EmOC(Emergency Obstetric Care)RUKMONO SISWISHANTO

What are we talking aboutMaternal deathEmergency obstetric servicesObstetric complicationsReducing maternal deathEffective measuresTriage & referral

MATERNAL DEATHThe death of woman from any cause related to, or aggravated by, pregnancy or its management (regardless of duration or site of pregnancy), does not include accidental or incidental causes.

DIRECT OBSTETRIC DEATHThe death of woman from obstetric complications of pregnancy, labor, or the puerperium; from intervention, omissions, or treatment; or from a chain of events resulting from any of these factors

INDIRECT OBSTETRIC DEATHThe death of woman from a previously existing disease or a disease that develops during pregnancy, labor, or the puerperium

EMERGENCY OBSTETRIC SERVICESCentral to the prevention of maternal deathTwo types:Basic EmOCComprehensive EmOC

BASIC EmOCAntibiotics (injectable)Oxytocics (injectable)Anticonvulsants (injectable)Manual removal of placentaRemoval of retained productsAssisted vaginal delivery

COMPREHENSIVE EmOCBasic EmOCSurgery (e.g., Cesarean Section)Blood transfusionMinimum acceptable level for every 500,000 population, there should be at least 4 basic EmOC and 1 comprehensive EmOC

THE CAUSES OF MATERNAL DEATH

Obstetric ComplicationsIncidenceFatalityHighHighLowLow

OBSTETRIC COMPLICATIONSHemorrhage (postpartum & antepartum)Obstructed laborPuerperal sepsisPreeclampsia/eclampsiaAbortus complicationEctopic pregnancyUterine ruptureShoulder dystocia

INCIDENCE ESTIMATIONMinimal 15% of all pregnanciesWHO estimation (1994):Hemorrhage10%Puerperal sepsis 8%Preeklampsia/E 5%Obstructed labor 5%

REDUCING MATERNAL DEATHSReduce the likelihood that woman will become pregnantReduce the likelihood that pregnant woman will experience a serious complication of pregancy or chilbirthReduce the likelihood of death among women who experience complications

THE THREE DELAYS MODELFactors Affecting Utilization and OutcomePhases of DelaySosioeconomic/ Cultural factorsPhase I:Decision to seek carePhase II:Identifying and Reaching Medical FacilityPhase III:Receipt of Adequate and Appropiate TreatmentAccessibility of FacilitiesQuality of Care

COMMUNITY EDUCATIONAny vaginal bleeding before laborHeavy bleeding during or after laborSevere headaches and/or fitsSwollen hands and feetFeverSmelly vaginal dischargeLabor from morning till nightfall or vice versaAny part of the baby showing except the head

EFFECTIVE MEASURESPostpartum hemorrhageActive management 3rd phase of laborPostpartum misoprostolObstructed LaborPartographPuerperal sepsisAntibiotic combination (Ampicillin Gentamycin Metronidazol)

EFFECTIVE MEASURESPreeclampsia/EclampsiaMagnesium sulfateAntihypertension (Nifedipin)Abortus complicationManually Aspirated VacuumEctopic pregnancy, uterine rupture, other hemorrhage problemBlood transfusionOperation

Triage & referralTriageSift as through sieve (or to prioritise)

ReferralPatient transfer to fulfill patients need of better care

TriageA quick assessment of an individual woman and her baby (born or unborn)Prioritise the order of treatment and allocation of staff

Quick assessment:ask, check, record, look, listen, feelClassify as one of the following:Emergency for womanLabourEmergency for babyRoutine care

Classify as emergencyThe woman is: unconscious, convulsing, bleeding from the vaginaThe woman has:Severe abdominal pain, headache or visual disturbance, severe difficult breathing, high fever, severe vomitingThe woman looks:Very ill

Prioritise the order of treatment and allocation of staffTo do most for the most and do this in the right orderExample: in labour ward with more than one patient[!] The management of care in the labour ward is a dynamic process and regular reassessment of priorities is vital

The priorityPriority 1A woman who requires emergency treatment and resuscitation soon or she may diePriority 2A woman whose care may be delayed for a few hoursPriority 3A woman who can sustain a significant delay

ReferralA good tranfer is well planned and prepared

Following the ACCEPT approachAssessmentControlCommunicationEvaluationPreparation and packagingTransportation

The right for patientThe right patient has to be taken at right time by the right people to the right place using the right form of transport and receiving the right type of care throughout

REFERENCEBuku Panduan Praktis Pelayanan Kesehatan Maternal Neonatal, Jakarta, 2002Maine D, Akalin MZ, Ward VM, Kamara A., The Design and Evaluation of Maternal Mortality Programs. Center for Population and Family Health School of Public Health School of Public Health Columbia University, 1997RCOG, Life saving skill essential obstetric care, 2006