Q. Indigenous women in Australia are more likely to die in pregnancy and childbirth. Their risk is?
- Twice as high
- Three times as high
- Three and a half times as high
- Five times as high
WOMEN ONLY PAGE - NO MEN
Just as we do today:
If the woman was bleeding after the birth the mother would rub her tummy to stop the bleeding. (Dixie, Mary, Elizabeth, Shirley and Molly)
They warm the babies, they rub their hands in the fire, and then put them on the babies face and all over their body to stop the bandy legs and all that. It helps to straighten their legs so that when they grow up they don’t look funny. Like some of the Balanda they have a funny walk from bandy legs. All over Maningrida they still do this, it makes them nice and beautiful, the heat from the fire. (Joy, Verity, Amanda and Sarah Lee)
When the fire goes down to the coals then you put the sand on top of the coals and it makes the sand warm and then the sand goes on top of the baby, it makes them grow quick and they get strong. (Tinica)
If you don't want anymore babies then you should cut the placenta up with a shell. (Molly)
You shouldn't bath the baby as the mother sometimes uses the sweat from under her arms to protect the baby. (RAN)
In the old days the women would only have periods for 1-2 days when they were younger, maybe 2-4 days as they get older. They would be fit and strong and the uterus would involute in 1-3 days. Things are different now, their muscles are different as they are not doing as much hunting. (RAN)
Case study | risk factors | Prevention | Recognition | Treatment | complications | Quiz
Postpartum haemorrhage is a topic that was mentioned by many of the remote practitioners who contributed to the planning of this guide, as one they wanted current and detailed information on. As a result this section is quite lengthy. There is a quiz at the end for you to test yourself.
Every year 515,000 women die in pregnancy and childbirth, which is approximately 1,410 every day, 58 women an hour, almost one every minute.[50] Maternal haemorrhage accounts for 25-50% of these maternal deaths, with postpartum haemorrhage (PPH: 5-15%) being the leading cause.[51,52] PPH is often sudden, unpredictable, frightening and can be catastrophic. Ninety nine percent of maternal deaths occur in developing countries, leaving at least one million children without a mother.[53] The mortality is highest where women are birthing without skilled attendants and have difficulties accessing referral services.[51]
Postpartum haemorrhage is not just a problem for developing nations as it occurs here in Australia too. In the 1994-96 Maternal Mortality Report, published by the National Health and Medical Research Council of Australia, there were eight women who had PPH as either the principle or contributory cause of death.[54] There were two very disconcerting things about this report. The first was that it showed a significant rise in maternal deaths in Australia, particularly in the ‘direct’ category, which means the death was directly related to the pregnancy. In the 1994-96 the direct deaths numbered 46 with the total deaths being 100 (13/100,000), whereas in the 1991-93 report the direct deaths numbered 27 with total deaths being 84 (10.9/100,000).[54] These reports are slow be compiled and released and it will not be until we see the 1997-99 and 2000-02 Maternal Mortality Reports that we will know if the latest rise in direct maternal deaths was simply an aberration; improved collection of statistics; or, worst-case scenario, the beginning of a trend. The second disturbing factor in this report was that maternal mortality for Indigenous women (34.8/100,000) is 3.5 times higher than it is for non-Indigenous women in Australia (10.1/100,000).[54]
Postpartum haemorrhage has been defined in many different ways and still we do not have a universally accepted definition, making incidence and prevalence figures difficult to compile. Additionally it is difficult to assess and often underestimated. Accepted definitions include blood loss of 500mls or more during or after birth, or, blood loss that causes haemodynamic compromise.[55] Postpartum haemorrhage is further categorised as primary PPH, occurring in the first 24 hours following birth, and secondary PPH, from 24 hours to 12 weeks Postpartum.[55,56,57] Severe PPH is defined as blood loss greater than 1,000mls.[55,56,57] It is very important not just to rely on quantity of blood loss as it is the impact of that loss that counts. Some women will adjust without problems to large volumes of blood loss whereas others will demonstrate signs of shock with much less blood loss.
In the NT in 1999 7% (n=90) of Aboriginal women and 4.2% (n=94) of non- Aboriginal women experienced a PPH greater that 600mls. It was the third most common complication of pregnancy next to meconium stained liquor and fetal distress.[58] In NSW, in 1997 there were 4,186 women who had a PPH of greater than 600mls, which was 4.8% of women who gave birth. The percentages were higher for Indigenous women (6.3% Indigenous and 4.7% non-Indigenous).[59] Subsequent NSW reports have not presented this data but the most recent report tells us that in NSW in 1999 there were four direct maternal deaths, three of which involved a PPH. One was due to uterine inversion and PPH, another to PPH associated with pregnancy induced hypertension and the third was caused by shock due to PPH.[60]
Given the above statistics it is not unfathomable that midwives, at some stage of their careers, will know of someone who dies in childbirth, particularly if you are working with Aboriginal women. Additionally, most midwives will be involved with the care of a woman who experiences a PPH. The following suggestions are how best to avoid or minimise morbidity or mortality from PPH, as being skilled in the management of PPH does make a difference!
One of the most distressing things about PPH is its unpredictable occurrence with two thirds of women having no identifiable risk factors.[51] This means that the best way to manage PPH is to have a skilled workforce able to respond rapidly and competently at the earliest sign of trouble. Understanding the physiology of normal third stage helps to ascertain the cause of excessive blood loss and plan the management of PPH. Usually the placenta is expelled by the contracting uterus. The muscles of the uterus have been termed the ‘living ligatures’ and as they contract they squeeze the blood vessels to stop them from draining blood.[56] If the uterus does not contract well, or if there are any products inside the uterus to prevent it contracting fully, or if similarly, a full bladder 'gets in the way' then the blood vessels will continue to allow blood to escape. Additionally, any trauma to the area, or unusual clotting disorder, may also cause excessive blood loss.
It’s 4am in a remote community and you are the only midwife on call. Janet, a 22 year old woman who you have been seeing antenatally has just had a normal birth of her first baby weighing 3200gms. She was 37.5 weeks gestation and had a normal pregnancy. Following the birth she starts to bleed. The fundus responds well to rubbing up, but every time you stop rubbing she recommences bleeding. What should you do, in what order and how quickly?
The key components of managing PPH are:
Remembering that PPH will often occur in women without risk factors a Cochrane Review has listed those factors that have been shown in some studies to be associated with primary PPH (>500mls within 24 hours of birth). Those identified are: a woman in her first pregnancy, maternal obesity, a large baby, twin pregnancy, prolonged labour, augmented labour and antepartum haemorrhage.[56] Contrary to popular view high multiparity has not been shown to be a risk factor for primary PPH.[56] Women who have had a manual removal of placenta at caesarean are at increased risk of both blood loss and infection (which can lead to secondary PPH).[55]
This is more common in developing countries and often associated with infection (possibly caused by retained products) and maternal mortality.[57] Treatment may involve antibiotics to treat the infection, and/ or surgery for retained products. Some of the risk factors for secondary PPH are multiple pregnancy, threatened miscarriage, placental abruption, fetal death in utero, pre-eclampsia, sepsis, antepartum haemorrhage, precipitate labour, possibly antenatal smoking, not breastfeeding and primary postpartum haemorrhage.[57,61]
Janet's only identifiable risk factor was that she was having her first baby.
Janet weighed 55kg in late pregnancy, had a Hb of 105gms/L and had an active third stage with an IM Syntocinon injection. What does this information mean?
Women with anaemia or poor nutritional status are at an increased risk of PPH as a small amount of blood loss may lead to haemodynamic compromise. Anaemia and nutritional status are conditions that are not uncommon in the remote setting and should be detected and treated early in the antenatal period if possible. Anaemia due to iron deficiency can be treated with the administration of iron (being aware of possible side effects such as constipation). Nutritional status may be harder to improve. If you have the resources to involve a nutritionist or dietician then this is advisable.
A Cochrane Review showed active management of the third stage, when compared to physiological management, decreases the risk of PPH and blood transfusion.[62]
The risk of a PPH, low haemoglobin in the postnatal period, and the use of blood transfusion are all reduced by 50% when routine oxytocics are used with an active third stage.[55] This becomes a strong argument for their use given PPH is a difficult condition to predict and can have such dire complications. This is particularly important in the remote setting where there is limited access to personnel or resources for managing emergencies. But no drug is without potential problems and if women are choosing not to have an active third stage their decision must be respected.
Uterotonics that increase the efficiency of uterine contractions, including oxytocin and ergometrine, were introduced for the treatment of atonic PPH in the 19th century (around 1822).[56]
Today there are several different types of oxytocics available:
One of the keys to successful treatment of post partum haemorrhage is to ensure all health providers involved in the care of birthing women are skilled in the recognition and treatment of PPH. Following birth it is important to keep a close eye on the woman for signs of increased blood loss and empty the bladder promptly. Understanding the difficulties associated with measuring blood loss, and knowing most PPH’s are underestimated, means it is important to monitor clinical signs as well. The first signs may be a rise in pulse, dizziness, palpitations, weakness, sweating and then a fall in blood pressure.[55] It is important to act on these signs as soon as you see them as what often happens is the increased fluid in the body following childbirth enables the body to compensate when there is increased blood loss. This may occur initially and then when compensation is no longer possible, the woman may show signs of shock very quickly.[55]
The causes of PPH have been divided into four main categories. These are Tone, Trauma, Tissue or Thrombin and are described below.[44]
| Seventy percent of PPH’s will be due
to a relaxed tone of the uterus when it does not contract adequately following
the third stage.[44]
The main actions that are going to assist contractions include massage
of the uterus, an empty bladder, and administration of drugs as discussed
above. If these are not effective then bimanual compression may be necessary,
particularly if you are in the remote or rural setting. This is done by
inserting a gloved hand into the vagina (anterior fornix) to form a fist
and placing upwards pressure on the anterior wall of the uterus. With
the other hand press down on the abdomen to apply pressure to the posterior
wall of the uterus. Continue compression till the bleeding stops (see
diagram). |
 |
Twenty percent of PPH’s are caused by trauma.[44] Cervical or vaginal trauma following the birth can lead to excessive blood loss that requires treatment. The site of trauma needs to be identified and repaired as soon as possible. If this isn’t possible then pressure to the area to stem the blood flow may be necessary. If the uterus is inverted then it will need to be replaced as soon as this is identified as very quickly it will cause neurogenic shock and can cause severe haemorrhage.[61] Correcting uterine inversion is described in the World Health Organisation's guide for midwives and doctors 'Managing Complications in Pregnancy and Childbirth'.[64] A rare cause of trauma that needs to be considered, particularly with no visible blood loss, could be a ruptured uterus. This would need resuscitation, stabilisation and transfer for surgical repair or a hysterectomy.
Refers to retained products, which will need to be removed for the uterus to contract fully and stop the bleeding. This usually accounts for approximately 9-10% of PPH’s.[44] Massage and drugs may assist this process but if they do not work then the woman may need to have a manual removal of the retained products or a curettage under anaesthetic. This will depend on your setting and local resources. In rare cases the placenta may be partially adhered to the uterus requiring a hysterectomy to stop the bleeding. You may need to stabilise the woman for immediate transfer to a larger unit. Manual removal of the placenta is described in the World Health Organisations guide for midwives and doctors 'Managing Complications in Pregnancy and Childbirth'.[64]
Inability of the blood to clot is attributed to approximately one percent of PPH’s.[44] Check for clotting as you would with a snakebite - put some blood in a red top tube and watch it to see how long before it clots – if it is not clotted by 7-10 minutes you can suspect a clotting disorder, alternatively watch to see if the blood is clotting on the floor. If this occurs it is important to tell the transfer team as they may need to bring blood products with them. Clotting disorders can be triggered by childbirth itself, may be related to an underlying condition, or may present in association with other conditions such as pre-eclampsia, eclampsia, abruption or severe infection. The coagulation factors will need to be replaced (FFP, Whole Blood, Platelets) and any anticoagulation present will need to be reversed. This is a rare and serious condition.
Intractable PPH occurs when you are unable to stop the bleeding. This needs a multidisciplinary approach and possibly surgery to either ligate arteries or if not possible a hysterectomy may be necessary.[55]
If in the remote setting then the major aim is to stabilise prior to transfer. Administration of blood products or clotting factors may be necessary to restore the oxygen carrying capacity of the body and stop the bleeding. Packing the uterus can be considered to assist with stabilisation prior to transfer. It has been used in many situations since the 1800’s and has a role when surgery is not immediately possible.[52]The immediate treatment is the same whether you are in a Level Three hospital in Sydney or a small Health Centre in a remote community. As always you should call for help! While managing the bleeding you should be continually assessing to try to diagnose the cause, as this will help you direct your management. Don’t forget: Airway, Breathing and Circulation.
Rubbing up the fundus to stimulate a contraction and emptying the bladder are next. Then you need to insert two wide bore cannula (14 gauge if possible), one for fluid replacement and one for drug administration. It may seem a bit overkill but if the bleeding continues and you need to administer a lot of fluids you will need this access and you do not want to be trying to insert a cannula in a woman who is in hypovolaemic shock. There has been much debate about the use of colloids verses crystalloids (Normal Saline or Hartman’s) and the jury is still out on what is the most appropriate. However most PPH guidelines in Australia recommend crystalloids (replacing three times the measured amount lost). If the blood loss is greater than two litres, or the shock is ongoing then you need to think about using blood to resuscitate and may need the transfer team to bring this out with them.[55] Some women will not accept blood transfusions due to religious beliefs. In these cases it is very important to manage any risk factors antenatally if possible, especially anaemia.
Other things to monitor or act on are oxygen, an indwelling catheter, regular monitoring of vital signs, nil by mouth, bloods for full blood count, cross match, group and hold and coagulation screen. Is tone the problem? If not assess for trauma. Are you sure the third stage was complete? Is the blood clotting? Do you need to consider bimanual compression, manual removal of the placenta or packing of the uterus? You should be preparing for transfer.
Most importantly, a PPH is an extremely frightening condition for the woman, her family and the health personnel involved. Communicating with sensitivity and compassion are essential if it occurs. Additionally it is important to document what happened very carefully and try to estimate the blood loss accurately. After it is all over do ensure you 'debrief' with all staff that have been involved in the event.
PPH can cause significant morbidity as well as mortality. Morbidity includes anaemia and exhaustion after birth leading to a longer stay in hospital, inability to establish breastfeeding and difficulties coping in the Postpartum period.[44,55] The pituitary gland can also be affected by hypovolaemia exacerbating breast feeding difficulties. More serious complications can include shock, disseminated intravascular coagulation (DIC), renal failure, hepatic failure, adult respiratory distress syndrome, coma and infertility due to hysterectomy.[44,55] Early diagnosis and correct management are essential to minimise morbidity. Additional follow up will be needed to ensure no long-term complications and ensure resolution of the anaemia.
Q. Indigenous women in Australia are more likely to die in pregnancy and childbirth. Their risk is?
ANSWER: The maternal mortality for Indigenous women (34.8/100,000) is 3.5 times higher than it is for non-Indigenous women in Australia (10.1/100,000).[54]
Q. If a woman is at risk of PPH what would you encourage during the birth?
ANSWER: The risk of a PPH, low haemoglobin postnatally and the use of blood transfusion are all reduced by 50% when routine oxytocics are used with an active third stage.[55] This is important to remember if you have a woman who has any of the risk factors and becomes a strong argument for their use given PPH is a difficult condition to predict and can have such dire complications. This is particularly important in the rural and remote setting where there is limited access to personnel or resources for managing emergencies. But no drug is without potential problems and if women are choosing not to have an active third stage their decision must be respected.
Q. Risk factors for a primary PPH:
ANSWER: Risk factors should be assessed at every visit as they can develop at any time during the pregnancy. However only 33% of women who will have a PPH will have any identifiable risk factors.[51] Those that have been identified are: a woman in her first pregnancy, maternal obesity, a large baby, twin pregnancy, prolonged labour, augmented labour and antepartum haemorrhage.[56] Contrary to popular view high multiparity (a woman who have had 5 or more babies) has not been shown to be a risk factor for primary PPH.[56] Women who have had a manual removal of placenta at caesarean are at increased risk of both primary PPH and infection (which can lead onto secondary PPH).[55]
Q. An active third stage does not include:
ANSWER: Uterine massage is not a part of either 'active' or 'physiological' management of third stage.
True. There is a theory known as the Barker Hypothesis which suggests maternal undernutrition and anaemia are linked to low birthweight which often leads to poor infant health and the development of chronic diseases in adulthood (such as diabetes, renal and cardiovascular disease).[40,65,66] Recent studies suggest that maternal stress hormones may cross the placenta and delay some parts of fetal brain growth, and maternal stress may cause the fetus to release its own stress hormones, also affecting fetal brain growth. One study using data from the Darwin Hospital attributed 28% of low birth weight and 15% of intrauterine growth retardation to maternal malnutrition.[67] Given this increasing body of evidence it would seem logical to intervene at the earliest possible opportunity to try to improve the health and well being of pregnant women, in an attempt to improve the birth weight and health of the neonate.
True. The carbohydrate that is available in most plant foods has a low glycaemic index and may have protected against diabetes. Most of the meat that was available was lean and did not have a high fat content and when there was a high fat content it was shared between many people. Additionally collecting the food usually involved many hours of physical activity.[68]
True.[69]Recent research has found an increased risk of unexplained stillbirth related to high cigarette usage.[70] Additionally there are higher rates of SIDS in women who smoke in pregnancy and babies that are exposed to cigarette smoke.[76] Women in remote areas are known to have higher rates of stillbirths[71] and Indigenous babies are 3.9 times more likely to die of SIDS.[77] Smoking has also been associated with lower rates of breastfeeding.[71] Teenage pregnancy is also a risk factor for low birth weight and is four to five times more common in the Aboriginal population.[72]
True. Smoking in some remote Aboriginal communities is as high as 70% amongst females & 83% amongst males[40] with one study discovering a prevalence of 76% amongst women of childbearing age.[41]
True.[77]
True.[69] A cochrane review regarding smoking cessation in pregnancy showed the above to be true.
False. Smoking cessation is often difficult no matter what approach is taken.
True.[67] Additionally the high rates of hospitalisation of LBW neonates results in: unacceptable social and financial costs to families and the health services; and long term outcomes on the families can be significant.[73] In 2000 in the NT, when looking at hospital admission rates for all infants less than one year of age, Indigenous admissions accounted for 94% of those with pneumonia, 85% with gastroenteritis and 73% of babies small for gestational age.[74]
True.[67]
False. It is more important to work with the family to see if there are any preventable causes of IUGR occurring. Working together to ensure the woman has enough food to eat, is not anaemic and offering support to try and give up smoking are more important than serial monitoring of the condition.
True.[58]
True.[75]Additionally anecdotal evidence suggests that where the strong women workers (SWW) are working closely with the health centre staff the health gains are greater than where they work outside the health system.
If you know that a preterm baby will soon be born make sure the room is warm and turn off the airconditioners. After birth dry the baby and keep the baby warm. The best way to do this is skin to skin contact with the mother, covered in warm blankets ensuring you cover the babies head as it is such a large surface area for losing heat.
The baby may have: breathing problems (this may occur several hours after birth so gives time for transfer), difficulty feeding, or low blood sugars. Observe the baby carefully with ¼ hrly temp, pulse and respirations.
Communication with the mother and her support people, the team your working with, and the referral team are all very important when you have a woman in preterm labour or when a small baby is born. Do not forget to consider cultural influences and remember if they are being transferred she and her baby may be leaving their family for a prolonged time.
When the baby is small you have to pinch your nipples to make them small so the baby can suck. But now if the girls have problems they use a titty bottle (formula feeding via a bottle) yuk, it isn’t good for their baby they should be breast feeding. For those young girls who come back from town with the small babies - if the milk has stopped if you get on the ant pit you will get the milk to start again. (Molly)
When the grandparents have special dreams and the babies are crying all night long till the daybreak, then we know the spirits have been in the room during the night. We get the special ironwood leaves and make the fire. On top of the fire the ironwood makes lots of crackling sounds and we call out to the spirit to tell them 'don't come around here, there are cheeky dogs here and they might catch you'. You have to stand in the smoke, the mother, the father, the whole family and the baby too. But these days they don't do that so much anymore, there are lots of lights and houses to keep the spirits away. (Margaret)
Sometimes the baby is crying a lot during the night for milk and that is because the spirit, the grandmother one, has scraped their eyes with their fingernail. You might need the witchdoctor to take it out. When they get sick, instead of the Balanda way where they go to hospital and get the needle, they need the smoking of the babies, it can help too. (Molly)
If the baby is hot then you can rub them with clay, and you can use the powder from the antpit, and water - that will cool them down. The antpit powder and white clay can help with diarrohoea too.
The following comment was expressed by many of the women we spoke to. They thought it would be good for the health centre staff to be involved in the smoking ceremony for the new babies.
It would make the mothers and the babies healthier and stronger if we did the smoking ceremony. They should do that. (Mary Nancy and Marie)
Clara has had three babies all in Darwin, but when she returned she had the smoking ceremony out bush in Bulukardaru. (Nellie)
The smoking ceremony is used to assist in healing the perineum following childbirth in a similar way that the ray lamp was used in hospitals.
The smoking ceremony helps to stop the bleeding, like when Balanda put the light on for them to make them hot inside. The smoke helps her breasts to be full of milk, and is good for the the feeding. It also stops another baby coming too quickly, till after about a year. The fire does the same thing. It also helps to settle the babies, when they smell the smoke from the heat they can grow up quickly. Some women are still doing this today, not everyone, but some. It is really important for the young girls to know about this story. (Alice)
Preparing the fire for smoking the baby.
This is a ceremony that is for women only. They would make a big hole (as big as a basketball) and they would make a fire, a really big fire. You have to be careful what tree to use as the wrong wood can cause swelling, usually they use a hardwood tree. Then they used an ant pit (any one - the red one or the orange one) and they would break it into small pieces and put it in the fire. When the fire has turned to ash and the ant pit goes really red then it is ready, they get it and put it in the hole. Then they get the lady who had the baby, she holds her baby and they cover her with a mat or a blanket and she squats over the hole. She gets really hot but she has to do a little wee in there and it makes the steam come up really high - and she has the baby with her too. She smells the smoke and when she is finished she gives the baby to someone else and she sits by herself for about 15-20 minutes and then gets out and the heat goes down and cools off. She does it in the night, sometime 3 or 4 nights she might do it. (Nancy, Marie, Margaret, Molly, Theresa, Nellie and Alice)
Maybe two times they might do it, to make their tummies strong, in the first week and then the second week after they come back from hospital. They do it here at their homes after the boys go away, still with the blanket or the sheet over them and having to do a little bit of wee. The steam will come up underneath and they will take the baby in there too. They don’t mind the young girls, they reckon it’s fun. Maningrida is good like that, won’t forget the culture. (Dora)
