AN Abergavenny mother-of-six tragically died just hours after giving birth to her baby daughter because of a rare condition which affects just one in 80,000, an inquest found.

Rachel Hollister was just 31 when she died during an operation at the Royal Gwent Hospital in the early hours of April 13, 2013.

She had been taken into emergency surgery less than two hours after giving birth after multiple attempts to remove her placenta – which usually happens soon after birth – had failed.

An inquest at Newport Coroner’s Court yesterday heard how Mrs Hollister had developed amniotic fluid embolism after giving birth, a condition where the toxic fluid from the amniotic sac enters the mother’s bloodstream.

It affects around one in 80,000 and sometimes mothers show only subtle signs of the condition before rapidly collapsing and haemorrhaging. It carries a mortality rate of 30 per cent.

Assistant coroner for Gwent, Wendy James, yesterday said Rachel Hollister died from “natural causes as a result of a known but rare complication of pregnancy and childbirth”.

Mrs Hollister had been rushed in to the Royal Gwent at 2.20am and baby girl Ava was born prematurely at 2.40am at just 32 weeks old. The baby girl was rushed to the special pre-term unit. Ava was Mrs Hollister's sixth child and fifth with husband Russell Hollister.

Mr Hollister told the inquest his wife was awake and talking following the birth but was “distressed as she wanted to see her baby".

But by 4am, less than one and half hours later, Mrs Hollister had lost 800 ml of blood - 300 ml over the level categorised as an emergency and her placenta was still unable to be removed.

Coroner Ms James said because of Mrs Hollister’s retained placenta, the diagnosis of AFE was “overlooked”.

But Ms James added: “On the balance of probabilities this did not alter the outcome.”

Mrs Hollister was rushed into emergency surgery where she suffered a cardiac arrest while under general anaesthetic. Doctors tried for over an hour to resuscitate her but she sadly died at 6.25am.

Anaesthetist at the Royal Gwent Hospital, Dr Anthony Short, who was the senior doctor present at the time, said: “It was tragic, Mrs Hollister was very young and we wanted to do everything we could for her.

"We wanted to do our best to resuscitate her."

Consultant obstetrician at the Royal Gwent Hospital, Sajitha Parveen, said: “The team did not realise it was amniotic fluid embolism.”

Asked by Ms James whether the diagnostic error was understandable, Dr Parveen said: “Yes.”

Ms James said: "Rachel Hollister’s condition deteriorated very rapidly and doctors were trying to manage a cardiac arrest and major blood loss while attempting to resuscitate her."

"LESSONS TO BE LEARNT" FROM CHILDBIRTH DEATH

THE assistant coroner for Gwent has said she will be writing to the Chief Executive of Aneurin Bevan University Health Board after mother Rachel Hollister died in childbirth.

Assistant coroner Wendy James said there are “lessons to be learnt” after an inquest found 31-year-old Rachel Hollister from Abergavenny died from a “known but rare complication of pregnancy and childbirth”.

She said: “Even in the 21st century childbirth is not without its risks for the mother.

The condition, amniotic fluid embolism, often shows only subtle signs before the mother rapidly deteriorates and begins haemorrhaging. There is a 30 per cent mortality rate.

Ms James told an inquest at Newport Coroner’s Court yesterday: “There is a delay in recognising the patient has AFE which increases the risk of death.

“It’s imperative that robust and effective guidelines and systems need to be in place.

“There are lessons to be learnt from Rachel’s death. I will be writing a report to the Chief Executive of Aneurin Bevan University Health Board requesting she considers a review of training of staff and a review of a major haemorrhage protocol in light of Royal College guidelines.”

David Tyack, representing husband Mr Hollister, had previously suggested to the inquest that delays and substandards in Mrs Hollister’s care could have contributed to her death.

But coroner Ms James said yesterday: “It’s apparent that delays did occur in Rachel Hollister’s care including the fact observations were not carried out quickly, a delay in transferring Rachel Hollister to theatre and a delay in returning blood. But I’m not satisfied these delays would have altered the outcome of Rachel Hollister.”