David Hirsch - Second Floor Selbourne Chambers - More lifting of the drapes: What really happens in...

Li#ing the Drapes Informa Obstetric Malprac.ce

Conference Melbourne -‐ 22 June 2015

David Hirsch, Barrister Selborne Chambers, Sydney

Neonatal stroke

What was it about?

• Forceps delivery in 1990 • AdmiGed to be trauma.c • Neonatal stroke

• Was the delivery negligently performed? • Did the delivery cause the stroke?

What happened?

• Delivery at term – long labour – no distress • Neville Barnes aGempted – discovered OP • Kiellands rota.on – turned body through 270 degrees • Difficult – ‘more from descent than the rota.on’

What happened?

• Seizures – skull x-‐ray – no fracture seen

• No vascular ultrasound studies

• Neonatal stroke -‐ hemiplegia

Defendant’s case • Even if the forceps delivery was negligent (denied), you cannot prove that this caused the stroke

• Forceps delivery is very common • Neonatal stroke is very rare • Literature is limited

• Causal connecDon is anecdotal and theoreDcal

PlainDff’s approach

• Overseas obstetric opinion • Describes posi.on and rota.on and trac.on forces

• Paediatric neurologist •  Iden.fies embolic stroke, excludes other causes

PlainDff’s approach

• Paediatric neuroradiologist • Confirms .ming of injury and trauma.c nature

• Vascular surgeon • Connects the dots

The outcome

Case seJled at mediaDon

What’s wrong with these records?

• Neville Barnes Forceps ……..

• Direct OA at spines • Neville Barnes forceps applied • Moderate trac.on to deliver head a[er episiotomy

• Head .ght fit •  Transverse shoulder rotated to just of midline

???

•  If s.ll ………please organise blood cultures in the morning

On the opposite page…..

PlainDff’s case

• Obstetrician should record details of shoulder dystocia delivery

• Destroyed records probably contain those details

•  Inference can be drawn that the details, if known, could aGract cri.cism of what was or was not done

Defence case

Can we talk?

Handover

What was it about?

•  21 year old primagravid • Rapid delivery • Midwife diagnosed and recorded 2nd degree tear • O+G registrar diagnosed 4th degree tear • Repair by registrar on the ward • Discharged home for follow up… • By Aboriginal Medical Service

What happened?

• Discharge summary referred only to the 2nd degree tear • Aboriginal Medical Service not aware of 4th degree tear for 10 days • Repair broke down •  Faeces in the vagina • No an.bio.cs were being taken • Rectovaginal fistula and chronic abscesses • Complaint made to hospital • Apology for handover error

What the lawyers found

•  Lawyers discover IIMS report “Best Prac/ce Guidelines for management of 4th degree tear, in OT with experienced Dr and correct follow up care & educa/on in ward and community” • Registrar wanted 4th degree tear repaired in theatre by obstetrician “OT staff and anaesthe/st refuse to admit to theatre. Repair is done in birth room by registrar under training supervision from VMO with local An”

The outcome


“You can never be too careful…”

What was it all about?

•  Emergency caesarean at term for bradycardia a[er epidural •  APGARS 8:1; 9:5

•  Suspected chorioamnioni.s •  “Uterus -‐ ? Slight odour”

• Mild respiratory distress at 20 hours • Neonatology registrar considered Early Onset Neonatal Sepsis

•  “pneumonia 2⁰ ? chorioamnioni/s”

• Complete sep.c workup •  Lumbar puncture

PlainDff’s case Mother • No GBS • No infec.ous illness during pregnancy • No prolonged rupture of membranes • No maternal fever • No histopathology evidence of chorioamnioni.s

PlainDff’s case Baby • Mild respiratory distress due to effects of caesarean •  Ear and eye swabs nega.ve • Chest x-‐ray clear • No temperature instability • No hypotension • Normal capillary refill • No skin moGling • Normal feeding • Alert and not grizzly

PlainDff’s case

• At it’s highest there were “so[ signs” of EONS •  Respiratory distress •  ? chorioamnioni/s

• No signs to jus.fy “suspected sepsis” •  Empiric an.bio.cs appropriate • No need for lumbar puncture

Defence case

•  EONS has high mortality and morbidity and requires a high index of suspicion

• Respiratory distress is a sign of EONS • A small percentage of mothers might have chorioamnioni.s with no pre-‐term delivery, no maternal fever, no prolonged rupture of membranes and no GBS

• A small percentage of neonates can be found to have sepsis with normal temperature, normal capillary refill, normal blood pressure and with normal neurological signs and no signs of meningi.s at all.

•  Lumbar puncture jusDfied

What happened?

• Registrar made two failed aGempts at lumbar puncture • No CSF – “Bloody Tap” • Baby deteriorated over 24 hours with apnoeic aGacks, s.ffening and reduced lower limb movement

• Baby had haemophilia •  Lumbar puncture caused a bleed into the spinal canal • Complete paraplegia

Legal argument

• Defence •  LP reasonable because of suspected EONS •  Haemophilia was not foreseeable

• PlainDff •  LP not reasonable in the circumstances •  Haematoma from LP is foreseeable •  The kind of injury was foreseeable, even if not the extent of the injury

The outcome


Second stage monitoring

What was it about?

• Primigravid – normal pregnancy • NVD at 41 weeks • Second stage 2 hrs 15 min • No meconium • APGAR scores: 6:1, 7:5, 7:10

• HIE – cerebral palsy

What happened?

• Cord pH 7.095, BE – 17.3 • Seizures at 14 hours • MRI – basal ganglia damage • Ausculta.on in second stage

• 0830 / 0845 / 0900 / 0930

• Loss of FHR at 0950 • Delivery at 1015

The plainDff’s case

• CTG monitoring would have detected late decelera.ons and bradycardia

• Ausculta.on was inadequate but… • Was CTG monitoring indicated? • 0930 FHR “120-‐160 between contrac.ons” • CTG monitoring should have been done • Delivery before 0950

The outcome

• Hospital admiJed liability

• SeJled at a mediaDon

Lawyers Doctors

and

Cerebral Palsy

It’s poliDcal.

Slide 37

CEREBRAL

PALSY IS NOT

PREVENTABLE

“Only an expert witness can prevent

cerebral palsy”

Prof Alastair MacLennan

O+G 8:1:28-30 (2006)

Slide 40

Over the last 40 years… •  S.llbirth rates fell •  Early neonatal mortality fell •  Total CP rates remained the same • CP rates in infants <1500gm rose significantly •  “The increased survival of low birthweight infants has resulted in more CP in this group.”

Stanley and Watson

Trends in perinatal mortality and CP in WA 1967-‐1985 BMJ 1992 June 27

CTG

MONITORING HAS A FALSE

POSITIVE RATE OF

99.8%

“Uncertain value of EFM in predic.ng cerebral palsy”

•  1983-‐1985 study of medical records •  Singleton infants > 2500gm who lived to age 3 •  Sharp increase in CP with mul.ple late decelera.ons + decreased variability (27% with CP, 9% of controls)

•  99.8% false posi.ve if all EFM abnormali.es were extrapolated over the en.re popula.on

Nelson, NEJM 1996;334(10):613-‐619.

However…. • No CTG strips • Unable to compare findings in early versus late labour to inves.gate changes during labour

• No informa.on on the dura.on of severe bradycardia (which was “especially regreZable”)

• No informa.on on how the “normal” babies were delivered a[er foetal heart rate abnormali.es were detected!

And this…

•  Clinicians use EFM to detect significant hypoxia and allow interven/on to prevent fetal injury rather than to accurately predict the specific adverse outcome of CP.

•  It is fully understood that the vast majority of abnormal EFM tracings are not associated with cri/cal hypoxia/acidosis resul/ng in measurable fetal injury. The role of clinical judgment, treatment, and /mely interven/on must be considered to play a part in this lack of correla/on rather than simply claiming a 99% false-‐posi/ve rate with abnormal EFM.

AJOG May 2010 May 2010Volume 202, Issue 5, Pages 411–412

And this…

•  The vast majority of diagnos/c tools, especially monitoring devices, have never been subjected to randomized trials where the endpoint was improved outcome.

•  EFM is a diagnos/c tool that was never proposed as a predictor of outcomes. Imagine how difficult it would be to prove that the use of a thermometer would improve outcome with any infec/on.

•  AJOG May 2010 May 2010Volume 202, Issue 5, Pages 411–412

Down Syndrome

What was it about?

Antenatal management •  34 year old G4P1 – pregnancy managed by private obstetrician •  1:37 risk of Down Syndrome

•  Blood test •  Nuchal translucency

• Declines CVS / amniocentesis •  20 week ultrasound •  The risk of a significant foetal anomaly is low

What happened?

20 week ultrasound report •  The images are subop/mal due to maternal body habitus • No signs specific for trisomy 21 are iden/fied however some of the images are subop/mal

•  No gross morphologic or anatomic foetal abnormality is seen •  The risk of a significant foetal anomaly is low •  SHOULD THE DOCTOR HAVE RECOMMENDED A FURTHER ULTRASOUND?

What happened?

• No further ultrasound recommended • Baby delivered at private hospital • Obvious Down Syndrome

• Cyano.c spells and desatura.ons •  Fed formula in private hospital nursery • Complete Atrioventricular Canal defect • Bowel perfora.on and necro.sing enterocoli.s

What happened?

Removal of right and le# transverse colon

•  The serosal surface is blackened and the mucosal surface appears green with the wall of the bowel thinned.

•  The ae/ology of the necro/sing enterocoli/s is not readily apparent in this material but could be related to ischaemia.

• Could not be PEG fed

•  Short bowel syndrome

Issues…

• What would a specialised obstetric ultrasound have shown? •  Should the baby have been born at the private hospital? •  Should the baby have been fed formula? • What caused the bowel perfora.on? •  If Down Syndrome and the cardiac defect were known earlier would the treatment have been different?

The outcome

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David Hirsch - Second Floor Selbourne Chambers - More lifting of the drapes: What really happens in...

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