Wednesday, December 16, 2015

The death of a baby

Today I would like to comment on a case in which the baby died after induction of labour in a tertiary level obstetric hospital. 

It's a well staffed, well equipped modern facility, with all the bells and whistles.   It's a hospital where doctors and midwives and nurses are  being taught their professions, where evidence based practice is treated seriously.

This death was reported to the Victorian Coroner, who carried out an inquest and has recently published her findings.  The baby's name is Kylie.  I would like to refer to her by her name, as she is at the centre of the picture.  Other people will be referred to by their role.

I am writing about this sad case because it has a number of features are important in understanding an unexpected adverse event.  Please note that I don't have any inside knowledge.  I don't know any of the midwives or doctors who cared for Kylie or her mother, and I don't know anyone who knows Kylie's parents or family.  My source is the Coroner's report which has been placed on the public record. 


A layperson reading the report may well ask how was this allowed to happen?  Why was no action taken until (obviously, with the benefit of hindsight) too late, to hasten the birth of baby Kylie?  What's the point of having continuous CTG monitoring if the plan is to press on, even when the most basic understanding of cardio tocography indicates that baby Kylie was distressed? 

That's the big question

Although birth is not an illness, the process carries potential for damage and death.  In birth there is a finite point after which the baby will not do well, but it's impossible to predict where that point is.  Midwives have to accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth.  The decisions we make in the clinical setting take unpredictable and sometimes quick changes into account.


The language used to describe a CTG trace, such as 'non-reassuring', is, I think, deliberately vague.  We are all confident when we see a CTG trace that ticks all the boxes.  'Reassuring'!   It's the non-reassuring ones, placed in context with all the other clinical features, that challenge decision-making.  A normal trace now can not predict the condition of the baby in 2 hours' time, or 10 minutes, or any time in the future.


I found the record of the evidence of the obstetric experts very interesting (#70 onwards). Some hospitals/obstetricians have a low tolerance for non-reassuring traces.  Historically the CTG machine has become the catalyst for high rates of caesarean births, and many babies come out pink and complaining about the whole process, suggesting that the surgery was not really necessary.  The ability of the midwives and doctors who are providing professional care to know which mother-baby pair is progressing well, and who needs surgical intervention is a skill that cannot be overvalued.  The big teaching hospitals such as this one set up their guidelines that the staff are bound to follow with this in mind.
 
The idea of a chronically compromised fetus who may not have done well even if the baby had been delivered earlier is worth thinking about.  



Will this death, and the related report, lead to an even greater rate of elective surgery to avoid the possibility of low fetal reserves?  How many mothers will be operated on without valid reason, giving them and their children the increased life-long consequences of caesarean surgery?  More importantly, will the lives of babies like little Kylie be protected as they make their transition from mother's womb to our world? 



My response to this report is from a midwife perspective. For 20 or so years until my retirement last year I have been attending homebirths, without access to CTG at the primary care level. A midwife attending homebirth will usually listen to the fetal heart sounds using a doppler sonicaid machine after a contraction, and consider that observation within the context of other clinical features. If there are 'non-reassuring' features of that auscultation, such as a deceleration, it's a decision point that can have profound consequences.

Wednesday, December 09, 2015

searching for confidence

A young mother whose second pregnancy is at about 30 weeks phoned me, and we chatted for a while.   As I listened to her story, I felt enormous sympathy for her in her search for confidence. 

I have pondered the predicament of this young woman, who I will call Bea, and others in similar situations many times.  So, dear reader, I will share the story with you, and hope that those readers who are also searching for confidence as you approach your time to give birth will be given some useful tools.   If you think you know Bea, please read any of the more critical comments that I make as criticism of the system that leaves women dangling and lacking in confidence, rather than a criticism of any person.


Bea is booked to have her baby in a hospital, under the care of a team of doctors and midwives.  Bea is hoping to find someone who will palpate her abdomen (See RCM How to perform an abdominal examination) and tell her how her baby is growing, and whether she will be suitable for VBAC (vaginal birth after Caesarean).

Bea experienced an emergency Caesarean birth after a long and painful labour for her first child.  She felt traumatised, disappointed, confused, depressed; at times blaming herself and at times numb towards herself, her child, the child's father, and the world.

In preparing herself for this next birth, and in an effort to come to terms with her memories, Bea has had counselling.  One of the outcomes of that counselling is that Bea recognises a lack of confidence in the (nameless) people who will provide care for her in labour and birth.  Midwives, doctors, others: all with a role in the system that produces babies, yet Bea has no confidence in that system.

Bea is an intelligent woman who is used to researching every aspect of life, from the energy efficiency of white goods in her home, to the source of the food she buys.   She wants to know about pregnancy and birth specifically as it relates to her.  She reads posts from other mothers on social media.

Bea is particularly concerned about the size of her baby; whether he or she will 'fit'.  That's a big question.  It's a question that exercises the mind of every midwife.

Bea would like me to palpate her abdomen and (hopefully) tell her that her baby will fit through her birth canal.  I can palpate her abodmen, feel the fetal poles and hold her baby between my hands.  That gives me a good idea of the size of the baby - it's not much different holding a baby who is still in the womb to holding the baby in my arms.  But I can't tell if the baby will 'fit'! The only times when I would advise against progressing naturally and spontaneously into labour are when a complication presents - when the natural process would be likely to lead to damage or death.

Many times I have attended little women who have big babies.  Many of them have given birth spontaneously and quickly.  I have never tried to be a prophet, predicting events in the future.   The decision making processes in midwifery require the midwife to understand and work in harmony with the natural physiological processes, and only interfere if there is a valid reason to do so. 

Bea told me she has at least three birth plans: a vaginal birth; a caesarean after labouring; and an elective caesarean.

I told Bea that she should have only one birth plan: to do her best. 

You need to take ownership of your own natural processes which are essential if natural birth is to progress well. ...to make the best decision you can at any point when a choice or decision needs to be made.  Here are a few examples:
  • The doctor tells you at 38 weeks that he assesses the baby to be large and advises an elective caesarean (without labour) at 40 weeks.  Do you think the best decision at this point is to say yes, to say no, or to make a decision closer to 40 weeks?
  • It's a few days before (or after) that magical 40 weeks.  You think you are coming into labour - it's midnight and you woke up with a contraction, and felt baby make a few big moves.  Waters have not broken.   Do you get all excited and ring your support team, and ring the hospital, and wake your husband?  Or do you tell that baby to go back to sleep - you have a big day ahead if labour does begin, so you need to get some shut-eye!
  • Later ... You think you are really in labour now.  Memories flood back each time your womb contracts, and you remember the early part of your first labour.  You remember using the labour ap on your phone to track the contractions.  You know you need to get organised - little Johnny will go to his granny after breakfast, DH will stay home from work, and the birth support friends will need to make arrangements for their families and work.  Contractions are coming every 10 minutes, and feel good.  You need to walk and rock through them.   Do you ask your team to come now, or to wait for another call?  Do you call the hospital now?
...

These 'decision points' might seem insignificant, but I say they are some of the most important decisions you will make.  Each decision is a fork in the road.  If you take one, you cannot take the other.  There is no turning back.  Can you feel confident about these decisions?  If you have that confidence, and you establish labour without any outside (medical or psychological) assistance, I know that you are well on the way to successful and healthy VBAC.