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I find this really interesting as well, in that the doctor was believed
that VE wasn't brought to her attention, and the midwife was not, but also
that she needed direction from a doctor or senior midwife to do one. This
is exactly my point, that it has become a medical procedure and therefore
taken out of the midwifery range of practice in many centres, thus jeopardising
the health of women. Midwives used to doing ARMS on their own recognisance
would just as a matter of course do the VE before even calling a doctor
for either epidural or syntocinon augmentation. They would also follow
as a matter of course a confirmation of progress assessment in VBAC knowing
the dangers of a scar on the uterus.
But what is so sad about this story is the midwife becomes responsible
for the care of the woman in a VBAC (it does have an elevation of risk
above that of the unscarred uterus, though this risk is variously de-emphasised
or over-emphasised by some groups) but is not empowered to perform the
skills necessary to provide that care properly. Then she is scapegoated
(drawing many conclusions here and acknowledge I could be wrong about this
specific case, though have seen it myself elsewhere) when things go wrong.
All the more reason, really, for midwives to be very knowledgable, very
skilled and very outspoken both verbally and IN THE NOTES.... the converstation
should have been documented.
Trish
Marilyn Kleidon wrote:
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 -----
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.
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