Table 2 Operational definitions of Major Direct Obstetric Complications in the MSF Khost maternity hospital, Afghanistan, 2013–2014 (expanded and adapted from [16])

Haemorrhage

Antepartum

 • Severe bleeding before and during labour: placenta praevia, placental abruption

Postpartum (any of the following)

 • Bleeding that requires treatment (e.g. provision of intravenous fluids, uterotonic drugs or blood)

 • Retained placenta

 • Severe bleeding from lacerations (vaginal or cervical)

 • Vaginal bleeding in excess of 500 ml after childbirth

 • More than one pad soaked in blood in 5 min

Ectopic pregnancy

 • Internal bleeding from a pregnancy outside the uterus; lower abdominal pain and shock possible from internal bleeding; delayed menses or positive pregnancy test

Ruptured uterus

 • Uterine rupture with a history of prolonged or obstructed labour when uterine contractions suddenly stopped. Painful abdomen (pain may decrease after rupture of uterus). Patient may be in shock from internal or vaginal bleeding

Prolonged or obstructed labour: (dystocia, abnormal labour) (any of the following)

 • Prolonged established first stage of labour (> 12 h)

 • Prolonged second stage of labour (> 1 h)

 • Cephalo-pelvic disproportion, including scarred uterus

 • Mal-presentation: transverse, brow or face presentation

Postpartum sepsis

 • A temperature of 38 °C or higher more than 24 h after delivery (with at least two readings, as labour alone can cause some fever) and any one of the following signs and symptoms: lower abdominal pain, purulent, offensive vaginal discharge (lochia), tender uterus, uterus not well contracted, history of heavy vaginal bleeding. (Rule out malaria)

Complications of abortion (spontaneous or induced)

 • Haemorrhage due to abortion which was managed medically or surgically (manual vacuum aspiration or dilatation and curettage)

 • Sepsis due to abortion (including perforation and pelvic abscess)

Severe pre-eclampsia and eclampsia

 • Severe pre-eclampsia: Diastolic blood pressure ≥ 110 mmHg or proteinuria ≥3 after 20 weeks’ gestation. Various signs and symptoms: headache, hyperreflexia, blurred vision, oliguria, epigastric pain, pulmonary oedema

 • Eclampsia

 • Convulsions; diastolic blood pressure ≥ 90 mmHg after 20 weeks’ gestation or proteinuria ≥2. Signs and symptoms of severe pre-eclampsia may be present (adapted from [16])