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You are here: BAILII >> Databases >> England and Wales High Court (Queen's Bench Division) Decisions >> Webb v Liverpool Womens' NHS Foundation Trust [2015] EWHC 133 (QB) (28 January 2014) URL: https://www.bailii.org/ew/cases/EWHC/QB/2015/133.html Cite as: [2015] EWHC 133 (QB) |
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QUEENS BENCH DIVISION
LEEDS DISTRICT REGISTRY
Oxford Row Leeds LS1 3BG |
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B e f o r e :
____________________
COURTNEY ELLEN ![]() ![]() |
Claimant | |
- and – | ||
(1) ![]() ![]() |
Defendants |
____________________
Mr B Martin for the Defendant
Hearing date: 27, 28, 29, 30 and 31 October 2014
Date draft judgment circulated 27 November 2014
Date handed down 28 January 2014
____________________
DATE HANDED DOWN 28 JANUARY 2014
HTML VERSION OF JUDGMENT
Crown Copyright ©
Introduction
a. Was the defendant negligent in failing to proceed to Caesarean section at 13.50 hours, 15.00 hours, 15.30 hours or 16.15 hours?
b. If a decision to proceed to Caesarean section had been taken at any of those times would Courtney have been delivered by Caesarean section? If she had, it is accepted that she would not have sustained BPI. It is not suggested that Miss Perkins would have failed to consent to a Caesarean section if the defendant had told her that that was the appropriate course.
c. The decision having been taken to proceed to vaginal delivery was the shoulder dystocia that occurred during delivery negligently managed? In particular;
d. Was excessive force applied to Courtney's head and neck during delivery?
e. Were negligently inadequate efforts made to place Miss Perkins in the McRoberts position in order to attempt to free Courtney from shoulder dystocia?
f. Was fundal, rather than suprapubic pressure applied during the course of delivery in order to attempt to free Courtney from shoulder dystocia?
If the answer to any of these questions c to f is in the affirmative on balance did that cause the brachial plexus injury?
Medical definitions
Shoulder Dystocia, Erb's palsy, Brachial Plexus and McRoberts
For the purposes of the delivery of a child, the female pelvis has an inlet which is usually oval-shaped, being wider in the transverse diameter (side-to-side) than the anterio-posterior (front-to-back) diameter. The pelvic outlet is also oval, but wider in the anterio-posterior diameter. The normal mechanism of labour is that the fetal head will enter the pelvis through the inlet in a transverse or lateral position (i.e. with the baby's face facing to one side or the other), with the shoulders in the anterio-posterior diameter. The shoulders remain more or less in that diameter, whilst the head, upon reaching the pelvic floor, rotates to the same diameter to facilitate its delivery of the head, reverting to the lateral once it is delivered.
Usually, the head having been delivered, during the course of the next uterine contraction, the shoulders and body are delivered. Whilst the accoucheur guides the baby's body out, he or she does not impose anything more than modest traction: the baby is spontaneously pushed out by the force of the contraction.
However, where the shoulder girdle of the baby is wide, following delivery of the head, the leading or anterior shoulder can become impacted against the symphysis pubis, preventing the shoulders from spontaneously descending as they should. To enable delivery of the baby, this obstetric emergency (known as "shoulder dystocia") requires manoeuvres other than normal downward traction and episiotemy. The condition is difficult to predict, and its severity cannot be assessed until after the head has been delivered. By its nature, the accoucheur midwife is usually the first clinician to identify the problem. It is uncommon but, understandably, the rate of occurrence rises sharply with fetal size, being perhaps over 10% for babies over 4.5kg. It requires speedy and decisive action when encountered, to prevent fetal hypoxia which may lead to brain damage or death.
Shoulder dystocia is diagnosed by (i) the retraction of the delivered baby's head into the pelvis, known as "turtling", which (said Mrs Fraser) was a sign of more than moderate shoulder dystocia; or (ii) the failure of the delivery of the baby's shoulders and body during the first uterine contraction after the delivery of his or her head. It was common ground between the experts (and agreed by Midwife Haughton) that, if there is any sign of turtling, then any traction of the head would be inappropriate and dangerous. During the first uterine contraction after delivery of the head, it is appropriate for the accoucheur to apply some modest traction to the baby's head unless and until it is apparent that resistance is being encountered. As soon as resistance is apparent, then, again, it is common ground (and, again, agreed by Midwife Haughton) that any further traction to the head would be inappropriate and dangerous.
Once shoulder dystocia is diagnosed or suspected, the first step for the midwife is to summon assistance, because the recognised steps to overcome the problem require more than one clinician. First, the mother's hips are hyperflexed onto or towards her abdomen (the McRobert's manoeuvre): this change of position effectively straightens out the exit passage for the baby. Second, supra-pubic pressure may be applied (the Rubin manoeuvre): this may assist by mechanically disimpacting and hence dislodging the shoulder. One or both of these steps usually result in prompt delivery of the baby. If they do not, then more intrusive manoeuvres are available.
The brachial plexus is a group of nerves emerging from neck region of the spine, which supply the muscles of the shoulder and forearm. When stretched, these nerves may become damaged or even torn, leading to partial or total paralysis of the arm (a condition known as "Erb's palsy"). When the nerves are torn from the spinal cord or otherwise ruptured, the condition is usually permanent. Where there is no rupture, the prognosis is good and full recovery within a short period is common.
Erb's palsy is a known complication of birth delivery, during which the head may be the subject of lateral traction away from the shoulder. Of course, the condition might be iatrogenic in cause, i.e. it might result from the application of physical force to the head by the accoucheur, particularly after the head has been delivered and prior to the delivery of the shoulders and body. Indeed, until fairly recently, it was generally thought that natural uterine propulsive forces on the baby's neck during delivery were not sufficient, or in the right directional plane, to cause damage to the brachial plexus; and the accepted medical view of causation of such injuries during delivery was that in all cases the nerve damage was caused by the application of lateral and downward traction to the fetal head while the anterior shoulder was impacted against the symphysis pubis (see, e.g., Stirrat GM and Taylor RW, Mechanisms of obstetric brachial plexus palsy: a critical analysis, Clinical Risk 2002; 8: 218-222); or, at least, the majority of such injuries were caused thus so that, when a baby was born with a brachial plexus injury, there should be an assumption that the cause was excessive traction.
Fundal Pressure and Suprapubic Pressure
Fundal pressure involves the application of manual external pressure to the upper part of the maternal abdomen whereas suprapubic pressure is the application of manual external pressure to the maternal abdomen just above the pubic bone. The object of the latter is essentially to move the orientation of the fetal shoulder relative to the symphysis pubis so that it passes underneath the symphysis thus making it possible for the shoulders and the body of the fetus to proceed down the birth canal. Fundal pressure is not appropriate because it serves only to push the fetal shoulder further into the symphysis rather than guiding the shoulder under it.
Cephalopelvic disproportion
A disproportion between the maternal pelvis through which the fetus has to pass and the size of the fetal head i.e. the head is too large for the maternal pelvis and passage of the fetus through the pelvis is therefore impeded.
Ischial Spines
Two bony prominences on the pelvis that can be felt through the vaginal wall. They are not directly concerned in the birth process but provide a useful signpost as to where the fetus is in terms of descending. On medical notes a reference to the spines preceded by a negative number usually signifies height in centimetres of the presenting part of the fetus (usually and ideally the head) above the spines and a positive number the distance below the spines. "0" indicates that the head is level with the spines and is engaged in the pelvis.
Restitution
The term used to describe the baby's head turning to realign with the shoulders
Syntocinon
A synthetic drug used to induce labour by stimulating uterine contractions and hence also cervical dilation in the same way as the naturally occurring hormone, oxytocin. It is given to the expectant mother in a saline solution via a drip. A contraction occurs when the uterus alternates between a taut state and a relaxed state. This has the effect of pushing the fetus down towards the cervix which assists in causing the cervix to dilate.
The law
the test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill; it is well-established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art… he is not guilty of negligence if he has acted in accordance with practice accepted as proper by a reasonable body of medical men skilled in that particular art…… Putting it another way round, a man is not negligent if he is acting in accordance with such practice merely because there is a body of opinion who would take a contrary view.
A judge's preference for one body of distinguished professional opinion to another also professionally distinguished is not sufficient to establish negligence in a practitioner whose actions have received the seal of approval of those whose opinions, truthfully expressed, honestly held are not preferred.
A doctor is not negligent if he acts in accordance with a practice accepted at the time as proper by a responsible body of medical opinion even though other doctors adopt a different approach.
(Counsel for the claimant) submitted that the judge had wrongly treated the Bolam test as requiring him to accept the views of one truthful body of expert professional advice even if he was unpersuaded by its logical force. He submitted that the judge was wrong in law in adopting that approach and ultimately it was for the courts, not for medical opinion, to decide what was the standard of care required of a professional in the circumstances of each particular case.
My Lords, I agree with these submissions to the extent that, in my view, the court is not bound to hold that the defendant doctor escapes liability for negligent treatment or diagnosis just because he leads evidence from a number of medical experts who are genuinely of the opinion that the defendant's treatment or diagnosis accorded with sound medical practice.
In the Bolam case itself, McNair J. stated [1957] 1 W.L.R. 583, 587, that the defendant had to have acted in accordance with the practice accepted as proper by a "responsible body of medical men." Later, at p. 588, he referred to "a standard of practice recognised as proper by a competent reasonable body of opinion." Again, in the passage which I have cited from Maynard's case, Lord Scarman refers to a "respectable" body of professional opinion. The use of these adjectives -responsible, reasonable and respectable--all show that the court has to be satisfied that the exponents of the body of opinion relied upon can demonstrate that such opinion has a logical basis.
I emphasise that in my view it will seldom be right for a judge to reach the conclusion that views genuinely held by a competent medical expert are unreasonable. The assessment of medical risks and benefits is a matter of clinical judgement which a judge would not normally be able to make without expert evidence. As the quotation from Lord Scarman makes clear[1], it would be wrong to allow such assessment to deteriorate into seeking to persuade the judge to prefer one of two views both of which are capable of being logically supported. It is only where a judge can be satisfied that the body of expert opinion cannot be logically supported at all that such opinion will not provide the benchmark by reference to which the defendant's conduct falls to be assessed.
The chronology
"there is a wide variation in what would be regarded as normal progress and that is the purpose of having an alert line, to be indicative of the degree of progress".
He did not accept that the
"notion that a woman should dilate at 1cm/hr was uniformly accepted and was subsequently challenged by NICE[6]"
"During the active phase of labour the cervix should dilate at a rate of at least 1 cm/h and if not, then failure to progress in labour is diagnosed"
"Labour is diagnosed as dysfunctional when the progress of cervical dilation reaches/crosses the action line"[9]
And goes on to state that
"in the case of spontaneous labour[10] once the action line is crossed sytocinon infusion should commence and the senior registrar informed"
- Inadequate uterine contractions
- Cephalopelvic disproportion
Allegations of negligence
"the frequency of contractions with oxytocin use should not exceed 3-4 contractions in every 10 minutes"
"the minimum dose possible of oxytocin should be used and this should be titrated against uterine contractions aiming for a maximum of 3 to 4 contractions every 10 minutes".
"until there is effective uterine action ie 3-4 contractions per 10 minutes lasting 45 to 60 seconds".
The basis of the claim in negligence at 13.50
"correct management would have been either to proceed to an emergency Caesarean section or to perform a further obstetric review and VE by no later than 14.50 or 15.00 at the latest to assess progress."
Good size baby
On Syntocinon maximum of 96 ml/hr since 09.30
Just went off partogram
P/a cephalic 1/5[19]
VE 8 cm dilated
Head at "o" with contraction[20]
Fully effaced
Rim of cx[21]
IUP[22] catheter sited
Adv[23]. Monitor pressure
Continue Syntocinon
Maintain iup 150 to 200 montevideo units[24]
"If the fetal position is occipito anterior, as in this case, and the contraction frequency is optimal (3 to 4 in every 10 minutes) and the Syntocinon infusion rate is maximal, as it had been in this case for more than 3 hours, then it is usual to diagnose relative or absolute cephalopelvic disproportion and proceed to an emergency Caesarean section"
"If Labour is spontaneous and there are no maternal or fetal contraindications, then Syntocinon infusion should commence as soon as possible following diagnosis of dysfunctional Labour ….
maternal and fetal observations should be carried out in accordance with "Induction of Labour RBP"
If, on vaginal examination, progress continues to deviate despite the appearance of regular uterine contractions the SpR1-3 must be informed. At this point a decision has to be made to either a) insert an intrauterine catheter, or b) perform a Caesarean section
NB inserting an intrauterine catheter is the preferred management in most cases. The rationale for not choosing this option must be clearly documented".
"Although knowledge of uterine work is important the main evidence that the contractions are effective is that the cervix is progressively dilating at an appropriate rate and that there is descent of the presenting part. This fact emphasises the importance of carefully monitoring the changes in the cervix and the crucial role that the partogram has in management and labour."
"the management of putting in an IUP catheter was perfectly acceptable and a sensible approach to trying to decide whether there were adequate uterine contractions or whether this was actually a case of disproportion between the mother and fetus. Accordingly I would not criticise the management at this stage"
He goes on to indicate that
"having got the catheter in, it would then be appropriate to observe contractions, adjust the oxytocin and consider examining again about 2 hours after appropriate contractions had occurred. To increase the oxytocin to 64mu/min[32] is perfectly acceptable as long as there is careful monitoring of uterine contractions"
And at paragraph 14.2 he saw;
"nothing illogical in the use of the IUP because "progress was slower than average and despite the frequent contractions these did not appear on external monitoring to be that long lasting"
- Maternal body mass greater than 30kg/m2
- Induced labour
- Prolonged first stage labour
- Secondary arrest[36]
- Oxytocin augmentation
"MG observes that when the action line on the partogram was crossed at 13.30 hours a Syntocinon infusion at a maximal or near maximal infusion rate had been in progress for 4 hours with a recorded contraction frequency, during this time, of 6 in every 10 minutes indicating uterine hyperstimulation. In addition the fetal position was occipital anterior and the fetus had been noted to be large indicating cephalopelvic disproportion.
MG believes that as there had only been a cervical dilation of 1 cm between 09.30 hours and 13.50 hours despite effective Syntocinon induced uterine contractions it was, in his opinion, totally illogical to insert an IUP catheter at 13.50 hours and continue the Syntocinon infusion, as occurred. In accordance with the Trust Guideline quoted above[40] a decision should have been made to proceed to a Caesarean section"
MM notes that there was evidence of slow progress, dysfunctional labour with short lasting contractions and registrar involvement. He considers that trust guideline is well followed by insertion of an IUP catheter.
- Had been induced
- Was in secondary arrest
- Was in prolonged labour
- Had been on Syntocinon augmentation since 05.30 and for the preceding 4.5 hours or so had been on maximal or near maximal Syntocinon
- Was obese
And she was enduring uterine contractions of at least 6 every 10 minutes and had been for 4.5 hours
"MM would consider that this was evidence of slow progress in labour, which could be due to an element of cephalo-fetal disproportion, but certainly was not evidence of labour having stalled (secondary arrest)."[42]
"MM considers that it was appropriate to continue to use Syntocinon after 13.50 hours. There had been progress in labour and that with an IUP in situ to assess the strength of the contractions, which had previously not been possible with just an external pressure transducer, it was appropriate to continue with the Syntocinon infusion and adjust the rate according to the intrauterine pressure recordings"
In fact however there had, on any view, been no progress in labour since at least 12.30.
"the minimum dose possible of oxytocin….…. aiming for 3 to 4 contractions every 10 minutes"
Dr Maresh says merely that the clinical guidelines are just guidelines and that they are open to an exercise of discretion. I should say that I note that Dr Tanden herself notes that Miss Perkins is on the maximum dosage of Syntocinon. It is a strange concept that a "maximum" can be exceeded.
Dr Tanden
"we agree that if the decision had been made at 13:50 hours she (Miss Perkins) shall have been ready for a Caesarean section by just before 14:50 hours and on the balance of probabilities she would have not been favourable for a vaginal delivery and a Caesarean would have been performed"
The allegation of negligence at 15.00 hrs
"MG believes that as the cervical dilation was 8 to 9 cm at 13.30 hours, full cervical dilation should have been achieved by 15.00 hours (with unexpected cervical dilation of 1 cm/h). As a vaginal examination at 15:00 hours would have shown that significant cervical dilation had not occurred and full dilation of the cervix had not been achieved, accepted labour practice and the Labour Ward Guidelines at the hospital, at the time, both indicated that a Caesarean section would have been correct management at 15.00 hrs.
MG quotes from Turnbull's Obstetrics, the standard textbook in 1999. This states that
"if the baby is considered to be particularly large than a careful evaluation of the progress of labour is required and the potential for vaginal delivery reassessed"
And
"although shoulder dystocia can be difficult to anticipate, slow progress, particularly in the late 1st stage of labour can provide an important clue. Careful evaluation of the size of the baby at this time may save more serious problems later".
He remarks that
"This reassessment did not occur. The result was a brachial plexus injury that would, on the balance of probabilities, have been avoided if a Caesarean section had been performed"
"in accordance with accepted practice to continue with the Syntocinon infusion after 13:50 hours. Furthermore Stacy Perkins was reviewed by the registrar 1 hour after the catheter insertion and the midwife has documented that the pressures were then adequate with the oxytocin increased back to what it had been before".
"In hindsight it is relatively easy to conclude that the IUP was not functioning in a consistent manner"[49] and in paragraph 19 of the joint statement he concedes that "it is possible that it should have been appreciated earlier that the IUP was providing inconsistent information"
"at 16:15 hours the cervix had only dilated from 7 cm at 9.30 hours to an anterior cervical rim at 16:15 hours which was "pushed back". A dilation of just over 2 cm in 6 hours and 45 minutes"[54]
"a very slow rate that emphasises the relative cephalopelvic disproportion that was due to fetal macrosomia"[55]
"that dilating 2 cm in 2 hours and 25 minutes was indicative of slow progress and might have been indicative of a degree of cephalopelvic disproportion"
Causation
Allegation of negligence at 15:30 hours
Allegation of negligence at 16:15 hours
Conclusions as to allegations of negligent failure to proceed to Caesarean section at 13.50 hrs
"(He) considers that trust guideline is well followed by insertion of an IUP catheter".
"it was clear that there was an underlying evidence based philosophy atLiverpool
Women's Hospital that CS rates were too high, that the majority of first mothers could achieve a vaginal delivery, and should be given the chance to do so and that true cases of cephalopelvic disproportion were rare"
Conclusions as to allegation of negligence at 15.00hrs
Conclusion as to allegation of negligence at 15.30hrs and 16.15hrs
The Delivery
a. Miss Perkins was not placed in the McRoberts position
b. Excessive force by way of traction[69] or lateral flexion[70] was applied to endeavour to dislodge Courtney's right anterior shoulder which was the shoulder whose progress into the birth canal was impeded by the maternal symphysis pubis.
c. Fundal rather than suprapubic[71] pressure was applied during delivery in an endeavour to release the anterior shoulder.
"there were two midwives primarily involved in the delivery, firstly Midwife Charters (Horridge) followed by Midwife Adekoya (Gilbertson) with the delivery then achieved by Midwife Charters who is named on the delivery summary. Despite the appropriate steps being taken to resolve this emergency situation this changeover of personnel together with the speed with which the manoeuvres were apparently undertaken, in my opinion led to excessive traction being applied"
"If there was panic and all the midwife did was pull increasingly hard in order to deliver the baby then this is evidence of substandard care. If, as described in the records, there was recognition of delay with the shoulders due to a compound presentation, the midwife called for assistance, the maternal legs were hyperflexed and suprapubic pressure was applied then the care was appropriate"
It is therefore a question of fact.
"a clinician's first reaction to a difficult delivery is to exert considerably larger forces than he normally would."
That would support the contention that excessive but inadvertent pressure may have been applied here.
"it is very easy to apply pressure above 100 newtons if the head is out of line with the body or is moved laterally away from it"
Stacey Perkins
Kathleen Perkins
Kenneth Webb
Ruth Horridge nee Charters
Ronnie Gilbertson nee Adekoya
Conclusions regarding events surrounding delivery
McRoberts
Suprapubic versus fundal pressure.
Excessive Traction
Summary
Final Remarks
I am grateful to counsel for their very able assistance in this matter.
HHJ Saffman
Note 1 that in Maynard quoted above. [Back] Note 2 Bundle 4 tab1 p30 [Back] Note 3 Bundle 4 tab3 p117 [Back] Note 5 Bundle 3 tab 5 367 (JS paragraph 8.1) [Back] Note 6 National Institute of Clinical Excellence [Back] Note 7 It is right to say that there is nothing particularly significant in the 2 hour gap, it could have been 3 or even 4 hours. The RBP Partogram points out that the data as to the chronological distance between the alert line and the action line was inconclusive but that local research findings concluded that women were more satisfied with a 2 hour action line. [Back] Note 8 Bundle 4 tab3p120 [Back] Note 9 Bundle 4 tab 4 p 121 [Back] Note 10 this of course was an induced labour [Back] Note 11 As it was in this case because there is an entry in the hospital records at 13.30 indicating the fetus is LOA (left occipito anterior with head -1 at the spines (ie1cm above the ischial spines). LOA is optimal positioning for the fetus. [Back] Note 12 RCOG Guideline paragraph 4.4 bundle 3 tab1 p 104 [Back] Note 13 international units [Back] Note 14 Bundle 4 tab1 pp 52 to 94 [Back] Note 15 Bundle 3 tab1 p45. It is accepted that insofar as it is relevant to this matter the guidance merely reflected the practice that had been in place since prior to 1999. [Back] Note 16 Bundle 3 tab1 p94 [Back] Note 17 Bundle 3 tab1 page 95 [Back] Note 18 where cervical dilation has stopped (or, according to Dr Maresh, slowed) before full dilation of 10 cm but see Dr Maresh’s definition at paragraph 90 below [Back] Note 19 1/5 of head palpable [Back] Note 20 Head at level of ischial spines [Back] Note 22 Intrauterine pressure catheter [Back] Note 24 A unit of measure of uterine pressure to be measured by the IUP [Back] Note 25 Bundle 3 tab1 p28 [Back] Note 26 It is right to say that the dosage had exceeded the licenced dose specified by NICE by over 50% but it is not a point upon which the claimant relies because it is recognised that licenced doses can be, and are, justifiably exceeded. [Back] Note 28 Mr Gillmer’s hospital and indeed Dr Maresh’s hospital had not used them for a decade and its use was more for the purpose of research on progress in labour rather than as a practitioners tool. [Back] Note 29 Bundle 3 tab5 p400 [Back] Note 30 In fact she was 4.87kg at birth (10lb 7oz) [Back] Note 31 Bundle3 tab3 p319 [Back] Note 32 This did not occur until 15.40 and so may be relevant later but I point out at this stage that 64mu/min actually looks at first blush to be double the maximum dose but in fact the solution was halved so the strength remained constant [Back] Note 33 Bundle 3 tab 3 p327 [Back] Note 35 Mrs Brydon contends at paragraph 29 of her report that only one factor, maternal obesity, was present here but she is not supported in that by the obstetricians. [Back] Note 36 Paragraph 3 of the report specifically confirms that Dr Maresh agrees that Miss Perkins went into secondary arrest at 8-9 cm but, as will become clear, later in the joint statement Dr Maresh disputes that there was secondary arrest here. [Back] Note 37 It will be recalled that Dr Tanden recorded this as a “good size baby” [Back] Note 38 The JS actually records that he agrees that cephalopelvic disproportion was the probable cause of secondary arrest but in his oral evidence in chief he took the opportunity to correct that on the basis that he had failed to spot at the time of signing that the report did not reflect his opinion. [Back] Note 39 In fact Mr Gillmer’s position is that the cervix probably reached 8cm dilation by about 10.30 and that secondary arrest occurred then or shortly thereafter. He forms that view on the basis that dilation had occurred normally up to 09.30 and it is likely that it would have continued doing so therefore until it stopped dilating completely. It was 7cm at 09.30 and on that basis would have been 8cm by 10.30.(as it was at 13.50). His evidence was that secondary arrest at 8cm is not unusual. [Back] Note 40 The RPB Dysfuctional Labour document [Back] Note 41 Mr Gillmer suggests that a 4 hour action line would have been crossed at 15.30 assuming 8cm at 13.50 and a straight line dilation from that point to 9.5cm at 16.15. But that , he says, is academic in the circumstances because this was clearly a dysfunctional labour on any view and the dilation to 16.15 was as a result of Syntocinon augmentation. I should add that Mr Martin did not accept that a 4 hr line would have been crossed because she was fully dilated (10cm) at 16.39. [Back] Note 42 It is right to record that his initial view that secondary arrest had not occurred was shared by Mrs Brydon (the midwives JS paragraphs 6 and 7) [Back] Note 43 It is right to recount that even subsequently when another doctor, Dr Adams had occasion to consider the progress of this labour and the quantities of Syntocinon to infuse that, despite what had originally been thought at the outset of this case, she did not order infusion in excess of the maximum but altered the ratio of Syntocinon to Hartmann's solution in order to achieve an infusion at a rate equivalent to 96 ml/hour i.e. by doubling the concentration but halving the fluid load. [Back] Note 44 MissTranter’s report page 21 (bundle 3 tab2 page 265) [Back] Note 45 Bundle 3 tab 4 page 337 [Back] Note 46 JS paragraph 13.2. [Back] Note 47 indeed it is Mr Gillmer's point at paragraph 14.2 the joint statement that in any event intrauterine pressure monitoring did not in practice improve clinical management. [Back] Note 48 bundle 3 tab 5 page 376 [Back] Note 49 JS paragraph 15 [Back] Note 50 JS paragraph 16 [Back] Note 51 The time from which Dr Maresh regarded the iup readings to be meaningful (JS paragraph 16) [Back] Note 52 See paragraph 65 above and Turnbull's Obstetrics page 572 [Back] Note 53 In answer to a question from me Dr Maresh confirmed that delivery even with moderate contractions was possible but would simply take longer. [Back] Note 54 JS paragraph 25 [Back] Note 58 JS paragraph 26 [Back] Note 59 Care during labour and delivery [Back] Note 61 except that frequency which allows form of relaxation is within a 10 minute timeframe suggests that contractions are not strong [Back] Note 62 See paragraph 43 above [Back] Note 63 Mr Martin’s final submission paragraph 40 [Back] Note 64 I do not overlook that the midwifery experts did not believe that continued Syntocinon after 13.30 was unreasonable (midwifery JS paragraph 13.3) but that is not the issue. Indeed Mr Gillmer does not criticise the continued use of Syntocinon if (wrongly) the opportunity to carry out a Caesarean section was not taken. [Back] Note 65 A point made by MissBrydon [Back] Note 66 See paragraph 109 above [Back] Note 67 A presenting part at the spines is considered to be engaged in the pelvis (Mrs Brydon report page 357) [Back] Note 68 Dr Adams witness statement paragraph 9 [Back] Note 69 Pulling of the baby’s head [Back] Note 70 Moving the baby’s head from side to side [Back] Note 71 See definitions in paragraph 12 above [Back] Note 72 Mrs Tranter’s report page 16 (bundle 3 tab2 page 260) [Back] Note 74 Mrs Tranter’s report page 18 (262) [Back] Note 75 Midwife Gilbertson statement paragraph 12 and Midwife Horridge statement paragraph 20 [Back] Note 76 Mrs Brydon report paragraph 70 [Back] Note 77 Mrs Brydons report paragraphs 83 and 84 [Back] Note 78 Her witness statement Paragraph 15 [Back] Note 79 Illustrated in bundle 3 tab 2 page 278 and called the Woods Manoeuvre. It involves placing the mother on all fours [Back] Note 80 I note that not even Myles referred to in paragraph 144 above strictly requires one to record the reasons for failing to achieve a manoeuvre. [Back]