Membership information 0800 561 9000
Medicolegal advice 0800 561 9090

Too much bleeding

01 May 2012

Mrs C, a 25-year-old mother of two, had an elective caesarean with her first pregnancy as that baby was breech, and she experienced a failed attempt at a VBAC (Vaginal Birth After Caesarean) with her second pregnancy. Her third pregnancy was uneventful and she was booked in for an elective caesarean section at 39 weeks.

Mr A, a staff grade obstetrician, carried out the operation under spinal anaesthetic. The operation was felt to be “routine” and there was minimal scarring from the previous caesareans. After initial observations concluded that everything was normal, the patient and her 3.5kg baby girl were returned to the postnatal ward. Three hours later, Mrs C started to feel unwell with dizziness.

Mr A was called by the midwifery staff, but as he was busy in the delivery suite, he sent his specialty trainee, Dr Q, to check on Mrs C. On examination, she looked pale and sweaty, although the visible blood loss per vaginum was minimal and the uterus appeared to be well contracted. She was, however, tachycardic (P110) and hypotensive (BP100/70 mm Hg).

Dr Q started appropriate fluid resuscitation, cross-matched blood and set up an oxytocin infusion and arranged for her to be transferred back to the delivery suite. As Dr Q was keen to get to his “protected teaching” session in the afternoon his notes were brief, but he had informed Mr A of his findings. As the midwifery staff were delayed by a change of shift, Mrs C was not taken back to the delivery suite for another hour and a half.

As soon as she was reassessed on the delivery suite, she had become more tachycardic (P120) with profound hypotension (BP70/50 mm Hg), and tachypnoeic with a respiratory rate of 28/min.

Only minimal urine was noted in the catheter bag and a decision for an immediate laparotomy was made. Mr A found 1.5l of blood within the peritoneal cavity and a tear at the left extremity of the uterine incision, extending into the broad ligament. This was successfully repaired, but Mrs C required a transfusion of three units of blood and stayed in the high dependency unit for 24 hours.

Both Mrs C and her baby were discharged home a week later and physically recovered well. However, Mrs C made a complaint against Mr A and his team for poor management of her condition. An internal investigation was begun.

Expert opinion on the issue was sought and there was agreement that although this was an unusual complication, it can be caused by the angle at which the baby’s head was delivered, and it should have been recognised and treated at the time of the initial caesarean section.

There was also considerable criticism regarding the delay in taking the patient back to theatre and the documentation that had been made in the notes. Following a face-to-face meeting where the case was discussed in detail, the complaint was resolved and no further action ensued.

Learning points

  • Although a caesarean section is a common operation nowadays, it is still a major surgical procedure. Mistakes do happen and complications do occur, even if you have done the same procedure thousands of times before.
  • The operating surgeon takes the ultimate responsibility for the patient’s outcome. Although it may be appropriate to delegate suitably trained personnel to review some patients, cases of pre-imminent shock need urgent assessment by appropriately experienced staff at the most senior level available.
  • Postpartum haemorrhage is an obstetric emergency.
  • It is important to remember the physiological changes that occur during a normal pregnancy (eg, increased circulating volume, increased cardiac output etc), such that the common signs of hypovolaemia (ie, tachycardia, increased respiratory rate, oliguria, narrowed pulse pressure, etc) may not become apparent until a significant amount of blood has been lost.
  • The abdomen can act as a “silent reservoir”, so the visible blood loss (ie, per vaginum) may not be apparent and hypotension is often a very late sign.
  • Postpartum haemorrhage may be caused by the 4Ts:
    • Tone – atonic uterus accounts for 70% of cases and should be treated with uterotonic agents
    • Tissue – check the notes that the placenta and membranes were “complete” during the delivery
    • Trauma – cervical/vaginal tears, ruptured uterus from previous scars, extension of uterine angles at time of caesarean section
    • Thrombin – clotting problems – often this can be a late complication after significant blood loss.
  • Although administrative procedures and teaching are important they should not be allowed to interfere with patient care.