Latest report: prevention and treatment of postpartum haemorrhage” by WHO 2012


Latest publication on “WHO recommendations for the prevention and treatment of postpartum haemorrhage” by WHO, 2012.

Every minute around the world 380 women become pregnant,

190 women face unplanned or unwanted pregnancies,

110 women experience pregnancy related complications,

40 women have unsafe abortions,

1 woman dies.”

The World Health Organization states that every minute, at least one woman dies from complications related to pregnancy or childbirth – that means 529 000 women a year. Unavailable, inaccessible, unaffordable, or poor quality care is fundamentally responsible.

 
Find the latest recommendations below.
The report in its guideline development method, section of the report reads out as follows: “The scientific evidence for the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. For each of the previous WHO recommendations on PPH (2007 and 2009) and for all the newly-added questions, evidence profiles were prepared based on 22 up-to-date systematic reviews. The revised and new recommendations were developed and adopted by an international group of experts who participated in the WHO Technical Consultation on the Prevention and Treatment of PPH, held in Montreux, Switzerland, 6–8 March 2012. The WHO Technical Consultation adopted 32 recommendations and these are shown in Boxes A, B and C. For each recommendation, the quality of the supporting evidence is graded as ‘very low’, ‘low’, ‘moderate’ or ‘high’………………”
Box A: Recommendations for the prevention of PPH
1. The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births. (Strong recommendation, moderate-quality evidence)
 
2. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. (Strong recommendation, moderate-quality evidence)
 
3. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 μg) is recommended. (Strong recommendation, moderate quality evidence)
 
4. In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 μg PO) by community health care workers and lay health workers is recommended for the prevention of PPH. (Strong recommendation, moderate quality evidence)
 
5. In settings where skilled birth attendants are available, CCT is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important (Weak recommendation, 
 
6. In settings where skilled birth attendants are unavailable, CCT is not recommended. (Strong recommendation, moderate-quality evidence)
 
7. Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care. (Strong recommendation, moderatequality evidence)
 
8. Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation. (Strong recommendation, moderate-quality evidence)
 
9. Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin. (Weak recommendation, low-quality evidence)
 
10. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. (Strong recommendation, very-low-quality evidence)
 
11. Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in caesarean section. (Strong recommendation, moderate-quality evidence)
 
12. Controlled cord traction is the recommended method for removal of the placenta in caesarean section. (Strong recommendation, moderate-quality evidence)
 
Box B: Recommendations for the treatment of PPH
 
13. Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH. (Strong recommendation, moderate-quality evidence)
 
14. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 μg) is recommended. (Strong recommendation, low-quality evidence)
 
15. The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous fluid resuscitation of women with PPH. (Strong recommendation, low-quality evidence)
 
16. The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly due to trauma. (Weak recommendation, moderate-quality evidence)
 
17. Uterine massage is recommended for the treatment of PPH. (Strong recommendation, verylow- quality evidence)
 
18. If women do not respond to treatment using uterotonics, or if uterotonics are unavailable, the use of intrauterine balloon tamponade is recommended for the treatment of PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
 
19. If other measures have failed and if the necessary resources are available, the use of uterine artery embolization is recommended as a treatment for PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
 
20. If bleeding does not stop in spite of treatment using uterotonics and other available conservative interventions (e.g. uterine massage, balloon tamponade), the use of surgical interventions is recommended. (Strong recommendation, very-low-quality evidence)
 
21. The use of bimanual uterine compression is recommended as a temporizing measure until appropriate care is available for the treatment of PPH due to uterine atony after vaginal delivery. (Weak recommendation, very-low-quality evidence)
22. The use of external aortic compression for the treatment of PPH due to uterine atony after vaginal birth is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, very-low-quality evidence)
 
23. The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, low-quality evidence)
 
24. The use of uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal birth. (Weak recommendation, very-low-quality evidence)
 
25. If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in combination with controlled cord traction is recommended. (Weak recommendation, very-low-quality evidence)
 
26. The use of ergometrine for the management of retained placenta is not recommended as this may cause tetanic uterine contractions which may delay the expulsion of the placenta. (Weak recommendation, very-low-quality evidence)
 
27. The use of prostaglandin E2 alpha (dinoprostone or sulprostone) for the management of retained placenta is not recommended. (Weak recommendation, very-low-quality evidence)
 
28. A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised. (Weak recommendation, very-low-quality evidence)
Box – C: Organisation of Care
29. The use of formal protocols by health facilities for the prevention and treatment of PPH is recommended. (Weak recommendation, moderate-quality evidence)
 
30. The use of formal protocols for referral of women to a higher level of care is recommended for health facilities. (Weak recommendation, very-low-quality evidence)
 
31. The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes. (Weak recommendation, very-low-quality evidence)
 
32. Monitoring the use of uterotonics after birth for the prevention of PPH is recommended as a process indicator for programmatic evaluation. (Weak recommendation, very-low-quality evidence)

Hygiene shocker! Now, cleaners assist in delivering babies at maternity homes #Indiashining


 

Pritha Chatterjee : New Delhi, Fri Aug 03 2012, 01:58 hrs
News

Usha Devi’s newborn came into the world a few hours after the Northern Grid collapsed for the first time early on Monday morning.

When Usha went into labour at the 14-bed municipality-run maternity home in Khichripur, East Delhi, late on Sunday night, a nurse who was assisted by a cleaning staff helped her deliver — in a room lit by candles.

The centre is one of the 30-odd maternity homes in the city, sponsored by the government as part of its Janani Suraksha Yojana programme to promote “institutional” deliveries. Most of these centres suffer from an appalling lack of facilities and staff.

“The labour room was dark and hot. I was in pain. I did not know that a nurse, not a doctor, was attending to me. She saved my life and my baby,” Usha said.

When the Northern Grid failed a second time on Tuesday, the healthcare centre was once again without power. Usha and her child lay in the ward, where another expecting mother, Aarti, was writhing in labour pain.

Though not qualified, a cleaning staff administered her a drip.

“We have learnt a few things because of the perennial staff shortage. We help the nurses,” she said.

The auxiliary nurse midwife agreed: “We have learned to work without doctors. The sweepers have become our assistants.”

SORRY STATE

Delhi Health Minister Dr A K Walia said: “Most of these centres are managed by the civic agencies. We have been telling them to arrange for basic facilities like ultrasound machines.”

These centres have been around for over a decade and were supposed to be open round-the-clock. But it has been alleged that doctors — some of who are posted under National Rural Health Mission — were seldom available at night.

“We have eight-hour shifts. If the doctor is on night duty, a nurse still has to manage the other shifts alone. Babies will not wait to be born at the hands of a doctor. There is acute shortage of doctors,” a doctor at the Tri Nagar maternity home in North Delhi said.

Sources said there’s no ambulance for emergencies, though the rules state that there should be one at each centre. And at Patparganj centre, which has an ambulance, the vehicle cannot be used as the driver has been on leave for a month.

There are instances, sources said, when nurses have to fetch water from outside for deliveries because of erratic supply and poor storage facilities. At Geeta Colony, Tri Nagar, Shakurpur Basti and Patparganj centres, there is no running water in the labour room.

Spokesperson for the city’s three municipalities, Yogendra Mann, said tender notices would be issued for generators and inverters at the these homes. “We discussed with the Delhi government ways to develop a system for making CATS ambulances available at these centres whenever necessary,” he said.

“We are getting doctors from NRHM and are in the process of recruiting more through UPSC,” he said.

SEPTIC CONDITIONS

Even without the basic facilities, these centres perform anywhere between 50 and 70 deliveries every month, government sources said.

Doctors said their hands were tied because of the lack of diagnostic equipment. Moreover, there is no operation theatre as, in accordance with the policy, they are supposed to perform only “routine deliveries”.

A doctor at the Patparganj home said: “At the slightest sign of complication, we are supposed to refer our patients to the nearest government hospital. I don’t know why we (doctors) are posted here when we don’t have any support system to help the patients.”

A gynaecologist of Hedgewar Hospital said: “We are already overburdened. Our gynaecology ward has a waiting list of three months for an ultrasound.”

That is not the only problem. A nurse posted at the Geeta Colony centre said: “Distance between (government) hospitals and our centre is a huge factor when the clock is ticking. There are instances of women delivering on the way to hospitals.”

Doctors at the Patparganj home said nurses conduct deliveries in “septic conditions” because no staff has been appointed to do the after-delivery cleaning.

“There is no water supply in the labour room. Shortage of sweepers means there is no one to do the cleaning,” a doctor said.

 

Maternal death 3 times more in tribal areas of Jharkhand


Tending to her flock in Jharkhand

CGNETSWARA REPORTS  

Tarpari Ji from Jharkhand says that they have found that in tribal areas of Jharkhand the rate of maternal death at child birth is 3 times more than  the average. He says in parts of 2 blocks in Godda District between April 2011 & Feb 2012 in a population of about 1,36,000 with an estimated births of 3117 there has been 23 Maternal deaths, which is about 3 times of the State reported figure (261 per 100,000 live births).72% of the deaths were in tribal communities (Santhal & Paharia) .For more Tarpari ji can be reached at 09934353484

Listen here

 

Man can’t force wife to conceive, rules high court


Feb 11, 2012

In a first, the Punjab and Haryana High Court has ruled that a husband cannot compel his wife to conceive and give birth to his child. Making it clear that relationships that know no limits too have boundaries, the high court has asserted intimacy is one thing, giving birth to a child another.

“Mere consent to conjugal rights does not mean consent to give birth to a child for her husband,” Justice Jitendra Chauhan of the High Court has asserted.

The judgment, pregnant with significance, also makes it amply clear that “to have and to hold, for better, for worse, for richer, for poorer, in sickness or in health” does not give a man the right to prevent his wife from going in for an abortion.

The ruling came on revision petitions filed by Chandigarh-based gynaecologist Dr Mangla Dogra and others petitioners. The controversy in the case hovered around the decision of a wife to go in for medical termination of pregnancy without her husband’s consent.

Married in April 1994, the couple and their son were initially staying in Panipat. Due to “hostilities and strained relations”, the wife started staying with her parents, along with her son, at Chandigarh.

The wife conceived after she agreed to accompany her husband to Panipat during the pendency of her application for maintenance. She then underwent an MTP carried out by Dr Mangla Dogra, who was assisted by Dr Sukhbir Grewal as anesthetist.

The husband, subsequently, filed a civil suit for the recovery of Rs 30 lakh towards damages for mental pain, agony and harassment against his wife, her brother and parents and Dr Dogra and Dr Grewal for getting the pregnancy terminated illegally.

Taking up the plea, a Civil Judge asserted: “There is a cause of action in favour of the plaintiff against the defendants (wife and others) at this stage”. Aggrieved by the orders, Dr Dogra and other petitioners preferred the revisions.

Justice Chauhan asserted: “The wife knew her conjugal duties towards her husband. Consequently, if the wife has consented to matrimonial sex and created sexual relations with her own husband, it does not mean that she has consented to conceive a child. It is the free will of the wife to give birth to a child or not…

“The wife is the best judge and is to see whether she wants to continue the pregnancy or to get it aborted… Keeping in view the legal position, it is held that no express or implied consent of the husband is required for getting the pregnancy terminated…

“A woman is not a machine in which raw material is put and a finished product comes out. She should be mentally prepared to conceive, continue the same and give birth to a child. The unwanted pregnancy would naturally affect the mental health of the pregnant woman…” Imposing costs of Rs 50,000 on the husband, Justice Chauhan concluded: “It is held that the act of the medical practitioners Dr Dogra and Dr Grewal was legal and justified.”

How Biriya delivered safely


Kounteya Sinha | February 11, 2012

A unique project in MP ensures that even women who live in remote tribal villages are only a phone call away from safe childbirth.

ON HAND: Call centre numbers for Janani Express are plastered on the walls of village homes

Scenario 1

Time: 1. 40 am February 6

Deepak Tiwari, posted at Mandla district hospital’s 24X7 call centre, receives a call informing him that Biriyabai from the tribal village of Sarra has gone into labour. He immediately dispatches an ambulance. At 2. 30 am, Biriya arrives at the Nainpur community health centre (CHC), 32 km from her home, and safely delivers a baby girl.

Scenario 2

Time: 1. 05 am February 4

Shiv Kali Maravi from Bamnigaon is in labour. Her family calls Rameshwar Khudape who is now manning the same call center. An ambulance is dispatched. At 2. 16 am, the patient reaches the CHC at Niwas, 33 km away. Soon after, Maravi gives birth to a baby boy.

While new born babies continue to die in hospitals across West Bengal – a tragedy that chief minister Mamata Banerjee calls “fictional, ” drama of a different kind is being played out in Madhya Padesh’s remote villages – one that can teach Banerjee a lot.
A fleet of 669 ambulances and 176 staffers in 48 call centres across 50 districts of Madhya Pradesh are working 24×7 to maximise institutional deliveries in distant tribal villages of the state. Jointly run by the state government in association with Unicef, Janani Express is now a major success story in the field of public health. The results talk for themselves.

More than 7, 00, 000 pregnant women have been transported free of charge across the state between January 2008 and December 11, 2011. Fewer children in the state are now being delivered outside hospitals. While the number of Janani Express beneficiaries was 2, 691 in 2007, it has steadily increased to 23, 545 in 2008, 35, 076 in 2009 and over 1. 7 lakh in 2010. In 2011, 4. 81 lakh pregnant women have delivered in hospital settings while 10, 000 new born children have benefited from it.
Each district in the state now has a call centre with a dedicated phone number. Around 22 vehicles are placed at different delivery points. “Somebody in a village has to have a phone. A single call now ensures a mother’s safety, ” says Dr Gagan Gupta, Unicef health specialist.

The infant mortality rate in Madhya Pradesh saw a fall of five points in 2010 – from 67 per 1, 000 to 62 per 1, 000 – the highest such fall recorded in the state. This is also the most dramatic fall documented in a year in the last decade, according to the registrar general’s latest data. “The analysis of two pilot call centres from Guna and Shivpuri for 50, 000 pregnant women transported from 2008-2011 revealed that half of the beneficiaries belonged to scheduled castes and tribes and half of the women were transported in the night hours between 8 pm and 8 am. In addition, 90 per cent of patients were transported within two hours of a call to a health facility, ” says Dr Gupta.

So how did the scheme start? In order to promote institutional delivery of children, the Union health ministry started the Janani Surakhsha Yojna (JSY) scheme which entitled all wouldbe mothers to free delivery, including a Caesarean section, in hospitals. They would be entitled to free transport from their homes to government health facilities and between facilities in case they are referred on account of complications. They would also be offered free drop back to their homes soon after.

This initiative was estimated to benefit more than one crore would-be mothers and newborns every year in both urban and rural areas. Under the scheme, accredited social health activists (ASHAs) were given Rs 250 as transportation charge for bringing pregnant women on the verge of delivering to the closest health facility. But an analysis showed that the lack of organised transport in the hinterland meant that it was hard for ASHAs to reach pregnant women to health facilities in time. Often they would be transported in lorries and on bike pillions.

Using a public-private partnership model, MP then decided to tie up with a private transport company – chosen through a tender – to start the Janani Express. “The cost of hiring of the vehicles is met from the Rs 250 marked for transportation under JSY funds. These funds are pooled based on number of institutional deliveries and provided to chief medical officers to make payments to the hired agency, ” says Dr Gupta.

The first call centre was set up in Guna in 2006. Each centre is manned by four people. Says Tania Goldner, chief of UNICEF Madhya Pradesh of the project: “Such 24×7 call centres, the Janani Express, strengthening of health sub-centres and cash linked maternity benefits, are part of the continuum of care for pregnant women and contributed to a significant increase in institutional deliveries in MP and progressive decrease of the maternal mortality ratio for the state. ”

Dr Archana Mishra, deputy director, maternal health at that state directorate of health services, says the state is committed towards reduction of high maternal mortality rate and maternal deaths caused by the shortage of referral transport facilities.
“The scheme is providing free referral transport facilities to pregnant women coming for delivery. Nearly 50 per cent of pregnant women going for institutional delivery are availing the free services under the scheme. These facilities are available to both the mother and the new born after discharge from the government health institutions, ” says Dr Mishra.

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