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i
A RETROSPECTIVE STUDY ASSESSING THE CAUSES OF
POSTPARTUM HAEMORRHAGE IN WOMEN ADMITTED TO KISUMU-
EAST DISTRICT HOSPITAL BETWEEN JANUARY – JUNE 2014
BY:
OMONDI PAULINE AWILI
(REG NO: BMS/0007/91/DF)
A DESSERTATION SUBMITTED TO FACULTY OF CLINICAL
MEDICINE AND DENTISTRY IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF BACHELOR OF MEDICINE
AND SURGERY AT KAMPALA INTERNATIONAL UNIVERSITY.
NOVEMBER, 2014
ii
Contents DECLARATION........................................................................................................................................ iv
CERTIFICATION ...................................................................................................................................... v
DEDICATION............................................................................................................................................ vi
ACKNOWLEDGEMENT ........................................................................................................................ vii
LIST OF ABBREVIATIONS/ ACRONYMS ........................................................................................ viii
ABSTRACT ................................................................................................................................................ ix
CHAPTER ONE ......................................................................................................................................... 1
1.1 Background ........................................................................................................................................... 1
1.2 ProblemStatement ................................................................................................................................. 2
1.3 StudyObjectives ..................................................................................................................................... 3
1.3.1 BroadObjective .................................................................................................................................. 3
1.3.2 SpecificObjectives .............................................................................................................................. 3
1.4 Research Questions ............................................................................................................................... 3
1.5 Study Justification ................................................................................................................................ 4
CHAPTER TWO ........................................................................................................................................ 5
2.0 Literature Review ................................................................................................................................. 5
2.1 Introduction/ Definition ........................................................................................................................ 5
2.2 Burden/ Epidemiology .......................................................................................................................... 5
2.3 Risk factors for Postpartum Haemorrhage ........................................................................................ 6
2.4 Causes of Postpartum Hemorrhage .................................................................................................... 8
2.4.1 Tone ..................................................................................................................................................... 8
2.4.2 Trauma................................................................................................................................................ 8
2.4.3 Tissue ................................................................................................................................................... 9
2.4.4 Thrombin ............................................................................................................................................ 9
2.5 Active management of the third stage of labor (AMTSL) ................................................................. 9
CHAPTER THREE .................................................................................................................................. 12
3.0 Research Methodology ....................................................................................................................... 12
3.1 Study Design ........................................................................................................................................ 12
3.2 Study Area ........................................................................................................................................... 12
iii
3.3 Study Population ................................................................................................................................. 12
3.4 Sample Size Determination ................................................................................................................ 12
3.5Data Collection Method ....................................................................................................................... 13
3.7Inclusion Criteria ................................................................................................................................. 13
3.8 Exclusion Criteria ............................................................................................................................... 13
3.9 Ethical Considerations ........................................................................................................................ 13
3.10 Study Limitations .............................................................................................................................. 13
CHAPTER FOUR ..................................................................................................................................... 14
4.0 DATA PRESENTATION AND ANALYSIS .................................................................................... 14
4.1 MOST COMMON TYPE OF PPH ................................................................................................... 14
4.2 CAUSES OF PPH ............................................................................................................................... 15
4.3 MANAGEMENT OF PPH ................................................................................................................. 16
CHAPTER FIVE ...................................................................................................................................... 18
5.0 DISCUSSION OF FINDINGS ........................................................................................................... 18
5.1 The Most Common Type of Postpartum Hemorrhage .................................................................... 18
5.2 The Causes of Postpartum Hemorrhage ........................................................................................... 18
5.3 Management of Postpartum Hemorrhage ........................................................................................ 19
CHAPTER SIX ......................................................................................................................................... 20
6.0 CONCLUSION AND RECOMMENDATIONS .............................................................................. 20
6.1 Conclusion ........................................................................................................................................... 20
6.2 Recommendations ............................................................................................................................... 20
REFERENCES .......................................................................................................................................... 21
APPENDIX ONE ...................................................................................................................................... 23
APPENDIX TWO ..................................................................................................................................... 24
APPENDIX THREE ................................................................................................................................. 25
iv
DECLARATION
I, OMONDI PAULINE AWILI (REG NO: BMS/0007/91/DF), declare that this research thesis
titled “CAUSES OF POSTPARTUM HAEMORRHAGE IN WOMEN ADMITTED TO
KISUMU EAST DISTRICT HOSPITAL” is the original record of project work I carried out
under the supervision of Dr. Saima and has never been submitted to any other University or
Institution of higher learning for scrutiny for the purpose of an academic award.
Signature……………………………. Date…………………………
v
CERTIFICATION
I certify that this thesis titled “CAUSES OF POSTPARTUM HAEMORRHAGE IN WOMEN
ADMITTED TO KISUMU EAST DISTRICT HOSPITAL”, is the original record of project
work carried out by, Omondi Pauline Awili (Reg No: BMS/0007/91/DF), and has been done
under close supervision.
Supervisor: Dr. Saima
Signature………………………… Date………………………..
vi
DEDICATION
I dedicate this piece of work to God Almighty, who has brought me this far; my dear mum,
Jennifer Olal and my dad, Joshua B. Omondi, who have been very supportive and all the
understanding they have given me throughout the courseand gave me all I asked for.
I also dedicate this research to my dear friend Dr. Jackline Ombura for moral support in terms
of encouragement and ideas and my friends for the discussion to make the research a success.
Great gratitude goes to my supervisor, Dr. Saima for guidance, ideas and support throughout this
period.
vii
ACKNOWLEDGEMENT
I acknowledge the Almighty God for bringing me this far and enabling me to accomplish this
piece of work; I will forever be grateful to Him.
I also acknowledge my parents, Joshua Omondi and Jennifer Olal, for the faith they have had in
me, the good will, moral support and financial sacrifices they have made to give me an
opportunity to ascend the academic ladder to this point.
I acknowledge my supervisor, Dr. Saima, who kindly guided me through this work despite her
tightschedule.
I also do acknowledge the management of Kisumu East District Hospital, for allowing me carry
out this study in their setting.
viii
LIST OF ABBREVIATIONS/ ACRONYMS
PPH Postpartum Haemorrhage
WHO World Health Organization
ICM International Confederation of Midwives
OR Odds Ratio
CI Confidence Interval
AMTSL Active Management of Third Stage of Labour
ix
ABSTRACT
Postpartum Hemorrhage is one of the leading causes of maternal mortality and is a very critical
obstetric emergency. This study was designed to determine the causes of Postpartum
Hemorrhage (PPH) in women admitted to Kisumu East District Hospital, the most common type
of PPH and also to determine the various strategies used in the management of PPH.
Data was collected from records of eligible patients. It was noted that the most common type of
PPH was primary PPH with 88% of the patients.The causes of PPH were perineal trauma(tears
and episiotomies) (48.5%), uterine atony (42.4%), and retained products of conception e.g.
placenta and blood clots (9.1%).
The major strategies used in the management of PPH were episiotomy/ perineal repair (45.5%),
haematinics (36.4%), I.V.oxytocin (33.3%), blood transfusion (27.3%). Others included;
antibiotics (12.1%), Manual evacuation of retained placenta (9.1%), uterine massage (9.1%),
vaginal packing (9.1%), I.M. ergometrin (6.1%), and sublingual cytotec (3.0%).
The management protocols used were effective according to the various causes. There is need for
health workers to be constantly reminded on the proper techniques involved in the active
management of third stage of labour in order to reduce on the mortality rates associated with
PPH.
1
CHAPTER ONE
Introduction
1.1 Background
Postpartum hemorrhage (PPH) denotes excessive bleeding (> 500 mL in vaginal delivery)
following delivery. Some practitioners measure PPH by a blood loss of greater than 500 ml of
blood following vaginal birth, or 1000 ml of blood following cesarean section(Wikipedia March
2007).Blood lost during the first 24 hours after delivery is primary postpartum hemorrhage;
blood lost between 24 hours and 6 weeks after delivery is secondary postpartum hemorrhage
(Poggi, 2007).PPH is the most common cause of perinatal maternal death in the developed world
and is a major cause of maternal morbidity worldwide (Wikipedia March 2007).Some half a
million women die annually across the world from causes related to pregnancy and childbirth
(UNICEF 1996; WHO 1990).
In the developing world, the risk of maternal death from postpartum hemorrhage (PPH) is
approximately one in 1000 deliveries (AbouZahr 1991). In the United Kingdom (UK), the risk of
death from obstetric haemorrhage is about one in 100,000 deliveries (DoH, 1998).
PPH may result from failure of the uterus to contract adequately (atony), genital tract trauma
(i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal
bleeding disorders. Uterine atony is the most common cause and consequently the leading cause
of maternal mortality worldwide (ICM, 2003). Twenty five percent of all maternal deaths are
caused by severe hemorrhage (WHO, 2005).
A recent study reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania
(7.2%), with an overall rate globally of 10.8% (Calvert, 2012). The rate in both Europe and
North America was around 13% (Calvert, 2012). The rate is higher for multiple pregnancies
(32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared with
10.0% for women in subsequent pregnancies) (Calvert, 2012). The overall rate of severe PPH
(>1000 ml) was much lower at an overall rate of 2.8%, again with the highest rate in Africa
(5.1%) (Calvert, 2012).
2
Postpartum hemorrhage/ obstetric hemorrhage accounts for 25 per cent of total maternal deaths
in Kenya (Chege, 2012). These deaths are attributed to lack of a birth plan and adequate
preparedness.
The changes in labour ward practice over the last 20 years have resulted in the re-emergence of
PPH as a significant problem. Thus, there is a high need for the assessment of the causes of PPH
in order to strategize on ways to alleviate this issue i.e. PPH is best managed by a high level of
awareness of the causes of hemorrhage and a systematic approach to management when this
problem develops.
1.2 ProblemStatement
Postpartum haemorrhage (PPH) is the most common type of obstetric haemorrhage and accounts
for the majority of the 14 million cases that occur each year. Despite widespread reduction in
maternal deaths due to improved antepartum, intrapartum, and postpartum care in developed
nations, mortality rates are persistently high in many countries unable to provide advanced
medical care. Postpartum haemorrhage accounts for a substantial proportion of maternal deaths
in developing countries.
The gap between the mortality rates from PPH in developed countries and developing countries
underscores the need for effective and timely response by health workers to pregnancy and
childbirth related complications. There is also an urgent need to identify low-cost interventions
that can be implemented in poor resource settings.
There are also policy gaps that create barriers to improving skilled attendance at births outside
the health care facility. In many countries there is no clear policy direction on how to increase
access to skilled care, and whether the focus should be on changes at the institution, community
or home level.
Lack of appropriate policies and resource allocation has perpetuated the status quo with regard to
maternal mortality ratios due to PPH. In other words, women are dying because countries are
simply reluctant to act. Despite known intervention options, additional research on effective
3
management strategies and their implementation is needed to address postpartum haemorrhage in
countries of the developing world.
1.3 StudyObjectives
1.3.1 BroadObjective
To determine the causes of postpartum haemorrhage in women admitted at Kisumu - East
District Hospital.
1.3.2 SpecificObjectives
a) To determine the commonest type of postpartum haemorrhage that occurs in Kisumu- East
District Hospital.
b) To determine the causes of postpartum haemorrhage in women admitted at Kisumu- East
District Hospital.
c) To determine the variousstrategies used to manage postpartum haemorrhage in Kisumu- East
District Hospital.
1.4 Research Questions
a) What are the possible causes of postpartum haemorrhage in Kisumu- East District Hospital?
b) What is the most common type of postpartum haemorrhage that occurs in Kisumu- East
District Hospital?
c) What are the various strategies used in the management of postpartum haemorrhage in
Kisumu- East District Hospital?
4
1.5 Study Justification
Postpartum hemorrhage (PPH) is one of the world’s leading causes of maternal mortality. Thus,
this research has been designed to help bridge the knowledge gap about the causes of postpartum
haemorrhage so as to help in preventing further mortality rates associated with PPH.
This knowledge about the causes of PPH in Kisumu- East District Hospital will enable the
medical practitioners there to act appropriately in order to ensure the availability of resources
required in the prevention and management of PPH.
5
CHAPTER TWO
2.0 Literature Review
2.1 Introduction/ Definition
Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean
delivery. PPH is the loss of blood following childbirth resulting in hypovolemia or otherwise
causing a woman to become symptomatic due to the blood loss ("Overview of postpartum
hemorrhage," 2014). Some practitioners measure PPH by a blood loss of greater than 500 ml of
blood following vaginal birth, or 1000 ml of blood following cesarean section. Blood lost during
the first 24 hours after delivery is primary postpartum hemorrhage; blood lost between 24 hours
and 6 weeks after delivery is secondary postpartum hemorrhage (Poggi, 2007). Hemorrhage is
the most common reason postpartum women are admitted to intensive care units and arguably
the most preventable cause of maternal mortality.
2.2 Burden/ Epidemiology
Postpartum hemorrhage (PPH) is a major cause of maternal morbidity, and one of the top three
causes of maternal mortality in both high and low per capita income countries, although the
absolute risk of death from PPH is much lower in high income countries (1 in 100,000 deliveries
in the United Kingdom versus 1 in 1000 deliveries in the developing world) (Belfort, 2014).
Methods of measuring blood loss associated with childbirth vary, complicating comparison of
prevalence rates (Calvert, Thomas and Ronsmans, 2012). A systematic review reported the
highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate
globally of 10.8% (Calvert, Thomas and Ronsmans, 2012). The rate in both Europe and North
America was around 13% (Calvert et al, 2012). The rate is higher for multiple pregnancies
(32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared with
10.0% for women in subsequent pregnancies) (Calvert et al, 2012).The overall rate of severe
PPH (>1000 ml) was much lower at an overall rate of 2.8%, again with the highest rate in Africa
(5.1%) (Calvert et al, 2012).
6
The incidence of postpartum hemorrhage varies widely, depending upon criteria used to define
the disorder. A reasonable estimate is 1 to 5 percent of deliveries (Lu MC, Fridman M, Korst
LM, et al, 2005). In an analysis of population-based data from the United States National
Inpatient Sample for the years 1994-2006, the discharge diagnosis of PPH increased 26 percent
over this period (from 2.3 to 2.9 percent)(Callaghan, Kuklina and Berg, 2010).
Uterine atony was the most common cause of PPH and accounted for most of the increase. The
proportion of women diagnosed with uterine atony increased from 1.6 to 2.4 percent over the 12
year period (Callaghan, Kuklina and Berg, 2010).
In the developed world, PPH is a largely preventable and manageable condition. In developing
countries, mortality from PPH remains high and recent studies have shown that PPH causes up to
60 per cent of all maternal deaths (WHO, 2007). PPH accounts for 59 per cent of maternal deaths
in Burkina Faso, 53 per cent in the Philippines, and 43 per cent in Indonesia (WHO, 2007).
Postpartum haemorrhage accounts for 25 per cent of maternal mortality in Africa (WHO, 2007).
A systematic review conducted by the WHO found that postpartum haemorrhage is the leading
cause of maternal mortality in Africa and Asia, accounting for up to half of the total number of
deaths in these regions (Lancet, 2006).
In Kenya, severe PPH (blood loss exceeding 1,000 ml) is particularly common among mothers
who do not deliver in hospitals, and this is estimated to be around 56 per cent of all expectant
mothers (Chege, 2012).
2.3 Risk factors for Postpartum Haemorrhage
Determinants of, and risk factors for, postpartum hemorrhage have been studied to identify
pregnant women with increased risk.The factors most significantly associated with postpartum
haemorrhage include advanced maternal age, prolonged labour, pre-eclampsia, obesity of
mother, multiple pregnancy, a birth weight of more than 4000 g, and previous postpartum
haemorrhage (Pentti, 1995). It seems that multiparityitself is only a weakly associated factor
(Pentti, 1995).
7
A previous study was took in a Latin- American population and the findings showed that
retained placenta, multiple pregnancy, macrosomia (defined as a birth weight of 4,000 grams or
more) episiotomy and suture were all risk factors for this Latin-American population (Claudio,
Fernando and Pierre, 2009).However, other risk factors such as maternal age, nulliparity,
augmentation and/or induction with oxytocin during first or second stage of labor and preterm
birth were not associated with increased risk of postpartum hemorrhage in that study (Claudio et
al, 2009). Findings in the Latin- American group showed that active management of third stage
of labor, low birth weight and multiparity (more than three deliveries) are protective factors
against developing moderate post-partum hemorrhage (Claudio et al, 2009).
Multiparity has been cited in many previous studies as an important risk factor, and it has been
used as an important clinical marker for postpartum hemorrhage by practitioners e.g. in China
(Xiong, Zhang and Chen, 1994), in Zimbabwe (Tsu, 1993).
A previous study in Israel was aimed to identify obstetric risk factors for early postpartum
hemorrhage (PPH) in singleton gestations and to evaluate pregnancy outcome. The results
showed that significant risk factors for PPH, identified using a multivariable analysis, were:
retained placenta (OR 3.5, 95%CI 2.1–5.8), failure to progress during the second stage of labor
(OR 3.4, 95%CI 2.4–4.7), placenta accreta (OR 3.3, 95%CI 1.7–6.4), lacerations (OR 2.4,
95%CI 2.0–2.8), instrumental delivery (OR 2.3, 95%CI 1.6–3.4), large for gestational age (LGA)
newborn (OR 1.9, 95%CI 1.6–2.4), hypertensive disorders (OR 1.7, 95%CI 1.2–2.1), induction
of labor (OR 1.4, 95%CI 1.1–1.7) and augmentation of labor with oxytocin (OR 1.4, 95%CI 1.2–
1.7) (Sheiner, Sarid and Levy, 2005).
A Dutch population-based cohort study reviewed that the most important risk factors for
standard and severe PPH were related to an abnormal third stage of labour—third stage ≥30min
and retained placenta (in severe PPH: odds ratio (OR) 14.1, 95% confidence interval (CI) 10.4–
19.1). High birth weight and perineal damage were less important, but independent, significant
risk factors (Bais, Eskes and Pel, 2004).
8
2.4 Causes of Postpartum Hemorrhage
Causes of postpartum hemorrhage are uterineatony, trauma, retained placenta, and coagulopathy,
commonly referred to as the "four Ts" (Anderson, 2007).
Causes of postpartum hemorrhage and their incidence (Anderson, 2007)
Cause Incidence
Uterine atony 70%
Trauma 20%
Retained tissue 10%
Coagulopathy 1%
2.4.1 Tone
Uterineatony is the inability of the uterus to contract and may lead to continuous bleeding.
Retained placental tissue and infection may contribute to uterine atony.
Uterine atony is the most common cause of postpartum hemorrhage ("Overview of postpartum
hemorrhage," 2014).It is estimated that 99% of maternal deaths in the world occur in Africa,
Asia, and Latin America, and PPH is the cause of 1/4 to 1/3 of these deaths. Seventy percent of
the PPH corresponds to uterine atony (Bustillo, 2013). Patients at increased risk for uterine atony
include those with high parity, over distended uterus (e.g., multiple gestation, polyhydramnios),
prolonged or rapid labor, use of oxytocin for induction or augmentation, and use of magnesium
sulfate (Andersen and Hopkins, 2008). The real problem with atonic PPH is that you cannot
predict who will bleed excessively after the birth, and this is because two-thirds of women who
develop atonic PPH have no known risk factors (“Labour and Delivery Care,” 2014).
2.4.2 Trauma
Trauma from childbirth may tear tissue and vessels leading to significant postpartum bleeding
(Anderson, 2007). Globally, the commonest type of trauma to the genital tract includes
lacerations of the perineum, vagina, cervix, or uterus and this may result in visible or concealed
hemorrhage (Andersen and Hopkins, 2008).A study done in PCEA Kikuyu Hospital in Kenya, in
2009, reviewed thatgenital tract trauma was the commonest morbidity faced by pregnant women
9
in that facility during delivery. Episiotomies were significantly associated
with primigravidity whereas perineal tears were noted to besignificantly less in primigravidas
(Ukachukwu, 2009).An episiotomy rate of 33% is high, although not unusual in the African
context (Onwuhafua, 2006). It is thought that episiotomy rate of over 30% is unacceptable
(Maral, 2002).However, research has shown episiotomy rates to be 49% in Nigeria and up to
71% in Germany (Onwuhafua, 2006).
2.4.3 Tissue
Retention of tissue from the placenta or fetus may lead to bleeding (“Overview of Postpartum
Haemorrhage”, 2014).Retained placenta causes uterine atony by preventing uterine contraction,
which compresses the myometrial spiral arteries. Retained products may cause delayed PPH by
interfering with involution of the placental site (Andersen and Hopkins, 2008).A study guide
showed that retained placental tissue as a cause of PPH, in the developing countries, was
commonin settings where a large proportion of women delivered at home under the care of semi-
skilled and unskilled birth attendants (Kumar, Dadhwal and Sharma, 2011).
2.4.4 Thrombin
A bleeding disorder occurs when there is a failure of clotting, such as with diseases known
as coagulopathies ("Overview of postpartum hemorrhage", 2014). According to “The Global
Library of Women’s Medicine” in 2008, it was reviewed that most coagulopathies (e.g.,
idiopathic thrombocytopenic purpura, von Willebrand's disease) may cause PPH. Disseminated
intravascular coagulation from abruptio or severe preeclampsia may also result in PPH.
Coagulopathies have the potential to cause PPH up to several days after delivery (Strickland,
Galey and Hauth, 1982).
2.5 Active management of the third stage of labor (AMTSL)
Active management of the third stage of labor (AMTSL) is an evidence-based, low-cost
intervention used to prevent postpartum hemorrhage that can help to prevent primary PPH. The
Bristol 23 and Hinchinbrook 12 randomized control trials provided conclusive evidence that
active management of the third stage of labor (AMTSL) significantly reduces postpartum
hemorrhage, decreases blood loss and decreases the need for blood transfusions (Cotter et al,
2001).
10
AMTSL involves three main components: 1/ the use of auterotonic agents within one minute
following the birth of the baby, 2/ delivery of the placenta with Controlled Cord Traction (CCT)
and 3/ massage of the uterus after delivery of the placenta (ICM/FIGO, 2003).
The third component – uterine massage - was not present in the Hinchingbrooke randomized
controlled trial in 1998 but it was the International Confederation of midwives (ICM) that took
the initiative to add the uterine massage so that skilled birth attendants would stay alert for late
PPH. These three interventions hasten placental delivery by increasing uterine contractions,
decreasing blood loss and preventing postpartum hemorrhage by averting uterine atony (PATH,
2001). Oxytocin being the uterotonic drug of choice, findings from a WHO multi-center study
indicated that 10 IU oxytocin (intravenous or intramuscular) is preferable to 600 microgram of
oral misoprostol in the AMTSL in hospital settings where active management is the norm
(WHO, 2004).
2.6 Management of PPH
Intravenous oxytocin is the drug of choice for postpartum hemorrhage. Misoprostol may also be
effective if oxytocin is not available (“The Lancet,”2014).The World Health Organization started
recommending the use of a device called the Nonpneumatic Anti-Shock Garment (NASG) in
2012 for use in delivery activities outside of a hospital setting, the aim being to reverse shock in
a mother suffering from obstetrical hemorrhage long enough to reach a hospital (Craig, 2013).
A detailed stepwise management protocol has been introduced by the California Maternity
Quality Care Collaborative(“Overview of Postpartum Hemorrhage,” 2009). It describes 4 stages
of obstetrical hemorrhage after childbirth and its application reduces maternal mortality(Barbieri,
2009).
Stage 0: normal - treated with fundal massage and oxytocin.
Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble
personnel, increase oxytocin, consider use of methergine, perform fundal massage,
prepare 2 units of packed red blood cells.
Stage 2: bleeding continues - check coagulation status, assemble response team, move
to operating room, place intrauterine balloon, administer
additional uterotonics (misoprostol, carboprosttromethamine), consider: uterine artery
11
embolization, dilatation and curettage, and laparotomy with uterine compression stitches
or hysterectomy.
Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional
personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.
Misoprostol is a simple and effective medicine that can contribute significantly to our efforts to
reduce maternal mortality(Karanja, Muganyizi&Rwamushaija, 2012).Misoprostol is recognized
by the World Health Organization (WHO) as an essential medicine for addressing two major
causes of maternal mortality: postpartum hemorrhage (PPH) and unsafe abortion (WHO, 2011).
In Mozambique, a country represented at the Regional Expert Summit the Mozambican
Association of Obstetricians and Gynecologists (AMOG) piloted the introduction of misoprostol
for PPH prevention through antenatal care and by traditional birth attendants in rural areas where
only 34% of women deliver with skilled attendance (Karanja et al., 2012). The availability of
misoprostol for home deliveries paired with a community awareness campaign on the importance
of facility deliveries (which involved Traditional Birth Attendants) contributed to near universal
uterotonic coverage in the postpartum sample (Karanja et al., 2012).
12
CHAPTER THREE
3.0 Research Methodology
3.1 Study Design
This is a descriptive cross-sectional institutional based retrospective case study on the causes of
postpartum haemorrhage in women admitted at Kisumu- East District Hospital.
3.2 Study Area
Kisumu East District Hospital is a government hospital located in Winam division, Kisumu
County, Kenya.
The hospital servesa population of 150,124 people and has a bed capacity of 195 beds.
3.3 Study Population
The study involved the female patients, at the obstetricunit in Kisumu East District Hospital, who
visited the facility in preceding period of six months prior to data collection i.e. between 1st
January, 2014 and 30th June, 2014.
3.4 Sample Size Determination
The following formula was used to calculate the sample size
n=Z²P (1-P) (Lwanga and Tye 1986).
D²
Where;
D= margin of error of setting a significance level of 0.07 (i.e 7%)
P= prevalence 0.5
Z= level of significance (1.96) for confidence interval of 95%
Hence;
n=1.96x0.5x0.5/(0.07)^2=100
13
3.5Data Collection Method
Data was collected from the determined sample size using a data collection sheet designed for
the study.
3.6Data Analysisand Presentation
The data obtained was analyzed usingStatistical Packaging for Social Scientists(SPSS).The results
will be presented in forms of charts, tables and graphs.
3.7Inclusion Criteria
All patients referred to Kisumu East District Hospital due to PPH, and those who developed PPH
after delivery, in Kisumu East District Hospital between 1st January, 2014 and 30th June, 2014.
3.8 Exclusion Criteria
All patients admitted to maternity ward for other complications other than postpartum
haemorrhage.
3.9 Ethical Considerations
Permission was sought from the research committee of KIU western campus and the concerned
authorities in the administration and the research approval wassought from the ethical review
board of Kampala International University Western Campus. Then, permission was sought from
the medical superintendant of Kisumu East District Hospital for the approval of data collection.
Confidentiality was observed strictly at all stages of this research.
To ensure anonymity, no names were used but instead codes only known to the researcher.
3.10 Study Limitations
Financial constraints, missing records, power supply interruptions and shortage of time were
some of the challenges to be faced.
14
CHAPTER FOUR
4.0 DATA PRESENTATION AND ANALYSIS
4.1 MOST COMMON TYPE OF PPH
TYPE OF PPH FREQUENCY PERCENTAGE
Primary 29 88%
Secondary 4 12%
TOTAL 33 100%
From the above table and pie chart, it is evident that the most common type of PPH in Kisumu
East District Hospital is primary PPH with 29(88%) patients out of 33(100%).
88%
12%
MOST COMMON TYPE OF PPH
Primary PPH
Secondary PPH
15
4.2 CAUSES OF PPH
CAUSE OF PPH FREQUENCY PERCENTAGE
Uterine Atony 14 42.4
Trauma 16 48.5
Retained Products of
Conception
3 9.1
Thrombin Disorders 0 0
Total 33 100.0
The bar graph above shows that the causes of PPH in Kisumu East District Hospital were trauma
to the perineum(48.5%), uterine atony (42.4%), and retained products of conception e.g. placenta
(9.1%). The most common cause was trauma to the perineum.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Uterine Atony Trauma RetainedProducts ofConception
Thrombindisorders
Causes of PPH
Causes of PPH
16
4.3 MANAGEMENT OF PPH
MANAGEMENT FREQUENCY ( Out of 33
patients)
PERCENTAGE
I.V. Oxytocin 11 33.3%
Blood transfusion 9 27.3%
I.M. Ergometrin 2 6.1%
Episiotomy/ perineal
repair
15 45.5%
Haematinics 12 36.4%
Antibiotics 4 12.1%
Manual evacuation of
retained placenta
3 9.1%
Uterine massage 3 9.1%
Sublingual cytotec 1 3.0%
Vaginal packing 3 9.1%
17
The above pie chart and table shows that the major strategies used in the management of PPH
were episiotomy/ perineal repair (45.5%),haematinics (36.4%), I.V.oxytocin (33.3%), blood
transfusion (27.3%). Others included; antibiotics (12.1%), Manual evacuation of retained
placenta (9.1%), uterine massage (9.1%), vaginal packing (9.1%), I.M. ergometrin (6.1%), and
sublingualcytotec (3.0%).
All women with PPH were given I.V. fluids i.e. normal saline.
Management of PPH
I.V. Oxytocin
Blood transfusion
I.M. Ergometrin
Episiotomy/ Perineal repair
Haematinics
Antibiotics
Manual evacuation of retainedplacenta
Uterine massage
Sublinguall cytotec
Vaginal packing
18
CHAPTER FIVE
5.0 DISCUSSION OF FINDINGS
5.1 The Most Common Type of Postpartum Hemorrhage
According to the findings of this study, the most common type of PPH is primary PPH with
29(88%) patients out of 33(100%). Secondary PPH was not common with4(12%) patients out of
33(100%) patients, and it was due to poorly repaired episiotomy.
According to a research done by Poggi (2007), blood lost during the first 24hours after
delivery(Primary PPH) was the most common obstetric complication.
This statement is actually true according the findings in Kisumu East District Hospital that,
primary PPH is the most common type of PPH.
5.2 The Causes of Postpartum Hemorrhage
From the findings of this study, the causes of PPH in Kisumu East District Hospital were trauma
to the perineum (48.5%), uterine atony (42.4%), and retained products of conception e.g.
placenta (9.1%).
The most common cause was trauma to the perineum, which were basically perineal tears and
episiotomies. These were mostly due to macrosomia.According to a study done byAndersen and
Hopkins (2008), globally, the commonest type of trauma to the genital tract includes lacerations
of the perineum, vagina, cervix, or uterus and this may result in visible or concealed hemorrhage
.A study done in PCEA Kikuyu Hospital in Kenya, in 2009, reviewed thatgenital tract trauma
was the commonest morbidity faced by pregnant women in that facility during delivery.
The second cause of PPH according to this study was uterine atony, which was basically due to
multiparity and multiple gestations. According to "Overview of postpartum hemorrhage,"
(2014), uterine atony is the most common cause of postpartum hemorrhage. A study done by
Andersen and Hopkins(2008) showed that,patients at increased risk for uterine atony include
those with high parity, over distended uterus (e.g., multiple gestation, polyhydramnios),
19
prolonged or rapid labor, use of oxytocin for induction or augmentation, and use of magnesium
sulfate.
The third cause of PPH according to this study was retained placenta and blood clots. A study
done byKumar, Dadhwal and Sharma(2011) showed that retained placental tissue as a cause of
PPH, in the developing countries, was commonin settings where a large proportion of women
delivered at home under the care of semi-skilled and unskilled birth attendants.
5.3 Management of Postpartum Hemorrhage
From this study, the major strategies used in the management of PPH, in Kisumu East District
Hospital, were episiotomy/ perineal repair (45.5%), haematinics (36.4%), I.V.oxytocin (33.3%),
blood transfusion (27.3%). Others included; antibiotics (12.1%), Manual evacuation of retained
placenta (9.1%), uterine massage (9.1%), vaginal packing (9.1%), I.M. ergometrin (6.1%), and
sublingualcytotec (3.0%). I.V. fluids bylarge-bore intravenous access were given to all PPH
patients as the first intervention.Episiotomy/ perineal repair was the most common management
intervention performed due to the high number of cases of perineal tears and episiotomies done
in most of the women.
A study from “The Lancet,” (2014) showed that intravenous oxytocin was the drug of choice for
postpartum hemorrhage. Misoprostol may also be effective if oxytocin is not available. A
research done by Karanja (2012) showed that the availability of misoprostol for home deliveries
paired with a community awareness campaign on the importance of facility deliveries (which
involved Traditional Birth Attendants) contributed to near universal uterotonic coverage in the
postpartum sample (Karanja et al., 2012).
This is evident that the management of PPH is highly dependent on the cause. Thus, the various
protocols used in Kisumu East District Hospital were highly appropriate.
20
CHAPTER SIX
6.0 CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion
The research was set up to study the causes of postpartum hemorrhage in Kisumu East District
Hospital with specific objectives of determining the most common type of PPH, the causes of
PPH and finally, the strategies used in the management of PPH. It was noted that the most
common type of Postpartum Hemorrhage was primary PPH. The most common causes included
perineal trauma (tears and episiotomies) due to macrosomia; uterine atony due to multiparity and
multiple gestations; and retained placental fragments and blood clots. The various management
strategies used to manage PPH depended on the cause. Proper management protocols were
observed and thus led to the reduction of the high mortality rateassociated with PPH.
6.2 Recommendations
According to the findings of the study, I came up with the following recommendations:
Due to the high rate of perineal tears, there is need for the implementation of proper
midwifery skills and guidelines in the management of PPH.
Since the most common type of PPH is primary PPH, close monitoring of the mothers
immediately after delivery should be observed.
The community should be sensitized on the common risk factors that predispose to PPH
e.g. multiparity, in order to reduce on the incidence of PPH.
Health workers should be constantly reminded on the proper techniques involved in the
active management of third stage of labour.
As a matter of emergency, prompt and quick management strategies should be put in
place whenever a mother is going to deliver e.g. availability of blood and the presence of
a competent obstetric team.
Mothers with risk factors predisposing to PPH should be identified during antenatal and
followed up post-delivery.
21
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4. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum
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23
APPENDIX ONE
DATA COLLECTION SHEET
NAME OF HOSPITAL: Kisumu East District Hospital
LOCATION: Kisumu Town, Kisumu East District, Nyanza Province, Kenya
Retrospective Data from January, 2014 to June, 2014
In- patient number Type of PPH Cause of PPH Management option
24
APPENDIX TWO
TIME FRAME/SCHEDULE
PHASE
RESEARCH ACTIVITIES
TIME PERIOD
1
Writing of the research
proposal
3 weeks
2
Data collection
1 month
3
Data processing and editing
2 weeks
4
Consultation with the
research supervisor
2 days
5
Final data analysis
1week
6
Drafting of the final report
and presentation
2weeks
TOTAL DURATION
3 months and 2 days
25
APPENDIX THREE
BUDGET
ITEMS
COSTS (UShs)
STATIONARIES
6,000
TYPING AND PRINTING MATERIALS
30,000
BINDING SERVICES
10,000
PHOTOCOPYING SERVICES
10,000
INTERNET SERVICES
15,000
FARE
35,000
MISCELLANEOUS
20,000
TOTAL
126,000
26
LOCATION OF KISUMU COUNTY
Location of Kisumu County (Green)
Recommended