HIGH RISK OBSTETRICS CARE IN THE DEVELOPING COUNTRIES

BY
ABHISHEK JAGUESSAR

IDEAL APPROACH - AT RISK STRETEGY

All pregnant mothers are at high risk some at higher-higher risk DEFINE AND IDENTIFY HIGH RISK
COMMUNITY & FAMILY ADOLOSCENCE WOMEN & CHILDREN NEWBORNS

IN RELATION TO VITAL PARAMETRS

NUTRITIONAL LEVEL ANTHROPOLOGICAL PROFILE SOCIO-ECONOMIC STATUS EDUCATION & AWARENESS LEVEL Vs

DISEASE BURDEN RATE AND SPECIFIC MORBIDITY-MORTALITY PATTERN

KEY IMPACT FACTORS

AVAILABILITY OF AFFORDABLE QUALITY HEALTH INFRASTRUCTURE TECHNOLOGICAL SUPPORT BASE COMMUNICATION AND TRANSPORT FACILITES POLITICAL & PEOPLES COMMITMENT

Develop HIGH RISK scoring system (1)

Based upon simple clinical parameters

GROWTH PARAMETERS--BMI,HEIGHT, WEIGHT NUTRITIONAL/DIET INDEX - HAEMOGLOBIN, S.PROTEINS, CALCIUM, BONE MASS INDEX, MIDARM SKIN FOLD THICKNESS

HIGH RISK SCORING (2)

Based on social-health indicators i.e.,

AGE AT MARRIAGE, CONSUMMATION AND FIRST CONCEPTION FERTILITY RATE, ABORTION RATE, LOW BIRTH WEIGHT RATE, EXISTING MATERNAL MORTALITY AND INFANT MORTALITY RATE, UNMET NEED FOR CONTRACEPTION,RTI RATE

SET RISK SCORING (3)

MATERNAL - PERINATAL MORBIDITY & MORTALITY PATTERN/RATE FEMALE LITERACY/AWARENESS LEVEL,GENDER EQUALITY IN DECISION MAKING

AVAILABILITY OF PRE-MARITAL & PREPREGNANCY COUNSELING

DEVELOP NETWORKING OF HEALTH CARE

LEVEL I
HEALTHY MOTHER

ICU

LEVEL II

&
HEALTHY CHILD

LEVEL III
LEVELI--PRIMARY, LEVELII-SECONDARY, LEVELIII-TERTIARY, ICU-INTENSIVE CARE

THROUGH STRENGTHENING AND/OR INTRODUCING EFFECTIVE

REPRODUCTIVE HEALTH AWARENESS PROGRAM SAFE WATER AND SANITATION PRACTICES NUTRITION SUPPLEMENTATION PROGRAM, SAFE COOKING FUEL ROAD AND TRANSPORTATION SERVICES INTENSIVE MOBILE SERVICE/CARE UNIT WHILE TRANSPORTING HIGH RISK CASES TELEMEDICINE & COMMUNICATION SYSTEM TO CONNECT TERTIARY WITH THE PRIMARY & SECONDARY CARE CENTERS

Through Strengthening and/or Introducing Effective (Health sector)

PERIODIC TRAINING-RETRAINING OF THE HEALTH STAFF IN EARLY INTERVENTION/PREVENTIVE MANAGEMENT OF APH/PPH/PE/ ANEMIA/ FETAL DISTRESS/OBSTRUCTED LABOR/BREACH/SHOULDER DYSTOICIA/AFEMBOLISM/ LOW BIRTH WEIGHT BABIES, PUERPERAL INFECTIONS WELL REGULATED AUTO-TRANSFUSION & BLOOD BANK SERVICES DEVELOP RED ALERT SYSTEM IN MATERNITY HOMES

FETO-MATERNAL DISTRESS MANAGEMENT ( RED-ALERT SYSTEM IN MATERNITY HOMES ]

In developing countries

CRITICALLY ILL MOTHERS COME LATE & IN LABOR

DEATHS GENERALLY OCCUR IN LABOR ROOM DURING or SOON AFTER BIRTH EFFECTIVE FETO-MATERNAL MONITORING DURING THIS CRITICAL PERIOD CAN SAVE MANY FETOMATERNAL DEATHS & COMPLICATIONS

INTENSIVE LABOR UNIT { ILU }- RED ALERT PROTOCOL

REGULAR ORIENTATION OF STAFF ON BASIC RESUSCITATIVE MEASURES NURSES ORIENTATION ON BAG & MASK, AIRWAY MAINTENANCE, SETTING UP IV LINE, DOCTORS ON INTUBATION AND OTHER RESCUSCITATIVE MEASURES DAILY CHECKING OF EMERGENCY TROLLY

INTENSIVE LABOR UNIT { ILU }- RED ALERT PROTOCOL

EARLY DETECTION AND INTERVENTION

ONE TO ONE STAFF & PATIENT RATIO

STABILIZE THE PATIENT and SUBSEQUENT TRANSFER TO ILU-bed

GENERAL EVALUATION

MATERNAL AND FETAL VITAL SIGNS GENERAL PHYSICAL EXAMINATION PER ABDOMEN EXAMINATION SCAN, DOPPLER, CTG INVESTIGATIONS: FBC, COAGULATION PROFILE BLOOD GROUP & CROSS MATCHING URINE, ABG IF AVAILABLE

ACTIVATE RED ALERT SYSTEM

CALL FOR OBSTETRICIAN,INTERNIST & ANESTHESIOLOGIST SET UP IPPV, CVP, PUL. WEDGE PRESS MONITOR,& OT IF NEED ARISE FOR LSCS KEEP READY FFP,CRYOPPT, PLATELET CONCENTRATES, FRESH BLOOD, ACTIVATE SIMULTANEOUS FETAL MONITORING SYSTEM AND PARTOGRAM RECORDING

FETAL WELL-BEING IS JEOPARDIZED INUTERO

INTRAUTERINE ENVIRONMENT IS HOSTILE FETAL ABILITY TO ADAPT IS DIFFICULT

PHYSIOLOGY: NORMALLY FETUS CAN UTILIZE ANAEROBIC METABOLISM - CAN BUFFER LACTIC ACID

BRAIN CAN WITHSTAND DESATURATE BLOOD UPTO 10 (2ND STAGE) - ALL DUE TO GLYCOGEN STORE BRAIN DAMAGE CEREBRAL PALSY

TOOLS FOR DIAGNOSIS OF FETAL DISTRESS

( As per the availability )
DFMC PINARD STETHOSCOPE MECONIUM STAIN AMNIOSCOPE ELECTRONIC FETAL MONITOR FETAL BLOOD SAMPLING FETAL ECG INFRA-RED SPECTROSCOPY DOPPLER & SCAN

MANAGEMENT PROTOCOL

ANTENATAL: CLINICAL, DFMC, NST,OCT, MANNINGS, DOPPLER, BIOCHEMICAL

INTRAPARTUM : LOW RISK : INTERMITTENT AUSCULTATION (IA) SAME AS CTG

HIGH RISK : SHORT CTG TRACING

FOLLOWED BY CONTINUOS TRACING ABN. CTG +/_ MECONEUM FBS

NORMAL CTG + MECONEUM - FOLLOW UP

INTRAPARTUM MANAGEMENT

SHIFT POSITION : CORRECT CORD COMPRESSION, SUPINE HYPOTENSION OXYGEN MASK & CORRECT ACIDOSIS 5% DX 500 ML EVERY 3 HR STOP OXYTOCIN B-MIMETICS (RITRODIN) IF HYPERTONIC CONTRACTIONS AVOID PATHIDINE

INTRAPARTUM MANAGEMENT (PREVENT COMPLICATION)

DIAGNOSE AND CORRECT: SHOULDER DYSTOCIA BREECH (AFTER COMING HEAD) CORD PROLAPSE DEEP TRANSVERSE ARREST PERSISTENT OCCIPITOPOSTERIOR POSITION EXPEDITE DELIVERY: BY SUITABLE MODE AND TIMING

IMPORTANT RECOMMENDATIONS FOR DEVELOPING COUNTRIES

LIMIT LSCS IF POSSIBLE FOR FUTURE PREVENTION OF RUPTURED UTERUS

SUPPORT AND TRAIN DOCTORS ON OPTIMAL USE OF FORCEPS/VENTOUSE/SYMPHYSIOTOMY/EXTERNAL CEPHALIC VERSION/ STABILIZING INDUCTION
LEARN VAGINAL BREACH DELIVERY

IMPORTANT RECOMMENDATIONS FOR POST-PARTUM PERIOD

INTRODUCE CONCEPT OF INTENSIVE 4TH STAGE MONITORING ( IST 2 HRS OF POST-PARTUM PERIOD )
TO PREVENT

PULMONARY EDEMA, HYPOVOLUMEA, RENAL SHUT DOWN, DI VC, EMBOLISM ETC.--MAJOR CAUSE OF IMMEDIATE MATERNAL DEATHS

ACTIVE CARE OF THE PUEPERIUM PERIOD TO PREVENT INFECTIONS, PROMOTE BREAST FEEDING,
PROMOTE AWARENESS ON CONTRACEPTION