Any midwives around? Or anyone else with medical knowledge maybe.

[mrsdang]

I've namechanged for this as don't want to compromise what could be a delicate sitution.

I've received my obstetric notes today, asked for them have a SN child and wanted to find out more info.

There are a few things I need a bit of help with to understand.

Firstly - what would the usual protocol be after a pathological CTG trace (not in labour at the time) ? (zero accelerations, zero fetal movement, unexplained decels, variability 5-10bpm).

In a large consultant led high-risk unit would you expect more than one anesthetist(sp) available at any one time?

What are implications of grade 3 meconium in a pre-term baby and would you expect follow-up from a paediatrician?

Any reason for lack of apgar scores recorded at 1 minute? (available for 5+10 mins)

Given a pre-term EMCS with grade 3 meconium would you expect some investigation into causes ie- evaluation of placenta?

Sorry to be medically specific, my head is chock full of questions, it's a bank holiday and I can't begin to get to talk to anyone until after the weekend.

I've deliberately tried to keep the details a bit vague as I don't want to implicate myself or anyone who helps me but any advice at all would be really good. Thanks.

bump for anyone around this morning.

Morning mrsdang,

I'm a midwife, so I canhelp you find some info on the scenario's you mention [rl to you, scenario's to me] I can't comment on individual cases nor give you my opinion because I have rules given to me by my ruling body. It would also be unhelpful Disclaimer ends

Re: Apgar, in the case of a pre term baby who clearly needs substantial support at birh, the resusitating dr/midwife/team would probably not need an apgar. They would act on the heart rate and respiratory effort. It [apgar] wouldn't give any information they didn't know already. As an example, if I recieve a baby with a heart rate less than 100 and a glazed look - I don't start adding up scores for colour, I think 'right, let's go to work' and start the necessary actions and procedures.
At 5 and 10 mins, it shows the situation is being formally reasessed. But this would be happening fairly constantly in reality.

Am off to find some written guidance on some of your other points.

Scenarios. am in grammar hell, and spelling rehab.

This is the link to the nice guidelines for labour here

The actual research analysis makes for heavy going, but the bullet point recommendations are very helpful.

Your CTG based question is very hard to give guidence on without knowing the case, and then I couldn't for so many reasons. So not much use then am I?
In very general terms, that CTG you describe would need a medical review and a plan - based on the gestation, run-up events and other factors such as baby/maternal problems and so on. Possible follow up plans could range [for example] from scan with a senior clinician to check umbilical doppers and fetal well being to immediate delivery, and many things besides. There are so many variables to consider. Sorry I can't be more prescriptive!

Re: the meconium and the placenta being investigated. I don't know the answer. It would something an obstetrician would request. The level of prematurity and the antenatal history would affect this decision I believe.

Re: follow up. Depends on what is meant by follow up really. In the immediate post delivery hours, I would expect a preterm infant with meconium to need a degree of support, for a degree of time. There are huge variations in 'pre term' - 35 weeks is different to 28 weeks.So this support could range from wiping away meconium at delivery and help maintaining temp - to addmission to a neonatal unit. So in answer to this, it would depend on the condition at birth and the immediate neonatal period. This however fall under paeds in which I am not trained. I can only offer some insight into the general sort of thing that goes on in units.

Re: the back up staff. This will depend on the labour ward management in any one unit. In general terms, there will be one oncall anaesthetic doctor, with a second on call or consultant 'on'. The speed at which these can be made available will vary depending on how the staff are used. For example, the second on may be intesive care based.

Your hospital will be able to answer these questions for you and I wish you a constructive meeting.

Nice is always a good place to start when trying to gain knowledge into management. Then the professional bodies of the professionals involved. As you know your own case, you will glean more from reading the guidelines. However, they can not replace, nor should they, the need for flexible decision making based on the complex cases in front of the professional involved. That is why the notes and the review of them with someone from the unit will be so helpfull to you.

I really hope this sort of helps, if only to show there are no black and white answers, or at least, very rarely!

can;t really add anything, but i hope that you get the answers that you need.. a pathological CTG would IME expedite all the things treedelivery had said.

the amount of staffing can depend on day of the week , bank holiday time. i.e skeleton staff not unusual from friday afternoon until monday, so one anaesthatist might not be that unusual, but consultant would be on call and poss on other as tree has said. that is the case in the local CLU.

i really hope that you get the answers you need

i would advise you take someone with for support, take a list of questions, do not be fobbed off, if oyu don;t understand anything, ask for clarification.

don;t know who you are , if that helps !

thanks for the help, I appreciate the info and appreciate that you can't comment on an individual case.

Just say that at 35 weeks someone had not felt fetal movement for 20 hours, took themselves to local hospital for CTG. Monitored for an hour, CTG pathalogical as described in previous post. Transferred by ambulance to consultant led unit across town - then monitored for a further 8 hours with no improvement in trace at all. Finally a change in shift and new doctor dictated immediate EMCS, which was then delayed by a further 2 hours waiting for the correct staff. On delivery grade 3 meconium noted but parents not informed. Baby not in NICU and home after a week when BF established. No paediatric follow-up - told we could consider baby a 'normal full-term baby'.

Fast forward some time and this person having to fight to see a paediatrician and to get the child diagnosed with a neurological condition.

I am going to arrange a meeting but it's all hard to deal with and exacerbated by the fact that I'm due to give birth again at the same hospital soon and sadly have no confidence that I will receive the care I need.

Thanks again for the info, the nice guidelines are very useful.

the only other piece of advice i could give is this:

make sure you make and keep several copies of the notes you have. it is not unknown for notes to get lost.

and can you swap to a different hospital, is there another one near you that you could go to instead?

Oh mrsdang. for you.

You are perfectly able to transfer your care to another hospital if this is what you want. Even one near relatives if you have childcare issues etc.

As to if the sn developments can be traced back - I just don't know. Regardless of this, if you have concerns over the management of your delivery then you need a meeting with a consultant and a senior midwifery manager. This applies whatever the developmental pattern of all dc's, and to all with concerns.

Really big good luck. It would be good to hear how you go. x

P.S. If the difficulty seeing a paed is at gp level - simply ask for it. Then demand. Then ask for a practice manager and refer to the PCT. And do this within one appointment.

I have no patience with hp's not referring on, it's not like they have to pay for it themselves so what is the problem?

Someone I know had their solicitor loose it the ctg. Imagine.

A person in this position might ask -

1 - what were the assessed needs and what was the plan, during the 8 hours at the cons unit. What knowledge/management guideline/normal practice/percieved diagnosis was the plan based on?
-Were the plan and the reality the same.
-If not why not?
-Why was there a change in plan at the staff change-over. What knowledge/management guideline etc etc prompted this change. Had the clinical picture altered?
-At the change in plan to 'immediate cs'. Was decision for delivery asap, urgent, this morning, crash, at the next natural oppurtunity within the delivery suite work load.....this might be clarified futher.
-If the plan for delivery timing and the reality differed, why?

2 - the issues of follow-up, information sharing, staffing and so on.
I won't go into those as the people involved will know all the things they are unhappy about better than anyone else.

Can I try to help you with some of the paed stuff?

If your baby was 35 weeks and did not need significant resuscitation at the time of birth, even with the meconium, and then went to the post-natal ward with mum then follow-up would not be routine.

Whilst the meconium is certainly a sign of distress in the baby how it affects the baby then depends on whether or not it is inhaled/aspirated which can in itself make the baby pretty sick. If the baby's airway was clear or easily cleared by the attending staff and the baby responded well to initial resuscitation with a mask and did not have ongoing respiratory distress then the meconium would not have been thought to have harmed the baby's chest.

I'm sorry that all of this has happened to you. I hope I'm being helpful.

I'd agree with paesincognito - and would also like to at the name.

There is fair evidence that the grade of the meconium isn't all that at predicting what future care and follow up should be. NOt as accurate as the baby its self for sure!

Hence my former post - concentrate on the management of points where critical decisions were made/critical actions taken or omitted. That is the crux of judging the effects of the management on the dc.

imo that is, and for what it is worth. If asked to review, the team who do it will do this with greater clarity and skill than I could.

thank you. xx

sorry, forgot to add that I'm feeling much calmer and rational today anyway. Still want answers but can cope till I get them. I think I was in a state of shock Saturday reading my notes for the first time and re-living it all.

Mrsdang. I bet you were. When do you have an appointment or some sort of follow up?