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How baby got brain damaged at Free State public hospital

SHOCKING negligence by maternity staff during a baby boy’s birth at a Free State public hospital meant signs that the foetus was in distress were not acted on, resulting in him suffering brain damage.

Born on 19 October 2012 at the Mofumahadi Manapo Mopeli Regional Hospital in Phuthaditjhaba, he was later diagnosed with severe cerebral palsy as a result of oxygen deprivation during prolonged labour.

Children with cerebral palsy may have exaggerated reflexes and their arms, legs and trunk may appear floppy, with common symptoms including irregular posture, movements that can’t be controlled, a walk that’s not steady or some combination of these.

The minor’s mother will now receive compensation from the Free State provincial health department after the High Court recently found the medical staff who attended to the pregnant woman during labour and birth liable for his condition.

The mother, aged 17 at the time she was expecting, had a normal pregnancy with the boy, with no congenital abnormalities recorded either with her or the foetus.

Her settlement claim rested on the testimony of Professor Anna Nolte and Dr Franelize Hofmeyer, while the MEC for Health, cited as the defendant, called Dr Meshack Mbokota and Sister Mmaselo Motaung as witnesses.

The plaintiff’s witnesses were both of the view that the young woman was provided with substandard medical care during labour and birth, especially when it became apparent that there were abnormalities of the foetal heartrate.

When she was admitted at Elizabeth Ross Hospital, another public healthcare facility in Phuthadithjaba, at 1235 hours on 18 October 2012, the plaintiff was already in “spontaneous labour including painful contractions and raptured membranes”.

According to the evidence presented in court by Professor Nolte, a retired nursing lecturer who taught both basis and advanced midwifery, her cervix was two centimetres dilated and the foetal heartrate was a healthy 120 to 140 beats per minute (bpm).

Therefore, the expert said, maternal observations had to be performed four hourly and foetal heart observations hourly as required by the maternity guidelines.

“Instead, the next maternal observations were only carried out some five hours later at 1750 hours – at this stage the cervix was still two centimetres dilated, foetal heart rate still at almost the same range and the fluid draining from the raptured membranes was still clear,” Professor Nolte said.

A cardiotocography (CTG) – a scan that monitor’s an unborn baby’s heartrate and a mother’s contractions during labour – conducted at 1922 hours showed a “deceleration of a foetal heartrate indicating some abnormalities requiring a CTG to have ben continued for an extended time in order to assess the foetal wellbeing but for unknown reasons it was stopped”.

Ten hours later at 2100 hours a vaginal examination revealed that labour had not progressed – the plaintiff was still two-centimetres dilated.

On the next morning at 0320 hours, the plaintiff was in prolonged latent phase of labour because although she was experiencing stronger contractions.

About 30 minutes later, Pethidine was administered for pain relief.

She was examined by the doctor at 0600 hours and it was discovered that she had progressed to just four centimetres dilation.

“There is no proof that the CTG was performed because there is no graph regarding the readings recorded,” Professor Nolte noted.

“The plaintiff was at an active phase of labour now therefore it was expected that she will dilate at least one centimetre per hour and if two hours went by without the expected progress she would be referred to another hospital.”

However, at 0925 hours the plaintiff had still not been referred to another hospital – at this stage she was only six centimetres dilated even though she should have been seven centimetres dilated.

“A CTG also showed a deceleration of a foetal heartrate and in order to determine whether there was foetal compromise arising from the decreased variability, the CTG should have been continued for longer but it was stopped,” Professor Nolte said.

At 1300 hours it is recorded that the progress of labour was good as the plaintiff had progressed to nine centimetres dilation and, as a result, she was transferred to the delivery room.

However, an hour later progress was recorded as poor – the plaintiff did not move to 10 centimetres and the foetal heartrate was irregular ranging between 109 to 225 bpm.

It was Professor Nolte’s testimony that a reading of 109 is too slow and 225bpm is too fast the foetal heartrate was thus varying between Bradycardia (a slow heart rate condition) and Tachycardia (too fast heart rate), “both abnormal indicators that the oxygenation of the foetus was compromised and indeed the foetus was struggling as it had to be resuscitated by means of oxygen per mask on the plaintiff”.

Despite this catastrophic event, there is no evidence of continuous monitoring with the CTG.

The plaintiff continued to suffer from prolonged labour with strong contractions but no progression.

The records reflect that the baby “seemed stuck, not ascending when asked to bear down”.

According to Professor Nolte, there is no record of what was being done at that time except that the doctor was notified.

At 1500 hours progress was still poor, with the dilation still at nine centimetres, but it was only 10 minutes later that a decision to transfer the plaintiff to Manapo for a caesarean section was made.

Reasons for the transfer included foetal distress resulting from Cephalopelvic Disproportion (CPD).

The plaintiff was admitted at Mofumahadi Manapo Mopeli Regional Hospital at 1650 hours.

An examination revealed that her cervix was swollen, while her urine was also tinted with blood which is an indicator that her bladder had sustained injuries due to the prolonged labour.

At 1810 hours, there was a failed vacuum delivery and this is despite the fact that the reason for transfer from Elizabeth Ross Hospital was CPD – vacuum delivery is not advised as a procedure in cases of CPD.

According to Professor Nolte, as would be expected, there were more decelerations indicating foetal distress.

Again, there is no indication that a CTG was performed until the baby was ultimately delivered at 1850 hours.

In response to the defendant’s assertion that the small abnormalities seen on the CTG could not be relied upon because they were not done continually, Professor Nolte reiterated that CTG monitoring was pertinent under these circumstances and that, due to the absence of the CTG recordings, it was not possible to determine what the actual foetal condition was at a specific time.

Her concludions were corroborated by Dr Hofmeyer, who said the plaintiff’s small body stature and this being a teenage pregnancy were signs which ought to have alerted the healthcare providers that there might be difficulty with the foetus passing though the birth canal due to size disproportions.

According to the National Guidelines, active intervention is required once the latent phase exceeds eight hours.

Yet, on the available facts, at 1300 hours on 19 October 2012, the plaintiff had already crossed the line which required the staff to take action to expedite labour which include administering Oxytocin.

According to the available CTG records, foetal deterioration started as early as 1400 hours at Elizabeth Ross Hospital and at that stage the doctor should have considered an expedited delivery to avert the brain injury.

According to the experts, had they transferred and performed emergency section earlier the foetal brain injury would have been avoided.

Instead, there were further delays at Mofumahadi Manapo Mopeli Regional Hospital as they inexplicably attempted a vacuum delivery.

Appearing for the MEC for Health, Dr Mbokota conceded that the medical care rendered by the defendant’s employees was of substandard quality but denied that it contributed to the minor child’s brain injury.

He also conceded that the reason for the referral from Elizabeth Ross to Manapo was due to the foetus not doing well but insisted that intervening measures such a vacuum extraction were implemented and the fact that it failed did not mean it was contraindicated.

It was put to him that expediting the caesarean section among other interventions would have prevented the injury, his response what no one can know the outcome of any action and it is for the same reason that the defendant’s employees only took the decision to transfer after 1500 hours when complications arose.

Dr Mbokota told the court that the delay of the caesarean section was not extreme and that, even if the plaintiff had been transferred earlier or the caesarean section performed earlier, the minor child’s brain injury would still have occurred though the effects would have been less severe.

Sister Motaung, a registered midwife employed at Manapo, was on duty when the plaintiff arrived by ambulance after having been transferred from Elizabeth Ross.

However, in her testimony for the defence, she admitted she had no independent recollection of the events.

Under cross-examination, she confirmed that in the transfer records from Elizabeth Ross the reasons for the transfer were stated which included foetal distress and CPD requiring delivery by caesarean section.

As this was an emergency, the referring doctor contacts the receiving doctor and alerts him of the inbound patient and the reasons for the transfer.

This is to ensure that time is not wasted by investigating the history of the patient but she could not remember if this was done in this case.

Sister Motaung could also not remember whether when she contacted the doctor upon the plaintiff’s admission she informed the doctor about the reasons why the plaintiff was transferred to Manapo – due, in particular, to foetal distress and that the baby “seems stuck” as recorded in the medical records.

She could also not recall the reason why the vacuum delivery failed.

Justice Nokuthula Sylvia Daniso, who heard the case on in March and July this year, was not convinced by the defence which she described as “simply unconvincing, contradictory and implausible”.

“Dr Mbokota was not an honest witness . . . Similarly, Sister Motaung’ s memory seemed to fail her when her version was tested under cross-examination to determine the truth in it,” she said.

Handing down her judgment on 4 December, Justice Daniso said the plaintiff’s claim had succeeded.

“On the facts germane to this matter, it is indisputable that both the plaintiff and the foetus had no prenatal or postnatal congenital abnormalities prior to labour and that the brain injury suffered by the minor child occurred intra-partum for that reason, I cannot think of any other reason that could have caused the brain injury but for the defendant’s negligence,” she said.

“As a consequence of the brain injury, the minor child has been rendered cerebral palsied. The plaintiff’s claim succeeds.”

The judge ruled that the defendant was liable for payment of 100 percent of the proven or agreed plaintiff’s damages in her representative capacity as the mother and natural guardian of the minor child.

The quantum will be determined in due course. — Staff Reporter

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