PRACTICE PARTNER
PATIENT SAFETY
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Level 1 Hospitals Urged to Better
Prepare for Difficult Obstetrical Cases
T
wo deliveries in Level 1 hospitals resulting
in the deaths of both infants were the sub-
ject of recent reviews by the Maternal and
Perinatal Death Review Committee. This
Committee reports to the Chief Coroner.
The first case involved a mother who was a healthy
35-year-old woman, with all routine prenatal labora-
tory investigations within normal limits. An ultra-
sound documented on Antenatal 2 identified the
fetus to be 90 percentile in size at 30 weeks gesta-
tional age. Her past obstetrical history was significant
for a vacuum assisted vaginal delivery of a 6 pound
4 ounce female at 37 weeks gestational age after an
eight hour labour.
In the birth under review, the baby died at two days
of age, with the post-mortem revealing a cephalohe-
matoma, moderately severe subarachnoid hemorrhage
and severe anoxic-ischemic encephalopathy.
During the baby’s birth, there was a shoulder dysto-
cia. The on-call obstetrician was 45-60 minutes away
at the time of the emergency consultation. A physician
on duty in the emergency room was called and applied
a vacuum. The physician and a midwife persisted with
a vacuum operative delivery because of the profound
bradycardia. There was no option for a Cesarean sec-
tion due to the absence of the obstetrician.
In its review, the Committee noted that:
• Given that the estimated fetal weight was in the
90th percentile, a shoulder dystocia could have
been anticipated and communicated with the team
of midwives, labour and delivery nurses and obste-
trician on call.
ISSUE 3, 2017 DIALOGUE
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