Cutting the cord
16. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
17. Miss U complains there was no reason for the Trust to cut the cord when it did and could have left it longer. She says she requested the Trust delay the clamping of the cord.
18. The Trust said Miss U’s son had poor muscle tone and did not cry immediately.
The Trust tried to initiate stimulation of her son but his condition did not improve. Therefore, the Trust made the decision to clamp and cut the cord.
19. To reach a view for this complaint part, we sought advice from a midwife adviser (our midwife adviser).
20. Our midwife adviser considered the records and noted they were comprehensive and detailed. There are a number of entries in the records indicating Miss U’s son did not have good tone.
21. Tone refers to muscle tone. Good muscle tone is shown by a baby being tense when picked up and the arms and legs are able to resist extension. Poor muscle tone is shown by a baby being floppy.
22. The records show the medical professionals correctly tried some gentle stimulation by rubbing the baby’s back which is often enough to stimulate a baby to cry and improve tone. However, as Miss U’s son did not cry spontaneously and the tone did not improve, the Trust made the decision to clamp and cut the cord and transfer her son to the resuscitaire in case he needed further resuscitation by the paediatrician who was already present in the room. A resuscitaire is a machine which health professionals use in a clinical emergency when resuscitation is required.
23. This was the right thing to do given the poor muscle tone the baby was showing in accordance with section 1.15 of National Institute for Health and Care (NICE) Guidance, cg190 Intrapartum care for healthy women and babies, 2014 updated 2017 and sections 4 and 5 of Resuscitation Council UK Guidelines, Resuscitation and support of transition of babies at birth, 2015.
24. The decision to move the baby to the resuscitaire should be viewed in the context of the overall condition of Miss U’s son. The Trust had already been concerned about the condition of her son just before birth. It was worried about his heart rate which led to the decision to use the kiwi cup to help deliver him quickly.
25. A neonatologist recorded Miss U’s son was brought to the resuscitaire, dried with a towel and stimulated. This can be enough to stimulate a baby so their tone improves as happened in this case. The Trust has documented her son did not need further resuscitation.
26. Our midwife adviser explained soon after birth clinicians are required to make observations of a baby’s heart rate, breathing, colour, muscle tone and response to stimulation. These are carried out at 1 minute and 5 minutes and the purpose is to determine if a baby needs extra support. There may be a third assessment at 10 minutes. The five observations are each given a score of 0, 1 or 2. The total of these scores is referred to as the baby’s APGAR score. The lower the score the greater the need for a baby to receive additional support.
27. The Trust first recorded Miss U’s son’s APGAR score 1 minute into his life as is required by the NICE Guidance referred to above.
28. A score of 2 for ‘tone’ was recorded which is the maximum (out of 0, 1 and 2) that could be scored. Overall, the baby had an APGAR score of 9 out of 10 with colour being the only section of the APGAR criteria (out of 5 criteria) that recorded less than a 2.
29. Our midwife adviser explained it is reasonable for the baby to have developed its good tone within the first minute of its life and improve sufficiently for it to score a 2 on the APGAR score.
30. Miss U’s son went on to have a maximum APGAR score of 10 at five minutes and 10 at ten minutes. This is within normal limits.
31. The Trust documented in the records at 1.10pm on 10 May 2020 it gained consent from Miss U to attempt a kiwi birth in theatre with potential to progress to a caesarean section. At the time the Trust further recorded Mr E restated his request not to cut the cord. The Trust explained this would be possible providing the baby did not need resuscitation.
32. The medical records showed a consultant spoke to Miss U and Mr E following their son’s birth and apologised for having to cut the cord. The consultant gave the reason of the urgent need to move their son to the resuscitaire.
33. We appreciate Miss U wanted the Trust to delay clamping the cord and she was worried about the effect on her son. However, in view of all the available evidence, including the relevant guidelines and our clinical advice, we are satisfied there is no indication anything went wrong with the care and treatment provided in relation to this complaint. We will take no further action.
Giving Vitamin K
34. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
35. Miss U says the Trust gave her son a dose of vitamin K after he was born which was against hers and her husband’s wishes.
36. The Trust said there is no evidence it gave a dose of vitamin K to Miss U’s son. It refused to carry out a test to confirm vitamin K levels in her son’s blood because vitamin K levels vary significantly and would not identify whether he had received a dose of vitamin K.
37. To reach a view for this complaint part, we sought advice from our midwife adviser.
38. Our midwife adviser notes the Trust recorded Miss U declined vitamin K being administered to her baby at various times:
· antenatally in the birth plan
· while she was in labour on 10 May 2020 at 5.30am, 8.20am and 1.10pm
· after she gave birth on 10 May 2020 at 3.45pm, 7pm and 10.20pm
· on 11 May 2020 at 9.50am and 1.50pm
· on 12 May 2020 at 3pm.
The records indicate the Trust tried to persuade Miss U to change her mind and gave her leaflets about vitamin K.
39. There is no evidence anywhere in the medical records of the Trust giving Miss U’s son vitamin K. The record keeping is comprehensive and written by the multi-disciplinary team.
40. In its’ actions the Trust has followed the following guidance:
· The Nursing and Midwifery Council (NMC) The Code, Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2018.
· The General Medical Council (GMC) Good medical Practice, Working for Doctors working with patients, 2014.
41. Our midwife adviser explained NMC, The Code, 2018 is clear midwives must respect, support and document a person’s right to accept or refuse care and treatment. It also states midwives should make sure that properly informed consent is obtained and documented before carrying out any action.
42. Section 17 of GMC, Good Medical Practice, 2014 says doctors must be satisfied they have consent or valid authority before they provide treatment. This would include giving vitamin K to a baby.
43. To consider whether the Trust should have carried out a test to confirm vitamin K levels in Miss U’s son’s blood, I sought advice from a consultant neonatologist (our neonatologist adviser).
44. Our neonatologist adviser explained there are no tests that accurately measure the level of vitamin K in the blood. It is not standard practice to measure vitamin K levels in blood and there are no guidelines about this.
45. Vitamin K is one of many factors that helps to make blood clot. The test clinicians use if they are worried about a vitamin K deficiency is called ‘Prothrombin Time’ test. This measures how long blood takes to clot. If this test is abnormal, clinicians consider giving vitamin K to correct it. However, this decision is not based on obtaining a specific reading for vitamin K levels in the blood. The ‘Prothrombin Time’ test does not measure vitamin K levels in the blood. All newborn babies have lower levels of vitamin K (30-60% of adult levels) in their bodies and it takes about six weeks to reach adult levels.
46. It is possible to test whether a baby is unable to make their own vitamin K. This test is called PIVKA (protein induced by vitamin K). This is a blood test which is used to see if an increased Prothrombin Time is caused by a vitamin K deficiency. This is not testing the same as the ‘Prothrombin Time’ test. Again, this test does not measure high levels of vitamin K in the blood. All babies will have some vitamin K in their blood so measuring a level would not prove if vitamin K had been given.
47. In the circumstances, it was reasonable for the Trust to refuse to test for vitamin K levels in Miss U’s son’s blood.
48. We acknowledge Miss U believes her son was given vitamin K and is worried about the effect this may have on him in the future. However, based on all the evidence available, including relevant guidance and the advice of our clinical advisers, we are satisfied there is no indication the Trust did anything wrong in respect of this complaint. We will take no further action.
Use of the Kiwi Cup
49. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
50. Miss U says the Trust used a kiwi cup to deliver her son which was not necessary.
51. The Trust said it used the kiwi cup in the operating theatre to deliver Miss U’s son quickly and safely. It was concerned her son may be experiencing fetal hypoxia (being deprived of adequate oxygen) which was the reason it moved Miss U to the operating theatre.
52. To reach a view for this complaint part, we sought advice from a consultant obstetrician and gynaecologist (our obstetrician adviser).
53. The relevant guidelines in relation to this complaint are The Royal College of Obstetricians and Gynaecologists’ guidance, Green Top Guidance no.26, 2011.
54. The Trust advised an operative delivery. This was because it had concerns about the CTG tracing which gave rise to worry about the baby becoming short of oxygen whilst Miss U was in the second stage of labour. CTG is a recording of the fetal heartbeat and the uterine contractions. The second stage of labour is after the cervix has become fully dilated.
55. Our obstetrician adviser explained this is a very common indication for operative delivery and was in this case, in line with paragraph 4.3 of the guidance. There is evidence in the records which indicated the need for an operative delivery.
56. The medical records based on an examination of Miss U also confirm a delivery in an operating theatre was appropriate in this case. The delivery was classified as ‘mid cavity’. Mid cavity deliveries are when the baby’s head is still relatively high within the pelvis and therefore such a delivery has a higher chance of being unsuccessful.
57. The kiwi cup is commonly used for such deliveries and is specifically mentioned in paragraph 5.3 of the guidance. A kiwi cup is a type of ventouse extractor. Our obstetrician adviser explained the operator should use the instrument which is most appropriate to the clinical circumstances and their own experience and skill. The kiwi cup is in line with the guidance in this respect and the notes demonstrate the doctor undertaking the delivery was properly trained in its use and was directly supervised by a consultant obstetrician.
58. The delivery itself was undertaken over three contractions using three pulls on the kiwi cup once it had been applied to the baby’s head. This was in line with paragraph 5.4 of the guidance which says ‘operative vaginal delivery should be abandoned where delivery is not imminent following three contractions of a correctly applied instrument’.
59. Taking into account the records and our clinical advice, we have not seen any indications the decision the Trust made to deliver the baby using a Kiwi cup was wrong. The decision was made in line with the applicable clinical guidance and we will take no further action on this issue.
60. Our decision is not made without recognising the anxiety Miss U suffered at the time of the events.