Obstetric haemorrhage was the third most common cause of maternal deaths. The primary cause of death was antepartum haemorrhage in 27 (4,6%) cases and postpartum haemorrhage in 48 (8,2%) cases. The proportions of deaths due to haemorrhage were below 10% in two provinces and above 15% in three provinces. Most of these deaths occurred at Level 1 and 2 hospitals. Abruptio placentae was the most common specific cause of death in the antepartum haemorrhage group and in the postpartum haemorrhage group, retained placenta, uterine atony and rupture of the uterus. In 82,7% of cases the final cause of death was hypovolaemic shock. Non-attendance at antenatal clinics was the most common patient-related avoidable factor in the antepartum haemorrhage group and a delay in seeking help in the postpartum haemorrhage group. Administrative problems occurred with a reasonably low frequency with lack of transport from a clinic or hospital to another hospital the most common problem. There was often a delay in referral to a secondary or tertiary level of care. Inadequate initial assessment and problem recognition occurred commonly at the secondary level of care. Women in the antepartum haemorrhage group were often managed at an inappropriate level of care. A lack of adequate resuscitation was the most common defect in the management of these women. Anaesthetic problems occurred in the antepartum haemorrhage group at secondary level of care.
Active resuscitation and prompt referral to specialist care is mandatory when the diagnosis of abruptio placentae has been made. The goal of the provinces should be to reduce the proportion of deaths due to haemorrhage to less than 10%, by focussing mainly on the quicker attainable reduction in deaths due to postpartum haemorrhage. This could be achieved by implementing the key recommendations.
Key recommendations
Continuing in-service training regarding the emergency management of postpartum haemorrhage at primary levels of care must be instituted. This must include protocols for managing obstetric haemorrhage.
Attention of the nursing staff needs to be directed to the effective and adequate observation of patients at risk for postpartum haemorrhage.
Early recognition of haemorrhage during the third stage of labour that appears more than normal requires aggressive fluid replacement.
The partogram must be used for every woman to prevent prolonged labour.
Trials of scar must be conducted using a strict protocol.
Oxytocin must always be used with caution during labour.
Blood must be available at all hospitals providing secondary level care and district hospitals where caesarean sections are conducted.
A continuing audit of the management of obstetric haemorrhage needs to be done at primary and secondary levels of care, with "fire drills" being instituted where obstetric haemorrhage occurs infrequently.
Obstetric haemorrhage caused the death of 75 (13.3%) of the 565 maternal deaths. This was the third most common cause of maternal deaths. The primary cause of death was antepartum haemorrhage in 27 (4.8%) cases and postpartum haemorrhage in 48 (8.5%) cases.
The magnitude of the problem may be underestimated because of the poor reporting from some of the Provinces. However, there is a broad distribution of cases from rural, peri-urban and rural areas, which make the problems identified here highly likely to represent the real situation.
In the antepartum haemorrhage group 3 (9,8%) of the 27 women were <20 years and 3 (9,8%) >35 years. In the postpartum haemorrhage group 8 (18,2%) of the 44 women were <20 years and 8 (18,2%) >35 years. In the antepartum haemorrhage group 6 (22,2%) of the 27 women were null parous and 4 (14,8%) a parity of >5. In the postpartum haemorrhage group 10 (24,4%) of the 41 women had a parity of 0 and 2 (4,9%) a parity of >5. (See Tables 4.1 and 4.2)
Provinces with a low proportion of deaths due to haemorrhage were the Western Cape with 2 (7,1%) of 28 deaths and Gauteng with 10 (7,9%) of 126 deaths due to haemorrhage. Provinces with a high proportion of deaths due to haemorrhage were the Eastern Cape with 14 (25,9%) of 54 deaths, North West with 7 (19,4%) of 36 deaths and Mpumalanga with 9 (16,4%) of 55 deaths. Caution must be used when interpreting this data because of poor reporting in some Provinces.
The level of care where the deaths occurred is shown in Table 4.3. The majority of both antepartum haemorrhage and postpartum haemorrhage deaths occurred in level 1 hospitals.
The primary cause of death for antepartum and postpartum haemorrhage are shown in Table 4.4. Abruptio placentae was the specific cause of death in 19 (70,4%) of the 27 deaths.
In maternal deaths due to postpartum haemorrhage, retained placenta was the most common specific problem, followed by uterine atony due to prolonged labour and uterine atony due to an over-distended uterus. Rupture of the uterus with a previous caesarean section scar and rupture of an unscarred uterus comprised the other specific causes of death in this group.
The final cause of death in this group was hypovolaemic shock in 62 (82,7%) of the 75 cases. DIC was present in 16 (21,3%) and cardiac failure as manifested by pulmonary oedema or cardiac arrest in 14 (18,6%) of the cases. (See Table 4.5)
The patient-related avoidable factor that were most common in the group with antepartum haemorrhage was non attendance of antenatal clinics and in the postpartum haemorrhage group delay in seeking help. (See Table 4.6).
Administrative problems occurred reasonably frequently. Lack of transport from a clinic or hospital to another hospital being a major problem. There were significant delays in 25% of women transported with APH, and in 62% of cases who were transported with postpartum haemorrhage. Deficient health facilities resulted in blood not being available for 12% of cases with antepartum haemorrhage and 14% with postpartum haemorrhage. A lack of appropriately trained medical officers (5 cases) was cited as the most common problem on the health personnel side.
Initial assessment and making a diagnosis or problem list was poorly done with problems being detected in over 40% of cases in each aspect for each disease category. The majority of these problems occurred at level 2 hospitals.
In managing the cases, there was a delay in referral to a secondary or tertiary level of care with 3 and 8 cases respectively. Inadequate initial assessment and problem recognition occurred commonly in both groups at a secondary level of care (7 and 12 cases respectively). Women in the antepartum haemorrhage group were more commonly managed at an inappropriate level of care (5 cases). A management protocol was used inappropriately at secondary level of care in 4 and 5 cases respectively. A standard protocol was not followed in 14 and 24 cases respectively at primary and secondary level of care. A delay in getting treatment performed occurred in 5 cases in the postpartum haemorrhage group. Proper monitoring was often lacking with observations being infrequent (6 and 9 cases), incomplete (3 and 9 cases), prolonged abnormal observation without action (2 and 4 cases) and ongoing monitoring not performed (3 and 6 cases).
A lack of adequate resuscitation was the most common defect in the management of these women. The circulation was not adequately supported in the antepartum haemorrhage group in 8 cases and the postpartum haemorrhage group in 15 cases. Adequate amounts of blood were not given in 6 and 5 cases.
Anaesthetic problems occurred commonly in the antepartum haemorrhage group with 6 of the 11 cases that received anaesthesia of which 5 were at secondary level of care.
Below are a few case histories that illustrate some of the avoidable factors, missed opportunities and substandard care.
Case 1: A 31 years old G1 P0 with a gestational age assessed to be 30 weeks developed a sudden onset severe abdominal pain accompanied by vaginal bleeding. She was taken to hospital by ambulance. Abruptio placenta with intra-uterine death was diagnosed and an emergency caesarean section done to "stop the bleeding". A 900g still born baby was delivered. Disseminated intravascular coagulation was diagnosed intra-operatively. The patient collapsed post operatively and could not be resuscitated.
Case 2: A 19 years old G1 P0 was admitted to hospital with vaginal bleeding. She did not attend antenatal clinics and reported to also have bled 3 days ago at home. Her blood pressure was 100/50 mmHg and the fetal heart rate 148 beat per minute. The doctor on call took one and a half-hours before coming to see the patient. The medical officer on call for obstetrics was notified about the case, who then booked the case for a caesarean section without coming to see the patient. A fresh stillborn baby (2,6Kg) was delivered. Emergency blood was administered in theatre. Post operatively the patient became more shocked with a haemoglobin concentration falling to 4g/dl. The nurse receiving the patient back in the ward from a porter and theatre nurse, noticed that the patient was very pale and made jerking movements. Oxygen was administered and the foot of the bed was elevated. The doctor came immediately but the patient died before resuscitation commenced.
Comment: In both cases inappropriate caesarean sections were performed for abruptio placentae. The condition of the mother must be fully assessed before performing a caesarean section. In most cases a vaginal delivery can be successfully completed without resorting to a caesarean section. Part of the initial procedures should involve rupturing of the membranes to induce labour.
Case 3: A 42 years old G9 P8 had an unexplained intra-uterine death at 34 weeks gestation. She was referred to the hospital from the clinic but only reported there 11 days later. An induction of labour was commenced with 10 units of oxytocin in 1 litre of 5% dextrose water, in a district hospital without theatre facilities for a caesarean section. The infusion rate was increased by 6 drops every hour until she had 3 strong contractions in 10 minutes. Two hours later she developed a clonic uterine contraction accompanied by a profuse vaginal haemorrhage. An hour later she was transferred to the regional hospital but died on the way.
Comment: This case illustrates the incorrect use of oxytocin. Induction of grand multiparas can be a difficult clinical problem. In this case consideration should have been given to managing the case expectantly, i.e. waiting for spontaneous labour. An alternative could have been to induce labour using mechanical means using a Foley's catheter with a 30-ml bulb placed through the cervix and inflating the bulb to 30ml. Traction is then applied to the bulb by taping the catheter to the inside of the thigh. This is often successful in inducing labour. Failing that, the patient should have been referred to a hospital that could perform caesarean sections. Oxytocin is dangerous in multiparas as it can cause tetanic contractions, as occurred in this case.
Case 4: The patient had an uncomplicated pregnancy and delivery, followed by a postpartum haemorrhage. An intravenous infusion was commenced and Syntometrine given again. The doctor on call was informed who ordered "Konakion 10 mg immediately intramuscular followed by 4 hourly doses", oxytocin 20 units to be added to the infusion and another dose of Syntometrine, this time 1 ampoule intravenously. The bleeding persisted and the breathing became shallow and no pulse could be palpated. The doctor was again informed, but the patient died before he/she arrived. The doctor then assessed the patient and said the bleeding came from a cervical laceration.
Comment: This is clearly inappropriate management of a postpartum haemorrhage. A protocol is available in all obstetric textbooks and is clearly stipulated in the Maternal Manual of the Perinatal Education Programme1.
Case 5: A 30 years old G5 P4 had a normal delivery in a Midwife Obstetric Unit following an uneventful pregnancy and normal labour. She had a retained placenta during the third stage of labour and an infusion was commenced with oxytocin and appropriate ambulance transport was arranged. The uterus was well contracted and there was no haemorrhage. No further observations were made while waiting for the ambulance. In spite of several more telephone calls the ambulance arrived only 3 and a half-hours later. The patient arrived at the hospital in severe hypovolaemic shock and died in spite of vigorous resuscitation following a third cardio-respiratory arrest.
Cases 6-8: All 3 patients were at high risk for postpartum haemorrhage, two had had a manual removal of retained placentas and one had a twin delivery. All 3 were found in severe hypovolaemic shock hours later in postnatal wards following profuse haemorrhage. During this time no or completely inadequate observations were recorded. At this late stage the patients were moribund and attempts at resuscitation unsuccessful.
Comment: Poor monitoring of patients is clearly demonstrated in these patients. Postpartum monitoring of patients is often neglected with disastrous consequences as illustrated by these cases. Failure to classify postpartum haemorrhage as the highest level priority by ambulance services can lead to unnecessary delays.
Deaths due to antepartum haemorrhage in women with a parity of >5 and due to postpartum haemorrhage in the age group >35 years were in excess compared to the norm.
The goal of the provinces should be to reduce deaths due to haemorrhage to less than 10% of their total maternal deaths. This can be achieved by focussing mainly on the quicker attainable reduction in deaths due to postpartum haemorrhage. The large geographic size of the provinces with a high proportion of deaths due to haemorrhage requires an effective and functional ambulance transport infrastructure. This often does not function well as illustrated by the fact that 62% of the women who died due to postpartum haemorrhage, who were transported experienced significant delays in waiting for ambulance transport to another health institution.
The proportion of deaths due to antepartum haemorrhage at the first level of care is too high. Active resuscitation and prompt referral to level 2 or 3 hospitals is mandatory when the diagnosis of abruptio placentae has been made. It must be noted that level 2 hospitals are supposed to have full-time obstetric specialists on their staff. If this is not the case for a level 2 hospital, the patient is best referred to a level 3 hospital.
Few deaths occurred due to postpartum haemorrhage in level 3 hospitals, however time is essential in the management of these cases. Only 27% of women who died were transferred between institutions. This is in contrast to the 53% who were transferred with complications of hypertension in pregnancy. This indicates the rapidity at which events occur in postpartum haemorrhage. Therefore emergency care at level 1 care must be improved and standard protocols for managing postpartum haemorrhage must be known by all health workers at an institution who deal with pregnant women. Where deliveries are infrequent and postpartum haemorrhage is consequently rare, "fire drills" should be performed to ensure the staff is familiar with what to do with a woman with a postpartum haemorrhage. All patients where bleeding persists after following the initial steps as described in unit 11 section 11-29 of the Maternal Care Manual of the Perinatal Education Programme (PEP)1, must be referred to a level 2 care.
Preventative measures that will reduce the incidence of postpartum haemorrhage are:
Prevention of prolonged labour by using a partogram for all women in labour.
The active management of the third stage should be practised on all women. There is overwhelming evidence that active management significantly reduces the incidence of postpartum haemorrhage2.
Trial of scar in the event of a previous transverse lower segment uterine incision must include:
- use of the partogram;
- normal progress of labour during the active phase first stage of labour;
- oxytocin must never be used to augment labour.
- augment labour in multigravid patients once in the active phase of the first stage of labour;
- must be discontinued following induction of labour (e.g. for prelabour rupture of membranes) once in established labour.
Identify all women with a risk factor for postpartum haemorrhage for delivery at level 2 care.
Continuing in-service training regarding the emergency management of postpartum haemorrhage at level 1 and 2 care.
Good communication between different levels of care to enable immediate action in the receiving hospital when patients are referred, which must include:
- no delays on admission;
- direct access to the labour ward;
- prompt initial assessment by the person in charge of the labour ward.
During the third stage of labour early recognition of haemorrhage that appears more than normal requires aggressive fluid replacement.
Level 3 hospitals must provide ongoing continuing professional development for medical officers required to administer anaesthetics in level 1 and 2 hospitals.
A swift and effective ambulance transport infrastructure must be in place to provide the link between different levels of care. It must be explained to the ambulance services that obstetric haemorrhage has the highest priority for transport. Where necessary negotiations must take place amongst the health administrators to ensure this occurs.
The non-availability of blood was associated with the death of 12% of women with antepartum haemorrhage and 14% of those who died due to postpartum haemorrhage. Blood must be available at all hospitals providing level 2 care and level 1 hospitals where caesarean sections are performed.
To ensure that the changes occur, audit needs to be done at all levels of care regarding obstetric haemorrhage. This can be achieved using the "near miss" methodology3. These cases can be used for in-service training.
Poor observations contributed significantly to the death of women in 46% of patients who died from antepartum haemorrhage and 55% of women dying from postpartum haemorrhage. The following important improvements are required with regards to observations of patients at risk for postpartum haemorrhage:
Many women are dying unnecessarily due to obstetric haemorrhage. Obstetric haemorrhage is a good indictor of the quality of maternal care. Clearly, maternal care is poor in some areas of South Africa. Attention must be paid to rectifying this.