NON-PNEUMATIC ANTI SHOCK GARMENT: A Tool For Reducing Maternal Morbidity & Mortality In Nigeria

     

In developing countries post partum Hemorrhage (PPH) continues to be the single most common cause of maternal morbidity & mortality, accounting for approximately 25% of maternal deaths Globally and over 90% of these deaths occurs in developing counties, for women suffering from uncontrollable PPH, a method to control the bleeding, reverse the shock and stabilize the patients is a life saving skill, one method to manage PPH is the use of a Non – pneumatic Anti Shock garment (NASG).

NASG is a low technology first aid device used to treat hypovolemic shock. Its efficacy for reducing maternal deaths due to obstetrical haemorrhage is being researched. Obstetrical hemorrhage is heavy bleeding of a woman during or shortly after a pregnancy. Many women in resource poor settings deliver far from health care facilities. Once hemorrhage has been identified, many women die before reaching or receiving adequate treatment. The NASG can be used to keep women alive until they can get the treatment they need.

Every year, an estimated 342,900 women die from complications of pregnancy and child birth, 99% of these deaths occur in developing countries. Worldwide, for every 100,000 live births, about 251 women die. In some industrialized countries such as the U.S, this is 13 death for every 100,000 live babies born with American women having a life time risk of 1 in 2,100 of dying from childbirth related complications. However in some countries, such as Afghanistan up to 1,600 women die for every 100,000 live births and women have a I in II life time risk of maternal death.

“World Health Organization (WHO)” defined MM as “the death of a woman while pregnant or with in 42 days of termination lof pregnancy, irrespective of the duration, site of the pregnancy, from any cause related or aggregated by the pregnancy or its management but not from accidental or incidental causes”

For every woman who dies, there are 30 women who suffer a disability as a result of pregnancy or child birth related complications (or maternal mortality) and 10 who experiences a near miss mortality. (a life-threatening obstetric complication). Morbidities can be serious, lifelong ailment which compromise a woman’s health, productivity, quality of life, family health and ability to participate in community life. If a mother die after childbirth, the newborn is then ten times more likely to die before the age of two, other children are more likely to suffer from poor nutrition and schooling. Many motherless families find it difficult to survive; often with older children having to drop out of school in order to work to help supports the family or being sent to live with a relative. In addition to this, maternal and newborn death , have estimated to cost the world 15 billion US dollars in lost of productivity annually, with maternal health proven to support a country’s economic growth and cut poverty. Maternal death and disability is a human rights issue. It also means hardships and loss of productivity for families, communities and nations.  This is of such great concern that in 2000, world leaders decided that improving maternal health should be one of the 8 millennium development Goals for the international community. To prevent these deaths, there are some emerging technologies which are currently being researched and implemented that seek to prevent these unnecessary deaths. One of these device is NASG, Which is a low technology first-aid device.

In the 1900s an inflatable pressure suit was developed by Crile. It was used to maintain blood pressure during surgery. In the 1940s and after undergoing numerous modifications, the suit was refined for use as an Anti-gravity suit (G-Suit). Further modification led to its use in the Vietnam war for resuscitating and stabilizing soldiers with traumatic injuries from and during transportation. In the 1970s the G-Suit was modified in to a half suit which became known as MAST (Military Anti-Shock Trousers) PASG (Pneumatic Anti-shock Garment).

During the 1980s the PASG garment became used more and more by emergency rescue services to stabilize patient with shock due to lower body haemorrhage. During the 1990s the PASG was added to the American College of obstetrics and Genecology making the part of the recommendation treatment for use by obstetricians and gynecologists in the USA. From the 1970s the new version of a non-preumatic anti-shock garment was developed which was originally used for hemophiliac children but has since been developed into the garment known as NASG.

In 2002 Dr. Carol Bress and Dr. Paul Hensleigh introduced the garment into a hospital in pakistan. Dr. Suellen Miller and colleagues in Mexico, Egypt and Nigeria have completed studies of the NASG (also named the lifewrap). An implementation program with the NASG as part of a continuum of care for post-partum Hemprrhage (CCPPH) has been under way since 2008 in India, Nigeria, Tanzania, Zamfara, Zimbabwe and Peru. The NGO pathfinder international is the lead implementing organization on the CCPPH project and done extensive clinical trials with the device as an obstetric first aid.

The non-preumatic anti-shock garment (NASG) is a simple neoprene and velcro device that looks like trouser, cut into segment, which is used to treat shock, recusitate, stabilize and prevent further bleeding in women with obstetric hemorrhage.

The non-pneumatic Anti-shock garment is a low technology first aid device use to treat hypovolemic shock. When in shock the brain, heart and lungs are deprived of oxygen because blood accumulates on the lower abdomen and legs. The NASG reverses shock by returning (Like 1.5 – 2 litres) of blood to the heart, lungs and brain and so also kidneys. This restores the womans consciousness, pulse and blood pressure. Additionally, the NASG decreases bleeding from the parts of the body compressed under it.

Mechanism of actions are based upon law of physics. Recent research has identified that the pressure applied by the NASG serves to significantly increase the resistive index of the internal iliac artery (which is responsible for supplying the majority of blood flow to the uterus via the uterine arteries another recent study has shown the NASG to decrease blood flow in the distal aorta.

Another research shown that circumferential compression of the abdomen and legs reduces total vascular volume while expanding the central circulation. It increases pre-load, peripheral resistance and cardiac output. Tamponade of vessels particularly the splanchnic plexues (are paired visceral nerves that contribute to the innervation of the internal organs) can diminish further bleeding. After a simple training session, anyone can put the garment on a bleeding woman including Doctors, Nurses, Midwives, Ambulance Driver, Health attendant, Traditional Birth Attendants. Once the bleeding is controlled she can be safely transported to a referral hospital for further management.

The NASG can be applied

– If pulse is 100 bpm and above

– Systolic blood pressure is 100 and below MMHG while NASG can be removed

– If pulse rate is 100 bpm and below

Systolic blood pressure is 100 and above mmHg

1. If possible it should be on a flat surface.

2. Open NASG and place under the woman with the top of the garment at her lower ribs. If the patient is unconscious, two people can roll her on to her side placing the garment under health her similar to making an occupied bed.

3. Stretch and fasten the garment tightly until it makes a snappy sound, starting with the ankle segment (#1)

4. Continue with #2 segment below the knee and #3 segment around the thighs, for shorter women fold segment #1 into segment #2 before starting.

5. Secure the pelvic segment (#4) tightly at the level of the symphysis pubis. Only one person should secure the pelvis and abdominal segments

6. Place segment #5 over the navel (umbilicus), close by securing segment #6

CAUTION: – If woman is conscious and experiences or complains of difficulty in breathing, slightly loosen but do not remove the abdominal segment. If NASG application does not result in prompt increase in SBP and decrease pulse, check for adequate tightness and give additional I/V fluids.

NASG must be removed only by a skilled health care provider in a setting where vital signs can be monitored, and there are adequate I/V fluids and blood (should in case). It should not be removed until the woman is haemodynamically stable for at least 2 hours with blood loss of 50ml/hour. start removing from the ankle and proceed upwards allow 15 minutes between opening each segment for the redistribution of blood. Make sure pulse is 100 and below bpm and systolic BP is 100 and above mmHg

In Egypt and Nigeria, in separate and combined analyses, findings showed that women treated with the NASG fared much better than women who were not treated with the NASG. Results showed significant reductions in blood loss, rate of emergency hysterectomy and incidence of morbidity and mortality. Analyses examining the use of the NASG on cases of uterine atony, post partum hemorrhage and non-atonic etiologies (ante and post-partum) fund similar results.

In conclusion, Qualitative research in Mexico and Nigeria has examined acceptance of the NASG and found that overall, there were positive reactions to the garment as a relevant technology for saving womens lives. Research is currently on going in Zambia and Zimbabwe to investigate whether the NASG is more successful if implemented at primary health care facilities where hemorrhage is first identified.

In 2012, the world health organization included the NASG in its recommendations for the treatment of post partum hemorrhage.

BY BILKISU UMAR BAYERO (RN, RM, RNT, HPDCS, BNSC)

Commission on Behavioral and social Sciences and Education (CBASSE) (2000). The consequences of maternal morbidity and mortality. Report of workshop. Washington, D.C. the National Academes

Cutler BS, Daggett WM. application of the “G-suit” to the control of hemorihage in massive trauma Annsurg. 1971

Huggerty J. Anti shock Garment 1996 [cited: Available from:http://www.sti.nasa.gov/tto/spinoff1996/28html

Miller, Hadiza Galadanchi et.al (2010) “Obstetric hemorrhage and shock management: using the low technology Non-preumatic Anti shock Garment. In Nigerian and Egyptian tertiary care facilities”.

Procedure manual for BNSC programme (2015) Department of Nursing Sciences, Bayero University Kano.

WHO, UNICEF, UNFPA. Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNfPA: 2004

Wikipedia