|09. Appropriate Obstetric Technologies to Deal with Maternal Complications|
In the list of five major obstetric complications presented here there are two, that are more directly related to the birth itself, postpartum haemorrhage and obstructed labour. The remaining three, genital sepsis, pregnancy induced hypertension/eclampsia and cerebral malaria are not directly related to the birth process itself but occurs commonly associated with the peripartal period.
Puerperal sepsis as consequence of postpartum endometritis-myometritis occurs typically several days up to two weeks after delivery (Libombo et al. 1994). New evidence regarding the etiology of genital sepsis indicates that unhygienic handling of the birthing process itself (repeated vaginal examinations with poor manual hygiene) is not the only or even predominant cause of this pathology. An unexpected association between low birth weight deliveries and childbed fever/ genital sepsis has been demonstrated in Mozambique (Bergström & Libombo 1995). It appears that sub-clinical intrauterine infections during pregnancy provoke preterm birth of low birth weight newborns with high risk of congenital foetal infection, leaving behind an infected uterine cavity with ensuing clinical endometritis-myometritis, which may deteriorate in puerperal sepsis (Nadisauskiene et al ., 1996). One interesting feature is the suggestion that the birth canal might benefit from washing with antiseptic solutions, whereby a vulnerable, low birth weight newborn might not be further infected by vaginal pathogens. Some studies indicate that a routine using vaginal washing might be beneficial (Stray-Pedersen et al . 1999). If both endometritis and congenital infection of the newborn are related to subclinical, antenatal intrauterine infection such vaginal washing would offer insufficient protection. Against the additional danger of ascending, vaginal pathogens postpartum (associated or not associated with the manual hygiene of the birth attendant) such flushing may potentially provide some additional protection for the mother and also for the newborn. There have been doubts expressed, however, regarding this routine (Rouse et al . 1997) and more research remains to be carried out particularly in settings where puerperal sepsis is prevalent.
Cerebral malaria is coming up as a major maternal killer and contributor to severe maternal morbidity in several countries in sub-Saharan Africa and in southern Asia (Brabin 1991). It might be argued that appropriate obstetric technology is not relevant when discussing treatment of cerebral malaria during pregnancy. However, as has been stated already, we have opted to consider technology in a broad sense and we do think that the specific therapeutic requirements in pregnancy malaria make it necessary to mention these management aspects here. The increasing drug resistance (above all to chloroquine but also in some areas to sulfadoxine-pyrimethamine/Fansidar) has made more and more countries reluctant to provide conventional chloroquine prophylaxis during pregnancy. Instead the concept of repeated therapeutic treatments (clearance of parasitaemia) has won more and more acceptance. Intermittent sulfadoxine-pyri-methamine treatment in pregnancy has shown that such a regime will lead to a highly significant reduction in the incidence of LBW in infants born to primigravidae, even if the women have HIV infections (Verhoeff et al ., 1998). The pregnancy malaria situation in the world is by and large deteriorating and frustrated attempts are legion to curb the growing threat of malaria maternal mortality (Granja et al. 1998). There are no immediately available appropriate obstetric technologies to manage this growing malaria threat. New drugs are not available or accessible for wide utilization in the countries most affected or they are too expensive to be considered appropriate.
Pregnancy-induced hypertension/eclampsia is a major contributor to severe maternal morbidity and maternal mortality. The management routines have been quite variable over the last decades but hopeful signs of a scientific approach have emanated from the multicentre study comparing magnesium sulphate and diazepam (Anonymous 1995). This study indicates that the drug of choice in treating eclamptic patients should be magnesium sulphate, since this drug gives fewer recurrent convulsions than diazepam. Still, several centres, above all in the UK prefer other drugs than magnesium sulphate. The understanding of the pathofysiology of pregnancy-induced hypertension/ eclampsia has contributed largely to the choice of magnesium sulphate with concurrent volume substitution to maintain optimum circulation in the vasospastic, and hypovolemic disease of eclampsia, where hemoconcentration and hypoperfusion are important characteristics.