Re: forceps, fibroids,skull fracture
From: Laureano Folgar (lfolgar@correovia.com)
Mon Jul 28 13:52:11 2008
Dear ¿?.
I am not familiarized with US legal system, actually more i read more i
fell in the unknown dimension, but following the logical process: First
al all, you must know the cause of fetal death. Obiusly, there is
nothing to litigate with you if the death was produce by asphyxia. Also
if he/she was dying the only way to help him/her is immediate evacuation
even if, because the myomas, the maneuver could produced a skull
fracture. It is the basis of emergency medicine, first life, second
organs, third functionality.
L. folgar
med225 escribió:
> Some 6 months ago I became involved in a distressing case that is likely
> to have significant professional and legal consequences for me. The
> scenario is as follows:
>
> A young primigravida was admitted in early established labour at 37.5
> weeks gestation. Prenatal and intrapartum care were provided by family
> physician. The pregnancy had been complicated by hypertension and
> suspected IUGR. Ultrasound had revealed presence of fibroids.
>
> At 5-6 cm an ARM was performed. This was followed by a 2 or 3 deep
> decelerations following which the FH seemed to recover to a baseline of
> 120. Poor variability, no accelerations or decelerations and a wavering
> baseline. Maternal pulse was similar to the FH.
>
> Some 3 hours later patient was fully dilated. After 1 hour of pushing
> OB on call (me) was called in consult. No progress, contractions were
> decreasing, family physician described FH as "beautiful" and
> presentation as deflexed "but not a brow". I suggested augmentation
> with oxytocin and 25 minutes later arrived to assess patient. At this
> point there was pandemonium in the delivery room. The epidural had worn
> off and patient was out of control. FP had placed a scalp electrode
> revealing an FH of 60 with no recovery, an agonal pattern.
>
> I confirmed full dilatation, LOT position, 1 cm below spines and
> proceeded to do a vacuum delivery using Kiwi cup. After removal of
> internal lead external monitoring suggested FH returned to over 100. In
> the next 3 contractions vertex was brought down to just above pelvic
> floor. Seal was difficult to maintain, cup was removed, still OT
> position. Kielland forceps were applied without difficulty. Anterior
> blade wandering method, posterior blade directly. During application of
> posterior blade a spontaneous rotation to OP occurred, after which baby
> was delivered with minimal traction in one pull (it just about fell out)
>
> Although there was a heart rate at birth the baby died within minutes.
> It weighed 5.5 lbs, cord gases not available to me but cord blood looked
> bright red suggesting no significant acidosis. Post mortem report
> showed a posterior skull fracture (report not available to me at this
> time). Paediatrician told me afterwards there were no significant
> forceps marks on baby.
>
> 1.5 hours later I performed a manual removal of retained placenta under
> GA. At this point it became clear there were numerous (6-8) potato
> sized fibroids of a firm, almost bony consistency forming a ring inside
> the lower segment. I could barely dilate enough to put 3 fingers
> through and marveled how this baby had emerged through this obstruction.
>
> Needless to say I am being blamed for this outcome, the College is
> involved, legal action is imminent and priviliges are under review. In
> other words, a career ending case.
>
> I cannot see how the very minimal force I used in this delivery could
> have caused a skull fracture. I speculate that after ARM the presenting
> part descended further into the pelvis and the fibroids caused the skull
> fracture. Fetal distress went unrecognized for several hours as
> maternal heart rate was being monitored. Of course I cannot prove any
> of this and the literature on spontaneous skull fractures during vaginal
> delivery is scarce, as is information regarding fibroids causing skull
> fracture.
>
> I would be very grateful for any comments, relevant experiences and
> literature references.
>
> Thanks
>
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