204 research outputs found
Frequent brief on-site simulation training and reduction in 24-h neonatal mortality—An educational intervention study
No full textAim of the study “Helping Babies Breathe” (HBB) is a simulation-based educational program developed to help reduce perinatal mortality worldwide. A one-day HBB training course did not improve clinical management of neonates. The objective was to assess the impact of frequent brief (3–5 min weekly) on-site HBB simulation training on newborn resuscitation practices in the delivery room and the potential impact on 24-h neonatal mortality.
Methods Before/after educational intervention study in a rural referral hospital in Northern Tanzania. Baseline data was collected from 01.02.2010 to 31.01.2011 and post-intervention data from 01.02.2011 to 31.01.2012. All deliveries were observed by research assistants who recorded information about labor, newborn delivery room management, perinatal characteristics, and neonatal outcomes. A newborn simulator was placed in the labor ward and frequent brief HBB simulation training was implemented on-site; 3-min of weekly paired practice, assisted by local-trainers. Local-trainers also facilitated 40-min monthly re-trainings. Outcome measures were; delivery room management of newborns and 24-h neonatal outcomes (normal, admitted to a neonatal area, death, or stillbirths).
Results There were 4894 deliveries pre and 4814 post-implementation of frequent brief simulation training. The number of stimulated neonates increased from 712(14.5%) to 785(16.3%) (p = 0.016), those suctioned increased from 634(13.0%) to 762(15.8%) (p ≤ 0.0005). Neonates receiving bag mask ventilation decreased from 357(7.3%) to 283(5.9%) (p = 0.005). Mortality at 24-h decreased from 11.1/1000 to 7.2/1000 (p = 0.040).
Conclusion On-site, brief and frequent HBB simulation training appears to facilitate transfer of new knowledge and skills into clinical practice and to be accompanied by a decrease in neonatal mortality
Positive pressure ventilation at birth and potential pathways to newborn deaths in rural Tanzania
No full textBackground: There are 2.6 million neonatal deaths that occur globally each year, with more than 80% of these deaths occurring in low-income countries. In Tanzania, available estimates report that approximately 40,000 newborn deaths occur each year, mainly due to intrapartumrelated causes, prematurity-related complications, and sepsis. The majority of intrapartum-related neonatal deaths can be avoided by improving care around births. Interventions that have the potential to reduce intrapartum-related neonatal deaths include foetal monitoring during labour, availability of emergency obstetric care, and newborn resuscitation at birth for non-breathing newborns. Low-income countries are faced with many challenges in providing this care, including unskilled providers and inadequate training strategies that do not support the acquirement and retention of skills in newborn resuscitation.
Aims: The overall aim of this thesis was to investigate the causes of early newborn deaths and the contribution of intrapartum-related events and their association with ventilation immediately after birth. Furthermore, we wanted to describe the human factors and interactions that influence effective newborn resuscitation practices in this rural setting.
Methods: We applied a mixed-methods design and conducted three studies from October 2014 to July 2017. An observational study of all admitted newborns, delivered at Haydom Lutheran Hospital (n=671) between October 2014 and July 2017, was conducted to determine the presumed causes of 7-day newborn deaths and potential pathways contributing to death in this setting (Study I). A study that included the admitted newborns who received positive pressure ventilation in the delivery room (n=232) between October 2014 and November 2016 was then performed to compare ventilation characteristics with the newborn outcome at 7 days (Study II). Infants who died within the first 30 minutes of birth were excluded from both Studies I and II because they died in the delivery room. Building on the findings of the quantitative studies, a third study was conducted, consisting of in-depth interviews with midwives who performed deliveries and newborn resuscitations at Haydom Lutheran Hospital to explore factors affecting the provision of effective ventilation during newborn resuscitation (Study III).
Results: In Study I, intrapartum-related complications (birth asphyxia and meconium aspiration syndrome) contributed to almost two-thirds of all deaths within 7 days. Prematurity, presumed sepsis, and congenital abnormalities were other causes of death. Intrapartum hypoxia and prematurity were the major pathways leading to death. Severe hypoxia and hypothermia upon admission were important additional contributing factors.
In Study II, we showed that depressed newborns at birth who eventually died within 7 days had an abnormal foetal heart rate during labour, presented signs of bradycardia immediately after birth, and had delayed heart rate responses to positive pressure ventilation. Abnormal foetal heart rate during labour, heart rate at the end of positive pressure ventilation, and duration of positive pressure ventilation were the perinatal predictors of death in this setting. These newborns developed seizures and moderate/severe encephalopathy, likely related to intrapartum hypoxia. Despite inconsistencies in adhering to the Helping Babies Breathe algorithm, the tidal volume and heart rate responses that were recorded did not significantly influence the outcome of death or survival.
In Study III, midwives reported the importance of monitoring labour and being prepared for resuscitation before delivery. They also cited good teamwork and frequent ventilation training as factors to facilitate effective ventilation. Barriers to effective ventilation were identified as being anxious and/or feeling fear during ventilation, and difficulties in assessing clinical responses during ventilation.
Conclusion: The findings in this PhD thesis demonstrate the contribution of intrapartum-related neonatal deaths to early newborn mortality in a rural sub-Saharan setting. Furthermore, the data demonstrate a link between intrapartum events, likely through interrupted placental blood flow, and a state of depression in the foetus at birth, as represented by low heart rate at birth, delayed heart rate responses to positive pressure ventilation, and, eventually, death. Hypothermia and hypoxia during admission likely played a role in increasing mortality. The included studies highlight the potential for improving intrapartum care through enhanced foetal monitoring during labour to identify those at risk, as well as the benefits of optimizing positive pressure ventilation during resuscitation in the delivery room.
The latter should be the focus of frequent resuscitation training sessions to address the providers’ uncertainties and inconsistencies during resuscitation. Frequent resuscitation training should build the confidence of providers to quickly assess newborns immediately after birth, and to act without delay in order to optimize the provision of positive pressure ventilation
Management of congenital absence of the cervix: A case report
No full textCervical agenesis or dysgenesis is an extremely rare congenital anomaly. Conservative surgical approach to these patients involves uterovaginal anastomosis, cervical canalization, and cervical reconstruction. In failed conservative surgery, total hysterectomy is the treatment of choice. Success of reconstructive surgery depends on the amount of cervical tissue available. Hence, congenital absence of the cervix is a complex surgical problem and should be dealt with after thorough evaluation. We report an 18 year old girl presented with primary amenorrhoea and cyclic monthly abdominal pain. Initial attempted reconstructive surgery failed and hysterectomy was done. At laparotomy, there was only fibrous tissue and no cervical tissue at all. No findings related to endometriosis were observed .The uterus was removed and sectioning the fibrous tissue level of the blind vaginal cuff. Gross tissue examination showed a non communicating uterine cavity, filled with menstrual blood of about 200mls and a diffusely hypertrophy myometrium. The cervix was absent. Microscopically, there was no cervical tissue in the specimen; the uterine muscles had evidence of adenomyosis. In conclusion, re-canalization and cervical reconstruction procedures may be performed on carefully selected patients, consideration should be directed to the presence of adequate cervical stroma absence of which warrants hysterectomy
Management of congenital absence of the cervix: A case report
No full textCervical agenesis or dysgenesis is an extremely rare congenital
anomaly. Conservative surgical approach to these patients involves
uterovaginal anastomosis, cervical canalization, and cervical
reconstruction. In failed conservative surgery, total hysterectomy is
the treatment of choice. Success of reconstructive surgery depends on
the amount of cervical tissue available. Hence, congenital absence of
the cervix is a complex surgical problem and should be dealt with after
thorough evaluation. We report an 18 year old girl presented with
primary amenorrhoea and cyclic monthly abdominal pain. Initial
attempted reconstructive surgery failed and hysterectomy was done. At
laparotomy, there was only fibrous tissue and no cervical tissue at
all. No findings related to endometriosis were observed .The uterus was
removed and sectioning the fibrous tissue level of the blind vaginal
cuff. Gross tissue examination showed a non communicating uterine
cavity, filled with menstrual blood of about 200mls and a diffusely
hypertrophy myometrium. The cervix was absent. Microscopically, there
was no cervical tissue in the specimen; the uterine muscles had
evidence of adenomyosis. In conclusion, re-canalization and cervical
reconstruction procedures may be performed on carefully selected
patients, consideration should be directed to the presence of adequate
cervical stroma absence of which warrants hysterectomy
Improving quality of perinatal care through clinical audit : a study from a tertiary hospital in Dar es Salaam, Tanzania
No full textPerinatal audit has been tested and proved an important tool for reduction of perinatal mortality and assessment of quality of perinatal care. At Muhimbili National Hospital (MNH), a tertiary hospital in Dar es salaam, Tanzania we performed a retrospective cross-sectional study using data from an obstetrics database to classify all perinatal deaths during 1999-2003. We also determined the prevalence of anaemia in pregnancy and its impact on perinatal outcome. Furthermore, we conducted a perinatal audit to study potential determinants and causes of perinatal and neonatal deaths and their avoidability. We also assessed the quality of care of patients admitted with eclampsia using a criteria based audit. Stillbirth, early neonatal and perinatal mortality rates (PMR) were 96, 27 and 124 respectively. A large proportion of foetuses (38%) had no audible foetal heart beat on admission at MNH labour ward and the majority of the neonatal deaths were asphyxiated at delivery. The PMR for multiples and singletons were 269 and 118 respectively resulting in a rate ratio of 2.4 (95%CI: 2.1-2.4). The prevalence of anaemia and severe anaemia was 68% and 5.8%, respectively. Severity of anaemia increased the risk of preterm delivery with ORs of 1.4, 1.4 and 4.1 for women with mild, moderate and severe anaemia as compared to women with normal haemoglobin levels. The corresponding risks for LBW and VLBW were 1.2, 1.7 and 3.8, and 1.5, 1.9 and 4.2 respectively. The prevalence of preterm delivery and LBW was 17% and 14% respectively. The hospital-based incidence of eclampsia was 504 per 10,000 women or 5.1 % of all mothers admitted. Suboptimal care were identified on criteria regarding management plan by senior staff, review of the plans by specialist obstetrician, delay on caesarean section, monitoring patients on magnesium sulphate and inadequate use of the laboratory. Two out of three patients requiring operation were not operated within set standards. Birth asphyxia was the main cause of intrapartum fresh stillbirth (47%) and early neonatal deaths (51%), whereas eclampsia (25%) and preeclampsia (8.3%) were main maternal medical conditions. The majority of stillbirths were fresh, indicating foetal demise during labour or just before delivery. The audit study identified suboptimal care in about 80% of audited cases out of which about 50% were found to be the likely cause of the adverse perinatal outcome. Inadequate maternal and foetal monitoring during labour were the main suboptimal factors, though delay in referral and operative interventions were also prominent. Based on these studies, we conclude that: The perinatal mortality (PMR) in this study was higher than the national average. About one in four perinatal deaths at MNH can be attributed to avoidable factors linked to obstetric care Main causes of perinatal and neonatal deaths were intrapartum birth asphyxia, immaturity related and infections Management of patients in labour needs to be improved Suboptimal care that is essentially avoidable included: inadequate monitoring of patients during labour, delay of care, e.g. long decision to surgery interval, and delayed referral of patients fromprimary hospitals The prevalence of anaemia in pregnancy was very high; and low birth weight and preterm delivery was independently associated with severity of anaemia The prevalence of eclampsia at MNH was high and the case management needs to be improve
Management of congenital absence of the cervix: A case report
No full textCervical agenesis or dysgenesis is an extremely rare congenital
anomaly. Conservative surgical approach to these patients involves
uterovaginal anastomosis, cervical canalization, and cervical
reconstruction. In failed conservative surgery, total hysterectomy is
the treatment of choice. Success of reconstructive surgery depends on
the amount of cervical tissue available. Hence, congenital absence of
the cervix is a complex surgical problem and should be dealt with after
thorough evaluation. We report an 18 year old girl presented with
primary amenorrhoea and cyclic monthly abdominal pain. Initial
attempted reconstructive surgery failed and hysterectomy was done. At
laparotomy, there was only fibrous tissue and no cervical tissue at
all. No findings related to endometriosis were observed .The uterus was
removed and sectioning the fibrous tissue level of the blind vaginal
cuff. Gross tissue examination showed a non communicating uterine
cavity, filled with menstrual blood of about 200mls and a diffusely
hypertrophy myometrium. The cervix was absent. Microscopically, there
was no cervical tissue in the specimen; the uterine muscles had
evidence of adenomyosis. In conclusion, re-canalization and cervical
reconstruction procedures may be performed on carefully selected
patients, consideration should be directed to the presence of adequate
cervical stroma absence of which warrants hysterectomy
"What about the mother?" : Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates
No full textObjective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision makers Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness
Is time of birth a predictor of adverse perinatal outcome? : A hospital-based cross-sectional study in a low-resource setting, Tanzania
No full textBackground: Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods: A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients' socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results: Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50-1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45-0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07-2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07-2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31-2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3-2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7-8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1-2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02-2.6, p = 0.004, for abnormal breech deliveries). Conclusion: Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths
Sickle cell disease in pregnancy: trend and pregnancy outcomes at a tertiary hospital in Tanzania.
No full textSCD in pregnancy is associated with increased adverse fetal and maternal
outcomes. In Tanzania where the frequency of sickle cell trait is 13% there has
been scanty data on SCD in pregnancy. With progressive improvement in childhood
survival the burden of SCD in pregnancy will increase. We analyzed all deliveries
at Muhimbili National Hospital (MNH) from 1999 to 2011. Fetal and maternal
outcomes of SCD deliveries were compared with non-SCD. Data were analyzed using
IBM SPSS statistics version 19. Chi square and Fisher Exact tests were used to
compare proportions and the independent t-test for continuous data. To predict
risks of adverse effects, odds ratios were determined using multivariate logistic
regression. A p-value<0.05 was considered significant. In total, 157,473
deliveries occurred at MNH during the study period, of which 149 were SCD
(incidence of 95 SCD per 100,000 deliveries). The incidence of SCD had increased
from 76 per 100,000 deliveries in the 1999-2002 period to over 100 per 100, 000
deliveries in recent years. The mean maternal age at delivery was lower in SCD
(24.0±5.5 years) than in non-SCD deliveries (26.2±6.0 years), p<0.001. Compared
with non-SCD (2.9±0.7 Kg), SCD deliveries had less mean birth-weight (2.6±0.6
Kg), p<0.001. SCD were more likely than non-SCD to deliver low APGAR score at 5
minutes (34.5% Vs 15.0%, OR = 3.0, 95%CI: 2.1-4.2), stillbirths (25.7% Vs 7.5%,
OR = 4.0, 95%CI: 2.8-5.8). There was excessive risk of maternal deaths in SCD
compared to non-SCD (11.4% Vs 0.4%, OR = 29, 95%CI: 17.3-48.1). The leading cause
of deaths in SCD was infections in wholly 82% in contrast to only 32% in non-SCD.
In conclusion SCD in pregnancy is an emerging problem at MNH with increased
adverse fetal outcomes and excessive maternal mortality mainly due to infections
Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania.
No full text\ud
Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR). From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient. The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors. There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.\u
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