Babies, parents and Cork University Maternity Hospital may suffer without fetal anomaly scan
TRAUMATIC, distressing, inappropriate care, potential litigation — Dr Keelin O’Donoghue does not mince her words in a hard-hitting letter to 10 senior clinicians and managers within the local and regional organisations relevant to Cork University Maternity Hospital (CUMH).
As the hospital’s lead clinician for obstetric ultrasound and foetal medicine, she has serious concerns about the ongoing failure to routinely offer a foetal anomaly scan to all women attending for antenatal care.
Her concerns echo those of the new Master of the Rotunda, Professor Fergal Malone, in an interview published in the Irish Examiner last month. Prof Malone said that due mainly to personnel issues, there were, “unfortunately, some women in some maternity units around the country that do not get a routine anomaly scan.
“The challenge with obstetric ultrasound is the majority of foetal abnormalities occur in women who have no obvious recognised risk factors, so you will only find the anomalies if [you are] doing routine 20-week anomaly scanning on the entire population,” Prof Malone said.
“If you just restrict it to women over a certain age, or who previously had a baby with an abnormality, that will only cover the minority of cases with foetal abnormality. So we really do have to get routine anomaly scanning into routine clinical practice in all 19 units (it’s currently in just seven), so yes, there are women missing out.”
But, while you might legitimately expect some of the country’s smaller units not to be in a position to offer this particular scan due to resources and difficulties attracting suitably qualified staff, it’s surely unacceptable in a major tertiary referral centre such as CUMH?
Offered in the first instance to the “high risk” population attending for ante-natal care, thereafter it’s pot luck. The problem with this approach is most diagnoses are in the “low risk” population, as Prof Malone points out.
Dr O’Donoghue says it’s an issue “that has defied resolution” and exposes pregnant women attending CUMH, as well as clinicians and midwives, to an “unacceptable level of risk”.
Since it opened in 2007, Ireland’s newest maternity hospital has never been in a position to offer a foetal anomaly ultrasound scan in the second trimester to all women attending the antenatal service.
In 2008, just 10% of pregnant women were offered the scan. This had risen to 40% by 2014 and peaked at 70% by the end of 2015. Dr O’Donoghue, who oversaw and drove the improvement, says much of it was due to significant investment in staff training, re-scheduling timing of scans, reorganising the working of the foetal assessment unit and changing many work practices of the staff.
But what she is looking at now, with reduced staffing for 2016, is a serious backward slide in foetal anomaly scanning, from that 70% peak last year “back to around 30% of women attending.”
You could argue that a very small proportion of pregnancies — 2%-3% — are complicated by a major foetal anomaly, and that the resources necessary to make this scan universally available render it economically unviable. But the economic argument is a hard sell compared to the moral issues involved.
Is it right that parents of a baby with a major foetal abnormality only find out in the delivery suite when the resource exists to prepare them psychologically for that eventuality?
Is it acceptable that staff are caught unawares, denying them the opportunity to plan appropriate care, including, as Dr O’Donoghue points out, the option of foetal therapy to improve the eventual prognosis?
Is it sensible to expose staff to potential litigation because, in the absence of prenatal diagnosis, the appropriate care was not available? And most of all, is it fair on the baby? As Dr O’Donoghue points out, “Babies with undiagnosed anomalies will have worse outcomes due to being born outside centres of paediatric surgery.”
For the mothers, she warns it will mean “unnecessary caesarean sections performed for infants who cannot survive.” For families whose child will not survive, Dr O’Donoghue says the deficit means they will “not have to opportunity to avail of prenatal palliative care to enable them to prepare for their baby’s inevitable death.”
Amid these dire warnings, the ultrasound service faces more challenges posed by working arrangements. Dr O’Donoghue says staff working in the department have, over time, been allowed flexible working arrangements.
“While this has been presumably to facilitate their retention within the workforce, it has impacted on our overall WTE [whole time equivalent] complement. By March 2016 we will have over six WTE of staff on long-term leave (sick leave, parental leave, maternity leave, maternity related sick leave), meaning that many of our services in the ultrasound department will be impossibly stretched.” The number of scans offered will be cut further.
Dr O’Donoghue acknowledges there is plenty that is good about CUMH’s ultrasound services which include the Ultrasound Department, the Foetal Assessment Unit (FAU) and the Aislinn Suite. Between them, these areas recorded over 30,000 patient interactions in 2014.
Dr O’Donoghue describes the staff as “hard-working individuals” providing good quality care in appropriately designed ultrasound facilities, using up-to-date machinery. Dr O’Donoghue says, unlike several other units, all women attending CUMH are offered a dating ultrasound scan, performed between 11 and 13 weeks by a trained sonographer.
“This is important to determine pregnancy viability, to detect foetal anomalies in the first trimester, as well as for the diagnosis of multiple pregnancies,” she says. At the foetal assessment unit, the detection rate of late anomalies and foetal growth restriction is good, she says.
However, Dr O’Donoghue now despairs that improvements she’s worked on since 2008 are unravelling. Furthermore, she says failure to make an anomaly scan universally available is jeopardising recognition of the unit as suitable for training doctors to higher specialist level.
An RCSI inspections committee met with hospital management in 2013 and recommended the scan be offered to all antenatal patients. The committee said a progress report was required by January 2016.
Dr O’Donoghue says they were clear from that meeting and a subsequent report by the committee that recognition of the unit for HST [higher specialist training) was “conditional upon this issue being resolved”.
“This unit is now falling far behind national and international practice, and widely accepted standards of antenatal care,” Dr O’Donoghue warns.
“Neither can CUMH realistically claim to be a tertiary-level maternity hospital ‘leading’ the new South/South West hospital Group.”
