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.

Reflecting on yesterday's webinar

great artwork from our girl!

Yesterday, 5 May, was International Midwives' Day, and I was very pleased to participate in a global webinar organised by Sarah Stewart, and hosted by the Otago Polytechnic University in New Zealand.  Click here for the program, and to find links to the recordings of all the sessions.

I heard most of the first 10 hours of program, which continued through the night; 24 hours in all.  My mind was overloaded when I stopped.  I look forward to listening to other presentations.

Through the night I found myself churning through what I consider to be idealistic midwifery. This matter concerned me as I listened to some of the presentations, and as I engaged with others in the 'comment' function by which participants were able to type in questions or comments.  I could not help comparing the situation of under-resourced independent midwives in Pakistan, with what I know of Australian independent midwifery.

Idealistic midwifery presents the woman as someone who will achieve whatever she chooses, whatever she really wants, if she goes about it the right way.  The idealistic midwife seems to believe in a perfect world, where women have a goddess status, where there are no regulatory or societal boundaries, and where the woman's choice is the only important issue.

A necessary by-product of idealistic midwifery seems to be the demonising of hospitals, doctors, medical interventions, and anything else that I might have referred to as 'Plan B'. 

I cannot accept the setting of the bar so high.  I accept that there will be some who need more than I as the midwife can offer.

The world in which we live and work has expectations of medical management.  There are many reasons why some women feel the need to give birth in hospital, to accept medical analgesics or antibiotics or IV fluids, or induction of labour or active management of the third stage.  I cannot appoint myself as judge and jury for each case.  I must respect that these are the result of mainstream care practices, leading to care decisions made by these women and their midwife or doctor.  When a woman in my care agrees that transfer to hospital is appropriate, the processes we must go through will be different from those at the woman's home, and so they should be.

The midwife in a primary care setting today, whether it's in Melbourne or in a developing country, has the opportunity to prepare women to accept the birthing work of their bodies, and to use their own natural resources to the best of their ability.  'Plan A' is essentially the same, across time and culture.  Women give birth spontaneously today the same way as our ancestor-mothers did hundreds of years ago.

'Plan B' is totally different for midwives and mothers in different parts of the world and different times.  It's a matter of availability of resources and emergency medical care.  While in my practice I can refer a woman to a well staffed and equipped, modern obstetric hospital where a team of highly trained and supported experts will address whatever the emerging complication or condition is, my sister-midwives in less well resourced parts of the world will face a very different 'Plan B'.  My friend who is working as a midwife with MSF in Africa has told me she had never imagined as many dead babies or dead mothers as she has seen in that place.

Idealistic midwifery ignores the fact that illness and infection and complication can strike down even the fittest and strongest among us.  Idealistic midwifery fails to notice that even people who eat well and exercise can become ill.  Idealistic midwifery forgets that the midwife's primary goal is the wellbeing and safety of mother and child.  Not natural birth, wonderful as that is; or drug-free birthing, or any other standard we might aim for.

Ideals are great.  Where there are no ideals, no vision, the prevailing culture can quickly over-ride, and principles be forgotten.  But ideals must be tempered with realism.  Life is often best when we can accept being 'good enough', doing our best with what we have, rather than being disappointed that we don't achieve perfection.
 
Thankyou for your comments