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. - 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 examinaons of pregnant mothers in the rural areas. USS Exams should be done under the following recommendaons: 1. For diagnosis of pregnancies especially in the early trimester, by observing a gestaonal sac, +/- a fetal pole, +/- a fetal heart acvity or fetal movements. 2. For finding out if the fetus is alive at any trimester of the pregnancy by observing the fetal heart acvity, posive or not. 3. For finding out the presenng part, the placental site, the liquor volume and a fluid pocket, and the fetal heart acvity in the late trimester, between 34 and 40 weeks gestaon. Any abnormality detected e.g., abnormal fetal lie, low lying placenta or previa, low liquor pocket 2cm or less, no heart acvity seen, the paent 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 evaluaon of suspected postdate pregnancies (40 to 42+ weeks) by doing No.3 above and paying special aenon 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 paent urgently to the Obstetrician via a phone call and discuss appropriate arrangements for referral. If phone communicaon fails, refer the paent directly to the Labour & Delivery room at TTM with all appropriate informaon and documentaons. 5. For confirmaon of the fetal presenng part in late trimester (at 34+ weeks of gestaon) especially when the abdominal palpaon is difficult and indecisive as in very obese mothers. If it is an abnormal presentaon, refer to HRC/ TTM within the next few days 6. For diagnosis of suspected mulple pregnancies and make appropriate referral. 7. For idenficaon of the placental site in pregnancies presenng 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: _____.