In 2013, a patient had seen a family practitioner for the delivery of her first child. She delivered at 38 weeks gestation. The fetus was in breech position, which was corrected. The patient had extra bleeding, and no further complications. The infant was 9 pounds.
On 10/9/2014, the family practitioner started providing prenatal care to the patient for her second pregnancy with an expected due date of 5/4/2015. At 28 weeks on 2/10/2015, glucose level was noted to be elevated. The family practitioner scheduled the patient for an elective induction of labor on 4/28/2015 given expectation that the second child would be large. Induction began at 10:30 a.m. on the scheduled date. At around 1:30 p.m., the patient was dilated to 3 cm and underwent rupture of membranes. At around 2 p.m., the patient requested medication for pain. The family practitioner instructed the nurse to administer IV fentanyl. Afterwards, the patient became nauseated, lost consciousness, and stopped breathing. After 30-60 seconds, the patient turned dusky bluish. Nasal cannula with high flow oxygen was inserted. The patient failed to respond. The family practitioner left the room to instruct staff to call 911. The family practitioner administered naloxone to the patient. Bag valve mask was administered to establish artificial ventilation. The heart rate of the fetus was slowly dropping. EMS arrived at around 2:15 p.m. The nurse was ventilating the patient with a bag valve mask. Oropharyngeal airway was not in place, no one was performing chest compressions, and patient was pulseless. The family practitioner was unable to tell EMS how much fentanyl or naloxone was administered. EMS initiated CPR. At around 2:30 pm, fire and rescue personnel arrived and intubated the patient, started an IV, and continued chest compressions. The patient was transported to the ED where she arrived pulseless without respirations. The patient expired.
A post mortem C-section was performed and a 9 pound male infant was delivered. Upon delivery, the infant expired. The cause of death was discovered to be amniotic fluid embolism. The pathologist noted “The Decedent’s cause of death is attributed to amniotic fluid embolism experienced during childbirth. This process is relatively rare occurring in approximately 1 out of 50,000 pregnancies although has a reported mortality in excess of 80%. This reportedly accounts for approximately 10% of all maternal deaths. An associated or contributing additional visceral or toxicologic disease is not identified.”
The recommendation was that the family practitioner complete Advance Trauma Life Support training and complete a course on safe opioid prescribing. The family practitioner was prohibited from managing obstetrics patients during labor and delivery.
Date: May 2015
Diagnosis: Obstetrical Complication
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF
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