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.

When birth is no longer normal

Midwives consider ourselves the guardians or keepers of normality in birth. We attend conferences and repeat slogans about keeping birth normal. We talk about sitting on our hands, about trusting the natural process, about protecting the woman's space so that she can give birth naturally and safely.

Our definition declares that our duty of care includes the promotion of normal birth.

Here is an excerpt from that definition of the midwife (ICM 2005):

"...
The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
..."

Australian midwives need to know this definition well. It has been adopted by our regulatory agency AHPRA, and the Australian Nursing and Midwifery Council, and is foundational to current midwifery education, codes and standards.

The big challenge for the midwife is to balance each aspect of our professional duty. Our desire to promote normal birth must not be allowed to over-ride our responsiblity to carry out preventative measures, or to detect complications in mother or child, access medical care and other appropriate assistance in a timely manner, and the carrying out of emergency measures.


I have reflected many times on what it means for a midwife to be a responsible and accountable professional. In recent submissions to government inquiries, I and other midwives have written about the processes by which midwives are required to give an account of what we do, and this is especially so when there is an adverse outcome. Our society has an expectation that professional care will be in the public interest; that the safety and wellbeing of mother and child are the primary concern of the midwife and any other person who provides professional maternity care.

A recent report by the Queensland Coroner on the death of a baby Samara Hoy has been distributed in midwifery circles.  It is a public document.  The Coroner's findings were critical of both midwifery and obstetric care (or the lack thereof) in this case. Reading the report has left me with many questions about the standard of care and culture of maternity services in that hospital.

If this woman had been planning homebirth, and her midwife had taken her to the local public hospital when meconium, fetal tachycardia, decelerations ... were observed, there would have been no question about continuous electronic fetal heart monitoring (EFM), or offering a theoretical set of options, one of which was waiting for nature to take its course.

That's the essence of midwifery: that if complications are detected, we have a process to follow, including "accessing of medical care or other appropriate assistance".

The tragedy in this story in my mind is that the woman was so alone. Although there was a person there with the role and title of midwife, there was no person with whom that mother had a partnership based on reciprocity and trust. There appears to have been no informed decision making by the woman. The decision by various midwives, and the collaborating doctor, to not even use the facilities available for checking the baby's response to the contractions suggests either a misplaced reliance on natural processes, or just plain incompetence. The physical findings of the Coroner of strangulation marks left by a tight umbilical cord around the baby's neck, and meconium aspiration, suggest that severe fetal distress would have been observable, particularly with EFM, for some time prior to the birth.

I can only surmise that the midwife was committed to a skewed idea of keeping birth normal, by sitting on her hands and keeping her head in the sand.

A young mother who has engaged me as her midwife for planned homebirth asked me under what circumstances would I think she would need a Caesarean birth.  I don't have an easy answer, but we chatted about how I know when birth is no longer normal, and what would happen in such a situation.

I know it's easy for me to be an armchair critic, but I have written this post with the hope that other midwives who read it will also reflect on what we do when birth is no longer normal.