saraswathi vedam, rm, msn, facnm, sci d (hc) director, division of midwifery
DESCRIPTION
De la Evidencia a la Acción: Estrategias Multidisciplinarias para la atención efectiva en maternidad. Saraswathi Vedam, RM, MSN, FACNM, Sci D (hc) Director, Division of Midwifery University of British Columbia 2010. Intervenciones Prioritarias de la FIGO. - PowerPoint PPT PresentationTRANSCRIPT
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De la Evidencia a la Acción:
Estrategias Multidisciplinarias para la atención efectiva en
maternidadSaraswathi Vedam, RM, MSN, FACNM, Sci D (hc)
Director, Division of Midwifery
University of British Columbia
2010
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Intervenciones Prioritarias de la FIGO
1. Mejorar la habilidad y uso de la atención obstétrica esencial para el manejo de complicaciones
2. Fortalecer servicios de planificación familiar
3. Asegurar atención calificada en el parto
4. Promover servicios de salud amigables para las mujeres
5. Aumentar planeación de distritos con participación
comunitaria
6. Monitoreo de procesos con indicadores de procesos
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Por que la atención de Partería?Perspectiva desde la Salud Publica
(WHO 2000, APHA 2001, SOGC 2008, Cochrane 2009)
• Atención basada en la evidencia– Mejores resultados maternos y fetales
– Uso apropiado de la tecnología
– Distribución de recursos
– Efectividad de costo
• Satisfacción de Clientes
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Resultados
• La literatura internacional ha demostrado la eficacia de las practicas de la partería con:– Resultados (Cochrane 2009; Gabay et al 1997; Jackson 2003; Turnbull 1996;
Walker J 2000)– Seguridad del Parto en Casa ( Janssen 2009, Hutton 2009, de Jonge
2009, Johnson and Daviss 2005; Weigers et al 1996; Olsen 1997; Ackermann and Liebrich 1996)
– Satisfacción del proveedor (Hundley et al 1995) and client (Rowley et al 1995; Hundley et al 1997; Morgan et al 1998; Jannssen et al 2006; Hildingsson et al 2003)
• La investigación en Norte América ha demostrado la seguridad del parto en casa y el deseo y la necesidad de parteras en entornos rurales (Kornelsen et al. 2005a; 2005b, 2008)
–
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Tasas de Atención de la Partería
• 10-80% atención a mujeres en países desarrollados (Malott, JOGC,2009)
• 30% Atención ginecológica dada por parteras
• 30-40% Atención primaria para mamas y bebes
• 70% atención a mujeres de bajos recursos a nivel internacional
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Quien elije la Partería?
• Socioeconomic status
• Education
• Rural vs. Urban
• Race
• Occupation
• Age and parity
• Marital status
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Estrategias Globales para integrar la parteria
• Regulation
• Education
• Recruitment and Retention
• Association
• Collaboration
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Acreditación y Rutas de Entrada
• CNM- Certified Nurse-Midwife
• CPM- Certified Professional Midwife
• LM- Licensed Midwife
• CM-Certified Midwife
• Registered Midwife
• Direct-Entry Midwife
• Traditional Midwife
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Partería Profesional• Atención y apoyo prenatal, durante el parto y
postparto
• Atención primaria del RN y nonios – Consulta de Lactancia – Valoración inmediata del RN
• Crianza y la Educación en Salud Publica– Vacunas, nutrición, crecimiento, primeros auxilios
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Regulación
• Europa, NZ, Australia, Canada, UK– Financiamiento publico para la regulación,
educación y la atención en partería
• Asia, África, Centro y Sur América
• EEUU
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Autonomía y Colaboración
• Códigos Federales y Estatales:– La partera es “un miembro independiente e
interdependiente del equipo de salud”
– Además de manejar y proveer servicios de salud, se asume que la partería “utilizara conocimientos y habilidades avanzadas para identificar condiciones anormales, diagnosticar problemas de salud, implementar planes de tratamiento y consultar, colaborar o referir a otros miembros del equipo de salud cuando sea apropiado en la atención de servicios”
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Colaboración Partera/Medico
• Consulta – eg. endocrine disorders, postdates, external version, dystocia, fear, comfort, culture, second stage
• Colaboracion – gestational diabetes, PIH, multiple gestation, preterm labor, gyn complications
• Referencia – surgical intervention – RM in supportive role for birth, resumes primary role PP
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Educación
• Competencias básicas• Habilidades expandidas• Rango de atención para distintos roles basados en
competencias• Programas de universidad, programas a distancia,
programas indígenas• Evaluación, revisión entre pares, control de calidad,
educación continua
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Modelo de Atención de la Partería
• Physical and psychosocial care• Antepartum and intrapartum testing• Time-prenatal, intrapartum, postpartum• Focus on education, self-care, partnership,
individualized care• Preventative model• Philosophy: normalcy and empowerment• Family centered care• Collaboration with health care team
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RN
RM RM
MD
RM
MDRN
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Contribuciones a la investigación en salud materna
• Métodos para asegurar mejores resultados
• Dolor y progreso del parto– Fisiología materna y los resultados de la
atención– Fisiología fetal y los efectos de la atención
• Valoración fetal
• Experiencia materna
• Depresión postparto
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Normal Labour & Birth: 5th International
Research Conference
The Benefits & Challenges of Preserving Physiologic Birth
Coast Coal Harbor Hotel
Vancouver, BCJuly 20-23, 2010
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Temas del Congreso 2010• Definir y describir el parto normal • Practicas • Información al Publico• Educación• Políticas publicas
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Atención Basada en la Evidencia:
El Parto en CasaSaraswathi Vedam RM, MSN, FACNM, Sci
D(hc)
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Quieres unparto en casa?
EstasLoca?
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Que tan común es el Parto en Casa?
• Tasas internacionales:– Great Britain (30% in 1960, 2-10% & today)
– Switzerland, Denmark, Canada ,US (2-5%)
– Australia and New Zealand (2-5% and )
– Netherlands (70% in 1970, 31% in 1991, 35%)
– WHO observations (82% of all birth)
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Es Seguro el Parto en Casa?
• Planeado vs. no planeado• Mortalidad o morbilidad• Problemas metodológicos con la
investigación– Falta de aleatoriedad
– Co-Factores (tipo de proveedor, traslado,etc)
– Pequeños estudios homogenizados
– Diferencias en definiciones entre países
– Datos incompletos (estudios de actas de nacimiento)
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Recent Controlled Trials
• Northern Region Perinatal Mortality Survey• National Birthday Trust Study• Ackerman-Liebrich et al.,1996• Wiegers, Keirse, et al., 1996• Meta-analyses, Olsen, 1997, 2000• Murphy and Fullerton, 1998• Janssen, 2002, 2006, 2009• Hutton 2009, de Jonge 2009
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Calidad de la Evidencia - 2009
• Janssen et al, CMAJ
• Hutton et al, Birth
• de Jonge, BJOG
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de Jonge, et al, BJOG
• 529,688 women in midwifery care at labour onset (2000-2006)
• Planned home births: 321,301 (60%)
• Planned hospital births: 163, 261 (31%)
• No significant differences between home and hospital for perinatal mortality and morbidity
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Hutton, et al, Birth
• 6692 women planning home births matched with 6692 planning hospital births
• Lower CS rates, and neonatal morbidity/mortality among women planning a home birth, no maternal loss
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Janssen, et al, CMAJ
• Prospective five-year long cohort study – midwife-attended PHB (2802) – physician attended hospital birth group (N=5985)
– midwife attended hospital birth group (N=5984).
• Similar or reduced rates of adverse outcomes with significantly fewer intrapartum interventions
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Mortalidad y Morbilidad• Mortalidad Perinatal
– comparable home birth populations - 1-2/1000– U.S. Birth Centers - 1.3/1000– Uncomplicated hospital births - 1-2/1000
• Resultados Maternos y Fetales– less medical interventions (induction,augmentation,
episiotomy, operative vaginal birth, and cesarean)– better Apgar scores, less severe lacerations– findings supported by clinical trials of elements of
care
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Traslados de Casa al Hospital
• 10-20% antepartum referrals for obstetric reasons (IUGR, previa, PIH, twins, preterm)
• 5-8% intrapartum referrals • 1% postpartum maternal referrals• 1% neonatal referrals• urgent transfer 1/1000• 30 minute rule
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Razones de Traslado
• Falta de dilatación (65-75%)• Deseo de apoyo farmacológico/anestesia • Ruptura de membranas prolongada• Meconio• Presentación no-cefalica• Foco Fetal Anormal• Sangrado• Hipertensión
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Razones de Traslado postparto• Materno
– Reparación de laceración– Retención de placenta– Hemorragia postparto
• Neonatal– Falta de establecimiento de respiraciones
normales– Anomalías congénitas– Bajo peso al nacer– Bajo APGAR– Trauma al nacer– Sepsis
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Conclusiones• “Seguridad en mujeres seleccionadas, con
infraestructura y apoyo adecuados” Springer and VanWeel, BMJ, 1996
• Meta debería ser “maximizar el resultado [materno/fetal] con intervenciones mínimas” Weigers, Keirse, et al, BMJ 1996
• Buenos resultados y partos en casa exitosos están fuertemente relacionados a una fuerte relación entre proveedora y paciente
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong infrastructure support
• Access to medical consultation and referral
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong provider/patient relationship
• Timely access to consultation and referral
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The Midwife’s Lens:
Does this mother or baby have some condition that would benefit from the additional equipment or personnel that the hospital has to offer?
04/19/23 43
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General Criteria
– good general health and a healthy pregnancy– shared responsibility for care– adequate social support network– birth without pharmacologic analgesia or
anesthesia– preparation of participants and the birthing
environment – open and clear communication with the midwife– transport plan
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Medical Consultation
• Rh incompatibility with a rise in titer• Drug or alcohol addiction • Multiple pregnancy• Polyhydramnios or oligohydramnios• Insulin dependent diabetes• Maternal history of small-for-dates babies• Intrauterine growth retardation• Significant maternal anemia at term
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Medical Consultations (2 of 2)
• History of severe postpartum hemorrhage• Pre-eclampsia• Placenta previa• Prematurity• Abnormal presentation • Primary herpes infection in labor• Positive serology for syphilis• Positive surface antigen for Hepatitis B• Positive HIV• Unexplained antepartum bleeding (especially after first
trimester)
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Labor and Delivery Complications Requiring Hospitalization
• Fetal heart rate persistently over 160 or under 100• Abnormal intrapartum bleeding• Prolonged labor with no evidence of progress• Cord prolapse• Elevated maternal temperature with ruptured membranes• Severe or persistent postpartum hemorrhage• Retained placenta• Newborn health status unstable• Discretion of attendant
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong provider/patient relationship
• Timely access to consultation and referral
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Basic Skills for Attendants
• Ability to monitor maternal and fetal condition, and assess and treat common ob conditions, with low tech methods
• Ability to screen for complications requiring hospitalization and initiate referral
• Ability to manage complications if delivery is imminent or condition prohibits transfer
• Neonatal resuscitation• Specialized competencies for rural and remote
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong provider/patient relationship
• Timely access to consultation and referral
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Essentials for the “Birth Bag”
• Sterile tray (delivery instruments, gloves, etc)• Doppler, fetascope, BP cuff, stethoscope• Resuscitation equipment (O2, suction, ambu)• Medications (pitocin, methergine, antibiotics)• Suturing supplies• IV supplies• Scales, blood collection tubes, catheters,….
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Parent Supplies for Home Birth
• Sources of Heat, Light, and Water
• Foods and fluids
• Clean pads, baby supplies, etc
• Emergency plan - numbers, maps, car
• Clear surfaces, firm surfaces
• Cleaning supplies
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong provider/patient relationship
• Timely access to consultation and referral
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Framework for Optimal Care
• Screening criteria
• Basic skills necessary as attendants
• Basic equipment
• Continuity of care
• Strong provider/patient relationship
• Access to consultation and referral
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Homebirth Integrated
• Midwife in attendance from active labour• Notifies Hospital on arrival and after birth• Sets up equipment• Completes regular assessments• Documents care• Contacts 2nd attendant when indicated• Cleans up after birth• Departs home 2-3 hours after birth
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MD/Midwifery Relationships
• MD consultant chart review antepartum• Specific MD consultants, AP and OB
competencies• Labor and delivery summaries shared with
pediatric consultants• Joint reviews of transfers
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Obstetric Consultant Role
• 24hr availability by phone or pager
• Provides consultant or collaborative care
• Willing to preserve as much of birth plan as possible
• Involves RM (as primary OB provider) in decision making process
• Assumes primary care role as necessary
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Pediatric Care of the Normal Neonate
• RM roles and responsibilities
• Client responsibilities
• Client meeting with pediatric provider
• Lactation Consultation
• Immediate newborn assessment
• Newborn screening
• Follow-up care
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MD/RM Collaborative Care of the At-Risk Neonate
• Conditions requiring consultation and/or transfer of care
• Anticipation and preparation for unforeseen complications
• Communication with and transport to pediatric staff
• RM roles in ongoing care
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Barriers to Practice
• Lack of knowledge in hospital staff or community providers re:– home birth standards of care– planned vs unplanned home birth
• Inability to secure hospital privileges• Hostile tx of clients• Lack of neonatal trained transport personnel• Payment, access to appropriate facility
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Resolviendo los retos en Recursos Humanos
• Servicios de maternidad rurales– Aumentar oferta de proveedores– Modelos y apoyo para colaboración inter-
profesional– Preparar a las graduadas para la practica rural
• Apoyar la salud materna basada en la evidencia– Mantener la actualización de los proveedores– Evaluar practicas y modelos de practicas– Documentar y evaluar métodos para aumentar el
acceso
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Hornby Island
Squamish
Maple Ridge
Haida Gwai
Comox
Bowen Island
Mission
UBC Midwiferymeeting the needs of
rural communities
Penticton/Naramata
Class of 2010
Class of 2009
Class of 2008
Duncan
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Salud de las Mujeres en el Nuevo Milenio
• Medicina basada en la evidencia• Uso apropiado de la tecnología y los recursos• Mas investigación sobre factores mas allá de la
mortalidad y la morbilidad– Los efectos del entorno del parto en el trabajo de
parto– La influencia de la ansiedad materna y del
proveedor– Efectos de la experiencia del parto en el bienestar
físico y psicológico a largo plazo
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La Partera profesional en Mexico
Continuidad y Colaboración