RECORD OF INVESTIGATION INTO DEATH
Coroners Act 1995
Coroners Regulations 1996
These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995
I, Rod Chandler, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
(a) Baby W died on 18 June 2007.
(b) Baby W was born at the Royal Hobart Hospital (‘the RHH’) on 9 June 2007 and at the time of her death was 9 days old.
(c) Baby W died as a result of hypoxic brain damage due to birth asphyxia.
Circumstances Surrounding the Death
In mid to late December 2006 Ms S and her partner Mr W moved to Tasmania from South Australia. At this time Ms S was 3 1/2 months pregnant. She and Mr W favoured a home birth and they were introduced by friends to Ms Terry Stockdale, a midwife.
Ms Stockdale completed her general nursing training in Queensland in 1972. She has been a registered nurse in Tasmania since 1975. Up to 2007 she had worked in a casual capacity as a nurse at the RHH for about 20 years. In 1980 she also began working as a midwife for home births and subsequently has assisted with 16 to 20 home births each year.
Ms S first saw Ms Stockdale in January 2007. Thereafter she consulted her monthly. The pregnancy proceeded uneventfully. On Ms Stockdale’s advice Ms S informed the RHH of her intention to proceed with a home birth. On 8 June Ms S met with Ms Stockdale. At this time the 40 week gestation period had passed by about 13 days. Ms Stockdale advised that if labour did not begin that day then Ms S should attend at the RHH the following day for an examination including a cardiotocograph. (‘CTG’) However, signs of labour began after a cervical “sweep” by Ms Stockdale and by 9.30 that evening labour was well established. At 10.30pm. Ms Stockdale was called and she arrived at Ms S’s home 5 minutes later.
Events Prior to Transfer to the RHH
When she arrived at Ms S’s home Ms Stockdale observed that Ms S was experiencing contractions every 2 to 3 minutes which lasted about 45 seconds and which she described as of “moderate strength.” The maternal heart rate was recorded at 90 beats per minute (‘bpm’) and the foetal heart rate (‘FHR’) was 160 bpm.
Ms Stockdale’s history of events over the following four hours is recorded in these terms:
“At midnight the maternal pulse was 76 bpm and the fetal heart rate was 140. Strong contractions were every 2-3 minutes lasting 50 – 60 seconds, Ms S was coping well.
Ms S was complaining of anal pressure. Voided, birthing pool nearly ready.
00:30 hrs (9/6/2007) FH 140, contractions every 2-3 minutes, lasting 50 seconds in the pool
01:00 Ms S complained of backache. FH 150, contractions every 2-3 minutes, 50 seconds, strong.
01:35 UTV FH 144, no dips, contractions every 2-3 minutes, 50 seconds strong, 02:00 UTV FH 140, no dips, contractions every 2-3 minutes, 50-90 seconds strong.
02:40 UTV FH 130, no dips, contractions every 2-3 minutes, 90 seconds, occasional slight involuntary pushes.”
At 3.15am on 9 June Ms Stockdale carried out a cervical examination. She noted the cervix anterior lip to be very small with bulging membranes which broke on contact. She records; “…There was about half a cup of meconium/liquor, with some further trickles of fluid following my examination.” Ms Stockdale then attempted unsuccessfully to push the lip of the cervix over the baby’s head. The FHR was recorded at 130. It was also noted that the “pushing urge was getting progressively stronger.”
Another cervical examination was carried out at 4.45am By this time “the cervix was much more swollen and (Ms S) was pushing strongly” and “meconium 2” was noted. Ms Stockdale decided that Ms S should be taken to the RHH and she ‘phoned hospital staff to alert them to Ms S’s imminent arrival. They then immediately drove to the hospital arriving at about 5.10am
Events at the RHH
Ms S was initially attended at the RHH by Midwife, Ms Nancy Westcott. Shortly afterwards Obstetrics and Gynaecology Resident, Dr Irena Nikakis arrived. Ms Stockdale also remained present and reported the history of the labour to Dr Nikakis. CTG monitoring was commenced at this time and showed the FHR to be “reasonably variable.”
At about 6.00am an epidural was inserted and Ms S received analgesia for comfort. By 6.30am a gradual reduction of FHR was noted with a recording of 135 to 140 bpm. This was brought to Dr Nikakis’ attention and she called Obstetrics and Gynaecology Registrar, Dr Chaminda Amarasekara who then attended to review Ms S. By this time Ms S was fully dilated and he directed Ms S to "start pushing.” Dr Amarasekara then left to attend to other patients.
The variability in the FHR did not improve and at 7.10am Dr Nikakis was requested by nursing staff to review the CTG trace but it is not clear whether this occurred. However, someone summoned Dr Amarasekara and he attended at about 7.20am. He carried out a vaginal examination and noted that the “foetal head was very high in the pelvis.” He asked Ms Stockdale to also do a vaginal examination during which she was able to rotate the foetal head from a posterior to an anterior position.
At about 7.15am Ms Westcott had left the delivery room to attend to the nursing shift changeover. Shortly afterwards Ms Stockdale also left the room and complained to Ms Westcott that “the foetal heart’s on 80 and they aren’t doing anything.” By about 7.40am Ms Westcott had returned to the delivery room. Both Drs Amarasekara and Nikakis were still present. At this time she observed; “The CTG showed absent variability and FHR was dipping to 70 and recovering only to ~90-100…” Both Ms Westcott and Ms Stockdale told Dr Amarasekara that the baby needed to be delivered. Ms Stockdale suggested a caesarean section. However, Dr Amarasekara told them both that he was waiting the morning arrival of a consultant. That morning the on-duty consultant was Staff Specialist, Dr Steve Raymond.
Midwife, Ms Christine Browning began work that morning after changeover at 7.30. She was also concerned by the delay in delivering Ms S’s baby. She asked Dr Nikakis whether she could call Dr Raymond and received a nodded assent. Dr Raymond was then called at 7.50am. He arrived at the hospital 10 minutes later.
Dr Raymond reports upon his involvement and Baby W’s delivery in these terms:
“Examination of Mrs. S showed that she was fully dilated and that the fetal head was in the pelvis and at a level that was safe for a vaginal delivery. The position was occipito-anterior. In order to expedite the delivery I applied a pair of Kielland's obstetric forceps and was able, with a firm pull, to deliver the baby, after performing an episiotomy. The time of birth is recorded as 0814.
The baby weighed 3045 grams and was assessed as asphyxiated with a 1 minute Apgar score of 1. The baby went to the paediatricians for neonatal care.”
In the Neonatal Intensive Care Unit Baby W was categorised as having Grade 3 (severe) hypoxic ischaemic encephalopathy. Scans showed that she had suffered a catastrophic insult to her brain as well as a spinal injury. Her prognosis was extremely poor. Following meetings with family it was decided that supportive treatment would be withdrawn and palliative care only provided. Baby W’s parents wished to provide this care at home and arrangements were made to facilitate this. Baby W died at home on 18 June 2007.
The Coronial Investigation
State Forensic Pathologist, Dr Christopher Lawrence undertook a post-mortem examination involving an external examination with review of the medical records. An autopsy was not considered necessary by Dr Lawrence to establish the cause of death. In Dr Lawrence’s view Baby W died as a result of hypoxic brain damage due to birth asphyxia. It was his further view that medullo-cervical trauma was a factor contributing to the death. Of this specific trauma Dr Lawrence commented;
“…the likely cause of this was damage during delivery. This could relate to the forceps extraction, however, there is no clear external sign of trauma. According to clinical opinion the infant had already sustained severe hypoxic damage already and had poor muscle tone, and the poor muscle tone may have contributed to the neck injury.”
Consultant Medical Opinion
Associate Professor Ross Haslam is a Specialist Neonatologist and is the current head of Neonatal Medicine at the Women’s and Children’s Hospital in Adelaide. He has provided a report for the assistance of the coroner. Upon the cause of death Associate Professor Haslam expresses this opinion;
“I have no doubt this infant died as a result of extensive cerebral infarction most likely as a result of a profound hypoxic ischaemic brain insult suffered in labour. Whilst there was also clear MRI indications of damage to the medullo-cervical area of the spine at the base of the brain, I do not believe this was a significant contributing factor to the cause of death.”
Of Ms S’s clinical history Associate Professor Haslam makes the following observations which he describes as “significant.”
• “Ms was a known carrier of Group B Streptococcus [GBS] who had not had [refused] prophylactic antibiotics in labour. The value of antibiotic prophylaxis as a prevention of early onset neonatal sepsis is well proven [ref. 4]. Furthermore, the progress of her labour and the assessment of [deteriorating] fetal status does constitute a "red flag" for a Neonatologist — indeed for an obstetrician — and has to be considered as a factor for expediting delivery. Of course, baby W was subsequently shown not to be suffering from a GBS infection but nonetheless this was not known during labour.
• Ms S was in her 42nd week of pregnancy. An ultrasound done around 25 weeks of gestation made her 41 weeks and 6 days when labour occurred although her historical dates made her just a little less than this. That is, she was by definition post mature and as such there was an increased risk for fetal hypoxia in labour (ref. 5). Given this association between post maturity and intrapartum fetal hypoxia, it is appropriate for clinical carers to have a lower threshold for intervention given any non-reassuring signs of fetal status.
• Meconium staining of the liquor is a sign of fetal compromise. Whilst it is a more frequent occurrence in the absence of any hypoxia in postmaturity [ref. 6] it nonetheless remains a cause for concern for fetal status. I am not familiar with the classification of meconium staining that the clinicians in this case used ["Meconium I, 2 and 3"] but take it to reflect increasing degrees/thickness of meconium. The greater the amount and the increasing amount of meconium present in the liquor corresponds to an increasing likelihood of significant fetal compromise.
• The CTG recording of the fetal heart rate seems to have started to indicate concerns for the fetal status some time after 0630 hours on the day of delivery when several staff [senior midwives plus obstetric resident and registrar] report decreased variability. The interpretation of the CTG and the appropriate clinical responses, are best made by a currently practising tertiary care obstetrician. However, it is evident all carers were [correctly] cognisant of baby W's evolving compromised state.
• In a high-risk labour (post maturity and evolving non-reassuring fetal status signs and symptoms) it is important for the most senior available obstetric opinion to be obtained as early as possible. Again an independent obstetric opinion would be valuable in identifiying the point in time that the referral was indicated but it does seem that this was sometime soon after 0700 hours. The reports from the various carers involved, particularly the O&G Registrar and Resident, leave me a little unclear as to precisely when and who called the Senior Consultant, Dr Raymond. However, midwifes Browning and Westcott state they at least suggested at 0730 this was appropriate and then Dr Raymond indicates he did not actually receive a call until 0750. It is concerning that there appears to be no medical [obstetric] notes in Ms S's case record describing assessment of her condition and management plans — either contemporaneous or retrospective.”
• “The hypoxia and ischaemia to which this baby was subjected occurred in an increasing degree over probably some hours. The signs of fetal status are simply not precise enough to identify a particular point in time of significant injury. Insults of a mild degree and even a severe insult of a very short duration are variously recoverable by the fetus without any permanent cerebral effect.”
In Associate Professor Haslam’s opinion it is not possible to identify a precise or even approximate time when Baby W sustained her significant brain injury. However, he makes these relevant observations –
“I feel that the evidence is clear this baby’s insult occurred during labour and so if caesarean section occurred before labour even began then brain damage could have been averted. Clearly however this was not reasonable. However, given the degree of risk associated with post maturity, the significance of meconium staining of the liquor and the rate of progress of the labour, the point in time where sustained absence of foetal heart rate variability was observed, probably identifies the time where the most senior obstetric opinion available needs to be obtained for consideration of the best mode of expeditious delivery. Thus it is likely that a caesarean section delivery soon after 07:00 may well have averted significant brain injury – certainly before the profound foetal bradycardia occurred… It seems the time for active intervention if possible was sometime between 07:10 and 07:40… It is likely that had delivery occurred in this time a significant degree – although not necessarily total reduction – of brain injury might well have been avoided, but this could not be said with absolute certainty.”
A response of the RHH to Associate Professor Haslam’s opinions was sought. It was provided by Dr Raymond. His report includes these points:
- “To have been delivered without hypoxia the delivery would have had to have been effected before the CTG changes indicating hypoxia. In this case that would have been before 0710.
- In my view, this patient was ready for an assisted delivery, vaginally or abdominally, well before that time. The presence of an ‘Anterior lip of cervix’ is, practically speaking, not a contraindication to assisted delivery, as it is merely the result of a malrotation of the head and usually due to a persistent occipito-posterior position.
- To wait for the persistent lip to disappear is simply an unnecessary delay as rotational forceps or Ventouse could, and probably should, have been carried out soon after her admission at 5.30am, or, at the latest, as soon as the epidural was effective at 0650.
- Post-maturity increases complications in labour and a prudent midwife in independent practice should have a low threshold for referral when that is present.
- Meconium staining of the liquor is regarded as an indication for continuous foetal heart monitoring and finding this should have been followed by immediate referral to hospital for that to take place.
- The specialist should have been notified of the abnormality on the CTG at 0720.
- The transfer to hospital should have been done earlier. As stated above she was deliverable at any time after the anterior lip was discovered and was effectively in the second stage from around 0330. A second stage of four hours is too long even for primigravida.”
Serious Incident Panel Review
A Serious Incident Panel was commissioned by the RHH to investigate the circumstances of Baby W’s death. It led to these recommendations being made:
1. Regular case discussions to be conducted at Perinatal Morbidity and Mortality meetings. The Obstetric Department to undertake a review and discussion of unusual case presentations with the view of increasing awareness of medical staff to differential diagnoses and possible earlier interventions.
2. The Obstetric Department to develop a process which informs the responsible consultant of presentations where thickened meconium is observed.
3. The Obstetric Department to develop a protocol for the use of scalp electrodes where CTG traces are inadequate.
4. The Obstetric Department to develop a process which notifies the responsible consultant of CTG traces showing persistent foetal tachycardia with decelerations.
5. The Obstetric Department to develop a process which demonstrates an improvement in medical documentation in the medical record.
Associate Professor Haslam makes these comments upon the recommendations:
“…Recommendations one and four address the issue of timing of referral or notification to the responsible senior obstetrician which could have, and perhaps should have, been earlier in this case. Whilst the recommendations do not deal with the details of the necessary processes highlighted, such details would be expected of the Obstetric service. Given that such processes should have already been in place because they are standard especially in teaching hospitals with junior staff – indeed I would be surprised if in fact they were not already in place but maybe only informally – perhaps there could be a further recommendation that new formal processes should be presented for assessment to the Panel.
Processes and protocols need to be understood by all staff thus formal orientation and instruction sessions need to be scheduled for all new staff, particularly when they have come from other hospitals and cultures. Thus such a recommendation would be useful.”
The RHH reports that as a consequence of the Serious Incident Panel’s recommendations it has developed two specific policies, namely Management of Intrapartum Fetal Heart Rate Abnormalities Guidelines and Care of Normal (Low Risk) Labour within the RHH Maternity Unit. Of the latter, Dr Raymond highlights these features:
• “DELAY IN THE SECOND STAGE OF LABOUR:
- If the established second stage lasts more than 1.5 hours, the RMO is to be notified if birth is not imminent. Birth should take place within 3 hours of the start of the established second stage in the presence of epidural anaesthesia, or 2 hours in the absence of epidural anaesthesia.
• ASSESSMENT AND MANAGEMENT
- Hourly blood pressure and pulse.
- Continued 4 hourly temperatures.
- A vaginal examination should be offered hourly in the established second stage, or in response to the woman's wishes (after abdominal palpation and assessment of vaginal loss).
- Half-hourly documentation of the frequency of contractions.
- Fluid input/output:
- Encourage sips of oral fluids.
- Documentation of frequency of bladder emptying.
- Where there is a palpable bladder and the woman is unable to void, consider urinary catheterisation.
- Ongoing consideration of the woman's emotional and psychological needs.
- At the beginning and during the second stage of labour, communication between the woman and carer should include discussion about how she is feeling, what she feels she needs and what would help.
- If there are signs the woman is excessively distressed and feels she is losing control, measures should be taken to assist her. These may include reassurance, change of position or analgesia.
- Intermittent auscultation of the fetal heart should occur after every contraction and/or every 5 minutes and should be recorded. (The maternal pulse should be checked, if there is suspected fetal bradycardia).
- Auscultation should be by hand held Doppler with signal on speaker after a contraction for a minimum of 60 seconds every 5 minutes in the absence of active pushing, and after each contraction with active pushing.
- Liquor - 1/2 hourly assessment of liquor colour.
• ASSESSING THE PROGRESS OF THE SECOND STAGE OF LABOUR:
- The midwife is responsible for monitoring the progress of second stage. This ensures early identification of problems and action taken to ensure appropriate care is provided.
- The midwife will assess for:
- The presence of regular, effective, expulsive uterine contractions, and descent of the fetal head.
- Progress can be determined with increasing rotation, flexion and descent of the fetal head. Assessment (including abdominal palpation and vaginal examination and verbal pain score) should be recommended to women after an hour of pushing in nulliparous women, and half an hour of pushing in parous women. In the absence of progress, a referral to the Registrar should be considered. Also, consider the woman's hydration, position and need for pain relief. Support and sensitive encouragement are particularly important in these circumstances." (NICE 2006).”
Findings, Recommendations & Comments
I am satisfied and find that Baby W died as a result of hypoxic brain damage due to birth asphyxia. Whilst I accept that Baby W did, in all likelihood, sustain medullo-cervical trauma during the birthing process I am not satisfied that this injury was a factor which made a significant contribution to her death.
Ms S was post-term being in the 42nd week of her pregnancy when her labour began. It was her first child. She was also a known carrier of Group B Streptococcus. These factors, in my view, made it necessary for Ms Stockdale to have been particularly vigilant in her monitoring of Ms S’s labour and for her to have been ready to refer Ms S to the RHH as soon as any sign of potential fetal compromise presented. I accept that meconium staining is a sign of fetal compromise. I accept too the opinion of Dr Raymond that it’s occurrence requires the prompt use of fetal heart monitoring. It follows, in my view, that Ms Stockdale should have, immediately following the first meconium staining, referred Ms S to the RHH. This would have been shortly after 3.15am. Ms S was not in fact taken to the hospital until after the second meconium staining occurring at 4.45am. However, the evidence shows that the FHR recordings were not a cause for any alarm when Ms S arrived at the RHH and this remained so until about 6.30am. In these circumstances I am satisfied that any delay on Ms Stockdale’s part in delivering Ms S to the RHH was not a factor which caused or contributed to the hypoxia and Baby W’s subsequent death.
Dr Amaresekara first attended Ms S shortly after 6.30am. By this time there had been the first and second meconium staining’s. Further Ms S had been in second stage labour for 3 hours. Critically, the FHR was by this time indicating a decreased variability, a factor which had caused attending staff concern and prompted them to call for a Registrar’s advice. These factors, when combined with the fact that Ms S was post-term and was a Group B Streptococcus carrier should have prompted Dr Amaresekara to have delivered Baby W immediately or at least when the epidural became effective. Alternatively, Dr Amaresekara should at this time have immediately called for the consultant’s attendance.
Both Associate Professor Haslam and Dr Raymond are of the opinion, which I accept, that if Baby W had been delivered by about 7.00am then any significant brain injury would have been avoided and as a result her life would have been saved. This outcome would, in all likelihood, have been achieved if Dr Amaresekara had responded as I have suggested at the time of his 6.30am attendance upon Ms S.
I acknowledge that the RHH has investigated the circumstances surrounding this death and taken some steps to address some identified shortcomings. However, it is my recommendation that those steps taken by the hospital be supplemented by a requirement that it adopt a policy requiring each woman who presents, following a failed home delivery, to be immediately reviewed by a consultant obstetrician upon arrival at the hospital. It is hoped that these steps together will go some way to reducing the likelihood of a similar preventable death occurring in the future.
I conclude by conveying my sincere condolences to Baby W’s family.
DATED: 9 June 2012 at Hobart in the State of Tasmania.