Regrettably, however, the structure of clinical education here does not afford the same opportunities for students to learn a systematic approach to managing clinical problems. For example, at Duke, there are upwards of 50 ObGyn faculty members; at KCMC, there are only four—yet they handle similar numbers of deliveries, outpatient visits, and surgeries. Such a level of staffing is inadequate to manage the clinical load and to teach residents and medical students.
Consequently, students often learn “on the fly,” independently, and without the benefit of a systematic approach to OB emergencies.
We teach a systematic, evidence-based approach to the management of OB emergencies with the Advanced Life Support in Obstetrics (ALSO) program. We modified the course for an under-resourced setting and to meet the specific needs of this place. So far, we have taught the course to more than 250 OB providers in the region, with help from our colleague from Denmark, Dr. Bjarke Sørenson. We have watched the nurses and physicians grasp this knowledge and apply it with great success and satisfaction.
Postpartum hemorrhage. PPH remains the leading cause of death of pregnant women in under-resourced countries—even though it is often one of the easiest complications to prevent. By teaching active management of the third stage of labor and a progressive, staged approach to managing PPH at KCMC, the rate of maternal mortality from PPH has dropped substantially: Of 26 maternal deaths at KCMC in 2008, 25 % were related to PPH; after emergency OB instruction, not a single maternal death in 2009 was attributable to PPH. We think this is at least in part related to the teaching of ALSO and the rapid uptake of the methodology by the doctors and midwives there.
Pre-eclampsia. This condition, on the other hand, remains stubbornly resistant to quick change. The ALSO course teaches management of pre-eclampsia, but we often encounter patients too late in their course to intervene meaningfully. After KCMC’s success managing PPH, complications of hypertensive disorders rapidly became the #1 cause of maternal death here in 2009. Few drugs to control hypertension (we have hydralazine most of the time; labetalol, never; and no other IV options) and a frequent lack of magnesium sulfate make management of women with severe preeclampsia difficult, almost impossible.
Lack of sophisticated life support systems and trained personnel make the very sick patient much more likely to succumb to her illness. Some of the most tragic cases we’ve seen here are adolescent mothers with preeclampsia who died from a cerebral accident or renal failure, either of which could have been prevented with timely access to OB care, proper medication, trained personnel, and at times, advanced imaging modalities and hemodialysis.
Stillbirth. Even more common are the staggeringly high numbers of stillbirths that we encounter, either as referrals from smaller hospitals or on site during labor.
Use of continuous electronic fetal monitoring (CEFM) in resource-rich settings has been analyzed and scrutinized at length, mostly because of the high rate of unnecessary cesarean deliveries that false-positive interpretations of the fetal heart rate inspire in the cautious obstetrician. Every OB, we would guess, has intervened surgically because of what seemed to be an ominous fetal heart rate tracing—only to have the newborn nearly jump out of your delivering hands with its vigor.
Where there is no electronic fetal monitoring—and there is certainly none in Moshi—one must rely on a fetoscope (we still can’t hear the fetal heart with one of those) or a hand-held Doppler device to divine the fate of the fetus.
Intermittent auscultation has been shown to be as reliable as CEFM in low-risk patients, but the technique requires a high nurse-to-patient ratio to be effective. This is nearly impossible in many under-resourced settings. The nurse-to-patient ratio at KCMC may be as high as 30 to 1 (it’s higher still in other hospitals in the surrounding areas), and patients sleep, even labor, two or three to a bed. That makes true intermittent auscultation impossible.
Intrapartum stillbirths are a tragedy wherever they occur; the reality is that 95% occur in under-resourced countries. Concern over preventing stillbirth often leads to a quicker decision to perform a cesarean delivery where this service is available. Audible decelerations or meconium may be benign findings if one has the luxury of CEFM, but may prompt a cesarean when the outcome is less certain. Paradoxically, therefore, both the availability of CEFM in resource-rich settings leads—and the absence of CEFM in under-resourced settings—lead to unnecessary cesareans.
Finding a means of reliably monitoring the fetus during labor is critical in both settings, but is needed most acutely where resources are scarce. As the capacity for performing cesarean deliveries increases in these settings, so does the rate of cesarean deliveries—to a point at which the rate exceeds 50% in some centers. This situation will, ultimately, lead to its own set of complications, including future placentation abnormalities and their potentially life-threatening consequences.