Its true what they say- bad times come in waves. we had 3 maternal deaths in the last 10 days alone :(
The first had been refered from a health center having been fully dilated for 2 days!! 2days!! when she got to us she had a macerated fetus still inside, a necrotic vagina and most probably a vesico-vaginal fistula which is a devastating complication of obstructed labour where the pressure of the babies head erodes a hole between the mothers bladder and vagina, causing her to leak urine constantly, be prone to lots of infections not to mention the social implications. A rapid c-section was done, but the mother died of the complications and sepsis.
The second arrived having already ruptured her uterus, Im not too sure of her history as i wasn't involved but i heard the tear in her uterus was very extensive and tore down into her bladder, she had lost a lot of blood, we did a hysterectomy and she went to ITU but died the next morning.
The third patient died while i was oncall- it was very sad as it was the first patient who has died that i was directly involved with. she was on her 5th pregnancy, she came from home already fully dilated and delivered in the admissions room a fresh still born baby. she was taken to a bed and then had a massive postpartum hemorrhage- when i was called she already looked like she was in shock, had an unrecordable bp and was lying in about a liter of blood. w started aggressively resuscitating her, took v\blood tests and gave her lots of fluids. on assessment her uterus wasn't contracted and we thought this to be the cause - we started massaging it to help it contract and giving her medication to do the same- in the uk there are about 4 different drugs you can use here there is only 2 so we are already disadvantaged. All this helped to slow down the bleeding but it did not stop, we decided then to transfer to theater, to see if there were any products and possible do a hysterectomy if the bleeding didn't settle soon. we also ordered blood but was told only one unit was available.
in theater the bleeding didn't improve and we couldn't find her pulse - we started chest compressions and she came back, wed called the consultant who arrived and we decided to operate on opening her abdomen it was clear why she was bleeding- her uterus had ruptured- straight into the broad ligament and there was massive bleeding into the retro-peritoneal space. Id never seen anything like it- we quickly removed her uterus and with the help of a general surgeon we stopped the bleeding. In total she probably lost 6 L of blood which is almost all the blood she has! With out more blood she was surely going to die- we managed to find 2 more units but no more :( I remember a similar case who survived but blood was more available and she had 8 units in total. blood is a strange thing here sometimes its plentiful and other times very scarce, although there is a blood donation drive in Malawi.
My consultant the next day asked why she died and i said lack of blood- his reply was no- lack of family planning and in this case he may have a point! After 5 pregnancies the uterus becomes tired and thin, is less likely to contact properly after delivery and more likely to rupture.
Family planning in still very underutilised in the developing world, there are many teenage pregnancies ( a major cause of death of girls in this age group) and many women who have more than 5 or 6 babies which put them at risk of great obstetric compications.
Heres hoping thats the bad patch is over for awhile.
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