Stillborn inquiry finds no fault

Recommends dedicated obstetrical anesthesiology service

An independent, external review of a stillborn delivery at  Victoria General Hospital has concluded the availability of anesthesiologists was not a factor in the case.

The review, however, did make several recommendations to improve obstetrics on the Island.

The Vancouver Island Health Authority commissioned the review Aug. 19  after anesthesiologist Dr. Sue Ferreira publicly raised questions about a possible link between the incident and a shortage of anesthesiologists.

In an email to media, Ferreira said a labouring mother required an emergency cesarean section at a time when the hospital’s lone anesthesiologist was occupied with other surgeries.

“What we know is that there was a delay in care. What we need to find out is whether that delay was the reason this baby did not survive,” Ferreira wrote.

On Aug. 9, a woman came to the hospital in labour. After several hours, the fetus showed sudden signs of severe distress.

An obstetrician was called and made two failed attempts to deliver the baby with a vacuum suction and forceps, according to the review.

The patient was then delivered to the operating room for a cesarean. Upon delivery, however, the baby had no heartbeat and did not breathe and attempts at resuscitation did not work.

“After examining this case detail the review team was quite satisfied that there was no delay in the provision of anaesthesia care to the patient,” wrote review lead Dr. Ward Flemons, a professor of medicine at the University of Calgary and board member with the Canadian Patient Safety Institute.

“Although for a short period of time the anesthesiologist was responsible for two patients, which although not an ideal situation, did not have any untoward impact on either patient.”

While a second anaesthesiologist and obstetrician were called in, their service was not required, and the c-section began within about 20 minutes from the time it was called. The timeline meets the guidelines by the Society of Obstetrician and Gynaecologists of Canada.

Beyond the particulars of this case, however, the review also examined obstetrics more generally in Victoria. It made 21 recommendations.

They include the need for a dedicated obstetrical anesthesiology service as soon as possible, and a call for VIHA to establish an equitable pay plan for its obstetricians and anesthesiologists.

In response, VIHA says it is working toward both recommendations.