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Postmortem cesarean section
Postmortem cesarean section ROBERT High
Point,
K.
ARTHUR,
North
Carolina
M.D.
Podmortem cesarean section continues to carry a bleak fetal outkxk The present report adds to the literature three recent cases in which the infant was not saved. Analysis of the literature is used to produce guideposts to timing and performance of the procedure. The possible impact of today’s technology on the problem is discussed. The need for earlier intervention in the patient near death is presented as a possible method of improving fetal salvage. (AM. J. OBSTET. GYNECOL. 132: 175,
1978.)
IN X950, in the first edition of WiUimn’s he edited, Eastman’ made this statement the chapter on cesarean section:
that at the end of
Obstetrics
“From the earliest times, when a patient died undelivered at nearly full term, cesarean section was sometimes performed immediately after the death in the hope of saving the life of the child. The number of children rescued by this procedure, however, has always been small. Despite this fact, it is my opinion that it should be done, provided the fetal heart is audible a few minutes before the mother’s death and provided full written permission has been obtained from the patient’s husband.” Some 28 years later, this statement is essentially unchanged in current texts and in the obstetric literature. It may be that the operation is done more frequently but the results remain less than satisfying. Postmortem cesarean section remains at best an obstetric calamity. More often than not, the delivery of a stillborn infant or a badly compromised child who does not survive compounds the tragedy of the mother’s death. There have been three postmortem cesarean sections performed at High Point Memorial Hospital in recent years. I performed two in a space of less than three months. An associate performed the third; all were to no avail. Case reports Case 1. Mrs. B. M., a 23-year-old white woman, para 2-O-O-2, was admitted to the hospital January 5, 1967, From the Obstetrics-Gynecology Memorial Hospital.
Section, High
Poinf
Presented as Official Guest at the Fortieth Annual Meeting of the South Atlantic Associutkm of Obstetih?~ and Gynecologists, Acapulco, Mexico, Janumy 21-26, 1978.
Reprint requests: Dr. Robert K. Arthur, High Paint, North Carolina 27262. OOOZ-9378/78/02132-0175$00.50/O@
1978
TheC.V.
P. 0. Box 5128,
Mosby
Co.
at seven and a half months’ gestation with a history of recent near-syncope at home. Pertinent history on admission revealed a strong family history of vascular disease and a personal history of puerperal thrombophlebitis following each of her previous pregnancies. Examination revealed tachycardia and cyanotic ear lobes. The pregnancy was commensurate with dates and the fetal heart tones were normal. Examination of the extremities revealed no abnormality. Homans’ sign was bilaterally negative. Laboratory work revealed mild anemia and uncompensated respiratory alkalosis on acid-base studies. Chest roentgenograms on January 9, 1967, and January 12, 1967, were normal. Electrocardiogram on January 12, 1967, showed “nonspecific T-wave changes.” Sometime between 7:30 P.M. and 8:00 P.M. on January 12, 1967, the patient collapsed in the bathroom. She was seen immediately by a staff pediatrician who was on rounds. He found slight cyanosis and an irregular, weak pulse. The patient was put to bed and nasal oxygen was started as cyanosis deepened. Medical and obstetric help were summoned immediately but cardiac arrest occurred within moments of return to bed. Cardiopulmonary resuscitation was begun by a nurseanesthetist and the pediatrician, On arrival of an obstetrician, the pulse had been absent for three minutes, and the pupils were fixed and dilated. A rapid cesarean section was performed with delivery of a 1,556 gram infant in poor condition at 8:00 P.M. The infant died at 9:30 P.M. that night. Postmorten examination revealed massive pulmonary embolism (recent) and an older infarct of the right lower lobe. Case ‘2. Mrs. J. M., a 27-year-old, white, primigravid woman, was admitted to the hospital on the afternoon of August 5, 1969, with a history of five to six days of nausea and vomiting, at approximately 36 weeks’ gestation. She was found to be deeply jaundiced the morning of admission by her family physician. On admission, the patient was weak but cooperative. She received antinausea medication and intravenous fluids. Laboratory studies were compatible with severe 175
176
Arthur
hepatitis. She became progressively more lethargic. Postmortem cesarean section was contemplated and a surgical kit was placed in her room. The patient’s condition deteriorated with hypotension, oliguira, and anuria developing. Death occurred at 8:00 A.M., August 7, 1969. Immediate cesarean section resulted in delivery of a stillborn male infant weighing 2,495 grams. Case 3. Mrs. P. McM., a 29-year-old, white woman, para 4-O-l-3, was admitted to the Labor Room at 11:OO P.M., October 21, 1969, approximately 17 days beyond her expected date of confinement. She was in early labor and the membranes were intact. Vital signs were normal. Blood pressure was 130/100. The fetal heart rate was normal. Past history revealed three uneventful vaginal deliveries prior to a stillborn hydrocephalic infant (3,028 grams) delivered vaginally in 1965. The perineum was prepared and an enema was given. Pentobarbital, 200 mg., was administered. At 2:45 A.M., October 22, 1969, she received promethazine, 50 mg., and meperidine, 50 mg. Blood pressure was 128/90. The membranes had ruptured spontaneously at 2: 15 A.M. The cervix was 3 to 4 cm. dilated; the vertex was at the spines, and contractions occurred every two to three minutes. Forty minutes after medication (3:25 A.M.), the patient grunted and was found to be without a pulse and apneic. Resuscitative measures were begun. Intubation and suction were performed and respirations were supported artificially. Intravenous infusion and external cardiac massage were begun. All this was ineffective. Only irregular apical beats were heard. The pupils became fixed and dilated at 3:40 A.M. She was delivered by cesarean section at 3:47 A.M. of a stillborn, mildly hydrocephalic baby (3,231 grams) with spina bifida. Postmortem examination was “consistent with a diagnosis of amniotic fluid embolism.”
Comment Weber,‘in his study, presented an excellent overview of the history of this first of obstetric procedures. In 715 B.C., it was the “Lex Regia” in the Roman Empire that no woman advanced in pregnancy who died should be placed in her tomb until the baby had been removed from the womb. Under the Emperors of Rome, the Caesars, this became the “Lex Caesaris,” hence the name “cesarean operation.” Pliny the Elder referred to the birth of Scipio Africanus by postmortem cesarean section in 237 B.C. Scipio later became one of Rome’s greatest generals. Pope Gregory XIV and the infant King Edward VI were reported to have been delivered by postmortem cesarean section. Hellmar? disputed this, saying that Lady Jane Seymour’s death did not occur until seven days after her son’s birth.
In 1280 A.D., the Catholic Church in the Council 01 Cologne decreed that postmortem crsarean section must be accomplished so that the soul of the unhortt child might be saved through baptism. In 1500 A.D., Jacob Nufer, a Swiss sheep gelder. performed the first cesarean section on a living patient who survived (his own wife). This was carried out after failure of local midwives to secure delivery. Mrs. Nufer, incidentally, later became the first woman to be delivered vaginally after section. She was delivered of six children, including twins, foilowing her operation. Notice that the procedure was first commanded to get the child into a separate coffin, later in an effort LO save the mother, and last in an effort to save mother and child. Most of the literature on postmortem cesarean section involves reports of small numbers of cases, usually successfi11.4-g It appears that unsuccessful cases rarely make their way into print. It is difficult to compile a report on the exact number of successful postmortem cesarean sections reported. Certainly the number is well below 200. Where efforts have been made to compile survival rates of the infants, these figures range from 11 to 40 per cent (1: 9, 2 : 5, etc.). There seems to be broad general agreement in recent reports on the following statements: 1. If pregnancy is over 28 weeks’ duration at maternal death, cesarean section is justifiable. 2. Fetal heart tones heard “some minutes” before maternal death would necessitate delivery. 3. The chronology of maternal death should influence the neonate’s chance of survival, i.e., chronic maternal disease should be associated with low fetal survival and sudden maternal death with higher salvage rates. There is little justification for this in the literature, however, probably because of the small numbers involved and differing approaches to the problem. 4. Delivery should be accomplished by classical cesarean section as quickly as possible after death, certainly within 25 minutes. 5. Cardiopulmonary resuscitation should be carried out in the interval between maternal death and delivery of the infant. 6. Resuscitation of the infant shouid be prompt and thorough. 7. Any critically ill patient in the third trimester of pregnancy should have a surgical kit close by-whether in the obstetric, medical, or surgical area. 8. Permission for the procedure should be obtained in advance if possible, but failure of approval should not be a deterrent to the procedure. Most authors sug-
Volume Number
132 2
Postmortem cesarean section
gest a strong moral obligation to attempt to save the infant. Definition of death. It is necessary that we be aware of the definition of death if we are to perform postmortem cesarean sections. The traditional definitions for determining the state of or time of death is that given in Blacks Law Dictionary*: “The cessation of life; the ceasing to exist; defined by physicians as a total stoppage of the circulation of the blood and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc.” This definition has become inadequate in certain situations involving brain death with survival dependent on respirators, pacemakers, and parenteral fluids, in essence, the laboratory “brain-stem preparation.” A new defini tion’O was needed and has been generally accepted. This requires: (1) no response to painful stimuli; (2) no muscular movement and no spontaneous breathing for one hour (or three minutes off respirator); (3) no reflexes, ocular movements, or blinking, and the presence of fixed, dilated pupils; (4) a flat isoelectric electroencephalogram; (5) no change in the above when repeated 24 hours later; (6) the above must be unrelated to deep barbiturate intoxication or hypothermia. More recently, isotope angiography has been utilized” to prove the absence of cerebral blood flow and thus brain death. There will be few applications in our specialty for this definition. *Black, Publishing
H. C.: Law Co.
Dictionary,
ed. 4, St. Paul,
1968,
177
A radical departure will be needed to improve fetal survival with postmortem cesarean section. Infants of mothers who die suddenly probably have a fixed rate of survival, provided previously mentioned criteria are utilized. It is in the area of the mother who is dying from chronic disease that we may be able to do a better job. Hibbard and Rolf, in commenting on Weber’s2 paper, speculated on the possible justification of earlier delivery in the case of the moribund patient. This is not a pleasing prospect as surgery under the best of circumstances may hasten death or in itself be fatal for the mother. The possible reversibility of maternal disease is ever present. Today we have tools that may make such a decision easier. Amniotic fluid lecithin-sphingomyelin ratios may give us assurance of the infant’s chances of surviving operative delivery. Ultrasound biparietal head measurements will reinforce this confidence in assuring fetal maturity. There is no literature available on the use of fetal monitoring in patients near death. Certainly monitoring will influence the care of these patients. Observations of the progressive deterioration of the intrauterine fetus in a failing environment will have an impact on the observer who previously only checked the fetal heart “at intervals” in the dying patient. It will be difficult to be casual in this situation. It is pure speculation but this may result in “antemortem cesarean section” in some situations. Antemortem cesarean section should improve fetal salvage. Circumspection and moderation will be important in application of cesarean section in the case of the nearly moribund patient.
West
REFERENCES
1. Eastman, N. J.: Williams’ Obstetrics, ed. 10, New York, 1950, Appleton-Century-Crofts, chap. 42, p. 1123. 2. Weber, C. E., Postmortem cesarean section: Review of the literature and case reports, AM. J. OBSTET. GYNECOL. 110: 158, 1971. 3. Hellman, L. M.: AM. J. OBSTET. GYNECOL. 111: 1123, 1971. 4. Smith, G. E.: Post-mortem section following accidental death, Br. J. Obstet. Gynaecol. 80: 181, 1973. 5. Toonsuwan, S.: Successful post-mortem section, Aust. N. Z. J. Obstet. Gynaecol. 12: 265, 1972. 6. Molapo, J. L.: Fatal meningitis followed by post-mortem section, S. Afr. Med. J. 46: 98, 1972.
Discussion DR. WALTER G. BISHOP, JR., Greenwood, South Carolina. With the recent epidemic of medical mal-
7. Weil, A. M., and Graber, V. R.: The management of the near-term pregnant patient who dies undelivered, AM. J. OBSTET. GYNECOL. 73: 754, 1957. 8. Behney, C. A.: Cesarezan section delivery after death of the mother, J. A. M. A. 176: 617, 1961. 9. Lattuada, H. P.: Cesarean section on women who die near term. Clin. Obstet. Gvnecol. 2: 1043, 1959. 10. Report of the Ad Hoc Committee on the Harvard Medical School to Examine the Definition of Brain Death, J. A. M. A. 405: 337, 1968. 11. Goodman, J. N., and Heck, L. L.: Confirmation of brain death at bedside by isotope angiography, J. A. M. A. 238: 966, 1977.
practice suits, doctors feel, more often than not, “damned if they do, and damned if they don’t.” The subject of postmortem cesarean sections is one in which
178
September Am. ,I. Obstrt.
Arthur
the doctor may feel the need to practice “defensive medicine” because the procedure itself brings into call a wealth of legal and philosophical issues. For example, there are the problems of the legal definition of death,’ the doctrine of informed consent to surgical procedures, and the surviving spouse’s legal “ownership” of the body of his deceased spouse. Additionally, postmortem cesarean sections are situations saddened by the loss of the mother and the infrequency of a healthy baby. Surviving infants are often severely damaged. Most physicians will never be confronted with the question of protecting their legal interests with respect to a postmortem cesarean section, because circumstances necessitating such deliveries are rare. There is no time to debate philosophically or legally the issues in the 25 or 20 minute span2 necessary for postmortem delivery, and fortunately most doctors’ instincts and commitments to saving life compel them into acting quickly and professionally and not into worrying about calling their lawyers or insurance companies. However, postmortem cesarean sections do conjur up numerous legal issues. The purpose of this discussion is to confront some of these legal issues in a basic fashion by looking at some of the case law on the evolving concept of prenatal rights, the use of court orders to protect the rights of children to medical treatment over parental objections, and analogies to instances of tissue donation. However, since law is made on a case-by-case basis, this discussion is in no sense “perscriptive.” I cannot tell you how to avoid being sued as a result of a postmortem cesarean section, but I may be able to make you feel better about doing what you must as a doctor. An undelivered child (en ventre sa mere) has been considered as a child “in being” (in esse) “if it will be for its benefit to be so considered” (La Blue v. Specker, 358 Mich. 558, 100 NW2d 445; Mackie v. Mackie, 230 N C 152, 52 SE2d 352). However, these decisions have typically had to do with estates and a posthumous child’s right to inherit property and to benefit from the distribution of estates. In 1884, Justice Holmes wrote the opinion inDietrich v. Northhampton, 138 Mass 14, which held that a child en ventre sa mere was an inseparable part of the mother and consequently without a separate existence or legal rights. The Dietrich case is one of many of Justice Holmes’ decisions which set a legal precedent in most jurisdictions until the middle of this century. In other words, with respect to prenatal injuries a child’s biological and legal existence depended on the mother. It was not until 1946 that there was case law to allow a child to recover for prenatal injuries. Bonbrest v. Katz, (Dist. of Columbia), 65 F Supp 138, held that injuries to a viable unborn infant were compensable in tort when suit was brought by the child after birth. In 1949, it was further found that the representative of a stillborn infant could sue for damages in a wrongful death action if the child was viable at the time of the prenatal in-
15. 197X Gynecd
juries (Verkennes v. Comeiu, 229 Minn 365, 38 NLVPd 838, 10 ALR2d 634). When the Verkennes case is considered, it seems that the next logical extension of that holding (that the representative of a stillborn but viable child can sue for wrongfui death) would be that the representative of an undelivered but viable baby of a deceased mother would have legal standing to sue also. (Although postmortem cesarean sections are only performed with respect to viable infants, as a point of information, the concept of prenatal injuries has frequently been expanded now so that a child or its representative can recover in tort when the child was not viable at the time of the injuries.) What the above trend means is that although a child’s biological existence may depend on its mother its legal existence does not. Historically, children have been protected by the state. In England, the source of our common law heritage, the Court of Chancery (the equity court), had jurisdiction over cases of child neglect. abandonment, etc., because the King was seen as standing e?r parum patriae to his minor subjects3 Courts of equity also have jurisdiction over such matters in the United States. The Heinman case is a landmark case in which the court ordered medical treatment for a child over the religious protestations of its parents.* Presumably, there is seldom time for a court to order a postmortem cesarean section over the objections of the husband. However, if recovery of the mother is uncertain or death expected but for various reasons cesarean section cannot be performed while the mother is alive, a court could order a postmortem cesarean section. A court order in such a situation has never been reported, but it could be a means of protecting a doctor’s liability under one set of unusual circumstances. Also, to draw an analogy from the field of tissue donations, a mother could presumably direct that a postmortem cesarean section be performed upon her death. It is a gloomy thought indeed to envision an expectant mother confronted with such a situation or even being asked as a regular obstetric procedure to execute such a directive. However, a doctor’s contract with an expectant mother is to take care of her and her baby. Every obstetric patient could be asked to execute such a document at the time of her first office visit or, if the particular circumstances warranted and if there would be no unfavorable results to her own condition, at the time of any hospital admission. As can be seen, what is needed is adequate legislation to cover postmortem cesarean sections. As Ritter’ reported: “There is practically concerning postmortem
no adequate specific legislation cesarean section in the United
“This case concerned a blood transfusion for a minor of parents who would not consent due to religious reasons. Courts have since, as a. matter of course, ordered surgery and other means of medical treatment for minors in similar situations.
Volume
132
Number
2
Postmortem cesarean section
States. . No physician has ever been successfully prosecuted in the United States for performing a postmortem cesarean section, even done against the wishes of the husband of the deceased.”
my advice is: (1) Whenever possible, of the husband. (2) Where the husband’s consent is unattainable, either: (a) consider a court order or (b) get the consent of the mother before death. (3) Perform the procedure even without consent, because (a) even if you are sued, the likelihood of being found liable is slim and (b) the courts may well hold next that you may be sued, if youfail to perform the section, by the legal representative of the child (and that case may be yours).
In conclusion, obtain the consent
REFERENCES 1. Ritter, J. W.: Postmortem 715, 1961. 2. Lattuada, lj. P.: Cesarean
cesarean
section,
section
on women
J. A. M. A. 175: who die near
term, CIin. Obstet. Gynecol. 2: 1043, 1959. 3. J. Fam. Law 14: 581, 1975. DR. JAMES D. VIA, Norfolk, Virginia (Official Guest). Postmortem cesarean section should be an unexpected procedure. Dr. Arthur stated: “Postmortem cesarean section remains at best an obstetric calamity.” In the review by Weber,’ one series of 987 maternal deaths involved 72 postmortem cesarean sections with only 11 infants (15 per cent) being discharged from the hospital in good
condition.
We should
do everything
possible
to prevent this situation, including antemortem delivery if death appears imminent. However, should maternal death occur and the fetus is viable, there should be no delay in delivery. In Weber’s review, it was noted that if postmortem cesarean section is considered, ‘tve are not justified in delaying the procedure for the purpose of obtaining an operative permit.” We might in fact be legally negligent in delaying delivery for any reason since fetal well-being would depend upon our action or inaction. The key to management of postmortem cesarean section is prevention. This can best be achieved by more diligent prenatal care and more intense management of medical and surgical complications of pregnancy. We concur with Dr. Arthur that: “The possible reversibility of maternal disease is ever present.” All three of the cases presented by Dr. Arthur could have been managed more decisively based on the evidence presented. The first patient, B. M., had a strong family and personal history of vascular disease. In fact, she had thrombophlebitis following her two previous pregnancies. On admission she was first noted to have tachycardia and cyanotic ear lobes. The classic triad of hemoptysis, pleuritic chest pain, and dyspnea are noted in
179
only 20 per cent of patients with pulmonary emboli.* Two chest roentgenograms were normal, but a lung scan was not done. Compensated respiratory alkalosis is a normal feature of pregnancy.3 Uncompensated respiratory alkalosis in view of a history of thrombophlebitis should have raised the question of pulmonary emboli. This patient should have received heparin, in addition to bed rest and antiembolic stockings. The second case, J. M., was known to have hepatitis (“acute yellow atrophy of the liver”). We do not know how she was managed prior to admission, the state of hydration, or what type of intravenous fluid therapy was used. MacKenna and colleagues4 noted in a recent report from Durham, North Carolina, that patients with acute fatty metamorphosis of the liver need a high caloric intake of carbohydrate. They used 10 per cent dextrose in water and even 50 per cent dextrose through a central venous pressure tube to provide up to 2,000 calories per day. Although both patients were delivered of stillborn infants, the mothers survived and subsequently were delivered of term infants. Dr. Arthur indicated that antemortem cesarean section might have been a wiser choice. Fetal well-being should have been assessed. More aggressive management of this serious medical complication of pregnancy might have been helpful. The third case, P. McM., involved an amniotic fluid embolus, an unfortunate event that cannot be anticipated or prevented. Membranes ruptured at 2: 15 A.M. and at 3:25 A.M. amniotic fluid embolus developed. Had fetal monitoring been used, evidence of fetal distress would have been apparent before 3:40 A.M. when the pupils were fixed and dilated. Dr. Arthur presented three cases of postmortem cesarean section involving six deaths. In the best of circumstances, there is only about a 15 per cent chance that a fetus delivered by postmortem cesarean section will be in good condition. Better prenatal care should be our concern and preventive medicine our goal. In all
obstetric
patients,
assessment
of
fetal
well-being
must receive greater emphasis. If maternal death occurs and delivery is considered, it must be accomplished
swiftly.
REFERENCES 1. Weher, literature
C. E.: Postmortem and case reports,
cesarean section: Review of the AM. J. OBSTET. GYNECOL. 110:
158, 1971. 2. Pritchard, J. A., and MacDonald, P. C.: Williams’ Obstetrics, ed. 15, New York, 1976, Appleton-Century-Crofts, p. 773. 3. deswiet, M.: Diseases of the respiratory system, Clin. Obstet. Gynecol. 4: 1977. 4. MacKenna, J., Pupkin, M., Crenshaw, C., Jr., McLeod, M., and Parker, R. T.: Acute fatty metamorphosis of the liver, AM. J. OBSTET. GYNECOL. 127: 400, 1977.
Point,
K.
ARTHUR,
North
Carolina
M.D.
Podmortem cesarean section continues to carry a bleak fetal outkxk The present report adds to the literature three recent cases in which the infant was not saved. Analysis of the literature is used to produce guideposts to timing and performance of the procedure. The possible impact of today’s technology on the problem is discussed. The need for earlier intervention in the patient near death is presented as a possible method of improving fetal salvage. (AM. J. OBSTET. GYNECOL. 132: 175,
1978.)
IN X950, in the first edition of WiUimn’s he edited, Eastman’ made this statement the chapter on cesarean section:
that at the end of
Obstetrics
“From the earliest times, when a patient died undelivered at nearly full term, cesarean section was sometimes performed immediately after the death in the hope of saving the life of the child. The number of children rescued by this procedure, however, has always been small. Despite this fact, it is my opinion that it should be done, provided the fetal heart is audible a few minutes before the mother’s death and provided full written permission has been obtained from the patient’s husband.” Some 28 years later, this statement is essentially unchanged in current texts and in the obstetric literature. It may be that the operation is done more frequently but the results remain less than satisfying. Postmortem cesarean section remains at best an obstetric calamity. More often than not, the delivery of a stillborn infant or a badly compromised child who does not survive compounds the tragedy of the mother’s death. There have been three postmortem cesarean sections performed at High Point Memorial Hospital in recent years. I performed two in a space of less than three months. An associate performed the third; all were to no avail. Case reports Case 1. Mrs. B. M., a 23-year-old white woman, para 2-O-O-2, was admitted to the hospital January 5, 1967, From the Obstetrics-Gynecology Memorial Hospital.
Section, High
Poinf
Presented as Official Guest at the Fortieth Annual Meeting of the South Atlantic Associutkm of Obstetih?~ and Gynecologists, Acapulco, Mexico, Janumy 21-26, 1978.
Reprint requests: Dr. Robert K. Arthur, High Paint, North Carolina 27262. OOOZ-9378/78/02132-0175$00.50/O@
1978
TheC.V.
P. 0. Box 5128,
Mosby
Co.
at seven and a half months’ gestation with a history of recent near-syncope at home. Pertinent history on admission revealed a strong family history of vascular disease and a personal history of puerperal thrombophlebitis following each of her previous pregnancies. Examination revealed tachycardia and cyanotic ear lobes. The pregnancy was commensurate with dates and the fetal heart tones were normal. Examination of the extremities revealed no abnormality. Homans’ sign was bilaterally negative. Laboratory work revealed mild anemia and uncompensated respiratory alkalosis on acid-base studies. Chest roentgenograms on January 9, 1967, and January 12, 1967, were normal. Electrocardiogram on January 12, 1967, showed “nonspecific T-wave changes.” Sometime between 7:30 P.M. and 8:00 P.M. on January 12, 1967, the patient collapsed in the bathroom. She was seen immediately by a staff pediatrician who was on rounds. He found slight cyanosis and an irregular, weak pulse. The patient was put to bed and nasal oxygen was started as cyanosis deepened. Medical and obstetric help were summoned immediately but cardiac arrest occurred within moments of return to bed. Cardiopulmonary resuscitation was begun by a nurseanesthetist and the pediatrician, On arrival of an obstetrician, the pulse had been absent for three minutes, and the pupils were fixed and dilated. A rapid cesarean section was performed with delivery of a 1,556 gram infant in poor condition at 8:00 P.M. The infant died at 9:30 P.M. that night. Postmorten examination revealed massive pulmonary embolism (recent) and an older infarct of the right lower lobe. Case ‘2. Mrs. J. M., a 27-year-old, white, primigravid woman, was admitted to the hospital on the afternoon of August 5, 1969, with a history of five to six days of nausea and vomiting, at approximately 36 weeks’ gestation. She was found to be deeply jaundiced the morning of admission by her family physician. On admission, the patient was weak but cooperative. She received antinausea medication and intravenous fluids. Laboratory studies were compatible with severe 175
176
Arthur
hepatitis. She became progressively more lethargic. Postmortem cesarean section was contemplated and a surgical kit was placed in her room. The patient’s condition deteriorated with hypotension, oliguira, and anuria developing. Death occurred at 8:00 A.M., August 7, 1969. Immediate cesarean section resulted in delivery of a stillborn male infant weighing 2,495 grams. Case 3. Mrs. P. McM., a 29-year-old, white woman, para 4-O-l-3, was admitted to the Labor Room at 11:OO P.M., October 21, 1969, approximately 17 days beyond her expected date of confinement. She was in early labor and the membranes were intact. Vital signs were normal. Blood pressure was 130/100. The fetal heart rate was normal. Past history revealed three uneventful vaginal deliveries prior to a stillborn hydrocephalic infant (3,028 grams) delivered vaginally in 1965. The perineum was prepared and an enema was given. Pentobarbital, 200 mg., was administered. At 2:45 A.M., October 22, 1969, she received promethazine, 50 mg., and meperidine, 50 mg. Blood pressure was 128/90. The membranes had ruptured spontaneously at 2: 15 A.M. The cervix was 3 to 4 cm. dilated; the vertex was at the spines, and contractions occurred every two to three minutes. Forty minutes after medication (3:25 A.M.), the patient grunted and was found to be without a pulse and apneic. Resuscitative measures were begun. Intubation and suction were performed and respirations were supported artificially. Intravenous infusion and external cardiac massage were begun. All this was ineffective. Only irregular apical beats were heard. The pupils became fixed and dilated at 3:40 A.M. She was delivered by cesarean section at 3:47 A.M. of a stillborn, mildly hydrocephalic baby (3,231 grams) with spina bifida. Postmortem examination was “consistent with a diagnosis of amniotic fluid embolism.”
Comment Weber,‘in his study, presented an excellent overview of the history of this first of obstetric procedures. In 715 B.C., it was the “Lex Regia” in the Roman Empire that no woman advanced in pregnancy who died should be placed in her tomb until the baby had been removed from the womb. Under the Emperors of Rome, the Caesars, this became the “Lex Caesaris,” hence the name “cesarean operation.” Pliny the Elder referred to the birth of Scipio Africanus by postmortem cesarean section in 237 B.C. Scipio later became one of Rome’s greatest generals. Pope Gregory XIV and the infant King Edward VI were reported to have been delivered by postmortem cesarean section. Hellmar? disputed this, saying that Lady Jane Seymour’s death did not occur until seven days after her son’s birth.
In 1280 A.D., the Catholic Church in the Council 01 Cologne decreed that postmortem crsarean section must be accomplished so that the soul of the unhortt child might be saved through baptism. In 1500 A.D., Jacob Nufer, a Swiss sheep gelder. performed the first cesarean section on a living patient who survived (his own wife). This was carried out after failure of local midwives to secure delivery. Mrs. Nufer, incidentally, later became the first woman to be delivered vaginally after section. She was delivered of six children, including twins, foilowing her operation. Notice that the procedure was first commanded to get the child into a separate coffin, later in an effort LO save the mother, and last in an effort to save mother and child. Most of the literature on postmortem cesarean section involves reports of small numbers of cases, usually successfi11.4-g It appears that unsuccessful cases rarely make their way into print. It is difficult to compile a report on the exact number of successful postmortem cesarean sections reported. Certainly the number is well below 200. Where efforts have been made to compile survival rates of the infants, these figures range from 11 to 40 per cent (1: 9, 2 : 5, etc.). There seems to be broad general agreement in recent reports on the following statements: 1. If pregnancy is over 28 weeks’ duration at maternal death, cesarean section is justifiable. 2. Fetal heart tones heard “some minutes” before maternal death would necessitate delivery. 3. The chronology of maternal death should influence the neonate’s chance of survival, i.e., chronic maternal disease should be associated with low fetal survival and sudden maternal death with higher salvage rates. There is little justification for this in the literature, however, probably because of the small numbers involved and differing approaches to the problem. 4. Delivery should be accomplished by classical cesarean section as quickly as possible after death, certainly within 25 minutes. 5. Cardiopulmonary resuscitation should be carried out in the interval between maternal death and delivery of the infant. 6. Resuscitation of the infant shouid be prompt and thorough. 7. Any critically ill patient in the third trimester of pregnancy should have a surgical kit close by-whether in the obstetric, medical, or surgical area. 8. Permission for the procedure should be obtained in advance if possible, but failure of approval should not be a deterrent to the procedure. Most authors sug-
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Postmortem cesarean section
gest a strong moral obligation to attempt to save the infant. Definition of death. It is necessary that we be aware of the definition of death if we are to perform postmortem cesarean sections. The traditional definitions for determining the state of or time of death is that given in Blacks Law Dictionary*: “The cessation of life; the ceasing to exist; defined by physicians as a total stoppage of the circulation of the blood and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc.” This definition has become inadequate in certain situations involving brain death with survival dependent on respirators, pacemakers, and parenteral fluids, in essence, the laboratory “brain-stem preparation.” A new defini tion’O was needed and has been generally accepted. This requires: (1) no response to painful stimuli; (2) no muscular movement and no spontaneous breathing for one hour (or three minutes off respirator); (3) no reflexes, ocular movements, or blinking, and the presence of fixed, dilated pupils; (4) a flat isoelectric electroencephalogram; (5) no change in the above when repeated 24 hours later; (6) the above must be unrelated to deep barbiturate intoxication or hypothermia. More recently, isotope angiography has been utilized” to prove the absence of cerebral blood flow and thus brain death. There will be few applications in our specialty for this definition. *Black, Publishing
H. C.: Law Co.
Dictionary,
ed. 4, St. Paul,
1968,
177
A radical departure will be needed to improve fetal survival with postmortem cesarean section. Infants of mothers who die suddenly probably have a fixed rate of survival, provided previously mentioned criteria are utilized. It is in the area of the mother who is dying from chronic disease that we may be able to do a better job. Hibbard and Rolf, in commenting on Weber’s2 paper, speculated on the possible justification of earlier delivery in the case of the moribund patient. This is not a pleasing prospect as surgery under the best of circumstances may hasten death or in itself be fatal for the mother. The possible reversibility of maternal disease is ever present. Today we have tools that may make such a decision easier. Amniotic fluid lecithin-sphingomyelin ratios may give us assurance of the infant’s chances of surviving operative delivery. Ultrasound biparietal head measurements will reinforce this confidence in assuring fetal maturity. There is no literature available on the use of fetal monitoring in patients near death. Certainly monitoring will influence the care of these patients. Observations of the progressive deterioration of the intrauterine fetus in a failing environment will have an impact on the observer who previously only checked the fetal heart “at intervals” in the dying patient. It will be difficult to be casual in this situation. It is pure speculation but this may result in “antemortem cesarean section” in some situations. Antemortem cesarean section should improve fetal salvage. Circumspection and moderation will be important in application of cesarean section in the case of the nearly moribund patient.
West
REFERENCES
1. Eastman, N. J.: Williams’ Obstetrics, ed. 10, New York, 1950, Appleton-Century-Crofts, chap. 42, p. 1123. 2. Weber, C. E., Postmortem cesarean section: Review of the literature and case reports, AM. J. OBSTET. GYNECOL. 110: 158, 1971. 3. Hellman, L. M.: AM. J. OBSTET. GYNECOL. 111: 1123, 1971. 4. Smith, G. E.: Post-mortem section following accidental death, Br. J. Obstet. Gynaecol. 80: 181, 1973. 5. Toonsuwan, S.: Successful post-mortem section, Aust. N. Z. J. Obstet. Gynaecol. 12: 265, 1972. 6. Molapo, J. L.: Fatal meningitis followed by post-mortem section, S. Afr. Med. J. 46: 98, 1972.
Discussion DR. WALTER G. BISHOP, JR., Greenwood, South Carolina. With the recent epidemic of medical mal-
7. Weil, A. M., and Graber, V. R.: The management of the near-term pregnant patient who dies undelivered, AM. J. OBSTET. GYNECOL. 73: 754, 1957. 8. Behney, C. A.: Cesarezan section delivery after death of the mother, J. A. M. A. 176: 617, 1961. 9. Lattuada, H. P.: Cesarean section on women who die near term. Clin. Obstet. Gvnecol. 2: 1043, 1959. 10. Report of the Ad Hoc Committee on the Harvard Medical School to Examine the Definition of Brain Death, J. A. M. A. 405: 337, 1968. 11. Goodman, J. N., and Heck, L. L.: Confirmation of brain death at bedside by isotope angiography, J. A. M. A. 238: 966, 1977.
practice suits, doctors feel, more often than not, “damned if they do, and damned if they don’t.” The subject of postmortem cesarean sections is one in which
178
September Am. ,I. Obstrt.
Arthur
the doctor may feel the need to practice “defensive medicine” because the procedure itself brings into call a wealth of legal and philosophical issues. For example, there are the problems of the legal definition of death,’ the doctrine of informed consent to surgical procedures, and the surviving spouse’s legal “ownership” of the body of his deceased spouse. Additionally, postmortem cesarean sections are situations saddened by the loss of the mother and the infrequency of a healthy baby. Surviving infants are often severely damaged. Most physicians will never be confronted with the question of protecting their legal interests with respect to a postmortem cesarean section, because circumstances necessitating such deliveries are rare. There is no time to debate philosophically or legally the issues in the 25 or 20 minute span2 necessary for postmortem delivery, and fortunately most doctors’ instincts and commitments to saving life compel them into acting quickly and professionally and not into worrying about calling their lawyers or insurance companies. However, postmortem cesarean sections do conjur up numerous legal issues. The purpose of this discussion is to confront some of these legal issues in a basic fashion by looking at some of the case law on the evolving concept of prenatal rights, the use of court orders to protect the rights of children to medical treatment over parental objections, and analogies to instances of tissue donation. However, since law is made on a case-by-case basis, this discussion is in no sense “perscriptive.” I cannot tell you how to avoid being sued as a result of a postmortem cesarean section, but I may be able to make you feel better about doing what you must as a doctor. An undelivered child (en ventre sa mere) has been considered as a child “in being” (in esse) “if it will be for its benefit to be so considered” (La Blue v. Specker, 358 Mich. 558, 100 NW2d 445; Mackie v. Mackie, 230 N C 152, 52 SE2d 352). However, these decisions have typically had to do with estates and a posthumous child’s right to inherit property and to benefit from the distribution of estates. In 1884, Justice Holmes wrote the opinion inDietrich v. Northhampton, 138 Mass 14, which held that a child en ventre sa mere was an inseparable part of the mother and consequently without a separate existence or legal rights. The Dietrich case is one of many of Justice Holmes’ decisions which set a legal precedent in most jurisdictions until the middle of this century. In other words, with respect to prenatal injuries a child’s biological and legal existence depended on the mother. It was not until 1946 that there was case law to allow a child to recover for prenatal injuries. Bonbrest v. Katz, (Dist. of Columbia), 65 F Supp 138, held that injuries to a viable unborn infant were compensable in tort when suit was brought by the child after birth. In 1949, it was further found that the representative of a stillborn infant could sue for damages in a wrongful death action if the child was viable at the time of the prenatal in-
15. 197X Gynecd
juries (Verkennes v. Comeiu, 229 Minn 365, 38 NLVPd 838, 10 ALR2d 634). When the Verkennes case is considered, it seems that the next logical extension of that holding (that the representative of a stillborn but viable child can sue for wrongfui death) would be that the representative of an undelivered but viable baby of a deceased mother would have legal standing to sue also. (Although postmortem cesarean sections are only performed with respect to viable infants, as a point of information, the concept of prenatal injuries has frequently been expanded now so that a child or its representative can recover in tort when the child was not viable at the time of the injuries.) What the above trend means is that although a child’s biological existence may depend on its mother its legal existence does not. Historically, children have been protected by the state. In England, the source of our common law heritage, the Court of Chancery (the equity court), had jurisdiction over cases of child neglect. abandonment, etc., because the King was seen as standing e?r parum patriae to his minor subjects3 Courts of equity also have jurisdiction over such matters in the United States. The Heinman case is a landmark case in which the court ordered medical treatment for a child over the religious protestations of its parents.* Presumably, there is seldom time for a court to order a postmortem cesarean section over the objections of the husband. However, if recovery of the mother is uncertain or death expected but for various reasons cesarean section cannot be performed while the mother is alive, a court could order a postmortem cesarean section. A court order in such a situation has never been reported, but it could be a means of protecting a doctor’s liability under one set of unusual circumstances. Also, to draw an analogy from the field of tissue donations, a mother could presumably direct that a postmortem cesarean section be performed upon her death. It is a gloomy thought indeed to envision an expectant mother confronted with such a situation or even being asked as a regular obstetric procedure to execute such a directive. However, a doctor’s contract with an expectant mother is to take care of her and her baby. Every obstetric patient could be asked to execute such a document at the time of her first office visit or, if the particular circumstances warranted and if there would be no unfavorable results to her own condition, at the time of any hospital admission. As can be seen, what is needed is adequate legislation to cover postmortem cesarean sections. As Ritter’ reported: “There is practically concerning postmortem
no adequate specific legislation cesarean section in the United
“This case concerned a blood transfusion for a minor of parents who would not consent due to religious reasons. Courts have since, as a. matter of course, ordered surgery and other means of medical treatment for minors in similar situations.
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Number
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Postmortem cesarean section
States. . No physician has ever been successfully prosecuted in the United States for performing a postmortem cesarean section, even done against the wishes of the husband of the deceased.”
my advice is: (1) Whenever possible, of the husband. (2) Where the husband’s consent is unattainable, either: (a) consider a court order or (b) get the consent of the mother before death. (3) Perform the procedure even without consent, because (a) even if you are sued, the likelihood of being found liable is slim and (b) the courts may well hold next that you may be sued, if youfail to perform the section, by the legal representative of the child (and that case may be yours).
In conclusion, obtain the consent
REFERENCES 1. Ritter, J. W.: Postmortem 715, 1961. 2. Lattuada, lj. P.: Cesarean
cesarean
section,
section
on women
J. A. M. A. 175: who die near
term, CIin. Obstet. Gynecol. 2: 1043, 1959. 3. J. Fam. Law 14: 581, 1975. DR. JAMES D. VIA, Norfolk, Virginia (Official Guest). Postmortem cesarean section should be an unexpected procedure. Dr. Arthur stated: “Postmortem cesarean section remains at best an obstetric calamity.” In the review by Weber,’ one series of 987 maternal deaths involved 72 postmortem cesarean sections with only 11 infants (15 per cent) being discharged from the hospital in good
condition.
We should
do everything
possible
to prevent this situation, including antemortem delivery if death appears imminent. However, should maternal death occur and the fetus is viable, there should be no delay in delivery. In Weber’s review, it was noted that if postmortem cesarean section is considered, ‘tve are not justified in delaying the procedure for the purpose of obtaining an operative permit.” We might in fact be legally negligent in delaying delivery for any reason since fetal well-being would depend upon our action or inaction. The key to management of postmortem cesarean section is prevention. This can best be achieved by more diligent prenatal care and more intense management of medical and surgical complications of pregnancy. We concur with Dr. Arthur that: “The possible reversibility of maternal disease is ever present.” All three of the cases presented by Dr. Arthur could have been managed more decisively based on the evidence presented. The first patient, B. M., had a strong family and personal history of vascular disease. In fact, she had thrombophlebitis following her two previous pregnancies. On admission she was first noted to have tachycardia and cyanotic ear lobes. The classic triad of hemoptysis, pleuritic chest pain, and dyspnea are noted in
179
only 20 per cent of patients with pulmonary emboli.* Two chest roentgenograms were normal, but a lung scan was not done. Compensated respiratory alkalosis is a normal feature of pregnancy.3 Uncompensated respiratory alkalosis in view of a history of thrombophlebitis should have raised the question of pulmonary emboli. This patient should have received heparin, in addition to bed rest and antiembolic stockings. The second case, J. M., was known to have hepatitis (“acute yellow atrophy of the liver”). We do not know how she was managed prior to admission, the state of hydration, or what type of intravenous fluid therapy was used. MacKenna and colleagues4 noted in a recent report from Durham, North Carolina, that patients with acute fatty metamorphosis of the liver need a high caloric intake of carbohydrate. They used 10 per cent dextrose in water and even 50 per cent dextrose through a central venous pressure tube to provide up to 2,000 calories per day. Although both patients were delivered of stillborn infants, the mothers survived and subsequently were delivered of term infants. Dr. Arthur indicated that antemortem cesarean section might have been a wiser choice. Fetal well-being should have been assessed. More aggressive management of this serious medical complication of pregnancy might have been helpful. The third case, P. McM., involved an amniotic fluid embolus, an unfortunate event that cannot be anticipated or prevented. Membranes ruptured at 2: 15 A.M. and at 3:25 A.M. amniotic fluid embolus developed. Had fetal monitoring been used, evidence of fetal distress would have been apparent before 3:40 A.M. when the pupils were fixed and dilated. Dr. Arthur presented three cases of postmortem cesarean section involving six deaths. In the best of circumstances, there is only about a 15 per cent chance that a fetus delivered by postmortem cesarean section will be in good condition. Better prenatal care should be our concern and preventive medicine our goal. In all
obstetric
patients,
assessment
of
fetal
well-being
must receive greater emphasis. If maternal death occurs and delivery is considered, it must be accomplished
swiftly.
REFERENCES 1. Weher, literature
C. E.: Postmortem and case reports,
cesarean section: Review of the AM. J. OBSTET. GYNECOL. 110:
158, 1971. 2. Pritchard, J. A., and MacDonald, P. C.: Williams’ Obstetrics, ed. 15, New York, 1976, Appleton-Century-Crofts, p. 773. 3. deswiet, M.: Diseases of the respiratory system, Clin. Obstet. Gynecol. 4: 1977. 4. MacKenna, J., Pupkin, M., Crenshaw, C., Jr., McLeod, M., and Parker, R. T.: Acute fatty metamorphosis of the liver, AM. J. OBSTET. GYNECOL. 127: 400, 1977.