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Management of labour, delivery and post-delivery care (03HDC10782)
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(03HDC10782, 29 June 2005)
obstetrician ~ Labour ~ Second-stage labour management ~ Postnatal
care ~ Record-keeping ~ Workload ~ Standard of care ~ Professional
standards ~ Rights 4(1), 4(2)
A general practitioner (GP)
obstetrician was responsible for the antenatal care and delivery of
a 35-year-old woman's first child. He was the lead maternity carer
(LMC), although the woman had also engaged the services of a
midwife. A complaint was made about the GP's management of the
delivery, in particular the second stage of labour, and about his
follow-up of complications post-delivery.
The first stages of the woman's
labour were supervised by the midwife in telephone consultation
with the GP. The labour was prolonged, but the woman wanted a
natural birth and refused pharmacological or medical intervention.
By the time the GP arrived at the hospital, the woman had been in
phase two labour with no progress for two hours and forty minutes;
a further hour and forty minutes passed before a decision was made
to intervene to expedite delivery of the baby.
Following the birth, the woman
complained of unpleasant discharge from her vagina and "gurgling"
sounds. The GP attributed this to a swab that had inadvertently
been left in the woman's vagina at delivery, and consequent
infection. He prescribed antibiotics and limited his physical
examination of the woman in deference to post-delivery tenderness.
Six weeks later a recto-vaginal fistula was identified and repaired
It is debatable whether the fistula
was as a result of the prolonged second-stage labour and whether it
could have been identified easily by the GP. However, it was held
that the GP breached Right 4(1) when he did not personally attend
the woman in the maternity unit after the birth, and when he did
not investigate the woman's complaints of discomfort and discharge
adequately and vigorously. A digital rectal examination would have
identified the anal sphincter damage. In light of the ongoing
symptoms, the GP should have referred the woman to a specialist
much earlier. His poor record-keeping breached Right 4(2).
Although not an excuse for the
delivery of inadequate care, the GP's heavy workload was noted, as
were the pressures put on GP obstetricians in areas where a
dwindling number of GPs are providing obstetric care.
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