Organizing Maternal Health Services in Hospital

Dr Ajesh N Desai
Profesor & head O&G Dept GMERS Medical college Sola Ex Maternal Health consultant GOG Ex Director SIHFW GOG, Advisor Elimination of Congenital Syphilis WHO, WHO Fellow (Community Health care & Research) Nodal Officer GMERS GOG

MDG Goals
MDG 5 Reduction of maternal mortality to less than 100 by 2012

New Paradigm Every pregnant women is at risk

ANY PREGNANT WOMAN CAN DEVELOP LIFE THREATENING COMPLICATIONS WITH LITTLE OR NO ADVANCE WARNING
ALL WOMEN NEED ACCESS TO QUALITY MATERNAL HEALTH SERVICES THAT CAN DETECT AND MANAGE LIFE-THREATENING COMPLICATIONS

EXTENT OF MATERNAL MORTALITY, MORBIDITY. AND DISABILITIES

Place of Severe maternal morbidity (Near Miss) in simple terms

PLACE OF NEAR MISS IN OBSTETRIC SERVICE DELIVERY

MMR BASED ON SOCIOECONOMIC STATUS

Global Causes of Maternal Mortality

Hemorrhage 24.8% 19.8 7.9 Obstructed Labor 6.9% Unsafe Abortion 12.9% Other Direct Causes 7.9% Indirect Causes 19.8% Infection 14.9% 24.8 Eclampsia 12.9%

12.9 6.9 12.9

14.9

Timings of maternal deaths

Timing % of Maternal death 50
50 45 40 35 30 25 20 15 10 5 0 %

First 24 hours

24 hrs 2-7days 2-6 wks during pregnancy

2 to 7 days after delivery

2 to 6 wks During Pregnancy

20

5 25

How Much Time Do We Have?

It is estimated that, if untreated, death occurs on average in:

2 hours 12 hours 2 days 6 days

from Postpartum Hemorrhage from Ante partum Hemorrhage from Obstructed Labor from Infection

Maternal Mortality Reduction

Sri Lanka 19401985

85% births attended

Maternal Deaths per 100 000 livebirths

2000 1600 1200 800 400 0 194045 195055

by trained personnel

196065

197075

198085

Maternal Mortality (per lakh live births) in Gujarat 500

Maternal Dealth
400 300 200 100 0 1989 1999-01 2001-03 2010 202 172
Target

389

100

SRS Maternal Mortality in India:1997-2003

Types of Maternity Health Services

Adolescent Health Antenatal care Intranatal Care Post Natal care Family planning Cancer detection Geriatrics

Levels of Health Care

Primary Health Care
Primary Health center, Subcenters

Secondary Health Care

Community Health Centers

Tertiary Health care

First Referral Units (District Hospital & Medical college Hospitals)

Out Reach Services

Mobile health units

Level vise Provision of services

Primary Health care At Center Antenatal Care, Intranatal Care, Postnatal care, Family planning, Referral services, National health programs Field Surveys &Family health registers, Early detection of pregnancy

Level vise Provision of services

Primary Health care At Center Antenatal Care, Intranatal Care, Postnatal care, Family planning, Referral services, National health programs Field Surveys &Family health registers, Early detection of pregnancy

Level vise Provision of services

Community Health centers Essentially Curative Basic Emergency Obstretic care, Cancer detection Medical termination of pregnancy Other Family planning secrvices

FRU Guidelines

Level vise Provision of services

First Refferal Units Essentially Curative Comprehensive Emergency Obstretic care, Cancer detection Medical termination of pregnancy Other Family planning secrvices

Distribution of services
Level of Health care
SC

Personnel
ANM

Type of services
Survey, Diagnosis of pregnancy, Conducting delivery Refferal Basic Emergency obstretic care Basic Emergency obstretic care Comprehensive obstretic care

PHC CHC FRU

MO, SN, ANM Gynecologist, MO SN, Gynecologist, MO, SN, anesthetist, Blood Storage staff

Division of health Care services

Health centers
SC

Population
3000 5000

PHC
CHC FRU

25000
100000 500000

Out Patient Department

Antenatal General Gynec Infertility Cancer detection PPTC/VTCC Equipments
Furniture, Speculum, Vulsellum, Ant vag wall retractor, BP, Stethoscope, Lab equipment, Cytology Antiseptics etc

Infrastructure
Examination room-4 Nursing Store & Station Record room Toilet block Waiting area for Patients

Separate wing for antenatal and gynec desirable Facilties of USG is desirable

Stations of Antenatal care

History Weight HB Urine protein Obstetric examination Tetanus toxoids Counseling

Stations of Intranatal care

Examination Labour room ( Normal, Eclamsia, Septic) Recovery room Operation theatre & Post operative room Record room New born corner & NICU Dirty corridor Nursing station, store, doctors duty room Referral support in BemONC centers

Indoor facilities

Ward (3) Antenatal ward Postnatal ward Gynec ward

Oxygen supply Fowlers bed(1) Monitors Infusion pump Trolleys, pint stand, cot & lockers

Nursing station & Store Minimum distance of 1 mtrs bet beds, examination room Doctors duty room Pantry, ward lab, dirty linen room etc

Gynec operation theatre

General, microsurgical, endoscopic, Septic Equipment Pre-anesthetic & Post operative ward

Post partum care

First visit in institution if it is institutional delivery 2nd & 3rd visit at home by ANM.

Outreach services
ANM & Asha to cover uncovered villages Mobile health units manned by MO, ANM, SN to cover difficult hilly, dessert & remote areas Traditional practioners Dais, Self help groups, youth circles, tribal healers etc can also participate

Monitoring of Maternal health services

Type of health service
ASHA SC

Monitoring Supervision agencies

ANM MO PHC District Health Society (DPMU)

CDHO

PHC
CHC FRU

Block
CDMO CDMO Add Dir PH Add Director MS State Health Society ( SPMU)

OBSTETRIC ICU

Obstetric ICU

 There is agreement in the developed world on the need for Intensive care facilities for the obstetric patient. This level of care may not be attainable for the pregnant in the developing world as lack of access to health facilities is one of the major factors responsible for high maternal mortality rates in the region

OBSTETRIC ICU is the setting for an expert medical, nursing, and technical staff to use Sophisticated state-of-the-art equipment for intensive monitoring and the immediate life-saving interventions that may be necessary.

Critical care team

The multidisciplinary team of health care professionals who care for critically ill and injured patients. The critical care team includes the critical care intensivist, critical care nurse, respiratory therapist and pharmacologist. Other allied health therapists and technicians, social workers and clergy may also participate as members of the critical care team.

Criteria for ICU admission

1. Critically ill patients in a medically unstable state who require an intensive level of care (monitoring and treatment). 2. Patients requiring intensive monitoring who may also require emergency 108 interventions.

Criteria for ICU admission

3. Patients who are medically unstable or critically ill and who do not have much chance for recovery due to the severity of their illness or traumatic injury. 4. Patients who are generally not eligible for ICU admission because they are not expected to survive. Patients in this fourth category require the approval of the director of the ICU program before admission.

OBSTETRIC ICU
However, care in an ICU sometimes becomes focused on the machinery, rather than on the patient. It is imperative that the humanizing aspects of critical care be addressed in caring for a pregnant patient and her family.

OBSTETRIC ICU
PROCEDURES USED
Catheterization of the Urinary Bladder (Foley Catheterization) Stomach Tubes Arterial Catheterization Central venous Catheterization Right Heart Catheterization Mechanical Ventilator Weaning From Mechanical Ventilation

CLINICAL CONDITIONS
ARF, eclampsia, pre eclampsia.. coma Hypovolemia,fluid monitoring, cardiac disease Shock. ARDS Respiratory depression During recovery

OBSTETRIC ICU
PROCEDURES USED
Tracheostomy Lumbar Puncture Paracentesis(Taking a sample of fluid from the abdomen) Chest Tube Thoracostomy Fibreoptic Bronchoscopy Haemodialysis

CLINICAL CONDITIONS
Prolonged ventillation Encephalitis, meningitis Hemoperitoneum, septic peritonitis, pelvic abscess Pneumothorax Suction in prolonged mechanical ventillation ARF