What do doctors think their caseload should be to maintain their skills for delivery care?

OBJECTIVES: To seek the opinions of doctors on what they thought the minimum, maximum and optimum annual caseload should be for the maintenance of skills and competence in a variety of obstetric procedures. METHODS: An expert panel of respondents from Africa and Asia was asked to give their opinions on what they believed the minimum, maximum and optimum caseload should be for 11 obstetric procedures via a series of structured questionnaires (Delphi exercise). In subsequent questionnaires, participants were asked if they wished to reconsider their opinions in light of the group response. RESULTS: The median values of responses given for the minimum, maximum and optimum caseloads for the 11 obstetric procedures did not change substantially over time, though greater consensus was developed as indicated by reductions in the size of inter-quartile ranges in later rounds. CONCLUSIONS: We encountered several problems associated with using the Delphi technique in this context, which throws doubt on the validity and usefulness of our results. Caseload is just one of many factors, as indicated by our expert panel that need to be considered when planning the delivery of obstetric services in remote areas. High quality training, continued medical education, appropriate quality assurance procedures, and provision of a supportive enabling environment are also important requirements. In addition, the views of clinicians need to be balanced against more objective evidence of quality of care and patient outcome in relation to procedural volume. Such evidence is lacking in the field of obstetrics and requires further investigation.

Reducing maternal mortality from eclampsia, using magnesium sulphate.

Since the introduction of low dose magnesium sulphate to treat eclamptic patients at Dhaka Medical College, mortality rates have fallen from 16% to 8%. Personal communications from other centres in Bangladesh show similar findings.

Evaluation of chemical tests for fetal bleeding from vasa previa.

OBJECTIVES: To evaluate different alkaline denaturation tests and compare with hemoglobin electrophoresis and the Kleihauer test, and to identify the simplest and most sensitive test that may help to rapidly show the presence of fetal hemoglobin and establish the diagnosis of fetal bleeding from vasa previa. METHODS: Maternal and fetal cord blood were obtained from 20 women with uncomplicated deliveries and the samples were mixed in known concentrations ranging from 0-100% fetal blood. Further samples were prepared in which maternal and fetal blood mixtures were diluted with amniotic fluid so that the final concentration of fetal hemoglobin similarly ranged from 0-100%. Alkaline denaturation tests (Apt, Ogita, Loendersloot), hemoglobin electrophoresis and Kleihauer tests were performed on all 40 samples. RESULTS: The Apt and Loendersloot tests were clearly positive at 60% concentrations of fetal blood. It took approximately 7 and 4 min, respectively, to complete the tests. The Ogita test was positive from fetal blood concentrations of 20% and took approximately 5 min. Hemoglobin electrophoresis took approximately 1 h to complete and the Hb-F band was present even at 0% concentration of fetal blood and the band became more marked with increasing fetal blood concentration. The Kleihauer test was negative at 0% but positive from 0.01% fetal blood concentration. The test took approximately 45 min to perform. CONCLUSIONS: The Ogita test is the best all round alkaline denaturation test that may help to rapidly identify the presence of fetal hemoglobin and so establish the need to expedite delivery when there is fetal bleeding from vasa previa. It is simple to perform, does not require sophisticated equipment, unlikely to give false positive results, and takes only 5 min. The simplicity of the test makes it attractive for routine use on the labor ward.

Obstetric skills at district and sub-district hospitals.

A new policy for emergency obstetric care (EOC) which should be provided at district and sub-district hospitals has been adopted in Bangladesh. Therefore a survey of the obstetric skills of doctors at these institutions was performed. The current skills of the doctors was compared with their self-perceived skills when they left their medical college hospitals. Although in many cases self learning had occurred it was shown that, unless a doctor had been competent to perform a skill under indirect supervision, competency was often not reached.

A simple alternative to parenteral oxytocics for the third stage of labor.

OBJECTIVE: To determine the effect of nipple stimulation on uterine activity during the third stage of labor. METHODS: Randomized controlled study comparing; (i) 15 min of nipple stimulation (n = 6), (ii) routine syntometrine injection (n = 3), (iii) no action/control (N = 5). Uterine activity was continuously measured using the placenta as an in-situ hydrostatic bag connected to a pressure transducer. RESULTS: Compared to controls uterine pressure was higher during nipple stimulation (103 mmHg vs. 70.8 mmHg, P = 0.04). The duration of the third stage and blood loss tended to be reduced with nipple stimulation compared to controls (20.3 vs. 12.3 min) and (257 vs. 166 ml) respectively but was not significant. Similar differences were observed between syntometrine and control groups. CONCLUSIONS: For women in developing countries where parenteral oxytocics are not available, nipple stimulation might reduce the incidence of postpartum hemorrhage. A larger trial now seems warranted.

Action in international medicine and maternal health care in developing countries.

PIP: Action in International Medicine (AIM) was founded in 1988 with 88 institutes of medicine and professional organizations as members to assist in health care in developing countries. The Royal College of Obstetricians and Gynecologists (RCOG) was present at the 1st World Assemble in Toronto in 1991. The development of district health systems for improvement of health in developing countries was envisioned. Primary health care has developed well since the Alma Ata Declaration in 1978, but basic lifesaving interventions have received scant attention. AIM's World Assembly identified the issue of Safe Motherhood, and issued the Toronto Declaration on Global Health Care for the promotion of culturally appropriate health care infrastructure integrated at the district level, and for the training of professional working with deprived populations. The rationale was prompted by the inconsistencies of health care and inequitable distribution of physicians in developing countries. RCOG is involved in postgraduate education of doctors, and it developed a diploma course in maternal and neonatal health focusing on epidemiology, community health, medical manpower, and management to provide maternity care. Obstetric training of district doctors is also necessary as most undertake emergency obstetrics. Another objective of AIM is to foster the exchange of experiences of doctors in other countries, since professional organizations in overseas countries could raise the compensation, status, and conditions of district level doctors.^ieng

[A simple statistical method for achieving reliability in anthropometric measurements]. / Un método estadístico simple para obtener confiabilidad en las mediciones antropométricas.

Most anthropometric studies fail to comment on the reliability of the measures. The authors assume that the complexity of the classical analysis of variance approach is one of the reasons for this. They therefore describe a simpler, yet scientifically sound method which assesses three sources of measurement error: intra and inter-observer as well as instrument errors. The measure of upper-arm-circumference of pregnant women, which has been proposed to be a predictor of birth-weight, is used as an example. Reliability was assessed by calculating agreement of a series of pairs of measurements. Inter and intra-observer-errors were found to be of the same size. Both types of human errors were statistically significantly greater than the error arising from the use of two different types of tapes (instrument error). It is hoped that other authors find this approach useful so that information on reliability in anthropometric studies becomes the rule rather the exception.

Effect of early suckling on term neonates' core body temperature.

The purpose of this study was to determine whether the practice of early suckling, through an effect on maternal behaviour, would improve neonatal temperature control. One hundred and sixty mothers having daytime spontaneous deliveries of healthy babies at term were randomized into two groups. The treatment group were encouraged to put the baby to the breast immediately after delivery. In the control group, the baby was placed in a cot immediately after birth and breastfeeding occurred some time later at a time of the mother's choice. Observations of the mother's behaviour towards her baby and the baby's core body temperature were recorded at 2 and 4 hours after birth and at 8 a.m. the next day. The early suckling group mothers were observed breastfeeding their babies more often than those of the control group. Significantly more of the control babies had temperatures below 36.5 degrees C at 8 a.m. the next day. Women of either group who were breastfeeding immediately prior to temperature recording were significantly less likely to have a baby with a low body temperature. It is concluded that a policy of early suckling, when compared with one of delayed contact, appears to reduce the incidence of low body temperature in the neonate.

Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants.

A randomised, controlled trial was carried out to determine whether suckling immediately after birth reduces the frequency of post-partum haemorrhage (PPH), the mean blood loss, and the frequency of retained placenta. The trial subjects were attended by traditional birth attendants (TBAs), and randomisation was by TBA and not by mother. 68 TBAs attended a course on third stage management and data collection; 19 had to be excluded from the trial. 23 TBAs in the early suckling group and 26 in the control group recorded blood loss in 2104 and 2123 deliveries of liveborn singletons, respectively. The frequency of PPH (loss greater than 500 ml) was 7.9% in the suckling group and 8.4% in the control group and the mean blood loss 258 ml and 256 ml, respectively. Neither of these results differed significantly between the groups. Analysis of the results by individual TBA showed no significant difference between the groups. The frequency of PPH in women of higher parity and in those with multiple pregnancies and stillbirths was high, as expected, which seems to validate the results. The frequency of retained placenta was too low to be analysed.

Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants

A randomised; controlled trial was carried out to determine whether suckling immediately after birth reduces the frequency of post-partum haemorrhage (PPH); the mean blood loss; and the frequency of retained placenta. The trial subjects were attended by Traditional Birth Attendants (TBAs); and randomisation was by TBA and not by mother. 68 TBAs attended a course on third stage management and data collection; 19 had to be excluded from the trial. 23 TBAs in the early suckling group and 26 in the control group recorded blood loss in 2104 and 2123 deliveries of liveborn singletons; respectively. The frequency of PPH (loss greater than 500 ml) was 7.9 percent in the suckling group and 8.4 percent in the control group and the mean blood loss 258 ml and 256 ml; respectively. Neither of these results differed significantly between the groups. Analysis of the results by individual TBA showed no significant difference between the groups. The frequency of PPH in women of higher parity and in those with multiple pregnancies and stillbirths was high; as expected; which seems to validate the results. The frequency of retained placenta was too low to be analysed

Postnatal care.

PIP: Early contact between mother and baby and early breastfeeding are essential elements of postnatal care. They promote bonding and a better breastfeeding performance, and cannot be overemphasized. Thereafter, in hospital practice, the next essential is a separation of abnormal from normal cases so that those in greatest need may receive the care they require. Commonly occurring postnatal problems should be managed according to standard protocols, so that effective management can be instituted by midwives or junior medical staff as necessary. Special attention must be paid to those with severe puerperal sepsis. There should be a readiness to recognize and treat such rare but curable conditions as acute tubular necrosis. Proper advice to the mother and the recording of significant events of the pregnancy in a document kept by the mother is the doctor's final responsibility.^ieng

Herbal medicines used by traditional birth attendants in Malawi.

Some herbal medicines used by Traditional Birth Attendants (TBA) in Malawi are identified, and the way in which the TBAs use them described. Two of the medicines were found to possess the oxytocic properties which the TBAs claimed for them.

Herbal medicines used by traditional birth attendants in Malawi

Some herbal medicines used by Traditional Birth Attendants (TBA) in Malawi are identified; and the way in which the TBAs use them described. Two of the medicines were found to possess the oxytocic properties which the TBAs claimed for them

Analysis of maternal deaths in the Central Region of Malawi.

PIP: A maternal death survey was conducted in the Central Region of Malawi in 1977 in an effort to determine if most maternal deaths were caused by factors outside the control of the recognized maternity services. A secondary purpose was to determine whether the training of traditional birth attendants (TBAs) would be of value and to identify the critical lessons and skills that the TBA must learn. Questionnaire forms were sent in late 1976 to physicians in charge of the district and mission hospitals in the region and to midwives of the larger maternity units. Information was requested on every death occurring in pregnancy or within 42 days of delivery, ectopic pregnancy, or abortion, during 1977. There were 118 maternal deaths. 112 took place in the hospital and 6 at home. It is likely that many unreported deaths occurred at home; the mortality figures for the region appear to be a gross under-estimate. Information about the cause of death was received for 116 of the deaths. Analysis was based on 109 cases. Of these, 4 deaths were due to abortion, 3 to ectopic pregnancy and 6 others occurred before the 28th week of gestation. In 103 cases, where death occurred after the 16th week of gestation, only 33 women were known to have attended antenatal clinics. 42 women had not attended, and the information was unavailable in 28 cases. Toxic effects of herbal medicines was diagnosed in a significant number of cases. Shortage of blood for transfusion was a problem of major significance. The training of TBAs is recommended as a means for strengthening maternity services.^ieng