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

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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.

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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

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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).

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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

REFERENCES

1. AbouZahr, C., T. Wardlaw, and K. Hill. 2001. "Maternal Mortality in 1995: Estimates

Developed by WHO, UNICEF, UNFPA." WHO/RHR/01.9, WHO, Geneva.

2. Anderson JM, Etches D (March 2007). "Prevention and management of postpartum

hemorrhage". American Family Physician 75 (6): 875–82.

3. Barbieri RL. "Planning reduces the risk of maternal death. This tool helps". OBG

Management (2009) 21 (8):8-10.

4. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum

hemorrhage in a large, nationwide sample of deliveries. AnesthAnalg 2010; 110:1368

5. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States,

1994-2006. Am J ObstetGynecol 2010; 202:353.e1.

6. Calvert, C; Thomas, SL; Ronsmans, C; Wagner, KS; Adler, AJ; Filippi, V (2012).

"Identifying regional variation in the prevalence of postpartum haemorrhage: a

systematic review and meta-analysis.". PloS one 7 (7):

e41114. doi:10.1371/journal.pone.0041114.

7. Carroli G, Cuesta C, Abalos E, et al; Epidemiology of postpartum haemorrhage: a

systematic review. Best Pract Res ClinObstetGynaecol. 2008 Dec;22(6):999-1012. doi:

10.1016/j.bpobgyn.2008.08.004. Epub 2008 Sep 25.

8. Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya],and

ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton,Maryland:

CBS, MOH, and ORC Macro.

9. Chang J, Elam-Evans LD, Berg CJ et al: Pregnancy-related mortality surveillance--

United States, 1991--1999. MMWR SurveillSumm 2003 Feb 21;52(2):1-8

10. ICM. (2011). Essential competencies for basic midwifery practice. 2011 update.

11. Kaunitz AM, Hughes JM, Grimes DA et al: Causes of maternal mortality in the United

States. ObstetGynecol 65: 605, 1985

12. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes

of maternal death: a systematic review. Lancet 2006; 367: 1066-74.

13. Ministry of Health, Kenya. A Question of Survival? Review of Safe Motherhood,Division

of Primary Health Care, June, 1997.

22

14. Newton M: Postpartum hemorrhage. Am J ObstetGynecol 94: 711, 1966

15. Onwuhafua PI. Childbirth in Germany and Nigeria compared. Niger J Med. 2006Oct-

Dec;15(4):387-92

16. Prevention and management of postpartum haemorrhage; Royal College of Obstetricians

and Gynaecologists (May 2009 with revisions April 2011)

17. WHO/UNICEF/UNFPA. Maternal Mortality in 2000: Estimates of WHO, UNICEF and

UNFPA. Department of Reproductive Health and Research, World Health Organisation,

Geneva 2004.

18. World Health Organisation (WHO). The Challenge of reducing Maternal andPerinatal

morbidity and Mortality Worldwide. Department for ReproductiveHealth and Research,

WHO, Geneva, 2001.

19. World Health Organization. World Health Report. Geneva: 2005.

20. Xiong Q, Zhang GY, Chen HC. Analysis of risk factors of postpartum hemorrhage in

rural women. Zhonghua Fu Chan KeZaZhi. 1994; 29:582–5. 635

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)