Princess Charlotte

This is the full version which started off as 'a historical catch', if you'd rather read it as it unfolded then go there first, but some asked for a complete version

One of the biggest changes to obstetrics, and midwifery happened after November 1817. Prior to this time there was no way of listening to the fetal heartbeat, it was first recorded as being heard the following year, and although forceps had been invented any progress was seen as preferable to an instrumental delivery and caesarean sections were performed only as a last resort, as the vast majority killed the mother. Childbirth was a dangerous event and without the drugs and interventions we take for granted in modern times many mothers and children died.

You would imagine that the heir to the throne of England would have had the best possible care available at the time, however the labour which became known as the triple obstetric tragedy did not have the happy outcome we take for granted in the 21st century.

Princess Charlotte, the only child of King George IV, then Prince Regent, was pregnant with her first term pregnancy and followed a strict diet prescribed by her physician Richard Croft and had undergone bloodletting several times in the pregnancy, as too much blood was thought to be bad and it was current medical practice that a few ounces of blood would be removed at a time to prevent this. In hindsight this probably resulted in the Princess starting her labour in an anaemic state. Charlotte was depressive about this pregnancy and had written letters to her mother in the weeks before her labour in which she appeared to accept that her child would not survive.
When she was overdue (probably over the accepted norm of up to 42 weeks) on November 3rd at 7pm her waters broke, accompanied by short, painful contractions 8 minutes apart, she took to her bed and these contractions continued overnight and at 11am the following morning she was half a crown dilated (approximately 3.5cm). To modern eyes it appears that the Princess had a long latent phase, suggesting a malpositioning of the fetus, possibly an OP positioned baby which would fit with going post-dates, prelabour rupture of membranes and a long latent phase.
At 6pm on November 4th 1817 the liquor was still clear, and while the contractions were recorded as ‘not as strong as you’d expect’ they were doing their job and the cervix was nearly completely dilated with just an anterior rim remaining. The suture lines on the head showed the baby was in a transverse position, while not the best position for birth there is still time for rotation, if it is assumed the previous assumption of an OP position was correct then things are moving along correctly, the fetus is rotating towards an anterior position ready for birth and the Princess had dilated 6cm in 7hours.
Three hours later it was recorded that the cervix was completely dilated, although the contractions had not improved and the head was still transverse.
At 1am on November 5th although there had been descent the vertex was not yet visible and Richard Croft, and his forceps, were called for. So far the labour was managed in a similar way to that of current practice, although without any fetal monitoring, however the differences from here on are very different.
Despite the fact that Charlotte had been fully dilated for 4hours Dr Croft felt that as there had been some progress that nature should continue.
At 12.00noon thick, fresh meconium was seen. The unborn child was obviously in distress, perhaps this meconium was the final relaxing of the anal sphincter which occurs with death. However the head had descended further and so the waiting continued.
15.30pm the vertex was now distending the perineum, although with 18hours of the second stage it must be wondered how much of what was seen was the head and how much was caput.
21.00pm on the 5th November 1817 Princess Charlotte finally gave birth to a 9lb baby boy, with the head still in a transverse position (presumably there had been a deep transverse arrest). Unfortunately the infant showed no signs of life and despite attempts at resuscitation, which included putting brandy into the mouth, inflating the lungs before cutting the cord, a warm bath and rubbing with salt and mustard, he was declared stillborn.
The placenta only partially separated after the birth and the decision was made to manually remove the placenta. Although the risk of infection without today’s antibiotics was huge the risk of postpartum haemorrhage was greater. Princess Charlotte underwent this procedure as she had her entire labour, including a 24hour second stage, without any pain relief.
Everything appeared to go straightforwardly. She was loosing a moderate amount of lochia but not seen to be excessive, she was bound , around abdomen and chest, and the uterus appeared to be moderately well contracted. The Princess was given nourishment and cordials, including port wine which made her tipsy after 50 hours without food.
Nearly 4 hours after the birth Princess Charlotte complains of nausea and singing noises in her head, her loss is still moderate, over the next hour she starts vomiting and having trouble breathing and her pulse was rapid, feeble and irregular.
Despite medications available at the time she died on 6th November 1817 at 2.30am.
Postmortems were undertaken and found that the boy was well formed and every part of his internal structure was sound. Therefore it can be assumed that he died from the stresses of an overlong labour.
Charlotte’s heart, brain, lungs and bladder were all normal. Her stomach had fluid in it, presumably the nourishment and medicines she’d been given following the birth.
Her uterus had a markedly hourglass shape and contained a considerable quantity of congealed blood. This would fit with a Bandl’s ring and an obstructed labour. She died from a slow PPH and accumulation of blood loss, presumably compromised by anaemia.

The public outcry at her death is said to be matched only by the grief shown at the death of Princess Diana. The general assumption was that had forceps been used earlier the baby may not have survived but the mother would have had more of a chance had she been less exhausted (and the blood loss may have been less).
The ‘triple’ tragedy comes as the Dr Croft shot himself as he felt so guilty over their deaths

Following her death there was a huge amount of work and development gone into the safety of childbirth
- the use of ergot (what our syntometrine and ergometrine is based on - to stimulate contractions and get placentas out)
- experimentation with blood transfusions
- the introduction of birth anaesthesia
- more likely to intervene and use forceps in prolonged second stages