This case report was sent in by a reader, focusing on the importance of keeping clear medical records, good communication and working within your own limits.
Readers who wish to share the educational value of case reports based on their own experiences are welcome to do so, by submitting contributions to firstname.lastname@example.org.
In line with the approach we adopt for case reports in Casebook, it is critical that patients are not identified in case reports and that any other people mentioned are also kept anonymous. All individuals mentioned must provide written consent to say they agree to the case report being published. Evidence of this consent must be submitted to MPS along with your contribution.
NB. Please understand that not all submissions will be used.
Ms X made a self-referral to the triage unit on the labour ward. She was aged mid-30s at 26/40 weeks gestation, in her sixth pregnancy. She had four late second trimester losses (22 – 25/40 weeks) all resulted in poor outcome. She had only one child alive, that she carried to term with the help of a cervical stitch.
In this pregnancy, she had a cervical stitch inserted by consultant Dr Y. After the surgery, Dr Y discussed the findings of cervical scarring to Ms X, explained that this was a high-risk pregnancy and recommended an abdominal suture for any future pregnancy. This was documented and a copy was sent to her GP.
On admission, she complained of sudden abdominal pain and irregular contractions and she was examined by a junior doctor, Dr Z. Dr Z documented that on speculum examination “the cervix was not seen”, but she visualised the cervical stitch with the knot in the posterior vault of the vagina, and there was minimal amount of vaginal bleeding. Dr Z requested cocodamol and planned to review her later. The fetal monitoring – CTG (cardiotocogram) was normal.
Within one hour, Ms X delivered in triage. She had a massive postpartum haemorrhage requiring several units of blood and blood products, and high dependency unit admission. Mother and baby made satisfactory progress.
However, while Ms X remained in the high dependency unit, her baby was transferred more than 100 miles away because the special care unit was full. The paediatric team had only been informed of Ms X after the delivery. Ms X later wrote an official complaint about being separated from her baby.
- Ms X praised the standard of communication from the obstetric team prior to this incident; she felt fully informed about the common complications of having a cervical stitch and was offered assistance
- For patients with such bad obstetric history and vaginal bleeding, junior trainees should discuss the case with a senior doctor. Ms X should have been transferred from triage to the labour ward.
- The speculum examination was inadequate – Dr Z’s documentation was ambiguous because it said “cervix not seen”. This could have meant that the cervix was too posterior (common in primigravida), or that the cervix was fully dilated thus absent.
- Dr Z did not review the cervical stitch surgical notes. This was important because the documentation commented on the cervical scarring and the anterior suture knot.
- Ms X praised the standard of communication from the obstetric team prior to this incident; she felt fully informed about the common complications of having a cervical stitch and was offered assistance with a future pregnancy. She was warned and had accepted the risk of preterm delivery. Most important she was pleased that she understood the advice given after surgery, and presented to hospital early before the haemorrhage started at home.
- There was no clinical negligence claim forthcoming, in spite of substandard care resulting from poor communication: within a team – the obstetric team (late identification and managing the massive haemorrhage in triage) and between teams (obstetric and paediatric teams, as the baby was denied steroids to improve lung maturity and survival).
- Junior doctors’ management should include looking at things from the patient’s point of view. This case confirms it is good to talk – both to colleagues and to the patient.
[This case report was produced with full consent from the patient involved.]