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EmOC

(Emergency Obstetric
Care)

RUKMONO SISWISHANTO

What are we talking


about

Maternal death
Emergency obstetric services
Obstetric complications
Reducing maternal death
Effective measures
Triage & referral

MATERNAL DEATH
The death of woman from any cause related
to, or aggravated by, pregnancy or its
management (regardless of duration or site
of pregnancy), does not include accidental
or incidental causes.

DIRECT OBSTETRIC DEATH


The death of woman from obstetric
complications of pregnancy, labor, or the
puerperium; from intervention, omissions, or
treatment; or from a chain of events resulting
from any of these factors

INDIRECT OBSTETRIC DEATH

The death of woman from a previously existing


disease or a disease that develops during
pregnancy, labor, or the puerperium

EMERGENCY OBSTETRIC
SERVICES
Central to the prevention of maternal
death
Two types:
Basic EmOC
Comprehensive EmOC

BASIC EmOC

Antibiotics (injectable)
Oxytocics (injectable)
Anticonvulsants (injectable)
Manual removal of placenta
Removal of retained products
Assisted vaginal delivery

COMPREHENSIVE EmOC

Basic EmOC
Surgery (e.g., Cesarean Section)
Blood transfusion

Minimum acceptable level for every 500,000 population,


there should be at least 4 basic EmOC and
1 comprehensive EmOC

THE CAUSES
OF MATERNAL DEATH
Hemorrhage 24.8%
19,8

Infection 14.9%

24,8

Eclampsia 12.9%
7,9

14,9

12,9
6,9

12,9

Obstructed Labor
6.9%
Unsafe Abortion
12.9%
Other Direct Causes
7.9%
Indirect Causes
19.8%

Obstetric Complications
Incidence
High

High

Low

Low

Fatality

OBSTETRIC COMPLICATIONS

Hemorrhage (postpartum & antepartum)


Obstructed labor
Puerperal sepsis
Preeclampsia/eclampsia
Abortus complication
Ectopic pregnancy
Uterine rupture
Shoulder dystocia

INCIDENCE ESTIMATION

Minimal 15% of all pregnancies


WHO estimation (1994):

Hemorrhage
Puerperal sepsis
Preeklampsia/E
Obstructed labor

10%
8%
5%
5%

REDUCING MATERNAL DEATHS


Reduce the likelihood that woman will
become pregnant
Reduce the likelihood that pregnant
woman will experience a serious
complication of pregancy or chilbirth
Reduce the likelihood of death among
women who experience complications

THE THREE DELAYS MODEL


Factors Affecting
Utilization and Outcome
Sosioeconomic/ Cultural
factors

Accessibility of Facilities

Quality of Care

Phases of Delay
Phase I:
Decision to seek care

Phase II:
Identifying and Reaching
Medical Facility

Phase III:
Receipt of Adequate and
Appropiate Treatment

COMMUNITY EDUCATION

Any vaginal bleeding before labor


Heavy bleeding during or after labor
Severe headaches and/or fits
Swollen hands and feet
Fever
Smelly vaginal discharge
Labor from morning till nightfall or vice versa
Any part of the baby showing except the head

EFFECTIVE MEASURES
Postpartum hemorrhage
Active management 3rd phase of labor
Postpartum misoprostol

Obstructed Labor
Partograph

Puerperal sepsis
Antibiotic combination (Ampicillin
Gentamycin Metronidazol)

EFFECTIVE MEASURES
Preeclampsia/Eclampsia
Magnesium sulfate
Antihypertension (Nifedipin)

Abortus complication
Manually Aspirated Vacuum

Ectopic pregnancy, uterine rupture,


other hemorrhage problem
Blood transfusion
Operation

Triage & referral


Triage
Sift as through sieve (or to prioritise)

Referral
Patient transfer to fulfill patients need of better
care

Triage
1. A quick assessment of an individual
woman and her baby (born or unborn)
2. Prioritise the order of treatment and
allocation of staff

Quick assessment:
ask, check, record, look,
listen, feel
Classify as one of the following:
1. Emergency for woman
2. Labour
3. Emergency for baby
4. Routine care

Classify as emergency
The woman is:
unconscious, convulsing, bleeding from the
vagina

The woman has:


Severe abdominal pain, headache or visual
disturbance, severe difficult breathing, high
fever, severe vomiting

The woman looks:


Very ill

Prioritise the order of


treatment and allocation
of staf
To do most for the most and do this in the
right order
Example: in labour ward with more than
one patient
[!] The management of care in the labour ward is a
dynamic process and regular reassessment of
priorities is vital

The priority
Priority 1
A woman who requires emergency
treatment and resuscitation soon or she
may die
Priority 2
A woman whose care may be delayed
for a few hours
Priority 3
A woman who can sustain a significant
delay

Referral
A good tranfer is well planned and
prepared
Following the ACCEPT approach

Assessment
Control
Communication
Evaluation
Preparation and packaging
Transportation

The right for patient


The right patient has to be taken at
right time by the right people to the
right place using the right form of
transport and receiving the right
type of care throughout

REFERENCE
Buku Panduan Praktis Pelayanan Kesehatan
Maternal Neonatal, Jakarta, 2002
Maine D, Akalin MZ, Ward VM, Kamara A., The
Design and Evaluation of Maternal Mortality
Programs. Center for Population and Family
Health School of Public Health School of Public
Health Columbia University, 1997
RCOG, Life saving skill essential obstetric
care, 2006