Maternal deaths following cesarean delivery can be reduced

Aug 4 2008

Maternal death rates have remained constant in the United States for many decades. Are there any improvements in health care that could reduce these rates further?

In a study published in the July 2008 issue of the American Journal of Obstetrics & Gynecology, researchers examined all maternal deaths in nearly 1.5 million birth records from the last 6 years to look for possible keys to saving more mothers. The study demonstrated that the risk of death attributable to cesarean delivery, approximately 2/100,000 procedures, can realistically be reduced only with universal thromboembolism prophylaxis for patients delivered by cesarean.

The study identified 95 maternal deaths among 1,461,270 births (6.5/100,000 births). Leading causes of death were complications of preeclampsia, amniotic fluid embolism, obstetric hemorrhage, cardiac disease, and pulmonary thromboembolism.

The risk of death causally related to cesarean delivery is approximately 2/100,000 cesareans vs 0.2/100,000 deaths caused by vaginal birth. This statistically significant difference (P<.001) translates into approximately 20 US deaths caused by cesarean delivery annually.

Nine patients died from pulmonary thromboembolism, 7 after cesarean delivery and 2 after vaginal birth. None had received peripartum thromboembolism prophylaxis in the form of either fractionated or unfractionated heparin or pneumatic compression devices.

Writing in the article, Steven L. Clark, MD, Medical Director of the Women and Newborns Clinical Program, Hospital Corporation of America, states, "In nearly every population of adult surgical patients, either medical or mechanical thromboprophylaxis reduces venous thromboembolism by approximately 70%...If one assumes similar efficacy in pregnant women, 5 of the 7 deaths from pulmonary embolism in women undergoing cesarean delivery would have been prevented if a policy of universal use of medical or mechanical thromboprophylaxis for patients undergoing cesarean had been in place. Such a policy would reduce the mortality rate attributed causally to cesarean delivery to 0.9/100,000, or approximately 9 US deaths annually, eliminating the statistical difference in deaths attributed to cesarean vs. vaginal birth." Dr. Clark notes that the Hospital Corporation of American has instituted such a policy to improved patient safety throughout their system, the largest in the United States.

Dr. Clark continues, "It seems clear that the majority of maternal deaths in the United States are not preventable. The most common preventable errors in preeclampsia management leading to maternal death involved inattention to blood pressure control and signs or symptoms of pulmonary edema; those involving postpartum hemorrhage deaths were related to inadequate surgical hemostasis. In all these cases, more prompt attention to clinical signs of hemorrhage and associated hypovolemia would also have prevented death."

http://www3.us.elsevierhealth.com/ajog/