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Asherman's syndrome and infertility due to complications of delivery (00HDC03447)

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(00HDC03447, 20 June 2002)

Obstetrician ~ Midwife ~ Standard of antenatal and postnatal care ~ Intrauterine infection ~ Rare complications ~ Infertility ~ Follow-up care ~ Record-keeping ~ Right 4(1)

A 28-year-old first-time mother received shared care from an obstetrician, a midwife and a GP. With regard to her antenatal care, she complained that the obstetrician failed to detect that her waters had broken. The obstetrician advised that a small amount of fluid had been lost, but this was not persistent, and he had reviewed her history, conducted an ultrasound scan to identify amniotic fluid volume and ordered a midstream urine test. This was appropriate management.

When the woman first went into labour she was unable to contact the obstetrician or the midwife. The Commissioner suggested that the obstetrician and midwife review the explanations they give women about arrangements for cover in their absence (including names and contact details).

Following delivery, the woman complained that she was in constant pain and that the obstetrician did not detect an infection in her uterus. The obstetrician was aware that the woman was in pain and considered the source to be her episiotomy repair, haemorrhoids and a rash. Consideration was also given to the possibility of an intrauterine infection, but the lochia remained clear and non-offensive and her temperature was normal. It was accepted that conservative management was appropriate.

The obstetrician made a provisional diagnosis of retained placental products due to the heavy bleeding, and performed a dilatation and curettage. The woman complained that her clinical records stated that no retained products had been found and that IV antibiotics may have been sufficient treatment. As secondary postpartum haemorrhage is most commonly due to retained products, the obstetrician's assumption was considered reasonable. However, once the histology results had been received the obstetrician should have explained their significance to the woman.

The woman also complained that the obstetrician and midwife did not investigate the causes of her pain over the following months in hospital. However, clinical records indicate that the midwife frequently checked the woman's perineum and uterus and provided various local treatments for her perineal pain and severe haemorrhoids. The obstetrician also provided treatments and arranged a referral to a dermatologist. This was considered appropriate follow-up care. The woman was subsequently diagnosed with Asherman's syndrome and infertility, a rare complication of evacuation of the uterus, but the midwife and obstetrician were not considered to have breached the Code.