Tonkin, Nixon Martin

Contributing factors

• Deeply impacted fetal head during caesarean section
• Excessive focused pressure from two fingers (rather than cupped hand) applied vaginally during disimpaction attempt
• Lack of specific training in correct disimpaction technique for midwife and registrar
• Delayed recognition of obstructed labour
• Prolonged second-stage labour (two hours 24 minutes of pushing, 24 minutes longer than recommended)
• Delayed diagnosis of cervical regression from full dilation to 9cm
• System failure to reach consulting obstetricians for immediate assistance
• Delayed commencement of caesarean section (98 minutes from decision to incision)
• Registrar Dr B perceived difficult working relationship with consultant Dr M., affecting communication about delivery difficulty
• Cumulative delays throughout labour exacerbating fetal head impaction
• Incomplete discussion of mode of delivery with mother during antenatal period
• Fragmentation of care across multiple clinicians without adequate documentation of birth plan
• Syntocinon continued during second stage without recognition of possible obstructed labour in context of large-for-gestational-age fetus
• No tocolytic agent administered to relax uterus during difficult disimpaction
• Lack of direct consultant supervision at operating table despite anticipated difficult delivery

Coroner's recommendations

1. RCA Recommendation #1: Develop a Procedure or Guideline for Category 2 LSCS identifying acceptable timeframe from decision to delivery, with audit of compliance
2. RCA Recommendation #2: Medical staff must document any changes to patient's plan of care or issues identified in the Medical and Obstetric Issues Management Plan in Pregnancy Health Record, with random audits to measure compliance
3. RCA Lesson Learnt #1: Multidisciplinary team must work collaboratively to ensure timely progression through second stage of labour; pro-active decision making to minimize delays and identify clinical changes at earliest point; random audits of total time in second stage labour
4. RCA Lesson Learnt #2: Consider use of Tocolytic agents (e.g. GTN, terbutaline) to relax uterus during suspected difficult delivery at LSCS, with communication to staff and monitoring of use
5. Coroner Recommendation: Reinforce with staff that decisions recorded in Medical and Obstetric Issues Management Plan must be considered and reviewed; continue audits to measure compliance
6. Coroner Recommendation: RANZCOG reconsider policy statement C-Obs 37 'Delivery of Fetus at Caesarean Section' to include more information about techniques to be adopted in event of deeply impacted fetal head, consistent with expert evidence (use of cupped hand rather than two fingers, reverse breech extraction, T incision extension, flexion through uterine incision)
7. Coroner Recommendation: National training programs for obstetricians and midwives, and within teaching hospitals such as RBWH, ensure ongoing training in simulated emergencies involving impacted fetal head, recognizing this is rarely taught or practised; training should be mandatory for midwives likely to be involved in emergency theatre situations