ppt

1. ARSI UNIVERSITY COLLEGE OF
HEALTH SCINCE
DEPARTMENT OF OBSTETRICS & GYNACOLOGY
THREE MONTH FINAL REPORT
MAY15 – AUG11 2017
Prepared By - - Dr. Endalamaw A.(MI) (Presenter)
Dr. Yasin Y.(MI)
Moderator- Dr. Bedhasa (Obstetrician & Gynecologist)
August 2017
8/14/2017 1

2. Out lines
• Introduction
• Objective
• Method
• Data Source
• Total cases seen
• Obs Cases
• Gyn Cases
• OPD Cases
• Maternal Mortality
• Recommendation
• Acknowledgement
• Sources /References
8/14/2017 2

3. INTRODUCTION
• Asella Referral and Teaching Hospital is one of the tertiary
hospital In Central Ethiopia ,Arsi Zone Oromia Region.
• About 170 km away from AA.
• It Comprises of the major four departments and some minor
department
• Established in 1982 E.C by Ethio -Italian cooperation &Starts its
service in 1983.
8/14/2017 3

4. • Serves around 3.5 million of people of the catchment area.
• Is Currently under the newly established ARSI University.
• The Gyn/Obs Dep't is subdivided in to
 Obs and Gyn Wards
 ROPD and MCH
 Fistula and precancer check up clinic
8/14/2017 4

5. Team Composition
• 5-Gynecologist/Obstetricians
• 7-Residents (R1)
• 5-General Practitioners
• 19-M.Interns
• MW &Nurses
8/14/2017 5

6. Objective
• To Analyze the 3 month Activities of the department.
• To identify draw backs of department in patient Care
• To compare this group activities with the previous
groups
• To draw recommendations
8/14/2017 6

7. Method
• Study Design
• Descriptive Study Design
• Study Period
• 07/09/09 to 05/12/09 E.C
8/14/2017 7

8. Data Source
• Admission &Discharge Log Book
• Registration Book at MCH &Regular OPD
• OR Registration Book
• Procedure Registration Book
• Pre cancer (VIA)check up Registration Book
• Fistula clinic Registration Book
8/14/2017 8

9. Total Cases seen
We have seen a Total of 4143 cases in our stay in gyn/obs.
Last group (Group 1) -4530;
Previous batch (1st group=3382 ,2nd=3037 ,3rd group 3755)
• Obs-1370 (33.06%)
• Regular OPD- 1302 (31.42%)
• MCH – 846 (20.42%)
• Gyn-463(11.2%)
• Pre cancer checkup- 109 (2.6%)
• Fistula-53 (1.3%)
8/14/2017 9

10. Total cases seen when compared with
group 1 of this batch
0
200
400
600
800
1000
1200
1400
1600
Obs R OPD MCH Gyn Pre ca Fitula
This group
Group 1
8/14/2017 10

11. Obstetrics
We have seen a total of 1370 cases
Last group (Group 1) =1524
Previous batch (1st group=1320 ,2nd group =1314 ,3rd group
=1349)
• C/S-268 (20.5%)
• SVD- 987 (75.5%)
• Operative VD-47 (3.6%)
• Vacuum- 39 (82.9%)
• Forceps- 8 (17.02%)
• Destructive delivery-5 (0.38%)
• PPH-63 (4.6%)
8/14/2017 11

12. Mode Of Delivery
8/14/2017 12

13. Cesarean Section
• Total cases of Cesarean section –268
Last group (Group 1) -342
Previous batch (1st group = 235 , 2nd group= 337 ,3rd group =347)
• The top five indications for C/S during our stay
-NRFHRP-95 (35.4%); Last group (Group 1)- 89(26%)
-CPD-54 (20.1%); Last group (Group 1)- 67(19.5%)
-Previous C/s scar-23 (8.5%); Last group (Group 1)- 48(14%)
-Breech Presentation-18 (6.7%); Last group (Group 1)-
47(13.7%)
-Failed induction-15 (5.5%); Last group (Group 1)- 26(7.6%)
-Others-63(23.5%)
8/14/2017 13

14. The top five indications for c/s during our
stay
8/14/2017 14

15. Types of Cesarean section
• Types cesarean Section
• LUST C/S- 261 (97.3%); (Group 1)- 336 (98.2%)
• Cesarean hysterectomy- 4 (1.5%); (Group 1)- 3 (0.9%)
• Inverted T- 3(1.1%); (Group 1)- 3 (0.9%)
• Classical C/S- 0
8/14/2017 15

16. Spontaneous Vertex delivery
• Total cases of SVD- 987
Last group (Group 1 )-1009
Previous batch(1st group= 715 , 2nd group= 883, 3rd
group=852)
• Episiotomy-111(11.24%)
Last group (Group 1 )- Episiotomy-198(19.6%)
8/14/2017 16

17. Operative VD
• Vacuum=39(75%)
• Forceps delivery=8(15.38%)
• Destructive delivery-5(9.6%)
Last group (Group 1 )-
Forceps=16(20%),vacuum=62(77.5%),
Destructive delivery-2(2.5%),
8/14/2017 17

18. Neonatal Out come
• Total Deliveries-1294
• Singleton-1255(96.9%)
• Twin-37 (2.8%)
• Triplet-1(0.07%)
Last group (Group 1 )-
Total Deliveries-1478
• Singleton-1387(93.8%)
• Twin-39(2.6%)
• Triplet-3(0.2%)
• Quadriplet-1(0.06%)
96.90%
2.80%
singleton
Twin
8/14/2017 18

19. Birth Out Come
• Total Deliveries-1294
• Alive-1252(96.7%)
• Dead-42(3.2%)
Last group (Group 1 )-
Total Deliveries-1478
• Alive-1402(94.8%)
• Dead-74(5%)
Alive
97%
Dead
3%
Alive
Dead
8/14/2017 19

20. Gynecology
• Total Cases Seen-463
Last group (Group 1 )- 608 cases
Previous batch (1st group= 279 , 2nd group= 340,3rd
group=396)
• Total Admissions- 455
• Total Minor Procedures-151
• Major operations-110
• Elective -94(85.45%)
• Emergency-26(23.6%)
8/14/2017 20

21. Admission
• We have a total of 455 Admissions
• The Top seven admission in gyn ward are
1. Abortion-213 (46.8%)
2. Hyper Emesis Gravidarum-35(7.7%)
3. PPH-25(5.5%)
4. Puerperal Sepsis-21(4.6%)
5. Myoma-20(4.4%)
6. Uterine Rupture-16(3.5%)
7. GTD-14(3.07%)
8/14/2017 21

22. Common Gynecologic Admissions
8/14/2017 22

23. Abortion-213(46.8%); Last group (Group 1 )- 277(45.5%)
a. Incomplete-134(62.9%); Last group (Group 1 )-
144(68.2%)
b. Missed-29(13.6%); Last group (Group 1 )- 24(11.3%),
c. NTD-19(8.9%); Last group (Group 1 )- 13(19.6%)
d. Inevitable-12(5.6%); Last group (Group 1 )- 28(13.2%),
e. Threatened-6(2.8%); Last group (Group 1 )- 15(7.1%),
f. Blithed Ovum-6(2.8%)
8/14/2017 23

24. Minor Procedures
• We have a total of 151 Procedures done
• In Patient -143(94.7%)
• Out Patient-8(5.3%)
• Last group (Group 1 )- 141
• Previous batch (1st group= 157 and 2nd group= 113,3rd
group=151)
8/14/2017 24

25. Specific Procedure
1. MVA-138 (91.4%), Last group (Group 1 )- 126(89.3%)
2. E&C-11 (7.3%), Last group (Group 1 )- 14 (9.9%),
3. D&C-2 (1.3%), Last group (Group 1 )-1 (0.7%)
8/14/2017 25

26. • Of these about 102(67.5%) have got Family planning Service.
Last group (Group 1 )- 125 (88.6%)
- Injectable = 53(51.9%); Last group (Group 1 )- 67(53.6%)
- OCP =32(31.4%); Last group (Group 1 )- 23 (18.4%),
- Implanon = 17(16.6%); Last group (Group 1 )- 31(24.8%)
8/14/2017 26

27. Major Operations
We have A total of 110 Major operations
Last group (Group 1 )- 72
Previous batch ( 1st group= 66 and 2nd group= 70,3rd
group=81)
Elective operation -94(85.45%); Group 1- 45(62.5%)
Emergency operation-26(23.6%); Group 1- 27(37.5%)
8/14/2017 27

28. Elective operation
Common Elective operation
• VVF&RVF-24(25.53%); Group 1- 10(22.2%)
• Myoma-20(21.27%); Group 1- 7(15.5%)
• UVP-20(21.27%); Group 1- 21(46.6%),
• Ovarian tumor&cysts-15(15.9%); Group 1- 6(13.3%),
• GTD-14(14.9%); Group 1- 6(13.3%)
• Asher man syndrome-1(1.06%)
8/14/2017 28

29. Common Elective operation
8/14/2017 29

30. Emergency operations
• Commonest gynecologic emergency
• 1.Uterine Rupture-16(61.5%); Group 1- 8(27.5%)
• 2.Ectopic pregnancy -9 (34.6%); Group 1- 20(68.9%)
• 3.Tortion of ovarian Cyst-1(3.8%); Group 1- 1(3.4%)
8/14/2017 30

31. OPD Cases
• Total OPD cases-2158
Last group (Group 1 )- 2330
Previous batch (1st group= 1761 and 2nd group= 1347,3rd
group=1953)
• Regular OPD-1302(60.3%); Last group (Group 1 )-1385(59.4%)
• MCH-856(39.6%); Last group (Group 1 )- 945(40.6%)
8/14/2017 31

32. Regular OPD
• Total Cases of OPD Visits-1302
• Common Cases Of OPD visits are
• Check Up-324(24.8%); Group 1- 352(25.4%),
• AUB-148(11.36%) Group 1;117(8.4%),
• STI-115 (8.8%);Group 1;108(7.8%),
• Abortion-106(8.1%); Group 1 86(6.2%),
• UVP-103(7.9%)
• Sexual Assault-81(6.2%); Group 1 108(7.8%),
• Others-425(32.6%)
8/14/2017 32

33. 8/14/2017 33

34. MCH
• Total cases-856
Last group (Group 1 )- 945
Previous batch (1st group= 1076 and 2nd group= 948, 3rd group =1024 )
• ANC Visits -570(66.6%); Group 1- 732(77.5%),
• Contraception -286(33.4%); Group 1 -213(22.5%),
8/14/2017 34

35. ANC VISITS
• Total cases of ANC Visits-570
• 1st Visit -202(35.4%); Group 1- 650(88.7%)
• 2nd Visit-174(30.5%);Group 1- 36(4.9%),
• 3rd Visit-109(19.1%); Group 1- 26(3.55%)
• 4th Visit-85(14.9%); Group 1- 20(2.7%)
8/14/2017 35

36. Contraceptive
• Total no of mothers that Received contraceptive -286
Last group (Group 1 )- 213
Previous batch (1st group= 152 , 2ndgroup=201,3rdgroup=235 )
• Commonly used Types of contraceptives in our hospital
• Injectable-163(56.9%); (Group 1 )- 166(77.9%),
• Implanon-67(23.4%); (Group 1 )- 23(10.7%),
• OCP-39(13.6%); (Group 1 )- 21(9.8%),
• Jaddele-11(3.8%); (Group 1 )- - 2(0.97%)
• IUCD-6(2.09%); (Group 1 )- 1(0.46%)
8/14/2017 36

37. Commonly used Types of contraceptives
8/14/2017 37

38. FISTULA CLINIC
• Established in 2004 EC
• Patients have got free service
• There are 15 beds
8/14/2017 38

39. • Total cases admitted– 53 -Group 1- 37
- VVF and RVF -24(45.3%); Group 1 -16(43.2%)
- UVP – 20(37.7%); Group 1 -11(29.7%)
- Other – 9(16.9%); Group 1 -10(27%)
Of this 39(73.6%) of them had surgical intervention
8/14/2017 39

40. Cervical pre cancer check up center
• Total cases had VIA – 109, (Group 1-31)
• Of this 39(35.78%) are HIV Positives , (Group 1-6)
• 6(5.5%) of them reactive for pre cancer check up of VIA, and
treated with cryotherapy.(Group 1-8)
• Only one case of HIV positive mother was reactive to VIA
• This center provide VIA check up for all women based on
indications and also provide Cryotherapy and LEEP for those
test positive for VIA
8/14/2017 40

41. Maternal Mortality
• The Death of a woman while pregnant or within 42 days
of termination of pregnancy, Irrespective of the
duration and site of the pregnancy, from any cause
related to or Aggravated by the pregnancy or its
management, but not from accidental or incidental
causes.
8/14/2017 41

42. • Late maternal death — The death of a woman from
direct or indirect obstetrical causes more than 42 days,
but less than one year, after termination of pregnancy.
• Pregnancy related death — Death of a woman while
pregnant or within 42 days of termination of pregnancy,
irrespective of the cause of death. These deaths may be
from accidental or incidental causes.
8/14/2017 42

43. • Direct Obstetric death is defined as maternal death resulting from
obstetric complications of the pregnancy state (pregnancy, labor and
and puerperium), from interventions, omissions, incorrect treatment
treatment or from a chain of events resulting from any of this above.
8/14/2017 43

44. MATERNAL MORTALITY
WORLDWIDE
• An estimated 358,000 women died globally in 2008 as a result
of pregnancy-related conditions.
• Estimate of women who die globally as a result of pregnancy
related conditions.
• 289,000 /year
• 792/day
• 33/hr
• 1/2min
8/14/2017 44

45. • Developing countries bear a disproportionate share of maternal
deaths:
• 99 Percent occur in developing countries compared to
• 1 Percent in more developed nations.
• Sub-Saharan Africa and South Asia accounted for 87 percent of
global maternal deaths in 2008.
8/14/2017 45

46. • The lifetime risk of dying as a result of pregnancy or childbirth
is
• Afghanistan1 in 11 and
• Somalia1 in 14,
• sub-Saharan Africa 1 in 31, whereas
• In the industrialized nations of Northern Europe, the lifetime
risk ranges from 1 in 7600 to 11,400.
8/14/2017 46

47. CAUSES
• The "Three Delays"
• 1.Delay in the decision to seek care
• 2.Delay in arrival to an appropriate medical care facility.
• Transportation
• 3.Delay in receiving adequate care once a woman arrives to
medical facility.
• Inadequate facilities for severity of disease.
8/14/2017 47

48. 8/14/2017 48

49. • The four pillars of the Safe Motherhood Initiative to reduce
maternal death in developing countries.
• Contraception
• Skilled Birth Attendant
• Emergency Obstetrical Care
• Ultrasound
8/14/2017 49

50. Death case
• Identification
• AD
• Age=35
• Address-D/T
• Ethnicity –Oromo
• DOA-01/10/09
• TOA-3:30PM
8/14/2017 50

51. c/c-gush of fluid per vagina of 14 hrs duration
• HPP=
• A 35 yrs old GVI PV(All alive mother) who doesn’t remember
her LNMP but claimed to be ammenorric for the last 09
months.
• She had ANC follow up at LHC
• Currently she is presented with gush of fluid per vagina of 14 hrs
duration.
• Otherwise, no hx of foul smelling Vx discharge, fever, chills,
rigor.
• No Hx of pushing down pain
• No hx of other danger sign of pregnancy
8/14/2017 51

52. P/E
• GA : Well looking
• V/S
• BP: 100/70 mmHg
• PR:82 bpm
• RR:20 Br/min
• To: 36.7 oc
• HEENT-pink conjunctiva, NIS
8/14/2017 52

53. • Abdomen:
• 36 wk Sized Gravid Ux
• Longitudinal Lie
• Cephalic
• FHB- 140
• Contraction-NILL
• GUS:
• PV- Cx admit tip of finger, thick & posterior
8/14/2017 53

54. • CNS –COTPP
• ASST: 3rd TM Px + Grand multipara + prolonged PROM + Unknown
date + unfavorable BISHOP score
8/14/2017 54

55. Investigations
• CBC – WBC – 11,000 (N – 81.2%, L – 12.2%)
• Hgb- 13.2 mg/dl
• Hct- 36.1%
• Plt -296,000
• U/A – non revealing
• BG & RH -O+ve
• HBsAg, VDRL & PIHCT – Negative
8/14/2017 55

56. • Obstetric U/S – SIUPx
• Longitudinal
• Cephalic
• FHB +ve
• AGA 35+5 wks
• EFW 2856gm
• GBM, BM,FT Seen
• Placenta fundal & posterior
• No gross congenital anomaly seen
• Grossly adequate AF
• Index;- 3rd TM Px + RBPP
8/14/2017 56

57. Plan
• Admit to Labour ward
• Ampicillin 2gm IV QID
• Ripened with folly catheter
• Induce on next morning
8/14/2017 57

58. • Ripened with Foley catheter at 10:00pm
• Induction started at 9:30 am as protocol
PV :
• Cx admits one finger
• Station high
• Vertex presentation
8/14/2017 58

59. • Oxytocin drip maintained at Phase-I 60 drops with
• Ux contraction 3 & 5 /10’/45’’-55’’/
• FHB 132-156
8/14/2017 59

60. After 4hr reevaluation (@ 2:00 pm)
• Cx 3cm dilated & 60% effaced
• M-R-Clear
• Station -1
• Vertex
• No caput or molding
• Ass’t;- Grand multipara + LFSOL + prolonged ROM
• Plan;- continue induction
• Follow FMC & labour progress
• Reevaluate after 4 hrs
8/14/2017 60

61. After 4hr reevaluation (@ 5:15pm)
• Cx 4cm dilated
• M-R-Clear
• Station-high
• No caput or molding
• Ass’t;- Grand multipara + AFSOL + prolonged ROM
• Plan;- continue induction
• Follow FMC labour progress
• Reevaluate after 4 hrs
8/14/2017 61

62. @ 6:50 pm
• FHB=168
• Cx – 8 cm dilated
• Station +1
• M-R-Clear
• No caput or molding
• Ass’t ;- Same + NRFHRS
• Plan ;- Hold oxytocin drip
• Put on free fluid, LLP,
8/14/2017 62

63. Delivery summary
• Date of delivery – 02/10/09 E.C
• Time of delivery - 6:55pm
• Out come – 3000gm female alive neonate with APGAR score of
7 & 8 at 1st & 5th min respectively
• P/E after delivery
• G/A- ASL
• V/S- BP= 110/60, PR= 120, RR= 24, T=38.1
• HEENT – Pinc conj, NIS
8/14/2017 63

64. • Abd- 20 wk sized laxed Ux
• GUS- Torrential bright red Vx bleeding
• CNS- COTPP
• Ass’t;- PPH 2nd to uterine atony + Immediate post partum time
8/14/2017 64

65. MANAGEMENT
• Double iv line secured
• Put on oxytocin drip 30IU in 1000ml of NS
• Free fluid on the other side
• But she continued to have active vaginal bleeding and
• She was taken to OR
• Just on arrival in the OR,BP=125/83,PR=93,SPO2=96%
• Ergometrine 0.4mg IM stat was given
• Cervical tear was explored but no tear identified
8/14/2017 65

66. • Balloon catheter was inserted
• She continued to have Vx bleeding and transfused with Four
unit of blood
• The patient vital sign deteriorated, BP=82/43,PR=130
• Laparotomy was decided and TAH was done
• IOF-Intact laxed, soft boggy uterus
• After surgery, she was followed in the recovery room.
8/14/2017 66

67. • Then the BP become un recordable and
• She is deteriorating and start to gasp
• CPR was tried for 30min and
• She passed away at 8:40pm local time with possible immediate
cause of death MOF 2nd to hypovolemic shock.
8/14/2017 67

68. Pitfall of the mg’t
• Misoprostol was not inserted
• The patient was not taken to ICU
• Laparotomy was not early decided
8/14/2017 68

69. Recommendation
• Documentation should be improved.
• ICU should be improved
• Instruments ( BP Cuff,O2,Glucometry, fetoscope)
• OR Material
• Blood Bank
• BCG & OPV0 vaccination should be given at birth
• Induction protocol should be revised for multi and
primigravidas
• Patient medication care out log book should be prepared.
8/14/2017 69

70. Acknowledgment
 I Would Like To thank
• Dr. Bedhasa for giving us the Valuable information and guide us
how to Present
• Residents and GPs for Being with us the whole three month &
Sharing your experience and Skills.
• Those medical interns who participated in the data collection
process
• Obs and gyn head nurses and midwifes
• The whole Staff for your Interest to help us
8/14/2017 70

71. Reference
1.FMOH management protocol for obstetrics 2010
2. Trends in Maternal Mortality:1990 to 2015
3. Strategies toward ending preventable Maternal
Mortality (EPMM)
4. WHO, World Health Statistics 2013.
5.Upto Date 21.6
6.EDHS 2016
8/14/2017 71

72. 8/14/2017 72