26. Miss E complains about aspects of care and treatment the Trust provided when she went into labour on 7 March 2020.
27. We have carefully considered the evidence from Miss E’s account, the Trust’s account, and her clinical records, alongside the relevant standards. We will address each part of the complaint below, first setting out what should have happened in Miss E’s case.
Pain relief before delivery
28. Miss E says the midwife did not give her Entenox (gas and air) or appropriate pain relief while she was in labour. She says she told a midwife she was in pain following the membrane sweep and asked for gas and air. She says the midwife refused her request and advised her a doctor would need to review her first. Miss E says she then asked for pain relief at 5.20pm and 6.00pm.
29. The Trust has not addressed this directly in its response. It says it is sorry Miss E felt she was denied pain relief. It explained that following a membrane sweep, walking around is usually encouraged to help labour, without the need for unnecessary interventions.
30. The Trust says gas and air is known to cause dizziness, nausea and can reduce mobility so it is not always given as a first choice of analgesia (pain relief) following a membrane sweep. The Trust says it was acting in Miss E’s best interests.
31. The Intrapartum Care guidelines say: ‘Latent first stage of labour: Section1.3.8 If a woman seeks advice or attends a midwifery-led unit or obstetric unit with painful contractions, but is not in established labour: •recognise that a woman may experience painful contractions without cervical change, and although she is described as not being in labour, she may well think of herself as being 'in labour' by her own definition •offer her individualised support, and analgesia if needed’.
32. The Nursing and Midwifery Council’s (NMC) ‘The Code’ says ‘analgesia must be administered when a patient requests, to control their pain’.
33. The NMC code says midwives must ‘listen to people and respond to their preferences and concerns’ by ‘working in partnership with people to make sure they deliver care effectively’.
34. If a patient asks for pain relief, a midwife should listen to the patient, consider her history, and provide adequate pain relief.
35. The records show midwife one gave Miss E a membrane sweep. Miss E says shortly after the sweep her pain started to get worse. She says midwife two then introduced themselves and she says she asked for gas and air.
36. We have carefully looked at the medical records. This interaction is not recorded in the evidence. The Trust’s complaint response also does not confirm or deny if this interaction took place.
37. Our adviser says there are insufficient records to confirm if this interaction took place. The account from Miss E is not supported by the statement from the second midwife. We have considered all the available evidence and it is not possible to determine what happened at this time.
38. The midwife’s statement says she returned to triage at 5.20pm and Miss E requested gas and air. The midwife says they explained to Miss E she was having irregular tightening, and gas and air would not be recommended as she may not be in active labour. This interaction is also not documented in the medical notes but is taken from the midwife’s statement and Miss E’s account.
39. The midwife went on to prescribe Miss E with co-codamol. The treatment sheet supports this was given at 5.20pm. The Trust says the midwife did not deny Miss E pain relief but discussed alternative options which they felt were more suitable.
40. Our adviser has looked at the medication given to Miss E at 5.20pm and considered if this was in line with the guidance.
41. It is not documented in the records that Miss E requested gas and air at 5.20pm. However, the midwife confirmed she did in their statement. This is supported by Miss E’s account and that co-codamol was subsequently given on the treatment sheet. Although the records are limited, we can see Miss E requested gas and air at this time as it is confirmed by both accounts.
42. Our adviser says the midwife should have offered Miss E gas and air at 5.20pm in line with the guidance. The NMC code sets out that pain relief must be administered when a patient requests to control their pain. Section 1.3.8 of the Intrapartum guidance sets out that even if Miss E was not in established labour, she may have thought of herself in labour. The midwife should therefore have offered individualised support and pain relief.
43. If the midwife had completed a full clinical assessment, which supported giving Miss E co-codamol instead of gas and air, this should have been recorded and documented.
44. The NICE guidance says midwives should listen to a patient’s story and take into account her needs. It is important that midwives ensure a woman’s choice is supported. Miss E had previously had four children and it is reasonable to assume she asked for gas and air knowing she found it to be effective in the past.
45. Our adviser says the decision to offer Miss E co-codamol, and not provide gas and air, is not in line with the NMC code which explains midwives must listen and respond to a person’s preferences and concerns. The evidence is supportive that Miss E’s preference was gas and air. We have found a failing here.
46. Miss E says the co-codamol did not help her pain and that she asked for gas and air again around 6.00pm. There are also no records documenting this interaction. This is not referred to in the midwife’s statement.
47. We do not have enough evidence to confirm if this interaction took place, or what was said, due to the lack of records. We have taken into account however that as Miss E was complaining of pain at 5.20pm, it is reasonable to suggest Miss E would still have been in pain shortly afterwards.
48. We have considered the management of Miss E’s pain after 5.20pm.
49. The NICE Intrapartum Care guidelines explain for all women giving birth the principles in the NICE guideline on patient experience in using adult NHS services apply. Section 1.2.8 of this guidance says:
‘If a patient is unable to manage their own pain relief: · Do not assume pain relief is adequate · Ask them regularly about pain · Assess pain using a pain scale if necessary · Provide pain relief and adjust as needed’.
50. The NICE intrapartum care guideline also says: ‘Section 1.2.2: Assess the woman’s knowledge and strategies for coping with pain and provide balanced information to find out which available approaches are accepted to her. Section 1.3.8: Offer individualised support and analgesia if needed’.
51. The guidance sets out that health professionals should not assume pain relief has been adequate and should ask patients regularly. We can see from the records Miss E had been given co-codamol at 5.20pm. However, there are no further entries checking back in with Miss E to see if this had been effective, or if she required any further pain relief.
52. The next entry in the records is at 6.45pm showing Miss E had a spontaneous rupture of membranes (waters breaking). We recognise Miss E’s account she asked for pain relief at 6.00pm. Although we cannot confirm this from the records, the evidence does not suggest she was reviewed after 5.20pm. Regardless of if Miss E did ask for pain relief at 6.00pm, she should have been reassessed to review the effectiveness of the co-codamol.
53. There is no evidence to suggest Miss E’s pain levels were checked after this time. This is not in line with the guidance, and we have found a failing here.
Midwife did not recognise Miss E was in labour
54. Miss E says the midwife did not recognise she was in labour when they reviewed her at 5.20pm.
55. The Trust says the midwife reviewed Miss E at 5.20pm and documented she appeared to be comfortable and on palpation (examination of the stomach) was tightening 1-2:10, mild irregular and short lasting.
56. NICE Guidance on Intrapartum Care for Healthy Women and Babies (2017) Section 1.4.1 says: ‘When performing an initial assessment of a woman in labour, listen to her story and take into account her preferences and her emotional and psychological needs’.
57. Section 1.4.2 says: ‘if there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment, but is not always necessary’. They also say, ‘if the woman appears to be in established labour, offer a vaginal examination’.
58. Section 1,12,3 says: ‘Inform women that, while the length of established first stage of labour varies between women: second and subsequent labour’s last on average five hours are unlikely to last over 12 hours’.
59. The medical records do not detail this interaction between Miss E and the midwife. Looking at other sources of evidence, we can see the midwife’s statement explains at 5.20pm they told Miss E she may not be in active labour. They advised that too many vaginal examinations would not be recommended. This is because of an increased risk of infection and discomfort.
60. The midwife agreed if Miss E’s contractions became more painful and regular, they would re-examine Miss E. They said they offered, and gave her, two co-codamol. This is supported by an entry on the treatment sheet confirming the midwife gave Miss E co-codamol.
61. Given the formal account from the midwife and Miss E, alongside the treatment sheet, on a balance of probabilities we accept it appears the midwife did review Miss E and not think she was in labour at this time.
62. Our adviser says the midwife did not carry out a full assessment before reaching the decision Miss E was not in established labour. The midwife should have assessed Miss E by abdominal palpation and documented this clearly. This would have determined the position of the baby as well as the number, strength, and frequency of the contractions.
63. Performing a vaginal examination would have enabled the midwife to make a cervical assessment confirming whether Miss E was in established labour. We will consider the midwife’s decision not to carry out a vaginal examination later in the report.
64. We have considered the Trust’s own policy when considering how often a midwife should check a woman believed to be in the latent (first) stage of labour. Our adviser says the Trust did not act in line with its own latent phase guidelines.
65. The records show a midwife took initial observations of Miss E when she arrived on the ward. There are no further records of any other observations being taken. We know there was an interaction at 5.20pm but any observations were not formally recorded.
66. The recording of observations is an essential part of care which allows for an ongoing assessment of both the mother and the unborn baby. This ensures that both mother and baby are seen to be coping with the labour process, and that any deviations from normal monitoring results can be acted upon.
67. Our adviser noted the Trust’s Latent Phase guideline which say, ‘it is important to recognise the transition from the latent phase of labour to the active phase to institute appropriate fetal and maternal monitoring’.
68. This did not occur as there was minimal evidence the midwives attended to Miss E, until Miss E’s mother alerted the midwives that her waters had broken. We have found a failing here.
The Trust did not carry out vaginal examinations
69. Miss E says the midwife did not carry out vaginal examinations to monitor the progress of her labour.
70. The Trust says too many vaginal examinations can be difficult for mothers, increase the risk of infection, or lead to discomfort and unnecessary exposure. It says the midwife did discuss with Miss E if her contractions became more regular and painful, then they would perform a further vaginal examination.
71. Section 1.4.2 of NICE guidelines of intrapartum care states that ‘if there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment but is not always necessary’ and ‘If the woman appears to be in established labour, offer a vaginal examination.’
72. Our adviser has considered if the midwife should have carried out a vaginal examination of Miss E. We know the midwife had an interaction with Miss E at 5.20pm, due to her statement as set out above.
73. Our adviser says it is not always necessary to carry out a vaginal examination. However, before reaching this decision it is important to assess the patient, spend time with her, and palpate her contractions.
74. The available evidence and records show the midwife decided not to carry out a vaginal examination at 5.20pm. Our adviser says the midwife should have carried out an assessment before reaching this decision and documented their findings.
75. As the midwife did not document their interaction with Miss E formally in the records, it is difficult to establish if they did enough before deciding not to carry out a vaginal examination.
76. Our adviser considered the Trust’s comments and rationale that too many vaginal examinations can be difficult for mothers, increase the risk of infection, or lead to discomfort.
77. Our adviser acknowledges these statements are true. They do not account for the specific circumstances in this case. The Trust had been trying to induce Miss E’s labour with a membrane sweep and she was not someone at greater risk of infection.
78. Our adviser says, on balance, it appears the midwife did not do enough. This is because there is no indication the midwife carried out a sufficient assessment, in line with the guidance. We cannot see any evidence to support whether the midwife considered Miss E’s maternity history. The decision not to carry out a vaginal examination was not in line with the NICE guidance. We have found a failing here.
Pain relief during delivery
79. Miss E says she was not offered gas and air during the delivery of her baby and the placenta. She says she requested this.
80. The Trust says Miss E’s waters breaking progressed very quickly to the birth of her baby. It says pain management at this time is particularly challenging because the events are progressing quickly. It says in this case, the baby was born within 15 minutes of the second stage being recognised. The Trust says most pain relief given to mothers in labour takes a short period of time to take effect and would not have proved effective at the point of her baby’s birth.
81. The NMC code says you must: ‘1.4 make sure any treatment, assistance or care for which you are responsible is delivered without undue delay.
82. The Intrapartum guidelines say: ‘Observations during the second stage Section 1.13.2: Continue to take the woman’s emotional and psychological needs into account. Ongoing consideration should be given to the woman’s position, hydration, coping strategies and pain relief throughout the second stage’.
83. The Intrapartum guidelines specifically say at section 1.8.1 that healthcare professionals should ensure their care supports a woman’s choice. It sets out at section 1.8.11 that gas and air should be available in all birth settings as it may reduce pain in labour.
84. We recognise it is not documented that Miss E asked for gas and air during the delivery of her baby. However, there is no evidence to contradict her account. We have determined that Miss E was asking for gas and air at 5.20pm. It is reasonable to conclude the pain did not go away. It appears to be accepted by all parties Miss E would have been in pain at the time of her delivery.
85. Our adviser says most forms of pain relief take some time to start working and therefore would not have been helpful during the delivery. Gas and air takes effect almost immediately. Therefore, it would have been appropriate for the midwife to offer Miss E gas and air for the delivery of the baby and placenta, in line with the guidance.
86. Our adviser said the Trust’s rationale for not managing Miss E’s pain is not sufficient. Although things were moving quickly, the midwives present should have considered that Miss E may be in pain and offered her pain relief, as per NICE Intrapartum Guidance and section 1.4 of NMC’s The Code. We have found a failing here.
Impact of these provisional failings
87. We will now go on to consider the impact of the above failings we have found in Miss E’s care.
88. Miss E says she was in unnecessary pain during labour. She says she felt frustrated as she had always been allowed gas and air in previous labours. She says the birth of her baby should have been a happy day, but when she thinks about it all she has is bad memories. She says the experience was traumatising and it still affects her now, for example if she sees a TV advert of a baby, all the memories from that day come flooding back.
89. Based on the clinical records of Miss E’s history and admission, our adviser has considered if it is likely Miss E was in established labour at 5.20pm.
90. Looking at the records alone, they are insufficient to confirm if Miss E was in established labour. Looking at the whole clinical picture, labour can progress very quickly, especially when a woman has had several babies before, like in this case. This was Miss E’s fifth baby, she was at 40 weeks and three days gestation, arrived at the hospital experiencing contractions and had a two cm dilated cervix.
91. The records show Miss E had a membrane sweep at 3.00pm. A sweep is intended to bring on labour. It was 5.20pm by the time of this interaction and Miss E was asking for pain relief, showing she was in pain. These are indications the labour was progressing, and the membrane sweep had taken effect.
92. Miss E gave birth at 7.00pm. Our adviser said that physiologically it was highly unlikely that Miss E was not in pain/did not feel her labour progressing by 5.20pm, and that it was likely that Miss E was displaying signs of being in pain.
93. Our adviser pointed out that maternity care is much clearer in hindsight and that the midwife did not know that Miss E was going to give birth at 7.00pm. This does not detract from the fact that Miss E was in pain and the midwife should have reviewed this with a documented clinical assessment, in line with the guidance.
94. Miss E says that she was not given appropriate pain relief as a result. She says the pain was excruciating.
95. Our adviser says if the midwife had carried out an appropriate assessment at 5.20pm, in line with the guidance, it is reasonable to conclude they would have recognised Miss E’s labour was progressing. Miss E would have then been offered pain relief. We know her preferred choice was gas and air.
96. The NHS webpage on pain relief in labour says ‘gas and air will not remove all pain, but it can help reduce it and make it more bearable. It’s easy to use and control yourself’.
97. Our adviser explains that gas and air is a mixture of half oxygen and half nitrous oxide. It is often used to treat pain during childbirth. It is thought to work in the brain and spinal cord, stopping pain from being felt. It is self-administered and quick to work, usually within two minutes. The woman is in control of how much pain relief she receives.
98. We recognise if the Trust had offered Miss E’s pain relief, this would not have eliminated all her pain. Our adviser says it would have reduced her pain and made it more bearable.
99. Miss E would have known the extent to which gas and air could help her due to her previous labours. As she had been given gas and air in previous labours, it is understandable she felt frustrated and unsupported. We recognise Miss E has negative memories from this birth as a result.
100. The evidence suggests Miss E would have been offered her pain relief of choice from 5.20pm, until the delivery of her baby at 7.00pm. She suffered almost two hours of unnecessary pain and suffering, alongside the distress and frustration.
101. The NICE guidelines for established labour say a woman should be provided with supportive one to one care. There were indications Miss E was in established labour so she should have been moved into a labour room and given one to one care. As this did not happen, Miss E was not given the psychological and physical support which she should have received.
102. It is understandable this would have added to the distressing experience.
CTG monitoring
103. Miss E says when she arrived at the hospital, she reported she was experiencing reduced fetal movements. This was the third time she had reported experiencing reduced fetal movements.
104. The Trust commented to say the midwife caring for Miss E felt she was not in established labour, so CTG monitoring was not required.
105. The Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline Number 57 Reduced Fetal Movements February 2011 say that ‘Women who present on two or more occasions with reduced fetal movements are at increased risk of a poor perinatal outcome (stillbirth, FGR or preterm birth) compared with those who attend on only one occasion’.
106. They also say: ‘after fetal viability has been confirmed and history confirms a decrease in fetal movements, arrangements should be made for the woman to have a CTG to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation. CTG monitoring of the fetal heart rate, initially for at least 20 minutes, provides an easily accessible means of detecting fetal compromise’.
107. The NICE Intrapartum care guidelines section 1.4.9 says: ‘offer continuous cardiotocography if any of the risk factors listed in 1.4.3 are identified on initial assessment and explain to the woman why this is being offered. 1.4.3 includes ‘reduced fetal movements in the last 24 hours reported by the woman.’
108. The records show when Miss E presented at the Trust it commenced a CTG trace at 2.10pm. Following Miss E’s membrane sweep, the fetal heartrate was measured and found to be slightly higher. A peer review by another midwife considered the results to be normal.
109. According to the medical records and Miss E’s account, the hospital did not use the CTG at any point after this. There is an entry in the records to say ‘for review in light of reduced movements’.
110. We can see from the evidence, the Trust monitored Miss E for an initial 20 minutes when she arrived as suggested in the guidance.
111. Our adviser says she should have been placed on continuous CTG monitoring throughout her labour, not just for the first 20 minutes. This is because she was reporting reduced fetal movements within the last 24 hours. We have found a failing here. We will now consider the impact of this.
112. Miss E says because the Trust did not put her on CTG monitoring she was very anxious about her unborn baby’s safety.
113. It is understandable this caused Miss E anxiety and distress as she had been reporting reduced fetal movements previously. We recognise that Miss E also experienced reduced movements in her last birth which added to her distress in this situation.
114. In paragraphs 89 to 104 we have set out the distress Miss E was already experiencing when she was suffering unnecessary pain and did not have supportive one to one care. We consider the anxiety she had about the reduced fetal movements meant she experienced even more distress.
115. We do not think the Trust has recognised this impact or done enough to put things right. We have made recommendations below to address this.