Chapter 29 Strategies to improve global maternal and

neonatal health
5 main causes of direct obstetric maternal mortality :
(a) Haemorrhage
- antepartum bleeding (abruption of placenta)
-bleeding during delivery (ruptured uterus, placenta previea)
- postpartum (atonic uterus, retained placenta)
Oxytocics prevent postpartum haemorrhage
Treat uterine atony
drugs which induce uterine contractions to stop bleeding
Retained placenta manual removal using simple general anaesthesia
(IM ketamine)

(b) obstructed labour

-

attributed to rupture of uterus (due to persistent malposition)

Caused by cephalopelvic disproportion (CPD), a disproportion between
the size of the fetal head and the maternal pelvis; or by the position of
the fetus at the time of delivery.
Increased incidence among women with poor nutritional status
Use of assisted vaginal delivery methods such as forceps, vacuum
extractor, or performing a Caesarean Section can prevent adverse
outcomes.
CPD is the leading cause of obstetrical fistula
uterus rupture > fetal heartbeat absent + fetal part palpate easily
abdominally > bleeding > women in shock

Bandls ring visible constriction seen in abdominal contour, warning

sign of impending rupture of uterus, seen in cephalo-pelvic
disproportion
Pressure necrosis of genital tract > obstetric fistulae (treated initially
with continuous bladder drainage and antibiotic / surgery)

(c) Sepsis
-

Can be prevented or managed with high standards for infection

control, appropriate prenatal testing and treatment of maternal
infection, and appropriate use of intravenous or intramuscular
antibiotics during labor and post-partum period.
Related to poor hygiene and infection control during delivery or to the
presence of untreated sexually transmitted infections during
pregnancy.

membrane rupture
Due
to
retained products
of
conception
(incomplete
miscarriage
/
unsafe abortion)

Can l/t chorioamnionitis,

premature delivery, major
systemic sepsis :
prophylactic antibiotic
Manual
Vacuum
Aspiration(MVA) in early
pregnancy
under
local
anaesthesia
Dilatation and Curettage
(D&C) requires general
anaesthesia

(d) Eclampsia

prolonged fit l/t

maternal death
cerebral
haemorrhage
common cause of
death

Treatment available during childbirth includes the use of sedative

or anti-convulsant drugs.
Magnesium suphate
reduce eclamptic fit

(e) Unsafe abortion

-

l/t maternal death through uterine perforation, haemorrhage,

sepsis
Can be prevented by providing safe abortion, quality family
planning services, and competent post-abortion care.

______________________________________________________________________________________

Medical conditions contributing to maternal mortality

and morbidity
(a) anemia
-

Hb < 11.0g/dL
Usually chronic anemia, asymptomatic at rest
Decompensate easily in labour, high risk of death in obstetric
haemorrhage

(b) Malaria
-

Malaria
anemia
maternal death
Severe malaria prone to :
hypoglycaemia
loss of
consciousness
:Pulmonary edema
:Anemia
:Cerebral malaria
Thick blood film use to detect parasite
Plasmodium Vivax And Plasmodium falciparum most common

maternal / infant
death

characterized by
kidney failure,
seizures, and
coma during
pregnancy or postpartum

Eclampsia

Pre-eclampsia

toxemia of
pregnancy
characterized by
proteinurea,
general edema
and sudden
weight gain
identified in the
prenatal period by
monitoring blood
pressure,
screening urine for
protein, and
through physical
assessment

(c) HIV / AIDS

-

Increased susceptibility to infection

sepsis
maternal
mortality
HIV associated infection : TB, Crytpcoccal pneumonia, meningitis
Antiretroviral therapy : prevent transmission from mother to child
Deliver by c-section and avoid breastfeeding

(d) Tuberculosis
-

Leading cause of death in HIV / AIDS women

Multiple drug treatment : rifampicin, isoniazid, ethambutol,
pyrazinamide, streptomycin (all except streptomycin are
considered safe for mother and child)
BCG vaccination give to newborn

Strategies to improve global maternal and newborn

health
(a) Skilled birth attendance (SBA)
-

Term used for skilled birth attendant + enabling environment

(b) Essential (or emergency) obstetric care (EOC)

-

Help reduce maternal mortality

Consists of up to 9 signals : inexpensive, require basic obstetric
knowledge and skill
Divided into basic emergency obstetric care (BEOC) by nursemidwives and comprehensive emergency obstetric care (CEOC) by
medical doctors
Manual vacuum aspiration : need trained healthcare providers
BEOC :antibiotics, oxytocic, anticonvulsant,manual removal of a
retained placenta, MVA, assisted vaginal delivery, basic neonatal
resuscitation
CEOC : Caesarean section, blood transfusion

(c) Early newborn care

5 common causes of death in newborn : preterm birth, infection,

intrapartum asphysia, congenital abnormalities, tetanus
Infections (sepsis, pneumonia, meningitis) prevented antenatal and
hygienic care, care of the cord, breastfeeding
Tetanus : vaccination of mother + clean cord care
Pre-term birth : give mother antenatal corticosteroids + Kangaroo
Mother Care