ALERT FOR MATERNAL DEATHS DUE TO OBSTETRIC HAEMORRHAGE
National Committee for Confidential Enquiries into Maternal Deaths, South Africa.
Correspondence to:
Prof J Moodley
Women’s Health and HIV Research Group
Nelson R Mandela School of Medicine
Private Bag 7
Congella, 4013
Email: jmog@ukzn.ac.za
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Introduction
Maternal deaths due to obstetric haemorrhage are the second most common cause of
maternal death in South Africa and the most common direct obstetric cause. As the table
below shows, both numbers and rates of deaths from this cause have increased in the last
decade.
Maternal deaths due to obstetric haemorrhage
Numbers
Haemorrhage MMR
(per 100,000 LBs)
2002-2004
442
20.7
2005-2007
491
18.8
2008-2010
688
24.9
2011
221
23.6
Over 80 % of all these deaths are avoidable. They occur at all levels of care, but are most
frequent at district and regional hospitals
Of particular concern is the increasing number of women who die from bleeding associated
with Caesarean Section (C/S) (about 60 women every year, constituting 27.6% of all
haemorrhage deaths).
The NCCEMD would like to draw your attention to the recommendations concerning
reduction of deaths from haemorrhage that arose from the recent Saving Mothers report
(2008-2010) which follows in Appendix 1.
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In addition the NCCEMD circulated a memorandum two years ago on the Prevention of
Bleeding at and after C/S (see Appendix 2) and the Management of excessive bleeding
associated with C/S (Appendix 3).
The NCCEMD urges all relevant personnel: health managers, teachers at training institutions
and maternity care health workers to address both the recommendations and the
memorandum found in the Appendices as a matter of urgency.
Obstetric haemorrhage after vaginal delivery and after C/S should become an auditable
indicator and all attempts made to implement the recommendations and memorandum in
order to reduce these unnecessary and tragic deaths.
Appendix 1: Key recommendations to reduce maternal deaths from obstetric
haemorrhage1
1. Train community health workers to educate pregnant women about obstetric
haemorrhage and promote transport plans.
2. District and facility managers to ensure (a) that district hospitals have 24 hour functioning
theatres with continuous supply of emergency blood and sufficient staff for the
anaesthesia, surgery and recovery area; and (b) adequately staffed labour wards.
3. Emergency transport to be onsite for transfers from district hospitals
4. Clinical managers to ensure implementation of PPH monograph, ESMOE skills training,
PPH drills and early warning monitoring charts. A particular focus on skills to perform
C/S safely is required.
5. Facility auditing of severe PPH and display of trends by graphs/charts in labour wards
and theatres.
6. Use of misoprostol for induction of labour to be closely monitored and all health care
providers to be trained on correct use so as to prevent uterine rupture. Foley catheter
induction to be promoted as a safer method.
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7. Avoid performing C/S for abruptio placentae with an intra-uterine death, and without
appropriate indications.
8. Syntometrine or ergometrine to be used as second line treatment for uterine atony in
preference to misoprostol, unless contraindicated; and to be considered for prophylaxis
at C/S.
9. Monitoring after C/S, complicated NVD, and manual removal of placenta to be improved
in terms of frequency of observations and action on abnormal observations; this to be
facilitated with early warning monitoring charts. At risk women to be monitored in a
special care area.
10. All women with blood loss in excess of 1000mls need to be immediately assessed by a
doctor
Appendix 2. Prevention of Excessive Blood Loss at Caesarean Section2
The following steps should be taken to minimize haemorrhage associated with C/S:

Ensure that the partogram is completed fully and that the labour graph is interpreted
properly, so that prolonged labour is diagnosed timeously, the appropriate interventions
made, and late first and second stage C/S is avoided.
 Ensure that the strict indications for C/S are followed. If you know in advance that there
is a major placenta praevia, this case should be referred to a second level or tertiary
hospital
 At least two units of emergency blood should be available in the hospital when any C/S is
being performed.
 Ensure that the Haemoglobin is known prior to the C/S and if <8 gms/dl at least one unit
of blood should be transfused before or during the operation
 If the C/S is being performed for obstructed labour, ensure that the most experienced
medical officer performs the surgery
 Intern doctors must not conduct C/S or anaesthesia unsupervised
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 All new medical officers or registrars at a hospital must have their competence in
performing C/SC/S formally evaluated and confirmed by a senior colleague before being
allowed to operate unsupervised
 Ensure a dedicated doctor provides anaesthesia i.e. at least 2 doctors should be
available for the procedure; one to carry out the anaesthesia and one to do the surgery.
If a third doctor is not available, a nurse can assist at the surgery.
 Ensure that appropriate surgical technique is used and that the incision in the uterus is
not too low in the lower uterine segment, particularly in C/S for obstructed labour and
those in the second stage of labour.
 The use of blunt dissection rather than sharp dissection for abdominal entry and
Controlled Cord Traction rather than manual removal to deliver the placenta have both
been shown to reduce blood loss at C/S (3).
 DO NOT “RUSH” THE SURGICAL PROCEDURE. A C/S SHOULD TAKE ABOUT 30 to
40 minutes;
 Do not “close the abdomen” prior to checking that haemostasis has been achieved and
the uterus is contracted and check with the anaesthetist that the patient is
haemodynamically stable (i.e. systolic BP> 100 and maternal pulse <110). If intraoperative bleeding persists call for help
 Ensure that after delivery of the baby, 2.5 i.u. of Oxytocin by slow iv injection is given and
10 to 20 units is inserted into a litre of fluid and continues to “run” during the operation,
following the operation in the recovery room and in the ward for at least 2 hours. Do not
stop the Oxytocin drip at any stage during the transfer of the patient from the theatre to
the ward
 Ensure that prior to the patient leaving the operating table and the recovery room – the
uterus is palpated to ensure that it is not atonic. Also check to assess the amount of
vaginal bleeding and empty the uterus of all blood clots
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 Transfer the patient from the operating theatre /recovery room only after ensuring that the
pulse rate, blood pressure are stable and that the spinal is <T8 and receding. Also
check for uterine /vaginal bleeding (“pad checks”)
 After arrival in the post-natal ward, ensure observations in the following manner
Half hourly for 2 hours
Hourly for a further 4 hours
2- hourly for a further 6 hours and then 4 hourly until discharge.
Observations to be recorded:
- pulse rate
- blood pressure
- vaginal bleeding (pad checks)
- urine output and temperature 4 hourly
 The patient should be nursed in an area where there are health care professionals that
can do the observations regularly and not put in a ward where observations are difficult
to perform.
Apppendix 3. Management of Excessive Bleeding at C/S3
The following algorithms have been developed for the prevention and management of bleeding at and
after C/S and can also be found in the Monograph of the Management of Postpartum Haemorrhage.
They should be displayed in Obstetric theatres and recovery/ postnatal areas
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References
1. Deaths from Obstetric Haemorrhage. Chapter 4 in: Fifth Saving Mothers report of
Confidential Enquiry into Maternal Deaths in South Africa. 2008 – 2010. NDoH,
Pretoria.
2. Department of Health, NCCEMD communiqué 2011. NDoH, Pretoria.
3.
Practical algorithms for managing PPH. Chapter 3 in: A monograph of management
of postpartum haemorrhage in South Africa. NCCEMD, NDoH 2011. NDoH, Pretoria.
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