Teamwork in obstetric critical care

Whether seeing a patient in the ambulatory clinic environment, performing a delivery or managing a critically ill patient, obstetric care is a team activity. Failures in teamwork and communication are among the leading causes of adverse obstetric events, accounting for over 70% of sentinel events according to the Joint Commission. Effective, efficient and safe care requires good teamwork. Although nurses, doctors and healthcare staff who work in critical care environments are extremely well trained and competent medically, they have not traditionally been trained in how to work well as part of a team. Given the complexity and acuity of critical care medicine, which often relies on more than one medical team, teamwork skills are essential. This chapter discusses the history and importance of teamwork in high-reliability fields, reviews key concepts and skills in teamwork, and discusses approaches to training and working in teams.     

Equipment needed for an obstetrician/gynecologist to practice primary care

To meet the needs of the changing health care system, more obstetrician/gynecologists will be practicing primary care, and they will require extra office equipment to facilitate the provision of these services. As the scope of primary care is vast, this article discusses only the equipment needed to manage the 12 most-common reasons to visit an internist as determined by the National Center for Health Statistics. Review of the management of these problems reveals that for a small investment, the office can be easily outfitted for primary care as most of the equipment needed is already standard for the practice of obstetrics and gynecology.     

Teamwork and quality during neonatal care in the delivery room.

OBJECTIVE: Experts believe good teamwork among health care providers may improve quality. We sought to measure the frequency of team behaviors during delivery room care and to explore how these behaviors relate to the quality of care. STUDY DESIGN: We video recorded neonatal resuscitation teams then used independent observers to measure teamwork behaviors and compliance with Neonatal Resuscitation Program (NRP) guidelines (a measure of quality of care). RESULTS: Observer agreement was either fair or good for all teamwork behaviors except workload management, vigilance, and leadership, for which agreement was slight. All teams (n=132) exhibited the behaviors information sharing and inquiry, and all but one team exhibited vigilance and workload management. Other behaviors were present less often: assertion in 19.9% of teams, teaching 16.7%, leadership 19.7%, evaluation of plans 12.9%, and intentions stated 9.1%. Factor analysis identified three fundamental components of teamwork: communication (comprised of information sharing and inquiry); management (workload management and vigilance); and leadership (assertion, intentions shared, evaluation of plans, and leadership). All three components were weakly but significantly correlated with independent assessments of NRP compliance and an overall rating of the quality of care. CONCLUSION: Most team behaviors can be reliably observed during delivery room care by neonatal resuscitation teams, and some are infrequently used. We found weak but significant and consistent correlations among these behaviors with independent assessments of NRP compliance and an overall rating of the quality of care. These findings support additional efforts to study team training for delivery room care and other areas of healthcare.     

Appropriate technology in primary health care for better midwifery services

Focus is on the various improvised techinques devised for better delivery of midwifery services for an entire community. The various technological devices described were worked out for the 1st time and subsequently implemented in the entire area of 60 program villages of Primary Health Center, Kasa in India during 1974-1976. The Integrated Mother-Child Health-Nutrition Project, Kasa had a population of 56,364 in the program villages. About 19% of the population were women in the reproductive age group of 15-45 years. The following improvised and simplified field techniques assisted the health workers in the maintenance of surveillance, community diagnosis and community management including a diferrent system of referral: 1) a mother's card which provided menstrual registry, information on pregnancies and their outcome, and help in identifying cases for family planning; 2) tri-colored arm tape for assessing nutritional status of women; 3) surveillance system on at-risk pregnant women; 4) anemiometer for identification of mild or severe anemia without pricking for blood; and 5) a very small midwife's kit for conducting safe deliveries. These techniques have been tried out in a wider area, and the results have been promising.     

Abnormal uterine bleeding, a new terminology is needed

The current terminology describing abnormal uterine bleeding (AUB) is not universally agreed upon. A new AUB terminology must be uniform, unambiguous, and symptom focused. A prototype letters and numbers formula covering the entire spectrum of AUB is proposed that may contain sequences such as B1D2F1A2P1 (i.e., moderate-1 bleeding, lasting for 2 days-duration, with frequent monthly-1 presentation, causing significant-anemia and mild-1 pains). Universal acceptance of a similar standard and reproducible terminology will add semiquantitative information, enable accurate reporting, and facilitate clinical research.     

Is routine hospitalization needed in antenatal care of twin pregnancy?

A prospective study was carried out to evaluate the significance and efficacy of routine hospital bed rest in prevention of premature birth and pregnancy complications compared to specialized antenatal care at the outpatient clinic of 73 twin pregnancies. The twin pregnancies were screened in health centers by means of symphysis-fundus measurement, and the diagnosis was confirmed by ultrasound examination at the outpatient clinic. On the average the ultrasonic diagnosis was performed during the 23rd gestational week; at this visit the women were divided into two groups with similar follow-up to the end of the 29th gestational week. At this stage one of the groups was hospitalized unless there had been indications for earlier admission. In the hospital group, the mean for gestational week at delivery was 36.7 (+/- 2.4) and in the outpatient group 37.4 (+/- 1.8) respectively (N.S.). There was no difference in the rate of pregnancy complications between the groups too. No statistical differences in the perinatal mortality (7.1% and 1.1% respectively) or birthweights of the newborns were found, either. Present results do not support the idea of using routine hospital bed rest. It could not be proved to have positive effects on the gestational age, birth weight and perinatal mortality of the newborns, nor to the pregnancy complications. In our opinion early diagnosis of twin pregnancy is of decisive importance and specialized ambulatory follow-up could be employed instead of routine bed rest in antenatal care of twin pregnancy.     

Emergency obstetric care in Punjab, Pakistan: improvement needed.

INTRODUCTION: This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services. METHODS: In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis. RESULTS: No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality. CONCLUSION: The study may be taken as a baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications.     

How to coordinate the home care with the hospital care for a better quality of life in cancer patients

The author explain some problems concerning the coordination between home and Hospital care for the cancer patients. The problems are Psychological not only for the patients but also for the family and organizing not only for the family but for the Hospital and the social health service.     

Pulmonary complications of antepartum pyelonephritis: more alertness is needed.

Three cases of pulmonary complications associated with antepartum pyelonephritis are presented, in two of them tracheal intubation and mechanical ventilation were required. All three cases were related to recurrent urinary infections with failure of first line antimicrobial therapy and a concomitant usage of tocolytic therapy. The possible etiology, risk factors and clinical approach, aimed to prevent pulmonary complications in antepartum pyelonephritis are discussed.