Aspects of Quality of Clinical Care in Labor & Delivery

Stephan Brenner

Rationale• Obstetric complications intra- & postpartum

phase.

• Timely initiation & organization of EmOC ability of SBAs to detect high-risk pregnancies.

• early identification & prevention of obstetric complications routinely in every pregnancy.

Quality of Care Focus:

• Evidence-based routine care processes in L&D1. Screening for early signs of complications.

2. Monitoring for signs of complications.

3. Preparedness to timely intervene once complications occur.

Objectives

1) Early Identification of emergencies:– Screening processes Danger Signs, risk factor

assessments, APGAR, etc.– Monitoring processes partograph, early

postpartum observation

2) Prevention of emergencies:– Infection maternal/neonatal sepsis– Hemorrhage AMSTL

3) Preparedness in emergencies:– Anticipation of need for neonatal resuscitation

Methods• Observational checklists:

– Routine processes performed by providers during labor & delivery care

– Basic equipment, supplies related routine labor & delivery care

– Information on facility type

• Sampling:– Convenience samples

• Analysis:– Descriptive summary of frequencies of

performed routine processes– Composed scores

Distribution of Observations

District

Balaka Dedza Mchinji Ntcheu Total

Faci

lity

leve

l BEmOC 11 10 14 10 45

CEmOC 10 8 5 14 37

Total 21 18 19 24 82

27.5

32.5

20

5

2.5

5

7.5

24.24

21.21

12.12

9.091

21.21

6.061 6.061

05

10

15

20

25

30

35

0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8

BEmOC CEmOC

Pe

rcen

t

ScreenScore4Graphs by facility type

Screening: Initial assessment Danger Signs & risk factors (Hx)

Score components:

• Vaginal bleeding

• Abdominal pain

• Breathing difficulties

• Fever

• Headache

• Convulsions

• HTN

• Diabetes______________________________

Max score: 8

• Only approx. 7% of cases assessed for all 8 medical history components.• About 1/4 of cases no history on risk factors or Danger Signs was obtained. • Most commonly asssessed risk factors: „vaginal bleeding“ (62%) and „abd. pain“ (51%).

(n = 40) (n = 33)

Screening: Initial assessment vital signs (PE)

Score components:

• Pulse

• BP

• RR

• Temp

• FHR______________________________

Max score: 55.714

31.43

5.714

14.29

25.71

17.14

3.226

22.58

6.452

16.13

32.26

19.35

05

10

15

20

25

30

35

0 1 2 3 4 5 0 1 2 3 4 5

BEmOC CEmOC

Pe

rcen

t

ScreenScore1Graphs by facility type

• In about 5% of all cases no vital signs taken during initial assessment.• In only about 18% of cases all 5 vital sign parameters were assessed.• Most commonly performed assessment was “fetal heart rate” (94%)• least commonly performed assessment was “respiratory rate” (27%)

(n = 35) (n = 31)

2.439

7.3174.878

75.61

9.756 8.571

85.71

5.714

01

02

03

04

05

06

07

08

09

0

0 1 2 3 4 0 1 2 3 4

BEmOC CEmOC

Pe

rcen

t

ScreenScore7Graphs by facility type

Screening: Focused assessment of Newborn (PE)

Score components:

• APGAR 1 min

• APGAR 5 min

• Temp

• weight______________________________

Max score: 4

• Only 10% / 6% of cases assessed for all 4 components.• Approx. 80% of cases assessed for 3 components most commonly omitted

assessment was “Temperature check” (8%)

(n = 40) (n = 35)

Vital signs vs. Equipment availability

Blood Pressure:• In 58% cases without initial BP check a functional BP-

cuff and stethoscope available.

Heart and Respiratory Rates:• In 89% cases without initial pulse check, and • in 93% cases without initial respiratory rate check a

functional clock/watch available.

Body temperature:• In 90% maternal (93% neonatal) cases without initial

temperature check a functional thermometeravailable.

43.33

20

3.333 3.333

13.33

16.67

53.57

3.571

7.143 7.143 7.143

14.29

7.143

01

02

03

04

05

06

0

0 1 2 3 4 5 6 0 1 2 3 4 5 6

BEmOC CEmOC

Pe

rcen

t

MonitorScore2Graphs by facility type

Prevention: Partograph documentation (S1L) Partograph used in only 67% / 76% of cases

Score components:

• FHR Q 30 min

• Contractions Q 60 min

• Heart rate Q 60 min

• BP Q 60 min

• Fetal descent Q 60 min

• Temp Q 4 hrs______________________________

Max score: 6

• Only approx. 12% of cases complete stage 1 monitoring documented.• In 43% / 54% of cases no documentation of stage 1 monitoring.• Most frequently documented parameter “FHR Q 30 min” (41%).

(n = 30) (n = 28)

35

2.5

20

12.5

25

2.5 2.5

44.44

16.67

13.89

22.22

2.778

01

02

03

04

05

0

0 1 2 3 4 5 6 7 8 9 10111213141516 0 1 2 3 4 5 6 7 8 9 10111213141516

BEmOC CEmOC

Pe

rcen

t

MonitorScore5Graphs by facility type

Monitoring: maternal 1st hour postpartum 2-hr postpartum observation in only 68% / 69% of cases

Score components:

• Uterus tone Q 15 min (4x)

• Vaginal bleeding Q 15 min (4x)

• BP Q 15 min (4x)

• Heart rate Q 15 min (4x)

______________________________

Max score: 16

• No case with recommended minimum monitoring checks.• 35% / 44% of cases were not monitored during the 1st hour postpartum.• Approx . ½ of cases had “vaginal bleeding” and “BP” checked only once within

the 1st hour postpartum.

(n = 40) (n = 36)

82.5

2.52.5

12.5

83.33

11.11

2.7782.778

01

02

03

04

05

06

07

08

09

0

0 1 2 3 4 5 6 7 8 9 10111213141516 0 1 2 3 4 5 6 7 8 9 10111213141516

BEmOC CEmOC

Pe

rcen

t

MonitorScore7Graphs by facility type

Monitoring: neonatal 1st hour postpartum 2-hr postpartum observation in only 68% / 69% of cases

• None of the cases received the recommended minimum monitoring checks. • 83% of cases were not monitored during the 1st hour of life.• “responsiveness” was the most common parameter monitored within 1st hour

of life (17%).

Score components:

• Respiratory rate Q 15 min (4x)

• Heart rate Q 15 min (4x)

• Responsiveness Q 15 min (4x)

• Temp Q 15 min (4x)

______________________________

Max score: 16

(n = 40) (n = 36)

Monitoring vs. Equipment availability

Stage 1 Labor Monitoring:

• In 84% cases without partograph use partograph forms available.

Postpartum Monitoring:

• In 67% of cases without early postpartum monitoring at least one dedicated recovery bed available in maternity unit.

3.226 3.226

22.58

16.13

12.9

25.81

16.13

3.333 3.333

6.667

23.33

30

20

13.33

05

10

15

20

25

30

35

0 1 2 3 4 5 6 0 1 2 3 4 5 6

BEmOC CEmOC

Pe

rcen

t

PrevScore1Graphs by facility type

Prevention: Infection prevention during assessment and delivery

• Most commonly omitted processes were “hand hygiene vaginal exam” (61%) and “hand hygiene” ( 55%).

• Most frequently performed processes were the use of sterile gloves for vaginal exam (79%) and stage 2 labor (83%).

Score components:• Hand hygiene

physical exam• Hand hygiene S2L• Sterile gloves

vaginal exam• Sterile gloves S2L• Perineal cleansing

vaginal exam• Perineal cleansing

S2L______________________________

Max score: 6

(n = 31) (n = 30)

7.692

38.46

53.85

2.778

11.11

30.56

55.56

01

02

03

04

05

06

0

0 1 2 3 4 0 1 2 3 4

BEmOC CEmOC

Pe

rcen

t

PrevScore4Graphs by facility type

Prevention: Hemorrhage (use of oxytocin)

• 97% of all cases received oxytocin.• In only about ½ of all cases oxytocin was given according to the recommended

standard actions.• Ruling out twin pregnancy prior to oxytocin administration was the most

omitted action.

Score components:

• Setting up oxytocin

• Rule out twin pregnancy

• Inform patient

• Oxytocin administration

______________________________

Max score: 4

(n = 39) (n = 36)

2.5

10

2.5 2.5

37.5

45

2.778

16.67

19.44

61.11

01

02

03

04

05

06

07

0

0 1 2 3 4 5 6 0 1 2 3 4 5 6

BEmOC CEmOC

Pe

rcen

t

PrevScore5Graphs by facility type

Prevention: Hemorrhage (delivery of placenta)

• Overall, in about 82% of all cases all or 5 actions were performed.• Most frequently omitted action was “estimation of total blood loss”

Score components:• Place cord-clamp

proximally• Transabdominal

pressure on uterus• Downward cord

traction during contraction

• Ensure completeness of placenta

• Massage uterus• Estimate blood loss______________________________

Max score: 6

(n = 40) (n = 36)

Infection prevention vs. Supplies

Hand Hygiene:

• In 92% of cases during physical exam and

• In 85% of cases during newborn delivery without provider performing some form of hand hygiene some source of water plus soap available.

• In 19% of cases during physical exam and

• In 86% of cases during newborn delivery without provider performing some form of hand hygiene hand desinfectant available.

Preparedness: neonatal complications

• Overall, in about 31% of all cases all or 5 devices were set up prior to delivery.• “oxygen source” and “oxygen delivery system” were not prepared in 2/3 of

cases.

Score components:

• Resuscitaire

• Ambu-bag

• Suction device

• Oxygen source

• Oxygen delivery system

______________________________

Max score: 513.89

25 25

2.778 2.778

30.56

44.44

8.333 8.333

5.556

2.778

30.56

01

02

03

04

05

0

0 1 2 3 4 5 0 1 2 3 4 5

BEmOC CEmOC

Pe

rcen

t

PrepScore1Graphs by facility type

(n = 36) (n = 36)

Preparedness vs. Equipment

• In 32% of cases without oxygen set-up prior to delivery oxygen source and delivery system available.

Steps ahead…

• Analysis of ANC observation data.

• Analysis of provider knowledge assessment data.