Study Of Maternal Near Miss Events At The Tertiary Care Hospital

Background:A maternal near miss case is defined as a “a woman who nearly died but survived a complication that occurred during pregnancy,child birth or within 42 days of termination of pregnancy”1.MMR is defined as ratio of number of maternal deaths per 1000 live births. All pregnant women deserve a good quality of care especially Emergency Obstetric Care including proper infrastructure, human resources that can detect and manage such complications earliest. The objective of this study was to evaluate the causes of maternal near miss cases, various management modalities performed and maternal and fetal outcome in near miss cases. Material And Methods:A retrospective study was carried out in obstetrics and gynaecology department of SCL municipal general hospital, Ahmedabad for identification of MNM as per MNM-R operational guidelines (2014) in a tertiary care hospital from August 2020 to March 2022. Result:Total deliveries during our study period were 9266 out of which 535 number of patients developed complications, 75 patients ended up becoming near miss cases and 30 maternal mortalities were observed.Hypertensive disorders (38.6%) followed by severe anemia (18.6%) and haemorrhage (13.3%) were the commonest underlying causes leading to MNM. More than one management modality was followed in one case. 25% of patients required blood transfusion. Out of which 11 patients required massive blood transfusion (>5 units of blood) and 16% of patients required blood products along with blood resulting from either severe anemia or altered coagulopathy (DIC). 69.3% of patients required ICU stay of <5 days and majority of patients required hospital stay of 9-14 days.63.6% of patients required ICU stay of 1-4 days.Live birth rate was 82.6%.Conclusion:Maternal health is the direct indicator of prevailing health status in a country. Reduction in maternal mortality is one of the targets of MILLENIUM DEVELOPMENT GOALS13for 2015 but in spite of full efforts by all the health care professionals, it still remains a challenge in developing countries.There should be prompt and proper management of high-risk groups by frequent antenatal visits. Aggressive management of each complication and close monitoring of women in labour, decision making in mode and time of termination of pregnancy are important to prevent further complications.

Reflections on the use of shared decision-making in obstetric care / 中国实用护理杂志

Shared decision-making as a new model of healthcare culture is gaining more and more popularity and attention among healthcare participants. The paper successively described the concept of shared decision-making and the key points of the steps of applying shared decision-making in obstetrics, and analyzed the internal and external conditions and problems of applying shared decision-making in obstetrics wards with the help of SWOT analysis, in order to provide reference for further research and clinical practice related to shared decision-making in obstetrics wards in the future.

The effect of a two-day training and refresher program on the basic emergency obstetric and newborn care knowledge and skills of health workers in Legazpi City, Albay

@#<p style="text-align: justify;"><strong>Objectives:</strong> The availability of emergency obstetric and newborn care (EmONC) services is one of the key strategies in improving maternal health and achieving Sustainable Development Goal 3. Health staff knowledge and competency on these interventions are crucial to ensure the effective handling and management of obstetric and newborn emergencies. Health workers, despite having undergone formal training, require regular refresher courses to keep up with new, evidence-based information on EmONC intervention; and to ensure compliance with national and local referral guidelines. A two-day workshop was implemented to assess the knowledge and skills of health workers in Legazpi, Albay, regarding obstetric emergency cases and referral guidelines.</p><p style="text-align: justify;"><strong>Methods:</strong> A pretest was conducted on the first day to assess the knowledge of the participants. A series of lectures were given before administering a posttest at the end of these lectures. An Objective Structured Clinical Examination (OSCE) was conducted on the second day, which aimed to assess the skills of the participants.</p><p style="text-align: justify;"><strong>Results:</strong> The pretest findings indicated that the participants are generally knowledgeable about areas such as handwashing and prenatal care. Results of the posttest show that participants had difficulty with the category of referrals. Moreover, comparing the pretest and posttest scores, there is strong evidence that there is a difference in the median values of the pretest scores as compared to the posttest scores. The results of the OSCE also indicate the need for further training on partograph use and adherence to an EINC protocol. More than half of the participants passed all five parts of the OSCE.</p><p style="text-align: justify;"><strong>Conclusion:</strong> The workshop contributed to an improvement in the knowledge of health care workers in obstetric emergency cases. Skills-wise, more frequent training may need to be conducted to improve other competencies such as partograph utilization and the practice of EINC interventions.</p><p style="text-align: justify;"><strong>Key Words:</strong> emergency obstetric care, training, skilled birth attendants, knowledge, skills</p>

Accessibility and Utilization of Emergency Obstetric Care in Rural Settings of Wardha District- Beneficiaries Perspective

In India, Emergency Obstetric Care services were started under RCH-II with the goal to reduce MMR to less than 100/lakh live births, and increase institutional deliveries to 80% by 2010. Strategy was to enhance availability and access to EmOC, for averting unpredictable death during pregnancy and childbirth. We wanted to determine the perception of beneficiary women about accessibility and utilization pattern of EmOC at peripheral health care facilities. METHODSThe present qualitative study was conducted in one of the eight blocks of Wardha (Maharashtra) from May to October-2017. Data was collected by in-depth interview of service users (21 beneficiaries). Notes were transcribed and then translated into English. Respondents’ verbatim that are significant and illustrative as per theme of study were used for analysis.RESULTSFacilitators for EmOC were found to be birth preparedness, promotion of institutional delivery, registration for JSY/JSSK through health workers along with provision of some EmOC services. Socio-cultural beliefs, leading to delay in recognition of danger signals to access care, transportation delay due to poor access of ambulance and identified vehicles along with insufficient coverage of JSSK program, were the main barriers. Beneficiaries who required EmOC were dissatisfied due to frequent referral & travelling, expenditure on transport & food, loss of daily wages, managing dependent family members and domestic work.

Healthcare workers’ knowledge and attitude towards prompt referral of women with postpartum haemorrhage in Nigeria: a community-based study

Background: Postpartum Haemorrhage (PPH) is a major contributor to maternal mortality in developing countries most especially in the rural areas where Emergency Obstetric Care (EmOC) are not available. Delay in referring women from rural health facilities to settings where EmOC services are available have been reported. This study assessed community-based healthcare workers’ (CHWs) knowledge and attitude towards the prevention, early recognition and prompt referral of women with Post-Partum Haemorrhage (PPH) for Emergency Obstetric Care (EmOC).Methods: Descriptive cross-sectional design was used. Structured questionnaire was used to collect data from 200 CHWs recruited from community-based healthcare. Data analysis was done in SPSS version 20 at significance level of 0.05.Results: Findings show that 86.5% (n=173) of the respondents had good knowledge while 12% (n=24) and 1.5% (n=3) had moderate and poor knowledge respectively. Negative attitude towards prompt referral of women affected with PPH was found among 51% (n=102) of the respondents. Unavailability of blood drapes to estimate blood loss [χ2 (1, n=200) = 4.51, p=0.03], lack of ambulance [χ2 (1, n=200) = 4.46, p=0.03], and poor state of the roads [χ2 (1, n=200) = 4.44, p=0.03] were factors linked to poor attitude of CHWs towards prompt referral of affected women.Conclusions: The study concluded that there is a need for intervention that can help improve community healthcare workers’ attitude towards prompt referral of women affected with postpartum haemorrhage. There is also a need for general overhaul of community-based facilities to effectively support prompt referral.

Referral pattern of pregnant women coming to Cheluvamba Hospital, Mysuru, Karnataka

Background: Maternal morbidity and mortality remains a major challenge. At present pregnant women can visit any level of health care irrespective of severity of their health condition. Most of the burden of these pregnant women is on tertiary centers, hence depriving the seriously ill of the expert care. Most of the pregnancies can be managed at primary level itself. This study was therefore conducted in order to describe the referral pattern of pregnant women coming to Cheluvamba Hospital, Mysuru.Methods: It was a cross sectional study conducted during September 2018 with sample size of 100. All the pregnant women who were referred in the second week of September 2018 were included in the study without using any sampling technique and data was collected by interview using the semistructured questionnaire.Results: Mean distance travelled by study participants from their residence to Cheluvamba hospital was 42.1±29.8 kilometers. Main obstetric and logistic reason for referral was because of hypertensive disorders and non-availability of doctors respectively. Average number of ANC visits and mean gestational age upon arrival at Cheluvamba hospital was 6.71±2.3 visits and 37.4±3.6 weeks respectively.Conclusions: Most common obstetric reason for referral was hypertensive disorders. A structured referral system would help both the patient and the doctor in providing necessary obstetric care.

Availability and utilization of emergency obstetric care public health facilities in Zaria, Northern Nigeria

Background: Maternal mortality rates continue to soar high in Northern Nigeria despite all sorts of interventions being put in place. This has necessitated the need to emphasize on Emergency Obstetric Care (EmOC) to tackle obstetric complications which are the largest direct causes of maternal mortality. The study was conducted to assess the availability of Emergency Obstetric Care facilities in Zaria Local Government Area (LGA) located in Northern Nigeria.Methods: This was a hospital based cross- sectional descriptive study carried out in Zaria LGA. Data was collected from seven public health facilities using a structured interviewer administered questionnaire.Results: The LGA met the WHO requirement for the population served while none of the designated BEOC met the UN criteria for such designation. Only 8% of births took place in the health facilities and 0.7% of deliveries were by caesarean section. The met need for EmOC in Zaria LGA was 25.1%. Human resources were lacking in number and skills. Some key drugs and equipment needed to carry out signal function were also absent.Conclusions: Public health facilities in Zaria did not meet the requirements of the United Nations (UN) process indicators. There is need to upgrade the health facilities with the necessary human resource, equipment and facilities to enable them perform their designated EmOC functions.

Utilization of 108 EMRI obstetric care services for institutional delivery in Jamnagar district of Gujarat, India

Background: Robust emergency transport system is vital in the reduction of maternal mortality ratio (MMR) by curtailing delay and thus, it helps in reaching the sustainable development goals of MMR. The emergency management and referral institute (EMRI) model has shown good results in various states of India including Gujarat. There are some demographic and other reasons which may affect the choice of transport service for institutional delivery. Objective: The objective of this study was to assess the factors for utilization of 108 EMRI obstetric care services for institutional delivery in Jamnagar district of Gujarat. Materials and Methods: It was conducted in eight Primary Health Centre areas of different four talukas of Jamnagar district with a sample size of 384. Pregnant women whose institutional delivery occurred during past 6 months from the study date were included as the study population. The sampling frame consisted of a list of such woman recorded in E-Mamta from which samples were selected by systematic random sampling. Results: Among 384 institutional deliveries, 150 (39.1%) mothers used 108 EMRI for transport from their place to a health facility. Statistically significant higher utilization of 108 EMRI services was observed among scheduled caste (49.2%), scheduled tribe (42.8%), and among socioeconomic Class V (55.3%) followed by Class IV (45.2%). Absence of felt need was the major reason for not utilizing 108 EMRI. Among user, 78.7% were satisfied with the services of 108 EMRI. Conclusion: A total of 108 GVK EMRI has been the lifeline for transport of institutional deliveries for the socially disadvantaged and economically challenged community.

Training of maternal health care providers in newer modalities of management of post-partum haemorrhage

Background: Postpartum haemorrhage (PPH) is a life-threatening complication, that occurs suddenly and unexpectedly. Institutional delivery by skilled birth attendant who are trained in active management of third stage of labour and those who can use of Uterine Balloon Tamponade and Non-pneumatic anti shock garment can reduce incidence and morbidity related to PPH. The objective of the paper was to share the experiences of the training programmes held for maternal health care workers in the newer modalities of PPH management.Methods: During one and a half year period, 32 Continuation of Medical Education (CME) programmes, with the theme of “Managing Obstetric Emergencies and Obstetric Trauma”, covering important topics related to high risk pregnancies like Hypertension, Eclampsia ,Anaemia and Haemorrhage at 32 health institutions, spread over 11 states and 2 union territories in India, were conducted .In addition,42 hands on workshops  at various health facilities were conducted with training of more than 2575 maternal health care providers.Results: The pre and post test scores revealed that 95 percent of the maternal health care providers were unaware about the use of Uterine Balloon Tamponade (Bakri balloon) in PPH and Non-pneumatic anti shock garment (NASG). Seventy percent were unaware about the proper sequence of steps of active management of third stage of labour. Training programmes helped to improve the knowledge, whereas hands on workshop, helped in skill development of the health care providers. The participants expressed great satisfaction regarding the knowledge and skills they acquired through training programme on management of post-partum haemorrhage. They gave positive feedback about the quality, contents and conduct of training programme.Conclusions: There is need for refresher training of maternal health care providers in newer modalities like AMTSL, NASG and Bakri balloon, which have potential to save lives.

Use of non-pneumatic anti shock garment in hemorrhagic shock

Background: Non-pneumatic anti-shock garment (NASG) is a first-aid device that reverses hypovolemic shock and decreases obstetric haemorrhage. It consists of articulated neoprene segments that close tightly with Velcro, shunting blood from the lower body to the core organs, elevating blood pressure and increasing preload and cardiac output. The use of an NASG can stabilize a patient while awaiting transport, during transport, or during delays in receiving care at referral facilities.Methods: A prospective observational study of use of non-pneumatic anti shock garment (NASG) in cases with obstetric hemorrhagic shock was carried out at a tertiary referral center. As soon as severe shock was recognized in the hospital, the anti-shock garment was placed. Data on various parameters related to use of NASG was collected and interpreted to draw conclusions.Results: NASG was used in 25 cases of hemorrhagic shock during one-year period. Post-partum hemorrhage (36%) was the commonest indication for NASG use, followed by ruptured tubal ectopic pregnancy (28%). It was observed that 68% and 32 % of women had shock index of 1-1.5 and above 1.5 respectively at the time of application of NASG. The shock index rapidly improved to 0.5-0.9 in 92% and 1-1.5 in 8 percent of cases respectively after the application of NASG. The NASG was mainly used in labour room (40%) and emergency department (36%).  NASG was applied by nurses and doctors together in 64% of cases. NASG was kept for a period 24 hours in 92% cases. The survival rate was 96% following use of NASG.Conclusions: NASG is a temporizing alternative measure in hemorrhagic shock management that shows a trend to reduce hemorrhage related deaths and severe morbidities. NASG should be made available at all health facilities that deal with high risk pregnancies and deliveries.

Concepções sobre humanização do parto e nascimento nas teses e dissertações brasileiras / Conceptions on childbirth humanization in Brazilian theses and dissertations

Resumo Este artigo analisa as concepções de humanização do parto e nascimento presentes nas teses e dissertações brasileiras, expondo de que modo essas concepções estão vinculadas à defesa de um novo modelo de assistência em oposição às práticas da obstetrícia moderna preponderantes no país. São estudadas quatro dissertações e sete teses, apresentadas de 1997 a 2012, representativas dos principais centros de pesquisa sobre o tema e realizadas por pesquisadoras com trajetória acadêmica e profissional vinculada à história da humanização do parto e nascimento no Brasil. A análise descreve os diferentes arcabouços conceituais e enunciativos das teses e dissertações. Especificamente, de que forma a expressão "humanização", em especial a crítica técnica fundamentada no movimento "baseado em evidências", contribuiu para qualificar a crítica ao modelo de obstetrícia tradicional e hegemônico no país. Dentre os resultados, evidenciam-se nove eixos que estruturam as concepções de parto e nascimento humanizados nos trabalhos de pós-graduação brasileiros.

Abstract The article analyzes the conceptions on childbirth humanization within Brazilian theses and dissertations, exposing how such conceptions are linked to the defense of a new assistance model, in opposition to the prevailing practices of modern obstetrics in the country. We have studied four dissertations and seven theses, which were presented from 1997 to 2012, representative of the main research centers on the subject and carried out by researchers with academic and professional trajectory related to the childbirth humanization in Brazil. The analysis describes the different conceptual and enunciative frameworks of theses and dissertations. Specifically, how the expression "humanization," especially the technical critique grounded on the "evidence-based" movement, has contributed to qualify the critique of the traditional and hegemonic obstetrics model. Among the results, we have listed nine axes that structure the conceptions on humanized childbirth in graduate studies in Brazil.

Aprendizaje del cuidado obstétrico, experiencia de los estudiantes de enfermería en la práctica clínica / Obstetric care learning, experience of nursing students in the clinical practice / Aprendizagem do cuidado obstétrico, experiência dos estudantes de enfermagem na prática clínica

Introducción: La práctica clínica es un elemento medular en la formación de los profesionales de enfermería, así, el aprendizaje del cuidado está estructurado por un proceso individual, influenciado por el contexto que cada sujeto vive y el entorno que lo determina. Objetivo: Determinar el sentido y la importancia pedagógica de los fenómenos educativos vividos cotidianamente por los estudiantes en el aprendizaje del cuidado obstétrico a partir de las experiencias en la práctica clínica. Método: Estudio cualitativo-descriptivo, enfoque fenomenológico, interpretativo. Se realizaron 8 entrevistas a profundidad, a estudiantes de 7.o semestre de la Licenciatura en Enfermería y Obstetricia. Se empleó análisis temático de contenido, se señalan conceptos significativos y se asignan identificadores para generar categorías. Validación de resultados a través de criterios de credibilidad, confirmabilidad, transferibilidad y confiabilidad. Resultados: El estudio del cotidiano del estudiante de enfermería en el aprendizaje del cuidado a la gestante permitió reconocer como categoría «Praxis en el aprendizaje¼, con 2 subcategorías: a) Construcción del saber en la práctica para la transformación y b) Manteniendo motivación, iniciativa y confianza. El individuo construye el conocimiento a partir de la interacción con el entorno físico y social, donde pone en juego el desarrollo de sus capacidades cognitivas mediante la aplicación y el reajuste de sus propios esquemas cognitivos y de aplicación de destrezas. Conclusiones: El deseo por aprender algo lleva a las personas a procurar y adquirir conocimientos, habilidades, actitudes o valores que más tarde le permitirán desarrollarlas en diversos ámbitos. El impulso e interés por aprender sobre determinada temática que llame particularmente la atención o sea placentera será el motor que conduzca a profundizar en la búsqueda de conocimientos y/o mayores habilidades con resultados ampliamente satisfactorios.

Introduction: Clinical practice is a modular element within the formation of nursing professionals, and this care learning is structured through an individual process which is influenced by the specific context and its determinants. Objective: To determine the sense and pedagogical importance of the educational phenomena lived by students in their obstetric care learning process. Method: This is a qualitative-descriptive study with a phenomenological and interpretative focus. Eight in-depth interviews were performed on students of the seventh semester of a Baccalaureate in Nursing and Obstetrics program. Topic-content analysis was used. Significant concepts were pointed out, and diverse identifiers were assigned to different categories. The validation of the results is founded on the criteria of credibility, confirmability, transferability, and trustworthiness. Results: The exploration of nursing students in their pregnant women care learning process allowed us to acknowledge a ''Praxis at Learning'' category with 2 sub-categories: a) building of knowledge in the transformation practice; and b) maintenance of motivation, initiative, and confidence. Indeed, the individual builds knowledge from the interaction with the physical and social surrounding; where he/she applies and adjusts his/her cognitive capacities and skills. Conclusions: The desire for learning drives persons to procure acquiring knowledge, skills, and values which they will eventually put into practice in diverse environments. The impulse and interest for learning on a specific area of interest will be the motivation to deepen into the pleasure of acquiring more knowledge and skills.

Introdução: A prática clínica é um elemento medular na formação dos profissionais de enfermagem, assim, a aprendizagem do cuidado está estruturada por um processo individual, influenciado pelo contexto que cada sujeito vive e o ambiente que o determina. Objetivo: Determinar o sentido e a importância pedagógica dos fenómenos educativos vividos cotidianamente pelos estudantes na aprendizagem do cuidado obstétrico a partir de experiências na prática clínica. Método: Estudo qualitativo-descritivo, abordagem fenomenológica, interpretativa. Realizaram-se oito entrevistas a profundidade a estudantes do sétimo semestre da Licenciatura em Enfermagem e Obstetrícia. Realizou-se análise temática de conteúdo, assinalaram-se conceitos significativos e atribuíram-se identificadores para gerar categorias. Validação de resultados a través de critérios de credibilidade confirmabilidade, transferibilidade e confiabilidade. Resultados: O estudo do cotidiano do estudante de enfermagem na aprendizagem do cuidado à gestante permitiu reconhecer como categoria ''Práxis na aprendizagem'', com duas sub-categorias: a) Construção do saber na prática para a transformação e b) Mantendo motivação, iniciativa e confiança. O indivíduo constrói o conhecimento a partir da interação com o ambiente físico e social, onde põe em jogo o desenvolvimento de suas capacidades cognitivas a través da aplicação e o reajuste de seus próprios esquemas cognitivos de aplicação de competências. Conclusões: O desejo por aprender algo leva às pessoas a procurar adquirir conhecimentos, habilidades, atitudes ou valores que mais tarde permitirão desenvolvê-las em diversos âmbitos. O impulso e interesse por aprender sobre determinada temática que chame particularmente a atenção, quer dizer, prazeroso; será o motor que conduz a aprofundar na busca de conhecimentos e/o maiores habilidades com resultados amplamente satisfatórios.

Atenção em saúde reprodutiva no Brasil: eventuais diferenciais étnico-raciais / Reproductive health care in Brazil: searching for ethnic differentials

Resumo Este estudo teve por objetivo comparar indicadores da atenção à saúde reprodutiva das mulheres negras e brancas. São utilizadas informações obtidas no âmbito da Pesquisa Nacional de Demografia, Saúde da Criança e da Mulher (PNDS 2006). Trata-se de uma pesquisa domiciliar por amostragem probabilística complexa com representatividade nacional. Permite inferência para cinco macrorregiões, incluindo o contexto urbano e rural. Foram estudadas 14.625 mulheres brancas e negras de 15 a 49 anos de idade, que representam, respectivamente, 40% e 54% da amostra total da pesquisa. Para análise da assistência à gestação, ao parto e ao puerpério avaliaram-se as gestações dos filhos nascidos vivos nos cinco anos anteriores à entrevista segundo seis variáveis: ter feito pelo menos uma consulta de pré-natal; ter realizado no mínimo seis consultas; o tipo de parto; ter tido a dor no parto normal aliviada; ter contado com presença de acompanhante no parto e ter feito consulta no puerpério. Além da cor, constituíram-se em variáveis independentes para cada um desses desfechos: idade da mulher na data da entrevista, macrorregião de moradia, residência urbana ou rural, estar ou não casada/unida, anos de estudo, religião atual, classificação econômica (critério Brasil) e posse ou não de convênio/plano de saúde. Na análise bivariada, mulheres negras, com menor escolaridade, pior classe econômica e não portadoras de plano de saúde apresentaram desfechos mais desfavoráveis. No entanto, após análise multivariada, as diferenças entre brancas e negras perderam significância estatística. Desigualdades sociais e econômicas mantêm-se determinantes das iniquidades na atenção em saúde reprodutiva.

Abstract This study intended to compare reproductive health care indicators between white and black women in Brazil. Data collected at the 2006 Demographic and Health Survey (DHS) were analyzed. The sample allows inferences for the country's five great regions and rural/urban residence. Among 14.625 females aged 15 to 49, white and black women accounted respectively for 40% and 54% of the total sample. Health care during pregnancy and child bearing were assessed by six indicators: attendance to at least one antenatal care visit, having attended to at least six antenatal care visits, attendance to at least one health care visit after child bearing, type of delivery, having received pain relief during a vaginal birth and having someone (relative or friend) with her during delivery. Besides skin color, the following independent variables were considered: age, region of residence, urban/rural residence, religion, marital status, schooling, economic status and having or not private health insurance. At bivariate analysis, all outcomes were unfavorable for black women, for those with low both educational level and economic status, as well for those without health private insurance. However, after multivariate analysis results showed no statistical differences between black and white women. On the other hand, social and economic inequalities remained important determinants of inequities on reproductive health services access.

A study of spectrum of referral pattern at a tertiary teaching hospital towards better obstetric care

Background: 22% of the population are constituted by women of child bearing age of 15-45 years in India. They are a vulnerable risk group which is due to pregnancy and child bearing. For providing access to essential obstetric care, the referral system is an essential component of any health systems which are important in pregnancy and child birth. Aim: This study was done to review the pattern of obstetric cases referred and to identify the clinical course, mode of management, maternal and perinatal outcomes. Materials and methods: This prospective observational study reviewed 100 obstetric cases. Thorough history was taken; complete physical and obstetric examination and relevant investigations were done. Management of the patient, clinical course, mode of delivery, both maternal and perinatal outcomes were documented. Results: Most common diagnosis at referral was medical disorders complicating pregnancy (45%) among which hypertensive disorders accounted for 34%, followed by severe anemia (17%). Twentyone percent of the patients were in serious or critical condition on arrival, 29% patients required surgical intervention, 19% received intensive care management and there were no mortalities. Total number of live births were 73 (78.5%) among which 28 (30%) required neonatal admission and 5 (5.3%) had early neonatal death. Vaginal delivery rate was 78% in spite of high risk conditions and various complications. Only 30% had the required three visits and 18% had a delay ranging from 3hrs to 18 hours to reach the referral centre. Conclusion: Most common diagnosis at the time of referral was hypertensive disorders of pregnancy and its various presentations like eclampsia, HELLP, DIC, Abruption. There is still scope for Devineni K, Sodumu N. A study of spectrum of referral pattern at a tertiary teaching hospital towards better obstetric care. IAIM, 2016; 3(8): 193-198. Page 194 improving antenatal care, reduce 1st delay, 2 nd delay and need to strengthen FRU and emergency obstetric care centres at some of the districts.

Pattern of Obstetrical Emergencies and Fetal Outcomes in a Tertiary Care Center.

Introduction: Th ere is increasing awareness and facilities provided by various government and non government organizations regarding antenatal care and safe delivery practices but it is still a public health concern due to high maternal and perinatal mortality. Th e aims of present study is to assess the availability of manpower which provided services to the mothers in the peripheries, role of demographic characteristics, educational status, common pregnancy complications and there maternal and fetal outcome along with the hospital stay. Material and Methods: It was a retrospective study carried out in the Teerthanker Mahaveer Medical College. All the patients who were admitted through casualty were analysed with respect to Age, parity, Socioeconomic status, antenatal check-up, reason for referral from periphery, maternal and fetal condition at the time of admission, mode of delivery, maternal and fetal outcome along with NICU admission & hospital stay. Result: It has been observed that most of the patients with poor obstetrical outcome are multiparous or grand multiparous with low socio economic status not receiving any antenatal care. Th e common obstetrical emergencies came out were PIH (18%), obstructed labor (10.3%) followed by APH (8.2%), fetal mal-presentation (7.5%) and anemia (7.2%). Conclusion: Illiteracy and ignorance of female regarding healthcare requirements came out to be a major contributor of poor pregnancy outcome. Early diagnosis and management of high risk pregnancies is one of the measures which can reduce poor pregnancy outcomes. It is to be emphasized that majority of the maternal death from pregnancy are preventable by sample priority intervention. Co-ordination between healthcare providers at gross root level to tertiary care centre is the need of time. Health care providers at PHC and CHC levels should have adequate knowledge of antenatal requirements and importance of immunization. Th ere must be referral of high risk cases for their early and timely management. Th ere must be adequate transport facility and systematic referral system as well as provision of immediate management of referred cases at tertiary care centre. So it is high time for urgent strategic planning and investment for upgrading eff ective obstetric and neonatal care.

Significado del cuidado obstétrico desde el cotidiano del estudiante de enfermería / Meaning of the obstetric care from the everyday-perspective of nursing students

Introducción: El proceso educativo implica interacción entre sus participantes con acciones comunicativas y de intercambio dinámico donde intervienen deseos, intereses, motivaciones, expectativas e interpretaciones. La cotidianidad implica admitir una realidad compleja, con significados particulares, ya que las acciones humanas poseen sentido y significados personales; por lo que comprender el mundo social implica comprender a los actores desde lo particular. El análisis se sustenta en la teoría de Lefebvre acerca del cotidiano, quien asegura que las personas tienen que aprender a adentrarse a su espacio en beneficio propio, para satisfacer sus necesidades y deseos. Objetivo: Analizar el significado del cuidado obstétrico en el cotidiano del aprendizaje de los estudiantes. Métodos: Estudio cualitativo-descriptivo. Se recolectó información a través de ocho entrevistas a profundidad, a estudiantes de 7º semestre de la Licenciatura en Enfermería y Obstetricia. El análisis de discurso permitió señalar conceptos significativos, asignar identificadores para generar categorías. Los criterios para la validación de resultados fueron credibilidad, confirmabilidad, transferibilidad y confiabilidad. Resultados: Se presenta el análisis de la primer categoría: 1) Significado del cuidado obstétrico; con dos subcategorías: a) Participar en el milagro de la vida; y b) Responsabilidad con la familia y la comunidad en función del bienestar materno-fetal. Conclusiones: Los estudiantes otorgan significado diverso al cuidado obstétrico que tiene que ver con la responsabilidad del profesional en el bienestar materno fetal y con la experiencia de ayudar a dar vida. El aprender el cuidado obstétrico les ofrece seguridad y orgullo en el colaborar con la recepción de una nueva vida.

Introduction: The education process implies interactions among its actors which involve communication, desires, interests, motivations, expectations, and interpretations. An everyday-perspective implies admitting a complex reality with particular meanings because, human actions bear personal sense and meaning; and thus, understanding the social world implies a comprehension of its actors from the particular point of view. This analysis is based on Lefebvre's everyday-perspective theory, which states that people have to learn to insight into their own space in order to satisfy their own needs and desires. Objective: To analyze the meaning of obstetric care from the learning everyday-perspective of nursing students. Method: Qualitative-descriptive study. Data were obtained through 8 in-depth interviews to students in their 7th semester of the Nursing and Obstetrics Baccalaureate program. The analysis allowed addressing significant concepts and identifiers in order to generate diverse categories. The validation criteria of the results were credibility, trustfulness, and capacity of confirmation and transference. Results: The first category analysis is shown: 1) Meaning of obstetric care; which included two sub-categories: a) Participation in the miracle of life; and b) Responsibility with the family and the community towards the mother-fetus well-being. Discussion and conclusions: Students assign diverse meaning to the obstetric care in relation to the professional responsibility in the mother-fetus well-being. Learning about obstetric care gives students security and pride to collaborate in receiving a new life.

Utilidad de las drogas vasoactivas en la paciente obstétrica en estado crítico / Usefulness of vasoactive drugs in the obstetric patient in critical state

La paciente obstétrica en estado crítico por determinadas afecciones, pueden ser tratadas con drogas vasoactivas y demandan una atención especial por parte del obstetra. Con esta revisión bibliográfica se persiguió dar a conocer las entidades clínicas que requieren la administración de estas drogas en obstetricia, entre ellas: el embolismo del líquido amniótico, el choque séptico, el tromboembolismo pulmonar y las pérdidas de sangre, con persistencia de la inestabilidad hemodinámica después de la reposición adecuada de volumen. Igualmente, se revisan las dosis y los efectos deseados de cada medicamento, según los receptores que estimula y sus posibles efectos detrimentales. La paciente en estado crítico puede presentarse en cualquier institución hospitalaria y, en muchos casos por la urgencia de la situación, puede ser necesario el empleo de las drogas vasoactivas fuera de las unidades de cuidados intensivos, por lo que es necesidad de los obstetras estar a la altura de tales conocimientos.

The obstetric patient in critical state due to certain disorders can be treated with vasoactive drugs and demands a special care by the obstetrician. With this literature review the aim was to make known the clinical entities which require the administration of these drugs in obstetrics, among them: embolism of the amniotic fluid, the septic shock, the lung thromboembolism and blood loss, with persistence of the hemodynamic unsteadiness after the appropriate replacement of volume. Equally, the doses are checked as well as the effect of each medication, according to the receptors they stimulate and their possible harmful reactions. The patient in critical state can attend any hospital institution and, in many cases due to the emergency of the situation, it can be necessary the use of the vasoactive substances outside of the intensive care units, so it is necessary that the obstetricians get to know such knowledge.

Fundamentaciones fisiopatológicas sobre la asfixia en el periparto / Physiological and pathological bases on asphyxia during peripartum

Tomando en consideración que la asfixia es uno de los episodios más importantes en la atención perinatológica, por su repercusión intraútero y posnatal, a corto y largo plazo, se decidió efectuar una revisión bibliográfica relacionada con su fisiopatología, para así poner a disposición de la comunidad médica especializada, la información que permita dar a conocer con claridad su modo de presentación y daño sobre los órganos. Asimismo, se tuvo en cuenta que esta insuficiencia de oxígeno puede ocasionar una gran limitación en la calidad de vida de un elevado número de infantes, y que constituye una de las causas más frecuentes de cesárea en la práctica obstétrica, con el consiguiente riesgo materno y perinatal. Finalmente, se determinó la necesidad de poseer los conocimientos que permitan tomar decisiones más acertadas ante tal situación de salud.

Taking in consideration that asphyxia is one of the most important episodes in the perinatological care, due to its intrauterine and postnatal consequences, at short and long terms, it was decided to make a literature review related to its pathophysiology, so as to put to at the disposal of the specialized medical community, the information that allows to make known clearly its presentation and the damage on organs. Also, it was kept in mind that this oxygen scarcity can cause a great limitation in the life quality of a high number of infants, and which constitutes one of the most frequent causes in Caesarean sections in the obstetrical practice, with the subsequent maternal and perinatal risk. Finally, the necessity of having the knowledge that allows to make more proper decisions when facing such a health situation was determined.

A retrospective observational study of obstetric care in rural Andhra Pradesh by Dangoria Charitable Trust (1979 to 2009).

Background & objectives: In India several models of health care delivery have been explored to increase access to skilled obstetric care in rural areas, where there is a lack of specialists and appropriate facilities. We present here an innovative and affordable approach to the delivery of antenatal and obstetric care provided by the Dangoria Charitable Trust (DCT) since 1979, twinning a not-for-profit hospital in rural Andhra Pradesh with a for-profit one in the capital Hyderabad. Methods: A retrospective observational study of a random sample of the deliveries performed from 1979 to 2009 by the Dangoria Charitable Trust, based on the maternity hospital birth register, was conducted. The profile of mothers, such as their age, parity and previous miscarriages, as well as type of delivery, gender and birth weight of the newborn, and frequency of stillbirths and in hospital deaths as they evolved over time were presented using simple descriptive methods. The risk of stillbirth and in hospital death over time was explored by logistic regression after allowance for selected factors. Results: From 1979 to 2009 the cumulative number of deliveries at the Narsapur maternity hospital was 9333, from a few dozens per year in the early 1980s to over 1000 in 2009. The number of primiparae significantly increased over time, while the percentage of low birth weight babies (less than 2.5 kg) did not change appreciably. Caesarean section increased significantly over time, from 8.6 per cent in the first decade to 20.3 per cent in the last. The risk of death (stillbirths and in hospital death) consistently decreased over time, reaching 15 per thousand in the last decade. The results of a logistic regression adjusted for potential confounders showed that low birth weight babies had 4 times the risk of dying as compared to those weighing 2.5 kg or above. Conclusions: Over the 30 year period the percentage of babies discharged alive from DCT improved considerably. Caesarean sections increased significantly from the first decade to the third decade. The model adopted by the DCT to improve maternal and child health in rural areas could be replicated in other rural parts of the country.

Cobertura de atención del parto en México: Su interpretación en el contexto de la mortalidad materna / Coverage for birth care in Mexico and its interpretation within the context of maternal mortality

Objetivo. Evaluar la cobertura de atención del parto en México en el contexto de la reducción de la mortalidad materna. Material y métodos. Se utilizaron dos fuentes de información: 1) la comparación de las Encuestas Nacionales de Salud y Nutrición 2006 y 2012 (ENSANUT 2006 y 2012); 2) La base de datos que monitorea las defunciones maternas de 2012 en México (hasta el 26 de diciembre de 2012) y las estimaciones de los nacidos vivos (NV) del Consejo Nacional de Población (CONAPO) para el mismo año. Resultados. La cobertura de atención del parto en unidades médicas es cercana a 94.4% a nivel nacional, pero entidades federativas como Chiapas (60.5%), Nayarit (87.8%), Guerrero (91.2%), Durango (92.5%), Oaxaca (92.6%) y Puebla (93.4%) todavía tienen coberturas de atención del parto que son menores al promedio nacional. En las mujeres adscritas a la seguridad social, se han alcanzado coberturas cercanas a 99%, y en aquéllas afiliadas al SPSS -denominado Seguro Popular- la cobertura de atención médica del parto fue de 92.9%. También en términos de la razón de mortalidad materna (RMM), se observan grandes disparidades por entidades federativas, con un promedio nacional de 47.0 por 100 000 NV (preliminar para 2012, hasta el 26 de diciembre de este año). Esta última estimación ha sido actualizada de acuerdo con las proyecciones más recientes de la población. Conclusión. En México no existe correlación entre la elevada atención del parto en unidades médicas y la RMM, por lo que no sólo es necesario garantizar la atención universal del parto por un profesional de la salud sino que ésta la debe proporcionar personal calificado de acuerdo con el nivel de atención y con un sistema de redes de atención funcionales, además de fortalecer la calidad de la atención obstétrica y los programas de planificación familiar, e implementar políticas innovadoras de salud con acciones intersectoriales en un marco de derechos humanos que disminuyan la enorme inequidad social.

Objective. To evaluate health coverage for birth care in Mexico within the frame of maternal mortality reduction. Materials and methods. Two information sources were used: 1) The comparison between the results yield by the Mexican National Health and Nutrition Surveys 2006 and 2012 (ENSANUT 2006 and 2012), and 2) the databases monitoring maternal deaths during 2012 (up to December 26), and live births (LB) in Mexico as estimated by the Mexican National Population Council (Conapo). Results. The national coverage for birth care by medical units is nearly 94.4% at the national level, but in some federal entities such as Chiapas (60.5%), Nayarit (87.8%), Guerrero (91.2%), Durango (92.5%), Oaxaca (92.6%), and Puebla (93.4%), coverage remains below the national average. In women belonging to any social security system (eg. IMSS, IMSS Oportunidades, ISSSTE), coverage is almost 99%, whereas in those affiliated to the Mexican Popular Health Insurance (which depends directly from the Federal Ministry of Health), coverage reached 92.9%. In terms of Maternal Mortality Ratio (MMR), there are still large disparities among federal states in Mexico, with a national average of 47.0 per 100 000 LB (preliminary data for 2012, up to December 26). The MMR estimation has been updated using the most recent population projections. Conclusion. There is no correlation between the level of institutional birth care and the MMR in Mexico. It is thus necessary not only to guarantee universal birth care by health professionals, but also to provide obstetric care by qualified personnel in functional health services networks, to strengthen the quality of obstetric care, family planning programs, and to promote the implementation of new and innovative health policies that include intersectoral actions and human rights-based approaches targeted to reduce the enormous social inequity still prevailing in Mexico.