AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths from Obstetric Haemorrhage 2020-2022 Managed as outpatient till 38 weeks Booked for CD plus tubal ligation. No preparation for potential complications (not counselled for hysterectomy, no arrangements for high care, and no obstetric or anaesthetic specialist involved) CD by medical officer. Placenta praevia percreta. Called more senior medical officer. Attempted placental removal. Massive bleeding. Delay calling specialist. Specialist performed hysterectomy, bladder injury. Patient severely shocked. No intensive care unit in this regional hospital so referred to another RH. No non- pneumatic anti shock garment (NASG). Died soon after arrival at second RH Assessment Primary obstetric cause: Morbidly adherent placenta praevia. Final cause: Hypovolaemic shock. Contributory: Coagulopathy (DIC) Avoidable factors: Patient: Nil. Administrative: Lack critical care capacity at RH Medical Care: Substandard management of major placenta praevia and suspected percreta antenatally Substandard preparation for very high-risk CD No specialist at the CD Incorrect for medical officer to attempt placenta removal No re-laparotomy /packing prior to referral. No NASG Suggestions for prevention. Surgery for major placenta praevia and suspected morbidly adherent placenta should be performed at tertiary or regional level with available skilled specialists, blood products and appropriate pre-operative preparations should be made with multi-disciplinary team, and patient consent for hysterectomy. DISCUSSION OH deaths represent the second most common cause of maternal death in South Africa, and account for the most preventable deaths; 85.5% could have been prevented by health system and medical care improvements. OH is therefore considered as ‘low hanging fruit’ that must be urgently addressed in order for SA to reduce its MMR and achieve the sustainable development goal (SDG) of 70 MDs per 100,000 LBs by 2030. Over the years, the Saving Mothers reports described the similar issues in the management of OH. Many interventions were developed following the 2014- 2016 triennial report which contributed to the decline of OH mortality in 2017-2019: the focus on Safe CD, updated ESMOE OH protocols and introduction of emergency drills, together with improved health of HIV positive women due to expanded ARV provision. Other interventions introduced in 2019 (non-pneumatic anti shock garment for referrals, massive haemorrhage transfusion protocols and use of tranexamic acid for PPH) would have been expected to have reduced OH MMR further in this triennium, but the potential impact was counteracted by the impact of the Covid 19 pandemic in 2020 and 2021, previously mentioned in this chapter. At an international level, three important contributions have been made to PPH management: (a) International PPH roadmap developed in 2023 by a WHO led consultative process has highlighted the importance and urgency of reducing preventable maternal deaths from OH 7 ; (b) Recent research has shown that anaemia is not only a risk factor for death from PPH, but actually is a cause for PPH 8 , and (c) The E Motive trial, conducted in four African countries including SA has shown how improving accurate early detection of OH with a calibrated drape and using a bundle of interventions concurrently as first response for PPH treatment can reduce severe bleeding and adverse outcomes by 60% 9 . These are all important in defining new Recommendations. CONCLUSION: • Deaths from OH and iMMR increased in 2020-2022 to become the second most common cause of MD. • The increase occurred in 2020 and 2021, probably due to the collateral effects of the Covid pandemic, but in 2022 numbers were lower than pre-pandemic. • PPH after vaginal delivery and after CD are the main causal subcategories followed by antepartum haemorrhage and ruptured uterus. • Wide inequities between provinces remain. • 85.5% of OH MDs were preventable within the health system. • The problems identified in this report that contribute to these OH maternal deaths must be urgently addressed. KEY RECOMMENDATIONS • Protect maternity services in future pandemics. • Implement E Motive nationally at all levels of care. • Focus on preventing and treating anaemia in pregnancy as well as in childhood and adolescence: addressing heavy menstrual bleeding in women, screening and treatment of chronic infections, and adequate nutrition. This requires advocacy. • No woman should be discharged from labour ward or theatre to the postnatal area if Systolic BP is <100, and/ or Pulse is ≥ 110, and/or there is ongoing bleeding. The shock-index should be promoted as a management guide. • Resume implementation of ESMOE/EOST training, use of NASG, and the Safe CD audit. • Implement the updated PPH algorithms in the updated Integrated SA Maternal and Perinatal care guidelines (10), which incorporate E Motive and massive obstetric haemorrhage transfusion protocols. • Direct telephonic / IT links for 24-hour specialist support to district hospital doctors. • Inequities in outcomes between provinces require attention to staffing levels and clinical governance. • Develop training packages for community health workers and ward-based outreach teams to sensitise communities to problem of APH and PPH. • Work with ambulance services to ensure appropriate prioritisation of bleeding patients, training of ambulance personnel in OH, and availability of urgent paramedic assisted ambulances. REFERENCES ¡¡ ¡ ¡ ¢ £ £ ¡ African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 11