Primary Postpartum Hemorrhage- Still a Nightmare in Our Country

Abstract

More than 8,000 women die and about 150,000 women suffer from postpartum hemorrhage complications every year in Pakistan, Primary postpartum hemorrhage, rightly called as obstetrician's nightmare, is defined as the loss of more than 500 ml of blood in the first 24 hours after childbirth.1 It is still one of the major causes of maternal mortality and morbidity all over the world2. In the developing country like ours the situation is even worse, where it accounts for 2131% of maternal mortality and morbidity.3 It's an obstetric catastrophe leading to hemorrhagic shock and even death.4 The management of postpartum hemorrhage is very much challenging as it is the most notorious for severe obstetric morbidity in terms of hysterectomy and maternal mortality. The main causes of PPH are uterine atony, which is the failure of uterus to contract and retract, trauma to the genital tract, retained placental tissue, coagulopathies, placenta previa and morbidly adherent placenta. The management of PPH involves both medical and surgical management. Medical management includes use of uterotonics like oxytocin and prostaglandin analogues e.g. prostaglandin E1, E2 and F2α. Surgical management involves conservative measures like uterine and internal iliac artery ligation, application of Brace sutures (B-lynch)5 and definitive and the most drastic measure i.e. hysterectomy with its short term and long-term sequelae. With the passage of time special focus is given to the development of conservative techniques like balloon tamponade technique and radiological
interventions (internal iliac artery embolization) so that ultimate life saving step of hysterectomy which has a definite physical, social and psychological impact on a patient, can be avoided. PPH is the leading cause of death among Pakistani women. Factors contributing to increased incidence of PPH related maternal deaths in Pakistan are, poor infrastructure, lack of appropriate training for health care providers, Lack of female education and empowerment, hesitation for birth spacing, mal nutrition in antenatal period, unbooked antenatal period, delivery by unskilled traditional birth attendants (dais) ,increased rate of un indicated caesarean sections in periphery and even in main cities by non-qualified persons (quacks) leading to placenta previa in subsequent pregnancies.6 Particular attention should be directed to preventive measures that may be adopted, and practiced by obstetricians. They should transmit these to other health care professionals and traditional birth attendants. Trainings by the Government should be provided to community health workers, including doctors, midwives, lady health workers and lady health visitors regarding proper antenatal care, safe delivery practices and use of life saving drugs for prevention of the catastrophic hemorrhage. Early detection and correction of anaemia in the antenatal period should be done. Women with optimum hemoglobin perform really well if they face postpartum hemorrhage. The commonest cause of PPH is uterine atony, which usually occurs within few hours after childbirth. Uterine massage every 15 minutes in the immediate postpartum period by the health care attendant,
Primary Postpartum Hemorrhage- Still a Nightmare in Our Country
Sardar Muhammad Alfareed Zafar
56 J. Soc. Obstet. Gynaecol. Pak. 2017; Vol 7. No.2
reduces blood loss significantly. This has been proved very useful especially in low resource settings. More than 60 per cent of uterine atony cases can be prevented with the effective usage of uterotonic medicine like oxytocin, ergometrine and misoprostol. Oxytocin 10mg IM given at delivery is very effective in prevention of uterine atony but in the country like ours the maintenance of cold chain is really a problem and same is true for ergometrine which is even more thermolabile. Misoprostol 600 mcg given orally is an effective and better alternative to other uterotonics as it can be stored at room temperature (easier to maintain stocks of Misoprotol in remote areas without refrigeration facilities), cost effective and safe. It’s a lifesaving drug and every obstetrician, female doctor, nurse and midwife should familiarize herself with the use of misoprostol and should keep at least 10 tablets in their pocket all the time. The government should include misoprostol in the essential drug list and ensure its availability all over the country to reduce maternal mortality.7,8,9 In our country, the role of a midwife is also very important. Pakistan needs more than 200,000 midwives.10 These workers at basic health units will not only save lives of women from pregnancyrelated deaths but will also create health awareness. Awareness regarding proper birth spacing should also be created by doctors, lady health workers, health visitors and also through media so that prevention of PPH can be done by reducing parity and promoting female health. Awareness programmes should be arranged at public level to create awareness regarding seeking care from skilled medical professionals rather than quacks and unskilled traditional birth attendants. The rate of caesarean sections should be lowered by carefully selecting the patients and caesarean section on demand should be discouraged. Government should take necessary actions regarding the quack practices in towns and small cities of the country as they are doing substandard and unindicated caesarean’s leading to placenta previas and morbidly adherent placentae in the
subsequent pregnancies with life threatening hemorrhage. In short by proper public awareness regarding contraception, maternal nutrition and proper antenatal care, by use of life saving uterotonics like misoprostol, by training our health care professionals like traditional birth attendants and lady health workers and reducing the rate of caesarean sections, we can effectively control the No. 1 maternal killer of our country that is primary postpartum hemorrhage