By Emily Hart
Cases involving injured children as a result of birth trauma are some of the most challenging and complex cases we deal with in the Medical Negligence Department.
In Victoria birth trauma cases rarely proceed to trial, frequently settling out of court at an earlier date. However, the case of Darcy Hanssen, which commenced in the Supreme Court last month, was a significant exception.
Represented by Maurice Blackburn, Darcy is a severely disabled 12-year-old boy who was diagnosed with Cerebral Palsy following an hypoxic brain injury at the time of his birth. The case focused on the management of his mother's labour and his birth and whether the obstetrician and the hospital had provided negligent medical care.
Details of the labour and birth
Darcy's mother was admitted to Peninsula Private Hospital under the care of a private obstetrician at about 9.00am on 10 March 2000 for an induction of her labour at 38 weeks and 4 days gestation.
At about 9.30am the obstetrician performed an artificial rupture of the membranes and commenced an infusion of Syntocinon, to commence labour. The mother's labour continued for approximately 13 hours, during which time the Syntocinon was frequently increased. She was monitored by the midwives at the hospital throughout the labour, and reviewed in person by the obstetrician twice.
At 11.04pm Darcy was born in very poor condition with the assistance of forceps. He was transferred to the special care nursery soon after birth, and his parents were told that he was unlikely to survive. He developed seizures, heart problems and feeding difficulties, and was diagnosed with hypoxic ischaemic encephalopathy (HIE).
The use of Syntocinon during labour
Syntocinon is widely used during labour to artificially augment uterine contractions, to help speed up labour. However, practitioners must monitor the labour closely for hyperstimulation of the uterus, which can cease uterine blood flow and deprive the foetus of oxygen.
The manufacturers of Syntocinon note that:
"The frequency and duration of contractions and foetal heart rate must be carefully monitored during oxytocin administration, the latter preferably by electronic means, and the infusion must be discontinued immediately in the event of uterine hyperactivity, foetal distress or foetal heart abnormalities."
According to its manufacturers, the maximum rate of Syntocinon that should be given to a woman in labour is 20 milliunits (mU) per minute. The Australian Royal College of Obstetricians and Gynaecologists suggests that a higher rate can be given, to a maximum rate of 32 mU/minute.
The maximum rate used in Darcy's case was 113.3 mU per minute, over four times the maximum dose of Syntocinon recommended by the manufacturers, and three times the maximum dose recommended by the Royal College of Obstetricians and Gynaecologists. The dose was also above the highest rate recommended in the obstetrician's own standing orders.
Monitoring of the baby when using Syntocinon- recognising signs of distress
A key component of the use of Syntocinon is to ensure that the baby is being adequately monitored. The best means of monitoring the labour is with the use of a cardiotocograph (CTG), to measure the baby's heart rate and the mother's contractions in real time.
During this labour a CTG was used at times to monitor Darcy's condition, and not at others. Portions of the CTG trace recorded during the labour could not be located in Darcy's medical records. The CTG traces that could be located are recorded at the wrong time, as it appears the machine had not been corrected for daylight savings time.
The Plaintiff claimed in his Statement of Claim that at approximately 8.30pm the CTG trace became grossly abnormal, with 6 to 7 contractions in 10 minutes, foetal tachysystole and little, if any, heart rate variability. The Plaintiff alleged that at that time a decision should have been made to turn down the Syntocinon and deliver the baby.
The obstetrician telephoned the midwives at approximately 8.30pm to check on the baby's condition. While the details of the conversation were a point of dispute between the defendants at trial, it was alleged that details of the baby's condition were not adequately conveyed to the obstetrician.
The obstetrician conceded that he should have been told by the midwives of critical signs regarding the baby at that time. The case centred on a real dispute between the midwives and the obstetrician as to what he should have been told, and when. The obstetrician blamed the midwives for not calling him in sooner.
It is unclear whether the midwives who were present throughout the labour were checking the CTG trace. If they were reviewing the trace, it was alleged that they were unable to identify the developing signs of distress on the trace.
After two days of trial the matter resolved with a settlement in Darcy's favour.
The focus of this case was to ensure that Darcy received the 24-hour/day care he requires as a result of his disabilities. The settlement will ensure that his needs are met, and he is well cared for, for the rest of his life.
As the trial did not run its full course, there was no ruling made by the Judge in relation to any practices at the hospital, and no liability was admitted.