Our client found out she was pregnant at the end of 2013. Her pregnancy progressed without complication and she was booked in at North Devon District Hospital for a planned induction or labour. However, prior to her planned induction she reported a second episode of reduced fetal movement, of waking with wet pyjamas and a show that was strange in appearance.
She was admitted to hospital. A cardiotocograph (CTG) was initiated and reported as normal. A vaginal examination (VE) assessed the cervix as being 2cms dilated with her membranes intact. The Claimant was advised that an induction of labour would take place later that morning at 08:30.
At 08:00 she reported feeling fetal movements and was identified as requiring an obstetric review. However there was no evidence that this review actually took place.
At 14:00 the CTG was assessed as normal and at 14:50 the CTG was discontinued as the claimant was mobilising.
At 18:54 the CTG recorded the baby’s heartrate as 135 bpm.
She was transferred to the delivery suite and identified as a suitable candidate for a pool birth. A partogram was commenced at 20:45 and the baby’s heart rate was recorded at 136 bpm (beats per minute).
At 21:02 a "bloody liquor show" was observed. The claimant was assisted into the pool at 21:08. Additional midwifery support was requested as the midwife present was heavily pregnant herself and unable to safely deliver a baby in the pool.
At 21:10, the baby’s heart rate was recorded as 105 bpm and the care was handed over to the receiving midwife. The first midwife remained in the room to record notes.
At 21:15, the baby’s heart rate was recorded as 115 bpm post contraction.
At 21:18 an examination was performed whilst the claimant was in the pool. Her cervix was noted to be fully dilated, but the midwife was unable to auscultate the baby’s heart rate, so a CTG machine was requested. The plan was to remove the claimant from the pool if not reassured by the fetal heart from the ultrasound Doppler attached to the CTG machine.
At 21:19 she had a further bloody vaginal loss. The baby’s heart rate was recorded as 112 bpm and the claimant’s pulse as 90 bpm.
The baby’s heart rate then varied considerably from 105 to 123 bpm until 21:51. The baby’s heart rate recordings during this period appeared to be similar to those for the claimant’s pulse.
At 21:53 she was assisted out of the pool as the baby’s heart rate was recorded as being below 110 bpm. At this point there had been a significant change in heartrate for 43 minutes. The midwife, who was coming to the end of her shift, described the situation to the Labour Ward Coordinator as “progressing slowly”, and there were no further concerns.
At 22:00 the fetal heartrate was recorded as 132 bpm but there was uncertainty in relation to the maternal or fetal heart being heard. A CTG was commenced at 22:01. There was difficulty in the CTG maintaining contact with the claimant due to her position and that she was in distress.
At 22:15 the midwife asked the midwifery assistant to call for assistance as shoulder dystocia was suspected. An additional midwife arrived at 22:16.
At 22:26 the emergency call bell was pulled as the midwife anticipated shoulder dystocia and was concerned about the fetal heartrate.
At 22:27 an episiotomy was attempted, but the midwife found the scissors to be blunt. A second attempt made by another midwife with the same scissors was also unsuccessful.
At 22:28 the neonatal team were requested to attend and a staff grade obstetrician was called.
At 22:29 a new pair of scissors had arrived and an episiotomy was successfully performed. At 22:30 a paediatric staff grade and special care baby unit nurse arrived in the room.
At 22:27 a 2333 call was made to switchboard for the neonatal team and obstetrics and gynaecology specialist grade by the midwife to attend for suspected shoulder dystocia.
At 22:30 “turtle necking” was noted and the bed was laid flat by the midwife so pressure could be applied to the claimant’s lower abdomen to aid delivery.
At 22:31 the shoulders were delivered with some assistance from the midwife. The baby was noted to be pale and floppy and resuscitation commenced following immediate clamping of the cord. The baby was taken to the resuscitare in the adjoining room by another midwife.
the claimant’s partner, supported by a midwife, went to the resuscitare with the baby and the door to the delivery room was left open so that the claimant was aware of what was happening.
At 22:32 the midwife called switchboard requesting the paediatric consultant.
At 22:38 and 22:40 the medical notes document that further calls were made to the switchboard requesting a paediatric cardiac arrest team.
At 22:46 the anaesthetist arrived.
At 22:51 a further paediatric cardiac arrest call was made to switchboard. Between 22:38 and 22:53 three cardiac arrest calls were made to the switchboard by the Labour Ward for this incident, each time activing a cardiac arrest call out and this is evidenced by the switchboard log. There was confusion as to what number should have been called be it 2333 or 2222.
At 22:48 the decision was made to stop resuscitation after 15 minutes with no signs of life.
the couple, having witnessed the resuscitation attempts, were informed of this decision by the midwife. However, at 22:49 a faint apical pulse was seen by the neonatal doctor and resuscitation recommenced.
At 22:53 a further call was made to the switchboard requesting the paediatric cardiac arrest team to the Labour Ward.
At 22:54 the decision was made to stop resuscitation at 22 minutes as there were no signs of life.
Slee Blackwell’s medical negligence team were instructed to investigate the circumstances surrounding the baby’s death and to pursue a negligence claim.
The claim was funded by way of a no win – no fee agreement. The case was initially defended by the NHS despite the fact the Trust had carried out an in depth investigation and identified a number of failings by the hospital.
Without prejudice discussions took place and eventually an out of court settlement was reached which provided for a compensation package to be paid.