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Ignoring the guidelines

01 January 2013

Mrs H, a 23-year-old professional photographer in her first pregnancy, was pregnant with twins. The pregnancy progressed without any complication, until week 36 when she went into preterm labour. Mr L was the obstetrician on duty. As the first twin was a breech presentation, an emergency caesarean section was performed under spinal anaesthetic and both twins were delivered in good condition.

Soon after the procedure, whilst still in the recovery room, Mrs H began bleeding steadily vaginally and became hypotensive. She was resuscitated with intravenous fluids. Mr L administered oxytocin with little effect, followed by insertion of misoprostol per rectum.

He did not follow hospital protocol for postpartum haemorrhage which advised the administration of ergometrine and carboprost if the bleeding continued despite the use of oxytocin. As the bleeding continued, Mr L decided to take Mrs H to theatre for an examination under general anaesthesia to identify the source of bleeding. In the meantime, resuscitation continued with blood products.

During laparotomy, the uterus was found to be atonic, but there was no rupture or evidence of any retained products of conception. Unfortunately, Mrs H’s condition deteriorated and she began to develop disseminated intravascular coagulation. Mr L reported this to the patient’s husband, informing him that "there were no options" other than removing the uterus.

It was impossible to gain informed consent from the patient as a consequence of her clinical condition at that time. Mr L proceeded to perform a hysterectomy. Mrs H made a satisfactory recovery from her surgery, but made a claim against Mr L for his management.

Experts were critical of Mr L, as he had failed to follow the hospital guidelines on the management of postpartum haemorrhage and secondly by not considering alternative surgical options such as internal iliac artery ligation or ligation of the uterine and ovarian arteries.

Furthermore, Mr L had not documented why he had not considered less radical intervention before resorting to a hysterectomy in such a young woman in her first pregnancy. The case was settled for a moderate sum.

Learning points

  • Postpartum haemorrhage remains a leading cause of maternal morbidity and mortality.
  • As part of good clinical governance, obstetric departments will have guidelines on the management of massive haemorrhage.
  • The management of massive obstetric haemorrhage should be included when practising emergency drills on the labour ward, as well as forming part of regular education for all staff that look after pregnant women. This would help ensure staff are familiar with local guidelines.
  • It may be justifiable to deviate from local guidelines in an emergency, but it is very important to document any reasons for doing so.
  • Women at high risk of postpartum haemorrhage should have a written management plan, including any prophylactic measures that need to be implemented. Multiple pregnancy is a risk factor for postpartum haemorrhage as a result of uterine atony.
  • The decision to perform a postpartum hysterectomy can be a difficult one to make as it will have irreversible consequences. It is good practice to discuss the decision with an experienced consultant colleague.
  • Women who have suffered a major obstetric complication should be offered the opportunity to discuss the events with a consultant obstetrician and senior midwife and be offered the necessary support.
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