Sunday, May 20, 2012

What can we learn from a coroner's report

Readers may wonder why I would post comment on a coroner's report.

The publishing of this redacted report enables me to reflect on similar situations that I or other colleagues have experienced. Coroner Audrey Jamieson concluded "I hope the lessons learnt from the death of baby Oscar will prevent another such occurrence in the future."

 The report I am reflecting on today is of an investigation by the Victorian Coroner into the death of 'Baby Oscar'.

The Coroner concluded that baby Oscar's death was preventable, and that the midwifery care provide by a midwife who had been employed privately by the mother had contributed to the tragic outcome.  The Coroner noted that, in the opinion of a midwife who gave expert witness, neither the parents nor the midwife fully appreciated the potential risks in this case.

I need to make it very clear that I have no knowledge of the facts, apart from what has been made public in the report. In attempting to reflect and learn from this case, I question how I would act in a similar situation.

Suppose I palpated and advised a woman in my care that her baby was in a breech presentation ...
... that referral to the obstetric hospital had confirmed my palpation using ultrasound ...
... and that attempts to perform external cephalic version had been unsuccessful ...
... and that the hospital had told the woman that she should be booked in for an elective caesarean ...
... and that the woman had told me she did not want a caesarean; that she intended to arrive at hospital in advanced labour ...
... and that the woman had told me she was in labour ...
... and that when I went to her home she was already in advanced labour ...
[you can read a similar scenario in 'Baby Oscar']

Without knowing or trying to understand the conversations that transpired between this mother and her midwife, I do say without doubt that a midwife's duty in this sort of situation includes the difficult exploration of why the 'mainstream' obstetric recommendation is that a breech baby be born via caesarean surgery.  Yes, a competent woman has autonomous right of refusal in this and in any other situation where a medical procedure is offered.  But, it is not sufficient for a midwife to delegate responsibility for 'choice' to the mother.  Informed choice means much more than a preference for a particular mode or place of birth.

The midwife's primary concern must be the wellbeing of mother and child.  The midwife's professional advice may conflict with the mother's wishes.

A midwife who practises independently, and who is able to establish a partnership based on reciprocity and trust with each woman in her 'caseload' is in a privileged position when compared with the mainstream midwifery profession.  However this privilege does not excuse me from facing up to difficulties.

Since the paper by Hanna et al (2000) relating to the Term Breech Trial, the mainstream maternity community has accepted as 'evidence based' the interpretation that
"Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups."

This culture, I believe, has increased the likelihood of adverse outcomes for breech babies when either the mother does not want to undergo elective caesarean, or when the baby's breech presentation is undiagnosed.  The de-skilling of midwives and obstetricians in vaginal breech birth has led to tragic outcomes.

I consider that a major public maternity hospital has a duty to accept women who intend to labour and give birth to breech babies.  I wonder what would have been the outcome if, in this case, the hospital had responded positively to baby Oscar's mother.

What have I learnt from reflecting on the report into baby Oscar's death?

I am certain that there will be times when I need to challenge a mother's plans or choices.

I know that there will be times when women in my care are better cared for in hospital than at home.

I also know that there will be times when, despite the best care plans and preparations, I may need to provide professional care in a birth that is outside my usual scope of practice.  My decisions at the time may be challenged in professional and statutory settings.  Births are not always predictable.  That's why a midwife attends a birth.

Thankyou for your comments

Added 6/6/12
The SA Coroner's findings have been released today on a recent high profile case, involving the death of three babies born at home.

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