Dear Editor,
Once again the issue of maternal mortality raises its head, forcing me to utter the already overworked exclamation, ‘No! Not again!’ on reading the news of the post-partum demise of Alexis Syfox. As a UK trained and certified midwife, I know that the risk of having a complication increases each time a caesarean section is done. These are risks such as injury to the bladder and intestines, in addition to the accompanying scarring which occurs with surgery, and which makes having a second, third or fourth child a much trickier venture. Every time a caesarean is performed bands of scar tissue or surgical adhesions take place, so more adhesions are created, which may ultimately take a surgeon a considerable period of time to cut through.
As trainee midwives we were also made aware that there are other more serious complications such a placenta praevia, placenta accrete, increta, percreta (the difference between placenta accreta, increta or percreta is determined by the severity of the attachment of the placenta to the uterine wall), uterine atony and uterine dehiscence or rupture that could occur with each increase in the number of C-sections in a particular patient. Last but certainly in no way least, there is a direct association between placenta previa and the number of cesarean deliveries that substantially increases the risk of placenta accrete, which is oftentimes referred to as morbidly adherent placenta. Sadly, Alexis Syfox had all the ingredients for obstetrical complications prior to parturition, as she was surrounded by red flags. She was certainly a high risk patient.
What type of post-partum/ family planning advice was given to Alexis following her second C-section? Was she advised on family planning and the possibility discussed of post-delivery tubal ligation following any future delivery? Was the obstetrical team aware of the presence of placenta accreta during the ante-partum period, as the patient due to her history was certainly at risk for such an occurrence? Or was this an at-delivery realization?
What ante-partum radiological tests, if any were conducted (MRI/ investigative ultrasound)? Patients such as Alexis are traditionally screened for placenta accreta using antenatal sonography, due to her previous c-section history, and the high risk for this abnormality.
Although most patients with placenta accrete are asymptomatic, the fact should not be overlooked that placenta accrete is associated with placenta praevia (placenta covering the cervical opening). The outcome of these high risk pregnancies is severely impacted by the timing of the discovery of placenta accreta. On account of its potential emergent nature and the associated risk of life-threatening haemorrhage, it is imperative that both obstetricians and radiologists alike are familiar with the risk factors. Was there any bleeding during the third trimester of pregnancy, which is the warning sign of the presence of placenta accreta? The need to be fully cognizant of time of discovery, parity, prior modes of delivery, placental status, gravity and possible maternal mortality, and to optimize patient outcome and enhance patient safety make it important that an experienced team including pelvic surgeon, neonatologist, urologist, haematologist, (risk of massive blood loss) gynaecological oncologist, radiologist, etc, be mobilized at the time of delivery. Planned pre-term c-section hysterectomy with the placenta or afterbirth left in situ is the usual recommended management of suspected placenta accreta, although surgical management may be individualized. Significant haemorrhagic morbidity is linked to removal of the placenta.
In 2014 Guyana was listed as one of the five countries in the Caribbean and the Americas with the highest maternal mortality rate, and it has also failed to achieve Millennium Development Goal 5A, which called for a reduction of the maternal mortality ratio by three quarters.
A conclusion from the WHO, UNICEF, UNFPA and the World Bank in a study of maternal deaths in 181 countries during the years 1990-2010 was that maternal deaths are preventable. The Guyana Govern-ment especially the Minister of Public Health is called upon to immediately put in place all necessary measures (especially specialist staff trained in obstetrics) aimed at averting such tragedies. Every maternal death evokes new rhetoric which must now be translated into tangible evidence of change. Every death is one death too many. Enough is certainly enough. An arrival into the world must not equal a departure from it.
Yours faithfully,
Yvonne Sam
