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Action Taken
AI-generated response summary• The Trust revised its Guideline for Assisted Vaginal Delivery to provide greater clarity on consultant presence for trials in theatre and added guidance on flexion points, complications, and disimpaction.
• The guideline was further reviewed and revised to address ambiguities, including adding an explanation of 'imminent' and 'crowning', and removing the term 'gentle' from traction guidance.
• The amended guideline has been circulated to the obstetric medical team for comments and is scheduled for ratification in June 2015, with a further review planned once RCOG recommendations are received.
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Dear Ms Hashmi Re: Inquest for Baby Thomas Beaty 24th 27t March 2015 am responding to the concerns you raised in the Regulation 28 Report (o Prevent Future Deaths issued on 31s March 2015, in relation Baby Thomas Beaty. In light of the findings from the inquest the investigation the Trust taken the following actions described below: Instrumental Delivery Guidance Since the sad death of Thomas Beaty, the reviewed revised the Guideline for Assisted Vaginal Delivery order provide staff with greater clarity and guidance regarding the requirement for Consultant presence for trial in theatre if the operator is less than ST6. Additional guidance was also added with regards to the flexion point, complications of instrumental deliveries_ and disimpaction of the head. This guideline was ratified in December 2014, Inemediately following the inquest & directive Was issued to Ihe obstetric medical team highlighting the; requirement for a Consuitant Obstetrician to be present in theatre for all trials of instrumental deliveries regardless of the level of experience of the Middle Grade operator The guideline was amended to reflect this requirement and an audit undertaken on both inpatient sites in April to provide assurance that this requirement was being met consistently. Upon receipt of the concerns you raised in the Regulation 28 Report to Prevent Future Deaths the guideline has been reviewed and revised further order address the areas that were considered ambiguous, misleading and potentially open to misinterpretation Instrumental Delivery Guidance Guideline amended to state to abandon the procedure When there is no descent even after the Ist pull: Terminology An explanation of the terms imminent and crowning has been added to the guideline: It is now stated in Section 6.2.6: delivery is imminent as evidenced by crowning (when the widest part of the babys head (bi-parietal diameter) is at the perineum and does not slip back in between contractions) and has Trust and
Traction The guidance around traction was taken from the ASLO (Advanced Lile Suppor Obstetrics) course manual ard has been amended and the lerm gentle' removed_ The 'G of the algorithm now reads' Moderate traction pulling downwards, sweeping in a large arc lowards (he operator, almost completing a 180 degree curve (Pajot's manoeuvre): Development of Trust Guidance We have made interim changes to the Trust guideline whilst waiting for the RCOG to respond the recommendations. However we will review again once the RCOG recommendations have been received The amended guideline has been circulated to the obstetric medical team for their comments . The final document will be ratified in June 2015 and will be sent t0 you following this_ am also including the Guideline for Assisled Vaginal Delivery for your information would wish to offer sincere condolences behalf of myself the maternity team to Thomas' parents and family. Kind regards