1. Excessive Bleeding before Labour
This is referred to as antepartum haemorrhage. It
is a leading cause of maternal mortality and is defined as any blood loss from
the genital tract of a pregnant woman after 28 weeks of gestation but before
the onset of labour. The two major reasons why a pregnant woman can bleed at
this stage of pregnancy are low-lying placenta (placenta praevia) and premature
separation of a normally situated placenta (abruptio
placentae). In placenta praevia, the placenta which normally connects
mother and baby occupies the lower segment instead of the fundal (upper)
portion of the uterus. Consequently, every time the head of the foetus presses
on the low-lying placenta, the woman bleeds. In the second condition, abruptio
placentae, the placenta is located where it should be. However, as a result of
several risk factors such as trauma to the abdomen (from accidents or physical
assault) and smoking, the placenta is prematurely separated from the uterus
leading to vaginal bleeding. This may lead to the death of both the foetus and
the mother. Note that if a woman spots or bleeds per vaginam at any point during pregnancy, it is enough reason to
visit her doctor and be properly evaluated.
2. Excessive Bleeding after Delivery
While it's expected that a woman would normally
bleed immediately after delivery, any blood loss in excess of 500ml following
vaginal delivery should never be taken lightly. It's referred to as postpartum
haemorrhage and is currently the leading reason why many women die from
childbirth in developing countries. Postpartum haemorrhage can occur as a
result of poorly contracted uterus (uterine atony), retained products of
conception such as placenta tissue, tears or lacerations within the genital
tract and less often, bleeding disorders in the mother. Unfortunately, most of
these cases can be traced to poorly managed labour by unskilled traditional
birth attendants many of whom do not recognise their limits and often delay in
referring the woman when things get out of hand. Furthermore, it is rather
disheartening that less than 46% of deliveries in developing countries like
Nigeria are conducted by skilled birth attendants including trained midwives
and doctors. Such simple practices as timely administration of oxytocics,
rub-up contractions and complete evacuation of retained products can go a long
way in stemming the tides of postpartum bleeding.
3. Prolonged Obstructed Labour
When labour becomes prolonged and obstructed, it
simply means it is no longer progressing as expected, necessitating timely
intervention. However, many of the traditional birth attendants patronised by
some of our women hardly ever recognise the signs and symptoms of poor progress
in labour. By the time they do so and refer, it's often too late. Prolonged
obstructed labour is especially common in teenage pregnancies whose pelvic size
is rather too small to allow passage of the foetal head, a condition described
as cephalopelvic disproportion. Cephalopelvic disproportion is also common
among women with contracted pelvis due to previous accidents involving the
pelvis and diabetic mothers who end up with very big babies (macrosomia) that
cannot pass through their pelvis. Sometimes, it's just a full bladder that is
preventing the baby's head from descending and as soon as the bladder is
emptied, foetal descent progresses normally. Typically, a woman with obstructed
labour may have been in the active phase of labour for over 12 hours and is
already exhausted, agitated and dehydrated. The urine may be concentrated and
the vulva edematous ('tomato' vulva).
Once a diagnosis of obstructed labour is made, the next option is to prepare
the woman for an emergency caesarean section to forestall complications like
foetal and/or maternal death, vesicovaginal fistulas and obstetric palsy among
others.
4. Infections
It's also quite common for women to die as a result
of infections in the post-delivery period. This is referred to as puerpereal sepsis. It can occur when delivery
(vaginal or caesarean) is conducted in unhygienic conditions or when there are
infected retained products of conception in the mother. Usually, the woman may
start experiencing continuous high-grade fever, abdominal pain with
foul-smelling vaginal discharge. If the woman delivered by caesarean section,
the surgical site may break down with associated discharge of foul-smelling
pus. If aggressive treatment with effective antibiotics is not commenced, the
woman may die from complications such as septic shock or disseminated
intravascular coagulopathy (DIC).
5. Hypertensive Disorders of Pregnancy
Preeclampsia-eclampsia is a major cause of death
among pregnant women. Some pregnant mothers had been hypertensive before
pregnancy while in others, the hypertension is pregnancy-induced i.e. they are
diagnosed as hypertensive for the first time during pregnancy. Whichever is the
case, any pregnant woman with persistently elevated blood pressure needs to
have her urine tested for protein. If the urine contains significant quantities
of protein, she has pre-eclampsia which must be promptly managed to forestall
convulsions as a result of eclampsia, a lethal condition that is associated
with significant maternal mortality before, during and after childbirth. Safe
antihypertensives and prophylactic magnesium sulphate are usually employed to
stop the progression of pre-eclampsia to eclampsia. However, hypertension can
only be promptly detected and managed in a pregnant woman who registers for
antenatal care at a hospital and keeps her clinic appointments.
