Chapter 29 Strategies to improve global maternal and neonatal health5 main causes of direct obstetric maternal mortality :(a) Haemorrhage - antepartum bleeding (abruption of placenta)-bleeding during delivery (ruptured uterus, placenta previea)- postpartum (atonic uterus, retained placenta) Oxytocics prevent postpartum haemorrhage Treat uterine atonydrugs which induce uterine contractions to stop bleeding Retained placenta manual removal using simple general anaesthesia (IM ketamine)

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

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

(c) Sepsis Can be prevented or managed with high standards for infection control, appropriate prenatal testing and treatment of maternal infection, and appropriate use of intravenous or intramuscular antibiotics during labor and post-partum period. Related to poor hygiene and infection control during delivery or to the presence of untreated sexually transmitted infections during pregnancy.

Can l/t chorioamnionitis, premature delivery, major systemic sepsis : prophylactic antibiotic

membrane rupture

Due toManual Vacuum Aspiration(MVA) in early pregnancy under local anaesthesiaDilatation and Curettage (D&C) requires general anaesthesiaretained products of conception (incomplete miscarriage / unsafe abortion)

(d) Eclampsia

Treatment available during childbirth includes the use of sedative or anti-convulsant drugs. Magnesium suphate reduce eclamptic fit(e) Unsafe abortion l/t maternal death through uterine perforation, haemorrhage, sepsis Can be prevented by providing safe abortion, quality family planning services, and competent post-abortion care.______________________________________________________________________________________Medical conditions contributing to maternal mortality and morbidity(a) anemia Hb < 11.0g/dL Usually chronic anemia, asymptomatic at rest Decompensate easily in labour, high risk of death in obstetric haemorrhage

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

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

(d) Tuberculosis Leading cause of death in HIV / AIDS women Multiple drug treatment : rifampicin, isoniazid, ethambutol, pyrazinamide, streptomycin (all except streptomycin are considered safe for mother and child) BCG vaccination give to newborn

Strategies to improve global maternal and newborn health(a) Skilled birth attendance (SBA) Term used for skilled birth attendant + enabling environment

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

(c) Early newborn care 5 common causes of death in newborn : preterm birth, infection, intrapartum asphysia, congenital abnormalities, tetanus Infections (sepsis, pneumonia, meningitis) prevented antenatal and hygienic care, care of the cord, breastfeeding Tetanus : vaccination of mother + clean cord care Pre-term birth : give mother antenatal corticosteroids + Kangaroo Mother Care