EXPLORE PAST ISSUES
Death
Vol. 11 No 1 | Autumn 2009
Feature
Maternal death
Dr Sarah Tout
FRANZCOG


This article is 11 years old and may no longer reflect current clinical practice.

A collection of personal experiences

It is estimated that 600,000 women die globally each year as a result of pregnancy-related conditions. A disproportionate share of these (99 per cent) occur in developing countries, many of which would be preventable with appropriate resources and training.1

It is a sad reality though that depending on where we work, how much we work and for how long, we will all have some contact with a maternal death during our careers. Working in the developed world, thankfully, this is a relatively uncommon outcome and it is also that very fact that makes this such a distressing event for all those involved.

As an Integrated Training Program (ITP) interviewer, I frequently hear a similar response to the question, ‘What attracts you to the specialty of obstetrics and gynaecology?’ I hear the answer, ‘It is a happy area of medicine with good outcomes, dealing with young and healthy women.’ This is certainly true most of the time and probably has something to do with why many of us chose this area of medicine, but as we are also aware, this is not always the case.

Much more commonly than maternal death, we deal with fetal demise, or intra-uterine death. We are very used to dealing with these scenarios and even though they are always sad, we are better prepared, with protocols and counsellors in place as required. We are also very used to dealing with stressful situations on a busy delivery suite, which we manage on a daily basis using our clinical judgement, skills and knowledge. However, being involved in a maternal death is something we are less well prepared for and it often has a long-lasting effect on us, more perhaps than we would have expected.

This being the case, it was not easy to find someone to write an article on their own experience of maternal death. Instead, I approached a few of my obstetric colleagues, at varying stages in their careers, from trainees, through junior consultants to those approaching retirement. This is a collection of their personal experiences. Some have provided detailed descriptions of the events and others a more personal overview of how they felt and how it affected their practice thereafter.

I would like to thank all those who have very generously put ‘pen to paper’ and written on what is not an easy topic. I am very grateful for their honesty and believe you, as the readers, will agree that this is an important area to have looked at which is not easily accessible from a text book.

Case 1.
Anonymous

I was still a registrar, working on my elective in a unit where I was given considerable responsibility and hence felt very responsible. My patient was sadly admitted with an intra-uterine death at 29 weeks. This was her first pregnancy and she was devastated. The hospital had strict visiting hours, even for partners, and so that evening she was alone. It was in the early days of misoprostol and her response was extremely effective. She was transferred to delivery suite that evening with perhaps, in retrospect, a hyperstimulated uterus.

Progress was rapid. I was next called to her seizure. I was confronted with a woman not responding and not breathing who had arrested. The crash team was called, basic resuscitation was commenced and I successfully intubated her. The resuscitation was, however, unsuccessful and the family were called. Her postmortem confirmed an amniotic fluid embolism. The next day, at the end of the ward round, my consultant asked me if I was ‘OK’. I said I was, continued my day’s work and then went home and cried.

I will always remember this woman. I feel quite sad that she died away from her family in such a terrible situation, having just lost her very wanted baby. I think her case continues to bring home to me how important it is to always be caring and compassionate to our patients. It also highlighted to me that sometimes what we do can cause harm and we must be particularly questioning when introducing new protocols, drugs and techniques.

‘Every intervention has a risk which must be weighed against the risks of non-intervention in each individual circumstance.’

‘…sometimes what we do can cause harm and we must be particularly questioning when introducing new protocols, drugs and techniques.’

Case 2.
Anonymous

The child lay still and pale on the woven peasant blanket. The evening breeze lifting the dust and dried leaves in the rough yard. Stillness after such noise and bemoaning. Attention, finally summoned.

Labouring alone with the shame of a concealed pregnancy, she had delivered the tiny infant only to succumb to relentless bleeding. The child lay still, pale and dead at just 14 years of age. The feeble newborn barely stirred as we lifted her mother.

Human society can have thick walls to those whose lives do not fit normal expectations. Access to care is a right no one should take lightly.

Fear of discovery for those caught with an unintended pregnancy is perhaps greater than the fear of death itself.

Case 3.
Anonymous

She was 23 years old and had been a mother for less than three weeks. Her antenatal course had been uncomplicated, she was not overweight and she had delivered normally, with an epidural for analgesia. Over the previous week she had complained of some backache and had taken herself to her GP and physiotherapist for some treatment.

She then ended up in our emergency department on the Thursday afternoon to be assessed for possible retained products. She had opted to go home for the night and return in the morning for a scan.

I first met her when her mother pushed her into the gynaecology ward in a wheelchair, clutching the scan report and with the baby capsule perched on the handles of the chair. She was crying, in pain and looked pale, almost blue.

Within an hour she was dead, after major resuscitation attempts by gynaecology, medical and (very rapidly) intensive care staff. A post mortem revealed a saddle embolus which, in retrospect, had been causing the symptoms of the previous few days.

She was the classic young, fit, healthy patient who compensates until the last minute. She had no risk factors for thromboembolism and her death, understandably, came as an enormous shock to everyone involved, a salient reminder that, in obstetrics, you can never be too complacent.

Case 4.
Anonymous

She was an attractive, 28-year-old, tall, slightly overweight nurse (BMI 31), whose warm, kindly sense of fun brightened the unit. At 38 weeks after an uneventful antenatal course, there was no fetal heart eight hours after normal fetal movements. The very unfavorable cervix failed to respond to 12 mg of prostin gel, given in divided doses over four days (including rest), despite mifepristone (RU486) being added with the first dose. 100 mcg of misoprostol finally established labour and she delivered a heavily macerated baby 18 hours later. Only acute anoxic changes were found at the baby’s postmortem. A thrombophyllia screen was done, as it had recently been identified as a cause of recurrent miscarriage and possibly late pregnancy loss, but we did not think of thromboprophylaxis.

On the tenth day of the puerperium, she suddenly died at home of a massive pulmonary embolus. The following day, a report of severe Antithrombin III deficiency was in my in-tray, dated three days previously – laboratory staff shortages precluding a phoned result.

Lessons

  1. Antithrombin III deficiency can kill.
  2. Patients with unexplained stillbirth need thromboprophylaxis, until major thrombophyllia has been excluded.
  3. Lateral thinking may be blunted by familiarity with the patient.
  4. Communications become particularly important when there are staff shortages.

Case 5.
Anonymous

Her third pregnancy had been uneventful but went post-term. The decision for an induction of labour, with her midwife, was routine and a common procedure. The Sunday afternoon progressed uneventfully. Regular contractions established and syntocinon was commenced according to the normal protocol.

An urgent call for assistance was made when there was a sudden maternal collapse and all efforts were made at resuscitation without success. The postmortem confirmed an amniotic fluid embolus.

She was a lifelong friend of a colleague who went on to adopt her children.

The hold on life is tenuous. Every intervention has a risk which must be weighed against the risks of non-intervention in each individual circumstance. Always consider and explain possible complications.

Case 6.
Anonymous

A 38-year-old infertile primigravida was booked for an elective caesarean section for a marginal placenta praevia. When the anaesthetist saw her preoperatively, he noted her poorly formed lower jaw and the serious risk of tongue induced apnoea. Her particularly loud snoring had been noted during her previous admission for antepartum haemorrhage (APH), requiring single room accommodation to facilitate other patients’ sleep. Elective epidural anaesthesia was rarely offered in that peripheral hospital (30 years ago), but proved very effective.

Due to intensive treatment unit staff shortages, a calculated decision was made to nurse her on the (then) quiet maternity unit. When the epidural wore off, she had a small dose of morphine for pain relief in addition to diclofenac and paracetamol.

Unfortunately, the unit became extremely busy and careful monitoring was temporarily in abeyance. Ninety minutes later, the snoring stopped, because the patient’s tongue had occluded her airway. Resuscitation failed when the midwife returned some time later.

Lessons

  1. Mechanical obstructive airway disease of the type that can cause sleep apnoea is particularly dangerous postoperatively.
  2. Postoperative pain relief can induce an obstructive airways risk similar to the immediate postoperative recovery period.
  3. If a high-risk patient is nursed outside an intensive care/high dependency unit for staffing reasons, changing workloads in the unit must not allow the patient to be put at risk.
  4. The clinical details in a ‘confidential’ enquiry may breach patient confidentiality, especially when maternal death numbers are low.
‘If a high-risk patient is nursed outside an intensive care area for staffing reasons, changing workloads in the unit must not allow her to be put at risk.’

‘Lateral thinking may be blunted by familiarity with the patient.’

 

Case 7.
Monique Williams, Midwife

I have only been involved with one maternal near death. The experience is well imprinted in my mind. I can summon up images and feelings around it without much effort.

It was December 2006, just a few days before Christmas. The woman was a primigravida, had been diagnosed with grade four placenta praevia, had had a number of antepartum haemorrhages and had spent the last five weeks in the postnatal ward.

The woman was prepared on the day of her elective caesarean. She’d had all the necessary tests, understood all the preparations and the need for the caesarean to be performed under general anaesthetic. Her partner was present and excited, but also very anxious.

My role at the time was attending elective caesareans as the support person for the family, completing the pre-operative checks and midwifery documentation, attending the caesarean, initial care for the baby, and transfer from the recovery ward back to the maternity postnatal ward.

We had all been prepared for the worst case scenario, which at the time was a possible hysterectomy and some blood loss. The woman had had numerous antepartum haemorrhages which were all closely monitored. We were relieved she had made it to the day of the elective ceasarean when there was adequate staffing and all preparations had been made.

I was feeling quite optimistic about the whole procedure and was attempting to relieve some of the anxiety for the family by being confident and relaxed.

Once in theatre, all the checks were done and the woman was given the general anaesthetic. The baby was delivered quickly, needed minimal assistance and was wrapped and taken out by myself to the waiting father. It was an emotional moment introducing dad to his baby. I was able to say that all seemed to be going well in theatre and we continued upstairs to the postnatal ward to do all the baby checks.

After a while, I went back to theatre to see how the woman was doing and to see how long it would be before she would be awake to breastfeed. As I walked in, I could sense the tension and the quiet efficient manner of the theatre staff and knew that something was wrong. Usually, in theatre there is a sense of joy as a newborn baby is delivered. Everyone is relaxed and enjoys the moment.

Almost at once I could see the amount of blood being called for and the amount of blood she was losing. I was willing to help but the theatre staff were amazing and had everything under control. People came from everywhere to help.

The things I remember are:

  • The porters running in with bags of blood after running up and down four flights of stairs and then immediately running to get more
  • Theatre nurses counting out bags of blood soaked swabs and the bags lining up around the walls of theatre
  • Anaesthetists and anaesthetic technicians being so focused, efficient and capable, not flustered at all, just getting on with all that they could do
  • General surgeons arriving and seeing four pairs of hands all trying to work in one woman’s abdomen.

I realised how serious the situation was when the emergency trolley was called for and the cardiac compressions were started. I remember standing glued to the wall of the theatre watching all this going on and trying to understand what everyone was doing and thinking. When the cardiac compressions started I thought this is it, we are going to lose her.

All I could think of was that a partner and a baby are going to be left by a loved one and before Christmas. I was thinking about them and was putting myself in their place and how devastating it would be if the woman died.

I felt disbelief that this was all happening before my eyes. I looked at one of the obstetricians performing the surgery. He glanced up and saw me looking horrified and he managed somehow to smile at me. I can’t tell you how much relief that gave me and somehow I realised that everything was going to be alright. No one was giving up yet and I prayed that the woman would keep fighting and live for her family.

Soon after this, through the amazing ability of the theatre staff, anaesthetists and surgeons, the bleeding was brought under control.

I found out later that the woman’s blood volume had been replaced three times. She had used the entire volume of blood available at the blood bank.

I then thought about what I was going to say to her partner when I get back to the postnatal ward. I was quite stunned by everything and it hit me how close the woman had come to dying as I walked back to the postnatal ward.

I went in to the partner and explained that everything had not been straightforward, but that the she was alright. I suggested that he bring some family in to be with him when the obstetricians were able to come and explain what had happened. My midwifery colleagues were very supportive of me and were really helpful with the partner as well.

I was in the room when the obstetricians came and explained what had happened and was also in the room when extended family arrived, a very emotional time.

The next few days were a bit touch and go for the woman, with further surgery and time in ICU. It was a huge relief to see her make a recovery and move back to the postnatal ward just after Christmas.

I went to visit the woman, her partner and the baby on Christmas Day with a bag of goodies to say I was thinking of them and as I handed the bag to her partner, there were more tears from both of us. About a week later the woman and her family went home.

I think of this family every Christmas and we have caught up a few times since they left the hospital. I am pleased to say they are all doing really well.

It has been an interesting exercise for me to reflect on this experience again. I think often about this experience when I attend caesareans. I don’t take the surgery as lightly now and have a renewed respect for our obstetricians, surgeons, anaesthetists and theatre staff.

Case 8.
Dr Ian Page, FRANZCOG

Technically I have been present at one maternal death and one very near-miss death. Fortunately, they both survived and being a pragmatist who moves on I haven’t dwelt on either case – except when the occasion to recount ‘war stories’ to trainees or other senior colleagues arises.

I was the ‘surgeon who smiled’ in Monique’s account of our patient with torrential haemorrhage from known placenta praevia but unknown accreta (see Case 7 above). Why did I smile? Heaven knows, but I guess it was to try and reassure her that, although the patient had almost exsanguinated and required CPR because of it, I still felt we had the situation under some sort of control. Two consultant surgeons, two consultant obstetricians, three consultant anaesthetists – to say nothing of a large support team – might suggest just how little control we really had and how near to losing the patient we were.

‘I felt gratitude to everyone in the hospital who had been involved in her care that morning and recognised (again) that I was just part of a large team.’

 

What was I thinking? Primarily relief, as my conservative tendencies had allowed me to observe quite significant bleeds on a number of occasions during her admission. It was clear that if I had operated on the patient during one of her nocturnal bleeds, I could not have had the support that let us keep her alive. I felt relief too that we had chosen a midline incision, rather than a Pfannenstiel incision.

I felt a little bit of vindication, as not all of my colleagues had been convinced by my willingness to watch and wait, with the patient having had quite significant bleeds, but it is nice under pressure to realise that earlier decisions turned out to be best.

Then I was scared as well – would she die? If she did, would I be viewed as negligent? How would I tell her husband? What would his reaction be? What would everyone else in the hospital think – after all, pregnant women don’t die any more, do they?

And what about my colleague who I was assisting? This case was her return to practise caesarean section, just to ensure she was still confident and capable. It wasn’t meant to be going so horribly wrong. Would she be alright and still want to help out with our staff shortages or would it put her off? Then how would we run the department?

All those thoughts went through my mind at different points during the procedure. None stayed for long, as there was haemostasis to achieve. What else could we do to stop the bleeding? Would tying off the internal iliacs help and if so, where were they? Thank heavens for the Vietnamese experience of one of my surgical colleagues, who I knew would be able to find them (though fortunately we didn’t need to do that).

Finally, after the hysterectomy and with a large pack in her pelvis, she seemed stable enough for us to close and for her to go to the intensive care unit for further excellent teamwork to help pull her through. I felt relief again that we had managed to finish the operation with her alive. I felt gratitude to everyone in the hospital who had been involved in her care that morning and recognised (again) that I was just part of a large team.

Now I will move on to a case of patient who suffered cardiac arrest, but whom we resuscitated. She experienced persistent bleeding after a casearean section under spinal anaesthesia, so for the laparotomy, she was put under general anaesthesia (GA). I went in to help my on-call colleague. The anaesthetic consultant gave the GA, on her last night on-call before moving to another hospital. It should have been straightforward, except for the patient’s unexpected allergic reaction to the anaesthetic agents. Severe bronchospasm and cardiac arrest ensued. Cardiac massage was necessary. Could I remember how to do it? Would it be successful? Would I be asked to use the defibrillator – never yet done that, would I do it correctly? Now I was doing it and we seemed to be getting some output. Gosh, it was hard work. After two minutes I needed a break. Fortunately, there were two senior house officers and my colleague present, so we could rotate the task. In between, was there anything else I could do to help? What would we do once spontaneous cardiac output had returned? We still had to stop the bleeding.

I felt more detached with this woman, probably because I hadn’t been responsible for the decisions around her care. The need to focus on rarely used skills probably stopped me thinking about much else at the time. But how was my colleague? She looked shattered. Was it alright to leave her on-call for the rest of the night, assuming the woman survived? Should I offer, or would that be patronising?

Well, once cardiac output returned, the bleeding restarted and we undertook a relatively simple and effective hysterectomy. The lady then went to ICU and I slept well. Going to see her the next morning was unnerving. She appeared to have had a major cerebral insult, as she couldn’t speak and had strange (athetoid) movements. What had we done? Would she recover? Nobody knew, so it was an anxious day.

‘What have I gained in practice? A deeper respect for the value of teamwork at all levels in these critical situations.’

 

The next morning I felt total relief. She spoke clearly, moved normally, remembered who I was and went home a few days later.

So those are the memories of my two near maternal death experiences. They are still quite vivid when brought out of memory, but otherwise packed peacefully away. What am I most grateful for, apart from the patient’s survival? That at the time I had plenty to do, to stop me worrying too much about the gravity of the situation.

Would I have benefited from better preparation about the impact on me of these situations? I don’t think so, but who knows for certain?

What have I gained in practice? A deeper respect for the value of teamwork at all levels in these critical situations. We all talk about it, but until I was involved in these cases I don’t think I really understood what it meant.

‘Communications become particularly important when there are staff shortages.’

 

Case 9.
Anonymous

In 2004, I ‘retired’ from acute O and G practice. I had never experienced a maternal death, well not a mother directly under my care, and in the last few months of acute call it crossed my mind a few times. Would that be how my acute call career would finish? How had I been so lucky to escape that most traumatic of maternity events over so many years of practice? I was not so foolish as to believe it was anything but luck that had saved me from this dreadful scenario. I felt blessed when I finished my last day on call and all were alive and well as far as I knew.

I left a fully staffed department (the first time in more than a decade) and felt confident that the ‘acute’ part of my O and G career was completed. I enjoyed sleeping at night and having weekends with my family but the ‘retirement’ was short-lived. Less than two years after my ‘new life’ began, the staffing situation became critical again and I volunteered to help out in the short- term. I felt apprehensive of course, so I went into theatre for a few sessions, reviewed my Advanced Life Support in Obstetrics (ALSO) manual a couple of times and performed a couple of elective caesarean sections with my consultant colleagues, to make sure I hadn’t forgotten it all. I also set the g[round rules. I must have a consultant available in town in case I needed help and there were some situations I would definitely call them, for example, anterior placenta praevia and caesarean hysterectomy. I wasn’t sure I still had the nerve to deal with massive obstetric haemorrhage.

‘During the event, there was so much to be considered surgically that little emotion intruded.’

 

My first day back on call, at the daily department handover meeting, my colleague cheerfully informed me he had a booked caesarean section for an anterior placenta praevia. ‘How about you do it and I assist?’ he said. This was a perfect opportunity to see if I would keep my nerve in the face of significant haemorrhage.

I met our patient for the first time in the anaesthetic room. Our patient was anxious but entirely aware of the seriousness of her surgery. She was starting a family late in life and was very happy to be bringing new life into the world.

The delivery was straight forward and easy. Nothing had changed about anterior placenta praevias. There was no way around or above the placenta so we went through. The accreta was not unexpected either. I recognised that easily, knew what we had to do without question and what’s more, there were two consultants operating so the decision-making was easy as it was shared.

The rest was the surprise: the cervical implantation; the ‘snake nest’ of huge pelvic veins; the haemorrhage that got worse rather than better with everything we did. It was a frightening but not uncontrolled situation. It was out of the ordinary, so we had to think, reason and go back to basic surgical principles. I initially thought perhaps this was happening because I was out of practice. When I realised my colleague was having exactly the same problems on the other side, I forgot about myself and concentrated on the job. We had to adapt to the situation and try different ways to get control. I felt we would be able to get the haemorrhage under control, we had the best possible help and everything was being done as it should. I heard the anaesthetic team say the cardiac output was low, so they were starting cardiac massage, and an almost detached thought occurred to me that this had the potential to be my first maternal death. Somewhere, an image of talking to the father flashed by but was dismissed to deal with later. There was much we could do yet. During the event, there was so much to be considered surgically that little emotion intruded.

In the next week or two, I spent time considering what we could have done differently and whether I had done my part adequately. Mostly though, my thoughts dwelt on how lucky we had all been. Firstly, the planning had been done well and I had not faced the situation alone at 3am. Secondly, we had such a great team in theatre: the anaesthetic team, general surgical staff, nurses, theatre orderlies, intensive care staff, and laboratory staff all performed their parts of this story to perfection. The key to this success was everybody knowing their jobs well, performing their jobs efficiently and calmly, and communicating well. We had functioned like a team and I was grateful for the many years we had all worked together, which meant we could trust each other’s expertise and therefore just get on with our own part.

Going back up to the ward to talk to our patient’s husband, I was feeling mixed emotions. I was so thankful to be able to tell him she was alive, but also very mindful that he needed to know she was still critically ill. I felt almost guilty to be happy about her being alive because we had come so close to seeing her die and her husband’s happiness would have turned to such sadness. That feeling dissipated as she steadily got better, but my image of having to tell a husband that his wife has died has never gone away. The image was there long before this event and has only been made more vivid by this experience.

I was also very grateful to be able to hand over care to the on coming team 24 hours later and eventually to the postnatal ward staff, who continued great emotional support for the parents. I needed recovery time. More valued support from the team approach.

This delivery is not an experience I want to repeat in a hurry, as I am still acutely aware how close our patient came to dying, but it still feels a privilege to have been a part of such a well-functioning team. It didn’t scare me away from acute obstetrics. I am still filling in the gaps on the roster most weeks, but I know there are some days when, if the same scenario occurred, we would not have such a good outcome for many reasons. I also know that should I ever have to deal with a maternal death, no matter how many years of experience I have, it will be difficult and it will take an emotional toll, but nothing like the toll on the patient’s family.

References

  1. Graham, WJ. Now or never: the case for measuring maternal mortality. Lancet 2002; 359:701.

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