A project in a Papua New Guinean hospital has changed the way staff manage the second stage of labour and reduced the perinatal death rate.
Papua New Guinea (PNG) is one of the countries in the world that still is experiencing high maternal mortality, currently 230 per 100 000 live births. PNG was ranked in the bottom 20 of 161 in the recent index of health workers’ impact of the countries that were surveyed. It is well documented that PNG will not meet the UN’s 2015 Millennium Development Goals. UNICEF is also warning that the country may fail to meet targets on reducing infant mortality.
Although postnatal and child mortality rates have declined dramatically in many developing countries in recent years, neonatal mortality rates remain high in many developing countries and PNG is one of those countries. These deaths either occur at home or at a health facility and most are attributable to infections, birth asphyxia and injuries, consequences of prematurity, low birthweight and congenital anomalies.
St Mary’s Hospital
Saint Mary’s Hospital at Vunapope, East New Britain in PNG is a Catholic-church-run health facility. Established in the 1930s by German missionaries, St Mary’s has been delivering health services for more than 80 years to a population of more than 100 000 living in the Gazelle Peninsula and the nearby provinces. After the twin volcanic eruption, in 1994, a large portion of the population was shifted to the surroundings at Kokopo; and this has greatly impacted on the current service delivery in the hospital. The town itself is rapidly growing and, just recently, the government of PNG announced the town will become the tourist city. In coming years the town will truly experience an economic boom.
The hospital functions as the second referral hospital in the province, catering for referrals from 19 health facilities in the surrounding region. St Mary’s has 200 beds, however, most of the time it has more patients than its capacity, just as in other areas in PNG where provincial hospitals are overcrowded.
The Churches Medical Council established and approved a staff ceiling of 40 nursing officers and 41 community health workers in 1995 and, to date, the ceiling has remained in place, despite the tremendous increase in workload.
Obstetrics and gynaecology is the busiest unit in the hospital. There has been an increase in the number of deliveries in the last five years owing to a variety of reasons: the influx of people into Kokopo for business or other activities and because the hospital has a good reputation in providing quality healthcare in the region, therefore more patients choose to come to St Mary’s.
The maternity wing is a complex and a busy department in the hospital, with a capacity of 74 beds. The postnatal section has a total of 30 beds, gynaecology has 20 beds, the surgical section four beds, full nursing care has three beds, the labour ward has seven beds and the special care nursery has ten baby cots and is taken care of by the maternity ward staff. There is also a bed in the consultation clinic.
The maternity department needs to provide a high-quality care service to the majority of the women in the province. To this end, standard medical equipment must be available and appropriate adaptations and applications of inexpensive simple methods to improve antenatal, obstetric and neonatal care are needed to assist clinical nursing and obstetrics and gynaecology medical staff with the procedures to save lives. Currently, clinical staff are functioning with whatever resources are available to save the lives of women and babies, especially in cases of obstetric complications and emergencies. The wing also needs a mini clinical lab where ongoing clinical training can be conducted onsite. This includes mannequins, updated library books and an office space to do clinical presentations and teachings.
A project is currently being carried out to find a way to reduce the number of stillbirths and perinatal deaths that occur in the labour ward. It has been discovered that improving on the management of second stage of labour makes a difference. This project is being conducted by a team consisting of two medical doctors and three midwives. The mission is to reduce the number of neonatal deaths as a result of improved management of women during the second stage of labour.
As part of the project, a number of key interventions have been instituted: a labour ward inventory checklist and neonatal emergency trolley checklist; regular training of students and staff; neonatal death reviews; case study exercises; debriefing; regular in-service training on the use of the partogram; active management of second stage of labour; and neonatal resuscitation.
From January to September 2012, 110 perinatal deaths were recorded. From October to December 2012, after improving on the management of second stage of labour and preventative measures – such as neonatal resuscitation, delaying in cutting umbilical cord when baby cries immediately, breastfeeding the baby within an hour of delivery and exclusively breastfeeding the baby – the stillbirth and perinatal death rate decreased by 30 per cent. From January to June 2013, there was a big improvement in the reduction of stillbirths and perinatal deaths where we saw only about ten per cent of the total deaths.
With limited resources available, normal nursing duties are performed, but not to always to the total satisfaction of patients’ expectations. The clinical staff, regardless of their qualifications, can perform deliveries competently and are able to detect problems and act accordingly before complications arise.
A number of measures are in place to maintain the improvements in practice in the labour ward; these include ongoing education and training, understanding of the documentation of protocols and guidelines used in the PNG Standard Management Manuals; and strengthening the current systems to guide practice. A number of future plans are underway to strengthen services and networks for hospital medical and nursing staff, including the provincial family health service coordinator.
To maintain our practice, there is ongoing training and education of clinical staff by the specialist obstetrician and gynaecologist, Dr Tanmay Bagade (WHO-UTS), assisted by the registrar and the midwives. All documentation of protocols and guidelines for clinical staff are maintained and taught to junior nurses.
The hospital has started another pilot project to train community health workers, these community health workers to have the midwifery skills. This project is also contributing in training the nurse assistants to identify problems and refer or report immediately to keep perinatal and neonatal death statistics low.
In conclusion, this project saw that improved management of the second stage of labour lowered the stillbirth and perinatal death rate in our hospital.
The author would like to thank the following people: Carmel Walker, RANZCOG; Dr Tanmay Bagade, for his teaching and the running of the obstetrics and gynaecology division; Sr Maria Posanek, midwife, for sharing her wealth of knowledge and experience; the hard working nurses in the maternity division; all other ancillary staff of the hospital; and, finally, the management of St Mary’s Hospital.