Tuesday, December 22, 2015

Investigation: Australian Mother Dies Giving Birth At Home

Note: This post is part of a series called "Birth Apologetics". "Apologetics" comes from the Greek and means "to speak in defense". (Often used in relation to defense of a particular idea or viewpoint, such as "Christian Apologetics".) In these posts, I will be taking blog posts and articles that are critical of home birth and natural birth and doing a critical analysis on the data and arguments. The idea is that if natural birth and home birth are safe for most women, arguments against them will have serious flaws.
Claims: Australian homebirth advocate Caroline Lovell suffered a cardiac arrest an hour after the birth of her second baby at home and subsequently died at a hospital. This is yet another proof of the dangers of homebirth and childbirth in general. A detailed news article is here, many of the facts cited in this post will come from this article.
Analysis: The first thing to understand in dealing with an individual case is what it can and can't tell us. The death of Caroline Lovell is one incident and can not be used alone as proof of the safety of homebirth in all cases. What it can tell us is what happened in her specific case and possibly whether a homebirth was a bad decision for her individually, or if in this specific case the midwives were some how lacking in the care they gave to her. It could possibly highlight problems within the homebirth and medical communities within Australia specifically. It can not tell us about homebirth as a whole, especially when we consider that other countries like the Netherlands and the United Kingdom which have a greater degree of cooperation between midwives and doctors than countries like Australia and the United States.
While this proved to be a very emotional topic in the media, we would all do well to remember that mothers also die in hospitals. For example, when a London mother died after an elective c-section at an upscale maternity clinic, there were no news reports about the dangers of elective c-sections or calls to outlaw elective c-sections, even though elective c-sections carry an increased risk of neonatal death and c-sections have an increased risk of maternal death as well. So I really feel that there is a double standard the media and the public have when it comes to maternity care.
However, examining the case of Caroline Lovell as an individual incident has definite merits. If something went wrong at the birth that could be prevented by better preparation on the part of the midwives or by giving birth in a hospital I think we need to know so that we can learn from it.
During 2015, most of the news reports have had little to say about the actual facts of the inquest or any new developments. Most have been speculation about whether the midwives called an ambulance soon enough or whether midwives were competent. Some of the more concrete data came from 2014. As of 2014, the inquest had narrowed the cause of death down to what the  experts think are the three most likely causes of death: postpartum hemorrhage, pulmonary embolism or amniotic fluid embolism. So let's take a look at each of these possibilities.
Postpartum hemorrhage: The news media has paid a great deal of attention to the possibility of postpartum hemorrhage and reports of Caroline Lovell having lost "litres of blood". However, when understood from a clinical standpoint, the possibility of postpartum hemorrhage becomes less likely. The inquest found that the midwives knew that Caroline had a uterine fibroid, but did not know that she had a history of postpartum hemorrhage from her previous birth at a hospital. It seems the records they received about the previous birth may not have been complete. Uterine fibroids do carry an increased risk of postpartum hemorrhage, though most women with uterine fibroids have uncomplicated pregnancies. Much of this depends on where the fibroid has grown. Fibroids in the pelvic area can be especially problematic, where as those in the upper part of the uterus tend to cause fewer problems. For a great discussion from several UK midwives on fibroids during pregnancy and labor, check out this link here.
In areas of the United States where midwives are allowed to attend homebirths, it is typical for the midwife to be required by law to carry pitocin with her to the birth to stop postpartum hemorrhage. (If you've seen The Business of Being Born, you might remember the New York midwife who talked about having pitocin ready before hemorrhage becomes a problem.) So while it's possible that Caroline Lovell was at an increased risk for postpartum hemorrhage, there are ways to handle it at home. Also problematic with this theory is the fact that the amount of blood she lost was 400 milliliters of blood and postpartum hemorrhage is generally defined as a loss of 500 milliliters or more. A minor postpartum hemorrhage is usually defined as between 500ml and 1000 ml, and a major hemorrhage is usually defined as a loss greater than 1000 ml of blood, so the amount of blood loss is not consistent with a severe hemorrhage.
Pulmonary embolism: A pulmonary embolism is when the pulmonary arteries of the lung become blocked, usually by a blood clot. A pulmonary embolism can cause cardiac arrest, which was the cause of death for Caroline Lovell.  Cardiac arrest from pulmonary embolism usually happens very fast and is typically fatal, and usually the cause of death is only discovered during autopsy. The symptoms of pulmonary embolism are consistent with the symptoms Caroline displayed after the birth such as fainting and loss of consciousness. In fact, pulmonary embolism is one of the leading causes of maternal death in the developed world. (As a side note, research has found that there has been a significant increase in pulmonary embolisms during pregnancy because of the increasing cesarean rate.) So there is a pretty strong case for death being due to a pulmonary embolism. If that is the case, a hospital may have been able to provide resuscitation if the staff figured out that a cardiac arrest was about to occur, however, this would be no guarantee. One study found that of patients who died suddenly and unexpectedly in hospitals, 80% had died from a massive pulmonary embolism. (Interesting trivia bit- If I am remembering right, the Ben Affleck/Liv Tyler movie Jersey Girl attributes Jennifer Lopez's character's death in childbirth to a blood clot.)
Amniotic fluid embolism: This is a rare, but very serious complication where amniotic fluid enters the mother's bloodstream. It is very hard to detect, even by doctors in hospitals and it kills the mother very quickly. In fact, there was a recent case of a mother dying in a hospital from an amniotic fluid embolism, even with a c-section. Amniotic fluid embolism presents with some of the symptoms that Caroline displayed, such as anxiety and circulatory failure. However, often the baby goes into distress as well and Caroline's baby did fine during and after the birth.

Conclusion: Of the three causes of death listed as most likely by the inquest, postpartum hemorrhage is treatable at home with the right skill and preparation. This is probably the least likely cause of death considering that Caroline Lovell's blood loss at autopsy was not within the range of a hemorrhage. A pulmonary embolism or amniotic fluid embolism is more likely, (with pulmonary embolism being the most likely based on the evidence given). However, even in hospitals, mothers die from these conditions. While this was a homebirth and the mother did die, there is strong evidence that even in a hospital she may still not have survived. This does not mean that the midwives were necessarily providing adequate care- this is a subject of much debate. But even with excellent midwife care or excellent hospital care, Caroline Lovell still may not have survived as maternal pulmonary embolisms remain frustratingly difficult to diagnose and predict, even with current technology.

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