Thursday, April 7, 2011

A coroner's perspective on the death of a baby

The coroner, in his report released today on the intrapartum death of a baby girl at a private hospital in Queensland, was critical of both the midwife and the obstetrician involved in the labour and birth care of the mother.

The care was found to be substandard by the coroner on many levels.  The midwife was found to have altered the woman's medical records after the event; did not follow hospital protocols regarding monitoring and documentation and did not refer to an obstetrician in a timely manner. The coroner will be reporting the midwife to the Director for Public Prosecutions.

The coroner found the doctor's response to the clinical situation to be ''inadequate" and recommended that he be reported to the hospital board.  I wonder why the coroner is not reporting the doctor to the Director of Public Prosecutions too?

The coroner made 21 recommendations from the content of antenatal education and the way they are formatted to the essential nature of good collaborative care for safe care of mothers and their babies.

The president of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Dr Rupert Sherwood commented that this case highlighted the reasons why the college "has always insisted on collaborative arrangements between doctors and midwives".  He further claimed that there were two aspects of good collaborative care: adherence to protocols and timely referral. Those aspects, while very important, are not the key to what constitutes either collaboration or safe maternity care.

There is no doubt that collaborative maternity care is the safest for both mothers and babies. I have had the supreme good fortune of working collaboratively with a number of skilled, compassionate and insightful obstetricians. I have sadly, had the misfortune of working with the others too. The key to collaborative maternity care provision is the way the organisation is structured. There are two aspects to that positioning. One, that the organisation overtly recognises that birth is a normal natural event which sometimes needs expert and timely intervention. The other, fundamentally crucial aspect is the acceptance and promotion of the woman's right to self determination, evidenced by the woman being treated as an equal partner in the care planning and giving. A woman centred maternity service, where both obstetrics and midwifery AND the organisation has the woman, her wellbeing, her desires, needs & requirements at the centre of their practice leads to the leveling of hierarchies and the destruction of professional 'silos' which engenders an atmosphere of trust with optimal communication.  I found in my research that without that organisational structure creating the culture of collaboration, with warm, trusting relationships of mutual respect and woman centred practice, both doctors and midwives lose their emotional and social competence, they act stereotypically, the turf war is in full swing and mothers and their babies suffer.

The loss of this little baby Samara is a tragedy for all concerned.  The fact that with good collaborative care, this baby's death could most likely have been avoided is heart wrenchingly tragic.

This coroner's report is a must read for everyone associated with maternity services, from caregivers to managers as it contains important directions and information regarding staffing, culture and practice.


10 comments:

Lisa Barrett said...

I find it very eye opening to see that the coroner didn't conclude that, since the woman paid the Ob he should have returned to check up on her at 10.30 without the need to be summon or at least rang in to check up on HIS client..
Also even though there was a tachy the baby could have died because of the crap attempts at a ventouse and the time taken from beginning of the procedure to successfully getting the baby out. It looks like the criminal proceedings would be for the changing of the notes attempting to pervert the course of justice, rather than the midwives behaviour.

midwifethinking.com said...

Poor outcome under the care of a homebirth midwife = midwife's fault
Poor outcome under the care of a private obstetrician = midwife's fault

Perhaps if obstetricians actually provided the birth care for their clients they wouldn't have to rely on 'sub-standard' midwives to do so. They expect to rush in at the last minute to remove the baby. The 'midwives' are unable to develop their midwifery knowledge due to the lack of experience in normal birth (see stats for private) and lack of access to education (in the private sector). No wonder they miss warning signs.

I'm waiting for the call to ban private hospital births as this would be the recommendation if this had happened at home... then again just ban midwifery since we are the ones killing babies.

*sigh*

Carolyn Hastie said...

Good points you make Lisa. You are spot on Rachel - no education opportunities, few normal, unhindered births in private hospitals, the stats do 'speak' for themselves about that state of affairs. I wonder about the staffing levels too.

Sarah Stewart said...

What concerns me about that report is the emphasis on routine continuous CTG, including admission CTG. Hope we don't see back-lash making continuous CTG "compulsory" for all women.

Carolyn Hastie said...

I feel concerned with the recommendations on CTG's too Sarah. I also have concerns with the way the recommendations talk about antenatal education too. There is much to ponder in these recommendations from many perspectives.

midwifethinking.com said...

I've just read the full report through. The recommendations are mostly fair. Tachycardia and meconium is not a good combination and really a CTG should have been put on and the obstetrician called to attend. Admission CTGs and CTGs in the absence of concern are not evidence based. But in this case a CTG should have been suggested once ongoing tachy was established via doppler. I would love to see obs involved in the 'mundane' business of childbirth education - ha ha can you imagine?

Anna Simpson said...

I'm a student midwife in Melbourne and we were forwarded this coroner's report from our course coordinator. What struck me at the time was the coroner's insistence that neither midwife/midwives nor Ob had adhered to hospital policy, as if that were in fact best practice. No mention appeared to be made of what best practice was, just hospital policy. I'm sure many of you (Lisa and Rachel included) could have much to say about the gaps between individual hospital policy and best practice.

Carolyn Hastie said...

Hello Anna, thanks for your comment. Did you get to discuss the situation and the coroner's conclusions/recommendations with the other students and your tutor? That would be a vibrant conversation I'm sure. Policies and procedures seek to homogenise care, to reduce guesswork and provide a proforma. When they are followed slavishly, workers of all kinds become robotic and personal desires of the recipient of care are ignored. For maternity services, ignoring women's personal needs and desires for the birth of their babies is associated with long standing mental anguish and sub optimal attachment/mother/infant relationships. How health care translates from the sick to the well is to do a 'cookie cutter' approach which simply does not work for the well (in this case, childbearing women). Each woman should be considered and worked with individually so that what is done is most appropriate for her. Policies and procedures can be useful for health care practitioners to refer to and use to guide decisions and actions. In this situation the practitioners did neither

Carolyn Hastie said...

I should have said, in this situation, it would appear that the practitioners did neither

Kate said...

I read this report several times as I was coming to terms with my son's birth (pre-birth cutting of tight nuchal cord).

How is the intervention of immediately clamping Samara's umbilical cord factored in any of the reports and recommendations? We will tragically never know how Samara may have faired with placental transfusion and stem cell repair.

I read this paper by Judith Mercer and was struck by how similar the cases are. Why can't the coroner do a Google search at least before worrying about bloody birth plans????

http://cordclamping.info/publications/Cardiac%20asystole%20at%20birth%20article%20-%202009.pdf