- Maternal mortality is still a battle we are fighting and while some of the causes are well-known, the more rare occuring are often overlooked as a result of underskilled practitioners
One quiet morning, exactly seven days after she gave birth, Doctor Kuduishe Kisowile who was a first time mother was taking a bath when she began to experience lower abdomen pain and a few seconds later, felt blood clots coming out.
Trying to calmly make sense of the escalating situation, her mother asked if that was okay to which she nodded, simply to ease her mother and quietly dismissed the thoughts that began to cloud her head.
When she bent to thoroughly wash herself, a heavy blood flow gushed down her legs. It was at that moment that both Kuduishe and her mother knew that they had to head for the hospital.
“Having a medical background, I understand that a woman should not be bleeding by day seven, in my case I had even stopped wearing diapers by that time. By bleeding a whole week after birth, it automatically indicates that something is not right,” Kuduishe explains.
What went wrong?
Postpartum hemorrhage (PPH) is a nightmare that haunts a lot of mothers and Kuduishe was one of the many women who’ve had to endure its scare.
She gave birth a short while before getting to the hospital and when she did, the doctors stitched her up to repair the tear she suffered during labour. A day later, she was released and went back home.
While her pregnancy was uneventful in terms of complications, she began to experience symptoms that hinted at PPH a few hours before she decided to go back to the hospital.
Kuduishe narrates that “As a doctor, I have attended the worst case of PPH and the patient in question did not make it. When I saw the blood flow getting heavier, I knew that I had fallen victim to this condition. I was worried that I would not make it because things could go wrong in a very short space of time.”
When Kuduishe arrived at the hospital, she was taken in as an emergency patient. The doctors ran a number of tests and kept her on an IV due to all the blood she’d lost. The drip was followed by an ultrasound that revealed leftover residue in Kuduishe’s uterus that had caused her cervix’s failure to contract back to normal and close, leaving her prone to the heavy blood flow shortly after she gave birth.
“I was first given a pill that was supposed to act as a catalyst to push the remnants out. I was then taken to the labour room and the wait began. After a long wait, to no avail, the doctors prepared me for the procedure to remove the placenta fragments in my uterus. The doctors first checked if my body had any reactions to the anaesthesia and then I slept through the procedure. When I woke up, they were done with the removal of the residue,” she reveals.
After the cleaning procedure, the bleeding had stopped. The doctors hospitalised Kuduishe for three days and when they were satisfied with her results, she was released.
According to Dr Isaya Kimwage, a gynaecologist at Sarib Healthcare, PPH is a condition where a woman severely bleeds after giving birth. He says that when a woman who gives birth vaginally loses over half a litre of blood, the condition is then termed as PPH.
“PPH starts during labour to six weeks after giving birth and sometimes women exceed this time according to the type of PPH they have and there are two of PPH; primary and secondary. Primary begins before the woman gives birth to the time the placenta comes out of her womb. Primary PPH can happen when either the baby or placenta is born,” he explains.
On the other hand, Isaya details that Secondary PPH usually occurs a few days after a woman has given birth.
“The causes of this condition are two-sided, there are primary and secondary causes. Collectively, they include the uterus not contracting enough hence causing the mother to not be able to push the baby out. This leads the blood vessels to rupturing and she starts bleeding,” he says.
He further reveals that this is one of the reasons why it is important for women to give birth in hospitals because in cases like this, she gets timely medical assistance that helps her to give birth much safer.
Isaya says that another cause is the retaining of tissue factor which simply means that parts of the placenta remain in the uterus after the woman has given birth.
“Another cause is the thrombin factor which happens to women whose blood does not clot. One of the most common causes of all is called trauma which is also called tears. These can happen on the cervix, on the vagina or on the place between the vagina and anus that is called perineum and at times, all three places can get tears all at once. Trauma is caused by many things such as a woman giving birth to a baby weighing over 3.5 kilograms. When a woman gets a tear, she severely bleeds and can become a victim of PPH condition,” he says.
Isaya also explains that another cause of this condition is poor management of caesarean section for the women who give birth this way. He says that the medical practitioners are always at fault with this because they fail to return the stomach to the environment it had before the surgery.
“This condition can’t be detected until there is bleeding. The doctors have to first conduct an estimation of the blood loss through a complete blood count and full blood picture that displays the amount of blood lost. Most of the time the patient would experience an increase in the speed of her heartbeat, scientifically called palpitation. Other symptoms include dizziness, fainting, headache and fatigue.”
“However when the condition gets worse, the patient would experience bluish discoloration whereas their skin colour will resemble that colour and some of the body parts that are used to estimate the amount of blood will show paleness such as eyes, under the tongue or fingertips,” he says.
According to Isaya, PPH is treated according to the causes that led to the condition in the first place.
“For example, if the cause of this condition is uterus contraction, we would massage the area of the uterus as well as administer medicines that would fasten her delivery process. If the cause was retaining uterus products, the doctor would conduct an evacuation to remove the remnants so as to stop bleeding,” he says.
“Social awareness on this condition is still very low despite how dangerous and rare this condition is. Tanzanian societies have to be made aware of PPH because it would prevent a lot of deaths knocking on the doors of motherhood,” he advises.
Isaya also advises that the required minimum number of clinic visits for a pregnant woman be extended so that both she and her doctors get to understand conditions that are caused by motherhood.
“A pregnant woman is supposed to have a minimum of four clinical visits throughout her pregnancy until the moment she gives birth. However this limits the knowledge about changes and conditions her pregnancy is exposed to. There needs to be more than four times for a woman to master reproductive education,” he details.
Isaya also emphasises that the government needs to increase the number of skilled medical practitioners and birth attendants especially in rural areas because it will save a lot of women when they experience this condition.
His explanation of the condition echoes that of Kuduishe who shares that the worst case of PPH is called Disseminated Intravascular Coagulation (DIC).
“DIC is the last stage of this condition where doctors will only help to stabilise the bleeding however she will keep on bleeding. In other cases, the doctors perform a hysterectomy which is the removal of the uterus to treat uncontrollable PPH,” she details.
While I was not able to get the recent general data on this condition, a 2020 study dubbed ‘Improving prevention, detection and management PPH in Tanzania’ that was conducted by Dr Joseph Massenga in Lake Zone details that PPH is the leading cause of maternal deaths as it amounts to 29 percent of all other causes including abortion, Anaemia and Sepsis.
In this study, Joseph highlights things such as shortage of human resources and lack of skilled medical practitioners as the root causes of PPH.
His broader perspective of the condition aligns with the discussion of PPH on an online clinic named ‘My Cleveland Clinic’ which describes it as the vaginal bleeding after childbirth that can lead to death.
“Postpartum haemorrhage can affect anyone after childbirth. There are many risk factors for PPH, but approximately 40 percent of haemorrhages occur in women without any risk factors. Most postpartum haemorrhage occurs right after the placenta is delivered. PPH may be more likely after a C-section. It is a serious and potentially fatal condition,” the article states.
It further explains that the best way for healthcare providers to prevent postpartum haemorrhage is to identify those at high risk for postpartum haemorrhage before delivery. This is dependent on you sharing your complete medical history and symptoms with your healthcare provider.
Routinely giving medications like oxytocin at the time of delivery to help your uterus contract is also important.
Ensuring adequate iron intake and red blood cell levels during pregnancy can minimize the impact of postpartum haemorrhage should it occur.