Introduction
In this article, THEMIS’s Lead Clinical Partner, TMLEP, discusses the risk factors that develop during labour and considerations that should be given to a decision to convert the delivery to caesarean section.
A Case Example
In a recent case reviewed by TMLEP, the patient was appropriately identified as being low risk and was booked for midwifery-led care. Once in labour, the patient attended the labour ward/birthing centre, and was initially managed as a low risk labour.
Despite a number of risk factors developing during labour, a decision to convert the delivery caesarean section was not made early enough and the baby unfortunately did not survive delivery.
Independent Recommendations to Improve Healthcare Standards and Patient Safety
Labour is a complex and dynamic process, with risks relating to both the mother and baby continuously evolving. Deterioration in the maternal condition can be subtle, hence it is imperative to look at all parameters, including maternal observations, progress in labour and foetal well-being. If there are concerns, clinicians should be mindful of considering a ‘helicopter view’ of the whole clinical situation, rather than focusing on one specific element. If there is clear evidence that a vaginal birth is unlikely to be successful, there should be recourse to a caesarean section in a timely fashion.
Whilst there is no specific guidance available providing a clear threshold as to when a C-section becomes mandated, through its independent investigations, TMLEP have detected that wherever a C-section opportunity was missed, a number of the following factors were present:
1. The birth is the mother’s first labour
Generally speaking, these will last the longest with some taking 12 to 18 hours and therefore, should an issue develop, there is a potential for the issue to manifest itself for a longer period of time and have a more devastating impact. An example of this would be intrauterine infection, which can frequently be insidious.
2. The mother is suffering from pre-eclampsia
This condition makes the labour high risk and increases the chance of an adverse outcome for the mother or baby as the function of the placenta is reduced.
3. The pregnancy is overdue
Post-mature babies have higher risk of poor perinatal outcome due to a decrease in placental function.
4. Slow progress of labour
Where the labour is not progressing at an appropriate rate (according to NICE guidance), there is an increased risk of fetal hypoxia, infection and difficult caesarean delivery due to impaction of the foetal head.
5. Abnormal maternal temperature and/or increase in maternal and fetal heartrate
Where high temperature is present, this can indicate an infection around the baby. Whilst a pyrexia is the classic presentation of infection, a low temperature is frequently more concerning. It is crucial that the general maternal condition is monitored, as well as signs of infection on the foetal heart rate, such as a rising baseline.
6. Inappropriate use of syntocinon
Syntocinon used for augmentation of labour (as opposed to induction) does not change the outcome of a labour, it simple changes the time at which it happens. Inappropriate use of syntocinon can cause hyperstimulation and hypoxia, which can go unrecognised. It can also cause the foetal head to be more impacted in cases of obstructed labour, leading to a more challenging caesarean section.
Conclusions
TMLEP’s independent clinical recommendation is that a C-section should be considered where 5 or more of the above factors are present, as such a combination of factors is likely to amount to a substantial risk to the mother and baby, if delivery is not expedited.
It is important to highlight that a holistic view should always be considered, as conversely, an unnecessary C-section can also present significant risk, such as increasing the maternal risk of infection, bleeding, thrombosis, prolonged hospital stay amongst other things.
By raising awareness of the above issues, THEMIS aims to assist in developing guidance as to when a C-section should be considered, therefore increasing healthcare standards and patient safety.