A birth gone horribly wrong 2

Saturday January 25 2020

 

By Dr Sylvester Onzivua

Ms Nadine Montgomery, a graduate of Glasgow University working as a hospital specialist with a pharmaceutical company, sued the Lanarkshire Health Board when her child suffered very severe birth injuries at Bellshill Maternity Hospital, Lanarkshire, during what should have been a normal delivery.

The baby’s shoulders got stuck in the birth canal (a medical condition known as shoulder dystocia) after his head had passed through. The health workers had to forcibly pull out the baby and this resulted in the severe injuries that the baby sustained.

Ms Montgomery was told in the course of the pregnancy that she was having a larger than usual baby. But she was, however, not warned about the risks of her experiencing mechanical problems during labour. In particular she was not told about the risk of shoulder dystocia.

It is well known that the risk of shoulder dystocia is about 10 per cent in diabetic mothers and Dr McLellan, the doctor who attended to Ms Montgomery, accepted in court. However, the doctor told court that her practice was not to spend a lot of time, or indeed any time at all, discussing potential risks of shoulder dystocia.

She explained that this was because, in her estimation, the risk of a grave problem for the baby resulting from shoulder dystocia was very small. It is actually estimated that in this condition the risk of injury to the nerves roots supplying the arms is about 0.2 per cent.

The doctor told court that in her opinion if this condition was mentioned to all mothers, most women would opt for a Caesarean Section. She further told court that “if you were to mention to any mother who faces labour that there is a very small risk of the baby dying in labour, then everyone would ask for a caesarean section, and that is not in the maternal interests for women to have caesarean sections”.

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During her fortnightly attendances at the antenatal clinic, Ms Montgomery underwent ultrasound examinations to assess the size and growth of the baby. The final examination was done at 36 weeks of pregnancy. The doctor decided that patient should not have a further scan at 38 weeks, as it should normally have been, as the patient was becoming anxious about the size of her baby. The anxiety was related to her ability to deliver the baby normally.

The doctor, in her evidence, accepted that the patient had expressed concern about the size of the baby and about the risk that the baby might be too big to be delivered normally and admitted that these concerns had been mentioned more than once.

The doctor, however, told court that the patient had not specifically asked about the risks of shoulder dystocia. Had the patient so asked, the doctor told court, she (the doctor) would have advised the patient not only about the risk of shoulder dystocia but also about the risk of cephalo-pelvic disproportion (the risk of the baby’s head being stuck in the birth canal during delivery).

Doctor confident
And to the doctor, it was only fair to allow somebody to deliver normally. The doctor, therefore, told the patient that she would be able to deliver normally and that if any difficulties were encountered during the labour then the option of a caesarean section remained open.

The patient accepted that option. The patient, however, told court that if she had been told of the risk of shoulder dystocia, she would have wanted the doctor to explain to her what it meant and what the possible risks of the outcomes would be. If she (the patient) considered that it was a significant risk to her (and, in light of what she subsequently learnt, she would have assessed it as such) she would have asked the doctor to perform a caesarean section.

Dr McLellan estimated that the weight of the baby would be 3.9kg at 38 weeks of pregnancy, when the baby was planned to be delivered. She made this estimate based on the last scan. The doctor told court that if she thought that the baby’s weight was likely to be greater than 4kg she would have offered Ms Montgomery a caesarean section. The general practice is to offer a caesarean section to diabetic mothers where the estimated birth weight is 4.5kg. The doctor, in this case, decided to reduce the threshold to 4kg because of the mother’s small stature.

The doctor was aware that estimating birth weight by ultrasound has a margin of error of plus or minus 10 per cent. But she decided not to take this into consideration stating: “If you do that you would be sectioning virtually all diabetics”.
By the time Ms Montgomery had her last antenatal check at 36 weeks, the doctor had already made arrangements for labour to be induced at 38 weeks and five days of pregnancy.

The doctor, further, admitted in court that she should have estimated the baby’s birth weight at 38 weeks and five days rather than at 38 weeks, and that the estimated birth weight would then have been over 4kg, which was even beyond the threshold that she herself had set. In the event, the baby was born on the planned date and weighted 4.25 kg.

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