Is it right to wait for normal delivery after the 'water breaks'?
Q: I am a 29 years old woman and had delivered a 10 days premature baby girl 6 months back. A day before delivery my water broke and on the doctor's advice I got admitted in the hospital. After internal examination, she said that she would wait till next morning so that I could deliver the baby normally. She did the internal examination two more times till next morning and noticed a coloured discharge next morning and fearing that the baby might have swallowed the fecal matter, she advised to go for a caesarean section. I delivered a girl child by operation. The girl did not cry after delivery and was not able to breathe properly so she was shifted to a nursery where she was kept on ventilator for 11 days. During these days doctors at the nursery did various tests on the girl. Since she did not show any chance of survival without ventilator, we asked doctors not to put her on ventilator again and we brought her back home the same day she was removed from ventilator. She could not breathe properly and around 12 midnight she passed away. The reports given by nursery doctors suggest that her chord choked her neck and in stress she passed fecal matter and ingested it. Was it a right decision taken by the gynaecologist to wait for a normal delivery till morning even when my water broke? There was no instrument other than her stethoscope and a Doppler machine, which she used to check baby’s heart beat. Some other doctor has told that it was purely her negligence, and another said she couldn’t be blamed. I don’t know whom to trust. Please suggest.
A:You said that the cord choked the baby by its neck is not scientific. The baby in the womb does not breath through the neck and there is no question of choking. The baby gets its oxygen through the cord blood. And if indeed the cord is wound 3 or more times to any part of the foetal body, including the neck, the cord can get stretched and the umbilical vessels kinked and narrowed providing less blood and oxygen to the foetus causing asphyxia, or lack of oxygen. The whole process is complicated and is generally associated with an abnormally short cord. It is also possible that accidentally a loop of cord precedes the foetal head and gets stuck in between the foetal skull and the mother’s pelvic bone, which will cause kinking of the vessels and cut off of the foetal oxygen supply. Cord around the neck more than 3 times, Short cord, Cord prolapsed and accidental separation of the placenta, which may be caused by pulling of the cord, in essence contribute what are called cord and placenta accidents which indeed can cause asphyxia in labour. Now theoretically they can and should be detected before birth before serious damage is done and the caesarean section done, by picking up foetal heart rate abnormality and thick muconium detection, cord pH, etc. This is the whole purpose of delivering in a hospital. So your query if it was right to wait overnight after water bag ruptured, the answer is yes! You had a perfectly normal low risk pregnancy till then and in such cases we generally wait for normal labour to start on its own for 6 to 24 hours (individual doctors and hospitals have different policies but that is the prescribed line of management). So there is no negligence in waiting for normal delivery, which was the right thing under the circumstances. Water bag rupture before labour pains start is common and in most case waiting for pains is all that is required. I am not sure if the foetal heart was OK, why was internal examination done, this is done only if we suspect a loop of cord coming through vagina (cord prolapse and the foetal heart is abnormal, or when the patient is in active labour). Either way there is no problem with that except it increases the risk of infection to the baby while waiting for labour pains. You wrote that the doctor saw you thrice through the night, what is not clear is: were you having pains at that time or not? Were you in labour? Because if you were not having labour pains, why were two more internal examinations done. Waiting was the right thing to do if you were not in labour, and internal examinations justified if you were in active labour. And seeing 3 times through the night is more than enough if they were only waiting, while if you were in active labour, getting strong pains every 2-3 minutes. I am sure someone, a nurse or a junior doctor was looking after you in the absence of the consultant by hearing the foetal heart by a stethoscope or a monitor every 15 minutes, or by electronic monitors. While listening to the foetal heart every 15-30 minutes once a woman is in active labour is essential. You are wondering if Doppler machine and stethoscope are enough to monitor the foetal heart, the answer to that is also yes! However, there is no proof that electronic foetal monitors are essential in low risk patient, the kind you had. The second problem is muconium, as many as 10% of all babies delivering at full term pass some muconium before birth and in most cases it is of no consequence. The problem is that when the foetus is really distressed, the muconium is also passed as the anal control goes away due to shortage of oxygen (hypoxia). Now it is very difficult to say when you see muconium whether it is of ‘normal’ type or the one, which shows that the baby is in trouble. That is why we see the heart rate. Muconium coupled with heart rate abnormalities are certainly a bad sign. Once detected a prompt delivery, within an hour or two, normally or through caesarean section is the treatment, which was done for you. Now we believe that by the time muconium was first diagnosed, or foetal heart abnormality first appeared, the baby probably was already ‘distressed’. This is called intrauterine muconium aspiration and is nearly impossible to predict. Now the muconium is foetal fecal matter and is acidic. This if goes into the lungs will cause injury and make the lungs more prone to infection. This need to be sucked properly under direct vision from the deepest parts of the lungs and this can be done by an experienced neonatologist. Now was a neonatologist present for the delivery and was this done? If the baby does not cry immediately, it is generally not a very big problem. What it needs is an expert resuscitation by neonatologist. Another possibility is in attempt to put a tube into the baby’s throat it may cause major injury to the breathing passage and lungs inside which may be serious or even fatal, like pnemothorax. This we shall never know as autopsy was not done.