HIGH RISK OBSTETRICS CARE IN

THE DEVELOPING COUNTRIES

DR. AMIT SENGUPTA

MBBS; MD (OBGYN); Ph.D (BIOMED ENGINEERING)
Member-Editorial Advisory Board, Fetal
Monitoring, OBGYNET.
IDEAL APPROACH - AT RISK STRETEGY

All pregnant mothers are at high risk

some at higher-higher risk

DEFINE AND IDENTIFY HIGH RISK

COMMUNITY & FAMILY

ADOLOSCENCE
WOMEN & CHILDREN
NEWBORNS
IN RELATION TO VITAL PARAMETRS

NUTRITIONAL LEVEL

ANTHROPOLOGICAL PROFILE

SOCIO-ECONOMIC STATUS

EDUCATION & AWARENESS LEVEL

Vs
DISEASE BURDEN RATE AND
SPECIFIC MORBIDITY-MORTALITY PATTERN
 KEY IMPACT FACTORS

❂ AVAILABILITY OF AFFORDABLE QUALITY HEALTH

INFRASTRUCTURE

❂ TECHNOLOGICAL SUPPORT BASE

❂ COMMUNICATION AND TRANSPORT FACILITES

❂ POLITICAL & PEOPLES COMMITMENT

 Develop HIGH RISK scoring system (1)

Based upon simple clinical parameters

❂ GROWTH PARAMETERS--BMI,HEIGHT, WEIGHT

❂ NUTRITIONAL/DIET INDEX - HAEMOGLOBIN,

S.PROTEINS, CALCIUM, BONE MASS INDEX,

❂ MIDARM SKIN FOLD THICKNESS

 HIGH RISK SCORING (2)

Based on social-health indicators i.e.,

❂ AGE AT MARRIAGE, CONSUMMATION AND FIRST

CONCEPTION

❂ FERTILITY RATE, ABORTION RATE, LOW BIRTH

WEIGHT RATE, EXISTING MATERNAL MORTALITY
AND INFANT MORTALITY RATE, UNMET NEED FOR
CONTRACEPTION,RTI RATE
 SET RISK SCORING (3)

❂ MATERNAL - PERINATAL MORBIDITY &

MORTALITY PATTERN/RATE

❂ FEMALE LITERACY/AWARENESS LEVEL,GENDER

EQUALITY IN DECISION MAKING

❂ AVAILABILITY OF PRE-MARITAL & PRE-

PREGNANCY COUNSELING
DEVELOP NETWORKING OF HEALTH CARE

LEVEL I
HEALT HY MOTHER

ICU LEVEL II &

HEALT HY C HILD

LEVEL III

LEVELI--PRIMARY, LEVELII-SECONDARY,
LEVELIII-TERTIARY, ICU-INTENSIVE CARE
 THROUGH STRENGTHENING AND/OR
INTRODUCING EFFECTIVE
❂ REPRODUCTIVE HEALTH AWARENESS PROGRAM

❂ SAFE WATER AND SANITATION PRACTICES

❂ NUTRITION SUPPLEMENTATION PROGRAM, SAFE
COOKING FUEL

❂ ROAD AND TRANSPORTATION SERVICES

❂ INTENSIVE MOBILE SERVICE/CARE UNIT WHILE

TRANSPORTING HIGH RISK CASES

❂ TELEMEDICINE & COMMUNICATION SYSTEM TO

CONNECT TERTIARY WITH THE PRIMARY &
SECONDARY CARE CENTERS
 Through Strengthening and/or
Introducing Effective (Health sector)

❂ PERIODIC TRAINING-RETRAINING OF THE HEALTH

STAFF IN EARLY INTERVENTION/PREVENTIVE
MANAGEMENT OF APH/PPH/PE/ ANEMIA/ FETAL
DISTRESS/OBSTRUCTED LABOR/BREACH/SHOULDER
DYSTOICIA/AFEMBOLISM/ LOW BIRTH WEIGHT
BABIES, PUERPERAL INFECTIONS

❂ WELL REGULATED AUTO-TRANSFUSION & BLOOD

BANK SERVICES

❂ DEVELOP RED ALERT SYSTEM IN MATERNITY HOMES

 FETO-MATERNAL DISTRESS MANAGEMENT
( RED-ALERT SYSTEM IN MATERNITY HOMES ]

In developing countries

❂ CRITICALLY ILL MOTHERS COME LATE & IN LABOR

❂ DEATHS GENERALLY OCCUR IN LABOR ROOM

DURING or SOON AFTER BIRTH

❂ EFFECTIVE FETO-MATERNAL MONITORING DURING

THIS CRITICAL PERIOD CAN SAVE MANY FETO-
MATERNAL DEATHS & COMPLICATIONS
INTENSIVE LABOR UNIT { ILU }- RED ALERT
PROTOCOL

❂ REGULAR ORIENTATION OF STAFF ON BASIC

RESUSCITATIVE MEASURES

❂ NURSES ORIENTATION ON BAG & MASK, AIRWAY

MAINTENANCE, SETTING UP IV LINE,

❂ DOCTORS ON INTUBATION AND OTHER

RESCUSCITATIVE MEASURES

❂ DAILY CHECKING OF EMERGENCY TROLLY

INTENSIVE LABOR UNIT { ILU }- RED ALERT
PROTOCOL

❂ EARLY DETECTION AND INTERVENTION

❂ ONE TO ONE STAFF & PATIENT RATIO

❂ STABILIZE THE PATIENT and SUBSEQUENT

TRANSFER TO ILU-bed
GENERAL EVALUATION

❂ MATERNAL AND FETAL VITAL SIGNS

❂ GENERAL PHYSICAL EXAMINATION
❂ PER ABDOMEN EXAMINATION
❂ SCAN, DOPPLER, CTG

❂ INVESTIGATIONS:
FBC, COAGULATION PROFILE
BLOOD GROUP & CROSS MATCHING
URINE, ABG IF AVAILABLE
 ACTIVATE RED ALERT SYSTEM

❂ CALL FOR OBSTETRICIAN,INTERNIST &

ANESTHESIOLOGIST

❂ SET UP IPPV, CVP, PUL. WEDGE PRESS

MONITOR,& OT IF NEED ARISE FOR LSCS

❂ KEEP READY FFP,CRYOPPT, PLATELET

CONCENTRATES, FRESH BLOOD,

❂ ACTIVATE SIMULTANEOUS FETAL MONITORING

SYSTEM AND PARTOGRAM RECORDING
 FETAL WELL-BEING IS JEOPARDIZED IN-
UTERO

❂ INTRAUTERINE ENVIRONMENT IS HOSTILE

❂ FETAL ABILITY TO ADAPT IS DIFFICULT

PHYSIOLOGY:
❂ NORMALLY FETUS CAN UTILIZE ANAEROBIC
METABOLISM - CAN BUFFER LACTIC ACID

❂ BRAIN CAN WITHSTAND DESATURATE

BLOOD UPTO 10’ (2ND STAGE) - ALL DUE TO
GLYCOGEN STORE
❂ BRAIN DAMAGE

❂ CEREBRAL PALSY
TOOLS FOR DIAGNOSIS OF FETAL DISTRESS
( A s per th e a vail ab ili ty )

» DFMC
» PINARD STETHOSCOPE
»
ME CON IUM S TAIN
AMNIO SCO PE
ELE CT RO NIC FE TAL M ONITOR

FE TAL BLO OD SAMPLIN G

FE TAL E CG

IN FRA-RE D SP ECT ROS CO PY

DO PPLE R & SCAN
 MANAGEMENT PROTOCOL
❂ ANTENATAL: CLINICAL, DFMC, NST,OCT,
MANNING’S, DOPPLER, BIOCHEMICAL

❂ INTRAPARTUM :
LOW RISK : INTERMITTENT
AUSCULTATION (IA) SAME AS CTG

❂ HIGH RISK : SHORT CTG TRACING

FOLLOWED BY CONTINUOS TRACING
❂ ABN. CTG +/_ MECONEUM - FBS
NORMAL CTG + MECONEUM - FOLLOW UP
INTRAPARTUM MANAGEMENT

❂ SHIFT POSITION : CORRECT

CORD COMPRESSION, SUPINE
HYPOTENSION
❂ OXYGEN MASK & CORRECT ACIDOSIS
5% DX 500 ML EVERY 3 HR
❂ STOP OXYTOCIN
❂ B-MIMETICS (RITRODIN) IF HYPERTONIC
CONTRACTIONS
❂ AVOID PATHIDINE
 INTRAPARTUM MANAGEMENT
(PREVENT COMPLICATION)

❂ DIAGNOSE AND CORRECT:

SHOULDER DYSTOCIA
BREECH (AFTER COMING HEAD)
CORD PROLAPSE
DEEP TRANSVERSE ARREST
PERSISTENT OCCIPITO-
POSTERIOR POSITION

❂ EXPEDITE DELIVERY:
BY SUITABLE MODE AND TIMING
 IMPORTANT RECOMMENDATIONS FOR
DEVELOPING COUNTRIES

❂ LIMIT LSCS IF POSSIBLE FOR FUTURE PREVENTION

OF RUPTURED UTERUS

❂ SUPPORT AND TRAIN DOCTORS ON OPTIMAL USE

OF
FORCEPS/VENTOUSE/SYMPHYSIOTOMY/EXTERNAL
CEPHALIC VERSION/ STABILIZING INDUCTION

❂ LEARN VAGINAL BREACH DELIVERY

 IMPORTANT RECOMMENDATIONS FOR
POST-PARTUM PERIOD
❂ INTRODUCE CONCEPT OF INTENSIVE 4TH STAGE
MONITORING ( IST 2 HRS OF POST-PARTUM PERIOD )

TO PREVENT

❂ PULMONARY EDEMA, HYPOVOLUMEA, RENAL SHUT

DOWN, DI VC, EMBOLISM ETC.--MAJOR CAUSE OF
IMMEDIATE MATERNAL DEATHS

❂ ACTIVE CARE OF THE PUEPERIUM PERIOD TO

PREVENT INFECTIONS, PROMOTE BREAST FEEDING,

❂
PROMOTE AWARENESS ON CONTRACEPTION