AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 23 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths due to Pregnancy-Related Sepsis arising from bowel injury: A retrospective folder review from the NCCEMD triennium 2020-2022 Assessment (qSOFA) hindered our evaluation of critical care admission needs. Nevertheless, most women presented with MODS, indicating a need for admission to a critical care unit, which was often delayed or not executed at all. Vital signs were frequently reported as stable despite the absence of recorded data, while many women exhibited several abnormal vital signs shortly before their deaths. Bowel injury as the primary source of infection was often overlooked, resulting in inadequate source control, exacerbating the women’s clinical conditions. The American Association for the Surgery of Trauma (AAST) defines small bowel injury scores as follows: • Grade I: Hematoma or laceration of partial thickness, without perforation. • Grade II: Laceration < 50% of the circumference. • Grade III: Laceration > 50% of the circumference without transection. • Grade IV: Small bowel transection. • Grade V: Small bowel transection with loss of segmental tissue or vascular injury with segmental devascularization. In our study, the most reported bowel injuries were small bowel injuries, occurring in over 50% of cases, either as isolated incidents or in conjunction with large bowel injuries or bladder injury, as reported in one of our cases. A bowel injury at the time of caesarean delivery is not, in itself, evidence of substandard care. Bowel injuries can occur even in expereinced hands. However, the management of delayed bowel injuries is often complicated and may have dire consequences if mishandled. STRENGTHS AND LIMITATIONS This study is valuable as it provides insights into the demographic data, risk factors, and real-life management of women experiencing pregnancy-related sepsis from bowel injury, an important cause of maternal mortality, both globally and in South Africa. The original case files of 14 maternal deaths over three years were reviewed. This type of audit is essential to identify missed opportunities and propose potential solutions to reduce maternal mortality and achieve Sustainable Development Goal 3.1. However, as this review was limited to maternal deaths, it does not illuminate how patients with maternal sepsis from bowel injury is managed, nor does it assess bowel injury from other causes of maternal death, such as obstetric haemorrhage, ectopic pregnancies, or management of miscarriages. It is possible that many women receive adequate care and experienced favourable outcomes, particularly given the low number of cases analysed. Additionally, while every effort was made to extract data comprehensively, certain actions (such as early detection of bowel injury during caesarean delivery) may have been taken but not documented in the files. It is also crucial to acknowledge that avoidable factors may exist on the patient side, notably in cases where patients refuse treatment and leave the facility before they are fit for discharge or present only in critical condition, thereby limiting healthcare workers' ability to act according to protocols. Finally, although the initial NCEMD data indicated 172 cases of pregnancy-related sepsis with 16 instances of bowel trauma, we identified only 14 cases of bowel trauma out of 172 cases reviewed. We believe it is unlikely that the missing files would significantly alter these findings. CONCLUSION Maternal sepsis remains one of the leading causes of maternal mortality, and while the rate of PRS deaths has shown a slow but steady decline in recent years, the high proportion of avoidable deaths is still of great concern. Caesarean section in the background of previous caesarean section is associated with increased risk for bowel injury and high mortality. Identification of risk factors, meticulous surgical techniques, a high level of vigilance following a caesarean section, and compliance with septic bundles during resuscitation are critical. RECOMMENDATIONS: • Ensure capacity and accessibility of facilities for outpatient postnatal care within six days of delivery in all districts. On discharge from the place of delivery, advise women on signs of infection, and what to do if these are noticed. • Strengthen systems to ensure detection and treatment of HIV infection as early as possible in pregnancy, including strategies to ensure initiation of antenatal care as early as possible in gestation (before 14 weeks). • Ensure that surgeons and operating theatre staff follow standard precautions before and during caesarean sections, including asepsis, good and safe surgical technique, and routine prophylactic antibiotics. Extended doses of antibiotics must be given to women with risk factors for PRS. • Remind and educate clinicians about suspecting and recognizing septic shock in ill postpartum women, using forums such as morbidity and mortality meetings, formal ESMOE training, or other training platforms. • No woman should be discharged from the hospital if any abnormal vital signs are recorded, and immediate readmission is advised in women with any symptoms and signs suggestive of sepsis. • Proper initial triage of these patients and immediate implementation of maternal sepsis bundles must always be done at all levels of care. • In district hospital protocols, especially in rural areas, must emphasise recognition of septic shock and the need for early transfer of such women to higher levels of care, after the immediate implementation of sepsis bundles as outlined in the maternity care guidelines (14). • In regional hospitals, audit the capacity of staff and facilities to manage women with septic shock. Recommended norms and standards for staff and facilities, including intensive care units, should be followed. • Educate all doctors performing caesarean sections about precautions for preventing bowel injury at repeat caesarean section or any previous abdominal surgery. Ensure protocols are in place for intraoperative management of bowel injuries, including general surgical help, and transfer to higher levels of care with immediate treatment. • Ensure that all junior healthcare professionals receive full supervision. Declaration None. ACKNOWLEDGMENTS : • The Ministers of Health of South Africa, for their ongoing support and guidance in the Confidential Enquiry into Maternal Deaths process • The Deputy Ministers of Health of South Africa, for their ongoing support and guidance in the Confidential Enquiry into Maternal Deaths process • The Members of the Executive Committees for Health