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Maternal collapse: Training in resuscitation
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Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e9
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Maternal collapse: Training in resuscitation
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Mergan Naidoo, MBChB, MFamMed, FCFP, MSc (Sports Med), Dip HIV Management, DipPEC, PhD, Head Clinical Unit and Lecturer Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Keywords: maternal collapse resuscitation training simulation training
The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) of South Africa has recommended in the Sixth Saving Mothers Report that health-care professionals (HCPs) training in managing obstetric emergencies be improved. One such measure is to ensure that the Essential Steps in Managing Obstetric Emergencies (ESMOE) with its Emergency Obstetric Simulation Training (EOST) be rolled out to every HCP working in the obstetric environment. The programme has been strengthened and rolled out in the province of KwaZulu-Natal, South Africa. This review focuses on the various teaching methods used to improve maternal resuscitation training in a South African context. Evidence-based interventions in maternal resuscitation will be highlighted, and recommendations for clinical practice will be suggested. Common causes of maternal collapse will be explored, and measures to improve training in these areas will be outlined. In order to ensure sustainability, quality improvement measures need to be introduced and evaluated. © 2015 Published by Elsevier Ltd.
Introduction Q1
The Sixth Saving Mothers Report for South Africa spanning the period between 2011 and 2013 placed the institutional maternal mortality ratio (iMMR) for South Africa at 154.06 deaths per 100,000
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001 1521-6934/© 2015 Published by Elsevier Ltd.
Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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live births [1]. Although a 12.6% decrease in the iMMR was noted from the previous report, of concern was the large number of avoidable deaths. Lack of appropriately trained doctors and nurses contributed significantly towards maternal deaths accounting for 15.8% and 8.8% of maternal deaths, respectively. The main causes of maternal deaths in South Africa have still remained the same for the last evaluated triennium with non-pregnancy-related infections, mainly acquired immune deficiency syndrome (AIDS) (37.71%), obstetric haemorrhage (15.79%), hypertensive disorders of pregnancy (14.77%), medical and surgical disorders (11.38%) and pregnancy-related sepsis (5.22%) making up the top five causes of death [1]. Health-care professional (HCP) training and a commitment to quality were identified as two of the 10 priority recommendations [1]. The need to train all HCPs in the Essential Steps in Managing Obstetric Emergencies (ESMOE) using Emergency Obstetric Simulation Training (EOST) as the means of delivery is included in these recommendations. A commitment to quality included clinical governance and the need to have regular EOSTs or fire drills at the workplace as well as ensuring that managers appropriately assess and accredit HCPs to ensure that they have the requisite competencies [1]. The training of HCPs is a major challenge in South Africa, which is beset with problems of high attrition rates of staff in the public health sector due to unfavourable working conditions [2,3]. Despite initiatives to roll out the ESMOE training programmes to all institutions through a structured ‘master trainer’ initiatives, the high attrition rates of HCPs place an additional burden on institutions providing the training. For training to be effective, sustainability at an institutional level needs to be maintained preferably with a local champion who can ensure that training is ongoing and relevant. Simulationbased training such as EOST can be effectively implemented in rural- and resource-constrained settings in South Africa as evidence exists that it does improve HCP competencies [4]. Training in maternal resuscitation Maternal collapse can be used to define a range of medical events varying from a simple faint to cardiac arrest [5]. For the aim of this review, only collapse resulting in life-threatening events will be discussed. The adage coined from Dr. Thomas Petty: “... the best treatment of status asthmaticus is to treat it three days before it occurs,” can easily be applied to maternal collapse [6]. There may be early signal signs and symptoms that a woman has a potentially life-threatening illness, which is often ignored or treated nonchalantly. Vignette: A 36-year-old patient presented to the antenatal clinic on multiple occasions during her third pregnancy with dyspnoea. She was treated by various midwives and doctors for various conditions, which included bronchitis and ‘panic attacks’. After the birth of her third child, she elected to have a tubal ligation that was done under spinal anaesthesia. During the procedure, she developed distress from severe pulmonary oedema. She required intubation and subsequent transfer to an intensive care unit (ICU). It was later discovered that this patient had severe mitral stenosis. She died in the ICU many days later. The early recognition and investigation of her symptoms that suggested severe underlying cardiac disease may have prevented this death. The key learning point from this case is that doctors working in obstetrics and anaesthetics need to have good baseline clinical competencies on being able to recognize and manage/refer high-risk pregnancies. The ESMOE course has the following modules: maternal resuscitation and the unconscious patient, resuscitation of the newborn, sepsis and miscarriage, eclampsia and severe pre-eclampsia, haemorrhage, obstetric emergencies (breech and twin delivery), obstetric emergencies (shoulder dystocia and cord prolapse), assisted delivery, human immunodeficiency virus (HIV), surgical skills, intrapartum care and interpreting the cardiotocograph [7]. Participants undergoing this course, which includes undergraduate students, midwives, paramedics, interns, medical officers, registrars and specialists, are first given short lectures. Factual knowledge provided through PowerPoint presentation is reinforced when this knowledge is applied in the EOST, which speaks to ‘shows how’ in Millers framework for clinical assessment [8]. Participants are encouraged to work as a team, which may comprise doctors and nurses or nurses only to better simulate the true work environment. Reflection and feedback from the participants as well as from the observers and finally the facilitator input reinforce understanding and application. The group then does the simulation again, and they invariably tend to improve their performance quite significantly. It is anticipated that EOST if done regularly in the clinical unit will also strengthen teamwork and interdisciplinary collaboration [9]. Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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Maternal collapse, usually identified by a loss of consciousness, results in the activation of the emergency response system in the clinical unit. It is therefore important that all nursing and medical personnel are adequately trained in providing basic life support (BLS) [5]. Nursing personnel are usually the first respondents, so training in BLS including early defibrillation using an automated external defibrillator (AED) is critical for all nursing personnel [10]. One local hospital has implemented a performance management system for all nurses, which requires them to have an updated BLS certificate in order to qualify for an annual pay progression. Maternal resuscitation requires that the first respondent to a cardiac arrest activates the emergency response system, documents time of the collapse, places the patient supine and begins chest compressions according to the BLS algorithm [11]. When the team arrives with the resuscitation equipment, certain interventions are standard as per Advanced Cardiac Life Support (ACLS) algorithms. These include the following: i. ii. iii. iv.
Prevent delays in defibrillation Give ACLS drugs and doses as per normal ACLS protocols Ventilate with 100% oxygen Ideally, one should use continuous capnography for the confirmation of tube placement and ongoing monitoring, but this is not always available in South African settings v. Monitor the quality of cardiopulmonary resuscitation (CPR) vi. Provide postcardiac arrest care as appropriate [11]
Maternal resuscitation is taught by first making participants aware of the differences between resuscitating an adult patient and an adult pregnant or postpartum patient. The physiological differences are highlighted. The important changes that are specific to pregnancy especially when a woman is >20 weeks pregnant include the following: i. Ensuring at least 15 of lateral tilt of the pelvis or manual displacement of the uterus. Manual displacement is thought to have less of an effect on the quality of chest compressions [11e14]. ii. Perimortem hysterotomy or caesarean delivery (CD) needs to be considered at the onset of cardiac arrest, implemented within 4 min of starting resuscitation and completed within 5 min of cardiac arrest [11e14]. iii. Early intubation to prevent aspiration with a smaller endotracheal tube [11,12,14]. iv. Woman in the third trimester should have chest compressions performed 2e3 cm above the inter-nipple line [11]. In addition, the following are important practice points: i. Start intravenous (IV) lines above the diaphragm. ii. Assess for hypovolaemia and give fluid boluses when required. iii. If the woman has been receiving magnesium sulphate, stop this infusion and give IV calcium chloride/gluconate. iv. Continue with all maternal resuscitative efforts during and after hysterotomy/CD [11]. Training in the maternal resuscitation module is then reinforced with skill sessions dealing specifically with airway management, which teaches candidates how to appropriately administer different concentrations of oxygen using various oxygen delivery devices, performing endotracheal intubation, using the laryngeal mask airway when a difficult airway is encountered and performing a surgical cricothyroidotomy when there is an obstructed airway. BLS skills are taught, and emphasis is placed on the quality of chest compressions, ventilating using a bagevalve mask and performing defibrillation using an AED or a defibrillator. Finally, participants are asked to work in a team performing a resuscitation of a patient with cardiac arrest as well as an unconscious patient with a pulse. A fire-drill scoring sheet is used, which includes a clinical score and a drill execution score. The drill execution score consists of activation of the emergency response system, communication skills, teamwork, Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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documentation and the sequence in which the drill is performed. Reflection, feedback and re-practice are then performed. Designation of team members, which include a team leader, a scribe who also keeps the time, a person who performs chest compression, a person who performs ventilation, a person who is responsible for the monitors and who also performs the defibrillation and finally a person who sets up the IV lines, does the necessary investigations and administers the IV drugs, and also helps with role definition in the simulation [11]. Communication among team members is facilitated using the ‘checkerecheck’ when interventions are suggested and confirmed [11]. The team is also encouraged to identify the causes of cardiac arrest in the scenarios being painted, and to also define pathways for definitive management. Causes of maternal collapse Soar et al. [12] identified the following causes of cardiac arrest, which is covered in the ESMOE training, and it comprises the top five causes of maternal death accounting for 86.2% of all maternal deaths in South Africa [1]. These are as follows: i. ii. iii. iv.
Sepsis Obstetric haemorrhage, which includes a ruptured ectopic pregnancy Hypertensive disorders of pregnancy Cardiac disease in pregnancy
Other causes of maternal collapse include problems related to psychiatric disorders, amniotic fluid embolism and pulmonary embolism [5,12]. Anaesthetic complications, although not common, have devastating consequences when they occur [1]. In excess of 90% of these anaesthetic deaths occurring in district hospitals in South Africa are avoidable [1]. Simulation-based training has been demonstrated to improve performance and patient outcomes [14e16]. In addition, experience with undergraduates has demonstrated that students obtain much higher marks in the ESMOE skill stations compared with other skill stations in the summative assessments at the end of the clinical block. This may be due to the simulation-based training that these undergraduate students are exposed to. 1. Sepsis Non-pregnancy related sepsis and sepsis accounted for the majority of maternal deaths in South Africa [1]. The sepsis module is based on recommendations from the surviving sepsis campaign [17]. The initial identification of a woman who has SIRS (systemic inflammatory response syndrome), sepsis, severe sepsis or septic shock using a systematic clinical approach is taught in this module. The simulated patient is assessed using an organ system evaluation comprising the ‘Big 5’ namely the central nervous, cardiovascular, respiratory, gastrointestinal (including the liver) and the renal systems; the ‘forgotten 4’, which includes the immunological, endocrine, musculoskeletal and haematological systems; and finally the ‘core’, which is the obstetric examination. Each system is evaluated to see if the sepsis originates from the system and if there is an organ system dysfunction. Emphasis is placed on clinical evaluation followed by focused investigations. The team then decides on a management plan that includes the ability to administer inotropic support in patients with septic shock [17]. Providing a simple algorithm helps nurses to systematically manage their ‘ill-simulated patient’. Practically, applying case vignettes such as a patient with a septic miscarriage who presents to a primary health-care clinic with signs of severe sepsis allows participants to use their clinical skills more effectively by following an algorithmic approach to the management of sepsis, which may take into account inotropic support whilst awaiting transfer to a referral centre. Emphasis on early goal-directed management [17] is reinforced, which includes the following: i. Administration of appropriate IV antibiotics within 1 h ii. Obtaining relevant specimen cultures iii. Maintaining a systolic blood pressure of >100 mmHg Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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iv. v. vi. vii.
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Maintaining a central venous pressure of between 8 and 12 cm of water when appropriate Maintaining an appropriate oxygen saturation Ensuring that the haemoglobin is optimized Maintaining and monitoring urine output
One of the fire drills involves managing a woman who needs stabilization and referral for surgical intervention because there have been avoidable cases of maternal deaths resulting from late referral to regional or tertiary hospitals [1,18]. Because of the large amount of deaths due to HIV, a separate HIV module focuses on teaching HCP skills in managing an HIV-positive pregnant woman. The South African Department of Health 2015 guidelines for managing the pregnant woman and her newborn forms the basis of the module content [19]. Case scenarios are presented, and discussion on management then ensues. Fire drills are covered in the sepsis, which incorporates the HIV-positive woman who presents with sepsis. Teaching also involves dealing with serious adverse effects associated with antiretroviral treatment. 2. Obstetric haemorrhage Haemorrhage is of great concern to maternal death assessors in South Africa as the problem of obstetric haemorrhage and in particular bleeding during or after CD seems to be on a steady rise [1,18,20]. Training in the ESMOE includes the identification of a woman with haemorrhage based on the clinical signs. The module also includes interventions detailing the active management of the third stage of labour, the use of uterotonic agents, sequential management of postpartum haemorrhage and removal of a retained placenta. The two fire drills deal with ‘simulated patients’ presenting with uterine atony and management of a retained placenta. The team is allowed to practice, reflect and repractice resuscitative and procedural skills (bimanual compression, aortic compression, balloon tamponade and manual removal of the placenta). A section recently introduced deals with a safe CD, and it covers the teaching of surgical skills to control haemorrhage such as uterine artery ligation, the placement of B-Lynch sutures and using a Foley catheter as a tourniquet to control bleeding before transfer to a regional hospital [21]. Resuscitative efforts including the use of blood products early in the resuscitation are incorporated into the fire drill [22]. 3. Hypertensive disorders of pregnancy The two sections covered in this module are eclampsia and severe pre-eclampsia. Early identification of these conditions is emphasized in the training. The systematic evaluation of the patient (and fetus) described earlier is again used in the secondary survey. The emergency management includes the management of a patient with depressed level of consciousness, which includes skills dealing with the protection of the airway. Simulated patients presenting with eclampsia and pre-eclampsia are used in the fire drills, and emergency skills including the administration of magnesium sulphate are replicated. 4. Cardiac disease Medical and surgical disorders have slowly become recognized as an important cause of maternal death [1]. Although not specifically covered in ESMOE, these cases are often dealt with in maternal death enquiries at institutions. Cardiac disease in particular has gained prominence as an important cause of maternal collapse in the last decade [1]. Many of these patients were managed at district hospitals or at lower levels of care, and 51.7% of these deaths were evaluated as avoidable [1]. To prevent such adverse incidents, it is important that HCPs are able to recognize and refer potentially lifethreatening cardiac conditions to higher levels of care. Training should be targeted at undergraduate and postgraduate medical curricula with special emphasis on clinical skills, clinical reasoning, appropriate investigations and early referral [23]. Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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5. Anaesthetic complications Many obstetric anaesthetics are administered by medical officers, working in district hospitals in South Africa, who do not have any formal training in anaesthetics [24]. The misconception that a spinal anaesthetic is a safe option that can be performed by medical officers who lack skills has resulted in avoidable anaesthetic deaths [24]. In order to improve anaesthetic skills, the anaesthetic division of the ESMOE committee has developed a 1-day training programme that improves skills of medical officers working at district hospitals. Skills taught in this workshop include airway assessment, managing a ‘high’ spinal anaesthetic and dealing with bleeding during and after caesarean section (CS). An additional component added to the anaesthetic module is the introduction of the World Health Organization surgical safety checklist that may serve as a cognitive aid in ensuring that safety steps are adhered to resulting in improved maternal outcomes [25]. The aim of this module was in keeping with one of the recommendations of the Sixth Saving Mothers Report, which is to advocate for a safe CS [1]. The American Heart Association (AHA) has coined a pneumonic called BEAUCHOPS to assist with remembering the cause of cardiac arrest in pregnancy [26]. This is a useful aid and stands for the following: i. ii. iii. iv. v. vi. vii. viii. ix.
Bleeding/disseminated intravascular coagulation (DIC) Embolism: coronary/pulmonary/amniotic fluid embolism Anaesthetic complications Uterine atony Cardiac disease: myocardial infarction, aortic dissection/cardiomyopathy/valvular heart disease Hypertension/pre-eclampsia/eclampsia Other: Differential diagnosis of standard ACLS protocols Placental abruption/praevia Sepsis [26]
Maternity units are encouraged to develop checklists of commonly encountered causes in their local context, and to use these as aids during a cardiac arrest [11]. Clinical governance and quality improvement It is important to identify designated HCP at each institution that will be primarily responsible for maintaining regular fire drills in the local institution. Many of these ‘master trainers’ have attended the ESMOE training as well as the annual updates, and they have developed weekly skill sessions in their institutions. The advantage of performing fire drills in the local setting is that it allows the team to identify system issues that can be rectified before an actual emergency [11]. Skill audits of staff working in the maternity department should be performed on a regular basis to identify gaps and ensure that personal development plans are formulated for staff members. The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) of South Africa [1] has recommended in the Sixth Saving Mothers Report that a commitment to quality be implemented through the following mechanisms: i. Heads of clinical units should improve clinical governance, clinical supervision and respond appropriately to local findings ii. HCPs should make themselves available for training iii. Managers should ensure that fire drills occur regularly in their institutions iv. Managers should evaluate and accredit HCPs to ensure that they have appropriate skills [1] In addition, regular audits of maternal deaths and adverse events should be performed, and quality improvement measures should be put in place to prevent such events from occurring again [1,27]. Conclusion Emergencies are rare events by their nature, and because of this, HCPs tend to lose their technical expertise when faced with an event that they may encounter once every 2 years. In order to maintain Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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their skills and competences, clinical heads of units need to develop a simulation training programme (using EOSTs) at their local institutions, which is carried out regularly. Reflection, feedback and evaluation should be incorporated into the fire drill so that the drill is made relevant to the local context. There are many challenges facing HCPs working in resource-constrained environments, which hinder their ability to render a high-quality level of service. Introducing regular training, which fosters teamwork and collaboration, improves communication, and it helps develop individuals in the organization. One such measure could include the introduction of ESMOE training with the EOSTs at all institutions. Rewarding HCPs who attain high levels of competence and expertise is one way of recognizing excellence. Measurable outcomes could include the number of adverse events including maternal deaths that occur in the unit. Linking performance management and pay progression to these measurable indicators may provide the necessary incentives to improve the quality of care for pregnant women and their newborn babies.
Acknowledgement of funding The author would like to acknowledge the University of KwaZulu-Natal's Medical Education Partnership Initiative (MEPI) (Grant No: 5R24TW008863) that provided funding and support for the ESMOE programme. MEPI is an NIH/PEPFAR-funded grant awarded to UKZN in 2010, which aims to develop, expand and enhance models of medical education in Sub-Saharan Africa.
Conflicts of interest The author of this publication received research funding from The University of KwaZulu-Natal's Medical Education Partnership Initiative (MEPI), Enhancing Training, Research and Education programme (Grant No: 5R24TW008863) that provided funding and support for the research (ENTREE) on the WHO surgical safety checklist for maternity care, which is described in this publication. In addition, the author received research scholarships from the Discovery Foundation for research on implementing the WHO surgical safety checklist for maternity care to improve maternal outcomes in KwaZulu-Natal. No conflicts of interest exist.
Practice points 1. Clinicians and nurse practitioners should be aware of the anatomical and physiological changes that occur in pregnant woman. 2. Awareness of the slight deviations from BLS and ACLS protocols needs to be borne in mind when performing resuscitation on pregnant woman <20 weeks, >20 weeks and in the third trimester. 3. The focus of training needs to be based on minimal didactic content and more on using simulation-based training with greater emphasis on teamwork and collaboration. 4. Reflection and feedback of behavioural, cognitive and technical skills should be integral to the simulation training (fire drills). 5. Master trainers are essential to develop capacity at an institutional level. 6. Performing fire drills in the workplace is key to ensuring that skills are maintained for rare obstetric emergencies. 7. Knowledge of the common causes of maternal collapse is essential for midwives and clinicians working in obstetrics. The application of this knowledge in fire drills of these causes is important to develop and maintain professional competencies. 8. A regular programme of clinical audit and quality improvement needs to be built into the facility-based training.
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1 2 Research agenda 3 4 1. The impact of master training in maternal resuscitation must be evaluated based on the following: 5 Staff attitudes of their own knowledge and competencies before and after training 6 Teamwork in the institution 7 Quality assurance in the clinical unit 8 2. Evaluate the impact of training on the quality of care by the monitoring, over time, of adverse 9 events at the institution 10 3. Evaluate the impact of ongoing training on clinical decision-making at the institution 11 4. Evaluation of the fire drill as a teaching and learning tool 12 13 14 15 2 Q 3 References 16 Q Q4 Q5 17 [1] National Committee for Confidential Enquiry into Maternal Deaths. Saving Mothers 2011e2013, Sixth report on the Q6 18 Confidential Enquiries into Maternal Deaths in South Africa. Pretoria: South African Department of Health; 2015. [2] Ross A, Reid S. 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[24] Farina Z, Rout C. ‘But it's just a spinal’: combating increasing rates of maternal death related to spinal anaesthesia: forumclinical practice. South African Medical Journal 2013;103(2):81e2. [25] Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009;360(5):491e9. [26] Hoek TLV, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl. 3): S829e61. € Souza JP. Maternal near-miss audits to improve quality of care. BJOG: An International Journal of Obstetrics and [27] Tunçalp O, Gynaecology 2014;121(Suppl. 4):102e4.
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Maternal collapse: Training in resuscitation
Q7
Mergan Naidoo, MBChB, MFamMed, FCFP, MSc (Sports Med), Dip HIV Management, DipPEC, PhD, Head Clinical Unit and Lecturer Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Keywords: maternal collapse resuscitation training simulation training
The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) of South Africa has recommended in the Sixth Saving Mothers Report that health-care professionals (HCPs) training in managing obstetric emergencies be improved. One such measure is to ensure that the Essential Steps in Managing Obstetric Emergencies (ESMOE) with its Emergency Obstetric Simulation Training (EOST) be rolled out to every HCP working in the obstetric environment. The programme has been strengthened and rolled out in the province of KwaZulu-Natal, South Africa. This review focuses on the various teaching methods used to improve maternal resuscitation training in a South African context. Evidence-based interventions in maternal resuscitation will be highlighted, and recommendations for clinical practice will be suggested. Common causes of maternal collapse will be explored, and measures to improve training in these areas will be outlined. In order to ensure sustainability, quality improvement measures need to be introduced and evaluated. © 2015 Published by Elsevier Ltd.
Introduction Q1
The Sixth Saving Mothers Report for South Africa spanning the period between 2011 and 2013 placed the institutional maternal mortality ratio (iMMR) for South Africa at 154.06 deaths per 100,000
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001 1521-6934/© 2015 Published by Elsevier Ltd.
Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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live births [1]. Although a 12.6% decrease in the iMMR was noted from the previous report, of concern was the large number of avoidable deaths. Lack of appropriately trained doctors and nurses contributed significantly towards maternal deaths accounting for 15.8% and 8.8% of maternal deaths, respectively. The main causes of maternal deaths in South Africa have still remained the same for the last evaluated triennium with non-pregnancy-related infections, mainly acquired immune deficiency syndrome (AIDS) (37.71%), obstetric haemorrhage (15.79%), hypertensive disorders of pregnancy (14.77%), medical and surgical disorders (11.38%) and pregnancy-related sepsis (5.22%) making up the top five causes of death [1]. Health-care professional (HCP) training and a commitment to quality were identified as two of the 10 priority recommendations [1]. The need to train all HCPs in the Essential Steps in Managing Obstetric Emergencies (ESMOE) using Emergency Obstetric Simulation Training (EOST) as the means of delivery is included in these recommendations. A commitment to quality included clinical governance and the need to have regular EOSTs or fire drills at the workplace as well as ensuring that managers appropriately assess and accredit HCPs to ensure that they have the requisite competencies [1]. The training of HCPs is a major challenge in South Africa, which is beset with problems of high attrition rates of staff in the public health sector due to unfavourable working conditions [2,3]. Despite initiatives to roll out the ESMOE training programmes to all institutions through a structured ‘master trainer’ initiatives, the high attrition rates of HCPs place an additional burden on institutions providing the training. For training to be effective, sustainability at an institutional level needs to be maintained preferably with a local champion who can ensure that training is ongoing and relevant. Simulationbased training such as EOST can be effectively implemented in rural- and resource-constrained settings in South Africa as evidence exists that it does improve HCP competencies [4]. Training in maternal resuscitation Maternal collapse can be used to define a range of medical events varying from a simple faint to cardiac arrest [5]. For the aim of this review, only collapse resulting in life-threatening events will be discussed. The adage coined from Dr. Thomas Petty: “... the best treatment of status asthmaticus is to treat it three days before it occurs,” can easily be applied to maternal collapse [6]. There may be early signal signs and symptoms that a woman has a potentially life-threatening illness, which is often ignored or treated nonchalantly. Vignette: A 36-year-old patient presented to the antenatal clinic on multiple occasions during her third pregnancy with dyspnoea. She was treated by various midwives and doctors for various conditions, which included bronchitis and ‘panic attacks’. After the birth of her third child, she elected to have a tubal ligation that was done under spinal anaesthesia. During the procedure, she developed distress from severe pulmonary oedema. She required intubation and subsequent transfer to an intensive care unit (ICU). It was later discovered that this patient had severe mitral stenosis. She died in the ICU many days later. The early recognition and investigation of her symptoms that suggested severe underlying cardiac disease may have prevented this death. The key learning point from this case is that doctors working in obstetrics and anaesthetics need to have good baseline clinical competencies on being able to recognize and manage/refer high-risk pregnancies. The ESMOE course has the following modules: maternal resuscitation and the unconscious patient, resuscitation of the newborn, sepsis and miscarriage, eclampsia and severe pre-eclampsia, haemorrhage, obstetric emergencies (breech and twin delivery), obstetric emergencies (shoulder dystocia and cord prolapse), assisted delivery, human immunodeficiency virus (HIV), surgical skills, intrapartum care and interpreting the cardiotocograph [7]. Participants undergoing this course, which includes undergraduate students, midwives, paramedics, interns, medical officers, registrars and specialists, are first given short lectures. Factual knowledge provided through PowerPoint presentation is reinforced when this knowledge is applied in the EOST, which speaks to ‘shows how’ in Millers framework for clinical assessment [8]. Participants are encouraged to work as a team, which may comprise doctors and nurses or nurses only to better simulate the true work environment. Reflection and feedback from the participants as well as from the observers and finally the facilitator input reinforce understanding and application. The group then does the simulation again, and they invariably tend to improve their performance quite significantly. It is anticipated that EOST if done regularly in the clinical unit will also strengthen teamwork and interdisciplinary collaboration [9]. Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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Maternal collapse, usually identified by a loss of consciousness, results in the activation of the emergency response system in the clinical unit. It is therefore important that all nursing and medical personnel are adequately trained in providing basic life support (BLS) [5]. Nursing personnel are usually the first respondents, so training in BLS including early defibrillation using an automated external defibrillator (AED) is critical for all nursing personnel [10]. One local hospital has implemented a performance management system for all nurses, which requires them to have an updated BLS certificate in order to qualify for an annual pay progression. Maternal resuscitation requires that the first respondent to a cardiac arrest activates the emergency response system, documents time of the collapse, places the patient supine and begins chest compressions according to the BLS algorithm [11]. When the team arrives with the resuscitation equipment, certain interventions are standard as per Advanced Cardiac Life Support (ACLS) algorithms. These include the following: i. ii. iii. iv.
Prevent delays in defibrillation Give ACLS drugs and doses as per normal ACLS protocols Ventilate with 100% oxygen Ideally, one should use continuous capnography for the confirmation of tube placement and ongoing monitoring, but this is not always available in South African settings v. Monitor the quality of cardiopulmonary resuscitation (CPR) vi. Provide postcardiac arrest care as appropriate [11]
Maternal resuscitation is taught by first making participants aware of the differences between resuscitating an adult patient and an adult pregnant or postpartum patient. The physiological differences are highlighted. The important changes that are specific to pregnancy especially when a woman is >20 weeks pregnant include the following: i. Ensuring at least 15 of lateral tilt of the pelvis or manual displacement of the uterus. Manual displacement is thought to have less of an effect on the quality of chest compressions [11e14]. ii. Perimortem hysterotomy or caesarean delivery (CD) needs to be considered at the onset of cardiac arrest, implemented within 4 min of starting resuscitation and completed within 5 min of cardiac arrest [11e14]. iii. Early intubation to prevent aspiration with a smaller endotracheal tube [11,12,14]. iv. Woman in the third trimester should have chest compressions performed 2e3 cm above the inter-nipple line [11]. In addition, the following are important practice points: i. Start intravenous (IV) lines above the diaphragm. ii. Assess for hypovolaemia and give fluid boluses when required. iii. If the woman has been receiving magnesium sulphate, stop this infusion and give IV calcium chloride/gluconate. iv. Continue with all maternal resuscitative efforts during and after hysterotomy/CD [11]. Training in the maternal resuscitation module is then reinforced with skill sessions dealing specifically with airway management, which teaches candidates how to appropriately administer different concentrations of oxygen using various oxygen delivery devices, performing endotracheal intubation, using the laryngeal mask airway when a difficult airway is encountered and performing a surgical cricothyroidotomy when there is an obstructed airway. BLS skills are taught, and emphasis is placed on the quality of chest compressions, ventilating using a bagevalve mask and performing defibrillation using an AED or a defibrillator. Finally, participants are asked to work in a team performing a resuscitation of a patient with cardiac arrest as well as an unconscious patient with a pulse. A fire-drill scoring sheet is used, which includes a clinical score and a drill execution score. The drill execution score consists of activation of the emergency response system, communication skills, teamwork, Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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documentation and the sequence in which the drill is performed. Reflection, feedback and re-practice are then performed. Designation of team members, which include a team leader, a scribe who also keeps the time, a person who performs chest compression, a person who performs ventilation, a person who is responsible for the monitors and who also performs the defibrillation and finally a person who sets up the IV lines, does the necessary investigations and administers the IV drugs, and also helps with role definition in the simulation [11]. Communication among team members is facilitated using the ‘checkerecheck’ when interventions are suggested and confirmed [11]. The team is also encouraged to identify the causes of cardiac arrest in the scenarios being painted, and to also define pathways for definitive management. Causes of maternal collapse Soar et al. [12] identified the following causes of cardiac arrest, which is covered in the ESMOE training, and it comprises the top five causes of maternal death accounting for 86.2% of all maternal deaths in South Africa [1]. These are as follows: i. ii. iii. iv.
Sepsis Obstetric haemorrhage, which includes a ruptured ectopic pregnancy Hypertensive disorders of pregnancy Cardiac disease in pregnancy
Other causes of maternal collapse include problems related to psychiatric disorders, amniotic fluid embolism and pulmonary embolism [5,12]. Anaesthetic complications, although not common, have devastating consequences when they occur [1]. In excess of 90% of these anaesthetic deaths occurring in district hospitals in South Africa are avoidable [1]. Simulation-based training has been demonstrated to improve performance and patient outcomes [14e16]. In addition, experience with undergraduates has demonstrated that students obtain much higher marks in the ESMOE skill stations compared with other skill stations in the summative assessments at the end of the clinical block. This may be due to the simulation-based training that these undergraduate students are exposed to. 1. Sepsis Non-pregnancy related sepsis and sepsis accounted for the majority of maternal deaths in South Africa [1]. The sepsis module is based on recommendations from the surviving sepsis campaign [17]. The initial identification of a woman who has SIRS (systemic inflammatory response syndrome), sepsis, severe sepsis or septic shock using a systematic clinical approach is taught in this module. The simulated patient is assessed using an organ system evaluation comprising the ‘Big 5’ namely the central nervous, cardiovascular, respiratory, gastrointestinal (including the liver) and the renal systems; the ‘forgotten 4’, which includes the immunological, endocrine, musculoskeletal and haematological systems; and finally the ‘core’, which is the obstetric examination. Each system is evaluated to see if the sepsis originates from the system and if there is an organ system dysfunction. Emphasis is placed on clinical evaluation followed by focused investigations. The team then decides on a management plan that includes the ability to administer inotropic support in patients with septic shock [17]. Providing a simple algorithm helps nurses to systematically manage their ‘ill-simulated patient’. Practically, applying case vignettes such as a patient with a septic miscarriage who presents to a primary health-care clinic with signs of severe sepsis allows participants to use their clinical skills more effectively by following an algorithmic approach to the management of sepsis, which may take into account inotropic support whilst awaiting transfer to a referral centre. Emphasis on early goal-directed management [17] is reinforced, which includes the following: i. Administration of appropriate IV antibiotics within 1 h ii. Obtaining relevant specimen cultures iii. Maintaining a systolic blood pressure of >100 mmHg Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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iv. v. vi. vii.
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Maintaining a central venous pressure of between 8 and 12 cm of water when appropriate Maintaining an appropriate oxygen saturation Ensuring that the haemoglobin is optimized Maintaining and monitoring urine output
One of the fire drills involves managing a woman who needs stabilization and referral for surgical intervention because there have been avoidable cases of maternal deaths resulting from late referral to regional or tertiary hospitals [1,18]. Because of the large amount of deaths due to HIV, a separate HIV module focuses on teaching HCP skills in managing an HIV-positive pregnant woman. The South African Department of Health 2015 guidelines for managing the pregnant woman and her newborn forms the basis of the module content [19]. Case scenarios are presented, and discussion on management then ensues. Fire drills are covered in the sepsis, which incorporates the HIV-positive woman who presents with sepsis. Teaching also involves dealing with serious adverse effects associated with antiretroviral treatment. 2. Obstetric haemorrhage Haemorrhage is of great concern to maternal death assessors in South Africa as the problem of obstetric haemorrhage and in particular bleeding during or after CD seems to be on a steady rise [1,18,20]. Training in the ESMOE includes the identification of a woman with haemorrhage based on the clinical signs. The module also includes interventions detailing the active management of the third stage of labour, the use of uterotonic agents, sequential management of postpartum haemorrhage and removal of a retained placenta. The two fire drills deal with ‘simulated patients’ presenting with uterine atony and management of a retained placenta. The team is allowed to practice, reflect and repractice resuscitative and procedural skills (bimanual compression, aortic compression, balloon tamponade and manual removal of the placenta). A section recently introduced deals with a safe CD, and it covers the teaching of surgical skills to control haemorrhage such as uterine artery ligation, the placement of B-Lynch sutures and using a Foley catheter as a tourniquet to control bleeding before transfer to a regional hospital [21]. Resuscitative efforts including the use of blood products early in the resuscitation are incorporated into the fire drill [22]. 3. Hypertensive disorders of pregnancy The two sections covered in this module are eclampsia and severe pre-eclampsia. Early identification of these conditions is emphasized in the training. The systematic evaluation of the patient (and fetus) described earlier is again used in the secondary survey. The emergency management includes the management of a patient with depressed level of consciousness, which includes skills dealing with the protection of the airway. Simulated patients presenting with eclampsia and pre-eclampsia are used in the fire drills, and emergency skills including the administration of magnesium sulphate are replicated. 4. Cardiac disease Medical and surgical disorders have slowly become recognized as an important cause of maternal death [1]. Although not specifically covered in ESMOE, these cases are often dealt with in maternal death enquiries at institutions. Cardiac disease in particular has gained prominence as an important cause of maternal collapse in the last decade [1]. Many of these patients were managed at district hospitals or at lower levels of care, and 51.7% of these deaths were evaluated as avoidable [1]. To prevent such adverse incidents, it is important that HCPs are able to recognize and refer potentially lifethreatening cardiac conditions to higher levels of care. Training should be targeted at undergraduate and postgraduate medical curricula with special emphasis on clinical skills, clinical reasoning, appropriate investigations and early referral [23]. Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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5. Anaesthetic complications Many obstetric anaesthetics are administered by medical officers, working in district hospitals in South Africa, who do not have any formal training in anaesthetics [24]. The misconception that a spinal anaesthetic is a safe option that can be performed by medical officers who lack skills has resulted in avoidable anaesthetic deaths [24]. In order to improve anaesthetic skills, the anaesthetic division of the ESMOE committee has developed a 1-day training programme that improves skills of medical officers working at district hospitals. Skills taught in this workshop include airway assessment, managing a ‘high’ spinal anaesthetic and dealing with bleeding during and after caesarean section (CS). An additional component added to the anaesthetic module is the introduction of the World Health Organization surgical safety checklist that may serve as a cognitive aid in ensuring that safety steps are adhered to resulting in improved maternal outcomes [25]. The aim of this module was in keeping with one of the recommendations of the Sixth Saving Mothers Report, which is to advocate for a safe CS [1]. The American Heart Association (AHA) has coined a pneumonic called BEAUCHOPS to assist with remembering the cause of cardiac arrest in pregnancy [26]. This is a useful aid and stands for the following: i. ii. iii. iv. v. vi. vii. viii. ix.
Bleeding/disseminated intravascular coagulation (DIC) Embolism: coronary/pulmonary/amniotic fluid embolism Anaesthetic complications Uterine atony Cardiac disease: myocardial infarction, aortic dissection/cardiomyopathy/valvular heart disease Hypertension/pre-eclampsia/eclampsia Other: Differential diagnosis of standard ACLS protocols Placental abruption/praevia Sepsis [26]
Maternity units are encouraged to develop checklists of commonly encountered causes in their local context, and to use these as aids during a cardiac arrest [11]. Clinical governance and quality improvement It is important to identify designated HCP at each institution that will be primarily responsible for maintaining regular fire drills in the local institution. Many of these ‘master trainers’ have attended the ESMOE training as well as the annual updates, and they have developed weekly skill sessions in their institutions. The advantage of performing fire drills in the local setting is that it allows the team to identify system issues that can be rectified before an actual emergency [11]. Skill audits of staff working in the maternity department should be performed on a regular basis to identify gaps and ensure that personal development plans are formulated for staff members. The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) of South Africa [1] has recommended in the Sixth Saving Mothers Report that a commitment to quality be implemented through the following mechanisms: i. Heads of clinical units should improve clinical governance, clinical supervision and respond appropriately to local findings ii. HCPs should make themselves available for training iii. Managers should ensure that fire drills occur regularly in their institutions iv. Managers should evaluate and accredit HCPs to ensure that they have appropriate skills [1] In addition, regular audits of maternal deaths and adverse events should be performed, and quality improvement measures should be put in place to prevent such events from occurring again [1,27]. Conclusion Emergencies are rare events by their nature, and because of this, HCPs tend to lose their technical expertise when faced with an event that they may encounter once every 2 years. In order to maintain Please cite this article in press as: Naidoo M, Maternal collapse: Training in resuscitation, Best Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.07.001
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their skills and competences, clinical heads of units need to develop a simulation training programme (using EOSTs) at their local institutions, which is carried out regularly. Reflection, feedback and evaluation should be incorporated into the fire drill so that the drill is made relevant to the local context. There are many challenges facing HCPs working in resource-constrained environments, which hinder their ability to render a high-quality level of service. Introducing regular training, which fosters teamwork and collaboration, improves communication, and it helps develop individuals in the organization. One such measure could include the introduction of ESMOE training with the EOSTs at all institutions. Rewarding HCPs who attain high levels of competence and expertise is one way of recognizing excellence. Measurable outcomes could include the number of adverse events including maternal deaths that occur in the unit. Linking performance management and pay progression to these measurable indicators may provide the necessary incentives to improve the quality of care for pregnant women and their newborn babies.
Acknowledgement of funding The author would like to acknowledge the University of KwaZulu-Natal's Medical Education Partnership Initiative (MEPI) (Grant No: 5R24TW008863) that provided funding and support for the ESMOE programme. MEPI is an NIH/PEPFAR-funded grant awarded to UKZN in 2010, which aims to develop, expand and enhance models of medical education in Sub-Saharan Africa.
Conflicts of interest The author of this publication received research funding from The University of KwaZulu-Natal's Medical Education Partnership Initiative (MEPI), Enhancing Training, Research and Education programme (Grant No: 5R24TW008863) that provided funding and support for the research (ENTREE) on the WHO surgical safety checklist for maternity care, which is described in this publication. In addition, the author received research scholarships from the Discovery Foundation for research on implementing the WHO surgical safety checklist for maternity care to improve maternal outcomes in KwaZulu-Natal. No conflicts of interest exist.
Practice points 1. Clinicians and nurse practitioners should be aware of the anatomical and physiological changes that occur in pregnant woman. 2. Awareness of the slight deviations from BLS and ACLS protocols needs to be borne in mind when performing resuscitation on pregnant woman <20 weeks, >20 weeks and in the third trimester. 3. The focus of training needs to be based on minimal didactic content and more on using simulation-based training with greater emphasis on teamwork and collaboration. 4. Reflection and feedback of behavioural, cognitive and technical skills should be integral to the simulation training (fire drills). 5. Master trainers are essential to develop capacity at an institutional level. 6. Performing fire drills in the workplace is key to ensuring that skills are maintained for rare obstetric emergencies. 7. Knowledge of the common causes of maternal collapse is essential for midwives and clinicians working in obstetrics. The application of this knowledge in fire drills of these causes is important to develop and maintain professional competencies. 8. A regular programme of clinical audit and quality improvement needs to be built into the facility-based training.
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1 2 Research agenda 3 4 1. The impact of master training in maternal resuscitation must be evaluated based on the following: 5 Staff attitudes of their own knowledge and competencies before and after training 6 Teamwork in the institution 7 Quality assurance in the clinical unit 8 2. Evaluate the impact of training on the quality of care by the monitoring, over time, of adverse 9 events at the institution 10 3. Evaluate the impact of ongoing training on clinical decision-making at the institution 11 4. Evaluation of the fire drill as a teaching and learning tool 12 13 14 15 2 Q 3 References 16 Q Q4 Q5 17 [1] National Committee for Confidential Enquiry into Maternal Deaths. Saving Mothers 2011e2013, Sixth report on the Q6 18 Confidential Enquiries into Maternal Deaths in South Africa. Pretoria: South African Department of Health; 2015. [2] Ross A, Reid S. 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