CONSULTANT PAEDIATRICIANS IN THE LABOUR WARD: HOW BEST TO FORGESUCCESSFUL PARTNERSHIPS?A/Prof Ted Weaver OAMDeputy Head Sunshine Coast Clinical SchoolSchool of Medicine, University of Qld SMO in Obstetrics and GynaecologyNambour General Hospital

How many patients?• Clearly one• Maybe two• Both may get sick unexpectedly

• Need careful organisation of systems of care

Example case - Part 1• 38 year old woman having her first baby• Generally healthy• Worked as a National Park Ranger in NT• Most of her ante-natal care in Alice Springs• Came to Sunshine Coast at 34 weeks gestation for

continuing care to be closer to family

Nambour General Hospital (Referral Hospital for SCHHS)• About 3000 births annually

• Take all comers from 32 weeks onwards

• Training hospital for RANZCOG and RACP

• Obstetricians all on proximate call (5 min)

• Paeds up to 30-35 mins away

Example case - Antenatal Care• Triaged into midwifery model of care at her request after

review by obstetric PHO• Some questions posed by junior midwife about fetal

growth in late third trimester• Checked by more senior midwife and reassured growth

normal and all was well• Went 10 days overdue• Not keen on induction of labour• Wanted ‘everything to be natural’

Labour• Presented with ruptured membranes at term plus 12 days• Draining meconium stained liquor• Agreed to CEFM• CTG initially normal• Contracting ‘strongly’• Reassured by junior midwife that ‘all was going well, and

baby will be here soon’

3 hours later: Labour Progress• Pain ’intolerable’ so agreed to VE and assessment• 6 cm dilated, so wanted epidural• CTG becoming abnormal prior to epidural insertion but

removed to facilitate anaesthesia• Epidural inserted uneventfully• CTG afterwards abnormal and suspicious for fetal

compromise• Not picked up by junior midwife and Birth Suite team

leader involved in managing emergency next door• Birth Suite that night full +++

Further progress• After 30 mins, CTG recognised as abnormal by RMO and

Registrar notified• ‘Suspicious for fetal compromise’• Woman fully dilated with head in mid cavity pelvis• Thick meconium• Notified consultant on call – he will ‘attend immediately’

and ‘asked registrar to get started’• Meanwhile Registrar (3rd yr RANZCOG) performed easy

vacuum extraction of baby over 3 pulls

Birth• O&G consultant arrived just as baby born• Baby ‘scrawny’ with no SC fat • Meconium +++• Paediatric PHO for resus who had been in job for 2 weeks

• She had notified Senior Reg urgently• Baby had Apgar of 0 at birth• Commenced bag/mask breathing and CPR done by O&G consultant who was directing the resus

• Paediatric code Blue called• Both Paed consultant and Senior Reg 30+ mins away

Resuscitation of baby• Therefore Met call activated• ICU/DEM doctors attended• None confident to intubate or insert UAC• Baby still having CPR, and being ventilated reasonably• Apgar 3 at 5 minutes • Eventually Paed consultant arrives, 35 mins after birth,

intubates baby and inserts UAC

Then….• Baby to SC nursery• CXR = meconium aspiration• After 6 hours – seizures with signs of HIE• Cooling commenced• Retrieved to Brisbane with ‘Grade 2-3 HIE’

To be continued……

This talk will focus on…• Maternity in Australia• Increasingly complicated case mix in obstetrics• Milestones in neonatology• Current clinical practice guidelines on Paediatric attendance in Labour Ward

• Training in neonatal resuscitation• ‘Right care, by right person, in right place at right time’How best to ensure this to improve perinatal outcomes?

Maternity in Australia 2014

Sex TotalsMales 153,592Females 146,105Sex Ratio 105.1

299,267

Maternal Characteristics 2013 (AIHW)

Maternal Age• Average maternal age = 30 years and 9 months

• Rise of 40-45s giving birth

• Most prolific: women 30-34 years of age

• ‘Best age = 22 years

http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3301.0

Obesity

Case Mix in Obstetrics - ObesityJuly 2007 to 31 December 2011• Singleton pregnancies from

Indigenous (n = 13 582) and non-Indigenous (n = 241 270) women in the Queensland Perinatal Data Collection

• In 57% of Indigenous pregnancies and 49% of non-Indigenous pregnancies, mother was overweight, obese or severely obese.

Med J Aust 2014; 201 (10): 592-59

Why is this important?• Because obesity is associated with

- higher rates of perinatal death- higher rates of diabetes- higher rates of hypertensive disease in pregnancy- higher rates of fetal macrosomia- higher rates of operative birth- higher rates of shoulder dystocia

All of these contribute to poorer perinatal outcomes and make demands on paediatric service

Maternal Expectations• Many women want natural birth with few interventions• Want practices such as - fewer inductions of labour- less CEFM- delayed cord clamping- immediate skin to skin contact- water birth

All of these factors may hamper or delay neonatal resuscitation should it be necessary

Adverse obstetric events are associatedwith significant risk of cerebral palsy• Aetiology of cerebral palsy complex• Retrospective population-based study of children with

cerebral palsy (as of Nov. 30, 2006), matched to their maternal/infant delivery records (Jan. 1, 1991 to Dec. 31, 2001) was performed in USA

• Demographic data and intrapartum events were examined• Six adverse birth-related events were chosen.• Children without cerebral palsy acted as controls

Am J Obstet Gynecol 2010;203:328.e1-5

Six adverse birth-related events• Placental abruption (ICD-9CM641.2)• Uterine rupture during labor (ICD-9 CM665.1)• Fetal distress (ICD-9CM 656.3, 768.2-4)• Birth trauma(ICD-9 CM 767)• Cord prolapse (ICD-9 CM 663.0, 762.4)• Perinatal asphyxia (ICD-9CM768.5-9) (HIE)

Outcomes of study• 7242 children had cerebral palsy and 31.3% had 1 or

more of the 6 adverse intrapartum events (12.9% in controls P .0001).

• This held for both term (28.3% vs 12.7% controls) and preterm (36.8% vs 15.9%, controls) neonates (both P .0001).

• Maternal (15.1% vs 6.6%) and neonatal (0.9% vs 0.1%) infection were increased in cerebral palsy cases (P.0001).

Conclusions of this study• Adverse events in labour can be harmful, for both mother

and baby.• Therefore we need to have systems of care so that

mothers and their babies can get the most appropriate care when they need it

• Majority of CP NOT related to intrapartum events

Yesterday’s neonatologyMethod of resuscitation included:• Swinging the neonate upside down (Schulze swinging)• Rhythmic traction on the tongue (Laborde method)• Dilating the rectum using a raven’s beak or corn cob• Nebulisation with brandy mist• Instilling tobacco smoke into the rectum• Yelling at, shaking or electrically shocking the baby• Ticking the nose, face or throat with a featherO’Donnell C. P Arch Dis Child Fetal Neonatal Ed 2006; 91:F369-F373

Today’s neonatology

Development of Neonatology –Eminent quotes

“There is need for specialization in neonatal medicine. This applies to doctors and nurses as well as teaching and construction of hospitals. The specialist in neonatal diseases and the nurse intensively trained and expert in the management of delicate newborns will be commonplace ere long.” Ballantyne JW 1923 The new midwifery. BMJ 1:617–621

“In previous times the problems of the newborn child have been the province of the obstetrician, a field in which he has taken comparatively little interest and to which he has contributed little. As pediatricians we have but scratched the surface.” Grulee CG 1939 The newborn. President's address to the American Pediatric Society. Am J Dis Child 58:1–7

BJOG 1952Prof Wilfred Gaisford• When is an infant paediatric?• At the end of the puerperium?• When the mother leaves hospital after birth?• Is there a place for the paediatrician on the labour ward?

Virginia Apgar’It is now hard to appreciate the benign neglect that

occurred in most delivery rooms in the world until the late 1950s’

Virginia Apgar :- Reported her new born scoring system in 1958 - Proposed that someone other than the delivering

obstetrician or midwife should concern him - or herself with the infant or infants.

- Suggested that infants should be evaluated using 5 parameters—

1. Heart rate 2. Respiration 3. Reflex activity4. Tone 5. Colour

within the first minute, and, if necessary, intervention to improve the situation should occur before re-evaluation of the infant at 5 min

Still standard practice today‘Makes practitioners actually look at the baby’

Apgar V 1953 A proposal for a new method of evaluation of the newborn infant. CurrRes Anesth Analg 32:260–267

Neonatology 1960 and beyond1960: terms “neonatology” / “neonatologist” were introducedThereafter, an increasing number of pediatricians devoted themselves to full-time neonatology

1975: first examination of the Sub-Board of Neonatal-Perinatal Medicine of the American Board of Pediatrics and the first meeting of the Perinatal Section of the American Academy ofPediatrics

In 1960a 1-kg infant who was born had a mortality risk of 95% but had a 95% probability of survival by 2000.

Many factors have contributed to this :

- Better obstetric care/better recognition of the ‘at risk’ fetus/advent of ultrasound/ antenatal corticosteroids/Anti D use

- Better neonatal ventilation/surfactant/antibiotics/ better training of staff to name but a few.

• Pediatric Research (2005) 58, 799–815

Neonatal death rates• Over the last 10 years of

the 20th century, neonatal death rate from conditions originating in the perinatal period declined by 26%

3.1 deaths per 1,000 live births in 1987-1990

↓ 2.3 deaths per 1,000 live

births in 1997-2000.

Neonatal death rate in Australia 1960-2000

(Source ABS)

Neonatal Death Rates Australia 1990-2015

Perinatal Deaths Australia 2002-11

Neonatal Deaths Australia 2011814 neonatal deaths were

registered in 2011This was - 3.3% lower than the

number registered in 2010 (842)

- 5.0% decrease from registrations in 2002 (857).

Need for neonatal resuscitation at birth• ≈ 85% of babies born at term will initiate spontaneous

respirations within 10 to 30 seconds of birth. • An additional 10 % will respond during drying and

stimulation• ≈ 3 % will initiate respirations following positive pressure

ventilation • 2% will be intubated to support respiratory function • 0.1 % will require chest compressions and/or adrenaline

to achieve this transition

Archives of pediatrics & adolescent medicine 1995;149:20-5.

The questions we now face• The problem is that we are not very good at picking who

will be in the 5 % who need significant resuscitation• Therefore, where should we deploy our best trained work

force in neonatal resus, ie our consultant paediatrician who has received training in neonatology and advanced paediatric life support?

• Is a ‘person trained in paediatric life support’ enough when neonatal resus may be required?

ANZCOR Guideline 13.1 April 2016• All personnel who attend births should be trained in neonatal

resuscitation skills which include: basic measures to maintain an open airway, ventilation via a facemask / laryngeal mask and chest compressions. At least one person should be responsible for the care of each infant.

• A person trained in advanced neonatal resuscitation (all of the above skills plus endotracheal intubation and ventilation, vascular cannulation and the use of drugs and fluids) may be needed even for low-risk births and shouldbe in attendance for all births considered at high risk for needing neonatal resuscitation.

Improving Resuscitation Performance• Training as a team including consultants• Should occur at least annually• Should be targeted to improve individual skillsAnticipation of at risk babiesRecognition of emerging maternal /fetal/intrapartum riskGood communication with patient and between obstetrics and paediatricsEnsuring potentially really sick babies are ‘in born’ where they will receive care

Ethical issues• Initiating resuscitation• Escalating resuscitation • Discontinuing resuscitation• Resourcing resuscitation

Decisions about all these measures need senior input and should not be left to junior paediatric staff

Aust Resus Council Guideline available at http://resus.org.au/guidelines/

Should senior staff ‘live in’ when on call?• Study of 450,000 births showed increased risk of

intrapartum/neonatal death at night compared with day when consultants not resident or close

Gijsen etal BMC Pregnancy Childbirth 2012;12:92

• When senior staff resident or close, no such differences are apparent

Caughey et al Am J Obstet Gynecol 2008;199:496.el-5

ACOG Statement on Neonatal Encephalopathy• Statement calls for RCA on each case to identify

causative factors that are open to potential remediation by better practice, surveillance or hospital systems

• Important to have adequate hospital governance to enact RCA findings and audit subsequent outcomes, to ensure the problem is ‘fixed’

• Thus need senior input in all of the above

Contributory factors and potentially avoidable neonatalencephalopathy associated with perinatal asphyxiaObjective of study to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy in NZ that arose following the onset of labor in the absence of acute peripartum events in 2010&2011 to determine • frequency of contributory factors• proportion of potentially avoidable morbidity and mortality• identify themes for quality improvement.

Sadler L et al Am J Obstet Gynecol 2016; 214:747.e1-8

NZ study of perinatal asphyxsia• 83 babies fulfilled criteria (No acute peripartum event)• Contributory factors were identified in 84% of 83 cases,

most commonly personnel factors (76%).• 55% of cases with morbidity or mortality were considered

to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors.

• The most frequently identified theme related to the use and interpretation of cardiotocography in labor.

But… NZ study of perinatal asphyxia (2)Case review documented • 10 cases with issues that related to inadequate neonatal

resuscitation (as assessed by the multidisciplinary team) • 23 cases where there was failure to recognize potential

neurological compromise and/or identifying the potential for benefit from induced cooling.

• Several examples in which abnormal fetal/neonatal status was either missed by the team providing care or normalized

Would a consultant paediatrician attending in these cases made a difference?

Personnel Factors• 36/46 potentially avoidable cases were associated with

poor CTG interpretation• 10/46 inadequate neonatal resuscitation• 23/46 included failure to recognise potential neurological

abnormalities and introduce other therapy eg cooling which may have helped

3 delays defined in adverse outcomes in Maternity Care (WHO)• Delay in a decision to seek care• Delay in arriving at appropriate facility• Delay in receiving correct careImportant that healthcare facilities look at outcomes of care and decide if any poor outcomes can be related to these delays

Delay in Correct Care• Wrong diagnosis• Poor escalation of care• Communication errors• No recognition by junior staff of potential risk• ‘Wellness’ paradigm• Consultant reluctant to attend

Surgical Safety Check List• In use in most hospitals • Opportunity for the ‘team’ to ensure they know each other, they have had an opportunity to review potential hazards in up coming surgery

• Can be adapted for emergency CS/Birth Suite• Opportunity to call for senior Paed help should it be deemed necessary

J Obstet Gynaecol Can 2013;35(1):82–83

What do the professional bodies have to say?

RANZCOG and RACP• RANZCOG/RACP had a joint statement till 2008 titled:

‘Paediatrician Attendance at Caesarean Section’• Amended in late 2007 by RACP and new statement not

endorsed by RANZCOG• Main difference related to ‘appropriately trained medical

practitioner vs appropriately trained practitionerRANZCOG’s main trouble with this is that advanced paedresus may be left to junior staff/obstetricians/anaesthetistsprior to arrival of paediatricians

Responsibility for Neonatal Resuscitation at Birth (RANZCOG Statement C-Obs-32)

• An appropriately trained practitioner, skilled in neonatal resuscitation, should be present at all births.

• Health care facilities must ensure that all staff attending births with the responsibility for neonatal resuscitation have adequate and appropriate training in accord with national guidelines.1,2

More C-Obs-32 • Attendance of a paediatrician at the discretion of accoucher managing

the birth, taking into consideration the following.• The presence of specific additional risk factors for neonatal

compromise including (but not limited to):• significant fetal compromise;• multiple birth;• preterm birth; • breech presentation3;• general anaesthesia.4,5

And yet more….• Availability / proximity of urgent Paediatrician attendance

should such assistance become necessary. Factors affecting this would include (but not be limited to ):

• The presence of an immediately adjacent NICU, staffed with neonatologists capable of reliably attend within seconds. This may raise the threshold for paediatrician attendance at birth.

• A situation where the most available paediatrician is a considerable time away. This would lower that threshold.

Public vs Private• Parental/hospital/obstetrician expectation that a consultant Paed attend CS of mother delivering privately

• Duties include- Any resuscitation- Timely neonatal screen of the baby- Commencement of professional relationship between paed and motherLack of other staff to do these jobs in private settingTudehope D et al. J Paed Child Health 2006;42: 323-4

Paediatric Presence at Elective CS• Numerous studies attesting that there is no necessity for

consultant paeds to attend these sorts of births• Little increased risk compared with vaginal birth in low risk

women, if woman is having regional block• Adequate consensus in literature about this

Gordon A.et al American Journal of Obstetrics and Gynecology (2005) 193, 599–605

Reducing Friction between Obstetricians and Paediatricians• Try to do elective work ‘in hours’• Adequate clinical handovers including ’guesstimates’ of when at risk babies will be born

• Including senior paediatricians in “code’ calls• Ensure adequate equipment is available eg in OT• Timely notification of eg at risk transfers• Properly conducted multi-disciplinary perinatal review

Int J Surg 2008;6:5-6

Example Case - The ConclusionThis outcome? This outcome?

Outcome for Baby• Baby arterial blood gas 6.8/venous 6.85 BE -25• Anaemic/thrombocytopenic at birth• Jittery in first few hours of life, then developed seizures• Cooled and retrieved to NICU, Brisbane• Baby had stormy course, and died on day 3• Parents declined post mortem• Parents told by Paediatricians in Brisbane that

‘unquestionably’ baby died of meconium aspiration and HIE

Placenta and Baby Imaging• Gross placental vasculopathy with multiple infarcts

• 1 UA completely occluded, other partially occluded

• UV 75% occluded• Perinatal pathologist – baby had major thrombophilia likely affecting all vital organs

• Brain MRI prior to birth demonstrated ‘gross gliosis consistent with previous haemorrhages’ with later changes consistent with HIE

In other words…..• Neonatologist at the tertiary hospital was wrong in1. Telling the patient ‘unquestionably’ why her baby died2. Advising against a post mortem for baby3. Failing to communicate this advice to the referring

hospital4. Failing to recognise the significance of the older bran

injuries suffered sequentially through T3, which would have had an impact on baby’s long term prognosis

We have to do better!

De brief with parents• Why do we have junior staff relatively unsupervised in Labour Ward?

• What was cause of the baby’s death?• What would the prognosis for the baby have been if the baby lived?

• Why were they told the cause of death was HIE when the pathology reports suggested otherwise?

• Why were senior staff not present for the birth to care for the baby?

Conclusions• Importance of training of junior medical/midwifery staff

and development of team care that allows for prompt escalation when problems anticipated or arise

• Importance of consistent messages by all when communicating with patients

• Importance of timely inter-professional communication/documentation

• Importance of senior staff involvement in training/service delivery/guideline development/safety and quality

• Importance of autopsy/adequate perinatal death investigation and audit

2 questions to finish….

1. Can we really afford to have senior staff 30 minutes away when they are on call?2. Should consultant paediatricians continue to rely on junior staff/obstetricians/anaesthetists to try to do advanced paediatric resus till they arrive at a neonatal emergency?