A 36-year-old mother died less than two hours after giving birth to her third child because of a rare condition which critically affects fewer than 15 in 100,000 pregnant women, an inquest has heard.
Tracey Campbell-Fitzpatrick died in the early hours of Easter Monday last year after suffering a “massive” post-partum haemorrhage within minutes of the birth of her son Max at St Luke’s Hospital in Kilkenny.
She was originally from Knock in Co Mayo but lived in Carlow with her husband Bernard and their children.
The coroner’s court in Kilkenny heard that she suffered an amniotic fluid embolism, meaning some of the fluid surrounding her baby travelled into her own circulation, preventing her blood from clotting and causing blood loss.
The court was told there were a number of “gushes” of blood during the time following Max’s birth at 12.55am on March 28th of 2016, and also a trickle between gushes. By about 1.25am her blood loss was estimated at 1.2 litres.
A decision was made to transfer her from the labour suite to the operating theatre for examination under anaesthetic, but she deteriorated on the trolley on the way and became pale and unresponsive in the theatre, the coroner’s court heard.
She suffered a cardiac arrest at 2.30am and the resuscitation team worked on her for over 70 minutes but she was pronounced dead at 3.45am.
The woman's husband Bernard Fitzpatrick said in a statement to the inquest that her blood pressure had been "up and down" in the days before Max was due to be born and she was in hospital to have it checked on a number of occasions.
She was admitted to St Luke’s on Saturday, March 26th. Mr Fitzpatrick said consultant obstetrician Dr David McMurray and another doctor met her at about 7am the next day when she asked them if she could have a Caesarean section. The consultant replied “we won’t break any eggs on Easter Sunday,” Mr Fitzpatrick said.
Her waters broke at 9pm that night and as time went on she was in a lot of pain. A nurse said she could not have an epidural in the ward she was in, and the floors were wet in the delivery suite so she couldn’t go there yet.
By 11.30pm, Ms Campbell-Fitzpatrick was “screaming in pain”. A doctor arrived and decided they would use suction to deliver the baby. Max was born at 12.55am.
An anaesthetist arrived and she was moved out of the room to be brought to theatre. “We were told there was a tear in the uterus,” her husband said. “We were told everything would be okay... I gave her a kiss goodbye and told her I’d see her soon. Tracey smiled at me.”
Mr Fitzpatrick said his wife’s parents arrived in Kilkenny at 3.15am and about an hour later Dr McMurray came out to them and said he had bad news: “I’m sorry, Tracey is no longer with us.”
Next day
Mr Fitzpatrick said the next day he had asked Dr McMurray if Tracey would be alive if she had had a Caesarean section, and he replied: “Yes”. Mr Fitzpatrick said the doctor told him “she didn’t ask for one” but Mr Fitzpatrick said to the doctor “she pleaded for one”.
In court, Dr McMurray said it was incorrect to say that Ms Campbell-Fitzpatrick had asked for a C-section. He said she had asked if he thought it was “necessary” for her to have one.
Dr McMurray said if he had arrived an hour earlier he would have administered the same drugs as were given to her by the medical staff, and in the same sequence.
He said one of the “critical things” in her case was that it was “very difficult” to get intravenous access to her veins, to administer blood and fluids. Where he trained, in west Scotland, they always insert a large cannula, used to deliver fluids into a patient, beforehand in case an emergency arose during or after labour.
“It just means you can give more fluids, more quickly”.
Dr Peter Kelehan, a perinatal paediatric pathologist, said that during the autopsy he found foetal skin cells within the capillaries in the woman's lungs. This was "definitive evidence" of amniotic fluid infusion syndrome, he said, which is "unpredictable and unpreventable" and very rare, causing death in between 6 and 15 out of 100,000 women in pregnancy. The fluid prevents the mother's blood from clotting, causing bleeding.
This was the “sole cause of death,” he said.
“It’s not preventable, but it may be treatable, if you have everything on site,” he said.
The jury returned a verdict that death was by natural causes, in line with the medical evidence, and was told the the HSE had carried out an “extensive” investigation into the death. Some of the hospital systems had since been changed and a procedure for fitting “wide-bore” cannulae to pregnant women to allow the rapid delivery of fluids, if needed, is now in place.
The jury also recommended that a consultant should attend a patient to monitor the situation if blood loss reaches emergency levels.
After the inquest, Mr Fitzpatrick said his wife “loved life” and lived for her family. “She never got to see her new baby, all she got to see was the photo I showed her,” he said. “To be in this situation is just heartbreaking.”
Mr Fitzpatrick said the legal process following his wife’s death “isn’t finished yet” and the family would be considering their options. “Tracey has no voice, we’re her voice now, and by God we will shout for her.”
Pauline Campbell, the mother of the deceased, said the family were “devastated” by their loss.