Obstetrician Dr C was overseeing the labour of Mrs P, a woman in her thirties, who presented to the delivery suite in spontaneous labour at term. Mrs P’s pregnancy had been uneventful, with a normal anomaly scan at 20 weeks.
When, after almost 12 hours of labour, Mrs P’s contractions tailed off, Dr C artificially ruptured the membranes and started oxytocics to try to augment the labour. When Mrs P’s cervix was fully dilated, and as she was under an epidural anaesthesia, Dr C decided an instrumental delivery was necessary.
He applied a ventouse cup and the vacuum pressure was increased appropriately. The cup slipped once due to leakage, but was re-applied and baby K was delivered nine minutes later.
Initially, K appeared to be in good condition, with a good Apgar score. Later she was diagnosed as having had a subarachnoid haemorrhage.
K failed to develop normally, having developed brain atrophy and a dilated right cerebral ventricle, in addition to having a ventricular septal defect in her heart.
Three years later, a claim was made against Dr C. It was alleged that K had developed the subarachnoid haemorrhage during the vacuum extraction when the metal vacuum cup became detached and her head slipped back into the vagina.
On detailed analysis of the case and the cardiotocograph (CTG), experts concluded that K’s subarachnoid haemorrhage had occurred before labour began. They felt that, although analysis of the CTG is easy in hindsight, a prospective diagnosis would have been difficult to make. It would also have been difficult at the time to identify whether the CTG was abnormal and, if so, for how long.
The experts could find no evidence of chronic fetal hypoxia; the baby was not growth restricted and had no evidence of profound fetal acidosis at delivery. Furthermore, there was no evidence of multi-organ dysfunction. Careful clinical examination of K revealed some dysmorphic features and a small ventricular septal defect in her heart.
Overall, the experts concluded that the baby’s neurological status was not the result of an iatrogenic injury. Unfortunately, K’s neurological impairment could not have been prevented, even if a caesarean section had been carried out on admission.
In their opinion, the case had been managed appropriately and Dr C had conducted the intrapartum care diligently. There were no signs of misapplication of the instrument or evidence of prolonged or excessive pulling on the baby’s head.
The case was successfully defended and MPS was awarded costs.
- Careful documentation of the management and care of ALL obstetric patients is essential. It is important to retain all different records, including cord, blood results and CTGs if these are performed. Although written consent for instrumental vaginal deliveries is not required (at present), clear communication with the mother and other healthcare professionals is imperative.
- Forceps and vacuum extraction are associated with different risks and benefits and the operator should choose the instrument most appropriate for the clinical situation and their level of skill.
- There is no limitation on when a claim can be brought by a patient who has sustained mental impairment. This highlights the need for careful documentation of the procedure.
- This was a sad case, but a tragic outcome does not of itself mean that a patient’s care was negligent. Because K’s disabilities were not attributable to negligence, she received no damages to pay for the costs of her care and special needs. MPS has, for many years, advocated a no-fault compensation scheme for brain-damaged babies.
- Operative Vaginal Delivery – Guideline 26 (Oct 2005) Royal College of Obstetricians & Gynaecologists – www.rcog.org.uk
- Ventouse and Forceps Delivery, in R Johanson et al (ed) Managing Obstetric Emergencies and Trauma (MOET) Provider Manual, RCOG Press (2003)
- The Royal College of Anaesthetists and The Pain Society, Pain Management Services – Good Practice (2003)
- Macintyre P E, Safety and Efficacy of Patient- Controlled Analgesia British Journal of Anaesthesia 87 (1): 36–46 (2001)
- Stone P and Wheatley B, Patient-Controlled Analgesia British Journal of Anaesthesia