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Substandard Care Substandard Care and and Harmful PracticesHarmful Practices
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Purpose of the session:
The purpose of this session is to provide physicians with the different aspects of
substandard care and harmful practices by the health care providers that contribute to
maternal mortality.
By the end of this session, trainees will be able to:
Identify magnitude of the problem .
Identify avoidable factors contributing to maternal death.
Define Substandard Care .
Explain totality of Care
Identify Substandard Care in PPH and APH
Identify Substandard Care in Hypertensive disorders with pregnancy
Identify Substandard Care in Sepsis.
Identify Substandard Care in Ruptured uterus.
Identify Substandard Care in normal, abnormal labor and CS.
Identify Substandard Care and Harmful Practices in the Private Sector.
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Problem in Egypt
The ENMMS, 2000 estimated that The total MMR was 84/100,000.
One or more avoidable factors contributed to 81% of maternal deaths
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The maternal Mortality Stopwatch
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Avoidable Factors
Health Facility
Health ProviderWomen and Family
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54%
24%
22%
Health Facility Woman & Family Health Provider
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Health Facility Factors
Health Facility Factors contributed to maternal
death due to:
Lack of blood (16%)
distance of care(4%)
lack of drug(2%) lack of supplies(2%) and
equipment (5%).
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Women and family
Failure to recognize problems [27%]
and delay in seeking medical care [21%]
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Health provider Factors
Substandard care by health provider was the leading avoidable cause of death contributing to 36 maternal death per100,000 live birth.
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Definition of Substandard Care
It includes: The use of practices which are clearly harmful or ineffective.
Practices where insufficient evidence exists to support a clear recommendation
Practices which are frequently used inappropriately.
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Standard Care…The need of ‘Standardized Clinical Guidelines’
Clinical guidelines are:
‘Systematically developed statements which
assist clinicians and patients in making decisions
about appropriate treatment for specific
conditions’
Developed using a standardised methodology
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NICE guidelines
USAID Recommendations for
Updating Selected Practices
in Contraceptive Use
JHPIEGO Infection
Prevention reference manual
CPI guidance documents
RCOG green top guidelines
Evidence Based and Updated Guidelines
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- Ila Evidence obtained from at least one well- designed controlled study without randomization. - Ilb Evidence obtained from at least one
other type of well-designed quasi- experimental
Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies .
Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
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- Ia Evidence obtained from meta-analysis of randomized controlled trials. - Ib Evidence obtained from at least one randomized controlled trial.
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Classification of Evidence Levels
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Forms of Care…
Beneficial Forms of care.
Forms of care likely to be beneficial.
Forms of care with a trade off.
Forms of care with unknown effectiveness.
Forms of care likely to be ineffective.
Forms of care likely to be harmful.
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Grades of Recommendation
AAt least one controlled trialLevel
Ia, Ib
BRequires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations.
Level
IIa, IIb, III
CRequires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality
Level
IV
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Totality of Care
1. Check that all the basic steps were followed.
2. Monitor the patient throughout the entire care process :
Antenatal care periodIntrapartum care period
postpartum care period.Emergency events or admission Anesthesia and recovery
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Skilled Attendant..Is a professional caregiver
Has the knowledge and skills to:Manage labor, childbirth and postpartum period
Recognize complications
Diagnose, manage or refer woman or newborn to higher level of care if complications occur that require interventions beyond caregiver’s competence
Performs all basic obstetric interventions
WHO 1999.
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Substandard Care …A Cause of Maternal Deaths
Let’s examine instances where substandard care by providers is one of the major contributing causes of maternal death in Egypt.
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Major Maternal Killers
Bleeding
Hypertension
Sepsis
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Postpartum Hemorrhage (PPH)
Substandard care by obstetricians contributed to 50% of deaths due to PPH.
Antenatal careLack of or poor antenatal care
Failure to recognize the predisposing factors for PPH, e.g. previous history of PPH
Emergency roomFailure to provide appropriate first aid management e.g. not
giving fluid replacement while waiting for blood
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Pre-delivery and delivery room
Incorrect use of oxytocin in high doses with no titrationFailure to recognize predisposing factors of PPH
as in cases were there is APH or when there is twin pregnancy or overdistension
Absence of a senior specialistPushing on the abdomen to force delivery that leads to a ruptured uterus, laceration or tearsNot following a protocol for PPH managementPacking the vagina during atonic PPH, thus masking the conditionIgnoring the active management of the third stage of labor
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Operating roomDelaying decision of hysterectomy
Waiting for a senior obstetrician or surgeon to perform other life-saving interventions for which providers do not have skills or which are inappropriate.
Recovery room or postoperative follow-upThere is a lack of monitoring of the patient post-labor or postoperatively, resulting in unnoticed bleeding and rapid deterioration.
Early discharge of patients from the hospital, without complete treatment.
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Antepartum Hemorrhage (APH)
Substandard care by obstetricians contributed to 61% of deaths due to APH.
Antenatal careFailure to recognize the problem, e.g. attributing the blood to delayed menstruation or local causes without confirming the diagnosisFailure to admit a patient who needs admission
Emergency roomFailure to provide appropriate first aid management by not giving fluid replacement while awaiting bloodDigital examination of patients with APH before excluding placenta previa
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Pre-delivery room
Failure to request or assess a coagulation profile
Delivering patients with APH without considering the high probability of PPH
Operating room
Delaying interventions until blood is available
Absence of senior specialist
Recovery room or postoperative follow-up
Antepartum hemorrhage is the main cause of PPH, and lack of close observation could easily miss early diagnosis of the condition.
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Hypertensive disorders with pregnancy
Substandard care by obstetricians contributed to 47% of deaths due to hypertensive diseases of pregnancy.
Antenatal carefailure to recognize hypertension, as in some cases the blood pressure is not correctly taken.
If the problem is detected, some physicians adopt what they think is conservative management and delay delivery, which can put both the mother and fetus at risk.
In some instances the physician tends to postpone delivery
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Emergency room and pre-delivery room
Prescribing sedation and anti-hypertensive drugs for patients with severe cases who are not in labor and discharging them
Inability to provide correct first aid management for patients with convulsions because IV access was not established
Failure to control convulsions immediately by administering correct doses of MgSO4
Waiting for delivery to occur spontaneously even though it may take a long period of time
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Delivery roomAdministering MethergineProlonging the second stage of laborAbsence of a senior specialist
Operating roomFailure to inform the anesthesiologist of the patient’s medical historyPatient not stabilized before the operationFailure to request the presence of a neonatologist
Recovery room or postoperative follow-upFailure to monitor the toxic effects of MgSO4Failure to continue MgSO4 for48hrs in sever cases.
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Sepsis
Substandard care by obstetricians contributed to 38% of sepsis deaths.
Antenatal careSevere deficiencies in or lack of quality care, especially with regard to health education, e.g. hygiene
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Emergency room and pre-delivery room
Lack of infection control precautions
Little or no hand washing between patients
Failure to use sterile instruments
Failure to isolate patients with puerperal sepsis
Frequent vaginal examinations of patients with PROM
Delivery roomLack of infection control precautions
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Operating roomLack of infection control precautions, e.g., inadequate cleaning of the table and instruments between patientsAntibiotic prophylaxis in CS done with incorrect timing and wrong dose
Recovery roomPoor or no monitoring of cases for signs of infectionEarly discharge of patients with mild feverEarly discharge of patients with PROM
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Ruptured uterus
Substandard care by obstetricians contributed to 64% of ruptured uterus deaths.
Antenatal care
Poor quality of care
Patients with a previous history of uterine scars not counseled on the importance of a hospital delivery
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Emergency room and pre-delivery room
Poor history taking, which results in missing
high-risk cases of previous operations or
previous obstructed deliveries
Delay in diagnosis due to lack of experience
Delay in infusing fluids while waiting for blood
Inappropriate use of oxytocin
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Emergency room and pre-delivery room
Using drugs still under trial to induce labor, with no known dose for induction of labor, e.g., Misoprostol
Not using a partograph to monitor labor
Trial of a scar with incorrect judgment or essential pre-requisites
Lack of knowledge of signs of a ruptured uterus
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Delivery room
Pushing on the abdomen to force delivery
Obstructed labor not diagnosed early or dealt with properly
Operating room
Delaying intervention until blood is available
Delaying a hysterectomy to save the uterus
Senior obstetricians not attending in time
Recovery room
Lack of any postoperative follow
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Clinical Conduct of Labor Instances of substandard care can occur in the
following:Antenatal Care
No care or poor quality of care Emergency and pre-delivery care
No proper history taking, thus missing the opportunity to anticipate possible problems or complications that may have occurred beforeHigh-risk patients not identifiedLow risk patients are NOT properly followed upGeneral examination incorrectly done or omittedVaginal examination only procedure performed in the emergency room
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FHS not monitored
Partograph not used to monitor labor
Oxytocin used inproperly
High enema and catheterization still used as a
routine
Patients allowed to bear down early before full
cervical dilation
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Delivery roomForceps or vacuum extractor used inappropriately due to incorrect evaluation of cases from the startLate intervention in prolonged or obstructed laborMethergine routinely used
Recovery roomNo postpartum care or follow-upPatients discharged too early
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Abnormal labor and CS
Substandard care by obstetricians contributed to 68% of CS deaths.
Antenatal care
Poor quality of care
Emergency room
Medical history not taken properly
Admission procedures too slow
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Pre-delivery
No proper history taking, thus missing the
opportunity to anticipate possible problems
that may have occurred before
High-risk patients not identified
General examination not performed
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Investigations not ordered
Patients inappropriately referred due to lack of
blood
With a history of a previous CS, an attempt at
labor occurs without proper preparation
CS done without proper indication
Oxytocin used with a previous CS scar with
the incorrect dosage and poor or no follow-up
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Operating roomAnesthesia administered to patients by obstetriciansComplete hemostasis not reachedCS done by inexperienced providers with no supervisionDelay in intervention due to absence of appropriate personnelDelivery of fetal malpresentations by inexperienced staffApplying forceps if vacuum extraction fails
Recovery roomNo postoperative follow-up
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Substandard Care and Harmful Practices in the Private Sector
A considerable number of deliveries are
performed outside of hospitals at home,
private sector hospitals or clinics. Different
types of service providers are usually involved
When the process of delivery is complicated,
the woman is referred to a nearby health
facility.
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The most common forms of substandard care that may lead to maternal mortality or morbidity outside health facilities are:Poor quality of antenatal careFailure or delay in recognizing problemsDelay in correctly managing casesLate referral of complicated casesOperations sometimes performed by inexperienced persons Drugs given in the wrong way or in an incorrect dose
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To sum it up…
Most substandard care is due to:Not being aware of the latest knowledge and techniques or no following the proper guideline
A failure to supervise and train new providers in order to ensure that appropriate standards are maintained
A failure to observe and implement the protocols for management.