Obsteric negligence claims news


Vaginal birth after caesarean section (VBAC) - risks of rupture and RCOG recommendations

The RCOG Each Baby Counts programme’s recent report into the anaesthetic care which contributed to the serious brain injury, neonatal death and stillbirths suffered by 49 babies in 2015 highlights some of the highest risk areas in maternity patient safety. Aside from the essential teamwork, communication and forward planning which is needed to handle the multiple, time-sensitive, emergencies which occur in maternity units, the report emphasised that trial of vaginal birth after a previous caesarean (VBAC), if incorrectly counselled, undertaken and managed can result in uterine rupture, severely brain damaging the fetus and threatening the life of mother and baby. 

Serious injury was caused to a baby when signs of uterine rupture (including maternal tachycardia, breakthrough pain between contractions and a worrying CTG trace) were missed during a trial of VBAC labour. Despite these warning signs, the mother was incorrectly given syntocinon, a uterine stimulant, increasing the stress on her uterine scar. The report reiterated that pain breaking through a previously effective epidural in a woman with a history of uterine surgery must always trigger an obstetric review for scar rupture.

What are the risks of VBAC compared with a planned repeat caesarean section (ERCS)?

Assuming that delivery takes place at or after 39 weeks gestation in circumstances suitable for VBAC:

  • Planned VBAC has a 1 in 200 (0.5%) risk of uterine rupture, compared with 2 in 10 000 (0.02%) in a previously unscarred uterus. The risk increases when VBAC delivery is induced or labour is augmented with syntocinon.
  • The success rate for planned VBAC is 72-75% but increases if the mother has had a previous vaginal or successful VBAC delivery. If VBAC delivery is successful, it has fewer complications than ERCS.
  • Unsuccessful VBAC resulting in emergency caesarean section carries the greatest risk of adverse outcome.
  • The risk of unsuccessful VBAC and caesarean section increases if VBAC labour is induced or augmented.

Who is suitable for VBAC?

The RCOG guidelines for VBAC list the circumstances most suited to VBAC:

  • Singleton pregnancy (i.e. expecting one baby)
  • Cephalic presentation (baby is head down)
  • Pregnancy at 37 weeks or more
  • Single previous LSCS (lower segment caesarean section - scar across the lower part of the abdomen)

A successful VBAC delivery is more likely where the mother is taller, younger than 40, and has a BMI below 30, and the labour starts spontaneously before 40 weeks, and the baby is in vertex presentation with a birthweight below 4kg.

The risk of uterine rupture during VBAC increases with the mother’s age and the baby’s gestation and size, and where the mother’s last delivery took place less than 12 months previously.

Who can’t have a planned VBAC delivery?

Planned VBAC is contraindicated where there is:

  • A history of uterine rupture
  • Previous classical caesarean scar (scar goes vertically up the middle of the mother’s abdomen)
  • Placenta praevia (i.e. the placenta’s position would obstruct a vaginal delivery)
  • The mother has a history of other uterine surgery

Who decides whether the delivery will be by VBAC or ERCS?

The choice of delivery mode must be agreed by the mother and a senior obstetrician, based on her personal risk factors, before the planned date of delivery and after she has been counselled about the risks and the circumstances in which a trial of VBAC would be abandoned and caesarean section needed. All antenatal counselling must be documented in the medical records. If ERCS is planned, an agreed contingency plan for early spontaneous labour must be written in the records.

What additional safety measures are in place during VBAC delivery?

Labour must take place in a delivery suite equipped for continuous intrapartum care and monitoring, with facilities for immediate caesarean delivery and advanced neonatal resuscitation. The fetal heart must be continuously monitored electronically from onset of regular contractions throughout the VBAC, to ensure early detection of maternal or fetal compromise, obstructed labour or uterine scar rupture. The mother’s condition and progress of labour must be regularly monitored by one-to-one care.

What are the clinical signs of uterine rupture in labour?

The three classic signs of uterine rupture are pain, vaginal bleeding and fetal heart-rate abnormalities, but in 48% of all cases the scar breaks down without any maternal symptoms and is diagnosed later during surgery.

Clinical signs associated with uterine rupture include:

  • Abnormal CTG (most common sign)
  • Severe abdominal pain, particularly if the pain persists between contractions
  • Sudden scar tenderness
  • Abnormal vaginal bleeding
  • Haematuria (blood in the urine)
  • Previously efficient contractions stop 
  • Maternal tachycardia (elevated heart rate), hypotension (low blood pressure), fainting or shock
  • There is a change in abdominal shape and fetal heart-rate not detected at the previous transducer site
  • The fetus is no longer presenting properly

Suspected rupture of the uterine scar is an emergency requiring urgent caesarean section and neonatal resuscitation as the unborn baby is deprived of oxygen, leading to permanent brain damage or death.

As specialists in birth trauma claims, Boyes Turner’s medical negligence team are experienced in helping mothers and babies affected by uterine rupture during inappropriately counselled or managed VBAC deliveries.  

If you or your baby have suffered severe injury as a result of birth-related medical negligence contact one of our specialist solicitors by email mednegclaims@boyesturner.com.

MBRRACE - Sepsis and maternal deaths

The recent report, Saving Lives, Improving Mothers’ Care, from UK maternity services watchdog MBRRACE, found that in 2013-2015, 41% of the women who died during pregnancy, childbirth or postnatally, might have had better outcomes with improved care.

Whilst the number of deaths from indirect causes of maternal sepsis had decreased overall – an improvement they attribute in part to raised awareness of the condition resulting from the campaigning work of organisations such as the UK Sepsis Trust - 24 of the reviewed maternal deaths between 2013 and 2015 had sepsis as their primary infective cause. Nearly half of these were directly caused by sepsis and four arose from urinary tract sepsis or wound infection after caesarean section.

The report referred to the World Health Organisation’s (WHO) new international definition of maternal sepsis for 2017, which describes maternal sepsis as "a life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or post-partum period."

Multiple opportunities are being missed at all stages

It went on to make specific recommendations for prevention and treatment of sepsis in maternity services, many of which reflected the panel’s identification of a recurrent, dominant theme that multiple opportunities are being missed at all stages of pre-pregnancy, pregnancy, birth and postpartum to anticipate and take steps to reduce the patient’s risk.

With this in mind, recommendations were made for high level action to ensure that it is seen as the responsibility of all health professionals to facilitate opportunistic counselling and advice. Preventative measures should include increasing uptake of the flu jab, as influenza is a known cause of maternal sepsis-related death. In the recognition that women might be put off by having to attend yet another appointment, the report recommended that as pregnant women attend maternity services during pregnancy, funding should be made available for the delivery of influenza immunisation in maternity services as part of their antenatal care, rather than as a separate appointment in primary care.

Recommendations for the recognition and prevention of postpartum sepsis included the somewhat obvious instruction to community midwives to have a thermometer with them when they carry out home visits so that they can check the temperature of postpartum women who are unwell. The panel regarded having the ability to check the postpartum mother’s temperature as a minimum requirement, along with checking blood pressure, pulse and respiratory rate. They recommended that the new NICE Guidelines (not due for publication until 2020) should make this guidance clear.

In addition, health professionals were reminded to check the unwell woman’s overall clinical condition rather than relying solely on her MEOWS score which tracks changes over time in observations such as temperature, blood pressure, heart rate and respiratory rate. This is another recurrent theme, echoing the findings of the RCOG’s Each Baby Counts report which reminded maternity healthcare providers that accidents (and claims) could be avoided if they would assess the patient taking into account the full clinical picture rather than just looking at the CTG.

Following a reminder that the key actions for diagnosis and sepsis are:

  • Timely recognition
  • Fast administration of intravenous antibiotics
  • Quick involvement of experts with senior review noted as essential

…other recommendations included "declaring sepsis" – by invoking a protocol to ensure that all relevant members of the multidisciplinary team are informed, aware and act upon a potential diagnosis of sepsis, again drawing on the importance of escalation and communication between the various disciplines of health professionals who together are responsible for the woman’s care.

Multiple presentations by the woman, even in different settings (eg at the GPs surgery, then at A&E) should be seen as a "red flag" warning, requiring careful review and escalation to senior clinicians.

The panel emphasised that chronic illness and immunosuppression are in themselves risk factors for sepsis. Women with chronic illness, such as diabetes or sickle cell trait which put them at increased risk of infection should, therefore, have a lower threshold for admission to hospital, antibiotic administration and input from senior clinicians.

"Critical care is a management modality not a place."

In the event of a shortage of ITU or HDU beds, the report reminds healthcare providers that "critical care is a management modality not a place" If a woman is ill enough to need intensive care, she also needs close observation and support whilst awaiting transfer to ITU. The requisite level of care should be provided wherever the woman is located and not delayed whilst waiting for a critical care unit bed.

Whilst the significant reduction in maternal deaths from sepsis between 2010-2012 and 2013-2015 is a welcome demonstration of the value of the awareness raising work of the UK Sepsis Trust, there is much work still to do if the government is to meet its target of halving the number of maternal deaths overall by 2030.

Anticipating and reducing risk, adopting responsibility, communication and timely escalation emerge as the essential learning points for health practitioners, especially in times of high activity in maternity and A&E units.

If a family member or friend has died due to medical negligence and has left behind dependant children we may be able to help. Contact us on 0800 884 0718 or email mednegclaims@boyesturner.com for a free initial discussion.

MBRRACE UK's latest maternal deaths report (2013-2015) says no reduction in maternal death rate

MBRRACE-UK have published their 2017 report, Saving Lives, Improving Mothers’ Care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013-2015.

MBRRACE-UK is an acronym for ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK’, a national collaborative programme which audits and investigates maternal deaths, stillbirths and infant deaths. The 2017 report forms part of the NHS-funded Maternal, Newborn and Infant Clinical Outcome Review Programme, which aims to promote and increase quality improvement in patient outcomes through clinical audit and review. 

The ‘Saving Lives, Improving Mothers’ Care’ report summarises the lessons that a team of leading clinicians believes the NHS should learn from their review of the care of 556 women who died during or up to a year after the end of their pregnancies between 2013-2015.

Maternal deaths are reported to MBRRACE-UK by healthcare staff, coroners and other sources and are cross-referenced against national records. The deceased’s medical records are then anonymised before being reviewed by a pathologist and an obstetrician to establish the cause of death for the purpose of the review. They then undergo detailed scrutiny of the deceased woman’s care by a large panel of obstetricians, midwives, pathologists and other specialists, such as GPs, intensive care or emergency medicine specialists, psychiatrists or physicians, depending on which areas of medicine are relevant to the particular woman’s treatment. The reviews are then further examined by a multi-disciplinary group who identify the main themes and lessons to be learned which they present in their reports, together with their recommendations for future care.

The report combines a statistical analysis of the cases reviewed to facilitate comparison of outcomes year on year. Alongside the stats, we are given brief but more detailed insights into the events leading up to the deaths of some of the women, giving a clinical context to the commentary on their care. However, the most fitting context for the report’s findings is presented in the foreword, by Professor Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, when she says:

It is impossible to read a report of this nature, including the details of the women affected, and not feel a pressing need to act. We owe it to the 359 motherless children, and countless other family members and friends of the women whose deaths are reported here, to do all we can to try to prevent women from dying in the future.”

In 2013-2015, out of every 100,000 maternities in the UK there were 8.8 maternal deaths (during pregnancy or up to six weeks after the end of the pregnancy).

The figures suggest that there was no change in the overall maternal death rate since MBRRACE’s report on UK maternal deaths between 2010-2012 – a worrying finding which prompted a call for urgent further action if the government is to achieve its target of reducing maternal deaths in England by 50% by 2030.

Equally concerning was the assessors’ finding that 41% of the women who died might have had a different outcome with improvements in their care. 

Two thirds of the women who died had pre-existing physical or mental health problems. Whilst these patients are at higher risk, they should also be easier to identify at an earlier stage as needing specialist maternity care. The recurring, dominant theme was that there are multiple opportunities to reduce women’s risk of complications through early and forward planning of the care of women who are known to have pre-existing medical problems. It must be seen as the responsibility of all health professionals to use these multiple opportunities opportunistically and resources should be made available for them to do so. The report cited provision of appropriate advice and optimal medication before pregnancy, specialist referral in early pregnancy and planning of antenatal, intrapartum and postnatal care, along with postnatal advice about risks and planning for future pregnancies as the key improvements which are needed to prevent women from dying or experiencing severe complications.

Specific recommendations were also made for improvements in the care of women with various conditions, including epilepsy (which accounted for 52% of the cases in which better care would have altered the outcome), sepsis, stroke, haemorrhage and mental health problems.

The report recommended that all maternity units should have escalation policies for periods of high activity including plans to obtain more (including more senior level) obstetric and anaesthetic assistance as well as increasing midwifery staffing levels.

If a family member or friend has suffered a fatality through medical negligence we may be able to help. Contact us on 0800 884 0718 or email mednegclaims@boyesturner.com for a free initial discussion.

60 seconds with a medical negligence lawyer

Over the following year we will be sharing a series of question and answer articles about our day-to-day lives in the medical negligence team. This week, it’s Rachel Carey's turn, a solicitor in the team.

Rachel qualified in April 2016 and joined the medical negligence team at Boyes Turner in November 2016. Rachel’s clients have suffered obstetric and gynaecological injuries, Erb’s palsy, pressure sores, disability resulting from delayed diagnosis and treatment of cancer. She acts for the bereaved spouses and children of patients who have died as a result of negligent medical care.

What made you choose a career in medical negligence?

The driving force behind my decision to study law and specialise in claimant medical negligence work was my desire to help David, rather than Goliath. I have a keen interest in medicine and enjoy using my skills and expertise to help our clients get back on their feet or live a more fulfilling and stress free life following a medical accident. I find it incredibly satisfying to be in a position which allows me to guide clients through the legal process which I know many will find daunting and overwhelming.

Which personal skills does it take to succeed at this type of work? 

It is really important for a medical negligence solicitor to have empathy, be able to show understanding and have the ability to remain calm in stressful situations. As the majority of the medical accidents we deal with cause life changing injuries which devastating consequences to our clients and their families, I ensure that I always bear that in mind and treat them sensitively and patiently.

What is the most rewarding part of your work? 

I recently met with a young client’s Mum on a case where the hospital had admitted liability. She told me how relieved she was to know that, as a result of the compensation, her son, who has cerebral palsy, would be looked after and taken care of for the rest of his life when her and her husband were no longer able to. She was excited to be able to move into a more appropriately sized and adapted home which could cater for her son’s needs. I could see how much that meant to her and to know that the work I had been a part of had helped was incredibly rewarding and made me realise even more how important the work we do is for people.

International prenatal infection prevention month - Raising awareness of prenatal infections

February this year is international prenatal infection prevention month, which raises awareness of prenatal infections, including meningitis and group B Strep. Such infections are the UK’s most common cause of life-threatening infection in babies up to three months old.

What is group B Strep?

Group B Strep is a form of meningitis caused by Group B streptococcal bacteria: Streptococcus agalactiae. It is the biggest cause of neonatal meningitis in the UK and can also cause septicaemia (blood poisoning) and pneumonia.

Not all babies exposed to group B Strep become infected, but, for those who do, the results can be devastating. Group B Strep can cause babies to be miscarried, stillborn, born prematurely, become very sick, have lifelong handicaps, or die.

Protecting babies from group B Strep

There are many ways to help protect babies from group B strep and to prevent these harmful injuries, including giving antibiotics to women in labour who carry group B Strep late in pregnancy. These massively reduce the risk of your newborn baby developing a group B Strep infection. There are no symptoms of carrying group B Strep, so the only way to find out whether you are is through testing.

Researchers around the world are working on developing a vaccine that will one day prevent almost all group B Strep infection in babies, but it’s not available yet.

Our experience

Unfortunately the medical negligence team at Boyes Turner LLP know only too well the risks associated with group B Strep and meningitis.  We currently act for clients who have suffered life limiting injuries as a result of delays in diagnosis of infection.

Offer your support to the campaign by raising awareness on Twitter using #groupBStrep #ProtectYourUnbornBaby @GBSSupport @MeningitisNow.

Are home births the answer to our NHS funding crisis?

Draft guidelines have been produced by the National Institute for Health and Care Excellence (NICE) regarding the care of healthy women and their babies during childbirth.  These guidelines recommend that home births and midwifery-led care should be encouraged for women with a low risk of complications.

“Low risk” has been described as women without any pre-existing medical conditions or risk factors such as, high BMI, high blood pressure or a previous history of caesarean section.

First time mums with a low risk of complications will be advised to give birth at a midwifery –led unit which could be either based at the hospital site or elsewhere.

Low risk mums who have given birth before will be advised to give birth at home where possible.

The guidance is a result of new evidence that suggests that in low risk women, the rate of intervention during labour is much lower and the outcome for a baby who is born at home is comparably the same as a baby born at an obstetric facility.

The guidelines are only in draft form and are open to consultation until 24 June 2015.

Emily Hartland, a solicitor in the Medical Negligence team at Boyes Turner, commented:

“Whilst some organisations are in support of the new guidelines, others such as the Birth Trauma Association have expressed some concerns that there is ‘no robust evidence to justify NICE assuring low risk first time mothers that to give birth in a free standing midwifery unit is as safe as is a hospital…… there is evidence to suggest the contrary.’ Boyes Turner act for many families where urgent care has been delayed with tragic outcomes.  Whilst these draft guidelines refer to low risk mums only, women should think very carefully about the risks of delivering at home or at a midwifery-led unit without immediate access to emergency care should obstetric complications occur. It is crucial that women are able to make informed choices and that any risk factors are carefully assessed throughout their antenatal care.  We are concerned that the failure to recognise complications early, either in the antenatal period or at delivery, could led to an increase in birth injuries both for mum and child and that pressure to cut costs  may be a key factor in the development of these guidelines.” 

Each Baby Counts' - RCOG launch campaign

The Royal College of Obstetricians and Gynaecologists launched a 5 year project to halve number of baby deaths due to complications during labour

In the UK, around 500 full term babies die or are left severely disabled each year because something goes wrong during labour, such as they are starved of oxygen.

The Royal College of Obstetricians and Gynaecologists (RCOG) has launched a new five year project which aims to halve the number of stillbirths, early neonatal death and brain injuries occurring in the UK as a result of complications during labour by 2020.

From January 2015, the ‘Each Baby Counts’ project, which is part funded by the Department of Health, will being collecting, pooling and analysing data from all UK maternity units to identify avoidable issues to improve future care and prevent these tragic events.

Professor Alan Cameron, RCOG Vice President for clinical quality has stated:

“We will monitor where these incidents occur and why.  Sharing of these sensitive data will provide us all with a unique opportunity to improve the care we provide and save lives”.

Rhiannon Jones, solicitor with the Boyes Turner Medical Negligence team, comments:

“We have significant experience of dealing with cases where the stillbirth, neonatal death or birth of a baby with brain injuries has a devastating effect on women and their families. By collecting information from around the UK, hopefully much can be learned to prevent these tragedies from occurring.”

Compensation claim settled for £150,000 after hysterectomy causes bowel damage

An individual has received £150,000 to compensate her for the injuries she sustained following an unnecessary sub-total hysterectomy. The surgery was performed after an ovarian cyst was suspected to be malignant.  However, it was later discovered that the cyst was in fact benign and if the doctor had taken the appropriate steps in the circumstances, including a full review of the various ultrasound images, it would have been clear that the risk of the cyst being malignant was less than five per cent.

The individual had a previous medical history of endometriosis and ovarian cysts. Following concerns that a cyst on her ovary was malignant, she was advised by the doctor to undergo a sub-total hysterectomy, even though there was a high risk that she could develop bowel damage and had previously been told to avoid surgery.

It was alleged that the doctor had failed to review the individual’s various ultrasound images, failed to consider the CA125 tumour marker and failed to refer the matter to the multidisciplinary team before advising the individual to undergo surgery.

Following the advice of the doctor, the individual felt re-assured and underwent surgery. Unfortunately, during the surgery her lateral femoral cutaneous nerve and bowel were damaged. As a result, she suffered from peritonitis (an infection of the abdomen lining) and required emergency surgery to repair the bowel and treat the peritonitis. She sadly became infertile after experiencing early menopause and suffered from many other symptoms, including bowel obstruction, severe abdominal pain, poor mobility and a tingling sensation in her legs.

All of her symptoms were considered to be permanent and had a dramatic effect on her daily life. Her husband had to help her to get in and out of bed and help her with personal hygiene. As household chores became impossible, her husband had to resume the role, including cooking, cleaning, laundry and food shopping.

The hospital admitted liability and a settlement was reached in the sum of £150,000. £60,000 was attributable to the individuals pain and suffering which was considered extensive and permanent. £90,000 was attributable to past and future care costs.

Emily Hartland, a solicitor at Boyes Turner comments:

“This is a sad case involving permanent injuries which could have been avoided. Whilst the compensation will never reverse the damage caused, the money will help the individual and her husband to pay for any future care needs. ”

Shift in NHS policy could see increase in home births

NICE, the NHS watchdog have announced a radical shift in NHS policy which will see hundreds of thousands more women encouraged to give birth at home. Mothers-to-be will be told that unless there is a high risk of complications they do not need a hospital delivery. First-time mothers are to be advised they are just as safe having their baby in a small midwife-led unit as on the labour ward.

The encouragement for home births marks a major change in NHS guidance, which previously advised mothers to be cautious about having their baby at home.

NICE says its proposals reflect recent evidence. But the change of policy at a time when many hospital labour wards are struggling to cope with the highest birth rate in 40 years, will lead to concerns the NHS is simply trying to save money.

Home births are now recommended by NHS

NICE, the NHS watchdog, have announced a radical shift in NHS policy which will see hundreds of thousands more women encouraged to give birth at home. Mothers-to-be will be told that unless there is a high risk of complications they do not need a hospital delivery. First-time mothers are to be advised they are just as safe having their baby in a small midwife-led unit as on the labour ward.

The encouragement for home births marks a major change in NHS guidance, which previously advised mothers to be cautious about having their baby at home.

NICE says its proposals reflect recent evidence. But the change of policy at a time when many hospital labour wards are struggling to cope with the highest birth rate in 40 years, will lead to concerns the NHS is simply trying to save money.

Sue Brown, head of Boyes Turner’s  Medical Negligence claims team, comments:

“Most mothers say that they prefer to give birth in hospital in case anything goes wrong. But many midwives support home birth as a safe and far more personal and comfortable choice. The problem is that if something does go wrong, it can be more difficult to have a legal remedy as inevitably time will be lost in admitting a mother in labour to hospital. Certainly there is a place for home birth for many but not all and mothers reluctant to deliver at home should not be put under pressure to do so”.

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