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Management of labour, delivery and post-delivery care (03HDC10782)

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(03HDC10782, 29 June 2005)

General practitioner 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 by surgery.

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.