An epidural gone wrong: How a New York malpractice case highlights disparities in maternal care
Key Takeaways
A 26-year-old Brooklyn woman died after an epidural was inserted too deep, causing anesthesia to hit her cerebrospinal fluid.
Reports show that the anesthesiologist had a history of previous errors during epidural administration.
Infant mortality rates have risen for the first time in two decades, with a 3% increase in deaths from 2021 to 2022, according to the Centers for Disease Control and Prevention (CDC). The rise in infant mortality also sheds light on the risks women face during pregnancy and birth, including routine procedures such as receiving an epidural.[]
Epidurals are typically thought of as safe, with about a 1% or lower risk of serious complications. In fact, the use of epidurals has been linked to a 14% decrease in the risk of severe maternal morbidity. On July 3, 2020, however, anesthesiologist Dmitry Shelchkov, MD, administered an epidural that resulted in the death of Sha-Asia Semple.[][][]
Semple, 26, went into labor at Woodhull Medical Center in Brooklyn, NY. Records show that Dr. Shelchkov inserted an anesthesia catheter more than 13 inches into Semple’s lower back. He did not administer a test dose after inserting the catheter; instead, he immediately administered a full dose. The anesthesia hit Semple’s cerebrospinal fluid.[]
Semple’s breathing grew labored, and she told staff she was unable to breathe. Her breathing soon after stopped completely. According to later federal and state medical committee reports, Dr. Shelckhov then attempted to intubate Semple. He placed the breathing tube down her esophagus instead of the trachea, causing a ventilator to deliver air to Semple’s stomach for about 30 minutes. The error was then recognized, and the breathing tube was inserted correctly.[]
Unfortunately, the intervention was unsuccessful. The baby, a girl named Khloe, survived. Semple did not.[]
Medical malpractice response
Semple’s death led to a demonstration outside the Brooklyn hospital. Semple was Black, and news of her death added to a larger conversation about inequality in medical access and care in the United States. Woodhull Medical Center is a public hospital, and around 85% of the 1,500 mothers who give birth there each year are Black or Hispanic. Records show a pattern of errors in Dr. Shelchkov’s anesthesia administration and a lack of action from Woodhull to address it.[]
Dr. Shelchkov was stripped of his medical license in late 2021 when the State Board for Professional Medical Conduct ruled that he had “practiced medicine with negligence and incompetence.” A hospital inspection report shows that in the more than two years before Semple’s death, six other pregnant patients experienced severe reactions to anesthesia administration while in labor. Dr. Shelchov was involved in nearly all of these incidents.[][]
In later statements, including those made to the State Medical Board, Dr. Shelchkov attributed many of the incidents to the COVID-19 pandemic and its stress and regulations.[]
For instance, he stated that his incorrect intubation of Semple was due to infection-control goggles that had fogged up. Dr. Shelchov was involved in other serious incidents during the height of the pandemic. In May 2020, a 31-year-old woman had to be intubated after Dr. Shelckhov placed the epidural catheter too deep. Her baby was delivered via C-section, and she subsequently recovered. In June 2020, a woman complained that it took Dr. Shelchkov over an hour to insert her catheter for an epidural and that she was left with heavy bleeding from his numerous attempts.[]
Following these incidents, the hospital administration said that Dr. Shelchov should ask colleagues for assistance after three unsuccessful catheterization attempts. No other actions were taken.[]
In August 2018, Dr. Shelchkov placed an anesthesia catheter incorrectly and then administered a full dose of anesthesia without an initial test dose. The patient, a 42-year-old woman, became unresponsive. She was intubated and underwent an emergency C-section but later recovered. Woodhull’s interim chief anesthesiologist closely monitored Dr. Shelchkov for the next year until a new chief anesthesiologist came on board in the summer of 2019. This physician later told investigators that he was never informed about Dr. Shelchov’s prior incident.[]
Healthcare inequality
In New York City, around 20 women die of pregnancy and childbirth-related causes each year. Nationally, numbers from 2021 show that 1,205 women died. The overall national maternal death rate in 2021 was 32.9 deaths per 100,000 live births. In all locations, rates increase sharply for non-Hispanic Black women and women aged 40 and over. Nationally, the maternal death rate in 2021 was 26.6 deaths per 100,000 live births for non-Hispanic White women, 28.0 for Hispanic women, and 69.9 for non-Hispanic Black women. The difference in mortality rates by race is more severe in some locations. These rates have also been found to be higher among Indigenous women.[][][]
Experts attribute these numbers to multiple factors. Studies have shown that healthcare inequality is often a key factor at play. Over the past several decades, many hospitals, primary care offices, and other healthcare providers in already underserved neighborhoods across the US have closed, leaving residents with few options for treatment. Data shows that remaining hospitals often do not provide the same quality of care as hospitals in higher-income areas.[][]
In a 2022 study that analyzed hospital quality in US metropolitan areas, marked disparities were found. The authors wrote, “Hospitals in more socioeconomically disadvantaged neighborhoods have lower quality in terms of mortality, readmission, safety, patient experience, effectiveness, efficiency, timeliness, summary of care, and overall hospital star rating.”[]
Similarly, a 2019 survey and data analysis study concluded that lower-income patients had worse healthcare experiences at all levels of care. These factors, coupled with the US’s already comparatively high maternal mortality rate, racial biases that can affect care for Black Americans, and gender disparities in healthcare settings, can lead to tragedies. It’s impossible to say that a different hospital in a different neighborhood would have disciplined Dr. Shelchkov earlier, but it’s difficult not to wonder what factors played a role.[][][]