Dialogue Volume 13 Issue 3 2017 - Page 43

PRACTICE PARTNER PATIENT SAFETY We use this forum to regularly report on findings from patient safety organizations, expert review committees of the Office of the Chief Coroner, and inquests. Level 1 Hospitals Urged to Better Prepare for Difficult Obstetrical Cases T wo deliveries in Level 1 hospitals resulting in the deaths of both infants were the sub- ject of recent reviews by the Maternal and Perinatal Death Review Committee. This Committee reports to the Chief Coroner. The first case involved a mother who was a healthy 35-year-old woman, with all routine prenatal labora- tory investigations within normal limits. An ultra- sound documented on Antenatal 2 identified the fetus to be 90 percentile in size at 30 weeks gesta- tional age. Her past obstetrical history was significant for a vacuum assisted vaginal delivery of a 6 pound 4 ounce female at 37 weeks gestational age after an eight hour labour. In the birth under review, the baby died at two days of age, with the post-mortem revealing a cephalohe- matoma, moderately severe subarachnoid hemorrhage and severe anoxic-ischemic encephalopathy. During the baby’s birth, there was a shoulder dysto- cia. The on-call obstetrician was 45-60 minutes away at the time of the emergency consultation. A physician on duty in the emergency room was called and applied a vacuum. The physician and a midwife persisted with a vacuum operative delivery because of the profound bradycardia. There was no option for a Cesarean sec- tion due to the absence of the obstetrician. In its review, the Committee noted that: • Given that the estimated fetal weight was in the 90th percentile, a shoulder dystocia could have been anticipated and communicated with the team of midwives, labour and delivery nurses and obste- trician on call. ISSUE 3, 2017 DIALOGUE 43