Findings

Charge Characteristics

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Precis

Charge:  

The Director of Proceedings charged the Doctor with professional misconduct. The particulars of the charge were as follows:

1. On or about 13 November 1998, or at any time after that, the Doctor failed to adequately inform the patient of the possible consequences for her baby were her uterus to rupture during trial of labour/scar; and/or
2. On 8 June 1999, between 0800 hours and 0900 hours, or thereabouts, as on-call xx for the delivery suite at xx Hospital, the Doctor failed to:

1. adequately assess the patient; or
2. ensure that the patient was adequately assessed by a medical practitioner.

Background: 

In November 1998, when the patient was 12 weeks pregnant she consulted her general practitioner about a “trial of labour” for her third pregnancy. The patient wanted to know if she would be able to deliver her baby vaginally as she had had a Caesarean section in March 1997. Her general practitioner referred the patient to the Doctor.

The patient met the Doctor on 13 November 1998. The Doctor explained that because the patient had had a Caesarean section there was a risk that her uterus could rupture. The patient was certain the Doctor did not tell her about the potential consequences of a ruptured uterus for her baby. This was a crucial issue during the case. The Doctor was adamant that he did explain to the patient the risks for her baby if the patient’s uterus ruptured. After meeting with the Doctor the patient decided to proceed with a “trial of labour”.

The patient chose two lead maternity carers (LMCs). For her pregnancy, the patient chose to be managed by Dr A, a general practitioner and during the delivery of her baby, she chose to be managed by Mrs B, a midwife.

On 20 May 1999, when the patient was 38½ weeks pregnant she had an ante-natal consultation with Dr A. During that appointment Dr A told the patient that the baby had not descended into the pelvis. The patient was subsequently advised by Dr A, that Dr A and the Doctor had discussed her case and that the Doctor had agreed to a trial of labour. When the Doctor gave his evidence he explained that the circumstances under which this telephone conference took place meant that the Doctor would not necessarily connect this patient with previous or subsequent consultations.

The patient started to experience contractions on 7 June 1999 at 23.30 hours. At 00.20 hours on 8 June 1999 the patient and her husband went to the delivery suite at the Hospital where they were met by Mrs B and another hospital midwife.

The patient had an epidural for pain relief at 03.16 hours and at 03.30 hours Mrs B ruptured the patient’s membranes. At 05.45 hours the patient’s cervix was 5-6cm dilated and the baby’s head was at station –2cm. At 07.30 hours Mrs B advised Dr B, the obstetrician on call, of the patient’s progress.

The Respondent Doctor started duty at approximately 08.00 hours. He was certain he visited the patient at about 08.00 hours while she was asleep. The patient was equally certain the Doctor did not see her. There is a record of Mrs B contacting the Doctor at 08.10 hours. The Doctor explained that he used this telephone conversation to request a vaginal examination by Mrs B.

Dr A visited the patient at about 08.30 hours. Whilst Dr A was visiting the patient Mrs B performed the vaginal examination. The patient’s cervix was 5-6cm dilated and the baby’s head was still at station –2. The notes also record a telephone conversation between Mrs B and the Doctor at 08.30 hours during which the Doctor approved the administration of syntocinon to augment the labour process. Syntocinon was commenced at 08.52 hours.

Mrs B reassessed the cervix at 10.30 hours when it was noted the cervix was still 5-6cm dilated. The augmentation continued and at 13.00 hours Mrs B noted the patient’s cervix was fully dilated. The baby’s head was however still at station –2. Mrs B increased the syntocinon and topped up the epidural. At about 14.30 hours Dr A returned. A vaginal examination performed at about that time showed the baby’s head was still at station –2. Soon thereafter (between 14.35 and 14.45) the Doctor was told of the lack of progress and asked to attend.

At 14.55 hours the patient suffered severe abdominal pain. The foetal heart monitor recorded sudden foetal bradycardia. The Doctor was summoned urgently. He promptly arrived and expedited the Caesarean section. Baby L was delivered at 15.18 hours and was found to have an Apgar score of 0 at 1, 5 and 10 minutes. The patient had suffered a significant rupture of her uterus displacing the baby into the abdominal cavity.

The baby was flown to another Hospital on 10 June. He was unable to survive without artificial support and died on 10 June.

Finding:

The Tribunal found the Doctor not guilty of professional misconduct.

The Tribunal was satisfied Particular 1 was not established. It was confident that when the Doctor met the patient on 13 November 1998 he explained to her that there was a remote possibility her baby could be injured or even die if the patient’s uterus were to rupture during a trial of labour.

The Doctor said that he told the patient the risk of foetal death following uterine rupture was 1:10,000. The patient also referred to the Doctor talking about a 1:10,000 risk. However, the patient thought the Doctor was referring to the risk of uterine rupture, not the risk of death to her baby. The Tribunal was told by the Doctor that the figure 1:10,000 is the figure he always mentions and relies upon when explaining the risk of foetal death in the event of a uterine rupture during a trial of labour. The Doctor advised the Tribunal that the risk of uterine rupture is reported in the literature to be .5-1% in pregnant women.

Both the patient and the Doctor recalled the Doctor referring to a 1:10,000 risk. The Tribunal was satisfied that when the Doctor referred to that statistic he was referring to the risk of foetal death following uterine rupture. In addition, as the Doctor had had the misfortune to have experienced this type of tragic outcome on two previous occasions, the Tribunal considered it unlikely the Doctor would overlook warning a woman of the risk of foetal death following uterine rupture.

The Tribunal was satisfied Particular 2 was not established. Mrs B was the LMC from the time the patient arrived at hospital until the Doctor took over her care for the purposes of performing the caesarean section. Mrs B became the LMC at approximately 00.20 hours on 8 June and remained the LMC until approximately 14.45 hours that day. At no time prior to 14.45 hours did Mrs B seek to transfer the patient’s care to the secondary services.

The Tribunal was satisfied when the Doctor examined the patient’s notes at approximately 08.00 hours on 8 June he did not take over the patient’s care. The Doctor was simply familiarising himself with cases in the maternity suite who might require specialist care and assistance. Similarly, when the Doctor agreed to the patient receiving syntocinon in accordance with the hospital guidelines, he was not being asked by Mrs B to accept responsibility for the patient’s care. The Tribunal considered the Doctor did not have a professional responsibility to personally examine the patient, or arrange another doctor to examine her between 08.00 and 09.00 hours.

The Tribunal believed that it may have been appropriate for the Doctor to have insisted that he be allowed to assess the patient’s progress after syntocinon had commenced. In the Tribunal’s view the Doctor should have arranged, as part of his 08.30 telephone consultation, a formal follow-up approximately two hours after the introduction of syntocinon. This would have allowed him to assess the effect of syntocinon and to ensure satisfactory progress was being achieved. Ideally this follow-up should have been by a personal assessment and examination.

The Tribunal considered that the second particular of the charge could not be stretched to encompass the Doctor’s failure to personally assess the patient approximately two hours after syntocinon had commenced. The Tribunal wished to emphasise that in making these observations it was not suggesting that it would have necessarily found the Doctor guilty of professional misconduct if the second particular of the charge had been framed in broader terms. The Tribunal also stressed that even if there had been an examination of the patient during the course of the morning by the Doctor the ultimate outcome may not have been any different.

The Tribunal directed publication of a summary of the Tribunal's findings in the New Zealand Medical Journal.