Care of critically ill mothers at KNH - Gaps and

Opportunities.Zahida QureshiJohn Ongech

7th February 2014

Political will

• Maternal healthcare is a primary concern for the Jubilee Government. President Uhuru Kenyatta decreed free maternal healthcare for all women in Kenya.

• Courtesy of President Kenyatta’s policy, we shall strive to provide an environment where every pregnancy is wanted, every childbirth is safe, and every young person’s potential is fulfilled.

• In order to improve maternal and child health outcomes in the country, the First Lady of Kenya, Margaret Kenyatta launched the ‘Beyond Zero Campaign’ on 24 January in Kenya’s capital Nairobi.

• “I am deeply saddened by the fact that women and children in our country die from causes that can be avoided. It doesn’t have to be this way,” said Ms Kenyatta. “This is why I am launching the ‘Beyond Zero Campaign’ which will bring prenatal and postnatal medical treatment to women and children in our country.”

• The ‘Beyond Zero campaign’ is part of the initiatives outlined in the Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya that was unveiled on World AIDS Day 2013.The campaign aims to raise funds to help improve maternal and child health care in the country.

Deliveries July2012-June 2013

58%

39%

0% 1%

2%

2012/2013

Normal Delivery C/S Vaccum Breech BBA

Mode of Delivery 2012/2013Normal Delivery 6097

C/S 4059

Vacuum 21

Breech 70

BBA 196

Total 10443

Labour ward Admissions July12-June 2013

REPRODUCTIVE HEALTH MONTHLY REPORT DEC 2013 ADMISSIONS Pts booked (ANC 18) 470 Pts not booked 1049 Total 1519

MVA ward 1D 91 Ward 1C SVD 847 41 Caeserean section 404 46 Breech 2 0 Vacuum 3 0 BBA 21 0 Still Births 64 5 Post c/section sepsis 10

Average Decision-Theatre time No. of pts 392

Average(Hrs) 4.6

MATERNAL MORTALITY TREND (JULY 2012 – JUNE 2013= 119)

WARD AGE REFERAL FACILITY

DIAGNOSIS

1 1A 38 MARAGUA DH RENAL FAILURE, SEVERE ANAEMIA, PEUP SEPSIS

2 1D 20 - PEUP SESIS/HEPATIC ENCEPHALOPATHY

3 1D 32 KAJIADO DH AKI/ECLAMPSIA

4 1D 27 MAKUENI DH PEUP. SEPSIS

5 LW 30 MURANGA DH PPH

6 LW 29 - CHORIOAMNIONITIS

7 LW 24 THIKA DH SEPSIS

8 A/E 30 - SHOCK/INCOMPLETE ABORTION

9 A/E 22 - POSTARBORTAL SEPSIS

10 A/E 35 MAMA LUCY KIBAKI HOSP

PPH/RUPTURED UTERUS

11 ICU 35 PCEA KIKUYU PPH/POOR REVERSAL

12 ICU 25 - SEVERE PET/SEPSIS

13 RENAL 36 - AKI/PET/SEPSIS

Multicountry survey in 20 hospitals in Kenya 2012Hospital Deliveries Near miss Death

NairobiKenyatta* 1959 22 20Pumwani Maternity* 2770 4 3Mater 449 0 0Aga Khan University 748 7 0M P Shah 146 0 0Nairobi 607 1 0

CentralNyeri Provincial General 1305 4 0Karatina District 816 0 1Kerugoya District 1072 2 1Thika District * 1304 6 1Kiambu District* 1329 5 3Gatundu District 949 1 1Consolata Mathari 295 0 0

Rift ValleyRift Valley Provincial General* 1337 6 6Moi Teaching & Referral* 1339 3 8Naivasha District 1117 2 0Kabarnet District 492 1 2Kitale District 1101 3 5Iten District 439 1 0Tenwek Mission 861 8 4Total 20435 77 55

05_XXX_MM10

WHO Maternal Near Miss identification criteria

Critically sick mothers

• Haemorrhage • Hypertensive disease • Medical conditions • Infectious disease • Obstructed labour• Abortion complications• Sepsis – Acute kidney failure – Anemia

Obstetrical conditions requiring critical care Oct-Dec 2013

Conditions No. of patients

Eclampsia 31

Postpartum haemorrhage 65

Ruptured uterus 3

Postarbrotal sepsis 3

Total 102

Variable scored % of time documented reported

Cervical dilatation 56Contractions 59*Fetal heart rate 50*Maternal blood pressure 46*Fetal head descent 49*Maternal pulse rate 42*Liqour 34*Degree of moulding 27*Maternal temperature 17*Maternal respiratory rate 30*Done in ≤ 50% of the time

Table 5: Adequacy of partograph completion Variable scored at least one observation recorded

Variable scored % of time documented reported

Blood pressure charting 60Pulse rate charting 52Catheter 88Input-output chart 64*Respiratory rate charting 44*Done in ≤ 50% of the time

Level of care in patients with obstetric haemorrhage

Variable scored % of time documented reported

Blood pressure charting 92Pulse rate charting 88Fetal surveillance 84Loading dose-Magnesium sulphate 60Maintenance dose-Magnesium sulphate 72Input-output chart 96Full blood count 80U/E/C 68LFT 56*Tendon reflexes 12*Done in ≤ 50% of the time

Level of care in patients with severe pre-eclampsia and eclampsia

Normal Labour N= 29n(%)

Obstetric hemorrhage N=25n(%)

PET/ Eclampsia N= 25n(%)

Emergency Cesarean N=59n(%)

Fetal

Alive 28(97) 20(80) 15(60) 49(83)Fresh stillbirth 0 3(12) 4(16) 6(10)Macerated stillbirth 2(6.9) 2(8) 5(20) 3(5)

Immediate complications

1(3.4) 6(24) 11(44) 16(27)

*Immediate complications include: prematurity, asphyxia, RDS, congenital malformations, death Maternal

Mode of delivery Normal delivery 22(76) 8(32) 9(36) 0Cesarean section 6(21) 17(68) 16(64) 59(100)*Complications 0 5(20) 5(20) 9(15)

*Complications include: admitted to ICU, dialysis, coma, convulsions, death, resuscitation

Outcome by diagnosis

Posterior Tear

Decapitated Head

KNH/UON sits at the apex of the pyramid of the KEPH levels. This is the ultimate referral Centre.

• Referral system• Infrastructure • Human resource• Multidisciplinary management • Supplies, equipment • Support from Lab and imaging dept• Emergency response

– Teams – Skills/ drills

• There is need to set the standards, norms and SOPS for improved MCNH