Repost – The art of delivery

I would like to update this post with a link to a Coroner’s report from the 8th July 2014 concerning the death of a newborn. This occurred in the setting of a woman who previously had a uterine perforation as a result of a D&C, undergoing a prostaglandin induction. She developed hyperstimulation which caused uterine rupture at the site of perforation, and despite an emergency Cesarean section her baby died.

The Coroner’s report can be found at the SA Courts website. The report does go for 47 pages.

The report follows arguments as to whether the perforation was a contraindication to an induction of labour with prostaglandin and whether the woman should have been offered a cesarean section for delivery of her baby. In addition, the Coroner raises the case of Roger v Whitaker to discuss material risk. 

Exactly how much should we tell our patients – as a reminder……..

“…a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position if warned of the risk, would be likely to attach significance to it, or if the medical practitioner is or should  reasonably be aware that the particular patient, if warned of the risk, would be likely  to attach significance to it “

This tragic case reported by the Coroner also highlights how quickly a labour can go wrong when something bad like a uterine rupture happens. Prostaglandins in a 8 pm, 9:20 hyperstimulation (albiet recognised only in hindsight), 10:20 fetal tachycardia, 10:40 fetal bradycardia, 11:30 Cesarean section to delivery a baby who was resuscitated but ultimately died of hypoxic ischaemic encephalopathy 4 days later. The mother required a subtotal hysterectomy.

The Coroner also noted the difference in contraindications listed in the product information for prostaglandin gel and oxytocin which may well have been required for the remainder of this woman’s induction.

Back to my original post which did ended with a healthy mother and baby

Recently, I helped care for a young woman whose patience has finally been strained by her pregnancy. She had endured the previous 39 weeks pretty well I thought but with three nights of sleep deprivation because of irregular contraction she asked for an induction. I do wonder how well young Mums will cope with a new baby when they ask for an induction in this not uncommon situations. I put out of my mind the nearly 12 years of my own sleep deprivation due to on-call and then toddlers and thought through what I could offer her.

I know that the NICE Guidelines suggest that spontaneous labour is more likely after sweeping the membranes.

My own experience suggests the outcome can be better judged on a toss of a coin. More sophisticated studies have suggested better odd in favour of membrane sweeping. Cochrane suggests the NNT is about eight, that is if you can find eight women to put up with the discomfit.

I know a variety of other methods proposed.

  • I had seen one poor young woman disabled with terrible diarrhoea deliver a flat baby because she thought a bottle of castor oil would do the trick.
  • I usually use a list of corrugated roads, long walks, hot curries, hot sex, raspberry leaf tea. Which I guess reflects where I have worked after leaving the comfort of teaching hospital obstetrics. Some suggestions go down better than others.
  • Some midwives adds nipple stimulation to the list, but my opinion is the babe’s going to traumatise the nipples enough in the first few days so I suggest keeping that in reserve.

With consent, I examined my patient and gave her a bishop score of 5 then performed a stretch and sweep. There was an expected grimace. But according to Cochrane I had done my bit to reduces the chance of my patient still being pregnant at 42 weeks by 0.53.

Two days later and still incubating and with little restful sleeping, my patient asked whether she could really have an induction? So we discussed a plan and settled on dinoprostone gel then an amiotomy if favourable the next morning.

I explained that an induction with prostaglandin was safe and unlikely to increase the risk of a caesarean section beyond what she would face should she go into labour on her own.

In my experience, if a course of prostaglandins failed then we could try again after a good night’s sleep with the same or a mechanical method or decide on a caesarean. I have never used the mechanical alternatives a Foleys or Cook catheter as a form of induction.

That night her bishop score was now five (her cervix being a little easier to find), she had been having only irregular contractions; had the strip and stretch has done anything? We proceeded with our planned dinoprostone gel and amniotomy in next morning.

Within 30 minutes of inserting dinoprostone gel, she had started to be more uncomfortable with contractions. And then she has a contraction that continued beyond a minute. She looked more uncomfortable and worried. “Is this what labour is going to be”, she asked? She was still on the cardiotocograph. I watched the tocograph line continue its plateau, expecting any minute it would begin to return to normal. At two minutes the tocograph had no intention of returning to baseline and the uterus was still contracting. The fetal heart rate was still fine at that stage. Best find something to settle this contraction down. Instinctively, I thought lets get the gel out. So armed with speculum, saline and gauze swabs. But this made little difference. I have since been told the prostglandin is absorbed quite quickly and I had wasted my time.

We turned her onto her left side and started oxygen. As the midwife went for the IV trolley, I grabbed a bottle of Nitrolingual. Two sprays under the tongue didn’t seem to make any difference. The contraction distracted her even from the GTN headache I explained she may get. The patient now had a startled kangaroo look in her eye

I asked the midwife to get some salbutamol ready, it is fiddly to prepare. 0.25ml of 5mg/5ml solution in a 1ml syringe, dilute to 10ml with normal saline in a 10ml syringe then give a 50mcg bolus (2ml) IV.

As I gained IV access, pregnant women always seem easy to cannulate, I heard the baby’s heart rate drop below 100. By the time the first dose of salbutamol went in the heart rate was 80. I waited a minute then gave another. With my hand on her belly I’m sure the uterus felt less tense; the tocograph agreed and started to return to baseline. The baby’s heart rate picked up, and quickly rose to 180. There seemed enough variability, however.

Things seemed to quite stable now the contraction had settled. I had salbutamol at hand. Mum looked more settled, her heart rate was normal. The CTG revealed were no further decelerations, although I was looking at a persisting reflex tachycardia likely due to the anoxia caused by the contraction or the salbutamol. It was time to phone a friend. The on-call tertiary hospital consultant was helpful. She reinforced what I had done with the exception of the vaginal washout was fine. She recommended waiting an hour and if the CTG became more normal then to attempt the amniotomy. If not, then a Cesarean was indicated.

Over the next hour the CTG settled to normality and I did the amniotomy. The fluid was clear.

My patient finally went onto have a normal healthy little girl. Although, it was by Cesarean section after slow progress beyond 6cm and further decelerations with an epidural in place. Baby was delivered deflexed OP, cried at delivery with cord pH 7.21. She is thriving and Mum is managing very well.

The tertiary hospital consultant also suggested that Cervidil was probably more useful than the gel since the Cervidil could be removed in hyperstimulation. I had heard about the prostaglandin on a string when I did my DRANZCOG training, but the hospital did not adopt it because of the cost compared to the gel. This has been my first experience with this side effect of gel after being involved in about 500 inductions over the last 8 years. Was this enough reason to change my practice? Should I give up on dinoprostone gel even though I have never had a problem before? Or should I seek comfort that if similar happened the Cervidil string will allow easy removal? Or should I fiddle with pushing a Foleys or Cooks catheter into a cervix?

 

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