4. MMR/100,000 Risk of Mat.Death
1 in
World 400 75
Developed 21 2500
Developing 440 60
Impoverished 1000 16
----------------------------
Singapore 9 5400
UK 11 4600
Malaysia 44 270
South Africa 70 85
India 440 55
5. AIMS –To Establish
1. The Main Cause of Death
2. Whether Substandard Care present
3. To reduce Maternal Mortality and
Morbidity ratios still further by –
- recommending improved care
- directing future research and
audit
4. To illuminate Success where results have
improved.
6. Maternal Deaths
Direct Death – due to obstetric complications or obstetric
problems in management occurring in pregnancy or within 42
days of the end of pregnancy
Indirect Death – resulting from pre-existing disease or
disease that developed during or was aggravated by
pregnancy but was not due to direct obstetric causes
Late Death – due to Direct or Indirect causes but occurring
between 6 weeks and a year after pregnancy
Coincidental/Fortuitous Death – due to unrelated
causes occurring in pregnancy or in the puerperium
The ratio used in the UK is the no. of deaths/100,000
maternities ie.mothers delivered of live or still-born babes
after 24/52
In Malaysia – the denominator used is the number of babies
born
9. Maternal Death by Citizenship
Citizen 79.5%
Non citizen 17%
Unknown 3.6%
MMRs by Ethnic Groups
Race % MMR
Malay 48 39.5
Chinese 9.5 26.6
Indian 6.6 43.9
Ethnic/Mixed 17 69.3
Others 16.5 60.2
MMRs from PPH v. Ethnic groups
Malay - 5.16 Indian - 4.61
Chinese - 3.87 Others - 129.5
10. Other Features of Interest
MMR/100,000
Age – 25-29 (21%) 25.5
40-44 (13%) 136.7
45-49 (4%) 277.5
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Parity- Prims (21%) 28
Multips (60%) 42
Grand Multips (20%) 71
------------------------------
Place of Birth
State Hospital (63%) 37
Private Hospital(9%) 20.2
Home (24%) 75.7
11. Substandard Care
Remediable Clinical Factors - 53%
-inadequate/inappropriate/delayed treatment
-failure to inform seniors
-inappropriate delegation to juniors
Contributory non clinical factors
Facility/Personnel factors - 20%
-absence of O&G Specialist
-inadequate staff experience
-remoteness/inaccessibility
-Unavailable blood
Patient factors - 30%
-non compliance to advice,admission and/or treatment
12. Haemorrhage
(Substandard Care - 71%)
Constant vigilance is required : Check Hb ante natally
Identify the mothers at high risk for PPH. Previous PPH is the
best predictor
Each unit must have clear written Guidelines and regular drills
for the management of PPH and massive haemorrhage
Have adequate IV access and at least 6 units of blood
Senior staff- Obstetrician and Anaesthetist - should be
informed early in an emergency situation – and should come in
Utero-tonics and bimanual compression are basic in
Management
If surgery is required consider a Brace type suture early on
before the more complex procedures, int. iliac ligation or
hysterectomy.If concerned call a colleague for assistance
Consider UAE if appropriate and available
13. Haemorrhage
Senior staff should be in theatre for elective surgery where
there is a high risk of haemorrhage. Beware placenta praevia
and the scarred uterus.Difficult cases must not be delegated
Particularly in Malaysia – Midwifes to be trained in venous
access
- Retrieval teams to be made available
- If distance is a problem at risk mothers
to stay in pre- delivery centres or Hospital to await delivery
- Remember the importance of Family
Planning in the over 40s and in the grand- multipara
14. Pulmonary Thromboembolism
Substandard Care – 57%
Pulmonary embolism can occur early in pregnancy
- and after Vaginal Delivery
Know the at-risk patients – BMI 30 ; past or family
history of VTE etc.
Prophylaxis for all at Caesarean Section
Display Guidelines throughout the Unit
Use thrombo-prophylaxis more widely
All must think thrombo-embolism
If clinically suspected - treat first then investigate
Investigate properly!
15. Heart Disease in Pregnancy
Substandard Care –12%
The joint most common cause of Maternal Death in
the UK –
The fourth most common cause in Malaysia
Women may minimize or deny symptoms
All-important to diagnose before pregnancy or at
least at Booking Clinic – can be notoriously difficult
Counseling and Family Planning should be
emphasized
Women with pulm.hypertension are at great risk
Multidisciplinary care is required ; team-work is all
important
Balloon or surgical valvotomy becomes indicated if
Mitral Stenosis is not responding to medical
treatment
16. Hypertensive Disease of Pregnancy
Substandard Care - 80%
Watch mod. to severe PET closely
Watch multiple pregnancy closely
The pregnant patient with headache and epigastric pain – requires BP
and proteinuria check as a minimum check – all health-care providers
should be made aware of this
Beware automated BP readings alone
Treat hypertensive crises effectively – hydralazine; labetalol
MgSO4 is anticonvulsant of choice to prevent fits; Valium to abort fits
Run the patient “dry” : Beware fluid -overload
Have clear written Guide lines and regular drills for Management of
severe/fulminating pre-ecl/eclampsia
17. Genital Tract Sepsis
Substandard Care – 50%
Beware the insidious onset of low grade pyrexia
Careful assessment required of P.R.O.M. with
fever / tachycardia
With P.R.O.M. keep vaginal (aseptic)
assessments to the minimum
Use prophylactic antibiotics for CS
Where pyrexial - take repeated specimens
including blood culture for bacteriology
18. Ectopic Pregnancy
Substandard Care 65%
All Health-care workers - beware atypical
presentations
Urine dipstick testing for bHCG
Laporoscopic surgery only if competent
Don’t delegate difficult cases
Call for senior help in good time
Avoid unnecessary/unsupervised late night
operating – if experienced staff not available
Beware Cx Ectopics
19. Obstetric Trauma - CEMM
Malaysia 19995/96
Remediable clinical factors in 70%
Prstaglandins and Oxytocics must be used
only with extreme caution in the
grandmultiperous mother or in the presence
of a previous scar
Mismanagement of the 3rd
stage contributes
significantly to uterine inversion. All birth
attendants must know correct management
Uterine “massage” during labour by untrained
birth attendants should be banned
Beware disproportion in the patient with a
scarred uterus
