ETATMBA STUDENT RE-AUDIT
Period of Re-Audit; July to September 2012
CASE MANAGEMENT OF POST PARTUM HAEMORRHAGE NTCHEU
DISTRICT HOSPITAL
Analysis of post partum haemorrhage case management
Purpose:
To see if there is any change after intervention of first audit on how
post partum haemorrhage was being managed and determine their
contribution on maternal mortality deaths.
Method:
At the beginning of the audit decision on the audit period was chosen
and post partum cases file were retrieved and audited. In total were
36 from a 3 month period. Some causes were avoidable and
recommendations were made.
MAIN FINDINGS
There were 6 deaths during three months period and 2 of them were from Post
Partum Haemorrhage representing 33.3% on martenal death causes. This is no
difference as compared to global percentage causes of PPH which is at 27%
INTRODUCTION
Each year more than 529, 000 woman world wide die from complication of
pregnancy and child birth that is one every minute. Many more survive but will
suffer ill health and disability as a result of these complications. At least 80% of
deaths result from five complications that are well understood and can be readily
treated: haemorrhage, sepsis, eclampsia, obstructed labour and complications of
abortion. We know how to prevent these deaths – there are existing effective
medical and surgical intervention that are relatively inexpensive. The reduction of
maternal and neonatal mortality is one of the key goals of the millennium
Declaration. An important part of reaching this goal is the provision of skilled
attendance and essential (or emergency) obstetric care (EOC) for pregnant
women during labour, delivery and the immediate post partum period.
Pregnancy should be a normal life event for the majority of women and yet every
pregnancy faces risk.
Malawi has a maternal mortality ration of 675/100 000 live births which is among
the highest in the world. Malawi falls in sub Saharan Africa where maternal
mortality rate is very high and Ntcheu is one of the districts of Malawi.
Malawi has 13, 077, 160 people (NSO 2012) and Ntcheu district has 528088 people.
Ntcheu District is situated in the central region of Malawi and is half way through
major cities of Lilongwe and Blantyre. The District borders with Balaka and
Mangochi to the east,Neno to the South, Dedza to the North and the Republic of
Mozambique to the west.
POPULATION DISTRIBUTION OF NTCHEU DISTRICT
Total population
Under 1 population
Women of child bearing age
Expected deliveries
Maternal death of WCBA
528,088
26,404
121,460
26,404
155/100 000
During the three months period of audit from July to August 2012 there were 6
maternal deaths. On average we had 1,345 deliveries during 3 months period
which means we had 15 deliveries per day on average. From the death above
5.6% were accounted from post partum haemorrhage. Ntcheu has 44 Health
Facilities and 22 are Government sponsored health facilities, the rest are from
private, CHAM and NGOs. Out of the 44 health centres, 26 six conduct deliveries
and other maternal and child health services. The above deaths that occurred in
the district and deliveries were not included. This is too many deaths for the
district and the country to achieve millennium development goal number 5 by
2015.
METHODS
This study/audit was facility based on the implementation of post partum
haemorrhage case management during the six month period. This period was
chosen to determine the previous practices and identify gaps if any and improve
on the PPH case management.
Guidelines for PPH case management was reviewed and standards were
determined. From the standards then areas of audit were developed and in total
were 14. Case definition then was prescribed and was as follows:- Any woman who
bled 500mls and above soon or later after delivery (qualified for the study).`If the
cloths are soaked with blood within five minutes’( MAYES Midwifery, Therteeth
edition 2004) According to the criteria in total we had 36 cases of post partum
haemorrhage and these were audited using the areas that were set. This is to
identify where we did right or wrong so that service to be implemented to
improve case management. As earlier on stated 5.6% of maternal deaths were
from PPH.
Below are the areas that were set and used for the audit.
1. Health worker called for an assistant when blood loss was 500mls and
above?
2. IV access with big bore cannula and IV fluids and how much?
3. Recorded blood pressure and pulse rate?
4. How many times BP and PR were checked and if not why?
5. Was the patient with PPH given;
6. -Pitocin?,
- Ergometrine?
- Misoprostol?
-Antibiotics.
7. Was the patient examined and vital checked.
8. - immediately?
- After one hour?
- Two hours?
- Four hours?
If not why?
9. With PPH from uterine atony health worker did bimanual compression?
10. Established cause of bleeding;
- tear?
- Retained products/placenta?
- Others? Eg (surgical)
11. After identifying the cause, how many were assisted either by suturing
evacuation or bimanual compression?
12. Was blood given when still bleeding and BP < 90/60 pulse > 100?
13. How many were given antbiotics?
14. How many patients had their Blood Pressure not checked at all?
However in the table point number sero status and died or alive were reflected
not as a standard but just to give a clear picture
FINDINGS Data collected from the district hospital during the three month
period using case files. All 36 PPH case files were analyzed. Age group ranged
from 16 to 35 years. Average length of hospital stay was 5 days. 91% of women
were clinically health during time of admission, waiting for labour and delivery,
and 9% were critically ill. 5.5% of 36 PPH cases died.
TABLE OF FINDINGS COMPARING THE FIRST AND SECOND AUDIT
ACCORDING TO AREA OF AUDIT AND PERCENTAGE
No. Area
1
Called for help when blood loss >
500mls
2
Recorded BP
PR
3
IV Access with big bore cannula
4
How much IV fluids were given
(prescribed)
5
How many got Pitocin
Ergometrine
Misoprostol
Antibiotic (s)
6
7
8
9
11
12
13
14
How many were examined had vitals
checked
- Immediately?
- After one hour?
- After two hours?
- After Four hours
Bimanual compression to atonic uterus
PPH
Causes of PPH
- Tears
- Retained tissues
- Surgical
- others
How many were assisted
- Tear sutured
- Evacuation
- Surgical
- Others
Gave blood when still bleeding and BP
<90/60 pulse > 100?
Number of patient discharged
- Alive?
- Died?
Number of patients that were not
checked BP at all
Sero status
Known position
Known Negative
Unknown
Quantity %
Quantity %
Not
13
46.4% 23
63.0% 13
27
96.4% 28
78.o%
8
24
11
85.7%
39.3%
27
7
75.0% 9
19.4% 29
27
0
0
12
96%
0%
0%
42.3%
31
0
6
13
86.1%
100%
16.7%
36.1%
5
36
30
23
14
1
5
7
50%
3.6%
17.9%
25%
33
30
22
28
91.7%
83.3%
61.1%
78.0%
3
6
14
8
0
0%
15
42.0% 21
4
8
8
8
14.3%
28.5%
28.5%
28.5%
12
10
5
9
33.3%
28.0%
14.0%
25%
24
26
31
27
4
4
3
2
100%
50%
100%
100%
12
9
5
9
100%
90%
100%
100%
0
1
0
0
11
39.3%
19
52%
17
2
3
89.3%
10.7%
30
6
83.3%
16.6%
30
6
1
3.6%
0%
0%
4
13
11
14.3% 3
46.4% 25
39.3% 8
8.3%
33
69.4% 11
22.2% 28
RESULTS OF AUDIT
POST PARTUM HEARRHAGE RELATED CASES
The findings from 36 PPH cases were analysed based on the areas used and
calculated as percentages. The majority causes of PPH were seen to be avoidable
with essential obstetric care by skilled health workers. E.g. Slipping off of BTL
sutures,bleeding of patients during caesarian section and epsiotomies.
FINDINGS
1. Health workers in the labour ward have improved a bit call for help when
they were confronted with condition when can not cope from 46.4% to
63.0%.
2. Almost all patients were being checked vital signs including blood pressure
pulse rate and temperatures during hospital stay, this has changed to
better
3. Efforts were being made to insert IV line for resuscitation to almost all
patients with haemorrhage though there is a drop as seen in a table
4. Clinicians and nurses just giving IV fluids as per their wish without being
prescribed according to patient needs, this has not changed
5. A lot of patients with PPH were given pitocin and were given misoprostol
were doing bimanual compression to uterine atony in PPH cases
6. Ergometrine is no longer given at Ntcheu District Hospital to control
bleeding and this still the situation in general
7. All patients with cervical or perineal tear were sutured and 90% of the
patients with retained tissues were evacuated.
8. Health workers like nurses and clinicians were also contributing to PPH due
to poor technique of performing surgical procedure evidenced by e.g.
slipping off of BTL sutures, bleeding of epsiotomies, bleeding of patient on
theater table during procedures ie C/S and after due to under closing of
incision but now there is a change as there was no any case with slipping off
of sutures
9. Vitals were checked according to health workers wish not as per
requirement or by condition demands but patients are being monitored
though with minor shortfalls to other individuals
10. Patients were inadequately resuscitated as was shown by the way how IV
fluids were being given. E.g. IV fluids and still is a problem as seen in the
table
11. The hospital had not enough monitoring equipment e.g BP Machine and
still there is no enough diagnostic tools like BP machines
12. Health workers were not checking for HIV to all pregnant women at the
hospital during that six month periods and still some women are delivering
without knowing their sero status and the teason being lack of commitment
to other health workers
RECOMMENDATIONS
1. It is important to shout for help when you can not cope or have limited
capability to handle the case. There is a need to improve on dependence,
for calling others when a need arises and we are encouraging the ward incharges to closely monitor their subordinates
2. Vital signs have to be checked as a routine or according to the condition of
the patient. We need to encourage health workers to be vigorous in
checking vitals signs to all patients and this is a requirement
3. Big bore cannula is recommended for resuscitation of patients who are in
shock e.g. BP of < 90/60 and pulse rate >100 or if patients are still bleeding
actively need blood replacement regardless of Haemoglobin results.
4. IV fluids are to be prescribed as per patients need or condition rather than
distributing IV fluids and we are to put protocals on how to determine how
much to give
5. Clinicians to work together when doing other surgical procedures so that
where there is gap of knowledge should be covered and improve on surgical
skills
6. Orient other health workers on the use of misoprostol to control PPH
without necessarily depending on pitocin only. Where a patient has no any
other contra indications, ergometrine is also a good choice of drug to
prevent bleeding and the problem is our policy at now
7. Bimannual compression can play a good role to prevent PPH especially
those caused by uterine atony and now some are doing this.
8. Management to make sure that disgnostic equipments should be always
available e.g. BP machine at all facilities where deliveries are conducted I
will keep on reminding them
9. All waiting mothers need to access HIV/AIDS services including HTC/provider
initiated Testing and counseling and supplies on site mechanisms are to be
putin place to work with HIV/AIDS Counselor
10. Antibiotics are vital to be given to mothers who have bled as are exposed to
infection during intervention to control PPH especially in the advent of
HIV/AIDS. Therefore clinicians and nurses reminded on the need for
antibiotic coverage.
CHALLENGES
Ideally we do normally meet as maternal death audit team that is meet within
48 hours of maternal death has occurred but we do not implement the agreed
action in full and this is a challenge. This will be planned again to how best we
can deal with this problem as a team
 I had a problem to get case files since the period of audit was from July last
year ie 2011 at first but now problem sorted once and for all

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I lost the audit report to computer viruses started all over again since I
no back up and now no any challenge about this issue
ACKNOWLEDGEMENTS
DHO Ntcheu District Hospital for allowing the audit to take place
Dr. Saliya Chipwete for supervision
Nurses and clinicians for providing technical support
Mrs. Dandalo Assisted a lot in collecting data
REFERENCES
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MDHS 2004
NSO 2012 (Population and housing census)
Life saving skills manual
Mayes Midwifery,therteeth edition (2004)
Nynke Van den Broek DTM+H, FRCOG PhD (2006)