Mrs. N.O, a 35-year-old woman, was admitted for cervical ripening and induction of labor in her 38th week of pregnancy following subfertility. She delivered a live male newborn but began bleeding heavily after an episiotomy and repair of a cervical laceration. Attempts to control the bleeding were unsuccessful and she underwent an emergency laparotomy and total abdominal hysterectomy, but died approximately 1 hour after surgery due to primary postpartum hemorrhage from uterine atony.

1. MORTALITY REVIEW
BY
DR IBENEME’S UNIT
18-06-2013

2. Mortality Review
• Mrs N.O, a 35 yr old booked G5 P3 +1 2A an Igbo
christian of the Anglican denomination who is a lecturer
with PhD in education management and planning who
presented on the 1/6/2013(12:10PM) at a GA of 37+3
days for cervical ripening and IOL for unclear indication
following subfertility.
• She booked at GA of 18wks in present pregnancy and
had no problems during her antenatal period.During the
ANC visits her weight ranged from 95kg to 110kg(no
record of FBS/2hrspp).Early USS showed no
abnormality.There was no record of booking
investigations.
• 2005: Twin pregnancy with SVD at 36 weeks(male and
female) with birth weight 2.6kg and 2.5kg respectively.
Both are alive and well.

3. Mortality Review
• 2009: Live female newborn at term by SVD with birth weight
3.6kg. Died at 7 month old following febrile illness.
• 2004: She had a missed abortion at GA 12 weeks with no
post- abortal complications.
• She had no known medical illness.
• No history of drug allergy.
• She was a twin and had no family history of chronic illness.
Married to a 45year old clergyman.
• SUMMARY: Mrs N O, a 35yr old booked G4P2+1 A2 admitted
via the antenatal clinic for cervical ripening and induction of
labour in her 38th week GA following subfertility.
• 0/E- A young woman, afebrile, not pale, anicteric, no pedal
oedema.
c

4. Mortality Review
• CVS: PR- 84bpm, BP- 110/80mmHg
• RESP SYS: chest clinically clear
• ABD: Enlarged, mwr.
• Singleton fetus in longitudinal lie and
cephalic presentation
• Descent 5/5. FHR- 148bpm S/R
• V.E- N/v/v, Cx posterior, soft, not effaced,
admitted tip of finger, station 0-3
• Ass: Multigravida for IOL

5. Mortality Review
• PLAN; Insert 50mcg misoprostol into
posterior vaginal fornix
• Urgent PCV, GXM 2 units of blood
• Close fetomaternal monitoring.
• 5:10pm- About 5 hours later, she entered into active
phase labour ( 4cm cervical dilatation). Fetomaternal
signs were stable and labour was monitored
partographically.
• 7:oopm: Was having moderate uterine contractions.
Fetomaernal signs were stable. Cx was 7cm dilated.
• Augmentation of labour was commenced .

6. Mortality Review
• 9:35pm: She delivered a live male newborn with A/S 6 in1,
7in 5 and 9 in 10mins, birth wt-4.7kg and was transferred to
NICU.
• 3rd stage of labour was managed actively and episiotomy
was sutured .
• 11:30pm: She was noticed to be bleeding vaginally after
episiorrhaphy.
• o/e: she was pale++,
• pulse rate: 120bpm BP- 80/50mmhg
• ABD: Uterus was flabby, extremely atonic & approx 28/40
• VE: blood smeared vulva. Active vaginal bleeding approx 1
litre. Cx – posterolateral cervical tear noted 3cm long

7. Mortality Review
• Ass: Pry PPH 2ry Uterine atony
• PLAN: Urgent PCV, GXM 3 units of blood.
• IVF N/S 1 litre+80 I.U oxytocin
• Pass & retain urethral catheter
• Transfuse blood ASAP
• Insert 1000mcg misoprostol per rectum
• Cervical tear sutured.
• iv hydrocrtisone 200mg stat

8. Mortality Review
• Apply antishock garment
• Book pt for emergency lap if bleeding persists
• Inform theatre, anaesthetist and consultant on call.
• All the above measures were carried out b/w 11:30pm and
12:45am
• However, bleeding continued following repair of cervical
laceration.
• 2 units of blood were loaned and 1st unit was set up by
12:55am. At this time, PR was 130bpm, BP-80/50mmhg.
• 0xygen therapy was commenced and antishock garment
applied

9. Mortality Review
• By 1:50am(02/06/13), PR was barely
recordable, and BP was 50/?mmHg. Patient was
still on intranasal Oxygen. The 2nd unit of blood
was commenced while patient was wheeled to
the theatre.
• 2:40am: Emergency laparatomy and TAH was
commenced which ended by 4:00am.
• Findings: Bulky atonic uterus
• She received 2 units of blood intra op and was
moved to I.C.U after surgery.

10. Mortality Review
• 5:00am- She died after resuscitation in the
I.C.U
• Summary: A 35 yr old booked P4+1 A3 who
had induction and augmentation of labour
that resulted in a live 4.7kg newborn with
episiorrhapphy and repaired cervical
laceration. She had exp laparatomy and TAH
following 1ry PPH due to uterine atony. She
subsequently died 1 hour post op.