A Welsh study¹ found a significant excess of deaths attributable to asphyxia among night (9 pm to 9 am) births and during popular staff vacation months of July and August. The researchers drew the conclusion that overreliance on inexperienced staff was the most plausible explanation.

Asphyxia means the concurrence of abnormally low oxygen and abnormally high carbon dioxide concentrations in the blood. This combination triggers a cascade of progressively more severe and irreversible metabolic consequences, which lead to brain damage or death.

Management factors which have been shown², ³ to increase the occurrence of intrapartum (during labour) asphyxia include pre-term (prematurity) and post-term delivery (postmaturity), maternal diabetes, prolonged labour, breech delivery and cesarian section.

Clear, practical and authoritative guidelines for the management of these variables have been developed and published by the Society of Obstetricians and Gynecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG). For some modalities, ACOG have a scoring system for the medicolegal assessment of clinical records.

For the majority of low-risk labours, continuous Electronic Fetal Monitoring (EFM) is no longer recommended. Widely accepted Clinical Practice Guidelines mandate such monitoring in specified high-risk situations.

Persistently low fetal heart-rate (bradycardia), dips in heart-rate with an onset after the nadir of contraction of the uterus (late decelerations), and progressive loss of minute-to-minute variation in heart-rate (variability) are indicators for concern about asphyxia. However, EFM has failed to fulfil its initial promise as a means of identifying the reversibly distressed fetus. Indeed, some researchers have suggested that there are no EFM patterns of predictive value.

Against a background of societal pressure for Canadian obstetricians to reduce cesarian section rates, there is a frequent theme among obstetric plaintiffs that it is obvious (with hindsight) that the obstetrician should have recommended, or acceded to requests for, cesarian section.

Quite apart from any self-serving financial and convenience motives, obstetricians are undoubtedly opting for more cesarian sections as a defensive response to growth in medical malpractice litigation. However, this operative procedure carries materially more risks for the both the fetus and the healthy mother. Balancing those risks without hindsight in a given situation is a clinical judgment call, irrespective of pressures, both political and for expediency.

Copyright © 2009 Electronic Handbook of Legal Medicine