Pain relief
21. Miss I complains the Trust did not provide her with additional pain relief during labour and when she was giving birth.
22. The Trust said it is documented in the records that Miss I was managing her pain well with gas and air. It said there is no further documentation of a request for additional pain relief.
23. The Intrapartum guidance says health professionals should take into account that every woman’s experience of pain is unique and may be expressed in different ways, both verbally and non-verbally. Health professionals should also think about how their own values and beliefs inform their own attitude to coping with pain in labour. They should ensure their care supports the women’s choice.
24. In terms of specific methods of pain relief, the Intrapartum guidance says Entonox (a 50:50 mixture of oxygen and nitrous oxide) is available in all birth settings as it may reduce pain in labour. It also says to ensure pethidine, diamorphine and other opioids are available in all birth settings. Both types of pain relief require the healthcare professional to inform the woman of the side effects to her, and if there are any risks for the baby.
25. Shortly after arriving at the assessment centre at the Trust, the Trust noted Miss I was coping well with Entonox. Throughout the notes of Miss I in labour, the Trust still note that Miss I was managing pain using Entonox. The last entry in the records for Entonox is approximately 30 minutes before Miss I gave birth, and it states the pain relief was adequate.
26. Our nursing adviser also explained that if Miss I did request pain relief, we would expect this request to be in the records. As set out above, there is no mention in the records of Miss I requesting pethidine on arrival at the Trust. Nor is there any mention of Miss I requesting further pain relief during labour and the birth.
27. In Miss I’s original complaint to the Trust, she says she requested pethidine from the midwife when she arrived. For Miss I to have requested this specific pain killer, we think it is likely that the Trust must have made her aware of other pain medication available for labour.
28. It is not clear whether the Trust did this antenatally or at the time of Miss I being in labour. On balance, we think it is likely Miss I did request pain relief on arrival at the Trust.
29. Miss I says the labour and birth was a very traumatic and painful experience for her. She says the pain was unbearable and that the midwives attempted to take the Entonox from her. Miss I says the midwives told her not to scream when she was in pain, as if this was something she could control.
30. In the Trust’s complaint response, the Trust said it was concerned about the distressing pain management situation Miss I experienced. The midwife apologised that it did not control Miss I’s pain, as she believed her pain was being controlled.
31. Considering what the Trust said in its complaint response, as well as what Miss I has told us, we do not think its actions are in line with the Intrapartum guidance. It appears the midwife did not seemingly consider how Miss I was coping with pain in labour, regardless of whether they deemed she was coping well on Entonox.
32. Based on the evidence, on the balance of probabilities, the Trust did not provide Miss I with additional pain relief when she needed this. We will consider the impact of this later in the report.
SPD
33. Miss I complains the Trust did not take into consideration her SPD during labour and the procedure used to deliver the baby.
34. The Trust said it was concerned there was a lack of acknowledgement of Miss I’s SPD during labour and birth. It also explained that a ventouse delivery is conducted with the patient’s legs in stirrups which can be uncomfortable and cause discomfort.
35. The SPD article, and the SPD guidance, both say to encourage the woman to adopt any comfortable position and to help change position and to move around. The SPD article says the Lithotomy posture, if required, should only be used for a short period of time. This posture is where a patient lies on their back with their hips and knees flexed, legs separated and supported in stirrups, often with the buttocks at the table’s edge.
36. We can see in the records that the Trust noted Miss I’s SPD during the antenatal period. However, we cannot see any reference to Miss I’s SPD when she was in labour. Our midwife adviser said this may indicate the midwifery team caring for Miss I were not aware of her SPD, or that they did not take it into account. There is also nothing in the records to suggest it encouraged Miss I to adopt a comfortable position, or whether it helped Miss I change position and to move around.
37. In terms of the delivery of the baby, our obstetric adviser explained it would be for the midwifery team to position Miss I for delivery. This would mean placing Miss I’s legs elevated in leg rests. Our obstetric adviser said this would happen when the obstetrician expressed their intention to conduct an instrumental (ventouse) delivery. They say this is the standard approach to undertaking this type of delivery. There is no reference to this, or Miss I’s SPD in the records.
38. We know from the records that the Trust was aware of Miss I’s SPD during the antenatal period. We can also see that Miss I attended physiotherapy appointments related to this during the same period.
39. Following this, there are a lack of records regarding Miss I’s SPD during labour. We would have expected to have seen this documented as it would demonstrate the midwives were accommodating Miss I’s SPD, helping her adopt any comfortable position and helping with her movement overall.
40. On the balance of probabilities, it is likely the Trust did not take into consideration Miss I’s SPD during labour and the delivery of the baby. There are failings here. We will consider the impact of this later in the report.
Birth
41. Miss I complains the Trust did not explain the risks associated when using a ventouse, to her and her baby, as well as the use of an episiotomy.
42. The Trust explained that there is a small risk associated with ventouse births, with the baby having a bruise to their head depending on where the ‘cup’ was placed to support delivery. This can take time to settle down.
43. The RCOG guidance says that as there is usually an urgent indication for assisted delivery, this limits the time for a discussion in the moment. As such, women should be informed during the antenatal period about the possible indications, and types of instrumental delivery. They should also be informed about the possible requirement for an episiotomy as part of the assisted delivery process.
44. The RCOG guidance continues to say this is particularly the case for women having their first baby where the chance of requiring assisted delivery is high. That said, the principles of obtaining valid consent during labour should be followed.
45. In the records we can see Miss I’s birth plan. In this birth plan, it outlines what Miss I would like to happen. It also outlines the different scenarios that can happen, and whether Miss I is aware of these. Specifically, it says that Miss I is aware of why an obstetrician might recommended an assisted birth. It also says Miss I is aware of why of episiotomy might be recommended to help facilitate birth.
46. The Trust’s actions here are in line with the RCOG guidance as the records show it discussed with Miss I the different types of assisted delivery, and why these might be needed.
47. During Miss I’s labour, our obstetric adviser says an assisted delivery was appropriate. This was due to the persistent and sudden drop in Miss I’s baby’s heart rate late in labour. Our obstetric adviser explained that if not immediately delivered, the baby could have been at risk of brain injury due to lack of oxygen.
48. In terms of the obstetrician explaining and offering this (ventouse) to Miss I, there are no notes in the records to evidence this. Nor is there anything in the records to show whether a discussion took place about the episiotomy, and the associated risks for this as well as for the ventouse.
49. The only notes we have are from the midwife who has documented the various steps leading to delivery. For example:
• 1.07am – VE (vaginal examination) conducted by doctor • 1.07am – decision for instrumental [birth] given • 1.21am – episiotomy given…
50. Due to the lack of notes, we do not know whether a discussion took place at the time, how detailed this discussion was and whether this discussion also explained the risks.
51. However, as explained earlier in paragraph 47, the situation called for an immediate delivery due to the risk of injury to the baby. Our obstetric adviser also says the records suggest the baby had already been subject to a short period of acute hypoxia (low levels of oxygen) due to its slow heart rate.
52. Due to the urgent and immediate situation unfolding, we would not necessarily expect an obstetrician to go through all the risks and explanations at the time. This is the reason why the RCOG guidance says to discuss this antenatally, which the Trust did in Miss I’s case.
53. We do not underestimate how traumatic Miss I found the delivery and birth of her baby to be. We also do not wish to undermine the distress Miss I has been through due to the shape of her baby’s head.
54. We acknowledge the Trust may not have explained the risks associated with using a ventouse and episiotomy in detail at the time. However, we can see this was an emergency situation, and that in line with the RCOG guidelines, the Trust had previously explained about assisted deliveries and the risks associated with these.
55. On balance, we have found the Trust has acted in line with the RCOG guidelines. It informed Miss I during the antenatal period about instrumental delivery and episiotomy. We do not think there are any failings here.
Impact
56. On the balance of probabilities, we have found failings in the following:
• the Trust did not provide Miss I with additional pain relief when she needed this, and • the Trust did not take into consideration Miss I’s SPD during labour and delivery.
57. Miss I says by the Trust not listening to her request for additional pain relief, and therefore not providing the pain relief, this caused her upset and did not help resolve her pain. Then, by the Trust not considering her SPD, it caused Miss I further distress as she is still experiencing issues with her legs and pelvis due to the episiotomy.
58. As a result of the Trust’s actions, Miss I says the whole experience has traumatised and frightened her from having another baby, as well as future family planning.
59. We can understand it would have been upsetting for Miss I to have felt she was not listened to regarding her request for pain relief. We acknowledge this meant Miss I experienced pain which could have been avoided.
60. Due to the lack of records regarding Miss I’s SPD, we do not know whether the Trust assessed the range of pain-free movement for Miss I. For a ventouse delivery and episiotomy the lithotomy type of position is the standard approach. We acknowledge that placing Miss I in a position for this would have been uncomfortable due to her SPD, particularly as this may have needed to happen quickly.
61. We do not know whether the Trust could, and should, have done more to accommodate Miss I’s SPD during labour and when moving her into the lithotomy position. We acknowledge this uncertainty around whether some of the discomfort she experienced could have been avoided will cause Miss I further distress.
62. The Complaint Standards say organisations should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned. It also says where failings have been found, organisations should seek to return someone to the position they would have been in. If this is not possible, a financial remedy which compensations them appropriately should be provided.
63. The Trust apologised that it left Miss I feeling like she was not listened to regarding her choice of pain relief. It also apologised that its actions meant Miss I was left feeling unsupported. This is both the case for the lack of acknowledgement of Miss I’s SPD, and the distressing pain management situation.
64. We think the Trust’s apologies given to Miss I are in line with the Complaint Standards, and so we will not be asking it to provide a further apology. We have outlined our recommendation below.