Packing the Drape

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By: Isabella Ochieng, nurse midwife and maternal and newborn health technical advisor for Jhpiego, worked on the E-MOTIVE trial.

I double checked my packing list in preparation for my trip to Rwanda. Three weeks away from my home in Kenya was a long time, so I wanted to make sure I had all the essentials. 

Already in the suitcase were a couple pair of shoes, both open and closed-toe. Also, my favorite black trousers and a black and white top, a pairing that constitutes my best “official” attire, suitable to wear while presenting to a technical working group of maternal health care providers.  

A nurse midwife colleague had requested that I join her on this trip, the purpose of which was to introduce the E-MOTIVE bundle as described in the World Health Organization’s latest recommendations. I was fortunate to have had the experience of previously participating in the landmark study that showed this bundle of care resulted in a 60% reduction of severe postpartum hemorrhage (PPH) 

PPH, the leading cause of maternal deaths worldwide and is a driver of Rwanda’s 259 maternal deaths per 100,000 deliveries. Severe bleeding after birth– when a woman loses 500 milliliters or more of blood within 24 hours of giving birth is not always predictable but can be typically be managed or treated with medication.  It happens to 14 million women annually, with one dying every six minutes because of it, according to the WHO. Among the contributing factors: visual estimation of blood loss because it is known to be inaccurate.  

Our team in Rwanda was eager to learn and practice how to recognize and treat PPH using the E-MOTIVE bundle, a proven management strategy that depends upon the use of a calibrated drape to collect and measure blood loss alongside first-response treatments of uterine massage, oxytocic drugs, tranexamic acid, IV fluids, and examination. 

I was assured that our team in Rwanda had procured all of the required training materials and medications, including the uterotonics, tranexamic acid and IV fluids. A vital supply was missing, however: calibrated drapes that allow birth attendants to accurately and objectively measure blood loss, which is vital for the timely—and therefore lifesaving—diagnosis of PPH. 

It concerned me that training was set to begin in just a week—without calibrated drapes. Essentially, these are plastic sheets marked with two colored lines: yellow indicates 300 milliliters of blood loss, alerting providers that all is not well and that more attention is needed; and red indicates 500 milliliters of blood loss, calling for action without delay.  

When I learned there weren’t drapes in Rwanda, I realized that my packing list was incomplete.  

Two days before setting off, I contacted a colleague with whom I had worked during the E-MOTIVE trial in Kenya. She currently is supporting hospitals to offer E-MOTIVE in Kenya with drapes made right here in Kenya.  

The drapes we used during that study had been imported and were relatively costly.  After the study, they were no longer available in our facility much less across our country. Having experienced firsthand how efficiently and often we could prevent PPH, our team of obstetricians, nurses and midwives was not about to go back to business as usual for lack of a piece of equipment; we were not going to resume guesstimating blood loss and risk mothers’ lives. We had wholeheartedly embraced E-MOTIVE, even before the results of the trial of the WHO’s first-response bundle for PPH were published 

It is not surprising that we took matters into our own hands. With the help of a local tailor, using a waterproof bed sheet, we created our own makeshift solution: a drape-like apron that funnels blood into a pan with calibrated markings. 

When I told my E-MOTIVE study colleague that our upcoming training of the management approach in Rwanda would be compromised for lack of necessary drapes, she promised to help.  

The day before my travel I answered a knock at my door.  With excitement, my colleague handed over a small package containing 10 drapes.  

It was a very special gift for me as I knew it would prove to be a lifesaving gift to many. After hugging her, I rushed to my bedroom where I  packed the drapes in my travel bag. 

I took off for Rwanda where, on February 18th, together with two co-trainers, we gave a quick orientation on how the drape is used in diagnosing PPH, thus setting into motion the E-MOTIVE bundle of care in Rwanda. 

I could feel the anticipation growing as we conducted three sets of training that first week. We started with 23 master trainers, followed by the training of 35 trainers, and lastly training 18 providers in Kibagabaga Hospital. All were grateful to learn about the new PPH management intervention. They appreciated that the name for the E-MOTIVE bundle stands for Early detection using a drape that measures blood loss accurately after delivery, uterine Massage, Oxytocic drugs such as oxytocin and misoprostol, Tranexamic acid injection, IV fluids, and Examination/Escalation. Most Importantly, they understood the importance of administering all these interventions sequentially within 15 minutes of diagnosing PPH.  

It was interesting and very gratifying to see how participants practiced using the drape and how adept they became at managing PPH as a team within a very short time.  

At the end of the three weeks I knew that we had accomplished a lot. The 10 drapes that I had packed were used to train a total of 76 maternity staff. Those who were trained promised to be champions for change. They would start implementing the E-MOTIVE bundle immediately, relying on clinical judgment as they sought to procure drapes and identify a local manufacturer. A remaining 43 maternity staff in the hospital were scheduled to be trained over the following few weeks in order to fully standardize the practice. 

Importantly, Rwanda’s ministry of health is committed to reducing maternal mortality. It recognizes the need for further action on the heels of this latest training of providers, which is one of many vital steps towards the reduction of maternal mortality here and globally. 

The E-MOTIVE bundle works — but only when it’s started on time and all the supplies needed for it are available, including drapes and drugs like tranexamic acid. Hospital administrators and procurement officers need to be made aware of what the E-MOTIVE bundle can mean for keeping women safe during childbirth, as should health ministries, which have the power to update policy recommendations and procure supplies. 

If all my colleagues in Kenya are trained to implement the bundle and have all the necessary resources, I think that my country could reduce severe PPH by even more than 60% — maybe as much as 80%. I have no doubt that Rwanda and others who aspire to this goal will help ensure a thriving future generation.