Obstetrics

Rupert sustained an obstetric brachial plexus injury (OPBI) in his left arm at delivery. It was alleged that this was due to negligence in performance of the delivery. PMS Expert Report considered that the antenatal care was of a poor standard, with a failure to diagnose Rupert as a very large baby despite having a scan at 35 weeks. The delivery was indeed performed negligently, with a failure to recognise shoulder dystocia, leading to a failure to perform the right movements to safely deliver him. The case was settled, and Rupert was compensated.

Chloe was admitted with premature rupture of membranes and went into labour at 32 weeks. Instrumental delivery was performed and the baby was delivered in good condition. She was admitted to the neonatal unit for treatment of respiratory distress due to prematurity and appeared to make good progress. However, right hemiplegia with abnormalities on a brain scan was later diagnosed. This was a complex case, requiring careful analysis, but PMS concluded that the brain injury had probably occurred in the antenatal period and that there was no evidence of breach of

In 2006 Rosie suffered an inter-uterine fetal death at term +13 days, subsequently delivered vaginally. She alleged that if labour had been induced earlier, her baby would have survived. PMS Expert Report concluded that most reasonable Obstetricians would have induced labour at +4 days. Furthermore, the finding of severely reduced liquor volume in an earlier scan suggested strong reasons for immediate induction. Had this happened, the baby would almost certainly have survived. The case settled and Rosie was compensated.

Emma was carrying monochrionic twins when at 33 weeks she developed abdominal pain and went into premature labour. A caesarean section was performed for foetal distress, but the first twin showed no sigh of life and could not be resuscitated. A post mortem showed that acute hypoxia due to late onset twin to twin transfusion was the cause of the baby's death. PMS was asked to investigate whether the baby's death was a result of negligence. PMS Expert Report concluded that there was clear evidence of foetal distress 70 minutes

Andrea was delivered by Caesarean section because of failure to progress in labour and her head circumference was on the 94th centile. Severe hydrocephalus due to aqueduct stenosis was diagnosed at 6 weeks of age. It was alleged that there had been a negligent failure to detect the condition at the 20 week anomaly scan. PMS concluded that the size of the head was normal at 20 weeks and there was no evidence of this type of hydrocephalus, which can develop in the second half of a pregnancy. The obstetricians and

Following Violet's delivery by Caesarean section, it was noted that she had a fracture of her right femur. It was alleged that this was due to negligence during delivery. PMS Expert Report concluded that there was no evidence of any negligence in the performance of the Caesarean section. Femoral fractures are a rare but recognised complication of Caesarean section, occurring at a frequency of 0.14 per 1000, and often no obvious cause. The case was dropped.

Bladder injury following Caesarian section Georgie suffered a bladder injury during her second Caesarean section, as well as a post partum haemorrhage of more than 3 litres. PMS Expert Report concluded that the bladder injury is a recognised complication of the operation, caused due to difficult circumstances, noting that once the injury was recognised it was repaired in a very competent manner. Therefore there was no negligence in Georgie's treatment. The case was not pursued any further.

Bowel injury following Caesarean section Lola underwent a Caesarean section for fetal distress in September 1999. The baby was born in good condition, but two days later Lola was diagnosed with peritonitis, and a laparotomy discovered a small bowel perforation. A small bowel resection and anastomosis was performed, and Lola was in intensive care for 10 days. PMS Expert Report concluded that the bowel was negligently perforated during the Caesarean Section and that it was also negligent not to identify the perforation before closing the abdomen. Lola's unusual lack of symptoms

Ureteric injury following Caesarean section Eleanor was booked for an elective Caesarean section in her second pregnancy, but went into labour before this. Delay in getting into theatre resulted in the Caesarean being performed in the second stage of labour and profuse haemorrhage occurred from a lateral tear in the uterus. Ureteric obstruction and fistula were later diagnosed. PMS concluded that the delay in going to theatre was a breach of duty, which increased the risk of complications. However, a lateral tear in the uterus into the broad ligament

Juno had a Caesarean Section in November 2006, following a trial of ventouse. The baby was in good condition, but she suffered a massive postpartum haemorrhage. The bleeding was only controlled by a hysterectomy with internal iliac artery ligation. Harrie thought that both the delivery and haemorrhage treatment were negligent. PMS Expert Report concluded that Caesarean Sections performed in the second stage of labour have a high complication rate. There was evidence of an area of unusually adherent placenta, a condition also associated with severe post partum haemorrhage. Nevertheless, if

Jackie was an insulin dependant diabetic, who became pregnant for the first time. Her blood sugar levels were difficult to control and there was evidence of a very large baby: as a result, it was decided to perform a Caesarean section at 37 weeks. The procedure appeared to be straightforward and the baby was delivered in good condition. However, there was a massive postpartum haemorrhage due to an atonic uterus, followed by disseminated intravascular coagulation (DIC). After drug treatment failed , a hysterectomy was performed. PMS concluded that it was reasonable

Christie suffered a complete wound dehiscence following an emergency Caesarean section in May 2003. She alleged that this was due to various counts of negligence before, during and after the procedure. PMS Expert Report concluded that the wound dehiscence should have been detected at an earlier stage. Although a recognised complication of Caesarean Sections, it should have been identified as soon as serious discharge occurred, which would have prevented Christie's intestines bursting out of the wound as well as the psychological trauma and pain this caused. The case settled, and

Kylie was an obese 35 year old woman in her 3rd pregnancy. Gestational diabetes was detected and the fetus was noted to be much larger than her previous babies. Spontaneous labour started at 41 weeks but, after a long first stage, failure to progress was diagnosed and Caesarean section was performed. She was discharged home, but was readmitted on the 6th day, with sepsis due to wound infection. Intravenous antibiotics did not resolve the problem and she went back to theatre for debridement of the wound, which was left open.

Adele achieved a full term normal delivery in her 3rd pregnancy, but persistent bleeding was noted after delivery of the placenta. The placenta was complete and an atonic uterus was diagnosed. Uterotonic drugs, including Syntocinon, Ergometrine and Haemabate, were given over several hours, but the bleeding continued and the patient became shocked. EUA and bimanual compression were carried out in theatre without resolving the problem and hysterectomy was performed. It was alleged, in court, that inadequate blood transfusion had allowed the claimant to become shocked and develop DIC, but PMS convinced

Carrie suffered heavy bleeding following the vaginal delivery of her second child in November 2008. 16 days after delivery she lost 2.5 litres of blood in a secondary postpartum haemorrhage, but was discharged without an ultrasound. 12 days later in early December, she was readmitted, passing a large piece of tissue identified as a lobe of placenta. PMS Expert Report concluded that the failure of the midwife to realise that a piece of placenta might be missing represents negligent care. Had this been suggested, the heavy bleeding following delivery would

Bobbi suffered a third degree perineal tear following the forceps delivery of her first child in 2009. The injury was not recognised and the external anal sphincter was not repaired at this time, leading to persistent symptoms of faecal incontinence. PMS Expert Report concluded that although the severe tear was not an optimal result, it was the failure to identify and repair it immediately that constitute medical negligence in this case. Perineal trauma is a recognised complication of forceps delivery, and the doctor was in significant breach of duty by

Yaela had a normal vaginal delivery in 2009. She sustained several tears to the vaginal and perineum which became infected and broke down. Following this she developed urinary incontinence and a rectocoele. Yaela alleged that this was due to negligence in her obstetric care. PMS Expert Report concluded that all of Yaela's problems were well-recognised complications of vaginal delivery, and that her subsequent treatment was entirely appropriate. The case was dropped.

Alice developed problems with vaginal prolapse after the normal delivery of her second child in 2000. During the delivery she got a second degree tear, which was repaired. In 2005 she presented with a cystocele and underwent an anterior repair with perineorrhapy. This did not relieve her symptoms, so in 2006 she had a vaginal sacrospinous fixation with perinorrhapy. Alice alleged that the second degree tear was not repaired properly, and that this was the cause of the problems. PMS Expert Report concluded that there was no evidence of negligence

Florence had her first baby delivered by forceps in 2000, following a failed attempt at a ventouse delivery. During this an episiotomy was performed and repaired. Subsequently Florence suffered severe pain from the episiotomy scar and discomfort in intercourse as well as post natal depression. In 2002, Dr O'Molloy diagnosed problems in the perineal scar. Florence became pregnant again in 2003, and the baby was delivered by Caesarean section. Dr O'Molloy performed an operation to refashion the perineum a few months later. Unfortunately Florence suffered further problems leading to a

Nurit was 39 when she became pregnant for the second time. She developed problems with hypertension during the pregnancy, but delivered normally following inducement. After delivery, Nurit developed pain in the right calf and was diagnosed with a deep vein thrombosis (DVT). She alleged that she should have been prescribed effective thromboprophylaxis initially, which would have avoided that problem. PMS Expert Report concluded that the behaviour of the midwives and medical staff was clearly negligent. No risk assessment was carried out, and had this been done, Nurit would have been

Cecily was born with Tetralogy of Fallot and underwent cardiac surgery to repair this as an infant. During her first pregnancy, she went into premature labour at 33 weeks. The labour progressed spontaneously and a Neville Barnes forceps delivery was performed for a face presentation. The placenta was retained and she suffered a major postpartum haemorrhage. She went to theatre for manual removal of the placenta and repair of a third-degree tear before being admitted to the High Dependency Unit for careful monitoring of her cardiac condition. She made a

Emma had been on anti-epileptic drugs for many years and decided to stop them when she became pregnant because she was concerned about fetal abnormalities associated with these drugs. She then suffer a grand mal fit resulting in a serious injury. She alleged that she had not been properly counselled about this problem before trying for a pregnancy.

Acute or subacute evidence of brain injury due to birth asphyxia, primarily caused by systemic hypoxemia and/or reduced cerebral blood flow. When John was born in 1994, he was in poor condition, with no heart beat or other signs of life. Although he was resucitated and survived, he never fully recovered. All the signs arising from postnatal treatment indicated birth asphyxia. As he grew up, John continued to have problems, including cerebral palsy, severe learning difficulties, an intermittent squint, asthma, eczema and seizures. He also suffers from constipation and insomnia on

In 2008, Sandy had a Caesarean Section in her fourth pregnancy. She requested female sterilisation at the same time, and this was carried out by tubal ligation. However, in 2010 she became pregnant. Sandy decided to terminate the pregnancy. She alleged that she was not advised of the risk of failure of sterilisation, and that the operation was performed negligently. PMS Expert Report could find no evidence of negligence in the operation, and noted that Sandy was clearly warned of a failure rate of the sterilisation procedure. The case was

Gertrude was delivered by forceps in 2001 at 39 weeks gestation. Following delivery she suffered a pelvic pain and developed an offensive vaginal discharge. On examination a tampon and a swab were found in the vagina. By 2004, the baby, Eric, had been diagnosed as suffering from global development delay, and remained under constant assessment. PMS Expert Report considered it totally negligent to leave two swabs in the vagina after suturing the episiotomy in preparation for forceps delivery. Routine checks to ensure that this does not happen had not been

Pandora developed a vesicovaginal fistula after an instrumental delivery in 2008. She was treated with an indwelling catheter for three months, before undergoing a vesicovaginal fistula repair. As negligence had already been established, PMS was instructed to prepare a condition and prognosis report on Pandora's condition. PMS Expert Report noted that Pandora was unlikely to have any long term physical problems as a result of the surgery. However, her psychological condition had been severely damaged: she was depressed, suffered psychosexual problems leading to a lack of sexual desire, and was

Dina was 31 when she underwent forceps delivery of her first child in February 2005. A few days later presented with a distended lower abdomen, and an ultrasound scan found the bladder to be over-distended. She subsequently required management with an indwelling urinary catheter and then a suprapubic catheter. Dina alleged negligence on behalf of the maternity department. PMS Expert Report concluded that Dina was at high risk of developing urinary retention following delivery of her baby, and that there was no negligence in the delivery. The diagnosis and management

After an apparently uneventful pregnancy, Melanie collapsed 4 minutes after being born and died despite efforts to resuscitate her. The post-mortem reported that the cause of death was intrauterine pneumonia with the enterococcus bacteria. PMS Expert Report concluded that this was a rare and tragic case: it is extremely unusual for a baby to deteriorate so rapidly in this way. However there was no case for negligence, as the pregnancy and labour were managed appropriately. The case was dropped.

Saga underwent a Caesarean section at 25 weeks. Her baby, Noah, was subsequently diagnosed with cerebal palsy. PMS was instructed to investigate Saga's antenatal care, labour and delivery. The Expert Report concluded that Noah's cerebal palsy was due to his severely premature birth, rather than any negligence on the part of the hospital. The case was dropped.

Congenital abnormality resulting in developmental delay Aditya was born in 2008 by emergency Caesarean section for fetal distress. She was in good condition at birth, but was later diagnosed with global developmental delay and other disabilities. PMS was instructed to review to assess whether there was any evidence of negligence in her obstetric management. PMS Expert Report concluded that Aditya's disabilities were probably the result of a gene delation. As there was no evidence of negligence in the obstetric care, the case was dropped.

Ursula had an eventful first pregnancy. Induction of labour for post maturity was arranged in 23rd May 2007. Labour was established the next day after artificial rupture of membrane and Sytocinon infusion.The second stage of labour was detected at 6pm, but progress was slow. At 10pm Ursula was given an intravenous injection of Augmentin. She went into anaphylactic shock, causing hypoxia and cardiac arrest within minutes. Circulation was restored after 34 minutes, but by this time multi-organ damage had occured. She was maintained in the Intensive Care Unit for two

Ganesha was diagnosed with Antiphospholipid Syndrome in 1992. At the time she was advised against another pregnancy and sterilised. Seven years later she sought advice about attempting a further pregnancy, and was referred to a Contraception Clinic for consideration of IVF and a discussion about the risks and benefits of a further pregnancy. Ganesha subsequently underwent IVF and became pregnant. At 22 weeks she became unwell, and was admitted to the obstetric ward. As her condition deteriorated, it was decided to terminate the pregnancy. Ganesha then developed severe respiratory symptoms

Ruby suffered a massive intra cranial haemorrhage within a few hours of delivering twins. She was intubated and ventilated, but was later shown to be brain dead. Ventilatory support was turned off. It was alleged that there was a failure to diagnose pre-eclampsia (PET) as well as a failure to control severe hypertension that developed after delivery. PMS Expert Report concluded that there was a failure to diagnose PET. Had PET been diagnosed, then there would have been half hourly measures of pulse and blood pressure, other examinations and anti-hypertensive

Tess developed a recto-vaginal fistula following the forceps delivery of her first child. This was treated with a loop colostomy initially, and then she underwent several operations to repair the recto-vaginal fissure. Tess alleged that the forceps delivery and the episiotomy repair afterwards were both negligently performed. PMS Expert Report concluded that Tess's isolated rectal injury was very rare, and that even a reasonable obstetrics could have missed it. There was no evidence of damage to the anal spincter complex or anal canal, and so the injury could not have

Maisy had an uneventful pregnancy, but intrauterine Growth Restriction (IUGR) was not detected. She went into spontaneous labour at Term +12 days. A prolonged bradycardia was detected and so it was decided that an immediate Caesarean section should be performed. The baby, Heidi, was in poor condition, requiring resuscitation and ventilation. Hypoxic ischaemic encephalopathy (HIE) Grade 3 was diagnosed and so the baby was transferred to the Neonatal Intensive Care Unit. It was alleged that detection of IUGR would have prevented Heidi's brain damage and disibilities. However, PMS Expert Report

Danielle was found to have an intra-uterine fetal death at 35 weeks. The post mortem showed that the baby had been suffering from the effects of undiagnosed gestational diabetes. Danielle alleged that the failure to diagnose the diabetes earlier constitutes negligent care. PMS Expert Report noted that if the diabetes had been diagnosed earlier, the fetal death would have been avoided. Danielle's doctor had already written admitting liability for his error in not recognising the abnormal fasting blood glucose level earlier in the pregnancy. However, the midwives acted reasonably given

"Just a quick e-mail to say thank you for all your input in this case. It was invaluable and very important in achieving the settlement. My suspicion is that the Defendant made the offer of settlement knowing that it was in difficulty in particular in relation to the surgical issues within the claim (i.e. your remit). In any event, I’d personally like to thank you once again for all your dedicated input and assistance." Barrister for a recently settled obstetrics case