C-section
18. Mrs R says the Trust missed chances to do a c-section sooner.
19. At 7.40pm on 2 December 2022, Mrs R arrived unplanned at the maternity unit. The Trust reported she had a gush of fluids and had been leaking clear fluids since 6.00pm and was in pain. The diagnosis at that time was ‘?labour’. The Trust’s midwife asked Mrs R if they could do a vaginal examination, which she declined. Mrs R has vaginismus (involuntary cramps in the vaginal wall). Our obstetrician adviser told us this would have made it significantly difficult for Mrs R to tolerate vaginal examination.
20. Mrs R had a birthing plan in place and her preference for delivery was a c-section. Mrs R told the Trust on admission on 2 December that she still wanted a c-section birth. The Trust does not appear to have then fully established if Mrs R was in labour as it was unable to do a vaginal examination.
21. NMC guidance says ‘1.4 make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’.
22. The Trust’s midwife escalated Mrs R’s case to the medical team. It does not appear they took further action themselves to establish whether Mrs R was in labour. We asked our midwifery adviser if there were any other methods, other than a vaginal examination, the midwife could have used to find out if Mrs R was in labour.
23. Our midwife adviser said there were clear clinical signs Mrs R was in labour. These were that her waters had broken, that she was in pain and having regular contractions and required pain relief. Our midwife adviser told us these are signs Mrs R was in labour at 7.40pm when she arrived.
24. Overall, it appears Mrs R was likely in active labour when she arrived at the delivery unit. The records are incredibly light on detail about what was happening at that time. There are only three entries from midwives from when she was admitted at 7.40pm to when the doctor arrived 10.45pm and established she was in labour. This was a period of three hours. We find that not recognising the signs that Mrs R was in labour during those three hours was a failing.
25. We asked our obstetrician adviser if the Trust could have done Mrs R’s c-section earlier than it did. They told us that if the Trust had diagnosed labour earlier as it should have done then it could have done a c-section earlier. Our adviser said a c-section was already indicated for a number of reasons such as the baby being in breach position and Mrs R’s medical history of vaginismus. Our midwife adviser told us that it was also clearly indicated as that was Mrs R’s preference for method of delivery.
26. In summary, the Trust should have recognised Mrs R was in labour and escalated her care three hours sooner than it did. If it had done this it is likely she would have been moved to a delivery suite. This would have led to an earlier delivery.
Vaginal examination
27. Mrs R says the Trust kept asking her if it could perform a vaginal examination when she had already said she did not want one. She says staff told her she needed one in order to have a c-section sooner.
28. The Trust’s midwife reviewed Mrs R at 7.40pm and asked her if they could a vaginal examination. Mrs R declined this and the midwife wrote in the record ‘for no – minimal VE’.
29. There is no further documentation in the records about a vaginal examination until the doctor arrived at 10.45pm and again noted she was unable to tolerate such an examination. The midwife then asked Mrs R again at 11.05pm if they could do a vaginal exam, and it noted she was not for examination. The Trust later gave Mrs R a spinal block, and carried out a successful vaginal examination with Mrs R’s consent at 11.45pm which found she was fully dilated.
30. NMC guidance says midwives should ‘balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment’ and ‘respect, support and document a person’s right to accept or refuse care and treatment’. GMC guidance says doctors must ‘recognise a patient’s right to choose whether to accept your advice’.
31. Mrs R’s birthing plan clearly said she was unable to tolerate vaginal examinations. This documentation was included in her medical record for midwifery staff to view.
32. We asked our midwifery adviser if it was inappropriate to offer Mrs R a vaginal examination given her history. They said that as the situation had changed, and Mrs R had come to hospital unexpectedly early, it was not unreasonable for the midwives to offer her a vaginal examination when she was first admitted at 7.40pm. They correctly offered her advice and offered a vaginal examination to help establish whether she was in labour. When she declined midwives did not carry it out. This was accepting Mrs R’s wishes in line with the NMC guidance.
33. The Trust then offered Mrs R a vaginal examination at 10.45pm, 11.05pm and 11.45pm. We can understand why the Trust wanted to perform a vaginal examination, as this would have allowed it to establish if Mrs R was in labour. Our midwife adviser said this is the best way to determine labour (but, as we have already set out, not the only way). But Mrs R had already declined a vaginal examination once, and her birthing plan also stated she was unable to tolerate vaginal examinations. We find the Trust acted appropriately by asking her once, but to continue asking her when she had already said no was not respecting her right to refuse treatment or her choices. This was a failing.
34. In its comments the Trust told us that it was right to offer Mrs R further vaginal exams, because it has ‘a professional responsibility to reoffer at appropriate intervals in case her wishes change, her clinical situation evolves, or she seeks further information. This is consistent with personcentred care and informed choice’. We considered these comments. We are not saying that, in general, Trust should not ask questions more than once as a clinical situation evolves. But in this individual case the Trust was aware Mrs R did not want a vaginal examination from her birthing plan, she also expressed these when she arrived at the unit, and the Trust’s midwife called the ward to tell them about her wishes. In other pregnancies it would be right for the Trust to offer further examinations, but in Mrs R’s unique case it is clear she did not want one.
Pain management
35. Mrs R says the Trust did not manage her pain when she was in labour, and that she could not have an epidural.
36. The records are incredibly light about Mrs R’s pain management before she was moved to the delivery suite at 10.45pm. Sometime before the doctor arrived the midwife documented that Mrs R ‘appears uncomfortable and shaking’. It is not noted if this was because she was in pain. The Trust does not appear to have given Mrs R any pain relief before 10.45pm.
37. NICE CG190 says women in established labour can be offered opioid pain relief and regional pain relief. Our obstetrician adviser said the issue with pain relief likely stems from the fact that the Trust failed to establish at 7.40pm that Mrs R was in labour as it should have (see above). Our adviser said that if it had done so Mrs R would have been eligible for pain relief under the NICE guidance.
38. We find that because it did not recognise Mrs R was in labour, the Trust did not provide Mrs R with access to pain relief. That was a failing.
39. After the Trust determined Mrs R was in labour, at 10.45pm, it inserted a spinal anaesthetic at 11.11pm. Our midwifery adviser said Mrs R was likely in some discomfort before this, as her pain was only being controlled with Entonox (gas and air), and Mrs R would have still felt pain with this.
40. We are saddened to see the Trust left Mrs R in avoidable pain for around three hours because of its failure to recognise she was in labour soon enough.
Consent
41. Mrs R says the Trust did not gain consent properly before doing the c-section, or explain the new risks associated with being fully dilated when having a c-section.
42. The NHS website on caesarean sections lists some of the risks of the procedure. They include infection, bleeding and damage to other organs. The consent form Mrs R signed had these risks included. Our obstetrician adviser told us the Trust listed correctly the risks of the procedure.
43. We note that at the time Mrs R signed the consent form the Trust had not completed a vaginal examination so it did not know she was fully dilated. The Trust only found Mrs R was fully dilated only when she was in theatre and it offered her a vaginal birth. The records are silent about whether the Trust’s doctor spoke to Mrs R about if there are any new risks associated with having a c-section whilst fully dilated. Our midwife adviser told us that there is evidence that when having a c-section whilst fully dilated slightly increases the risk of preterm birth in a future pregnancy. However, Mrs R is already at risk of this due to her bicornuate uterus.
44. We do not however consider a better explanation of this would have changed Mrs R wanting a c-section. Mrs R’s birthing preference before giving birth was outlined in her birthing plan, that she wanted a c-section. Mrs R also wanted a c-section when she arrived at the unit. We find that taking this into account, even if the Trust did explain any further risks she would have still likely have chosen to go ahead with a c-section delivery.
45. Overall, the issue here is that the Trust missed chances to recognise Mrs R was in labour earlier as we have explained above. When it asked Mrs R to sign this consent form she was likely in significant discomfort, had it recognised she was in labour sooner, she would likely have been able to sign this form under calmer conditions. The risks included on this form were right, but there was no evidence the Trust explained if there would be any additional risks to having a c-section fully dilated as the records are silent on this. We do not however think this would have changed Mrs R’s mind on having a csection even if any additional risks were explained.
Surgery
46. Mrs R says the Trust’s surgeon was not aware of her medical history, specifically that she had a bicornuate uterus before starting the surgery.
47. RCS guidelines says surgeons should ‘Take full responsibility for the management of patients admitted under your name’. GMC guidelines say ‘adequately assess a patient’s condition(s), taking account of their history’.
48. When the Trust’s surgeon performed a c-section on Mrs R they were unaware of Mrs R’s bicornate uterus. The Trust said that is not a normal check it carries out.
49. We asked our obstetrician adviser if the surgeon should have been aware of Mrs R’s medical history before doing the c-section. Our adviser said the surgeon should have been aware of this and the RCS and GMC guidance above means doctors should make themselves aware of a patient’s medical history before carrying out a procedure.
50. We find it is the surgeon’s responsibility to adequately assess a patient’s history and this would include knowing about Mrs R’s bicornuate uterus. We find that not taking the adequate steps to familiarise themselves with this was a failing.
51. We understand the Trust has told us it is not routine for its surgeons to do this and we recognise that in these types of clinical situations things move fast. This however, does not make the Trust’s actions on this occasion in line GMC and RCS guidance.
Birthing plan
52. Mrs R says the Trust did not follow her birthing plan.
53. Earlier in the pregnancy the Trust and Mrs R created a birthing plan. This birthing plan outlined Mrs R’s history and information around her pregnancy. The Trust scheduled Mrs R for a planned c-section on 9 December. Mrs R arrived at the Trust as an emergency on 2 December as she went into unexpected labour.
54. NMC guidance says ‘make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’. This plan was put in place on the basis Mrs R was coming into the Trust as a planned admission. As she arrived as an emergency the Trust was reacting to the emerging situation which had changed and was unplanned. We find no failing in not following the birthing plan because the situation had changed and it needed to deliver care without delay.
Urine sample
55. Mrs R says the Trust took a urine sample and did not tell her the results.
56. NMC guidance says to ‘respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing’ and ‘recognise when people are anxious or in distress and respond compassionately and politely’.
57. The Trust collected a urine sample from Mrs R when she arrived at hospital. The midwife documented that Mrs R had ‘? mec in sample’. Meconium is stool of an infant after birth. The records do not show the Trust sent the sample for testing.
58. Our midwife adviser told us that it is not routine to send urine samples for testing that include meconium as it would impact the test results.
59. We would not be able to say that the Trust took a urine sample for testing as the records do not reflect that. It is not clear that meconium being in the sample was communicated to Mrs R. Our midwife adviser told us there was a lack of information enabling them to comment on what was discussed with Mrs R at the time. We find the Trust’s midwife should have discussed what was happening with Mrs R, recognising she was clearly anxious about this. Not doing so was a failing.
Impact
60. In this part of our report we will consider the impact the Trust’s failings had on Mrs R.
61. We found the Trust missed chances to recognise Mrs R was in labour for three hours.
62. Mrs R says the delay in doing the caesarean section caused her to be distressed, and as her pain was not managed this left her in avoidable pain for longer.
63. Once the Trust recognised Mrs R was in established labour it performed the c-section within an hour. On the balance of probabilities, we find that if the Trust had recognised that Mrs R was in labour earlier, as it should have, it would have likely led to her having a c-section around three hours earlier than she did.
64. During the time between Mrs R’s admission and the Trust recognising she was in labour, it prescribed her Entonox only. Had the Trust recognised she was in labour sooner it would likely have offered other pain relief medication as per the NICE guidance. It is also likely the Trust would have offered Mrs R an epidural/spinal block sooner, use of which is also supported by the NICE guidance. As Mrs R birthing preference was c-section she would have needed a spinal block inserted anyway.
65. There is little in Mrs R’s medical record about her pain management. This is because the Trust did not recognise she was in labour so did not record her pain levels. Mrs R told us she was in high levels of pain, and this is also evident in her account to the Trust when she was complaining to it. On the balance of probabilities the Trust’s failure to recognise she was in labour sooner meant she was in pain for longer. We cannot say that Mrs R would have experienced no pain as NICE guidance says these steps ‘will provide limited pain relief during labour’. Labour is often an incredibly painful process. But for three hours the Trust took limited steps to help make Mrs R more comfortable. The Trust’s failings meant Mrs R was likely in significant pain without pain relief for three hours.
66. We also find the Trust asking her further times if it could do a vaginal examination had an impact on her.
67. Mrs R was a vulnerable woman whose history meant her birthing was more complicated. The Trust recognised this by putting a birthing plan in place. This plan clearly noted she would not be able to tolerate vaginal examinations. It was right for the Trust to offer her a vaginal exam when she was first admitted as this was unexpected, but once she declined this it offered her a further two exams this was not reasonable or respecting her right to refuse treatment or her preferences.
68. Our midwife adviser said during labour women should feel supported. The Trust did not make Mrs R feel supported during labour. It missed signs she was in labour, and it twice did not respect her wishes for no vaginal examinations. This likely made Mrs R feel like she was not being listened to and caused her distress.
69. We also considered if Mrs R was aware of the risks of a c-section when fully dilated, and if this could cause premature labour in future pregnancies. When the Trust got Mrs R to sign her consent form our midwife adviser told us the Trust were not aware she was fully dilated as it had not done a vaginal exam.
70. We note that when the Trust found that Mrs R was fully dilated it did not write in the records if there were any additional risks to her. We asked our obstetrician adviser if Mrs R was at risk of future pre-term labour, and they said that as her baby was in breach position there would likely have been no additional risks. We did however consider for completeness if the Trust did explain this to Mrs R would it have changed what happened. Mrs R wanted a c-section that was in line with her birthing preferences, she did not want to give birth by vaginal delivery. We find that even if the Trust told her about this potential additional risk, Mrs R would have still chosen to have a c-section. However, we find a sooner recognition of labour would have meant she likely would not have been fully dilated when she had the c-section.
71. The issues all stem from the Trust not recognising Mrs R was in labour as soon as it should have done. If it had it is likely she would have had her c-section sooner, her pain would have been managed better, and she would have consented in a calmer environment as she likely would not have been fully dilated. The failings, and impact caused, were all likely avoidable.
72. We find the surgeon not reviewing Mrs R’s medical record before completing the surgery did not cause any immediate impact on her, as we have not found there were any complications during the surgery. We do, however, think later finding out this information likely caused her distress given her overall experience.
73. We also found failings in the Trust’s surgeon not knowing Mrs R’s medical history before undertaking the procedure. The Trust has said the surgeon has reflected on this but did say in its response that ‘this is not a check that is routinely performed by surgeons prior to a c-section’. But RCS guidelines say surgeons should ‘Take full responsibility for the management of patients admitted under your name’. GMC guidelines says ‘adequately assess a patient’s condition(s), taking account of their history’. The surgeon and Trust have a duty of care to its patients to ensure it is aware of a patient’s history. We are concerned the Trust are not performing checks in line with its duties or the above guidelines, we are therefore likely to make recommendations to the Trust on its policy relating to c-sections.
74. We also found failings in the Trust’s communication of her urine results, and it is not clear if the midwife explained the results to Mrs R. The records are silent on this, NMC guidance says ‘Keep clear and accurate records relevant to your practice’. We do not find the Trust kept proper records here. We can understand why these failings will have led Mrs R to lose trust in the NHS.