Tuesday, 6 September 2011

Who is to blame?

Who is to blame?

5th september

Death of a newborn
Another very tough day.

Found out at the ward meeting today that the newborn baby the midwife, AJ and I rescucitated late thursday evening had died at 11pm on friday. I was shocked and horrified by this news. As you can see from my last blog, I thought this baby was now doing ok and I was hoping he wouldn't suffer any long term consequences as a result of his birth asphyxia.

Aj and I have been wracking our brains trying to work out why he deteriorated again and whether anything could have been done to prevent his death. From a self centered point of view we really wanted to know whether our own actions contributed in anyway to him not surviving.

The baby’s notes say that on Friday morning he had started breastfeeding but at 11pm the doctor had been called because the baby had no vital signs and he then failed to respond to resuscitation.

Why? At birth he was probably suffering from Meconium aspiration syndrome (MAS) which is where the fetuses draw amniotic fluid containing fetal stool into their lungs. This only occurs when the baby was already asphyxiated in the uterus (as he would have been due to the uterine rupture) leading them to effectively gasp for air but as they are still in the uterus they take in the amniotic fluid surrounding them instead. The meconium both irritates the lungs and causes a sort of valve where the baby can inhale air past the meconium blockage but can't exhale it back out again meaning their lungs soon distend too much to inhale anymore. This plus the asphyxia in the uterus means the babies vital organs may have been without sufficient oxygen for some time leading to anaerobic respiration and the buildup of lactic acid and other acids - the acidaemia/tissue ischaemia can damage organs. Some damage can present later - e.g. if the kidneys were damaged eventually electrolyte imbalance would occur due to filtration failure which can lead to cardiac arrest. So perhaps something like this happened causing the babies delayed deterioration that occurred after breast feeding (so potentially when there were more waste products to be filtered/removed?) this is all just academic debate though and as no post mortem is going to be carried out, the exact cause of his death cannot be known.

Did anyone cause his death/ could anyone have prevented it?

• The mother presented very late to hospital (well into the 2nd stage of labour) even though she had had 2 caesarreans in the past so should have known she needed to have him this way as well. Sadly if she had presented earlier then the uterine rupture could undoubtedly been avoided and so the woman would not have needed a hysterectomy, plus in all likelihood her baby would have been born healthy. So mothers fault? Unfortunately probably quite a lot of the blame might be hers, but by no means all as there are other factors. One such factor might be poor education of patients - possibly she didn't understand she had to present to hospital early/ had to have another c-section.
• The style of caesarreans carried out here is the "classical" form and is more prone to uterine rupture than the form done in the UK. So maybe had the original surgeons performed the better form of c-section then the uterus would not have ruptured...
• Slow action of medical staff in getting the mother into theatre - AJ has researched and in the case of uterine rupture there will be significant neonatal mortality if the baby is not delivered within 18minutes of there being signs of fetal distress (and apparently blood loss like seen in this patient is a later sign than fetal distress). Well fetal distress was not checked for and I do not think they delivered the baby within 18 minutes of seeing blood so the baby’s chances of survival were decreased as a result.

• Actions during resuscitation - this refers to the actions of the midwife and me; did we carry out CPR in the best way possible? I wish I could say we did everything textbook perfectly, but as I said in last blog, I don't think we did. Some of this was to do with lack of resources and some of it was to do with the midwifes incorrect instructions to me on how many chest compressions I had to do to each of her bag squeezes. Therefore some of the reason for imperfect CPR was also my own failure to speak up and quote the current guidelines rather than meekly following her directions. Could a better ratio have made a difference? Potentially yes, more chest compressions could have meant more oxygen got to the babies vital organs (rather than just being bagged into his lungs but exhaled out before it could be picked up by red blood cells and carried away in the blood) meaning less hypoxia and damage but it’s hard to know though whether a critical amount of damage had already been done before CPR was even attempted.

• Better monitoring of babies who had required special care at birth. Whether or not this particular baby could have been saved if his deterioration had been observed, I don't know but babies here are definitely not observed closely enough in the first days and for some of the neonatal deaths that occur I'm sure closer observation would make a big difference.
• Lack of proper newborn examination, separate problem? Could have had a congenital heart defect or something that also contributed to the baby’s poor condition. Unlikely but possible.

I guess all I can console myself with is the thought that had I not been there the CPR ratio would not have been done any differently (and indeed I think we tried to do the right ratio when the midwife wasn't there, but it’s already all a bit of a blur so I can't remember 100%). So did I personally kill that baby? No. Did I possibly fail to prevent the baby’s condition from deteriorating further when I might have been able to make a difference? Yes. If I could go rewind time and tell the midwife my opinion about the advised CPR ratios rather than doing what she told me to, would she listen to me? If she did listen to me would it make a difference to the end outcome? I don't know and I guess I never will and it sucks. I wish I could rewind and try again though and I hope an infinite amount that by not saying anything to the midwife I didn't cause an unnecessary death.

One thing’s for sure, I’m definitely going to try and find away to educate staff about CPR now.

Attempted murder of a newborn

When we visited the labour ward later to see if there were any imminent deliveries we could assist in we were told that one lady had given birth but then thrown her baby head first into a toilet. Fortunately a nurse had found the baby. The baby was ok but put in warm baby room as it was very cold and is now being given penicillin to prevent infection as a result being in an unhygienic toilet.

Apparently the mother had hidden her pregnancy from everyone throughout the 9 months so it seems she hadn't wanted the baby for some reason (abortion here is illegal so it would have been difficult for her to terminate the pregnancy had she wanted to). I don't know if the woman was married (single mothers are VERY frowned upon here) but she worked as a maid so maybe it was the child of her employer or someone else that it shouldn't have been.

Perhaps more likely considering the extremity of her actions is that she was not just acting out of desperation but suffers from some form of psychiatric condition. I don't think it could be post natal depression though because it seems too soon after the birth - normally occurs around 6-12 weeks, but this doesn't mean she didn't have another psychiatric condition causing her to not be to blame for her actions. Though with the seriously substandard mental health care I have experienced here I doubt she will be successfully diagnosed / treated if she is suffering from a psychiatric condition.

I hope the child will be looked after somewhere safe.

Death of an expectant mother and foetus

We also discovered when we visited the labour ward that a 7 month pregnant lady had just passed away due to hypovolemic (decrease in volume of circulating blood) shock secondary to internal haemorage. One of the other medical students was there when she died and was not convinced she received the best possible care. For starters the hospital did not have any large cannulas available which means she was being given fluid through tiny cannulas - in hypovolemic shock you need to get lots of fluid in very very quickly. Also as the doctors thought the cause of the internal hemorrhage was uterine rupture or rupture due to an ectopic pregnancy, she should have been rushed to theatre as soon the cannulas were in where the damage could be repaired (and baby delivered just in case it could be resuscitated - there were no fetal heart sounds) before she lost even more blood.

If it was an extra uterine pregnancy (ectopic) then in England this would have been detected a long time before 7 months of pregnancy due to the widespread use of ultrasound check ups. The actual cause of her internal haemorrage will remain unknown though because apparently here post mortems need permission from the police or relatives. The relatives did not give permission - apparently post mortems are not very acceptable in tanzanian culture. I suppose people don't particularly like them in England either but if patients die under particular circumstances then legally they are required and no permission is needed.

But to summarise this is yet another tragedy we have seen caused by lack of resources and poor management of uterine rupture. Not a good day.

Rest of day consisted of a ward round on the male ward in the morning, which was interesting as AJ and I got to alternate writing in doctors notes or prescribing under doctors directions, great practice for being an F1. Then we spent some time in OPD- this time with a fully qualified and experienced clincal officer but even so for a number of patients he didn't know what the problem was and asked AJ and me and used our impression and plan in the notes. Pressure!

Nothing going on mid afternoon onwards so we went home for a bit then went back to labour ward early evening, but still no imminent labours so gave them our phone number and asked them to call, no matter how late if someone was giving birth. 11pm now and no call as of yet! Update: no call all night, so at least lots of sleep.

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