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Table of Contents
POINT OF VIEW
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 32-39

Delivering obstetrical critical care in developing nations


1 Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India

Date of Web Publication11-Apr-2012

Correspondence Address:
Sukhminder Jit Singh Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.94897

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   Abstract 

Obstetrical critical care has not been able to achieve the same level of peaks in developing nations like India, as in the western countries. Numerous factors, including clinical and economical, have played a major role in widening the gap of quality care delivery in severely ill obstetric patients, between the two extreme worlds. Moreover, this wide gap can be, to a large extent, attributable to the lower literacy rates, paucity of research in obstetrical critical care, poverty, lack of awareness, and the sociocultural and behavioral factors prevalent in these developing nations. The most common indication for Intensive Care Unit (ICU) admission of such patients throughout the world is hemorrhage, both antepartum and postpartum. Hypertensive disorders, pre-eclampsia, and its related complications are also major contributory factors for such admissions. The pattern of the disease necessitating such admissions influences maternal mortality to a great extent. The present article reviews the most common indications of obstetrical admissions to the ICU, the challenges and obstacles in the treatment of severely ill obstetric patients, their possible outcome in the developing nations, room for improvement, and the need for a change in the system for better delivery of critical care obstetrical services.

Keywords: Antepartum hemorrhage, eclampsia, maternal mortality, obstetrics, postpartum hemorrhage


How to cite this article:
Bajwa SK, Bajwa SJ. Delivering obstetrical critical care in developing nations. Int J Crit Illn Inj Sci 2012;2:32-9

How to cite this URL:
Bajwa SK, Bajwa SJ. Delivering obstetrical critical care in developing nations. Int J Crit Illn Inj Sci [serial online] 2012 [cited 2019 Jun 26];2:32-9. Available from: http://www.ijciis.org/text.asp?2012/2/1/32/94897


   Introduction Top


Advancements in diagnostic and therapeutic techniques have ushered a new era in obstetrical medicine, as a result of which maternal mortality and morbidity statistics are touching the lowest ebbs in the developed countries. However, to date, there are no established universal criteria for the admission of critically ill obstetric patients to the intensive care unit (ICU). As a result, all the prospective and retrospective studies carried out to date show huge variations in the indications of ICU admission, mortality and morbidity rates, as well as the demographic characteristics. [1],[2],[3],[4] Economic factors, sociocultural characteristics, and different hospital protocols and management policies, further widen the gap of bringing a uniform admission criteria and a statistical equivalence to such admissions. However, one of the most striking similarities in all such patients is their young age, which in fact is a good prognostic indicator, provided these patients receive timely interventions for their acute pathologies. [5],[6] The most common indication for ICU admission of such patients throughout the world is hemorrhage, both antepartum and postpartum. Hypertensive disorders, pre-eclampsia and its related complications are also major contributory factors for such admissions. [7],[8] However, a huge variation exists between the developed nations and the developing countries in the prevalence and incidence of ICU admission, which is mainly determined by various social, economic, and health infrastructures, as also policies and other factors, besides the clinical scenarios. [5],[9],[10],[11],[12],[13] The pattern of the disease necessitating such admissions influences maternal mortality to a great extent.


   Clinical Challenges Top


The biggest challenge in dealing with such a large load of critically ill obstetric patients is the shortage of qualified intensive care specialists for handling such cases in a developing nation like India. Although numerous programs are being carried out for learning and orientation toward dealing with emergency obstetrical care, these programs have not been very successful in roping in a large majority of medical personnel. [5] Moreover, to deal with such a delicate emergency and critical situations, the real skills can be acquired only after working in such set-ups for a fairly long time. For this reason, a closed ICU is preferable as it helps in imparting intensive and focused training to the doctors and paramedics. In reality, such models of care are distant dreams in developing nations. The concept of an open ICU may be feasible in a few centers, but obstetrical critical care can be delivered best only in a closed ICU. [14] However, even in the closed ICU, the obstetrician has to coordinate continuously to provide regular and timely help to the attending intensivist in delivering obstetrical critical care. In countries like India, where Emergency Medicine has not been able to make its place till now, how can one expect such coalescence of different clinical specialities? The multidisciplinary approach is very essential in decreasing the mortality and morbidity. The different levels of ICU may be ideal for these critically ill obstetric patients, but for such patients in developing countries, a single level ICU will be of immense significance in decreasing the mortality and morbidity statistics. [15],[16]


   Statistical Impact of Developed Nations on Developing Countries Top


A deep insight and complete understanding of the physiological needs of both the mother and the fetus pose a big challenge during critical illness situations. In developed countries like the United States, only 0.2 - 0.9% of the obstetric patients are admitted in critical care units. The availability of well-equipped and state-of-the-art modern labor rooms, quality obstetrical services, evidence-based practice, financial adequacy, and specialized centers for such admissions are responsible for such a small number of obstetric admissions to Intensive Care Units. [17] The approximate data depicts that only about 40000 - 120000 women in the US require critical care services in proportion to 4.3 million births per year. The exact similar data for developing nations is very difficult to obtain, but it reflects a very dismal picture, as the maternal mortality rates are quite high in most of the Asian and African countries. [18],[19] The improved outcomes of developed nations have failed to cast a significant impact on the functioning of obstetrical services, leading to poor statistical figures in the developing nations. [20],[21] The failed alignment of these health services with the universal guidelines have led to a huge gap between the provision of tertiary care services and the final outcome of such advanced health improving initiatives in the developing countries. [22] To a large extent, this wider gap may be attributable to the lower literacy rates, paucity of research in obstetrical critical care, poverty and lack of awareness, and the sociocultural and behavioral factors prevalent in these developing nations. The disintegrated health infrastructure and not-so-efficient health policies of the respective governments widens the gap still further.


   Indications for Intensive Care Unit admission Top


The admission pattern of critically ill obstetric patients in the ICU is almost similar to the triage principle, as per the guidelines of the Joint Commission, and is based on the critical nature of the underlying disease process. The criteria may differ from country to country and in different setups, but admission should be within the purview of these guidelines [Table 1]. The pathophysiological derangement should be a priority consideration during the decision-making for ICU admission. [23]
Table 1: Causes of mortality and morbidity in pregnant patients that necessitate admission to the Intensive Care Unit

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Hemorrhage, both antepartum and postpartum, as well as hypertension, still remain the most common causes for admission of parturients to the ICU, reflecting upon the lack of proper antenatal care and timely management of obstetrical emergencies, especially in the developing countries. Among these, postpartum hemorrhage remains the most common cause of ICU admission and has a higher mortality and morbidity among young parturients. [24],[25],[26] The problem assumes a gigantic dimension in countries where the ratio of intensivists is very low when compared to the general population and the resources are meager. [11],[21] Various clinical management guidelines have been published and circulated worldwide time and again by the various committees of critical care physicians, anesthesiologists, obstetricians, and the like, which have thoroughly addressed the evidence-based strategies to deal with these challenging situations. Provision of quality intensive care requires acquisition of special procedural skills and thorough up-to-date knowledge of the pathophysiological aspects of various clinical disease entities. The obstetrician's involvement is of prime importance when managing such cases in the ICU, irrespective of whether it is a closed or an open ICU. [27] Their supervision and cooperation can decrease the maternal mortality and morbidity to a large extent. The outcomes are always best when a multidisciplinary approach is adopted in managing critically ill obstetric patients. [28] During the ICU stay, a continuous vigil monitoring by the intensivist is mandatory, but for other signs and symptoms a regular evaluation by the obstetrician is also necessary. The obstetrical evaluation includes, but is not limited to, any pathology leading to vaginal or intra-abdominal bleeding, evidence of infection from the obstetric source, ongoing treatment for pregnancy complications, various therapeutic regimens prescribed by the obstetrician, and ensuring breastfeeding of the neonate in the ICU.


   Issues and Challenges During Transportation of Critically Ill Obstetric Patients Top


Roads are the most common means of transport in developing nations when such a subset of patients are referred from smaller hospitals and nursing homes or are brought directly to the tertiary care hospitals. The condition of the link roads in villages, especially in India, is far from satisfactory, as compared to national highways, and thus transportation of critically ill patients is a huge challenge in India. Moreover, the shortage of well-equipped means of transportation adds to the already existing challenges, as transportation of critically ill patients on bumpy roads becomes extremely difficult. Even the means of communication are not adequate in spite of the advancement in telecom technology. There are no established guidelines in the Indian setup for the pre-hospital transportation of critically ill patients. Also, there are no uniform guidelines about equipping the ambulances as per international standards and a majority of the ambulances lacks even the basic monitoring gadgets required during transportation, such as, pulse oximetry, echocardiogram (ECG), non-invasive blood pressure, and so on. [17]

A good IV access is an essential requirement for administration of any emergency drug during transportation, and an emergency tray containing all the life saving drugs should be available in the ambulances. The ventilator may or may not be available in such ambulances, but alternatively the Bains circuit with an attached connector to the oxygen cylinder can serve the purpose. The use of such a circuit can help in 'feeling' the compliance of the lungs and the timely estimation of any respiratory obstruction necessitating urgent suction to remove the secretions. The main disadvantage is that one of the emergency caregivers will be dedicated to this job only. Availability of the foot suction apparatus can tide over the crisis generated during failure of the electrical vacuum suction apparatus. Presence of a relative or an acquaintance of the patient alongside ensures not only the transparency of healthcare, but it also helps in making them understand if any eventuality occurs during transportation. Once the maternal condition is stabilized, fetal monitoring can be done using a stethoscope only, as a Doppler's availability is not feasible in a majority of our ambulances. Fetal resuscitation in utero can be initiated during this phase by providing oxygen therapy and circulatory support to the mother. [29]

Once the patient is safely transported, the responsibilities on the part of the obstetrician increase significantly during the stay of the patient in the ICU. Any potential obstetrical source of infection, vaginal or uterine bleed, ongoing treatment of pre-eclampsia and eclampsia, need for any emergency surgical intervention, antepartum and postpartum complication, as well as feasibility of breast feeding, has to be taken into consideration, and planning should be formulated by the obstetrician in consultation with the intensivist. The ICU may be of a closed or open type, but in such emergent situations where two lives are concerned, a coordinated team effort of obstetrician, neonatologist, and intensivist is an essential requirement for smooth delivery of critical care services in critically ill obstetric patients. The continuous monitoring and re-evaluation on a regular basis, by this multi-disciplinary team, goes a long way in decreasing the maternal morbidity and mortality. [28],[30]


   Maternal Mortality Top


Every parturient deserves special care during pregnancy and immediately post partum as she gives birth to future mankind. Any unfortunate incident leading to a higher mortality in this subset of patient population leaves a big question mark on the functioning of health administrators and society as a whole. Critical care services have improved vastly over the last two decades, and as such, have also helped in delivering quality and safe obstetrical practices.

The exact data regarding maternal deaths due to critical illness, from the developing nations, is lacking, although from the inferences of various isolated reports, the incidence varies anywhere from 1-25% in different setups. [3],[18],[31],[32],[33] However, it has been established on numerous occasions that the prevalence of maternal mortality is 10 times more in developing nations as compared to the developed world. [34] One of the main reasons for the underreporting of maternal deaths in the developing nations is the poor classification of the mortality pattern and lack of uniformity in the application of various clinical prognostic scores such as Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Simplified Acute Physiology Score (SAPS), and Mortality Probability Models (MPM). Predictors of maternal mortality are different in different scores, therefore, it leads to the development of wide conflicts during the analysis of statistical results. [34],[35] MPM seems to be the best scoring pattern, at least in the Indian ICU setup, as it takes into account the need for mechanical ventilation, cardiopulmonary resuscitation, as well as acute and chronic comorbid diseases. [36],[37] However, various research studies have established almost similar mortality statistics with respect to these scores. The main drawback of all the scoring systems is that they do not take into consideration the wide physiological alterations during pregnancy. One of the most dreadful and feared complication during pregnancy is the Hemolysis, Elevated Liver Enzymes, Low Platelets (HELLP) syndrome, which does not find a suitable place in any of these scores during evaluation of the physiological health status of the parturient.

Obstetric patients requiring intensive care can have a complicated clinical course as compared to non-pregnant patients during various surgical and medical emergencies. Factors such as hypoxemia, hypotension, severe infection, severe anemia, and so on, can influence the obstetric outcome as both the parturient and fetus become extremely vulnerable to these clinical insults. [38] The diseases, both specific and non-specific to pregnancy, affect equally in terms of increasing the morbidity and mortality in obstetric patients. [39] Respiratory diseases like acute exacerbation of asthma, pneumonitis, pulmonary edema, acute respiratory distress syndrome (ARDS), and acute lung injury can have serious implications both on the mother and the fetus, and special considerations during these episodes include maintaining oxygen saturation greater than 90%. Cardiovascular diseases, such as rheumatic heart disease, mitral stenosis, and other valvular lesions can cause cardiac failure, which necessitates intensive care admission. Cardiac surgery during pregnancy is extremely challenging and should best be avoided, unless a life-saving procedure is required. Renal diseases like pyelonephritis can be accentuated in the presence of sepsis, which again propels the patient to the Intensive Care Unit. Coagulation disorders, hepatic derangements, including the HELLP syndrome, warrants urgent intensive care intervention in many instances as these disease entities can sometimes prove fatal. Neurological disorders can mimic the picture of eclampsia and the appropriate therapy involves a complete investigation profile. Gestational diabetes, thyroid disorders, and other endocrinal diseases can also be responsible for medical emergencies in obstetric patients requiring urgent critical care. [40],[41] Surgical emergencies, although they occur with equal frequency in both the obstetric and non-obstetric population, require urgent attention, especially in critically ill obstetric patients. Then again, the decision to perform surgery has to be taken after evaluating the pros and cons of the surgical procedure, as critically ill patients may not be able to sustain the anesthetic and surgical insults, and also, fetal compromise is most likely to occur during these circumstances.


   Modalities of Monitoring During Critical Illness Top


Minimum mandatory monitoring, which is widely practiced in developing countries may not be sufficient to guide the therapeutic interventions in such patients, and as such, invasive monitoring becomes essential in a majority of critically ill patients both during surgical procedures and during the ICU stay. Central venous pressure monitoring is being increasingly used for guiding fluid administration, but it has its own drawbacks. The pulmonary artery catheter, however, may be used rarely in the ICU's of developing nations, but it is extremely useful for measuring ventral venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance (SVR), cardiac output (CO), pulmonary artery (PA) pressure, and mixed venous oxygen saturation. [42],[43] During pregnancy, the altered physiological status may cause a wide variation and discrepancies between the estimation of various invasive pressures such as CVP, PCWP, intra-abdominal pressure (IAP), and so on. [44] Moreover, the economic factors become more decisive during the planning of invasive hemodynamic monitoring. [45],[46],[47] In pregnant cardiac patients having valvular heart diseases or in cardiac failure with associated comorbidities, such as, massive hemorrhage, pulmonary edema, acute respiratory distress syndrome (ARDS) or renal failure, such invasive hemodynamic monitoring becomes mandatory. The simple monitoring parameters such as electrocardiogram (ECG), heart rate (HR), Non-invasive Blood Pressure (NIBP), SpO2, and EtCO2, which are routinely used in these setups must always be augmented with additional invasive monitoring during the admission of critically ill obstetric patients. [48]


   Comorbid Disorders Complicating Pregnancy Top


Sepsis

Approximately 10% of total deaths occur due to sepsis in developed nations like US, and account for one death per 8000 deliveries. [49],[50] The major cause of higher mortality due to sepsis in obstetric patients of developing countries is the higher prevalence of septic abortions. The general consensus and current guidelines state that a pregnant patient having signs and symptoms of sepsis should be managed by following interventions irrespective of her nationality status: [51],[52]

  • Early goal-directed therapy [53]
  • Tight control of hyperglycemia
  • Steroid therapy
  • Protein C
  • Symptomatic and supportive treatment
Diabetes

Tight glycemic control with insulin is recommended in diabetic patients as it has been well-established that exercising such control decreases mortality and the morbidity. [54],[55] Pregnant women invariably develop resistance to insulin and as such there are high chances of developing maternal and neonatal hypoglycemia. The fluctuating blood sugar levels are more dangerous than sustained hyperglycemia and can cause numerous fetal complications such as macrosomia, still births, and severe refractory neonatal hypoglycemia. Tight glycemic control is associated with a better outcome. [56]

Cardiac diseases

Cardiac diseases are the most common cause of mortality among pregnant patients admitted in the ICU. Mortality can rise to as high as 50% among this subset of patients. [57] The challenges in these patients are further potentiated by significant cardiovascular and physiological changes. The increased CO, increased blood volume, increased red cell mass, and decreased hemoglobin and hematocrit values also contribute to the deterioration of heart ailments during pregnancy. Morbidity is further increased in cardiac pregnant patients with a potential risk of thromboembolic phenomenon, which can get precipitated by a higher incidence of atrial fibrillation or presence of prosthetic valves. [58] The maternal mortality and morbidity arising out of this deranged cardiac physiology is significantly influenced by various predictors, such as:

  • A history of heart failure, transient ischemic stroke or severe arrhythmias
  • Severe valvular heart disease
  • New York Heart Association (NYHA) class II and above
  • Ejection fraction < 40%
These predictors and other potential risk factors determine the maternal outcome in critical conditions. [59] Other than just the maternal mortality, these cardiac disease entities can also compromise the neonatal status to a large extent resulting in intra-ventricular hemorrhage, pre-term delivery, and neonatal death. [60] Besides valvular heart diseases, peripartum cardiomyopathy is another major cause of maternal ICU admission, either in the last month of pregnancy or within five months of delivery. [61],[62],[63] Maternal mortality rises exponentially in peripartum cardiomyopathy (PPCM) to an extent of 50%and major risk factors for determining the incidence and mortality in PPCM include, but are not limited to, advanced maternal age, multiple gestation, pre-eclampsia, black ethinicity, and hypertension. [61],[64] In obstetrical critical care, while analyzing the ECG pattern, the normal ECG changes such as sinus tachycardia, shortened PR and QTc interval, left axis deviation, and non-specific ST changes must be taken into consideration.

Pulmonary diseases

Pulmonary edema, advanced chronic obstructive pulmonary disease, infections, and pulmonary embolism are among the major causes for respiratory failure, which necessitate the admission of pregnant patients to the ICU. [65],[66] The incidence of pulmonary edema can be quite high to the extent of one in 1000 pregnancies. [67] The most common implicated underlying etiology includes cardiac diseases, non-judicious use of tocolytics, over-enthusiastic use of intravenous fluids, and to some extent pre-eclampsia. However, the most feared complication is ARDS, which should ideally be treated only in a dedicated obstetric ICU. Sepsis is the most common cause that puts the pregnant patient at risk of developing ARDS. It is worth mentioning the role of amniotic fluid embolism here, as it can increase the maternal mortality in a rapidly progressive manner. The spectrum of symptoms include sudden hypoxia, shock, coagulopathy, and cardiac arrest.


   Therapeutic Dilemmas Top


Currently there are no universal guidelines stating the management of critically ill obstetric patients, although at times different guidelines and protocols have been published by the various international societies of obstetricians, anesthesiologists, intensivists, and so on. The application of the American College of Critical Care Management guidelines seems to be the most appropriate and is being followed to a major extent in most of the developing nations. [23] However, strict compliance and adherence to these protocols and guidelines is not feasible in a majority of these developing nations, due to numerous factors, including economic constraints, sociocultural beliefs, levels of education, attitude toward the criticality of clinical conditions, poor means of transportation and communication, and so on. [23] Even as obstetric anesthesia has fairly made advancements in the last three decades in developing countries, a lot is yet desired in bringing up obstetrical critical care. [68] Furthermore, the indications may vary from place to place during admission to the ICU, although any critical illness during pregnancy warrants immediate admission to the ICU. The concept of the newly built High Dependency Units (HDUs) or dedicated obstetrical ICU have been gaining popularity in recent times, and the services are coming up with giant leaps of progress in many developing nations. The success of such dedicated units depends largely on the coordinated efforts of various team members, including obstetrician, anesthesiologists, intensivists, pediatricians, and doctors from various surgical and medical super-specialities. [1],[2],[15],[69] The main indication for the critically ill obstetrical patient's admission to the ICU is respiratory failure and a definite need for mechanical ventilation. [2]


   Delivery in the Intensive Care Unit Top


The delivery of the parturient during the ICU stay also poses a multitude of challenges to the intensivist, obstetrician, and the peditrician. The critical illness of the patient, lack of proper training of the intensive care staff in conducting a normal delivery, the degree of difficulty of various interventions, the inadequate space, the possibilities of contracting infection by the mother, and the neonate from other patients are some of the challenges that have to be dealt with. [65] The therapeutic and diagnostic interventions for maternal safety should be carried out on a priority basis, but as far as possible the best alternatives should be considered keeping in mind the safety of the fetus also. These include the administration of various drugs, techniques, and imaging studies. Fetal heart rate monitoring also provides very valuable information, as it helps in the identification of maternal MAP, end-organ perfusion, hypoxemia, and metabolic derangements. [70]


   Room for Improvement Top


Currently the statistical figures reveal an astounding disparity in the maternal mortality rate in the developed and developing nations, to the tune of 30 - 100 times higher than the respective figures in developing nations. The concerned figures for the African and Asian representative countries project a very dismal picture, as statistics reveal exponentially higher maternal mortality rates in South Africa (340/ 100000) and India (440 / 100000). The scope for improvement rests on the initiatives taken to deliver quality obstetric critical care and identification of 'near miss' cases, as well, which had prompted admission of the patient to obstetrical ICU. [15],[23],[28],[68],[71],[72],[73],[74],[75],[76] To bring the quality of critical care in obstetric patients at par with the developed nations, a coordinated multidisciplinary approach is needed at various levels in the developing nations, so as to bridge the wide gap of obstetric critical care delivery, and thus save precious young lives. [15] The health infrastructure has to be strengthened at the grass root levels, to ensure an early admission of critically ill obstetric patients to the ICU, so as to prevent a delay in the logistics. [59],[77]

Whatever the level of critical care an obstetric patient needs, the underlying fact is that simple interventions, close monitoring, and symptomatic care are more than adequate, as these patients are often young and healthy and the clinical profile of these patients is largely reversible. Among non-obstetric causes, sepsis is a major factor that necessitates admission of such patients to the critical care units. The treatment of sepsis should start immediately and should be goal-directed - supporting the circulation and oxygen supplementation is a must, as all these steps improve maternal prognosis as well as help in fetal resuscitation.

During the setting up of an obstetrical ICU, a neonatal ICU is a pre-requisite, and close coordination among the intensivists, obstetricians, anesthesiologists, and peditricians is required. Transportation of critically ill obstetric patients to the tertiary care ICU is a very challenging and responsible clinical task. During transportation, the maternal parameters have to be monitored continuously, especially the heart rate, blood pressure, and pulse oximetry. A well-secured intravenous access, availability of all emergency drugs, equipment for intubation, and mechanical ventilation are the standard requirements for safe transportation.


   Need for a Change Top


Various ICUs across the globe have their own individual admission criteria, but when it comes to the admission of obstetric patients, they should not be denied admission to such units as these patients are often young and healthy and the spectrum of sickness is very much reversible with timely intensive care. Although the guidelines published by the joint commission specify admission criteria for both obstetric and non-obstetric patients to the ICU, the scenarios in developing nations are not conducive for the complete application of such protocols. [78] Numerous factors including poverty, illiteracy, lack of proper transportation and communication modes, superstitions, lack of awareness, and sociocultural behaviors are detrimental in the provision of timely and quality critical care to these parturients. Meager resources, inadequate facilities at the peripheral health centers, and shortage of well-qualified and trained staff at these centers, increases the burden on the limited available critical care units in these countries. [79] There is an increasing need for arriving at a new consensus by the various international committees and societies, for carrying out coordinated planning and developing new strategies in collaboration with representatives from the various developing nations. These new programs should review the present health conditions, socio-political circumstances, and the optimal utilization of the available resources, so as to enable practical and thorough applications of the universal guidelines, to provide quality critical care in high-risk obstetric emergencies.

 
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