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University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Kennedy Memorial Hospital. Material and Methods: A retrospective analysis was carried out on all 24 cases of postpartum hemorrhage due to uterine atony with an estimated blood loss of more than 800 mL, in which standardized guidelines were obtained. Data on IMCI clinical symptoms and signs, classification and treatment given at the clinics before referral to the hospital were collected from patients' referral letters. A series of modules covering various topics relating to the prevention and management of side effects associated with the use of ARV medications. An interview with the caregiver on counselling received at the clinic was done using an adapted World Health Organization health facility survey tool.
7 case-based learning modules for clinicians, from the Northwest AIDS Education and Training Center and the University of Washington. Journal ArticlesAdverse events associated with nevirapine and efavirenz-based first-line antiretroviral therapy: a systematic review and meta-analysisShubber Z, Calmy A, Andrieux-Meyer I, Vitoria M, Renaud-Thery F, Shaffer N, Hargreaves S, Mills EJ, Ford N.
IMCI classification was done in just over half (52.9%) of 34 children with cough and 73% of 15 children with diarrhoea.
Review.Nucleoside reverse transcriptase inhibitor toxicity and mitochondrial DNAKoczor CA, Lewis W. Prereferral treatment for all children with severe dehydration had been given correctly but not so for children with severe pneumonia and severe malnutrition. The average blood loss of the 24 cases with uterine atony was 1342 mL. Department of Health and Human Services; Panel on Antiretroviral Guidelines for Adults and Adolescents.
None of the children with severe disease had been checked for glucose levels before referral. Conclusion: The management process of postpartum hemorrhage due to uterine atony deviates from the hospital’s guidelines in many cases. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents; February 12, 2013.
A comprehensive online book for patients covering a wide variety of common ARV side effects. Children, particularly those with severe disease, had been incorrectly classified, leading to inadequate prereferral treatment. Review.Adverse effects of antiretrovirals in HIV-infected pregnant womenZuk DM, Hughes CA, Foisy MM, et al. A patient-education booklet discussing possible adverse effects of ARV medications and how to manage them. Beyond the neonatal period, the latter four conditions contributing to U5MR are included in the IMCI case management guidelines in an attempt to reduce case fatality rates.[4] The IMCI strategy was developed by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) in the early 1990s to reduce the U5MR through the integrated management of common childhood diseases, in contrast to vertical programmes that focused on individual disease. The IMCI strategy has three components, namely case management guidelines, health system strengthening and community health messages.
A series of fact sheets for patients on major side effects, including hepatotoxicity, hyperglycemia, hyperlipidemia, lactic acidosis, and skin rash. The case management guidelines of the IMCI use algorithms of specific symptoms and clinical signs. The patient's condition is classified and recommended treatment administered, including treatment administered at the clinic before hospital referral (prereferral treatment).[5] The major difference from the usual assessments of children is that classification of severity of illness rather than diagnosis is used. Department of Health and Human Services (DHHS) project providing information on antiretroviral treatment and drugs that treat or prevent AIDS-related illness.


Recent data on the numbers and the coverage of IMCI-trained HCWs in SA are not available. No research was found to have been carried out in the referral hospital setting to assess adherence to the IMCI guidelines.
The motivation to conduct this study in the hospital setting was to reduce the likelihood of the Hawthorne effect, where HCWs in clinics might adhere to guidelines because they are being observed for research purposes.
The methodology has some limitations in that it relies on the documented information in the referral letter and the condition of the patient might have changed en route to the hospital. INTRODUCTION Postpartum hemorrhage is the leading cause of maternal morbidity and mortality. All children referred from PHC clinics to Kala-fong Hospital were recruited between 08h00 and 16h00 on the days when the researcher was available (on average 1 day per week) as there was no funding to employ a full-time person to conduct the research. According to the World Health Organization (WHO) criteria, primary postpartum hemorrhage is defined as blood loss more than 500 mL in the first 24 hours postpartum [2]. Every woman with massive postpartum hemorrhage should receive red blood cell transfusions in time to prevent the consequence of cardiovascular shock or disseminated intravascular coagulation [3]. Postpartum hemorrhage due to uterine atony is treated initially by bimanual uterine compression, followed by oxytocin, prostaglandins and ergot alkaloids [4]. On average, 16 - 20 cases are referred daily from PHCs to the paediatrics outpatient department (POPD) over a 5-day working week.
Surgical interventions such as uterine artery ligations, compressive uterine sutures as the B-Lynch surgical technique or an arterial embolization in patients with stable vital signs should be used to obviate the need for hysterectomy. Because of these uterus preserving techniques, the indication for hysterectomy in cause of excessive postpartum hemorrhage is very rare. It was anticipated that the subjects would be recruited over a period of 8 - 10 weeks with the assumption that ~50% would give consent to be recruited into the study, thus giving a minimum sample size of 80 subjects for analysis. This figure also includes other causes like an abnormally adherent placenta or uterine rupture.
But it is still the last resort in all cases of persistent hemorrhage after conservative and uterus preserving surgical therapy [6].
Information on counselling received by caregivers regarding the child's condition at the clinic before referral was collected in an interview with the caregiver on arrival at the hospital.
It should be considered in the management of massive postpartum hemorrhage unresponsive to conventional therapy as a last try to avoid hysterectomy [7]. For each symptom present, a list of clinical signs should be checked in the child for the IMCI classification to be done; classifications are categorised according to the severity of the illness. Thirdly, the HCW should consider the following conditions: measles, HIV infection and tuberculosis (TB) if clinical symptoms and signs listed for consideration are found.
Children between 2 and 60 months old who met the inclusion criteria and with written consent to participate in the research were enrolled. During the study period, 699 new patients were referred to the POPD (not only from the PHC clinics).
Of the original 110 recruited, 80 children were enrolled - 30 with surgical and dermato-logical conditions were excluded. Children were referred from 12 surrounding clinics in the Tshwane subdistricts 3 and 4. A total of 76 occurrences of IMCI symptoms in 55 children and 15 occurrences of non-IMCI symptoms were documented in the referral letters.
MATERIALS AND METHODS A retrospective analysis was carried out on all cases of postpartum hemorrhage due to uterine atony with an estimated total intraand postpartum blood loss of 800 mL and more identified during the period from 1st January 2003 and 31st December 2009 at the General Hospital of Vienna, the Medical University Vienna. The most common single symptom at presentation was cough, followed by diarrhoea and fever (Table 1). The only general danger sign documented was lethargy in an infant who presented with cough and diarrhoea; this was classified as cough and cold, and severe dehydration.
Our prime intention was to focus on massive postpartum hemorrhage, but as it is difficult to estimate or measure blood loss exactly and blood loss tends to be underestimated, we decided to include cases with an estimated blood loss of 800 mL as well. For inclusion in our analyses the cases had to be classified as uterine atony in the medical records. Table 2 shows the clinical signs, classifications and urgent prereferral treatment given at the clinic before referral to the hospital. Only 18% of children with chest indrawing were classified correctly as severe pneumonia, and half with fast breathing were classified correctly.
Data were obtained by the clinical documentation system of the maternity clinic, PIA® database, and the general documentation system KIS (hospital information system). The guidelines for management of postpartum hemorrhage due to uterine atony at our clinic were established by the Department of Obstetrics and Gynecology, Medical University Vienna, referring to the OEGGG, the Austrian Society of Gynecology and Obstetrics. Of the six children with severe malnutrition, only one had received vitamin A, three had received antibiotics, and blood glucose levels had not been checked in any of them. Application of recombinant activated factor VII as an optional item in consultation with the anesthesiologists was added in 2007.
As this item is considered as an optional item the addition was not accounted for in our analyses.
The classification of the conditions was incomplete and incorrect in some cases, as only 18% of children presenting with cough and chest indrawing were correctly classified as severe pneumonia. The use of carbetocin as treatment of a present atonic postpartum hemorrhage has not been evaluated in studies, but in this emergency situation it is recommended by this guideline (1 ampule with 10 mL saline as an iv bolus). The use of 10 IU oxytocin intravenously as a bolus is known to be associated with hypotension, myocardial changes, decreased cerebral perfusion and tachycardia, but it is recommended in this life-threatening situation.
This high percentage indicates the value of the integrated guidelines as opposed to single disease-focus guidelines.
Blood glucose was also not checked in all children with severe pneumonia and severe malnutrition, resulting in failure to recognise hypoglycaemia, a cause of death in children with severe acute malnutrition. Concentration: 20 mg prostaglandin F2? diluted with 500 mL saline.
Assessment for severe malnutrition and HIV is important as these children may require additional care before transfer to hospital, which may improve survival.
If vital signs are stable, uterine packing tamponade or uterus preserving surgical therapy is recommended. Counselling on the clinical signs to be used to determine when to return to the health facility was low, possibly because the patients were being referred to the next level of care rather than going home. Item a) through f) are the most important items and the items that are easiest to perform. Another limitation is that not everything done to the patient at the clinic had been documented in the referral letter. Prereferral treatment given at the clinic but not documented in the referral letter may result in a child receiving high or excessive doses of medication, which might have side-effects.
Children managed at the clinic level by healthcare workers not IMCI trained means that the high coverage of IMCI interventions required to have child survival benefits is not reached. These measures should by chosen with regard to the vital signs of the patient and the expertise of the attending team. If the bleeding stops, no more items of the guidelines need to be performed. Children with chest indrawing and fast breathing were classified incorrectly, resulting in inappropriate treatment being received before referral to hospital.
For this purpose the guidelines were divided into 14 main steps.


None of the children with severe pneumonia and severe malnutrition had glucose levels checked before referral.
We set up a table with all 24 patients in the horizontal line and the 14 steps of the guidelines in the vertical line. For each patient and each item of the guideline, there was a “yes”, if the item had been undertaken or a “no”, if the item had been omitted. Furthermore, we calculated the percentage rate of each step of the guideline, how often it had been performed. For each patient, the percentage rate was calculated, how many steps had been implemented in sum.
We classified a step as “yes”, if it had been documented in any of the hospital documentation systems.
We also recommend that appropriate IMCI referral forms or equivalent should be used to assist in adequately documenting information and treatment done at the clinic before referral. If there was no documentation, we classified a step as “no”. Furthermore, we created a time line with all steps of the guideline in the correct order from point of delivery to the successful stabilization of the patients. We calculated the cumulative percentage rate how often they had been performed. SmartDraw was used for creating the timeline in Figure 1.
RESULTS Table 1 shows every step of the guideline and the percentage, how often it had been implemented and it shows every case and the percentage, how many steps of the guidelines were operated in each case in sum in descended order of frequency. For each case we stated the total intraand postpartum amount of blood loss.
The average blood loss of all 24 cases with postpartum hemorrhage due to uterine atony was 1340 mL.
An evaluation of the quality of IMCI assessments among IMCI trained health workers in South Africa. WHO Health Facility Survey: Tool to Evaluate the Quality of Care Delivered to Sick Children Attending Outpatient Facility. Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania. Bottlenecks, barriers, and solutions: Results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths.
United Nation International Children's Fund (UNICEF), developed by the UN Inter-agency Group for Child Mortality Estimation.
All cases of postpartum hemorrhage due to uterine atony and their management process.
To correlate clinical adherence with outcome, logistic regression analyses need to be performed. However, the small number of series would not reach statistical power. DISCUSSION Documentation turned out to be a limitation of our retrospective analysis.
Heterogeneity in quality and form of documentation and inconsistency of documentation in some cases were obvious. Relevant data should have been recorded in the PIA® database, the official documentation system of the maternity clinic. In several cases retrospectively we were not able to find it in this database and had to search patient charts, surgery reports, records of the anesthesiologists, records of the midwives and hospital discharge summaries as well. The apparent inconsistency of documentation may be explained by the life-threatening situation of massive postpartum hemorrhage.
Due to the enormous stress of dealing with this life-threatening situation, the consequence seemed to be that documentation of the management process was disregarded by all participants. Thus, as the medical records may not be entirely complete or accurate, it may be hypothesized that in a few cases more therapeutic interventions had been implemented than documented, but it may almost be excluded that it is vice versa. Complete and accurate documentation is not only important for the actual success of the treatment of the patients, but also for the purpose of research and evaluation and for forensic reasons. In case of severe complications that occur at therapeutic interventions that are not documented in any of the hospital’s documentation systems, it would draw serious legal consequences with an adverse situation for all obstetricians and anesthesiologists involved. In spite of these presentations of surgical treatment, specific guidelines, staff education and the guidelines in form of quick reference cards the management process of postpartum hemorrhage due to uterine atony deviates in many cases from the hospital’s guidelines.
It is recommended to place the check list at every delivery room and operating room in an easily accessible way, not only to have the guidelines close at hand in case of severe postpartum hemorrhage, but also to improve quality of documentation. In order to avoid legal consequences in case of any treatment processes with negative outcome or in case of any complications, checking off every implemented step of the guideline is suggested.
We designed a check list in this form, where checking off all medical interventions is possible. Arrangement of the check list is according to our findings of most relevant and most achieved interventions. There are data about effect of multi-professional obstetric skills training on postpartum hemorrhage [10], but the concept of team leadership may be transferred from other subjects as trauma management or advanced life support where it has been well established. From the experience with leadership in trauma management we may transfer the requirements of an ideal team leader to the department of obstetrics.
The ideal leader must be highly experienced, should communicate clearly and radiate confidence [11] and should be comfortable directing and being responsive to other members of the team [12].
As an effective team leader is one that remained “hands off” delegating tasks wherever possible [13], we suggest establishing a team documenter as well. The team documenters should not only document all performed steps of the guidelines, but they should also document causes for not implementing specific therapeutic interventions such as contraindications and any complications that occur during the management process. In order to ensure the best performance of the team and to improve the care of patients with massive postpartum hemorrhage due to uterine atony, we suggest introducing the concept of a team leader and a team documenter into staff training.
CONCLUSIONS 1) In sum the guidelines were in use for 14% - 71%, which means that not all measures were necessary to achieve the best possible maternal outcome. However by using 100% of all measures, it might be assumed that the options were insufficient.
Norbert Pateisky (Department of Obstetrics and Gynecology, Divison of Clinical Risk Managment and Patient Safety, Medical University Vienna) for their kindful help. Journal of Obstetrics and Gynaecology Canada: JOGC, 28, 967-973. The Journal of Obstetrics and Gynaecology Research, 35, 453-458. Acta Obstetricia et Gynecologica Scandinavica, 89, 1040-1044. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 137, 172-177.
The Journal of the Pakistan Medical Association (JPMA), 56, 26-31. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 18, 66.



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