THE UNSFAE DELIVERY

HOW TO AVOID UNNECESSARY CAESAREAN SECTIONS

1.                  Carry out a Pelvic examination before getting pregnant. Ovarian tumours and/or uterine fibroids previously unknown to the woman can be discovered. An ovarian tumour that is a solid tumour that can block the descent of the baby into the pelvis during labour can be removed surgically.

This is to avoid repeated caesarean sections that can follow if this not done.

2.                  A submucous fibroid (one lying just below the inner living of the womb) can be the reason for recurrent miscarriages and excessive bleeding of the woman during menses. This can deplete her blood leading to severe anaemia (lack of blood) and the need for repeated blood transfusions. This is a major reason for reproductive failure (inability to have a child in spite of many pregnancies).

Fibroids located in the lower segment of the uterus may not necessarily prevent conception but will definitely in most cases prevent vaginal delivery as they block the descent of the baby into the pelvis. An operation done to remove such a fibroid will prevent the woman from undergoing repeated caesarean sections if such fibroid was not removed. A bimanual pelvis palpation can be done and a pelvis ultrasound should also be done.  

 

3.                  A woman who wants to avoid unnecessary caesarean section, should

register for antenatal care on time in a centre where tests can be done and where the attendants are safe motherhood compliant. Urine testing done especially in the first three months of pregnancy can reveal the reason why some women will end up with caesarean section later. If there is sugar in the urine and it is later confirmed that the person has diabetes mellitus she can be advised to go on non-sugar food like unripe plantain, beans and bean products like moi-moi, akara, leafy vegetables, etc. She will be told to minimize taking sugar -containing drinks, alcohol, carbohydrate foods like rice, yam, garri,  akamu etc.  These will help to keep her blood sugar level at normal range. If that does not happen she can be given insulin injections.

If no tests are done especially in early pregnancy, the baby can grow very big and may be unable to pass her pelvis thereby leading to caesarean section to save her life and that of the baby. The baby can also die suddenly before delivery. If vaginal delivery taken place she and the baby can sustain a lot of injuries.

 Haemoglobin estimation (level or quality of blood) done in early pregnancy can help care givers detect women with anaemia (lack of blood) such woman will be encouraged to eat food that can improve the quality of their blood like crayfish, oysters, vegetables, fruits, bone marrow liver, milk. They will be given blood building drugs such as folic acid, fersolate, vitamin C, B complex tablets, multivites. If the anaemia is severe, iron dextran infection can be given to improve the haemoglobin level. If the level of the haemoglobin is very low before the labour stars blood can be transfused. No woman should go into labour with haemoglobin less than 10g% (70%). Those with haemoglobin level of 6g% (42%) or less should be transfused.

Anaemia causes weakness. The cervix may fail to dilate completely with anaemia in place. The woman in labour with anaemia will be unable to push her baby out and can even go into heart failure in the later part of labour and die. Such woman may end up having a caesarean section. If a vacuum extractor is available such women are better off delivered by vacuum extraction can assisted vaginal delivery.  During caesarean section they can bleed excessively due to the paucity of platelets and clotting factors responsible for clotting of blood

A urine test done in early pregnancy can also reveal that protein is in the urine. This may be a pointer to infection of the urinary system (presence of poisonous germs).

Another test known as urine microscopy, culture and sensitivity need to be done to find out what type of germs are prevent and the antibiotics that can clear them off.

Antibiotics that are safe in pregnancy should be used. If the infection is not discovered and treated, it can lead to pyelonephritis (an infection of the kidneys) which causes high fever and pain in the loin of the woman. This infection causes prolong labour and weakness of the woman and may make her care givers opt for caesarean section to deliver her.

Blood pressure should be checked at every antenatal visit. When blood pressure is high it can be reduced using anti hypertensive agents and anxiolytics (drugs that reduce anxiety).

Uncontrolled high blood pressure can make doctors opt for caesarean section to deliver the woman to avoid fits and death of the baby and the woman.

Early registration for antenatal care and adherence to instructions by skilled care givers can reduce the in accidence of unnecessary caesarean sections.

Women who go to Safe Motherhood compliant care givers have the benefit of being to assume for babies not staying well to stay well. When babies persist in abnormal positions and presentations, caesarean section may be the only way to ensure safe delivery.

Women who registered for antenatal care in centres knowledgeable about this can benefit from instructions on how to stay for the babies to turn to normal positions and presentation. The babies can only turn to normal postions, however, if there are no mechanical reasons such as fibroids ovarian tumours and low-lying placentas or cord accidents responsible for the abnormal positions. Babies may also not turn if the woman has drained liquor (loss most of the fluid around the baby). 

The woman will also have the benefit of buying and reading books like "Coping with labour" where such information are available.

Sitting upright most of the time with knees at a lower position then wash enhance good positioning of the baby.  The  best position for a baby to assume to 

be delivered vaginally is to bend its head completely on the neck (well flexed) and for the back of the head to face the mother’s front directly. The back of the head is known as occpito     

Picture here of well flexed baby and pictures of abnormal positions and presentations that do not favour vaginal delivery.

Manoeuvres that assist a baby stay in the right position can be resisted by these aforementioned reasons. Cord accidents, fibroids and other tumours can make it difficult for babies to stay permanently in a normal position even when attempts are made to have the babies turn to the normal positions.

Babies in abnormal positions can turn to the correct position if the woman stays in all fours on the floor. This happens most often if there are no mechanical reasons as has been mentioned that can hamper this manoeuvre.  The baby also may not turn if the water around it is insufficient to permit it such as can happen with premature drainage of liquor (breaking of bag of waters).

Picture of all fours

How do we know a baby in an abnormal position?

1. The pregnant abdomen does not look rounded. It has a depression at the  centre around the umbilicus.

  

Abdomen showing baby                     abdomen showing a 

                         in normal position.                            mal positioned baby.

2.                  The limbs or small parts of the baby are palpated felt at the front side of the abdomen. Such parts usually shift in position when touched unlike the back that is smooth and consistent.

3.                  The fetal heart sounds are heard best towards the back of the women, not in the front below the umbilicus. 

4.                  Relatively flat suprapubic area (area above the pubic hair).

5.                  Baby can be born face to pubic (baby is delivered facing the mother’s pubic hair).

Normally positioned babies are born backing their mother’s pubic hair.

Normal positioning of a baby is very crucial for vaginal delivery especially when the woman’s pelvis is sizeable enough to allow the baby pass. Even a woman with a borderline pelvis (hip neither large enough or too small) can have a safe vaginal delivery if the baby’s head is well positioned. Most caesarean sections are performed to deliver babies who got stuck in their mothers’ waists as a result of persistent abnormal positions like the direct occipito posterior position ( direct Opp).  Many families in our sub-region detest caesarean sections. Therefore all stake holders in the delivery business such as pregnant women, their spouses, midwives, doctors, Pastors, women and community leaders should take seriously the simple manoeuvres a pregnant woman can perform to keep her baby in a normal position. This will reduce the number of caesarean sections. It will also reduce number of women and babies dying from complications of prolonged obstructed labour.

These simple manoeuvres of pregnant women being in the upright position most of her working  moments and being in the all-four position during labour can save countless numbers of lives and reduce the cost of pregnancy and delivery. They are also learnt by all that attend the Safe Motherhood pregnant women’s health seminars and those that read "Coping with labour".

Knowledge of methods to reduce caesarean section rate as imbibed by pregnant women, their husbands and advisers will help to engender confidence in orthodox health care settings where such knowledge are got. People will feel their best interests are considered since caesarean sections are not done indiscriminately. Those that actually need caesarean section will accept it happily since they are aware that everything has been considered before such a decision was made.

Treating dehydration and infection to avert caesarean section

 It has been noted that dehydration, hypoglycaemia (low sugar level) due to prolonged period of abstinence from food and fluids can stall cervical dilatation and progress of labour. Some childbirth attendants withhold food and fluids from the labouring women and so inadvertently stop labour. Urinalysis done on such labouring women can show the presence of acetone. This is a pointer to starvation. This has led to a number of caesarean sections done on account of prolonged labour. Giving parenteral fluids to the women like Dextrose/saline infusion can solve the problem. Labour can continue until delivery. Moderate or severe chorioamnionitis (infection of the amniotic fluid and membranes) can also stall labour. Many women have undergone unnecessary caesarean sections because of that. Examining labouring women who have drained liquor especially with bare hands or unsterile hand gloves can lead to this. Prolonged drainage of liquor or frequent vaginal examinations can also lead to this. Treatment with parenteral antibiotics can kill the germs and recommence labour and vaginal birth can take place

Ceftriaxone, gentamicin and metronidazole injections are usually given.

THE BABY’S POSTURE, PRESENTATION AND LIE, AND THEIR EFFECTS ON DELIVERY.

Fetal Attitude or Posture. The baby that will be delivered safely vaginally has a characteristic posture or attitude. It is folded or bent on itself in such a manner that the back becomes well curved, the head sharply bent (flexed) on the neck so that the chin is almost in contact with the chest, the thighs are bent (flexed) over the abdomen, the legs are bent (flexed) at the knees. The arms are crossed over the chest. This type of posture may partly be due to a process of accommodation to the uterine cavity. This characteristic posture results in a vertex presentation (baby coming out with the centre of the head presenting.)
Vertex presentation. A. Left occipito – anterior. B. Left occipito posterior
When the head is not well bent and the baby is staying like a military man on attention, this results in a sinciput presentation (baby attempting to come out with the forehead foremost)
When the baby bends its head a little backwards it will result in a brow presentation (baby attempting to be delivered with the brow foremost)
When the baby bends its head completely backwards it will result in a face presentation (baby coming out with the face foremost). When the chin of such a baby is pointing to the front, the baby can be delivered normally (mento – anterior face presentation) if the pelvis is adequate. When the chin of the baby is pointing backwards (mento – posterior face presentation) it can hardly be delivered vaginally safely. Such babies are best delivered by caesarean section. Apart from the vertex presentation the other presentation that can cause difficulties during vaginal delivery is shoulder presentation or transverse lie.
In a transverse lie (baby lying across the abdomen), it is the baby’s acromion or tip of the shoulder that presents (makes attempt to come out). Such a presentation is best delivered by caesarean section. A transverse lie can lead to prolapse of the umbilical
cord(umbilical cord drops out of the vagina) which can lead to the death of the baby if the baby is not delivered by caesarean section speedily.
Another presentation that can cause difficulties during birth is breech presentation (buttocks or lower limbs coming out first). Prolapse of the umbilical cord and/or trapping of the fetal head are complications that can lead to fetal death or severe injury if breech delivery occurs inappropriately. Fetal and/or maternal injuries can also occur during breech delivery. It is recommended that if the breech is presenting in a first timer, she should have a caesarean birth. It is a safe approach to delivery. In other situations, the pelvis should be assessed by an expert. If found to be adequate, the woman can be delivered vaginally using for example assisted breech delivery approach.

THE DANGER OF HIGH VAGINAL AND THE VALUE OF ENDO CERVICAL SWABS
High vaginal swabs are not very reliable in picking organisms causing pelvic infectious. Endocervical swabs taken properly in aseptic conditions are more likely to reflect what is happening in the pelvis. High vaginal swabs pick mainly normal vaginal flora (germs that live normally in the vargina and not causing problems). Clearing such normal flora with antibiotics can even lead to emergence of resistant organisms that can cause a life threatening infection in the people concerned or lead to inability to actually treat the real germs causing a pelvic infection for example.
Picture – How swabs are taken
Collecting endocervical swabs is the job of a Gynaecologist.
Send your questions to info@smeei.com, or WhatsApp 08063389935. Support the Safe Delivery campaign.

VTS 01 2

HAEMOGLOBIN ESTIMATION – A WAY TO AVOID WRONG PRACTICE

HAEMOGLOBIN ESTIMATION – A WAY TO AVOID WRONG PRACTICE
When the haemoglobin estimation of a patient is low it is said that the patient has anaemia (lack of blood).
Anaemia is very prevalent in our society. Majority of people when tested are found to be anaemic (have less than 10g% or 70% haemoglobin estimation). The incidence of anaemia is worse among those who are sick as many of them do not have appetite for food and so are unable to take enough proteins, vegetables, vitamins and minerals
which are raw materials for the formation of Heamoglobin. Heamoglobin carries oxygen from the lungs to the various organs and tissues of the body. Heamoglobin is present in red blood cells found in the blood stream. Oxygen is needed by the cells of the body to release energy trapped in the food we eat. Energy is required for the metabolic processes of the body. That is why people who are anaemic complain of tiredness and difficulty in breathing. They also complain of lack of appetite which worsens the anaemia as they are unable to eat food that can give them blood. They look pale and can have swollen leys and face.
When people who are anaemic are given drugs to treat some other ailments like malaria or typhoid fever they don’t recover fast or can even get worse.
This is because energy is needed to metabolize or handle the drugs given and when such energy is in short supply on account of anaemia, the drugs given are unable to work as the body does not have the capacity to handle the drugs. It is very important that health care providers should have the habit of checking the heamoglobin (HB) or packed cell volume (PCV) of people they are treating.
The patients that are very anaemic such as people with haemoglobin that is 6g% or (42%) or less should be given blood transfusion before treating the other problems they have. Those that reject blood on religious or personal grounds can be given erythropoietin injection to boost their haemoglobin levels. Those who are not very anaemic can be treated with haematinics (drugs that improve haemoglobin). These include:
 Folic acid
 Iron tablets like fersolate, ferrous gluconate etc
 B. Complex tablets
 Multivites
 Vitamin C. This helps the patient absorb iron from the stomach and intestines. Such patients can also be encouraged to take a lot of green leavy vegetables, fruits and food high in protein like fish, meat, beans, periwinkles, crayfish, snails, oysters, etc.
Such people can also be given treatment for the illness for which they came. It is wrong practice to be giving people drugs and injections when they are anaemic without treating the anaemia first or together with the other treatments. It is difficult to know who is anaemic except haemoglobin estimation is done. The use of blotted paper where a little blood of the patient is put and checked against a chart is not a reliable way to know those who are anaemic. Collecting the patient’s blood and doing a haemoglobin estimation and/or packed cell volume (PCV) is the standard way to rule out anaemia.

Send you questions to info@smeei.com, or WhatsApp 08063389935. Support the Safe Delivery campaign.

URINALYSIS – A SIMPLE WAY TO ASSESS PATIENTS

URINALYSIS – A SIMPLE WAY TO ASSESS PATIENTS
Every person that takes care of the sick should use urinalysis – a simple test to check his patients. Combi 9 Dip Stixs that can check various parameters in the urine are available and should be used by all health care providers.
Urinalysis is a very important investigation used to depict the state of health of a pregnant mother or any other sick person. It can draw attention of a health worker to the possibility of the following health concerns
 Diabetes
 Pregnancy - induced hypertension
 Urinary treat infection
 Hepatitis (inflammation of the liver)
 Chronic Renal (Kidney) disease
 Malaria.
DIABETES MELLITUS
When there is glucose in the urine further tests can now be performed to establish the diagnosis of diabetes in pregnancy. Such tests include fasting blood sugar and oral glucose tolerance test (OGTT).
PREGNANCY INDUCED HYPERTENSION
Protein in urine may mean pregnancy – induced hypertension in a pregnant woman if her blood pressure is also high. It protein in urine is up to three to four pluses (+++ or ++++) and the woman’s blood pressure is high coupled with swelling of the hands and legs the woman has severe pregnancy – induced hypertension. Such women need immediate specialist care. If the woman’s blood pressure is normal, urine – microscopy, culture and sensitivity should be done to rule out urinary tract infection which is another reason for protein in urine.
URINARY TRACT INFECTION
This disease can show in urine as:
 Protein in urine
 Presence of pus cells or white blood cells
 Presence of bacteria
 Nitrites positive in urinalysis.
When there indices are seen in urine, a microscopy, culture and sensitivity should be done to discover the organism responsible for the infection and the drugs that can kill such organisms. This helps the health care provider give the appropriate medications that can lead to a cure.
KIDNEY DISEASES
Excessive protein in the urine like three or four pluses, (+++ or ++++) can be a signal of a serious kidney disease like renal failure or Nephrotic syndrome. In nephrotic syndrome the patient is swollen all over.
Red blood cell casts seen on urine microscopy, is a signal of intrinsic kidney disease.
Red Cell Casts, leucocytes (white blood cells) and epithelial casts are found in acute glomerolonephritis (inflammation of the glomeruli (filtering apparatus) of the kidneys).
Hyaline Casts consist of coagulated (congelled) protein without cellular elements. They are found in glomerolonephritis and occasionally in small numbers in normal urine especially after vigorous exercise.
Epithelial and Granular Casts are indicative of inflammation and degeneration of renal (Kidney) tubules. Granular Casts are formed by degeneration of the impressed cells.
In such cases in order to assess the kidney function further tests are required like kidney scan and serum urea and creatinine estimation.
HEPATITIS
Inflammation of the liver known as hepatitis can cause the following symptoms:
 Severe fatigue or weakness
 Loss of appetite
 Headaches
 Jaundice [Yellowness of the skin and conjunctiva (white of the eyes)]
 Dark urine
 Muscle or general body aches
 Joint pains
It can be caused by hepatitis viruses A,B,C,D, or E. Some poisons or toxins can also damage the liver and cause hepatitis.
Hepatitis can cheaply be detected in the urine. Bilirubin seen in the urine is a sign of hepatitis. This will alert a health care provider of its presence.
MALARIA
Can even be suspected by doing a urinalysis. The presence of urobilinogen in significant quantity in urine can be a sign of malaria. During acute malarial attacks red blood cells that carry oxygen are haemolyzed (broken down) by the malaria parasites.
These broken down fragment of red blood cells can be seen in the urine as urobilinogen.
KIDNEY STONES (RENAL CALCULUS)
Crystals (e.g Calcium oxalate, cysteine (an amino acid) or urate (derived from nucleic acid metabolism) may be seen in renal calculus (stone in the kidney or urinary tract). The patient with renal calculus can have episodic or severe colicky pain in the flanks, some times radiating towards the tip of the penis in males.
Red blood cells can also be noted in the urine of people with renal calculus.
NB: It is important to note that the fact that some body is passing urine frequently is not synonymous with a diagnosis of diabetes mellitus. It can also mean urinary tract infection. It is only a urinalysis and microscopy, culture and sensitivity that can settle the issue and give a sense of direction of treatment. Even though frequent urination can be a symptom of diabetes mellitus, health care providers should not give patients with such complaints drugs for diabetes when they have not confirmed the diagnosis through the relevant tests already mentioned.
FASTING STATE OR MATERNAL DISTRESS FOR A WOMAN IN LABOUR
The presence of acetone in the urine of a pregnant woman indicates a fasting state and in a woman in labour can mean maternal distress following prolonged labour, which has depleted her energy reserve.
Acetone is a product of fat metabolism. Fat is usually called in to provide energy when glucose the primary energy provider is exhausted. Such a woman will benefit from an intravenous infusion of dextrose or energy giving food intake if not contraindicated.
A comprehensive examination of the urine of a pregnant woman is therefore very useful to assess her baseline state of health or make accurate diagnosis of any body sick that needs medical attention. Every health care provider should know the enormous information that can be got from checking the urine of a client. It is also important to note that people who take care of the sick can easily carry out urinalysis on their patients using a dip stix like combi 9. they can also send the urine of their clients to the laboratory using sterile urine bottles for microscopy, culture and sensitivity. These will make a lot of information available to them for the correct handling of their patients. It will also enable them refer patients with serious problems like kidney diseases, diabetes mellitus, hepatitis to specialists that can handle them instead of delaying such patients.