Beatrix Campbell used in-vitro fertilization (IVF) and tried for five years to conceive her child. When June came, and it was time for their baby to arrive, the Campbells were ecstatic. The Scottish couple went to the hospital to have labor induced because Beatrix was two weeks past her due date. She met all the criteria for a “difficult case”–though nobody told her that. In addition to being past her due date, the baby was lying sideways (transverse position) and was large, considering that Beatrix was only 5’ 2.” (This condition is known as cephalopelvic disproportion (CPD), which means there is a mismatch in size between the baby or the baby’s position and the mother’s pelvis.) Thirty hours after induction started, exhausted and barely dilated, Beatrix told the midwife she wanted a C-section. As the hospital later admitted, this would have saved the baby’s life. The request for C-section was refused.
When the Campbells asked to see a consultant obstetrician, a junior doctor insisted on carrying out an examination first, and in the process, he broke Beatrix’s waters to speed up her labor. This failed, and ten hours later, she was finally seen by a consultant who told her that the baby was still sideways and needed to be turned. Beatrix thought the physician would do this with her hands, but she was then transferred to an operating room. Though the hospital later told Beatrix that she had given informed consent for forceps delivery, Beatrix had no idea what was about to happen. The Campbells begged for a C-section. In fact, when she signed a form, her husband thought she had given consent to a C-section.
The consultant obstetrician was in the operating room for only a short time, and then left to take care of another patient. Beatrix was left with a junior physician in his second year of training to carry out his first unsupervised delivery using forceps. The junior physician didn’t say a word; he just inserted the forceps and started rotating the baby. Beatrix was petrified.
The baby, named Alexandra, did not cry at birth and was rushed to the neonatal intensive care unit. Alexandra had suffered a severe injury to her spinal cord. She was put on life support because she couldn’t breathe on her own and had no control over her body, apart from facial expression. The Campbells were told that Alexandra would not live, and she passed away three days later.
The hospital later stated that the forceps must have turned the baby’s head, but not her body, which injured her spinal cord. It is very important to note that Beatrix had CPD, and CPD is a contraindication to forceps delivery.
There Is A Lack Of Skill And Training In Forceps Delivery Technique
Maureen Treadwell of the Birth Trauma Association believes that some hospitals are becoming dangerously focused on holding down the rate of C-sections. The reason for this is because they cost twice as much as natural deliveries, and the National Institute for Health and Clinical Excellence (NICE) has recommended that hospitals (in the United Kingdom) keep the C-section rate at 15% (the national average is 25%). Treadwell stated, “There seems to be a belief that telling the truth about risks of forceps and the relative safety of Caesarean might push up the rates of expensive surgery.”
Commenting on this issue, Professor Steer said that when it comes to forceps, there is a lack of training. In the seventies, Steer would perform several forceps deliveries a day, as a junior physician. He feels that changes in obstetric practice where more junior doctors are working fewer hours and consultants are required to do more deliveries themselves means it is impossible to really learn the skill. Steer further stated that unlike C-sections, instrument delivery involves highly skilled manipulation that is difficult and time-consuming to teach, and he is worried that the caseload is too low to allow new physicians to gain sufficient experience. Steer’s strategy is to identify difficult cases in advance so a C-section can be planned. If a delivery runs into problem in the second stage of labor, he proceeds to C-section as the safest intervention.
Some experts believe that there will always be some normal deliveries that become obstructed much too late for a C-section, thereby making forceps the best, and perhaps the only, solution. But these experts also agree that obstetricians need to be trained to use forceps, and it is a complex procedure that requires expertise and experience. And there is consensus in the medical community that difficult forceps cases should not be carried out by inexperienced physicians.
The Campbell’s case is under investigation.
The Campbell’s case highlights the importance of a physician having a thorough discussion with the patient, and making sure the patient understands all the risks, benefits and alternatives to potential procedures. This includes answering the patient’s questions, understanding what the patient wants, and making sure valid consent is given for all procedures. This sad story emphasizes how critical it is for a mother and baby to be closely and continuously monitored, especially when the delivery is one that is high risk, as in cases of CPD and macrosomic babies. A mother must consent to all procedures, and physicians who perform deliveries that involve instruments, such as vacuum extractors and forceps deliveries, must have the skill to perform the delivery, as well as to quickly switch to a C-section delivery.
Standards Of Care Must Be Followed When Forceps Are Utilized
Forceps deliveries account for only 1% of births in the U.S. Thus, skill in this area may be lacking. When a baby is in distress, the use of forceps may be appropriate to facilitate birth. However, this is a very risky procedure, with a high risk of traumatic injury to the baby. It therefore is crucial that standards of care be followed when forceps are used during delivery.
The standard of care includes the lists below.
These prerequisites must be met in order for a forceps delivery to take place:
- The cervix must be fully dilated
- The membranes must be ruptured
- The baby’s head must be engaged
- The fetal presentation, position, lie and any asynclitism (tilted head) must be known. If any of these are uncertain, an ultrasound should be performed. If ultrasound is not available, no more than one-fifth of the fetal head should be palpable abdominally if the vertex is engaged.
- The fetal size must have been estimated, with clinical pelvimetry showing adequate dimensions and no obstructions or contractures
- Maternal anesthesia must be satisfactory
- Maternal bladder must be empty
- The risks of the procedure must have been fully explained to the mother
- The physician must have experience and be skilled in forceps use
- There must be a willingness to abandon attempts if the forceps are not working/labor is prolonged
If any of the aforementioned prerequisites are not in place, a forceps delivery is contraindicated. Most contraindications to forceps delivery are related to the potential for unacceptable risks, and they include:
- The baby is less than 34 weeks gestation.
A forceps delivery should be abandoned if descent does not occur with appropriate application and traction, and delivery should occur by the third pull. It is essential that the physician be willing to abandon a forceps delivery and have the ability to perform a prompt C-section.
Other indications for abandoning forceps use during delivery include the following:
- It is or becomes difficult to apply the instrument
- Descent does not easily proceed with traction
- The baby has not been delivered within a reasonable time
Injuries That Can Be Caused By Utilization Of Forceps
Improper use of forceps can result in the following injuries:
- Skull fractures
- Spinal cord injury
- Nerve damage. Improper use of forceps can result in nerve damage to the side of the baby’s face, which can cause facial nerve palsy.
- Head and facial trauma. Inappropriate use of forceps can result in trauma to the baby’s head, which can lead to cerebral palsy, seizures and other forms of brain damage.
- Intracranial hemorrhages
- Brachial plexus / erb’s palsy.
Forceps Injuries And Medical Malpractice
Due to the potential for severe injury, it is critical for the physician to be very skilled in forceps delivery technique and follow all standards of care. Failure to follow guidelines and standards of care is negligence. If this negligence leads to injury in the baby, it is medical malpractice.
If your child experienced forceps delivery and sustained permanent damage, the national law firm of Reiter & Walsh ABC Law Centers can help. Our nationally recognized attorneys have many years of experience in handling complex forceps cases. We can help you understand your legal rights and we’ll help you obtain the compensation you and your child deserve. Contact Reiter & Walsh ABC Law Centers for a free review of your case: 888-419-2229.