PRACTICE PARTNER
• It would have been appropriate to put a plan in place when the woman presented in labour. It is currently believed that delivery by elective Cesarean section for suspected fetal macrosomia has not been proven to be protective for the fetus / neonate, and the decision to proceed with a vaginal delivery was reasonable. Delivery by vacuum extraction may be associated with shoulder dystocia independent of fetal weight.
• The obstetrician on call was 45-60 minutes away at the time of the emergency consultation. This response time was inadequate. With earlier notification of the risk of shoulder dystocia, the obstetrician could have been closer to the hospital. With earlier consultation at the time when the change in fetal heart rate was first noted, there could also have been earlier intervention by an obstetrical provider skilled in both assisted vaginal delivery and Cesarean section.
• There was no documented discussion with the mother concerning birth in a Level 1 hospital where emergency obstetrical services were not immediately available and physicians were not required to remain on site while on call for obstetrical consultations and births. Availability of emergency obstetrical services should have been considered before attending this Level 1 hospital with a woman with a large for gestational age fetus and with a previous similar history.
Recommendations:
1. Hospitals providing Cesarean section services should be able to mount the procedure within approximately 30 minutes from the time of decision to proceed.
2. Obstetrical care providers are reminded of the importance in identifying risk factors and for timely and clear communication with the entire labour and delivery team. Obstetrical care providers must be aware of the availability of obstetric, anesthesia, neonatal and operating room staff.
3. Obstetrical care providers are encouraged to review Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline, JOGC, Volume 29, Number 9, September 2007.
4. Hospital health-care professionals in Level 1 institutions where obstetrical care is being provided should be encouraged to attend Advances in Labour and Risk Management( ALARM) and Neonatal Resuscitation Program( NRP) or equivalent training on a regular basis.
********** In the second case reviewed by the Committee, an infant died at two days of age after withdrawal of life-sustaining medical therapy following clear evidence of severe central nervous system injury. He had sustained bilateral skull fractures during birth as a result of efforts to extract his head from the pelvis during an emergency Cesarean section. Manual pressure exerted directly against the soft neonatal skull may result in direct, blunt trauma to the underlying brain and vascular structures. This degree of pressure can be unknowingly applied when there is an urgent need to affect delivery and the head is impacted. The difficult delivery of the fetus at the time of Cesarean section is not uncommon, particularly in advanced labour. Anticipation of this by the attending obstetrical team is extremely important, but not always possible. Although, it is unlikely to have impacted the outcome in this case, a few concerns about the neonatal management were noted:
• It does not appear that there were attempts to have a qualified pediatrician or other individual skilled in neonatal resuscitation attend the delivery even though it was an emergency Cesarean section for suspected fetal compromise. As stated in the Neonatal Resuscitation Program( NRP) textbook,“ every birth should be attended by at least one person skilled in neonatal resuscitation whose only responsibility is management of the newborn.”
• The anesthetist was mobilized when it was evident that the infant was compromised but they had some difficulty procuring an airway. The infant’ s
44
DIALOGUE ISSUE 3, 2017