Traumatic Birth at Worcestershire Acute Hospitals NHS Trust Could have been Avoided

This was AM’s first pregnancy. Throughout the later stages of the pregnancy, AM had high blood pressure and was measuring large for dates. Despite this, no additional growth scans took place and there was no discussion regarding earlier induction of labour or options for delivery.

On 7 July 2019, at 40+6 weeks, AM attended Worcestershire Royal Hospital with contractions. After being assessed and again being told her baby was measuring large, she was sent home to await progression. AM then called the midwifery unit to advise of more frequent contractions but was again told to stay home. Later that evening, AM re-attended hospital with increased contractions but was again sent home with the same advice.

On 8 July 2019, at 41 weeks, AM’s waters broke. She called the midwifery unit and was told to wear a sanitary pad and call again in a few hours.

On the morning of 9 July 2019, AM attended again hospital and it was confirmed that her waters had broken. An investigation later found that AM’s care was not handed over properly and the receiving staff didn’t know that she had been in early labour for two days already, with a predicted big baby, both of which can be risk factors for shoulder dystocia.

AM was transferred to the delivery suite for an induction of labour to help progress. Shortly after the induction was started with an oxytocin infusion, the baby’s heartrate dropped. Whilst this was being monitored, AM began to also suffer symptoms of infection. Despite this, there was no escalation to an Obstetrician or consideration given to expediting delivery.

After some time, on 10 July 2019, AM was fully dilated and encouraged to push. Unfortunately the baby became stuck with shoulder dystocia and interventions were needed to achieve delivery. The baby needed full resuscitation and cooling treatment for Grade 2 Hypoxic-Ischaemic Encephalopathy. Thankfully, the baby is now five years’ old and developing normally and has been discharged from paediatric services.

A catalogue of failures were identified in AM’s maternity care. AM’s traumatic labour and delivery could have been avoided. There was a failure to recognise the advancement of AM’s labour, a failure to appropriately escalate and monitor and a failure to expedite delivery.

AM sadly suffered a psychological injury and required Cognitive Behavioural Therapy to process the events surrounding her baby’s birth.

We are pleased that settlement has been achieved so AM can continue to access specialist psychological treatment. Alongside the settlement, we were able to secure a written apology from the Trust, which meant a lot to the family.