Source · Prevention of Future Deaths

Noah Poole

Ref: 2020-0206 Date: 9 Oct 2020 Coroner: Laurinda Bower Area: Nottingham City and Nottinghamshire Responses identified: 1 / 2 View PDF

The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.

Date 9 Oct 2020

56-day deadline 4 Dec 2020

Responses identified 1 of 2

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.

View full coroner's concerns

(1) Lack of professional Guidance regarding the use of a vaginal push to disimpact the fetal head

Almost all of the Midwives in this case told me that they had been asked perform a ‘vaginal push’ in theatre at some point in their career, but it is not something that frequently occurs, nor is it something they are trained to do. Furthermore, practice varies between doctors as to whether they ask a fellow doctor to provide the vaginal push, or a midwife, and whether they provide the individual with any guidance on exactly what they should do. The Midwife did exactly what was asked of her to “push” Noah’s head. She performed this in the usual way that midwives perform a vaginal examination, that is, with two pointed digits. I have been unable to determine whether it was the Doctor’s fingers or the Midwife’s fingers that caused the depressed fracture to Noah’s head, but both are a possibility, and the issue remains that midwives are asked to perform a manoeuvre in a theatre environment for which they have received no training nor is there any professional guidance. Equally, there is no guidance for the Doctor as to whether and what information they ought to impart to the midwife before they embark on the procedure.

(2) Lack of Professional Guidance in relation to the use of fetal pillows

The inquest further discovered that the understanding on the use of fetal pillows in this scenario is inconsistent. The manufacturers appear to suggest that the mother’s cervix should be at least 8cm dilated, but again, practice and understanding seems to vary.

I made enquiries of the Health Sector Investigation Branch. They were not aware of any national guidance either on vaginal pushes in theatre or the use of fetal pillows. Nor could I find any guidance on the RCNM website. The Trust has made enquiries of the RCOG and other Trusts, but again there appears to be an absence of guidance and variation of practice across the Country.

While I accept the incidence of traumatic head injury as a result of difficult fetal extraction is, thankfully, rare, and that midwives are only asked to provide a vaginal push ‘in extremis’, any procedure should be performed by a competent and capable individual who has the support of robust professional guidance to assist them.

##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>>

All witnesses in this case said it would be useful to have multidisciplinary guidance and training on this issue.

Responses

1 respondent

Royal College of Obstetricians and Gynaecologists Education

3 Dec 2020 PDF

Action Planned

The RCOG commits to developing a Scientific Impact Paper on the management of IFH to inform practice and scaling training nationally to improve outcomes. (AI summary)

View full response

Dear Miss Bower,

Re: Regulation 28 report into the death of Baby Noah Richard Poole

Thank you for your letter of 9 October detailing the sad death of Baby Noah Richard Poole in January 2019.

For background, impacted fetal head (IFH) at caesarean section delivery is an emerging issue nationally that has been recognised by NHS Resolution [1] who made a series of recommendations:

• Increase awareness of impacted fetal head and difficult delivery of the fetal head at caesarean section, including the techniques required for care.

• Research to understand the prevalence, causes and management of impacted fetal head is a priority, along with effective training in the management techniques

IFH is also recognised as an emerging problem in Australia and the US.

In your report you raise two matters of concern:

(1) Lack of professional guidance regarding the use of a vaginal push to disimpact the fetal head

(2) Lack of professional guidance in relation to the use of fetal pillows

In our response we would like to address these issues in turn, setting out the current guidance and state of the evidence around each issue.

1. The use of a vaginal push to disimpact the fetal head

Several techniques are described to deliver an IFH:
• The push technique: assistant inserts a hand into the vagina to elevate the head with cupped fingers [2].
• The pull technique, or reverse breech extraction: operator grasps one/ both fetal legs from the upper segment delivering them through the uterine incision [3, 4].

• The Patwardhan method for occipito-anterior and transverse positions: operator delivers shoulders first and applies gentle traction at the fetal waist to deliver the body. The technique for occipito-posterior positions is a modification of the pull technique [5].
• The Fetal Pillow : a disposable soft silicone balloon device is inserted vaginally and inflated with saline to elevate the fetal head [6].
• Use of tocolytic agents to relax the uterus [7].

A systematic review and meta-analysis published in 2015, including 9 observational studies and 3 prospective randomised comparative studies (734 births) [8], demonstrated a lower risk of maternal complications such as extension of the uterine incision with the pull method compared with the push method. Although there were no statistically significant differences in neonatal outcomes, one randomised comparative study suggested a possible increased risk of fetal morbidity with the push method. Studies of the Patwardhan method were small but there were fewer maternal complications compared with the push method [8].

A Cochrane review of IFH (4 randomised studies) [9], identified that the pull method may improve maternal outcomes, particularly reduced operative duration, compared to pushing. Tocolysis did not confer any significant benefit [9].

Currently, the first line approach for management of IFH tends to be based on individual familiarity and experience, rather than evidence of effectiveness. The pull and Patwardhan methods are infrequently used, despite possible advantages.

In conclusion, given the lack of training in alternative techniques, it is reasonable that teams use the vaginal push technique.

2. The use of fetal pillows Please see our formal response to the NICE consultation on their fetal pillow guidance – enclosed.

Summary The RCOG recognises that there is a current dearth in both guidelines and training for the management of IFH and we are committed to addressing this:

• We have commissioned a Scientific Impact Paper on the management of IFH to inform practice.

• There are at least two research groups in the UK working on training for IFH, including new mannequins. The RCOG commits to scaling this training nationally to improve outcomes.

Thank you for your letter. I hope the above is helpful and demonstrates that the RCOG is very much committed to working to prevent tragedies such as the death of Baby Noah. If you require any further information, please do not hesitate to contact me.

Report sections

Investigation and inquest

On 20 January 2019, I commenced an investigation into the death of NOAH RICHARD POOLE.

The investigation concluded at the end of an inquest heard over 5 days on Monday 14 September 2020 with judgment handed down today, 9 October 2020. The conclusion of the inquest was that NOAH RICHARD POOLE died as a result of a head injury sustained during his delivery by caesarean section

1a. Head Injury 1b 1c II

Circumstances of the death

Noah Richard Poole was born by emergency caesarean section delivery at the Pilgrim Hospital, Boston, Lincolnshire, on 11 January 2019. He was transferred to the Neonatal Tertiary Centre at the City Hospital, Nottingham, on 12 January 2019, and died there on 19 January 2019, aged 8 days. Noah died as a result of complications of a head injury that was sustained during his difficult extraction by caesarean delivery. The Doctor or Nurse attempting to free Noah’s head from inside the maternal pelvis caused a depressed fracture to his skull by the force applied from a finger or fingers. The fracture more than minimally contributed to his death.

There was a missed opportunity to deliver Noah safely by way of a caesarean section at 36 weeks in accordance with maternal wishes. The Trust failed to expressly inform Noah’s Mother of her right to request an elective caesarean section, in accordance with NHS guidance for a twin pregnancy. Furthermore, the medical professionals caring for Mrs Poole, failed to properly take account of her expressed wishes to have a pre-planned caesarean section.

The Trust failed on multiple occasions to properly counsel Noah’s Mother as to the risks and benefits of the two modes of delivery.

##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> Senior Obstetric Staff were confused about what guidance ought to be given to Mother’s expecting multiple births, and when those conversations ought to happen. This important conversation was repeatedly deferred to the next appointment such that it never happened and there was no agreed birth plan. The Trust’s guidance is unclear and excluded any reference to elective caesarean sections, in conflict with national guidance.

As a result, Noah’s Mother was not in a position to provide properly informed consent to the induction of labour procedure that occurred on 11 January 2019. If Noah’s mother had been properly counselled as to the two modes of delivery, she would have chosen a pre-planned caesarean section delivery at around 36 weeks gestation when there is no reason to suggest Noah would not have survived. Therefore, the failings with regards to agreeing a mode of delivery between patient and any doctor, more than minimally contributed to Noah’s death.

Action should be taken

In my opinion action should be taken to prevent future deaths and I believe you have the power to take action in relation to the above matters.

The Royal College of Obstetrics and Gynaecology The Royal College of Nursing and Midwifery

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Report details

Reference: 2020-0206
Date of report: 9 October 2020
Coroner: Laurinda Bower
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 1 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Dec 2020.

Sent to

Royal College of Nursing and Midwifery

Royal College of Obstetrics and Gynaecology

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.