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Extremely preterm baby dies from natural causes

June 19, 2018

Cord prolapse during breech birth

But the head became detached after death, or as The Sun put it last week: “Doctor decapitated baby in botched birth” (click here), and the story flew round the world (click here). The obstetrician was criticised by a public enquiry, but found fit to continue practice. The mob called for blood, and even level-headed lawyers raised their eyebrows.

              

What happened? I only know what was in the papers.

The baby was 25 weeks, i.e. 15 weeks early. Average weight at this gestation would be about 600 grams (1.5 lbs). Not so long ago, this would have been classed as a miscarriage, albeit a late one, and the mother would never have gone near a maternity ward. But over the last couple of generations, advances in neonatal care have pushed the limits of viability ever lower. In the best centres survival rates at 25 weeks are now about 60%, although about half the survivors will have some form of disability (click here). In this pregnancy the membranes had ruptured and the heart beat was slowing due to cord prolapse, so this baby’s chances were probably somewhat worse. 

Nevertheless the tribunal criticised Dr Laxman’s decision not to do a Caesarean. In fact they went further and said it “was negligent and fell below the standards ordinarily to be expected”. Not surprisingly the lawyers raised their eyebrows.

But unless the tribunal members had additional unreported information, this is an odd ruling. Caesarean is not mandatory for preterm breech births. The National Institute for Clinical Excellence (NICE) considered the matter at length (click here) and, even after 26 weeks, limited their recommendation to (my italics) “consider Caesarean […] between 26+0 and 36+6 weeks of pregnancy with breech presentation.” Below 26 weeks they decided not to make any recommendation.

NICE’s reasoning was sound. At term Caesarean is a bit safer for a breech baby. But preterm is less clear. Caesarean might be less traumatic, but it also brings forward the birth; preterm labour is difficult to diagnose, and may stop for days or even weeks. Unless you are certain the baby will deliver rapidly, the risk of Caesarean increasing prematurity often trumps the hypothetical benefit of reduced birth trauma. The uncertainties are such that the NHS has recently commissioned research to see if a randomised trial is feasible.

But what about after the cord prolapse? The baby will certainly die if not delivered within a few minutes.  But it’s not obvious that Casearean even then is the best option. For a very preterm baby in advanced labour, Caesarean is also traumatic, and the baby may deliver quickly vaginally. I know of two cases (not in my hospital!) where doctors did an emergency preterm Caesarean and found an empty uterus – the baby had delivered by the normal route under the drapes while the surgeon cleaned and incised the skin! 

NICE also considered whether at these limits of viability it is worth monitoring the fetal heart at all. Slow heart rate detects cord prolapse but may also push obstetricians into unwise Caesarean against their better judgment. It’s difficult to refuse a maternal request even at 25 weeks.

This is a controversial area, and again NICE’s experts wisely fudged the issue (again my italics): “Involve a senior obstetrician in discussions about whether and how to monitor the fetal heart rate for women who are between 23+0 and 25+6 weeks.” In my experience most UK experts advise against monitoring before 26 weeks, but even those who recommend it should also agree that Dr Laxman, who was a senior obstetrician, was working right at the limit of viability where even the best experts say there are no hard and fast rules. 

So why did the tribunal rule that not performing a Caesarean was negligent? I can’t read their minds, and perhaps they had further information, but I’ve sat on similar panels. It’s often politically difficult to say that an emotive tragedy was unavoidable. Easier to be wise after the event and blame someone. Dr Laxman, was in the frame because of what happened next. 

The baby didn’t deliver quickly. The body slipped through the incompletely dilated cervix and the head got trapped. Any obstetrician knows this is a horrible problem. For a larger baby the forceps can be applied to the trapped breech head, but not at 25 weeks and not with the cervix only 4 cm. Some experts advise incising the cervix but that’s a desperate, dangerous measure. Dr Laxman decided against. The baby died. 

Dr Laxman should have taken stock at this point. There’s no longer any clinical urgency, an oxytocin infusion could have been started and the baby would have soon delivered spontaneously. But emotions were high; the mother was awake, and perhaps the father was present too. They must have both been distressed. Assisting staff would also have been upset. Dr Laxman pressed on, urged the mother to push, and pulled again.

The head detached from the body. Extraordinary, but not unheard of, especially if a baby has been dead some time, although that situation did not apply here. Did anyone check whether the baby had some sort of connective tissue disorder? The newspapers don’t say. 

At this point other doctors got involved. They decided to perform a Caesarean to retrieve the head. Again we can criticise. Patience and an oxytocin drip, or slow removal through the vagina with the mother under a general anaesthetic and the father out of the room, would be my preferred option. But now I’m being wise after the event. Caesarean retrieval was reasonable.

In summary, a baby at the limit of viability died of natural causes, but a dreadful thing happened afterwards. The consultant involved, under pressure, pulled the head off. We don’t know whether she pulled too hard, or if some abnormality in the baby caused unusually weak ligaments. She had a previously unblemished record. No-one suggests it was anything other than an accident. It certainly wasn’t malicious. She did her best in a horrible situation. 

So what was gained by the public enquiry? Do the parents feel better? Will Dr Laxman, an ethnic minority doctor with a previously unblemished record – Dr Bawa Garba (click here) comes to mind – return to work? Baby decapitation headlines all over the world don’t make birth safer; they make sensitive doctors choose less demanding specialties, and the remainder defensively perform even more Caesareans. No lives are saved, and mothers are harmed. 

But newspaper readers had a pleasurable frisson of horror, and the mob had a chance to bay for blood. That’s something.

Jim Thornton

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5 Comments leave one →
  1. Martine Hollander permalink
    June 19, 2018 9:27 am

    Jim, we had an almost exact copy of this case over here a few years ago. One of my colleagues was involved.
    There was no public enquiry, however, the parents started a media witch hunt against the colleague involved, a respected senior whose last few years in practice were overshadowed by this event.
    Thank you for your clear and convincing analysis of the situation. I couldn’t agree more.

  2. Jessica Davison permalink
    June 19, 2018 1:38 pm

    Well written Prof! Hope you’re well. Jess (and Matilda!)

  3. Sumana Narain permalink
    June 20, 2018 12:25 pm

    So well written Prof…very tragic event turned in to sensational headline leading to awful witch hunt for the poor obstetrician. Absolutely brilliant article.. I am sharing it!

  4. Vicky permalink
    June 20, 2018 7:54 pm

    Well written Prof, such a sad case for all involved.

  5. June 25, 2018 3:56 pm

    The BMJ reports, https://www.bmj.com/content/361/bmj.k2506, that the cord had prolapsed outside the vagina, so would have been detected even if the fetal heart had not been monitored. But I still think many colleagues would have made the same decision about Caesarean as Dr Laxman.

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