Obstetric Mishap Writ Large

At the Medical Practitioners Tribunal Service (MPTS) in May Dr L was pilloried for attempting to deliver a 25 week fetus presenting as breech and with a prolapsed cord through a 5cm dilated cervix, resulting in the decapitation of the baby and a subsequent hysterotomy (described as a caesarean section) to retrieve the fetal head and reattach it to reduce the stress to the mother when presented with her stillborn offspring. Unsurprisingly the atmosphere was highly charged, the mother stated that Dr. L was un-forgiven and Dr. L herself was frequently in tears.

In a small paragraph tucked away in a side column in the ‘Times’ I read that Dr. L has not been sanctioned by the MPTS and according to the report the fetus was dead at the start of the delivery. So was there a fetal heart at the start of the procedure and crucially was the prolapsed cord pulsating? Not a difficult thing to assess and not requiring a complex emergency ultra-sound assessment in a critical situation. Crucially too, as the cervix had already been attacked with a pair of scissors and by this time a general anaesthetic had been administered would it not have been possible to deliver the fetal head vaginally and spare the woman abdominal cervical and uterine scarring all in one go.

Now I have no special knowledge of this case other than what I have read in the press, but a child of borderline viability, possibly even dead has been mutilated, a mother scarred for life both emotionally and physically and a presumably caring if misguided doctor subjected to opprobrium and public humiliation. The MPTS with presumably greater awareness of the passage of events have not withdrawn the doctor’s registration and we do not yet know if the General medical Council will appeal the decision. All this happened in a presumably adequately staffed leading teaching hospital and referral centre in the north east of Scotland but apparently at the end of a shift.

What is apparent is that nobody stepped back and engaged their brain. Looking at fact sheet for parents available on the web from Southampton University Hospital at the start of this piece we see the following.

Assuming a normal fetal heart rate at the start and a possible fast classical caesarean section to reduce fetal trauma to a minimum these figures suggest that this is an appropriate course of action. An absent lower segment of the uterus and a small transverse incision is likely to lead to a difficult delivery, fetal bruising and a jaundiced neonate, and you are after all doing this for the baby.  A really slow or absent fetal heart rate or no palpable pulsations in the cord means that you should withdraw and allow labour to proceed. At full dilatation, which we are told was not the case here, it would be reasonable to deliver the fetus vaginally but with the ever present risk that the after coming head may extend and have difficulty passing through the cervix. But that will be less traumatic than trying to pull the fetus up through the vagina and uterus to effect delivery. Whatever, you are very unlikely to effect a straight forward and least traumatic delivery through a cervix that is only partially dilated and you should not have tried.

So was the baby already dead, if so it would go some way to explaining how it came to be decapitated, though with no reports of skin pealing or anything it is difficult to say, certainly you would have had to pull very hard to tear off skin, ligaments and bone. What I fail understand is why it was felt necessary to open the abdomen to retrieve the head when presumably in lithotomy it should have been possible to manipulate the head into the cervix and deliver it that way then presumably repair the rents made into the cervix.

So despite the best intentions of the team there were no prizes for this delivery and both the mother and the team will bear the emotional scars forever. Why?

Frankly probably a combination of fatigue, a degree of arrogance and inexperience, without a pause for reflection before proceeding down this disastrous path. Having a consultant on the delivery suite did not help here and with training as it is now may well be a recurring pattern. Equally the default option of abdominal delivery may well have resulted in the abdominal delivery of a stillborn fetus, or a neonatal death, but mum would have thought that everything that could be done was, and an obstetrician would not have had her career trashed. In a low or medium income setting regrets would have been expressed and a fetus with an already low chance of intact survival would sadly have died, as it probably would have anyway and nobody would have been hurt. But this is the world we live in. But the question that we have not asked is should the GMC have pursued this case and what have they gained by doing so?