Clinical Risk >
Volume 14, Number 6 >
Pp. 251-252
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In the course of giving birth to her first child, a healthy baby girl, D sustained utero-vaginal prolapse and now suffers from stress incontinence. She alleged that she had been urged by a midwife to push, notwithstanding the fact that her cervix was not fully dilated; and that an epidural anaesthetic, which would have prevented her from pushing, ought to have been administered.
D was admitted to the labour ward of Macclesfield General Hospital at 02:00 on 21 August 2000. Up until 07:20, she was attended by Midwife Whitfield, against whom no allegations were levelled. At 02:30, dilatation was 4 cm (full dilatation being 10 cm). By 03:00, D was experiencing strong contractions and by 04:15, she was getting ‘urges to push’ according to the notes. By 04:30, dilatation was 7 cm and at 06:45, 9 cm, with the Claimant feeling ‘desperate to push’ by 07:00.
At 07:20, there was a change of shift and Midwife Arrowsmith took over. She recorded ‘strong expulsive urges’ at 07:25 and 07:45, and noted a cervical lip on the latter occasion. The Claimant was ‘actively pushing’ at 08:15 and at 08:30 syntocinon was administered, having been approved by the consultant obstetrician. By 10:15 there had been no significant progress and the registrar therefore took D to theatre, where the baby was born at 11:34.
The maternal urge to push, or ‘Ferguson reflex’, is very strong and difficult to resist. However, it was common ground between the parties that it is bad practice to encourage a mother to push before full dilatation of the cervix, because birth cannot be achieved in such a situation. It can also cause premature maternal exhaustion.
D agreed that the first midwife had encouraged her not to push. However, she maintained that the second midwife had asked her to do so upon discovery of the cervical lip at 07:45. The parties were agreed that pushing so as to attempt to displace the lip was good practice, because it can achieve full dilatation. However, D interpreted the midwife's comments as an encouragement to push generally, so she did on every contraction after about 08:30. Midwife Arrowsmith insisted that she would not tell a mother to push before full dilatation, and that had she done so, she would have recorded it in the notes.
At 08:25, the anterior rim was still present. The notes recorded that D was ‘now sitting on the toilet – actively pushing’. This comment was the subject of considerable debate. It was argued on behalf of D that it meant that Midwife Arrowsmith was actively encouraging the patient to push, but Judge Teague concluded that the midwife had asked D to go to the lavatory in the hope of inducing bowel movement and thereby reducing the expulsive urge.
At 09:20, Midwife Arrowsmith noted that the anterior rim was still present and made another attempt to push it back. She believed that she had succeeded, but included ‘?’ in her note to indicate that she was not sure. In fact, at 10:00, she noted that the rim was still there so she called the registrar, and D was taken to theatre.
Dr Gibbons, the registrar, identified that the baby was in the occipito posterior (OP) position, i.e. head first but with the head facing forwards. This is not the most favourable position for vaginal delivery as the head presents a larger width than if it is facing the other way. Dr Gibbons tried unsuccessfully to rotate the baby; he then attempted ventouse delivery, which failed; delivery was eventually achieved by the use of Wrigley's forceps and an episiotomy.
Held: the labour notes were ‘reliable and complete in all significant respects’. The evidence of Midwife Arrowsmith, that she would have recorded in the notes if she had instructed D to commence actively pushing throughout contractions, was to be preferred. The Claimant's recollection was honestly mistaken.
Turning to the question of anaesthetic, Midwife Arrowsmith said that she had no recollection of any specific request for an epidural. Had there been one, she would have noted it. The parents maintained that Mr D had requested one, but was told that it was too late.
Sue Brydon, the midwifery expert instructed by the Trust, considered that if such a request had been made between 09:00 and 10:00 it would not have been inappropriate to respond that it was too late.
Dr Backx, formerly an anaesthetist at the hospital, said that there was at the relevant time a 24-hour epidural service at Macclesfield. However the average delay between request and attendance of an anaesthetist was about one hour in a non-emergency situation such as this, although it could be as much as two hours.
Dr Plaat, the Claimant's anaesthetic expert, regarded a response time of one hour as substandard. Mr Anthony Johnson, the obstetric expert called by the Claimant, went further and maintained that it was substandard care not to have inserted an epidural by 08:15, or at the latest by 09:20. The Defence anaesthetist, Dr Wendy Scott, called this ‘a hugely gold standard’.
Mr Derek Tufnell, the Defence obstetric expert, thought that units should aim for a response time of 30 minutes, but considered that the Macclesfield situation was ‘not outside what is normal for such small units’.
Held: the midwives and doctors were justified in not administering an epidural. There was no good reason to do so. The purpose of an epidural is neither to reduce pelvic floor damage nor to remove the Ferguson reflex. Indeed, a low-dose epidural would probably not have removed the urge to push or even significantly reduced it.
The opinion of Mr Tufnell was to be preferred: had he been consulted about an epidural at 09:20, his only response would have been to give the syntocinon (which had been administered at 08:30) more time. There was therefore no breach of duty in not administering an epidural. Even if one had been administered, it would have made no difference to the outcome.
As to causation, although the findings already made were sufficient to dispose of the claim, Mr Anthony Johnson considered that prolonged pushing against an undilated cervix would attenuate and stretch the ligaments, thus causing the Claimant's injuries. Mr Tufnell, however, thought that passage of the baby's head had caused the damage. In other words, his view was that delivery rather than labour had caused D's injuries.
Held: the mechanism suggested by Mr Tufnell was more compelling. A passage in a 1990 textbook, cited by Mr Johnson in support of his view, had been omitted from more recent editions. The causative event had occurred when the baby passed through the pelvic floor.
Accordingly, there would be judgment for the Trust. No one was to be blamed for what had happened: the injury resulted from trauma unavoidably sustained at the point of delivery.
Jeremy Roussak (instructed by Thorneycrofts) appeared for the Claimant. Yaqub Rahman (instructed by Hill Dickinson) appeared for the Trust.
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