A quality improvement tool - driver diagram: a model of driver diagram to reduce primary caesarean section rates

Background: Quality improvement in health care is emerging as a science with proven, effective tools and methodologies. This article aims at presenting the importance of adopting one of the effective and simple methodologies and gives an example of a Driver Diagram in obstetrics.Methods: Usefulness of driver diagram in understanding the aim and the interventions or changes.Results: Various quality improvement tools can be used in the clinical context. Among them, driver diagram is most widely used at the start of an improvement initiative. The driver diagram in this article shows its applicability in one of the clinical aspects of obstetrics, to reduce primary caesarean section rates.Conclusions: Driver diagram is an easy and a simple tool widely used in quality improvement activities. It is essential to use at the beginning of improvement initiatives.

An unusual case of long standing vaginal foreign body removed with obstetric forceps

This is a case of retained foreign body in vagina for 10 years, a wood apple which was inserted to reduce uterine prolapse. It was retained without any symptoms for 10 years. The foreign body was removed using obstetric forceps after other methods were failed

An evaluation of the practice of active management of third stage of labour in a teaching hospital

Background: Worldwide post-partum haemorrhage (PPH) is the most common cause of maternal mortality. Atonic PPH accounts for 80% of the cases. Risk of PPH can be reduced by 60% by actively managing the third stage of labour. International Federation of Gynecology and Obstetrics (FIGO), International Confederation of Midwives (ICM) and World Health Organization (WHO) recommend routine use of active management of third stage of labour (AMTSL). The present study was done to evaluate the practices of AMTSL.Methods: 100 Case sheets of women who had vaginal delivery were randomly taken and analyzed for the data regarding the components of AMTSL. Microsoft excel was used for analysis.Results: The main component of AMTSL, Oxytocin 10 IU IM was used in 80% of the cases for prevention of PPH. Methylergometrine was used in 20% of the cases. Documentation of controlled cord traction was not present. Uterine massage was not routinely done and documented.Conclusions: WHO recommends all the components of AMTSL and uterotonic is the most significant component. Controlled cord traction should be used where trained person is available. It is necessary to train the staff and create awareness about the AMTSL. Correct documentation is essential for feedback and auditing. Methylergometrine should be used as a second line drug for the treatment of post-partum haemorrhage

Study of intrapartum fetal distress with the help of cardiotocography and its correlation with umbilical cord blood sampling

Background: Even in low risk mothers, fetal acidosis occurs as in high risk groups. Aim of fetal monitoring is to detect early response to intrauterine hypoxia and prevent irreversible neurological damage and death. Objective of this study was to correlate the intrapartum fetal distress with the help of cardiotocography CTG with umbilical cord blood sampling.Methods: A total 100 consecutive patients attending the labor ward were studied. Immediately at birth, before the baby’s first breath and before delivery of the placenta, the umbilical cord blood was collected as per the standard guidelines laid down in the standard textbooks. Fetal acidosis was assessed by umbilical cord arterial blood pH. Fetal acidosis was considered when umbilical artery pH <7.2. Cardiotocography features were used to clinically diagnose fetal distress.Results: Most of the mothers were multigravida. They belonged to the age group of 20-25 years. Only 18% had abnormal CTG. Out of 50 mothers with normal vaginal delivery, all had normal CTG. Out of 43 mothers who were delivered by LSCS, no one had normal CTG, 25 had indeterminate CTG and 18 had abnormal CTG. As CTG became abnormal, proportion of mothers with the thick meconium increased. NICU admission proportion increased as CTG changed from normal to the abnormal. There was a significant association between the abnormal CTG and the umbilical cord blood pH being acidic.Conclusions: CTG is a simple test, easy to perform and can alert obstetrician for necessary interventions in case of an abnormal CTG. It can detect fetal distress in labor thus helping to reduce neonatal morbidity by early intervention in cases of abnormal tracing

A comparative study of early postoperative feeding versus conventional feeding for patients undergoing caesarean section

Background: Early alimentation after caesarean delivery probably has limited clinical significance in terms of improved energy and protein intake. Decreasing the post-operative ileus is possible with early feeding. Objective of this study was to study efficacy of early postoperative feeding versus conventional feeding for patients undergoing caesarean section.Methods: Present study was hospital based comparative study carried out among 200 women who fulfilled the selection criteria. The cases were divided into 2 groups of 100 each by suitable random sampling technique. Group A included 100 cases who were given early feeding within 6 hours of caesarean delivery. Group B included 100 control who were given the feeding after 24 hours of caesarean delivery.Results: The mean duration of postoperative hospital stay in Group A and Group B was 4.59±0.65 and 4.81±0.81 days respectively (p <0.05). The mean time to return of bowel sounds in Group A and Group B was 2.79±1.36 and 3.55±1.49 hours respectively (p <0.01). 2(2%) cases in group A had postoperative ileus symptoms, whereas 3 (3%) cases in Group B had the same. Statistically significant difference (p <0.05) was seen in terms of vomiting 1% versus 17%, nausea 5% versus 16%, abdominal distention 2% versus 7%, diarrhea 4% versus 90% in the early feeding versus conventional feeding groups.Conclusions: It can be concluded from present study that fast return to the normal diet is possible with early feeding among women undergoing cesarean section compared to the conventional feeding among women undergoing cesarean section

A critical analysis of factors for delayed initiation of breast feeding in a district level hospital

Background: Breastfeeding is the cornerstone for child survival. Poor breastfeeding practices contribute to 20 per cent of neonatal deaths and nearly 13 per cent of deaths in children below five years. In south Asia, 40% of the babies are initiated breastfeeding within one hour despite increase in institutional deliveries, 80%.Methods: This prospective study was conducted to critically analyse the factors for delayed initiation of breast feeding. A prospective study was carried out among randomly selected postnatal mothers in the postnatal ward of a district teaching hospital. Data was collected by face to face interviews using a pre-validated structured questionnaire.Results: Above 90% of the women did not know the importance of initiating breast feeding within one hour of delivery as none of them received antenatal counselling. Baby was not given to the mother in 90% of the cases. 70% believed that colostrum is not good for the baby. 60% gave pre-lacteal feeds and 60% reported pain of surgical site or perineum as the cause for delayed initiation of breast feeding.Conclusions: UNICEF estimates that if all children receive the benefits of breastfeeding – globally, 8,23,000 child deaths can be averted every year. All health care facilities should adopt Baby Friendly Hospital Initiative’s Ten successful steps for breast feeding to initiate early breast feeding within one hour to reduce morbidity and mortality of infants and under five children

A quality improvement tool - driver diagram: a model of driver diagram to reduce primary caesarean section rates

Background: Quality improvement in health care is emerging as a science with proven, effective tools and methodologies. This article aims at presenting the importance of adopting one of the effective and simple methodologies and gives an example of a Driver Diagram in obstetrics.Methods: Usefulness of driver diagram in understanding the aim and the interventions or changes.Results: Various quality improvement tools can be used in the clinical context. Among them, driver diagram is most widely used at the start of an improvement initiative. The driver diagram in this article shows its applicability in one of the clinical aspects of obstetrics, to reduce primary caesarean section rates.Conclusions: Driver diagram is an easy and a simple tool widely used in quality improvement activities. It is essential to use at the beginning of improvement initiatives.

A comparative study of early postoperative feeding versus conventional feeding for patients undergoing caesarean section

Background: Early alimentation after caesarean delivery probably has limited clinical significance in terms of improved energy and protein intake. Decreasing the post-operative ileus is possible with early feeding. Objective of this study was to study efficacy of early postoperative feeding versus conventional feeding for patients undergoing caesarean section.Methods: Present study was hospital based comparative study carried out among 200 women who fulfilled the selection criteria. The cases were divided into 2 groups of 100 each by suitable random sampling technique. Group A included 100 cases who were given early feeding within 6 hours of caesarean delivery. Group B included 100 control who were given the feeding after 24 hours of caesarean delivery.Results: The mean duration of postoperative hospital stay in Group A and Group B was 4.59±0.65 and 4.81±0.81 days respectively (p &lt;0.05). The mean time to return of bowel sounds in Group A and Group B was 2.79±1.36 and 3.55±1.49 hours respectively (p &lt;0.01). 2(2%) cases in group A had postoperative ileus symptoms, whereas 3 (3%) cases in Group B had the same. Statistically significant difference (p &lt;0.05) was seen in terms of vomiting 1% versus 17%, nausea 5% versus 16%, abdominal distention 2% versus 7%, diarrhea 4% versus 90% in the early feeding versus conventional feeding groups.Conclusions: It can be concluded from present study that fast return to the normal diet is possible with early feeding among women undergoing cesarean section compared to the conventional feeding among women undergoing cesarean section.</jats:p

Study of intrapartum fetal distress with the help of cardiotocography and its correlation with umbilical cord blood sampling

Background: Even in low risk mothers, fetal acidosis occurs as in high risk groups. Aim of fetal monitoring is to detect early response to intrauterine hypoxia and prevent irreversible neurological damage and death. Objective of this study was to correlate the intrapartum fetal distress with the help of cardiotocography CTG with umbilical cord blood sampling.Methods: A total 100 consecutive patients attending the labor ward were studied. Immediately at birth, before the baby’s first breath and before delivery of the placenta, the umbilical cord blood was collected as per the standard guidelines laid down in the standard textbooks. Fetal acidosis was assessed by umbilical cord arterial blood pH. Fetal acidosis was considered when umbilical artery pH &lt;7.2. Cardiotocography features were used to clinically diagnose fetal distress.Results: Most of the mothers were multigravida. They belonged to the age group of 20-25 years. Only 18% had abnormal CTG. Out of 50 mothers with normal vaginal delivery, all had normal CTG. Out of 43 mothers who were delivered by LSCS, no one had normal CTG, 25 had indeterminate CTG and 18 had abnormal CTG. As CTG became abnormal, proportion of mothers with the thick meconium increased. NICU admission proportion increased as CTG changed from normal to the abnormal. There was a significant association between the abnormal CTG and the umbilical cord blood pH being acidic.Conclusions: CTG is a simple test, easy to perform and can alert obstetrician for necessary interventions in case of an abnormal CTG. It can detect fetal distress in labor thus helping to reduce neonatal morbidity by early intervention in cases of abnormal tracing.</jats:p