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I’ve been writing about safe and effective maternity care for years and direct a coordinated national effort to transform maternity care, but this is a post where the political gets personal.

Last weekend, I attended the birthday party for the sweetest one year old. There were all of the typical rituals – hands and face covered in cake frosting, a pile of toys and new clothes, and a tuckered out babe falling asleep as the party wound down. But this birthday was bittersweet, because it also marks the anniversary of a crisis that very nearly cost the life of this child’s mother, my friend.

Nine days after giving birth, rather than gazing with equal parts sheer love and sheer exhaustion at her baby, my friend – we’ll call her  Near Miss Mom – was unconscious in an ICU on a ventilator, recovering from the emergency hysterectomy and blood transfusion that had saved her life.

I’d say Near Miss Mom had become a “statistic” but we keep no statistics on near miss maternal events, even though multiple agencies and organizations have sounded alarm bells about the rising rate of maternal mortality and have cautioned that for every maternal death, there are many more near misses. Legislation just introduced in the House by Representative Conyers would, among other provisions, establish steps toward a standard definition and routine counting and reporting of maternal near misses.

Because if we’re not counting near misses, we’re not systematically learning what our health care system could be doing to avert them, and for that matter the deaths that do occur. A  just-released report from a state-wide, multi-year investigation of maternal deaths in California found that 38% were likely to be preventable. Let’s take Near Miss Mom’s case, which almost certainly could have been averted far before she was so close to death.

Near Miss Mom almost died:

  • Because her postpartum discharge teaching didn’t include anything about how to recognize and get help for postpartum hemorrhage – even though she had three major risk factors for hemorrhage
  • Because the hospital had no protocol to systematically deal with late postpartum hemorrhage – even though the largest maternal quality collaborative in the country has a freely available toolkit for that
  • Because no one was measuring her blood loss while she sat in the ER on two different occasions for hours at a time – even though she was sitting in a pool of blood so deep it was pouring over the tops of her thighs and the sheets had to be changed more than once
  • Because she had to “wait in line” for the MRI and then wait some more for someone to interpret it – even though there are less sophisticated but equally effective methods to rule in or out the rare defect they were concerned about.
  • Because no one in the ER communicated the severity of her condition to the obstetrician who was “overseeing” her care – even though the OB was in house and could have visited her herself. When she finally reached Near Miss Mom’s bedside, it didn’t take her long to call a Code Red and assemble the team for the emergency hysterectomy.

Patient safety advocates and experts will see some familiar themes in this list – lack of standards and accountability, poor communication, system failures – and although  maternity care is the most common reason for hospitalization, how often do we think of hospital safety as it pertains to maternal health? My best guess is that the disconnect arises from the fact that childbearing women are usually healthy and therefore (physically at least) resilient. Unlike patients who enter the hospital sick or injured, it can take many errors and system failures to actually kill a mother. Yet this means the problems can get so immense and intractable before we see the accumulation of harm. That adds up to a lot of women coping with preventable injury, illness, and emotional trauma at the same time that they should be experiencing the joys and taking on the challenges of new motherhood.

I recently asked Near Miss Mom recently what it felt like to be bleeding to death. Her response wasn’t what I expected, but knowing what I know of the fractured and fragmented system, it’s not surprising.

“Honestly, I don’t know. I was so overwhelmed with the lack of care in the ER and by my OB practice that I wasn’t really thinking about bleeding to death. But why would I? No one thinks about that as a possibility. I mean, I assume no one does. Why would we when we have an expectation of proper care? It wasn’t until I was admitted and in my room, and the OB was asking why the blood was taking so long that I realized I was potentially screwed. My first thoughts were my daughter and husband and would I be there for them. Right after that I went into shock so not much time to truly think about actually dying. I mean, dying? Really? I knew I was bleeding all day but I never thought they would let me reach the point of near death.”

Since the moment Near Miss Mom began her recovery, her most fervent hope has been to help make sure this doesn’t happen to any one else ever again. Unfortunately, when we met with her OB team after the fact, they declined her offer to be involved in quality improvement efforts because those matters are confidential. They also told her that she would need to meet separately with the ER team because they run their own quality improvement programs and the OB Department can’t influence what the ER does (if that’s not silo thinking, I don’t know what is). Then they asked if either of the companions she brought with her for support and advocacy were lawyers and, just for good measure, billed her insurance company for the time spent meeting.

Near Miss Mom has been trying for a year to use her story to spark desperately needed improvements in maternity care, but has encountered road blocks at every turn. Even writing down her story has been too much at times, as she deals with still incomplete medical records, post traumatic distress triggers, and the time and energy constraints all new mothers face.

But she is ready to make change and as her first public acts of activism, Near Miss Mom will join a delegation to get lawmakers to sponsor the Maternal Health Accountability Act and she will use her story to ask others to donate blood in the month of May to honor Mother’s Day. Near Miss Mom writes,

“Without the people who donated blood, I would not be here. It wasn’t only the surgery that saved my life. It was the blood. Eleven strangers saved my life. And saved my baby’s mother.”

I will be at Near Miss Mom’s side for both of these courageous acts of activism. We hope others will do the same in their own communities. Will you join us?

Amy Romano, MSN, CNM, is the Project Director of the Transforming Maternity Care Partnership coordinated by Childbirth Connection.

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37 Responses for “A Mother’s Day Manifesto: Blood, Toil, Tears, and Sweat”

  1. steve says:

    Vital signs and a few quick return labs should have been enough to determine the severity of the bleed. An experienced clinical just looking at a patient is often enough to get things rolling. Your protocol may help, but this sounds mostly like an ER miss.

    Steve

  2. Greta says:

    Thanks, Amy. Great article!!!

  3. L. says:

    So – because there is no way for the patient to get what she really wants – systemic change to increase safety for all patients – she has to sue, right? When you doctors talk about the need for personal responsibility and accountability – do you include yourselves in that mandate? Or, is that just something for patients?

  4. NMM says:

    I was under my OB’s care as soon as I entered the ER as the OB practice I went to is the hospital’s. So ER miss? Yes. But OB practice miss? YES.

    During my first ER visit, the head ER doc said “If it were up to me, I’d release you. You’re just cleaning out. But I have to defer to your OB because you’re under their care.”

  5. Tim says:

    “I was under my OB’s care as soon as I entered the ER…”

    No, you weren’t. You might argue that you should have been, or that some future legislation might make it true, or you might litigate it into existence, but under existing conditions in American health law you were not.

    • NMM says:

      When I asked who’s care I was under during my ER visits, my OB said “Me.” I was quite surprised by this as I thought I was under ER care and saw umpteen people but never my OB.

      Health law be what it may, this is all I have to go on.

      • RN says:

        I would argue that you were under the OB’s care on paper only. If the OB was not being properly updated by the ER nurses, and didn’t bother to come to the ER and actually provide any type of assessment or care, then you weren’t really under his care. You were under the care of ER doctors who probably had far too many patients to give good care to any of them, and nurses who routinely see “vaginal bleeding” that turns out to be a boring old period, and who are overworked and quite frankly usually very unfamiliar with anything pertaining to pregnancy including identifying normal or abnormal postpartum bleeding. Your OB may have been in charge on paper but if he didn’t bother to come and actually do any work then someone else was forced to run the show. Or nobody was, because the OB assumed that the ER docs were taking care of you, and the ER docs understood the OB to be taking care of you, and you fell through the cracks.

        I’m glad you’re okay. I’m sorry this happened to you.

  6. Heather B says:

    Tim, whether or not she actually was under her OB’s care is less of an issue than the ER doc informed her that she was. Don’t you think that’s a concern in and of itself? Did he lie to her? Or did he truly believe it? If he was lying, was that to avoid possible future litigation? Have we, with lawyers, blackmailed our doctors into providing inferior health care for our mothers? Mothers can’t be expected to have an intimate knowledge of US health law. Or at least they SHOULDN’T require an intimate knowledge of US health law to receive good care. And anyway, maybe it’s a good thing the ER doc thought (or pretended) that she was under her OB’s care, because if that doc had sent her home, she wouldn’t be a near miss mom, she’d probably be dead.

    Rather than condemn the woman who’s hospital experience was truly traumatic (that’s called blaming the victim, by the way) when she expresses a desire to improve the system that nearly failed her, maybe you should turn to the people who ACTUALLY did something wrong. By the way, I don’t know if you’ve ever experienced true trauma in your life, but it’s indescribably difficult to talk about, or even think about. Near Miss Mom is trying to improve things for other women at a great personal sacrifice that you clearly do not understand.

    Those of us who HAVE experienced trauma at the hands of the US medical establishment stand with Near Miss Mom.

    • Tim says:

      Heather,
      Good questions, all. Yes, it is a concern that the ER doc told her she was “under the care” of the OB doc; I’m sure he (he?) believed it and in fact those words mean something different to him than they did and do to her. She was under the OB’s care for the pregnancy; she was under the ER doc’s care for the bleeding.

      I agree mothers should not need to understand health law to receive good care — but that’s not actually our subject now. Our subject now is whether activists need to understand the American system. If NMM just wants to tell us her story, she’s done that; but she seems to want to do more than that.

      “Have we, with lawyers, blackmailed our doctors into…inferior care…?”

      Well, “we” have certainly produced an environment where the expected behavior is “silo thinking”. I’m not saying it is right, just pointing out that it should be expected by anyone who understands human incentives. I don’t like the way you put it, because that would exonerate the doctors and blame the lawyers. The lawyers are wrong, the culture is wrong, many individual doctors are wrong, and all that is because the incentives are wrong. The people in the system (except for shining exceptions) will never act differently in response to…appeals to act differently.

      I didn’t intend to condemn NMM, but to point out to her that there is a part of her own story she does not understand. Her effort to “improve things for other women at a great personal sacrifice” — which I applaud, though I understand it as little as you suggest — could only be helped by understanding the system she is trying to change.

  7. Amy Romano says:

    I’ll reiterate one line from the post: “They also told her that she would need to meet separately with the ER team because they run their own quality improvement programs and the OB Department can’t influence what the ER does (***if that’s not silo thinking, I don’t know what is***)”

    Whether it was the ER doctors or the OBs who were overseeing her care, they were both involved from the get-go and should have been functioning as a reliable team. Furthermore, the patient should know who is the head of that team so she can summon them to her bedside if the situation is urgent.

    My experience as a clinician has been that the ERs don’t want to deal with anything OB-related but the L&D floor doesn’t want their rooms filled with women having prenatal or postpartum complications that could be dealt with in an ER. Meanwhile, 1 in 20 new moms will present to an ER within 6 weeks of giving birth, according to a 2010 study from the HCA network of hospitals. That doesn’t include the many prenatal ER visits. Coordination among hospital units was called out as a major area of focus in the just-released California report of maternal deaths, 26% of which occurred in emergency departments.

    Different EDs will arrange care differently depending on local circumstances, size of the facility, etc., but there should be a clear chain of communication and protocols to deal with common obstetric complications, beginning with hemorrhage, which is the most common emergent complication that ERs see. This ER didn’t even have the basic drugs for PPH immediately available and had to order them from the pharmacy. Not that anyone ordered that drug for Near Miss Mom until hours into her second ER visit. While they were waiting for the pharmacy to deliver it, she went into shock.

  8. Amy Romano says:

    Thank you Heather B.!

  9. Sktaz says:

    Where is the outrage from physicians? Where are all the docs who decry the litigious state of medicine who believe we need a better way? More than one doctor failed in his/her duty to this patient it would seem.

    Is this a situation of “everyone makes mistakes. oh, well – sucks to be you?” How many NMM’s or even dead moms are acceptable as the cost of doing business? I assume you have a number in mind. Why not share it?

    The silence on this post from the physicians is very telling. Hard to push this one off as the fault of the patient? Maybe she was obese. That would let you all off the hook, right?

  10. steve says:

    The siloing is a major concern. When we have a critical event everyone from every specialty is required, not asked, to attend. Post-partum hemorrhage, indeed hemorrhage in general, occurs often enough that I am surprised they did not have a protocol for this. Was this a trauma center?

    Steve

    • NMM says:

      No, not a trauma center. I’m amazed there was no protocol for PPH. After the event, I did ask if there was one and did not receive an answer.

  11. mj says:

    This story really touched me. I too started bleeding more then was normal at 8 days post c.s. delivery. And I also got terrible service at the hospital. I am so very grateful that the bleeding stopped on it’s own (probable retained tissue). Being at the hospital, where I thought I was going to feel safe, was terrifying when met with no care and even hostility. (I think the head nurse was angry because I had called 911 and then driven myself and the 911 operator wanted the nurse to confirm I had arrived. Not sure why this pissed her off, but she referred to it.)
    So glad near miss mom is alive. Glad to see so many rallying to improve maternal health. It needs it.

  12. J.D. Kleinke says:

    Unfortunately, this is a classic of the genre, not of maternity care disasters, but of health system failures.

    The very fact that some readers on here aren’t even sure who was at fault – the L&D unit or the ER – speaks volumes about how lost we are in complexity and ambiguity, and how broken the entire system really is. The obvious legal answer is the ER: in a hospital, possession of the patient is 9/10th of the law, hence the importance of “turfing”; but the real answer is the entire maternity care non-system, in this case, an L&D that turfs post partum patients out the door and into the abyss. No follow-up, no data feedback loops, no aftercare, nothing. Why not? Because who’s paying for those services? No one. (Except that all of us actually pay, indirectly, when these horror stories bounce all the way back into the ICU.)

    While we are all supposedly racing to “wire” our health care system with EMRs, data exchange, and ACOs, fee-for-service medicine continues to rule the day in America, and one of the nasty, logical by-products of fee-for-service has always been and always will be system fragmentation, workflow breakdowns, and missed hand-offs. And fragmentation only gets worse over time, not better, as we exert every greater economic pressure on providers and fail to incentivize clinical reforms. Small wonder the public health suffers, and our maternal and newborn mortality rates are going backwards compared to the rest of the civilized world. Shame on us for that NMM almost bleeding to death before our eyes.

    Beautiful piece of writing, Amy, about a very ugly situation.

  13. Lauren @ MRS says:

    I can’t believe they didn’t take it as a red flag when she was bleeding profusely on her bed, that you know, it might be something fatal. We really do gamble a lot when we admit ourselves to the care of another establishment/human.

  14. Nicholas fogelson says:

    This is a case of bad emergency medicine practice, perhaps contributed to by a culture of docs and staff not sure who is in charge. I wouldn’t be surprised if there was an OB and an ED doc that both thought the other was responsible for the patient. The answer, however, is clearly the ED doc. The ED doc is the one with their name on the chart, and until the OB arrives and assumes care, the patient is theirs. Bases on what was told, it sounds like the ED underestimated the severity of the problem and thus failed to communicate that to the OB.

    Gawande has argued that checklists are helpful in nearly every medical situation. A PPH checklist might be helpful, especially in the ED where the docs are less familiar with what to do.

    • Guesty McGuesterson says:

      “This is a case of bad emergency medicine practice, perhaps contributed to by a culture of docs and staff not sure who is in charge. I wouldn’t be surprised if there was an OB and an ED doc that both thought the other was responsible for the patient.”

      and this makes this okay because……..

      ummm does anyone there know how to draw up a syringe of methergine? Maybe? I think I might be able to I have to give my goats injections on a regular basis, I’d know whose responsibility it was.

  15. This was NOT a near miss maternity event and it is unfortunate that Ms. Romano has chosen to misrepresent it as such.

    This is an example of a patient presenting to the emergency room with a rare complication who should have had an immediate specialist consult, but did not. Late postpartum hemorrhage is typically due to sub-involution of the placental bed. Most physicians, like this ED doc, have never seen a case and therefore may fail to recognize it.

    This was a mistake on the part of one physician (failure to obtain immediate specialist consultation) and not a systemic failure. If an ED doc failed to recognize a complaint of jaw stiffness and drooling as tetanus, we would not conclude that it was a “neurology near miss” and indict the neurology care “system.”

    That’s not to say that there isn’t room for improvement in maternity care, but it is deeply cynical to use the case of an ED doc failing to diagnose a rare postpartum complication as a failure of maternity care and deeply cynical to use it as a Mother’s Day parable.

  16. Guesty McGuesterson says:

    Great Article Amy Romano!
    I found this portion especially interesting because I had the same experience when I had a sit down with my local hospital after I met with them regarding the lackluster care I received that in part contributed to the death of my baby as a result on health care team negligence.

    “Since the moment Near Miss Mom began her recovery, her most fervent hope has been to help make sure this doesn’t happen to any one else ever again. Unfortunately, when we met with her OB team after the fact, they declined her offer to be involved in quality improvement efforts because those matters are confidential. They also told her that she would need to meet separately with the ER team because they run their own quality improvement programs and the OB Department can’t influence what the ER does (if that’s not silo thinking, I don’t know what is). Then they asked if either of the companions she brought with her for support and advocacy were lawyers and, just for good measure, billed her insurance company for the time spent meeting.”

    and to Dr. Amy:
    We can’t ALL be imagining bad care and a broken maternity system can we? the fact is we can’t ALL be wrong.

  17. MomTFH says:

    Without more information, it is difficult to say how much the OB was aware of, and how much NMM was “under his care” while in the ER. At our ER, we would have called the OB immediately, and that’s what it sounds like happened in her case. While late postpartum hemorrhage may be rare, the patient should have been informed what was outside the range of normal for her bleeding, the ER should have a low threshhold of suspicion, and the OB should have known how to assist the ER in properly evaluating her, even if he was giving orders over the phone.

    I also think the maternity care system should care and be responsible for adverse events even if the happen after discharge from the hospital. I agree that NMM is fighting for something worthwhile, and am saddened that anyone would say this is simply an ER failure.

  18. If we really want to improve the quality of care (as opposed to merely criticizing the “maternity care system”), we need to be honest about what happened in this situation. The mistake here was the failure to call for a specialist consult on an emergency basis. This happens in ob-gyn emergencies. Consider that a substantial portion of women who subsequently die of ectopic pregnancy were seen in the 48 hours prior to their deaths, usually by non ob-gyn providers who are unaware of the meaning of abdominal pain in early pregnancy.

    Suggesting as Romano does that this incident could have been prevented by implementing the postpartum prevention “tool kit” is profoundly disingenuous. That tool kit does not address late postpartum hemorrhage; that’s not surprising since 99% of postpartum hemorrhage occurs early.

    This is a classic technique borrowed from the purveyors of “alternative health.” According to Paul Wolpe, in the paper “The playbook for challenging conventional medicine, ” the first step is to portray the particular discipline as “in crisis”:

    “…Modern medicine’s conquering of infectious disease set up a quasi-religious belief in its ability to reduce suffering and disease that now seems stalled by … medical, economic, organizational and social problems. [Critics try] to portray the biomedical orthodoxy as responsible for the problems confronting organized medicine … and suggest that orthodoxy is ill suited to solve the developing challenges to care…”

    This is certainly the tactic adopted by Romano’s employer, the Childbirth Connection, in an attempt to promote midwifery care.

    I would never deny that there is plenty of room for improvement in the current maternity care system, but this has nothing to do with that issue. An emergency doctor failed to call for an emergency specialtist consult. To elevate this to a parable about the maternity care system (in association with Mother’s Day, no less) is deeply disingenuous and does nothing to improve care for women.

  19. MomTFH says:

    Dr. Tuteur, the patient states:

    “During my first ER visit, the head ER doc said “If it were up to me, I’d release you. You’re just cleaning out. But I have to defer to your OB because you’re under their care.”’

    The specialist was clearly consulted.

    Maternal mortality and near misses in the United States, like most developed countries, involve rare events, thank goodness. However, these are the events we need to learn from. What is wrong with creating a system of looking at near misses and maternal mortality?

    Also, I have looked over the checklists and protocols at the California Maternal Quality Care Collaborative, and I fail to see how these only apply to early hemorrhage. This case easily falls within these algorithms.

    You say you don’t deny there is plenty of room for improvement, but you call discussions for improvement disingenuous. You are disingenuous by 1. claiming a specialist was not consulted when it is clear that one was and 2. saying that this toolkit does not apply to late hemorrhage, when it clearly does.

    It is a shame when the hospital system that NMM was treated is so resistant to quality improvement, and when people involved in the dialog online are openly hostile to improvement to the point that they misrepresent aspects of the discussion in order to make their point.

    I attended a presentation today at the rotation / residency site about quality improvement, checklists, protocols, and resistance in hospital systems. ACOG and obstetricians were used as the main example. I sent this article to the presenter, since this case and the resistance in the hospital system and in some of the comments (i.e. Dr. Amy’s) is emblematic of the old guard this hospital system CMO and physician was lamenting.

  20. Guesty McGuesterson says:

    “…Modern medicine’s conquering of infectious disease set up a quasi-religious belief in its ability to reduce suffering and disease that now seems stalled by … medical, economic, organizational and social problems. [Critics try] to portray the biomedical orthodoxy as responsible for the problems confronting organized medicine … and suggest that orthodoxy is ill suited to solve the developing challenges to care…”

    Okay Dr, Amy, so many ellipsis so little time.

    And to cut cut and paste a portion from this paragraph that supports MY world view (just like you did):
    “[Critics try] to portray the biomedical orthodoxy as responsible for the problems confronting organized medicine.”

    and it isn’t in all cases right? The “orthodoxy” of medicine hasn’t lead us in any adverse directions….right? Again, we can’t all be wrong.

    This is a parable about Mother’s Day, we have made so many strides against maternal morbidity and neonatal mortality why do these simple blunders still go on. We live in a country with one of the most modern and industrialized societies in the world with more biomedical technology then we could ever need yet we still have these needless disasters. MomTFH is correct, this is about changing old guards and using patient safety protocols to avoid needless disasters.

  21. If this is a failure of the “maternity care system,” surely its detractors should be able to specify just which aspect of the system failed and what must be done to remedy that failure. Curiously, I find no mention of either in the original piece or the comments attempting to defend the original piece.

    What was the failure of the “maternity care system”?

    It wasn’t the lack of appropriate training on the part of the OB; she recognized the problem immediately. It wasn’t the lack of resources on the part of the hospital; once the obstetrician arrived, the patient received blood, a hysterectomy and ICU care. It wasn’t that the wrong outcome occurred. Although the delay in referral to the OB may have resulted in the need for more blood products, it did not lead to the hysterectomy.

    So what did the “maternity system” do wrong? Evidently, the obstetrician failed to demonstrate ESP in divining that the patient was far more ill than the emergency room doctor told her.

    This piece has nothing to do with the “maternity care system.” It is a classic smear. It is a story of an emergency room doctor who made a mistake in failing to recognize an obstetric emergency.

    Romano embeds it within a variety of references and reports that discuss maternal mortality, implying that this type of mistake is a common cause of maternal mortality. She alleges that it was the result of failure to employ a a postpartum hemorrhage “toolkit,” although that toolkit does not even address the issue of late postpartum hemorrhage. And, in case, her readers still don’t get it, she hammers them over the head by making this a parable associated with Mother’s Day.

    This is a smear, pure and simple, written by an employee of the Childbirth Connection, a professional lobbying organization that represents the interests of the natural childbirth community including midwives, doulas and childbirth educators. A great deal of their lobbying efforts include blatant attempts to encourage mistrust of obstetricians.

    They are entitled to do so, of course, and Amy Romano is entitled to help them, but let’s be clear about what is really going on. This piece has nothing to do with improving the “maternity care system.” It does not even bother to identify the purported deficiency or recommend a remedy. This piece is intended solely to smear obstetricians and obstetrics.

  22. MomTFH says:

    Dr. Amy, just because you assert something, it does not make it true.

    Amy Romano and I both give specific examples of how the maternity health care system could have improved her care.

    From the original post:

    “Because her postpartum discharge teaching didn’t include anything about how to recognize and get help for postpartum hemorrhage – even though she had three major risk factors for hemorrhage”

    From my comment:

    “..the OB should have known how to assist the ER in properly evaluating her, even if she was giving orders over the phone.”

    Also from the original post:

    “Unfortunately, when we met with her OB team after the fact, they declined her offer to be involved in quality improvement efforts because those matters are confidential. They also told her that she would need to meet separately with the ER team because they run their own quality improvement programs and the OB Department can’t influence what the ER does”

    As for the toolkit, if you read it, and I did, there is absolutely no reason why her case does not clearly fall in the algorithm and checklist. Just because she presented after discharge instead of while still on a postpartum floor (which is irrelevant to the protocol), this was clearly postpartum bleeding, and easily could be managed, in fact should have been managed exactly as the toolkit checklist and tables specify.

    Unfortunately, as your irrelevant and undeserved sniping about the Childbirth Collection makes abundantly clear, you have absolutely no interest in furthering the conversation towards improved maternity care. This is unfortunately another unfortunately common example of you ruining a potentially good discussion because of a personal vendetta against midwives in general and Amy Romano in particular.

    I have no interest in rearguing the same points with you if you continue to ignore what is clear – again, the responsibility of her OB and postpartum care team (not to say this wasn’t primarily a huge failure in the ER department), and the appropriateness of applying already established standards of care.

  23. Amy Romano says:

    I don’t really know where to start, but here we go:

    With respect to Childbirth Connection as a lobbying organization for midwives and natural birth, it should be noted that the Blueprint for Action (http://transform.childbirthconnection.org/blueprint/) that guides all of our current work is a consensus document prepared collaboratively by a group of stakeholders among whom doctors significantly outnumber midwives. Childbearing women, nurses, insurance companies, hospital administrators, employers, quality collaboratives, and others were all at the table as well, as were all of the major professional organizations involved in maternity care including ACOG. Childbirth Connection does take part in legislative work, the great majority of which has been our involvement in the Partnering to Improve Maternity Care Quality Act of 2010, a bill with bipartisan support to which ACOG and other organizations signed a letter of support. ACOG has also supported the bill I wrote about in this post.

    With respect to the specific system issues that could be improved that might have changed the outcome:
    - Better postpartum education and follow-up. Clark’s (2010) article showing that 4.8% of postpartum women present to the ER within 6 weeks of birth concluded “The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.” There is no “system” of PP follow-up care. Women are more likely to get coupons for baby gear or free formula samples than personalized education about their risk for wound infection or hemorrhage, how to identify neonatal jaundice, and how to get help for breastfeeding difficulties. When the 911 operator told NMM to massage her fundus, she had no idea what to do or even what a fundus was, because no one had taught her this basic self-care technique.
    - Better teamwork and communication. I don’t have to offer a specific recommendation here, because ACOG makes its own recommendations in their 2009 Committee Opinion on patient safety. The call out the TeamSTEPPS program, which is just one of many safety programs Childbirth Connection includes in our resources for improvement at http://transform.childbirthconnection.org/resources/safetycourses/
    - Apology, disclosure and analysis of adverse events – Again, quoting ACOG’s patient safety paper, “Women’s health care should be delivered in a learning environment that encourages disclosure and exchange of information in the event of errors, near misses, and adverse outcomes.” There was no disclosure of the errors. Nobody reached out to NMM after the fact. At her scheduled post-op visit, when she asked what the cause of her hemorrhage was and if anything could have been done to prevent it, she was told she’d have to ask the team who took care of her because the information wasn’t in her medical record. When she asked for a meeting with the team and a copy of her records, all of a sudden she got multiple phone calls from the hospital and a fruit basket showed up on her doorstep. Then four months later there was finally the meeting she did have, which I’ve already described. To her knowledge, there has been no systematic internal analysis of the communication problems or other errors/delays that occurred.

    I’m having a hard time not getting extremely angry at the assumptions made about what did and did not happen, and the horrendous statement that the hysterectomy could not have been prevented. NMM was in the ER on two different days for many hours each time (my recollection is a total of 15 hours over the two days, but I may be off by a few hours.) There was no delay whatsoever in referring her to the OB team. And to be fair to the OBs, they were concerned about a suspicious ultrasound finding consistent with a rare defect that may have required a complicated surgery involving specialist surgeons. It’s great that the OBs were being as careful as they were to assemble the team for the potential problems they might have encountered during surgery. However, while the OBs were “overseeing” the orchestration of this possible surgery, no one was apparently “overseeing” the bleeding patient. Sadly, there is no objective evidence anywhere that substantiates the diagnosis of this defect. Instead, it all points to atony and subinvolution. Meanwhile, while her team was chasing a zebra diagnosis, she never received any medication to manage atony and staunch her blood loss. And as I mentioned, no one person was keeping track of her total blood loss. After one nurse changed her blood soaked sheets she told NMM to “make sure that the doctor sees the sheets so she knows how much you bled” and then when NMM was out of the room for a diagnostic test, another staff person removed the sheets. The medical record for that period states that her bleeding was “scant”. The OB told her afterward that if she’d known how much she was bleeding, she would have come to her bedside much sooner.

    Who knows why the ER docs didn’t communicate the extent of the blood loss? Maybe they were busy because the ER was full of people who can’t access primary care providers (a “system” problem), maybe they didn’t have enough training in postpartum complications (a training problem), maybe there is a history of OB staff telling ER staff not to bother them (a culture problem), maybe they tried and the OB didn’t answer her pager and the ER doctor didn’t know who else to call (a process problem), maybe maybe maybe. We have no idea because no one bothered to look and see what underlying problems might have been going on. It’s just point and blame and CYA.

  24. “With respect to the specific system issues that could be improved that might have changed the outcome”

    Let’s put my recommended remedy and Ms. Romano’s to the ultimate test. Let’s see if they would have resolved the issue.

    My recommended remedy (to address an individual failure, not a systemic failure):

    The ER doc would have told the obstetrician that there was a postpartum patient bleeding out in the emergency room.

    Result:

    The obstetrician would have come to see the patient immediately, diagnosed the problem immediately, and begun treating it immediately. It is not clear that it would have changed the outcome, but at least Near Miss Mom would not have had to endure the anguish of a postpartum hemorrhage without anyone taking effective measures to treat it.

    Ms. Romano’s recommended remedy for systemic failure:

    1. “Better postpartum education and follow-up”

    Result: Nothing. There is no evidence that improved postpartum education would have prevented the late hemorrhage, or changed the outcome since the patient herself knew to go to the emergency room and did so.

    2. “Better teamwork and communication.”

    It’s difficult to see how better teamwork and communication guidelines or instructions would have made a difference here. This was not a systemic failure to communicate, such as a system that informs doctors of an abnormal result, but fails to pass on the information to the patient. This was one doctor failing to do his job in recognizing that a patient was bleeding out and calling for immediate assistance.

    3. Apology, disclosure and analysis of adverse events.

    I can’t disagree with that, but I don’t see how it would have prevented this situation or prevent a similar situation in the future, unless there seems to be an ongoing problem with emergency room doctors failing to call for specialist consults in the advent of massive postpartum hemorrhage.

    Moreover, just because the patient was not privy to the analysis does not mean no analysis was done or that no disciplinary action or review was instigated. Peer review is protected by absolute confidentiality; that’s part of the law of peer review. Perhaps we should change that law, but that’s not in the hands of the maternity care system.

    “and the horrendous statement that the hysterectomy could not have been prevented”

    A hysterectomy is done for late postpartum hemorrhage when efforts to stop the bleeding have failed. It is not done for prolonged bleeding; the treatment for that is blood replacement.

    As I have said repeatedly, the maternity care system is not perfect, but this situation is not an example of what is wrong with it and it is disingenuous to treat this as a Mother’s Day parable about poor maternity care or to use it to promote patient distrust of obstetricians and obstetrics.

  25. Amy Romano says:

    “A hysterectomy is done for late postpartum hemorrhage when efforts to stop the bleeding have failed.”

    And therein lies your assumption. There were no efforts to stop the bleeding. None. No oxytocin, no methergine, no bimanual compression, no surgical techniques. On top of that when she asked for a breastpump just to relieve the engorgement they told her it would be “impossible” (her friend got her a hand pump at Walgreens), so she wasn’t getting any marginal benefit of breast stimulation either. She sat there with an IV in her arm getting plain old fluids.

  26. Janie Nottingham says:

    Well, there clearly is nothing more you can say is there Dr Amy.

    This woman received sub standard and unsafe care, in any country to not assess and monitor blood loss seems an absurdidty. To fail to initiate measures to staunch blood loss also is just insane. Who does that?

    To dirty the atrocity that is this womans story with all the argument and tit for tat that has gone on between you both is unfortunately neither helpful or appropriate. It reflects the chasm that exists and the inability for solutions to be sought, found and implemented.

    Dr Amy the phrase if you are not prepared to be part of the game and actually engage honestly and fairly, then get the hell out of the way of others who are stands out to me. It is time for you to either move on or reevalute whether your online behaviour and comments do anything to further humanity.

  27. What a coincidence, Ms. Nottingam. You, too, are an midwife activist who has agitated extensively for greater government funding and support for midwives in your own country.

    In fact, you’ve complained that the use of technology in birth will have “lasting implications for civilization.”

    I wish that activist midwives would get their complaints straight. First they complain that obstetricians have created a “crisis” by the overuse of technology. Now they complain that obstetricians have created a “crisis” by the underuse of technology.

    Which is it? Or does it not really matter, when the goal is to use any means at hand to disparage obstetrics and encourage mistrust of obstetricians?

  28. What a heart-wrenching post this is! People should open their eyes and do something about these “near miss” fatalities. Thanks for sharing, great blog!

  29. Craig "Quack" Vickstrom, M.D. says:

    @Dr. Tuteur,

    There you go again, injecting intellectual rigor into emotional debate, a debate which is based on a grab-bag of assumptions and dubious evidence.

    To all the doc-haters on this board: there is a systemic problem here. As an occasional ER physician, I am required to assess every patient that presents to the ER no matter the complaint. Back in the day, the ER was for…emergencies. This poor woman did not get the attention she deserved. This is probably due to all the sore throats, acne and headaches clogging up the system. Hemorrhage = emergency. At the end of the day, the ER doc is still left holding the bag. No excuse. But I wonder how much better a job s/he could have done if s/he was required to see only emergencies, and the non-emergencies would have to go home and see their regular doc in the morning. What? They don’t have a regular physician? There is another systemic failure for you. There are systemic failures here, you are just looking in the wrong places.

    • mysticalbeast says:

      @Dr Vickstrom:

      but you can also see the systemic failure in the postpartum treatment. In my country every woman in childbed (eg six weeks after giving birth) has access to ten visits of a midwife who looks after involution, lochia, helps with breastfeeding problems etc.
      In NMM´s case the midwife would have directed her to the gyn station after the first unnormal bleeding occurred – here she wouldn´t have to go through ER hoping the staff would recognizing the bleeding as sth critical and not “normal cleaning”

  30. Melissa says:

    when i suffered a late PPH on june 14 2011, 8 days after delivering twins, i made the decision to go to labor and delivery rather than to the ER, mainly because i have heard of moms bleeding to death waiting to be seen in the ER. since i think of blood loss as an emergency, it upsets me that ERs all over the country allow patients to sit in their own pools of blood. my decision to initially avoid the ER was a good one, since we ran directly into my OB while he was doing rounds (he had not yet received the message from his office that i was bleeding). since i had already delivered my twins, L&D could not see me; however, my OB made a promise to me that he would oversee my care in the ER if surgical intervention was warranted. he kept that promise. i think that the ER was probably more than happy to have him there since this medical emergency – at the level of my severity – is quite rare. my understanding is that late PPH (i do not know about early PPH suffered by NMM) is very rare, and near misses requiring hysterectomy are extraordinarily rare. my OB is a high risk doctor with many, many years in practice in the Bay Area (CA) and he commented to me that he has only had to perform a hysterectomy due to PPH twice in his decades long career. my case was one of those times. not only do i think the ER was not trained to deal with such a crisis, but i believe that many OBs are not sufficiently trained to make the decisions necessary to deal with this life threatening event. i know that women’s lives have been lost at the hands of very experienced OBs when faced with the rare emergency of PPH requiring hysterectomy. my OB told me he was reviewing a recent local case “very similar to mine but with quite a different and tragic outcome”. without getting into detail, he said it looks like there was some indecisiveness on how quickly to move to removal of the uterus. my heart breaks for that family. i would really love to be in touch with Near Miss Mom, if at all possible. my private email is spartamac@mac.com if she wants to communicate. i am being treated for PTSD directly related to the event, and the therapy i have chosen (EMDR) has been very effective. all my best to you, Near Miss Mom. i am so thankful you are alive.

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