Haemorrhage associated with caesarean section in South Africa--be aware.

FORUM The National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD), which since 1998 has produced triennial reports of maternal deaths in South Africa, has identified the increasing rate of haemorrhage during and after caesarean section (CS) as a problem. Obstetric haemorrhage is the third most common cause of maternal death, accounting for 491 of the total 3 959 deaths in 2005-2007, but constitutes one of the most avoidable causes of maternal death, over 80% of cases being thought to be 'clearly avoidable'. Deaths from obstetric haemorrhage are further categorised as follows: abruptio placentae, placenta praevia, uterine atony, retained placenta, uterine rupture, uterine inversion and 'other uterine trauma'. This latter group predominantly comprises severe bleeding during and/or after CS, and is the largest group, accounting for 141 deaths (28.7% of all haemorrhage-related maternal mortality) in 2005-2007. 1 Of concern is that this has increased compared with 2002-2004, when it accounted for 78 deaths (17.6% of haemorrhage mortality). Also, some deaths classified under other causal groups such as uterine atony, abruptio placentae and placenta praevia were due to severe bleeding at CS. This gives a total of 201 maternal deaths during 2005-2007 with severe bleeding at CS (41% of the total deaths from obstetric haemorrhage). During 2005-2007 a total of 477 210 CSs were performed in public sector facilities; 35% at district hospitals, 40% at regional hospitals and 25% at tertiary hospitals, giving a national public sector CS rate of 18.4% (District Health Information Systems data). Therefore, of a total of 477 210 women who underwent CS during the years 2005-2007, 201 died from haemorrhage at CS, giving a CS haemorrhage fatality rate of 0.042% (4.2 deaths from haemorrhage at CS for every 10 000 CSs performed). Further analysis of 103 of these deaths revealed the following: • Of the CSs 92.2% were emergencies, compared with 7.8% elective operations. • Of the CSs 37.9% were performed at district, 41.7% at regional and 20.4% at tertiary hospitals. • The commonest indications for emergency CS were obstructed labour, abruptio placentae, patient with a previous CS presenting in labour, placenta praevia and fetal distress. • In many cases, postoperative bleeding followed intra-operative problems with haemostasis, frequently due to an atonic uterus or uterine tears from a distended lower segment after difficult delivery of an impacted head. In a few cases the bleeding originated from the placental bed, such as in placenta praevia or previous …