Cause of death: post-partum haemorrhage (PPH) with death in the ambulance during transfer from primary hospital to next level district hospital. | |
Why was there failure to control post-partum bleeding 4 hours after birth? (from last to first circumstance) | |
1. The bleeding was not controlled – post-partum haemorrhage and resuscitation was inadequate. | |
2. The seriousness of the patient’s condition was not recognised or acted upon. | |
3. There was delay in identifying that the laceration to her cervix was severe and continuing to bleed. | |
4. The delivery of the baby was not controlled leading to tears in posterior cervix. | |
5. At the ANC clinic, staff failed to refer a high risk grand multiparous woman for management at a higher level hospital where blood transfusion was available in case of need. | |
Sequence of events: contributory factors: asking why | Interventions required to address the gaps/weaknesses in health system identified in this case |
Why was there inadequate resuscitation prior to transfer, including no blood transfusion? | 1. Training on clinical skills and principles of resuscitation. |
2. Assessment that the training leads to improved practice (clinical audit) in future. | |
3. Enquiry as to why blood was not transfused: if it was not available at the primary hospital, this was a higher indication for early transfer or referral for management. | |
Why was there a delay in detecting PPH? A laceration was sutured post delivery but a deep tear in the posterior cervix was initially missed, then the attempted repair was insufficient with blood loss of at least1 litre over 2 hours. | 1. Supervision of management of high risk patients: need for high level of suspicion in grand multiparous woman who develops post-partum bleeding. |
2. Training in management of lacerations and tears following delivery, especially those with severe bleeding. | |
3. Guideline for management of lacerations in high risk patients by the highest level of surgical skills available in that health facility. | |
Why did the delivery result in lacerations? | 1. Training and assessment of proficiency in controlled delivery of baby by skilled birth attendants. |
Why wasn’t her hypotension more aggressively managed? It dropped from 100/60 to 80/? over two hours or more. She was given 2 doses of oxytocin in 10 IU boluses. There was poor documentation of the patient’s clinical condition and actions taken. | 1. Training in assessment of the seriously ill obstetric patient. |
2. Need for a protocol on the use of oxytocin in such cases since this may have contributed to her hypotension. | |
3. Need for evaluation of clinical skills of the medical and nursing staff involved with provision of refresher training. | |
4. Supervision of record-keeping and documentation, with training on competent documentation of the patient’s vital signs, clinical condition and the actions taken. | |
Why was the woman’s care provided at a primary hospital when she had multiple risk factors? Despite 6 ANC visits her risks were not anticipated. | 1. Need for protocol on referral of grand multiparous woman to a higher level hospital due to risk of PPH. |
2. Training and supervision of risk assessment by ANC staff. | |
Patient characteristics: 36 years old, G5P4, HIV positive on ART. She stopped her oral contraception because she wanted to change to an injectable one which was out of stock. | 1. Need for training in communication skills: she should have been advised to continue with oral contraception or barrier methods until her alternative preference available. |
2. Primary PMTCT of HIV: prevention of unintended pregnancy (abortion not permissible under Botswana law for contraceptive failure despite risk to mother). |