This is part of a series of posts aimed at attempting to uncover possible causes behind maternal and neonatal mortality. Often, these deaths are said to be “unpreventable” or have “unknown causes”. The “Investigation” series of posts will delve into some of these cases and see what possible causes might be applicable so that greater awareness and education can hopefully lead to lower death rates for mothers and babies.
Case: A 36 year old mother with an uncomplicated pregnancy had a scheduled elective c-section at 39 weeks gestation for her third baby. The hospital is an upscale gynecological clinic in London that caters especially to celebrities, but has previously had a death of a mother due to negligence of the staff. The c-section is performed under general anesthetic because the mother had a phobia of needles. The c-section itself went well and the baby was delivered safe and healthy, but during recovery, the mother became restless and very stressed. She pulled the breathing tube from her mouth, but was not re-intubated afterwards. She was still communicating and acknowledged things being said to her, but was moving her limbs erratically and breathing rapidly. Her pulse was racing and she was starting to turn blue. Almost two hour after the cesarean, doctors are unsure of what to do, but eventually decide to send the mother to another hospital.
They call for an ambulance. The ambulance arrives about an hour after being summoned. At this point, it has been about three hours since the c-section was performed. The mother dies after transfer to the second hospital and two inquests are performed. The coroner reports that the mother died of acute cardiac failure of unknown cause, though presumably related to the c-section. A news article here details the events and the results of the inquests. Another one here has a few more details right after the death and before the inquests were finished. An article here has information on the hearing for one of the doctors. (He was later cleared of any wrongdoing. The verdict ruled that his performance had not fallen far below the level of competence of other doctors in his field and the facts of the case were insufficient to support a ruling of misconduct on the doctor’s part.)
Analysis: While two inquests on the death and a hearing have been performed, I think there are still some things to investigate with this case. A lot of attention has gone to the breathing tube, but there are a couple of other factors that could have been problematic. The first thing to consider is the general anesthesia. Death and heart attack are very rare risks of general anesthesia, though these are usually much more likely to happen in older patients or those with pre-existing conditions, not a healthy woman, even during pregnancy.
What might be a more likely case here is hypovolemic shock, which can occur after traumatic injuries or from a loss of fluids, including blood. In fact, the agitation that the mother was exhibiting could have been a sign of a class III hemorrhage, which causes hypovolemic shock. The mother’s rapid breathing and rapid heart rate are also indicative of hypovolemic shock. (The clinical terms are “tachypnea” and “tachycardia”, respectively.) Reports that she was starting to turn blue could also be indicative of hypovolemic shock. Untreated, hypovolemic shock can cause cardiac failure. Though little has been said about the possibility of hemorrhage here, I think it is worth considering that a hemorrhage could have gone undetected or untreated in this case.
We know the doctors were unsure about what was going on, as evidenced by statements that they needed to come up with a diagnosis and that they had never seen anything like it before. So it’s possible they may have overlooked signs of failure and hypovolemic shock. Failure to monitor a mother after a c-section has happened before and resulted in blood loss and death. This was the case of Joanne Hatton, who died at another hospital in the United Kingdom when staff failed to carry out a blood transfusion that had been ordered and did not connect up the signs of organ failure with loss of blood. We do know that this particular clinic had been cited for failure to monitor another mother properly and that case resulted in death. We also know that the doctor who accompanied the mother on transfer to another hospital was accused of failing to give full and proper information to the transfer hospital about the mother’s condition and what had taken place at the clinic. So it is not out of the realm of possibility that a hemorrhage could have gone undetected. Pregnant women also have an increased volume and often the clinical signs of hypovolemic shock don’t become evident until a large amount of blood has been lost.
Another contributing factor to hypovolemic shock could have been inadequate fluid intake. Most of the time, women are advised not to eat or drink anything for 8-12 hours before a c-section. Low intake of fluids and dehydration can cause hypovolemic shock on its own in extreme cases. If the mother was hemorrhaging, dehydration could have potentially complicated her condition.
Conclusion: The symptoms reported here are consistent with hypovolemic shock and this could be the cause of the cardiac failure. It is possible that better monitoring and education amongst the staff could have prevented the problems seen here.