SAFE MOTHERHOOD PSRH BSM/BGM TH TH, OUTREACH SERVICES(SMOS) VANUATU, JULY 13 -19 2017 SALAUSA DR. JOHN AH-CHING SAMOA
RURAL OUTREACH ANTENATAL PROGRAM
Ò A new Innovative Approach in 2012: q Outreach Antenatal program by a visiting obs/gyn physician started Feb. 28th, 2012. q Three day per week – Tues, Wed, Thurs. q Clinic starts at 0800hrs until all are seen. q Portable Ultrasound machine started on 29/5/12 at Poutasi DH. q Started screening USS for ALL mothers in August, 2014. q Collect blood & urine specimens. POPULATION DISTRIBUTION OF SAMOA
Ò Total population ~ 188,000. (2011) Ò 76% live on Upolu ~ 142,880. Ò 19% live at Apia urban~27,147. Ò 33% live at NW Upolu ~ 47,150. Ò 24% live at rest of rural Upolu ~ 34,291. Ò Therefore 57% of Upolu population is covered by the program. ISLAND OF UPLOU – DISTRIBUTION OF HEALTH CENTRES
WHAT IS THE EXPECTED IMPACT?
Ø Elevate quality of ANCare for mothers in the rural areas. Ø Elevate clinical support to the rural Midwives. Ø Promote clinical problem solving skills for the rural midwives through discussions, team playing and regular perinatal mortality meetings. Ø Decentralizing health service delivery, taking the service closer to the people, as part of Primary Health Care approach. Ø Reduce workload in ANClinics at TTM. Ø Improve quality of AN attendance in numbers & frequency of visits in the rural areas – USS examinations as an incentive. Ø Improve national status of MDG 4 & 5 by 2015. Ø Empower mothers through health education to understand appropriate clinical aspects of their pregnancies, have responsible attitudes in looking after their pregnancies, themselves and their families.
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ANTENATAL FEATURE PROBLEMS: Ò 1. Overall average %tage of mothers with unsure, unreliable, unknown, or nil LMP – 54% (33-69) Ò 2. Overall average number of weeks of gestation on the first scan – 30 weeks (12-39) Ò 3. Overall %tage of mothers @ 28/more wks of gestation on the first scan – 69% (50-81) ANTENATAL RISK FACTOR/S: 1. Previous C/ sections Ò 2. Multiparity, G6P5+ Ò 3.Malpresentation>34w Ò 4.Postdates pregnancy Ò 5.Multiple pregnancies Ò 6.Anemia Ò 7.Placenta preavias Ò 8.Unengaged head >37w in primigravida Ò 9.HOP Ò 10.Ovarian Cyst** WAY FORWARD:
Ò SHORT TERM: q Regular Perinatal Mortality Meetings for the rural health services – MWs & Dr. q Birthing Beds. q Fetal Monitors. q A new USScanner with additional capabilities, higher resolution, more user-friendly, truly portable. q Analyzing data collected to improve evidence-based practice. q Lab Tech to collect blood at L/ moega & Faleolo. q ANC ready-available Catchment area for health talks – for any group.
WAY FORWARD:
Ò LONG TERM: Ò 1. Nursing specialization – a more focused responsibility. Ò 2.Extension of program to Savai’i?? Ò 3.Sustaining the program thereafter – semi-retired obs/gyn Dr. with USS skills. -- training MWs on basic USS skills. (PSRH) Study by Dr. U.T. Fidow for 2013 2014 TOTAL Source Master of Medicine Obs/ Gyn 2016.
Number of Stillbirths N=31 N=44 N=75 Birth registry in (1000gm/28w) Labour Room
Number of deliveries 4060 4125 8185 Birth registry in Labour Room
Number of Folders 31 29 60 (80%) Central Records retrieved Dept
Missing Folders 0 15 15 Data extracted from birth registry in LR in TTM hospital
Stillbirth Rate (SBs/No. 8/1000 10/1000 9/1000 Estimated 10/1000 of births x 1000) on WHO repository database, 2009
STILL BIRTHS AT TTM HOSPITAL 2013 – 2014
Ò Total SBs for 2 years: 75.
Ò Overall, 28% occur during labour (21) Ò But…… for 2013 alone where all Pt. folders were found (14/31), 45% SB occurred during labour (intrapartum).
Ò (Dr. Tapa Fidow) BEFORE OR DURING BIRTH – DEATHS (NHS)
IUD2014-2016
60
50
40
30
20
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
No of Mothers Gestation Perinatal Death Rate (PMR)
NHS WHO
9.7 8.7 7.5
4.3
2014 2015 2016 Centres No. LMP >2w diff No. LMP Actual %tage %tage of 2015 & single stated with USS unsure No. actual initial clinics patients unsure unsure unsure LMP LMP LMP
Poutasi 178 132 55 46 101 57 26 (20) L/moega 268 195 80 73 153 57 27 (21)
Lufilufi 185 142 59 43 102 55 23 (21)
Laloman 199 111 45 88 133 67 44 u (22) Sa’anapu 210 145 64 65 129 61 31 (21)
Faleolo 180 123 52 57 109 61 32 (18)
TOTAL 1,220 848 355 372 727 60 % av 31% av Centres 2016 No. LMP >2w diff LMP Actual % actual %tage single stated with USS unsure unsure unsure initial Patients LMP LMP LMP unsure
Poutasi 101 75 32 26 58 57 31 (11)
L/moega 187 141 62 46 108 58 25 (15)
Lufilufi 131 103 38 28 66 50 21 (10)
Lalomanu 145 79 29 66 95 66 45 (11)
Sa’anapu 105 68 25 37 62 59 36 (9)
TOTAL 669 466 186 203 389 58% av 32% av SAMOA CURRENT ANTENATAL PICTURE (NHS)
2016 Antenatal NHS visits
no visits , 435 3rd trimester, 2436
not recorded, 44
1st trimester, 392 2nd trimester, 537 BASIC LEVEL ULTRASOUND TRAINING IN OBSTETRICS FOR RURAL MIDWIVES (BLUTORM) FOR SAVAI’I MONDAY 21/11/ 2016
OBJECTIVES: To train the rural midwives on the use of the ultrasound machine to obtain basic information on the status of the pregnancy at anytime a pregnant mother is presented with a suspected problem. After mastering the skills for the basic level, the training will move onto a more advance level at a much later date.
The ultrasound skills taught and learnt, should not be regarded as an added burden or responsibility to the already overwhelming duties of the rural midwife, but should be regarded as an empowerment or an added tool on the knowledge and skills of the midwife for better and more efficient, effective management of obstetric mothers and their foetuses.
AT THE END OF THE BLUTORM, the midwife should achieve the following knowledge and skills: Know and understand the basic principles of ultrasound technology. Know how to turn-on and set the machine at its required functions. To detect if the foetus is alive or not by observing the heart beat. To detect the number of foetuses. To know the foetal presentation especially in late pregnancy. To locate the site of the placenta. To determine the amniotic fluid or liquor volume, usually by measuring a fluid pocket or the deepest pocket. Know how to take good care and look after the machine and all its attachment parts.
SECTIONS OF THE TRAINING Part 1. Introduction and explanation on the Objectives and the Expected Outcomes of the training.
Part 2. Practical introduction on the ultrasound machine and doing basic examinations on actual patients.
(Ia fa’amanuia Iesū i lau a’oga aua lana galuega.)
Preparation & Trainer, Salausa Dr. John Ah Ching with materials provided by Prof. Peter Stone of PSRH(jac1-02/2017) PROTOCOL FOR BASIC LEVEL ULTRASOUND EXAMINATION BY MIDWIFE (BLUTORM PROGRAM – NHS/SMOS) These are protocol guidelines for the rural midwife in performance of the basic level ultrasound examina ons of pregnant mothers in the rural areas. USS Exams should be done under the following recommenda ons: 1. For diagnosis of pregnancies especially in the early trimester, by observing a gesta onal sac, +/- a fetal pole, +/- a fetal heart ac vity or fetal movements. 2. For finding out if the fetus is alive at any trimester of the pregnancy by observing the fetal heart ac vity, posi ve or not. 3. For finding out the presen ng part, the placental site, the liquor volume and a fluid pocket, and the fetal heart ac vity in the late trimester, between 34 and 40 weeks gesta on. Any abnormality detected e.g., abnormal fetal lie, low lying placenta or previa, low liquor pocket 2cm or less, no heart ac vity seen, the pa ent must be referred within the next few days (1 to 6 days depending on the urgency) to the doctors’ High Risk Clinic (HRC) at TTM. 4. For evalua on of suspected postdate pregnancies (40 to 42+ weeks) by doing No.3 above and paying special a en on on the liqour volume and the deepest fluid pocket. (Make sure you exclude the umbilical cord during measurement of the fluid pockets.) If the deepest fluid pocket is 2cm or less, refer the pa ent urgently to the Obstetrician via a phone call and discuss appropriate arrangements for referral. If phone communica on fails, refer the pa ent directly to the Labour & Delivery room at TTM with all appropriate informa on and documenta ons. 5. For confirma on of the fetal presen ng part in late trimester (at 34+ weeks of gesta on) especially when the abdominal palpa on is difficult and indecisive as in very obese mothers. If it is an abnormal presenta on, refer to HRC/ TTM within the next few days 6. For diagnosis of suspected mul ple pregnancies and make appropriate referral. 7. For iden fica on of the placental site in pregnancies presen ng with Antepartum Heamorrhage and make appropriate urgent contact and referral.
USScan REPORT BY MIDWIFE {BLUTORM}
NHS/SMOS (NATIONAL HEALTH SERVICE/SAFE MOTHERHOOD OUTREACH SERIVES)
DISTRICT CENTRE: ______. DATE OF SCAN: ____/____/______.
PATIENT: ______. AGE: _____ G____P____. LMP:____/___/______. GESTATION BY LMP: ______. GESTATION BY PREVIOUS DR/SONOGRAPHER USS: ______. EDD: ____/___/_____.
PERIOD OF SCAN: First trimester: _____. INDICATION OF SCAN: ______Second trimester: _____. ______Third trimester: _____. ______. FIRST TRIMESTER FINDINGS: Gestational sac seen: Yes ___. No___. Fetal pole seen: Yes___. No___. Yolk sac seen: Yes ___. No ___. Fetal movement observed: Yes ___. No ___. Fetal heart activity observed: Yes ___. No ___. Liqour volume: Normal ___. Low ___.
SECOND TRIMESTER FINDINGS: Complete fetal body parts observed: Yes ___. No ___. Fetal movements observed: Yes ___. No ___. Fetal heart activity observed: Yes ___. No ___. Fetal presenting part: ______. Placental site: ______. Liqour volume: ______. Pocket: ______cm.
THIRD TRIMESTER FINDINGS: Presenting part: ______. Fetal heart activity observed: Yes ___. No ___. Placental site: ______. Liqour volume: ______. Pocket: ______cm. Deepest pocket: ______cm. From abdominal palpation, if fetal head is presenting, is it engaged? Yes ___. No ___.
COMMENTS: ______.
Midwife. (jac1-02/2017) NEED SCANNER WITH HIGH RESOLUTION ‘THE END ----- FA’AFETAI/THANK YOU AUDIT OF ANTENATAL VISITS – RURAL UPOLU
Year 2012 2013 2014 2015 ANPt-visits Dr. 2806 2168 2298 830* MW/S 180+ 1037 1131 542* Total 2986+ 3205 3429 1372* Other Pts. Dr. 291 109 59 17* USS 612 980 1294 671* exams ANPts with 556 243* Risk Factor Referrals 211 100* HRC/TTM
(*figures of Jan to April) Centres 2016TotalCentres Patients No. PatientsSingle LMPLMPLMP stated stated LMPUnsureLMP unsure LMP% unsure % LMP stated Patients stated unsure LMP Poutasi 100 75 25 69
Leulumoega 187 141 46 75
Lufilufi 131 103 28 79
Lalomanu 145 79 66 55
Sa’anapu 105 68 37 64
TOTAL 669 466 203 68.4 average STILL BIRTHS IN SAMOA PROTOCOL FOR BASIC LEVEL ULTRASOUND EXAMINATION BY MIDWIFE (BLUTORM PROGRAM – NHS/SMOS)
These are protocol guidelines for the rural midwife in performance of the basic level ultrasound examina ons of pregnant mothers in the rural areas.
USS Exams should be done under the following recommenda ons: 1. For diagnosis of pregnancies especially in the early trimester, by observing a gesta onal sac, +/- a fetal pole, +/- a fetal heart ac vity or fetal movements.
1. For finding out if the fetus is alive at any trimester of the pregnancy by observing the fetal heart ac vity, posi ve or not.
1. For finding out the presen ng part, the placental site, the liquor volume and a fluid pocket, and the fetal heart ac vity in the late trimester, between 34 and 40 weeks gesta on. Any abnormality detected e.g., abnormal fetal lie, low lying placenta or previa, low liquor pocket 2cm or less, no heart ac vity seen, the pa ent must be referred within the next few days (1 to 6 days depending on the urgency) to the doctors’ High Risk Clinic (HRC) at TTM.
1. For evalua on of suspected postdate pregnancies (40 to 42+ weeks) by doing No.3 above and paying special a en on on the liqour volume and the deepest fluid pocket. (Make sure you exclude the umbilical cord during measurement of the fluid pockets.) If the deepest fluid pocket is 2cm or less, refer the pa ent urgently to the Obstetrician via a phone call and discuss appropriate arrangements for referral. If phone communica on fails, refer the pa ent directly to the Labour & Delivery room at TTM with all appropriate informa on and documenta ons.
1. For confirma on of the fetal presen ng part in late trimester (at 34+ weeks of gesta on) especially when the abdominal palpa on is difficult and indecisive as in very obese mothers. If it is an abnormal presenta on, refer to HRC/TTM within the next few days
1. For diagnosis of suspected mul ple pregnancies and make appropriate referral.
1. For iden fica on of the placental site in pregnancies presen ng with Antepartum Heamorrhage and make appropriate urgent contact and referral.
(jac1-02/2017)
A BIRTHING BED = FOR LABOUR & FOR.…… DELIVERY!!!! OBS/GYN EXAMINATION TABLE:
ADVANTAGES OF THE PROGRAM: q Support to the rural Midwives - continuous. q Decentralizing the ANC services/Taking the service closer to the people. q Quicker turn-around in specimen results, early Rx. q More effective screening of High Risk AN patients. q USS support on screening for high-risk pregnancies & make appropriate action plan.
GENERAL PRINCIPLES ON CONTROL OF DISEASES & CONDITIONS – NATURAL HISTORY
Ò COMMUNICABLE DISEASES: Mode of SOURCE RECEPIENT Transmission
SITES OF INTERVENTIONS Ò NON-COMMUNICABLE DISEASES:
cured ONSET OUTCOME controlled death
TIMES OF INTERVENTIONS TOPICS FOR DISCUSSION
Ò Antenatal & Postnatal Care Ò Family Planning Ò Methods of Improving
Ø INNOVATIVE APPROACHES: - ‘aikia fou, - ‘auala fou, ‘ae fa’aosofia ai le fia iai. Ø Improve on what we already have; Ø We need to bring substandard areas up to the required standards before we could improve on the quality of care; (quality(n) = degree or std of excellence; (adj) = excellent or superior) Ø Analyse & translate information into better practices;
2012 OUTREACH ANTENATAL CLINICS - UPOLU NHS/SMOS
NUMBER OF ANTENATAL VISITS - 2012 PO LEUL UT UMO FACILITY ASI EGA LUFILUFI LALOMANU SA'ANAPU TUANA'I
MONTH Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS
JAN
FEB 19 34
MAR 42 144 73 2 55 37 50 10
APR* 33* 4 77 ? 4 47 20 27 13
MAY 58 13 154 ? 3 62 28 55 15
JUNE* 20* 4 82 21 31 42 16 20 26 11
JULY 51 2 18 134 ? 1 46 87 11 22 29 11 11
AUG 67 5 27 147 12+ 3 37 101 8 29 59 4 7
SEPT 56 5 22 65 ? 29 29 100 5 30 55 4 16
OCT 60 1 24 115 ? 32 94 3 25 83 5 25
NOV 33 1 13 112 ? 3 38 111 5 31 45 6 17
DEC* 51* 15 1 27 62 53 1 11 41 6 8 9 21 4
TOTAL 490 15 32 135 1126 159+ 46 224 740 6 141 166 450 72 87
537 1331+ 887 522 3277++ Total AN Pts seen by Dr = 2806 Total AN Pts seen by MW = 180+ Non-ANC Pts seen by Dr = 291 Total USS exams = 612 (22%), ( Grand total of All Pts seen by Dr = 3097 ( * ) = Incomplete ANC visits for the month.
Key: Dr = doctor. MW = midwife. OT = other pa ents/non-antenatal. USS = ultrasound exams. OUTREACH ANTENATAL CLINICS - 2013 UPOLU NHS/SMOS NUMBER OF ANTENATAL VISITS - 2013 PO LEUL UT UMO FACILITY ASI EGA LUFILUFI LALOMANU SA'ANAPU TUANA'I
MONTH Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS Dr MW OT USS
JAN 36 19 12 68 145 32 82 11 9 32 39 2 2 9
FEB 57 1 16 62 145 30 70 5 24 31 6 2 15
MAR 21* 11 2 8 70 119 27 46 5 10 22 2 10 17 1 7
APR 35 18 13 41 41 14 80 8 15 65 1 18 82 4 2 32 23 1 12
MAY 43 11 3 19 36 38 19 16* 7 1 7 54 2 14 43 36 6 20 34 1 18
JUNE 36 14 2 24 41 34 22 40 2 23 31 16 4 17 35 3 15 22 1 8
JULY* 38 26 1 17 57 57 32 11* 2 7 15* 1 10 11* 4 7 10* 6
AUG 23 8 1 13 22* 18 2 11 30 11 2 21 23 6 4 12 34 2 10 22 1 9
SEPT 25 20 16 34 36 1 21 51 2 3 27 18* 10 3 13 21 16 14 18 2 8
OCT 37 15 1 25 36 49 22 46 4 1 9 50 13 7 25 39 15 2 26 28 7 19
NOV* 17* 9 12 20* 31 9 16* 8 8 15* 1 10 13* 2 9 10* 10
DEC*
TOTAL 368 151 11 175 487 713 3 239 488 45 36 183 363 53 28 153 278 75 17 133 184 14 97
530 1203 569 444 370 198 3314 Total AN Pts seen by Dr = 2168 Total AN Pts seen by MW = 1037 Non-ANC Pts seen by Dr = 109 Total USS exams = 980 Grand total of All Pts seen by Dr = 2277 ( * ) = Incomplete ANC visits for the month.
Key: Dr = doctor. MW = midwife. OT = other pa ents/non-antenatal. USS = ultrasound exams. FAMILY PLANNING
Ò What is FP? q Is it about the methods of contraception? (7) q Is it about the number of children a couple should have? q Is it about the spacing of children? q Is it about the holistic viewing of your family development?, house? car? education? socioeconomic status? CONTRACEPTIVE METHODS
1) Depo Provera Inj. 2) Combined pills. 3) Progesterone-only pill. 4) Condoms. 5) IUCDs. 6) Implants. 7) Ovulation method – Natural method. SOIFUA !!! ANTENATAL CLASSES HEALTH EDUCATION NUTRITIOUS SOUP