The three delays

Preventing maternal mortality and morbidity is often looked at using the three delays model, it is thought that reducing/ preventing these delays will substantially reduce maternal mortality.  These are  delay in seeking care, delay in transportation to healthcare facility and delay in receiving treatment at the facility. The 3 delays are all closely linked, and all need to be targeted to reduce maternal death and disability.

I've just finished a busy 24hr shift and two mothers stick in mind as perfect examples of this. 

The first mother was at a health center, she had been fully dilated at 9 am in the morning,  4 hours later they decided that she should have delivered by now and so referred her to us ( you can say that this is delay no.1- as it should take about an hour in those who have had babies before to deliver ), it then took a further 3 hours to transport her to us as there was no transport available.  So on arrival she was dehydrated, and was now fully for 7 hours!  When we listened to the babies heart is was beating very slow so we really needed to deliver fact.  The babies head was low and also showed signs that it had been there awhile, unfortunately it was in an awkward position  but we managed to do an instrumental delivery with difficulty.   Unfortunately the baby did not survive. 

The  second mother went into labour at home and delivered a baby at 11am without complications- however the placenta would not deliver and so eventually she went to a health center (3pm).  After assessment  they realised that she had twins (she had not attended antenatal visits so this was undetected) and the second baby was yet undelivered, on top of this the umbilical cord had prolapsed ( this is obstetric emergency as the pressure on the cord prevents oxygen reaching the baby causing fetal death- at this point the cord was still pulsating indicating the baby was alive.  ) And to prove bad things happen in threes she was also bleeding heavily as the first placenta was detaching, she was referred and reached us at 7pm- again transport being a problem.  It was clear at this point that she had lost a lot of blood, her clothes were soaked, her Bp was low and pulse high and we started resuscitating her with fluid.  Unfortunately the cord had now stopped pulsating, but luckily she was still fully dilated  and we could do a quick breech extraction to deliver the baby, followed by the placenta which settled her bleeding.   She still looks pale this morning but is doing well- it wouldn't have taken much more bleeding before the outcome would have been much worse.   So delay in self referral to a health center, delay in appropriate care- she did not receive fluids and no measures were taken with the cord prolapse, and delay in transport  caused a fetal death and could have caused another maternal mortality.