Maternal and foetal outcome in patients referred to tertiary hospital

Objective: To know the incidence of referred patient to Sultaniazanana hospital. To evaluate maternal and foetal outcome in referred patients.To identify lacunae in appropriateness and timeliness of referral and to provide universal referral proforma for all patients referred from various health care facilities. 
Methods: The present study was done in Sultaniazanana hospital, Department of Obstetric& Gynecology Gandhi Medical College, Bhopal, to study the referral from within Bhopal with respect to age, parity, place of referral, time of transport used, causes of referral, maternal & perinatal outcome & finally maternal deaths & their causes. 
Results: Maximum patients are primigravida and of 20-30 years of age.Majority of patients used private vehicle & only few have been provided with hospital ambulance. Most patients reached Sultaniazanana hospital within 2 hours, which is adequate for management of complications unless the patients is referred timely from the referring site. About 22.11% of patients are referred with no high risk factors & 83.7% of patients are referred during emergency hours. 
Conclusion: Early identification, initiation of early treatment and timely referrals are the crucial components for success of any maternal health intervention.Minimizing the causes of delay to emergency obstetric care significantly decrease maternal and neonatal morbidity and mortality.


Introduction
Madhya Pradesh is a state with high maternal mortality ratio which is now showing a declining trend because of various interventions that have been planned and implemented. However current trends are still far from achieving millennium development goals. Sultania Zanana hospital is Obstetric and Gynaecology department of Gandhi Medical College. Being a tertiary care center it caters lot of high risk obstetric patients. These referred patients are from various government and private hospital from within and outside Bhopal.
Obstetric complications claim 514,000 women's lives each year. Nearly all of these lives would be saved if good quality emergency obstetric care in made available 24 hours a day, 7 days a week. Most of these deaths are caused by haemorrhage obstructed labour, infection (sepsis), unsafe abortions and eclampsia. Indirect causes like malaria, HIV and anaemia also contribute to maternal deaths [1].
About fifteen percent of all pregnancies will have some complication. Most complications occur randomly in both high and low risk patients. Life threatening complications can occur any time before, during and after delivery and quite often they are neither predictable nor preventable. However, if they are identified and addressed timely and if the basic and comprehensive emergency obstetric services are provided to all pregnant women closer to their homes; most of the maternal and perinatal deaths can be averted [2,3].
Early identification, initiation of early treatment and timely referrals are the crucial components for success of any maternal health intervention. Therefore, it is imperative to impart the knowledge and skills for early identification of complications and initiation of early treatment to all the health functionaries of the state.
The delay occurs at the following three levels - Delay in decision to seek medical care.  Delay in reaching health facility.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 38 |P a g e  Delay in receiving appropriate care at health facility due to staff insensitivity, lack of appropriate resources or poor organizational setups that is not conducive for emergency care.
The third delay (delay in receiving appropriate care at health facility) relates to factors in the health facility including quality of care. In practice it is crucial to address the third delay first, for it would be useless to facilitate access to a health facility, if it was not available, well-staffed, well equipped and providing good quality care [4].
Various health facilities within Bhopal are supposed to provide emergency obstetric carebut are not doing so, which causes overutilization of higher-level facilities like Sultaniazanana hospital. This is important because it has cost implications in resource constrained situations and because it may be detrimental to quality of care as the higher level facility becomes overburdened.
This study was conducted to evaluate obstetrics outcome in patients referred to Sultaniazanana hospital from within Bhopal. Various health facilities must provide the emergency obstetric care 24 hours a day, 7 days a week for successful implementation of safe motherhood programme.

Materials and Methods
The present study was a 1year prospective study conducted in Department of Obstetrics & Gynaecology, Sultania Zanana Hospital & Gandhi Medical College Bhopal, on 1249 obstetric patients in two phases. Each phase was of 6 month duration, In between two phases a workshop was conducted on strengthening of referral services to orient medical officers posted in various levels of health facilities regarding the referral system and protocol to be followed before referring the patient.
Selection of patients-All obstetric patients referred from inside Bhopal with or without referral letter.

Exclusion criteria
 All obstetric patients referred from outside Bhopal.  Booked patient of Sultaniazanana hospital.  All unbooked direct obstetrics patients to Sultaniazanana hospital.
A proforma was designed and data collected.The arrival time was recorded at Sultaniazanana hospital receiving room. The duration of stay at referring health institution was estimated by the patient in few and by their relatives in most cases.
Methods: All obstetric patients referred from inside Bhopal to Sultaniazanana hospital were studied. Detailed history was taken from patients or attendants regarding the age, Obstetric history, place of referral, duration of stay at referral centre, Management done at referral centre, Time and date of referral, Mode of conveyance and time taken Information given on referral letter.
Detailed clinical examination of the patient and findings noted in proforma.
The maternal outcome i.e. vaginal delivery, operative delivery and any other operative intervention and conservative management done was recorded.
Fetal outcome was recorded with reference to condition, need for NICU admission and still births and early neonatal deaths.

Statistical Analysis:
The data of the present study was fed into the computer and after its proper validation, checking for error, coding and decoding were compiled and analysed with the help of SPSS 11.5 software for windows. Appropriate univariate and bivariate analysis and ANOVA (analysis of variance) for more than two means were carried out using t-test, calculated and tested. All means are expressed as mean + standard deviation. The critical values for the significance of the results were considered at 0.05 levels.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 39 |P a g e The present study is a prospective study of 1year period on 1249 obstetric patients conducted in two phases of 6 months each. In between the two phase, divisional level workshop on "Strengtheningof Referral Services" was conducted.
Observations recorded in the study are as follows:  Maximum 16.9% of patients were referred in intrapartum period with no high risk factor associated, which proves to be unnecessary overburdening of the SZH. Among the high risk pregnencies, hypertensive disorders accounted for maximum i.e. 15.3% of the referrals followed by anaemia (14.5%) and Premature rupture of membrane (6.7%). Hypertensive disorder (50%) remain, the major cause of maternal death of followed by Haemorrhage (30%) [7].
de Bernis L et al emphasized on skilled attendants for pregnancy, childbirth and postnatal care. Their paper sets out the rationale for ensuring that all pregnant women have access to skilled health care practitioners during pregnancy and childbirth. It described why increasing access to a skilled attendant, especially at birth, is not only based on legitimate demand and clinical common sense, but is also cost-effective and feasible in resource-poor countries. Skilled attendants need to be supported by a health system providing a legal and policy infrastructure, an effective referral system and the supplies that are necessary for effective care. A skilled attendant providing skilled care will help achieve the goals of reducing both maternal and child mortality. Health care professionals as individual practitioners, leaders and informers have an important role in making this a reality [8]. Rabia  Indra N.did study of maternal and perinatal outcome in obstructed labour Obstructed labour (OL) is a major cause of both maternal and newborn morbidity and mortality. Obstructed labour ranked 41st in GBD 1990, representing 0.5% of the burden of all conditions and 22% of all maternal conditions. It was estimated to be the most disabling of all maternal conditions.
Obstructed labour accounts for 8% of maternal mortality in developing countries. Hence this study was conducted to study the causes, clinical feature and maternal and perinatal outcome in obstructed labour. It was concluded that majority of the patients were, emergency admissions and were from rural areas with high prevalence of and hence maternal morbidity and perinatal mortality was high. This can be improved with good antenatal care, patient education, early diagnosis and timely referral to higher centres. At tertiary centre with aggressive management and good neonatal care improves perinatal and maternal outcome [14].