Pro-Chancellor and Chairman of Council, Federal University, Lokoja, Nigeria. February 2016
Member, Court of Governors, College of Medicine, University of Lagos, October 2015 for four years.
Achieving Safe Delivery Through Multidisciplinary Care GUEST LECTURE, 2ND ANNUAL SCIENTIFIC CONFERENCE LEAGUE OF OBSTETRIC ANAESTHETISTS OF NIGERIA(LOAN) BY NIMI D. BRIGGS EMERITUS PROFESSOR OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF PORT HARCOURT on September 03, 2012
Let me applaud the League of Obstetric Anaesthetists of Nigeria (LOAN) for the choice of the topic of today’s Guest Lecture which emphasizes the value of multidisciplinary care as a way of achieving safe delivery in mothers. By placing the search light on synergy which is the essence of multidisciplinary care, LOAN is effectively advocating that the important lesson of collaboration between professionals and disciplines in the care of the parturient woman, should not be lost on anyone of us.
My last clinical contact with anaesthesiology as it is called in some climes, was at the Birmingham Maternity Hospital of the University of Birmingham, in the United Kingdom. This was in 1973 when the science and practice of continuous epidural blockade as a method of pain relief in labour, was being worked out under the late J. Selwyn Crawford, one of the founding fathers of Obstetric Anaesthesia in the United Kingdom. I was then a Commonwealth Scholar and a trainee obstetrician in the hospital under the late Wilfred George Mills. Selwyn, as we all fondly called him, incorporated us – some of the obstetricians – into his research team and captioned us “Our Obstetricians”. Outside the obstetricians and anaesthetists that were directly involved in the research, there were Hospital Administrators who made sure that orders for supplies were placed on time, midwives who cared for the mothers and occasionally administered the “top ups”, technicians who ensured that the sterile materials – drapes, catheters, drugs, syringes, needles and many others – were all in placed in their proper order on the trolleys, as well as paediatricians who meticulously evaluated the responses of the newborns to ensure that we were not sacrificing neurological competence in the babies for pain relief in their mothers. It was that multidisciplinary approach that determined the value and guaranteed the success of continuous epidural analgesia in labour, resulting in the widespread acceptance that the procedure currently enjoys in all parts of the world.
Permit me then to adopt the same structure as it was operated in Birmingham in addressing today’s matter. I will start by looking at parturition – the delivery process – which is the converging point for all of us – the patient, midwife, obstetrician, anaesthetist, and paediatrician as well as its consequences. From these consequences, I will synthesize the nature of care that a parturient woman would require and identify the type of skills needed to deliver this care. Here, obviously, the skills of the midwives, obstetricians, anaesthetists paediatricians and other physicians and laboratory scientist who assist in the management of the pregnant woman, will take preeminence. Following this, I will examine “care” in a wider sense and show that for the “care” that is given during childbirth, which usually involves the application of acquired skills by experts, to have the desired outcome, the health and well-being of the would – be- mother, ought to have been adequately addressed even before she became pregnant. Here, issues such as proper upbringing of the girl child, her formal education , including family life education, and her access to the basic necessities of life, which are provided from multiple sources, will be ventilated. For, available evidence confirms that healthy, well-nourished and informed women, who embark on childbearing, benefit most from care, from any source, during pregnancy and labour. They and their babies, accordingly, go through childbirth safer than any other group1. But first, a word or two about the events in labour, if by way of a reminder.
EVENTS IN LABOUR AND THEIR CONSEQUENCES
Childbirth is an emotional event in every mother, however experienced2. Anxiety and trepidation on the one hand, and happiness and great expectations on the other, are some of the emotions women experience in childbirth. But whatever the emotions, it is the physiological events that occur in labour that determine its course and in addition give rise to the consequences which have to be addressed. By way of a summary, these major events are:
Under normal circumstances, these events occur in a well-coordinated cascade manner that lasts no more than twenty hours at the most.
The presence of strong and painful uterine contractions with periodicity, constitute the strongest evidence that labour has commenced, even though, there is as yet no consensus on what triggers this event. The contractions occur in the upper uterine segment and unlike what happens when muscles elsewhere contract, contractions here are not followed by relaxation but by retraction. By this phenomenon, myometrial muscles do not return to their original lengths in between contractions. They get shorter and commence the next set of contractions from their shortened lengths. When labour is fully established, contractions typically occur every two to three minutes, last about 50 to 70 seconds with intensities of 40 to 60 mm Hg.
Contractions and retraction of the upper uterine segment first lead to thinning and ballooning of the lower uterine segment and then a gradual effacement of the cervix. In effacement, the cervical canal is obliterated as the cervix itself gets incorporated into the lower uterine segment. Dilatation of the cervical os commences at the end of effacement, first slowly and then at the rate of about 1cm per hour to full dilatation at 10cm. Fetal membranes usually rupture during cervical dilatation giving rise to the release of amniotic fluid.
With contractions and retractions of the upper uterine segment, thinning and ballooning of the lower segment and dilatation of the cervical os, propulsion of the content of uterus, the baby, begins. Other than the pain that is felt, uterine contractions use energy – calories, enhance fluid loss and reduce ph which may give rise to acidosis.
Expulsion of the fetus in cases of normal deliveries commences at crowning with the presenting part which is situated between the parietal eminences on both sides, the bregma in front and the posterior fontanel behind. This is then followed by the birth of the fetal head by extension and then the rest of the body. The expulsion itself is preceded and made possible by some complicated internal and external rotational movements by which the fetus accommodates itself to the architecture of the pelvic bone.
The same process of contraction and retraction of the muscles of the upper uterine segment which resulted in the birth of the baby also brings about the separation of the placenta from its site of attachment usually at the fundus of the uterus, to the lower segment from where it is delivered by cord traction. The separation and delivery of the placenta involves bleeding which under normal circumstances, does not exceed 500ml and so, is easily borne by the woman who commenced childbearing in a healthy state.
The consequences of the events that have been described are many. For one thing a mother’s emotion towards childbirth could influence her performance and so would have to be managed. Furthermore, labour involves confinement to some extent and so the mother would need help even with the ordinary things which she could normally do for herself, like putting on her clothing, having her bath or visiting the toilet. This may be accentuated by some of the drugs she may receive in labour. Then there are the consequences of uterine contractions, the work that the parturient woman does. These include, pain, using up calories, acid build up and fluid loss. So the woman in labour may need to be infused with fluids in which calories may be delivered.
In passing through the pelvic bone, the fetal head compresses the urethra and urinary bladder, which may result in urinary retention. The issue of infection is another matter to contend with for once the fetal membranes are ruptured, the protective barrier around the fetus and placental sites are no more present. Infection therefore can occur especially when the labour process becomes prolonged or there are too frequent internal examinations. Finally the issues of trauma and blood loss, especially those associated with the birth of the baby and that of the placenta, have to be kept in mind. Blood loss may need to be replaced and trauma may require surgical intervention.
CARE DURING PREGNANCY AND LABOUR
“The position of woman in any civilization is an index of the advancement of that civilization; the position is gauged best by the care given her at the birth of her child”3. For the care that is “given at the birth of her child” to be most beneficial, that care should commence during pregnancy. Mothers therefore require a combination of ANC and intrapartum care to enhance safety in the child bearing process. The combination of care should include:
Listening to pregnant women, talking with them, examining them and obtaining information about their babies as is provided for by the most basic form of ANC that is run by skilled health care providers, is of tremendous value to the course and outcome of pregnancy and labour. The women get exposed to the environment of a health facility, where they are encouraged to have their babies. They make friends among themselves and with the health care providers. In the interactions that follow, their fears and anxieties are allayed; myths, dispelled2 and existing illnesses, identified and treated before they get bad enough to threaten the life of the mother or baby. In addition, the mothers are taught health-seeking behaviour and given medications that help to prevent and in some cases actually treat existing illnesses4. Such illnesses include anaemia, pre eclampsia, disproportion, abnormal lies and presentations, HIV positivity, congenital fetal malformations, and small for gestational age babies. Antenatal care from multidisciplinary sources – midwives, obstetricians, laboratory scientists and technicians, – is now accepted as a very important way of improving the safety of pregnancy and childbirth, especially in resource-poor environments5.
General Care in Labour
Neither pregnancy nor the labour that follows it is a disease. But they both require some level of care and supervision because things can easily go wrong. Furthermore, labour at best is restrictive and so precludes the mother from being in a good shape to help herself in a number of diverse ways. Encouragement, reassurance and general care are therefore of utmost value from the time of admission. A record of her vital signs – temperature, pulse, blood pressure and respiratory rate has to be kept from time of admission and steps taken to meet her general needs. Bladder catheterization may be necessary if difficulty in micturition becomes a problem.
Supervising the Course of Labour
Labour has to be supervised to ensure it is progressing satisfactorily and that the mother and her baby are remaining in good health. In addition to the record of maternal vital signs, fetal heart beats have to be ascertained. Dehydration is prevented, if the need exists, by the infusion of dextrose in water solution which also reduces the chances of acid-base imbalance. Additionally, such an infusion supplies calories. An intake and output chart is opened and all fluid in intake and urine output measured. A close supervision is kept on the progress of labour through abdominal palpation and periodic internal examination. A partogram, which graphically illustrates the events in labour – fetal and maternal, is opened. If all goes well, delivery is taken at full dilatation of the cervical os. Next the placenta is delivered and the mother’s perineum checked for injuries. The baby is cleaned and handed over to the mother for the commencement of breast feeding.
Pain Relief in Labour
Most care providers in labour regard pain relief as part of the normal care of every woman in labour as this has become a very important aspect of the training of care providers to women in labour. Except those who insist on “natural childbirth”, the vast majority of women also accept to have some form of pain relief in labour.
The available options for pain relief in labour are many. They range from inhalers, injections, infiltrations, general anaesthetics, and regional procedures. Not all care providers can administer all the available agents used for pain relief. Whereas the midwife can administer some on her own, even without a prescription from a doctor, others are only dispensed by physicians and in some cases, only by anaethetists.
All agents used for pain relief in labour depress uterine contractions and fetal respiration. Consideration is usually given to this fact while using these agents and this, to some extent, determines the agent that is used, its time of administration, dosage and route. The standard pain relief agents used at the Labour Ward of the University of Port Harcourt Teaching Hospital, are pentazocine and promethazine. Epidural analgesia is available on demand for a small fee of N15, 000. 00, in mothers without contraindications.
Attention to Blood Loss
Bleeding from the genital track during pregnancy and before the birth of the baby is always pathological and requires investigation to ascertain its cause and significance. On the other hand, such bleeding after the birth of the baby, is not necessarily so. Placental separation and birth involves some bleeding – usually under 500ml – which is easily accommodated by women who commenced pregnancy in good health or had had the benefit of ANC, where pre existing anaemia may have been corrected. Also minor injuries at the perineum may cause some slight bleeding which again is self limiting and not normally associated with problems. But it is the responsibility of the care provider to ascertain the quantity of blood loss and to ensure it is not excessive. Where this is so, the care provider is expected to take appropriate corrective measures.
Managing the Pueperium
The first six weeks after the birth of the baby, which is known as the pueperium, is the period during which many organs in the mother return to their pre-pregnancy sizes and functions through the biological process of involution. Lochia, essentially a mixture of blood, blood exudates and mucus is discharged from the vagina for about a fortnight. Lactation is properly established and injuries which may have been sustained during childbirth heal during the period. Also, the mother gradually recovers from the stress and pains associated with childbirth, even as she bonds with her child. At the end of the pueperium contraception for birth spacing or family planning is discussed with the mother. Skilled health care providers are therefore required to manage the pueperium in order to identify and act when things are seen to be going wrong. Common disorders of the pueperium include excessive blood loss, infection in the genital pathway, breast engorgement, cracked nipples, sub involution of the uterus and emotional problems.
Caring for the Newborn baby
Caring for the newborn baby properly is important because most babies, who die, do so within the first week of life6. First, is to ensure the general comfort of the baby at all times, by keeping it in a warm environment, appropriately clothed and paying regular attention to wet napkins. Next is the nutrition which should commence with having the baby on the mother’s breast for breast feeding within 30 minutes of its birth. Breastfeeding from then should continue on demand as exclusive breast feeding for the next six months. The baby should be commenced on immunization against the vaccine preventable childhood diseases and should be weighed to ensure it is gaining weight. Again this requires the services of a trained health provider.
Having recognized the nature of care that enhances safe delivery, I will now identify the various professionals in the health care delivery team, who have the expertise to deliver this specialised care.
CARE PROVIDERS IN PREGNANCY AND LABOUR
The midwife is a registered nurse who has also trained and registered as a midwife. Such a person has therefore acquired the specialised skills of a general nurse as well as those of a midwife by which she is able to look after women in pregnancy and labour. The midwife provides care at the ANC. She conducts enlightenment classes in which pregnant women are taught the rudiments of pregnancy, events in labour and how to care for their newborn babies. She examines women whose pregnancies are proceeding satisfactorily and refers those with problems to the doctor. She dispenses routine medications like antimalarials, haematinics, including folic acid tablets.
Labour Wards are usually manned by midwives too. Where the mother is in good health and there is no obvious problem with the mother or baby, the midwife takes up the care of such a mother from admission to delivery and up to the time of discharge from hospital. The midwife is also trained to recognize abnormalities early and to draw the attention of the doctor to such a woman. An important method used in assessing the state of the newborn baby directly after delivery, by midwives and physicians, is the Apgar Scoring System7, by which the baby’s activities are recorded and scored and the information so obtained, used to determine the baby’s state of health. The midwife therefore serves as a very important member of the care delivery team in pregnancy and labour. It is this fact that informs the current effort of the federal government in using the Midwifery Service Scheme (MSS) as a way of making pregnancy and labour safer for mothers and reducing maternal mortality8.
The obstetrician is a physician, who like the midwife, has had additional training in the art of looking after women in pregnancy and labour, but at a much higher level of competence, covering all forms of abnormalities. He therefore takes the ultimate responsibility for the care of all pregnant women who make contact with the health facility where he works.
Whereas the obstetrician can supervise normal pregnancies, it is usually those with abnormalities that he concerns himself with most, reserving the normal ones for the midwives. He identifies specific illnesses like anaemia, diabetes, preeclampsia and treats them, the idea being to get the mother into a fit enough state as possible before labour commences. Furthermore, he conducts many clinical evaluations and tests to assess the feasibility of a mother achieving successful vaginal delivery and then acts in the best interest of mother and baby.
Again, in labour, the obstetrician manages all mothers with abnormalities while the midwife takes care of cases without complications. Accordingly, the obstetrician conducts all vaginal instrumental as well as abdominal deliveries, like forceps, ventouse and caesarean sections. He also looks after such patients and their babies in the immediate pueperium.
Approaches to pain relief, including those that are done through the administration of general anaesthetic agents, which result in complete unconsciousness constitute the special skills of all anaesthetists. In addition, anaesthetists are skillful in acute medicine, including the management of patients with fluid and electrolyte imbalance.
The first use of a modern anaesthetic agent for pain relief in labour is normally put down to that by James Young Simpson in Edinburgh on January 19, 18478. Well received by many parturient women, etherization of childbearing was followed by the use of a number of other anaesthetic agents including chloroform, opium derivatives and local anaesthetics. But it was not until 1953, that the effects of these agents on the babies became understood. For in that year, Virginia Apgar, of the Columbia Presbyterian Hospital, published information from her seminal work and described a simple and reliable system for evaluating newborns. The result of the studies showed that infants delivered of caesarean section with general anaesthesia, were more depressed (they had lower Apgar scores) than those delivered following spinal anaesthesia7
More recently, advances in fetomaternal medicine and pharmacology, have brought about a clearer understanding of the effects on the mother and the fetus, of the various anaesthetic agents that are used in labour, outside the pain relief effect. These effects are dose and route dependent and include:
All skilled care providers to women in labour – midwives, obstetricians, anaesthetists and paediatricians are now conversant with these facts and apply them in their care of women
Intramuscular injection of opiate derivatives, usually administered by midwives, is the commonest source of pain relief used at the University of Port Harcourt Teaching Hospital. The obstetricians also use various forms of field anaesthesia like pudendal block and perineal infiltration for minor surgical procedures. For caesarean sections, general anaesthesia was used almost for all cases until recently, when a study that canvassed the use of infiltration of the abdominal muscles with local anaesthetics in patients with eclampsia10, was published. In addition, single shot spinal analgesia and lumbar epidurals have recently been introduced for normal labour for patients who indicate such a wish and pay the prescribed fee. The results of the 78 and 113 respectively that have so far been done, are encouraging.
Paediatricians are physicians with special skills in looking after healthy as well as sick babies. Whereas the care of healthy newborns, including the establishment of breast feeding, is normally undertaken by midwives, asphyxiated newborns or those with obvious abnormalities are placed under the care of paediatricians. Such babies may be cared for in the labour ward, by their mothers’ sides or taken away for closer observation and more intensive care in the Special Care Baby Unit (SCBU). In their care for newborns, paediatricians always seek to ensure that babies are thriving well, are gaining weight, have established exclusive breast feeding and have commenced immunization.
The essence of multidisciplinary care as a means of achieving safe delivery is that the mother should benefit from the best care available in the health facility, irrespective of its source. So, if the skills required to give an epidural anaesthetic are best acquired by anaesthetists, then they, rather than the obstetricians should give the anaesthetic. To be able to do this, we as professionals must have utmost respect for one another and recognize the limitations of our individual professional skills. We must maintain our skills and knowledge by committing to life-long self improvement and showing willingness to learn from one another especially in patient care. We should be involved in joint researches and scientific publications and invite one another to teach specialised areas to our students. Such collaboration engenders mutual respect and recognition, promotes knowledge acquisition and serves the purpose of students and patients, better.
WIDER ISSUES OF CARE
Several factors determine the state of the mother at the time she is received for anaesthetic care in the operation room or labour ward. Some of these factors initiated from her childhood, well before she commenced childbearing. Anaemia from chronic malnutrition resulting in stunting, structural defects from accidents and elsewhere- pelvic fracture, poliomyelitis, rickets and kyphoscoliosis, could all determine the ease of administration as well as success or failure of the care we give, such as intubation in general anaesthesia and dural puncture in regional block.
Oftentimes, there are cases of teenage mothers who arrive in hospital dreadfully ill with high fever, dehydration, keto-acidosis and septicaemia. They have been in labour for over five days at home and their babies had died in their wombs. They are illiterate, were given away in marriage between 10 and 14 years of age and had not had antenatal care. Others come, with fulminating eclampsia. Again they are young and have not had ANC. Yet some more, come exsanguinated and severely anaemic from an undelivered placenta that had been retained for a week or more. The horrific list can go on and on; indeed 60% of delays that add to maternal morbidity and mortality are the types I and II delays which occur at the community level. It is these shortcomings that constitute the crux of the matter.
Women in the circumstances described would have benefited from an orderly society where care is provided as a right from childhood. Proper nutrition, including exclusive breast feeding and the application of the various child survival strategies, including immunization would have ensured they grew up as healthy children without the crippling effects of poliomyelitis or tuberculous kyphoscoliosis. An orderly society where education is recognized as an important component of a continuum of care, again from childhood, would have prevented them from being given away in marriage as teenagers, when they were still growing and their pelves had not attained their full sizes. Furthermore, it would have impressed on them, the value of antenatal care to a pregnant woman. The net effect of these collective intersectoral failures is that women become chained down by ignorance, poverty and deprivation and are shortchanged and compromised in many ways. Not infrequently, they are compelled by circumstances beyond their control, to embark on childbearing in less than optimal states. Consequently, some of them are not in the best conditions to benefit from the expert care you and I are able to offer when things go wrong. So, they die, despite our stopping the eclamptic fits; end up with vesico-vaginal fistulae despite our relieving the obstructed labour; develop secondary amenorrhoea despite our delivering the retained placenta and their babies, become stillborn, despite our skillful interventions11, 12.
Let me commence my closing remarks on a note of gratitude to LOAN for this interdisciplinary invitation to deliver today’s guest lecture. Not really being one of your subset, I consider the trans-border invitation a rare honour and privilege.
Unsafe delivery resulting in high maternal and perinatal deaths is the most striking consequence of absence of sufficient care for women especially during child bearing. By synergizing our efforts and diligently applying our specialised skills as midwives, obstetricians, anaesthetists and paediatricians, we can, no doubt, do something about the problem especially through prompt and appropriate intervention, when the need arises. We can treat anaemia, and hypertensive disorders; operate on a woman with disproportion and so prevent her labour from being obstructed; anaesthesize a mother who is bleeding profusely from a retained placenta and then deliver the placenta, manually; resuscitate a baby who is badly asphyxiated at birth. Indeed, we can and have done much more in our professional lives. But the fact remains that the roots of the problems that bring about unsafe delivery, oftentimes, lie in issues that are beyond the confines of the health institutions in which you and I see the women who die in pregnancy related circumstances. Thus, the real solution is not just amongst us as professionals; it calls for actions from everyone.
As parents, we should desire and love the girl child. We should ensure her proper nutrition commencing with exclusive breastfeeding, immunize her against the vaccine preventable diseases and send her to school to enable her to read and write and to attain her full growth potential. Girls and would-be-mothers should aim high in life and should take their education seriously, avoiding unwanted pregnancies by applying lessons learnt from family life education. Pregnant women should have antenatal care and deliver in well-equipped health facilities. As government, we should provide a peaceful environment that will support decent living for girls (and boys) to attain their full potentials in life – good housing, clean piped water, functional heath facilities, especially at the rural levels where common ailments can be easily treated and more serious ones expeditiously referred to better equipped centres, good quality educational institutions and an orderly environment. As teachers we should be conscientious and realise that in teaching our pupils properly we are making positive contributions to the lives of present and future generations of children, including their reproductive performances. And as physicians we should apply our skills assiduously to the benefit of our patients.
It is these collective actions, taken correctly and effectively at various stages of the life of a female, by various sectors of the society, that make her fit and informed. They put her in a position to take some responsibility for her own health and life. Furthermore, they place her in the best shape to embark successfully on pregnancy and also ensure that she would benefit maximally from the expert care that she may receive from various care providers during pregnancy and labour. No caring society can consider these too much.
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2. . Joyce Emmanuel in Caesarean Section. A Curse or A Blessing? Media Publishing. Port Harcourt. 2012
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5. Harrison KA ed. Childbearing health and Social Priorities – a survey of 22774 consecutive hospital births in Zaria, northern Nigeria. BJOG 1985, 92 supplement 5
6.Nte, Alice. Child Survival in Resource-limited settings: the issues, challenges and way forward. University of Port Harcourt Inaugural Lecture series 91. 2012.
7. Virginia Apgar. A Proposal for a New Method of Evaluation of the Newborn Infant. Current Researches in Anesthesia and Analgesia July-August 1953.
8. Pate AM. Safe Motherhood Day 2012 Abuja Nigeria
9. Donald Caton. History of Obstetric Anesthesia. in Chestnut’s Obstetric Anesthesia, Principles and Practice. Fourth Edition. Mosby. Elsevier. 2009
10. Fyneface-Ogan S and Uzoigwe SA. Caesarean section outcome in eclamptic patients: a comparison of infiltration and general anaesthesia. West African Journal of Medicine.2008.27,250-254
11. Briggs ND. The Nigerian Child and the Health Care Delivery System. A Lecture Delivered to the participants at the Senior Executive Course. National Institute for Policy and Strategic Studies, kuru, Jos, Nigeria. May, 2003.
12. Briggs ND. Women’s Health :A Nation’s Wealth. Valedictory Lecture Series No.2.. University of Port Harcourt. February 2009
Achieving Safe Delivery Through Multidisciplinary Care GUEST LECTURE, 2ND ANNUAL SCIENTIFIC CONFERENCE LEAGUE OF OBSTETRIC ANAESTHETISTS OF NIGERIA(LOAN) BY NIMI D. BRIGGS EMERITUS PROFESSOR OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF PORT HARCOURT on September 03, 2012