In the November 2010 issue of The Female Patient, Dr. Steven Clark wrote about a tragic maternal death that should never have happened.
A 36 year old woman having her fourth baby was admitted to the hospital for a repeat cesarean section. Her first cesarean had been for a breech baby, and her second and third c-sections were simply “routine”. She had experienced a normal pregnancy. Her routine mid-pregnancy ultrasound had shown a low-lying posterior placenta, meaning that the placenta was in the lower part of the uterus, toward the mother’s back.
The woman received a spinal anesthetic, and her surgery was uneventful until the physician had reached the uterus and noted that there were some unusually large, distended veins visible. He made the normal low transverse incision into the uterus and partially through a placenta that was not posterior, but instead was directly under and to the side of the incision. He delivered the baby easily. It was then that he noticed heavy bleeding.
At this time, the normal procedure would be to deliver the placenta as quickly as possible and begin to close the uterine incision to help stop the bleeding. However, the placenta was difficult to deliver and began to come out in pieces, as it had grown into the uterus along the old scar site. As the physician continued to try to remove placental pieces, the heavy bleeding continued uncontrolled, and the anesthesiologist notified the doctor that the blood pressure was falling. The physician called for instruments to perform a hysterectomy, but as the instrument pack was being opened, the anesthesiologist reported the woman had no blood pressure and no pulse, and resuscitation attempts were begun. Although blood was transfused and a hysterectomy performed during the resuscitation attempts, the operating room personnel were unsuccessful, and the woman was declared dead. I can only imagine the horror and grief of the father who sat by his wife’s side while things began to go downhill, and then was escorted quickly from the operating room, only to be told later that his wife had died.
Dr. Clark discusses critical errors in this case, including the assumption that because the placenta was toward the back side of the uterus (posterior) when viewed on the 20-week ultrasound, there was no risk of accreta. Dr. Clark explains that a 20-week ultrsound cannot precisely locate a placenta or predict the amount of growth and whether the uterine scar will be involved. Other errors occurred during the surgery itself.
But what about the bigger picture here? This is a woman who had a potentially unnecessary cesarean birth for her first baby, because the baby was breech. In the United States today, nearly all breech births occur surgically. Despite evidence indicating that selected breech births can safely occur vaginally, most women are not even given an option of vaginal delivery.
The next problem is that after her first cesarean birth, she had two more ‘routine’ cesarean deliveries. Despite clear evidence that each subsequent cesarean birth increases the risk for placenta accreta, physicians and hospitals continue to place obstacles in the way of women who seek to have a vaginal birth after cesarean (VBAC). Despite an NIH consensus statement and ACOG position statement urging changes that will make VBAC more accessible for women, the reality is that this is not happening in most places. Women are still being forced to make the choice between accepting another routine c-section or traveling long distances and spending large sums of money in order to birth the way they choose. All the while, the maternal mortality rate is rising, and the CDC acknowledges that the dramatic increase in c-sections is partially to blame.¹
The only thing that will stop this madness is for women to stand up and refuse to be forced into the American birthing machine. Every woman, regardless of where and how you have chosen to give birth, needs to speak up and be a voice for the women who are dying needlessly from unnecessary surgeries.
1. Ob.Gyn.News, Policy and Practice. Mortality Trends Diverge. November 2010. Retrieved 11/16/10 from: http://download.journals.elsevierhealth.com/pdfs/journals/0029-7437/PIIS0029743710704092.pdf