Are there circumstances when the maternity guidelines should not be applied?

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20 October, 2020

"Things should be made as simple as possible, but not any simpler" Albert Einstein (1879-1955).

The principle is that guidelines are just that. Sir Michael Rawlins, the former Chairman of NICE commented that "no guidance can cover 100%, because people vary. It is up to the doctor or other health professional to decide when the guideline is no longer applicable and what to do in its place".

The legal question is whether the clinician acted in accordance with a responsible and logical body of reasonable opinion. A lawyer assisted by medical opinion must look at whether that is satisfied.

The applicability of the guidelines was considered in the case of Sanderson - v - Guy's and Thomas's NHS Foundation [2020]. ALL ER (D) 52 Jan, [2020] EWHC 20 (QB). This was a delay in delivery case. The issues were based around the interpretation of the CTG trace, and use of a fetal blood sample, alongside a decision to proceed to instrumental delivery rather than immediate caesarean section.

The NICE Guidelines appear to promote two contradictory management positions. One was conservative measures to include the fetal blood sampling where possible, and the other urgent delivery where it was not indicated. A Clinician should interpret the guidelines which are a practical tool to assist them.

In this case it was found that a reasonable obstetrician would exercise judgement alongside the guidelines with reference to features of the CTG, the depth of heartrate, presence of recovery in the heartrate, and the response of the fetal heart during the vaginal examination. Based on the interpretation of the CTG it was concluded that the infant was suffering from a chronic, rather than an acute hypoxia. Chronic hypoxia is oxygen starvation that is progressive. Acute oxygen starvation occurs when there is a sudden drop in oxygen levels without warning. In those circumstances the judgement concluded that the CTG had not mandated urgent delivery. To do so might encourage a rise in unnecessary caesarean sections.

What this case also highlights is that where there is departure from guidelines, it ought to be well reasoned and documented within the records.

Where relevant in birth injury cases, the maternity guidelines must be applied according to the individual facts of the case.

For more information contact Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

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