Prevention of Future Deaths report – Mollie Dimmock (9 November 2021)

Summary

Mollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.

Content

In this report, the Coroner states their concerns as follows:

• NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
• Within this Guidance, whist there is reference at paragraph 1.17 to mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby.
• There does not appear to be any national guidance or accepted definition of large-for-gestational-age, meaning that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance, and, in turn, the interpretation of obstetricians and other clinicians advising parents in anticipation of delivery modes.
• It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and decisions about mode of delivery. Application of section 1.17 includes consideration of shoulder dystocia and options for continuing labour or caesarean section, relevant to both the life of the mother and the baby. The uncertainty surrounding when section 1.17 should be relevant arises through the lack of a definition of a large-for-gestational-age baby.

This report was sent to the National Institute for Health and Care Excellence (NICE), Buckinghamshire Healthcare NHS Trust, the Healthcare Safety Investigation Branch, NHS England (National Maternity Lead) and the Royal College of Obstetricians and Gynaecologists.

In their response, NICE stated:

“During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.

Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.

We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.”