Bec travelled from her home in Central Queensland to see me for consultation in my office in Norwest NSW. The distance was about 1,500 km and it would have taken almost 17hrs if travelling by road without a break according to Google maps.
She had found out about me online. She considered the trip very important as she was not getting the answers she needed from doctors locally about what went wrong in her labour and delivery that resulted in the death of her baby. She had sent me a very well written summary, the coroner’s autopsy report and other information, so I had lot of background information for when I saw her.
When she attended, she was 34 weeks pregnant in her second pregnancy. This time she had booked with an obstetrician in Brisbane rather than at the local hospital. The distance between where she lives and Brisbane was about 900km by road, so it was quite a commitment, but an important commitment.
She was an average size woman and had no relevant health issues. So, she was classified ‘low risk’ for her first pregnancy and had concluded that all would go well with her labour and childbirth. She had booked to have her baby at the local hospital in the town where she lived. This hospital had maternity services. Pregnant women in that town are managed by GP obstetricians with the support of hospital midwives.
She was told she had a ‘low risk’ pregnancy. Her antenatal journey was uneventful.
While I have some concerns about aspects of her labour management before her cervix was 9cm dilated, the real concerns started at that stage of her labour.
There was no cervical change found when a vaginal examination (VE) was done 1 ¼ hrs after the VE that reported her cervix to be 9cm dilated. With good strong contractions this suggests cephalo-pelvic disproportion / obstructed labour. The correct management would be to offer Bec a Caesarean section delivery after explaining the risks of obstructed labour. The GP obstetrician decided not to do this. This suggests the GP obstetrician did not realise it was likely to be an obstructed labour scenario and / risks of an obstructed labour for mother and baby. Also very concerning was that Bec requested a Caesarean section at this stage, but her request was denied. Bec had the right to choose a Caesarean section delivery.
20 minutes later there was another VE. The cervix was still 9cm dilated. It was reported “anterior lip of cervix present but presenting part well applied station below the ischial spines +1 and moderate caput (++).” It could have been that caput was below the level of the ischial spines and the baby’s head was still not engaged. This is an easy mistake to make. Bec wrote “Obstetrician attempted to push the lip of the cervix back during a contraction unsuccessfully. The plan was to wait another hour, for passive descent and re-examine”. Again, there was no consideration of a Caesarean section delivery by the GP obstetrician. Bec reported diagram in her notes indicated her baby was in a “deflexed direct occiput posterior position”.
I hr 25 min later Bec reports “Midwife performed VE – Unchanged from 1045hrs. Anterior lip of the cervix remained with cervical oedema. Obstetrician repeated VE – no head palpable above the pelvic brim. On vaginal examination the anterior lip of cervix remained present and fully effaced; soft and stretchy; presenting part well applied; vertex presentation; station below the ischial spines and moderate caput (++). Meconium liquor was present.” Sometimes there can be head above the pelvic brim that is not obvious to the person doing the abdominal palpation. “Obstetrician again attempted to push the lip of cervix back during a contraction, unsuccessfully. Obstetrician offered epidural likely instrumental delivery which may result in C – section anyway. I was never offered but requested a C section. Obstetrician appeared very reluctant to accept my decision for C section.” This is all very concerning. Bec’s cervix had been 9cm dilated for at least 3 hours now. Her cervix may have been 9cm before the first VE when it was reported to be 9cm. The GP obstetrician appears not to have recognised this was an obstructed labour scenario and that a Caesarean section should be done, which was the mother’s wish.
I would never consider doing an operative vaginal delivery in this situation as it is very high risk and extremely dangerous for mother and baby. As well, the accoucheur is a GP obstetrician and not an experienced obstetrician specialist and so the risk of such an operative vaginal delivery would have been even greater.
Bec then comments: “ I insisted on C section. Obstetrician still reluctant and tried to tell me <5% of babies don’t turn. The decision was made to progress to a Cat 2 caesarean section…Maternity unit manager presented to birth suite to try and convince me to keep going vaginally, I declined.” I am amazed and very concerned that the GP obstetrician still failed to appreciate the gravity of the situation. I am also amazed and very concerned that the head midwife (maternity unity manager) also failed to appreciate the gravity of the situation and the obvious need for Caesarean section.
50 minutes after the decision to do a Caesarean section the operation started. Bec had been in obstructed labour with strong uterine contractions and with her cervix 9cm dilated for over 4 hours. There was VE just prior to the Caesarean section and the findings were the same with the cervix still 9cm dilated. Bec reported diagram in notes indicated her baby was in a “deflexed direct occiput posterior position”.
It then proved to be very difficult delivery because of a rare condition called Bandl’s ring. Bandl’s ring is a pathologic retraction ring of the uterus. It is a uterine constriction ring located at the junction of the thinned lower uterine segment and the thick retracted upper uterine segment that is associated with obstructed labour. This ring is so tight that the baby cannot usually be delivered through it. In my opinion Bec’s Bandl ring was a consequence of her obstructed labour and the delay in delivery. It over 4 ¼ hrs from when Bec was found to be 9cm dilated and birth of her baby.
Personally, I have managed about 15,000 pregnancies and have done thousands of Caesarean section deliveries. I have never personally encountered a Bandl ring situation. I attribute this to correctly managing obstructed labour situations. If Bec’s labour had continued, it is my opinion uterine rupture would have soon happened.
This would have been a very difficult high-risk situation for the baby. While I have never had a Bandl’s ring situation, my understanding, from the medical literature articles I have read and thinking logically, is that a key factor in management is adequate relaxation of the uterus. That means an adequate dose of tocolytic (uterine relaxant) agents must be administered. Bec’s notes report: “GTN x 2” was given. GTN is glyceryl trinitrate and is a recognised uterine relaxant that is popular especially for the management of preterm labour. I don’t know what doses were given but it appears, it was not adequate to relax the uterus. Terbutaline also could have been administered. I have found terbutaline effective in labour. I use subcutaneous terbutaline in labour on many occasions when there is foetal distress. It relaxes the uterus and without contractions the abnormal CTG changes usually resolve.
As the Bandl ring is at the junction of the upper and lower segment an adequate vertical midline incision through the ring is considered appropriate and relevant. While there was vertical incision I don’t know whether there was small or adequate vertical incision to divide the Bandl ring and facilitate delivery. GP obstetricians are not gynaecologists and so it would have been tempting to make smaller incision which would not be adequate. It is my opinion, from Bec’s report, the vertical uterine incision was not adequate. It may not have included the Bandl ring as there was still so much difficulty with delivery after the vertical uterine incision was made.
All sorts of manoeuvres were tried to deliver the baby. Such force to deliver the baby could have been contributory factors to the baby’s death.
Bec’s baby gave one audible gasp at birth and then died, despite resuscitation attempts. Her son had a birth weight of 3390gms. Bec reported the umbilical cord had very little blood in it.
It is my opinion that adequate tocolytic agents to relax the uterus and an adequate vertical midline uterine incision through the Bandl ring are the key factors to improve the likelihood of good outcome.
Bec’s baby’s weight and dimensions an average. Bec is an average sized woman and so a baby of Bec’s son’s size should logically have fitted through her birth canal and there should not have been an obstructed labour scenario. But when there is an occipito-posterior position situation, as happened here, the baby’s head can be deflexed and so there is bigger diameter presenting. Then an obstructed labour can happen. I had this situation recently. A patient had a normal delivery of an average sized baby first time. In her second labour she needed an emergency Caesarean section because of an obstructed labour. While the second baby was of similar average size to her first the second baby was in an occipito-posterior position.
It was reported: “Placenta encountered and incised” with the uterine incisions. The placenta being incised is likely to have resulted in the loss of foetal blood. I am aware of this scenario when I have a Caesarean section with an anterior placenta praevia. With an anterior placenta praevia the placenta (which is located between the uterine wall incision and the baby) must be traumatised to deliver the underlying baby. There is urgency in delivering a baby and clamping the umbilical cord, because there is foetal blood loss when the placenta is traumatised, and foetal blood loss needs to be kept to a minimum. Foetal blood loss could have been considerable, unless there had been immediate delivery of Bec’s baby after the placenta was traumatised. This was not the case. Bec advised me there was foetal blood loss for probably a full six minutes. This was the time interval between placenta being traumatised and delivery of baby. This is too long a time period. Baby’s condition at birth and especially the lack of umbilical cord blood is consistent with considerable foetal blood loss. In my opinion this foetal blood loss would have been a significant contributary factor, if not the principal reason, for the baby’s death.
Another consideration with trauma to the placenta is that the traumatised placental may not have functioned well and there may have consequentally been a reduction in baby’s oxygenation. This can happen with a placental abruption situation. With a major placental abruption there is significant bleeding between the placenta and uterine wall and so a baby can die in the uterus because it does not get enough oxygen.
In my opinion this would have been an extremely stressful situation for the GP obstetrician. It would have been a very stressful situation for a specialist obstetrician. It is likely most specialist obstetricians in Australia would not have encountered a Bandl ring situation.
The adverse outcome was totally avoidable. If the GP obstetrician had done a Caesarean section delivery when an obstructed labour was first suggested by VE findings, and when it was requested by Bec then the outcome would have been very different. Most likely there would not have been significant time delay in delivery of baby, placental probably would not have been traumatised and there would not have been a Bandl ring scenario. There would have been a healthy baby.
For this current pregnancy Bec is under the care of an obstetrician in Brisbane. This is a very wise decision by her. A Caesarean section delivery is planned. This is also a very wise decision. There is increased risk of uterine rupture this pregnancy because of all the uterine trauma and scar tissue last pregnancy. Indeed because of this I suggested to Bec the Caesarean section be done at 37 weeks. I also suggested a careful ultrasound assessment of the anterior uterine wall in advanced pregnancy by a specialised pregnancy ultrasound unit to check thickness of the uterine scars and whether there is the suggestion of uterine scar dehiscence.
Bec told me she was classified ‘low risk’. Low risk does not mean no risk. Over the years I have had many so called ‘low risk’ patients who have had major adverse developments. Sometimes these major adverse developments happen with minimal warning (e.g. a severe postpartum haemorrhage). As there are no specialist obstetricians in many country towns, I believe it is safer for pregnant woman to travel to the closest major centre where there are specialist obstetricians for confinement management. A GP obstetrician is not trained to manage high-risk scenarios. While I am sure they do their best, there is greater risk of an adverse outcome. I have managed many women who live in the country. Often there is sharing antenatal care with the local country GP and with my managing the labour and delivery.
