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Chapter 23 Fetal and maternal misadventure

David T Y. Liu, Mentor: Charles Rodeck

CHAPTER CONTANTS

Fetal abnormalities 207
Fetal trauma 208
Procedure 208
Fetal death 208
Death of a co-twin 208
Management 208
Dichorionic twins – more than 34 weeks 208
Dichorionic twins – before 34 weeks 208
Monochorionic twins 208
Fetal/neonatal death at margin of viability 211
Maternal trauma 211
Procedure 211
Maternal death 211
Procedure 212

It is a sad but undeniable fact that, despite the best intentions, fetal and maternal damage or death occasionally complicate labour. The maternal mortality rate in England and Wales is around 1 per 10 000 live births (see Chapter 3). This can mean a tragedy about every two years in an obstetric department subserving 5000 pregnancies annually. The corrected perinatal mortality of around 1 per 100 births is 100 times higher than the maternal mortality rate. When misfortune presents itself appropriate counselling is essential. In most units a risk management form must be completed.

FETAL ABNORMALITIES

• The mother and her partner should be informed at the earliest opportunity of any major abnormality found at birth. Minor defects, which are detected, can be discussed later, at an appropriate time. Monstrosities are best not shown to parents unless explicitly requested and only after sensitive preparation.
• Discuss fully the likely cause and consequence of the abnormality. If appropriate arrange paediatric and genetic counselling for the couple.
• 3% of births are associated with an abnormality of some sort. Parents naturally want to identify a possible cause. Discuss all queries or suggestions and discourage any feelings of guilt.
• Rejection of the abnormal baby is a natural first reaction. Frequent discussion and counselling in the postnatal period is essential.
• All congenital abnormalities incompatible with life should be photographed, X-rayed and karyotyped to enhance subsequent genetic counselling.
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• In contemporary practice most abnormalities are detected antenatally by ultrasound scan to allow proper care after birth.

FETAL TRAUMA

Fetal injuries can range from minor trauma, such as bruising or forceps marks, to major damage, such as fractures.

Procedure

• Inform the parents.
• Attend to the trauma if necessary.
• Discuss fully the likely cause and consequence of the trauma. Where appropriate offer an apology when the cause is clearly iatrogenic (e.g. skin incision to baby at caesarean section).
• Investigate fully where the cause is uncertain and inform the parents of the direction of the enquiry and its subsequent verdict.
• Document all proceedings in detail for medicolegal reasons.

FETAL DEATH

The stillbirth rate is around 5 per 1000 total births. Most stillbirths (80%) are unexplained fetal deaths where antepartum asphyxia is considered a direct cause (80%). In some 20% there may be a history of antepartum haemorrhage. Bleeding after 20 weeks and hypertensive disease remain as fetal risk factors.

Intrapartum asphyxia or trauma accounts for 10–15% of stillbirths. Failure to recognise a problem, inappropriate management and poor communication contribute to the adverse outcome.

Apart from the obvious disappointment facing all concerned, the response evoked in an individual can only be fully appreciated when the psychological background is considered. Medical personnel involved and a senior obstetrician should interview the couple jointly or on planned separate occasions. A tragedy such as this can greatly distress the staff as well as the couple concerned. Before counselling we must examine:

• our attitudes towards fetal loss
• our sense of guilt in terms of personal failure and the reasons why the obstetric system may have failed
• our ability to assess the aetiology objectively and identify avoidable factors
• our ability to detect pathological grief in the parents necessitating referral for psychiatric or social support
• our competency to conduct counselling.

Do not discourage discussion of the death or over-reassure and gloss over the tragedy. Too often clinicians have been viewed by parents as insensitive, unsympathetic and unconcerned. A suggested approach is shown in Box 23.1.

Box 23.1 Stillbirth or fetal death protocol

• Confirm fetal death or stillbirth has occurred – inform the mother immediately.
• Allow ample time for both the mother and her partner to ventilate their feelings and seek causes.
• Do not make excuses. Adopt an accepting attitude. Guilt feelings in mothers are common. Expression of anger is therapeutic, allowing a mother to offload some of her guilt feelings.
• Remember fetal death or stillbirth may be viewed by the mother as further evidence of her failings and inadequacies. It can also be felt as the loss of part of herself and stimulate fantasies analogous to that of phantom limbs after amputation. The birth of a child may hold symbolic significance as a means of redeeming some of the mother’s shortcomings in life. Search for these background factors in the discussion to understand the mother’s responses and to assist in subsequent counselling. Existing children can be affected by the tragedy and may need help and counsel. Support for the couple must extend into the next pregnancy and next birth.

Management

• Confirm suspicion of fetal death by auscultation, cardiotocography and ultrasound scanning.
• Obtain detailed history. This may help determine the cause and is important for the management of subsequent pregnancies.
• Note condition of the mother, clinical assessment, blood pressure, urinalysis, vaginal bleeding.
• Take blood from the mother for haemoglobin, full blood count, cross-matching, clotting screen and Kleihauer count.
• Consider delivery. Women seldom wish to continue pregnancy once fetal death is confirmed. A quarter to a third may develop disseminated intravascular coagulation if the fetus is not delivered within 3–4 weeks.
• Transfusion or resuscitation may be necessary if fetal death followed placental separation. Problems with clotting may need to be corrected.
• Avoid caesarean section unless there are mechanical problems such as transverse lie. Aim for a delivery with minimum intervention, discomfort or surgical intervention.
• Allow labour to continue if contractions are present; otherwise if there is no contraindication induce labour at a time acceptable to the mother. The most effective method is the combination of the anti-progesterone agent mifepristone (600 mg) followed 36–48 hours later by oral or vaginal misoprostol (50 μg).
• Intravenous oxytocin (Syntocinon) can be used to augment labour.
• Leave membranes intact until labour is advanced (5 cm cervical dilatation) and delivery is assured. Prolonged rupture of membranes increases risk of intrauterine infection.
• Use analgesia (morphine or diamorphine) liberally. Discuss with the woman the degree of sedation she requires. An epidural block can be given provided there is no clotting defect.
• Keep delivery as uncomplicated as possible.

Following stillbirth

• Encourage the parents to see and hold the baby. If there is reluctance a photograph should be taken and kept for future reference. This practice will help identify the dead baby as an entity and facilitate parental mourning. The mother and father must be warned if there is gross abnormality or maceration. Display the baby to show as much normality as possible.
• Interview the couple on at least three occasions to provide opportunities for repeated discussion, to express empathy and to assess the couple’s psychological status. Grief and the usual reactions to loss such as denial, guilt and aggression are normal responses but inappropriate behaviour indicates the need for psychiatric counselling.

Documentation

• Obtain consent.
• Conduct detailed inspection for malformations, deformities, infection and trauma.
• Photograph abnormal or dysmorphic features.
• Skeletal radiography is mandatory to assist subsequent genetic counselling.
• Record occipitofrontal circumference, crown–heel length, limb length, etc.
• Conduct detailed inspection of the placenta, record weight, take swabs for culture and dispatch for pathological examination.
• At an appropriate time broach the sensitive question of post mortem or histology. Emphasise the value of this investigation to determine aetiology of fetal death and for subsequent care. If full autopsy is not allowed seek permission for limited biopsy of skin, lung and liver. Make sure the consent form is signed and full ethical details are on the request form. See Box 23.2.

Investigation

• Obtain parental consent.
• Maternal blood should be screened for infection (TORCH, parvovirus, etc) Kleihauer count, liver and thyroid function, anti-cardiolipin antibodies, blood sugar, urea, liver function and bile salts.
• Take swabs from vagina, placenta and baby.
• Take fetal blood (cardiac puncture) for infection screen and examination of fetal chromosomes. Fetal skin (from the axilla so as not to disfigure) can be used for karyotyping (if no maceration otherwise use muscle or cartilage).
• Dispense placenta (in formalin) for histological examination.

Administration

• Inform as soon as possible all relevant people such as general practitioners, community midwives, health visitors and other involved colleagues to avoid unnecessary or inadvertent comments. This will allow early arrangements for after care following discharge from hospital.
• Allocate a family room so the partner can stay. The baby, cleaned and dressed, is left with the couple to allow time to grieve in privacy. Notify religious advisor if this is requested.
• When gestation is more than 24 weeks a stillbirth certificate (issued by the obstetricians) and a certificate of burial or cremation (issued by a registrar of births and deaths) is required. Unless mothers request otherwise the law does not require burial or cremation for gestations before 24 weeks. If burial of the baby is intended, a certificate stating that the fetus was stillborn is required.
• In the United Kingdom, a maternity grant allowance is payable for fetal death after 24 weeks.
• All women must be given a postnatal follow-up appointment at the gynaecological clinic (away from an obstetric environment) to allow further discussion and counselling with the consultant obstetrician. Where appropriate refer for genetic counselling or psychiatric support.

Box 23.2 Post-mortem request

• Consent for post-mortem examination should be by a senior member of the obstetric team able to understand the sensitivity of the task; discuss reasons for the request; identify where and who performs the examination and provide comprehensive information.
• Parents should know value of the post mortem for identifying time and cause/causes of death; to confirm or elicit structural abnormalities and search for placental pathology.
• Information should include how the post mortem is performed (usually incision over back of the head to examine the brain and a midline neck to pelvis cut for access to relevant organs) and if organs (e.g. brain or heart) or tissues are likely to be retained.
• Consent for organ retention must be specifically notated. This will include use for teaching, research or dispense for tests, e.g. metabolic and any additional consultation. If there is doubt consult the perinatal pathologist.
• Parents must be told when results are available and the length of time organs/tissues are retained (usually 3 weeks to 3 months).
• Where full post mortem is declined approach parents for a limited post mortem to answer specific questions or confirm diagnosis, e.g. heart lesion. In certain circumstances, e.g. metabolic disorders, tissue samples may need to be taken early (within hours).
• Parental consent is not needed for a coroner’s autopsy.
• Fill in the structured post-mortem request form. This will include a detailed history. A copy will be kept by the parents.
• A father can countersign to support consent but usually cannot give consent by himself, i.e. without the mother’s consent.

Post mortem: specific steps

• Placenta: take appropriate samples (e.g. for genetics and microbiology) then place in formalin and send with baby to the pathologist.
• Obtain consent for: chromosome analysis (skin, blood, placenta, radiological examination and photographs).
• Document: clinical assessment of baby and placenta; record weight and measurements. Take photographs and x-ray if indicated. All these steps will help geneticist even if post mortem is refused.

DEATH OF A CO-TWIN

Both counselling of parents and management of complication are challenging due to risk of preterm birth and fetal brain damage.

• There is up to 30% of vanishing twin in first trimester with up to 4% death of a co-twin after 20 weeks. For monochorionic twin pregnancies this complication may be as high as 25%.
• After fetal death onset of labour occurs within a few weeks (usually three weeks).
• Monochorionic twins share their circulation. Hypotension and thrombotic episodes following death of a co-twin result in death (25%) and varying degrees of cerebral damage (25%) in the remaining twin. Leukomalacia is detectable 2-5 weeks after a hypotensive episode.

Management

Dichorionic twins – more than 34 weeks

• Discuss delivery with parents.
• Give steroids if not full term.
• Consider abdominal delivery if the lead twin is dead. Otherwise manage according to usual practice.

Dichorionic twins – before 34 weeks

• Negotiate with parents to delay delivery to gain fetal maturity.
• Monitor surviving twin by Doppler and cardiotocography.
• Monitor mother’s clotting factors, e.g. fibrinogen, platelets, thrombophilia screen at least weekly. Changes usually not obvious for 4 weeks after intrauterine death.

Monochorionic twins

• In addition to above management some 50% of remaining twins may die or suffer brain damage (porencephaly observed by ultrasound or magnetic resonance five weeks after death).
• Damage more likely if survivor is anaemic.
• Delay delivery if possible to allow examination of the fetal brain by weekly ultrasound scans.
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FETAL/NEONATAL DEATH AT MARGIN OF VIABILITY

Babies delivered at known gestation of 23 weeks or less are previable (physical appearance, fused eyelids, etc). Heart activity and gasping movements may be evident at birth.

• Discuss fully with mother and partner to ensure appreciation of situation and obtain indication of their feelings and wishes (e.g. question of resuscitation, holding baby after birth, request for neonatal death certificate despite gestation; baby will be classified as neonatal death if there is sustained breathing and heart activity).
• When appropriate or at parents’ request, a neonatologist should attend to support staff and parents.

MATERNAL TRAUMA

Maternal trauma in the pelvic region can occur spontaneously during labour and delivery or as a consequence of operative delivery. Where possible minimise long term damage to urethral and anal sphincter.

Procedure

• Elicit the nature and the extent of damage.
• Explain and discuss any requirements for surgical repair and prognosis.
• If the cause is iatrogenic, offer an apology, explain the reason for the damage and adopt a neutral accepting role during any discussion.
• Document all proceedings fully for medicolegal reasons.

The medical profession is not taught to dispense harm or damage, but accidents can happen. An objective appraisal of the situation is instructive and experience gained can be used to benefit others. In current practice untoward incidence forms must be completed for audit and action to avoid a recurrence.

MATERNAL DEATH

The death of any young person as a result of a natural function, which usually brings happiness, is a catastrophe. The fact that it occurs is a constant reminder of Nature’s capriciousness, our need for further knowledge of obstetrics and, above all, a reminder that events may be difficult to predict and that constant vigilance is necessary in the care of our expectant women.

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Procedure

• The most senior person should inform, console and interview the husband/partner and relatives. Discuss fully all possible aetiologies.
• Notify the relevant staff and personnel, e.g. community midwives and general practitioners.
• Document fully all the proceedings for medicolegal reasons.
• Complete a death certificate.
• A post mortem is usually mandatory.
• A thorough investigation is always necessary.
• Adopt the same attitude as suggested for other misadventures during interviews.

Box 23.3 describes how maternal deaths are defined by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the process involved in reporting a maternal death.

Box 23.3 Maternal death

The Government requires all involved health professionals to provide full and accurate information for the CEMACH, which is a work remit for the National Institute of Health and Clinical Excellence (NICE). This allows audit of cases and trends in maternal deaths. Avoidable or substandard factors are identified to improve care of future expectant women.

Definition

• Maternal death is defined as death occurring during or within 1 year of pregnancy, childbirth, miscarriage or termination of pregnancy.
• Direct maternal death – death due to complications or management of pregnancy, labour and puerperium.
• Indirect maternal death – death due to pre-existing disease, disease developed during pregnancy or disease compromised by the physiological changes of pregnancy.
• Fortuitous maternal death – death not related to the woman being pregnant.
• Late maternal death – death between 42 days and 1 year due to direct or indirect causes of pregnancy.

Process

• Appoint a coordinator to review medical records, institute internal investigation, collate documentation, list names of all involved and obtain their reports. An untoward incident form is generated. The coordinator is tasked to inform relevant personnel involved (in the United Kingdom this will involve notifying regional midwife assessor, regional coordinator for CEMACH and the mortuary department for the post mortem).
• Appoint a supporter for the mother’s family to provide a point of contact and relay of consistent available information.
• Photocopy of medical records for relevant personnel.
• Arrange support for involved medical personnel, e.g. chaplain, occupational health department or mentor.
• Arrange contact with the family’s religious leaders, e.g. priest or rabbi.
• Arrange further meeting with consultant to ensure findings can be discussed comprehensively.

Bibliography

CESDI. Report focusing on stillbirths etc, project 27/28. London: Maternal and Child Health Research Consortium, London, 2000.

Fisk NM, Bennett PR. Prenatal determination of chorionicity and zygosity. In: Wald RH, Whittle MJ, editors. Multiple Pregnancy. London: RCOG Press; 1995:56-67.

Maternal and Child Health Consortium. Confidential enquiry into stillbirths and deaths in infancy. London: Maternal and Child Health Consortium, 2002.

Murphy KW. Intrauterine death in a twin: implications for the survivor. In: Wald RH, Whittle MJ, editors. Multiple Pregnancy. London: RCOG Press; 1995:218-230.

Pharaoh POD, Adi Y. Consequences of in utero death in a twin pregnancy. Lancet. 2000;355:1597-1602.

Hughes P, Riches S. Psychological aspects of perinatal loss. Current Opinions in Obstetrics and Gynaecology. 2003;15:107-111.

Roger MW, Baird DT. Pre treatment with Mifepristone (RU 486) reduces the interval between prostaglandin administration and expulsion in second trimester abortion. British Journal of Obstetrics and Gynaecology. 1990;97:41-45.