Induction of labour
13. Miss R says due to a heart condition, she needed special precautions for her pregnancy and birth. Miss R says a doctor was not involved in the decision to induce labour and that it began in the evening with no doctor present. She says the only doctor available was already engaged in an emergency caesarean procedure. Miss R says the decision to induce labour early was due to high blood pressure, which the Trust did not communicate to her. She says this decision contributed to the brain injury and physical problems her daughter experienced.
14. The Trust says it admitted Miss R for a few days of bed rest before she was due to give birth and planned to induce labour when she was at 37 weeks of her pregnancy. It brought her induction forward by one day but did not document the reason for this decision. It says this decision was likely due to bed availability on the induction suite at the time and to reduce any possible delays in induction on the original date.
15. The Trust apologised to Miss R for not explaining the reasons for bringing the induction forward. It says there was no evidence Miss R’s blood pressure was high at the time of the decision and that this had no bearing on its decision. It says the midwife in charge of the delivery suite made the decision to induce labour earlier and that this decision was appropriate. The Trust says there were four obstetric doctors on call overnight on the day she was induced, three of which were onsite with the fourth on call available from home.
16. The NHS website says a pregnancy at 37 weeks is considered full-term and that a baby is ready to be born from this time. Miss R was at 37 weeks at the time the Trust induced her.
17. The guidelines we have identified which were in use at the time were the RCOG’s Good Practice No.13 and NICE CG70. The RCOG’s Good Practice No.13 is a summary of expert opinion to assist in the planning and management of cardiac disease in pregnancy. There is nothing within these guidelines which might advise against an induction being carried out at a specific time. NICE’s CG70 sets out clinical guidelines on inducing labour. However, these guidelines do not make any specific reference to labour complications including maternal heart disease.
18. NICE published clinical guidance (NG121) in April 2019 which outlines the care during labour and birth for women who need extra support because they have a medical condition or complications in their current or previous pregnancy. It says:
‘Mode of birth for women with heart disease 1.3.16 Offer planned birth (induction of labour or caesarean section) for women with mechanical heart valves.’
19. While this guidance was not in use at the time, we can see it is clinically appropriate for an induction to be arranged in cases where someone has a medical condition or complication. We can also see that 37 weeks is a reasonable time from which labour can occur.
20. Miss R’s medical records show that her blood pressure was normal, and her blood and urine test results were all within normal ranges at the time. Our adviser says the Trust carried out the induction on a weekday which is the safest time, particularly when there are maternal complications as the necessary clinicians are available. Our adviser says, due to the lack of a reason noted in the records, they can only assume why the Trust brought the induction forward and that it is likely due to the available capacity on the labour ward, allowing the clinicians to start Miss R’s induction safely.
21. Our adviser says that generally with a first birth, induction can take 12 hours or more. They say that as a first-time mother, it was appropriate for Miss R’s induction to begin in the evening as this would mean a long labour would take place the following day. Our adviser says that while Miss R progressed extremely quickly there were no issues in the induction taking place a day earlier.
22. There is no specific reason for the Trust to have brought Miss R’s induction forward. However, Miss R was at 37 weeks and her observations were normal at the time. We have seen no evidence that the Trust’s decision to bring the induction forward was a failing.
23. The Trust has admitted it did not properly communicate its decision to bring the induction forward, which it apologised for. This will have led to uncertainty and worry for Miss R during an already difficult time.
Birth plan
24. Miss R says the Trust failed to follow the process set out in her birth plan, which an obstetrician and a cardiologist formulated. She says the Trust made changes to her plan based on incorrect judgements, failures in planning and observation and due to a lack of staff availability. She says it has not admitted to any failings in the birthing process or acknowledged any link to the physical impact on her daughter.
25. The Trust says it followed the plan and apologised if it did not fully communicate this and the induction of labour to Miss R. It says the midwifery and medical team were fully aware of Miss R’s condition and complex medical needs.
26. In creating a birth plan, the NHS website says: ‘Be flexible
You need to be flexible and prepared to do things differently from your birth plan if complications arise with you or your baby, or if facilities such as a birth pool aren't available. The maternity team will tell you what they advise in your particular circumstances. Don't hesitate to ask questions if you need to.’
27. According to this guidance, there is a risk of complications which can arise during birth and which can therefore lead to changes in a birth plan.
28. Our adviser says Miss R’s birth plan was comprehensive, well written and clear. They say it outlined the timings of events which demonstrates the Trust managed Miss R’s labour as quickly and appropriately as it could have. The Trust noted at 10.44pm that Miss R was feeling uncomfortable and scared on the Antenatal Ward. Within an hour, she was on the Central Delivery Suite having an epidural for pain relief arranged. The records say she was fully dilated by 2.30am and the passive phase of her labour began as directed in her birth plan.
29. Miss R’s records note that an obstetric registrar carried out a vaginal examination at 5.30am, exactly three hours later as directed within the birth plan. Miss R’s baby was delivered by forceps at 5.46am. The records show there was a neonatologist present in the room at the time which was in line with the recommendation for delivery.
30. The Trust says it did not communicate properly with Miss R, which is a failing. This will have given Miss R the impression it did not follow her birth plan which will have caused her distress and worry during what would have been a difficult experience. However, from the evidence we have seen, the Trust did follow the birth plan appropriately.
31. Our Principles of Good Complaint Handling set out our views on what we consider is good complaint handling and what we expect to see from organisations when dealing with a complaint. Our principle on putting things right includes what we consider are appropriate responses to a complaint, which include an apology, explanation and acknowledgement of responsibility. There is no evidence the Trust altered the birth plan or failed to appropriately manage the labour. The Trust acknowledged and apologised for its failure to properly communicate with Miss R. We feel this was in line with our Principles of Good Complaint Handling and was reasonable in the circumstances.
32. Miss R says she noticed something was wrong with her daughter immediately at birth. She says staff missed signs that her daughter needed intensive care and did not take her to the Neonatal Intensive Care Unit (NICU) until three hours had passed. She says her daughter worsened after this and had to be put on a ventilator.
33. The Trust says Miss R’s daughter needed resuscitation initially, but staff described her as pink with excellent oxygen saturation (the amount of haemoglobin in the blood containing oxygen). It says staff gave her inflation and ventilation breaths, which is normal when babies are unresponsive to stimulation by rubbing with a towel. It says these techniques are used to stimulate a baby’s breath on its own and apologised to Miss R for not explaining this at the time and the anxiety it caused her.
34. The Newborn Life Support Guidelines from Resuscitation Council UK cover the management and support of transition of infants at birth. These guidelines say:
‘Initial assessment
A rapid initial assessment should usually occur before the umbilical cord is clamped and cut:
· Observe tone (and colour).
· Assess adequacy of breathing.
· Count the heart rate.
· Take appropriate action to keep the baby warm during these initial steps.
· This rapid assessment serves to establish a baseline, identify the need for support and/or resuscitation and the appropriateness and duration of delaying umbilical cord clamping.
· Frequent re-assessment of heart rate and breathing will guide whether further interventions are needed.’
35. These guidelines also set out what actions should be taken depending on the birth. They say:
· Clamp cord immediately and transfer to the resuscitation platform. Delay cord clamping only if you are able to appropriately support/resuscitate the infant.
· Dry, stimulate, wrap in a warm towel.
· Maintain the airway, - lung inflation and ventilation.
· Assess changes in heart rate and breathing.
· Apply a saturation probe +/- ECG.
· Continue newborn life support according to response.
· Help is likely to be required.
36. The Apgar score is a method used to quickly summarise the health of newborn children. It relates to observations made soon after birth of a baby’s heart rate, breathing, colour, muscle tone and response to stimulation. These are performed at 1 minute and 5 minutes of age, and the purpose is to determine if the baby needs extra respiratory support. The five observations are each given a score of 0, 1 or 2. The total of these scores is referred to as the Apgar score. The lower the score the greater the need for the baby to receive additional support.
37. Miss R’s daughter’s Apgar score was 7 at 1 minute, 8 at 5 minutes and 8 at 10 minutes. Our adviser says this high score would indicate she did not require any additional support initially. However, the records say, ‘poor respiratory effort and poor tone, cord clamped and cut and baby taken to the resuscitaire’. The neonatologist was present and received Miss R’s baby immediately and gave her five inflation breaths and 30 seconds of ventilation breaths. The records note that she responded well.
38. An umbilical cord blood gas analysis provides a measure of a baby’s wellbeing. This measures the pH (acidity), the base excess (the deficit or excess of acid) and the partial pressure of carbon dioxide (pCO2) which is the measure of carbon dioxide of blood within an artery or vein. A normal pH reading of venous cord gas is 7.35.
39. The records show there was only one venous cord gas reading of pH 7.3. Our adviser says ideally there should also be a cord gas reading of arterial blood. However, it is reasonable to assume Miss R’s daughter was in good condition at birth based on the one cord gas result.
40. Miss R’s daughter was born weighing 2.4kg. Her records show that the midwife noted her first pre-feed blood sugar level as 1.6mmols at 9.40am, four hours after her birth. The Trust’s guidelines on hypoglycaemia, ‘Identification and management of neonatal hypoglycaemia’, says this is low. The Trust’s complaint response says this may have been due to antihypertensive medication (used to treat high blood pressure) Miss R was taking.
41. The records say the midwife contacted the neonatologist who advised them to insert a nasogastric tube to give Miss R’s daughter formula milk and to check her blood sugar level later. Staff checked her blood sugar level again at 11.00am and recorded this as 1.9mmols, which was still low. An advanced neonatal nurse practitioner who reviewed Miss R’s daughter advised to give her more formula and her blood sugar level rose to 5.6mmols. Our adviser says this was within the normal range.
42. We considered the Trust’s own guidelines, Identification and management of neonatal hypoglycaemia guide. These guidelines were published by the Trust in May 2018 and were not therefore in use at the time. However, these guidelines are based on the British Association of Perinatal Medicine’s framework, Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant, which was published in April 2017. We have seen that the Trust managed Miss R’s daughter’s low blood sugar levels appropriately, in line with this framework.
43. The midwife reviewed Miss R’s daughter at 9.40am and observed bruising on her right buttock and left leg. This was immediately referred to the neonatologist, who reviewed the bruising and took a blood sample to complete a blood clotting screen and platelet count. This was to see if there was an issue with her blood clotting. The neonatal notes indicate the results were abnormal. The records say the Trust transferred Miss R’s daughter to the NICU at 12.03pm for further management. Our adviser says there is nothing in the labour or delivery notes or the neonatal records regarding the cause of the bruising, other than the clotting screen coming back abnormal.
44. Based on what we have seen, the Trust acted in line with the relevant guidelines and provided appropriate treatment to Miss R’s daughter at the time of her birth and immediately afterwards. We have already seen that the decision to bring Miss R’s induction forward was not a failing. We have seen that the Trust took appropriate actions to manage these complications in line with relevant clinical guidelines.
45. It is clear that Miss R’s labour and the birth of her daughter were difficult events which will have caused her worry and distress. Particularly due to her own health complications and the Trust’s decision to bring the induction of her labour forward. This decision will have caused concern to Miss R if not explained properly as it gave the appearance of altering Miss R’s birth plan. Bringing the induction of labour forward without proper explanation would also have given Miss R cause to question whether the Trust acted appropriately, particularly due to the brain injury and physical problems which her daughter developed after her birth. However, we have seen no evidence that the Trust’s actions led to these issues.
46. The Trust has apologised to Miss R for its failure to properly communicate with her and the distress this caused. We are satisfied the Trust has recognised this error and feel it took reasonable actions in line with our Principles of Good Complaint Handling. We do not uphold this complaint.
47. This concludes our report.