Two Contemporary OB/GYN readers share their experiences with losing a patient.
When things go wrong on L&D
Dear Dr. Lockwood:
Sure, as a resident in New York City, I had been exposed to maternal mortality but in private practice in California, with almost exclusively private patients all had been well. Until, that is...
The patient was a Hispanic G5P4. The prenatal care was uneventful until she kept missing appointments. After phone calls without any results, I felt forced to write her a letter stating that unless she kept her appointments, I would sever our relationship and refer her to another facility.
The patient returned and went to term. I saw her in the office 2 days after her EDC when her cervix was 4- to 5-cm dilated. Having four kids at home, she wanted to be delivered that day. Before leaving the office, she said: “I will die today!” This, I felt, was a strange comment but coming out of the blue, it didn’t seem too relevant.
The patient delivered uneventfully a baby with nonspecific facial dysmorphia and after spontaneous placental delivery, she just kept bleeding. The placenta was intact, there was no cervical laceration. In spite of manual massage, oxytocin, and methergine, she just kept bleeding. I called for help from a gynecological oncologist and had the woman cross-matched. We took her to the operating room, tied the uterine arteries and did a hysterectomy. The patient just kept bleeding and eventually expired on the operating room table.
I met the husband and some family members in the hospital chapel. I felt guilty, I couldn’t explain what happened. The post mortem exam showed that an amniotic fluid embolus had led to disseminated intravascular coagulation. A few days later, I was hit with a lawsuit that settled for $12,000.
It turned out that the patient’s husband lived with a girlfriend, having abandoned his pregnant wife. The patient started drinking a quart of whiskey every day and the baby had fetal alcohol syndrome.
Even after reading the pathology report, I felt deflated and, like all my colleagues, have to live with the knowledge that things go wrong in ob/gyn in spite of our best efforts.
Eberhard S. Neutz, MDAnaheim, CA
Memorial to another mother
Dear Dr. Lockwood:
When a healthcare team reviews a maternal death, they often identify a missed opportunity. It may have been on the part of the patient or family, who lacked knowledge or awareness that would have led them to seek help sooner. It could also have been on the part of the health care provider.
I will never forget a patient who I had instructed about fetal kick counts. When I saw her on a Monday, she said “The baby has not been moving as much as you told me it should over the weekend and I have not felt it move today.” She had not called over the weekend because she did not want to bother anyone. Unfortunately, the infant was dead. We started an induction of labor and the mom suddenly could not breathe, and collapsed. Even with a resuscitative cesarean at bedside, we could not get her back. She had an amniotic fluid embolism. Mother and baby were buried together, the baby in her arms. I always wonder, whether she and her baby would have lived if I had stressed the importance of assessment and that mother had come in on Saturday. I will never know.
Sharon T. Phelan, MDAlbuquerque, NM