Two days after giving birth to her fourth child by caesarean section, a 38-year-old mother was discharged from hospital. Mother and baby were well, and the family was happy to receive a new member. Suddenly however, the mother developed complications, including bleeding, backache and headache, which forced her husband to rush her back to the same hospital.

Three operations were conducted on her in a space of five days. Sadly, she died. The mother, who joined the over 15 others lost to postpartum haemorrhage (PPH) on a daily basis in Uganda is Nuliat Nambaziira, a former journalist with the defunct WBS TV, who died at International Hospital Kampala on Friday, May 4.

“I started losing hope at the second operation when a towel was inserted in her stomach and was to be removed in two days…” narrated Nambaziira’s husband at her burial last weekend.

The widower’s statement, however, threw mourners up-in-arms, wondering how a towel could be inserted in a patient’s stomach, suggesting that it could have caused her death.

Many could not imagine how one could survive with such an object in their body.
Immediately, social media users took to the different platforms, especially Facebook accusing doctors and the hospital of negligence.

Most sympathisers in their desperate search for answers suggested the doctors had forgotten the towel in the mother’s womb, deriving their sentiments from past incidences where doctors have forgotten objects in patients during surgery.

Expert view
However, experts have clarified that what is referred to as a towel is actually a mop-like object used to stop bleeding, especially when the patient is too weak and unstable for surgery (intended to establish the source of the bleeding).

They say this happens when the drugs have also failed to induce sufficient contraction of the uterus to stop bleeding. Dr Sam Ononge, a senior consultant gynaecologist and obstetrician lecturer at Makerere University, says what the public call a towel is a gauze-like medical dressing that is used on wounds. The gauze, which is generally made of cotton is used to control postpartum bleeding after a c-section has been performed.

“The gauze is usually used for temporary control of bleeding if it comes from a local area around the cervix or vagina to exert pressure and stop the bleeding,” Dr Ononge explains. Although used as a temporary measure to control the bleeding as the patient stabilises before another surgery is conducted, Dr Ononge says it can also stop the bleeding permanently, thereby eliminating the need for another operation.

However, Dr Ononge says the mother can still die if the gauze is not inserted on time and the condition is irreversible or when the bleeding has spread to other vital organs such as the liver and kidney. “It is a complex procedure and varies from case to case. Sometimes the doctors can do everything they can, but still the patient dies,” he explains.

How long should it stay in?
Dr Daniel Tumwine, the president of the Association of Obstetricians and Gynaecologists of Uganda (OAGU), says the gauze or mop is usually left for 24 hours and antibiotics given to prevent infections and give the patient time to stabilise for surgery.

“Packing is an extremely effective way to control bleeding. It will stop bleeding in up to 98 per cent cases if done correctly. In most instances, the packs are covered with gel that helps the blood to clot,” Dr Tumwine says.
Although the procedure is helpful, Dr Tumwine further explains that the gauze has potential to cause infection. “If not done correctly, it can conceal bleeding,” Dr Tumwine says.

Statistics from OAGU indicate that last year alone, roughly 6,000 Ugandan women died due to pregnancy complications; either during pregnancy, child birth, or within 42 days after child birth. This also translates to 15 women who succumb to pregnancy complications a day with bleeding after child birth accounting for 25 per cent of all the above deaths, according to Dr Tumwine.

In support of the procedure, Dr Jafhar Nyombi, a gynaecologist at Naguru General Hospital in Kampala, says a mop inserted in the abdomen is meant to exert pressure on poorly controlled bleeding from ‘stubborn’ blood vessels. He warns that prolonged bleeding can lead to failure of blood to clot, which reduces survival chances.

“Abdominal mops are almost always put to control bleeding,” Dr Nyombi stresses.

Bleeding after birth
According to Dr Tumwine, whether bleeding occurs after a vaginal child birth or a C-section, it becomes deadly if the blood loss is more than 500mls in case of a vaginal delivery or 1,000mls for a C-section; which is roughly two to four cupfuls of blood loss respectively.

“In a caesarian section it is expected that one will lose 1,000 to 1,500mls of blood which is usually anticipated and replaced without any issue, he says, adding: “Caesarian section is a relatively safe operation and most complications are not due to the operation itself, but rather complications of the pregnancy that may have led to the surgery in the first place.

For example if the placenta separates too early, this can cause significant bleeding, and therefore will require an emergency C-section which may involve significant blood loss,” Dr Tumwine explains. Like non C-section births, he explains that the most common cause of bleeding after C-section is the inability of the uterus to contract back to size due to its very many blood vessels that supply the unborn child.

“After birth, the contraction of the uterus muscle causes the blood vessels to be squeezed shut and stop any bleeding. For any reason, the uterus is unable to contract (uterine atony), then these vessels do not shut and heavy bleeding occurs,” he says.

Maternal mortality
According to the World Bank, Uganda takes the fourth position after Tanzania, Kenya and Nigeria in nations with the highest maternal deaths in sub-Saharan Africa. Haemorrhage and hypertension were identified by experts as the two major direct causes of global maternal death, during the 18th General Membership Meeting on Reproductive Health Supplies Coalition (RHSC) in the Belgian capital Brussels.

The two are largely as a result of low quality medicine, poor infrastructure and inadequate personnel, which render women in developing countries vulnerable to maternal deaths.

A 2017 Commodities: Measuring Prices, Availability and Affordability Data collection Report - Uganda 2017 indicated among others, the rampant stock out of drugs including Oxytocin used in the treatment of post-partum haemorrhage.
Oxytocin was also commonly available in the public sector but less commonly available in the private and mission sector, according to the report. As such, experts advise mothers to deliver in a health facility where risks can be managed appropriately, although this may not guarantee survival.

Other
Causes According to Dr Daniel Tumwine, the president of the Association of Obstetricians and Gynaecologists of Uganda, the following factors explain the post-partum haemorrhage that can lead to death if not managed well:
• If, for any reason, the uterus is unable to contract (uterine atony), then vessels do not shut and heavy bleeding occurs.
• One is also likely to have uterine atony due to prolonged labour, causing the uterus to be ‘tired or if the uterus was over distended due to either a large baby, multiple babies such as twins or if there in an infection or; if there have been many previous pregnancies. Sometimes the uterus fails to contract for no identifiable reason or risk factor at all.
• Fibroids distort the muscular architecture of the uterus. If the placenta did not completely separate and remains stuck in the uterus wall or fragments remain inside the uterus, then the uterus will be unable to contract and bleeding occurs.
• Sometimes the caesarean delivery incision is not wide enough for the baby to pass through, especially when the baby is very large. As the baby is delivered through the incision, the incision may tear into areas not intended by the surgeon.

lnamagembe@ug.nationmedia.com