The Unpreventable Death of Princess Charlotte of Wales

Princess Charlotte Augusta of Wales died as a result of complications following the birth of her stillborn son on 6 November 1817. She was only 21, and the darling of Britain. The public mourning over her death would only be matched by the loss of Princess Diana nearly 180 years later.

The reasons the public grief was so intense was because Charlotte was so loved; as adored as her unpopular father, the Prince Regent, George, Prince of Wales, was despised. Where the Prince Regent was extravagant and self-indulgent and had become increasingly Tory over time, his daughter was an openhearted, progressive Whig who identified strongly with the emotional and empathetic Marianne Dashwood from Jane Austen’s first novel, Sense and Sensibility. Her sympathies, it was believed, were all on the side of the British public rather than with her wealth and status. Additionally, Charlotte loved the outdoors, was an accomplished horsewoman, and was excessively fond of music.

The public also pitied her due to the treatment she recieved from her royal father. Although he loved her, he was too selfish to consider her needs above his own concerns. He kept her away from her mother, Caroline of Brunswick, in order to vex his hated wife, uncaring as to how much this upset Charlotte. He also kept her as isolated as possible, inflicting the same strictures on her that his own younger sisters suffered under the auspices of Charlotte’s the depressed and anxious grandmother, Queen Charlotte of Mecklenburg-Strelitz.

By January of 1815 Princess Charlotte had nonetheless become determined to marry Prince Leopold of Saxe-Coburg-Saalfeld, the highly born but impoverished youngest son of a German duke. Leopold, known as the Prince of Coburg within the English court, was young and reasonably handsome, but more importantly he was intelligent and kind.

While her swain was serving as a Lieutenant-General in the Imperial Russian cavalry and fighting Napoleon on the continent, Princess Charlotte fought with her father about the would-be union. She convinced him to give up on the idea of her marrying “Slender Billy”, Prince of Orange, insisting that “No arguments, no threats, shall ever bend me to marry this detested Dutchman.” After a year of Charlotte’s steadfast determination to have “the Leo” as her husband, the Prince Regent gave in and invited Leopold back to Britain in January 1816. The betrothal of Princess Charlotte and the Prince of Coburg was finally announced in the House of Commons On 14 March 1816. They were married a short while later, on 2 May, and were by all accounts blissfully happy together.

Unfortunately, Charlotte suffered a miscarriage rather suddenly and publically while at the Royal Opera House with her husband. There was extreme concern among the populace, but the Princess recovered her health, much to everyone’s relief. She became pregnant again in February 1816, and the palace announced in April that there was an expected heir. This caused great rejoicing and then intense public interest in Britain. “Betting shops quickly set up book on what sex the child would be” and economists “calculated that the birth of a princess would raise the stock market by 2.5%; the birth of a prince would raise it 6%.” Excitement over the impending arrival was keen, and the media kept close tabs on the princess.

Sir Richard Croft, a man with impeccable obstetrical credentials, was chosen to be Charlotte’s accoucheur. Croft was considered one of the best man-midwives in the kingdom, and had an impressive record of saving both mother and baby in childbed.

Charlotte’s expected due date was 19 October, but she had gotten enormous by August, causing Croft extreme concern. Undue swelling and weight gain in pregnancy, then as now, can cause a chill to the heart of a competent obstetrician. Not only would Croft have feared a extremely large fetus, because big babies can cause horrific complications during the birth, but he would have also worried because Charlotte was showing signs of preeclampsia.

Preeclampsia, high blood pressure which endangers both mother and fetus during pregnancy, was more commonly called toxemia in the Regency era and signs of it rightfully terrified a midwife or physician. There was a significant chance a woman with toxemia would die as a result of her pregnancy, and there was very little anyone could do about it at the time. Croft did everything he humanly could with the technology at hand to treat the princess’s suspected toxemia. He sensibly tried diet and exercise first, instructing that:

the princess was to rise at 9:00 a.m.; take breakfast before 10:00; lunch at 2 p.m. (eat a little cold meat or some fruit and bread) and at dinner to take plainly cooked and easily digested food. She is to exercise both on walking and on horseback on days that weather permitted. She should bathe daily with warm water and to have her loins washed daily with cold water. She was advised to avoid any animalistic appetites [sex].

He also treated her in a way that would curdle the blood of a modern midwife: he resorted to bloodletting.  Even a Medieval barber could have told you was bloodletting was a no-no for expectant women, so what on earth was Croft thinking?

Simply put, it was the recommended medical practice for toxemia at the time and a desperate attempt to save Charlotte. Bloodletting was thought to help alleviate toxemia because “as the uterus expanded with pregnancy, greater pressure was placed upon the descending blood vessels” which caused the woman to swell. Letting some of the blood out would hopefully relieve the internal pressure and reduce swelling.

Croft would have also been trying to stave off eclampsia. Obstetrical experts knew that toxemia could lead to eclampsia, which is often fatal even today and was almost a guaranteed death sentence in the Regency period. Eclampsia is marked by convulsions, and Croft would have been taught that those convulsions were caused by “the regurgitation of blood in the head … [which would] overload of the cerebral vessels”. Bleeding the expectant mother was an attempt to drain off the excess blood that might overfill her head and kill her.

Adding to the complications, Charlotte carried her pregnancy to 42 weeks, meaning there would be a dangerous postterm delivery, and there was no way for Croft to induce her labor earlier.

Notwithstanding his conscientious and best efforts, without any modern medical equipment to help him, Croft’s endeavors were doomed to be insufficient.

On the evening of 3 November, Charlotte’s labor finally began. Croft coaxed her to exercise but didn’t allow her to eat, for fear she would throw up during labor and possibly aspirate the vomit. Croft, with the assistance of nurses and Dr Matthew Baillie, remained constantly with the princess while her labor stretched out into a hellish 48 hours.

Charlotte’s husband Leopold was also with her the whole time, bless him.

Charlotte’s labor was further protracted because her large fetus was in transverse lie, slouching sideways in the womb rather than presenting head down. Using what I can only assume was external cephalic version (ECV), Croft was eventually able to get the baby to face the correct direction. However, the size of the baby made the final stage of delivery difficult as well, since it took several hours for the princess, who was doubtlessly exhausted and seriously hungry by this time, to push the baby out.

On 5 November, around 9:00 PM, the princess delivered her stillborn son, who had sadly been dead for several hours before his birth.

Famously, Croft did not allow another obstetrician, Dr John Sims, to come in and use forceps to extract the baby during Charlotte’s final stage of labor. This has sometimes (erroneously) been blamed for her death, or at least the death of the son. Why did Croft deny her the aid of forceps?

For the simple reason that forceps were notorious at the time for killing both mother and child almost as often as they helped. With the best of intentions, obstetricians were prone to forcibly pulling the baby out of the laboring woman by the forceps-grasped head, often with ghastly consequences.

The baby could develop cuts and bruises in various body parts due to the forcible squeezing of his or her body through the mother’s vagina … there could be bruising on the baby’s face if the handler of the forceps were to squeeze too tight … [that] could cause temporary or permanent facial nerve injury … [or] twist the baby’s neck and cause damage to a cranial nerve, resulting in strabismus … [or] clavicle fracture to the baby … The use of the forceps gave rise to an increased risk in cuts and lacerations along the vaginal wall. This, in turn, would cause an increase post operation recovery time and increase pain experienced by the mother.

Worse, the use of forceps had a high risk of causing intracranial hemorrhage that would have killed the baby. From Croft’s perspective, there was rationally just as much of a chance that the baby would die if he did use forceps than if he didn’t.

He was also concerned with keeping Charlotte alive to have another child if the one she was delivering died. Forceps were likely to rip up Charlotte’s delicate vaginal tissues, and even if she didn’t bleed to death from the damage, Croft feared the higher risk of childbed fever that came with those forceps-induced injuries. Without our current understanding of hygiene or germ theory, postnatal infection was always an alarming risk, and Croft didn’t want forceps adding to it. Like many obstetricians of the time, he made the heartbreaking choice of risking the infant to potentially save the mother.

Charlotte’s baby boy weighed roughly nine pounds, a possible indicator of gestational diabetes and another sign that Charlotte probably had preeclampsia. Another indication that the princess suffered from preeclampsia was the abnormally formed placenta, which broke apart on delivery, and the baby’s oddly small umbilical cord.

Charlotte’s placenta detached incorrectly, and only a third of it was expelled naturally. This caused Charlotte to begin to hemorrhage, but Croft was able to prevent her from bleeding to death by manually detaching the remainder of the placenta from her womb. Far from being an incompetent obstetrician, Croft indisputably saved Charlotte’s life at least one during her calamitous delivery.

The princess initially seemed to be doing well (at least physically), and there was no immediate concern for her life. Leopold was convinced to try to get some rest now that the travail was over. He was given an opiate to help him sleep, since he was naturally very distraught over the death of the baby. Croft likewise went to rest, leaving the seemingly healthy Charlotte in the care of experienced nurses.

Tragically, a few hours after the birth Princess Charlotte started evincing the symptoms of what I am convinced was HELLP syndrome, a potentially deadly complication of preeclampsia. The symptoms of HELLP are epigastric pains the patient usually thinks is “heartburn” or right upper quadrant pain in their torso, malaise, with nausea and/or vomiting. Moreover, she began having spasms and using erratic speech, which were signs she may have developed full-blown eclampsia as well.

About 11:45 a.m., Charlotte became nauseated and complained of a singing noise in her head … Shortly afterwards she vomited. She took a cup of tea and went to sleep for about a half an hour. At that point she became more irritable and more restless and began to talk somewhat incoherently. She was given at that point 20 drops of laudenum in wine and water. About 12:45 am. on the 6th of November she complained of great uneasiness in her chest and great difficulty in breathing. Her pulse became rapid, deep and irregular, and she extremely restless and was not able to remain still for a single moment. Attempts were made to give her cordials, nourishment, and anti-spasmotic and opiates.

HELLP causes a woman’s death when it progresses to acute renal failure or liver rupture, and Charlotte’s end was abrupt enough to have been the effects of massive internal hemorrhage or shock. Dr Christian Stockmar, who was also attending her, began to leave her sickroom in the hopes of awakening Prince Leopold, when the princess shouted, “Stocky! Stocky!” to call him to return. He rushed to her bedside, but she was already gone.

The entire nation was plunged into despair when it learned of her death.

As almost everyone knows, with grief often come anger. The public soon began to look for a scapegoat to blame for Charlotte’s death, and their accusing eye fell on her man-midwife, Richard Croft. All the kind words of praise that Leopold and the Prince Regent heaped on Croft, absolving him of any negligence, fell on deaf ears. Although Sir Everard Home and Sir David Dundas performed an autopsy and “reported to the King that there was no evidence of neglect” and affirmed that everything that “human science could devise or human skill could effect” had been done, some people still blamed Croft for Charlotte’s death.

Sadly, Croft blamed himself as well. He had failed to save the beloved Princess of Wales or her son. He thought he had failed both a patient, and an entire nation.This is preposterous, because HELLP syndrome is life-threatening even under ideal modern conditions, and there was nothing Croft or any other physician could have done to save Charlotte in 1817.

Nevertheless, Croft was abjectly miserable. On 18 February 1818 the distraught obstetrician committed suicide by a single gunshot to the head. It may be apocryphal, but supposedly a copy of Shakespeare’s Love’s Labour’s Lost was found open near his body, open to the quote, “Fair Sir, God save you! Where is the Princess?”