Maternal near miss: an Indian tertiary care centre audit

Background: In practical terms, women are considered near-miss cases when they survive conditions which threaten their life i.e. organ dysfunction. Despite advances in medical science and increased awareness of measures for safe childbirth, unacceptably high maternal morbidity and mortality continues to plague developing countries like India. Our’s being a tertiary care centre, draws a lot number of high-risk patients and referrals. By auditing these near miss cases, we aim to identify the causes, factors leading to near miss, to identify management gaps to prevent near misses and maternal death.Methods: Retro-prospective cross-sectional study done over one and a half year. Patients were included based on the inclusion criteria. A questionnaire was used to evaluate the prospective cases and the indoor case sheets were used for retrospective cases. After data entry in excel sheet, data analysis was done using SPSS 21. Results were tabulated.Results: High number of Near Miss cases with preeclampsia being the commonest. Lack of proper facilities at the periphery health centers was the most common cause for referrals. Level 1 and level 2 delays were found in most cases.Conclusions: Timely referral, with adequate treatment at the peripheral hospitals will majorly reduce Near miss. Hence, proper development and functioning of peripheral hospitals are needed

Study of maternal and perinatal outcome in women with congenital heart disease

Background: Pregnancy induced changes in cardiovascular hemodynamics are generally well tolerated. However, the reversible but prolonged hemodynamic stress of pregnancy can have negative effects on the diseased heart. In our study we studied various uncorrected and corrected congenital cardiac lesions and their antenatal, intrapartum course, their ability to withstand labor and postpartum complications. Methods: Our study was a retroprospective observational cross-sectional study conducted at KEM hospital, Mumbai with enrolment of total 27 subjects over a period of 18 months between August 2020 to December 2021.The study included all the registered and emergency patients either post abortal or post-delivery with congenital cardiac diseases including the ones who were surgically corrected. Results: The present study was conducted to study demographic features and maternal and perinatal outcomes of pregnancy in these women. Majority of the subjects were diagnosed with heart disease at the age more than 20 years (40.74%) and very few at age less than 5 years. In the present study only 7.4% study subjects were aware about pre-marital counselling, and preconceptional counselling. Among the lesions ASD was commonest reported among 51.85% study subjects. ICU admission was required among 11.11% study subjects. Labour analgesia given to only 18.52% study subjects. We did not observe any association between surgically corrected CHD and ICU admissions, postnatal complications, and outcomes, p>0.05. Conclusions: This study concluded that pre-pregnancy diagnosis, counselling, appropriate referral, routine antenatal supervision and delivery at an equipped centre improve the overall outcomes

Postnatal bladder dysfunction

Background: Voiding difficulty and urinary retention is a common phenomenon in immediate postpartum period. Absolute or relative failure to empty the bladder resulting from decreased bladder contractility (magnitude or duration) or increased bladder outlet resistance or both are defined as voiding dysfunction. It needs high index of suspicion or else can go undiagnosed and can lead to magnitude of problems. The study aims to calculate the incidence of dysfunction of bladder in postnatal women and to study risk factors associated with development of bladder dysfunction and management strategies in cases of bladder dysfunction.Methods: Authors did a prospective observational study in a tertiary care hospital. 200 postpartum women were screened for complaints of voiding dysfunction within 6 hours of removal of catheter in post caesarean patients and of normal vaginal delivery. Authors found that the voiding dysfunction was relatively common with an incidence of 20.20%. Following risk factors were analyzed: parity, mode of delivery, pain at suture site, baby weight, para-urethral tear.Results: Postpartum voiding dysfunction was found to be relatively common with statistically significant association found for pain at suture site and para urethral tear. Intra partum events contributed to voiding dysfunction. 93% of patients who with voiding dysfunction could be managed conservatively, and only 7% had to undergo intervention in the form of re catheterization.Conclusions: The early identification and treatment can reduce the pain and discomfort. Majority of the cases resolves with conservative management and nursing staff plays a key role in early detection of the symptoms

Relevance of sociodemographic characteristics in care of HIV reactive pregnant women in the context of upscaled antiretrovial therapy in India

Background: The burden of HIV and AIDS comes with social, monetary and health related consequences. HIV is reported to be a pandemic, but the maximum burden of the disease is in the low and middle income \ countries. In obstetric context, sociodemographic factors influence health seeking, compliance and adherence to the advised regimen. These determine vertical transmission. Present study was undertaken to study the demographic characteristics among pregnant and postpartum HIV positive women, to study the high risk obstetric conditions, morbidities and obstetric outcome, among the women, to study the neonatal outcomes among HIV reactive women and to study the postnatal choices and compliance in these women.Methods: The study was conducted after approval from the institutional ethics committee. All antenatal patients delivering at the institute in the one and a half year of study duration, who consented to be a part of the study, were enrolled in the study. The mother-baby pair was followed up for six weeks postpartum.Results: Eighty patients formed the study cohort as per the inclusion criteria. 44% belonged to the age group of 26-30 years. 56.2% had attended up to secondary schooling, 55% belonged to class III of the Kuppuswamy socio-economic class, 96.2% were married. 91.2% were homemakers. 41.8% spouses were seropositive, 25.3% spouses were not willing to be tested. 75% were registered pregnancies out of which 56% had registered before 20 weeks of gestation. 25% of neonates weighed between 2.7-2.9 kg closely followed by those more than 3 kg. Fifty-four patients opted for top feeding (66.7%). Seven mother-baby pair did not follow-up.Conclusions: Social class and educational status play a vital role in establishing awareness and ensuring the antenatal care and compliance. Empathetic, inclusive and responsive by health care providers in convincing women to get tested goes a long way

Association of adverse pregnancy outcome and domestic/intimate partner violence

Background: Domestic/intimate partner violence is not a mere household issue. It is a global phenomenon that occurs in all the countries and cuts across all strata, races and countries. Apart from being an issue of human/individual rights, it also has major health consequences. The main aim of this study is to stress the need of screening and detecting violence in antenatal women.Methods: This was a questionnaire based observational cross sectional study done at King Edward Memorial Hospital, Mumbai, India over a span of one year. A total of 200 antenatal/postnatal patients seeking healthcare were enrolled after an informed consent with approval from the Institutional Ethics Committee. Percentages of various parameters were analysed. Test of significance was Chi square test and Odd’s ratio (p <0.05).Results: Prevalence of domestic/intimate partner violence in our study was 12.5% and 7% in the group with normal pregnancy outcome and 18% in group with adverse pregnancy outcome. It was found that violence was more prevalent in age group of 21 to 30 years, love marriages, nuclear families, lower educational level of partner, addiction in partner, unplanned pregnancies, lower economic conditions and families supporting dowry and gender bias and allowing freedom of choice and contraception.Conclusions: Need for routine screening for violence in women of reproductive age group with vulnerable subset of pregnant women. Creating awareness/sensitivity amongst healthcare professionals and to train them to identify and help these women

Caesarean scar defect: a histopathological comparative study

Background: We have evaluated the validity of this syndrome in Indian patients and analysed the gynaecological indications for hysterectomy in women with history of caesarean sections. We have studied pathological changes in the scar area and compared the findings with matched cases without previous caesarean scar.Methods: A prospective observational case control study was done at tertiary care hospital (Seth GS Medical College and King Edward Memorial Hospital) over two years (December 2018 to December 2020) with universal sampling and enrolled all consenting eligible patients. After hysterectomy histopathological study of the specimens was done. Total cases: 16 hysterectomy samples with history of previous caesarean section. Total controls: 40 hysterectomy samples with history of no previous caesarean section. The difference between the two proportions was analysed using Chi square or Fisher exact test. All analysis was 2 tailed and the significance level was set at 0.05.Results: Women with history of previous caesarean scar had gynaecological symptoms related to the caesarean scar defect such as abnormal uterine bleeding, dysmenorrhea and chronic pelvic pain, post-menopausal bleeding and the most frequent clinical symptom related to the scar defect was abnormal uterine bleeding. The clinical symptoms were found to be associated with histopathological changes at scar site.Conclusions: This study compared caesarean cases and no caesarean controls and sheds light on the role of histopathology in detection of caesarean scar site changes. It helped in comparison of various factors affected due to the presence of caesarean scar and its long-term complications, leading to hysterectomy

Obstetric violence: a health system study

Background: Disrespect and abuse during facility-based childbirth is a global problem with differing driving factors in different contexts. Obstetric Violence (OV) refers to professional deficiencies in maternity care. The objective of this study was to assess knowledge and attitudes towards OV in a cohort of members of the obstetric healthcare team at a tertiary care, teaching hospital in Western India (Mumbai).Methods: A questionnaire-based study involving 80 participants comprising of trainee doctors and faculty, nursing students, staff and teachers from the department of Obstetrics and Gynaecology and hospital administration.Results: 57.97% of participants had heard the term ‘Obstetric violence’ earlier. 75.36% reported verbal abuse as a form of OV, others being physical abuse, non-consented care, discriminatory care, abandonment/neglect or refusal of care and imposition of interventions without scientific basis. 53% and 89.8% of the participants did not consider routine episiotomies and artificial rupture of membrane respectively as forms of OV. 84.06% and 59.4% of participants considered instrumental delivery without consent and Caesarean section citing safety/convenience respectively as forms of OV. 82.6% participants endorsed the need of birth companion. Improving the number and training of healthcare providers and better institutional policies on respectful maternity care were suggested as solutions.Conclusions: Majority of the participants had witnessed some form of OV. The need for practical training of healthcare personnel and better infrastructure in the healthcare system were emphasised, but there appeared to be a lack of consciousness of the paternalistic mindset and approach to women in labour. Soft skills training of healthcare providers with emphasis on key ethical principles like autonomy, respect and dignity is crucial to address the issue of OV.

Gender analysis and training needs assessment of class 4 staff in a tertiary health care institute

Background: A health care team comprises of doctors, nurses, paramedical staff, medical assistants, administrators and support staff or class 4 workers. Each individual has a role in the execution of proper health care delivery to the patients. Obstetrics and gynecology is a dynamic branch requiring urgent attention in most cases right from admission to discharge. Delivery of prompt treatment is possible with better training and coordination of the health care team. In a tertiary care institute, referred patients have more critical health problems and need urgent assistance by well-trained staff. On the other hand, in a smaller set up with less human resource, agile and well-trained support staff would be an asset to overcome the limitations. Better-trained staff means less loss of man-hours from injuries and illnesses, less medico legal liabilities, reduced maintenance cost of equipment and less expenditure on health-related issues of staff. We conducted an interview based cross sectional observational cohort study of the situation and an assessment of needs for skill building of support staff in a tertiary care hospital. At the end, we propose a structured training program suitable to the local needs that can be conducted by experienced peers, technical staff and medical personnel. We studied unmet training needs of the staff and gender related issues.Methods: A questionnaire based cross sectional study involving 92 class 4 workers in the department of obstetrics and gynecology in a tertiary care hospital was conducted comprising questions regarding their demography, work profile, training, needs and problems faced. Key informants in the relevant area were also interviewed.Results: Graphical representation of the responses received has been made. Professional work profile, health issues, gender issues, training need of any specialized training has been highlighted.Conclusions: As an important part of the health care team, this study has brought out issues related to health especially occupational health, needs for training, hurdles faced at work amongst class 4 staff working in the department of obstetrics and gynecology