Saturday, January 26, 2008

HER DEATH WAS PREVENTABLE

Today’s newspaper carries a report on the coroner’s findings after investigating the death of a young mother, six hours after the birth of her first child. The coroner found that the cause of death was “post partum haemorrhage complicating amniotic fluid embolism”, and considered that there was a good chance that the death could have been prevented with better medical and nursing management.

Having read the coroner’s report, which is a public document, available at http://www.theage.com.au/ed_docs/coroner.pdf , I want to make a few comments. Several people have told me that they read this blog in order to obtain a better understanding of maternity issues, and I know that we all have big questions in our minds when we hear of a tragic death such as this one. I hope you find my comments useful. You may contact me joy@aitex.com.au or in the comments section of this page.

The only information I have on this case is the coroner’s report. However every midwife and doctor who attends births must be prepared to deal with post partum haemorrhage, and to that extent the coroner’s report is useful in focusing our thoughts on the topic.

Amniotic fluid embolism

Some readers may wonder about the significance of amniotic fluid embolism in this sequence of events. Expert opinion provided in the coroner’s report is worth reading. There is no doubt that amniotic fluid escaped from the baby’s sac to the mother’s blood stream. It is known that this event, though very rare, is likely to cause catastrophic consequences in the mother’s body.

How did the amniotic fluid embolism occur? The report states that there was “probably” a lower uterine segment rupture. This could have allowed amniotic fluid to pass into the mother’s blood stream.

Uterine rupture

How did a uterine rupture occur? This question is not addressed, and I don’t have enough information to form an opinion in this particular case. We are not told any details of the actual birth, whether it was spontaneous or assisted. The assumption is that it was a vaginal birth. We know that the labour was induced at 41 weeks’ gestation. Induction of labour is usually achieved by artificially rupturing the membranes, and administering an artificial oxytocic, Syntocinon® intravenously, gradually increasing the dose over time.

The women today who are most likely to be confronted with concerns about uterine rupture are those with previous uterine surgery – usually a caesarean birth. The scar itself can dehis or ‘buttonhole’, something that may even happen prior to the onset of labour. This is a serious complication, but may not lead to catastrophic haemorrhage. The rupture of the upper uterine segment in obstructed labour or following prior classical caesarean surgery is the most life-threatening complication in this group, as the muscle of the upper segment is thick and has a large blood supply. Tearing of the lower segment may occur in an assisted birth in which a tear in the cervix which was not fully dilated and taken up extends to the lower segment.

Post partum haemorrhage

The severity of the haemorrhage described in this account is far greater than most midwives will ever experience. In the six hours after the birth, from the description of events in the report, there would have been no time when this new mother would have felt well. Her blood pressure was low, her pulse weak, and when conscious she would have been aware that her life’s blood was flowing from her. Whether she experienced the joy of holding her baby or not, we will never know.

Large doses of oxytocics were administered to keep the uterus contracted, without success. It appears that there was no thought of possible uterine rupture in all the decision making and treatment that ensued. Even when the mother’s uterus was examined under anaesthetic, the doctor was looking for retained placenta as the possible cause of haemorrhage.

Coagulopathy

As the haemorrhaging continued over the hours after the birth, the mother’s ability to form clots became progressively worse. This is to be expected in serious haemorrhage of any kind, and requires expert medical management.

Model of care

The model of care in which this mother gave birth, with a specialist obstetrician being the primary carer in a private maternity unit for a healthy thirty-three year old primipara, received no comment from the coroner. It’s so *usual* that noone thinks critically of it in this country. The woman chose to have her baby in Melbourne, probably as ‘safe’ as any other place in the world from a maternity outcome point of view, and she chose the doctor. What more could one want?

In no other life event is there an expectation that well women will be given basic care by a specialist doctor. Yet this is the case in Australian maternity care, due in a large part to the government’s tax incentives to encourage private health insurance, and financial incentives through Medicare and the Medicare safety net.

An informed observer would ask “where was the woman’s midwife?” In this particular model of care the midwife who was present during labour would have been a stranger to the woman, and would not have acted autonomously in providing intrapartum care. Midwives working in private maternity hospitals in Australia usually work as assistants to the obstetrician, informing him or her of progress, administering treatments ordered by the doctor, and maintaining the record of observations. The baby girl was born at about eight in the morning, so a new midwife, rostered to work the day shift, would have taken over the care at about that time.

Perhaps the doctor had been called out to the hospital during the night, and was tired by the time the baby was born? We don't know - that's only conjecture. But had this woman's care been in the hands of a midwife, and everything else been the same, it's to be expected that a specialist obstetrician would have been called to manage the care as soon as the haemorrhage had been seen. Or, if the woman was in a primary care unit such as a birth centre without surgical facilities, or at home, a transfer would have been organised to a suitable backup hospital as soon as the haemorrhage had been seen. (note that a birth centre or midwife at home would not have provided induction of labour on maternal request, and that's a major difference in risk management.)

The point I am making is that when primary care is in the hands of the specialist, there is no further specialist to refer to when complications arise. The model of care put this woman at greater risk than another model, in which a specialist would have looked with fresh eyes at a woman who had experienced a severe post partum haemorrhage, and who was still in shock, and would have instituted aggressive measures to support the woman's circulation, and to stop further haemorrhage.

When a midwife attends a birth as primary carer, and the woman experiences excessive blood loss, the midwife acts quickly to prevent further loss. The uterine fundus is rubbed up and any blood expelled - an empty uterus does not bleed. The midwife administers oxytocics - my usual dose would be Syntocinon 10units intramuscularly, followed by Syntometrine 1ml intramuscularly if the first dose is inadequate. A woman who is still bleeding, with signs of low volume shock, would be transported to hospital by ambulance as soon as possible. An IV infusion would be started, and transfer of care to a backup medical team would occur without delay. This action would usually take place within an hour or so of the birth.

It's easy to be wise in hindsight. Errors of judgment clearly happened in this case, and the coroner described the decision making process as a "study in chaos". Whether the doctors concerned will be judged by their peers as having been professionally negligent or incompetent is up to the statutory body to decide. We expect the ‘eye for an eye’ – someone has to be punished. The lawyers will no doubt organise to sue for compensation, and the insurer will no doubt pay out. Yet nothing has been done to address the underlying cause, which had more to do with the model of care than the actual people involved. A precious life was lost; a baby began her life without her mother; and a new father lost the woman he loved, and who gave birth to their child. It's so sad.

No comments: