there was no improvement. An MRI scan was obtained, which revealed a cervicothoracic spinal extradural arachnoid cyst. During surgery, the cyst was found to communicate with the dura at the axilla of the C-7 nerve root. The cyst was excised in toto. Six months later, there was improvement in the infant's neurological status. This case illustrates that spinal arachnoid cysts should be entertained in the differential diagnosis when a child presents with obstetric brachial plexus palsy without known antecedent risk factors for obstetric palsy.

  5. Process-Improvement Cost Model for the Emergency Department.

    PubMed

    Dyas, Sheila R; Greenfield, Eric; Messimer, Sherri; Thotakura, Swati; Gholston, Sampson; Doughty, Tracy; Hays, Mary; Ivey, Richard; Spalding, Joseph; Phillips, Robin

    2015-01-01

    The objective of this report is to present a simplified, activity-based costing approach for hospital emergency departments (EDs) to use with Lean Six Sigma cost-benefit analyses. The cost model complexity is reduced by removing diagnostic and condition-specific costs, thereby revealing the underlying process activities' cost inefficiencies. Examples are provided for evaluating the cost savings from reducing discharge delays and the cost impact of keeping patients in the ED (boarding) after the decision to admit has been made. The process-improvement cost model provides a needed tool in selecting, prioritizing, and validating Lean process-improvement projects in the ED and other areas of patient care that involve multiple dissimilar diagnoses.

  6. Improving Suicide Risk Screening and Detection in the Emergency Department.

    PubMed

    Boudreaux, Edwin D; Camargo, Carlos A; Arias, Sarah A; Sullivan, Ashley F; Allen, Michael H; Goldstein, Amy B; Manton, Anne P; Espinola, Janice A; Miller, Ivan W

    2016-04-01

    The Emergency Department Safety Assessment and Follow-up Evaluation Screening Outcome Evaluation examined whether universal suicide risk screening is feasible and effective at improving suicide risk detection in the emergency department (ED). A three-phase interrupted time series design was used: Treatment as Usual (Phase 1), Universal Screening (Phase 2), and Universal Screening + Intervention (Phase 3). Eight EDs from seven states participated from 2009 through 2014. Data collection spanned peak hours and 7 days of the week. Chart reviews established if screening for intentional self-harm ideation/behavior (screening) was documented in the medical record and whether the individual endorsed intentional self-harm ideation/behavior (detection). Patient interviews determined if the documented intentional self-harm was suicidal. In Phase 2, universal suicide risk screening was implemented during routine care. In Phase 3, improvements were made to increase screening rates and fidelity. Chi-square tests and generalized estimating equations were calculated. Data were analyzed in 2014. Across the three phases (N=236,791 ED visit records), documented screenings rose from 26% (Phase 1) to 84% (Phase 3) (χ(2) [2, n=236,789]=71,000, p<0.001). Detection rose from 2.9% to 5.7% (χ(2) [2, n=236,789]=902, p<0.001). The majority of detected intentional self-harm was confirmed as recent suicidal ideation or behavior by patient interview. Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection. If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide. Emergency Department Safety Assessmentand Follow-up Evaluation (ED-SAFE) ClinicalTrials.gov: (NCT01150994). https://clinicaltrials.gov/ct2/show/NCT01150994?term=ED-SAFE&rank=1. Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc

  7. A program to improve the quality of emergency endotracheal intubation.

    PubMed

    Mayo, Paul H; Hegde, Abhijith; Eisen, Lewis A; Kory, Pierre; Doelken, Peter

    2011-01-01

    To assess the results of a quality improvement (QI) project designed to improve safety of emergency endotracheal intubation (EEI). Single center prospective observational. 16-bed intensive care unit. Nine pulmonary/critical care fellows. For 3 years, EEI performed by the medical intensive care unit team were analyzed to identify interventions that would improve quality of the procedure. By segmental process analysis, the procedure of EEI was subjected to iterative change. Major components of process improvement were development of a combined team approach, a mandatory checklist, use of crew resource management (CRM) tactics, and postevent debriefing. Quality analysis and improvement included training of fellows using scenario-based training (SBT) with computerized patient simulator (CPS) to improve mechanical skills of intubation and team leadership. Fellows received 15 sessions of SBT with CPS using a combined checklist and team approach before assuming team leadership position during real-life EEI. For a 10-month period, fellows carried digital voice recorders to EEI; which, when combined with recording of continuous oximetry and BP monitoring were used to assess the quality of EEI. 128 EEI were performed of which 101 had full data recorded. Complications were 14% severe hypoxemia (<80% saturation), 6% severe hypotension (SBP<70 mm Hg), 1% death, 20% difficult EEI (≥ 3 attempts), 11% esophageal intubations, 2% aspiration, and 1% dental injury; 62% EEI were successfully achieved on first attempt, 11% required >3 attempts. EEI may be performed by pulmonary/critical medicine (PCCM) fellows with safety comparable to that described in other studies on EEI. Important parts of the program included the use of formal iterative QI approach, the use of intensive SBT with CPS, basic CRM, a comprehensive checklist, and a combined team approach. A key benefit of the program was to make the process of EEI fully transparent for ongoing quality and safety improvement.

  8. [Providing vulnerable populations in subSaharan Africa access to obstetrical care: strategy for improving prenatal services].

    PubMed

    Dugas, M

    2011-12-01

    The outlook for reaching key Millennium Development goals in Africa in 2015 is mostly positive. However, two critical indicators, i.e., maternal and neonatal mortality, show lagging progress. The purpose of this report is to underline the importance of prenatal care in efforts to reduce maternal mortality. It describes the minimum prenatal care package recommended by WHO and propses strategies for increasing access to prenatal examination. Health education, improvement of care quality and outreach services are promising avenues to increasing the use of prenatal services.

  9. Obstetrics and Ernest Hemingway.

    PubMed

    King, C R

    1989-07-01

    Ernest Hemingway is one of the most popular and important American writers of the 20th century. His fiction, ranging from the short story to the novel, is well known, but his medical knowledge, and in particular his knowledge of obstetrics, often is not recognized. To achieve the realistic depiction of the childbirth scenes in A Farewell to Arms required that Hemingway acquire special knowledge of obstetrics practice.

  10. What is an Obstetrics/Gynecology Hospitalist?

    PubMed

    McCue, Brigid

    2015-09-01

    The obstetrics/gynecology (OB/GYN) hospitalist is the latest subspecialist to evolve from obstetrics and gynecology. Starting in 2002, academic leaders recognized the impact of such coalescing forces as the pressure to reduce maternal morbidity and mortality, stagnant reimbursements and the increasing cost of private practice, the decrease in applications for OB/GYN residencies, and the demand among practicing OB/GYNs for work/life balance. Initially coined laborist, the concept of the OB/GYN hospitalist emerged. Thinking of becoming an OB/GYN hospitalist? Here is what you need to know.

  11. Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence.

    PubMed

    Madzimbamuto, Farai D; Ray, Sunanda; Mogobe, Keitshokile D

    2013-06-10

    of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.

  12. Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence

    PubMed Central

    2013-01-01

    -associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones. PMID:23758987

  13. A novel resident-as-teacher training program to improve and evaluate obstetrics and gynecology resident teaching skills.

    PubMed

    Ricciotti, Hope A; Dodge, Laura E; Head, Julia; Atkins, K Meredith; Hacker, Michele R

    2012-01-01

    Residents play a significant role in teaching, but formal training, feedback, and evaluation are needed. Our aims were to assess resident teaching skills in the resident-as-teacher program, quantify correlations of faculty evaluations with resident self-evaluations, compare resident-as-teacher evaluations with clinical evaluations, and evaluate the resident-as-teacher program. The resident-as-teacher training program is a simulated, videotaped teaching encounter with a trained medical student and standardized teaching evaluation tool. Evaluations from the resident-as-teacher training program were compared to evaluations of resident teaching done by faculty, residents, and medical students from the clinical setting. Faculty evaluation of resident teaching skills in the resident-as-teacher program showed a mean total score of 4.5 ± 0.5 with statistically significant correlations between faculty assessment and resident self-evaluations (r = 0.47; p < 0.001). However, resident self-evaluation of teaching skill was lower than faculty evaluation (mean difference: 0.4; 95% CI 0.3-0.6). When compared to the clinical setting, resident-as-teacher evaluations were significantly correlated with faculty and resident evaluations, but not medical student evaluations. Evaluations from both the resident-as-teacher program and the clinical setting improved with duration of residency. The resident-as-teacher program provides a method to train, give feedback, and evaluate resident teaching.

  14. Improving the safety of remote site emergency airway management

    PubMed Central

    Wijesuriya, Julian; Brand, Jonathan

    2014-01-01

    Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management. A Rapid Sequence Induction (RSI) checklist was developed; this was combined with new advanced airway equipment and drugs bags. Additionally, new carbon dioxide detector filters were procured in order to comply with NAP4 monitoring recommendations. The RSI checklists were placed in key locations throughout the hospital and the drugs and advanced airway equipment bags were centralised in the Intensive Care Unit (ICU). It was agreed with the senior nursing staff that an appropriately trained ICU nurse would attend all emergency situations with new airway resources upon request. Departmental guidelines were updated to include details of the new resources and the on-call anaesthetist's responsibilities regarding checks and maintenance. Following our intervention trainees reported higher confidence levels regarding remote site emergency airway management. Nine trusts within the Northern Region were surveyed and we found large variations in the provision of remote site airway management resources. Complications in remote site airway management due lack of available appropriate drugs, equipment or trained staff are potentially life threatening and completely avoidable. Utilising the intervention package an anaesthetist would be able to safely plan and prepare for airway management in any setting. They would subsequently have the drugs, equipment, and trained assistance required to manage any difficulties or complications

  15. Improving the safety of remote site emergency airway management.

    PubMed

    Wijesuriya, Julian; Brand, Jonathan

    2014-01-01

    Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management. A Rapid Sequence Induction (RSI) checklist was developed; this was combined with new advanced airway equipment and drugs bags. Additionally, new carbon dioxide detector filters were procured in order to comply with NAP4 monitoring recommendations. The RSI checklists were placed in key locations throughout the hospital and the drugs and advanced airway equipment bags were centralised in the Intensive Care Unit (ICU). It was agreed with the senior nursing staff that an appropriately trained ICU nurse would attend all emergency situations with new airway resources upon request. Departmental guidelines were updated to include details of the new resources and the on-call anaesthetist's responsibilities regarding checks and maintenance. Following our intervention trainees reported higher confidence levels regarding remote site emergency airway management. Nine trusts within the Northern Region were surveyed and we found large variations in the provision of remote site airway management resources. Complications in remote site airway management due lack of available appropriate drugs, equipment or trained staff are potentially life threatening and completely avoidable. Utilising the intervention package an anaesthetist would be able to safely plan and prepare for airway management in any setting. They would subsequently have the drugs, equipment, and trained assistance required to manage any difficulties or complications

  16. Understanding Audit in Obstetrics.

    PubMed

    Eralil, Georgy Joy

    2016-10-01

    Aim of this audit is to analyse indication and proportion of babies delivered by elective caesarean section at less than 39(+0) weeks of gestation exposed to antenatal corticosteroids performed in a Premier Hospital, Hywel Dda Health University. The second aim was to learn how an audit can be done and used for improving clinical practice. Present study involved all patients who underwent elective caesarean delivery before 39 weeks completed period of gestation in August and September 2014. Data collected from medical record tracking using ICD-9 codes and analysed by clinical audit department. Patients who underwent elective caesarean section after 39 weeks completed period of gestation. The audit showed 66.6 % of patients were given antenatal corticosteroids. The observation was discussed in consultant meetings, labour forum, and was send as e-mail to every one working in Department of Obstetrics and Gynaecology. The goal was 100 %. Reaudit is to be performed in year time to know the effect of change in practice. All successful audits are structured programmes with realistic aims and objectives, leadership and attitude of senior management, nondirective, hands-on approach, support of staff, strategy groups and regular discussions, emphasis on team working and support, environment conducive to conducting audit.

  17. Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda.

    PubMed

    Alfonso, Y Natalia; Bishai, David; Bua, John; Mutebi, Aloysius; Mayora, Crispus; Ekirapa-Kiracho, Elizabeth

    2015-02-01

    The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable.

  18. Obstetric anaesthesia in low-resource settings.

    PubMed

    Dyer, Robert A; Reed, Anthony R; James, Michael F

    2010-06-01

    Close co-operation between obstetricians and obstetric anaesthesia providers is crucial for the safety and comfort of parturients, particularly in low-resource environments. Maternal and foetal mortality is unacceptably high, and the practice of obstetric anaesthesia has an important influence on outcome. Well-conducted national audits have identified the contributing factors to anaesthesia-related deaths. Spinal anaesthesia for caesarean section is the method of choice in the absence of contraindications, but is associated with significant morbidity and mortality. Minimum requirements for safe practice are adequate skills, anaesthesia monitors, disposables and drugs and relevant management protocols for each level of care. The importance of current outreach initiatives is emphasised, and educational resources and the available financial sources discussed. The difficulties of efficient procurement of equipment and drugs are outlined. Guiding principles for the practice of analgesia for labour, anaesthesia for caesarean section and the management of obstetric emergencies, where the anaesthetist also has a central role, are suggested.

  19. Obstetrical brachial plexus palsy: Can excision of upper trunk neuroma and nerve grafting improve function in babies with adequate elbow flexion at nine months of age?

    PubMed

    Argenta, Anne E; Brooker, Jack; MacIssac, Zoe; Natali, Megan; Greene, Stephanie; Stanger, Meg; Grunwaldt, Lorelei

    2016-05-01

    Accepted indications for exploration in obstetrical brachial plexus palsy (OBPP) vary by center. Most agree that full elbow flexion against gravity at nine months of age implies high chance of spontaneous recovery and thus excludes a baby from surgical intervention. However, there are certain movements of the shoulder and forearm that may not be used frequently by the infant, but are extremely important functionally as they grow. These movements are difficult to assess in a baby and may lead to some clinicians to recommend conservative treatment, when this cohort of infants may in fact benefit substantially from surgery. A retrospective review was conducted on all infants managed surgically at the Brachial Plexus Center of a major children's hospital from 2009 to 2014. Further analysis identified five patients who had near-normal AMS scores for elbow flexion but who had weakness of shoulder abduction, flexion, external rotation, and/or forearm supination. In contrast to standard conservative management, this cohort underwent exploration, C5-6 neuroma excision, and sural nerve grafting. Data analysis was performed on this group to look for overall improvement in function. During an average follow-up period of 29 months, all patients made substantial gains in motor function of the shoulder and forearm, without loss of elbow flexion or extension, or worsening of overall outcome. In select infants with brachial plexus injuries but near-normal AMS scores for elbow flexion, surgical intervention may be indicated to achieve the best functional outcome. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

  20. Sonographic assessment of placental location: a mere notional description or an important key to improve both pregnancy and perinatal obstetrical care? A large cohort study

    PubMed Central

    Gizzo, Salvatore; Noventa, Marco; Vitagliano, Amerigo; Quaranta, Michela; Giovanni, Valentina Di; Borgato, Shara; Saccardi, Carlo; D’Antona, Donato

    2015-01-01

    During a standard obstetrical sonogram, the assessment of placental location (PL) is often limited to a mere notional description without formulating any association to possible implications on pregnancy and childbirth. The aim of the study was to speculate if different sites of PL may have a role in influencing fetal presentation-(FP) at birth and if certain pregnancy-complications may be more closely associated with one rather than with another PL. We conducted an observational-prospective-cohort study on pregnant women referred to the Ob/Gyn Unit of Padua University for routine third-trimester ultrasound scan. For all eligible patients we evaluated the correlation between sites of PL and perinatal maternal/fetal outcomes. Non-cephalic presentation was found in 1.4% of anterior, 8.9% of posterior, 6.2% of fundal and 7.2% of lateral insertions. FP at the beginning of the third trimester as opposed to presentation at birth was concordant in 90.3% of anterior, 63.3% of posterior and 76.5% of lateral insertions. Considering only non-cephalic fetuses we observed a decreasing probability for spontaneous rotation in the following lies: 88% anterior-PL, 80% posterior-PL, 77% lateral-PL, and 70% fundal-PL. Patients with posterior-PL (significantly associated with previous-CS) had a significantly higher CS-rate (due to previous-CS and breech-presentation). Significant differences were found in terms of gestational-hypertension and fresh-placental-weight between different sites of PL. In conclusion our data showed that an understanding of the role that PL plays in influencing the incidence of certain maternal-fetal conditions may assist Clinicians in improving perinatal maternal/fetal outcomes. PMID:26550228

  1. Medical Observation Units and Emergency Department Collaboration: Improving Patient Throughput.

    PubMed

    Gabele, Danielle; Bugais, Charlene; Laguna, Joanne

    2016-01-01

    The aim of this study was to identify whether observation status patients placed in a dedicated unit would decompress the emergency department (ED) more than observation patients who were admitted to other available beds. An urban quaternary hospital has a high volume of patients with average daily census of 95% capacity. A medical observation unit (MOU) was created to improve patient throughput. In phase 1, the MOU charge nurse reviewed the ED patients to be admitted and selected appropriate patients based on unit inclusion criteria. In phase 2, the MOU charge nurse did rounds with the ED charge nurse once per shift. MOU observation patients demonstrated a 53-minute (16%) reduction in average overall ED length of stay compared with observation patients admitted to other units. Inclusion criteria, a rounding checklist, and engagement of MOU and ED nurses helped the MOU and ED with patient throughput.

  2. Smart garments for safety improvement of emergency/disaster operators.

    PubMed

    Curone, Davide; Dudnik, Gabriela; Loriga, Giannicola; Luprano, Jean; Magenes, Giovanni; Paradiso, Rita; Tognetti, Alessandro; Bonfiglio, Annalisa

    2007-01-01

    The main purpose of the European project ProeTEX is to develop equipment to improve safety, coordination and efficiency of emergency disaster intervention personnel like fire-fighters or civil protection rescuers. The equipment consists of a new generation of "smart" garments, integrating wearable sensors which will allow monitoring physiological parameters, position and activity of the user, as like as environmental variables of the operating field in which rescuers are working: both commercial and newly developed textile and fibre based sensors will be included. The garments will also contain an electronic box to process data collected by the sensors and a communication system enabling the transmission of data to the other rescuers and to a monitoring station. Also a "smart" victim patch will be developed: a wearable garment which will allow monitoring physiological parameters of injured civilians involved in disasters, with the aim of optimizing their survival management.

  3. Quality Improvement Project to Improve Timeliness Between Bronchodilator Treatments from Emergency Department to Medical Wards.

    PubMed

    Cockerham, Jennifer R; Lowe, Gary R; Willis, Randy; Stecks, Ryan M; Berlinski, Ariel

    2016-12-01

    Quality improvement methodology was applied to study sporadic reports that patients with asthma were not given bronchodilator treatments or assessed within an appropriate time frame when they were admitted from the emergency department to the medical ward. The goal was to increase the number of patients who had an interval between emergency department assessment/bronchodilator treatment and medical ward assessment/treatment of <120 min. A flow chart diagram, a fishbone diagram, data collection, intervention implementation, and data monitoring and analysis were used in this study. Data were collected on a pre-test of change cohort of 227 subjects with asthma from January 2013 to March 2014. A test of change adding a Q2H respiratory therapist assessment and as needed bronchodilator treatment order while the subject was in the emergency department was implemented during May of 2014. These data were compared with a post-test of change cohort of 278 subjects with asthma from May 2014 to July 2015. Data collection for both cohorts included the time from the last assessment/bronchodilator treatment in the emergency department to emergency department discharge, the time from emergency department discharge to assessment/treatment in the medical ward, and the sum of these 2 time periods. Mean times (minutes) were noted, and comparisons were made using 2-tailed independent t tests with significance set at P < .05. Mean monthly times were also compared in process control charts. There was a 124% increase noted in the percentage of subjects who received bronchodilator treatment within 120 min, a 53% increase within 180 min, and a 19% increase within 240 min. The interval time between treatments decreased 21%. Through quality improvement methodology, the group was able to significantly decrease the time between the last assessment/bronchodilator treatment in the emergency department and the first assessment/treatment in the medical ward for subjects with asthma. Moreover

  4. Safer obstetric anesthesia through education and mentorship: a model for knowledge translation in Rwanda.

    PubMed

    Livingston, Patricia; Evans, Faye; Nsereko, Etienne; Nyirigira, Gaston; Ruhato, Paulin; Sargeant, Joan; Chipp, Megan; Enright, Angela

    2014-11-01

    High rates of maternal mortality remain a widespread problem in the developing world. Skilled anesthesia providers are required for the safe conduct of Cesarean delivery and resuscitation during obstetrical crises. Few anesthesia providers in low-resource settings have access to continuing education. In Rwanda, anesthesia technicians with only three years of post-secondary training must manage complex maternal emergencies in geographically isolated areas. The purpose of this special article is to describe implementation of the SAFE (Safer Anesthesia From Education) Obstetric Anesthesia course in Rwanda, a three-day refresher course designed to improve obstetrical anesthesia knowledge and skills for practitioners in low-resource areas. In addition, we describe how the course facilitated the knowledge-to-action (KTA) cycle whereby a series of steps are followed to promote the uptake of new knowledge into clinical practice. The KTA cycle requires locally relevant teaching interventions and continuation of knowledge post intervention. In Rwanda, this meant carefully considering educational needs, revising curricula to suit the local context, employing active experiential learning during the SAFE Obstetric Anesthesia course, encouraging supportive relationships with peers and mentors, and using participant action plans for change, post-course logbooks, and follow-up interviews with participants six months after the course. During those interviews, participants reported improvements in clinical practice and greater confidence in coordinating team activities. Anesthesia safety remains challenged by resource limitations and resistance to change by health care providers who did not attend the course. Future teaching interventions will address the need for team training.

  5. Improving Emergency Department flow through optimized bed utilization.

    PubMed

    Chartier, Lucas Brien; Simoes, Licinia; Kuipers, Meredith; McGovern, Barb

    2016-01-01

    Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flow-interrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the post-intervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements.

  6. Improving Emergency Department flow through optimized bed utilization

    PubMed Central

    Chartier, Lucas Brien; Simoes, Licinia; Kuipers, Meredith; McGovern, Barb

    2016-01-01

    Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flow-interrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the post-intervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements. PMID:27752312

  7. Obstetrics and Gynecology: Considerations in Career Selection

    PubMed Central

    Stephen Petrilli, Edmund

    1981-01-01

    Current training programs in obstetrics and gynecology are not producing an excess of specialists in view of future manpower needs. In addition to being specialists and consultants, obstetrician-gynecologists also function as providers of primary care for women. During the last decade, three formal sub-specialties of obstetrics and gynecology have evolved: gynecologic oncology, maternal-fetal medicine and reproductive endocrinology. These have improved patient care and have altered the structure of resident education. With more American medical school graduates entering this specialty, the quality of resident applicants has improved, creating intense competition for desirable training positions. Those inclined toward a career in obstetrics and gynecology can be assured that it will provide an increasingly favorable and challenging environment for professional activity in the future. PMID:7210670

  8. Improving emergency department flow through Rapid Medical Evaluation unit

    PubMed Central

    Chartier, Lucas; Josephson, Timothy; Bates, Kathy; Kuipers, Meredith

    2015-01-01

    The Toronto Western Hospital is an academic hospital in Toronto, Canada, with an annual Emergency Department (ED) volume of 64,000 patients. Despite increases in patient volumes of almost six percent per annum over the last decade, there have been no commensurate increases in resources, infrastructure, and staffing. This has led to substantial increase in patient wait times, most specifically for those patients with lower acuity presentations. Despite requiring only minimal care, these patients contribute disproportionately to ED congestion, which can adversely impact resource utilization and quality of care for all patients. We undertook a retrospective evaluation of a quality improvement initiative aimed at improving wait times experienced by patients with lower acuity presentations. A rapid improvement event was organized by frontline workers to rapidly overhaul processes of care, leading to the creation of the Rapid Medical Evaluation (RME) unit – a new pathway of care for patients with lower acuity presentations. The RME unit was designed by re-purposing existing resources and re-assigning one physician and one nurse towards the specific care of these patients. We evaluated the performance of the RME unit through measurement of physician initial assessment (PIA) times and total length of stay (LOS) times for multiple groups of patients assigned to various ED care pathways, during three periods lasting three months each. Weekly measurements of mean and 90th percentile of PIA and LOS times showed special cause variation in all targeted patient groups. Of note, the patients seen in the RME unit saw their median PIA and LOS times decrease from 98min to 70min and from 165min to 130min, respectively, from baseline. Despite ever-growing numbers of patient visits, wait times for all patients with lower acuity presentations remained low, and wait times of patients with higher acuity presentations assigned to other ED care pathways were not adversely affected. By

  9. Improving emergency department flow through Rapid Medical Evaluation unit.

    PubMed

    Chartier, Lucas; Josephson, Timothy; Bates, Kathy; Kuipers, Meredith

    2015-01-01

    The Toronto Western Hospital is an academic hospital in Toronto, Canada, with an annual Emergency Department (ED) volume of 64,000 patients. Despite increases in patient volumes of almost six percent per annum over the last decade, there have been no commensurate increases in resources, infrastructure, and staffing. This has led to substantial increase in patient wait times, most specifically for those patients with lower acuity presentations. Despite requiring only minimal care, these patients contribute disproportionately to ED congestion, which can adversely impact resource utilization and quality of care for all patients. We undertook a retrospective evaluation of a quality improvement initiative aimed at improving wait times experienced by patients with lower acuity presentations. A rapid improvement event was organized by frontline workers to rapidly overhaul processes of care, leading to the creation of the Rapid Medical Evaluation (RME) unit - a new pathway of care for patients with lower acuity presentations. The RME unit was designed by re-purposing existing resources and re-assigning one physician and one nurse towards the specific care of these patients. We evaluated the performance of the RME unit through measurement of physician initial assessment (PIA) times and total length of stay (LOS) times for multiple groups of patients assigned to various ED care pathways, during three periods lasting three months each. Weekly measurements of mean and 90th percentile of PIA and LOS times showed special cause variation in all targeted patient groups. Of note, the patients seen in the RME unit saw their median PIA and LOS times decrease from 98min to 70min and from 165min to 130min, respectively, from baseline. Despite ever-growing numbers of patient visits, wait times for all patients with lower acuity presentations remained low, and wait times of patients with higher acuity presentations assigned to other ED care pathways were not adversely affected. By

  10. Obstetrics Hospitalists: Risk Management Implications.

    PubMed

    Veltman, Larry

    2015-09-01

    The concept of having an in-house obstetrician (serving as an obstetrics [OB] hospitalist) available 24 hours a day, 7 days a week provides a safety net for OB events that many need immediate intervention for a successful outcome. A key precept of risk management, that of loss prevention, fits perfectly with the addition of an OB hospitalist role in the perinatal department. Inherent in the role of OB hospitalists are the patient safety and risk management principles of improved communication, enhanced readiness, and immediate availability. Copyright © 2015 Elsevier Inc. All rights reserved.

  11. [Obstetrical APS: Is there a place for additional treatment to aspirin-heparin combination?

    PubMed

    Mekinian, A; Kayem, G; Cohen, J; Carbillon, L; Abisror, N; Josselin-Mahr, L; Bornes, M; Fain, O

    2017-01-01

    Obstetrical APS is defined by thrombosis and/or obstetrical morbidity associated with persistent antiphospholipid antibodies. The aspirin and low molecular weighted heparin combination dramatically improved obstetrical outcome in APS patients. Several factors could be associated with obstetrical prognosis, as previous history of thrombosis, associated SLE, the presence of lupus anticoagulant and triple positivity of antiphospholipid antibodies. Obstetrical APS with isolated recurrent miscarriages is mostly associated with isolated anticardiolipids antibodies and have better obstetrical outcome. The pregnancy loss despite aspirin and heparin combination define the refractory obstetrical APS, and the prevalence could be estimated to 20-39%. Several other treatments have been used in small and open labeled studies, as steroids, intravenous immunoglobulins, plasma exchanges and hydroxychloroquine to improve the obstetrical outcome. Some other drugs as eculizumab and statins could also have physiopathological rational, but studies are necessary to define the place of these various drugs.

  12. Improving Pediatric Asthma Outcomes in a Community Emergency Department.

    PubMed

    Walls, Theresa A; Hughes, Naomi T; Mullan, Paul C; Chamberlain, James M; Brown, Kathleen

    2017-01-01

    Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care. For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care. In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99). Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care. Copyright © 2017 by the American Academy of Pediatrics.

  13. Physician in triage improves emergency department patient throughput.

    PubMed

    Imperato, Jason; Morris, Darren Scott; Binder, David; Fischer, Christopher; Patrick, John; Sanchez, Leon Dahomey; Setnik, Gary

    2012-10-01

    To determine if a physician in triage (PIT) improves Emergency Department (ED) patient flow in a community teaching hospital. This is an interventional study comparing patient flow parameters for the 3-month periods before and after implementation of a PIT model. During the interventional time an additional attending physician was assigned to triage from 1 p.m. to 9 p.m. daily. Outcome measures were median time to attending physician evaluation, median length of stay (LOS), number of patients who left without being seen (LWBS), and total time and number of days on ambulance diversion. Non-normally distributed values were compared with the Wilcoxon rank sum test. Proportions were compared with Chi-square test. Outcome measures were available for 17,631 patients, of whom 8,620 were seen before the initiation of PIT, and 9,011 were seen after PIT was implemented. For all patients, the median time from registration to attending physician evaluation was reduced by 36 min (1:41 to 1:05, p < 0.01) while the median LOS for all patients was reduced by 12 min (3:51 to 3:39, p < 0.01) after the intervention. Both the number of days on diversion (24 vs. 9 days) and total time on diversion (68 h 25 min vs. 26 h 7 min) were decreased, p < 0.01. Finally, there was a slight reduction in the number of patients who LWBS from 1.5 to 1.3 %, but this was not statistically significant (p = 0.36). Patient flow parameters in a community teaching hospital were modestly improved as a result of PIT implementation.

  14. The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels.

    PubMed

    Schneider, Patrick D; Sabol, Bethany A; Lee King, Patricia Ann; Caughey, Aaron B; Borders, Ann E B

    2017-09-01

    Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. Measuring and improving cardiopulmonary resuscitation quality inside the emergency department.

    PubMed

    Crowe, Christopher; Bobrow, Bentley J; Vadeboncoeur, Tyler F; Dameff, Christian; Stolz, Uwe; Silver, Annemarie; Roosa, Jason; Page, Rianne; LoVecchio, Frank; Spaite, Daniel W

    2015-08-01

    To evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality. CPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing. A total of 52 cardiac arrest patients were treated in P1 (median age 56 yrs, 63.5% male) and 49 in P2 (age 60 yrs, 83.7% male). Chest compression (CC) depth increased from 46.7 ± 3.8mm in P1 to 61.6 ± 2.8mm in P2 (p < 0.001), with the percentage of CC ≥ 51 mm increasing from 30.6% in P1 to 87.4% in P2 (p < 0.001). CC release velocity increased from 314 ± 25 mm/s in P1 to 442 ± 20 mm/s in P2 (p < 0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p = 0.1), CC rate (125 ± 3 cpm P1 vs. 125 ± 3 cpm P2, p = 0.7), or pre-shock pause (9.7s P1 vs. 5.9s P2, p = 0.5), though CC fraction and pre-shock pause were within guideline recommendations. Implementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  16. Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women: an analysis of the death of Savita Halappanavar in Ireland and similar cases.

    PubMed

    Berer, Marge

    2013-05-01

    Issues arising from the death of Savita Halappanavar in Ireland in October 2012 include the question of whether it is unethical to refuse to terminate a non-viable pregnancy when the woman's life may be at risk. In Catholic maternity services, this decision intersects with health professionals' interpretation of Catholic health policy on treatment of miscarriage as well as the law on abortion. This paper explores how these issues came together around Savita's death and the consequences for pregnant women and maternity services worldwide. It discusses cases not only in Ireland but also the Americas. Many of the events presented are recent, and most of the sources are media and individual reports. However, there is a very worrying common thread across countries and continents. If further research unearths more cases like Savita's, any Catholic health professionals and/or hospitals refusing to terminate a pregnancy as emergency obstetric care should be stripped of their right to provide maternity services. In some countries these are the main or only existing maternity services. Even so, governments should refuse to fund these services, and either replace them with non-religious services or require that non-religious staff are available at all times specifically to take charge of such cases to prevent unnecessary deaths. At issue is whether a woman's life comes first or not at all. Copyright © 2013 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.

  17. Quality improvement primer part 2: executing a quality improvement project in the emergency department.

    PubMed

    Chartier, Lucas B; Stang, Antonia S; Vaillancourt, Samuel; Cheng, Amy H Y

    2017-09-22

    The topics of quality improvement (QI) and patient safety have become important themes in health care in recent years, particularly in the emergency department setting, which is a frequent point of contact with the health care system for patients. In the first of three articles in this series meant as a QI primer for emergency medicine clinicians, we introduced the strategic planning required to develop an effective QI project using a fictional case study as an example. In this second article we continue with our example of improving time to antibiotics for patients with sepsis, and introduce the Model for Improvement. We will review what makes a good aim statement, the various categories of measures that can be tracked during a QI project, and the relative merits and challenges of potential change concepts and ideas. We will also present the Model for Improvement's rapid-cycle change methodology, the Plan-Do-Study-Act (PDSA) cycle. The final article in this series will focus on the evaluation and sustainability of QI projects.

  18. Prevention in Obstetrics.

    ERIC Educational Resources Information Center

    Children in the Tropics, 1984

    1984-01-01

    The aim of this issue of "Children in the Tropics" is to describe work that may be done by a motivated health team having only the strict minimum of material resources. While not a handbook of obstetrics, this text serves as a reminder of basic information and procedures workers must be able to perform. Following a review of the…

  19. Prevention in Obstetrics.

    ERIC Educational Resources Information Center

    Children in the Tropics, 1984

    1984-01-01

    The aim of this issue of "Children in the Tropics" is to describe work that may be done by a motivated health team having only the strict minimum of material resources. While not a handbook of obstetrics, this text serves as a reminder of basic information and procedures workers must be able to perform. Following a review of the…

  20. Chemical and Biological Terrorism: Improvements to Emergency Medical Response.

    ERIC Educational Resources Information Center

    DeGraffenreid, Jeff Gordon

    The challenge facing many emergency medical services (EMS) is the implementation of a comprehensive educational strategy to address emergency responses to terrorism. One such service, Johnson County (Kansas) Medical Action, needed a strategy that would keep paramedics safe and offer the community an effective approach to mitigation. A…

  1. Obstetric acute renal failure 1956-1987.

    PubMed

    Turney, J H; Ellis, C M; Parsons, F M

    1989-06-01

    A total of 142 women with severe acute renal failure (ARF) resulting from obstetric causes was treated by dialysis at a single centre from 1956 to 1987. One-year survival was 78.6%, which compares favourably with other causes of ARF. Abortion, haemorrhage and preclampsia comprised 95% of cases, with survival being best (82.9%) with abortion. Survival was adversely affected by increasing age. Acute cortical necrosis (12.7% of patients) carried 100% mortality after 6 years. Follow-up of survivors showed normal renal function up to 31 years following ARF; 25-year patient survival was 71.6%. Improvements in obstetric care and the disappearance of illegal abortions have resulted in a dramatic decline in the incidence of obstetric ARF.

  2. Who will be there when women deliver? Assuring retention of obstetric providers.

    PubMed

    Anderson, Frank W J; Mutchnick, Ian; Kwawukume, E Y; Danso, K A; Klufio, C A; Clinton, Y; Yun, Luke Lu; Johnson, Timothy R B

    2007-11-01

    The Safe Motherhood Initiative has highlighted the need for improved health services with skilled attendants at delivery and the provision of emergency obstetric care. "Brain drain" has hampered this process and has been particularly prevalent in Ghana. Between 1993 and 2000, 68% of Ghanaian trained medical school graduates left the country. In 1989, postgraduate training in obstetrics and gynecology was established in Ghana, and as of November 2006, 37 of the 38 specialists who have completed the program have stayed in the country, most working in the public sector providing health care and serving as faculty. Interviews with graduates in 2002 found that the first and single-most important factor related to retention was the actual presence of a training program leading to specialty qualification in obstetrics and gynecology by the West African College of Surgeons. Economic and social factors also played major roles in a graduates' decision to stay in Ghana to practice. This model deserves replication in other countries that have a commitment to sustainable development, human resource and health services capacity building, and maternal mortality reduction. A network of University partnerships between departments of obstetrics and gynecology in developed and developing countries throughout the world sharing internet resources, clinical information, training curriculum and assessment techniques could be created. Grand rounds could be shared through teleconferencing, and faculty exchanges would build capacity for all faculty and enrich both institutions. Through new partnerships, creating opportunity for medical school graduates to become obstetrician-gynecologists may reduce brain drain and maternal mortality.

  3. Crystal structure engineering for improved performance of emerging nanoscale devices

    NASA Astrophysics Data System (ADS)

    Chimalgi, Vinay Uday

    Recent advances in growth techniques and increasing number of experimental studies have made nanostructures grown along different crystallographic directions a reality. These new structures could not only benefit the electronic devices used in mainstream information technology but also show great promise for applications in lasers, solid-state lighting, near-field photolithography, free-space quantum cryptography, consumer displays, quantum computation, as well as diagnostic medicine and imaging. However, only few theoretical investigations have been performed on these structures due to the complex nature of the interplay of atomicity, structural fields, polarization, and quantum size-quantization, all strong function of the crystallographic direction. The objective of this work is mainly four-fold: (1) Integrate a computational framework employing a combination of fully atomistic valence force-field molecular mechanics and 20-band sp3s*d5-SO tight-binding based electronic band­structure models, and numerically investigate the effects of internal fields on the electronic and optical properties of zincblende InAs/GaAs quantum dots grown on (100), (110), and (111) orientated substrates. (2) Augment/extend the open source NEMO 3-D bandstructure simulator by incorporating a recently proposed first principles based model to gauge the importance of nonlinear piezoelectricity on the single-particle electronic states and interband optical transitions in emerging In(Ga)N/GaN disk-in-wire LED structures having c-plane and m-plane wurtzite crystal symmetry. (3) Coupling the NEMO 3-D software toolkit with a commercial TCAD simulator to determine the terminal electrical and optical characteristics of InGaN/GaN disk-in-wire LEDs; and (4) Finding an optimum crystallographic device for InGaN/GaN disk-in-wire LEDs to achieve improved internal quantum efficiency (IQE).

  4. CHALLENGES OF OBSTETRIC ANESTHESIA: DIFFICULT LARYNGEAL VISUALIZATION.

    PubMed

    Alanoğlu, Zekeriyya; Erkoç, Süheyla Karadağ; Güçlü, Çiğdem Yildirim; Meço, Başak Ceyda Orbey; Baytaş, Volkan; Can, Özlem Selvi; Alkiş, Neslihan

    2016-03-01

    Obstetric anesthesia is one of the high risk subspecialties of anesthesia practice. Anesthesia related complications are the sixth leading cause of maternal mortality. Difficult or failed intubation following induction of general anesthesia for CS remains the major contributory factor to anesthesia-related maternal complications. The airway management of obstetric patients is a challenging issue for several reasons. Anatomic and physiologic changes related to pregnancy may increase the difficult and failed intubation rates compared to the general surgical population. Proper evaluation of the airway anatomy and airway structures is vital to prevent airway management related catastrophes. In addition to basic airway and intubation equipment, each anesthesia department must have difficult intubation equipment cart including fiber optic laryngoscope, video laryngoscopes, and different types of laryngeal masks. It is essential that all anesthesiologists have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.

  5. Total obstetric brachial plexus palsy in children with internal rotation contracture of the shoulder, flexion contracture of the elbow, and poor hand function: improving the cosmetic appearance of the limb with rotation osteotomy of the humerus.

    PubMed

    Al-Qattan, Mohammad M

    2010-07-01

    Rotation osteotomy of the humerus has been described by several authors to treat the internal rotation contracture of the shoulder in Erb palsy. The main aim of the osteotomy in Erb patients is to bring the functioning hand to the face which greatly improves function. The author has performed the rotation humeral osteotomy in children with total obstetric brachial plexus palsy aiming for the improvement of the cosmetic appearance of the limb rather than improvement function. This article specifically reports on this group of patients.Over the last 15 years, the author has performed rotation humeral osteotomy in 13 children (mean age 6 years; range, 4.5-9 years) with total obstetric brachial plexus palsy aiming for improvement of the cosmetic appearance of the limb rather than improvement of function. All children had a triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow, and poor hand function.After a mean follow-up of 2 years following the humeral osteotomy, all patients/parents were satisfied with the result and a panel of plastic surgeons confirmed the significant improvement in aesthetics. Reasons for this improvement following the osteotomy were as follows: the child no longer needed to stand with shoulder slightly abducted, the antecubital fossa became visible in the standing position, and the forearm no longer appeared excessively pronated. Of more importance, was the improvement in elbow flexion contracture which had major contribution in improving limb appearance and the perception of length discrepancy between the affected and the contralateral normal limb.The humeral osteotomy improves the cosmetic appearance of children with total palsy and the triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow and poor hand function.

  6. Anaphylaxis management in the pediatric emergency department: opportunities for improvement.

    PubMed

    Russell, Scott; Monroe, Kathy; Losek, Joseph D

    2010-02-01

    To determine the rate, immediate treatment, and outpatient management for anaphylaxis in patients receiving care in a pediatric emergency department (ED). This is a retrospective cross-sectional descriptive study of patients (21 years or younger) who received care for anaphylaxis for a 5-year period in the ED of the Children's Hospital of Alabama in Birmingham, AL, which has an annual census of 55,000. The diagnostic criteria for anaphylaxis were symptoms and/or signs involving 2 or more organ systems (dermatologic, respiratory, gastrointestinal, and cardiovascular), hypotension for age, 1 organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine. There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) patients who had involvement of two or more organ systems. There were 66 (64%) males and 33 (27%) patient visits that resulted in hospitalization. The most common organ system involvement was dermatologic in 121 (98%), followed by respiratory in 101 (81%), gastrointestinal in 33 (27%), and cardiovascular in 11 (9%). Medical interventions include 69 patients treated with intramuscular epinephrine (56%; either in pre-hospital setting and/or during ED visit), 97 patients treated with corticosteroids (79%), 114 patients treated with H1 and/or H2 antihistamine (93%), 15 patients treated with intravenous fluid bolus (12%), and 37 patients treated with albuterol nebulization (30%). Food was the most common inciting allergen (in 45 or 36% of patients). Among the foods that were listed as causing reactions were peanuts, shellfish, milk, ice cream, fruit, nuts, and fried chicken. Compared with ED care-only patients, the hospitalized patients had a significantly greater rate of cardiovascular system involvement and of receiving more ED interventions. Of 91 ED care-only patients, autoinjection

  7. [Maternal death of obstetrical origin. Medicolegal aspects].

    PubMed

    Chevrant-Breton, O; Lebervet, J Y; Vialard, J

    1985-01-01

    The authors have become interested in maternal mortality. This study has been carried out solely to look at the medico-legal aspect. Increasingly good health is seen as a right and the doctor the dispenser of this service. The rights of the mother (and of the infant) become of increasing importance. The improvement in obstetrical techniques, which are much better known to the public, have made families far more confident of the results of delivery. This is now seen as something without any danger. But delivering a baby still has lots of risks. Because of this, if an accident happens the obstetrician more than any other doctor perhaps can find himself in the courts. To avoid this he has to know very well the causes of maternal mortality in order to avoid them as far as possible. Furthermore, he must not undertake stupid emergency measures often initiated as measures of desperation caused by his emotional involvement for a patient who is approaching death. Finally, the expert should look for all the causes of death so that he does no wrongly blame the doctor for a maternal death.

  8. Obstetric antiphospholipid syndrome.

    PubMed

    Galarza-Maldonado, Claudio; Kourilovitch, Maria R; Pérez-Fernández, Oscar M; Gaybor, Mariana; Cordero, Christian; Cabrera, Sonia; Soroka, Nikolai F

    2012-02-01

    Antiphospholipid syndrome (APS) in pregnancy has a serious impact on maternal and fetal morbidity. It causes recurrent pregnancy miscarriage and it is associated with other adverse obstetric findings like preterm delivery, intrauterine growth restriction, preeclampsia, HELLP syndrome and others. The 2006 revised criteria, which is still valid, is used for APS classification. Epidemiology of obstetric APS varies from one population group to another largely due to different inclusion criteria and lack of standardization of antibody detection methods. Treatment is still controversial. This topic should include a multidisciplinary team and should be individualized. Success here is based on strict control and monitoring throughout pregnancy and even in the preconception and postpartum periods. Further research in this field and unification of criteria are required to yield better therapeutic strategies in the future.

  9. New opportunity to improve pediatric emergency preparedness: pediatric emergency assessment, recognition, and stabilization course.

    PubMed

    Ralston, Mark E; Zaritsky, Arno L

    2009-02-01

    The ideal first response to a life-threatening pediatric emergency includes early recognition of the emergency, activation of the appropriate emergency response system, performance of basic life support (cardiopulmonary resuscitation/automated external defibrillator treatment), and initiation of advanced life support, but the extent of resuscitation training among health care providers likely to be first at the side of a critically ill or injured child is often deficient. In the past, resuscitation courses beyond basic life support focused on training advanced providers. The Pediatric Emergency Assessment, Recognition, and Stabilization course was developed by the American Heart Association to target a broad range of health care providers who are likely to be first at the side of a child requiring resuscitation. It is hoped that training of health care providers through the Pediatric Emergency Assessment, Recognition, and Stabilization course will translate into early recognition of life-threatening pediatric emergencies and greater resuscitation success, but results will depend on the availability of instruction and the maintenance of skills.

  10. Regionalization of services improves access to emergency vascular surgical care.

    PubMed

    Roche-Nagle, G; Bachynski, K; Nathens, A B; Angoulvant, D; Rubin, B B

    2013-04-01

    Management of vascular surgical emergencies requires rapid access to a vascular surgeon and hospital with the infrastructure necessary to manage vascular emergencies. The purpose of this study was to assess the impact of regionalization of vascular surgery services in Toronto to University Health Network (UHN) and St Michael's Hospital (SMH) on the ability of CritiCall Ontario to transfer patients with life- and limb-threatening vascular emergencies for definitive care. A retrospective review of the CritiCall Ontario database was used to assess the outcome of all calls to CritiCall regarding patients with vascular disease from April 2003 to March 2010. The number of patients with vascular emergencies referred via CritiCall and accepted in transfer by the vascular centers at UHN or SMH increased 500% between 1 April 2003-31 December 2005 and 1 January 2006-31 March 2010. Together, the vascular centers at UHN and SMH accepted 94.8% of the 1002 vascular surgery patients referred via CritiCall from other hospitals between 1 January 2006 and 31 March 2010, and 72% of these patients originated in hospitals outside of the Toronto Central Local Health Integration Network. Across Ontario, the number of physicians contacted before a patient was accepted in transfer fell from 2.9 ± 0.4 before to 1.7 ± 0.3 after the vascular centers opened. In conclusion, the vascular surgery centers at UHN and SMH have become provincial resources that enable the efficient transfer of patients with vascular surgical emergencies from across Ontario. Regionalization of services is a viable model to increase access to emergent care.

  11. Potential Impact of Obstetrics and Gynecology Hospitalists on Safety of Obstetric Care.

    PubMed

    Srinivas, Sindhu K

    2015-09-01

    Staffing models are critical aspects of care delivery. Provider staffing on the labor and delivery unit has recently received heightened attention. Based on the general medicine hospitalist model, the obstetrics and gynecology hospitalist or laborist model of obstetric care was introduced more than a decade ago as a plausible model-of-care delivery to improve provider satisfaction, with the goal of also improving safety and outcomes through continuous coverage by providers whose sole focus was on the labor and delivery unit without other competing clinical duties. It is plausible that this model of provider staffing and care delivery will increase safety.

  12. Late preterm: obstetric management.

    PubMed

    Meloni, Alessandra; Antonelli, Antonello; Deiana, Sara; Rocca, Alessio; Atzei, Alessandra; Paoletti, Anna Maria; Melis, Gian Benedetto

    2010-10-01

    Late preterm is the recommended definition for infants born at 34 0/7 to 36 6/7 weeks' gestation after the onset of the mother's last menstrual period. Late-preterm infants are known to have greater mortality and morbidity when compared with term infants during the neonatal period. Obstetric management plays a substantial role in influencing neonatal outcomes. We conducted a retrospective study on late-preterm births based on data collected by regional certificates of birth attendance, comparing overall data with those relative to our Department, the aim of our study was to evaluate if obstetric management, related to different delivery settings, could influence the prevalence and the method of delivery in late preterm gestational age. Preterm births represent about 10% of 25,011 births in Sardinia, and 72.6% of them are late preterm. Elective cesarean section results significantly higher in late preterm than in term deliveries. In our Department, both late-preterm delivery rate and elective cesarean sections rate were lower if compared with country region data. Obstetric management strategies play an important role in delaying deliveries and reducing late-preterm birth rates.

  13. Blood transfusion in obstetrics.

    PubMed

    Nigam, A; Prakash, A; Saxena, P

    2013-01-01

    Transfusion of blood and blood components is a common practice in obstetric wards but it is not without risk. The incidence of transfusion reactions varies from 4 in every hundred transfusions for non-haemolytic reactions to one in every 40,000 for haemolytic transfusion reactions. The physiological basis of blood transfusion is outlined in this article. Most of the donated blood is processed into components: packed red cells (PRBCs), platelets, and fresh frozen plasma (FFP) or cryoprecipitate. Various alternatives to blood transfusion exist and include autotransfusion, pre-autologous blood storage, use of oxygen carrying blood substitutes and intraoperative cell salvage. Despite the risks associated with transfusions, obstetricians are frequently too aggressive in transfusing blood and blood products to their patients. Acute blood loss in obstetrics is usually due to placenta praevia, postpartum blood loss and surgery related. An early involvement of a consultant obstetrician, anaesthetist, haematologist and the blood bank is essential. There are no established criteria for initiating red cell transfusions and the decision is purely based on clinical and haematological parameters, which have been discussed along with the general principles of blood transfusion in obstetrics and some practical guidelines.

  14. A spatial analysis to study access to emergency obstetric transport services under the public private “Janani Express Yojana” program in two districts of Madhya Pradesh, India

    PubMed Central

    2014-01-01

    Background The government in Madhya Pradesh (MP), India in 2006, launched “Janani Express Yojana” (JE), a decentralized, 24X7, free emergency transport service for all pregnant women under a public-private partnership. JE supports India’s large conditional cash transfer program, the “Janani Suraksha Yojana” (JSY) in the province and transports on average 60,000 parturients to hospital every month. The model is a relatively low cost one that potentially could be adopted in other parts of India and South Asia. This paper describes the uptake, time taken and geographic equity in access to the service to transport women to a facility in two districts of MP. Methods This was a facility based cross sectional study. We interviewed parturients (n = 468) who delivered during a five day study period at facilities with >10 deliveries/month (n = 61) in two study districts. The women were asked details of transportation used to arrive at the facility, time taken and their residential addresses. These details were plotted onto a Geographic Information System (GIS) to estimate travelled distances and identify statistically significant clusters of mothers (hot spots) reporting delays >2 hours. Results JE vehicles were well dispersed across the districts and used by 236 (50.03%) mothers of which 111(47.03%) took >2 hours to reach a facility. Inability of JE vehicle to reach a mother in time was the main reason for delays. There was no correlation between the duration of delay and distance travelled. Maps of the travel paths and travel duration of the women are presented. The study identified hot spots of mothers with delays >2 hours and explored the possible reasons for longer delays. Conclusions The JE service was accessible in all parts of the districts. Relatively high utilization rates of JE indicate that it ably supported JSY program to draw more women for institutional deliveries. However, half of the JE users experienced long (>2 hour) delays. The delayed mothers

  15. The Impact of Standardized Acuity Assessment and a Fast-Track on Length of Stay in Obstetric Triage: A Quality Improvement Study.

    PubMed

    Smithson, David S; Twohey, Rachel; Watts, Nancy; Gratton, Robert J

    To prospectively assess the impact of a standardized 5-category Obstetrical Triage Acuity Scale (OTAS) and a fast-track for lower-acuity patients on patient flow. Length of stay (LOS) data of women presenting to obstetric triage were abstracted from the electronic medical record prior to (July 1, 2011, to March 30, 2012) and following OTAS implementation (April 1 to December 31, 2012). Following computerized simulation modeling, a fast-track for lower acuity women was implemented (January 1, 2013, to February 28, 2014). Prior to OTAS implementation (8085 visits), the median LOS was 105 (interquartile range [IQR] = 52-178) minutes. Following OTAS implementation (8131 visits), the median LOS decreased to 101 (IQR = 49-175) minutes (P = .04). The LOS did not correlate well with acuity. Simulation modeling predicted that a fast-track for OTAS 4 and 5 patients would reduce the LOS. The LOS for lower-acuity patients in the fast-track decreased to 73 (IQR = 40-140) minutes (P = .005). In addition, the overall LOS (12 576 visits) decreased to 98 (IQR = 47-172) minutes (6.9% reduction; P < .001). Standardized assessment of acuity and a fast-track for lower acuity pregnant women decreased the overall LOS and the LOS of lower-acuity patients.

  16. Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project

    PubMed Central

    Ellard, David R; Shemdoe, Aloisia; Mazuguni, Festo; Mbaruku, Godfrey; Davies, David; Kihaile, Paul; Pemba, Senga; Bergström, Staffan; Nyamtema, Angelo; Mohamed, Hamed-Mahfoudh; O'Hare, Joseph Paul

    2016-01-01

    Objectives During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. Design The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. Results 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282–232 cases/100 000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. Conclusions This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it

  17. Best practices for improving flow and care of pediatric patients in the emergency department.

    PubMed

    Barata, Isabel; Brown, Kathleen M; Fitzmaurice, Laura; Griffin, Elizabeth Stone; Snow, Sally K

    2015-01-01

    This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department. Copyright © 2015 by the American Academy of Pediatrics.

  18. The critical role of supervision in retaining staff in obstetric services: a three country study.

    PubMed

    McAuliffe, Eilish; Daly, Michael; Kamwendo, Francis; Masanja, Honorati; Sidat, Mohsin; de Pinho, Helen

    2013-01-01

    Millennium Development Goal (MDG) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015. In order to reach these goals, greater access to basic emergency obstetric care (EmOC) as well as comprehensive EmOC which includes safe Caesarean section, is needed.. The limited capacity of health systems to meet demand for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers. Although this does provide greater capacity for service delivery, concern about the performance and motivation of these workers is emerging. We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally. To investigate this, we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers (health workers trained for shorter periods to perform specific tasks e.g. clinical officers) delivering obstetric care in Malawi, Tanzania, and Mozambique. Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace. In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave. We find no evidence that facility level factors modify the link between supervisory methods and key outcomes. We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision. This will promote better job satisfaction and improve the retention and performance of obstetric care workers, something which has the potential to improve

  19. The Critical Role of Supervision in Retaining Staff in Obstetric Services: A Three Country Study

    PubMed Central

    McAuliffe, Eilish; Daly, Michael; Kamwendo, Francis; Masanja, Honorati; Sidat, Mohsin; de Pinho, Helen

    2013-01-01

    Millennium Development Goal (MDG) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015. In order to reach these goals, greater access to basic emergency obstetric care (EmOC) as well as comprehensive EmOC which includes safe Caesarean section, is needed.. The limited capacity of health systems to meet demand for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers. Although this does provide greater capacity for service delivery, concern about the performance and motivation of these workers is emerging. We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally. To investigate this, we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers (health workers trained for shorter periods to perform specific tasks e.g. clinical officers) delivering obstetric care in Malawi, Tanzania, and Mozambique. Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace. In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave. We find no evidence that facility level factors modify the link between supervisory methods and key outcomes. We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision. This will promote better job satisfaction and improve the retention and performance of obstetric care workers, something which has the potential to improve

  20. Emergency Cerclage: Improvement of Outcomes by Standardization of Management.

    PubMed

    Rius, Mariona; Cobo, Teresa; García-Posadas, Raúl; Hernández, Sandra; Teixidó, Irene; Barrau, Enrique; Abad, Carmen; Palacio, Montse

    2016-01-01

    Cervical dilatation followed by prolapse and ballooning of membranes into the vagina at mid-gestation is a critical situation. The aim of this study was to describe the outcome of emergency cerclage in a tertiary referral center during a 10-year period (2001-2010) in which a defined selection of women and standard protocol were introduced. Thirty-nine cases of emergency cervical cerclage performed before 24 completed weeks were retrospectively reviewed. Data related to maternal history, diagnosis, procedure details, postoperative management and perinatal outcome were recorded. Maternal characteristics and perinatal outcomes are described. Gestational age at cerclage (mean ± SD) was 22.1 ± 2.0 weeks with 61% (24/39) of women presenting bulging membranes. Gestational age at delivery and cerclage-to-delivery time (mean ± SD) were 28.6 ± 6.2 weeks and 49.1 ± 36.5 days, respectively. Only 38.5% (15/39) of the whole group and 44.1% (15/34) of those who reached 24.0 weeks delivered beyond 28 weeks of gestational age. Neonatal survival before discharge was 82.4% (28/34). Perinatal outcomes after emergency cerclage are still poor with more than half of the cases delivering before 28 weeks. A standard protocol may help in the management of these rare cases. © 2015 S. Karger AG, Basel.

  1. High-fidelity hybrid simulation of allergic emergencies demonstrates improved preparedness for office emergencies in pediatric allergy clinics.

    PubMed

    Kennedy, Joshua L; Jones, Stacie M; Porter, Nicholas; White, Marjorie L; Gephardt, Grace; Hill, Travis; Cantrell, Mary; Nick, Todd G; Melguizo, Maria; Smith, Chris; Boateng, Beatrice A; Perry, Tamara T; Scurlock, Amy M; Thompson, Tonya M

    2013-01-01

    Simulation models that used high-fidelity mannequins have shown promise in medical education, particularly for cases in which the event is uncommon. Allergy physicians encounter emergencies in their offices, and these can be the source of much trepidation. To determine if case-based simulations with high-fidelity mannequins are effective in teaching and retention of emergency management team skills. Allergy clinics were invited to Arkansas Children's Hospital Pediatric Understanding and Learning through Simulation Education center for a 1-day workshop to evaluate skills concerning the management of allergic emergencies. A Clinical Emergency Preparedness Team Performance Evaluation was developed to evaluate the competence of teams in several areas: leadership and/or role clarity, closed-loop communication, team support, situational awareness, and scenario-specific skills. Four cases, which focus on common allergic emergencies, were simulated by using high-fidelity mannequins and standardized patients. Teams were evaluated by multiple reviewers by using video recording and standardized scoring. Ten to 12 months after initial training, an unannounced in situ case was performed to determine retention of the skills training. Clinics showed significant improvements for role clarity, teamwork, situational awareness, and scenario-specific skills during the 1-day workshop (all P < .003). Follow-up in situ scenarios 10-12 months later demonstrated retention of skills training at both clinics (all P ≤ .004). Clinical Emergency Preparedness Team Performance Evaluation scores demonstrated improved team management skills with simulation training in office emergencies. Significant recall of team emergency management skills was demonstrated months after the initial training. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  2. Lean Manufacturing Improves Emergency Department Throughput and Patient Satisfaction.

    PubMed

    Kane, Marlena; Chui, Kristen; Rimicci, Janet; Callagy, Patrice; Hereford, James; Shen, Sam; Norris, Robert; Pickham, David

    2015-09-01

    A multidisciplinary team led by nursing leadership and physicians developed a plan to meet increasing demand and improve the patient experience in the ED without expanding the department's current resources. The approach included Lean tools and engaged frontline staff and physicians. Applying Lean management principles resulted in quicker service, improved patient satisfaction, increased capacity, and reduced resource utilization. Incorporating continuous daily management is necessary for sustainment of continuous improvement activities.

  3. Blood transfusion practices in obstetric anaesthesia.

    PubMed

    Jadon, Ashok; Bagai, Rajni

    2014-09-01

    Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Obstetric haemorrhage, especially postpartum haemorrhage, remains one of the major causes of massive haemorrhage and a prime cause of maternal mortality. Blood loss and assessment of its correct requirement are difficult in pregnancy due to physiological changes and comorbid conditions. Many guidelines have been used to assess the requirement and transfusion of blood and its components. Infrastructural, economic, social and religious constraints in blood banking and donation are key issues to formulate practice guidelines. Available current guidelines for transfusion are mostly from the developed world; however, they can be used by developing countries keeping available resources in perspective.

  4. Blood transfusion practices in obstetric anaesthesia

    PubMed Central

    Jadon, Ashok; Bagai, Rajni

    2014-01-01

    Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Obstetric haemorrhage, especially postpartum haemorrhage, remains one of the major causes of massive haemorrhage and a prime cause of maternal mortality. Blood loss and assessment of its correct requirement are difficult in pregnancy due to physiological changes and comorbid conditions. Many guidelines have been used to assess the requirement and transfusion of blood and its components. Infrastructural, economic, social and religious constraints in blood banking and donation are key issues to formulate practice guidelines. Available current guidelines for transfusion are mostly from the developed world; however, they can be used by developing countries keeping available resources in perspective. PMID:25535427

  5. The history of imaging in obstetrics.

    PubMed

    Benson, Carol B; Doubilet, Peter M

    2014-11-01

    During the past century, imaging of the pregnant patient has been performed with radiography, scintigraphy, computed tomography, magnetic resonance imaging, and ultrasonography (US). US imaging has emerged as the primary imaging modality, because it provides real-time images at relatively low cost without the use of ionizing radiation. This review begins with a discussion of the history and current status of imaging modalities other than US for the pregnant patient. The discussion then turns to an in-depth description of how US technology advanced to become such a valuable diagnostic tool in the obstetric patient. Finally, the broad range of diagnostic uses of US in these patients is presented, including its uses for distinguishing an intrauterine pregnancy from a failed or ectopic pregnancy in the first trimester; assigning gestational age and assessing fetal weight; evaluating the fetus for anomalies and aneuploidy; examining the uterus, cervix, placenta, and amniotic fluid; and guiding obstetric interventional procedures.

  6. Achieving higher-value obstetrical care.

    PubMed

    Woo, Victoria G; Lundeen, Tifanny; Matula, Sierra; Milstein, Arnold

    2017-03-01

    Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

  7. Obstetric triage: a systematic review of the past fifteen years: 1998-2013.

    PubMed

    Angelini, Diane; Howard, Elisabeth

    2014-01-01

    Triage concepts have shifted the focus of obstetric care to include obstetric triage units. The purpose of this systematic review is to examine the literature on use of triage concepts in obstetrics during a 15-year time frame. A systematic review was completed of the obstetric triage literature from 1998 to 2013 using the electronic online databases from PubMed, CINHAL, Ovid, and Cochrane Library Reviews within the English language. Reference lists of articles were reviewed to identify other pertinent publications. Both peer-reviewed and non-peer-reviewed documents were used. articles specifically related to obstetric triage or obstetric emergency practices in the hospital setting. Exclusion criteria included: manuscripts that focused on general, nonobstetric emergency and triage units, telephone triage, out-of-hospital practices, other clinical conditions, and references outside the time frame of 1998-2013. Key categories were identified: legal issues and impact of Emergency Medical Treatment and Active Labor Act (EMTALA); liability pitfalls; risk stratification (acuity tools); clinical decision aids; utilization, patient flow, and patient satisfaction; impact on interprofessional education and advanced nursing practice; and management of selected clinical conditions. Components of a best practice model for obstetric triage are introduced. Seven key triage categories from the literature were identified and best practices were developed for obstetric triage units from this systematic review. Both can be used to guide future practice and research within obstetric triage.

  8. Lived experiences of Ghanaian women with obstetric fistula.

    PubMed

    Mwini-Nyaledzigbor, Prudence P; Agana, Alice A; Pilkington, F Beryl

    2013-01-01

    Obstetric fistula is a worldwide problem that is devastating for women. This qualitative descriptive study explores the experiences of Ghanaian women who sustained obstetric fistula during childbirth. In-depth interviews were conducted with 10 participants. The resultant themes include cultural beliefs and practices surrounding prolonged labor in childbirth, barriers to delivering at a health care facility, and the challenges of living with obstetric fistula, including psychosocial, socioeconomic, physical, and health care access issues. Recommendations include strategies to address this complex problem, including education of men and women on safe motherhood practices, training of traditional birth attendants (TBAs), and improving access to health care.

  9. Ultrasound in obstetric anaesthesia: a review of current applications.

    PubMed

    Ecimovic, P; Loughrey, J P R

    2010-07-01

    Ultrasound equipment is increasingly used by non-radiologists to perform interventional techniques and for diagnostic evaluation. Equipment is becoming more portable and durable, with easier user-interface and software enhancement to improve image quality. While obstetric utilisation of ultrasound for fetal assessment has developed over more than 40years, the same technology has not found a widespread role in obstetric anaesthesia. Within the broader specialty of anaesthesia; vascular access, cardiac imaging and regional anaesthesia are the areas in which ultrasound is becoming increasingly established. In addition to ultrasound for neuraxial blocks, these other clinical applications may be of value in obstetric anaesthesia practice.

  10. [Obstetric brachial plexus injury].

    PubMed

    Pondaag, Willem; van Dijk, J Gert; Nelissen, Rob G H H; Malessy, Martijn J A

    2014-01-01

    Obstetric palsy is a birth injury that occurs when the brachial plexus is damaged by traction. In the majority of patients spontaneous recovery will occur; however, in case of incomplete spontaneous recovery early neurosurgical intervention may be indicated. We present 3 case reports in this article, as well as describing the strategy favoured in our clinic. We recommend referring patients who have incomplete spontaneous recovery at the age of 1 month. At that age a good prediction of prognosis can be made by combining neurological examination with needle electromyography (EMG) of the biceps muscle.

  11. A multifaceted quality improvement program improves endotracheal tube confirmation documentation in the emergency department.

    PubMed

    Phelan, Michael P; Hustey, Fredric M; Glauser, Jonathan M; Bena, James

    2015-01-01

    Confirmation of endotracheal tube (ETT) position is an essential part of emergency department (ED) airway care. The study team evaluated the effect of a multifaceted quality improvement initiative on improving confirmation documentation rates. Rates of documentation of appropriate methods of ETT position confirmation were better for patients undergoing ETT placement in the study site ED than for those arriving already intubated (103/127 [81.1%] vs 19/71 [26.8%]; relative risk [RR] = 3.03; 95% confidence interval [CI] = 2.04 to 4.49). Overall rates of documentation of appropriate methods of ETT position confirmation were higher after the intervention (557/758 [73.5%] vs 122/198 [61.6%]; RR = 1.19; 95% CI = 1.06 to 1.34), with a greater increase among the group presenting to the ED with an ETT already placed (116/259 [44.8%] vs 19/71 [26.8%]; RR = 1.67; 95% CI = 1.11 to 2.51) compared with those intubated in the study site ED (103/127 [81.1%] vs 441/499 [88.4%]; RR = 0.92; 95% CI = 0.8389 to 1.0039).

  12. Quality improvement primer part 1: Preparing for a quality improvement project in the emergency department.

    PubMed

    Chartier, Lucas B; Cheng, Amy H Y; Stang, Antonia S; Vaillancourt, Samuel

    2017-07-31

    Emergency medicine (EM) providers work in a fast-paced and often hectic environment that has a high risk for patient safety incidents and gaps in the quality of care. These challenges have resulted in opportunities for frontline EM providers to play a role in quality improvement (QI) projects. QI has developed into a mature field with methodologies that can dramatically improve the odds of having a successful project with a sustainable impact. However, this expertise is not yet commonly taught during professional training. In this first of three articles meant as a QI primer for EM clinicians, we will introduce QI methodology and strategic planning using a fictional case study as an example. We will review how to identify a QI problem, define components of an effective problem statement, and identify stakeholders and core change team members. We will also describe three techniques used to perform root cause analyses-Ishikawa diagrams, Pareto charts and process mapping-and how they relate to preparing for a QI project. The next two papers in this series will focus on the execution of the QI project itself using rapid-cycle testing and on the evaluation and sustainability of QI projects.

  13. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion.

    PubMed

    Beck, Michael J; Okerblom, Davin; Kumar, Anika; Bandyopadhyay, Subhankar; Scalzi, Lisabeth V

    2016-12-01

    To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children's hospital. The study was conducted at a tertiary care children's hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics' service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient's bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day's discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times. For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM. Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

  14. Obstetrical brachial plexus palsy.

    PubMed

    Romaña, M C; Rogier, A

    2013-01-01

    Obstetrical brachial plexus palsy is considered to be the result of a trauma during the delivery, even if there remains some controversy surrounding the causes. Although most babies recover spontaneously in the first 3 months of life, a small number remains with poor recovery which requires surgical brachial plexus exploration. Surgical indications depend on the type of lesion (producing total or partial palsy) and particularly the nonrecovery of biceps function by the age of 3 months. In a global palsy, microsurgery will be mandatory and the strategy for restoration will focus first on hand reinnervation and secondarily on providing elbow flexion and shoulder stability. Further procedures may be necessary during growth in order to avoid fixed contractured deformities or to give or increase strength of important muscle functions like elbow flexion or wrist extension. The author reviews the history of obstetrical brachial plexus injury, epidemiology, and the specifics of descriptive and functional anatomy in babies and children. Clinical manifestations at birth are directly correlated with the anatomical lesion. Finally, operative procedures are considered, including strategies of reconstruction with nerve grafting in infants and secondary surgery to increase functional capacity at later ages. However, normal function is usually not recovered, particularly in total brachial plexus palsy.

  15. Antiphospohlipid syndrome in obstetrics.

    PubMed

    Danza, Alvaro; Ruiz-Irastorza, Guillermo; Khamashta, Munther

    2012-02-01

    Antiphospholipid syndrome is characterised by a variety of clinical and immunological manifestations. The clinical hallmarks of this syndrome are thrombosis and poor obstetric outcomes, including miscarriages, fetal loss and severe pre-eclampsia. The main antiphospholipid antibodies include lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I. The combination of aspirin and heparin is considered the standard of care for women with antiphospholipid syndrome and embryo-fetal losses; however, aspirin in monotherapy may have a place in women with recurrent early miscarriage. A good benefit-risk ratio of low-molecular-weight heparin in pregnancy thrombosis treatment has been reported. Warfarin must be avoided if possible throughout the first trimester of pregnancy. Adequate pregnancy management of women with antiphospholipid syndrome should include co-ordinated medical-obstetrical care, a close follow-up protocol and a good neonatal unit. Close blood pressure control and early detection of proteinuria, together with Doppler studies of the utero-placental circulation should be included in the management protocol. Copyright © 2011 Elsevier Ltd. All rights reserved.

  16. Major obstetric hemorrhage.

    PubMed

    Mercier, Frederic J; Van de Velde, Marc

    2008-03-01

    Major obstetric hemorrhage remains the leading cause of maternal mortality and morbidity worldwide, and is associated with a high rate of substandard care. A well-defined and multidisciplinary approach that aims to act quickly and avoid omissions or conflicting strategies is key. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta, uterine atony, and genital-tract trauma in the postpartum period. Basic treatment of postpartum hemorrhage relies on manual removal of the placenta or manual exploration of the uterus plus bladder emptying and oxytocin administration. If this does not arrest bleeding, or if there is any suspicion of genital-tract trauma, examination of the vagina and cervix with appropriate valves and analgesia/anesthesia must follow quickly. Postpartum uterine atony resistant to oxytocin must be treated with prostaglandin within 15 to 30 minutes; uterine balloon tamponade can be also useful at this stage. Aggressive transfusion therapy and resuscitation are mandatory in major obstetric hemorrhage. Specific invasive treatment must be considered within no more than 30 to 60 minutes, if previous measures have failed -- and even earlier in some particular etiologies. The two main options are radiologic embolization and surgical artery ligations. Recombinant factor VIIa may also be considered, but should not delay the performance of a life-saving procedure such as embolization or surgery. Hysterectomy must be implemented when all other interventions have failed.

  17. Doing obstetrics and staying alive.

    PubMed

    Reynolds, J L

    1993-09-01

    Many family physicians have a love-hate relationship with childbirth care and struggle to balance their personal and family needs with the need to provide high-quality personal care during labour and birth. Many false assumptions undermine family practice obstetrics. Strategies are presented to simplify obstetric care for women and families while promoting reasoned self-care for physicians.

  18. [Obstetric care in Mali: effect of organization on in-hospital maternal mortality].

    PubMed

    Zongo, A; Traoré, M; Faye, A; Gueye, M; Fournier, P; Dumont, A

    2012-08-01

    Maternal mortality is still too high in sub-Saharan Africa, particularly in referral hospitals. Solutions exist but their implementation is a great issue in the poor-resources settings. The objective of this study is to assess the effect of the organization of obstetric care services on maternal mortality in referral hospitals in Mali. This is a multicentric observational survey in 22 referral hospitals. Clinical data on 42,929 women delivering in the 22 hospitals within the 2007 to 2008 study period were collected. Organization evaluation was based on explicit criteria defined by an expert committee. The effect of the organization on in-hospital mortality adjusted on individual and institutional characteristics was estimated using multi-level logistic regression models. The results show that an optimal organization of obstetric care services based on eight explicit criteria reduced in-hospital maternal mortality by 41% compared with women delivering in a referral hospital with sub-optimal organization defined as non-compliance with at least one of the eight criteria (ORa=0.59; 95% CI=0.34-0.92). Furthermore, local policies that improved financial access to emergency obstetric care had a significant impact on maternal outcome. Criteria for optimal organization include the management of labor and childbirth by qualified personnel, an organization of human resources that allows timely management of obstetric emergencies, routine use of partography for all patients and availability of guidelines for the management of complications. These conditions could be easily implemented in the context of Mali to reduce in-hospital maternal mortality. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

  19. Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project.

    PubMed

    Ellard, David R; Shemdoe, Aloisia; Mazuguni, Festo; Mbaruku, Godfrey; Davies, David; Kihaile, Paul; Pemba, Senga; Bergström, Staffan; Nyamtema, Angelo; Mohamed, Hamed-Mahfoudh; O'Hare, Joseph Paul

    2016-02-12

    During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it

  20. Improve the design of fire emergency relief systems

    SciTech Connect

    Stickles, R.P.; Melhem, G.A.; Eckhardt, D.R.

    1995-11-01

    In recognition of the potential severe consequences of a process vessel rupture under fire exposure, industry codes such as the National Fire Protection Association (NFPA) 30 and the American Petroleum Institute (API) Standard 2000 have been established for the specification of emergency relief systems (ERSs). The intent is to reduce the risk of human injury and asset losses associated with process plant fires. These codes are largely prescriptive in nature. That is, they provide specific details on how to achieve safe design. Prescriptive standards are easy to apply, because they are simplified approaches which generally apply to many (but not all) situations. But they also have limitations, including the tendency to result in, at best, suboptimal (overly conservative) designs, and in some instances potentially unsafe designs. As the fire community moves toward performance-based standards for building protection, perhaps it is time to consider a similar approach for vessel protection in a fire. The design issues addressed in this article include: Use of heat input based on actual fuel burning rate, heat of combustion, and flame emissive power, vs. NFPA 30 and API 2000 heat-input equations; Effect of drainage (from vessel to sump) on fire duration, rather than heat input; Use of risk assessment to determine the relative frequency of fire and process-induced incidents; and design for containment, rather than vessel protection when fire probability is low

  1. Predictors of obstetric complications in women with heart disease.

    PubMed

    Goya, Maria; Casellas, Manel; Merced, Carme; Pijuan-Domenech, Antonia; Galián, Laura; Dos, Laura; Casaldáliga, Jaume; Subirana, Mayte; Pedrosa, Valle; Rojas, Mireia; Martínez, Cristina; Ferreira, Ignacio; Monts, Montserrat; Gascón, Andrea; Mendoza, Manel; Baró, Francesc; Suy, Anna; Lopez-Gil, Victoria; Manrique, Susana; Tornos, Pilar; García-Dorado, David; Carreras, Elena; Cabero, Luis

    2016-01-01

    The objective of this study is to evaluate obstetric outcomes in women with heart disease and determine whether current multidisciplinary management approaches adversely affect the mother, the neonate, or both. Also to compare the accuracy of several risk scores (RS) including the modified World Health Organization classification (mWHO) and CARPREG to predict obstetric and neonatal complications and to study the addition value of Uteroplacental-Doppler flow (UDF) parameters to predict obstetric complications. A prospective cohort study examined outcomes in women with heart disease (HD), the majority of whom had corrective surgery and delivered between January 2007 and March 2012. One hundred and seventy-four patients with 179 pregnancies were included in the study. Obstetric complications, including premature labor, arose in 87 patients (48.6%). Neonatal complications were observed in 11 cases (7%). On multivariate analysis, maternal heart disease was predictive of adverse perinatal events (46 cases, 25.7%) and mode of delivery (Thierry's spatula) of third- or fourth-degree perineal tears (six cases, 3.2%). mWHO classification predicted obstetric complications (p = 0.0001) better than the CARPREG study. Impaired UDF (uterine artery pulsatility index-20 weeks and umbilical artery pulsatility index-32 weeks in HD versus healthy women: 20w 1.12 versus 1.34, p = 0.005; 32w 0.87 versus 1.09, p = 0.008) was associated with adverse obstetric and offspring outcome in the group of HD pregnant women. Nearly 50% of pregnancies were associated with an adverse obstetric outcome, particularly IUGR. mWHO was better at predicting obstetric and neonatal complications that CARPREG in all categories. Furthermore, compromised UDF combined with mWHO improved the prediction of obstetric and offspring complications in this population.

  2. Rural Tanzanian women's awareness of danger signs of obstetric complications.

    PubMed

    Pembe, Andrea B; Urassa, David P; Carlstedt, Anders; Lindmark, Gunilla; Nyström, Lennarth; Darj, Elisabeth

    2009-03-26

    Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania. A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi-square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs. More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8-19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care. Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium

  3. Effect of formative evaluation using direct observation of procedural skills in assessment of postgraduate students of obstetrics and gynecology: Prospective study.

    PubMed

    Kumar, Naina; Singh, Namit Kant; Rudra, Samar; Pathak, Swanand

    2017-01-01

    Direct Observation of Procedural Skills (DOPS) is a way of evaluating procedural skills through observation in the workplace. The purpose of this study was to assess the role of DOPS in teaching and assessment of postgraduate students and to know the effect of repeated DOPS on improvement of the skills and confidence of the students. In both phases, significant difference was observed between the two groups on first DOPS comparison (1st phase: p=0.000; 2nd phase: p=0.002), with simulation group performing better. Comparison of sixth DOPS in the two groups revealed no difference in both phases, but significant difference on first and sixth DOPS comparison in each group (p=0.000). Repeated DOPS results in improved skills and confidence of students in managing real life obstetric emergencies irrespective of the teaching modality. Repeated DOPS results in improved skills and confidence of students in managing real life obstetric emergencies irrespective of the teaching modality.

  4. An improved harmony search algorithm for emergency inspection scheduling

    NASA Astrophysics Data System (ADS)

    Kallioras, Nikos A.; Lagaros, Nikos D.; Karlaftis, Matthew G.

    2014-11-01

    The ability of nature-inspired search algorithms to efficiently handle combinatorial problems, and their successful implementation in many fields of engineering and applied sciences, have led to the development of new, improved algorithms. In this work, an improved harmony search (IHS) algorithm is presented, while a holistic approach for solving the problem of post-disaster infrastructure management is also proposed. The efficiency of IHS is compared with that of the algorithms of particle swarm optimization, differential evolution, basic harmony search and the pure random search procedure, when solving the districting problem that is the first part of post-disaster infrastructure management. The ant colony optimization algorithm is employed for solving the associated routing problem that constitutes the second part. The comparison is based on the quality of the results obtained, the computational demands and the sensitivity on the algorithmic parameters.

  5. The use of ultrasound in obstetric anesthesia.

    PubMed

    Weiniger, Carolyn F; Sharoni, Limor

    2017-06-01

    The current review considers an array of recent applications for point-of-care ultrasound in clinical practice including diagnostic and therapeutic procedures that may be relevant for the obstetric anesthesiologist. The rapid advancement of technology and clinical applications for bedside ultrasound in obstetric anesthesiology requires an appraisal of the limitations and uses. The review presents the most recent literature describing ultrasound-guided airway assessments, airway management, cricothyroidotomy, transthoracic echocardiography, gastric volume assessments, point-of-care lung ultrasound diagnoses, intracranial pressure assessments, vascular access, neuraxial blocks, and transversus abdominis plane blocks. Each ultrasound technique is presented along with the most recent advances in knowledge and some limitations to integration of these ultrasound skills in clinical practice. Anesthesiologists have clearly embraced this facile versatile tool for bedside diagnostics and procedures. One limitation to widespread adoption is availability of suitable ultrasound skills and technology. Many of these ultrasound techniques have not yet established clear patient benefit, yet the sheer breadth of ultrasound techniques reported in the past few years demonstrate that our colleagues are becoming more proficient. It is important to follow the development of this emerging field to be aware of limitations to learning these skills and their potential clinical benefit. Proficiency in some of these point-of-care ultrasound techniques may become prerequisite for obstetric anesthesiologists to provide the best care.

  6. Improving the non-technical skills of hospital medical emergency teams: The Team Emergency Assessment Measure (TEAM™).

    PubMed

    Cant, Robyn P; Porter, Joanne E; Cooper, Simon J; Roberts, Kate; Wilson, Ian; Gartside, Christopher

    2016-12-01

    This prospective descriptive study aimed to test the validity and feasibility of the Team Emergency Assessment Measure (TEAM™) for assessing real-world medical emergency teams' non-technical skills. Second, the present study aimed to explore the instrument's contribution to practice regarding teamwork and learning outcomes. Registered nurses (RNs) and medical staff (n = 104) in two hospital EDs in rural Victoria, Australia, participated. Over a 10 month period, the (TEAM™) instrument was completed by multiple clinicians at medical emergency episodes. In 80 real-world medical emergency team resuscitation episodes (283 clinician assessments), non-technical skills ratings averaged 89% per episode (39 of a possible 44 points). Twenty-one episodes were rated in the lowest quartile (i.e. ≤37 points out of 44). Ratings differed by discipline, with significantly higher scores given by medical raters (mean: 41.1 ± 4.4) than RNs (38.7 ± 5.4) (P = 0.001). This difference occurred in the Leadership domain. The tool was reliable with Cronbach's alpha 0.78, high uni-dimensional validity and mean inter-item correlation of 0.45. Concurrent validity was confirmed by strong correlation between TEAM™ score and the awarded Global Rating (P < 0.001), with 38.4% of shared variance. RNs praised the instrument as it initiated staff reflection and debriefing discussions around performance improvement. Non-technical skills of medical emergency teams are known to often be suboptimal; however, average ratings of 89% were achieved in this real-world study. TEAM™ is a valid, reliable and easy to use tool, for both training and clinical settings, with benefits for team performance when used as an assessment and/or debriefing tool. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

  7. Early Course in Obstetrics Increases Likelihood of Practice Including Obstetrics.

    PubMed

    Pearson, Jennifer; Westra, Ruth

    2016-10-01

    The Department of Family Medicine and Community Health Duluth has offered the Obstetrical Longitudinal Course (OBLC) as an elective for first-year medical students since 1999. The objective of the OBLC Impact Survey was to assess the effectiveness of the course over the past 15 years. A Qualtrics survey was emailed to participants enrolled in the course from 1999-2014. Data was compiled for the respondent group as a whole as well as four cohorts based on current level of training/practice. Cross-tabulations with Fisher's exact test were applied and odds ratios calculated for factors affecting likelihood of eventual practice including obstetrics. Participation in the OBLC was successful in increasing exposure, awareness, and comfort in caring for obstetrical patients and feeling more prepared for the OB-GYN Clerkship. A total of 50.5% of course participants felt the OBLC influenced their choice of specialty. For participants who are currently physicians, 51% are practicing family medicine with obstetrics or OB-GYN. Of the cohort of family physicians, 65.2% made the decision whether to include obstetrics in practice during medical school. Odds ratios show the likelihood of practicing obstetrics is higher when participants have completed the OBLC and also are practicing in a rural community. Early exposure to obstetrics, as provided by the OBLC, appears to increase the likelihood of including obstetrics in practice, especially if eventual practice is in a rural community. This course may be a tool to help create a pipeline for future rural family physicians providing obstetrical care.

  8. Emerging engineering principles for yield improvement in microbial cell design

    PubMed Central

    Comba, Santiago; Arabolaza, Ana; Gramajo, Hugo

    2012-01-01

    Metabolic Engineering has undertaken a rapid transformation in the last ten years making real progress towards the production of a wide range of molecules and fine chemicals using a designed cellular host. However, the maximization of product yields through pathway optimization is a constant and central challenge of this field. Traditional methods used to improve the production of target compounds from engineered biosynthetic pathways in non-native hosts include: codon usage optimization, elimination of the accumulation of toxic intermediates or byproducts, enhanced production of rate-limiting enzymes, selection of appropriate promoter and ribosome binding sites, application of directed evolution of enzymes, and chassis re-circuit. Overall, these approaches tend to be specific for each engineering project rather than a systematic practice based on a more generalizable strategy. In this mini-review, we highlight some novel and extensive approaches and tools intended to address the improvement of a target product formation, founded in sophisticated principles such as dynamic control, pathway genes modularization, and flux modeling. PMID:24688676

  9. Emerging engineering principles for yield improvement in microbial cell design.

    PubMed

    Comba, Santiago; Arabolaza, Ana; Gramajo, Hugo

    2012-01-01

    Metabolic Engineering has undertaken a rapid transformation in the last ten years making real progress towards the production of a wide range of molecules and fine chemicals using a designed cellular host. However, the maximization of product yields through pathway optimization is a constant and central challenge of this field. Traditional methods used to improve the production of target compounds from engineered biosynthetic pathways in non-native hosts include: codon usage optimization, elimination of the accumulation of toxic intermediates or byproducts, enhanced production of rate-limiting enzymes, selection of appropriate promoter and ribosome binding sites, application of directed evolution of enzymes, and chassis re-circuit. Overall, these approaches tend to be specific for each engineering project rather than a systematic practice based on a more generalizable strategy. In this mini-review, we highlight some novel and extensive approaches and tools intended to address the improvement of a target product formation, founded in sophisticated principles such as dynamic control, pathway genes modularization, and flux modeling.

  10. Obstetric analgesia - update 2016.

    PubMed

    Heesen, Michael; Klimek, Markus

    2016-07-07

    Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integra