Avoidable brain injuries will continue under new birthing guideline | Richard Halpern
Tuesday, November 24, 2020 @ 10:36 AM | By Richard Halpern
The Society of Obstetricians and Gynecologists of Canada (SOGC) issued the 2020 Clinical Practice Guideline No. 396 in March, offering guidance about fetal surveillance in labour. The society represents more than 4,000 members, including obstetricians, gynecologists, family physicians, nurses and midwives.
Instead of focusing on reducing birth asphyxia, a condition caused by oxygen deprivation during birth, the guideline instead puts an undue emphasis on the medico-legal considerations that arise after those troubled births. The SOGC should realize that improved outcomes are the best defence against medical malpractice claims; defensive guidelines work against this goal.
Fetal surveillance involves monitoring a fetus’ behaviour during delivery. The focus is on oxygenation and the heart rate, as heart rate patterns give the medical team a good indication of how well the baby is coping with labour stress. In some cases, a heart rate that deviates from normal doesn’t mean the baby is in trouble. It could just be the fetus’s way of saying, “I may need a break from all these contractions.” At other times, the fetus may be saying “Get me outta here!”
The last update to this guideline was in 2007, and wording changes between the two are particularly telling. For example, the 2020 guideline seeks merely to “minimize” the risks associated with birth asphyxia, rather than to “decrease” its incidence, the commendable goal of the 2007 guideline.
Some of the recommendations in the updated guideline are based on unreliable and dated studies. For example, the continued endorsement of intermittent auscultation (IA) over electronic fetal monitoring (EFM) in low-risk deliveries is based on dated research of dubious value when it comes to modern obstetrics.
The basis for permitting IA in low-risk labours is the presumption that EFM increases the risk of caesarean section, allegedly without evidence that EFM has reduced the incidence of cerebral palsy (CP). There is inadequate evidence to support that presumption. Carried to extremes, it could be argued that no monitoring at all would reduce the caesarean section rates even further, without a measurable effect on CP rates — reductio ad absurdum.
The new guideline also does not adequately address causation. Neuroimaging, which involves a head ultrasound, a computerized tomography (CT) scan or magnetic resonance imaging (MRI), can tell us within a window of weeks and sometimes hours when the baby was hurt. That is critically important but is something the SOGC has ignored in this guideline.
Decades ago, it was assumed birth asphyxia mainly occurred during delivery. But neuroimaging now allows doctors to determine when those injuries occurred with much more precision. The American College of Obstetricians and Gynecologists has recognized the importance of neuroimaging, so why is the SOGC guideline silent on the issue?
Though birth asphyxia is a relatively rare condition, the number of affected babies is still significant in absolute terms, and I believe that there are more babies affected than the obstetrical community will acknowledge. Greater efforts are essential to reduce that number, as this condition creates a terrible burden on affected families, as well as those in the legal and medical systems.
I realize that members of the obstetrical community are reluctant to be critical of the guideline since most are members of the SOGC. However, I hope that a discussion about the points I raise will lead to more effective recommendations that primarily focus on reducing the incidence of birth asphyxia.
Until then, unacceptable levels of completely avoidable newborn brain injury are likely to continue unabated.
Richard Halpern is a senior lawyer for Gluckstein Lawyers in Toronto, focusing on infants injured at or around the time of birth.
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