Serena Williams and postpartum shortness of breath: does the complaint require investigating an embolism?

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

Serena Williams has twice recounted what happened the day after her daughter was born, in 2017. In the February 2018 cover story in Vogue, the account is this: still in hospital after an emergency caesarean section, she felt short of breath; as she had already had clots in her lungs and was off her daily anticoagulant because of the surgery, she concluded on the spot that it was another pulmonary embolism. She asked for a CT scan with contrast and intravenous heparin. An ultrasound of her legs was done first, which showed nothing; then came the CT scan, which found small clots in her lungs. On 5 April 2022, in a first-person essay published by Elle, she added details. The nurse responded to the request by saying she thought all the medication was making her “talk crazy”; Serena insisted, the nurse called the doctor, and the doctor listened to her and ordered the investigation. She herself acknowledged that the reason for postponing the anticoagulant, the risk of bleeding from the caesarean wound, was real. Other surgeries followed: coughing opened her stitches, a haematoma was found in her abdomen and a filter was placed in a vein to stop clots from reaching her heart. The sentence that sums up the essay is hers: being heard and appropriately treated “was the difference between life and death”.

The account is hers and ends there: nothing is asserted here about the team, the hospital or the clinical decisions of that admission, which, by her own account, ended up performing the right test. What the article takes from that account is a question that applies to any Brazilian maternity hospital: when a woman who has just had a child says she cannot breathe, what does medicine require to be done and what does the law guarantee her? The magazine recalled, at the opening of the essay, that in the United States Black women die almost three times more often after childbirth than white women. In Brazil, the gap also exists and has been measured by the Ministry of Health.

Before the law, health: shortness of breath that starts suddenly, chest pain, fainting or coughing up blood in the weeks after childbirth call for emergency care now, at the emergency department or through SAMU (the public ambulance service), on 192. Say straight away that you recently had a baby, whether it was a caesarean and whether you have ever had a thrombosis or an embolism.

What science knows: the postpartum period is the window of highest risk

Pregnancy makes the blood more prone to clotting, and the French report on maternal deaths from 2016 to 2018 sums up the effect: the thromboembolic risk rises from the first trimester, “is highest in the first week of the postpartum period” and extends to three months after childbirth. The reference population-based study, by Heit and colleagues (Annals of Internal Medicine, 2005), followed thirty years of cases in a Minnesota county and measured an annual incidence of venous thromboembolism five times higher in the postpartum period than during pregnancy (511.2 against 95.8 per 100,000 woman-years); for pulmonary embolism, the difference was from 10.6 to 159.7. The population studied was almost entirely white, a limitation the authors record. Kamel and colleagues (New England Journal of Medicine, 2014), with 1.69 million women in California, found the risk of a thrombotic event more than ten times higher in the first six weeks after childbirth and still about twice as high between the seventh and the 12th week, with no significant increase after that.

The World Health Organization’s systematic analysis of the causes of maternal death between 2003 and 2009 (Say and colleagues, Lancet Global Health, 2014) attributed 3.2% of maternal deaths worldwide to embolism, about 78,000. Where haemorrhage and infection have receded, the relative weight is greater. In the United Kingdom, the 2024 MBRRACE-UK report recorded that thrombosis and thromboembolism had become “the leading cause of maternal death”; the 2025 report, on the 257 deaths from 2021 to 2023, kept clots in first place. In the United States, the state maternal mortality review committees classified thrombotic embolism as the cause of 8.7% of pregnancy-related deaths between 2017 and 2019, and of 11.9% among Black women. In France, there were 20 deaths from venous thromboembolism from 2016 to 2018, the fourth leading cause of maternal death, “with no decrease in twelve years”.

In Brazil, the picture is dominated by other causes. According to Joint Technical Note No. 227/2025 of the Ministry of Health, among direct obstetric deaths from 2012 to 2023 the predominant causes were hypertension (29.2%), haemorrhage (19.1%), puerperal infection (12.3%) and abortion (11.7%). Obstetric embolism (code O88 of ICD-10) accounted for 3.2% to 4.4% of maternal deaths from 1996 to 2018, depending on the age group, in the study by Motta and Moreira (Ciência & Saúde Coletiva, 2021). That is less than in the United Kingdom, but it is not residual.

The clinical problem is that embolism hides behind common complaints. The protocol on venous thromboembolism in pregnancy and the postpartum period of the Hospital das Clínicas of UFMG (Ebserh, 2022) acknowledges that the signs “may be non-specific”, because they overlap with the normal changes of pregnancy, and notes that “the most common presenting symptom is dyspnoea”, followed by chest pain and cough. The British guideline of the Royal College of Obstetricians and Gynaecologists observes that subjective clinical assessment of embolism is “particularly unreliable” in pregnancy. The hypothesis cannot be ruled out by eye, nor confirmed without a test; that is why the complaint has to become an objective investigation.

What the guidelines require when embolism is suspected

The two British guidelines on the subject, the RCOG Green-top Guidelines 37a and 37b (2015), separate prevention from acute management. Guideline 37a requires every woman to undergo a “documented” assessment of risk factors for thromboembolism early in pregnancy, repeated on any admission, at delivery or shortly after it, and provides for prophylactic anticoagulation for ten days or six weeks depending on the risk. Guideline 37b, which deals with suspected cases, is even more direct: any woman with symptoms or signs suggestive of thromboembolism should have “objective testing performed expeditiously” and receive low-molecular-weight heparin until the diagnosis is excluded, “unless treatment is strongly contraindicated”. Where pulmonary embolism is suspected, the pathway begins with an electrocardiogram and a chest X-ray and moves on to a lung scan or CT pulmonary angiography, and the woman should, wherever possible, take part in the choice between the two tests.

The French report follows the same line and is emphatic on a point that often stalls the investigation: pregnancy “must not be an obstacle” to imaging, because the risk of failing to diagnose the embolism is far greater than that of the radiation. The tension Serena described is real: right after a caesarean section, heparin protects against the clot and increases the risk of bleeding. The contraindication proviso in the British guideline exists for cases like this. It does not authorise ignoring the hypothesis; it requires a decision, based on objective testing, and a record of why it was decided that way.

Brazil: the scale of maternal mortality and the Rede Alyne

Joint Technical Note No. 227/2025 of the Ministry of Health gives the official picture. The maternal mortality ratio rose from 57.9 per 100,000 live births in 2019 to 117.4 in 2021, at the height of covid-19, and fell to 55.3 in 2023, the lowest level in the series. The commitment Brazil made under the Sustainable Development Goals is to reach 30 per 100,000 by 2030. Racial inequality is the hardest figure: from 2012 to 2023, the highest ratios occurred among Black and Indigenous women, “ranging between 100 and 200 deaths” per 100,000 live births; in 2023, the ratio for Black women fell to the lowest level of the period, 77.7, still well above the national average. On average, 61% of the deaths were due to direct obstetric causes, those which the document itself links to “interventions, omissions or inadequate treatment”.

The most recent regulatory response is the Rede Alyne (the Alyne Network), created by Ordinance GM/MS No. 5.350 of 12 September 2024, which updated the former Rede Cegonha within Consolidation Ordinance No. 3/2017. The name is that of Alyne da Silva Pimentel Teixeira, the young Black woman whose death in the Baixada Fluminense, in 2002, led to Brazil being found in breach by the CEDAW Committee, a case the firm examined in the article on the Alyne Pimentel decision (in Portuguese). The ordinance includes among the network’s principles “the promotion of equity, with regard to ethnic and racial inequities”, “the adoption of evidence-based practices” and “the guarantee of a companion of the woman’s free choice”, and sets as its objective reducing maternal and infant morbidity and mortality, “above all among the Black and Indigenous population”. The Ministry declared as its target reducing maternal mortality by 25% by 2027, and by 50% among Black women.

Three parts of the ordinance matter here. The postpartum period is a component of the network in its own right, and the high-risk pregnancy and postpartum outpatient clinics must follow up the postpartum period in coordination with primary care, “whenever necessary”. Those clinics must also “carry out actions and services of surveillance and investigation of maternal death” and be integrated with a maternal mortality committee. And the referral hospitals for high-risk pregnancy and postpartum care must have a “Hospital Commission or Committee on Maternal, Infant and Fetal Mortality”. The investigation of every maternal death has, moreover, been mandatory since Ordinance GM/MS No. 1.119/2008, which treats those deaths as “events subject to mandatory investigation” in order to establish their causes and prevent their recurrence.

There is also the right not to be alone. Much of what one reads cites Lei 11.108/2005, which guaranteed a companion during labour and the immediate postpartum period in the SUS (Brazil’s public health system), but that text has been replaced: since Lei 14.737/2023, art. 19-J of Lei 8.080/1990 (the Organic Health Law) guarantees “every woman”, in “public or private” facilities, the right to be accompanied throughout her care, as explained in the article on companions in childbirth (in Portuguese). The companion is often the one who repeats the complaint when the patient no longer has the breath to do so, and the one who remembers the time at which it was made.

In the private health-plan sector, a complication of the postpartum period is an emergency by legal definition. Art. 35-C, II, of Lei 9.656/1998 (the Health Plans Act) makes coverage of urgent cases mandatory, “understood as those resulting from personal accidents or from complications in the gestational process”, and ANS Normative Resolution (RN) 566/2022 sets “immediate” care for urgent and emergency cases (art. 3, XVII), with no need for prior authorisation (art. 4, § 3). What the health-plan operator may not do is treat a postpartum complication as an elective procedure, subject to authorisation and a waiting list.

Comparative law: three countries that audit their maternal deaths

None of the three countries has solved the problem; what they have in common is examining every maternal death methodically and publishing the result, by different routes.

1. United Kingdom: the confidential enquiry and listening as a recommendation

The United Kingdom maintains confidential enquiries into maternal deaths, today conducted by the MBRRACE-UK consortium, based at the University of Oxford. RCOG Guideline 37b records that those reports repeatedly identified failures to obtain an objective diagnosis and to treat thromboembolism adequately, and attributes the fall in deaths from that cause, from 41 in 2003–2005 to 18 in 2006–2008, in part to better recognition of risk and wider use of prophylaxis. The 2024 report criticised symptoms being attributed to pregnancy without investigation and wrote that warning symptoms “are not normal” and that care should be escalated when a woman raises a concern. The 2025 report measured mortality of 28.21 per 100,000 among Black women, against 12.44 among white women, and recorded accounts by Black and Asian women of microaggressions and of being ignored; the women heard said something that speaks directly to Serena’s account: having to advocate for oneself is exhausting and “should not be normalised”.

2. United States: state committees, safety bundles and California

In the United States, pregnancy-related mortality among Black women was 3.2 times that of white women between 2007 and 2016 (Petersen and colleagues, CDC, MMWR, 2019). The state review committees judged 84.2% of the deaths from 2017 to 2019 to be preventable, and 53% of the total occurred between 7 days and one year after childbirth. The Alliance for Innovation on Maternal Health, funded by HRSA, disseminates “patient safety bundles” for childbirth and the postpartum period, adopted as of February 2026 by 2,095 birthing facilities, about 74% of those in the participating areas. In California, the Department of Public Health began reviewing maternal deaths in 2006, the California Maternal Quality Care Collaborative, at Stanford, turned the findings into toolkits for haemorrhage and pre-eclampsia, and mortality fell to 6.9 per 100,000 in 2011–2013, when the national rate was projected at almost three times that. In 2020, the CDC launched the Hear Her campaign, whose stated aim is to encourage those around pregnant and postpartum women to “listen carefully and act” when she reports a concern.

3. France: the expert who judges whether the death was avoidable

France has maintained since 1996 the Enquête nationale confidentielle sur les morts maternelles, under Santé publique France, operated by the EPOPé team at Inserm. Every death occurring during pregnancy or up to one year afterwards is investigated by a pair of experts, an obstetrician or midwife and an anaesthetist-intensivist, anonymised and judged by a national committee, which decides the cause, whether care was adequate and whether the death was avoidable. The seventh report, from 2024, covering 2016–2018, counted 272 deaths and judged 60% of them avoidable. For thromboembolism, avoidability rose from one case in three to “one case in two”, and 47% of the women who died were in a situation of social vulnerability, against 22% of women giving birth in general; those born in sub-Saharan Africa had a risk of maternal death three times higher.

Brazil has the basic building block, the mandatory investigation of every maternal death and the network of committees, and the 2025 Technical Note lists among the actions under way the creation of a National Committee for the Prevention of Maternal, Fetal and Infant Mortality. The three examples show the next step: judging avoidability by a uniform method and returning the result to maternity hospitals as a rule of care.

Liability: the complaint heard, the hypothesis recorded

The legal question is not whether the patient may choose the test, but what the service must do with what she says. The reading that protects those providing care has sound foundations: a CT scan with contrast carries risks, anticoagulating right after a caesarean section can cause bleeding, and an embolism confirmed hours after the complaint, with the investigation under way, is hardly a failure. The opposite reading treats the account as clinical data: a postpartum woman with a previous embolism and sudden shortness of breath hands the team, in a single sentence, the elements of the highest risk.

Brazilian law accommodates both readings through the record. The Code of Medical Ethics forbids the physician from “failing to use all available means” of diagnosis and treatment that are scientifically recognised and within reach (art. 32). Lei 15.378/2026, the Estatuto dos Direitos do Paciente (the Patients’ Rights Statute), guarantees the right to take part in decisions about one’s own care and treatment plan (art. 11), to receive information that is “accessible, up to date and sufficient” to decide (art. 12, § 1) and to have access to the medical record, with a copy free of charge (art. 19). In public services, and subsidiarily in those provided by private entities (art. 1, § 3), Lei 13.460/2017 (the public-service users’ law) imposes the “presumption of the user’s good faith” (art. 5, II) and exempts “cases of urgency” from the order of arrival, with legal priority for pregnant and breastfeeding women (art. 5, III). None of this turns the request into a prescription; it does, however, prevent the complaint from being dismissed as exaggeration, without a test and without a note.

The hospital and the health-plan operator are strictly liable for the services that are their own, such as nursing, protocols and the availability of tests (Consumer Protection Code, CDC, art. 14); the physician’s personal liability depends on proof of fault (art. 14, § 4). At the international level, CEDAW, promulgated by Decreto 4.377/2002, requires the State to ensure “appropriate services in connection with pregnancy, confinement and the post-natal period” (art. 12, § 2); the obligation is the State’s, not the duty doctor’s. When the investigation is delayed and the embolism progresses, it is rarely proved that the outcome would have been different; that is where loss of a chance comes in. The reference precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, 2012), a case of inadequate treatment of breast cancer, not of embolism, whose headnote accepts the doctrine in medical malpractice and sets the limit: “Compensation could never correspond to the final loss, but only to the lost chance”. And when the embolism is treated in time and overcome, with no sequela linked to the delay, the most likely outcome is that there is nothing to claim. The general logic is in the guide to medical malpractice (in Portuguese); prophylaxis after surgery, in the article on thrombosis without prophylaxis (in Portuguese); complications of childbirth, in the one on obstetric malpractice (in Portuguese).

Everything depends on the record: the time of the complaint, what the team thought and what it did. For the family, this means requesting a complete copy of the medical record, with nursing notes, vital signs and the times of tests. For the maternity hospital and the physician, the hypothesis of embolism written in the progress notes, even if ruled out on stated grounds, is the best defence; a complaint missing from the medical record tends to weigh against whoever should have noted it.

Before deciding

In my view, the lesson of Serena Williams’s account is not that the patient knows more than the doctor, but that the hypothesis she raises has to be examined and, if ruled out, ruled out for a recorded reason. That is what the guidelines ask for and what Lei 15.378/2026 makes it possible to demand. Anyone whose complaint was ignored in the postpartum period has three things to do, in this order: seek care if the symptoms persist; gather the medical record, the tests and the times; and only then ask whether a chance was lost, with the guideline of the time set beside what was done. If the complaint of shortness of breath never reached the medical record, if the test was delayed without written justification or if the health plan denied emergency care for a postpartum complication, get in touch with the firm: the analysis starts from the timeline of the complaint, the requests and the responses, and does not replace medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).