Bimanual Uterine Compression Research Articles

Prehospital Management of Postpartum Hemorrhage-A National, Cross-Sectional Study in Norway.

Postpartum hemorrhage (PPH) is a critical birth complication, and is stated by the World Health Organization (WHO) as among the five most frequent causes of death during pregnancy. External aortic compression (EAC) is recommended by the WHO as an intervention to achieve temporary bleeding control. An increasing number of births outside hospital underlines the importance of competence in handling potential birth complications, such as PPH. The aim of this study was to assess prehospital personnel's education, training, knowledge, and experiences regarding PPH and EAC across Norway. Prehospital personnel were invited to respond to a questionnaire through social media. Questions included those on education, training, knowledge, and experience regarding PPH and EAC. The Statistical Package for the Social Sciences (SPSS) version 28 was used to analyze the data, using descriptive statistics. Over a two-month period, 211 prehospital personnel responded to the questionnaire, of whom 55.5% were male. The respondents had an average of 10.3 years of prehospital experience. About half of the respondents had received education (48.6%) and training (62.4%) in PPH management. Still, 95.7 percent reported a need for more education and training. On knowledge questions, only half of the responses were correct (43.7% to 60.5%). Only 21 percent of the respondents had experienced patients with PPH, and of these only 3.8 percent had used EAC. Bimanual uterine compression was the most frequent intervention used (62.5%) across hospital trusts. Even if prehospital personnel receive education and training in the management of PPH and EAC, almost all report needing more. The results indicate a national variation, which may be discussed as to whether it is appropriate.

Why the Mostafa Maged maneuver is better: Mostafa Maged maneuver compared with bimanual uterine compression for postpartum hemorrhage

Why the Mostafa Maged maneuver is better: Mostafa Maged maneuver compared with bimanual uterine compression for postpartum hemorrhage

ROLE OF VARIOUS MODALITIES IN MANAGEMENT OF POSTPARTUM HAEMORRHAGE(MEDICAL+SURGICAL)

Background: PPH is responsible for 25% of all maternal deaths. In India, PPH incidence in India is 2%-4% following vaginal delivery and 6% following cesarean section. PPH as the important cause of 19.9% of maternal mortality in India. Objectives:The objectives of the study were to study the incidence, risk factors, cause,complications and management of PPH. Materials and Methods: This prospective observational study was conducted in the Department of OBGY, SVPIMSR,Ahmedabad, India. A total number of 50 cases of postpartum hemorrhage that fullled the selection criteria were included. The records were analyzed with respect to maternal Results: age, parity & etiological prole and maternal consequences in cases of PPH at our tertiary care center. Main cause of PPH in this study was uterine atony i.e. 56.38%. Second common cause was traumatic i.e. 21.27%. 20% of cases were given blood transfusions. However,maternal death due to hemorrhage in our study was negligible. Conclusions: Active management of the third stage of labor is crucial.Availability of blood and blood products is very crucial. Prediction and assessment of blood loss and timely identication of uterine atony are remaining the cornerstone for prompt and effective management of PPH. 60% cases were managed by medical methods while the rest of the cases required surgical management. Among the medical management uterotonic drugs and bimanual uterine compression was used while among the surgical methods repair of cervical and vaginal laceration was mostly required.

Post-Partum Hemorrhage in Khost Post Graduate Medical Education Hospital

The leading cause of maternal deaths in both industrialised and developing nations is Post-Partum Haemorrhage (PPH). It results from deviations in one of four fundamental processes, with uterine atony constituting the majority of cases. It's crucial to have a diverse approach to management. It is considered the importance of oxytocin and prostaglandins, such as misoprostol, in therapy. Uterine tamponade and compression sutures, two recently created, less invasive therapeutic options, are quickly emerging as viable substitutes for the conventional procedures of pelvic devascularization and hysterectomy. Public health initiatives and medical measures meant to reduce maternal mortality from PPH, which differs significantly across developing and industrialised nations, are further examined.
 Dr. Sakhi Sardar and Dr. Sherzad Gul Sharif did this prospective observational research in the department of obstetrics and gynaecology at the Khost Provincial Hospital in Afghanistan. There were a total of 80 instances of Post-Partum Haemorrhage that met the criteria for inclusion. Data were gathered and examined in PPH patients who had both medicinal and surgical treatment.
 In the current research, more than 50% of patients needed blood and blood products, and 60% of cases were multigravida. The majority of Post-Partum Haemorrhage (PPH) cases in the current research were treated medically. uterine toxins (42.5 %) Early detection and prompt intervention made this feasible.
 In every situation, active management of the third stage of labour is advised. 70% of patients were handled medically, while the remaining 30% needed surgical intervention. Uterotonic medications and bimanual uterine compression were employed in medical care, although cervical and vaginal laceration repair was mostly needed in surgical management.

Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation.

ObjectiveTo systematically develop evidence‐based bundles for care of postpartum hemorrhage (PPH).MethodsAn international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated “GRADE Evidence‐to‐Decision” framework. Twenty‐three global maternal‐health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6‐month period, the expert panel met online and via teleconferences, culminating in a 2‐day in‐person meeting.ResultsThe consultation led to the definition of two care bundles for facility implementation. The “first response to PPH bundle” comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The “response to refractory PPH bundle” comprises compressive measures (aortic or bimanual uterine compression), the non‐pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements.ConclusionFor the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a low-resource setting

BackgroundPostpartum haemorrhage (PPH) is a major cause of maternal mortality. Prevention and adequate treatment are therefore important. However, most births in low-resource settings are not attended by skilled providers, and knowledge and skills of healthcare workers that are available are low. Simulation-based training effectively improves knowledge and simulated skills, but the effectiveness of training on clinical behaviour and patient outcome is not yet fully understood. The aim of this study was to assess the effect of obstetric simulation-based training on the incidence of PPH and clinical performance of basic delivery skills and management of PPH.MethodsA prospective educational intervention study was performed in a rural referral hospital in Tanzania. Sixteen research assistants observed all births with a gestational age of more than 28 weeks from May 2011 to June 2013. In March 2012 a half-day obstetric simulation-based training in management of PPH was introduced. Observations before and after training were compared. The main outcome measures were incidence of PPH (500–1000 ml and >1000 ml), use and timing of administration of uterotonic drugs, removal of placenta by controlled cord traction, uterine massage, examination of the placenta, management of PPH (>500 ml), and maternal and neonatal mortality at 24 h.ResultsThree thousand six hundred twenty two births before and 5824 births after intervention were included. The incidence of PPH (500–1000 ml) significantly reduced from 2.1% to 1.3% after training (effect size Cohen’s d = 0.07). The proportion of women that received oxytocin (87.8%), removal of placenta by controlled cord traction (96.5%), and uterine massage after birth (93.0%) significantly increased after training (to 91.7%, 98.8%, 99.0% respectively). The proportion of women who received oxytocin as part of management of PPH increased significantly (before training 43.0%, after training 61.2%). Other skills in management of PPH improved (uterine massage, examination of birth canal, bimanual uterine compression), but these were not statistically significant.ConclusionsThe introduction of obstetric simulation-based training was associated with a 38% reduction in incidence of PPH and improved clinical performance of basic delivery skills and management of PPH.

Helping Mothers Survive Bleeding After Birth: retention of knowledge, skills, and confidence nine months after obstetric simulation-based training.

BackgroundIt is important to know the decay of knowledge, skills, and confidence over time to provide evidence-based guidance on timing of follow-up training. Studies addressing retention of simulation-based education reveal mixed results. The aim of this study was to measure the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care in order to understand the impact of training on these components.MethodsAn educational intervention study was carried out in 2012 in a rural referral hospital in Northern Tanzania. Eighty-nine healthcare workers of different cadres were trained in “Helping Mothers Survive Bleeding After Birth”, which addresses basic delivery skills including active management of third stage of labour and management of postpartum haemorrhage (PPH). Knowledge, skills, and confidence were tested before, immediately after, and nine months after training amongst 38 healthcare workers. Knowledge was tested by completing a written 26-item multiple-choice questionnaire. Skills were tested in two simulated scenarios “basic delivery” and “management of PPH”. Confidence in active management of third stage of labour, management of PPH, determination of completeness of the placenta, bimanual uterine compression, and accessing advanced care was self-assessed using a written 5-item questionnaire.ResultsMean knowledge scores increased immediately after training from 70 % to 77 %, but decreased close to pre-training levels (72 %) at nine-month follow-up (p = 0.386) (all p-levels are compared to pre-training). The mean score in basic delivery skills increased after training from 43 % to 51 %, and was 49 % after nine months (p = 0.165). Mean scores of management of PPH increased from 39 % to 51 % and were sustained at 50 % at nine months (p = 0.003). Bimanual uterine compression skills increased from 19 % before, to 43 % immediately after, to 48 % nine months after training (p = 0.000). Confidence increased immediately after training, and was largely retained at nine-month follow-up.ConclusionsTraining resulted in an immediate increase in knowledge, skills, and confidence. While knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. These findings indicate a need for continuation of training. Future research should focus on the frequency and dosage of follow-up training.

Uterine balloon tamponade in combination with topical administration of tranexamic Acid for management of postpartum hemorrhage.

While uterine balloon tamponade is an effective modality for control of postpartum hemorrhage, the reported success rates have ranged from the level of 60% to the level of 80%. In unsuccessful cases, more invasive interventions are needed, including hysterectomy as a last resort. We developed a modified tamponade method and applied it to two cases of refractory postpartum hemorrhage after vaginal delivery. The first case was accompanied by uterine myoma and low-lying placenta. After an induced delivery, the patient had excessive hemorrhage due to uterine atony. Despite oxytocin infusion and bimanual uterine compression, the total blood loss was estimated at 2,800 mL or more. The second case was diagnosed as placental abruption complicated by fetal death and severe disseminated intravascular coagulation, subsequently. A profuse hemorrhage continued despite administration of uterotonics, fluid, and blood transfusion. The total blood loss was more than 5,000 mL. In each case, an intrauterine balloon catheter was wrapped in gauze impregnated with tranexamic acid, inserted into the uterus, and inflated sufficiently with sterile water. In this way, mechanical compression by a balloon and a topical antifibrinolytic agent were combined together. This method brought complete hemostasis and no further treatments were needed. Both the women left hospital in stable condition.

Helping mothers survive bleeding after birth: an evaluation of simulation‐based training in a low‐resource setting

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting. Educational intervention study. Rural referral hospital in Northern Tanzania. Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care. In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression. Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training. Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage). The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.

Two‐Provider Technique for Bimanual Uterine Compression to Control Postpartum Hemorrhage

Bimanual uterine compression may provide a reasonable treatment option for controlling or arresting postpartum hemorrhage in areas where access to care and advanced medical interventions are limited. Preliminary evidence suggests that correctly performed bimanual uterine compression is unsustainable for more than a few minutes, despite empirical evidence and practice recommendations that support extended compression for optimal effect. The objective of this study was to examine the impact of team-based (pairs) bimanual uterine compression for managing postpartum hemorrhage from uterine atony. Obstetricians, nurse-midwives, midwifery students, and unskilled birth attendants (N = 30) in Ghana performed bimanual uterine compression using a simulator with objective performance feedback (6 lights) corresponding to pressure sensors on the uterus. For each participant, we tracked the degree and duration of maintained uterine compression. Birth attendants were then paired (15 pairs) and were similarly assessed performing the technique as a team, with 1 attendant providing external compression to the uterine fundus using 2 hands and the other providing internal pressure against the body of the uterus with a single hand. Individuals were unable to fully compress the uterus and maintain compression for more than 150 seconds without fatiguing. All paired teams were able to fully compress the uterus and maintain the compression for the maximum allotted time of 5 minutes. Results suggest that bimanual uterine compression is more effective when performed by a team, with a primary attendant maintaining internal lower uterine segment pressure and monitoring the patient's condition and a partner applying external pressure to the uterine fundus. For cases where access to advanced medical care is limited or delayed, team-applied bimanual uterine compression could enhance the ability to control or arrest postpartum hemorrhage and increase the likelihood of maternal survival.

Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid

Background Maternal mortality from postpartum hemorrhage remains high globally, in large part because women give birth in rural communities where unskilled (traditional birth attendants) provide care for delivering mothers. Traditional attendants are neither trained nor equipped to recognize or manage postpartum hemorrhage as a life-threatening emergent condition. Recommended treatment includes using uterotonic agents and physical manipulation to aid uterine contraction. In resource-limited areas where Obstetric first aid may be the only care option, physical methods such as bimanual uterine compression are easily taught, highly practical and if performed correctly, highly effective. A simulator with objective performance feedback was designed to teach skilled and unskilled birth attendants to perform the technique. Objectives To evaluate the impact of simulation-based training on the ability of birth attendants to correctly perform bimanual compression in response to postpartum hemorrhage from uterine atony. Methods Simulation-based training was conducted for skilled ( N = 111) and unskilled birth attendants ( N = 14) at two regional (Kumasi, Tamale) and two district (Savelugu, Sene) medical centers in Ghana. Training was evaluated using Kirkpatrick's 4-level model. Results All participants significantly increased their bimanual uterine compression skills after training ( p = 0.000). There were no significant differences between 2-week delayed post-test performances indicating retention ( p = 0.52). Applied behavioral and clinical outcomes were reported for 9 months from a subset of birth attendants in Sene District: 425 births, 13 postpartum hemorrhages were reported without concomitant maternal mortality. Conclusions The results of this study suggest that simulation-based training for skilled and unskilled birth attendants to perform bi-manual uterine compression as postpartum hemorrhage Obstetric first aid leads to improved applied procedural skills. Results from a smaller subset of the sample suggest that these skills could potentially lead to improved clinical outcomes and additional study is merited.

Using cell phones to collect postpartum hemorrhage outcome data in rural Ghana

Objective To evaluate the use of cell phones by professional and traditional birth attendants in rural Africa for reporting postpartum hemorrhage (PPH) data. Methods Ten birth attendants from the remote Sene District of Ghana participated in the study. Subjects were trained to send Short Message Service text messages from cell phones using a simple numeric protocol to report data regarding PPH: maternal age; PPH; use of bimanual uterine compression; maternal and neonatal mortality; and prenatal care. Participants sent texts to a pre-programmed number to report data for all births they attended over a 90-day period. Results In total, 425 births and 13 (3.1%) cases of PPH were reported during the 90-day period after training. All attendants followed the reporting protocol correctly, although with uncertain data integrity. Conclusion The results indicate that it is possible to train professional and traditional birth attendants to use cell phones to report health-related outcome data via a specified protocol. Reporting from rural-based providers may present a more accurate picture of what occurs in remote communities because it happens in real time. These findings could be exportable to other program evaluation or population-monitoring applications (healthcare and other) where rural outcome tracking is necessary.

Skilled Birth Attendant Competence and Facility Readiness For Managing Obstetric Emergencies in Eritrea

Introduction: Skilled Care Attendance during pregnancy and child birth is crucial for the reduction of maternal and neonatal mortality. Various studies have demonstrated the correlation between increase in skilled care attendance and reduction of maternal mortality globally. Objective: The objective of the study was to asses the impact of life saving skills training in the improvement of knowledge and skills of health workers and the quality of health services provided to mothers and newborns. Methodology: The study was a cross sectional study on 137 Life Saving Skills trained health workers randomly selected out of the total trained staff. The competence study measured knowledge with a 50-question knowledge test that covered the topics of (1) aseptic technique, (2) uncomplicated labor and delivery, (3) immediate newborn care, (4) postpartum hemorrhage, (5) sepsis and (6) pre-eclampsia, and eclampsia. Observation of competency of health workers was used to assess the competency of health workers. Results: The competency test scores appear that nurses and associate nurses are retaining their level of knowledge fairly well. Aseptic technique had the highest average score of any of competency tests. The assessment results showed that most nurses and associate nurses can perform the active management of labor skill relatively well, with an average score of 73% among those assessed. Five zones had average scores above 75%, which indicates the performance is consistently high in most areas. The average score for Manual Removal of placenta was quite high in most zones, with an average score of 66%. Four of the six zones received scores above 70%. The average score for bimanual uterine compression (58%) was slightly lower than the other skills tests related to the prevention and/or treatment of postpartum hemorrhage. After completing LSS training, the providers are expected to be able to recognize the signs and symptoms of an infant who is having difficulty breathing and they should be able to complete the five basic steps of immediate newborn care: DRY, WARM, POSITION, SUCTION (if necessary), and STIMULATE. The scores for the skills of nurses and associate nurses in the five steps identified is an average score of 65%. The study was designed to assess the impact of life saving skills training in the improvement of knowledge and skills of health workers and quality of health services provided to mothers and newborns and represents the first comprehensive assessment of the knowledge and skills of nurses and associate nurses in emergency obstetric care.

Active management of third stage of labour: a survey of providers’ knowledge in southwest Nigeria

The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers' knowledge on the subject. To assess the level and determinant(s) of accurate knowledge of obstetric providers regarding AMTSL. Questionnaire-based survey of 361 labour and delivery professionals in public tertiary obstetric centres in southwest Nigeria. Female nurses at different cadres accounted for most of the respondents. Majority (90.6%) of the respondents reported being aware of AMTSL as an obstetric intervention and 49.7% were aware of FIGO/ICM recommendation on AMTSL. Out of 13 potential third stage interventions, 102 respondents (28.3%) correctly and exclusively identified the components of AMTSL as defined by FIGO/ICM. Many procedures reserved for treatment of complicated third stage of labour such as manual placental removal (37.7%), blood transfusion (20.2%), bimanual uterine compression (24.7%) and uterine artery ligation (13.9%) were also selected as AMTSL components. Multivariate logistic regression analysis indicated that being in administrative position (adjusted OR: 2.68; CI 1.19-6.02) and frequent compared to rare or no consultation of books, journal and internet sources for information (adjusted OR: 2.58; CI 1.21-5.52) increased the odds of having accurate knowledge of AMTSL while being a nurse/midwife (adjusted OR: 0.15; CI 0.05-0.39), matron (adjusted OR: 0.25; CI 0.08-0.79) or intern (adjusted OR: 0.07; CI 0.01-0.29) compared to postgraduate resident doctors reduced the odds of having accurate knowledge of AMTSL. AMTSL was a familiar but poorly understood intervention among obstetric care providers in this region. Improvement in healthcare quality and practitioners' adherence to recommended guidelines on AMTSL urgently requires educational interventions that target those who provide routine delivery care and organisation of the health care delivery system in such a way that enables providers to act on acquired knowledge.

Early Postpartum Hemorrhage After Induction of Labor

M.M., a 25‐year‐old Hispanic primigravida at 41 weeks and 6 days gestation, presented to the labor and delivery unit for postdates induction of labor, accompanied by the father of the baby. She reported normal fetal movement and denied any loss of fluid or vaginal bleeding. Her prenatal course was uncomplicated. The fetal heart rate was reassuring. Occasional contractions were recorded by the tocometer, but not felt by M.M. A pelvic exam found her cervix to be 1 cm dilated, 80% effaced, soft and posterior, with the vertex at −2 station with membranes intact. Based on a Bishop score of 7, the decision was made to proceed with induction of labor with intravenous oxytocin per hospital protocol of 1 mU every 15 minutes to a maximum of 5 contractions in 10 minutes lasting no more than 60 to 90 seconds or a maximum dose of 20 mU/min. Three hours after oxytocin was initiated, M.M.'s cervical exam was 2 cm dilated, 80% effaced, with the vertex at −2 station. The fetal heart rate baseline was 135 beats per minute with moderate variability and no decelerations. Six hours after admission, M.M. requested pain relief. Her cervical exam was 4 cm dilated, 90% effaced, with the vertex at −1 station. The oxytocin was infusing at 16 mU/min and the fetal heart rate was reassuring. Pain management options were discussed with the client and, after being counseled on the risks and benefits, she opted for epidural anesthesia.Eight hours after admission, M.M.'s uterine contractions became difficult to detect with the external tocometer. At examination, her cervix was found to be 7 cm dilated, 100% effaced, with the vertex at 0 station. The oxytocin was infusing at 20 mU/min. The midwife counseled the client on the need to monitor uterine contractions when receiving oxytocin and the decision was made to rupture M.M's bag of waters and place an intrauterine pressure catheter. M.M.'s membranes were ruptured and it was noted that she had a moderate amount of clear amniotic fluid. The intrauterine pressure catheter was placed without complications and recorded adequate uterine contractions of 230 MvU.Eleven hours after admission, M.M. reported rectal pressure and a desire to push. Her cervix was examined and found to be fully dilated with the vertex at +2 station, and again the fetal heart rate was reassuring. Pushing efforts were commenced.One and a half hours later—12 and half hours after the initiation of induction—M.M. gave birth to a vigorous baby girl weighing 3000 g, with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. The oxytocin infusion was discontinued immediately after delivery. Twenty‐five minutes later, the placenta was expelled spontaneously and appeared intact. An infusion of 20 units of oxytocin in 1000 cc of lactated ringers was given intravenously at 125 ml/hr.Fundal massage was started immediately after delivery of the placenta, because the uterine fundus was found to be boggy, and vaginal bleeding continued to increase. Bimanual uterine compression was added to control the hypotonic uterine bleeding. The urinary bladder was catheterized, producing 100 ml of urine. Ten units of oxytocin were administered intramuscularly in the thigh, again with poor response. Methylergonovine maleate 0.2 mg was then given intramuscularly. The obstetrician on call was notified of the client's uncontrolled immediate postpartum hemorrhage related to atony. Four minutes after Methergine administration, the fundus was firm and bleeding minimal. Twelve hours after delivery, M.M.'s hemoglobin (Hgb) and hematocrit (Hct) were noted to have decreased 23% from her levels at admission. Her Hgb was 7.8 g/dL, and she had an Hct of 23.9%. Her vital signs remained stable throughout, urine output satisfactory, and the client was able to tolerate walking without assistance.

Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward

Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%. There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

An unsuspected case of placenta accreta

Case report A 29-year-old school-teacher presented in her second pregnancy at term + 6 in spontaneous labour, with an undiagnosed breech presentation. A detailed ultrasound at 20 weeks had shown the placenta to be fundal. She had had an uneventful antenatal period. Her previous pregnancy had been uncomplicated and ended in a forceps delivery at term. Subsequently she developed postpartum endometritis, which was treated by antibiotics. She had wellcontrolled asthma and was a non-smoker. Vaginal examination revealed that the cervical os was 8 cm dilated. After discussing the mode of delivery she opted for caesarean section, which was performed under spinal anaesthesia. The placenta was removed manually but was apparently complete. The estimated blood loss was 800 ml. Intraoperatively, a slight tear of right uterine angle was noted and was sutured. A drain was left intra-abdominally and syntocinon infusion of 40 units in 500 ml of normal saline was administered. Two hours postoperatively she started bleeding vaginally. On examination abdomen was soft, nondistended and the drain contained only 30 ml of serous blood. Initial management included intravenous oxytocin; bimanual uterine compression and intramuscular prostaglandin F2 alpha (carboprost) did not arrest the bleeding. She was taken back to theatre for laparotomy. There was no intra-abdominal bleeding. The uterus was reopened. No obvious source of bleeding was identified; therefore all uterine and abdominal layers were closed again. The vaginal bleeding ceased, but soon after laparotomy she then started bleeding intra-abdominally due probably to disseminated intravascular coagulation (DIC), and finally a subtotal hysterectomy was performed. The estimated blood loss was approximately 6 l. In total she received 15 units of blood, 12 units of FFP, 9 units of cryoprecipitate and 2 units of platelets. Her postoperative care was managed jointly in the intensive care unit, and the high-dependency area of the labour ward, by the anaesthetist, haematologist and obstetrician. She made a good recovery. Pathological examination showed a uterus weighing 628 g and measuring 15 6 9 6 6 cm. The endometrial cavity contained blood and the endometrial lining was ragged. There was no residual placental tissue identified and there were no leiomyomata or other abnormalities seen. Random blocks were sampled from around the uterine cavity and in the blocks from the fundus two foci of residual chorionic villi were identified, the largest 6 mm across. These chorionic villi were lying in close proximity to the myometrium with some large veins and there was a cytotrophoblastic reaction nearby. There was minimal decidual change in this area, although elsewhere decidua up to 2 mm thick was present. The changes were considered consistent with placenta accreta (Figure 1).

B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section.

Primary atonic post-partum hemorrhage during lower segment cesarean section, which was not controlled by ecbolics--oxytocin, methylergometrine, 15-methyl-prostaglandinF2alpha--was managed by applying a B-Lynch Brace Suture. The test of potential efficacy was the control of hemorrhage by bimanual uterine compression. Six primigravida patients at their term gestation, who underwent emergency cesarean section, all except one under spinal anesthesia, received this type of suture. Interestingly, in every case hemorrhage was controlled successfully with the compression suture. None of them received blood or blood products transfusions or developed disseminated intravascular coagulopathy. Postoperative recovery was good and all patients are in follow-up to assess their future reproductive activity. B-Lynch Brace Suturing is an invaluable procedure for the control of atonic primary post-partum hemorrhage following cesarean delivery.

Two models of in-service training to improve midwifery skills: how well do they work?

This program evaluation compared the knowledge, confidence, and skills of Indonesian village midwives who attended an intensive in-service training with midwives who received an internship program and midwives who attended no program. The five key skills compared were prevention of infection, use of the partograph, manual removal of placenta, bimanual uterine compression, and neonatal resuscitation. Midwives from the intensive in-service that combined competency-based skill training with peer review and continuing education scored higher on the knowledge test and demonstration of the five key skills and reported managing complications better than midwives who attended no training program. Midwives from the internship program scored intermediate between the intensively trained and the untrained midwives. Overall, skill scores were 71% for midwives in the intensive program, 62% for the interns, and 51% for midwives with no in-service training. Village midwives from the intensive program scored significantly higher in the practical demonstration of manual removal of placenta, bimanual compression, and neonatal resuscitation than the interns, but the scores on infection prevention and use of the partograph were not different between the two groups. Differences in the volume of training opportunities between the two programs could be responsible for the different outcomes.

Cardiovascular Collapse Following an Overdose of Prostaglandin F2 Alpha

A case report is presented of a parturient who suffered severe hypotension and pulmonary oedema following an overdose of intramyometrial prostaglandin F2 alpha. Oxytocin induction of labour in this patient led to a rapid delivery, followed by a hypotonic uterus and postpartum haemorrhage. After resuscitation with blood and crystalloid fluids, the uterus was explored under general anaesthesia. The uterus was free of retained products but the lower uterine segment failed to contract despite bimanual uterine compression and intravenous oxytocin. Prostaglandin F2 alpha was injected into the lower uterine segment via a transvaginal approach. This was rapidly followed by cardiovascular collapse and later by pulmonary oedema. The differential diagnosis and subsequent management are discussed.