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Early-labour events

 

 

Cause identified in review

Number of babies

Pathological fetal monitoring (unknown cause) recognised and acted upon

11

Attended in early labour with no detectable fetal heart rate

11

Cord entanglement/true knot in cord

5

Unexplained

5

Placental pathology

1

Acute events (e.g. uterine rupture, placental abruption)         

10

Fetal pathology detected postnatally thought to be unrelated to labour (e.g. thrombosis, infarction)

7

Cord prolapse

3

 

 

Acute events

 

Situation

A low-risk mother presented with ruptured membranes. On admission, she had appropriate assessment with no concerns identified. After discussion regarding management options, she was discharged to await events at home with the advice to contact the unit if there were any concerns.

Later that evening she reattended with fresh vaginal bleeding. On examination the uterus was tense. The fetal heart rate was difficult to determine, but believed to be around 85 beats/minute. The obstetric team was summoned promptly and the baby was delivered by emergency caesarean with evidence of placental abruption.

The baby was resuscitated before transfer to a tertiary unit for cooling. Grade I HIE was confirmed.

Commentary

The placental abruption was promptly recognised and managed. The mother had no significant risk factors for placental abruption and she was cared for in line with the National Institute for Health and Care Excellence (NICE) guideline on inducing labour for term ruptured membranes[i] and the RCOG Green-top Guideline on antepartum haemorrhage.[ii]

 

Situation

A mother who had delivered by caesarean section in her previous pregnancy presented via ambulance with suspected labour. On arrival she was found to be tachypnoeic, mildly hypertensive and bleeding vaginally. She was immediately assessed by a midwife and an obstetric registrar who found her to be very distressed. The uterus was firm to palpate. An ultrasound scan revealed a bradycardia of 40 beats/minute. Immediate emergency caesarean section was performed and a uterine rupture was confirmed. The baby was born within 18 minutes of the mother arriving in the unit.

The baby was resuscitated in theatre and was transferred for active cooling.

Commentary

In this instance, the team acted promptly to recognise the uterine rupture and fetal distress. This mother had been counselled appropriately in the antenatal clinic regarding the risks of uterine rupture with vaginal delivery after caesarean section.

 

Fetal pathology unrelated to labour

 

Situation

A low-risk mother presented in labour at term. The mother opted for epidural analgesia and therefore a CTG was commenced with no concerns. Due to slow progress in labour, an oxytocin infusion was commenced. The obstetric consultant reviewed the CTG during labour. Fetal blood samples were appropriately taken, the results of which were within the normal range. A nonrotational forceps delivery was performed for fetal distress in the second stage based on the CTG.

The baby was born in poor condition with an Apgar score of 6 at 5 minutes and normal cord gases. Neonatal cardiovascular and respiratory problems resolved quickly, but the baby’s tone remained poor and active therapeutic cooling was commenced. After 1 hour, the baby developed a focal seizure. An MRI scan revealed multifocal areas of ischaemia that were not typical of classical HIE. It was suggested that an embolic or metabolic cause should be considered.

Commentary

 

There can be a tendency to ascribe all unexpected fetal outcomes to an intrapartum event. In this pregnancy, the management in labour followed national guidance[iii] and yet the baby still required therapeutic cooling. It is important to consider the possibility of antenatal adverse events when reviewing the care of these babies.

 

 


[i] National Institute of Clinical Excellence (NICE).  Inducing Labour. NICE Clinical Guideline 70. London: NICE; 2008 [https://www.nice.org.uk/guidance/cg70].

[ii] Royal College of Obstetricians and Gynaecologists (RCOG). Antepartum Haemorrhage. Green-top Guideline No. 63. London: RCOG; 2011 (update 2014) [https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf].

[iii] National Institute of Clinical Excellence (NICE). Intrapartum Care for Healthy Women and Babies. NICE Clinical Guideline 190. London: NICE; 2014 (update 2017) [https://www.nice.org.uk/guidance/cg190].