Transcript FUTURE STRATEGIES FOR MIDWIFERY

FUTURE STRATEGIES FOR
MIDWIFERY
IN TRINIDAD & TOBAGO
Betty Long, DNP, MPH, CNM, CNE, EFM-C, RNC-OB
MAIN FOCUS
• ADMINISTRATION
• EDUCATION
• CLINICAL PRACTICE
GOAL
• Nation’s Millennium Development Goal to reduce
maternal deaths by 75% by 2015.6
• Maternal and infant mortality are indicative of the
wellbeing of a nation
• To improve practice by ensuring that all pregnant
and recently delivered women receive the best
possible care delivered in appropriate settings and
taking account of their individual needs.
• To reduce the maternal and infant morbidity and
mortality ratio/rate: Main concern is with
reproductive, maternal and child health
Environmental scan/SWOT Analysis
• SWOT
– Strengths
– Weaknesses
– Opportunities
– Threats
– Basic to any strategic or business plan
development
Maternal Death
• The death of a woman while pregnant or
within 42 days of termination of
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management, but not from accidental or
incidental causes. (WHO)
Definitions of Maternal Death
• Direct - Deaths resulting from obstetric
complications of the pregnant state (pregnancy,
labour and puerperium), from interventions,
omissions, incorrect treatment or from a chain of
events resulting from any of the above
• Indirect - Deaths resulting from previous existing
disease, or disease that developed during
pregnancy and which was not due to direct
obstetric causes, but which was aggravated by
the physiologic effects of pregnancy
Definitions of Maternal Death
• Late - Deaths occurring between 42 days and 1
year after abortion, miscarriage or delivery that
are due to Direct or Indirect maternal causes
• Coincidental (Fortuitous) - Deaths from unrelated
causes which happen to occur in pregnancy or
the puerperium
• Pregnancy-related deaths - Deaths occurring in
women while pregnant or within 42 days of
termination of pregnancy, irrespective of the
cause of the death
The Numbers
• International: developed countries 1,600 women
and over 5,000 newborn babies die daily due to
complications that could have been prevented
• MMR: 400 per 100,000 live births overall
• UK 12 per 100,000
• US 7.1 per 100,000, NYS 20.5 hemorrhage – us
13.3 per 100.000
• Regional: Latin America/Caribbean 190 per
100,000
• National: T&T: 33.3 per 100,000
Beyond The Numbers
• WH O, Beyond The Numbers: Reviewing
Maternal Deaths and Disabilities to Make
Pregnancy Safer
• A detailed examination and evaluation of the
problems in both determining a baseline
MMR or interpreting what it actually means in
helping to address the problems facing
pregnant women in most developing
countries.
Beyond the Numbers
• Adopting this methodology to plan services will
improve maternal and child health.
• This concept of looking “beyond the numbers” to
understand the real reasons why women die,
through the use of a number of audit
methodologies including confidential enquires, is
now being promoted by the World Health
Organization (WHO) as a key component of its
Making Pregnancy Safer strategy.
ADMINISTRATIVE
• Environmental scan or SWOT analysis
• Midwifery education under the umbrella of
SANE
• To help inform government policy
• To set minimum standards of care,
Administration
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Promote annual mandates
Accurate recording of live births and stillbirths
Promote a Culture of Safety
Sentinel Event or Critical Incident Reporting
Use of vignettes to describe circumstances of
maternal deaths and lessons learned
QUALITY ASSURANCE COMMITTEE
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Monthly or quarterly
Review any near misses
Track and trend incidents
Root cause analysis of sentinel or
critical events
EDUCATION
• 5 yearly curriculum review to meet the needs
of current patient acuity
• Part of the postgraduate training and
continuous professional self-development
• Syllabus for all relevant health professionals to
identify areas for further research
Simulation Use
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Validate skills
Determine competency
Evaluate team communication
Prepare for life-threatening results
Reduce error
Improve safety
Shoulder Dystocia & Postpartum Hemorrhage
Simulation
Pictured above: L. Gioia, MD, A. Miller, RN, A. Hall, RN and other members of the L&D staff during a “Code Noelle” drill –
Delivery complicated by Shoulder Dystocia and Postpartum Hemorrhage
Courtesy Stonybrook University Hospital
Significance of Simulation
• Students rarely allowed to participate when OB
emergencies occur
• More complex patients create the need for simulation
• Experiential learning environment:
– Safe
– Risk-free
– Non-threatening
CLINICAL PRACTICE
• One methodology that has shown to be an
effective communication method is SBAR
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SBAR
S –SITUATION
B - BACKGROUND
A – ASSESSMENT
R - RECOMMENDATION
SBAR promotes:
• Organization of information
• Standardization of how we communicate
– Across all disciplines caring for patient
• Use of concise language
– Avoiding unclear/ambiguous terms – “She’s doing
fine”
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S = SITUATION
SITUATION describes:
• What is going on with the patient
• Concise statement of the problem
• “I am calling you about Mary Doe. She is
complaining of increased abdominal pain –
right lower quadrant.”
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B = BACKGROUND
BACKGROUND describes:
• What is the clinical background of the patient
– Pertinent to the situation
• “Mary Doe is post op day 2; status post open
cholecystectomy”.
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A = ASSESSMENT
ASSESSMENT describes:
• What is your assessment; what are your findings?
• “She is alert; BP is elevated 130/96 from 110/80; Pulse = 120;
Temp elevated to 1020 F; abdomen tender with guarding
noted; Bowel sounds negative; urine output less than 20cc
last 2 hrs; IV fluids – NS at 100cc/hr”
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R = RECOMMENDATION
Recommendation describes:
• What action is needed to correct the problem
• What do you want?
• “Last labs were 6am; recommend repeat labs; I
need you to assess patient. Would recommend
holding pain meds till physical assessment done.”
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Protocols/Policies/Guidelines
• Implement, audit and regularly update local
protocols for the referral of women with
problems, or potential problems, in pregnancy
and childbirth based on the health service
delivery framework.
• Local protocols should not only include the
relevant clinical guidelines but also identify
clear and agreed pathways of care and referral
mechanisms for women who develop
complications
Multidisciplinary Care
• Coordinated multidisciplinary or multi-agency
care should be available for all women with
medical, mental health or social problems,
including substance abuse and domestic violence,
who may require specialist advice or support in
pregnancy.
• Women with complex pregnancies and who
receive care from a number of specialists or
agencies should receive the support and advocacy
of a known midwife throughout their pregnancy
Annual Training
• All medical and midwifery staff should be trained
in:
• Basic life support and neonatal resuscitation/HBB
• Regular emergency drills for maternal resuscitation
in all maternity units.
• All health professionals: Regular and updated
training on the impact of domestic violence, mental
illness and substance misuse on the lives and health
of pregnant women, their babies and families.
British Study
• More than 50% of the women who died had
some aspect of substandard clinical care.
• Some died because their condition was not
diagnosed or they received ineffective or the
wrong treatment.
• Not all care was consistent with current national
clinical guidelines or provided by experienced
staff.
Are Mothers Dying because?
• They were unaware of the need for care, or
unaware of the warning signs of problems
in pregnancy?
• The services did not exist, or were inaccessible for
other reasons such as distance, cost or sociocultural barriers?
• The care they receive in traditional or modern
health services is inadequate or actually harmful?
Further Research
• To identify barriers which prevent women from
seeking care or maintaining contact with the
maternity services in order to help plan more
appropriate service provision.
• To estimate more robustly what, if any, is the
degree of increased risk of maternal deaths
associated with caesarean section particularly for
those undertaken without a clinical indication.
• To investigate the incidence of postpartum
hemorrhage in relation to previous caesarean
section and other direct causes
References
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice
nursing students: Communication, confidence, clinical judgment. Nurse Educator’s
Perspectives, 30(2), 79-82.
Bantz, B., Dancer, M.M., Hodson-Carlton, K., & Van Hove, S. (2007). A daylong clinical laboratory:
From gaming to high-fidelity simulation. Nurse Educator, 32(6), 274-277.
Department of Health. Building a Safer NHS for Patients. London: Department of Health;
2001[www.doh.gov.uk/buildsafenhs].
Department of Health. An Organisation with a Memory. London: Department of Health;
2000.
Jeffries, P. R. (2005). A framework for designing, implementing and evaluating: Simulations used
as teaching strategies in nursing. Nursing Education Perspectives, (2), 96-103.
National Patient Safety Agency [www.npsa.org.uk].
Roopnarinesingh, S., Ramoutar, S & Bassaw, B.Maternal mortality at Mt Hope Women’s hospital,
Trinidad. 1991. West Indian Medical Journal. Sept; 40(3): 139-41.
World Health Organization. Beyond the Numbers; Reviewing Maternal Deaths and Disabilities to
Make Pregnancy Safer. Geneva: WHO; 2004 [www.who.int/reproductive-health].
Thank You