Quick identification and management; the high-risk mothers’ stitch in time
By Dr Peter Muwereza | While on a technical visit to Luuka District I received a call from the District Health Officer to help conduct a caesarean section to save a mother who presented with labour pains but had been operated on her first pregnancy. She had an inadequate pelvis to support the birth process. I quickly got in touch with the midwife to ask her to prepare the mother for the operation. On reaching the maternity ward of Kiyunga HC IV, I found two ladies waiting, one of which was the reason for my coming.
However, I was curious and decided to review both ladies before carrying out the surgery I was called for. I started with the lady I was not called for, because I was sure the other mother I was called to operate had been examined and the diagnosis confirmed only waiting for an emergency surgery. I found out that the mother was lying in a pool of blood, with large clots by her side! She was in labor for her second child (pregnancy), with the first delivered normally.
A nursing assistant had been left to observe these mothers. The only midwife on duty was manning a very heavy ANC clinic alone. The nursing assistant without hesitation told me that the lady had a show (a mucous blood discharge that usually signifies onset of labor) and therefore did not require special attention.
My attention immediately shifted to the bleeding mother as she could die any time due to excessive blood loss. We were lucky that we had just helped Kiyunga HC IV to start blood transfusion services and the mother was still stable. We conducted a successful Caesarean section and delivered an asphyxiated baby who was resuscitated and did well on the requisite treatment for such cases. We then turned to the mother I had been invited to attend to. She was more stable, also went through a successful caesarean section with a live baby.
This scenario teaches us or reminds us that maternal and neonatal deaths can still occur at health facilities. Uganda has made improvements in maternal health indicators particularly skilled birth attendance currently at 74%, according to the 2016 Uganda Demographic and Health Survey, up from 42% in 2006. Skilled attendance is critical in saving mothers and their newborns. The Nursing assistant who was in the labour suit is not a skilled birth attendant and therefore could not appropriately monitor and make right and timely decisions.
It was not clear why there was only one midwife on duty that day. However, some studies in low income countries such as Uganda show that absenteeism, late coming and the general poor attitude by staff (where the staffing norm is met) towards their work are some if the issues that continue to put mothers at risk of death in some public health facilities.
Ironically, in the Kiyunga case, the bleeding mother was being monitored on a partograph, but the danger sign of bleeding was neglected/misdiagnosed given the state in which the mother was found. This is because the Nursing assistant was not skilled. She had no knowledge of danger signs and their management.
For Luuka and districts with such challenges, these findings indicate that health facility leadership and the District Health Office need to improve supervision of health service delivery to ensure quality care for the mothers and newborns.
It is such scenarios that have informed the current paradigm shift of interventions by the World Health Organisation and its member countries including Uganda with an aim of improving the quality of care in health facilities if we are to make further progress in MNCH indicators.
The Community in which Mothers and Newborns Thrive (COMONETH) project under whose auspices I was in Luuka which started in September 2017 will run for 3 years in in Luuka District. This project is focusing on high risk mothers and newborns. The intervention aims at improving the knowledge of health workers in identifying and managing high risk mothers and newborns among other interventions.