Empowering midwives to manage postpartum haemorrhage in rural areas of Islamic Republic of Iran: lessons learnt from cases of maternal death.

BACKGROUND: Postpartum haemorrhage is the main cause of maternal mortality in rural areas of low-income countries. AIMS: This study investigated the causes of maternal death from postpartum haemorrhage in rural areas of Sistan and Baluchestan, Islamic Republic of Iran, and determined the effect of three interventions on midwives' management of haemorrhage. METHODS: Maternal deaths in women with postpartum haemorrhage between 9 April 2012 and 9 April 2013 were reviewed to determine what contributed to the death. Following the review, prostaglandin was permitted for use in rural maternity units. A flowchart on managing haemorrhagic shock and a training workshop on management of postpartum haemorrhage were also developed for midwives working in rural areas. After the interventions, all cases of postpartum haemorrhage (n = 81) that occurred during 23 September 2014-23 February 2015 in rural maternity facilities were reviewed based on 19 indicators. A control group (n = 81) was selected from women with postpartum haemorrhage who had been admitted to the same maternity units before the interventions. RESULTS: After the training interventions, more midwives used more than one method to estimate blood loss and higher doses of oxytocin to control haemorrhage. They showed improvements in the use of intravenous fluid therapy, pulse and blood pressure checks, external uterine massage, and uterotonic drugs. Following training, more women were admitted to hospital in a stable condition and recovered and were discharged (P = 0.002), and fewer had surgical interventions (P = 0.007). CONCLUSION: Midwives' management of postpartum haemorrhage improved after the interventions. Training programmes should be based on study of the local situation to identify shortcomings. Regular monitoring of outcomes is needed to detect and resolve failures.

The effect of electroconvulsive therapy using propofol and succinylcholine on the intraocular pressure.

PURPOSE: Electroconvulsive therapy (ECT) is a therapeutic procedure in many mood and psychiatric disorders. After induction of general anesthesia by administering an induction dose of an intravenous anesthetic such as Propofol, intravenous succinylcholine is often used to prevent bone fractures and joint dislocations during ECT. Intraocular pressure (IOP) is raised by succinylcholine and tonic-colonic convulsion,and decreased by propofol administration. To our knowledge, there is no published paper on the effect of ECT using propofol and succinylcholine on the IOP. This study for the first time shows the effect of ECT on IOP. The source of the financial support is a grant allocation of Zahedan University of Medical Sciences. There is no financial relationship between authors and commercial interest with a vested interest in the outcome of the study. METHODS: One hundred patients 20 to 40 years old ASA class 1 or 2 without any ophthalmic disorders were enrolled. All of the psychiatric medications were discontinued 48 hours before ECT treatment. The baseline IOP values of the patients were checked after application of sterile eye drop tetracaine 0.5% by an applanation tonometer, and then the patients received atropine 0.5 mg, propofol 0.75 mg/kg, succinylcholine 1 mg/kg intravenously, with intervals of 1 minute. Then electrical stimulation was delivered via bi-frontal electrodes. IOPs were checked before any drug administration, before electrical application, as well as 1, 5 and 10 minutes after termination of the convulsion. RESULTS: The baseline IOP (14.81 +/- 3.6 mmHg) decreased significantly after administration of propofol (13.18 +/- 3.55 mmHg) but increased significantly after succinylcholine (15.52 +/- 3.58 mmHg), one minute (18.32 +/- 3.49 mmHg) and 5 minutes after convulsion (15.41 +/- 3.46 mmHg). However, IOP returned to the baseline 10 minutes after convulsion (14.68 +/- 3.57 mmHg). CONCLUSION: IOP increased after ECT but the IOP levels never reached to pathologic range in this study. Therefore, regarding IOP, ECT is a safe procedure in patients with normal eye condition. Further studies are recommended in older patients with ophthalmic diseases.

Effect of oral clonidine on acute intraocular pressure rise after cataract extraction under general anaesthesia.

OBJECTIVE: To evaluate the efficacy of preoperative oral clonidine (5 g/kg) in preventing ocular hypertension in the early period after cataract surgery with posterior chamber intraocular lens implantation under general anaesthesia. METHODS: This was a randomized double-blind clinical trial comprising of 62 eyes in 62 patients with senile cataract without using any viscoelastics. They were randomly assigned into two groups for preoperative oral clonidine (5 g/kg) and placebo. Intraocular pressure (IOP) was measured 6,12 and 24 hours postoperatively. RESULTS: Mean differences of lOPs at 6 and 12 hours after surgery were significantly lower in clonidine group [+0.41 4.55 (p = 0.612), 0.06 3.62 (p = 0.922)] than placebo group [5.77 4.25 (p = < 0.001), 4.70 3.19p < 0.001)] but was more than preoperative intraocular pressures in both. There was no statistically significant difference between the mean IOP 24hours post operatively in the two groups. But compared to preoperative IOP less increase in mean IOP was seen in clonidine group when compared to placebo group. CONCLUSION: A single dose of oral clonidine (5 g/kg) preoperatively can produce a significant IOP-lowering effect in early period after cataract surgery, specially in the first 12 hours.

Effect of oral clonidine on acute intraocular pressure rise after phacoemulsification: a prospective double-blind, randomized, clinical trial.

OBJECTIVE: To determine the efficacy and safety of oral clonidine in decreasing the prevalence and intensity of postoperative intraocular pressure (IOP) rise in those undergoing phacoemulsification. METHODS: This was a prospective randomized, double-blind, placebo-controlled, clinical trial including 62 patients (each with 1 affected aye) with senile cataract scheduled for phacoemulsification who were randomly assigned to receive preoperative oral clonidine (5 µg/kg, 31 patients) or placebo (1 tablet, 31 patients). The IOP was measured preoperatively and at 6, 12, and 24 h postoperatively. The prevalence and intensity of the acute postoperative IOP rise was compared between and within the groups. RESULTS: There was no significant difference between the 2 study groups regarding the baseline characteristics and the baseline IOP (P=0.628). Patients who received placebo as premedication had significantly higher IOP at 6 (17.96±5.49 vs. 13.61±4.09; P<0.001) and 12 (16.90±4.11 vs. 13.96±3.25; P=0.003) h postoperatively compared with those who received oral clonidine. However, there was no significant difference between the 2 groups regarding the IOP at 24 h after operation (15.41±3.96 vs. 16.01±3.41; P=0.0539). The prevalence of acute IOP rise (>21 mmHg) was significantly higher in placebo group compared with clonidine group (25.8% vs. 9.6%; P=0.091). CONCLUSION: Administering preoperative oral clonidine in a dosage of 5 µg/kg, 2 h before phacoemulsification, significantly decreases the prevalence and intensity of acute postoperative IOP rise in those undergoing general anesthesia. Oral clonidine is safe, cheap, and easily accessible and, thus, it is recommended for controlling the IOP after phacoemulsification, especially in high-risk patients.