Negligent induction of labour leading to birth injury

As with any medical procedure there are risks involved in induction, and mothers should be carefully advised of the pros and cons (benefits and risks) of induction, the different methods available to them and, once a decision has been made to proceed, for the correct safety steps and procedures to be undertaken.

Unfortunately, in some cases, if the correct safety steps are not followed induction can lead to birth injury.

In our experience there are a range of outcomes causing birth injury when induction of labour is negligently managed.

These include:

• failing to appreciate high risk of cord prolapse in some cases;
• uterine hyperstimulation or rupture;
• failure to diagnose fetal distress;
• impacted fetal head.

I felt it important to review these common themes and complications arising out of induction of labour cases I have litigated:-

Case 1 – Cord Prolapse and language barriers

A mother (who did not have English as her first language) was advised to undergo induction of labour at 36 weeks of pregnancy as her baby was showing signs of Uterine Growth Retardation (IUGR). Clinical staff advised her to have a propess pessary inserted however they failed in advance to assess the position of the fetal head, failed to assess the Fetal Heart Rate before and after induction and failed to advise mother of the risks of cord prolapse occurring with a small baby who is not engaged.

Once in labour mother did not have continuous fetal monitoring with a CTG trace and staff did not react to her complaints of extreme pain as there were issues with her ability to communicate with them in English. Eventually staff realised that there was an umbilical cord prolapse. However there were further delays in undertaking a caesarean section.

Very sadly the baby suffered a significant hypoxic ischaemic insult to her brain, this oxygen deprivation caused lasting damage and she was later diagnosed as suffering from cerebral palsy.

Case 2 – Uterine hyperstimulation and rupture

In a case where a mother (again who did not have English as her first language) went over her due date, she was advised to undergo induction of labour. This was despite the fact that mother had requested a caesarean section as she previously had one and did not want a VBAC (Vaginal Birth After Caesarean) birth. The maternal request was denied without any good medical reason and without any explanation to mother of the increased risks of induction associated with VBAC deliveries.

During the course of antenatal care the Trust failed to arrange for an interpreter and the mother was therefore only given very limited information and was unable to express per birth preferences.

Induction was undertaken by way of a propess pessary. When the first pessary fell out after a few hours the midwife inserted a fresh pessary without consulting with an obstetrician and at the same time removed the CTG monitoring both baby and mother’s uterine contractions.

Due to the excessive amount of stimulating drugs the mother suffered uterine hyperstimulation and there was a delay in diagnosing this and diagnosing fetal distress. By the time mother was taken to theatre she had suffered uterine rupture and significant bleeding, this in turn led to oxygen deprivation to the baby and brain damage with cerebral palsy.

Case 3 – Failure to progress and failure to note fetal distress

Mother in this case was almost 42 weeks pregnant when she underwent induction of labour with a propess pessary.

Despite the induction there was very little cervical dilatation and the baby was becoming increasingly distressed due to strong uterine contractions. The CTG trace monitoring the baby became very concerning (pathological) but despite this staff did not react and there was a delay in undertaking a caesarean section.

The baby was born in a very poor condition having suffered a period of damaging hypoxia and now has cerebral palsy.

Case 4 – Failure to give the option of caesarean section

A mother suffered from persistent hypertension and pre-eclampsia towards the end of the pregnancy. She was advised to undergo medical induction of labour and was not told of the associated risks of this in the presence of pre-eclampsia and was not categorised as a high-risk mother (needing obstetric management, rather than management on a general midwife led ward).

There was a negligent failure to advise mother of the risks of induction against the risks and benefits of an elective caesarean section.

The induction caused uterine hyperstimulation and there was a delay in diagnosing this and undertaking an emergency caesarean section. The baby suffered a significant deprivation of oxygen and has cerebral palsy.

Case 5 – Induction and sending mother home

Induction of labour was recommended in this first-time mother who was 12 days overdue. There had been concerns throughout the pregnancy of concerning mother’s low BMI, but despite this she was not considered high risk.

Mother came into hospital for induction of labour but was then sent home with little guidance. At home the labour quickly progressed and despite calling the labour ward three times, mother was told to stay at home and call back later.

On eventually being requested to come back to the ward the mother was passing meconium-stained fluids and the baby was in significant distress due to oxygen deprivation, she was born in a poor state requiring resuscitation and suffered a neurological injury.

Case 6 – An undiagnosed large baby causing impacted fetal head

A first-time mother was overdue and it was recommended she have an induction of labour. The staff were unable to ascertain the position of the baby prior to induction and did not appreciate how large the baby was, if they had done, then caesarean section should have been recommended instead.

The induction worked quickly and within 12 hours there was full cervical dilatation. Thereafter the mother was allowed to push for over 3 hours with no progression of the delivery. A decision was then made to undertake a caesarean section; however the fetal head had become impacted into the mother’s pelvis as this was a very large baby, who was in the back to back position and mother had been pushing for hours.

The baby suffered a lack of oxygen during this period and was born requiring resuscitation, and admission to NICU and cooling.

This small example of cases demonstrate the significant complications which can arise from:

• Failure to advise mother of all of the risks and options for mode of delivery
• Failure to undertake full assessments before induction takes place
• Failure to properly monitor the fetal heart rate and maternal contractions after induction.

The NICE Guidelines are clear for clinical staff and therefore likely issues associated with these failures relate to:

• A lack of training of clinical staff
• Under-staffing on wards leading to failures in monitoring
• The management of women as low risk when they should be managed as high risk under an obstetrician

I very much hope NHS Resolution feeds back to Trusts on lessons learned from these adverse events so that standards of clinical care around induction can be improved.