Emergency obstitric care

1. Emergency Obstetric
care

2. Prepared by
Yasmine Mahmoud

5. Maternal Death (mortality)
• A maternal death is “the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the
duration or site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management, but not from
accidental causes”. 99 % of maternal deaths occur in the developing
countries. Only 1% occurs in developed countries.

8. Leading causes of maternal deaths
1. A direct obstetric death which is caused by complication that
develops directly as a result of pregnancy, delivery or the
postpartum period. It accounts for about 75 % of all maternal
deaths in developing countries.
2. An indirect obstetric death which is due to existing medical
conditions that are made worse by delivery or pregnancy. It
accounts for about 25 % of all maternal deaths in developing
countries.

15. EmOC (emergency obstetric care):
 Is a package of medical interventions that has been developed to
treat the five direct obstetric complications—obstetric hemorrhage,
obstructed labor, septicemia, hypertensive disorders in pregnancy,
and unsafe abortion—that cause 75% of maternal deaths.
 It is a subset of EOC and refers to the management of complications

20. •EOC (essential obstetric care): Is used to describe the elements of obstetric
care needed for the management of normal and complicated pregnancy, labor, and
childbirth care.
•Basic EOC: includes the management of normal pregnancy, labor, childbirth, and
the postpartum period.
•Comprehensive EOC: Includes in addition to the elements of basic EOC—
blood transfusion, anesthesia, and surgical procedures such as cesarean section.
•EOC, whether basic or comprehensive, must be available 24hours a day, seven days
a week. All elements of comprehensive EOC should be available at district hospitals,
while all elements of basic EOC should be available at basic and comprehensive
health centers.

21. Characteristics of good EmOC program:
• Exist and function
• Be geographically and sustain equity
• Used by pregnant women
• Used by women with complications
• Provide sufficient and timely life-saving services
• Provide good-quality care
• Appropriately staffed and equipped
• Available 24hours in 7 days per week
•

24. International goals for EmOC:
1. For every 500,000 population, there should be at least one
comprehensive site (within 12 hours) and four basic EmOC facilities
(within 4 hours).
2. There should be appropriate geographic distribution of EmOC facilities.
3. At least 15% of births should take place in a health facility
4. 100% of obstetric complications should be treated.
5. Cesarean sections should be between 5% and 15% of all births.
6. Case fatality rate of direct obstetric complications should be less than
1%.
7. Skilled attendance at every birth

25. Barriers for effective EMOC

29. Criteria for Basic and Comprehensive EOC
Comprehensive EOC
Basic EOC
Require operating theater & usually
performed in district hospitals
Performed in a health center without
need for operating theater
All elements of Basic EOC,
plus
1.surgery (e.g., cesarean section) &
anesthesia
2.blood transfusion
Management of normal and
complicated pregnancy, childbirth,
and postpartum period, including:
1.(IV)Intramuscular(IM)antibiotics
2.uterotonics, and anticonvulsants
3.manual removal of placenta
4.removal of retained products
5.assisted vaginal childbirth

30. Basic Emergency Obstetric Care: First
Response
• 1. Essential equipment, medication, and supplies,
• 2. Skilled staff
• 3. A clear system to respond to emergencies
• 4. Financial systems to reduce barriers to emergency care, and
• 5. Emergency transport to a facility able to provide
comprehensive obstetric care(the referral facility).

31. (1)Essential equipment,
medication, and supplies

32. Emergency room requirement according to evidence
based
 The emergency room (ER) must be ready around the
clock to receive emergency cases.
 A wheelchair, trolley or stretcher must be available at
the hospital gate or reception area, and someone
should be designated to transport the patient to the
ER.
 Core staff must be available 24 hours a day.

33.  The ER should be equipped with the following items:
• 1- Emergency drugs and IV solutions
• 2- Examination table with privacy
• 3- Blood pressure (BP) apparatus, stethoscope,
thermometer, kidney basin, sterile gloves
• 4 -waiting room with seats for relatives
• 5- Wall charts describing EmOC guidelines

34. delivery room requirement according to evidence based.
• Labor and delivery staff should be available and prepared to handle
emergency cases around the clock.
• The room should be kept ready with the following items:
• Three sterilized delivery sets
• Delivery table with stirrups
• -sterilized gloves, gowns, gauze, cotton balls clean linen, e.g., gowns
• sterilized forceps set
• Functioning vacuum extractor
• Two manual vacuum aspiration (MVA) kits, including syringes and
cannulas
• Functioning suction machine with suction tube

35. • 8- Mucus extractors for neonates (for emergencies,not for routine
suction)
• 9- Filled oxygen cylinder with cylinder carrier and key
• 10- Emergency drugs, with list showing quantity and expiration dates
• 11- Adult and neonatal resuscitation equipment
• 12- ambu-bags
• 13- Functioning BP apparatus, stethoscope, thermometer
• 14- IV stands IV needles and cannulas
• 15- Stretcher or trolley
• 16- Wall charts describing EmOC guidelines

36. The operating theater
It should be equipped and made functional with the following items:
•1- At least three sets of sterilized Cesarean section instruments
•2-two dilation and curettage sets
•3- Sterilized linen packs
•4 -sterilized gloves, gowns, gauze, cotton balls
•5- Sterilized suction tube and nozzle
•6- Functioning OT light with spare bulbs
•7- OT table
•8- Functioning suction machine
•9- Emergency drugs, with list showing quantity and expiration dates
•10- resuscitator/ambu-bag

37. 2. Skilled staff

38. Skilled birth attendant (SBA):
• -Is a trained health provider who has completed a set course of study in
handling obstetric emergencies and is registered or legally licensed to
practice.
• -Include: doctors, nurses, midwives, and other health workers who:
1. Can diagnose and manage complications during pregnancy and childbirth
2. Can assist in normal deliveries
3. Are linked to a referral system for further care when necessary
4. Skilled attendance at birth reduces the risk of maternal mortality by 13-
33%

39. 2. Skilled staff
 Experience scenarios and intervene in clinical
situations within a safe, supervised setting
without posing a risk to a patient.
 Patient simulation is an instructional strategy
that can be implemented in a variety of
settings, is adaptable to most settings, and can
give providers opportunities to practice skills

40. 3. A clear system to
respond to emergencies

41.  Emergencies often happen suddenly and can progress quickly
to a negative outcome if appropriate and immediate action is
not taken.
 Responding to an emergency promptly and effectively requires
two things:
• (1) Clinical protocols that provide clear guidance on decisions
and criteria regarding diagnosis, management, and treatment
• (2) clear roles and responsibilities for each member of an
emergency response team

42.  Clinical protocols are based on the highest quality evidence
and most current data and identify all possible decision options
and their outcomes.
 When systematically applied, clinical guidelines help to
standardize medical care, to raise quality of care, and to reduce
risk for the patient and the health care provider.
 Checklists can be developed from established clinical
protocols and contain the individual steps or tasks required to
perform a skill or activity in a standardized way.

43.  The medical emergency team (MET) system is used worldwide to
improve patient outcomes and an opinion of the American College of
Obstetricians and Gynecologists (ACOG) committee emphasizes the
importance of crisis response teams for clinical obstetric
emergencies.
 While limited, these experiences had positive results measured in
response time and maternal and perinatal outcomes.
 Use of checklists and obstetric METs have the potential to improve
maternal and neonatal outcomes, reduce maternal and neonatal
morbidity and mortality, and reduce health care costs but will require
additional operational research to identify best practices.

44. 4.Financial systems to reduce
barriers to emergency care

45.  One of the major barriers to maternal health care is limited
financial resources.
 Women seeking obstetric services will usually have to pay for
drugs, various registration fees per visit or per day, and
treatment charges, even in emergencies.
 As most families have no medical insurance, they must pay
from the household budget, which is usually stretched to the
limit.
 This has led to delays in seeking and receiving care.

46.  A number of strategies have been developed to address the
problem of financial access to obstetric care in low-resource
settings, which include community emergency loans, insurance
schemes, and subsidized or free obstetric and/or emergency
obstetric services, as cesarean operations.
 Of these, insurance schemes and subsidization of services can
potentially be managed at the health care facility level.

47. 5.Emergency transport to
(the referral facility).

48. Emergency transport to a facility able to provide
comprehensive obstetric care(the referral facility).
 Once a woman receives immediate emergency care for an obstetric
complication, she may require definitive care at a referral facility,
such as the district hospital.
 Transfer from one level of the health system to another is usually
financed by the ministry of health (MOH).
 The Averting Maternal Death and Disability (AMDD) project is
currently researching referral systems in developing countries to help
MOHs make informed decisions about effective mechanisms for
referral.

49.  Research includes identifying gaps in the management of referral
systems, training for drivers, the use of clinical protocols, a
monitoring system for referral, and the availability of communication
and transportation.
 Needs assessment tools have been developed to assist MOHs in
analyzing referral readiness and determining where emergency
transport vehicles should be prioritized.
 Because of the heterogeneity of settings, it is difficult to recommend
strategies or solutions for the transport problem.