08/01/2026
This is a story about infertility, abnormal fetal blood flows and fetal injury at birth.
Emily and Alex had been trying for a pregnancy for several years and finally conceived on letrozole (ovulation induction) after 5 months with Dr Nicole Hope. Understandably, they were very nervous. Fortunately, the pregnancy progressed well until, at a routine check of fetal growth at 32/40, one of the fetal blood flow parameters was incidentally abnormal – the MCA PSV. This measures the blood flow to the brain and when elevated can indicate fetal anaemia (low oxygen carrying capacity). Other causes of an abnormal PSV include fetal movements, and their baby girl was very very active ALL the time! To be safe, we excluded other potential serious causes including infections, which thankfully all came back negative. We continued to monitor the blood flows which oscillated between being normal and elevated (this was a good sign that the cause was less likely to be serious). However, ultrasounds showed that the baby had dropped in growth and was at the 7th centile at 33/40.
Emily was keen for a vaginal birth. Fetal monitoring continued and at 38/40, due to the expected small size of the baby and a clinically static growth trajectory (drop from 23rd to 7th percentile), an induction of labour was planned for 38/40. Emily’s cervix was closed and so a cervical ripening balloon was inserted. The following morning, her cervix was 1cm dilated and I broke her waters at 0730. Her labour was long though she reached 6cm dilation reasonably quickly. From here, her cervix did not open further. On examination, the baby was in a deflexed (neck extended, chin up) (occipitoposterior (OP – baby’s back to mother’s back) position. This was likely contributing to the slow progress. In order to maximise her chance of vaginal birth, I attempted a manual rotation, a procedure I have performed safely countless times previously. However, with gentle manipulation, I was unable to manually (using my fingers) rotate the baby into a more favourable position. After she remained at 6cm dilated for 6 hours and the fetal heart rate became very high, I decided that a caesarean was required.
By the time we were at caesarean, their baby’s head was deeply impacted in her pelvis, in a suboptimal position (as expected). Despite this, due to her size, the baby was relatively easily delivered by caesarean with the aid of forceps (without undue force). Baby Hattie was born well with APGARS of 9 (1min) and 9 (5min) and normal oxygen levels, weighing 2500g. On Day 2, her astute midwife, Maree, noticed a swelling on the side of Hattie’s head. This was referred to the excellent paediatric team who arranged imaging. Scans showed that Hattie had sustained a left sided skull fracture and a small bleed outside the brain (epidural haematoma). The imaging suggests that the injury may have occurred during the disimpaction of the head from the pelvis or during the attempted manual rotation.
Naturally we were all quite concerned. I visited Hattie and Emily regularly and touched base with the NICU staff regularly. Emily, who had been quite anxious throughout her pregnancy handled the situation very well, and with the careful care , Hattie proved to us that she was a tough cookie. An MRI a month later confirmed almost complete resolution of the injury.
Hattie, now 6 months old, is kicking goals (figuratively, not literally (yet)!) and reaching all of her milestones. Her private paediatrician, Dr Ahmed Shaalen is extremely happy with her progress. She is a happy and healthy baby and doted on by her parents and family.
I have decided to share this story with the permission of Emily and Alex to illustrate that birth is not always straightforward. Contrary to what much of social media would have us believe, complications can and do occur. However, with the right debriefing, care and followup, these complications can be managed safely with excellent outcomes.
Congratulations, Emily and Alex on the arrival of baby Hattie, who kept us on our toes throughout your pregnancy, birth and neonatal period. I am glad that she is doing so well. She is very lucky to have such wonderful parents!
