AvMA Annual Clinical Negligence Conference June 2014, Hilton Brighton. Mr Duncan Irons Senior Consultant University Hospital Durham

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3 AvMA Annual Clinical Negligence Conference June 2014, Hilton Brighton Mr Duncan Irons Senior Consultant University Hospital Durham

4 CTG s common errors Uterine rupture Caesarean complications Episiotomy / third degree tears

5 Oct 2012 NHSLA Ten years of Maternity claims An analysis of NHS Litigation Authority Data

6 NHSLA 2012 CTG interpretation (1st place 1998, syntocinon) Uterine Rupture (C/S rate %, %) Perineal Trauma (3 rd degree tears) ( Awareness / diagnosis) Ultra sound (new)

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8 BMJ % intrapartum death secondary to suboptimal care 90% caused by hypoxia Start labour normal CTG risk death 1 in 10,000 Overall risk 1 in 3,000 (exclude prem SGA )

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10 CTG - Errors in Litigation Failure to recognise Suspicous/Pathological Failure to 16:30 20:30 08:30 Failure to review promptly Faffing instead of FBS ing Failure to follow NICE Failure to deliver NOW with bradycardia

11 Para 1, Previous normal delivery in 2007 Admitted at weeks gestation with regular contractions No Rupture Of Membranes 2.34 hrs; CTG commenced 3.00 hrs: VE Cervix 2 cm dilated Given codeine phosphate and paracetamol for analgesia

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14 3.35 hrs CTG- Decreased variability (no overall impression documented) Plan Lucozade and review in 15 min New midwife in to cover break

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16 4.10 hrs- CTG still very reduced variability Registrar asked to review. Reviewed by registrar at 4.20 hrs Overall suspicious - Plan For ARM and inform if any concerns Midwife returns from break and performs ARM-Cervix 7 cm dilated ARM done- Grade 2 meconium stained liquor FSE applied- Plan to reassess in 3 hrs

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18 5.18 hrs- Registrar bleeped but no response 5.20 hrs VE as patient has strong urge to push Cervix fully dilated, Spines to +1 station. Active pushing commenced.

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20 5.30 hrs - FH to 65 during contraction- Registrar bleeped 5.44 hrs- seen by registrar- vertex visible- Episiotomy and baby delivered in poor condiotin at 5.48 hrs

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22 Cord gases art ph 6.8 BE vein ph 7.0 BE -12. Baby needed resuscitation and head cooling after transfer to Level 3 unit

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24 Mistakes Failure recognise Pathological CTG Failure in communication midwives Failure to follow NICE/RCOG Document impression Plan Return/Review - 3 hrs!! Failure to respond to Bleep Ouch!!

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26 Failure to recognise Suspicous/Pathological Dr C BRAVAD O (beer mat S/Land) Gestation and decleration Variability

27 Faff ing instead of FBS ing When in doubt FBS Reasons not to FBS very prem HIV / hep B Face (not breech) Delay in second stage FTP Deliver Bradycardia

28 FORCEPS!!

29 Failure to review promptly 5-10 mins for suspicous/pathological SHO ask Reg or FY2 / ST 1-2 inform SpR Remember cons at home and free BUT reluctant to call WHY? Resident? Was senior Midwife informed/seen CTG? Midwife - More likely call cons (senior/not their boss)

30 Failure to deliver NOW with bradycardia Delay adds up timeline + 3 mins delay midwife calling doctor + 2 mins delay attending + 6 mins decision FSE or U/S!!! = 11 mins Up to 10 mins = normal After 21 mins = Damage / HIE

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33 04.00 Syntocinon increased to 36ml/hr. Midwife L with an abnormal CTG has increased the Syntocinon. This is performed despite LB contracting well at 4-5:10. National guidelines suggests there is no need to further increase the Syntocinon. Furthermore, with an abnormal CTG this would further increase the strength of contractions and further worsen the oxygen supply to baby KB. This is substandard care.

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35 By Pathological CTG - fetal blood sample,or delivery was mandatory Instead, the midwife waits until (page 98) Registrar asked to come and review trace as reduced baseline of 100bpm, good variability. Variable decelerations now taking longer to recover. Comment By this is a pre terminal trace

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37 FORCEPS!!

38 Outcome Cord three times tight round neck ph 6.9 CP Waiting

39 Action!!!! (lack of) Review later (after my shift finishes) Doctor to review (when? Who?) Continue CTG (then what?) Called to another patient or Unit Busy Senior midwife informed duty to do so Cons at home duty of care?

40 Action Pathological must stop Syntocinon NOT reduce nor halve FBS or deliver (gestation permitting) Suspicous Midwife MUST inform the doctor Doctor MUST attend Time to attend Duty of care Pathological 5 mins Suspicous 10 mins

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42 Litigation in Midwifery Intermittent Auscultation (listening in) First stage Listen in every 15 mins Second stage after every contraction for 1 min

43 Syntocinon = Big Bucks

44 Common Substandard Care with Syntocinon Reasonable Progress contraction 4 to 5 in 10mins Prev C/S 3 to 4 in 10mins Starting when CTG NOT reassuring

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46 Ante natal CTG vs Intrapartum Threshold ante natal decels = C Section Reduced variability and shallow decels with reduced FM = deliver For most AN abnormalities unlikely FBS possible so deliver?

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48 Uterine Rupture Very very rare antenatally /no contractions Spontaneous not substandard RISK hence substandard care is all VBAC

49 Risk is obvious

50 VBAC - substandard Ante natal discussion / documentation Patient wants elective C/S declined why? post 2011? Check prev op note extension? Assessment of Success VBAC No prev vaginal birth BMI > 30 IOL!! Prev C/S for dystocia

51 VBAC Counselling Documentation Is success 72-76% Prev VBAC 90% Unfavourable 40%

52 Its very easy even for lawyers!!

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54 Too posh to push Is it sub standard not to agree?

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57 Induction with VBAC Not substandard BUT duty for more counselling -RANGE OPINION Risk Rupture x 2-3 increase PG IOL increase rupture Synto IOL increase rupture Synto max 4 in 10 When progress in Labour arrests 2 hrs - QUIT

58 PRE Rupture CTG abnormalities is commonest finding Doctors think of Baby NOT Mum CTG is abnormal in 55-87% cases Push for vaginal delivery in unscarred uterus risk is negligible

59 Warning signs Abnormal CTG Abdo pain Chest pain/shoulder pain Scar tenderness Vaginal bleeding Loss contractions Maternal tachycardia / low BP Fetal head rising out pelvis

60 Great caution BUT not substandard for VBAC if Mum wants with Twins Breech / ECV? Large baby + prev large Less than 1 yr No/great caution Less than 2 yrs caution Counselling & Documentation MUST be by Consultant (RCOG 2007)

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62 Caesarean Complications Retained placenta =substandard because use hand / swab check inside Major haemorrhage Extension / tear to uterus much more often at full dilatation usually not substandard Bleeding rarely substandard from uterus long labour - muscle fails to contract

63 Caesarean Complications Bladder damage Mmmmm Notice damage & repair catheter 7-10 days fine? sub standard BUT no sig quantum Avascular necrosis = sub standard Cut or tear no repair = sub standard probably May lead to fistula 5-10%!! = quantum

64 Ureter damage at C/Section Uneventful C/Section how did they do it? = sub standard NOT acceptable complication With Massive haemorrhage NOT substandard (ureter close to uterine vein+artery cross) Life saving sutures, hysterectomy Eg Adrenaline infusion BUT get IVU / stent soon as reduce risk damage etc

65 Caesarean complications Wound breakdown Wound haematoma Wound infection Rarely Sub standard care Check use antibiotics / heparin + BMI

66 Bowel damage at Caesarean Nearly always sub standard Bowel is out of way unless adhesions from prev surgery & emergency - damage on way in Mark and repair after Un noticed bowel damage = peritonitis = quantum

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68 Perineal tears/episiotomy/third degree tears

69 Incidence of 3 rd /4 th degree tears reported is up three fold up over 20 yrs Source of concern at RCOG 2014 Increased incidence vs Increased awareness and diagnosis/misdiagnosis

70 The occurrence of 3 rd / 4 th degree tear rarely substandard (RCOG) Failure to recognise 3 rd is sub, 4 th? Sutured correctly % good outcome Fistula might be substandard Infections non substandard

71 3 rd degree tear repair Suture technique Overlap vs end to end no difference outcome Must use antibiotics Must use laxatives Later Endo Anal U/S- function vs U/S

72 Missed 3 rd degree Midwife/Doctor fails to do PR examn Leads to faecal incontinence Following successful repair may still have urgency Compare to urine incontinence Common temporary following forceps Will resolve most cases Rarely substandard

73 Episiotomy Breakdown occurs as recognised complication Rarely substandard? Student? time taken Increased chance if with missed 3 rd degree May cause fistula 5-10% if not recognised and repaired or colostomy if later

74 Episiotomy Suture too tight? - 2 finger V/E at end Then not substandard but healing No V/E poss sub standard If infection - leave to heal as open wound - reasonable standard of care

75 Episiotomy With operative delivery NOT substandard not to perform With Ventouse trend away from episiotomy Decision is with accoucher General- forceps epis, ventouse no epis

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