“We agree that the fetal heart recordings by the midwife in the final 5 to 10 minutes before birth are inconsistent with the fetal heart rates that would be expected during that period given the likely timings of the period of injury.” iv) Consistent with point (ii) above, the notes do not disclose that Midwife Kong, when she auscultated the fetal heart, heard any decelerations. In their joint statement, the expert obstetricians, Mr Ugwumadu and Professor Steer, were asked the question: “Do you consider that in the second stage of labour CTG monitoring and/or correctly administered intermittent auscultation would have likely shown variable or complicated decelerations due to cord compression as labour progressed? If not, please explain your reasoning”
“We agree that it is likely that CTG monitoring would have shown variable decelerations.”
“By definition, with such decelerations the heart rate is sometimes in the normal range and sometimes slow (below 110bpm). It is possible that by chance the auscultated rates were all when the FHR was in the normal range. While this would be uncommon, there is no fundamental impossibility that by chance this was what happened.”
“Baby taken to resuscitaire, dried and stimulated. Pale, floppy, HR equal/under 40bpm. No resp effort. X5 initiate breaths given & emergency buzzer pulled by C Kong. Neonatal team called on 2222 by St/M K Hudson + S/M A Doherty. No chest movement. Airway inspected under direct vision with laryngoscope Meconium + in airway, suction with neonatal yonker sucker, guedal airway inserted.”
“Meconium noted on baby’s skin. Cord around neck x3. Airway taken over by myself. Laryngoscopy performed. Meconium suctioned from between cords. 5 inflation breaths given with good effect. HR > 100. Good chest wall movements. Pinked up (no sats available yet). Ventilation breaths continued as baby remained floppy. No respiratory effort. Decision made to intubate at 7 minutes of life. Patient intubated with size 3.5 ETT, secured at 9 mins to the lips. Passive cooling started. Spontaneous irregular respirations noted at 10 minutes old, as he was breathing against the tube.”
“There are three main elements of the Claimant’s case. They relate to events during his mother’s labour on22nd July 2012 . They are: 1. Failing to pay adequate attention to the fact that Miss Burnett was passing blood-stained liquor, failing to commence CTG monitoring and failing to request medical review from about 12:45 onwards. 2. Failing to accurately monitor the Claimant’s heart rate. 3. Failing to identify the Claimant’s bradycardia/fetal heart rate abnormality from about 14:55 onwards.”
“3a Failing to identify the Claimant’s fetal heart rate abnormality in the form of complex variable decelerations from about 14:45 onwards; 3b Failing to identify the Claimant’s bradycardia from about 15:03 onwards.”
“In this case my recordings on the partogram show that the maternal pulse rate and the fetal heart rate were very different and I’m sure that I was not listening to the maternal pulse rather than the fetal heart in error.”
“min B/S liquor PV. B/S show”
“I was very surprised by the condition of the baby at birth. He was pale and floppy and made no respiratory effort. The umbilical cord was wrapped three times tightly around the baby’s neck and once around his body. I quickly untangled it and clamped and cut the cord. I passed the baby to my colleague, Sr Dunkley, and she immediately took the baby to the resuscitaire.”
“Parous women: • Birth would be expected to take place within 2 hours of the start of the active second stage in most women. • A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent.”
“That is what I heard and documented.”
“Whilst preparing the room I would have heard the fetal heart (via the Sonicaid when being taken by Midwife Kong) and would have commented if I had any concerns about what I could hear. The Sonicaid is at a volume that enables parents to hear the fetal heart, so it would not be difficult for me to have heard it too. After many years of experience, I am confident that I can intuitively recognise a concerning heart rate, for example one that is excessively low or high. If that is ever the case, I immediately raise it with the other midwife and either ask them to repeat the reading or suggest that CTG monitoring is commenced. Had any such concerns been noted or raised by me in this case these would have been noted in the medical records. I see that the records do not contain any note to indicate that I raised concerns about the fetal heart, which suggests that when I heard the same via the Sonicaid it was not concerning. The checking of the fetal heart (having heard the Sonicaid) and advice from supporting midwife is standard practice. If I’m ever asked to re-check a fetal heart (or I suggest to a colleague that they re-check) then that would be done without question. The re-checking and raising concerns would also be noted in the medical records at the time.” … Both midwives in the room would be able to hear the fetal heart rate via Sonicaid and had I thought that the fetal heart rate was concerningly low (or that the heart valves sounds were confusing the reading) I would have raised this with Midwife Kong immediately and requested that the reading be checked/repeated. I would also have noted those concerns in the medical records.”
“Without CTG monitoring, you cannot gain full assurance of no concerns with the fetal heart rate alongside a concerning feature (blood-stained liquor). I would have expected the CTG to have remained in situ until there was no longer evidence of blood-stained liquor and an otherwise normal CTG”
“It is for the court to determine whether the fetal heart rate readings recorded prior to delivery were accurate. However, given the baby’s condition at delivery, the fetal heart recordings made by midwife Kong in the period leading up to delivery are unlikely to be accurate”
“In my opinion the observation of new onset blood loss at 7–8cm cervical dilatation and beyond is more consistent with antepartum haemorrhage/abruption than “show” and should have prompted continuous CTG monitoring. “Show” is characteristically mucoid and seen in the latent and early stages of labour, not usually at 7–8cm cervical dilatation or in association with the amniotic fluid. Furthermore, the absence of blood loss up to 12.00 makes “show” a less likely explanation of the bleeding.”
“The Defendant failed in any event to appropriately perform intermittent auscultation of fetal heat rate from 08:30 hours to delivery at 15:11 hours to an acceptable standard. The Claimant will rely upon the recorded fetal heart rate obtained at intermittent auscultation during delivery, and specifically, the record at 15:10 hours which states that fetal heart rate was 128 bpm. It is the Claimant’s case that the auscultation was negligently performed on the basis of fetal heart rate on delivery at 15:11 hours (1 minute later) being recorded at 40 bpm and recovery heart rate being less than 100 bpm for a number of minutes.”
“From about 14:55 onwards (1) failing to identify that the Claimant was suffering from a bradycardia.”
“From the records, the fetal heart rate auscultation was in accordance with a reasonable and responsible body of midwives. None of the recordings represented a bradycardia … If the Court were to favour the Defendant’s case from the care documented in the records, then the care was in accordance with a reasonable and responsible body of midwives. If the Court were to favour the Claimant’s position, that the fetal heart was not auscultated every five minutes during the second stage of labour, as Midwife Kong was absent for periods of time greater than five minutes, as suggested by the Claimant’s parents in their witness statements, then the care was below the standard of any reasonable and responsible body of midwives.”
“The FHR recordings by the midwife in the final 5-15 minutes before birth are inconsistent with the timings above and I defer to expert obstetrics and midwifery opinion regarding the likely accuracy of the documented intrapartum FHR measurements.”
“I agree I haven’t addressed a central plank of the claimant’s case. I believed until pointed out by you [ie Mr Allen] now that it was in my report: I last read my report last night.”
“Jayden’s injury on MRI is attributable to acute profound asphyxia only. Therefore, in my opinion based on the balance of probabilities, it is likely that cord compression occurred in the second stage of labour leading to FHR collapse, probably related to the cord round his neck and body and changes in Janene’s birthing positions. It is my further opinion that an FHR bradycardia of sufficient duration and severity to cause Jayden’s condition at birth ought to have been detected by a competently conducted IA.”
“If CTG monitoring had been in place or the IA conducted competently it would have been possible to deliver the baby with episiotomy within 5 minutes of the onset of bradycardia since his head was already visible by 14.45, advancing with effort, the labour was efficient, and Janene was parous. If the midwife had summoned the doctor instead and prepared for instrumental vaginal delivery, and the doctor arrived within 2 minutes, the doctor would have delivered the baby with episiotomy within 2 – 3 minutes or ‘lifted the baby out’ with a vacuum device, also within 2 -3 minutes.”
“The recommended procedure for conducting IA is to listen to the FHR for 60 seconds after a contraction to detect late or complicated variable decelerations, which are associated with fetal acidosis. It is highly unlikely that the IA was carried out correctly as recommended. It is inconceivable that the Claimant’s FHR was 134bpm at 15:00, 132bpm at 15:05, 134 at 15:07, 127bpm at 15:09, 128bpm at 15:10 (Table 1), and he was delivered the very next minute with heart rate <40bpm for >5 minutes, in the absence of severe pneumonia, meconium aspiration syndrome, or congenital airway abnormality. It is a matter for the court and there was a second midwife in the room from 15:07, however, it is not credible that the FHR and MHR were counted for a full minute, and documented every other minute, whilst simultaneously assisting and managing a mother in active second stage of labour.”
“Of what significance, if any, is such distinction in relation to the recorded presentation in this case?”
“Blood-stained liquor”, “fresh bleeding”, and ”a bloody show” may look different to different observers depending on the relative amounts of blood, amniotic fluid, and/or mucus plug involved. Given that this was recurrent and reported as different things in late labour for 2 – 3 hours it qualifies for continuous electronic fetal heart monitoring in my opinion.”
“I would have expected extra consideration to be given from the number of times blood staining was mentioned and the fact that it continued in the second stage. It seemed a long time to me.”
“The assertion that there was a fetal bradycardia present is purely conjectural and has no obvious evidential base”
“The allegation of a bradycardia is not substantiated by the clinical records made at the time.”
“If CTG monitoring had been in place, given Jayden’s condition of birth and the fact that the umbilical cord was wrapped three times around his neck, I would have expected to see variable decelerations in the fetal heart rate produced by umbilical cord compression prior to the birth. They would likely have appeared as the baby's head descended through the birth canal, some time before the actual birth itself. The timing of the appearance of the decelerations would depend on the rapidity of head descent; one would not expect to see them until the umbilical cord was compressed or tightened as the head descended. This could have been as little as 10 min before the birth, or possibly up to an hour prior to the birth. As there was no indication for CTG monitoring, and therefore it was not performed, it is not possible to know when the variable decelerations would have appeared. Interference with blood flow between the baby on the placenta is unlikely to have occurred until the umbilical cord was compressed or tightened”
“I knew an issue was whether Jayden was bradycardic before delivery. I was focusing on what was contained in the notes. I did have access to the report of Dr Fox. I agree he highlighted the inconsistency between the notes and Jayden’s likely bradycardia.”
“I see that the records do not contain any note to indicate that I raised concerns about the fetal heart, which suggests that when I heard the same via the Sonicaid it was not concerning.”