When joy of birth turns to sorrow of loss
MEDICAL MATTERS:Maternal death is extremely rare in Ireland, writes MUIRIS HOUSTON
THE DEATHS of two mothers in childbirth in the Coombe women’s hospital earlier this month are extremely unusual. News reports suggest that both deaths, which occurred within 48 hours of each other, happened after the women had delivered their children by Caesarean section. It is a huge tragedy for the families of the deceased and is completely at odds with the joyful anticipation of a new arrival.
The news brought me back to my first night on call as a senior house officer in one of Dublin’s maternity hospitals. In the early hours of the morning the senior registrar decided to bring a woman to theatre for a Caesarean section after her baby showed signs of foetal distress.
The baby was delivered quickly and safely and, initially at least, the bleeding from the incision in the mother’s uterus was not unusual. However, within seconds this changed and she began to bleed heavily from a number of points. The registrar, now a respected consultant obstetrician, began to work furiously tying off the bleeding vessels with, it has to be said, limited assistance from her neophyte assistant.
Meanwhile, cross-matched blood was fed into additional intravenous drips set up by the anaesthetist.
We seemed to be winning until the mother’s blood pressure dropped sharply. Eventually we found another vessel, somewhat hidden from view; it was tricky to tie off but the registrar did a superb job and finally the situation stabilised.
Once the woman was safely on her way back to the labour ward, I remember sitting with my colleague and wiping the sweat from my face. We both knew it had been a close-run thing and I remember gingerly inquiring if all Caesarean sections were as challenging.
Of course, by the time I left the job six months later, I had learned the procedure was routine and usually anything but dramatic.
More than 9,000 mothers have children at the Coombe each year; out of 103,995 deliveries in recent years, there have been just five maternal deaths, aside from the two recent deaths. Significantly, none of the five deaths was directly related to the woman’s pregnancy.
Maternal death is defined as the death of a woman while pregnant or within six weeks of giving birth. The causes are classified as either directly linked to the pregnancy or as a result of a separate disease or event. Of those directly related to pregnancy, the following account for 80 per cent of maternal deaths worldwide: severe bleeding; infections; high blood pressure during pregnancy (pre-eclampsia and eclampsia); and unsafe abortion.
One cause of haemorrhage is antepartum bleeding, which occurs before labour and is due to either a low-lying placenta or a placenta that becomes partly detached from the wall of the womb. Postpartum haemorrhage is more common and occurs after the baby has been delivered, when the womb fails to contract adequately with the result that the mother bleeds heavily.
Untreated pre-eclampsia can cause stroke, seizures and acute renal failure with a consequent risk of death.
Maternal death from infection is rare in the developed world. Other causes such as rupture of the womb and deaths from anaesthesia during Caesarean section are also quite rare. But pregnancy is a known risk for clot formation in the leg; these clots can travel to the lungs causing pulmonary embolus, which can be fatal.
The indirect causes of maternal death include: pre-existing cardiac disease; cancer; complications of Aids; and road-traffic or occupational accidents. The maternal mortality rate for the Republic, defined as the number of maternal deaths per 100,000 live births, is one of the best in the world. It was six in 2008 and has gone as low as two in recent times.
It is almost certain that the recent maternal deaths at the Coombe will turn out to be a statistical “blip” when averaged out over a longer period of time. Nonetheless, they will be the subject of inquests, during which we will hear detailed postmortem results.
In the meantime, our thoughts and prayers are with the families of the two women as they try to come to terms with their loss.