ABSTRACT

Postpartum haemorrhage is blood loss of more than 500 ml following childbirth and more than 1000 ml following a caesarean section all this within 24hours after childbirth (WHO). The most common cause of PPH can be represented in 4 T’s; in which T stand for uterine Tone, Trauma for genital tear, Tissue for retained products of conception and Thrombin for coagulopathy. In Cameroon, increase in MMR in 2015 from PPH despite reported use of active management in third stage of labour, display slow progress towards achieving the sustainable development goal 3 by the year 2030 (Tebuet et al 2015). This project aimed at assessing the knowledge, practices and challenges faced by obstetric caregivers regarding the prevention and management of postpartum hemorrhage at the delivery room of the bonassama district hospital.

Methods: It was a descriptive cross-sectional study design with 31 health caregivers at the Bonassama District Hospital using the simple random sampling procedure. Data was collected using structured questionnaire and analyzed using MS Excel.

Result: All participants had good knowledge on PPH. Based on the knowledge of the causes of PPH, 54.8% said it is cause by uterine atony, 22.6% said retained products of conception and 16.1% said vagina tear. Regarding the prevention and management, the majority said PPH is prevented using AMSTEL and 25.8 % said uterine revision. About the challenges, 22.6% said blood bank are far away from the maternity unit, 19.4% patient blood inability to clot and 16.1% said late recognition and uncooperative patients.

Conclusion: From the overall result, we can conclude that obstetric caregivers have good knowledge on PPH with consistence definition, correct identification of the cause and had good attitude in the management of postpartum hemorrhage. But face numerous challenges in the management of PPH which could account for the consistently high MMR from PPH. Mitigating the challenges of these caregivers would certainly accelerate progress toward the achievement of SDG3.

  Key words: postpartum hemorrhage, prevention, management, and challenges.

CHAPTER ONE

INTRODUCTION

Postpartum hemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after birth (WHO, 2012). PPH is the leading cause of maternal mortality in low-income countries, and the primary cause of nearly one quarter of all maternal deaths globally. Most deaths resulting from PPH occur during the first 24 hours after birth; the majority of these could be avoided through the use of prophylactic uterotonics during the third stage of labour and by timely and appropriate management (WHO, 2017).

Definitions vary however and are often based on inaccurate estimates of blood loss. Moreover, average blood loss at birth frequently exceeds 500 or 1000ml.  The lack of consistency in the definition of PPH has been a major limitation to the ability to compare prevalence in different studies. However, this definition did not focus on clinical signs and symptoms of haemorrhage and thus prevented early detection in many cases. Therefore, in 2017 the American college of obstetricians and gynaecologist (ACOG) changed the definition to consist of the following criteria;

1. Cumulative blood loss > 1000ml or,
2. Bleeding associated with signs or symptoms of hypovolemia within 24h of the birth process regardless of the route of delivery.( ACOG,2017)

PPH is often classified as primary/immediate/early occurring within 24hours of birth or secondary/delayed/late occurring more than 24hours post birth up to 12 weeks postpartum. The causes of postpartum hemorrhage can be summarized by the four “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (Clotting-factor deficiency). The most common cause is uterine atony (accounting for approximately 70% of cases), followed by obstetrical lacerations (approximately 20%), retained placental tissue (approximately 10%), and clotting-factor deficiencies (<1%). Postpartum hemorrhage due to uterine atony is often preceded by chorioamnionitis, therapeutic use of magnesium sulfate, prolonged labor or precipitous delivery, labor induction or augmentation, uterine fibroids, or uterine over distention as a result of multiple gestation, fetal macrosomia, or polyhydramnios. Cesarean delivery is associated with a higher risk of postpartum hemorrhage than vaginal delivery. Advanced maternal age and extremes of parity (0 and >4) are additional risk factors. (ACOG, 2017)

WHO considers the 

WHO considers the active management of the third stage of labor (AMTSL) as the main intervention for prevention and consequent reduction of maternal deaths by hemorrhage, taking into consideration the clinical evidence? The active management of the third stage of labor involves interventions to promote the expulsion of the placenta and the uterine contraction with the intention of preventing or reducing blood loss.  The  interventions  include  use  of Uterotonic,  controlled  cord  traction  and  uterine  massage. Other  interventions  related  to  prevention  of  postpartum hemorrhage  are  being  studied,  such  as  skin-to-skin  contact, breastfeeding, early  cord  clamping  time.( WH0, 2017)

PPH is a leading cause of maternal mortality and morbidity in the US and worldwide. There have been several advances in the management of PPH, many of which can be implemented at the labour and delivery unit level (Nicole Higgins et al., 2019). PPH, the loss of more than 500ml of blood occurs in up to 18 percent of births. Blood loss exceeding 1000ml is considered physiologically significant and can result in hemodynamic instability. Even with appropriate management, approximately 3percent of vaginal deliveries will result in severe PPH (Magann EF, Evans S, 2005)

1.1 BACKGROUND

The World Health Organization (WHO) reports that every year, nearly 295 000 women die due to complications induced by the pregnancy and most of them are preventable or treatable. Maternal mortality from low and lower middle-income countries accounts for 94% (Say et al., 2017) highlight that more than 25% of these deaths result from postpartum bleeding, with almost 20% of all maternal deaths due to postpartum hemorrhage (PPH). In Rwanda, 70% of maternal deaths result from direct causes and postpartum bleeding is the leading direct cause of maternal death with 22.7% of all documented cases (Olivia Bazirete, Marilyn Evans, 2020).

PPH remains the major cause of maternal death worldwide with an overwhelming majority of bleeding deaths in low income countries (John Wiley & Sons Ltd, 2018). PPH contributes significantly to maternal morbidity and mortality worldwide with 6% prevalence. Maternal mortality remains a major challenge to the health system worldwide. Women can rapidly haemorrhage and die soon after giving birth. It can be a devastating outcome to many young families. Women giving birth in low-resource settings are at higher risk of death than their counterparts in resource-rich environments.

In Africa and Asia where most maternal deaths occurred, postpartum haemorrhage accounts for more than 30% of all maternal deaths. However, the proportion of maternal deaths attributable to postpartum haemorrhage varies considerably between developed and developing countries. Consequently, many health care workers in developing countries have little or no access to basic practical information of PPH making it difficult to assess women with the risk factors typically leading to the complication that develops due to PPH. This study is aimed to determine the level of knowledge and managements kills of birth attendants providing delivery services as regards to PPH in Jos North, Plateau State, Nigeria (Timothy Olugbenga, 2017).

In sub-Saharan africa, the probability of dying during childbirth is significantly higher,and uterine atony (failure of the uterus to contact adequately after birth) accounting for 60% to 80% of pph cases( Bia J et SQ 2014). Ethiopia is one of the countries with a high burden of postpartum maternal mortality (GT et Kebede D 2018). It was revealed that the main cause of  maternal death in  poor setting is hemorrhage (54%) that occurs after delivery followed by pregnancy-induced hypertension (20%).(Legess T et MA 2017). The government of Ethiopia provides free maternal and pre-delivery serves regardless of social and economic status of the women. Despite of these, there are inadequacy of literature regarding the extent of pph and its contributing factors in Ethiopia including the study setting. This study was aimed to assess the magnitude of postpartum and its associated factors among women who delivered at Yirgalem General Hospital, Sidama Regional State, Ethiopia in 2020

In Cameroon, the maternal mortality ratio has increased over the recent years, from 690deaths /100000 in 2010 to 789deaths /100000 live birth in 2014( Tabeu Pm et Tezeu ly). The main cause of maternal death was hemorrhage (38%) with primary Pph being the leading cause of death accounting for 4.1% of cases (Int Journal of Gys & Obs 2013). Studies conducted in the General Hospital and the Yaounde Central Teaching Hospital in 2008 and 2013 reported prevalence of primary pph of 1.68% and 4.1% respectively (Calvert C et Megan EF).

The health status of the women also matters for the woman to die not only the amount of blood she looses, the lifestyle,  poverty and malnutrition are some of the broad issues that have unfortunately come to be accepted as inevitable and unchangeable but which influences the outcome of a patient with pph ( Crowhurst ja et P f 1994). The reality about pph is that two- thirds (2/3) of the women who experience it have no identifiable risk factors such as multiple birth or fibroids (Lalonde A et Dba 2004-2006). This research was carried out at the Bonassama District Hospital Douala which was aimed to determine the prevalence, risk factors and maternal and fetal outcomes of primary pph.

1.2 STATEMENT OF PROBLEM

Globally, post-partum hemorrhage has been one of the most leading factors of maternal mortality and morbidity. In Cameroon, the prevalence of postpartum hemorrhage was reported at 25% in 2015(WHO 2015). From our experience at a hospital in the Littoral region, we observed that 3 out of 5 women suffered from pph after delivery either by vaginal delivery or ceserean section which could be prevented if good practical approaches were implemented following the WHO clinical guidelines on the prevention and management of pph. This is what boasted me to propose to carry out this research in order to determine if the obstetric caregivers have the knowledge and practice provided by the WHO in the prevention and management of pph in women.

• RESEARCH QUESTIONS
  • Main Question
• What knowledge, practices and challenges are faced by Obstetric Care givers in the Prevention and management of postpartum hemorrhage at BDH?
  • Secondary Questions
• What knowledge do Obstetric Care givers at BDH have on the prevention and management of PPH?
• What are the practices of Obstetric Care givers towards the prevention and management of PPH at BDH?
• What challenges do Obstetric Care givers at BDH face in the prevention and management of PPH?
  • RESEARCH OBJECTIVES
    • General Objective
  • To assess the knowledge, practices and challenges faced by Obstetric Care givers on the prevention and management of postpartum haemorrhage at BDH

• Specific Objectives

• To identify the socio-demographic data of Obstetric Care givers
• To assess the knowledge of Obstetric Care givers on the prevention and management of PPH at BDH
• To evaluate the practices of Obstetric Care givers on the prevention and   management of PPH at BDH
• To identify the challenges faced by Obstetric Care givers on the prevention and management of PPH at BDH
  • HYPOTHESIS
    • Null Hypothesis ( H0)          – Obstetric Care givers of BDH do not have adequate knowledge on prevention and   management
  • Obstetric Care givers of BDH do not carry out perform appropriate practices towards PPH management
    • Alternate Hypothesis ( H1)
  • Obstetric Care givers BDH have adequate knowledge on prevention and management of PPH
  • Obstetric Care givers of BDH perform appropriate practices towards PPH prevention and management