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When you have completed this unit you should be able to:
There are a number of steps which are needed:
An avoidable (or modifiable) factor is something which may have prevented the death, e.g. a woman not immediately going to a clinic or hospital when abdominal pain with vaginal bleeding occurs during pregnancy.
Many avoidable factors are due to missed opportunities.
An avoidable factor may have prevented a death.
A missed opportunity is a chance to provide the correct care which was not taken. The opportunity was there to provide the correct management but the opportunity was missed, e.g. failing to measure the blood pressure at an antenatal visit or not screening for syphilis.
Substandard care means that the care that the patient received fell below the standard that should have been offered to her. It is necessary to know what correct care is before substandard care can be recognised. Care may be substandard because of any of the following:
Substandard care often leads to avoidable factors and missed opportunities. Therefore, substandard care, avoidable factors and missed opportunities are usually considered together as problems resulting in poor care. Typical examples of substandard care are not monitoring the fetal heart during labour and not suctioning the mouth of a meconium stained infant before delivering the shoulders.
Answers cannot be found before the problems and avoidable factors are identified. As problems (i.e. causes of maternal and perinatal deaths) differ between different services, hospitals or clinics , the particular problems have to be identified for each service, hospital or clinic. The avoidable factors associated with each problem may also vary between services, hospitals or clinics.
Regular mortality meetings are an excellent way of identifying problems and avoidable factors.
Avoidable factors can usually be classified into one of three groups:
For example, if a fetus or newborn infant dies of congenital syphilis and the mother failed to attend antenatal care, then the avoidable factor would have been patient related. However, if the mother attended the antenatal clinic but the health care worker failed to screen her for syphilis or failed to collect the result and treat her, then the avoidable factor would have been health worker related. Finally, if the mother attended antenatal clinic and the health worker wanted to screen her for syphilis but either transport or the facilities to perform the test were not available, then the avoidable factor would have been administrative related.
Some avoidable factors are obviously the cause of a maternal or perinatal death while other avoidable factors may have contributed to the death. Therefore, avoidable factors can be divided into probable and possible factors. Probable avoidable factors are most important. Often more than one probably avoidable factor will be present.
In addition, some substandard care may not be related to the death of an infant. This poor care can still be discussed at a perinatal mortality meeting although it will not be included as an avoidable cause of infant death.
Only when the specific avoidable factor or missed opportunity has been identified can steps be taken to prevent similar deaths in future. If one does not know why the care was substandard, it would be very difficult to solve the problem. Finding avoidable factors is an important step in improving care.
There are many sources where answers can be found once the problem has been identified. Some answers are easy to find. Unfortunately some problems still do not have easy or effective answers, e.g. how to prevent pre-eclampsia.
Answers can usually be found:
Changes may be needed in a number of different areas:
Once answers are found, there are number of steps which can be taken to introduce changes:
However, it is not always easy to introduce the changes needed to reduce mortality. A clear idea of what changes are needed together with the ability to win the co-operation of the authorities and colleagues are essential.
Yes. In almost half of the maternal deaths there was a an avoidable factor (missed opportunity for preventing that death or substandard care). Avoidable factors were far more common for direct causes (e.g. postpartum haemorrhage) than indirect causes (e.g. AIDS). The maternal mortality rate is still far too high in South Africa.
Every effort must be made to get women to attend an antenatal care clinic from the time that pregnancy is confirmed. They must also be educated to recognise danger symptoms and signs and report immediately to a clinic or hospital as soon as these present:
Patient related factors often depend on the family and community. For example, a husband or mother-in-law may prevent a pregnant woman going to the clinic or hospital as soon as labour starts, or transport my not be available at night.
Every effort must be made to provide good, early antenatal care to all pregnant women.
Yes. The routine reporting and a confidential enquiry into maternal deaths must be expanded to include all maternal deaths, especially in districts, regions and provinces where maternal deaths are still under reported. It is important to include all maternal deaths from private hospitals and the deaths that occur at home. Only when the majority of maternal deaths are reported can a reliable estimate of numbers, causes and avoidable factors be obtained.
Yes. In about a quarter of perinatal deaths there was a missed opportunity for preventing that death. The commonest avoidable factors are patient related. Unfortunately an avoidable factor often cannot be identified because of poor notes.
The commonest avoidable factors in perinatal death are patient related.
The commonest patient related factors are:
Failing to book early and then regularly attend antenatal care is the commonest patient related factor associate with perinatal death. Little understanding of the importance of antenatal care, long distances to the clinic and inadequate public transport all play an important role in poor attendance for antenatal care.
Inadequate antenatal care is the commonest patient related factor associated with perinatal death.
Because of poor antenatal clinic attendance, complications of pregnancy such as hypertension, decreased fetal growth and syphilis are not identified and managed.
Inadequate transport to hospital is the commonest administrative related factor associated with perinatal death.
Health worker related factors may be divided into:
No response by health workers to antenatal warning signs is a common avoidable factor associated with perinatal death.
Inadequate fetal monitoring is the commonest health worker related factor associated with perinatal death during labour.
Inadequate resuscitation of the newborn is an important avoidable cause of perinatal death.
The three main primary causes of neonatal mortality are:
Yes. Many perinatal deaths can be prevented:
All that we now need is a clear plan of action and the will to make the plan work.
With simple, good management many of the perinatal deaths can be prevented.
There are many avoidable factors which can be addressed to reduce the perinatal mortality. The most important are:
It is essential that the facilities, necessary equipment, management protocols and adequate numbers of well trained health workers are available at each clinic and hospital. It is every woman’s right to have a safe delivery.
Intrapartum hypoxia means that the fetus did not receive enough oxygen before delivery (usually during labour). The main reasons for fetal hypoxia are:
The infant may also developed hypoxia after delivery if they breathe poorly and are not well resuscitated.
Every effort should be made to prevent fetal hypoxia, and detect fetal distress as soon as it develops. Careful monitoring of the fetal condition and the progress of labour is essential. The partogram must be used correctly to detect poor progress of labour.
Fetal hypoxia presents with the signs of fetal distress, i.e. meconium stained liquor and late fetal heart rate decelerations (and poor beat-to-beat variability on the cardiotocogram).
Correct use of the partogram with careful fetal monitoring is essential.
It is impractical to have a cardiotocograph (CTG) recorder in every labour ward. Therefore, the fetal heart must be monitored with an ordinary stethoscope, a fetal stethoscope or a hand held Doppler ultrasound fetal heart rate monitor (a ‘Doptone’). An ultrasound fetal heart rate monitor is by far the best as the fetal heart is often difficult to hear with an ordinary stethoscope or fetal stethoscope.
The fetal heart rate must be counted before contractions (to determine the baseline heart rate) and again during and at the end of a contraction (to detect any early or late decelerations). Late decelerations are caused by fetal hypoxia and indicate fetal distress. In a low risk labour, the fetal heart should be monitored every at least every hour.
Late decelerations must be carefully listened for.
The most important cause of hypoxia in the newborn infant is failure to establish good respiration after birth (neonatal asphyxia). This results in a 1 minute Apgar score of less than 7. It is essential to detect neonatal asphyxia early and to resuscitate the infant well. Everyone delivering a newborn infant must be able to provide basic resuscitation, especially bag and mask ventilation. Oxygen is not necessary for resuscitation.
The most important step in newborn resuscitation is bag and mask ventilation.
While it is difficult to prevent preterm delivery, a lot can be done to prevent the early neonatal death of preterm infants:
2. Early recognition of neonatal asphyxia and good resuscitation
3. Initial newborn care
4. Ongoing care
As the prevention of preterm labour is often not possible, every effort must be made to give preterm infants better care.
Kangaroo Mother Care (skin-to-skin care) keeps the infant warm, promotes bonding and breast feeding, reduces the risk of serious infection, and allows for earlier discharge. It is a simple, natural and cheap way of caring for small infants. It is very effective and significantly reduces the neonatal mortality of small infants, especially in poorly equipped facilities.
An adequate number of well trained staff are essential to reduce both maternal and perinatal mortality.
A young women presented at an antenatal clinic for the first time at 36 weeks of gestation, complaining of severe headache for two days. She was told to wait her turn but an hour later had a generalised convulsion. When she was found to be hypertensive, eclampsia was diagnosed. She was given an injection of phenobarbitone and an ambulance was ordered to transfer her to hospital. The referral hospital was not contacted. Unfortunately the ambulance was delayed. While waiting for the ambulance she had another convulsion and died.
The women booked very late for antenatal care. If she attended antenatal care from early in her pregnancy, she may have learned that severe headache was a danger sign and that she should have reported immediately to the clinic. Hypertension and proteinuria may also have been detected at an earlier visit.
There were a number of health worker related factors which were associated with this woman’s death. She should have been seen immediately but her severe headache was not recognised as a danger sign. The correct management protocol for convulsions was not followed and phenobarbitone was given instead. The staff should have discussed the problem with the referral hospital.
Yes. Transport was inadequate. The staff may also have been inadequately trained and there may not have been a management protocol for eclampsia.
Schools, community organisations, radio, newspapers, magazines and TV should be used to inform the general public, and young women especially, about the important of antenatal care.
The clinic staff must be well trained and must develop a culture of ‘patient friendly’ care. Clear management protocols and referral criteria are essential, and they must communicate with their referral hospital if patients need to be referred.
Adequate staffing and facilities, good communication and transport must be provided. Ideally, each community should be within reach of a clinic.
In a review of potentially avoidable causes of perinatal death in an urban health service, a case study is discussed. The woman presented in labour and reported poor fetal movements for the past two days. A partogram was not used as a short labour was expected. The fetal heart was recorded every 4 hours. After a prolonged second stage with meconium stained liquor, a fresh stillborn infant was delivered by the midwife. The doctor had not been called.
Yes. The mother should have come to the clinic when she first noticed that the fetal movements had suddenly decreased. Failure to report important danger signs in pregnancy remains a common patient related factor in perinatal deaths.
Yes. A partogram should always be used. Not using a partogram at all, or failing to use a partogram correctly, is common health worker related factor in potentially avoidable perinatal deaths. The condition of the mother and fetus, as well as the progress of labour, should have been carefully assessed at regular intervals. If this had been done correctly the stillbirth may have been avoided.
With meconium stained labour and a history of poor fetal movements, the fetal heart rate should have been very closely monitored (every half hour). In addition, the second stage of labour should not have been allowed to become prolonged. The doctor should also have been called. Important health worker related factors during labour, which are associated with perinatal deaths, include poor monitoring of the fetus, failure to detect fetal distress and poor response to fetal distress. Inadequate monitoring during labour is the commonest health worker related factor associated with perinatal deaths.
Inadequate resuscitation, poor monitoring of the infant, no management plan and a delay in calling for help. Inadequate resuscitation is a major preventable cause of early neonatal death.
Spontaneous preterm labour, intrapartum hypoxia and infection. The case is an example of intrapartum hypoxia.
After reading the summary of early neonatal deaths in a large teaching hospital, the doctor in charge of newborn care decided that something drastic had to be done to reduce the unacceptably high early neonatal mortality rate. He called all the nursing and medical staff together to discuss the problem and make suggestions to prevent further deaths.
Yes. With simple, good management many early neonatal deaths can be prevented.
Common causes of death and the important avoidable factors need to be identified. Then a clear plan to manage these common problems must be drawn up. As these are already available, all that is now required is the will to make the plan work.
Good antenatal care to prevent, detect and manage problems with the fetus should be made available to all pregnant women. It is better and cheaper to prevent than to treat a neonatal problem.
Staff must be taught to listen to and count the fetal heart rate between and immediately after the end of contractions in order to detect late decelerations. The fetal heart must be clearly heard, with a Doptone if necessary.