Would Dr. Clarkson’s Recommended C-Section Have Saved Sybil On Downton Abbey? Did Dr. Clarkson breech medical ethics by reassuring the family that the decisions of Earl Robert did not doom Sybil to an otherwise preventable death? These and other questions will be addressed in this post.
It took my wife’s questions about the death of the BBC Masterpiece Theatre hit series Downton Abbey’s Lady Sybil’s death to prompt me watch these episodes. In this post I’ll give a 21st century family physician’s analysis of the medical issues surrounding eclampsia, physician ethics and the physicians involved in the obstetric care of the youngest Crawley daughter. For non-fans Downton Abbey is in the third year of a series that depicts the aristocratic Crawley family and their household servants in the time surrounding WW1 in England on an estate called Downton Abbey. On Downton Abbey Robert Crawley, the Earl of Grantham, has absolute decision-making control of the household. He chooses to invite Sir Phillip Tapsell, a renowned and blatantly arrogant obstetrician from London, to attend and manage the delivery of his youngest daughter Sybil’s first baby. The rest of the family would prefer to have their longtime trusted family physician, Dr. Robert Clarkson care for Sybil and her delivery.
In Season 3, episode 4 Sybil is late in her third trimester and begins to exhibit signs and symptoms that Dr. Clarkson correctly recognizes as preeclampsia based on his medical knowledge and his experience with Sybil. Sir Philip confidently pronounces her symptoms as normal. He considers Sybil’s behavior and state to be the result of stress, anxiety and female fragility. He arrogantly guarantees that everything is normal. The symptoms presented in the episode are classic for preeclampsia; headache, confusion, swelling, and poor fetal growth. An objective sign proteinuria is even documented. Although no mention of blood pressure is made during the show, the relationship of high blood pressure and eclampsia was discovered as early as the very late 19th century. For an excellent and detailed history of preeclampsia-eclampsia see the NIH manuscript of a 2010 Journal of Obstetric and Gynecologic Neonatal Nursing.
Downton Abbey FAQ about Sybil and the Circumstances Surrounding Her Death:
Would a Cesarean section delivery have saved Sybil at the time proposed by Dr. Clarkson? A better question would be; what is the chance that performing a C-section then would have saved Sybil? This of course is unknown, but at least in part depends on the timing. It is somewhat unclear how much time passes between the initial recommendation for C-section by Dr. Clarkson and the actual delivery. It cannot be very long, as the discussion happened after dinnertime and Sybil delivered well before sunrise. I estimate 3-4 hours at most. It would have taken at least an hour or two to transport Lady Sybil to the hospital and accomplish a C-section, so at most an hour or two of time would have been saved, maybe less. It is likely that eclampsia and the attendant complications and death would have still occurred if C-section was attempted at this very late time.
What were the clues Dr. Clarkson used to suspect impending eclampsia? Preeclampsia is much more common in first pregnancies, so Sybil was at risk for that reason. Sybil’s complaints of headache, edema, delirium, and proteinuria were emphasized and these are the classic signs and symptoms of preeclampsia. The suspicion of the baby’s small size was mentioned repeatedly. Poor fetal growth is a clue that the common preeclampsia complication of placental damage may be leading to poor fetal weight gain. This is now usually called intrauterine growth retardation (IUGR). Since the 1980’s we have used ultrasound to monitor suspected IUGR, obviously not available to Sir Philip and Dr. Clarkson. Sybil’s delirium was the most important clue, correctly recognized by Dr. Clarkson and patronizingly discounted by Sir Philip, because it is a very late and ominous symptom of preeclampsia. It suggests that her blood pressure was so high that she was having signs of brain dysfunction we would now diagnose as hypertensive encephalopathy. The family and Dr. Clarkson who knew Sybil well recognized this as highly out of character for Sybil. The latecomer Sir Philip with his paternalistic and stereotypical view of women discounted this cognitive dysfunction.
Was delivery known to be the best management of preeclampsia and how could it have been accomplished? In the 1920’s the condition of eclampsia was widely known, but the prodromal condition now called pre-eclampsia was just beginning to be recognized. Even now we don’t know what causes preeclampsia-eclampsia, but we know how to recognize and diagnose the condition. We also have the means to safely accomplish delivery to prevent progression to eclampsia. Even today once eclampsia (the onset of seizures is when pre-eclampsia becomes eclampsia) occurs things are very dire. The key to reducing mortality of eclampsia is the recognition of preeclampsia and finding a way to accomplish delivery before eclampsia is likely to occur. Today a major part of good prenatal care is the monitoring for early signs and symptoms of pre-eclampsia. Once pre-eclampsia is diagnosed, very careful monitoring for worsening of the condition, and for the welfare of the fetus is undertaken. Delivery remains the only real cure of pre-eclampsia and many inductions of labor and C-section deliveries are done to avoid progression to eclampsia. Dr. Clarkson suspected something was wrong at least a day or two prior to Sybil’s death, but he lacked the tools we now have to further assess the condition, and also lacked the means of labor induction that now are commonplace. Could Dr. Clarkson have reasonably recommended a C-section days earlier when it nearly certainly would have prevented eclampsia and Sybil’s death from eclampsia? Given that the surgery carried a high mortality making this decision would have been bold and very controversial. Treatments such as intravenously magnesium sulfate and treatment of hypertension were just not available.
Did Dr. Clarkson lie to the family about Sybil’s fate, and if so was that wrong? As a family physician I stand behind Dr. Clarkson’s presentation of the facts of the case to the grieving parents. The family conference was at the insistence of Sybil’s grandmother, Violet Crawley the Dowager Countess of Grantham. It seems that he was pressured into the discussion for selfish reasons from the Dowager. Dr. Clarkson reasonably stated the facts; Sybil had advanced pre-eclampsia, eclampsia is highly unpredictable and has a very high fatality, no treatments were available, in fact the chances that his recommended C-section would have saved her life were very low. He graciously and reasonably gave the family the opportunity to heal by not overstating the chances that the poor decisions by Sir Philip and the Earl prevented a life-saving procedure. He may have overemphasized the slim chance that Sybil might have been saved, but if so his heart was in the right place and giving a chance for healing to Sybil’s mom was completely appropriate.
Although the setting for Downton Abbey is in the 1920’s in England, preeclampsia and eclampsia remain major causes of maternal and fetal morbidity and mortality today. I encourage Downton Abbey fans to ask any other questions you have in the comments below and I will try to answer them.