First published 19th June 2019 on jedaktari.wordpress.com
CODE PPH: MOTHER DYING
Few things are as distressing to both families and healthcare workers as a mother dying during childbirth. Of the causes of these deaths, Post Partum Haemorrhage, (PPH), holds a special place. Yet this is not as uncommon as we would love it to be.
Recently, I received a 10 second call from a healthcare worker in Western Kenya. “Daktari, we have a mother with PPH….!” That is a dreaded call and I will tell you how the story went.
In Kenya today, more than 5,000 mothers lose their lives every year while giving birth or due to pregnancy related complications. That is about fourteen mothers daily. The leading contributor to this grim state is post-partum haemorrage (PPH): a mother bleeding after birth. It is one of the most difficult complications to predict, to treat, and it claims more maternal lives than any other pregnancy related complication.
Why is it so dire and why is it so difficult to treat? The answer lies in two things: the importance of blood, and how the baby is attached to the mother while in the womb. An average human being has about five litres of blood in their system, and well, these five litres are your life. Lose three of them rapidly without replacement and you will probably die. During pregnancy, the baby is attached to the mother through the placenta (not just the umbilical cord). The placenta attaches to the mother’s womb in an area of approxiamtely 100cm square centimetres. Thats about 10cm by 10cm. The whole of this area is a complex network of tiny, highly effective blood vessels, that together ensure a consistent flow of blood to and from the baby. Immediately after birth, our Creator’s infinite wisdom takes over: After delivery, the womb contracts, and this contraction tightly squeezes the vessels closed and in this way, bleeding stops. However, sometimes, this contraction fails to happen and the bleeding continues.
In normal medicine, when a blood vessel causes bleeding, it is possible to tie it off or cauterize it (apply heat to the bleeding vessel forming a clot). However, how does one tie of off a 100cm squared area? How do you cauterize it without burning a hole straight through the patient? These options are not available. So, what happens when the womb fails to contract? Well, welcome to the scary world of PPH due to uterine atony! This is PPH because the womb has failed to contract as it should and now, all these effective blood vessels, are pouring out the mothers blood, not to a baby, but to the floor. The mother is therefore bleeding out and will surely die within minutes or hours, unless an intervention is put in place.
Now, the uterus can fail to contract following both a normal delivery and a caesarean section. (The only problem is that with the latter, there is no way the doctor is ever going to convince the family, or the public that the bleeding is from the Uterus and not from a cut or improperly sutured wound or a “botched procedure.” This is the danger of having the newspaper reporter determine what amounts to good quality care and what amounts to negligence). So what happens in this case?
There are number of manouvers that can be attempted. However, different patients will respond differently. In fact, the same patient may respond differently to the same procedure in different pregnancies. If conservative measure work, fantastic! Everyone celebrates. However, if all the manouvres fail, the only option left is a choice between losing the mother and removing the uterus. Now you know why and under what circumstances doctors are forced to remove uteruses after birth. This is often a life-saving measure that is undertaken as an emergency. Rarely would there be time to obtain consent for it. (The irony of it is that there are mothers who survived these life-threatening procedures but are now suing the doctors for removing their uteruses without consent. Once again, the reporter would have you believe that the doctors have conspired to sterilize Kenyan women. No offence intended but if you don’t know, you don’t know. Having the ability to write about it on a National paper doesn’t change that. It only endangers the lives of your readers who then lose trust in their providers. This is why many serious media houses, concerned about truth and accuracy and not just profit by cutting corners, hire healthcare professionals to guide and validate their health reports).
Even if one is successful in stopping the bleeding, whether operatively or conservatively, there is the question of replacing blood. And so the one case sadder than losing a mother is losing a mother whose PPH has been controlled, miraculously, but then dies because there is no blood to replace what has been lost. Before you tell me that doctors should make sure that there is blood before delivering the mother (believe me, there are those who will still think like this), babies will come when they come doctors can’t really stop them. Then its people who donate blood….When was the last time you donated blood? I have heard of doctors and other health workers giving their own blood in theatre to a patient bleeding out.
There are other causes of PPH: a patient may have a clotting/bleeding disorder meaning that their blood does not clot. The way the body stops bleeding, is by forming a clot. This clot acts as a plug. The clot in itself requires clotting factors precise systems within the body. In the event that there is a defect in the clotting factors or systems, the body’s ability to form clots is impaired and bleeding will continue for longer. The liver is particulary important in this process and liver disease or liver failure will present a similar picture. Bleeding after birth from these defects can lead to death and no even if doctors could diagnose the disorder before hand, the babies will not wait. They will still come out at 9 months.
Then there are tears to the birth canal that may occur if the baby is too big, the birth process is too rapid, or following instrumentation. And yes, there are cases of bleeding that may occur as a result of negligence from clinical staff: leaving a bleeder unstitched, inappropriate/erroneous cuts etc. Retained products of conception also causes bleeding that can be torrential and catastrophic.
Back to our story, I rushed to the private hospital (in Bungoma!) and a heavily bleeding mother, semi-conscious, with blood everywhere on the floor and one could see death beckoning. I also found a team of two consultant doctors, three medical officers, several nurses, pharmacy and laboratory staff living through a real-life episode of Grey’s anatomy. There were frantic efforts to stop the bleeding through all known emergency measures. There were frantic phone calls to the local National Blood Transfusion Service Satellite to avail blood. There were frantic efforts to get theatre ready within minutes: ready to stop the bleeding in the least desirable way. There were calls to update the partner and family members on what was going on, what options we were faced with, the real risk of death within minutes, and the dire nature of the emergency. The available blood was running, the fluids were in, the emergency medication had been given, the maneuvers performed, yet the blood continued to pour out in torrents. In the midst of all this, Dr. Amol Gadgil, 20 years plus of experience as a consultant obstetrician and gynaecologist conducted his orchestra of healthcare workers. He adjusted increased the pain associated with the aortic compression. “Make sure you reach the spine! Like this! I know its very painful but there is no other way….” A few more things for the team, a few more instructions and frantic efforts, a few more units of blood. but then we noticed that the flow had reduced. Was the patient running out of blood? Were we losing her?
“You know, we may just about make it. Let’s see, how she does in the next few minutes.” We all dared to breathe. Theatre was ready. We were now clear that we would likely save the mother, albeit at the cost of the uterus. A few more minutes. It was down to a trickle. Dr. Amol allowed a small smile as he turned to me. “We may even save the uterus. If it continues like this, we may save both mother and uterus.” And thus it was. Anxious clinical staff were all smiles and full of celebration! Thank God! This time we succeeded. Oh, and the baby boy? Warm and adorable throughout. I don’t know whether the baby knew the fight her mother was in.
Here’s the bottom line: if our health system were working as it should, most of these mothers could be saved. Unfortunately, our ever divided country has “first class citizens” who can afford care in big private hospitals or even go abroad on taxpayers money, and the rest of the citizens for whom policy makers propose corner-cutting, cheap and risky, ineffective, interests-heavy, short-sighted healthcare measures. As a result, PPH continues to kill thousands of mothers in Kenya every year.