Sometimes cases go out to independent third party reviewers as well, though this is more typical when there is a specific doctor or other practitioner who has shown a pattern of complications that needs unbiased investigation.

I agree there isn’t much to be gained by overly strong language. I think many people, when discussing many health issues, including pregnancy and birth, but also when discussing breastfeeding and parenting, need to step it down a notch with the sweeping judgments, name calling and accusations. It’s not only bad for relationships, it is bad for critically examining a topic if it is obscured by a bunch of emotion-fanning nonsense.

However, I do think paternalism in medicine is a real problem, and can be pointed out when it is an accurate criticism. I think Dr. O would agree with me on that one, as would the ACOG position statement on ethics and decision making for elective surgical procedures.

When I asked about the adverse event review, I meant like the original post, but with the people involved and peers in the hospital, not on a blog with non-involved people with varying levels of expertise, of course! Like, let’s say you and Dr. O worked at the hospital – it consist of you two (as peer experts) and the medical practitioners who were involved would meet with some hospital administrator, I am assuming (this is a hypothetical) and go over what might have happened with a list like the original post, and would probably add in stuff from the chart and the history (and recovery, hopefully) of the affected patient.

I was just wondering how common it was when there was not a mortality, and if there was a pressure to not have such reviews due to liability concerns. I have heard that whatever is reviewed is discoverable as evidence, i.e. can be requested and must be given to the plaintiff in a malpractice case. Not that I necessarily disagree with that – if there wasn’t negligence, I would think the review would substantiate this, but I know that is me speaking as a student and a mother, not as a defendant.

http://www.csaol.cn/img/Hypertextbook/a/c90.htm

“The large epidural doses required for analgesic effect are similar to intravenous doses for fentanyl and even higher for sufentanil supporting the theory that early respiratory depression, if it occurs, is the result of systemic absorption from the epidural veins with these agents. Following intrathecal administration, respiratory depression within 15-30 minutes has been reported with both fentanyl (5) and sufentanil (6).”

Patient hypersensitivity? Dosage error? Catheter migrated after repositioning the mother?

Not likely, unless it is initiated by the parents. The hospital personnel shouldn’t be divulging any more details to a journalist or reporter without the patient’s consent. And at this time, it doesn’t look like the parents are interested in debunking the idea of having been touched by a divine presence. But the dad mentioned keeping a scrapbook of press coverage for his son; maybe somewhere along the way they will stumble upon this post, or Henci’s post, or something else that makes them reconsider other possibilities. And maybe they will request a disinterested third party to do a complete review of the hospital records. But I suspect that we will never *know*.

My underlying point was that a high spinal is not hard to recognize, and if that had occurred, I don’t think there would be much mystery around it. But that being said, it is possible that doctors and the hospital, caught inside a media magnifying glass they never wanted, decided to play dumb for the cameras. I might do the same thing. Doctors are pretty well trained to not make statements about what happened until you really know what happened, and in this case, they probably didn’t know for sure at the time of the interviews, even if they had an idea.

Well, Ms Goer accused Dr Martin of sleeping through her anesthesia lecture and not knowing much about her chosen field and then claim that she knew a lot more about physiology than Dr Martin, which seemed quite inappropriate to me. I have never met an MFM physician who was not remarkably intelligent, and they tend to know a great deal about all of these issues. Ms Goer then went on to explain in great detail what happened with great apparent authority, without even considering other possibilities, or the flaws in her theory. I found her remarks offensive. She is passionate about her point of view and I respect that, but in this case I believe she made far too harsh a stand without backing it up with real physiologic knowledge. Passionate people cross the line sometimes, me included. I think that happened in this case.

>> However, you say this would be independent of the anesthesia. But, if an epidural frequently lowers venous return by lowering blood pressure and venous tone, wouldn’t it complicate and contribute to the aortacaval compression?

Yes they probably would have some additive effect. Dr Onyeije may be able to expand on this.

>> Is this what an adverse event review would be like?

I suspect that the hospital has had or will have a “Root Cause Analysis”. The big difference between a RCA and what we have done is that an RCA involves the people who were actually there who have access to all the available information. As such, I think what we did could not be considered an RCA – we have done some educated speculation. As we mentioned, we could be missing important pieces of the puzzle, pieces that tend to be lost when medical information is transmitted through the lay press.

>> Also, medical blogs are not immune from taking an adverse event that occurs in a homebirth (I am not linking, but I think it should be easy enough to find a recent post like that) or involving the refusal of an intervention, and blowing that up in an insensitive and often inaccurate way to support a point of view about paternalistic medicine.

I think we’re all guilty of forcing the facts to fit our preconceived notions at times. People aren’t so simple that we can be categorized as “good” or “bad” or “paternalistic” or “ignorant” or whatever. We all have characteristics that show at different times, and those parts of us are all real. The shame is when one person or group finds something they don’t like about another person or group and the decides that they are defined by that one thing. Its bad for relationships.

Thanks for reading!

I have a problem with the way many media outlets, from news stations to advocacy blogs to medical blogs sensationalize stories. The media, in this case, may have played up the Christmas miracle side to the story. Birth advocates may have played up the danger of epidurals (although I agree they need to be looked at more critically than they are, and I have personally witnessed incredibly poor informed consent for the procedure.

Also, medical blogs are not immune from taking an adverse event that occurs in a homebirth (I am not linking, but I think it should be easy enough to find a recent post like that) or involving the refusal of an intervention, and blowing that up in an insensitive and often inaccurate way to support a point of view about paternalistic medicine.

I have one question – I was leaning toward the aortacaval compression theory myself, which I had suggested on other posts about the case. However, you say this would be independent of the anesthesia. But, if an epidural frequently lowers venous return by lowering blood pressure and venous tone, wouldn’t it complicate and contribute to the aortacaval compression?

This is a little like the studies looking at heart attack patients in the hospital and asking whether or not shoveling snow was as risk factor. Turns out that it was, but they didn’t find it because the patients who had heart attacks shoveling snow tended to die and end up in the morgue, not in the hospital where they could be enrolled into the study.

AFE is an interesting thing. As Dr O. has mentioned, there may be amniotic fluid in maternal circulation in women not affected by the syndrome we call AFE. But conversely, injecting amniotic fluid of a pregnant animal into the animals bloodstream _does_ reliably cause the AFE syndrome and death of the animal. It may be a question of amount. Women who die rapidly of AFE have their small pulmonary arteries packed with fetal squamous cells, in essence creating a pulmonary embolism. This part of the AFE may be separate from the anaphylactic part of the syndrome. Perhaps this is why some women seem to be more affected by the AFE than others.

Thanks to all for the discussion. I’m glad people have found the time and interest to read our long post!

Nicholas Fogelson, MD

The reason is because AFE is so rare, even if there is an increased “statistical” risk, it is doubtful that this is important on a “clinical” basis for any individual patient.

Put another way. The study in the Lancet quotes a risk of 14 per 100,000 for AFE and a 1.8 adjusted odds ratio. This would mean (approximate numbers here) for any patient in spontaneous (non-induced) labor the chance of NOT having an AFE is 99.99989% whereas for the patient undergoing an induction of labor the chance of NOT having an AFE is 99.99981 . (the difference is between 10.5 per 100,000 and 19.0 per 100,000). Significant from a statistical standpoint but not from a per patient standpoint.

Nevertheless, while we cannot ignore the fact that induction *may* increase the risk for AFE, I would say that there are bigger reasons to avoid induction than the avoidance of amniotic fluid embolism.

Again, I have my doubts regarding AFE in this case. It would seem logical that if you “squeeze” the uterus too much that amniotic fluid would end up in the blood vessels and bad things would happen; however, what appears clear now from recent research is that the presence of amniotic fluid in the mothers blood is much more common than we think and that only a subset will essentially have an allergic reaction to amniotic fluid which results in the syndrome of AFE. In my experience (and yes this is a completely non-evidence based appeal to anecdotal evidence) patients with actual AFE are *very* sick and even when they survive the road to recovery is long and rough. Hence, I would put AFE on the list but lower in the list of possibilities.

Whew. I’ll say it again. Is there an investigative reporter out there willing to look into these questions for us?

Thanks for the contributions, everyone.

I think the term ‘amniotic fluid embolism’ misleads people into thinking that it is somehow similar to a thromboembolism or PE. In fact, the more recent research I’ve read suggests that AFE is more like an anaphylaxis, I don’t know how much support their is for that position. One issue is – we don’t know how common it is to have fetal cells circulating in the mother’s blood stream. (The new non-invasive Down’s testing will depend on the fact that fetal DNA does routinely get into the mother’s bloodstream). It may be that quantities of fetal cells/amniotic fluid getting into mother’s bloodstream is quite common in childbirth – with anaphylactic reaction very rare. However, we don’t measure this in normal circumstances (i.e. when there has been no reaction) so we have no way of knowing how rare/common an event it is.

“Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]).” http://www.ncbi.nlm.nih.gov/pubmed/17055946

Thanks for the fascinating discussion.

When a bit AFE hits, it causes a massive reaction that often leads to maternal death in a matter of minutes or even seconds. Smaller AFEs can progress more slowly, and can sometimes be successfully treated with massive blood product transfusion. Sometimes 50 or even 100 units of blood products can be used in a successful AFE rescucitation. I believe 20% would be an optimistic death rate for AFE. I have not seen recent numbers, but in my experience the death rate would be closer to 50%.

Just feeding my curiosity. Any comments are appreciated!

Thank you.

On the video (http://abcnews.go.com/video/playerIndex?id=9447356), the father clearly says, “…ONE of the nurses noticed that the color, etc…” May seem minor to you, but it means a lot to credit the nurse there who observed her patient going gray and took immediate action, along with the anesthesiologist and crash team.

You also correctly state that the benign course for the child and the rapid (seemingly uncomplicated) resuscitation points toward a shorter duration of arrest than has been reported in some places.

My personal assessment is that the “Touched my an Angel” angle was great to give the story legs in the media and the fact that it happened on Christmas eve also adds to the miraculous nature of the narrative. But I agree with you, however, that kind of focus takes away from the hard work and credit that should rightfully go to the hospital staff.

I remain hopeful that some reporter, somewhere, will go back and collect the missing information and provide a follow-up story as a public service to those of us who have followed this story and would like some cloture on this issue. I would say that it’s the least the media could do for the general public since they essentially brought us into this story and left us off at the climax. Knowing the eventual medical resolution of this case would be more than just denouement. It would represent completion of their duty and education of the public. It may also dampen some of the conjecture that has been spread in the blogosphere.

We can hope. But I’m not sure it’s going to happen.

Thanks again for your kind comments. And stay tuned.

I would like to thank you for giving props to the NICU team, it’s appreciated. It sounds like the baby recovered very rapidly with minimal resuscitation required. That makes me think the mom was not down for long (no way 15 minutes), so placental blood flow was not compromised for long. This would lead me to believe it was an acute, transient event that led to this mom’s respiratory, then cardiac collapse. I would be very curious to know what the cord blood gases showed, and if the placenta was sent for pathology. This story makes for a great case study. Thanks for your analysis.