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| Questions & Reasons | How to address the contributing factors |
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| Why the hemorrhage and shock could not be managed: Delay in operation due to the absence of senior obstetrician, Delay in blood transfusion, Incorrect assessment of blood loss with inadequate amount of blood transfused. No clotting screening done and no renal function assessed | Improve rosters and policies for timely availability of specialists, development of midwifery risk assessment teams at ER
Refresher training for pre-op management and preparation
Review policies to plan timely provision of blood, blood products and other essential supplies |
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| Why hemorrhage occurred: Posterior wall of the uterus ruptured for obstructed labour due to big baby (4 kg), with delays in accessing care at the hospital | Refresher training for better assessment of risks, management of risks hypertension, diabetes, and effective course of action for complications such as obstructed labour |
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| Why delays in accessing care at the hospital: Delay by the midwife at the centre to facilitate referral and transfer to woman to hospital, Poor referral communication causing woman to arrive first at a hospital with no CS facility. Delays at the terminal event occurred as there was no hospital registration and delivery plan | Develop, implement and monitor protocols for follow ups to assess if the referral was taken. Provide primary care workers, particular those midwives who are providing labour and delivery care in private sector, information about what services are available in which of the facilities |
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| Why there was no effective delivery plan: Earlier ANC provider midwife failed to effectively advise the woman to deliver in the hospital despite that there was a previous still birth and current baby is big, and despite that the nearest health care facility which can provide Caesarean Section is 6 hour away | Train primary care staff for risk assessment and for communicating the risk. Protocols for early assessment (first trimester) and subsequent categorization into high, intermediate and low risk, with each category having a plan of where to deliver. The plan should be included in the Pink Book |
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| Why ANC provider failed to effectively advise: Lack of application of best practice protocol and failure to recognize clinically big baby (4 kg baby at 8 months) and no request for an ultrasound scan, Risks were not carefully assessed | Retrain midwives, with a focus on best practice protocols, referrals, communication skills, assessment and management of risks with case studies based on situation in the district |
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| Why risks were not fully assessed early for a 37 years old, G5 with history of abortion and stillbirth, and who lived 6 hours from a hospital: Family planning services are un-integrated and are the responsibility of another department, ANC sessions are rushed with inadequate emphasis on geography, access, age, FP, past history and planning and communication for follow up | Primary care services in this district must include family planning, actively supporting woman offering them a selection of methods. Improved health education as part of centre based and home based ANC provision |
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