Damage control – also for deliveries
Where mothers suffer malnutrition and endemic diseases and have chronic poor antenatal capacity, we should regard delivery complications as a potential trauma both to the mother and the baby.
Like the injured patient, also the mother with uncontrolled post-partum bleeding starts dying when the physiological insult occurs – and she can be saved only if somebody near is able to temporarily control the bleeding.
Like the injured patient, also the “blue baby” starts dying if the birth attendant is not able to provide proper resuscitation.
An epidemic of maternal trauma
In low-income countries in South the maternal mortality rate (MMR) ranges from 0.8% to 4%, as compared to MMR at 0.02% for Europe. The Perinatal mortality rate is 8 – 10 times higher than the MMR. At least ¾ of maternal deaths are avoidable, the main killers being post-partum hemorrhage, eclampsia, and prolonged labour. For decades, humanitarian medical relief organizations have conducted training programs in “safe motherhood” in poor rural societies, but still maternal and perinatal mortality (PMR) remains high in the target areas. From this we should not conclude that training programs are in vain, but rather that intervention designs did not hit the target problem. From 1947 to 1957 countries like Sri Lanka and Malaysia reduced MMR from levels above 1,000 to less than 400/100,000. Their success was mainly due to extensive networking between well-trained rural midwives and the traditional birth attendants (TBA) in the villages.
Delivery Life Support: Breaking the hospitals’ patent on knowledge
Where most mothers deliver at home (80% in Cambodia, 90% in rural Afghanistan) damage control must start at village level. That means that we have to break the hospitals’ traditional privilege of live-saving interventions, and delegate certain life-saving skills to non-doctors at health centers and to lay persons at village level. Since 2005 TCF with Cambodian health authorities are running a prospective clinical study of Delivery Life Support in the mine belts in rural Northwestern Cambodia aiming at a 50% reduction of MMR and PMR. Results are pending.
Samples of Delivery Life Support interventions
At village level: compression of abdominal aorta.
The main reason for post-partum bleeding is atonic uterus that does not contract. Bleeding is reduced by external manual compression of the abdominal aorta at the level of umbilicus. This damage control technique is also useful in retroperitoneal bleeding from pelvic fractures.
At health center: Intra-uterine condom tampon.
Where uterus still does not contract on misoprostol treatment, uterine bleeding is efficiently controlled by a condom tampon of 4 – 500 ml fluid.
At district hospital: B-Lynch suture
This is a compression suture for flaccid and atonic uterus. B-Lynch suture and ligature of uterine artery is trained on animals under anesthesia.