A birth gone horribly wrong

Saturday January 18 2020

 

By Dr Sylvester Onzivua

On October 1, 1999, Nadine Montgomery gave birth to a baby boy at Bellshill Maternity Hospital, Lanarkshire. As a result of complications that occurred during the delivery, the baby sustained injuries that resulted into severe disabilities.

Montgomery attributed the injuries her son suffered to negligence on the part of Dr Dina McLellan, a consultant obstetrician and gynaecologist, the doctor who was responsible for looking after her during the pregnancy and delivery.

The case
During the birth, the baby’s shoulders failed to pass through the birth canal even after the head had passed through. This condition is medically known as shoulder dystocia. After a lot of difficulty the baby’s shoulders were finally delivered.

However, in the course of the delivery, the nerves in the baby’s armpit were damaged and the the umbilical cord got compressed and severely compromised the blood flow to the baby. The baby suffered very severe brain damage as a result.

Montgomery alleged two grounds of negligence. She contended that she should have been given advice about the risk of shoulder dystocia, a risk factor that may occur during normal delivery. She also contended that the doctor had negligently failed to perform a Caesarean Section in response to the big baby that was diagnosed during her antenatal period.

First judge’s decision
The judge who initially heard the case rejected both grounds of the negligence alleged. In the opinion of the judge, even if Montgomery had been given advice about the risk of serious harm to her baby as a consequence of shoulder dystocia, it would have made no difference since she would not have elected to have her baby delivered by Caesarean Section.

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This decision of the court was appealed. The appellant court was asked to re-consider the duty of a doctor towards a patient in relation to advice about treatment. The trial judge was faulted for not applying the conventional test of “but for” causation in this case.

Mother’s background
Montgomery studied molecular biology at Glasgow University and graduated with a Bachelor of Science. She then worked for pharmaceutical company as a hospital specialist. She was described as a highly intelligent person. Her mother and sister were both medical doctors.
In 1999, Montgomery was expecting her first baby. She was of small stature, being just over five feet in height. She was also known to be suffering from Insulin Dependent Diabetes Mellitus.

It is well documented that women suffering from diabetes are likely to have babies that are larger than normal, and there can be a particular concentration of the weight on the babies’ shoulders. Because of the diabetes, Montgomery’s pregnancy was regarded as a high risk pregnancy that required intensive monitoring. She, therefore, attended the combined obstetric and diabetic clinic during her pregnancy under the care of Dr McLellan, throughout her pregnancy.

The science
The widest part of a baby’s body is usually the head. If the head successfully descends through the birth canal, the rest of the body will be delivered uneventfully during a normal delivery. However, the widest part of a baby of a diabetic mother may be the shoulders. In such a case the head may descend successfully through the mother’s birth canal but the shoulders may be too wide to pass through without medical intervention.

This phenomenon, known as shoulder dystocia, is the prime concern in diabetic mothers who go into labour and are delivered normally. This condition has been described as a major obstetric emergency associated with a short and long term neonatal and maternal morbidity and associated neonatal mortality even when the condition is managed appropriately.

Interventions
Expert medical advice is to the effect that help should always be summoned immediately when shoulder dystocia occurs. When the mother is in hospital this help should include assistance from midwives, an obstetrician, a paediatric resuscitation team and an anaesthetist.

There are medical techniques that can be used to widen the pelvic outlet and pressure can be applied to the mother’s abdomen in order to dislodge the baby’s shoulders and push the baby down the birth canal. The joint uniting the pelvic bones may also be cut through to widen the pelvic outlet. Another alternative is to push back the head of the baby into the uterus and then carry out a Caesarean Section.

The dangers of shoulder dystocia to the baby include injury to the nerve roots that connect the baby’s arm to the spinal cord. This may result into a permanent disability, leaving the child with a useless arm as was the case with Montgomery’s baby. In a small percentage of cases, the umbilical cord becomes compromised in the process, depriving the baby of oxygen. This can lead to severe brain damage. This rare complication also occurred in this case.

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