Maternal Health at the District Hospital

Family Medicine Specialist CME

Oct. 15-17, 2012

Pakse

Objectives

● Use cases to review common causes for maternal morbidity and mortality in the community

● Review strategies to improve maternal health at the district or village health centre level

Case 1

● A 20 yo G2P1 comes to the district hospital complaining of lower abdominal pain.

● She states she hasn't had her menses for 8 weeks now, but yesterday started bleeding.

Physical Exam

● PR = 110 bpm, BP = 96/54, T=36.4● Pale, sweaty, c/o pain in lower abdomen● Abdomen tender suprapubically and RLQ● Speculum exam reveals ++dark blood in

the vagina● Tender adnexa, and possible mass felt in

RLQ

What is the Differential Diagnosis?

● Ectopic Pregnancy (most likely)● Septic abortion● Pelvic inflammatory disease / tubo-ovarian

abscess

● A positive pregnancy test confirms your diagnosis of ectopic pregnancy

What Do You Do Now?

● Apply Oxygen, if available● Start an IV, and give 2 L of crystalloid stat,

and more depending on condition● Consider blood transfusion if available● Arrange for patient to be transferred quickly

where she can have surgery to remove the ectopic pregnancy

Discussion

● What challenges to you face in the district hospitals with:– Diagnosing ectopic pregnancy?– Treating ectopic pregnancy?

Case 2

● A 30yo G6P5 presents to your district hospital at 38weeks GA

● She states she started having bleeding a few hours ago, and now its running down her leg

What Else on History?

● No pain with the bleeding, but did start having some contractions in the last few hours

● Feels baby moving● Last deliveries were uneventful and quick● Otherwise healthy, with no medical

problems● She has had no ultrasounds

What Physical Exam Would You Do?

● Vital signs – P=105, BP=90/50, T=37.0● Abdominal exam – uterus soft, non-tender,

head high above symphysis● NO speculum or vaginal exam

Antepartum Hemorrhage

What is Your Diagnosis?

● Placenta Previa

What Can You Do at the District Hospital?

● Start IV, give fluid resuscitation● If available, consider blood transfusion● Immediately arrange for C/S, transfer out of

District hospital if not available

Discussion

● Is transportation out of the district or village hospital a problem in your community?

Case 3

● A 28yo G7P7 has just delivered. ● Immediately after the placenta delivers,

there is a large gush of blood, and then continuous trickling of blood.

● You feel her uterus and it feels boggy/soft.

Questions

1) What are the most common causes of post-partum bleeding?

2) What can you do in the district hospital to stop the bleeding?

Causes of Post-Partum Hemorrhage

● Uterine Tone● Retained Tissue● Trauma to cervical/vaginal tissue● Bleeding Disorders

● Uterine Tone – the most common cause, the uterus won't contract– Prolonged labor– Rapid labor– Uterine overdistension (multiple gestation,

polyhydramnios)– Multiparity

● Uterine Tone– Treatment involves:

● Bimanual massage of the uterus● Administration of uterotonic agents, ie: oxytocin

IV/IM, misoprostol PO/PR/PV, carboprost IM/IMM, ergometrine IV/IM

Bimanual Uterine Massage

● Tissue in uterine cavity– Placenta tissue or even clots in the uterus or

upper vagina can prevent uterine contraction– Manual removal of the entire placenta, small

pieces of placental tissue or even clots from the uterus or vagina will correct this

● Trauma to cervical or vaginal tissues– Lacerations to the tissue can be a large source

of bleeding– must be recognized and repaired

● Bleeding Disorders– Patients may have an underlying bleeding

disorder– Patients may develop an acute problem with

bleeding in cases of sepsis, massive hemorrhage or trauma

– Treatment may require transfusion of clotting factors

Prevention of PPH

● Active Management of the Third Stage of Labour

(recommended by WHO)– Giving uterotonic immediately after delivery– Early cord cutting and clamping– Controlled cord traction

Case 3 (cont'd)

● After doing bimanual massage, her uterus begins to firm up

● An IV in started, and she is given 20U of Oxytocin in 1L of normal saline

● You change your gloves, and on exploring her uterus remove a small piece of retained placenta, and multiple large clots

● After examining her cervical and vaginal tissue, you find no lacerations

● Her bleeding slows to expected within 15 minutes

Discussion

● What can be done to encourage women to deliver in hospital instead of at home?

● Have there been any strategies that have worked in your community?