15. Table 1 shows the contributory factors/three delays that cause maternal deaths in developing countries (Source: Ms Deborah Maine, The Safe Motherhood Action Agenda 1998:p37)8 Total contributory factors cause 7% of the deaths Poor quality of maternal health care i.e. interventions, omissions, incorrect treatment, lack of supplies, inadequate theatre facilities, insufficient skilled attendants, and poorly motivated staff cause delay 3 3 Lack of good roads, poor transportation and communication which prevents the woman’s arriving at health facilities in good time cause delay 2 2 Lack of basic education and decision making power, poverty, traditional and cultural practices which restrict women from seeking health care cause delay 1 1 CAUSES: the 3 delays NO

16. Table 2 illustrates the indirect causes of maternal deaths in developing countries They are responsible for 20% of the deaths. (Source: W.H.O.,1999: 14)2 Hepatitis 6 Heart disease 5 Malaria 4 Anaemia 3 Sickle Cell disease 2 HIV/AIDS 1 Causes No.

17. Table 3 demonstrates the direct causes of maternal deaths in developing countries (Source: SMAA,1998:2)8 73% Total obstetric causes responsibly for - Other direct causes include ectopic pregnancy, embolism, and anaesthesia – related deaths * 8% Obstructed labour and ruptured uterus 5 12% Eclampsia/Pregnancy induced hypertension 4 13% globally but in Ghana 20-30% Unsafe Abortion 3 15% Infection 2 25% Excessive bleeding 1 Percentage Causes No.

29. ROUTINE MANAGEMENT For the uncomplicated pregnancy, at least four antenatal care visits should be made as follows: Counsel the client at every visit and advise her to report to any health facility if she feels unwell. (NSMSP, 2008)12. This however has caused maternal deaths due to lack of proper decision making on the part of care providers ROUTINE LABORATORY TEST Counselling and HIV test, G6PD, Hepatitis B, CD4 count if HIV is positive and pelvic ultrasound have all been added to what used to be the case, i.e. before the year 2000. At 36 weeks Fourth visit 4 At 32 weeks Third visit 3 Between 24 and 28 weeks Second visit 2 At up to 16 weeks gestation First visit 1 PERIOD VARIABLE NO

30. THE ROLE OF THE MIDWIFE – ANTENTAL CARE Give Nefedipine 10mgs sublingual and refer to hospital. In hospital give 10mgs sublingual and ask Doctor to see client Check B/p, urine for proteins and oedema at every visit – vigilantly P.I.H if diastolic pressure >100mmhg 4 Give: anti-retroviral prophylaxis at 28wks if mother is HIV positive and at 30wks and counsel client on feeding options (NSMP, 2008:10) Ask for counseling and HIV testing at first visit. Do CD4 count if HIV is Positive HIV/AIDS 3 Give: paracetamol, I.V fluids of quinine 600mgs and refer to hospital. In hospital give paracetamol. Have an infusion trolley always in readiness, assist Doctor intelligently Give 3 intermittent preventive treatment (IPT) sulfadoxine 500mgs and pyremethamine 25mgs between 16 and36 weeks at 4 weeks interval Malaria 2 Provide 4 basic antenatal care: 1 st visit up to 16 weeks Antenatal care 1 Secondary Intervention Primary Intervention Variable NO

31. Take blood for grouping and cross matching. Give I.V fluids of N/Saline or ringers lactate 1000 mls. Give oral misoprostol 400mg stat and repeat in 4hrs if necessary or I.M injection of Ergometrine 0.2mgs. Refer to hospital Educate public/clients on dangers of unprotected sex and abortions Inevitable abortion 6 Give Nefedipine 10mgs sublingual start magnesium sulphate 4 protocol and transport client to hospital if not in second stage. If she is in labour and near delivery deliver by vacuum extraction, do other delivery interventions accurately and transfer to Hospital. In hospital – make sure I.V infusion for emergency obstetric care (EOC) is always ready – call Doctor, inform labour ward staff. Check B/p, urine for proteins and oedema at every visit – vigilantly Severe pre – eclampsia diastolic >110mmhg 5

32. (National Safe Motherhood Service Protocol; NSMSP 2008:21) 12 *Ask for pelvic ultrasound by 20 weeks. Also G6PD and Hepatitis B *Educate client on neonatal care immunization and danger signs *Educate on birth preparedness and complication readiness, STIS, HIV/AIDS and family planning Miscellaneous 8 Same as inevitable abortion Educate and motivate on family planning services Unsafe Abortion. In Ghana it accounts for20-30% of the deaths. 7

34. Table below shows management strategy In hospital: take accurate history; examine woman physically. Make internal pelvic examination tray and I.V infusion trolley ready Call Obstetrician. Monitor client and foetus every 15 minutes and record accurately. Inform the theatre staff about a possible caesarean section. Carry out augmentation procedures intelligently. Call obstetrician in case of foetal or maternal distress immediately. Make sure resuscitation apparatuses are ready. Resuscitate baby accurately. Educate client and the significant others on the process of labour. Teach relaxation exercises. Educate client on birth preparedness and complication readiness. Screen short women with big babies and women with hip deformity for hospital delivery. Take history of labour and record observation on the partograph. If cervicograph crosses the alert line – reassure and refer to hospital without delay. Labour management – prolonged labour 1 SECONDARY PREVENTION PRIMARY PREVENTION CAUSE NO

35. Assess total amount blood loss through interview and observation of bed clothes and pads Check BP, pulse, temperature and assess for shock. Take blood for grouping and cross matching Give oxytocin IV 10 units IM and add 20 units to 500mls IV fluid of normal saline or ringers solution Pass urine catheter to monitor urine output Start broad – spectrum antibiotics Check uterus. Massage to stimulate contractions and also expel any blood clots. If bleeding is profuse and persists repeat oxytocin infusion Administer misoprostol rectally 800mcg Stat . Do bimananual compression of uterus Transfer to hospital In hospital do same as above. Make sure trolley for EOC is ready. Call Doctor Immediately . Continue broad spectrum antibiotics. Do not discharge before 48 hours. Check Hb at 1 st visit and at week 36 gestation. Administer iron folic acid and vitamins in pregnancy. Educate on family planning. Conduct active management of the 3 rd stage of labour. Give oxytocin 10 Units IM within one minute of delivery – after exclusion of another baby. Deliver placenta by controlled cord traction when bladder is empty. Massage uterus to maintain uterine contractions. Repeat every 15 minutes for 2 hours. Examine placenta very carefully. Inform obstetrician about missing membranes and lobes of placenta immediately. Do not discharge before 48 hrs after delivery. Because according to research findings the majority of deaths occur during the first 48 hours. Post partum haemorrhage causes 61% of maternal deaths P.P.H. 2

36. In hospital, assess accurately. Continue IV fluids and broad spectrum antibiotics Call Doctor for internal pelvic assessment and appropriate mode of delivery to ensure safe mother (and baby). Monitor accurately. Educate on good nutrition in childhood. Assess accurately. Make use of partograph in delivery. Transfer as fast as possible if cervicograph goes flat. Take blood for grouping and cross matching. Give IV fluids. Give antibiotics. Obstructed labour and ruptured uterus (account for 8% of the deaths) 4 In hospital, management same as in community Give broad spectrum antibiotics. Keep patient in a separate room. Continue strict infection prevention strategies especially frequent hand washing with soap and water Make use of mobile hand hygiene Unit and good decontaminants Test and manage STIs and anaemia during pregnancy. Observe strict infection prevention techniques during delivery (especially, wash hands with soap and water frequently). Make use of good decontaminants. Infection (accounts for 15% of maternal deaths) 3

37. If placenta has been delivered- take blood for grouping and cross matching. Give IV fluids of 500mls g/s or ringers lactate in 6 hours. Administer 10 units of oxytocin stat Give ergometrine 0.2mgs I.M or slowly I.V (NSMSP, 2007:3) Insert Foleys catheter for continues drainage. Do a bimanual compression of the uterus if bleeding still continues. Examine placenta for completeness or retention of membranes or lobes. Start broad spectrum antibiotic. Transfer to hospital. In hospital: make sure a trolley for the management of PPH is always at hand. Take blood for grouping and cross matching. Start I.V infusion of ringers lactate. Call Doctor and carry out all instructions of interventions intelligently and accurately. Organize for blood donors. Check B/P and pulse every 2 hours. Encourage client to empty bladder every 2 hours. Encourage her to breastfeed. Examine baby accurately. Report any abnormalities. Carry out routine eye instillation of antibiotics. Make both mother and baby comfortable. Organize for blood donors * 4 th stage of labour – post partum haemorrhage especially first 2 – 6hrs 5

38. Give broad spectrum antibiotic Give pethedine 100mgs, diazepam 10mgs I.V slowly in separate syringes. Remove placenta manually Give 20 units oxytocin in 500mls of ringers lactate at 40 – 60 dps/minute Give ergomentrine 0.2mgs I.M or misoprostol 800 – 1000mcg rectally Transfer client to hospital In hospital: Take a good history; take blood for grouping and cross matching. Start IV fluids. Call Doctor. Carry out all instructions accurately and intelligently. Advise on family planning Retained placenta – placenta not delivered within 30 minutes 6

56. May God help us to achieve the health MDGs 4, 5 and 6 by the year 2015. Thank you for your attention.

57. THE PRECONCEPTION CYCLE CARE 6.Educ. on the menstrual cycle 7Educ n . Exercise and Relaxation 8. Blood tests 10. General counseling 11. Immunization 12. Environmental pollutants 13. Psychosexual counseling 14. Family Planning 15. Sub fertility HEALTHY CONCEPTION 1.Weight& height for the calculation of.BMI mass inde x Weight and height 2.Educ. on Nutrition 3. General Check ups 3a. Urine 3b. Stool 3c. Blood Pressure 3d. Breast examination and self breast examination 4. Pre-marital sex avoidance 5. Avoidance of Social poisons 9. Referral to level ‘C’ health facility/hospital for the management of the indirect causes of maternal deaths – i. Anaemia ii. Malaria iii. Sickle Cell disease iv. HIV/AIDS v. Heart Disease vi. Hepatitis

61. DANSOA MOBILE HAND HYGIENE UNIT “DAMHHU”