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Record your reasoning

01 May 2014

Mrs G was seen at 35 weeks gestation in an uncomplicated pregnancy. The consultant, Mr A, documented this consultation and the mode and timing of delivery was discussed. Mrs G was naturally anxious as she had had two miscarriages and Mr A counselled her regarding induction of labour around the due date. He discussed the increased risk of instrumental delivery and caesarean section as a result.

Mrs G saw Mr A again two weeks later. Delivery by induction was revisited and agreed upon. Mr A made arrangements with the labour ward and used the indication “reduced fluid around the baby”, though he explained to Mrs G that this was to keep the midwife “happy”. An ultrasound scan reassured Mrs G that all was well with the baby.

Mrs G was admitted for induction of labour at 37 weeks gestation. On examination by Mr A the cervix was found to be soft, posterior and partially effaced. Induction by 2mgs intravaginal Prostin gel was commenced at 09:30. An amniotomy was performed seven hours later and labour ensued within two hours. The first stage of labour was completed at 00:05 and pushing commenced 45 minutes later.

Progress was slow, Mrs G’s temperature increased and the foetus developed a tachycardia. The midwife requested consultant review and Mr A assessed the patient. The baby’s head was in an occiput posterior position but low in the pelvis. There was discussion with the parents about the possibility of ventouse extraction. Initially they were reluctant, having seen the effects of ventouse delivery on head shape and facial bruising before. However they consented and the procedure went ahead.

A Kiwi cup was used with positive pressure over two contractions to effect delivery. The perineum stretched well and episiotomy was not deemed necessary. A second degree tear was sustained with labial bruising and was repaired with vicryl under local anaesthesia due to pain.

Later, both the midwife and Mr A noted the perineum to be swollen. Mrs G questioned the possibility of prolapse but this was excluded by Mr A. Soon after, relations with Mr A deteriorated for unknown reasons and Mrs G refused to see him again.

She remained in hospital and saw other doctors and a physiotherapist. Each clinician acknowledged that she had ongoing pain, urinary and faecal incontinence, but none identified a problem with the repair. There was neuropraxia and infection but the anal sphincter was intact. Mrs G was discharged six days following delivery and was improving.

Mr B saw the patient 11 days post-discharge and noted constriction of the introitus that was thought to be self-limiting (the risk of requiring surgery being 25%). The following week there was no improvement: pain persisted locally, there was difficulty recognising feelings in the bladder and intercourse was impossible. Examination revealed a very tight asymmetrical introitus.

A second opinion gynaecologist, Mr F, recommended a Fenton’s procedure, which was undertaken with ease and without complications ten weeks after delivery.

A claim was made against Mr A, alleging breach of duty for using oxytocin inappropriately, failing to rotate the head prior to delivery, using ventouse inappropriately, failing to perform an episiotomy, substandard repair of the perineum and failing to provide adequate postnatal care.

Expert opinion was supportive regarding breach of duty on all counts. Induction on psychological grounds was said to be reasonable, as was the use of oxytocin. Ventouse delivery without head rotation was cited as normal practice, as was allowing the perineum to stretch, avoiding the need for episiotomy.

The expert stated that it would be unusual that a consultant of Mr A’s standing would suture the labia together. The tissues were likely to have healed incorrectly rather than the repair having been performed in a substandard fashion. Induction of labour had had no bearing on the need for instrumental delivery.

Unfortunately, several key documents were missing from the notes and could not be traced. Despite the supportive expert opinion, in the absence of these key documents, we were advised it would be very difficult to defend the case. Accordingly it was settled for a moderate sum.

Learning points

  • Indications for induction of labour are set out in NICE guidelines as well as the RCOG green top guides. Psychological reasons and maternal choice are acceptable, but documentation regarding the counselling and consent process must be robust. The notes in this case were lost, which resulted in the case being indefensible.
  • Good record-keeping is imperative throughout pregnancy, but especially so in the intrapartum phase.
  • Delivery by ventouse is acceptable for most positions of the foetal head and is preferable to Kiellands forceps, which should not be used for rotational deliveries except in the most experienced hands.
  • Postnatal care is as important as antenatal and intrapartum care and should not be dismissed. The care of Mrs G in the postnatal period seems to have been adequate but for reasons that are not clear she refused to see Mr A. When things go wrong it is important to be open, honest, conciliatory and empathic to the patient.