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Maternal Care: Regionalised perinatal care


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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Regionalised perinatal care

  1. 1. 15 Regionalised perinatal careBefore you begin this unit, please take the care in that region must fall under a singlecorresponding test at the end of the book to health authority as this standardises care andassess your knowledge of the subject matter. You prevents wasteful duplication of services. Theshould redo the test after you’ve worked through borders of each healthcare region will have tothe unit, to evaluate what you have learned. be negotiated with the communities and local health authorities concerned. Similarly, other healthcare services should also be organised Objectives on a regional basis. When you have completed this unit you All perinatal care provided in a region should be should be able to: the responsibility of a single health authority. • List the advantages of regionalised perinatal care. 15-2 Do all women require the • Describe the functioning of a maternal- same care during their pregnancy, care clinic. labour and puerperium? • Communicate better with patients and All patients should receive good care. colleagues. However, all patients do not need the same • Safely transfer a patient to hospital. care as they do not all run the same risk of developing perinatal problems. Patients can be • Determine the maternal mortality rate. classified into three separate groups: 1. Most patients have only a small chance ofREGIONALISED developing problems during and after their pregnancy. These women are classified asPERINATAL CARE low risk. About 50% of women fall into the low-risk category. 2. About 30% of patients have an increased15-1 What is regionalised perinatal care? chance of complications during certainRegionalised perinatal care is the care of all periods of their pregnancy, labour andpregnant women and their newborn infants puerperium only. These patients are saidin a single health system within a clearly to be at intermediate risk. For example, adefined region. The responsibility for perinatal patient who has had a previous Caesarean
  2. 2. REGIONALISED PERINATAL CARE 267 section for cephalopelvic disproportion immediately available should complications is at low risk during her pregnancy and develop. The important feature of tertiary care may, therefore, be cared for at a clinic. is the immediate availability of specialist staff However, she is at increased risk during and facilities should they be needed. labour and, therefore, must be delivered in a hospital with facilities to perform a 15-5 What should be the relationship Caesarean section. between the various hospitals3. About 20% of women have an increased in a healthcare region? chance of medical or obstetric problems during their pregnancy and puerperium. Each healthcare region will have a regional They are classified as high-risk patients. hospital (level 2) which provides secondary care. Usually two or three regions are supported by a tertiary hospital (level 3). Some15-3 Should all pregnant women tertiary hospitals are attached to a medicalbe delivered in a hospital? school while most have a nursing college.No. Low-risk patients need primary Each region will also have a number of base orperinatal care only. This consists of good, district hospitals (level 1) which will providebasic perinatal care which can be provided level 1 care. The regional hospital is responsibleat a district hospital or primary-care clinic. for the district hospitals in that region.Low-risk patients should be delivered at a The staff at the regional hospital shouldclinic or district hospital. Patients at high or communicate closely with the staff at theintermediate risk need more than primary district hospitals. Patients at the districtcare. They require care at a district hospital hospitals needing tertiary care should bewith facilities to perform a Caesarean section, transferred directly to the tertiary hospital.secondary level care or tertiary level care. In turn, the regional hospital staff shouldSecondary perinatal care requires additional provide educational programmes for, and giveequipment as well as doctors and nurses management advice to, the district hospitalwith special training. Tertiary perinatal care staff. Each district hospital usually has ausually consists of very expensive intensive number of primary healthcare which requires highly specialised staff andsophisticated equipment. All medical and nursing staff in a health region should regard themselves as members of a team whose goal is to provide good quality About half of all patients are at low risk of care to all the patients in that region. All developing clinical problems during pregnancy, staff members should, therefore, co-operate labour and the puerperium and, therefore, need and help one another. The responsibility for primary perinatal care only. all mothers and infants in the region is then shared between all the staff working in that15-4 Should all patients be region. It is particularly important that thedelivered by a doctor? clinic and hospital staff work as a team and do not regard themselves as separate services.No. Patients at low risk who only needprimary perinatal care can be safely delivered The fragmentation of health services, withby a midwife. Patients needing care at a various hospitals and clinics falling underdistrict hospital with facilities to perform a different authorities, is a major cause of poorCaesarean section or secondary perinatal care perinatal care in many communities.may be delivered by a doctor or a midwife.Patients needing tertiary perinatal care areusually delivered by a doctor who has hadspecialist training, or a midwife with a doctor
  3. 3. 268 MATERNAL CARE15-6 How should the district hospital insist that you speak to a senior staffassist the perinatal clinics in that district? member if you are not satisfied with the advice you receive.Each primary-care clinic should be linked toa district hospital (level 1) within the sameregion. The district hospital is responsible 15-8 How can a referral hospital improvefor the perinatal care given at the clinics in communication with the clinic?that district. The clinic staff should contact 1. A telephone line for incoming calls only (athis hospital for help or advice, and problem ‘hotline’) should be available in the labourpatients should be referred to that hospital ward of the hospital so that the clinic staffwhen needed. The staff of the district hospital can contact the hospital staff without delay.should be able to rotate with the staff at the 2. The most senior and experienced nurse orclinics. This ensures that the standard of care doctor should receive the call. Each dayin the clinics is maintained at a high level, and night someone should be allocated toand also helps the hospital and clinics staff answer the clinic calls.understand each other’s difficulties. 3. Listen carefully, be patient, and try to obtain a clear idea of the problem.15-7 How should clinic staff communicate 4. Ask for important information which haswith the referral hospital? not been provided. 5. It is better to admit the patient if there is1. A telephone or two-way radio is essential any doubt about her condition. so that the clinic staff and the hospital staff 6. Arrange the transfer. Usually this is done can speak directly to each other. by the referring clinic or hospital. However,2. Clear guidelines are needed to indicate in an urban region the receiving hospital which patients should be referred to may prefer to arrange the transport. hospital. If the clinic staff are uncertain 7. Indicate any emergency treatment which whether a patient needs referral, they must must be given before or during transport. discuss the problem with the staff of the 8. If possible, inform the clinic after the referral hospital. patient has arrived at the hospital. A3. The staff at each clinic must know which reply letter should be used to indicate the hospital to contact if they need help. The patient’s condition on arrival, the diagnosis hospital’s telephone number must be made by the hospital staff and the patient’s displayed next to the clinic’s telephone. response to treatment. Feedback to the4. The clinic staff must collect all the relevant referring clinic is essential. information on the patient before phoning 9. Ideally, all patients transferred from a to discuss the patient. Good notes must clinic should be reviewed every month. always accompany the patient as they This should ideally be done during an are one of the most effective methods outreach visit from the referral hospital. of communication. Either the complete In this way problems with referrals can be patient record or at least the antenatal card identified and corrected. must be sent with the patient. If the patient 10. A checklist available at the emergency is in labour, the partogram must also be telephone in the referral hospital helps to sent. It is essential that the clinic staff ensure that a complete history is obtained identify the patient’s clinical problems. and that no important information is5. When speaking to the hospital staff, forgotten. If the person receiving the call stress the important information and does not know what advice to give, this summarise the problem. State clearly information is then used when discussing where advice is needed. the patient with a more senior colleague.6. Always give your name and rank and ask The name and telephone number of the who you are speaking to. If necessary,
  4. 4. REGIONALISED PERINATAL CARE 269 person making the call must always be 15-10 What are the functions of a recorded. midwife in a maternal-care clinic where deliveries are done? Excellent communication and co-operation The midwife is responsible for all the antenatal between the staff of hospitals and clinics in a care, the care during labour and delivery, region are needed to provide good perinatal care. and the postnatal care given at the clinic. The midwife should function as an independent nurse-practitioner and meet all the primary perinatal care needs of low-risk patients.THE MATERNAL-CARE CLINIC 15-11 What are the functions of a doctor in a maternal-care clinic?15-9 What is a maternal-care clinic? The doctor does not fulfil the usual functions of a medical practitioner and should not seeA maternal-care clinic (perinatal-care clinic) every patient who attends the clinic. Theis a special clinic where midwives provide functions of the doctor are:primary antenatal and postnatal care. Somematernal-care clinics also have facilities to 1. To consult, i.e. to examine and advise ondeliver low-risk patients. A maternal-care the management of patients referred by theclinic with a delivery facility is often called a midwives with various problems.midwife obstetric unit (MOU). These clinics 2. To teach. It is essential that the doctorfunction day and night, and should be situated teaches the midwives the essentialin or near to the community which it serves. knowledge and clinical skills whichPrimary maternal and newborn care (primary they need to function competently in aperinatal care) is part of primary healthcare maternal-care clinic.and, therefore, the facilities of a primary- 3. To administer. Together with the seniorhealthcare centre are often used to provide midwife, the doctor should plan,perinatal care. In practice, the staff providing implement and evaluate all care given atperinatal care usually provide other forms of the maternal-care clinic.primary healthcare as well. A maternal-care 4. To audit the number and reasons forclinic may also be run in a level 1 hospital. In referral.large urban or periurban communities, theremay be maternal-care clinics separate from 15-12 What is the role of the communityprimary-healthcare centres. Some clinics only in a maternal-care clinic?offer antenatal care with the mother having The maternal-care clinic should be acceptableto deliver at another clinic further away from to the community as a facility which providesher home. These antenatal-care clinics must excellent primary perinatal care for patientsfunction as an extension of the maternal-care from that community. Every effort should beclinic with a delivery facility as very close co- made to involve the community in establishingoperation is essential. and running the clinic. It is desirable to form a lay organisation (such as ‘Friends of the At a maternal care clinic midwives provide Maternal-Care Clinic’) to help meet this role. primary perinatal care to low-risk patients. Representatives from the community, together with medical and nursing staff, should sit on the management board of the clinic. The community can help raise funds for the clinic and can also help provide some of the care, e.g. help run breastfeeding clinics and to be
  5. 5. 270 MATERNAL CAREtrained as doulas to assist women delivering in If patients are delivered at a clinic and thenclinics or hospitals. discharged home after an average of six hours, many of the benefits of being close to the familyThe clinic staff should co-operate and and home surroundings can still be enjoyed.communicate with community members,such as village health workers, traditional NOTE In an affluent community it may bebirth attendants (TBAs), traditional healers, possible to safely deliver carefully selectedbreastfeeding advisors, social workers and low-risk patients at home provided aschoolteachers, who can all assist in improving telephone and immediate transport areperinatal services in that community. available in case complications develop.15-13 What are the advantages of a 15-15 Which patients should not bematernal-care clinic with delivery facilities? delivered at a maternal-care clinic but must be referred to a hospital?1. The patient remains close to her home and community. Every perinatal region must draw up its own2. More personal care can be given as labour detailed and easily understood list of criteria and delivery take place in a relaxed for referring patients from a maternal-care atmosphere. clinic (or level 1 hospital) to either a level 2 or a3. A saving in transfer and hospital costs. level 3 hospital. The responsibility for drawing4. The staff often can work close to their up the list of referral criteria rests with the homes which saves both time and money. senior members of the obstetric, neonatal and Staff also get great work satisfaction through nursing staff at the regional (level 3) hospital, being able to accept greater responsibility in consultation with the medical and nursing than in a hospital, provided that they staff at the level 1 and 2 hospitals and maternal- receive support from the hospital staff. care clinics. Referral criteria will differ between regions as the criteria will depend on theThe many advantages of delivering low-risk distance the patient has to be transferred,patients in a clinic only apply if the clinic the facilities and staff available at the clinics,is supported by a level 1 or 2 hospital. The and the quality of the available transport. (Acommunity will not accept care given at a complete set of guidelines for the referral ofmaternal-care clinic if rapid and safe transfer antenatal patients is listed in Appendix not available when patients developcomplications. NOTE These referral criteria should be frequently reviewed in the light of the15-14 Why is delivery in a maternal-care number and nature of the clinical problemsclinic safer than a home delivery? requiring referral of patients to hospital.Many low-risk patients can be safely delivered There must be referral criteria for the motherat home. However, many homes do not have as well as for the newborn infant.good lighting, a telephone, clean water andadequate space for a safe delivery. In addition, Each maternal-care clinic must have its own listmany homes are far from the hospital or clinic of referral criteria.should problems occur with the mother orinfant. In these circumstances it is far saferfor the patient to deliver at a maternal-care 15-16 How can communicationclinic with a delivery facility where staff and between the clinic staff and theirequipment are available to deal with most of the patients be improved?perinatal complications. In densely populated 1. Make time to speak to the patients.areas midwives working in maternal-care clinicsprovide a better service to the community.
  6. 6. REGIONALISED PERINATAL CARE 2712. If possible, find a place where the patient The clinical problem and the required can speak to you in private. management must be discussed between the3. Be honest when you tell patients about maternal-care clinic staff and the hospital their clinical problems. staff. Most patients who are transferred during4. Listen to what they say and ask. the antenatal period do not need to get to5. Use simple language. hospital urgently and, therefore, do not need6. Allow patients to ask questions. to be transported by ambulance. However, all7. Look at the patient when you speak to her. patients transferred to hospital during labour8. Address the patient by name. will require ambulance transport. Usually9. Watch, listen and learn when more the referring clinic or hospital will make the experienced colleagues speak to patients. arrangements for transferring the patient. If10. Try to understand what the patient is the clinic arranges transport, the hospital must feeling. be notified of these arrangements.11. Be kind and helpful.12. At the completion of an antenatal visit the patient must be clearly informed if the Always contact the referral hospital before findings were normal. transferring a patient.15-17 What can be done to simplify 15-19 What can be done to make thenote-keeping in a maternal-care clinic? transfer of a patient as safe as possible?The patient should carry a hand-held antenatal Before an ill patient may be transferred fromcard or patient record which contains all her a primary maternal-care clinic to a hospital,antenatal information. This is a simple, cheap both she and her fetus or newborn infantand highly effective method of recording must first be stabilised. They will then be inpatient information when caring for low- the best possible condition to be moved andrisk patients. Most patients look after their will have the best chance of arriving safely atcards and take them along to the clinic. It is the hospital. To achieve these objectives, theuncommon for patients to lose their cards. following must be done before the patientThis system avoids the frustrating situation leaves the maternal-care clinic:where the patient presents at a clinic or 1. The patient and/or the fetus or newbornhospital, but her folder is being kept elsewhere. infant must be fully resuscitated.Using an antenatal card instead of a folder also 2. An intravenous infusion (drip) must be inshortens the time the patient has to wait at the and reduces the workload of the staff. If 3. All the necessary drugs must be readilya hand-held antenatal card or patient record available while the patient is beingsystem is used, there is no need to issue patient transferred to hospital.folders before labour. 4. Oxygen and resuscitation equipment in good working order must be available. The latter includes equipment for face-maskTRANSFERRING PATIENTS ventilation and endotracheal intubation.SAFELY TO HOSPITAL 5. A person competent in adult and neonatal resuscitation must accompany the patient.15-18 How should the transfer of a patient 15-20 Who should care for the patient whilefrom a clinic to a hospital be arranged? she is being transported to the hospital?It is essential that the base hospital be There are a number of referral criteria where itcontacted before the patient is transferred. is quite safe for the patient to travel to hospital
  7. 7. 272 MATERNAL CAREwith only a lay person accompanying her, e.g. a the puerperium, and is expressed per 100 000patient in early labour who has had a previous deliveries. Therefore, if 25 women die duringCaesarean section can use her own or public pregnancy, labour, or the puerperium in atransport. These conditions must be detailed healthcare region where 50 000 deliveries arein the list of referral criteria. In all other done a year, the maternal mortality ratio forcircumstances, patients with complications that region in that year will be 50 per 100 000must be accompanied by a qualified person (i.e. 25/50 000 x 100 000).competent in adult and neonatal resuscitation. The maternal mortality ratio in developingThis may be a midwife, doctor or trained countries or poor communities in developedambulance personnel (ambumedics). To send countries is usually 50 or more per 100 000an ill patient or newborn infant to hospital deliveries. This contrasts with the maternalwithout being accompanied by such a qualified mortality ratio of less than 10 per 100 000person is dangerous and is likely to result in in most industrialised countries with goodserious complications or even the death of the health services.patient and/or her infant. It is important to note that women who die as15-21 What documentation should a result of complications in early pregnancy,be sent with the patient? e.g. septic miscarriage or ectopic pregnancy, are included under maternal deaths.All the clinical notes of the patient (and hernewborn infant) must be sent with her to thehospital. Good record-keeping is an essential The maternal mortality rate in developingpart of perinatal care. Before transferring a countries is high.patient you must, therefore, make sure thatthe patient record gives an accurate account 15-24 What is the value of knowing theof what has happened to the patient up to maternal mortality ratio in your region?the time of transfer. It is very important toinclude details of the complications and the It is very important to determine the maternalmanagement. Clearly state why the patient mortality ratio in each region of the countryrequires transfer to hospital. as this ratio reflects the quality of the care provided to women during pregnancy, and15-22 What are the main dangers during and after delivery. Even in a poorto the patient while she is being community, the maternal mortality ratio cantransported to the hospital? be reduced by the provision of good perinatal care. Knowing the maternal mortality ratio of1. Antepartum haemorrhage. a region also allows comparisons to be made2. Convulsions, i.e. eclampsia. with other regions or comparisons between3. Intracranial haemorrhage due to severe patients delivered in different years in a region. uncontrolled hypertension. As the quality of perinatal care improves, the4. Respiratory arrest. maternal mortality ratio should decrease.5. Cord prolapse.6. Delivery before arrival at the hospital. By determining the causes of maternal death, preventable causes, such as postpartum haemorrhage, may be identified. MeasuresMATERNAL MORTALITY to prevent these complications can then be introduced throughout the region. Information on maternal deaths should be15-23 What is the maternal mortality ratio? collected by the health authorities in eachThe maternal mortality ratio is the number of region and be interpreted by specialists atwomen who die during pregnancy, labour, or the tertiary hospital. A maternal mortality
  8. 8. REGIONALISED PERINATAL CARE 273notification form must be used for the data 4. Infection, often complicating prolongedcollection. obstructed labour. NOTE Since October 1997 it has been In many developing countries, haemorrhage compulsory to notify all maternal deaths in and infection are responsible for more deaths South Africa to the provincial Maternal, Child than the hypertensive disorders of pregnancy. and Women’s Health (MCWH) Directorate. As perinatal services improve, deaths due to Maternal death notification forms, as well as an haemorrhage and infection will decrease. explanatory document on the way the forms have to be completed, must be available at all In contrast, the commonest causes of maternal institutions dealing with pregnant women. mortality in a developed country, such as the United Kingdom, are thromboembolism,A photostat copy of the patient’s entire the hypertensive disorders of pregnancy,folder must accompany the maternal death and deaths resulting from complications ofnotification forms, as well as photocopies of anaesthesia.the patient’s folders from any other hospitalsor clinics where the patient had been managed 15-27 Should each maternal deathbefore. All information in these folders will be be discussed at a special meeting?kept strictly confidential. Yes. It is very important that each maternal15-25 What is the difference death is discussed to discover the cause. Thebetween primary and final causes aim is not to punish anyone who made anof maternal mortalty? error, but rather to learn from the case report in order to prevent the same mistake being1. The primary cause of death is the initiating made again. Once the common causes of complication or condition that triggered a maternal death in a region are identified, steps sequence of events ultimately resulting in a must be taken to prevent the problems which maternal death. lead to those deaths.2. The final cause of death is the complication that ultimately resulted in a maternal death.A woman develops severe pre-eclampsia during CASE STUDY 1pregnancy, her blood pressure is not controlled,and a fatal intracranial haemorrhage occurs. A patient is diagnosed as having poor progressThe primary and final causes of the maternal of labour at a community healthcare clinic.death will be pre-eclampsia and an intracranial The clinic functions independently and is nothaemorrhage respectfully. formally attached to a hospital. When the clinic staff attempt to contact the hospital they15-26 What are the important are unable to get any reply from the hospital’sprimary causes of maternal mortality telephone exchange. They, therefore, hirein a developing country? a taxi and send the patient to the hospital with a letter asking for help with the furtherThe commonest primary causes of maternal management of the patient.mortality in South Africa are:1. The complications of HIV/AIDS. 1. What is wrong with the2. The hypertensive disorders of pregnancy, administration of this clinic? especially uncontrolled hypertension causing intracranial haemorrhage. Every clinic which provides perinatal care3. Haemorrhage, especially postpartum should be attached to a hospital within the haemorrhage. same healthcare region. This will greatly
  9. 9. 274 MATERNAL CAREimprove the communication between a clinic 1. Was the patient correctly managed?and its referral hospital. No. The most senior and experienced person available at the clinic should have been2. How could the communication consulted first. The patient’s problems wouldby telephone between the clinic most probably have been solved at the clinic,and the hospital be improved? making the referral unnecessary.A direct telephone line from the clinic tothe labour ward is needed. This will avoid 2. What else could have been doneproblems with the telephone exchange and if none of the clinic staff knewprovide immediate contact between the clinic how to manage the problem?and hospital staff. The referral hospital for that clinic should have been contacted by telephone so that the3. Why should the clinic staff patient’s problem could have been discussedalways speak to the hospital staff with the doctor on duty.before transferring a patient?Sometimes the patient can be safely managed 3. If the patient did require referralat the clinic after the clinical problem has to hospital, which hospital wouldbeen discussed with the hospital staff. This have been the most appropriatewill prevent having to transfer the patient. The to care for the patient?management before and during transfer can The district hospital (level 1) in the samebe decided upon during discussion with the healthcare region as the at the hospital. If the patient has to betransferred, the hospital must be informedso that they can make arrangements for her 4. Why is it always important tomanagement at the hospital, e.g. prepare for a carefully consider the referral beforeCaesarean section. transferring a patient to hospital? Because unnecessary referral causes great4. What is the danger of inconvenience to the patient and her family.transferring a patient in a taxi? Transport and hospital fees also add to the patient’s health expenses. Furthermore,If a patient is moved to a hospital in a taxi, unnecessary referrals place an extra workloadequipment and a person trained in resuscitation on the already overburdened level 2 and 3usually are not available to handle an hospitals. These should reserve their resourcesemergency, such as haemorrhage, which may for patients with serious complicationsoccur while the patient is being transferred. requiring specialist care. Therefore, patients with minor problems should always be cared for at a maternal care clinic or level 1 hospitalCASE STUDY 2 as this is more convenient for the patient and reduces the cost of healthcare.A patient presents with a minor complaint at amaternal-care clinic. A junior member of theclinic staff sees the patient but does not know CASE STUDY 3how to manage her. The patient is, therefore,referred to a regional hospital (level 2) for All deliveries and maternal deaths arefurther care. recorded in a healthcare region. During a certain year there were 30 000 deliveries and
  10. 10. REGIONALISED PERINATAL CARE 27520 maternal deaths. The commonest cause of 5. Are you surprised that thematernal death was postpartum haemorrhage. commonest cause of maternal death was postpartum haemorrhage?1. What is the definition of a maternal death? No. Haemorrhage is one of the commonestThe death of a woman during pregnancy, causes of maternal death in many developinglabour, or the puerperium. communities. Most of these haemorrhages can be prevented by the correct management2. How is the maternal mortality of the third stage of labour at a maternal-careratio expressed? clinic with delivery facilities.Per 100 000 deliveries. 6. How can the common primary causes of maternal death be identified in a3. What is the maternal mortality ratio in perinatal care region so that steps canthe above health care region for that year? be taken to reduce their occurrence?20/30 000 x 100 000 = 67 per 100 000 By arranging regular meetings withdeliveries. representatives of all the staff in the region where each maternal death can be discussed.4. Is this maternal mortality ratio typical of The primary and final causes of the deatha developing or a developed community? should be identified and the management of the patient must be examined. In this way theA developing community where the ratio is staff can learn which clinical errors may resultusually 50 or more per 100 000 deliveries. in serious complications. Steps can then beIn contrast, the maternal mortality ratio in taken to avoid these errors in future.a developed community is usually less than10/100000 deliveries.