Case Type Summary Recommendations by Theme
EX-01 Maternal Executive The decedent was a 33-year-old G2P0A1 who had an invitro fertilization pregnancy. There were no reported antenatal complications. Presented to hospital with cramping and abdominal pain. She was diagnosed with intrauterine fetal demise.  She was admitted to hospital and labour was induced. During the induction, she became short of breath and nauseous. A short time later, she arrested and was thrombolysed due to concern for pulmonary embolism. Cause of death was thought to be probable pulmonary embolus due to a) deep vein thrombosis and b) full term pregnancy. None
EX-02 Maternal Executive The decedent was a 22-year-old G1P0 at 18 weeks' gestation with a history of seizures, congenital deafness, and developmental delay. Followed by a high-risk pregnancy unit. Witnessed collapse with seizure. Could not be resuscitated. Cause of death was epilepsy. None
EX-03 Maternal Executive The decedent was a 33-year-old woman who was approximately seven months pregnant at the time of her death. The woman was killed by her intimate partner. None
EX-04 Maternal Executive The decedent was a 33-year-old G1P0 previously healthy woman at six weeks' gestation.  Complained of upper abdominal pain, heart burn, nausea, vomiting, dizziness, and diarrhea, no pelvic pain or vaginal bleeding. Transported to hospital and died from ruptured ectopic pregnancy of the left fallopian tube. None
M-01 Maternal The decedent was a 24-year-old G3P1 previously healthy woman. She had two previous therapeutic abortions. After an uncomplicated pregnancy, she was admitted with onset of labour at 36 weeks’ gestation. Decedent and baby were doing well and there were no nursing concerns. Mother died three days after giving birth from sepsis due to postpartum Group A Streptococcus infection (site of infection unknown) Policy and procedure
  1. It is recommended that all facilities and/or organizations providing obstetrical care services develop a comprehensive maternal mortality review process based on standardized and thorough data and information collected.
Diagnosis and testing
  1. All hospitals are encouraged to utilize a modified early obstetric warning (MEOWs) system (as recommended by the Society of Obstetricians and Gynaecologists (SOGC)) and provide appropriate and recurring training to obstetrical care providers within their facilities.
Other
  1. It is recommended that the SOGC develop, distribute and promote the use of a standardized data and information collection tool in order to analyze and assess information pertaining to maternal deaths on a provincial and national level.
M-02 Maternal The decedent was a 36-year-old G1P0. Immediate postpartum recovery in hospital was uneventful and she was discharged home. Died on day 4 post partum from necrotizing fasciitis due to infection of episiotomy site following vacuum assisted vaginal delivery. Transfer
  1. Healthcare providers are reminded that necrotizing fasciitis is a medical/surgical emergency. In these severe cases, transfer to an appropriate level facility should be considered expeditiously. Consideration should be given to utilizing Criticall for assistance in referral to an appropriate facility.
Obstetrical care provider
  1. Healthcare providers are reminded that in order to avoid delay, surgical treatment of necrotizing fasciitis should generally be performed at the presenting hospital provided an appropriately trained general surgeon and critical care support is available.
M-03 Maternal The decedent was a 29-year-old developmentally delayed G3P2A1 at 29 weeks’ gestation. Witnessed cardiac arrest. Cause of death was not ascertained, and manner of death was undetermined. Other
  1. It is recommended that the Regional Supervising Coroner suggest genetic counselling for the decedent’s children and any of her siblings
M-04 Maternal The decedent was a 40-year-old G4P3. Antenatal course was uneventful until 31 weeks’ gestation when she called her obstetrician’s office due to a few-day history of swelling in leg. Advised to get up and walk around throughout the day, elevate her legs while sitting and apply a cool cloth to the leg. Next day, presented to hospital with shortness of breath. Cause of death was pulmonary embolus. Obstetrical care provider
  1. Obstetrical care providers are reminded that signs and symptoms of DVT in pregnancy require urgent objective assessment. All possible cases of DVT should be approached with a high index of suspicion and appropriate urgent assessment conducted.
Obstetrical care provider
  1. Obstetrical care providers should ensure that medical advice given by office staff to patients is appropriate, reviewed in a timely and thorough manner and prioritized accordingly by the primary care provider.  Virtual care (e.g., tele-practice) should be thoroughly documented, including dated and time-stamped in the chart.
M-05 Maternal The decedent was a 45-year-old G2P1. At 29 weeks and two days’ gestation, the woman presented to hospital in spontaneous labour. Fetus to be in a breech presentation. Caesarean section. Seizure-like activity. Cause of death was hemorrhagic shock due to placental abruption. Obstetrical care provider
  1. Obstetrical care providers are reminded that late maternal age is a significant risk that requires close surveillance and consideration for earlier planned delivery.
Policy and procedure
  1. Obstetrical care providers are reminded that massive transfusion protocol specific to the obstetrical patient should be established and may consider the early use of cryoprecipitate.
Obstetrical care provider
  1. Obstetrical care providers are reminded that unstable patients require a multidisciplinary (including most responsible physician) approach to care as is provided by critical care response teams (CCRTs) in hospital.
Diagnosis and testing
  1. Obstetrical care providers are reminded about performing and documenting post-delivery vital signs, including, but not limited to, fundal checks.
M-06 Maternal The decedent was a 26-year-old G3P2. Medical history was significant for a diagnosis of epilepsy. At 38 weeks’ gestation, found unresponsive in bed. Cause of death was consistent with a seizure disorder and possible positional asphyxia.   No recommendations.
M-07 Maternal The decedent was a 39-year-old G4P3. Arrived in Canada from Bangladesh approximately three months prior. Notation on the prenatal record of ‘complete placenta previa' - unsure if this information conveyed and appointments missed. Communication issues. Death was attributed to postpartum hemorrhage due to uterine atony Communications/documentation
  1. Obstetrical care providers are encouraged to utilize translation services and hospital or community resources when there may be language or cultural factors that could impact the patient’s ability to comprehend and/or participate in care plans and make informed choices.
Policy and procedure
  1. Obstetrical care providers are encouraged to review and update policies and procedures relating to the management of significant obstetrical bleeding events.
M-08 Maternal The decedent was a previously healthy 34-year-old G1 TPAL 0000. Noted pelvic pain and pressure. 36 weeks and six days’ gestational age, the woman called the labour and delivery unit of her intended delivery hospital with complaints of nausea, vomiting and decreased fetal movement for the previous 24 hours. Speech was abnormal and she was not answering questions appropriately. Caesarean section. Cause of death was acute fatty liver of pregnancy. Diagnosis and testing
  1. Obstetrical care providers are encouraged to consider alternatives for obtaining diagnostic imaging (e.g., portable units) for emergent obstetrical patients. 
Communications/documentation
  1. Obstetrical care providers are reminded that all conversations, including telephone assessments and decisions for care, should be well documented on the medical record.
N-01 Neonatal The mother was a 39-year-old G10T3P2A4. Infant born at 23 weeks’ gestation. Pregnancy was unrecognized and there was no prenatal care or serology completed. Cause of death was extreme prematurity. Concerns relating to the resuscitation in the emergency room. Obstetrical care provider
  1. Healthcare providers are reminded:
    • to confirm endotracheal tube placement using the steps outlined in the Neonatal Resuscitation Program (NRP) manual
    • early placement of the nasogastric tube is essential to effective ventilation
    • intravenous access is critical for fluid resuscitation to improve the outcome.
  Communications/documentation
  1. Healthcare providers are reminded that all observations and procedures should be clearly documented. Consideration may be given to the inclusion of a “code pink” template form in the emergency department neonatal resuscitation kit.
Quality
  1. The hospital involved should conduct a lessons-learned case review of the circumstances surrounding this death. 
N-02 Neonatal Mother was a 33-year-old G2T1P0A0L1 at 36 weeks and two days. Planned Caesarean section. Mother presented with abdominal pain. Emergency C section for placental abruption. Infant died at three days from hypoxic ischemic encephalopathy. Diagnosis and testing – EFM
  1. Obstetrical care facilities are reminded that electronic fetal heart rate (FHR) monitoring strips should be retained as part of the patient’s medical record.
N-03 Neonatal The mother was a 41-year-old primiparous parturient who presented in spontaneous onset of labour at 37 weeks and 2 days. Type 2 diabetic on metformin, had hypercholesterolemia and hypertension. Infant died from birth trauma. Policy and procedure
  1. Obstetrical care providers at the hospital involved should review the No. 396 March 2020 (Replaces No. 197, September 2007) Fetal Health Surveillance: Intrapartum Consensus Guideline.
Obstetrical care provider
  1. Obstetrical care providers are reminded that a double set up at time of trial of forceps can decrease the time interval from decision to abandon the trial of assisted vaginal delivery to Caesarean birth.
Diagnosis and testing – EFM
  1. Obstetrical care providers are reminded that fetal heart rate monitoring should be continued through delivery despite interventions such as a trial of forceps.
N-04 Neonatal Mother was a 35-year-old G4 TPAL 0030 who presented at 32 weeks. Concerns were identified regarding the decision to transport the mother to a tertiary centre.  Transfer
  1. Obstetrical care providers are reminded of the importance of timely transport of out-of-scope deliveries. Deliveries to centres with an appropriate level of care offer the best chances of survival of the fetus.
Transfer
  1. Obstetrical care providers are reminded that the timely delivery of in-scope neonates is preferable to transfer to another facility for delivery. Transportation of a laboring woman is a risk due to the limitations in monitoring and intervention.
Quality
  1. Hospital A (the referring hospital) should conduct a lessons-learned case review.
N-05 Neonatal Mother was a 35-year-old opioid-dependent G6P2A3. Recently released from correctional facility. Gave birth in community after receiving methadone. Infant died from global hypoxic ischemic injury. No recommendations.
N-06 Neonatal Mother of the deceased infant was a 35-year-old G 10 TPAL 4145 who presented to a local remote Indigenous health authority at 28 weeks and 2 days after falling down stairs. Transported to tertiary centre via air. Gave birth on route. Infant died from intraventricular hemorrhage. Transfer
  1. It is recommended that a standardized form for patient transfer be developed that includes all relevant information including obstetrical history, in order to assist the decision of whether to transport or not.
Transfer
  1. Consideration should be given to increasing resources for maternal and neonatal transport, including having teams attend rural/remote areas instead of risking transport of the patient.
Transfer
  1. It is recommended that the SOGC develop evidence-based recommendations to inform decision-making related to patient transport, including recommending a standardized form.
N-07 Neonatal The mother was a 33-year-old G1P0. Concerns about communication between midwife and obstetrical staff. Cause of death was complications of labour and delivery. Obstetrical care provider
  1. Obstetrical care providers are reminded that tachysystole can occur in the absence of an oxytocin augmentation. This, accompanied by abnormal fetal heart rate pattern with meconium and blood in the amniotic fluid, should be acted on with urgent delivery.
Communications/documentation
  1. Once a consultation has taken place and recommendations have been made, the most responsible physician (MRP) should document this and proceed with the course of care agreed upon. Timely transfer of care should occur.
Education/Training
  1. Obstetrical care providers asked to disengage the fetal head at Caesarian section should be appropriately trained to do so in order to minimize harm to the baby. Alternative techniques for disengagement of the head should be considered first.
Policy and procedure
  1. Obstetrical care providers are reminded of current fetal health surveillance guidelines (see SOGC No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline, March 2020.)
Transfer
  1. Obstetrical care providers are reminded that emergency medical services (EMS) should be utilized when transporting a woman in labour, particularly when there are complications. 
N-08 Neonatal Mother was a 28-year-old G9P5A3L5. Infant was an early-term newborn who died after presenting on day 4 of life with severe hyperbilirubinemia. Obstetrical care provider
  1. Healthcare providers responsible for assessment and management of newborns are reminded to screen all newborns for jaundice before hospital discharge or as an outpatient at 24 – 72 hours of age if discharge is to be undertaken prior to 24 hours. It is also important that parents be provided with information regarding normal newborn behaviour and feeding.
S-01 Stillbirth The mother was a 31-year-old G6P5. Stillborn at home with a midwife. Cause of death was extreme prematurity.  Other
  1. The regional supervising coroner may recommend obstetrical consultation for any future pregnancies that the mother might have due to the incidental finding of placenta accrete found on placental pathology.
S-02 Stillbirth Mother was a 37-year-old G3 TPAL 0111. Concerns about the adequacy of the prenatal care. High-risk twin delivery. No recommendations.
S-03 Stillbirth Mother of the stillborn was a 24-year-old primip. Pregnancy progressed normally until labour when there were ruptured membranes and meconium stained amniotic fluid from admission and inadequate labour which warranted augmentation. Cause of death was intrapartum haemorrhage. Diagnosis and testing
  1. When intervention is planned due to concern for fetal wellbeing, fetal heart surveillance should continue until the last moment.
Communications/documentation
  1. Obstetrical care providers are reminded that second trimester ultrasounds should include routine description of the cord insertion.
Obstetrical care provider
  1. Obstetrical care providers are reminded that when there are decelerations, the administration of syntocin should be stopped.