Introduction

The Sixth Saving Mothers Report for South Africa spanning the period between 2011 and 2013 placed the institutional maternal mortality ratio (iMMR) for South Africa at 154.06 deaths per 100,000 live births . Although a 12.6% decrease in the iMMR was noted from the previous report, of concern was the large number of avoidable deaths. Lack of appropriately trained doctors and nurses contributed significantly towards maternal deaths accounting for 15.8% and 8.8% of maternal deaths, respectively. The main causes of maternal deaths in South Africa have still remained the same for the last evaluated triennium with non-pregnancy-related infections, mainly acquired immune deficiency syndrome (AIDS) (37.71%), obstetric haemorrhage (15.79%), hypertensive disorders of pregnancy (14.77%), medical and surgical disorders (11.38%) and pregnancy-related sepsis (5.22%) making up the top five causes of death . Health-care professional (HCP) training and a commitment to quality were identified as two of the 10 priority recommendations . The need to train all HCPs in the Essential Steps in Managing Obstetric Emergencies (ESMOE) using Emergency Obstetric Simulation Training (EOST) as the means of delivery is included in these recommendations. A commitment to quality included clinical governance and the need to have regular EOSTs or fire drills at the workplace as well as ensuring that managers appropriately assess and accredit HCPs to ensure that they have the requisite competencies .

The training of HCPs is a major challenge in South Africa, which is beset with problems of high attrition rates of staff in the public health sector due to unfavourable working conditions . Despite initiatives to roll out the ESMOE training programmes to all institutions through structured ‘master trainer’ workshops, the high attrition rates of HCPs place an additional burden on institutions providing the training. For training to be effective, sustainability at an institutional level needs to be maintained preferably with a local champion who can ensure that training is ongoing and relevant. Simulation-based training such as EOST can be effectively implemented in rural- and resource-constrained settings in South Africa as evidence exists that it does improve HCP competencies .

Training in maternal resuscitation

Maternal collapse can be used to define a range of medical events varying from a simple faint to cardiac arrest . For the aim of this review, only collapse resulting in life-threatening events will be discussed. The adage coined from Dr. Thomas Petty: “… the best treatment of status asthmaticus is to treat it three days before it occurs,” can easily be applied to maternal collapse . There may be early signal signs and symptoms that a woman has a potentially life-threatening illness, which is often ignored or treated nonchalantly.

Vignette: A 36-year-old patient presented to the antenatal clinic on multiple occasions during her third pregnancy with dyspnoea. She was treated by various midwives and doctors for various conditions, which included bronchitis and ‘panic attacks’. After the birth of her third child, she elected to have a tubal ligation that was done under spinal anaesthesia. During the procedure, she developed distress from severe pulmonary oedema. She required intubation and subsequent transfer to an intensive care unit (ICU). It was later discovered that this patient had severe mitral stenosis. She died in the ICU many days later. The early recognition and investigation of her symptoms that suggested severe underlying cardiac disease may have prevented this death. The key learning point from this case is that doctors working in obstetrics and anaesthetics need to have good baseline clinical competencies on being able to recognize and manage/refer high-risk pregnancies.

The ESMOE course has the following modules: maternal resuscitation and the unconscious patient, resuscitation of the newborn, sepsis and miscarriage, eclampsia and severe pre-eclampsia, haemorrhage, obstetric emergencies (breech and twin delivery), obstetric emergencies (shoulder dystocia and cord prolapse), assisted delivery, human immunodeficiency virus (HIV), surgical skills, intrapartum care and interpreting the cardiotocograph . Participants undergoing this course, which includes undergraduate students, midwives, paramedics, interns, medical officers, registrars and specialists, are first given short lectures. Factual knowledge provided through PowerPoint presentation is reinforced when this knowledge is applied in the EOST, which speaks to ‘shows how’ in Millers framework for clinical assessment . Participants are encouraged to work as a team, which may comprise doctors and nurses or nurses only to better simulate the true work environment. Reflection and feedback from the participants as well as from the observers and finally the facilitator input reinforce understanding and application. The group then does the simulation again, and they invariably tend to improve their performance quite significantly. It is anticipated that EOST if done regularly in the clinical unit will also strengthen teamwork and interdisciplinary collaboration .

Maternal collapse, usually identified by a loss of consciousness, results in the activation of the emergency response system in the clinical unit. It is therefore important that all nursing and medical personnel are adequately trained in providing basic life support (BLS) . Nursing personnel are usually the first respondents, so training in BLS including early defibrillation using an automated external defibrillator (AED) is critical for all nursing personnel . One local hospital has implemented a performance management system for all nurses, which requires them to have an updated BLS certificate in order to qualify for an annual pay progression.

Maternal resuscitation requires that the first respondent to a cardiac arrest activates the emergency response system, documents time of the collapse, places the patient supine and begins chest compressions according to the BLS algorithm . When the team arrives with the resuscitation equipment, certain interventions are standard as per Advanced Cardiac Life Support (ACLS) algorithms. These include the following:

• i.

  Prevent delays in defibrillation

• ii.

  Give ACLS drugs and doses as per normal ACLS protocols

• iii.

  Ventilate with 100% oxygen

• iv.

  Ideally, one should use continuous capnography for the confirmation of tube placement and ongoing monitoring, but this is not always available in South African settings

• v.

  Monitor the quality of cardiopulmonary resuscitation (CPR)

• vi.

  Provide postcardiac arrest care as appropriate

Maternal resuscitation is taught by first making participants aware of the differences between resuscitating an adult patient and an adult pregnant or postpartum patient. The physiological differences are highlighted. The important changes that are specific to pregnancy especially when a woman is >20 weeks pregnant include the following:

• i.

  Ensuring at least 15° of lateral tilt of the pelvis or manual displacement of the uterus. Manual displacement is thought to have less of an effect on the quality of chest compressions .

• ii.

  Perimortem hysterotomy or caesarean delivery (CD) needs to be considered at the onset of cardiac arrest, implemented within 4 min of starting resuscitation and completed within 5 min of cardiac arrest .

• iii.

  Early intubation to prevent aspiration with a smaller endotracheal tube .

• iv.

  Woman in the third trimester should have chest compressions performed 2–3 cm above the inter-nipple line .

In addition, the following are important practice points:

• i.

  Start intravenous (IV) lines above the diaphragm.

• ii.

  Assess for hypovolaemia and give fluid boluses when required.

• iii.

  If the woman has been receiving magnesium sulphate, stop this infusion and give IV calcium chloride/gluconate.

• iv.

  Continue with all maternal resuscitative efforts during and after hysterotomy/CD .

Training in the maternal resuscitation module is then reinforced with skill sessions dealing specifically with airway management, which teaches candidates how to appropriately administer different concentrations of oxygen using various oxygen delivery devices, performing endotracheal intubation, using the laryngeal mask airway when a difficult airway is encountered and performing a surgical cricothyroidotomy when there is an obstructed airway. BLS skills are taught, and emphasis is placed on the quality of chest compressions, ventilating using a bag–valve mask and performing defibrillation using an AED or a defibrillator. Finally, participants are asked to work in a team performing a resuscitation of a patient with cardiac arrest as well as an unconscious patient with a pulse. A fire-drill scoring sheet is used, which includes a clinical score and a drill execution score. The drill execution score consists of activation of the emergency response system, communication skills, teamwork, documentation and the sequence in which the drill is performed. Reflection, feedback and re-practice are then performed. Designation of team members, which include a team leader, a scribe who also keeps the time, a person who performs chest compression, a person who performs ventilation, a person who is responsible for the monitors and who also performs the defibrillation and finally a person who sets up the IV lines, does the necessary investigations and administers the IV drugs, helps with role definition in the simulation . Communication among team members is facilitated using the ‘check–recheck’ when interventions are suggested and confirmed . The team is also encouraged to identify the causes of cardiac arrest in the scenarios being painted, and to also define pathways for definitive management.

Training in maternal resuscitation

Maternal collapse can be used to define a range of medical events varying from a simple faint to cardiac arrest . For the aim of this review, only collapse resulting in life-threatening events will be discussed. The adage coined from Dr. Thomas Petty: “… the best treatment of status asthmaticus is to treat it three days before it occurs,” can easily be applied to maternal collapse . There may be early signal signs and symptoms that a woman has a potentially life-threatening illness, which is often ignored or treated nonchalantly.

Vignette: A 36-year-old patient presented to the antenatal clinic on multiple occasions during her third pregnancy with dyspnoea. She was treated by various midwives and doctors for various conditions, which included bronchitis and ‘panic attacks’. After the birth of her third child, she elected to have a tubal ligation that was done under spinal anaesthesia. During the procedure, she developed distress from severe pulmonary oedema. She required intubation and subsequent transfer to an intensive care unit (ICU). It was later discovered that this patient had severe mitral stenosis. She died in the ICU many days later. The early recognition and investigation of her symptoms that suggested severe underlying cardiac disease may have prevented this death. The key learning point from this case is that doctors working in obstetrics and anaesthetics need to have good baseline clinical competencies on being able to recognize and manage/refer high-risk pregnancies.

The ESMOE course has the following modules: maternal resuscitation and the unconscious patient, resuscitation of the newborn, sepsis and miscarriage, eclampsia and severe pre-eclampsia, haemorrhage, obstetric emergencies (breech and twin delivery), obstetric emergencies (shoulder dystocia and cord prolapse), assisted delivery, human immunodeficiency virus (HIV), surgical skills, intrapartum care and interpreting the cardiotocograph . Participants undergoing this course, which includes undergraduate students, midwives, paramedics, interns, medical officers, registrars and specialists, are first given short lectures. Factual knowledge provided through PowerPoint presentation is reinforced when this knowledge is applied in the EOST, which speaks to ‘shows how’ in Millers framework for clinical assessment . Participants are encouraged to work as a team, which may comprise doctors and nurses or nurses only to better simulate the true work environment. Reflection and feedback from the participants as well as from the observers and finally the facilitator input reinforce understanding and application. The group then does the simulation again, and they invariably tend to improve their performance quite significantly. It is anticipated that EOST if done regularly in the clinical unit will also strengthen teamwork and interdisciplinary collaboration .

Maternal collapse, usually identified by a loss of consciousness, results in the activation of the emergency response system in the clinical unit. It is therefore important that all nursing and medical personnel are adequately trained in providing basic life support (BLS) . Nursing personnel are usually the first respondents, so training in BLS including early defibrillation using an automated external defibrillator (AED) is critical for all nursing personnel . One local hospital has implemented a performance management system for all nurses, which requires them to have an updated BLS certificate in order to qualify for an annual pay progression.

Maternal resuscitation requires that the first respondent to a cardiac arrest activates the emergency response system, documents time of the collapse, places the patient supine and begins chest compressions according to the BLS algorithm . When the team arrives with the resuscitation equipment, certain interventions are standard as per Advanced Cardiac Life Support (ACLS) algorithms. These include the following:

• i.

  Prevent delays in defibrillation

• ii.

  Give ACLS drugs and doses as per normal ACLS protocols

• iii.

  Ventilate with 100% oxygen

• iv.

  Ideally, one should use continuous capnography for the confirmation of tube placement and ongoing monitoring, but this is not always available in South African settings

• v.

  Monitor the quality of cardiopulmonary resuscitation (CPR)

• vi.

  Provide postcardiac arrest care as appropriate

Maternal resuscitation is taught by first making participants aware of the differences between resuscitating an adult patient and an adult pregnant or postpartum patient. The physiological differences are highlighted. The important changes that are specific to pregnancy especially when a woman is >20 weeks pregnant include the following:

• i.

  Ensuring at least 15° of lateral tilt of the pelvis or manual displacement of the uterus. Manual displacement is thought to have less of an effect on the quality of chest compressions .

• ii.

  Perimortem hysterotomy or caesarean delivery (CD) needs to be considered at the onset of cardiac arrest, implemented within 4 min of starting resuscitation and completed within 5 min of cardiac arrest .

• iii.

  Early intubation to prevent aspiration with a smaller endotracheal tube .

• iv.

  Woman in the third trimester should have chest compressions performed 2–3 cm above the inter-nipple line .

In addition, the following are important practice points:

• i.

  Start intravenous (IV) lines above the diaphragm.

• ii.

  Assess for hypovolaemia and give fluid boluses when required.

• iii.

  If the woman has been receiving magnesium sulphate, stop this infusion and give IV calcium chloride/gluconate.

• iv.

  Continue with all maternal resuscitative efforts during and after hysterotomy/CD .

Training in the maternal resuscitation module is then reinforced with skill sessions dealing specifically with airway management, which teaches candidates how to appropriately administer different concentrations of oxygen using various oxygen delivery devices, performing endotracheal intubation, using the laryngeal mask airway when a difficult airway is encountered and performing a surgical cricothyroidotomy when there is an obstructed airway. BLS skills are taught, and emphasis is placed on the quality of chest compressions, ventilating using a bag–valve mask and performing defibrillation using an AED or a defibrillator. Finally, participants are asked to work in a team performing a resuscitation of a patient with cardiac arrest as well as an unconscious patient with a pulse. A fire-drill scoring sheet is used, which includes a clinical score and a drill execution score. The drill execution score consists of activation of the emergency response system, communication skills, teamwork, documentation and the sequence in which the drill is performed. Reflection, feedback and re-practice are then performed. Designation of team members, which include a team leader, a scribe who also keeps the time, a person who performs chest compression, a person who performs ventilation, a person who is responsible for the monitors and who also performs the defibrillation and finally a person who sets up the IV lines, does the necessary investigations and administers the IV drugs, helps with role definition in the simulation . Communication among team members is facilitated using the ‘check–recheck’ when interventions are suggested and confirmed . The team is also encouraged to identify the causes of cardiac arrest in the scenarios being painted, and to also define pathways for definitive management.