Audit of Perinatal

Mortality and
Acute Maternal
Morbidity in
Northern KwaZulu
Natal

A Research Report
 AUDIT OF PERINATAL MORTALITY AND
ACUTE MATERNAL MORBIDITY IN
NORTHERN KWAZULU NATAL
Using the Perinatal Problem Identification Program

Researched by: Dr M.Gandhi, Dr A. Barnard, Dr P. West, Dr

C.Siderfin, Dr T.Welz, Dr A. Martineau, Dr A.
Dalrymple.
Written by: Dr. Meena Gandhi

AVOIDABLE PNMRs

35
30
Cumulative PMNR

25
Manguzi
20 Mosvold
15 Mseleni

10 Bethesda

5
0
Sep Oct Nov Dec Jan Feb Mar Apr May
Month

Funded and published by the Health Systems Trust

401 Maritime House
Salmon Grove, Victoria Embankment
Durban 4001, South Africa

Tel: +27 31 3072954

Fax: +27 31 3040775
Email: hst@healthlink.org.za
Website: http://www.hst.org.za

ISBN No. 1-919743-43-X

July 1999

1
 Acknowledgements:

Professor R.C. Pattinson, Dr G. Mantel, Dr D. Wilkinson, Paul

Deverill, Farhana Khan, Bongiwe Shongwe

Report editing: Fatima Suleman

2
 TABLE OF CONTENTS

INTRODUCTION......................................................................................................................4
STUDY AREA............................................................................................................................4
THE OBJECTIVES OF THE STUDY ........................................................................................5
PERINATAL MORTALITY: Setting Up and Method..................................................................5
PERINATAL MORTALITY: Criteria..........................................................................................6
PERINATAL MORTALITY: Feedback......................................................................................6
PERINATAL MORTALITY: Workshops ...................................................................................7
PERINATAL PROBLEM IDENTIFICATION PROGRAM (PPIP) ...........................................7
PPIP WINDOWS (PPIPWIN) ...................................................................................................8
NEAR MISSES: Setting up and Method......................................................................................9
NEAR MISSES: Definitions.........................................................................................................9
WHAT ARE YOU LEFT WITH? .............................................................................................10
PERINATAL MORTALITY: Results ........................................................................................10
PERINATAL MORTALITY: Discussion...................................................................................16
NEAR MISSES: Results............................................................................................................20
NEAR MISSES: Discussion.......................................................................................................20
SUMMARY AND RECOMMENDATIONS ...........................................................................23
Attachment 1 .............................................................................................................................24
Attachment 2 .............................................................................................................................25
Attachment 3 .............................................................................................................................26
Attachment 4 .............................................................................................................................30
Attachment 5 .............................................................................................................................31

3
 INTRODUCTION

Perinatal mortality rates have long been used as an indicator of the standard of maternal and
newborn care. Their importance in this regard is undisputed. Rates can be as low as 9/1000 births
in some developed countries but are considerably higher in the developing world. Information from
rural South Africa is limited and detailed analysis is made difficult by problems of isolation, poor
communications, staff shortages and often, incomplete record keeping.

From September 1998, a system of data collection and analysis on perinatal deaths and their causes
has been set up in Northern KwaZulu-Natal, which has the capacity to be both simple and
sustainable. A good network of communication between individuals at the collaborating hospitals
was essential for this process. Data collation was aided by the use of the Perinatal Problem
Identification Program (PPIP), developed by the University of Pretoria. The research has led to
further information about the causes of perinatal deaths, ways of preventing these deaths and a
reduction in the perinatal mortality rate (PNMR), as well as increasing the discussion and interaction
between hospitals in the area on maternal and neonatal management.

Acute maternal morbidity (maternal near misses) is a somewhat newer concept. The maternal
mortality rate in South Africa is thankfully low. However, a number of women become life
threateningly ill during pregnancy or in the puerperium such that, without medical intervention, they
would certainly have died. Analysis of these “near misses” and how they might have been avoided
provides further useful information on the standard of maternal care and problems that might be
averted in future.

STUDY AREA

The area of the study is the Jozini Health District, an isolated rural area making up the magisterial
districts of Ubombo and Ingwavuma. Figure 1 shows a map of the area.

The estimated population was 290,000 in

1998. The area is served by four primary
hospitals: Bethesda, Manguzi, Mosvold and
Mseleni. Each hospital has 200 - 280 beds and
runs 8 - 10 residential clinics and 15 - 20
mobile clinic points. As with most primary
hospitals, the Medical Officers (MOs) at each
hospital are generalists but may have an interest
in one particular field of medicine.

One or at most, two Medical Officers usually

run a hospital ward. The hospitals vary in their
isolation with Bethesda and Manguzi being
nearest to tar roads and Mseleni and Mosvold

4
being relatively inaccessible. The majority of roads in the area are gravel. The maternity
departments each deliver roughly 1800 babies per year. The departments differ in their facilities -
Manguzi and Mseleni have new departments, built in the early 1990s - and these two hospitals were
already carrying out some form of perinatal audit, Manguzi’s being quite detailed along similar lines
to this research. A Waiting Mothers Area is thought to be essential in isolated rural areas, where
high risk women can await labour - only Mseleni and Mosvold hospitals have buildings such as
these that are operational.

THE OBJECTIVES OF THE STUDY

v To calculate the perinatal mortality rate in the Jozini Health District

v To identify ways of decreasing this rate
v To introduce interventions to do so.

PERINATAL MORTALITY: Setting Up and Method

The medical officer at Bethesda hospital who worked part time for the first four months of this
process carried out the coordination of the data collection. In retrospect, with the newer computer
Programs and advice on how to begin the process, the setting up of such a collaborative research
audit between a number of hospitals need not take so much time - perhaps a month would suffice.

The method involved investigating each death individually as soon as possible after the event and
identifying a cause and any avoidable factors. By studying the avoidable factors, one can then
suggest and introduce interventions to decrease their occurrence.

The first step, right at the start, was to meet with all four of the hospital superintendents and explain
how the audit would be carried out and, through them, identify a suitable medical officer to collect
data at each hospital. The doctors in the best position to do this were those running the maternity
ward but in some cases another doctor with an interest in obstetrics was chosen and would visit the
ward regularly to gain information. It was felt that doctors would be best for the collection of data,
rather than nurses, as they tend to look at cases more critically - it may, however, be possible to use
Advanced Midwives for this.

Meetings were then held with the maternity departments to explain the research and ask that the
MO always be informed of any perinatal death. Once the aims of the study were explained, the
response was always positive.

All the MOs took part in the research voluntarily while working full time and all four hospitals have
now made it the duty of the maternity ward doctor to continue with the audit and run perinatal
mortality meetings as part of their daily work. Most have found that it adds a great deal to their
understanding of the issues involved in improving perinatal care and, once set up, the data collection
does not take a great deal of extra time.

5
The advantage of an audit such as this is that data is collected as soon as possible after the perinatal
death occurs, allowing a detailed look at the notes and also an interview with the mother if relevant.
This provides more information than a retrospective type of audit. A simple questionnaire
(Attachment 1) was formulated for the use of the medical officer when investigating a death. With
each case, a cause was identified and any contributory factors that could have been avoided and
thus would have prevented the death from occurring. The causes and avoidable factors are, to some
extent, subjective but where there was doubt, the case was discussed with other MOs and
consensus reached. Data from the questionnaires was entered onto the Perinatal Problem
Identification Program, which was installed at all four hospitals (See later section, page 7).

PERINATAL MORTALITY: Criteria

A perinatal death was defined as any death occurring from 28 weeks gestation up to the first week
of life. Where the gestation was not known, any baby over 1000g in weight was included. A cut
off of 500g was not used as none of the hospitals have the facilities to maintain such a low birth
weight/premature baby so these mortalities could not reasonably be classed as avoidable and
therefore there is limited value in analyzing them.

A major discussion point concerning criteria was the issue of babies born before their arrival at
hospital (BBAs). The actual numbers of BBAs arriving at hospital were only being recorded
formally at Manguzi and therefore the question was whether the deaths of babies who were BBAs
but died in hospital should be included in the data entered onto PPIP. After much discussion, it was
decided that they should not. Firstly, whilst every effort was made, there may have been errors in
the total numbers of BBAs and it would therefore be inaccurate to include the BBA mortalities with
the other deaths. Secondly, it was found that the numbers of BBAs differed between hospitals and
this in itself was important, so it was felt that they would provide more information if kept separate
and analyzed over a long period.

PERINATAL MORTALITY: Feedback

An important part of audit is regular feedback of results and constructive plans for improvements.
At the start of the research, Manguzi was holding monthly perinatal mortality meetings and Mseleni
three monthly. The other two hospitals had no regular arrangement. During the study period, the
coordinating MO established monthly perinatal mortality meetings at all the hospitals, again. The
meetings included midwives and doctors but their form varied from more formal presentations to
informal discussions. The MO presented PPIP data the midwives collected general statistics for the
month.

Interesting cases were then examined in more detail. After the discussion of these cases, suitable
interventions were also decided on e.g. teaching sessions, motivations for equipment etc. It was
found easiest to make the meetings at a regular time e.g. the first Thursday of every month, so that
they became part of the hospital routine. There were some initial objections that monthly meetings
were too frequent however, this was not found to be the case in practice.

6
 PERINATAL MORTALITY: Workshops

Four workshops were carried out during the study period. These were on an informal basis, usually
in a scenic area near one of the hospitals and involved all coordinating MOs and often MOs who
would be taking over the Maternity ward in the near future. These workshops were a key to the
continuation of the research as problems could be discussed and the relevance of the data becomes
more apparent when looked at as a whole. Given the large distances between hospitals, the
workshops allowed easy transfer of data to the central coordinator. It also allowed the MOs to get
to know each other! Suggestions from the workshops helped the study to evolve, be workable and
sustainable.

Six months worth of data was also presented at a Priorities in Perinatal Care Conference in Pretoria
in March 1999 and one further workshop was held, organized by the hospitals and the Jozini
Department of Health, where results were presented. This final meeting had some of the
superintendents, doctors, midwives and community nurses from all four hospitals present and
general aspects of maternal and neonatal care were discussed as well as the issue of statistics
collection. Unfortunately, there was no actual representation from the Department of Health.

PERINATAL PROBLEM IDENTIFICATION PROGRAM (PPIP)

This computer Program was developed by Professor RC Pattinson at the University of Pretoria and,
until March 1999, only an MS-DOS version was available. The discs for installation of the Program
were easily obtained from the University of Pretoria1, however installation required a fair amount of
computer knowledge and was not entirely straightforward. Extra help with this was needed at three
out of the four hospitals but it is now running well throughout.

Once installed, the Program was simple to use. General information was entered on each perinatal
death (Attachment 2) and then codes were entered for the primary obstetric cause of death, the final
cause of neonatal death and any avoidable factors (Attachment 2). The avoidable factors were
graded as 1 - possibly caused the death and 2 - probably caused the death. The list of codes had
to be printed out and referred to each time information was added, a problem that has been
eliminated with the new Windows version of PPIP, which is discussed later. It was necessary to
also include information on total numbers of deliveries and weights of babies for each month.

Once monthly information was complete, the computer was able to work out all the cumulative
perinatal mortality statistics. It calculated the avoidable perinatal mortality rates (PNMR) and
identified which were the common avoidable factors contributing to the deaths. It formulated easy
to understand graphs of various factors which could be printed out.

Clinic, community deaths and BBAs were not considered in the DOS version of PPIP so these

1
Professor RC Pattinson, Kalafong Hospital, Department of Obstetrics & Gynaecology, Private Bag X396,
Pretoria, 0001, South Africa. Tel: (012) 373 8041; Fax: (012) 373 9031; E mail: rcpattin@kalafong.up.ac.za

7
were collected and collated separately, although, in reality, there is no accurate data on the number
of community deliveries.

There was a Level 2 PPIP DOS where information from the different hospitals could be
amalgamated, however we were unable to work this Program successfully so data was combined
manually.

The PPIP calculates an figure known as the Perinatal Care Index (PCI) which is the percentage of
low birth weight (LBW) babies over the overall perinatal mortality rate. If the index is high, it shows
that the PNMR is low when compared to the number of LBW babies and has been extrapolated to
mean a good level of care, as one would expect a hospital with many LBW babies to have a high
PNMR, and visa versa. This was also a debated topic and not everyone agreed that the
straightforward connection of low birth weight, PNMR and level of care was correct. It remains,
however, an interesting parameter to examine.

As sited, there were a few minor problems but the Program was certainly extremely valuable and
aided greatly with data collation. It contributes to the sustainability of audits such as these. The
Windows version of PPIP has the potential to eliminate most of the above problems.

PPIP WINDOWS (PPIPWIN)

When PPIP Windows was released, the time period for this study was drawing to a close, therefore
data collection was completed using the DOS Program. On examination, PPIPWIN is easy to
install, using three floppy discs provided by the University of Pretoria and requiring no prior
computer skills. Entering data is self-explanatory. The codes for causes of death and avoidable
factors can be brought up on screen while data is being entered, making this process much simpler.
Collating data from different hospitals has not yet been tried but appears to be straightforward.
There have been difficulties producing graphs from the Program and these remain to be solved. The
problem of BBAs has still not been adequately tackled - there is a space for adding the number of
BBAs, but no way of analyzing the outcome of those BBAs and no indication of whether those that
subsequently die should be included in the overall PPIP statistics. There is also no space for
entering numbers of clinic deliveries.

When the graphics are working fully, the PPIPWIN is an improvement from the DOS version of
PPIP and will be installed at all four hospitals with a view to continuing data collection for the
coming years on this Program. There is a disc being produced to aid transfer of data from PPIP
DOS to PPIPWIN - this is not yet available.

8
 NEAR MISSES: Setting up and Method

The concept of ‘near misses’ has thus far only been looked at in urban settings at larger secondary
and tertiary hospitals. A near miss describes a patient with an acute organ system dysfunction
which, if not treated appropriately, could result in death. This definition is applied to women at any
time in their pregnancy from conception to six weeks post-partum. The advantage of studying near
misses is that they simply are greater in number than maternal deaths. The woman lives to be
interviewed post event thus giving more information on avoidable factors. The comparison of causes
of near misses to causes of maternal deaths is also of interest. Indeed, in urban studies, the pattern
of maternal near misses has differed to the pattern of maternal deaths.

Once again, the coordinating MO for each hospital collected information on maternal near misses
during this study. The aims were similar to perinatal deaths i.e. to identify the causes of the near
misses and to see how many of these were avoidable and how they could have been avoided. Data
collection involved not only regular checks on Maternity ward but also on Female and Malaria
wards. Patients in this situation were invariably in hospital for a longer period of time and, often,
most of the MOs would get to know about the case. A questionnaire developed by the University
of Pretoria was used as guideline for data collection (Attachment 3). Collation of data was done
manually.

NEAR MISSES: Definitions

A set of definitions of near misses was already in place at the University of Pretoria (Attachment 4)-
these looked precisely at what was meant by organ dysfunction. Within a week of beginning the
study in Northern KwaZulu-Natal, it became obvious that these criteria needed to be modified to
suit a primary, rural setting. The urban criteria often did not apply in this study since many patients
included as maternal near misses in these definitions would certainly have been maternal deaths in
the study sample population.

For example, cerebral dysfunction was defined as ‘coma lasting more than 12 hours’ - in our setting
any coma carried a very poor prognosis given no ITU facilities and the large distance from the
referral hospital.

Some urban criteria simply did not apply from a ‘facility’ point of view e.g. vascular dysfunction was
defined as ‘hypovolaemia requiring 5 or more units whole blood or packed cells for resuscitation’.
In rural setting this meant that blood was a scarce commodity and patients were rarely given more
than three units whatever their problem; the definition of respiratory dysfunction included a value for
arterial blood gases which could not be carried out in the primary, rural hospitals.

Thus, at the first workshop, the coordinating MOs devised a new set of definitions for near misses in
a primary, rural hospital setting (Attachment 5). It remains open for discussion as to whether these
criteria are the correct ones and certainly a few changes have already been made and will be
discussed later.

9
 WHAT ARE YOU LEFT WITH?

With the above audits in place, one is left with simple monitoring systems of maternal and perinatal
care that cost next to nothing and take up very little of the data collector’s time. The systems can be
analyzed over many years and information gained on where improvements may be needed. The
analysis can collate information for a region but can also allow comparative analysis between
hospitals in similar settings.

PERINATAL MORTALITY: Results

Data has been collected for the period 1st September 1998 to 31st May 1999. The total number of
hospital births for the nine-month period was 4,810. The total number of births occurring in the
residential clinics was 918, with most clinic deliveries occurring at Manguzi. The total number of
births within the health system in Jozini Health District was therefore 5,728 (See Figure 2).

TOTAL DELIVERIES 1 SEP 98 - 31 MAY 99: 4,810

Mosvold 1253 Manguzi 1236

Bethesda
1223 Mseleni 1098

CLINIC DELIVERIES
1 SEP 98 - 31 MAY 99: 918

Mosvold 194
Manguzi 317

16% of total
deliveries in the
Bethesda 234 area occur in
residential
Mseleni 173
clinics

Figure 2: Hospital and Clinic Deliveries

10
There were 151 hospital perinatal deaths and 16 clinic perinatal deaths, using the criteria described
above. This gave a total hospital PNMR for the area of 31.4/1000 births and a clinic PNMR of
17.4/1000 births. The overall PNMR for the Jozini Health District was therefore calculated to be
29.2/1000 births. The hospital PNMR was highest at Bethesda and lowest at Mosvold (See Figure
3). The total hospital PNMR, calculated after four months Data was collected i.e. from 1st
September 1998 to 31st December 1998, was found to be 35.4/1000 births. Of the deaths, 43.0%
were neonatal deaths, 33.1% were macerated stillbirths and 23.8% were fresh stillbirths. 20 babies
were born at home and died in hospital (BBAs) and the numbers varied at each hospital (Bethesda
7, Manguzi 7, Mosvold 2, and Mseleni 4). As mentioned above, these were not included in the
PPIP analysis.

Mosvold (24)
HOSPITAL PMNR
Manguzi (32.5)

Overall
Hospital
PMNR:
31.4/1000

Bethesda (41) Mseleni (24.7)

TOTAL PMNR

Mosvold (22.8) Manguzi (29.6)

Overall
PNMR for
area:
29.2/1000

Bethesda (38.4)
16 perinatal deaths were in Mseleni (25.2)

residential clinics.

Figure 3: Hospital and Total PNMR for Jozini Health District, September 1998 to May 1999

11
Table 1 shows the numbers of low birth weight babies, the Low Birth Weight PNMR and the
Perinatal Care Index (PCI) for each hospital as well as the PCI that was calculated after four
months of research. The total LBW PNMR for the area was 158.4/1000 births, considerably
higher than the total PNMR.

Table 1 . Numbers of LBW babies, LBW PNMR and PCI for each hospital 1 st September 1998 to 31 st May 1999

Weight Bethesda Manguzi Mosvold Mseleni

<1500g 17 13 12 24

1500-2000g 22 30 23 23

2000-2500g 70 72 88 67

TOTAL 109 115 123 114

LBW PNMR 174.3/1000 182.6/1000 130.1/1000 149.1/1000

PCI (Sep 98- 0.22 0.27 0.38 0.42

May99)

PCI (Sep98-Dec98) 0.19 0.22 0.28 0.46

Most LBW babies were delivered at Mosvold hospital, although most very LBW babies (those
fewer than 1500g) were delivered at Mseleni and Bethesda. The PCI was highest at Mseleni,
showing a low PNMR in relation to the high proportion of LBW babies. This figure was lowest at
Bethesda. When compared to the PCI values calculated at the end of December, there has been an
improvement in three hospitals and a decrease in one where the PCI was already very high.

The primary obstetric causes of death are shown in Figure 4. 27.8% of deaths were due to
asphyxia and almost 22% of deaths were unexplained intrauterine stillbirths, macerated or fresh.
Spontaneous preterm labour, infections, fetal abnormality and antepartum haemorrhage, usually
from abruptio placenta, were the other common causes identified. At Bethesda and Manguzi,
asphyxia was the cause of death in over a third of cases - this figure was lower in the other two
hospitals. Intrauterine deaths formed the largest proportion of causes at Mosvold and Mseleni.
None of the deaths were attributed to infection at Mseleni, whereas this was common elsewhere.
Fetal abnormalities made up 18.5% of Mseleni’s mortalities, a cause that ranged from 3% to 6% at
the other hospitals. Maternal disease, hypertension and related problems, trauma etc. were much
less common causes of perinatal mortality and only two deaths in total were attributed to syphilis.

12
 Intrapartum Others 15.9 %
Asphyxia 27.8 % APH 7.9%
Congenital
Abnormalities
7.3%

Unexplained SBs Preterm Labour

21.9% 10.6%
Infection 8.6%

Figure 4: Primary Obstetric Cause of Death

The final causes of neonatal death are shown in Figure 5. For neonates, nearly 51% of deaths were
due to asphyxia and birth trauma - this figure was a constant in all the hospitals. Prematurity made
up 15.4% of causes and infection 13.8%. As above, infection did not feature in any of the neonatal
deaths at Mseleni but congenital abnormalities made up 28.6% of their deaths

Congenital
Abnormalities
10.8%

Infection 13.8%

Asphyxia & Birth

Trauma 50.8% Others 9.2%

Prematurity 15.4%

Figure 5: Final Causes of Neonatal Death

The commonest avoidable factors are tabulated in Table 2. The number of times each factor
appeared is given as a percentage of the total number of occurrences of avoidable factors. Labour
management problems were the commonest avoidable factors given, accounting for almost 23% of
the total. These included fetal distress not being detected, incorrect use or no use of the partogram,
inappropriate management of 2nd stage etc. Antenatal problems were the next commonest
avoidable factors sited - these included a poor obstetric history not being noted, an incomplete
antenatal clinic examination, multiple pregnancies and breeches not being diagnosed etc.

13
Table 2. Avoidable factors as percentage of number of occurrences for all four hospitals and overall.

AVOIDABLE FACTORS Bethesda (%) Manguzi (%) Mosvold (%) Mseleni (%) Total(%)

Medical Personnel Problems

Labour management e.g. fetal 19.4 44.0 9.5 26.1 22.9

distress not detected, partogram not
used etc.

Antenatal management e.g. 19.4 14.7 14.3 8.7 15.7

incomplete examination, multiple
pregnancy not diagnosed etc.

Neonatal management e.g. 7.5 8.8 4.8 0.0 6.0

inadequate resuscitation

Patient Problems

Inappropriate response to 11.9 11.8 4.8 26.1 12.0

decreased fetal
movements/ROM/APH

Delay in seeking medical attention 10.4 5.9 11.9 4.3 9.0

during labour

Unbooked 3.0 5.9 4.8 0.0 3.6

Booked late and/or infrequent ANC 3.0 5.9 9.5 6.0

visits

Administrative Problems

Staff insufficiently trained to 7.5 0.0 23.8 8.7 10.2

manage patient or low staffing
levels

Inadequate facilities 6.0 0.0 11.9 8.7 6.6

Lack of Transport 7.5 2.9 4.8 4.3 5.4

(patient/clinic/hospital)

12% of the occurrences of avoidable factors were due to an inappropriate response by the mother
to certain things, mainly decreased fetal movements, and rupture of membranes and antepartum
haemorrhage. On interview in these cases, often the mothers simply did not know what they should
do when these things occurred. When the fetal movements went down, the mothers often said that
they thought the baby was ‘lazy’, without realizing that, for whatever reason, the baby was actually
in distress. A number of women had obtained the wrong advice from family members or had
consulted a traditional healer first.

6% of all the mothers who had suffered perinatal deaths were syphilis positive, however 41% of
syphilis results at Mosvold were not available so this percentage was not reliable. Only twice was
syphilis noted as the avoidable factor in the death.

14
15
 AVOIDABLE PNMRs

35

30
Cumulative PMNR
25
Manguzi
20 Msovold
15 Mseleni
Bethesda
10

0
Sep Oct Nov Dec Jan Feb Mar Apr May
Month

Figure 6: Avoidable PNMRs

Finally, Figure 6 shows a graph of avoidable PMNR plotted against time for the four hospitals.

PERINATAL MORTALITY: Discussion

The research has shown that nearly 6000 deliveries were carried out in the Jozini Health District
over a nine month period, roughly 1000 of those occurring in residential clinics.

The four hospitals differ widely in the number of clinic deliveries, the most being at Manguzi, who
have made a policy of encouraging clinic deliveries of low risk women. The two hospitals that
possess working Waiting Mother’s Homes do the fewest clinic deliveries even though they are by
far the most isolated of the four.

The number of home deliveries is not known and remains a crucial question. Previous studies in the
Mosvold area in the 1980s suggested this number was as high as 20% of the total deliveries in the
area. If the proportion is indeed this high, we still do not know why. Lack of transport is not the
commonest avoidable factor sited but this begs the question of how many women do not even try to
get to hospital, knowing the difficulties they will face getting there. How many are scared to come
into hospital, for whatever reason and how many simply believe that the best place to deliver a baby
is at home?

The overall PNMR for the area was found to be 29.2/1000, with a hospital PNMR of 31.4/1000.
Jon Larsen2, whose manual of obstetrics is regarded as something of a gold standard for rural

Obstetrics in Peripheral Hospitals - a South African Manual for Doctors and Midwives by Jon Larsen, 1996

16
practice, recommends that the PNMR in a rural hospital should ideally be 25/1000 or less. This has
certainly been achieved by some of the hospitals in the area but there is room for improvement/
reassessment at others.

Looking at causes of death, asphyxia is still the commonest, both as a primary and final cause.
Some would argue that almost all cases of asphyxia are preventable and indeed in the developed
world, in ‘ideal’ settings, perinatal deaths from asphyxia are extremely rare. As it is here, half of the
neonatal deaths are caused by asphyxia.

In this study, nearly 22% of deaths were unexplained stillbirths, fresh or macerated. This is a large
proportion and the reasons why these babies die remains unclear. The HIV rate in the antenatal
population of this area is 35-40% and the influence of this is not known, although, during
discussions, obstetricians at King Edward Hospital in Durban remarked that they have not found
that a particularly large proportion of their stillbirths were from HIV positive mothers.

As a primary obstetric cause of death, obvious infection contributed to 8.6%, however the level of
asymptomatic STDs is almost definitely much higher than this and therefore chorioamnionitis may
contribute to the stillbirths. Whatever the reason for the fetal distress, the study has shown that a
large number of women are totally unaware of the signs that would alert them that all is not well and
that they should seek medical help e.g. decreased fetal movements.

10.6% of primary obstetric causes and 15.4% of final neonatal causes of death were from
premature labour. Once again, infection can contribute to this, especially malaria. As the audit
continues, a pattern of increasing frequency of premature labour over the malaria season should
emerge.

Avoidable factors

A total of 45% of all the avoidable factors sited were management problems, in hospital, at
antenatal clinic or after the baby was born. The labour management problems made up the bulk
and most were basic mistakes. The conclusion can thus be drawn that, even with numerous
environmental and educational difficulties, the majority of deaths are actually caused by errors in
hospital after the patient has arrived.

Thirty percent of avoidable factors were sited as patient-related. This emphasizes the need for
good patient education on topics such as when to book, at what time to seek medical attention
during labour, when to await labour in hospital and what danger signs to look for during pregnancy.
One ideal time to do this is while the mothers are waiting to be seen at ANC but another underused
resource are the community health workers (nompilos) who visit most women in the community.
Perhaps traditional healers need to be incorporated (one of the Bethesda patients was a primip who
spent two days in obstructed labour with a traditional healer before attending hospital. On arrival,
her uterus was gangrenous and she required a hysterectomy) or a system of traditional birth
attendants be introduced. To be fair to the patients, a number of them delayed seeking medical
attention during labour because it was the middle of the night when their labour started and it would

17
simply have taken hours to come to hospital or a clinic.

Comparisons

As mentioned above, a very useful aspect of the research has been the ability to compare hospitals
that outwardly may seem almost identical. To illustrate this, a comparison of the hospital with the
lowest PCI, Bethesda, and the hospital with the highest PCI, Mseleni, follows. The points that may
have contributed to this difference are:

Expertise Mseleni has both an obstetrician and a paediatrician. Both have been working at
the hospital long term. i.e. over five years. Perhaps more importantly, Mseleni has a
constant set of eight midwives that stay on maternity ward and rotate through night
shifts.

Bethesda has a relatively fast turnover of doctors, often only running the maternity
ward for six months. The staffing levels on the ward are extremely low with only
four constant midwives. Many problems occur at night where inexperienced nurses,
who may not have done midwifery for years, are working alone.

Facilities Mseleni has a new, large maternity unit, housing seventy women. It is fully equipped
with six to eight incubators and individual labour rooms, each with a resuscitaire. It
is a large department in relation to the number of patients seen.
Bethesda has an old, small maternity unit, housing twenty women. There are two
incubators and one neonatal resuscitaire, which was broken for four months of this
study period.

Waiting Area Mseleni has a large waiting area for high-risk mothers. It can sleep twenty-five to
thirty women and is well liked by the patients. Clinics are now accustomed to
sending primips, grandmultips and ladies who have had previous Caesarian Sections
to the hospital to await labour.

Bethesda has no waiting area for mothers. There is a room attached to the ward
that is used informally but can only house four women comfortably. Clinics know
the patients who need to await labour but have nowhere to send them.

Population Differences between the maternal population were seen at each hospital, if any, has
not been considered in this study. Bethesda is situated close to a major tar road
and this, with the absence of a Waiting Area for mothers may mean that the patient
population differs or at least, the time they present in labour. The numbers of BBA
deaths at Bethesda and Manguzi, the two hospitals nearest to tar roads, were
highest. The numbers of near misses (see later) at Bethesda were high, but these do
not necessarily correlate with perinatal mortality.
Audit Mseleni has been carrying out some form of perinatal audit for over ten years.
Bethesda has not had a regular system of perinatal audit for a number of years.

18
 Simply being audited can have a positive effect on PNMR as will be discussed in
the next section.

Improvements

Perinatal audit is an ongoing thing and, viewed as such, the time period of this study is relatively
short. It does seem, however, that the situation in all four hospitals is improving over the nine
months. The hospital and overall PNMRs have decreased and the PCIs of three of the hospitals
have gone up. The graph in Figure 6 shows a steady reduction of avoidable PNMRs in all hospitals
at roughly the same rate. There may be a few reasons for this.

Perinatal mortality meetings are valuable teaching sessions, especially when cases are presented on
a monthly basis. Some hospitals used the meetings as an opportunity for more formal teaching.
Clinic teaching of sisters was already in place at Manguzi but was introduced at one of the other
hospitals.

However, perhaps one of the biggest factors in the improvement was awareness - doctors and
midwives are now far more aware of their management and decision making and this, in itself,
makes a huge difference to the way that work is carried out. Without any form of audit occurring, it
is easy to allow standards to slip without even noticing.

19
 NEAR MISSES: Results

Total numbers and details of near misses during this nine-month period in Northern KwaZulu Natal
are given in Table 3 below. The numbers of near misses seen at each hospital varied (Bethesda-
14, Manguzi - 5, Mosvold - 3, Mseleni - 9). There were 31 near misses in total and 17 of these
were classed as avoidable (54.8%). The number of occurrences of avoidable factors was 27. The
largest number of near misses had cerebral dysfunction, which included eclampsia in the definition
used. Coagulation dysfunction made up 6 of the cases and vascular dysfunction made up 5. There
were insufficient notes in one case to make an assessment on avoidable factors.

NEAR MISSES: Discussion

Acute maternal morbidity or near misses have not been examined previously in primary, rural
hospitals. The first step when beginning this research was to rewrite the definitions themselves to
suit the setting, whereas previously they were geared towards secondary and tertiary hospitals.

Whilst the new definitions are much more applicable, there are still some adjustments that can be
made. The definition for vascular dysfunction was hypovolaemia requiring transfusion of 4 units of
blood. In the rural setting, blood is very scarce and the thresholds for transfusion are much higher
and the volumes given are much smaller. It is rare for a patient to receive more than two units of
blood so a definition of transfusion of 3 units may suffice.

It was originally felt that, in a rural hospital, even simple eclampsia can be a near miss situation.
Nine months of data has shown 8 cases of eclampsia that had no other complications. Only 3 of
these were thought to be avoidable and it would seem the majority of the cases were women with
no previous history or risk factors. Perhaps eclampsia with no other complications need not be
included.

Coagulation dysfunction was defined as acute thrombocytopenia with a platelet count of less than
50 - malaria was forgotten when writing up definitions. It is common to have a low platelet count
when suffering from malaria and to be very well therefore all malaria cases such as these, where
there was no bleeding, were excluded.

Of the 31 near misses, 4 (12.9%) delivered their babies at home - all of these women then went to
Bethesda which may relate to previous comments about the population that hospitals are dealing
with.

20
 Table 3. Near Misses with details from 1 st September 1998 to 31 st May 1999, in Northern KwaZulu Natal

Organ System Details Number of cases Number classed as avoidable and why. Other problems
Dysfunction

Cerebral Eclampsia 8 2 - Unbooked 2 cases - delay in Magnesium

1 - Delay in seeking medical attention Sulphate being started.

Eclampsia with placental abruption 1 1 - High BP not noted antenatally. Delay in induction of labour. None

Eclampsia with sepsis 1 1 - Home delivery - no transport – river too high. None

Eclampsia leading to renal dysfunction 2 0 1 also had placental abruption

Coma -? Secondary to Cerebrovascular Accident 1 1 - Home delivery. Seizure and ?CVA at home. None

Vascular Antepartum Haemorrhage 2 ;1-placental abruption; 1- 1 - Delay in seeking medical attention & 5hr transport delay on transfer. None
placenta praevia

Ruptured Uterus 1 1 - Staff insufficiently trained to repair adequately. Also had coagulation dysfunction.

Others 2; 1-vaginal tear; 1-ruptured 1 - inadequate monitoring & staff insufficiently trained to notice tear after ventouse. None
spleen

Coagulation Antepartum Haemorrhage 2 2 - 1- Home delivery, not transport to hospital at night, FDP out of stock. 1- delay in seeking Both had DIC
medical attention and delay in diagnosis.

Postpartum Haemorrhage 1 1 - Home delivery. Delay in seeking medical attention, FDP out of stock. Had DIC

Ruptured Ectopic 1 1 - Delay in diagnosis & inadequate monitoring. Had DIC

HELP Syndrome 2 1 - late booker and infrequent ANC visits. Should have been in waiting mother’s area.

Renal Pre-eclampsia 1 0

Malaria 1 0

Sepsis 1 Notes not available

Respiratory Asthma & anaphylaxis 1 1 - incomplete history and inadequate staffing

Pneumonia 1 1 - unbooked & earlier diagnosis

Cardiac Pulmonary Oedema 1 0

Emergency Required hysterectomy 1 1 - delay in seeking medical attention. Obstructed labour. Gangrenous uterus. None
Ref

21
Twelve (44.4%) of the avoidable factors stated were patient-related e.g. unbooked patients, delay
in seeking medical attention, infrequent ANC visits. 8 (29.6%) of the factors were administrative
problems e.g. lack of transport, staff not sufficiently trained. 7(25.9%) of the factors were
management problems.

The numbers are small but it does seem that the rate of home deliveries, as estimated previously,
may be high in the area. In contrast to the avoidable factors identified in perinatal mortality, the
majority of problems here were with the patients and many women came to seek help only when
they were already severely ill.

Unfortunately, data was not collected in all hospitals on maternal deaths, although they are being
notified to the government, so comparisons cannot be made for the whole region. At Bethesda
there were 8 maternal deaths over the nine months. 4 of these were from cerebral malaria, a cause
that only features as a cause in one of the near misses. 2 deaths were from septic shock, 1 was
from HIV encephalopathy and 1 was from cardiac failure in a known heart disease patient. Sepsis
did not feature in any of the near misses and
there was only one patient with cardiac failure.
Case Study
S.M. 25yr old primip.
Booked at 12 weeks. Two antenatal BP readings of /90 and one of
Thus, it seems that while near misses are very 140/84. Urine - NAD. No oedema.
relevant to examining maternal care, they do
21/10/98
not correspond to the common causes of Admitted at 28 weeks with absence of fetal movements. IUD
maternal death in Northern KwaZulu Natal. diagnosed with 5x4cm bleed behind placenta.
BP 168/98 Urine- Blood++
Improvements in maternal care are less easy Later BP 170/100 Urine-Prot+Blood++
Bloods Urate 0.31, U&Es NAD, FBC NAD.
to quantify in the case of near misses as there
is no rate to calculate, however anecdotally 22/10/98
there seems to be an improvement in the 7am Seizure x1. Diazepam 10mg given.
management of some conditions. The case 9.50am Seizure x1 Magnesium Sulphate started.
10.30am Cervix 1cm dilated. ARM.
study illustrated here shows an avoidable 12.30pm BP 200/100. Urine-Prot+++
eclamptic case in October 1998. The Urate 0.47, ALT 295, AST 128, Platelets 114
management of eclampsia has since improved Started on hydrallazine
greatly - so much so that bloods are taken 2.30pm FSB delivered

and magnesium sulphate treatment started 26/10/98

often before the patient has seen the medical Discharged after good recovery.
officer.
ORGAN SYSTEM DYSFUNCTION: Cerebral due to eclampsia
AVOIDABLE FACTORS: ? BP not investigated antenatally
A further interesting comparison would be to abnormal blood results not noted. Delayed induction of labour.
compare avoidable factors of near misses in a Delayed commencement of Magnesium Sulphate and
primary hospital to those of secondary and antihypertensives.
tertiary institutions as these are the places to Since introducing the near miss audit, management mistakes
similar to those above have become rare.
which the sick mother is often referred so the
two are closely related. This may shed light
on the particular problems of primary, rural practice that may be very different to those of larger,
more urban hospitals. For any audit on maternal morbidity and mortality to be valid, the cases must
be examined from the very beginning i.e. at the level of the referral hospital or even clinic.

22
 SUMMARY AND RECOMMENDATIONS

With the cooperation of the hospitals concerned, systems of perinatal and maternal care audit have
been established in Northern Kwa Zulu Natal. The perinatal audit involved detailed analysis of each
case as soon as possible after the mortality occurred and assessment of how the death could have
been avoided. Using the Perinatal Problem Identification Program, the data was collated and
monthly feedback was given to each maternity unit at perinatal mortality meetings. The majority of
problems were management related. Over a nine-month period, a reduction in avoidable perinatal
mortality rates was shown in all hospitals involved. The perinatal care index in three out of four
hospitals had risen. The audit systems are fully operational and can now be continued indefinitely,
providing long term feedback.

A perinatal audit such as this can easily be expanded to other hospitals in the area or further afield.
PPIP is an easy way to formulate results that may otherwise never be looked at and when the
Windows version is established, it will prove even more useful.

Information on maternal morbidity is becoming an important part of maternal care assessment and
this research has shown that, even in a primary setting, its examination is useful. After redefining
near misses for the primary setting, the cases showed that the majority of problems lay with the
patients themselves. It seems that certain conditions are being much better managed since the start
of this audit.

The near miss audit would certainly be easier to carry out if the avoidable factors were more clearly
defined and if there was a method of simple collation. The concept itself is new and will take a little
longer to become fully established in the minds of doctors and midwives.

There are many offshoots from research such as this. The hospitals have been working together and
gaining from each other and all four have become more aware of problems that need to be
addressed when trying to improve care. Some are planning to introduce the Perinatal Education
Program, a distance learning Program for midwives, with a view to providing structured in-service
training. Others have started concentrating more on clinic problems and sending medical officers to
the residential clinics for teaching.

On a larger scale, the factors mentioned as contributing to increased mortality and morbidity rates
should be noted. Developing rural medical practice as a long term option for staff, ensuring
departments are adequately equipped, recognizing the well known importance of a Waiting
Mothers’ Area in any rural region and developing patient education about their own health have all
been identified as important.

Primary hospitals are often lumped together with secondary and tertiary institutions without the
acknowledgement that their situation is very different. Doctors are generalists, covering every
speciality, and patients are poorly informed, travelling immense distances to visit hospital. A great
improvement to care will come when primary rural practice is examined as a separate entity and
problems such as those identified in this study are tackled.

23
 Attachment 1
MEDICAL DATA COLLECTION FOR ALL PERINATAL DEATHS

Date of Delivery: Date of Death: Hospital:

(Same as date of del. if stillbirth)

Expected Date of Delivery: Investigator:

Patient Name: Hospital Number:

Age: Ward:

Ethnic Origin:
Gravidity: Parity:

Previous Obstetric History:

Circle Type of Care: CLINIC/HOSPITAL/PRIVATE/TBA/OTHER/NONE

How many weeks at booking?

Antenatal BP Antenatal Hb

Rhesus status Syphilis test result

If positive for syphilis, was the patient fully treated? If positive for syphilis, was the partner fully treated?

HIV status

Other relevant antenatal history e.g. premature rupture of Membranes, APH with no action taken, symptoms of
pre eclampsia etc.

Clinical state on admission (including relevant blood results)

Details of Labour (if relevant)

Perinatal Outcome Gestational Age (if known)

Route of Delivery
Birth Weight

Final Cause of Perinatal Death (ref. to PPIP)

Avoidable causes of Perinatal Death (ref. to PPIP) Suitable Intervention

24
 Attachment 2
EXAMPLE OF PPIP PROGRAMME SPREADSHEET

New data Change Data Statistics Admin functions

Hospital No : 7001/99
Delivery date : 1-06-99
Total Deliveries Date of death : 1-06-99
Perinatal Deaths
Maternal Deaths Born alive Fresh stillborn
Macerated
Birth Mass : 1700g

Single pregnancy Multiple pregnancy

RPR/VDRL :

(+) (-) Not Done Result not available

Primary Obstetric cause of death : 112

Final cause of neonatal death : 090

All items in bold indicate functions that have to be selected, or data that
needs to be entered into the programme.

25
 Attachment 3
MEDICAL DATA COLLECTION SHEET FOR ALL
MATERNAL DEATHS & MATERNAL “ NEAR MISSES”

INVESTIGATOR IDENTIFICATION: ____________________

Date: Investigator:

Hospital

Patient Identification: Study No.:

Name: Home address:

Hospital Number: Ward

BACKGROUND PATIENT INFORMATION:

Age: Race: Gravidity: Parity:

(years)

ANTENATAL CARE:
Circle type of care: CLINIC/HOSPITAL/PRIVATE/TBA/OTHER/NONE
Number of visits: HIV status: POSITIVE/NEGATIVE/UNKNOWN

Primary Secondary care: Tertiary

Care: Care:

ANTENATAL RISK FACTORS IDENTIFIED ACTED UPON

(yes/no/specify factor) (yes/no/specify action)
Previous Obstetric history:
Current Obstetric history:
Medical history:
Haemaglobin:
Blood Pressure:
Proteinuria:
Glycosuria:

PERINATAL DATA:
Under ‘Pregnancy outcome’ state whether abortion, ectopic, or give perinatal outcome:

Pregnancy outcome: Route of delivery:

Gestational age Birth weight

(specify/not known) (specify/not known)

If there was a perinatal death, give the final cause of perinatal death (ref. PPIP):

26
 PRESENT HOSPITAL ADMISSION: Background, if referred:

From where? By whom?

Referral problem(s) Management at

referring centre?

WAS PATIENT A “NEAR MISS” ON ADMISSION TO HOSPITAL (YES/NO)?

IF YES, GIVE REASON FOR CLASSIFICATION AS A “NEAR MISS”

Date: Time: IDENTIFIED ACTED UPON

PROBLEMS ON ADMISSION (yes/no/not clear) (yes/no/specify action)

COURSE OF EVENTS AFTER ADMISSION:

TIME & COMPLICATIONS IDEN.(yes/no/n ACTED UPON INDIC. DID ACTION
DATE AFTER ADMISSION ot clear (yes/no/specify (yes/no) OCCUR?
action) (yes/no/why not)

‘TIME’ informat of 24-hour clock.

Complications include any medical, obstetric or operative event including anaesthesia (local, regional or general) or an ICU or
high care area admission.
‘IDEN.’ Means, did the medical or nursing staff identify the problem or complication?
‘INDIC’ means, was the action taken indicated in the view of the investigators?

27
 MEDICAL ASSESSMENT BY INVESTIGATORS:

STATE REASON FOR CLASSIFICATION AS A MATERNAL “NEAR MISS”

PRIMARY OBSTETRIC PROBLEM:

FINAL SYSTEM DYSFUNCTION/FAILURE DIAGNOSIS:

Other complicating or associated system dysfunction/failure:

AVOIDABLE FACTORS
State WHAT the avoidable factor is, WHY it could have made a difference and indicate if
death/”near miss” could POSSIBLY/PROBABLY have been avoided.

PATIENT FACTORS:
WHAT? WHY? POSSIBLE/PROBABLE

MEDICAL FACTORS:
WHAT? WHY? POSSIBLE/PROBABLE

ADMINISTRATIVE FACTORS:
WHAT? WHY? POSSIBLE/PROBABLE

INSUFFICIENT NOTES TO MAKE JUDGEMENT

(yes/no/state area of deficiency):

28
OTHER NOTES (from other sources, e.g. the patients, other doctors/nursing staff):

FURTHER EVENTS AFTER IDENTIFICATION AS A “NEAR MISS”

TIME & COMPLICATIONS IDEN. ACTED UPON INDIC. DID ACTION

DATE AFTER ADMISSION (yes/no/ (yes/no/specify (yes/no) OCCUR?
not clear action) (yes/no/why not)

29

A. ORGAN SYSTEM BASED
1. Cardiac dysfunction:
2. Vascular dysfunction
3. Immunological dysfunction:
4. Respiratory dysfunction:
5. Renal dysfunction:
6. Liver dysfunction
more of proteinuria.
7. Metabolic dysfunction i)
8. Coagulation dysfunction:
9. Cerebral dysfunction:
B. MANAGEMENT BASED
1. Intensive care admission:
2. Emergency hysterectomy:
3. Anaesthetic accidents:
spinal or epidural anaesthetic.
lasting
Attachment 4
Proposed clinical criteria for a maternal near miss.
MARKERS
I) Pulmonary oedema: A clinical diagnosis necessitating intravenous
furosemide or intubation.
ii) Cardiac arrest
i) Hypovolaemia requiring 5 or more units whole blood or packed
cells for resuscitation.
i) Intensive care admission for Sepsis.
ii) Emergency hysterectomy for spesis.
i) Intubation and ventilation for more than 60 minutes for any reason
other than for a general anaesthetic.
ii) Oxygen saturation on pulse oximetry less than 90% and lasting
more than 60 minutes.
iii) The ratio of the partial pressure of oxygen in arterial blood to the
percentage oxygen in inspired air is 3 or less i.e. paO2 / FiO2 is 3 or less.
i) Oliguria, defined as less than 400ml per 24 hours, which does not
respond to either careful adequate intravascular rehydration or
attempts at inducing a diuresis with furosemide or dopamine.
ii) Acute deterioration of Urea to above 15 mmol/l or of Cratinine to above
400 mmol/l.
i) Jaundice in the presence of pre-eclampsia. Pre-eclampsia defined
here as blood pressure of 140/90 or greater together with 1 plus or
Diabetic keto-acidosis.
ii) Thyroid crisis
i) Acute thrombocytopenia requiring a platelet transfusion.
i) Coma in a patient lasting more than 12 hours.
ii) Subarachnoid or intracerebral haemorrhage.
MARKERS
i) For any reason.
i) For any reason.
i) Severe hypotension associated with a
Hypotension defined as a systolic
pressure less than 90 mmHg
more than 60 minutes.
ii) Failed tracheal intubation requiring
anaesthetic reversal.
30
 Attachment 5
PROPOSED CLINICAL CRITERIA FOR A MATERNAL NEAR MISS IN THE
RURAL PRIMARY REFERRAL SETTING.

Organ System Based Criteria

1. Cardiac Dysfunction i) Pulmonary Oedema: Diagnosed clinically necessitating intravenous frusemide.
ii) Cardiac Arrest

2. Vascular Dysfunction i) Hypovolaemia where, if available, one would transfuse 4 units of blood or
packed cells for resuscitation. (These women should be included even if blood
was not available.)

3. Immunological Dysfunction i) Blood Pressure < 90 systolic attributable solely to sepsis.

4. Respiratory Dysfunction i) Clinical signs of severe respiratory distress – respiratory rate > 50/min; central
cyanosis; nasal flaring; tracheal tug; use of accessory muscles of respiration.
ii) Oxygen saturation on pulse oximetry <90% off oxygen (if pulse oximeter
available)
iii) Intubation and ventilation for any reason other than a general anaesthetic. (If
ventilator available.)

5. Renal Dysfunction
i) Oliguria, defined as less than 400mls per 24 hours, which does not respond to
either careful adequate intravascular rehydration or attempts at inducing a
diuresis with frusemide, and lasting for at least 24 hours.
ii) Blood urea levels >15 mmol/l or creatinine levels >400mmol/l in a patient not
known to have pre-existing renal disease.

6. Liver Dysfunction i) Clinically jaundiced in the presence of pre-eclampsia. Pre –eclampsia is

defined here as a blood pressure of 140/90 or greater together with 1
plus or more of proteinuria.
ii) Raised INR in the presence of jaundice from causes other than pre- eclampsia.

7. Metabolic Dysfunction i) Diabetic Keto-acidosis.

ii) Thyroid crisis.

8. Coagulation dysfunction i) Acute thrombocytopenia with a platelet count of <50.

9. Cerebral Dysfunction i) Coma (not post-ictal).

ii) Clinical signs of subarachnoid or intracerebral haemorrhage.
iii) Eclampsia i.e. seizures in the presence of blood pressure of 140/90 or greater
together with 1 plus or more of proteinuria.
iv) Status epilepticus or a patient is having one seizure every hour or more in the
absence of pre-eclampsia.
Management Based Criteria

1.Emergency Hysterectomy i) for any reason.

2.Emergency Transfer to Secondary Centre with a view to intensive care admission.

3. Anaesthetic Accidents i) Severe hypotension associated with a spinal anaesthetic. Hypotension is

defined as a systolic pressure less than 90 mmHg lasting for more than
60 minutes.
ii) Failed tracheal intubation requiring anaesthetic reversal.

31