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
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DIALOGUE ISSUE 3 , 2017