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A story appeared in the New York Post that presents a tragic opportunity to discuss maternal mortality right here in America. You’d think since we spend more per capita on healthcare than any country on earth, we’d have the best maternal mortality rate, but according to Amnesty International, we rank 50th. Stories like this one about a young woman who died after delivering her first child demonstrates some of the reasons why too many women die in America. It also demonstrates how desperately important the Maternal Health Accountability Act is to preventing other senseless pregnancy-related deaths.
Athena delivered her baby girl vaginally, attended by a 2nd-year resident. After delivery, the doctor removed the placenta by hand and commented, “Oh, it broke. It’s coming out in pieces.” She later charted, however that it came out intact and complete, a phrase that means the entire placenta came out in one piece. Over the next 12 days, Athena was twice evaluated for pain, urinary problems and bleeding. She was hospitalized, but sent home and told she was healing perfectly. No one suspected part of her placenta was left inside her, preventing the uterus from healing and causing infection. Not until her husband found her not breathing. Athena died.
We don’t know the specifics of Athena’s case. Like most maternal deaths, there are many contributing and in the end, often all that’s left are unanswered questions, a grieving, confused family and a traumatized healthcare provider. It’s easy to place blame, but in reality it’s rarely the mother or healthcare provider who carries the full burden of guilt. As Athena’s case demonstrates, it’s often the way maternal care is managed that’s largely to blame. Let’s look at some of the factors in Athena’s story:
Athena was delivered by a doctor-in-training. That’s not unusual, especially in teaching hospitals. Doctors and midwives have to learn and most vaginal births are fairly straightforward. A second-year resident has enough experience to manage a birth like Athena’s well. But medical students are trained under brutal conditions in the US. Had she been on duty for days without rest? Was she juggling too many other active labors?
As an ex-nightshift nurse, I know working when you’re exhausted is unavoidable, but it impacts your decision-making processes and increases the likelihood of mistakes. Exhausted, stressed-out residents sometimes have to practice skills they aren’t adept at, which leads to mistakes. And when you’re delivering one baby and other patients need you and pronto, you might take shortcuts.
She removed the placenta by hand. Normally, a healthy placenta detaches from the uterus and slides out the vagina spontaneously within 30 minutes (more or less) after birth. Sometimes they’re poky, sometimes they tear and sometimes somebody has to remove them manually. It doesn’t happen often, especially on healthy mothers, though that’s what happened to Christy when she hemorrhaged having her first baby. We wonder what might have happened if the doctor didn’t remove the placenta. Would Athena have died sooner?
The placenta broke. When a placenta breaks (also rare. It usually comes out in one piece), doctors make sure all the pieces are removed and fit together before they’ve completed that delivery. If 1/3 was left inside, it should have been obvious that a chunk was missing. Could that placenta have had an extra lobe? It happens. Why didn’t the supervising obstetrician double-check that placenta?
The doctor charted the placenta came out intact and complete. Was she mindlessly clicking boxes on the delivery checklist in the electronic charting system? Did she really think she’d gotten the whole placenta? The dangerous thing about electronic charting is, it’s easy to click the wrong thing.
Desiree Bley, MD, OB-GYN in Portland, Oregon says, “When it comes to modern charting, the art of description is lost to computer simplicity. We used to put pen to paper to describe patient care. It took considerable thought and we included details the computer never asks for. Nobody does that anymore. Electronic charting is the norm, but it’s primarily a billing tool. Unfortunately, it’s inaccurate enough, it can crucify you in court.”
Athena was never evaluated for a retained placenta. Maybe that’s because it wasn’t mentioned in her chart or because she didn’t present with classic symptoms like heavy bleeding. Maybe it’s because she was seen in the ER, not by her delivering physician. Maybe it’s because there was no plan for continuity of care during the postpartum period. Doctors did a spinal MRI, but no ultrasound, which would have shown that placenta piece loud and clear. Bley asks, “Didn’t anybody think peek at the uterus? A nine-centimeter piece of placenta is as big as my hand. They’d have seen it. ”
What about that doctor? Bley says, “That poor doctor is living a nightmare. She’s undergoing routine emotional battery by hospital review administrators and from her own sense of doubt and guilt. I’ve met more than one doctor who felt so demoralized by a mistake they never completed training or quit practicing. You think you’re helping a patient and a tragedy occurs. You can’t separate your identity from that.”
The factors that led to Athena’s death aren’t uncommon. Healthcare providers work through blind exhaustion under stressful conditions and the constant threat of reprimand if they screw up. They’re trained to chart by clicking pre-answered questions, not by writing accurate descriptions. Mothers don’t see the same providers throughout their care. Sometimes the ball gets dropped.
Tragically, some patients die even under perfect conditions. Some families file suit, which is an understandable response to shock and grief that makes someone accountable for their loss. Unfortunately, it also contributes to the American culture of defensive medicine and over-intervention. It’s why malpractice insurance is ridiculously high and why fewer doctors are practicing obstetrics. It’s why insurance providers can control standards of care, even when they don’t represent best medical practices.
The death of any mother is tragic and most are preventable. Perhaps the answers that come from examining this case will help save the next mother at risk of losing her life.
We send our condolences to Athena’s family and doctors during this time of confusion and loss.
Source: Every Mother Counts