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Sooner or later

01 May 2008

Mrs K, a 36-year-old secondary school teacher, was pregnant with her third child. She had no significant past medical history and no known drug allergies. Her two previous pregnancies were uneventful and both were delivered by elective caesarean section.

Mr H, consultant obstetrician, discussed the risks and benefits of both vaginal delivery and a delivery by caesarean section. He noted that Mrs K had undergone two successful elective caesarean sections in the past. Mrs K opted for another elective caesarean section and signed the standard consent form.

Mr H performed a caesarean section and delivered Mrs K’s third child in less than an hour. Mr H noted that maternal blood loss during the procedure was greater than average but there was satisfactory haemostasis. Consultant anaesthetist Dr P began a continuous infusion of oxytocin.

Mrs K continued to bleed once she arrive on the ward in spite of 0.5mg of ergometrine. Her blood pressure was 98/59mmHg and she received two units of blood. Mr H explained that uterine atony was the likely cause of Mrs K’s bleeding and assured her this was a common complication and that they should be able to manage it expectantly. The oxytocin infusion continued, as did blood transfusions for Mrs K in an attempt to control her hypovolaemia.

Four hours later, when the oxytocin infusion had finished, Mrs K was still bleeding. Her blood pressure was 89/55 mmHg, despite a total of five units of blood. Mr H saw Mrs K for the second time post-delivery and ordered another bag of blood and 0.25mg doses of carboprost intramuscularly every 15 minutes until the bleeding ceased. He asked to be informed again if this wasn’t successful.

After a total of eight units of blood and four doses of carboprost, Mr H decided to take Mrs K back to theatre. During laparotomy, Mr H realised his suspicions of Mrs K’s atonic uterus were well founded and gave Mrs K a 0.5mg direct intramyometrial injection of carboprost. The bleeding continued despite the injection and uterine compression and massage. When stepwise uterine devascularisation was also unsuccessful, and Mr H performed an emergency subtotal hysterectomy.

Mrs K made a good recovery but was left with some minor neurological disability. She began a claim against Mr H and the hospital.

Expert opinion

An expert in obstetrics and gynaecology who reviewed the case was highly critical of Mr H's management of Mrs K. He felt that the management of the case should have been active and aggressive, rather than the expectant management practised by Mr H. It owed more to luck than judgement that Mrs K did not die.

The claim was settled for a moderate amount to reflect Mrs K's pain and suffering.

Learning points

  • Postpartum haemorrhage (PPH) is an obstetric emergency and a major killer of mothers, particularly in the developing world. Management of PPH should be active, in terms of monitoring maternal wellbeing, diagnosis and treatment. This was patently not what occurred in this case.
  • Despite the poor management in the case, the settlement was still relatively small. Through sheer good luck Mrs K’s outcome was similar to that expected from a good standard of care. Settlements in clinical negligence claims are not based on what might have been, but to what extent the patient is left in a worse state because of the negligence.