13. Before we decide if we should conduct a detailed investigation of 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 have not found any indications something has gone wrong.
Heart rate monitor
14. Miss P explained it was some time after her labour she gained knowledge that gave her cause for concern. She said experienced midwives she knew had read her labour notes and questioned why she had been on a CTG.
15. Miss P says she had no risk factors and so she did not meet the criteria to be on a CTG. She had a history of RFM but had not experienced this in the 24 hours before labour.
16. Miss P says had she not been on the CTG there would not have been such a great concern for her baby leading to an episiotomy.
17. The Trust said Miss P’s history of RFM was the risk factor for increased monitoring using a CTG.
18. The records show Miss P had five episodes of RFM during her pregnancy.
19. RCOG guidelines state ‘it has been suggested that reduced or absent foetal movements may be a warning sign of impending foetal death’
and
‘women who present on two or more occasions with RFM are at increased risk of a poor perinatal outcome (stillbirth, foetal growth restriction or preterm birth) compared with those who attend on only one occasion.’
20. RCOG guidelines recommend electronic foetal monitoring if the pregnant person has experienced RFM in the 24 hours before the onset of regular contractions.
21. It also says consider a CTG if there are concerns that may lead to foetal compromise following clinical assessment and multidisciplinary review.
22. We appreciate Miss P had not had RFM in the 24 hours before labour. Our adviser explained her history of this was still relevant. In line with RCOG guidelines, over two occasions of RFM meant there was increased risk of her baby dying.
23. Miss P says she did not want to be on a CTG. She wanted to be able to move freely. It is important to note if Miss P had declined the CTG, in line with NICE NG229, the midwife would still have had to complete intermittent foetal heart rate monitoring.
24. NICE NG229 says if there are foetal heart rate concerns the midwife should summon help and advise continuous CTG monitoring.
25. Our adviser explained if the midwife had been monitoring the foetal heart rate intermittently, it is likely the outcome would have been the same and Miss P would have still needed a CTG.
26. We can also assure Miss P about her statement that it was normal the baby’s heart rate to fall as it was coming through the birthing canal. Our adviser confirmed this can be true during the second stage of labour, however they said you would expect the baby’s heart rate to go back to normal quickly.
27. The records show the midwife documented their concern that the baby’s heart rate was dropping but not returning to normal.
28. Our adviser explained they could understand the midwife’s concern as at the time the baby’s heart rate dropped the head was visible. They said in this circumstance it was understandable to expedite (speed up) delivery.
29. We understand it must have been a shock to Miss P when she heard she may have been on the CTG unnecessarily. RCOG guidelines recommended the CTG so we can assure her the Trust did not do something wrong in continuously monitoring the foetal heart rate.
30. From what we have seen this was a precaution that was needed to help ensure the safety of her and her unborn child. For these reasons, we have not seen indications of a failing and will not take further action on this part of the complaint.
Episiotomy
31. Miss P’s friends also told her it was not normal to have an episiotomy without local anaesthetic.
32. We appreciate Miss P’s concern as she says she would not have had the procedure without anaesthetic had she known. Her friend told her even in an emergency, anaesthetic should be used.
33. The Trust acknowledged there was no anaesthetic stocked in the delivery room. It said as staff were concerned about abnormal foetal hear rate readings, they felt they should not delay delivery by seeking anaesthetic elsewhere. They were concerned Miss P’s baby may not survive if not delivered quickly.
34. In the Trust’s complaint response, the midwife said they made this decision in the best interest of Miss P and her baby. The Trust apologised for the distress caused.
35. NICE NG235 states:
perform an episiotomy if there is a clinical need, such as birth with forceps or ventouse or suspected foetal compromise
and
provide tested, effective analgesia before carrying out an episiotomy, except in an emergency because of acute foetal compromise.
36. Our adviser said under most circumstances it would be usual to administer local anaesthetic into the perinium before an episiotomy was undertaken.
37. The records show this was the midwife’s intention but there was no anaesthetic in the cupboard.
38. NMC code states midwives must:
• make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay
• accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
• arrange, wherever possible, for emergency care to be accessed and provided promptly.
39. Our adviser said the records show Miss P needed the episiotomy. The abnormal heart rate readings meant this looked to be an emergency and the midwife had to use their clinical judgement.
40. Miss P explained she remembered having the procedure well. She recalled the staff being in a panic and the sharp feel of the scissors. We are sorry to hear how traumatic it was. Her account corroborates the staff had significant cause for concern.
41. NICE NG235 guidelines state you can perform an episiotomy without pain relief in an emergency.
42. Our adviser noted the midwife performed the episiotomy at the height of a contraction. They said this was good practice as at that point the baby’s head would be pushing down on the perineum. This means there was a thinner amount of muscle to cut through. We consider this indicates the midwife did what they could in the circumstances to try and minimise distress and pain.
43. Our adviser also stated the midwife ideally should have checked the cupboards were stocked on entering the room. They said an episiotomy was a predictable eventuality and the midwife should have been prepared for it.
44. We are pleased to see the Trust took learning from Miss P’s complaint and arranged for its Matron to ensure the cupboards were fully stocked in the future.
45. We do not underestimate the impact this has on Miss P. We are sorry to hear Miss P feels she would not have another child after this experience. We appreciate it was a difficult time for Miss P especially as she suffered with complications from the episiotomy not healing properly.
46. We must also recognise the circumstances could be tragically different if the midwife had not acted in the way they did. We consider the midwife acted in line with NICE and NMC guidance which says to act quickly in an emergency. As we have not seen indications of a failing, we will not take further action.
47. We thank Miss P for sharing her experiences.