Summary of 2019 case reviews

Table: Summary of 2019 case reviews
Case Type Summary Themes Recommendations
EX-01 Maternal Executive The decedent was a 35-year-old woman who had a witnessed arrest 12 days after the delivery of her second child. She had a history of gestational hypertension and obesity. Cause of death was intra-abdominal bleeding from an unknown source during the postpartum period. n/a None
EX-02 Maternal Executive The decedent was a 34-year-old woman who had gestational diabetes. She was two months post-partum with her first baby when she developed shortness of breath and a cough.  The decedent had a severe presentation of peripartum cardiomyopathy and that she may have had a concurrent pulmonary infection. Cause of death was peripartum cardiomyopathy. OCP, Transfer




OCP, transfer
  1. Obstetrical care providers are reminded to consider early transfer to a tertiary cardiac centre when patients present with severe left ventricular dysfunction, cardiogenic shock and/or cardiac arrest secondary to peripartum cardiomyopathy.
  2. Obstetrical care providers are reminded that transfer considerations and communications should be documented in the medical notes. A transfer consideration documentation tool could be established to better record this aspect of patient care.
EX-03 Maternal Executive The decedent was a 37-year-old G3P1.    Emergency Caesarean section was performed after she collapsed and became unresponsive. Cause of death was attributed to amniotic fluid embolus. n/a None
EX-04 Maternal Executive The decedent was a 34-year-old woman who had delivered a normal full-term pregnancy approximately seven weeks previously. She had suffered a superficial clot in her right leg about one week post-partum and Doppler testing showed no deep vein thrombosis. Her routine six week post-partum check-up was normal and she was given a requisition to have a follow-up Doppler. The day prior to her death she saw her family physician regarding a possible nipple infection. She was found unresponsive, sitting in a padded chair in the baby's room, with the baby in her lap. It appeared that she was breast-feeding when her death occurred. Cause of death was undetermined. n/a The next-of-kin were advised to be assessed in a cardiovascular genetic clinic.
EX-05 Maternal Executive The decedent was a 35-year-old woman. When admitted to hospital for induction of labour, she began to vomit. Emergency Caesarean section was performed due to fetal bradycardia.  Cause of death was amniotic fluid embolism. n/a None
EX-06 Maternal Executive The decedent was a 33-year-old woman who was in her first trimester of pregnancy. The decedent had a long-standing history of mental health issues which began when she was a teenager. Approximately five years prior, she had been treated for trauma and a substance use disorder. Cause of death was noted as fentanyl toxicity. n/a None
EX-07 Maternal Executive The decedent was a 33-year-old G4P2 with a history of asthma for many years and had been experiencing more pronounced dyspnea in the previous month. Cause of death was Intrapartum Hemorrhage due to Caesarean Section/Emergent Hysterectomy for the Management of Placenta Increta. n/a None
EX-08 Maternal Executive The decedent was a 24-year-old G1P1 with type 1 myotonic dystrophy. On post-partum day 5, she presented to her family physician with retrosternal chest pain and was diagnosed with acute coronary syndrome. She was transferred to the heart institute where she underwent urgent cardiac catheterization that showed multiple areas of spontaneous coronary artery dissection. Cause of death was multi-organ failure due to left ventricular dysfunction due to healed myocardial infarctions due to healed spontaneous coronary artery dissections in the context of myotonic dystrophy (Type 1) cardiomyopathy. n/a None
EX-09 Maternal Executive This case involved the death of a 33-year-old G2P0.  Her pregnancy had been unremarkable until the development of elevated blood pressure in the third trimester.  She was diagnosed with preeclampsia at 37 weeks. Cause of death to be acute post partum blood loss in a woman with idiopathic pulmonary arterial hypertension.  Genetic testing revealed a variant of uncertain significance in GDF2. n/a None
EX-10 Maternal Executive The decedent was a 31-year-old woman who was in her first trimester of pregnancy when she was the victim of an assault that resulted in her death.  n/a None
EX-11 Maternal Executive The decedent was a 32-year-old woman with a long-standing history of intravenous drug use and who was on a methadone program.  She had  no fixed address and did not have any prenatal care.  Cause of death was attributed to Staphylococcal septicemia due to infective endocarditis due to intravenous drug use. n/a None
EX-12 Maternal Executive The decedent was a 37-year-old woman who was 44 days postpartum following a delivery that was complicated with shoulder dystocia and lateral vaginal wall tear. Post partum haemorrhage began during repair of the vaginal wall tear.  A cardiac arrest occurred during attempts to remove retained products of conception and effect tamponade. Amniotic fluid embolism was the cause of the shock and postpartum bleeding.  n/a None
EX-13 Maternal Executive The decedent was a 42-year-old G2P1 with a past medical history of metastatic breast cancer. In 2015,  bilateral metastases to her lungs was found and she underwent resection. The woman died from tumour lysis syndrome secondary to acute leukemia, with secondary contributing condition of metastatic breast cancer; specific relationship to her pregnancy was not identified. n/a None
M-01 Maternal The decedent was a 37-year-old G4P3. History of previous deep vein thrombosis (DVT).  She died from a pulmonary embolus and right leg DVT. Thrombo-prophylaxis was indicated, but was not implemented. OCP, diagnosis and testing


OCP, diagnosis and testing
  1. Obstetrical care providers are reminded that venous thromboembolism (VTE) remains an important cause of maternal morbidity and mortality in Canada with an overall incidence of deep vein thrombosis and pulmonary embolus of 12.1 per 10000 and 5.4 per 10000 pregnancies respectively.
  2. Obstetrical care providers are reminded of the management of venous thromboembolism and the need for close collaboration and communication with all teams involved in the maternal care as outlined in the Clinical Practice Guidelines.
M-02 Maternal The decedent was a 32-year-old primigravida. Risk factors included:  pre-pregnancy BMI 34.4 (height 6'1" and weight 250 lb), polycystic ovary syndrome (PCOS), low lying placenta (1.8 mm, repeat ultrasound in October 2016, clear of cervix), urinary tract infection (at 17 weeks treated with Macrobid), Group B streptococcus positive and it was noted on her anaesthestic questionnaire that she bruised easily.  Cause of death was pulmonary arterial hypertension.  OCP, diagnosis and testing                                                          Training/ Education, Quality
  1. Obstetrical care providers are encouraged to consider the use of an obstetrical early warning system (manual or computerized) to better identify changing patterns.
  2. The obstetrical department of the hospital involved should conduct a lessons-learned case review of the circumstances surrounding this woman’s death.  The review should include:
  • Monitoring of unstable post partum patients
  • Documentation
  • Ongoing blood loss with no identified source
M-03 Maternal The decedent was a 33-year-old G3P2. A non-invasive prenatal test (NIPT) was done and was subsequently reported as concerning for Klinefelter syndrome.  Amniocentesis was declined. Death was attributed to hemoperitoneum due to placenta percreta invading through the previous Caesarean section scar. OCP, Diagnosis and testing             


Diagnosis and testing
  1. Obstetrical care providers are reminded that placenta accrete spectrum is a serious pregnancy condition at any gestational age. Immediate and direct communication between the ultrasounographer and the healthcare provider(s) is required.
  2. Diagnostic imaging facilities should establish an effective and timely system of recognizing and reporting critical findings to other members of the healthcare team.
M-04 Maternal The decedent was an obese (pre-pregnancy BMI of 36) 37-year-old G3 TPAL 1011 who had a dichorionic diamniotic twin pregnancy by in vitro fertilization. The cause of death was determined to be “hemorrhagic shock” due to “intrauterine hemorrhage, post Caesarean twin delivery with concurrent myomectomy for uterine leiomyoma (fibroid). n/a None
M-05 Maternal The decedent was a 20-year-old G2P0 who died suddenly at 34 weeks and one day gestation. It was subsequently reported by the family that the woman had been experiencing swelling and tingling of her hands and feet in the last 1-2 weeks and a headache for three days prior to her death. Cause of death was sudden unexpected death in pregnancy with findings suggestive of a hypertensive disorder of pregnancy (preeclampsia). n/a None.
M-06 Maternal The decedent was a 31-year-old G6P6. Cause of death was noted as complications of endometritis and retained products of conception. She was five days post partum. n/a None
M-07 Maternal The mother was a 23-year-old G7 TPAL 2224 First Nations woman. Cause of death was septic and hemorrhagic complications of acute chorioamnionitis due to preterm premature rupture of membranes and ascending infection with Escherichia Coli. It was felt that the fetus had a “rare but distinctive pattern” of severe, fulminant intrauterine E. coli infection due to the ruptured membranes.  The infection went from fetus to placental villi without significant infection of the membranes as would be typical of chorioamnionitis. Other



Other



Other
  1. The SOGC should develop a rigorous, national database on maternity care. This would include data from all provinces and territories, including information pertaining to race/ethnicity, including First Nations, Inuit and Metis, key factors related to maternal health status and outcome.  Data should capture all maternal deaths from all causes in Canada, including sepsis.  Data should ideally include all deaths out to 365 days after the pregnancy.
  2. Health Canada/The Public Health Agency of Canada should dedicate funding into supporting better data collection and research related to Canada’s maternal deaths and their circumstances, with a focus on deaths due to sepsis. 
  3. Health Canada/The Public Health Agency of Canada should promote and provide support for implementation of the recommendations made by the SOGC to return births to rural, First Nation and Inuit communities.
M-08 Maternal The decedent was a 37-year-old G6P4A1 with a history that included multiple trauma’s, chronic pain syndrome, depression, hepatitis B and past hepatitis C and opioid use disorder. Cause of death from gestational Staphylococcus aureus septicemia. The septicemia resulted in the in utero fetal demise through the overall process of multi-organ damage. Although the skin culture grew different organisms, the puncture of the upper left arm showed histologic features of a drug injection site, with evidence of healing, and was likely the original entry point for the bacteria. OCP, Diagnosis and testing
  1. Obstetrical care providers are reminded of the risks associated with opioid use disorder and the need for a comprehensive integrated care plan for pregnant women with opioid use disorder. The comprehensive integrated care plan should consider the patient’s social determinants of health including nutrition, safe housing, and other psychosocial supports.
N-01 Neonatal The mother of the deceased infant was a 26-year-old G2P0. Cause of death was multi-organ hypoxic-ischemic complications of perinatal asphyxia of undetermined cause. n/a None
N-02 Neonatal The mother of the deceased infant was a 24-year-old G3 TPAL 0110. Newborn exam revealed a morphologically normal, appropriately grown 23 weeks 2 days’ gestational age fetus with fused eyelids. Previable Delivery Occurring at 23 Weeks, (a) Maternal Cervical Incompetence Transfer         




OCP, Diagnosis and testing
  1. Ontario ambulance services should develop a procedure for transportation of pregnant women in suspected preterm labour such that routing takes the woman to the closest hospital with appropriate neonatal care whenever possible.
  2. It is recommended that obstetrical care providers obtain pre-pregnancy consultation with a high-risk obstetrician in cases at risk for incompetent cervix.
N-03 Neonatal The mother of the deceased infant was a 33-year-old G2P1 receiving care from a midwifery practice. Cause of death was Hypoxic-Ischemic Encephalopathy at three days of age. OCP, Diagnosis and testing                 


OCP, Transfer


Quality
  1. Obstetrical care providers should be aware of the signs associated with impending or actual uterine rupture, especially with a trial of labour after Caesarean (TOLAC).
  2. Obstetrical care providers should ensure that there is a thorough and complete transfer of accountability between care providers.
  3. The midwifery practice involved should conduct a review of their protocol surrounding off-call and call coverage and remind midwives about the importance of documenting discussions and courses of care. 
N-04 Neonatal This case involved the death of a four-day-old male infant from hypoxic ischemic encephalopathy due to perinatal asphyxia.  Concerns were raised about the obstetrical care  provided to the infant’s mother. OCP, Training/ education                           

OCP, Diagnosis and testing


OCP, Diagnosis and testing
  1. Obstetrical care providers are reminded of the 2007 Antenatal Fetal Surveillance Guidelines. 
  2. Obstetrical care providers are reminded that a significant decrease in weight percentile should trigger further ongoing vigilant monitoring.
  3. Obstetrical care providers and medical imagers are reminded that if the estimated fetal weight is less than the 10th percentile (IUGR), then umbilical artery Dopplers are necessary. 
N-05 Neonatal The mother of the deceased female infant was a 19-year-old G2 TPAL 1001. This baby died due to cardiac changes resulting from a narrowing of the aorta known as coarctation.  Metabolic and cardiovascular genetic testing indicated variants of undetermined significance.  Toxicology was positive for methadone, diphenhydramine and tetrahydrocannabinol (cannabis). Diagnosis and testing


Other
  1. Most responsible care providers are reminded that they must verify the physical findings of undergraduate medical learners.
  2. The Regional Supervising Coroner should communicate with the mother to recommend that in subsequent pregnancies, a fetal ECHO be done at the time of the anatomy scan and in the third trimester.
N-06 Neonatal The deceased infant was born at 38 weeks and five days’ gestational age (GA) to a 26-year-old G1 TPAL 0000. The cause of death was determined to be due to the extensive blood loss and multiorgan failure from a large subgaleal hemorrhage caused by the vacuum used to assist in the vaginal delivery.  OCP, Comm/Doc        


Training and education        


OCP, Diagnosis  and testing


Policy and procedures 


Comm/Doc        


Diagnosis and testing
  1. Obstetrical care providers are reminded of the importance of proper documentation of fetal heart rate findings in labour.  This should include documentation of the maternal heart rate to ensure differentiation of maternal and fetal rates.
  2. All centers delivering obstetrical care and thus providing neonatal resuscitation, especially primary level centres where the frequency of resuscitation is low, should institute regular interdisciplinary training with rapid cycle deliberate practice for neonatal resuscitation.
  3. Obstetrical care providers are reminded:
  • to be more vigilant of subgaleal hemorrhage after vacuum (instrumental) delivery when scalp swelling is noted, and
  • that with scalp swelling, early imaging (ultrasound) is helpful in diagnosis.
  1. The hospital should establish an observational protocol for neonates who have had forceps or vacuum applied at the time of their delivery.
  1. The center should establish a template to assist in thorough documentation in assisted vaginal delivery.
  2. Measurement of the serial head circumference is not adequate to rule out significant bleeding. Closer monitoring of the hemoglobin and scalp examination should be part of the protocol. A minimum of eight hours of monitoring is recommended.
N-07 Neonatal The mother of the deceased infant was a 36-year-old G1P0. This pregnancy was conceived through in vitro fertilization (IVF). Cause of death was attributed to multiple placental pathologies and subgaleal and intracerebral hemorrhages in the context of arrested second stage of labour and instrumentation. OCP, Comm/Doc


Policy and procedure                           

OCP, Policy and procedure


OCP, Diagnosis and testing


OCP, Transfer, Diagnosis and testing


Quality
  1. Obstetrical care providers are reminded of the SOGC Guideline No. 197 for intrapartum fetal monitoring.  This guideline provides recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention.  (JOGC September 2007)
  2. Obstetrical care providers are reminded of the SOGC Guideline No. 148 for operative vaginal birth in the management of the second stage of labour. (JOGC November 2017)
  3. Obstetrical care providers are reminded to decrease or stop oxytocin when the fetal heart rate tracing is abnormal.
  4. Obstetrical care providers are reminded to consider the possible need for Caesarean section if operative vaginal delivery is unsuccessful. Transferring the mother to the operating room and advanced notice to the anaesthetist for operative vaginal birth may be prudent.
  5. The hospital involved should undertake a lesson’s learned case review of circumstances surrounding this death.  Topics for discussion could include:
  • intradisciplinary communication
  • management of Caesarean delivery of an impacted head
  •  management of instrument assisted delivery
N-08 Neonatal The mother of the deceased was a 33-year-old G6 P4 woman with four previous full-term deliveries.  Lab results and post mortem examination revealed the cause of death to be disseminated herpes simplex infection with sepsis syndrome.  Herpes simplex Type II was detected in the baby’s blood as well as post-mortem specimens from lung, liver and brain. Education and training


Comm/Doc        
  1. Neonatal healthcare providers are reminded of the need to provide general and targeted education to parents or guardians prior to the discharge of healthy newborns from hospital.  Topics should include infant feeding, normal newborn behaviour and recognition of early signs of illness.  Parents of infants with risk factors for sepsis should understand the signs of infection and when to seek medical help.   
  2. Those caring for hospitalized newborns should ensure that there is an appropriate discharge plan in place for each infant that includes identification of the infant’s primary health care provider and assessment 24-72 hours after discharge. 
N-09 Neonatal The mother of the deceased infant was a 19-year-old unemployed single woman with financial difficulties. Cause of death was complications of perinatal asphyxia. Diagnosis and testing       


Diagnosis and testing    


Comm/Doc        


Training and education
  1. Neonatal healthcare providers are reminded of the importance of endotracheal tube (ETT) placement and the use of a CO2 detector and chest x-ray. Nasogastric tube placement is critical for better ventilation.
  2. Neonatal healthcare providers are reminded of the importance of early fluid resuscitation and of the neonatal resuscitation algorithm.
  3. Neonatal healthcare providers are reminded of crucial monitoring and documentation of neurological status during resuscitation.
  4. Hospitals with low volume deliveries should consider ongoing, local practice in obstetrical/neonatal emergency situations (e.g. computer assistance).
N-10 Neonatal The mother was a 27-year-old G4T3P0A0L2S0N1 0-positive Indigenous woman .  Cause of death was determined to be natural recurrent fetal maternal hemorrhages with secondary brain injury, in the context of in utero growth restricting at full term gestation. n/a None
N-11 Neonatal The mother was a 29-year-old G1P0.  Cause of death was hypoxic-ischemic encephalopathy due to perinatal asphyxia of undetermined cause. OCP, Diagnosis and testing
  1. Obstetrical care providers are reminded that maternal heart rate artifact can occur with external fetal heart rate monitoring and the simultaneous use of a fetal scalp clip and continuous maternal pulse oximetry should be considered for clarification. (see SOGC 2019 Guidelines on Intrapartum Fetal Surveillance)
S-01 Stillbirth The mother was a 31-year-old healthy G1 TPAL 0000.  The mother wanted to have a vaginal breech delivery and sought out the care of a midwife that would provide the service. However, after the delivery, the mother expressed concerns about the lack of understanding of the risks of vaginal breech delivery. OCP, Diagnosis and testing


OCP, Diagnosis and testing


OCP, Diagnosis and testing


OCP, Diagnosis and testing
  1. Obstetrical care providers are reminded that fetal growth restriction is a contraindication to trial of labour for the vaginal breech. (Vaginal Delivery of Breech Presentation.  SOGC Clinical Practice Guideline, No. 226, June 2009)
  2. Obstetrical care providers are reminded that continuous external fetal monitoring should be universal in the second stages of a breech labour and is recommended in the active phase of labour.  (Vaginal Delivery of Breech Presentation.  SOGC Clinical Practice Guideline, No. 226, June 2009)
  3. Maternal movement can provide artifact that makes it difficult to accurately assess the fetal heart rate.  Obstetrical care providers are reminded to use additional measures such as checking maternal heart rate in labour to ensure that the heart rate being monitored is indeed that of the fetus.
  4. Obstetrical care providers are reminded to proceed to Caesarean section delivery after sixty minutes of active pushing in the second stage even if the fetal buttocks are visible on the perineum. (Vaginal Delivery of Breech Presentation.  SOGC Clinical Practice Guideline, No. 226, June 2009)
S-02 Stillbirth The mother of the stillborn was a 41-year-old G11T10P0A0 L10. The mother presented to hospital with a placental abruption. She had sustained significant hemorrhage, having lost an estimated 1L of blood at home. She continued to bleed in hospital.  OCP,   Diagnosis and testing

OCP, Diagnosis and testing (EFM)  


Diagnosis and testing,


Comm/Doc


Quality
  1. 1.Obstetrical Care Providers are reminded to enact timely interventions for patients with life-threatening conditions.
  2. Obstetrical Care Providers are reminded that electronic fetal heart rate (FHR) monitoring should continue until delivery when the FHR tracing is concerning or the clinical situation is concerning.
  3. Anesthesia care providers are reminded to employ various strategies, including type of anesthetic, for optimizing critically ill patients throughout the intraoperative course.  Use of medications must be in appropriate dosages to achieve effect.
  4. Anesthesia care providers are reminded to accurately document all aspects of intraoperative care of the patient.
  5. The Chief of Anesthesia/Chief of Staff at the hospital involved should conduct a lessons learned review of this case.  Topics for review could include:
  • documentation (nursing and physician)
  • fetal monitoring
  •  preparedness for obstetrical emergencies including antepartum hemorrhage.

Full, redacted versions of reports and responses to recommendations are available to the public by contacting:  occ.inquiries@ontario.ca.