Sadly, an estimated 275,000 women die annually as a result of pregnancy and childbirth. In other words, about 800 women lose their lives everyday due to preventable and manageable pregnancy-related complications and the joy that should normally grace the delivery of a newborn is truncated because of the demise of the mother. It’s even more unfortunate that 99% of these maternal mortalities occur in the developing countries of sub-Saharan Africa including Nigeria. But why should a healthy woman die during pregnancy, given that pregnancy in itself is not a disease state? Normally, pregnancy ought to be a safe and satisfying experience for the mother, culminating in the delivery of a healthy baby. However, a number of complications arising before, during or after delivery can alter this experience and spell doom for the woman. Some of these will be addressed in this article.
1. Excessive bleeding before labour
This is referred to as antepartum haemorrhage. It is a leading cause of maternal mortality and is defined as any blood loss from the genital tract of a pregnant woman after 28 weeks of gestation but before the onset of labour. The two major reasons why a pregnant woman can bleed at this stage of pregnancy are low-lying placenta (placenta praevia) and premature separation of a normally situated placenta (abruptio placentae). In placenta praevia, the placenta which normally connects mother and baby occupies the lower segment instead of the fundal (upper) portion of the uterus. Consequently, every time the head of the foetus presses on the low-lying placenta, the woman bleeds. In the second condition, abruptio placentae, the placenta is located where it should be. However, as a result of several risk factors such as trauma to the abdomen (from accidents or physical assault) and smoking, the placenta is prematurely separated from the uterus leading to vaginal bleeding. This may lead to the death of both the foetus and the mother. Note that if a woman spots or bleeds per vaginam at any point during pregnancy, it is enough reason to visit her doctor and be properly evaluated.
2. Excessive bleeding after delivery
While it’s expected that a woman would normally bleed immediately after delivery, any blood loss in excess of 500ml following vaginal delivery should never be taken lightly. It’s referred to as postpartum haemorrhage and is currently the leading reason why many women die from childbirth in developing countries. Postpartum haemorrhage can occur as a result of poorly contracted uterus (uterine atony), retained products of conception such as placenta tissue, tears or lacerations within the genital tract and less often, bleeding disorders in the mother. Unfortunately, most of these cases can be traced to poorly managed labour by unskilled traditional birth attendants many of whom do not recognise their limits and often delay in referring the woman when things get out of hand. Furthermore, it is rather disheartening that less than 46% of deliveries in developing countries like Nigeria are conducted by skilled birth attendants including trained midwives and doctors. Such simple practices as timely administration of oxytocics, rub-up contractions and complete evacuation of retained products can go a long way in stemming the tides of postpartum bleeding.
3. Prolonged obstructed labour
When labour becomes prolonged and obstructed, it simply means it is no longer progressing as expected, necessitating timely intervention. However, many of the traditional birth attendants patronised by some of our women hardly ever recognise the signs and symptoms of poor progress in labour. By the time they do so and refer, it’s often too late. Prolonged obstructed labour is especially common in teenage pregnancies whose pelvic size is rather too small to allow passage of the foetal head, a condition described as cephalopelvic disproportion. Cephalopelvic disproportion is also common among women with contracted pelvis due to previous accidents involving the pelvis and diabetic mothers who end up with very big babies (macrosomia) that cannot pass through their pelvis. Sometimes, it’s just a full bladder that is preventing the baby’s head from descending and as soon as the bladder is emptied, foetal descent progresses normally. Typically, a woman with obstructed labour may have been in the active phase of labour for over 12 hours and is already exhausted, agitated and dehydrated. The urine may be concentrated and the vulva edematous (‘tomato’ vulva). Once a diagnosis of obstructed labour is made, the next option is to prepare the woman for an emergency caesarean section to forestall complications like foetal and/or maternal death, vesicovaginal fistulas and obstetric palsy among others.
It’s also quite common for women to die as a result of infections in the post-delivery period. This is referred to as puerpereal sepsis. It can occur when delivery (vaginal or caesarean) is conducted in unhygienic conditions or when there are infected retained products of conception in the mother. Usually, the woman may start experiencing continuous high-grade fever, abdominal pain with foul-smelling vaginal discharge. If the woman delivered by caesarean section, the surgical site may break down with associated discharge of foul-smelling pus. If aggressive treatment with effective antibiotics is not commenced, the woman may die from complications such as septic shock or disseminated intravascular coagulopathy (DIC).
5. Hypertensive disorders of pregnancy
Preeclampsia-eclampsia is a major cause of death among pregnant women. Some pregnant mothers had been hypertensive before pregnancy while in others, the hypertension is pregnancy-induced i.e they are diagnosed as hypertensive for the first time during pregnancy. Whichever is the case, any pregnant woman with persistently elevated blood pressure needs to have her urine tested for protein. If the urine contains significant quantities of protein, she has pre-eclampsia which must be promptly managed to forestall convulsions as a result of eclampsia, a lethal condition that is associated with significant maternal mortality before, during and after childbirth. Safe antihypertensives and prophylactic magnesium sulphate are usually employed to stop the progression of pre-eclampsia to eclampsia. However, hypertension can only be promptly detected and managed in a pregnant woman who registers for antenatal care at a hospital and keeps her clinic appointments.