mothers and their babies need access to emergency obstetrical and newborn care .... with the Scanzoni manoeuvre, allowed rotation of up to 180 degrees within ...
LETTERS TO THE EDITOR
Moving Goals and Policy Into Effective Action for Mothers and Newborns Around the World: the Mother- and BabyFriendly Hospital Initiative To the Editor: As the global community continues to pursue the attainment of the Millennium Development Goals before their deadline of 2015, the goal of reducing maternal mortality by 75% (MDG-5) continues to lag behind other development goals. At the 69th Session of the UN General Assembly in New York, leaders gathered to examine 20 years of actions taken by governments to improve the lives of people and address important population issues. Many heads of state reaffirmed “their commitments to place people at the centre of development.” Canadian Prime Minister Stephen Harper named the prevention of maternal and newborn deaths as part of Canada’s top development priority. The Society of Obstetricians and Gynaecologists of Canada has actively prioritized this goal through its international women’s health program. There is widespread recognition that in order to realize improvement in maternal and newborn health, all pregnant mothers and their babies need access to emergency obstetrical and newborn care. But “access” is a very complex issue and involves more than the presence of a health centre within driving distance. Women (and their babies) won’t access care if they don’t have the permission or the finances to go to the hospital, the transportation to take them there, or the belief that they will receive care that will make a difference to their lives or that of their newborn. In areas such as sub-Saharan Africa, where maternal mortality is not reducing at expected rates, women have alternatives which have deep-seated cultural roots and seem more familiar to the mothers—these include delivery with family members at home or in the backroom of a traditional birth attendant’s home/hut—all places where emergency obstetrical/neonatal care are not readily accessible to save the life of the mother or newborn. It’s time we recognize the need to address mothers’ need (or the need of “clients”) for a place to deliver that is a bit closer to a “home away from home.” It has to be a package deal—one that will attract women and their families who otherwise would choose less safe options—a package that can effectively deliver quality care within enough time to 14 l JANUARY JOGC JANVIER 2015
prevent the death/disability of mothers and their babies. This is the basis of the Mother- and Baby-Friendly Hospital Initiative (MBFHI), a program launched by Save the Mothers, East Africa. The premise of the 10 steps to a Mother- and Baby-Friendly Hospital (which includes endorsement of the tenants of WHO’s Baby-Friendly Hospital1) is that each mother should have a SAFE and DIGNIFIED delivery. It is more than simply painting the delivery room and ensuring that life-saving medications are always available; it addresses the individual links in the chain of safe motherhood. From the decision to seek care in the village hut, to the ride on the back of a motorcycle, to the moment the mother enters the hospital and is met by the midwife, the Mother- and BabyFriendly Hospital is intentional about its care for mothers and their newborns. It continues with the quality of care offered to her during delivery and to her baby. It includes the partner, family, and community as important influences in the care of the mother. The program has been piloted in eight Ugandan hospitals to date with very promising results. Significant advances include the use of toll-free lines (ensuring mothers can communicate with the hospital), caller user groups (ensuring health workers can communicate to get advice and help), the provision of safe water supplies to hospitals without safe (or any) water, and on-site mentoring of midwives with protocol enforcement. Important lessons are that significant results can be achieved when the approach is multidisciplinary and locally driven. The strength of the program is not from simply increasing the resources at a hospital but from the use of trained, skilled personnel committed to a workplan developed by each hospital in partnership with MBFHI advisors to realize the hospital’s goals. Advisors are multidisciplinary leaders who can also address issues of client care, communication, mentoring, and resource acquisition that are necessary to ensure the hospital is “mother friendly.” Hospitals are graded for each step and move towards a higher score in terms of attaining MBFHI status. Ongoing assessment is essential so that standards are maintained and the hospital continues to provide mother-friendly services for mothers and their babies. We need a new paradigm to ensure that all mothers around the world can have a safe and dignified delivery—it’s not enough simply to provide emergency obstetrical newborn care within the four walls of the hospital/health centre. Poor women vote with their feet and will not return or seek care at a health facility if they are not respected and cared for appropriately—even at the risk of their own lives or the lives of their newborns.
Letters to the Editor
As world leaders strategize how to do things better for the global community, those of us providing care for mothers and newborns must rethink how to intentionally ensure that the world’s mothers receive quality care that is culturally appropriate, dignified and safe. It has to be a package deal. Jean Chamberlain, MD, FRCSC McMaster University, Hamilton ON Save the Mothers, Uganda Christian University, Mukono, Uganda Eve Nakabembe, MBchB, MMed (Ob/Gyn), DSRH Save the Mothers, Uganda Christian University, Mukono, Uganda Makerere University, Kampala, Uganda
REFERENCE 1. World Health Organization. Baby-Friendly Hospital Initiative. Geneva: WHO; 2009. Available at: http://www.who.int/nutrition/publications/ infantfeeding/bfhi_trainingcourse/en. Accessed November 4, 2014. J Obstet Gynaecol Can 2015;37(1):14–15
Kielland’s Forceps: Demise Before the 100th Anniversary? To the Editor: As the time for the centennial of the Kielland’s forceps approaches, one ponders: will this elegant instrument have its demise before its 100th anniversary? Introduced in 1915 by Dr Christian Kielland, a Norwegian obstetrician, for the “deep transverse arrest,” it evolved into the instrument of choice for arrest of descent with occipito-transverse or occipito-posterior position of a cephalic presentation.1 The malpresenting baby would often not be large, as opposed to a non-malpresenting baby that would usually be large to have arrested in the first place. With a high likelihood of failure with attempts at manual rotation or a rotational vacuum, the Kielland’s forceps became an ideal instrument for facilitating a vaginal birth for fetal malposition in cephalic presentation. The relatively straight handle with a gentle backward pelvic curve and a sliding lock were ingenious additions to the obstetric forceps design, allowing easy application to a severely asynclitic head. Further, this design, when combined with the Scanzoni manoeuvre, allowed rotation of up to 180 degrees within the tight constraints of the maternal pelvis due to a relatively small circle of rotation. Given the usual normal-sized baby being delivered, once the head could be successfully rotated, most skilled users would agree that the risk of a significant perineal laceration was small. However, the last decade has witnessed a rapid decline in the use of Kielland’s forceps.2,3 This can be attributed to concerns regarding poor neonatal outcomes that were associated with the use of Kielland’s forceps.4 In the litigious
field of obstetrics, it was tempting to give up a controversial practice for the easier option, the Caesarean section. Given the medico–legal climate, although North American centres were slow in adopting the use of Kielland’s forceps, they were quicker to let it go. However, more recent evidence suggests that the concerns regarding neonatal outcomes may have been misplaced. A retrospective review of deliveries at a tertiary care centre over a four-year period compared the use of Kielland’s forceps, rotational ventouse and emergency Caesarean section.5 With a 25% Caesarean section rate and a 13% operative vaginal delivery rate, a cohort of approximately 1300 cases that reached full cervical dilatation with fetal malposition was identified. With an intention-totreat analysis, 80% had an attempted Kielland’s rotation, 8% had an attempted rotational ventouse, and 11% had an emergency Caesarean section. The likelihood of needing a Caesarean section was eight-fold higher if a ventouse was used as opposed to the Kielland’s forceps. Failure of delivery with Kielland’s occurred in 4% of cases. Other than a trend towards an increased rate of shoulder dystocia, no increase in adverse outcomes was noted.5 However, obstetric practice changed before the evidence relating to the long-term outcomes of babies could become available,6 leaving a generation of obstetricians who are untrained in the science and art of a rotational forceps delivery. With increasing Caesarean section rates and associated maternal morbidity and mortality, we need ongoing efforts to find viable alternatives to Caesarean section. This leads to the question: is it time to revive the Kielland’s forceps delivery before it is too late? Or should we helplessly watch this endangered species disappear and become a part of the annals of the history of medicine? Venu Jain, MD, PhD Department of Obstetrics and Gynaecology, Royal Alexandra Hospital, University of Alberta, Edmonton AB
REFERENCES 1. Patterson WR. The Kielland forceps. Can Med Assoc J 1928;18(2):177–80. 2. Ramin SM, Little BB, Gilstrap LC 3rd. Survey of forceps delivery in North America in 1990. Obstet Gynecol 1993;81(2):307-11. 3. Vacca A. Current obstetric training programs are unlikely to provide registrars with sufficient skill in the safe use of Kielland forceps. Aust N Z J Obstet Gynaecol 2000;40(2):226-7. 4. Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ 2004;328(7451):1302–5. 5. Tempest N, Hart A, Walkinshaw S, Hapangama DK. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour. BJOG 2013;120(10):1277–84. 6. Kotaska A, Menticoglou S, Gagnon R; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline no. 226, June 2009. J Obstet Gynaecol Can 2009;31(6):557–66, 567–78. J Obstet Gynaecol Can 2015;37(1):15
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