Maverick Story's - December 15, 2024

Maternal Autopsy & Justice

December 15, 2024

0 10 min read

Need for Autopsy in every death –

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Maternal Autopsy & Justice

In the year 1986, Government of India under the visionary leadership of the then Prime Minister Mr. Rajiv Gandhi had passed the Consumer Protection Act (CPA) enabling anyone to dispute a case of

negligence against the treating doctor. A doctor is always considered to be a messiah, but when his alleged negligence causes physical injury, a mental condition and or death, it is shrouded in mystery, and the doctor is assumed to be a culprit. However, the Act has provisions to take into cognizance the relative contributory negligence of the patient & its family.

It is note-worthy that World Health Organisation (WHO), has termed ‘Maternal Death’ as “the death of a woman while being pregnant, or within 42 days of termination of pregnancy”, irrespective of the prima-gravida; or causes related to the aggravation due to the pregnancy or its management but not from accidental or incidental causes.

As per WHO, of late almost twenty lakh women worldwide die as a result of pregnancy each year, and out of which approximately 25% of all pregnancy and delivery related maternal deaths occur in India. The reasons, why a woman die in pregnancy, and during child birth are many. Beside the direct, indirect, and co-incidental causes, other factors are – lacuna in the health care system, lack of proper communications, shortage of manpower and apathy towards patient care.

A study was conducted to analyse the reports of the autopsies, those which were, undertaken by the different Forensic Departments to determine the factors causing such pregnancy related deaths. The autopsy records with clinical notes were retrieved and histopathological slides were studied to establish

the accurate cause of delivery deaths. The variables like age of the mother, gravidity, outcome of pregnancy, obstetrical characteristics, period of gestation, methods of delivery, death of patients after delivery, and place of deaths were used to classify and analyse the data.

The note-worthy observations were:

The maximum number of deaths were 36% recorded between the age group of 30 – 35 years; followed by 25% in the age group of 15 – 20 years. Again, 85.7% were related with delivery and 14.3% with medical termination of pregnancy (MTP).

The percentile of Primi-Gravida was 57.1%, and 42.9% were found to be multiparous. Normal Vaginal Deliveries were recorded at 57.1% including the MTP cases, and 42.9% were caesarean deliveries.

Atony of uterus was the cause of death in 28.6% of the cases; 21.4% died due to cervical and vaginal wall tear; 14.3% died due to uterine rupture; 7.1% had died due to amniotic fluid embolism, and 7.1% due to Bronchopneumonia. Elementarily, mostly 78.6% died in hospital and nursing home, while 14.3% died at home, and 7.1% on the way to hospital.

The unpredictable outcome was due to the primigravida associated with inadequate monitoring could be a factor. It is believed that admissions of moribund cases referred from periphery have

inflated mortality rate.

While assessing the time of death, it was registered that 57.1% died 01 day after delivery, 14.3% during delivery, 14.3% during MTP, 7.1% died 02 days after delivery, and 7.1% died 03 days after delivery. About, 50 – 70% maternal deaths occurred in post-partum period, of which 45% of deaths occurred in the first 24 hours after delivery, and more than two-thirds during the first week. Between 11 – 17% of maternal deaths occurred during child birth itself. Maternal deaths mostly occurred from the third trimester to the first week after birth. Studies show that mortality risks for mothers are particularly elevated within the first two days after birth. One study showed that maximum deaths occurred nearly equally, around 47% in antenatal & 43% in the post-partum period.

Some of these causes could have been prevented with proper obstetrical procedure. Most maternal deaths are related to obstetric complications including post-partum haemorrhage known to be the most common cause, infections, eclampsia, prolonged or obstructed labour and complications of abortion.

What was alarming is that 14.3% died due to uterine rupture at 40 weeks and 38 weeks, respectively, indicating the possibility of an intervention during the 36^th. week or so. Risk factors of uterine rupture among many others include inducing labour with oxytocin or prostaglandin and augmentation of labour with oxytocin. Rupture during labour is considered to be more dangerous than while occurring in pregnancy because shock is greater and infection becomes inevitable. Prostaglandins have a risk of uterine hyper stimulation, which carries an increased risk of uterine rupture. In most cases, it was demonstrated that an emergency caesarean delivery or caesarean hysterectomy could have been life-saving; but this necessary intervention was not performed.

Shock and haemorrhage due to atony of uterus and injury to the birth canal were found to be the major causes of pregnancy related deaths. Although, a delay in diagnosis, immediate treatment and decision to transfer, delay in transportation for reaching hospital and delayed therapy, may be the factors for these maternal deaths. However, the role of negligence from the patient’s side viz. late admissions, inadequate ante natal check-ups etc. cannot be completely ignored.