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GROUP C5WEJE CHITURU .C. U2005/4710398OPARANOZIE EMMANUEL U2005/4710368

OMUKORO FRED U2005/4710356

ETERIGHO-IKELEGBE .O. U2004/4710345

BIRABE .L. HADDY U2000/4710336

SOMIARI ABIYE U2005/4710380

AYERITE ABRAHAM .L. U2001/4710243


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OutlineCase PresentationIntroduction/Terminologies

Epidemiology

Causes/Risk Factors

Management of PPH

Complications

Prevention

Recommendations/ConclusionReferences


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Case PresentationI present Mrs RC, a 28 year old trader with primary level of

education, who resides at Deeper-life compound Umuoparavillage. She is Igbo and a Christian of the Pentecostaldenomination. She is Para 6+0 (6 alive).

She presented to the unbooked labour ward 5 days ago, witha 7 hour history of retained placenta and bleeding par vagina,following the delivery of a live female baby at a TBAs home.There was inability to deliver the placenta and concurrentvaginal bleeding. There was associated dizziness, weaknessand fast breathing. The attendant TBA gave intramuscularinjections , abdominal massage and intravenous fluids(names unknown), all to no avail, hence she was rushed toUPTH for expert management.


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Index pregnancy was not registered for antenatal care,uneventful and carried to term. Labour was prolonged and

outcome was a live female baby of an unknown birthweight, who is alive and well. There is no previous historyof retained placenta.

She has had 5 previous confinements between 2003 and2009. All pregnancies were uncomplicated and carried toterm, deliveries were by spontaneous vertex and theoutcomes were 2 males and 3 females. Puerperium wasnormal.

The age at which she attained menarche was unknown. She

has a 4 day menstrual flow in a regular 28 day menstrualcycle. There is no history of menorrhagia ordysmenorrhoea. She has not had any termination ofpregnancy. She is aware of contraceptives but dose not useany. She is not aware of papanicoloau smear .


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Past medical and surgical history were notcontributory.

She is the only wife of a 40 year old taxi driver in amonogamous setting. There is no family history ofdiabetes mellitus, sickle cell anaemia , hypertension,bronchial asthma nor twinning. She does not take

alcoholic beverages or tobacco product in any form.The review of her systems was essentially normal.


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On examination, she was anxious, severely pale, febrile withtemperature of 37.4c, anicteric, acyanosed, severely dehydrated

and had bilateral pedal oedema up to the level of the ankle.

Pulse rate was 118bpm (low volume and thready), BP was90/40mmHg. Heart sounds 1 and 2 only were heard.

Respiratory rate was 26cpm. Chest was clinically clear.

Abdomen was enlarged, moved with respiration and tender.Uterine size was 26 weeks and tonically contracted. There was noassociated organomegaly.

On Vaginal examination, vulva was smeared with blood and theumbilical cord was seen at the introitus , clamped with a thread.Placenta tissue was at the vault occluding the cervical os which

was about 4cm dilated.

An impression of primary PPH secondary to retained placenta was

made.


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The following investigations were done and revealed; PCVof 18%, urinalysis-NAD, and 4 units of whole blood wasgrouped and cross matched.

She was resuscitated with 2 litres of normal saline infusionand 40 IU of oxytocin in 1 litre of N/saline at 30dpm.

She was placed on intravenous antibiotics, analgesics andtransfused with 2 units of whole blood.

Subsequently, the placenta was delivered manually in thetheatre and she was later placed on oral medications.

She is currently in the unbooked lying in ward with herbaby, and has been counselled on the need forcontraception.


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CASE SUMMARY

In summary, I have presented Mrs. RC, a 28 yearunbooked para 6 +0 (6 alive), who was admitted andstill being managed as a case of primay PPH secondaryto retained placenta.


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The joy of motherhood . Many women have died while searchingfor this joy especially in developing countries as maternalmorbidity and mortality continues to rise . Photo ; cesr.org


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TERMINOLOGIES

MATERNAL MORTALITY: It is the death of a woman while pregnant orwithin 42 days of delivery or termination of pregnancy, regardless ofthe site or duration of the pregnancy from any cause related to oraggravated by the pregnancy or its management (10th Revision of theICD) but not from accidental or incidental causes.

Maternal mortality ratio: It is the number of maternal deaths during agiven year per 100,000 live births during the same period. Theappropriate denominator for the maternal mortality ratio would be thetotal number of pregnancies (live births, still births, abortions, ectopic and

molar pregnancies). These figures are seldom available especially in thedeveloping countries where most births take place, so the number of livebirths is generally used as the denominator. Here we use deliveries (live+stillbirths).


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Maternal mortality rate: Measures both theobstetric risk and the frequency with which women areexposed to this risk. It is the number of maternaldeaths in a given period per 100,000 women ofreproductive age (15-49yrs). Often usedinterchangeably (i.e. rate and ratio). It is essential forthe sake of clarity to specify the denominator used

when referring to either of these measures.


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a or causes o ma erna mor a yworld wide.


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Indirect causes includeHepatitisHeart diseasesTB

HIV/AIDSPulmonary embolismSequestration crisisJaundice in pregnancyAnaesthesiaRuptured ectopic pregnancy

Acute renal failureBlood transfusion reactionDiabetic comaBroncho pneumoniaAbdominal massage


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In UPTH in 12yrs (ranking)

Severe pre-eclampsia/eclampsia 22%Obstructed labour 14%

Abortions/ 14%

Haemorrhage 11%

Sepsis 10%Ruptured uterus 11%

Others are:

Hepatitis

Heart diseasesTB

HIV/AIDS


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INTRODUCTION 4

POSTPARTUM HAEMORRHAGEExcessive bleeding following delivery and is describedas primary or secondary

Primary PPH is traditionally defined as

Blood loss from the genital tract in excess of of 500mlfollowing vaginal delivery or 1000ml or more following a

caesarean section within 24 hours of delivery. OR

Any amount of blood that can cause haemodynamic or

cardiovascular instability within 24 hours of delivery.

Secondary PPH is defined as abnormal vaginal

bleeding from 24 hours after delivery until 6 weeks

postpartum.


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EPIDEMIOLOGYAn estimated 600,000 women die each year throughout the

world from complications of pregnancy and childbirth

55,000 of these deaths occur in Nigeria

Nigeria is only two percent of the worlds population butaccounts for over 10% of the worlds maternal deaths inchildbirth

Ranks second globally (to India) in number of maternal

deaths.Most occur in developing countries mm ratio (developed countries) =27/100,000livebirths. mm ratio in developing countries: 20 x or more (480/

100,000 live births and in some areas may be as high as 1,000/

100,000 live births.


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MATERNAL MORTALITY

RATIOS IN NIGERIA

1549

1025

286

165

351

828

704

0 500 1000 1500 2000

NORTH EAST

NORTH WEST

SOUTH EAST

SOUTH WEST

URBAN

RURAL

NATIONAL


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OTHER INDICATORS OF

MATERNAL MORBIDITY AND

MORTALITY

Risk of a woman dying from child birth is 1 in 18 in

Nigeria, compared to 1 in 61 for all developingcountries, and 1 in 29, 800 for Sweden

For every woman who dies from childbirth in Nigeria,

another 30 women suffer long term chronic ill-health(morbidity)


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EPIDEMIOLOGY OF PPH 14 million cases of obstetric haemorrhage occur annually.

128,000 maternal deaths are caused by PPH annually (25% of MM)

Tops the list of causes of maternal deaths

Major cause of postpartum morbidity worldwide

Incidence varies. In developed countries 5 12 % of all deliveries.

In Britain, the risk of maternal death from PPH is around 1 in

100,000 deliveries

In developing countries the risk is 1 in 1,000 deliveries.


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UPTH 2011From Jan 2011 June 2011

Unbooked Labour Ward admissions.

Making up a percentage of 2.45%

Month(s) Admissions Cases of PPH

Jan 52 -

Feb 26 3Mar 42 2

Apr 74 1

May 58 2

June 75 -

327 8


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Booked Labour Ward Admissions (Jan-June 2011)

Making up a percentage of 0.3%

Month(s) Admissions Cases of PPH

Jan 199 1

Feb 126 1

Mar 236 -

Apr 287 -

May 333 I

June 161 1

1342 4


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CAUSES/RISK FACTORSMedical

Social

MEDICALTonicity(uterine atony) Commonest

Trauma

Tissue(placental tissue)

Thrombopathy


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UTERINE ATONY Previous history of PPH

Overdistension of the uterus multiple gestation, fetal

macrosomia, polyhydramnios

Antepartum haemorrhage placenta praevia, abruptio placenta Precipitate labour

Prolonged labour (Uterine Inertia)

Grandmultiparity

fibrosis in uterine muscle Chorioamnionitis

Uterine fibroids

Drugs halothane, magnesium sulphate etc


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GENITAL TRACT LACERATION

Episiotomies Instrumental vaginal deliveries Forceps, vacuum extraction

Manipulative deliveries especially in shoulder dystocia, vaginal

breech deliveries Precipitate labour / bearing down before full cervical dilatation

Destructive vaginal operations craniotomy, decapitation,

cleidotomy

Injudicious use of oxytocics


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RETAINED PLACENTAL TISSUE

Poor management of third stage of labour e.g.

overzealous CCT

Abnormal placenta e.g. succenturiate lobe

Morbidly adherent placenta accreta, increta and

percreta


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COAGULOPATHY

Abruptio placentaPre-eclampsia

Amniotic fluid embolism

Septicaemia / Intrauterine sepsis

Retained dead fetus

Hypovolaemia

Hydatidiform mole

Intravascular haemolysis

Incompatible blood transfusion


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Causes of Type III Delay

Non-affordability of antenatal costs, delivery costsand post-natal costs

Delays in seeing staff in health facilities

Incessant strikes and lockouts

Delays due to poor supplies and consumables

Delay in referral of patients

Basic essential obstetrics care not available in most

facilitiesSystemic problems doctors and midwives refusing

rural postings

External brain drain


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MANAGEMENT

Medical management

PPH is an obstetric emergency

Call for help

Rub up contraction

Empty the bladder

Assess blood loss and resuscitate

Use of oxytocics Evacuate the uterus(for retained placenta)


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MANAGEMENT CONTDSurgical

Repair of genital tract lacerations / ruptured uterus

Application of sutures(B-Lynch suture)

Systematic devascularization

Hysterectomy

Interventional radiology

Uterine artery embolization


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COMPLICATIONS

MEDICAL

Anaemia

Hypovolaemic shock

Adult respiratory distress syndrome Pulmonary oedema

Acute Renal Failure

Hypopituitarism (sheehan`s syndrome)

Uterine synechiae

Sepsis.

Death


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COMPLICATIONS 2

SOCIAL (SOCIETAL IMPLICATIONS) Postpartum depression

Social withdrawal

Financial burden

Prostitution

Increased chance of u5m of surviving

offsprings Psycho-social implications on surviving

offsprings


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Millennium Development Goals,

UN (2000)

how far?Goal 4: Reduced child mortality - To reduce

mortality rate among children under 5 by twothirds by the year 2015

Goal 5: Improved maternal health - To reduceby 75%, the maternal mortality rate by the year2015

Eleven(11) years into the 15 years deadline forachieving these goals, there is no clear evidencethat Nigeria has yet achieved any remarkableachievements.


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PREVENTIONPRIMARY

SECONDARYTERTIARY


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PRIMARY PREVENTION

PUBLIC HEALTH EDUCATIONENLIGHTMENT CAMPAIGNS.

SEMINARS/TALK.

PUBLIC LEGISLATURE.

FEMALE EMPOWERMENT.GIRL CHILD EDUCATION.

FREE ANTENATAL SERVICES.

PROVISION OF HOSPITAL,HEALTH CENTRES ANDDRUG.

TRAINING AND RETRAINING OF HEALTHWORKERS/TBAs

IMPROVED BLOOD BANKING SERVICES

FAMILY PLANNING SERVICES


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Antenatal anticipation

Previous history Other risk factors

Prevent anaemia

Haematinics Treatment of malaria and

intercurrent infections

Blood transfusion

Ensure blood is available for delivery


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Secondary prevention


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SECONDARY PREVENTIONACTIVE MANAGEMENT OF THIRD STAGE OF

LABOUR

Obstetric emergency

Uterine atony

Rub up contractions

Empty bladder

Administer oxytocics

Bimanual compression

Evacuate uterus

Internal uterine tamponade


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Genital tract lacerations

Examine under good light source

Repair episiotomy promptly

Repair of vaginal lacerations

Examine cervix and repair any lacerations

Laparotomy for uterine rupture

Retained placenta Evaluation and resuscitation Antibiotics Attempt removal by CCT Manual removal in theatre under general anaesthesia Umbilical vein infusion


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TERTIARY PREVENTIONAdoption

Psychological support

Establishment of support groupsNGO intervention

Care for surviving infants

Limitation of disabilities

Recuperation into society

Rehabilitation


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Of great importance but often neglected are:reporting, record keeping, analysis of POSTPARTUM HEMORRHAGE. and near misses on a

case-by-case basis (auditing) to increase ourunderstanding of the pathway of survival and death,make local improvements, identify substandard careand avoidable factors. That is the use of health

information to improve quality of care.


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Recommendations Political leadership is needed-The Presidency should personally speak to the problemof the high rate of maternal mortality morbidity inNigeria, just like he has done for HIV/AIDS

Executive Governors and Local Government Councilchairmen should do the same in their States and LGAs

A multi-sectorial approach should be adopted wherebyall sectors (Legislative Assemblies, Information,Education, Women Affairs etc) should include MCHprogramming in their portfolios

Costs alleviation for women seeking antenatal care anddelivery services. Such a policy has been successful inreducing maternal mortality in Kano State

A more effective National Institute for maternal andchild health


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National Institute of Maternal and Child Health

Will provide an avenue through whichgovernment will providing funding for MCH

Will reduce donor dependency on MCH

programmingWill provide an avenue for research and data

collation on matters related to MCH

Will develop guidelines, policies and strategies

for reducing maternal and child mortality inNigeria

Will provide a forum for capacity building andresource mobilization for MCH


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Programs to reduce post partum haemorrhage in Nigeria1. Provision of information and services about family

planning and contraception

2. Programs to encourage all pregnant women to receive

antenatal care and to be delivered by skill birthattendant

3. Improvement of antenatal and delivery services inhospitals, especially emergency obstetrics care

4. Government should address the problem of womendying from poorly performed abortions5. The government should ensure the legislation for the

registration of all maternal deaths in Nigeria, as beenalready legislated in Edo State.


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What the federal Government is currently doing Maternal Mortality : Agency deploys 3500 midwives to rural

communitiesJune 14, 2011 BynigerianhealthjournalBy Hassan Ibrahim, Kaduna

The National Primary Healthcare Development Agency(NPHCDA), has so far deployed 3,500 midwives to ruralcommunities across the country to reduce the current high rateof maternal mortality in Nigeria, the NPHCDA ExecutiveSecretary, Dr. Muhammad Ali Pate, has said.

Speaking in Kaduna during the orientation of midwives underthe MSS scheme, Pate said adequate security arrangements hadbeen put in place for the fresh batch of 441 basic midwives whorecently graduated from 25 schools of midwifery and were nowbeing deployed to various communities in Nigeria.
http://nigerianhealthjournal.com/?author=1http://nigerianhealthjournal.com/?author=1


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U.N. Secretary-General Ban Addresses Maternal MortalityIn Nigeria.Monday, May 23, 2011

As part of a four-country tour, U.N. Secretary-General Ban Ki-

moon on Sunday arrived in Nigeria, where he highlighted theimportance of fighting maternal and child mortality in thecountry, which has one of the highest maternal mortality rates in

Africa,Agence France-Presse reports (5/22). He "commended theNigerian authorities for integrating services for maternal,newborn and child health, with programmes on HIV/AIDS,

tuberculosis, malaria and nutrition," according to the U.N. NewsCentre (5/22).

Ban, along with Jeffrey Sachs, his special adviser on theMillennium Development Goals (MDGs), met with NigerianPresident Goodluck Jonathan, The Nation reports
http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.thenationonlineng.net/2011/index.php/news/7162-ki-moon-in-nigeria-to-push-health-campaign.htmlhttp://www.thenationonlineng.net/2011/index.php/news/7162-ki-moon-in-nigeria-to-push-health-campaign.htmlhttp://www.thenationonlineng.net/2011/index.php/news/7162-ki-moon-in-nigeria-to-push-health-campaign.htmlhttp://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.un.org/apps/news/story.asp?NewsID=38468&Cr=maternal+health&Cr1=http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1http://www.google.com/hostednews/afp/article/ALeqM5jXgemqxLMGti7hmEqFJeezT6hiUA?docId=CNG.b4eb7b7b77167ad494e2239eff1c3199.12b1


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CONCLUSIONPostpartum haemorrhage has remained an important

cause of maternal morbidity and mortality especiallyin developing countries like ours. Therefore the need

for education of all stake-holders on the properunderstanding of the aetiopathology cannot beoveremphasized, as this may ultimately form thetemplate for improved safe motherhood in Nigeria.


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ReferencesWHO mortality database Geneva;WHO;2007(http://who.int/health info/morttables)

A publication on maternal and child health in Nigeria, by

Prof. Friday Okonofua.(FIGO) Provost, College of medicalscience, University of Benin. Executive Director ofObstetrics and Gynaecology

A publication on maternal mortality by Prof. S. A. Uzoigwe.MD,FWACS, FICS. Head of department of Obstetrics and

Gynaecology. College of Health Sciences, University of PortHarcourt

UNICEF Maternal Health database(http://www.childinfo.org/eddb/maternalhtn)
http://who.int/healthhttp://who.int/health


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