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Established-labour events

Cause identified in review

Number of babies

Difficult delivery (e.g. shoulder dystocia, second twin, unsuccessful instrumental delivery, difficult caesarean section)

37

Pathological fetal monitoring recognised and acted upon appropriately

33

Appropriate reassuring fetal monitoring throughout (continuous CTG or intermittent auscultation)

23

Acute events (e.g. placental abruption)        

17

Infection

4

Maternal complication (e.g. maternal decision not to have lower-segment caesarean section)               

1

 

 

Difficult delivery

 

Situation

 

A low-risk mother presented to her local birthing unit in spontaneous labour after a prolonged latent phase. Labour progressed well to 9 cm, when delay was diagnosed. She was transferred to the obstetric-led labour ward. On arrival her cervix was found to be fully dilated; after 1 hour of pushing, the mother was exhausted and a ventouse delivery was performed. Fetal monitoring was felt to be normal throughout labour. The head was delivered on the third pull. The shoulders did not deliver with the next contraction and the baby was delivered using the McRoberts position and suprapubic pressure. The head-to-delivery interval was 5 minutes.

The neonatal team was present at delivery and immediately initiated resuscitation of the baby. The baby had an apnoeic episode 10 minutes after delivery and seizures. The baby underwent active therapeutic cooling. An MRI scan was normal.

Commentary

Although the baby had a birth weight of 4.760 kg, symphysial fundal height measurements and a growth scan that had been performed opportunistically at 34 weeks did not demonstrate macrosomia. Risk factors for shoulder dystocia have a low predictive power.[i] This baby’s shoulder dystocia was well managed in accordance with the RCOG Green-top Guideline on shoulder dystocia[ii] and the neonatal team was present at the delivery to immediately assess and initiate resuscitation as required.

 

Appropriate reassuring fetal monitoring throughout labour, unexpected outcome

 

Situation

 

A low-risk mother presented with ruptured membranes in labour to her local birthing unit. The birthing pool was used for analgesia and the fetal heart rate was auscultated every 15 minutes for 1 minute after a contraction. No abnormalities were detected in either the maternal or the fetal observations. On the next vaginal examination, the mother was fully dilated and second-stage fetal monitoring was instigated, which revealed no abnormalities. After just over 1 hour of pushing, the vertex was visible at the perineum. After a further 20 minutes, the mother was helped out of the pool and an episiotomy was performed to assist delivery of the fetal head.

The baby was born with no respiratory effort and the cord was noted to have been tight around the neck. Neonatal resuscitation was started immediately by the midwife, and the neonatal team were crash-bleeped and arrived at 4 minutes. The baby’s Apgar scores were 0 at 1 minute, 4 at 5 minutes and 4 at 10 minutes. The baby underwent active therapeutic cooling and an MRI scan revealed mild changes.

Commentary

Despite following the current NICE guidance on intermittent auscultation[iii] and correctly assigning risk, this baby required active therapeutic cooling.  The midwife acted promptly summoning the neonatal team and initiating resuscitation in a timely manner.

 

 



[i] Royal College of Obstetricians and Gynaecologists (RCOG). Shoulder Dystocia. Green-top Guideline No. 42.London: RCOG; 2005 (update 2017) [https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf].

[ii] Royal College of Obstetricians and Gynaecologists (RCOG).  Shoulder Dystocia (Greentop guideline No. 42). London. RCOG; 2005 (update 2017). Available from : https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf. [Accessed on 27th May 2017]

[iii] National Institute of Clinical Excellence (NICE). Clinical Guideline CG190. Intrapartum care for healthy women and babies. London. NICE. December 2014, last updated: February 2017. Available from: https://www.nice.org.uk/guidance/cg190. [Accessed on 29th May 2017]