Canad. Med. Ass. J.July 30, 1966, vol. 95 Maternal Mortality Studies 219

aternal Mciriali^TTiis senes o/ articles has been arranged by an editorial subcommittee of theC.M.A. Committee on Maternal Welfare. These representative case reports are

offered as a contribution to the continuing education of physicians givingobstetrical care.

Vaginal and Uterine Lacerationsk 29-year-old primipara, married for nine years,

-£*¦ made her first prenatal office visit to her at¬tending physician when she was 12 weeks pregnant.She made prenatal office visits monthly up to 34weeks' gestation and then every two weeks untilterm. She had always enjoyed good health. Duringthe pregnancy her total weight gain was 35 lb. andshe had been cautioned during her prenatal officevisits about the excessive weight gain. The bloodpressure and urine were normal throughout thepregnancy and the hemoglobin (Hb.) was 11 g. %at term. She received supplementary prenatal ironand vitamins from the twelfth week of pregnancyto term.

She was admitted to the first hospital at term inlabour, and the cervix was 3 cm. dilated when shewas examined by the attending physician fourhours after her admission to the hospital. Duringthe first 12 hours of her labour in hospital she was

given 30 mg. of alphaprodine hydrochloride (Nis-entil) on two occasions and 90 mg. of pentobarbitalsodium (Nembutal).The attending physician and his partner both ex¬

amined the patient vaginally 19% hours after herhospital admission. The membranes were rupturedand "the cervix was almost completely dilated".They discussed the possibility of performing a

Cesarean section because of the "slow progress."The patient was allowed to continue in labour

for another hour and then vaginal examinationshowed that the fetus was presenting in the pos¬terior occiput position and had descended to thelevel of the ischial spines. Operative delivery was

accomplished under incomplete ether anesthesiausing Kielland forceps for the forceps rotation ofthe posterior occiput to the anterior occiput posi¬tion and then Simpson forceps for the extraction.Considerable traction was necessary and the at¬tending physician "felt something give and then thedelivery was easy". The 7-lb. baby had markedmoulding and bruises of the cranium. The infantdied one and one-half hours after the delivery de¬spite resuscitation using oxygen, mouth-to-mouthbreathing, adrenaline (Adrenalin) and nikethamide(Coramine). An autopsy was not done on the fetus;however, the attending physician considered theneonatal death to be due to the traumatic delivery.Following the delivery of the placenta, 15 minutesafter the delivery of the fetus, the patient received0.2 mg. of methylergobasine maleate (Methylergo-basine) and 0.25 mg. of ergotamine tartrate (Gyn-

ergen) intravenously. She was transferred to thepostpartum area with a systolic blood pressure of140 mm. Hg. three-quarters of an hour after thedelivery. Shortly after her arrival on the ward itwas noted that the vaginal bleeding was excessive;a large clot was expressed vaginally and she was

given 0.2 mg. of methylergobasine maleate intra¬venously.

She became very restless one and one-quarterhours after the delivery and the systolic blood pres¬sure was 90 mm. Hg. Emergency Group O Rh-negative blood, 500 c.c. of 5% glucose and waterand dextran (Dextraven) were given intravenous¬ly. The patient complained of ascending right lowerquadrant pain. Arrangements were made for thepatient's transfer to a larger hospital. She was given50 mg. of pethedine hydrochloride (Demerol). Sheleft the first hospital by ambulance two and three-quarter hours after the delivery.She was admitted to the second hospital in se¬

vere hypovolemic shock with a systolic blood pres¬sure of 40 mm. Hg, and was given additional emer¬

gency Group O Rh-negative blood and dextranintravenously. She was taken to the operating room

three-quarters of an hour after her admission to thesecond hospital. At this time she had a perceptiblepulse and her blood pressure was 90/60 mm. Hg.The uterus was firm and the vaginal blood loss wasexcessive. Vaginal examination showed that therewere deep sulcus lacerations on each side of thevagina extending up to the lateral fornices of thevagina and the "vagina appeared to be shearedoff". The vaginal lacerations were sutured as wellas possible. The uterine cavity was examined withtwo fingers, and the obstetrician did not feel anyuterine perforation or retained placental fragments.A retention Foley catheter was inserted and blooddrained from the bladder. The consultant felt thatalthough additional uterine and bladder traumacould not be excluded at this time, the patient'scondition was too serious for further investigationand the vagina was packed with gauze.The patient received 4500 c.c. of blood and 10

c.c. of 10% calcium gluconate intravenously in thefirst four hours of her admission to the second hos¬pital. She was returned to the operating room threeand one-quarter hours after admission to the sec¬

ond hospital because of continuous bleedingthrough the vaginal packing. At this time the bloodpressure was 110/70 mm. Hg but was droppingslowly. Additional vaginal suturing was done and

220 Maternal Mortality Studies Canad. Med. Ass. J.July 30, 1966, vol. 95

the obstetrician considered performing intra-arterialtransfusion or laparotomy with ligation of the in¬ternal iliac vessels, but he felt that the patient'scondition was "too precarious for further surgery".The patient deteriorated rapidly despite additionalblood transfusions and she died five hours afteradmission to the second hospital (nine and one-

quarter hours after the delivery).A complete autopsy demonstrated two perfora¬

tions of the lower uterine segment measuring 1.2cm. and 0.7 cm.; multiple sutured vaginal lacera¬tions; 1000 c.c. of intra-abdominal hemorrhage and2000 c.c. of retroperitoneal hemorrhage.DECISION OF THE PROVINCIALCOMMITTEE ON MATERNAL WELFAREThe conclusions reached by the Provincial Com¬

mittee on Maternal Welfare after a review of thiscase were as follows: "This was a preventable di¬rect maternal death. The cause of death was shockdue to hemorrhage from vaginal and uterine lac¬erations which resulted from a difficult forceps rota¬tion and extraction. The preventable professionalfactors were inadequate prenatal assessment of thepelvis, inadequate maternal sedation during la¬bour, not permitting the patient to have a longersecond stage of labour, attempting a difficult for¬ceps rotation and extraction in a hospital whereinadequate facilities were available for the seriouscomplications which occasionally result from suchobstetrical procedures, failure to examine com¬

pletely the birth canal, inadequate consultation andinadequate blood replacement before the patient'stransfer to the second hospital. In addition it was

considered possible that a laparotomy with totalhysterectomy and probable bilateral ligation of theinternal iliac vessels once the patient had beenpartially resuscitated might have been life-saving.This maternal death has been considered to beideally 'preventable' under the terms of referenceof the Provincial Maternal Welfare Committee andthere is no implication of any negligence."DISCUSSIONThis primipara had a fairly normal course of

labour, although cervical dilatation was slow. Shereceived inadequate sedation during labour andinstead of being given two doses of 30 mg. of alpha-prodine hydrochloride she should have receivedmore adequate sedation, such as 75 mg. of pethe-dine hydrochloride and 25 mg. of promethazine(Phenergan) or 50 mg. of promazine hydrochloride(Sparine) intramuscularly.When the cervix was found to be incompletely

dilated 19% hours after admission to the first hos¬pital, the membranes should have been artificiallyruptured, and the patient should have been re¬

turned to the labour bed and given additional seda¬tion. When the fetus is in a posterior occiput posi¬tion and a rim of cervix is remaining, it is not un¬

usual for a primipara to take two or more hours to

achieve full cervical dilatation. Furthermore, thispatient should have been allowed an additionaltwo hours of labour after full cervical dilatation hadoccurred, to give the normal forces of labour a

chance to push the head to the pelvic floor andeven possibly to allow spontaneous rotation of theposterior occiput to the anterior occiput position.

It is only after the progress of the fetus has beenarrested for two hours after the cervix is fullydilated without evidence of fetal distress that a

"trial forceps" should be considered. "Trial forceps"is an accepted obstetrical procedure but shouldonly be carried out with adequate anesthesia,trained personnel and instruments immediatelyavailable for Cesarean section if the head cannot bedelivered by forceps with relative ease. As demon¬strated by this case, mid-forceps rotation may on

occasion result in severe trauma to the birth canalwhich makes necessary the immediate availabilityof adequate anesthesia, obstetrical consultants andfacilities for the treatment of shock due to massiveblood loss. If a hospital lacks such personnel andfacilities, the patient should be transferred to thenearest hospital possessing these facilities beforesuch procedures are attempted. Most rural com¬

munities are now served with good highways per¬mitting rapid evacuation. Air transport is now com¬

monly used for more distant or isolated areas. In atleast one province an "Emergency ObstetricalTeam" is available which in such emergencies willgo (by air, if necessary) to any point in the prov¬ince. Also the C.M.A. Committee on Maternal Wel¬fare has recommended that physicians practisingobstetrics in areas with incomplete facilities and/orpersonnel establish liaison with specialists in neigh-bouring centres so that there will be immediatetelephone consultations and/or early and rapidpatient transfer to a better equipped hospital whensuch obstetrical emergencies occur.

After a difficult mid-forceps procedure or whenpostpartum hemorrhage occurs, a complete ex¬

amination of the birth canal (the vagina, the cervixand manual exploration of the uterine cavity)should be done to exclude rupture of the uterus.To do an adequate manual exploration of the uter¬ine cavity, it is recommended that the right sideand the anterior aspect of the uterus be examinedusing the right hand, and the left side and theposterior aspect of the uterus be examined usingthe left hand. In this case, the attending physiciandid not examine the entire birth canal and the con¬sultant could not perform this examination ade¬quately because, owing to hemorrhagic shock, anes¬thesia could not be given to relax the uterus.

It must be remembered that when catastrophicobstetrical hemorrhage occurs, the attending physi¬cian cannot afford to procrastinate but must imme¬diately put into action a prearranged plan of rapidmassive blood procurement and administration, ex¬

amine the entire birth canal for the cause of thehemorrhage, to treat the cause; and obtain immedi¬ate adequate consultation.

Canad. Med. Ass. . AEQIJANIMITAS: IN PRAISE OF ROSES 221July 30, 1966, vol. 95

A ruptured uterus calls for an immediate laparo-tomv and resuscitative measures including the ad-ministration of massive blood transfusions. Retro-peritoneal hemorrhage from traumatic rupture of theuterus often markedly distorts the pelvic anatomy.Even total hysterectomy often does not control thebleeding, and bilateral ligation of the internaliliac vessels may be necessary. During laparotomy,manual compression of the aorta at the pelvic brimis helpful in controlling the hemorrhage. It shouldl)e stressed that the surgery necessary in such in-stances may be very difficult technically, and thel)est available surgical assistance should be ob-tained. When a ruptured uterus occurs, the attend-ing physician should request immediate assistancefrom as many of his colleagues as necessary.With such vaginal and uterine lacerations as

were encountered in this case, it is impossible to

maintain or improve the patient's condition byblood replacement alone. The patient will die un-less immediate massive blood replacement is ac-companied by immediate laparotomy with totalhysterectomy and possibly by bilateral ligation ofthe internal iliac vessels. These procedures shouldbe done by a surgeon who is familiar with pelvicanatomy and .vith the marked distortion of thisanatomy that occurs with the retroperitoneal hem-orrhage that follows vaginal and uterine laceration.

SUMMARYA maternal death was reviewed by the Provincial

Committee on Maternal Welfare. The cause of deathwas massive intra-abdominal, retroperitoneal and vaginalhemorrhage due to birth canal lacerations followingforceps delivery. The preventable factors are discussed.

,,4,4. .44,444..,4 ,4. 444, 4.444. 4, ,,4..,,4

In Praise of RosesI CAN remember way back 18 months ago when-3-the conversation of rose fanciers bored me.I had, however, been softened up by a fortuitousvisit to a U.S. test garden at Portland where thebeautiful profusion was overwhelming. I knew thatShakespeare had dated himself by his observationsconcerning the naming of roses in relation to theirfragrance and I thought that Gertrude Stein'srepetitive poetry had summarized the rose situa-tion very well. Then a colleague who knew a manin the nursery business persuaded me to plantsome hybrid teas at the end of the season in 1965.Vem:y reluctantly I gave up a 10' x 12' portion ofmy back lawn. The sod was lifted. I had neverseen such unpromising soil. Builders' rubbleof 35 years ago, bricks, cement, inert grey clayconfronted me, but I was duly committed when myfriend turned up on a Sabbath morning with thebare-rooted plants and actually dug them in. Ihave since been improving the soil with all productsknown to man or beast, principally the latter.

Arlene Francis, Americana, Chicago Peace wereto me but names like P.che Melba, or the appela-tions of race horses. No longer, however. I am ableto hold my own in discussions of Royal Highness,Miss Canada and the lovely Canadian Centennial,Christian Dior and King's Ransom. I have plantedthese hybrid teas in the spring and in the autumnand, with careful protection over the winter, I havea score of 100% bloomers. Now the nursery cata-logues are my favourite winter reading, and I getSo much pleasure in anticipation that the actualevent is an anticlimax. Next year I propose todisregard the pictures and description of the

flowers and choose my additions from those havingdark shiny leaves. This may resemble the pickingof winners at the race track by means of a pinthrough the card, but in the case of roses every-body wins.Although I report as an amateur in Southern

Ontario I can't compete with our colleagues inBritish Columbia or in favoured spots like Leam-ington, but I'd like to suggest to my friends inMusquodoboit Harbour and Swift Current thatthey too can grow roses. I wish I could be asoptimistic about Whitehorse and Aklavic.

After I get back from the Annual Meeting inmid-June I enquire about the health and behaviourof the family and then proceed to the garden toobserve the progress of the buds and branches atthis season. I take my breakfast cup of coffee outto the backyard and feast my eyes on the progresswhich has occurred since last night. This affection-ate tribute to the beauties of hybrid tea roses ispenned in the flush of enthusiasm for my currentdelight and if I sound like a recent convert, I'll notdeny it.

I'll leave to more serious gardeners any discus-sion of thrips or black spot or any other parasiticdiseases for these lovely plants. I have not yet hadthe courage to pinch off surplus buds to producethe perfect specimen because I enjoy all of themso much.To me it has been a revelation, and to any of my

colleagues who desire to cultivate aequaniniitas Ican't do better than to recommend a rose bed tobrighten up their days and their lives. A.D.K