[ozmidwifery] Re: uterine rupture 1998

[Marilyn Kleidon]

Hi Fiona:   I for one think this is entirely appropriate for discussion. However, I was not previously aware of the case and hope this does not cause pain or duress to anyone on the list. If this is so then we should leave it alone.   While I do not support the notion that women desiring vbac are considered high risk or obstetric care, I do believe that once a decision is made to augment and/or induce a labour then the obstetrician needs to be consulted referred to and obstetric protocols need to be followed if the decision is made to augment/induce, even though midwives are providing the one-to-one care, it is now obstetric care. I know this is not the opinion of many, many, midwives, but it is mine and I look forward to a discussion on this.  To be honest I feel the same way about epidurals, but I think because they are now so common in many birth suites the recipient women are still considered midwifery clients. Umm! In any case I would agree that a VE should have been done before the synto went up: how else could you decide if the women needed augmentation ( I have seen women labour with seemingly mild incoordinate ctx's and upon VE be 8 to 10 cm and go on to birth normally); and a ctg should have been commenced at this time at least until an adequate ctx pattern was established and midwife and doctor were confident the baby was tolerating the increase in ctx frequency and strength. Certainly a VE should have occurred before the epidural was commenced unless it was implemented almost simultaneously with the synto.   That being said, in 1998 we had become quite blasé  about vbac around the world, and women seeking vbac were starting to be subjected to induction and augmentation as if they had an unscarred uterus. The result was that several women and/or babies did die due to catastrophic uterine ruptures. Then came the unfortunate and controversial VBAC retrospective study so that  unfortunately, we have now swung too far the other way in just about everything.   marilyn ----- Original Message ----- From: Fiona & Craig Rumble To: [EMAIL PROTECTED] Sent: Sunday, October 03, 2004 6:22 PM Dear List Many of you are probably all too aware of the Galea case. I just came across it looking for info on what effect might an epidural given to the mother in labour have on the foetal heart rate? http://www.courts.sa.gov.au/courts/coroner/findings/findings_2002/galea.finding.htm   Is anyone aware of the outcome for the midwife concerned? I am surprised anyone would be willing to work in these hospitals when so many protocols go against what so many of us believe about normal labour. I include some of the findings for those who are interested (scared me!). Does anyone think the midwife acted inappropriately? Tell me to drop the subject if this is not the forum for such a discussion. Thanks Fiona 4.6. Decision to use Syntocinon/assessment of progress of labour As I stated earlier, Professor Pepperell was critical of the fact that Syntocinon was infused without checking first whether Mrs Galea’s labour had progressed, and to what extent, by examining the cervix. He said: ‘Assessment of progress in labour. I am most critical that there was no assessment of progress in labour performed between the time a pelvic examination was done at 0100 hours, and the time of collapse at about 0930 hours. The usual rules in Obstetric practice are that pelvic examination should be performed approximately 4 hourly in patients who are having a trial of scar, to ensure adequate progress is being achieved and the trial of scar is then allowed to continue, and certainly it should also have been performed prior to the use of the epidural anaesthetic at 0750 hours, and again when this was topped up at 0910 hours. It is just not possible to know what is going on with the cervix without the performance of a pelvic examination, and had the cervix already been fully dilated when the epidural was inserted, it may well have been that delivery could have been effected at that stage without much difficulty. It will never be known whether the cervix was fully dilated at that time, and whether delivery was possible, but certainly failure to assess progress of labour during an 8 hour period in someone with a previous caesarean section, who is having labour stimulated, and who has an epidural anaesthesia, is not adequate care.’ (Exhibit C19a, p7) 4.7. Professor Pepperell expanded upon this in oral evidence, given via video-link with Melbourne, as follows: ‘Q: Are you able to say in Mrs Galea's case what might have been detected if pelvic examination had been done either at the four hourly interview intervals suggested by you or alternatively at the time of the administration of the epidural and/or the Syntocinon whether the outcome would have been any different in this case. A: I can’t say because we don’t know what those findings were. If that indicated that the cervix was still only minimally dilated then what was done was appropriate. If however they had shown that the cervix was eight or nine centimetres dilated then Syntocinon might not have been necessary at all and that action may well have been taken to the earlier stage prior to the uterine rupture which was presumably the cause of the amniotic fluid embolism’ (T146-147) 4.8. Dr Jodie Dodd is now a Consultant, but at the time was the Obstetric Registrar on duty, and was the Registrar with whom Midwife James conferred at 6:00am on 30 December 1998. Dr Dodd acknowledged that it was standard procedure to perform a vaginal examination before deciding to augment labour with Syntocinon (T164). 4.9. Dr Dodd was unable to recall the details of the conversation with Ms James, which is not surprising given the lapse of time since then. She said that she would normally ensure that a vaginal examination had been done, either by the midwife, the Intern, or personally (T164). She was sure that if it had been brought to her attention she would have done so, but could not say that it was, or was not (T173). It seems that the most likely explanation of her failure to arrange for a vaginal examination was that she overlooked it, or assumed that the midwife had done it (T168). 4.10. Ms James, on the other hand, asserted that she had no trouble recalling the incident. She said that she would not perform a vaginal examination unless directed to do so by a Senior Midwife or Medical Officer (T100). She also said that she was sure that she drew the fact that Mrs Galea had not had a vaginal examination to Dr Dodd’s attention, although she could not specifically recall the conversation (T113). 4.11. I have serious doubts about Ms James’ veracity on this issue. She has been a Registered Midwife since 1973, having trained in the United Kingdom, and had been at FMC since 1996. 4.12. It is my firm impression, after hearing both witnesses, that if the matter had been drawn to her attention, Dr Dodd would have either performed a vaginal examination herself, or asked Ms James or Dr Magno to do it. I do not believe Ms James when she alleges that she drew the matter to Dr Dodd’s attention. I find that the topic was not raised by either person, each perhaps assuming that the other had attended to it.