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HPA Magazine 18
Sub specialist in Maternal Fetal Medicine
Director of the Gynecology
& Obstetrics Unit
Devastating obstetric emergencies are rare. It the staff do not have the means, skills and knowhow to respond in an obstetric emergency situation, pregnant women are at risk of not receiving adequate care if required. During training sessions participants can make mistakes, reflect and learn from them, without exposing the patient to any risk.
In summary, Training in Obstetric Emergencies must be carried out periodically in order to maintain the entire team updated on procedures. Training promotes good routine practice, also permits correction of systems and individual practice, in order to optimize the clinical outcome. The importance of training is continuous, as obstetric emergencies cannot always be anticipated, but the impact of these adverse events can be reduced by training in obstetric emergency situations, resulting in an improvement in the ratio of positive perinatal outcomes.
To conclude, obstetric emergencies are unpredictable and sudden and can put the pregnant woman and the foetus at imminent risk, so an immediate and consistent resolution for a positive outcome is fundamental. A successful approach requires a quick and coordinated response by multidisciplinary teams. Physicians, Specialist Nurses, General Nurses and Medical Assistants of the Gynaecology and Obstetrics Unit as well as other professionals from other departments participate in the training sessions whenever necessary.
The organization of the training sessions consists of a first phase, where the most important obstetric emergencies are identified, a second phase of selected cases for in situ training, and a third and final phase where the performances are analysed, as well as the multidisciplinary team’s satisfaction results.
Two obstetric emergencies were selected for training in the month of May: postpartum haemorrhage and seizures. The health professionals that participated improved their skills significantly after training, and were highly satisfied with their training experience.
The training objectives achieved:
1. Improvement in the quality care provided in the Maternity Unit to both Pregnant & Puerperal women by the team at HPA Gambelas.
2. Teams trained in obstetric emergency situations in the unit itself, thus improving professional practice & teamwork.
3. Helping the team assess and improve their response in an obstetric emergency situation.
4. Identifying areas for quality improvement.
5. Testing the resolution time of an obstetric emergency.
6. Improving the unit’s overall performance.
Emergency|n.f.: serious situation or critical moment.
The pregnant woman is not oblivious to these situations. In fact, in addition to being potentially susceptible to the same risks as any adult, there are clinical situations that are specific to pregnancy and which may occur at any time during pregnancy: in the antepartum, intrapartum and postpartum.
Thus, in obstetrics, anticipating an obstetric complication is crucial for a positive maternal and foetal outcome.
Adequate surveillance and systematic follow-up in the Obstetric Consultation is of utmost importance. However, emergencies are often sudden and occur without warning or context and may occur during a consultation, in the emergency unit or during a hospital admission.
It is for this reason that training in obstetric emergencies is so important. The knowhow and coordination of the multidisciplinary team are essential for the resolution and control of an emerging situation. The Obstetrician, as a team leader, should with clarity, objectivity and tranquillity, evaluate the patient and the clinical situation, organize and guide the team, focused on the diagnostic and therapeutic approach.
Evolution and technology have resulted in an exponential evolution in medicine, and specifically in obstetrics, fostering an evolution also in diagnostic tests and treatment. Consequently, clinical protocols are constantly being updated, with a view to the best approach for the patient. Training in obstetric emergencies allows the whole team, and doctors in particular, to acquire additional knowhow, updates and to gain new and increasingly specific skills, preparing them for the most borderline situations.
Equally important, training in obstetric emergencies also improves communication, strengthens teamwork and enhances complementarity and respect among the team.
Emergency obstetric training was restarted in 2022 with two particularly important topics, due to their impact and frequency: postpartum haemorrhage and pre-eclampsia/eclampsia.
As a doctor and training instructor in obstetric emergencies, the updates inherent to these two clinical situations were notorious, with an impact on internal protocol alterations, which not only permitted us to systematize a targeted approach, but also to reinforce knowhow and skills previously acquired.
Our daily goal is the wellbeing of both mother and foetus. Focusing on how to avoid potentially serious complications in both mother and baby is the purpose of all Obstetricians. However, in the face of an emergency, with skills and knowledge the trained obstetrician will contribute to a timely and successful resolution.
Shall we book our next training course?
Obstetrics & Maternal Health
The promotion of Obstetric Emergency Courses at the HPA by the Gynaecology and Obstetrics Unit aims to optimize the multidisciplinary team's ability to respond to emerging situations involving the pregnant woman and the foetus and as they are not usual, require simulated training.
Emergency situations in obstetrics are generally rare and opportunities to experience them in a real-life context are scarce. Therefore, simulated training is essential for all health professionals, recreating scenarios and clinical cases in a work context.
Situations were therefore created in the three sectors of the Gynaecology and Obstetrics Unit where pregnant woman may be involved in an emergency: The Gynaecology and Obstetrics Consultation, the Puerperium and the Delivery Room. Professionals usually working in these sectors were faced with the sudden occurrence of an emerging episode involving a pregnant woman (convulsions and postpartum haemorrhage) with the need to ask for help and mobilize human and material resources to respond to the situation.
In emergencies, effective action requires both theoretical and practical knowhow in identifying situations as well as technical and communication skills, organization and teamwork by professionals. Asking for help in the face of a serious scenario that we are faced with and continuing with this attitude, linking all resources and decision-making effectively is fundamental for a favourable outcome.
Conducting these courses reveals that regular training is essential, highlighting and recognizing the role of different professionals – doctors, specialist nurses, general nurses and medical assistants – and the appreciation of their skills at the most diverse levels.
It is therefore important to standardize care and set global goals to achieve them. In 2015, the National Low-Risk Pregnancy Surveillance Program was created in Portugal, with the aim of providing updated information, to serve as support for professionals who monitor women of reproductive age. For an early identification of problems, adequate surveillance becomes essential, for both maternal and foetal health.
In 2016, the United Nations (UN) resolution came into force, entitled ‘2030 Agenda for Sustainable Development’ consisting of 17 goals. Relevant to this article, is Goal 3: Quality Health, where the aim is to reduce global maternal mortality rate to less than 70 deaths per 100.000 live births. End preventable new-born death and that of children under the age of 5 years. Try and reduce neonatal mortality rate to at least 12 per 1.000 live births in all countries. Mortality rate of children under 5 years to at least 25 per 1.000 live births, all by the year 2030.
According to the National Statistics Institute (INE), 85.900 births took place in 2019 in Portugal (the most recent data), however, in 2020 maternal deaths accounted for 20.1 per 100.000 births. All were linked to complications during pregnancy, childbirth and the puerperium, as were 166 Neonatal deaths. Records show that 31.6% of all foetal deaths were caused by complications during pregnancy, labour and delivery.
Although Portugal presents extremely good results in relation to the goals set by the UN, the importance of scientific updating and practical training in solving complications becomes crucial for statistical improvement. The low percentages of deaths described above are directly related to a low percentage of associated complications and inherent to a lower professional predisposition for effective resolution, in accordance with the most up-to-date and reliable evidence, mostly due to the scarcity of real training situations.
According to regulations on the duties attributed to a general nurse, nurses must develop continuous training procedures to contribute to the improvement of the quality of nursing care.
In the Gynaecology and Obstetrics Services of the HPA – Gambelas, there is an internal team predominantly made up of generalist nurses who are allocated mainly to the puerperium unit, where the mother and new-born infant are transferred after in the immediate postpartum period. Emergency situations occur mainly in the first twenty-four hours after birth. The associated complications can cause a lot of stress, where the lack of mechanization of procedures promotes mental disorganization in the team, making it difficult to solve the problem.
It is therefore important to emphasize the importance of the obstetric emergencies course provided by the institution, especially from the perspective of a generalist nurse, largely due to the knowledge acquired and the practice acquired in critical situations, in a context where the ratio of general care nurses is high, as in the case of the puerperium.
This year the month of May was dedicated to training in Obstetric Emergencies at our Unit.
For us, Medical Assistants, these trainings courses play an important role with numerous advantages.
We get a sense of reality, of a situation that may happen at any time. Knowing how to contribute and help health professionals, without disturbing or complicating the situation further is of utmost importance.
Knowing what is being done during an emergency process, and the relationships between professionals so that we can work as a team is fundamental.
During the simulation, we can analyse errors in more detail or make improvements, avoiding undesirable situations in a real situation.
We gain the ability to act in advance, to avoid or solve future problems.
With these training sessions, we can all contribute to success and good results, all for the well-being of our pregnant and postpartum women.
An example of this are the regular training sessions in obstetric emergencies, put together by the Unit´s Director, with the involvement of the entire multidisciplinary team of professionals, through training, combining practical role-playing techniques, based on case studies, following a script, where professionals recreate and simulate an emergency, in different contexts; in the Obstetric Emergency Unit, in the Out-Patients Unit, in the Operating Theatre and in the In-Patients Unit. At the end of each exercise and as a way of consolidating good practices, a debriefing is carried out.
This type of activity is, from a psychological point of view, a valuable instrument for improving communication and assertiveness. It results in a positive impact on the relationship between professionals, while learning and sharing information and knowledge, empowering the team to adopt the best possible option in the most adverse moments. These exercises are fundamental as they allow each element to handle any emergency situation related to their area of expertise.
This is a concern that requires constant updating and practice not only with the aim of providing the group with greater dexterity in clinical practice, but also as training to enable a quick response to a possible medical emergency.