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.

home midwifery in the (legal) spotlight

Melbourne in mid-winter is grey and damp and cold.  The tall concrete buildings block the weak, angled sunlight.

This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime:  not old enough to be interesting; not fresh enough to be attractive.  The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.

The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong.  Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'.  It sounded simple.    

Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.

'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much.  Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'.  A curious conundrum! 

A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.'  In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance.  When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.

In 6/7 cases, the baby deaths were declared by the Coroner to have been potentially preventable.  The Coroner does not attempt to apportion blame, merely to discover the facts, and to make recommendations.  The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.

I want to be perfectly clear here: I cannot speak for either the mothers or the midwives.  I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain.  I am also shocked at the tragedies that precipitated these cases into the Coroner's court.

The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective.   The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.

***
The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit.  I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.

The loss of a baby's life is, thankfully, uncommon in our world.  Yet it is one of the most heart-wrenching experiences imaginable.  Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case.  I ask myself, what lessons have I taken from these seven tragic cases?

***
I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices.  This is not going to be easy.  It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance.  This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy.  The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge.  This also needs to change, enabling midwives to practise more autonomously and accountably.

Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground.  The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.

And, we only want the best.



Your comments are welcome.

ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.