In a quiet homestead in Kosinyo village, Siaya County, Kenya, Lilian Achieng Omondi rocks her two-month old baby. Her first born, sits next to his mother as though to get a glimpse of the young one who is about to sleep. Their brother, plays outside the house. All three children are clearly oblivious of the challenges that their mother has undergone to give birth to them.
Achieng, 28, has experienced postpartum hemorrhage since giving birth to her first born son. Postpartum hemorrhage, contributes to 287,000 deaths in Kenya, 34% of overall maternal deaths.
During her first birth, Achieng experienced minimal complications and bleeding thereafter. Five years later, she would undergo the same experience for her second birth. But this time, she remembers, the bleeding got worse. Achieng sought help at a nearby health facility, and after being injected with oxytocin, the bleeding stopped.
However, the birth of her third child was the most complicated. “I experienced heavy bleeding and the injection did not help this time. It started with very painful labor that lasted about five hours.” Achieng took herself to a health facility at 06:00 and delivered at 12:30. “I saw my baby, breastfed her, and immediately I became unconscious,” she recalls.
Achieng was rushed to another health center – Akala Health Centre in Siaya County – where she regained consciousness.
“When I woke up, I noticed something strange in my body. The doctor was removing some water from my body using a syringe. It was not painful. At this time, I had gained consciences and the bleeding had stopped,” she explains. It was the ESM-Uterine Balloon Tamponade (UBT) kit that was used to stop Achieng’s excessive bleeding.
The ESM-UBT kit is locally assembled by the Kisumu Medical and Education Trust (KMET). It consists of a pair of condoms, a rubber catheter, a string, two data cards, a referral card and a 60ml syringe. KMET provides heath facilities with the ESM-UBT kits, a three hours simulation based training, pocket checklists, delivery room wall charts, and reference manuals. Field data highlights the high success rate of the ESM-UBT: persistent bleeding after birth can be successfully controlled in 98% of cases.
After KMET introduced the ESM-UBT kit to the Akala Health Center, Chris Opati, the Clinical Officer at the center, noted the ESM-UBT kit had saved the lives of two women, including Achieng. Opati remains hopeful.
In Colombia, postpartum hemorrhage has been an essential problem of maternal mortality; the entity has raised public sector alarms for the development and implementation of programs that optimize its management. Cali is located in the department of Valle del Cauca; it is the reference city of the Colombian Southwest due to the high complexity of its hospitals; one of them is the Hospital Universitario Fundación Valle del Lili. In this region an Obstetric Critical Care Unit has been established as a center of care for patients with a high risk of mortality and extreme maternal morbidity. We receive patients from all regions of the country, especially from the hospitals to which we perform the intervention that will be explained later (16 hospitals)
According to the most recent statistics (2018), the department has three municipalities where maternal mortality exceeds the national maternal mortality ratio.
Given the statistics of maternal morbidity and mortality reported in the last two decades, in 2013, the Obstetrician group composed of 24 Obstetricians decided to implement the American model of PPH treatment and began using bundles for postpartum hemorrhage as an approach to reduce complications derived from excessive bleeding. Initially, there were master classes, simulation exercises to disseminate and systematize patient care standards among the medical and nursing group. In that year, the red code included non-pneumatic anti-shock garment, uterine balloon tamponade, uterotonics, and hemostatic agents such as tranexamic acid. In addition to the international standard, rapid response teams in obstetrics, emergency transfusion packages, adequate equipment for obstetric emergency care were established. Bundles were well received in our hospital, but despite some positive results in indicators of maternal and perinatal morbidity and mortality, the treatment of postpartum hemorrhage was carried out differently depending on the Obstetrician on a particular shift. For this reason, in the second period corresponding to 2017 until today (2020), we created checklists which allowed all obstetricians to adopt the same standard to avoid delays and complications during a red code. Following a red code, we initiated reporting systems and post-event learning meetings (debriefing). This strategy had a positive impact on maternal and perinatal outcomes such as decrease days in-hospital stay, number of transfusions, decrease in the rate of hysterectomies, etc.
Despite the benefits of the implementation, in Colombia, we did not have enough evidence to justify the use of the bundles. Due to the socio-economic conditions of our country, it was difficult to find necessary equipment and drugs (like the NASG) for the red code in primary and secondary hospitals. So the group of obstetricians of Fundacion Valle del Lili decided to write a paper to demonstrate the effectiveness. We compared PPH patients from the period from 2011 to 2013 (77 patients) who received standard management without a non-pneumatic anti-shock garment (NASG) and (77 patients) 2014 to 2015 who received standard PPH management plus NASG. The results obtained were the following: the leading causes of PPH were uterine atony (96.1%), placental retention (9.7%), abruption of the placenta (6.5%), and placenta previa (4.5%). All patients in the first period showed shock rates higher than 1 which was directly related to hemodynamic instability secondary to hypovolemia, 89% of cases required massive transfusion.
The results showed that the need for blood products was statistically significant WHEN COMPARING THE 89% in the non-NASG group tO 39%and the NASG group, Abdominal hysterectomy was more common in the non-NASG group compared to the NASG group (98.2% versus 1.8%). In conclusion the use of NASG in critically ill patients demonstrated a speedy recovery from hypoperfusion, in addition to the prevention of the use of invasive procedures that produces an increase in maternal morbidity and an increase in costs.
These results allowed the Obstetrics team to make visits and to record which hospitals had all the necessary tools for the full practice of the red code. During the visits, some hospitals had the NASG, but staff did not know the technique and the right time to use it. In other cases, they did not have the NASG because it “represented a high cost” for the hospital (230.00 US) These findings stimulated staff and administration to seek funding and develop an action plan that would improve the care of obstetric patients and diminished mortality.
So, in 2017 with the Health Secretary of the district of Valle del Cauca, the group of Obstetricians began the training and on-site simulations in 5 nearby hospitals of Primary, Secondary and Tertiary care. Additionally, it was possible to carry out multiple simulation practices in our institution with collaboration from the remaining hospitals of Cali. Due to the positive feedback, Dr. María Fernanda Escobar initiated a Telemedicine strategy as a project leader for implementing the bundles in a red code for referring hospitals.
In August 2018, the project was extended to all the North of Cauca department, where maternal mortality far exceeded the national average. As of Dec 31 2019 the results show a major reduction of maternal mortality in the intervention area. These results present a challenge to expand open telemedicine to other regions of Colombia. As of January 2020 the group received more than one hundred tele-consults.
Now, when comparing pre and post-intervention statistics at the national level, it is observed how maternal mortality has been declining. (Table 1 and 2). These results provide hope and motivation to continue our magnificent work of improving the quality of care of obstetric patients.??? using bundles, red code and standard check lists for PPH diagnosis and treatment…
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