Emergency Obstetric Care.

Dr. R. N. Ogu
Dept. of Obstetrics & Gynaecology
UPTH
Port Harcourt, Rivers State.
 Overview

• Status of emergency obstetric care

• Contributory factors
• Role of Guidelines and Protocols in
emergency obstetric care in Nigeria
• New National response to emergency
obstetric care
 PREAMBLE
• 15% of pregnancies are complicated, requiring
EOC.

• Untreated, many of these end in maternal death.

• Wide disparity in MMR b/w developed and

developing countries.

• The complications are detected and treated

promptly in the developed world because 95-100%
of their women deliver in the hospital.

• In Nigeria only 37% of our women deliver in the

hospital hence no detection or late treatment
leading to high MMR.
 Country situation
Maternal mortality

• High MMR – 800 per 100 000 live births

(DHS, 2004)

• Risk of death – 1 in 18 (1 in 4 085:

industrialized countries)
 Maternal Mortality ratio by state

Lagos 947

Katsina 1169

FCT 447

0 500 1000 1500

Causes of maternal death
Severe bleeding Infection
24% 15%

Eclampsia
12%

Indirect causes Obstructed

20% Labour
8%

Unsafe abortion
Other direct
13%
causes
8%
Table 1: Medical Cause of Maternal Mortality
Post partum Haemorrhage 25%
Puerperal Sepsis 15%
Unsafe abortion 13%
Eclampsia 11%
Obstructed labour 11%

Others (ectopic pregnancy etc) 5%

Anaemia
Malaria
Anesthesia 20%
Hepatitis in pregnancy
HIV/AIDS in pregnancy
 Obstetric Emergencies
70% OF MATERNAL DEATHS
• Haemorrhage (including ruptured
uterus/ectopic pregnancies)
• Eclampsia
• Obstructed labour
• Complications of unsafe abortion
• Sepsis
Anticipated in 15% of pregnant women
COMPLICATION AV.TIME TO DEATH

Obstetric haemorrhage
PPH 2 hours
APH 12 hours
Ruptured uterus 1 day
P.I.H/eclampsia 2 days
Obstructed Labour 3 days
Puerperal sepsis 6 days

• 80% of maternal deaths are direct/preventable

Causes of Maternal Mortality

• Medical Factors
• Socio-economic Factors
• Reproductive Factors
• Health service Factors
 Health service Factors
Three-phase delay model
• Phase 1 delay – delay in seeking care
• Phase 2 delay – delay in reaching health
facility
• Phase 3 delay – delay in receiving
adequate care at a health facility
(accounts for 40% of maternal deaths)
Incidence of Type 3 delays by state

50
45
40
35
30
50 25
44
20
27 25.3 15
10
12.9 5
7.2
0
Lagos Cross Borno
State River State
State
(Source: SOGON, 2004)
 Components of Type 3 delay
• Delayed referral
• Lack of blood
• Inability to pay fees
• Lack of essential drugs
(anaesthetic/oxygen)
• Lack of electricity supply
• Use of wrong treatment protocols
• Poor attitude of health care providers
Structural Adjustment Programme and Obstetric Indices,
Zaria, Nigeria (1983 -1988) – Ekwempu et al (1990)

Index 1983 1985 1988

Obstetric 7450 5437 3376

Admissions (n)

Deliveries (n) 6535 4377 2991

Complicated 0 26
labour (%)

Maternal deaths 2 1 62
(n)

1983 – Free obstetric services

1985 – Fees introduced for some services (SAP)
1988 – Further increase in fees
 Rates of hospital supervised/skilled
attendance at delivery

50
41.6
40 37.3 Hospital
35.2
30 30.4 delivery

20
Skilled
10 attendant at
delivery
0
1999 2003
(Source: FMOH, 2004)
 Preventing/Reducing Maternal
Mortality in Nigeria

3. Previous efforts at reducing maternal

mortality in Nigeria and its Outcome viz
• Safe motherhood initiative (S.M.I)
• Prevention of maternal mortality Network
(PMMN)
• Making Pregnancy safer (MPS)

8. Principal strategy for reducing/preventing

Maternal Mortality and applications in Nigeria
• Focus on Alma-Ata declaration
 Global Efforts of Reduction of Maternal
Mortality in Developing Countries
(a) Safe motherhood initiative conference 1987

Objective: Reduce MMR by half by year 2000

Approach: No specific approach developed or measurable action to be taken by all.
Only advocacy call for all nations of the world for:
(a) Improved access to quality maternal health services

(b) Assist developing countries reduce the high maternal mortality

Ratio.

(c) Prevention of unwanted pregnancy and address unsafe abortion

(d) Improved Education and Nutrition for women.

(e) Women empowerment

 PMMN
PMMN is composed of multisectoral and multidisciplinary
research Team from Carnegie Corporation of New York
who executed interventions in many West Africa
Countries including Nigeria to reduce maternal mortality
as model that would be adopted for developing countries.

• Objective:
• (i) Develop effective strategy to reduce MMR in
the short term
• (ii) Evolve operation research model for use in
maternal mortality project.

• Approach:
• Evolved several models to achieve objectives
• Conceptual Model:
• Intervention to reduce MMR
must do one of three things
• (i) Reduce the no. of
pregnancies.
• (ii) Reduce the no. of
complication
• (iii) Reduce the like likelihood
that a complication will result in death
Strategic Model:
• (i) Serious complications maybe difficult to
prevent or predict but with treatment may avert
death.

• (ii) Strategy is to provide access for good

obstetric care at the facility for all parturients.

• (iii) Once an obstetric complication occurs any

barrier that prevent access to effective medical care
done increase the chances of such complication
resulting in death. Such barriers are unknown or
minimal in developed countries.

• In Nigeria and other developing countries such barrier

are common and comprise the
• complex of socio-cultural and non medical causes and
poor socio-economic in the
• rural populace. They are better known as delays.
• Program Model:
• Viz the three delays:
• (i) Delay in deciding to seek EmOC.

• (ii) Delay in reaching an EmOC facility

• (iii) Delay actually receiving care at EmOC

facility.

• Initial point to begin intervention.

• All these delays will translate a complication to
a maternal death any where.
 : Making Pregnancy Safer (MPS) (Lunched
2000 and on going)

• Objective:
Reduce MMR by 50% over a ten years Period.

• Approach:

To improve Condition in the Health facility to

ensure quality of care generally and especially
for capacity for emergency Obstetric care at
the primary health care level.
• Strategy:
• (a) Capacity building and adequate
equipment to ensure quality delivery
services and emergency Obstetric care
at PHC.

• (b) Functional referral linkage with a

secondary care facility with
comprehensive essential Obstetric care.
 EOC
Skilled care.

• Skilled birth attendants

• Signal / Medical functions

• Enabling environment

• All must be present

 SIGNAL FUNCTIONS
Basic EOC facility

•  Iv antibiotics

•  Iv Oxytocics/ Ergometrine

•  Iv anti-convulsants

•  Removal of retained products of conception

•  Manual removal of placenta.

•  Assisted vaginal delivery (Ventouse)

All must be present

 Comprehensive EOC facility

• All basic functions above, PLUS

(G) Caesarean section.

(H) Blood transfusion.

Table Definition included in UNICEF/WHO/UNFPA
Guidelines.
Obstetric Emergency Emergency obstetric care EmOC
function

Haemorrhage (antepartum or postpartum) Basic EmOC (BEmOC)

Prolonged/obstructed labour 1 Injectable antibiotics
2 Injectable oxytocics
Postpartum sepsis 3 Injectable anticonvulsants
4 Manual removal of placenta
Abortion complications 5 Removal of retained products
6 Assisted vaginal delivery

Pre-eclampsia/eclampsia Comprehensive EMOC (CEmOC)

Ectopic pregnancy; Ruptured uterus All basic function 1-6 plus
Cesarean section
Blood transfusion
• Five life-threatening obstetric emergencies

• obstetric haemorrhage

• Eclampsia

• genital tract infections

• obstructed labor

• uterine rupture
 Criteria (examples)
All complications (2 criteria)
∀ •          Patients history should be
documented in case note on admission, age,
parity and complications in current and or
previous pregnancies
∀ •          General clinical state on admission
should be recorded - pulse, blood pressure,
temperature
 Obstructed labour (6 criteria)

• Prompt delivery of the fetus should occur within 2

hours of diagnosis
• Urinary bladder should be drained
• An observation chart should be maintained – urine
output, pulse, blood pressure, and temperature
• Intravenous access and hydration should be achieved
• Broad – spectrum antibiotics should be given
• Typing and cross matching of blood should be carried
out
Obstetric haemorrhage
(12 criteria)
∀•  Experienced Medical Staff should be involved in the management of life-
threatening obstetric haemorrhage within 10 minutes of diagnosis
∀•    Intravenous access should be achieved
∀•     Patients haematocrit or haemoglobin level should be established
∀•     Typing and cross matching of blood should be performed
∀•     Coagulation tests should be performed if indicated – clotting time, platelet
count
∀•     Crystalloid and/or colloids should be infused until cross matched blood is
available
∀• Clinical monitoring to detect early deterioration should be done at least every
quarter of an hour for 2 hours: pulse, blood pressure
∀•  Urinary output should be measured hourly
∀•  Oxytocics should be used in the treatment of postpartum haemorrhage
∀•  Genital tract exploration should be performed in cases of continuing postpartum
haemorrhage
∀•  Women with antepartum haemorrhage should not have vaginal examination
unless placenta praevia has been excluded by ultrasonography or unless
emergency operative delivery is possible
∀•  In ectopic pregnancy emergency surgery should be performed
Eclampsia(8 criteria)
•Senior Medical Staff should take responsibility of
formulating a management plan for patient
•Antihypertensive treatment should be given to patients
with severe hypertension
•The treatment and prophylaxis of seizures should be
with magnesium sulphate
•Respiratory rate and tendon reflexes should be
monitored when magnesium sulphate is used
•Antepartum/intrapartum fluid balance chart should be
maintained
•Haematological and renal investigations should be done
at least once: clotting time, platelet count, and urine
albumin test
•Delivery should be achieved within 12 hours of the first
convulsion
•Monitoring of blood pressure and urine output should
continue for at least 48 hours after delivery
 Uterine rupture(3 criteria)
• In suspected or diagnosed uterine
rupture, emergency surgery should be
performed
• Urinary bladder should be drained
• An observation chart should be
maintained showing urine output, pulse
and blood pressure
 Genital tract sepsis (6 criteria)

• Delivery should be expedited in chorioamnionitis

irrespective of the gestation.
• Blood should be taken for culture
• Treatment of genital tract sepsis should be with
broad spectrum antibiotics
• Metronidazole should be included in the
antibiotic regimen
• An observation chart should be maintained: urine
output, pulse, blood pressure and temperature
• Exploration and evacuation of the uterus should
be performed if retained products of conception
are suspected
 WOMEN AND
CHILDREN
FRIENDLY HEALTH
SERVICES - A NEW
NATIONAL
INITIATIVE
Women and Children Friendly Health
Services

• Easily reached
• Affordable
• Respect the rights of women and
children
• Ensures satisfaction of both user and
provider
• Maintains the highest technical
standard
 Objectives of WCFHS
• Identification/timely management of
pregnancy related problems
• Provide availability/accessibility of skilled
attendants at antenatal, intrapartum, and
postpartum periods
• Identification/timely management of health
problems of newborns and U5s at
home/facility level
• Improve the two-way referral system
 Anticipated scope of WCFHS

• Patient/family – early recognition of

complications/decision – making (Type 1
delay)
• Community involvement – Type 2 delay
• Improved Health system emergency
readiness – Type 3 delay