Multi(Inter) discplinary approach in

Obstetrics Cases Management

DEPARTMENT OF OBSTETRI & GYNECOLOGY
MATERNAL-FETAL MEDICINE DIVISION
FACULTY OF MEDICINE UNIVERSITY OF UDAYANA / SANGLAH GENERAL HOSPITAL

JAYA KUSUMA, CMFM

11Th NICU PICU UPDATE AND FETOMATERNAL UPDATE 2019

BNDCC ,NUSA DUA ,BALI
28 Juni 2019
 The Triple Aim
Improve the health
of populations

Enhance the Reduce the per

patient capita cost of
experience healthcare
The Institute of Healthcare Improvement
SIX DOMAINS OF HEALTH CARE QUALITY

 Safe: Avoiding harm to patients from the care that is intended to help them
 Effective: Providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit (avoiding
underuse and misuse, respectively)
 Patient-centered: Providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient values guide
all clinical decisions
 Timely: Reducing waits and sometimes harmful delays for both those who receive
and those who give care
 Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy
 Equitable: Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic status

Jaya Kusuma,2019 Institute of Medicine

 SYSTEMS/REGULATIONS, MEDICAL/MEDICAL
RESOURCES (SEPARATED BUILDING, LACK OF
MEDICAL EQUIPMENT)

Hospital

LIMITATION SCOPE OF
SERVICES, FUNDING
COMPETENCE
PROFESSIONALISM
Payers/Re Patient RESPONSIBILITY
Safety Providers
gulation ACCOUNTABILITY
SALARY

Patients

HEALTH STATUS, EDUCATION, INVOLVEMENT

(POOR, BAD BEHAVIOUR)
 @ HOSPITAL
POSSIBILITY OF
1. READINESS OF HEALTH CARE PROVIDER
Maternal Mortality in 2. AVAILABILITY OF MATERIALS AND TOOLS
Childbirth 3. ATTITUDE OF HEALTH CARE PROVIDER
4. FUNDS/COSTS ??

@ PRIMARY HEALTH CARE

1. READINESS OF HEALTH CARE PROVIDER
2. AVAILABILITY OF MATERIALS AND TOOLS
3. ATTITUDE OF HEALTH CARE PROVIDER

En ROUTE
1. MEANS OF TRANSPORTATION Three “TOO LATE”
2. LEVEL OF DIFFICULTY
3. TRAVEL DURATION
• Too late in recognizing
danger sign and making a
@ HOME decision.
1. FAMILY DECISION • Too late in reaching a
• KNOWLEDGE health care facility
• AVAILABILITY OF FUNDS • Too late in getting the
• OCCUPATION OF FAMILY necessary care in the
• SOCIAL CULTURE health care facility
2. AVAILABILITY OF TRANSPORTATION
 BALI MATERNAL DEATH 2013-2018

 The Maternal Mortality Ratio in Bali in 2018 is 53.02 / 100,000 live births.
 Most maternal mortality occurred in hospital setting (94.29%) and were helped by
health care workers (97.14%).
 The highest number of maternal deaths occurred in the age group 20-35 years
(62.9%) and parity 2-5 (54.3%).
 The most common causes of maternal obstetric mortality were haemorrhage
(28.6%) and pre-eclampsia (22.9%)
 The most common cause of maternal non-obstetric mortality were cardiogenic
shock (11.4%), embolism (8.6%) and malignancy as well as Tuberculosis (5.7%
respectively).
 The number of cases of mortality base on the mode of delivery, namely through
cesarean section and vaginal delivery were 22,86% and 22,86% respectively
OBSTETRIC TRANSITION
A SIGNIFICANT NUMBER OF PREGNANCY HIGH RISK

 Preeclampsia,diabetes,sepsis,kidney disease,cardiac disease,twin complicated

pregnancy,preterm birth, congenital anomaly

 USA : PE- 6-8%, GDM 2-10%,1-800 twin/triplet, 30% birth defect

 Indonesia : OBSTETRIC TRANSITION 60 % DEATH ( NON OBSTETRICS) AND

CONGENITAL ANOMALIES ( HIDDEN PROBLEMS,HIGH COST )
 Coordination-multidiscpline prenatal-intrnatal-postnatal-neonatolgis-pediatrician-
pediatric surgery-internal medicine-infection physician- anesthetics --etc
 Preconception care : genetics problem,medical problems, reffer to various
specialist-refferal to appropriate consultants

 Caring for women with congenital anomaly --challenging– ethical and medical or
surgical  interaction team and parents absolutely need
 What is the attitudes, respons, opinion from Clinicians to Multi-D apporach ?
Perinatal Case Conference : Physicians, Nurses, Sonographers
Attitudes : process that aims to provide effective health service through
team work, among professionals from different background
Result :
64,3% agreed withn the statement : patients/client receiving
interprofessional care are more likely than others to be treated as a whole
persons
Regarding time and resources : 21% disagreed that statement time
consuming
78,6%  strongly agreed regarding that statement
88 %  working in an interprofessional environment keeps most helath
professional enthusiastic and interested in their jobs
92% efficiency was improved with interprofessional care
 Integration: process that cuts all levels of health care delivery

Continuity : degree of coherence,connection and consistency that he/she experiences in

relation on their needs and personal situation ( informational continuity,approach
continuiyt,relational continuity among providers Patients perception NOT organisation
Sequential Coordination : patients treated by > 2 professional at 1 episode
Reciprocal Coordination : patients treated simulatneously by a number of professional
Colective Coordintion : joint care
Postnatal period is critical transition and adaptation time for woman and
newborn.
Maintaining maternal and neonatal health.
Promoting and opportunity to discuss breastfeeding, usage of family
planning, immunisations, recognize early maternal and neonatal health
problem
 The Problem : woman oftenly failed to give priority to health care after
labor system etc
Development of startegies and increasing obstetrik neonatologis
utilisation care after labor are essential.
 Definitions for multidisciplinary approach
A multidisciplinary approach involves drawing appropriately from multiple disciplines to
redefine problems outside of normal boundaries and reach solutions based on a new
understanding of complex situations.

One of the major barriers to the multidisciplinary approach is the long established
tradition of highly focused professional practitioners cultivating a protective boundary
around their area of expertise. This tradition has sometimes been found not to work to the
benefit of the wider public interest, and the multidisciplinary approach has recently
become of interest to government agencies and some enlightened professional bodies who
recognise the advantages of systems thinking for complex problem solving.

The use of the term 'multidisciplinary' has in recent years been overtaken by the
term 'interdisciplinary' for what is essentially holistic working by another name.
The former term tends to relate to practitioner led working while the latter
term tends to carry a more academic overtone.

Complexs High Risk Pregnancy, 2108

Multidisciplinary: people from different
disciplines working together, each drawing
on their disciplinary knowledge,Stays
within their boundaries

Interdisciplinary: integrating knowledge

and methods from different disciplines,
using a real synthesis and harmonized links
between discplines into coordinated and
coherent whole of approaches.
 TEAM WORK

THREE LEVELS OUTCOME :

HEALTHCARE PROFESSIONALS,PATIENTS AND HEALTHCARE
ORGANIZATON

IMPACT : STAFF SATISFACTION, QUALITY OF CARE,COST

CONTROL, AND WELL-BEING

THREE INDICATORS OF POSITIVE TEAM WORK : PERSONAL QUALITY AND

COMMITMENT OF STAFFS,COMMUNICATION WITHIN THE TEAM,OPPORTUNITY TO
DEVELOP CREATIVE WORKING METHODS
 PRINCIPLES OF GOOD TEAM WORK
1. STRUCTURE (TEAM SIZE & COMPOSISITION,ORGANISATIONAL
SUPPORT, CLEAR OBJECIVE AND GOALS)

1. II PROCESS (TEAM MEETINGS,AUDIT PROCESS)

COLLABORATION: requires
Competence,Commitmen,Confidence, Respect
and trust each others

CONTRIBUTING FACTORS OF COLLABORATION : Joint venture,cooperative

endeavor,willing participation,shared plaaning and decission making,contribution of
experise,shared responsibility,non-hierrachial realtionships
 TERMINOLOGY : INTERCHANGEABLE
INTERDISCPLINE/MULTIDISCIPLINE/INTERPROFESSIONAL/MULTIPROFES
SIONAL AND OFTEN USED IN CONJUCTION WITH THE TERM OF TEAM
WORK

INTER/MULTI-PROFESSIONAL : NARROWER TEAM CONSISTEING

EXCLUSIVELY PROFESSIONALS FROM DIFFERENT PROFESSIONS AND
DISCIPLINES OR AT LEAST RELATIONSHIP BETWEEN PROFESSIONALS(
INCLUDE NON-PROFESSIONALS)

INTER/MULTIDISCPLINE: BROADER INCLUDE ALL MEMBERS OF

HEALTHCARE TEAM,PROFESSIONAL AND NON-PROFESSIONALS
 REFFER TO RANGE OF HEALTH SERVICE WORKERS TEAM

INTERDISCPLINES TEAM WORK ???

 FACTORS THAT NEED TO INTERDISCIPLINARY TEAM

1. Large numbers of patients with complex disease

2. Increasing complexity of skill and knowledge to provide compehensive
care to patients
3. Fragmentation of services
4. Need of continuity of care to improve quality of care
Common pregnancy related
complications
Pregnancy related hypertension
Preeclamsia
Eclamsia
HELLP syndrome
Ante-partum haemorrhage
IUGR
Pre-maturity, Abortion & Still
birth
Gestational diabetes (increased
by prednisone usedfor SLE
SLE Other maternal
in complications of lupus
Pregnancy
Infection
Deep vein thrombosis
Pulmonary embolism
Cerebro-vascular accident
(stroke)
Pulmonary hypertension
For patients with SLE, the multidisciplinary team
may include ;
a rheumatologist (ideally familiar with
pregnancy in patients with SLE), obstetrician,
nephrologist, fetal cardiologist, fetal medicine
specialist, neonatologist, and/or specialist
midwife .
JUMLAH PASIEN OHDU TAHUN 2019 (SD JUNI 2019)

N = 66

INTERDISCIPLINARY
CARE IN OHDU:
MFM,Obst anest,internal
med,neurologist,cardiolo
gist etc
 THE ROLES AND RESPONSIBILITES OF THE NEONATOLOGIST IN
COMPLEX FETAL MEDICINE:
PROVIDING A CONTINUUM OF CARE

(ACOG) has advocated for the concept of a fetal

center as a multidisciplinary team, composed of :
MFM,Perinatologists
Pediatric /Neonatologist/Pediatric surgeon specialists
Ancillary support practitioners/specialists working
together to provide optimal care
The fact that obstetricians, maternal-fetal medicine (MFM) specialists, pediatric
surgeons, and neonatologists possess backgrounds and knowledge bases that
may result in distinct, and possibly different, approaches to prenatal counseling
and guidance of parental decision making.
 THE MILESTONE OF HOW ANESTHESIOLGIST ANSWERS TO
SICENTIFIC QUESTIONS RE-ANESTHETIC EFFECT ON MOTHER,FETUS AND NEONATE

Early 20th Mid 20th

1847 centuries centuries 1980 Now
• The birth of • Twilight Sleep • Anesthesiologis • Neuraxial labor • Use of epidural
obstetric (morphine + ts began anesthesia test dose
anesthesia scopolamine) focusing their became • Incremental
• Introduction of became efforts on popular
ehter labor epidural
analgesia by James
common but reducing injection of
Young Simpson abandoned due general local anesthetic
• Interference of to depressant anesthesia- • Elimination of
labor pain which effect on related adverse bupivacain
was considered as neonates maternal and 0,75%
divine punishment neonatal
was considered • Lipid emulsion
outcomes,
sinful. therapy for
including
local anesthetic
airway
systemic
associated
toxicity
morbidity and
Grace Lim,et al 2018 mortality
A REVIEW OF THE IMPACT OF Anesthesiology
OBSTETRIC ANESTHESIA ON Contribution to Maternal
Neonatal Safety
MATERNAL AND NEONATAL
OUTCOMES DEBORAH J. CULLEY, GRACE LIM, FRANCESCA L. FACCO,
NAVEEN NATHAN,JONATHAN H. WATERS, CYNTHIA A.
WONG, HOLGER K. ELTZSCHIG

FEVER AND NEONATAL SEPSIS WORKUP

REPOSITIONING OF : Maternal Fetal Medicine Subspesialist/Consultant

Who are we ?
MFM Subspecialist,High Risk Pregnancy Physician :
“….Highly trained Obgin with advanced expertise in
obstetric,medical,and surgical complications of
pregnancy and their effects on the mother and fetus…”

What is the scope of Services/Responsibilities and what is

the goal ? : Manage Obsteric high risk, maternal
medical/surgical Ilness and Fetal Illness ,also their impact
to Mother and fetus by intervention to both  to reduce
morbidity of mother n fetus and their impact to Quality
of life

When should we do? : Before, During, and After

pregnancy—preventing complication and mortality

Where are we work ? : Secondary or Tertiary Hospital

Who the other specialties we are working with ?

Neonatologist,Pediatric
Surgeon,Geneticians,Obsos,Cardiologist,etc

Jaya Kusuma,2014, RSUP Sanglah

 MFM RESPONSIBILITY AND SCOPE OF SERVICES

MFM, often encounter this complex patients and are task with
coordinating their multisicpline prenatal,intarpartum and postpartum
care

Includes prconception : risk factor for genetic and adverse outcome of

pregnancy,refferal others specialits/subspecialist

Caring for fetal anomalies more challenging from ethical and surgical
obstacles not only on the treatment team , also parents

To care for complexs cases : Multi-D approach  MFM, neonatology,

pediatric surgeon, cardiology, anesthesiology, palliative, social work,
case management, and various institutional support
INTERPROFESIONAL COLLABORATION /CASE CONFERENCE MFM
OBGIN FK UNUD/RSUP SANGLAH DENPASAR

FM Cases Non MFM -OG

MFM specialist

MFM Case Manager MFM-Sub Division

Cardiologist/ Neonatologist/Pediatric Social obstetri Pathologist/Gene

Internist/Intesifist dll Surgeon specialist SpOG tician/Farmacist

MULTIDISCPLINARY FM CASE CONFERENCE- DECISION-REGISTRY-MONEV

 PERINATAL HIGH RISK CONFERENCE-MFM

TUESDAY
POLICLINIC, OBSTETRIC WARD,OHDU, ICU/ICCU
MFM,NEONATOLOGIST,ANESTETHIST, RELATED DISCIPLINE, MEDICAL
RECORD,HOSPITAL MANAGEMENT

-OUTPUT :
-1. SERVICE : PATIENT MANAGEMENT
-2 TRAINEE : COMPETENCE FOR COLLABORATIVE WORKING
-3. HOSPITAL: QUALITY DIMENSION ( EFFECTIVE,EFFICIENT AND PATIENT
SAFETY )

CONCEPT OF MFM-NEO-ANESTHETICS INTEGRATIVE CARE

Perinatal Care ( Obst-Neonatal) IN Hospital  became integrated Obstetrics

Transition : others specialists

Antenatl care-Labor Ward Care-Puerperal care- Operating theatre –Neonatal Care (

NICU- ICU )
Hospital Maternal death- Neonatal Death
Fragmented services
Last 4 years year integrating MFM Care-Neonatal
care-Obstetrics Care

Starting from SIDIC ( Sanglah Birth Defect Integrated Centre)

SIDIC ( SANGLAH BIRTH DEFECT INTEGRATED CENTRE)adalah pelayanan

kelainan bawaan yang dilakukan secara terpadu meliputi berbagai bidang
subspesialis sesuai dengan kelainan yang ditemukan pada janin dan bayi, meliputi
diagnostik, terapi/ obat2an dan tindakan bedah selama Ante natal dan Post
natal
 POLIKLINIK

SPESIALIS SUBSPESIALIS

Poliklinik obgyn Fetomaternal

Program BATAB Tunjung
Poliklinik anak
Neonatologi
Poliklinik bedah anak Hematologi Anak
Kardiologi Anak
Poliklinik bedah uro Endokrin Anak
Pliklinik urologi Bedah Anak
Tumbuh kembang Anak
Poliklinik saraf Bedah Plastik & Rekonstruksi
poliklnikik kardiologi Bedah Urologi
Bedah Jantung
Poliklinik bedah plastik Bedah Syaraf
Bedah Plastik Rekonstruksi
Poliklinik ortopedi Lab. Sitogenetika Klinik
Poliklinik anesthesia Pediatrik Radiologi Diagnostik
Patologi Anatomi

ANTENATAL DIAGNOSTIC AND COUNSELING SERVICE/ADACS (Interdisiplin)-SIDIC TEAM

 COMMON FETAL AND MATERNAL-FETAL
CONDITIONS MANAGED BY SIDIC

 Autoimmune
 Neck masses  Maternal Diagnoses disorders (SLE)
Common Fetal Diagnoses :
 Holoprosencephaly,hy  Autoimmune disorders
 Abdominal masses drocephalus and other (SLE)  Blood type or
 Bowel obstruction
brain malformations
 Blood type or platelet platelet
 Hydrops incompatibilities incompatibilities
 Bronchopulmonary
malformation (eg. Kidney and bladder  Diabetes Gestational
Congenital pulmonary

anomalies
 Diabetes
malformations)  Maternal drug Gestational
 Omphalocele exposure ( HIV with
 Congenital diaphragma
hernia  Sacrococygeal drug abuse, teratogenic  Maternal drug
drug)
teratoma exposure ( HIV
 Congenital heart disease
 Spina bifida,  Maternal cancer with drug abuse,
 Fetal heart rhytm encephalocele and treatment
disturbances other spinal anomalies
teratogenic
 Placental disorders (eg. drug)
 Gastrochisis  Trachesophageal fistula Placenta previa, accreta,
increta, and percreta)  Maternal cancer
 Genetic and metabolic  TTTS
conditions  Preeclampsia-PPH- treatment
Sepsis
 WHAT WE HAVE DONE ??: INTERDISCIPLINARY WORKING
FRAME OF SIDIC AND HIGH RISK PREGNANCY

 Routine interdisciplinary team conferences (

ANTENATAL DIAGNSOTIC AND COUNSELING
SERVICE/ADAC) are essential to review cases, with
real-time discussion among MFM specialists,
neonatologists, and other specialists
 Decisions can be made in this forum regarding follow-up
Maternal care, obstetric care and fetal surveillance, location
of care, timing of delivery, and mode of delivery
 Plans for neonatal disposition after birth are discussed,
including immediate care plans and expected challenges,
also specialty recommendations for outpatient
follow-up after discharge
KEEP CONTINUITY OF CARE
INTERDISCIPLINE- MORNING
HANDOVER
MORNING HANDOVER
PRAKTEK KOLABORASI INTERDISIPLIN
HARUS DIMULAI SEJAK MASA
PEDIDIKAN PPDS
 CHALLENGES OF
PERINATAL REFFERAL UNTRAINED BIRTH ATTENDANT,
DELAY IN DECISION,
SYSTEMS DEMOGRAPHIC,TRANSPORTATION

REFFERAL
REFFERAL

BRIDGING THE
GAP
INTEGRATING
PUBLIC
HELATH AND
HEALTH
SYSTEMS
LACK OF INTERPROFESSIONAL
COLLABORATION,RESOURCES QUALITY OF
ANC/FOCUSED ANC

REFFERAL
REFFERAL

INTEGRATED PERINATAL PRACTICE GUIDELINES,

RESOURCES
MIDWIFE WORKSHOP BIRTH MASTER CLASS

NICU NICU
 CONCLUSIONS

 The Interdisciplinary goal of a successful Maternal-Fetal center is to

provide a complete continuum of care for complex Obstetrics patients,
expectant mothers, and families
 A Maternal fetal center team of experts works to establish a supportive
partnership with families before and after the birth of their child
 A Maternal-fetal care center requires substantial resources and institutional
commitment to achieve these goals and to provide a true continuum of
care from Mother wellbeing and fetal life through the initial maternal and
neonatal hospitalization and childhood follow up
 Neonatologists and Obstetrics anestesia play a key role in complex
obstetrics cases care and should take a leadership role in the strategic
vision of maternal fetal centers