Yesterday, shortly after rounds with our residents, I was called urgently to the postpartum floor because a patient of ours was “coding” (cardiopulmonary arrest). She was a 31 year old woman who had just delivered her sixth child the day before. Her labor was uncomplicated but she had had a fever since delivery. Despite her pleas to go home, we had just finished convincing her that she really needed to stay for further evaluation. Actually, her husband had been the one to convince her with the prophetic statement that she “didn’t need to go home if she was just going to die there and leave me with six kids to raise by myself.” We left the room to make arrangements for her chest x-ray, she talked with her own mother on the phone, and moments after hanging up, clutched her chest and stopped breathing.
After an hour of heroic efforts by the code team to revive her, she was pronounced dead, probably from a massive pulmonary embolus (blood clot to her lungs). I walked out of the room with the resident, both of us with tears in our eyes, to tell her husband that the efforts to bring her back had failed. He was sitting at the end of the hall, a large man, definitely rough around the edges with tattoos decorating at least half of his body. He already knew the outcome from the expressions on our faces and before we could reach him, he collapsed in grief, sobbing inconsolably that “I know I don't look like much, but I love my children and now they will take them away from me.”
Ironically, just two days before, I had been asked by a local journalist to comment on home births. The lay midwife who had cared for the couple featured in the article was quoted as saying that “women had given birth for thousands of years, and I might add, do it very well.” When I read this, my initial thoughts were that with good screening, the risks could be minimized, but they are still greater for both mother and baby than they would be delivering at the hospital.
My reluctance to endorse the practice without reservation stems from my view that pregnancy appears to be one of the most dangerous and powerful forces of “natural selection” that has helped to mold the human race. You don’t have to be a Darwinist to recognize this. The biblical authors of Genesis had this perspective as well! At the turn of the 20th century, one out of every 100 women died during pregnancy in the U.S. Today that rate stands at less than 1 in 10,000. It is an ongoing tragedy, however, that worldwide more than 500,000 women still die annually during pregnancy, most of these in developing nations. In parts of sub-Saharan Africa, for example, mortality rates are as high as 1 in 10 to 20.
Before the modern era in obstetrical care (1940’s), women died most frequently in pregnancy from hemorrhage, infection, and arrest of labor. (This is still the case in developing nations). The availability of blood products, antibiotics, and operative deliveries (cesarean sections) under sterile conditions greatly reduced the risks of these complications. Today, the most common causes in the U.S. are thromboembolic (blood clot) events, hypertensive disorders, and trauma. Experience has taught us that when problems arise in obstetrics from these and other causes, they can arise quickly and unexpectedly and if you are not in a situation to address them, immediately, the opportunity for a good outcome is greatly diminished for mother, baby, or both. As we all learned yesterday sometimes even being in the right place at the right time isn’t good enough.