Care of critically ill mothers at KNH - Gaps and Opportunities. Zahida Qureshi John Ongech 7 th February 2014

Political will Maternal healthcare is a primary concern for the Jubilee Government. President Uhuru Kenyatta decreed free maternal healthcare for all women in Kenya. Courtesy of President Kenyatta’s policy, we shall strive to provide an environment where every pregnancy is wanted, every childbirth is safe, and every young person’s potential is fulfilled.

In order to improve maternal and child health outcomes in the country, the First Lady of Kenya, Margaret Kenyatta launched the ‘Beyond Zero Campaign’ on 24 January in Kenya’s capital Nairobi. “I am deeply saddened by the fact that women and children in our country die from causes that can be avoided. It doesn’t have to be this way,” said Ms Kenyatta. “This is why I am launching the ‘Beyond Zero Campaign’ which will bring prenatal and postnatal medical treatment to women and children in our country.” The ‘Beyond Zero campaign’ is part of the initiatives outlined in the Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya that was unveiled on World AIDS Day 2013.The campaign aims to raise funds to help improve maternal and child health care in the country.

Deliveries July2012- June 2013 Mode of Delivery2012/2013 Normal Delivery6097 C/S4059 Vacuum21 Breech70 BBA196 Total10443

Labour ward Admissions July12-June 2013

REPRODUCTIVE HEALTH MONTHLY REPORT DEC 2013 ADMISSIONS Pts booked (ANC 18) 470 Pts not booked 1049 Total 1519 MVA ward 1D 91 Ward 1C SVD Caeserean section Breech 2 0 Vacuum 3 0 BBA 21 0 Still Births 64 5 Post c/section sepsis 10 Average Decision-Theatre time No. of pts 392 Average(Hrs) 4.6

MATERNAL MORTALITY TREND (JULY 2012 – JUNE 2013= 119)

WARDAGEREFERAL FACILITY DIAGNOSIS 11A38MARAGUA DHRENAL FAILURE, SEVERE ANAEMIA, PEUP SEPSIS 21D20-PEUP SESIS/HEPATIC ENCEPHALOPATHY 31D32KAJIADO DHAKI/ECLAMPSIA 41D27MAKUENI DHPEUP. SEPSIS 5LW30MURANGA DHPPH 6LW29-CHORIOAMNIONITIS 7LW24THIKA DHSEPSIS 8A/E30-SHOCK/INCOMPLETE ABORTION 9A/E22-POSTARBORTAL SEPSIS 10A/E35MAMA LUCY KIBAKI HOSP PPH/RUPTURED UTERUS 11ICU35PCEA KIKUYUPPH/POOR REVERSAL 12ICU25-SEVERE PET/SEPSIS 13RENAL36-AKI/PET/SEPSIS

Multicountry survey in 20 hospitals in Kenya 2012 HospitalDeliveriesNear missDeath Nairobi Kenyatta* Pumwani Maternity* Mater44900 Aga Khan University74870 M P Shah14600 Nairobi60710 Central Nyeri Provincial General Karatina District81601 Kerugoya District Thika District * Kiambu District* Gatundu District94911 Consolata Mathari29500 Rift Valley Rift Valley Provincial General* Moi Teaching & Referral* Naivasha District Kabarnet District49212 Kitale District Iten District43910 Tenwek Mission86184 Total

05_XXX_MM10 WHO Maternal Near Miss identification criteria

Critically sick mothers Haemorrhage Hypertensive disease Medical conditions Infectious disease Obstructed labour Abortion complications Sepsis – Acute kidney failure – Anemia

Obstetrical conditions requiring critical care Oct-Dec 2013 ConditionsNo. of patients Eclampsia31 Postpartum haemorrhage65 Ruptured uterus3 Postarbrotal sepsis3 Total102

Variable scored % of time documented reported Cervical dilatation 56 Contractions 59 *Fetal heart rate 50 *Maternal blood pressure46 *Fetal head descent 49 *Maternal pulse rate 42 *Liqour 34 *Degree of moulding 27 *Maternal temperature 17 *Maternal respiratory rate 30 *Done in ≤ 50% of the time Table 5: Adequacy of partograph completion Variable scored at least one observation recorded

Variable scored % of time documented reported Blood pressure charting 60 Pulse rate charting52 Catheter 88 Input-output chart 64 *Respiratory rate charting 44 * Done in ≤ 50% of the time Level of care in patients with obstetric haemorrhage

Variable scored % of time documented reported Blood pressure charting 92 Pulse rate charting88 Fetal surveillance 84 Loading dose-Magnesium sulphate 60 Maintenance dose-Magnesium sulphate 72 Input-output chart 96 Full blood count 80 U/E/C 68 LFT 56 *Tendon reflexes 12 *Done in ≤ 50% of the time Level of care in patients with severe pre-eclampsia and eclampsia

Normal Labour N= 29 n(%) Obstetric hemorrhage N=25 n(%) PET/ Eclampsia N= 25 n(%) Emergency Cesarean N=59 n(%) Fetal Alive 28(97)20(80)15(60)49(83) Fresh stillbirth 03(12)4(16)6(10) Macerated stillbirth 2(6.9)2(8)5(20)3(5) Immediate complications 1(3.4)6(24)11(44)16(27) *Immediate complications include: prematurity, asphyxia, RDS, congenital malformations, death Maternal Mode of delivery Normal delivery 22(76)8(32)9(36)0 Cesarean section 6(21)17(68)16(64)59(100) *Complications 05(20) 9(15) * Complications include: admitted to ICU, dialysis, coma, convulsions, death, resuscitation Outcome by diagnosis

Posterior Tear

Decapitated Head

KNH/UON sits at the apex of the pyramid of the KEPH levels. This is the ultimate referral Centre. Referral system Infrastructure Human resource Multidisciplinary management Supplies, equipment Support from Lab and imaging dept Emergency response – Teams – Skills/ drills There is need to set the standards, norms and SOPS for improved MCNH