Paediatrician at Delivery? As Always It Depends

This is a VERY good question, without a straight-forward answer! The official answer is as follows:

• Normal, uncomplicated vaginal delivery – it’s not obligatory
• Caesarean section – it is obligatory
• Complicated scenarios ‘tend’ to require a paediatrician

The reason it isn’t easy because it depends how it goes! The following abstract shows the rate of complications judged by Apgar score. You don’t need to understand that. You just need to know that any score lower than 7 is a sign that the baby needs medical attention. The lower the score, the more help the baby needs to adjust outside the mother’s womb. So 6 or below indicates that the baby required some degree of medical intervention.

The Evidence

Br Med J (Clin Res Ed). 1984 Jul 7;289(6436):16-8.
Which deliveries require paediatricians in attendance?
Primhak RA, Herber SM, Whincup G, Milner RD.

The mode of delivery and one minute Apgar score were taken from the neonatal records of 2086 full term infants born at one obstetric unit over 12 months. There were 1554 spontaneous vaginal vertex deliveries, 26 vaginal breech deliveries, and 506 operative or instrumental deliveries. The obstetric records of the operative deliveries were reviewed to determine whether fetal distress had been an indication for intervention, and the obstetric records of the spontaneous vaginal vertex deliveries were also reviewed for fetal distress detected antenatally. When fetal distress was present antenatally in spontaneous vaginal vertex deliveries the frequency of a one minute Apgar score below 7 was 10.2%. In operative and instrumental deliveries where fetal distress was the indication for intervention the frequency of one a minute Apgar score below 7 was 15.6% after non-rotational forceps delivery, 13.9% after rotational forceps delivery, and 45.8% after caesarean section. In the absence of fetal distress the frequency of an Apgar score below 7 was 2.4% after spontaneous deliveries, 7.1% after non-rotational forceps delivery, 13.2% after caesarean section, and 18.4% after rotational forceps delivery. The presence of fetal distress considerably increased the frequency of an Apgar score below 7 in each category except rotational forceps deliveries. Paediatric services to an obstetric unit may be organised rationally in the light of local staffing conditions with the help of these findings.

The Interpretation

What this shows is the following:

• If the spontaneous delivery went as planned, the need for medical intervention was present in only 2.4% or roughly 1 in 40 deliveries – a comparatively low rate
• If the baby required delivery assistance using forceps, medical intervention was necessary in between 7.1% and 18.4% of deliveries depending on whether the baby needed rotating
• After caesarean, medical intervention was needed in 13.9% of cases

All of the above are ‘in the absence of fetal distress’. In the presence of fetal distress before birth i.e. pre-existing fetal distress, the rate was 10.2% or 1 in 10 deliveries, a much higher rate of complication and not dissimilar to the rate after uncomplicated caesarean section, which definitely requires a paediatrician to be present (an obligation in Cayman). So why the uncertainty?

Fetal distress also occurs during delivery, influenced by things such as the length of labour. Whereas your obstetrician will almost certainly know about pre-existing fetal distress and will plan accordingly, there is a proportion of births where it occurs during labour and delivery. The problem is always that you don’t necessarily know going in!

In the UK, normal deliveries don’t normally require a paediatrician and because it is a national health system, if you don’t officially ‘need’ it then you don’t get it unless you go private. In part, that’s also because for every delivery team there’s a neonatal team hovering close by, generally with 24-7 doctors on the rota. The point is that help is quickly on hand when required.

In Cayman, us paediatricians do liaise very closely with our obstetric colleagues and delivery suite. We are generally aware of who is delivering imminently. If I am going to do something like snorkelling, I tend to phone delivery suite to ask for any updates or alerts. In many cases, parents have requested a paediatrician anyway. Generally, we are also not that far away. For instance, when I get calls in the night, with my skates on I can be at the hospital within around 10 minutes from getting the call. For all paediatricians, the greater challenge comes at the busy times – when the Christmas lights on South Church Street cause a complete blockage, or Esterley Tibbetts is at a standstill in rush hour, or your paediatrician is enjoying Sunday brunch in Tukka’s out at East End. These are the points when the combination of urgency, timing and traffic work against everybody.

You can probably see there is no absolutely right answer. These are issues to discuss with your obstetrician and your paediatrician. They can help you come to a choice that you are comfortable with that balances risk, medical necessaity and cost too, of course. In my experience, none of the paediatricians will over-encourage you to engage them and so you can feel comfortable openly discussing your circumstances. I am certainly happy to talk through the issues and advise accordingly.