Case Study
A 33-year-old woman presented at 40 weeks’ gestation in spontaneous labor, requesting an epidural. She was low risk, with an uncomplicated vaginal delivery under epidural analgesia the year before. On assessment, the uterus was contracting well, the cardiotocogram (CTG) was normal, and her cervix was dilated 4 cm.
After a brief discussion of the risks and benefits of epidural analgesia with the patient (documented in the patient’s notes), the trainee anesthetist (in the third year of anesthesia training and practising obstetric anesthesia independently) sited an epidural uneventfully at L3–L4 in the sitting position using a 16-gauge Tuohy epidural needle and loss of resistance to saline, with an initial dose of 15 ml low-dose epidural mixture (0.1% bupivacaine with 2 µg/ml fentanyl). After 20 minutes, the patient reported good pain relief, and a bilateral sensory block above T10 to cold using ethyl chloride spray was documented.
As labor progressed, the CTG became abnormal and necessitated a Category II cesarean delivery (fetal or maternal compromise that is not immediately life threatening1) 6 hours after the epidural was sited. The epidural was reportedly working well, and the block height on arrival in the OR was T10 to cold on the left and T12 on the right. An epidural bolus of 20 ml 2% lidocaine with epinephrine 1:200,000 was given 12 minutes after the decision for delivery was made. After 10 minutes, the block was documented as T5 to first sensation of cold and T6 to first sensation of touch bilaterally. Surgery proceeded, and a baby girl was delivered 6 minutes after skin incision with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively.
The patient seemed to be comfortable until the uterus was incised but complained of right-sided abdominal pain during delivery. This worsened after delivery. IV acetaminophen and epidural diamorphine were administered with some benefit. Entonox and general anesthesia were offered but refused. The epidural catheter was removed before transfer to the recovery area following completion of surgery. Later that evening, the patient was seen by the on-call trainee, who documented a full discussion explaining the sequence of events and including an offer of further follow-up.
The following afternoon, the patient complained of severe postural headache with no other associated symptoms. An explanation was given, with advice for initial conservative management with oral analgesics and caffeine, and an epidural blood patch if required. The patient was seen by consultant anesthetists daily, the headache diminished over the next 4 days without a blood patch, and the patient remained headache free at the outpatient anesthetic follow-up clinic 6 weeks later.
A year later, the hospital received a letter from a solicitor indicating a claim of negligence on the basis that incorrect epidural insertion and top-up had resulted in both pain during surgery, which should have been predicted before starting the operation and should have been managed better when it occurred, and additional suffering due to headache.
Key Points
After receiving effective pain relief during her first delivery, this patient had epidural-associated complications (intraoperative pain and headache) with her second birth.
Despite apparently successful management and a good outcome, she clearly felt strongly enough that the anesthetist was at fault to initiate a claim against the hospital 1 year later.
Discussion
Although anesthesia-related claims account for only 2.5 percent of all medicolegal claims in England, approximately 29 percent of these pertain to obstetric anesthesia.2 It is important to note that patients sue the provider of care. Within the National Health Service (NHS) in the United Kingdom, although allegations may be made about a specific clinician, a claim of negligence would be directed against the hospital trust (in the United Kingdom, hospitals are usually managed by a body called an NHS Trust), not the trainee, who would be seen as an agent of the trust through vicarious liability. For a claim of negligence to succeed, the claimant must prove in court “on the balance of probabilities” that
1. The NHS Trust owed her a duty of care – this would not be in dispute because she was a patient of the Trust.
2. There was a failure (“breach”) in that duty – this would hinge around whether the care she received was of an acceptable standard. There are two important principles that apply to this decision:
a. Bolam principle: whether what was done (or not done) would be supported by a “significant body” of medical opinion, even a minority,3 and
b. Bolitho principle: whether this opinion is “reasonable” and “logical.”4
3. Harm occurred – this would be in terms of pain and suffering in the case described plus any further harm she were to suffer (e.g., posttraumatic stress syndrome or a physical complication).
4. The harm occurred as a result of that failure (“causation”).
From an anesthetic point of view, the main issues in this case were around breach of duty (i.e., standard of care) and causation. In the NHS, claims of negligence are managed by the NHS Resolution (formerly called the NHS Litigation Authority).2 After local investigation and discussion between NHS Resolution and the Trust, the opinion of an expert witness, an independent obstetric anesthetist, was sought to consider these issues.
Appropriateness of Epidural
The patient was low risk, in established labor, and requested an epidural. With no contraindications, it was considered an entirely appropriate procedure for the anesthetist to perform.
Consent
In order to respect patient autonomy, informed consent should be obtained before epidural insertion. This requires provision of adequate information to a patient with the capacity and time to make a balanced decision, free from coercion.5 The nature of the information given and whether a woman can have adequate capacity during painful labor are discussed further in Chapter 10. In this case, the documented discussion in the patient notes provided good evidence of the discussion that preceded the epidural, and care was considered acceptable. Such record-keeping is crucial to defend against an accusation of an inadequate consenting process, especially in cases where the woman’s capacity is in doubt.
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