An update to my last post on Maternal death.

UPDATE:

Since posting this on the death of Savita Halapannavar, a few more things came to my attention which add more context to this story. Initially I added them at the bottom of my original post, but Mac at Mulier Fortis pointed out that it wouldn't be picked up by RSS readers and so it might be worth putting the update in a separate post. Seems like a good idea, so here it is:

This article in the Hindu Times quotes the president elect of the Federation of obstetric and Gynaecological Societies of India, Dr. Hema Divakar defending the decision of the Irish doctors as being reasonable:

 Cause of death
 Delay or refusal to terminate the pregnancy does not in itself seem to be the cause of death. Even if the law permitted it, it is not as if her life would have been saved because of termination,” she said. “Severe septicaemia with disseminated intravascular coagulation (DIC), a life-threatening bleeding disorder which is a complication of sepsis, major organ damage and loss of the mother’s blood due to severe infection, is the cause of death in Savita’s case. This is what seems to have happened and this is a sequence which cannot be reversed just by terminating the pregnancy.”

Pain and infection

Analysing the situation, Dr. Divakar said: “Based on available information, Savita would have reported pain and infection and doctors would have indicated a miscarriage as the 17-week foetus may not have grown as expected. Its growth would have been deteriorating because of the infection. Having understood that the baby was not going to make it, the couple would have asked for termination. But as Savita’s infection may have required aggressive treatment at that stage, doctors must have felt the need to prevent complications. The usual [practice] is to meddle the least till the mother is stable.”

Asserting that it is wise to wait in cases with such complications at 17 weeks, Dr. Divakar said: “As per reports, the baby’s heartbeat stopped after three days. But that was expected.” 

The blogger Thirsty Gargoyle points out significant discrepancies in the various timelines of events which are being quoted in the press.

How has the Irish Times ran two conflicting versions -- one written, one aural -- of the same story, and not noticed that they contradict each other? Did Kitty Holland not notice, the second time she interviewed Praveen, that his sequence of events had changed?

How has nobody picked up on the fact that the sequence of events as described by the Irish Times, with Praveen as a source, and RTE, dependent on the hospital's viewpoint, are completely at odds with each other?

He also posts the timeline of events from Galway University Hospital which RTE reports on here.

Sunday 21 October:

Patient presents to hospital complaining of backpain.

Patient is admitted with a threatened miscarriage to the Obstetrics and Gynaecology Unit.

Monday 22 October:

After 24 hours of admission, antibiotics are given.

Tuesday 23 October:

Patient transferred to theatre.

Spontaneous miscarriage occurs.

Wednesday 24 October: 

Post-theatre patient is transferred to Intensive Care Unit.

Patient remains unwell.

Thursday-Saturday 25-27 October:

Patient continues to deteriorate.

Sunday 28 October:

Patient dies in ICU.

Post mortem examination ordered by coroner.

One of the commenters on my last post, Katie, asked about normal management of pre term premature rupture of membranes (PPROM).
With the important caveat that I am not an expert and I don't wish to add to the speculation before the facts, here is the answer I gave Katie according to my understanding:

 The central issue here appears to be whether or not the patient was showing signs of infection. If not then it is quite typical, as I understand it, for management to be expectant. That is, to wait for labour to start, but usually within a given time frame and with close monitoring for signs of chorioamnionitis.

If infection is present, there seems to be agreement in most places that induction would be normal management. However, as the article in the Hindu Times I linked to above says, it could be that inducing a woman already in septic shock may dramatically worsen her condition.

This is why I say that crises such as these are managed on a case by case basis, taking a number of other clinical factors into account.

Here's one article I found which explains management quite clearly..

 This quote refers to PPROM in the second trimester, which was the stage of pregnancy that Savita was at. It explains that, in the absence of infection, such patients may even be managed at home ( actually, in some ways this may be safer, from an infection control point of view, because hospital environments are full of foreign pathogens):

"Chorioamnionitis occurs in 30-60% of patients with second trimester PPROM. The risk of infection increases with duration of ROM and an AFI less than 2.0 cm. Frequent exams are necessary to ensure maternal safety. Patients need to be educated about the warning signs of intraamniotic infection and need to take their temperature 3 times a day at home. These patients do not need to be cared for in the hospital if no evidence of vaginal bleeding or infection exists. They may consider admission for inpatient management at 24 weeks, which currently is considered the point of viability at most institutions."

A couple of other things. There have been frequent references to the open cervix being akin to "an open head wound". The state of the cervix is more significant in terms of the inevitability of miscarriage. It is the torn membranes that pose a risk of infection.

Secondly, many commenters have said that the doctors ought to have agreed to termination of the pregnancy because the patient asked for it. But patient request, particularly in extremis, is not always good grounds for making important decisions about clinical management.

A personal anecdote here:
In September 2007  I was in labour with twins. I had been told that Olivia, "twin one", was dead.
Because we didn't know what had killed her and whether twin two might be next, I elected to have an emergency caesarean section. The prospect of labouring naturally, knowing that I would have to birth my stilborn baby first and that the living one might be at risk, was too frightening.
Traumatised and in shock, I'm ashamed to say that at this point I begged the registrar to sterilise me.
She refused saying that I wasn't in a fit state to know my own mind on the matter..
I insisted that I did and pleaded with her again, saying that I knew for a certainty that I couldn't go through this again.
She firmly refused.
Days later I was longing with all my heart to be pregnant again and grateful beyond words for her "no".

Maternal Death: When fools rush in. (UPDATED)

The desperately sad death of Savita Halapannaver along with her unborn daughter at only 17 weeks gestation is a grim blow to her poor husband and a salutory reminder to the rest of us that life, even with all the technological and medical advantages that our generation enjoys, is still fragile.

There will be an enquiry and an inquest and until then, the staff involved will not be able to speak about what happened. All we have to go on by way of information is the account of her devastated husband.

One can only imagine how dazed, confused and angry he must be. How does the human heart begin to absorb such a thing? To lose one's young wife just as she was looking forward to motherhood is a shattering reversal of fortune. It is completely understandable that he should be angry. Necessary even. Everyone's heart is moved to pity for the man who has had his life, his hopes and his love ripped away from him.

But as a midwife, my thoughts are also with the staff at the hospital where she died. I know that they will be in shock and grief. Maternity care is wonderfully fulfilling and challenging, it is also hugely demanding, physically, mentally and emotionally. No crisis is straightforward, even with the best clinical protocols in place, critical issues are dealt with on a case by case basis. Sometimes mistakes are made. Genuine errors, with catastrophic consequences.

What happens when you make a mistake at work? All responsibilities are stressful and burdensome at times, but imagine if your mistake potentially cost the life of two people who depended upon you for their well being?

I still recall with a chill the time when, as a student midwife, I infiltrated a perineum with lignocaine, anticipating the need for an episiotomy. We had learned how important it was to draw back the plunger to make sure the needle hadn't entered a blood vessel since, we were told, should lignocaine enter the bloodstream it could bind irreversibly to cardiac muscle and cause the heart to arrest. For some reason, amongst all the other dire warnings and 'thou shalt nots' my imagination was particularly seized by this picture. I turned over in my mind the horror of such a calamity happening in so banal a way.

So when, just after depressing the plunger, the labouring mother gasped weakly that she felt odd, that she couldn't see properly and was finding it hard to breathe, I was stricken with the thought that I had failed to do that vital check. I felt as though my brain was on fire and the joints in my knees literally began to give way. All I could think was that I had killed a mother just as her baby was entering the world.

Happily, it soon became apparent that I had done no such thing. The mother had merely been hyper ventilating and had become light headed. But I couldn't speak for fright. I handed over the scissors to the midwife who was with me. She took one look at my ashen face and understood that I had lost my nerve, but she didn't realise why until afterwards in the staff room when I told her how the bottom had fallen out of my world in that moment.

A friend of mine, tired towards the morning, having spent the entire night shift with a labouring woman, made an error that could very nearly have been fatal for the baby. A shot of pethidine for a multiparous woman in transition, very nearly fully dilated and ready to push her baby out, having laboured with no pain relief was now asking for something to get her over the final hump. After delivering the shot, he double checked the syringe and realised that instead of pethidine he had given her syntometrine. A drug which is given just as the baby is emerging, the effect of which is to cause the uterus to clamp down and cause the placenta to detach from its wall. A potentially catastrophic error of enormous magnitude. Obviously, until the baby is actually born, the last thing you want is the placenta to detach itself from the uterine wall.

Happily, unlike me with the lignocaine, he kept an extremely clear head. He quickly examined the woman, "encouraging" the cervix, now almost fully dilated, to open up all the way, and encouraged the mother to give a big push. This being her third or fourth labour a few pushes were all it took to get the baby out and everything ended well.

On another occasion I attended one of the monthly meetings held on labour ward where obstetricians highlighted some of that months difficult cases and peer reviewed the clinical management decisions. What went well, what some would have done differently etc.

One of the team put a picture on the overhead projector of a chubby stillborn infant. I stared at the greatly enlarged picture on the wall waiting for the awful account of whatever obstetric disaster had led to this. I remember the silence in the room as he paused before saying "This, is a healthy term infant, delivered by forceps at 40 weeks and 3 days. The only thing wrong with him...is that he is dead."

The senior registrar who had delivered the baby was in the room, with this evidence of her catastrophic failure before her, and us. And I felt the crushing weight, the awfulness of that. It seems that she had been called out in the night to this woman who had failed to progress in labour, attempted a somewhat difficult rotational forceps delivery, and in doing so ruptured the woman's uterus. The baby died and the woman had a life saving hysterectomy. Left with a dead baby and no hope of getting another one.

I don't know the extent of the senior registrars responsibility. But I shudder when I imagine how she must have felt.

So when the news of the hapless Savita's death emerged, my thoughts, as well as being naturally with her husband were also with the team of people who had been caring for her. No doubt they are shocked and traumatised too and many will be reproaching themselves for failures, real or imagined.

Despite the fact that actual hard information about this case is very thin on the ground, the story was quickly spun into a narrative in which she died because she was denied an abortion by staff so blinkered and hamstrung by religious dogma that they refused to act to save her life.

That she died owing to the denial of abortion on the grounds that Ireland "is a Catholic country" has been uncritically accepted and enthusiastically exploited by pro choice groups apparently seeking to make political capital out of this human tragedy. With the facts still far from clear, there has been an unseemly rush to appropriate the deceased young mother as an abortion rights martyr who died at the hands of Catholic doctors claiming that they couldn't help her because this was a "catholic country"

There are far more questions than answers at this stage, and no doubt there will be a proper enquiry which will thoroughly scrutinise the clinical judgements made in the management of this case. It is beyond grotesque however to witness the exploitation of such a desperately tragic circumstance by those who are evidently much more interested in abortion rights than sound maternity care.

A few sound bites from the subsequent feeding frenzy among the clear eyed apostles of evidence and reason:

Richard Dawkins tweets that " Irish Catholic bigotry kills woman"

Another shrieks that " Ireland's Roman Catholic Church murders Savita"

Yet another announces that a " European hospital tortures a woman to death over ideology. And adds for good rhetorical measure: "this is gender based violence"

The inflammatory and irresponsible title of this post "Woman dies in hospital because of catholic dogma" ( by a blogger whose stated aim is to promote reason, critical thinking and ethical atheism ) set the tone for the  hysteria which played out in the comments.

I weighed in with the caveat that all the information was not available. No one can assume to know all the facts in advance of an enquiry.

At this point it isn't at all clear whether Savita's E.coli infection had even been identified until it was already a galloping sepsis. In one of the audio interviews with the husband he seems to say that infection was initially ruled out and that she was given prophylactic antibiotics when she was admitted on Sunday.

That night she was told that she would lose the baby. On Monday she asked for an abortion because she found it distressing listening to the heartbeat and "just couldn't take it". Mr. Halapannaver doesn't say that she or anyone felt, at this stage that her life was at risk if management continued expectantly, it seems here as though her request for an abortion was in order to bring her distressing circumstance to a close.

Her husband Praveen describes her as being 'fine', albeit distressed, until Tuesday evening when she started to feel ill. The following day she is taken to theatre, and after that her condition rapidly deteriorates. He describes her as being critically ill on Thursday and on Friday Praveen is told she has an E.coli infection and she is put on dialysis. By Saturday she is in multi organ failure and on Sunday she dies.

In interviews elsewhere it appears that she didn't start antibiotics till Tuesday. Who knows what that means. Perhaps by Tuesday the lab report had come back and shown that she had an E.coli infection which was resistant to the antibiotics she was already on and her presription was changed?

In the absence of evidence of infection, abortion is not a typical treatment for pre term labour with ruptured membranes. Antibiotic prophylaxis is, as is very close monitoring ( bloods, temp, physical signs etc) . There is no real evidence yet that abortion would have made one bit of difference to the sad outcome in this case. It seemed to me as though pro choicers had seized upon this story to dishonestly claim that abortion would have certainly saved her life and that the decision of the team managing her care had been skewed by blind adherence to religious dogma.



I said that such a scenario as Savita presented with is not completely unusual and whether she aborted or not, what she most needed was presumably close monitoring and timely, effective prophylactic antibiotics. There are a number of similar cases of women who have also died of septicaemia following legal abortion. Had this unfortunate woman aborted, precisely the same risks of infection would likely have remained.

Here are some of the responses. I put them here because I think it is instructive how quickly the debate moved to personal attack. It demonstates the ugly tendency among those with political agendas, to cynically exploit a terrible human tragedy, beefing up the facts in order to score goals and, in this case, fashion a stick with which to beat pro life Ireland.

"I will never understand why is it so easy for christians to kill a full grown woman, with life, relationships, dreams, future"

"Claire, It worries me that you are a midwife. That actually proves how much an ideology can even blind a supposedly “knowledgeable” person. it’s quite telling that you insist on calling the fetus “baby”." ( Um, what kind of weirdo thinks that it's sinister to refer to a woman's unborn baby as a baby? Can you imagine your midwife or doctor referring to your 'fetus'?)

"Ahhh, a wonderful, pro-life troll with nothing better to do with their life than to verbally admonish a) a dead woman for even DARING to ask for the help denied to save her life and b) spout out more pro life rubbish that caused her death in the first place?"

"Be honest, Clare, you don’t care about the women, all you care about are the fetuses. You don’t care that what happened here stopped Savita’s beating heart. And, to be blunt, you are cruel and heartless."

"Everybody who treated her should be thrown in prison for murder. They knew exactly what would happen."

"Clare’s internalized misogyny is sad. Her gleefull recitation of misogynistic talking points designed to obscure the fact that catholic dogma straight up murdered this woman is expected."

"Clare’s obvious joy at the death of an innocent woman is sickening."

This gem stood out:

"Clare When you die the world will become a slightly more caring, humane place. Please hurry."

Humanity and kindness abounds among the hysterical Apostles of Tolerance! Wishing for the early death of a mother of six children is a strange way to demonstrate concern for the early death of the mother in question here.

That Savita has been claimed as an abortion rights martyr by pro choicers eager to make inroads into Ireland's abortion laws is simply repulsive to me. The protest they held outside the Irish embassy in London would have looked a damned sight more sincere were it not for their deafening silence over the death by post abortion sepsis of Jessie Maye Barlow . Or that of 18 year old Manon Jones.

In London alone, more than 100 mothers have died in childbirth over the last five years. That's more than 100 mothers who died in our capital city, none of whom were honoured by a single candle lit vigil outside an embassy, or Parliament, or the Department of Health as far as I'm aware.

While the UK trails at a pitiful 23rd in the global ranking league tables for maternal mortality, Ireland sits way above us in 6th place. Giving them ample reason to justifiably say that they are one of the safest countries in the world for a pregnant mother.

Hello abortion rights campaigners angrily denouncing Ireland's religiously motivated "killing" of women. Can you see perhaps why your sudden interest in Savita alone seems more than a little disingenuous to me?

Sepsis is now the leading cause of maternal mortality in the UK. So it's more than a bit rich when Brits congregate outside the Irish embassy in London to lament neglect of women in Irish hospitals.

It would be nice to see an outbreak of reason among the soi disant "Brights" such as Richard Dawkins and co. How about they wait for the results of the enquiry and set about getting our own house in order before lighting the torches and galvanising the mob for a lynching?

UPDATE:

I have moved the update to a new post here.

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