Global Public Health · Supplementary · from Global Public Health

Case 3: Maternal Mortality Reduction Program

Patient Presentation

Demographics: 24-year-old female subsistence farmer, G4P3 at 38 weeks gestation, rural district in Sierra Leone

Chief Complaint: "Heavy bleeding after delivery at home."

History of Present Illness: The patient delivered her fourth child at home 3 hours ago, attended by a traditional birth attendant (TBA). The delivery was spontaneous vaginal with the baby presenting headfirst. The placenta was delivered by the TBA using fundal pressure and cord traction. Approximately 30 minutes after placental delivery, the patient developed heavy vaginal bleeding that has been continuous and soaking through multiple cloths.

The TBA attempted to manage the bleeding with traditional remedies (herbal preparations applied vaginally) and abdominal massage for 2 hours before the family decided to bring the patient to the district health center. The journey from her village took 1 hour by motorcycle (the only available transport, as the village is 45 km from the nearest health facility with no paved road access).

The patient appears confused, pale, and is actively bleeding per vaginum on arrival. The TBA reports that the placenta appeared complete when delivered. The newborn is alive and was brought along, appearing healthy. The patient had no antenatal care during this pregnancy.

Past Medical History:

• G4P3 (three previous uncomplicated home deliveries)
• No prior cesarean sections
• Chronic anemia (never formally diagnosed or treated)
• No known HIV status
• Last delivery 14 months ago (short inter-pregnancy interval)

Medications:

• None
• No antenatal iron or folate supplementation
• No tetanus vaccination in this pregnancy

Social History:

• Subsistence farmer
• Married at age 16, first pregnancy at age 17
• No formal education
• Lives in remote village with no health facility
• Nearest comprehensive emergency obstetric care (CEmOC) facility: 120 km (referral hospital)
• Husband is the health decision-maker (delayed care-seeking)
• No mobile phone in household

Family History:

• Older sister: Died during childbirth at age 22 (hemorrhage reported)
• Mother: 8 pregnancies, 6 living children

Physical Examination

• Vital Signs: BP 78/42 mmHg (severe hypotension), HR 138 bpm (tachycardia), RR 32, Temp 36.1°C (hypothermic), SpO2 88% on RA
• General: Profoundly pale, confused, restless, cold clammy extremities — clinical picture of hypovolemic shock (Class III-IV hemorrhage)
• Estimated blood loss: > 1500 mL (based on soaked cloths, ongoing active bleeding)
• Abdomen: Uterus palpable 2 cm above the umbilicus, soft and "boggy" (atonic), not well-contracted
• Pelvic examination: Active bright red bleeding per vaginum, cervical os dilated 2 cm, clots expressed with fundal massage, no obvious cervical or vaginal lacerations on initial examination (limited by setting)
• Extremities: Cold, mottled peripheries, capillary refill > 5 seconds
• Neurological: Confused, responding to voice but not fully oriented

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• No ultrasound available at district health center
• No blood bank at district health center; 2 units of O-negative whole blood available from walking blood bank (pre-screened volunteer donors)
• Estimated blood loss based on clinical assessment: > 2000 mL (Class IV hemorrhage)

Clinical Image

Diagram illustrating the Three Delays Model of maternal mortality: Delay 1 (decision to seek care) driven by cultural factors, gender dynamics, and lack of recognition of danger signs; Delay 2 (reaching care) driven by distance, transport, cost, and road infrastructure; Delay 3 (receiving adequate care) driven by facility capacity, skilled workforce, blood products, and referral systems. Applied to the case with specific intervention points identified. Source: Educational illustration.

Diagnosis

Primary Postpartum Hemorrhage (PPH) due to Uterine Atony, Class IV Hypovolemic Shock, Severe Anemia (Hb 4.8 g/dL, pre-existing chronic anemia exacerbated by acute blood loss), Concurrent Plasmodium falciparum Malaria

Key Diagnostic Criteria:

• Postpartum hemorrhage defined as blood loss > 500 mL after vaginal delivery; this patient has estimated loss > 2000 mL (severe PPH)
• Uterine atony confirmed by soft, boggy uterus above umbilicus that is not well-contracted
• Hypovolemic shock: tachycardia, hypotension, altered mental status, cold peripheries (Class IV hemorrhage = > 40% blood volume loss)
• Severe anemia (Hb 4.8) reflecting both acute hemorrhage and pre-existing chronic anemia (likely iron deficiency from multiparity, short inter-pregnancy interval, malaria, and no supplementation)
• Contributing factors to atony: grand multiparity, no active management of third stage of labor (AMTSL), prolonged manipulation by TBA

Treatment Plan

IMMEDIATE EMERGENCY MANAGEMENT (at district health center):

1. Simultaneous resuscitation and hemorrhage control (team approach):

• Airway/Breathing: High-flow oxygen, left lateral tilt
• IV access: Two large-bore cannulae (16-18G), rapid crystalloid infusion (warmed Normal Saline or Ringer's Lactate 2 L bolus)
• Blood transfusion: Transfuse 2 units whole blood (from walking blood bank) immediately; activate additional walking blood bank donors
• Tranexamic acid: 1 g IV over 10 minutes (WOMAN trial: reduces death from bleeding by 31% if given within 3 hours of delivery; it is now recommended by WHO for all PPH)
• Keep warm: Blankets, warm IV fluids (hypothermia worsens coagulopathy)

1. Uterine atony management (stepwise approach):

• Bimanual uterine massage: Continuous until uterus contracts
• Uterotonics (all available agents simultaneously in severe PPH):
• Oxytocin 10 IU IM immediately + 40 IU in 1 L NS IV infusion (maximum 3 L oxytocin solution)
• Misoprostol 800 mcg sublingual (if oxytocin insufficient or as adjunct in resource-limited setting; heat-stable, requires no refrigeration)
• Ergometrine 0.2 mg IM (if available and no hypertension)
• Uterine balloon tamponade: If uterotonics fail, insert condom catheter tamponade (Ellavi UBT or improvised: condom tied to Foley catheter, inflated with 300-500 mL saline) — this is a life-saving bridge-to-referral device
• Bimanual compression if balloon not available
• Non-pneumatic anti-shock garment (NASG): Apply immediately if available — compresses lower body, autotransfuses approximately 500 mL to vital organs, stabilizes for transport

1. Concurrent malaria treatment: Artemether-lumefantrine (postpartum, safe in breastfeeding)
2. Referral for definitive care:

• If hemorrhage not controlled with above measures, immediate referral to CEmOC facility (120 km)
• NASG and uterine balloon tamponade in situ during transport
• IV fluids and blood running during transport
• Call ahead to referral hospital to prepare for possible surgical intervention (B-Lynch suture, uterine artery ligation, or hysterectomy)
• Arrange ambulance or fastest available transport

PUBLIC HEALTH / PROGRAM INTERVENTIONS (Addressing the Three Delays):

1. Delay 1 (Decision to seek care):

• Community health worker (CHW) training program: educate communities on obstetric danger signs (bleeding, convulsions, fever, prolonged labor)
• Birth preparedness and complication readiness (BPCR) plans: identify transport, save money, identify blood donor, identify decision-maker during pregnancy
• Engage TBAs as community health promoters (recognize danger signs and facilitate referral) rather than delivery attendants
• Address gender dynamics: involve men in antenatal education to enable timely decision-making

1. Delay 2 (Reaching care):

• Maternity waiting homes near health facilities for women in final month of pregnancy
• Community emergency transport schemes (motorcycle ambulances, community transport funds)
• Mobile phone networks for emergency communication
• Road infrastructure advocacy

1. Delay 3 (Receiving care):

• EmOC signal function assessment at district health center: ensure 24/7 capacity for basic EmOC (parenteral uterotonics, parenteral antibiotics, parenteral anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, neonatal resuscitation)
• Blood supply: establish and maintain walking blood bank with pre-screened community volunteer donors
• Skills training: ALSO (Advanced Life Support in Obstetrics) or LSTM EmOC training for midwives and clinical officers
• Supply chain: ensure constant availability of oxytocin (cold chain), misoprostol (heat-stable alternative), tranexamic acid, magnesium sulfate, UBT devices, NASG
• Quality improvement: maternal death surveillance and response (MDSR) implementation

Key Learning Points

• Postpartum hemorrhage is the leading cause of maternal mortality globally, responsible for 27% of maternal deaths, with the vast majority occurring in low- and middle-income countries; most deaths from PPH are preventable with active management of the third stage of labor (AMTSL), uterotonics, and timely access to emergency obstetric care
• Tranexamic acid (1 g IV within 3 hours of bleeding onset) reduces death from PPH by 31% (WOMAN trial, 20,000+ women); it is inexpensive, heat-stable, and should be available at every delivery facility — it is now a WHO Essential Medicine for PPH
• The condom catheter uterine balloon tamponade is a low-cost, life-saving intervention for uncontrolled PPH when surgical options are unavailable; it arrests hemorrhage in 80-90% of cases and serves as a critical bridge-to-referral in settings far from surgical care
• The Three Delays Model (delay in deciding to seek care, delay in reaching care, delay in receiving adequate care) provides the analytical framework for understanding and addressing maternal mortality; effective programs must target all three delays simultaneously
• Pre-existing anemia (from iron deficiency, malaria, and short inter-pregnancy intervals) dramatically reduces a woman's physiologic reserve to tolerate hemorrhage; a woman with hemoglobin of 7 g/dL who loses 1000 mL may die, while a woman with hemoglobin of 12 g/dL can survive the same loss — making antenatal anemia prevention a critical upstream intervention for hemorrhage mortality reduction

All cases for this lecture as Markdown