Poor management of labour endangers mothers’ lives
PRISCA, 32, is a mother of three, but she had never understood what happens after the birth of a baby until she almost bled to death when her last child was born. “I always thought that labour ends with the birth of a baby,†she recounts. “How wrong I was! <br>
By Irene Nabusoba
PRISCA, 32, is a mother of three, but she had never understood what happens after the birth of a baby until she almost bled to death when her last child was born. “I always thought that labour ends with the birth of a baby,†she recounts. “How wrong I was!
The placenta almost killed me. It failed to come out spontaneously like it did with my previous births. When I finally expelled it, I bled excessively and had I not got a blood transfusion, I would have probably died.â€
Prisca went through what doctors call third stage of labour, when the placenta and other membranes are delivered. Labour has three stages: birth pains, contractions and breaking of waters ; delivery of the baby; and delivery of the placenta.
However, just like Prisca, most people assume that labour ends with the birth of the child, yet expulsion of the placenta is potentially the most hazardous part of child birth for the mother, mostly because of the risk of dying from excessive bleeding (Post Partum Haemorrhage).
One may also suffer from anaemia, or other complications associated with blood transfusions or surgical removal of the uterus to contain bleeding.
Excessive bleeding after childbirth accounts for 25% of maternal deaths in Uganda and is commonly caused by failure of the uterus to contract, leaving its muscles unable to exert pressure on the open uterine blood vessels, which continue to bleed.
A mother may also bleed after childbirth because of small tears to the uterus, cervix,or vagina; retained placenta and failure of blood to clot.
Unfortunately, up to 90% of women who experience excessive bleeding after childbirth have no identifiable risk causes. That is why it is important for mothers to deliver in fully functional health centres assisted by health workers with midwifery skills.
However, certain factors like early detachment of the placenta from the uterus, excessive enlargement of the uterus due to excess amniotic fluid, a large baby or multiple babies, having many previous births and previous surgery on the uterus such as a caesarean section have been found to increase risk of bleeding and death.
High blood pressure, prolonged labour, infection in the uterus, being overweight, age of the mother (too young or too old) and delivery using instruments like forceps can also cause bleeding.
How is the third stage of labour managed then?
“Traditionally, the placenta would be expelled by gravity and maternal effort. After the birth of the baby, a mother would wait for contractions and push, to expel the placenta,†says Dr. Sam Ononge, an obstetrician/gynaecologist.
Ononge says health workers would wait until the placenta was expelled before cutting the umbilical cord. They would then encourage the mother to breastfeed, while seated in an upright position because the process increased uterine contractions that ease the expulsion of the placenta.
This physiologic or expectant management of the third stage of labour, though still practiced by some health workers has its problems.
“It increases the length of third stage of labour, the amount of blood loss and risk of death from excessive bleeding,†Ononge says.
We are now advocating Active Management of Third Stage of Labour (AMTSL), consisting of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and ensuring that the uterus contracts as it should within the shortest time possible,†he adds.
AMTSL involves administration of drugs like oxytocin, ergometrine or misoprostol within one minute after delivery to stop bleeding; delivery of the placenta by controlled cord traction-gently pulling on the umbilical cord while exerting pressure to the uterus — and massage of the uterus through the abdomen after delivery of the placenta.
The practice has proven so effective that the World Health Organisation (WHO) and the International Federation of Gynaecology and obstetrics approved its use in 2003.
With a high maternal mortality of 435 deaths for every 100,000 live births, Uganda is one of the countries that can greatly benefit from wide adoption and use of the AMTSL. “AMTSL is an evidence-based low cost intervention that can save many mothers.
It can cut obstetric bleeding by 60%,†Ononge says adding, “18% of women are vulnerable to Post Partum Haemhorrage but with AMTSL, it can be reduced to 6%. It should be applied in all vaginal birthsâ€.
He says a woman is most vulnerable to excessive bleeding after child birth during the first 24 hours after delivery.When administered correctly, AMTSL significantly reduces the risks of mothers dying.
Regrettably, in Uganda, a 2007 USAID-funded study conducted in 48 health care facilities revealed that less than 8% of deliveries are benefiting from AMTSL.The study found that the majority of health workers responsible for deliveries have never been trained in AMTSL.
“Skilled providers widely use physiological management as compared to AMTSL, which is considered a new practice that calls for training,â€the study report says.
But even where it is being practiced, AMTSL has been undermined by delayed administration of oxytocin immediately after child delivery, incorrect dosage of the drug and failure by health workers to carry out cord contraction and perform uterine massage after delivery of the placenta .
The study also discovered that the National Medical Stores, the main supplier of government hospitals had not stocked oxytocin, the drug recommended as first line for AMTSL for one year before the survey.
Aida, a midwife from Mulago says that inadequate stocks of oxytocin limits effectiveness of AMTSL.While the drug should ideally be administered one minute after delivery, this is usually not the case in most health units.
“We sometimes advise the mothers to buy the drugs from clinics. That delays the timing of administering it. Supplies do not often meet the patient load,†Aida adds.
Additionally, lack of adequate staff is a major barrier in a number of districts .
“We are very few to manage the delivering mothers.
What of when we bring in your AMTSL? Massaging the mothers’ stomachs every 15 minutes for two hours as recommended is just impossible,†says Agatha Wasike a midwife from Mbale.
Dr. Olive Sentumbwe, the national professional officer population and family planning at the WHO says AMTSL is also constrained by failure of mothers to deliver from health centres.
National statistics show that only 42% of expectant women deliver from health units. The rest deliver under the care of Traditional Birth Attendants, elderly women or by themselves, all of which undermine the application of AMTSL, which has to be carried out by trained health workers.
As Sentumbwe says ,
“Oxytocin is an injectable only to be administered by a health worker. That is why we need to lobby for licensing of misoprostol tablets because they are easier to administer,†But the challenges do not end there
One other limitation to effective administration of AMTSL is the fact that most mothers deliver in lower level facilities, many of which lack constant power supply to store drugs like oxytocin which require refrigeration
Despite the many challenges, Ononge firmly believes that universal application of AMTSL—every woman, every birth, every provider —is the way to go.
PRISCA, 32, is a mother of three, but she had never understood what happens after the birth of a baby until she almost bled to death when her last child was born. “I always thought that labour ends with the birth of a baby,†she recounts. “How wrong I was!
The placenta almost killed me. It failed to come out spontaneously like it did with my previous births. When I finally expelled it, I bled excessively and had I not got a blood transfusion, I would have probably died.â€
Prisca went through what doctors call third stage of labour, when the placenta and other membranes are delivered. Labour has three stages: birth pains, contractions and breaking of waters ; delivery of the baby; and delivery of the placenta.
However, just like Prisca, most people assume that labour ends with the birth of the child, yet expulsion of the placenta is potentially the most hazardous part of child birth for the mother, mostly because of the risk of dying from excessive bleeding (Post Partum Haemorrhage).
One may also suffer from anaemia, or other complications associated with blood transfusions or surgical removal of the uterus to contain bleeding.
Excessive bleeding after childbirth accounts for 25% of maternal deaths in Uganda and is commonly caused by failure of the uterus to contract, leaving its muscles unable to exert pressure on the open uterine blood vessels, which continue to bleed.
A mother may also bleed after childbirth because of small tears to the uterus, cervix,or vagina; retained placenta and failure of blood to clot.
Unfortunately, up to 90% of women who experience excessive bleeding after childbirth have no identifiable risk causes. That is why it is important for mothers to deliver in fully functional health centres assisted by health workers with midwifery skills.
However, certain factors like early detachment of the placenta from the uterus, excessive enlargement of the uterus due to excess amniotic fluid, a large baby or multiple babies, having many previous births and previous surgery on the uterus such as a caesarean section have been found to increase risk of bleeding and death.
High blood pressure, prolonged labour, infection in the uterus, being overweight, age of the mother (too young or too old) and delivery using instruments like forceps can also cause bleeding.
How is the third stage of labour managed then?
“Traditionally, the placenta would be expelled by gravity and maternal effort. After the birth of the baby, a mother would wait for contractions and push, to expel the placenta,†says Dr. Sam Ononge, an obstetrician/gynaecologist.
Ononge says health workers would wait until the placenta was expelled before cutting the umbilical cord. They would then encourage the mother to breastfeed, while seated in an upright position because the process increased uterine contractions that ease the expulsion of the placenta.
This physiologic or expectant management of the third stage of labour, though still practiced by some health workers has its problems.
“It increases the length of third stage of labour, the amount of blood loss and risk of death from excessive bleeding,†Ononge says.
We are now advocating Active Management of Third Stage of Labour (AMTSL), consisting of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and ensuring that the uterus contracts as it should within the shortest time possible,†he adds.
AMTSL involves administration of drugs like oxytocin, ergometrine or misoprostol within one minute after delivery to stop bleeding; delivery of the placenta by controlled cord traction-gently pulling on the umbilical cord while exerting pressure to the uterus — and massage of the uterus through the abdomen after delivery of the placenta.
The practice has proven so effective that the World Health Organisation (WHO) and the International Federation of Gynaecology and obstetrics approved its use in 2003.
With a high maternal mortality of 435 deaths for every 100,000 live births, Uganda is one of the countries that can greatly benefit from wide adoption and use of the AMTSL. “AMTSL is an evidence-based low cost intervention that can save many mothers.
It can cut obstetric bleeding by 60%,†Ononge says adding, “18% of women are vulnerable to Post Partum Haemhorrage but with AMTSL, it can be reduced to 6%. It should be applied in all vaginal birthsâ€.
He says a woman is most vulnerable to excessive bleeding after child birth during the first 24 hours after delivery.When administered correctly, AMTSL significantly reduces the risks of mothers dying.
Regrettably, in Uganda, a 2007 USAID-funded study conducted in 48 health care facilities revealed that less than 8% of deliveries are benefiting from AMTSL.The study found that the majority of health workers responsible for deliveries have never been trained in AMTSL.
“Skilled providers widely use physiological management as compared to AMTSL, which is considered a new practice that calls for training,â€the study report says.
But even where it is being practiced, AMTSL has been undermined by delayed administration of oxytocin immediately after child delivery, incorrect dosage of the drug and failure by health workers to carry out cord contraction and perform uterine massage after delivery of the placenta .
The study also discovered that the National Medical Stores, the main supplier of government hospitals had not stocked oxytocin, the drug recommended as first line for AMTSL for one year before the survey.
Aida, a midwife from Mulago says that inadequate stocks of oxytocin limits effectiveness of AMTSL.While the drug should ideally be administered one minute after delivery, this is usually not the case in most health units.
“We sometimes advise the mothers to buy the drugs from clinics. That delays the timing of administering it. Supplies do not often meet the patient load,†Aida adds.
Additionally, lack of adequate staff is a major barrier in a number of districts .
“We are very few to manage the delivering mothers.
What of when we bring in your AMTSL? Massaging the mothers’ stomachs every 15 minutes for two hours as recommended is just impossible,†says Agatha Wasike a midwife from Mbale.
Dr. Olive Sentumbwe, the national professional officer population and family planning at the WHO says AMTSL is also constrained by failure of mothers to deliver from health centres.
National statistics show that only 42% of expectant women deliver from health units. The rest deliver under the care of Traditional Birth Attendants, elderly women or by themselves, all of which undermine the application of AMTSL, which has to be carried out by trained health workers.
As Sentumbwe says ,
“Oxytocin is an injectable only to be administered by a health worker. That is why we need to lobby for licensing of misoprostol tablets because they are easier to administer,†But the challenges do not end there
One other limitation to effective administration of AMTSL is the fact that most mothers deliver in lower level facilities, many of which lack constant power supply to store drugs like oxytocin which require refrigeration
Despite the many challenges, Ononge firmly believes that universal application of AMTSL—every woman, every birth, every provider —is the way to go.