POST PARTUM HAEMORRHAGE: A LEADING CAUSEOF MATERNAL MORTALITY
By Peter Eyram Kuenyefu (Senior Physician Assistant: – Comfort Ofedie Memorial Clinic- Nkonya- Ahenkro)
Post-Partum Haemorrhage (PPH) is generally defined as blood loss from the genital tract in excess of 500mls after vaginal delivery or any amount of blood loss that is enough to compromise the health of the woman as evidenced by deterioration in her haemodynamic status. For Caesarean Section (CS), the cut-off for PPH is 1000mls (1litre) and not 500ml. Post- Partum Haemorrhage could be primaryor secondary.
Primary PPH occurs within the first 24 hours of delivery of the baby whereas secondary PPH occurs between 24 hours and 6 weeks of delivery.
The World Health Organization statistics suggests that 60% of all maternal deaths in developing countries across the globe are as a result of PPH, accounting for more than 100,000 maternal deaths yearly. It could therefore be comfortably concluded that Post-Partum Haemorrhage is the leading cause of maternal mortality and morbidity in developing countries, Ghana inclusive.
Other causes of maternal mortality include Abortions, Miscarriages, Sepsis, Obstructed Labour, Ectopic Pregnancies, Pre- Eclampsia and Eclampsia, Embolism, Ante- Partum Haemorrhage, etc.
All women who carry pregnancy beyond 20 weeks are at a risk of PPH and its attendant issues. Generally, majority of women who suffer PPH have no risk factors. The WHO has recommended measures to reduce maternal deaths from PPH.
- Anaemia in Pregnancy
- Previous PPH
- Prolonged 2ndand 3rdstage of labour
- Pre- eclampsia
- Instrument delivery
- Retained placenta and other products of conception, etc
CAUSAL FACTORS OF PPH
- Uterine Causes
- Placental Causes
- Retained placenta and other products of conception
- Genital Trauma
- Clotting defects
MANAGEMENT OF PPH
Management of PPH is an EMERGENCY!!!
- Call for help!!!!
- IV access with wide bore canulla
- Take blood for grouping and cross-matching
- Start IV fluids (Normal Saline/ Ringers Lactate) and/or haemotransfusion
- Give oxygen if necessary and available
- Pass a urethral catheter
- Condom tapponage
- Massage the uterus continuously
- Give a high dose oxytocin
- Give Misoprostol per rectum
- Identify the cause(s) of the PPH and correct
CAUSAL FACTORS AND THEIR SPECIFICMANAGEMENT/ INTERVENTIONS
|SN||CAUSAL FACTOR(S)||SPECIFIC MANAGEMENT/INTERVENTIONS|
|1||Uterine Atony||a. Massage uterus continuously
b. Give Oxytocin bolus and another high dose in infusion
c. Insert 800mcg (4 tablets) Misoprostol (Cytotec) per rectum
|2||Uterine Rapture||a. Requires laparotomy|
|3||Uterine Inversion||a. Requires laparotomy|
|4||Retained placenta||a. Manual removal of placenta and curettage
|5||Genital Trauma||c. Repair lacerations and haematomas|
|6||Clotting Defects||a. Requires haemotransfusion of whole blood and fresh frozen plasma|
MEASURES TO CURTAIL POST PARUM HAEMORRHAGE
Post- Partum Haemorrhage is a threat to maternal health, hence in the need to put in adequate, comprehensive and holistic measures to curtail its menace. All maternity units should be prepared at any given point in time to swiftly intervene when PPH arises at your facility because it can kill within minutes if not adequately and promptly managed.
However, the following measures must be enforced at all facility levels to reduce the menace of PPH:
- General measures
- ANC Measures
- Labour and delivery measures
- Management of established PPH
- Improve the general health of women so that they start cyesis in good health so that should PPH occur they would be able to withstand it better. This requires good nutrition, freedom from debilitating infections and good hemoglobin concentration
- Adequate History taking which must include past Obstetric history to rule our previous PPH
- Counsel all pregnant women to deliver at a health facility and under medically supervised care
- Counsel and book high risk patients to deliver at health facilities that have facilities like blood transfusion, operating theatre and surgeons
- Make sure that during ANC, no woman is anemic before delivery by
- Checking HB regularly as recommended
- IPT administration
- Fersolate and folic acid supplementation
- Treating hookworm infestation
- Prompt management of infections in pregnancy
- Counseling women about family planning
Labour and Delivery Measures
- Strict use of partograph during labour
- Active management of the third stage of labour
Management of Established PPH
- See earlier discussion on management of PPH
The writer is a practicing Physician Assistant, who has interests in Sub District Health Management, Public Health and Obstetrics and Gynaecology.