Severe Fetal Trauma during a Caesarean Section – Blog series – The case of baby Nixon - Authors Opinion
In the previous two posts we highlighted the case of baby Nixon and the coroners recommendations from his tragic death (Read What Happened? and Coroners Recommendations) our medical director shares below his thoughts on the case.
The complications arising from an impacted head continue to cause fetal injuries and deaths around the world. A study from Bristol in 2001 found that of 10,000 births 209 required c section and in 2 of those cases the baby suffered hypoxic-ischaemic encephalopathy (1). Maternal morbidity in this clinical situation is a lot more common and often under reported. All methods described and recommended in the hospital report are only used as extreme emergency measures to deliver the fetus when the standard methods have failed. Training in these methods is at best very difficult if not impossible due to reasons outlined below.
Why wait for the difficulty in the delivery of head to arise in the first place? Fetal Pillow is NOT indicated for use when there is difficulty in the delivery of fetal head as recommended in the guidelines from the hospital and the experts. Fetal Pillow is indicated to PREVENT the complications from occurring as a result of present methods used to deal with a deeply impacted head.
Prevention has to be the key as pushing from below is technically difficult due to:
Reverse breech has even bigger problems:
Tocolytics have no evidence of being effective in this situation. They are more likely to cause hypotension and atonic PPH rather than uterine relaxation to make the delivery of fetal head any easier.
Prediction of difficult delivery
The most important message is to try and anticipate a difficult delivery and prevent it from occurring. Data suggests that this difficulty is likely to be encountered when the cervix is fully dilated or even prior to full dilation if the head is deeply engaged. I recommend that whenever a clinician makes the decision to carry out a CS in advanced labour, an abdominal examination should be performed prior to commencing the CS. If it indicates deep engagement it should alert the clinician to the possibility of a difficult delivery. At this point a vaginal examination should also be performed to look for the station of fetal head, degree of moulding and caput.
At this point the decision to insert Fetal Pillow should be made with the aim of PREVENTING rather than treating the consequences of a deeply engaged head.
Consequences of severe fetal injury or death
A fetal death or severe injury affects many lives forever: of the parents and their children, siblings, grandparents and friends. Effects of this event on medical teams are often underestimated, in the short term there is the acute trauma of going through the difficult delivery and associated failure, followed by self-doubt and blame. In the medium term, there is the process of writing reports of the incident and having to speak to the family as well as the legal team in the hospital. Litigation invariably follows after such events leading to long-term stress. There have even been reports of doctors and midwives leaving their profession in the wake of such traumatic events.
To read what you can do to help prevent similar incidents occurring click here.
Please share your experiences and thoughts in the comments section below.
Dr R Varma (FRCOG) is the medical director of Safe Obstetric Systems and inventor of Fetal Pillow with 37 years’ experience in field of Obstetrics & Gynaecology
Severe Fetal Trauma during a Caesarean Section – Blog series – The case of baby Nixon - Coroners recommendations
In yesterday’s blog (available here) we outlined the findings of the inquest into the death of baby Nixon who died shortly after birth after suffering significant injuries including skull fractures which most likely were caused by two fingers pushing on the head to disimpact. Below we highlight the advice and recommendations made in the coroner’s report.
Hospital procedures introduced following the case:
In addition to the changes already made by the hospital the Coroner recommended:
The coroner stated;
‘I recommend that RANZCOG reconsider the policy statement C-Obs 37 Delivery of Fetus at Caesarean Section as to whether C-Obs 37 should include more information about the techniques to be adopted in the event of a presentation of a deeply impacted fetal head.’
Subsequent to the inquest report RANZCOG published new C-Obs 37 guidance in November 2016 available here.
Independent specialists also recommended:
What hospital guidelines do you follow for full dilation caesarean sections? Please share your experiences and thoughts in the comments section below.
Our medical director shares his opinion on the case here.
Severe Fetal Trauma during a Caesarean Section – Blog series – The case of baby Nixon - What happened?
In July 2017 the Coroners Court of Queensland reported findings of an inquest (click for link) into the death of Baby Nixon who died shortly after birth at 38 weeks. A Caesarean Section (CS) was performed for failure to progress. During the CS the Obstetric Registrar encountered difficulty delivering the fetal head. A midwife was asked to assist and pushed vaginally to help dis-impact the head.
The autopsy identified Nixon suffered significant injuries including skull fractures, subdural & subarachnoid haemorrhages and brain swelling. The fractures most likely occurred when the two fingers were pushing on the head via the vagina in an attempt to disimpact the head from the pelvis.
In an earlier Coroner’s report (click for link) from 2007 in another Queensland Hospital, sadly a very similar incident occurred,
“During the caesarean section it was identified that Benjamin’s head had become stuck in the pelvis and a procedure to disimpact his head was performed by the obstetrician and a midwife. At autopsy multiple skull fractures were found and severe brain injury was identified. According to the treating doctors, pathologists and independent specialist obstetricians, these injuries were very unusual, if not, unprecedented.”
These stories highlight that the situation is not unique, we are aware of many similar tragedies that have occurred in a number of hospitals throughout the UK, as highlighted in our earlier blog post: Medicolegal issues in a second stage Caesarean Section
Have you had a similar experience? How would you manage this situation? Please share your experiences and thoughts in the comments section below.
Read the advice and recommendations from the coroner’s report in the blog post here.