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?


Permissions obtained for this story


One reason why healthcare is so $$$$$$ in Australia.

Have you ever looked at a medical device and thought why is this so expensive?

Firstly, there is the price hurdle to get an item to Australia.

For example, the DermLite II Pro HR by 3Gen will cost $US895 from them; to buy the same in Australia will cost you $AU 1529 (including GST) . Given the current exchange rate that amounts to around $500 to get it into to Australia. I would have to spend three times that to actually get to the US to buy one off the shelf there. It seems someone is making a lot of money.

Unfortunately 3Gen wont sell ship to Australia but by searching eBay you may be able to find a US based seller who may and at a little bit less than the 3Gen price.


Then, there is definition of medical equipment which seems to be an invitation to add a couple of zero’s to the price

I use a LED H7 Lenserhead torch to do minor surgery with. I like the extra light and it does a great job. Nice whitelight. Just don’t look the patient in the eye with it on. It cost me something like $60. At a medical conference  I went to recently, a company rep tried to persuade me to consider their “medical” product. Now admittedly it did produce a nice light, but it also cost $1200. I remain content with my alternative.

A tiny grommet (sorry, myringotomy tube) placed in my young fella’s ear drum cost $150! Apparently, I can buy a fluoroplastic myringotomy tube for only $US68 for a box of 10! Mind you I was quoted $90 UPS shipping to get them here. But me and 8 of my friends would have been way ahead.


So why it is that we must pay so much extra for medical and surgical equipment?

I can appreciate that we need to use a higher grade of equipment which needs to be tested to greater tolerances. Afterall, industrial grade silicone proved to be the undoing of Poly Implant Prosthese.

I am not advocating buying screws from Bunnings, although I was tempted when I saw how much the Herbert screw in my scaphoid cost me, but I think that it is reasonable that the Hon Dutton and Hockey cast their eyes wider at  saving healthcare dollars than hit Australians with the proposed co-payment.

T’is the season to be sneezing, coughing and feeling absolutely yuk………

Its okay you’re not really dying, although  you feel it’s about to happen……. (in my mind I’m sing this to a famous Christmas carol)

Sorry to rehash a previous post but it is happening again.

I still think it is irresponsible to encourage someone who has an infectious illness like influenza to take a tablet so they can feel better. Go on Audrey, take Jen a cake to infect her birthday party guests…..some friend you are! Go Audrey. Go Johnson & Johnson Pacific Pty Limited.

Reckitt Benckiser (Australia) Pty Limited the makers of Nurofen Cold and Flu also puts profits ahead of common sense and evidence in their marketing.

Pfizer Consumer Healthcare has at least updated their Dimetapp web ad, no more encouraging sharing your virus in the local public pool. This can be still seen on Youtube.

Most people with a cold or influenza recover with rest, drinking plenty of fluids and use of paracetamol for the relief of pain and fever.

As reported by NPS recent systematic reviews and meta-analysis of randomised controlled trials suggest oral zinc may reduce the duration of a cold by about 1 day (24 hrs….yah) if administered within 24 hours of symptom onset in otherwise healthy adults and children.

There are specific prescription-only drugs that may be useful in influenza. These are not antibiotics; antibiotics are not useful for treating viral illnesses like influenza.

South Australia’s Health Department advises the best way to slow down the spread of influenza is to get vaccinated.  The Influenza Management Guideline for Emergency Departments and General Practice suggests isolation and face masks whilst being assessed. Furthermore, if the patient doesn’t require admission to hospital encourage the patient to stay at home and practice good hand hygiene and cough etiquette. If going outside house, strongly encourage the patient to keep at least 1 metre away from other people and to use cough etiquette. Patting kids on the head in the playground is neither.

The NSW Health Department specifically recommends symptomatic people should not attend school, child care, work or public gatherings. Is there any clinical evidence that any of these over the counter well marketed do any good? Has Reckitt Benckiser, Pfizer, Johnson &  Johnson or any number of Pharmaceutical companies conducted and published randomised clinical trials proving benefit of these products? It’s not as if there is a lack of suitable subjects. In a similar vein, Cochrane has shown there is no good evidence for or against the effectiveness of OTC medicines in acute cough. Studies often showed conflicting results with uncertainty regarding clinical relevance. And if these products don’t do any good can they do harm? Well yes and particularly in children. Sarfstein et al argue in the NEJM (Over the Counter but No Longer under the Radar) that there is no evidence of effectiveness particularly in children and documented harm. Cardiac arrhythmias, hallucinations, convulsions, altered consciousness and encephalopathy are some of the severe side effects. In the US, an FDA review implicated symptomatic cold and flu treatments in 123 deaths of children under six years of age. In Australia the TGA suggested in November 2012 that children under six should not be given these medications.

So my advise is to stay at home, call in sick to work or school, don’t spread the virus around, wash your hands, keep up fluids (not beer), eat some oranges (or take vitamin C for what its worth), try zinc and wait for you immune system to get you back to good health. You can try to control symptoms with paracetamol for pain, decongestant for nasal symptoms, lozenges for a sore throat.  Most symptoms apart from a cough are gone by a week.

Oh and if you smoke its a great time to given up something that is making you feel even worse!!

And lastly think about a influenza vaccination.

Save your co-payment for when you are really sick.


Come to Kangaroo Island

Interested in a rural lifestyle change?

Do you have valuable skills that can used in a remote area?

Consider Kangaroo Island Medical Clinic.

Contact or 08 8553 2880 for more details

Pension on fast track to 70

The Weekend Australian headlines suggest that by 2029 the government will have crept the retirement age to 70 years. I read that both Liberal and Labor treasurers believe pushing the retirement age will improve the sustainability of the Australian pension system in the face of improvements in life expectancy.

That’s fair enough for me, because as long as I am not shuffling around a nursing home, eating mash everything, wearing a nappy and painting the walls my poo. I intend to meaningfully continue to contribute to society with gainful employment

A few weeks ago, I went for a bike ride and had to push myself to keep up with the pack leader, who is just one year short of the current retirement age. I expect he will be going strong at 70, 80 and maybe 90.

Then I thought about some of the older than me people I have seen in clinic in the last week, some will probably reached the end of their telomeres by 65 let alone 70.

But how does Treasury’s theory account for those more weathered by the morbidity of aging?

I fear that in years to come I will be filling in even more TDRs to support disability pension claims for those whose health failure predates 70.

Just another symptoms of a society arbitrarily demarcated by chronology and gender rather more selective criteria. Like start school at 5, driving at 17…….

I wonder what would happen if I were to suggest  that women should retire latter?


life chartlife expectancy



You may have read in the same article the Joe Hockey quote that one in every three children born today will live to 100. I’m not sure where he gets his statistics from but from looking at ABS data it is closer t 1% rather than 33%



Triple 000 here, will that be paramedic or taxi?

This news items sounds like a victory for common sense.

Paramedics given power to send patients to GPs in NSW crackdown trial

People on the New South Wales central coast calling an ambulance for trivial matters such as tooth aches will be taken to their local doctor instead of hospital in a new trial.  The trial will give paramedics the power to decide whether a case warrants a hospital visit or a trip to a general practitioner (GP). The move has come out of recommendations from an Auditor-General’s report and is designed to relieve pressure on emergency departments.

Ambulance Service deputy commissioner Mike Willis says it will mean less time wasted on more trivial ailments.

“Sadly sometimes people call paramedics to their home for trivial things such as sore teeth, or in fact they’ve run out of their medication. That’s not what paramedics are for, that’s what taxis are for. This trial is designed to take those patients who are not life threatening and have low acuity illnesses direct to their GP where they can be assessed.”

It seems to me that the trial is still going to have paramedic crews acting as taxis. Instead of taking someone to an ED they are being taken to a GP. Maybe the ambulance service could just hand out taxi vouchers which can just be used to attend a health practitioner? Be it doctor, dentist or pharmacist…… iridologist, nutritionist, chiropracter??

I do see a problem for the paramedic crew as to which GP the patient may be taken to. I’m certain AHPRA would take a very dim view of any GP-paramedic collusion.

There seems to be a difference in what is an ambulance from state to state. A 2010 paper by Eburn and Bendall (The provision of Ambulance Services in Australia: a legal argument for the national registration of paramedics. Australasian Journal of Paramedicine, 2010; 8(4)) gives some background on the situation. Another example of how the laws of each Australian state differ (for no good reason) and can create confusion!