Oxford University Hospitals NHS Foundation Trust

5. Mrs A complains about the care and treatment provided to her by Oxford University Hospitals NHS Foundation Trust. Specifically, she says:

• on 12 September midwives’ ignored her concerns her waters had broken prematurely and did not keep her in for monitoring • on 13 September midwives’ advised her to wait for a planned appointment the following day rather than go straight to the maternity unit to be assessed.

6. Mrs A said as a result of midwives ignoring her concerns and not keeping her in for monitoring on 12 and 13 September, she had to deliver her baby by emergency caesarean section on 15 September 2023. Mrs A believes the midwives should have kept her in for monitoring when she told them she was leaking clear fluid. Mrs A feels traumatised by the midwives’ neglectful care.

7. Mrs A has lost faith in the Trust and now does not want to have any more children. She has not slept with her husband for 12 months as she cannot contemplate going through childbirth again. Prior to this experience, she wanted to have more than one child and feels the impact to her and her family is life changing.

8. Mrs A would like the Trust to acknowledge its mistakes and provide financial compensation at level six of our severity of injustice scale.

9. Mrs A was 39 weeks pregnant and had been experiencing loss of clear fluid. She called the maternity unit on 12 September 2023 to report this. The midwife invited Mrs A in for review but was unable to confirm Mrs A’s waters had broken. Mrs A was sent home with advice to call back if she experienced loss of fluid.

10. Mrs A called back on 13 September to report loss of clear fluid again. Mrs A says she was advised not to go to the maternity unit that day but to wait until her planned appointment on 14 September. On 14 September a midwife confirmed Mrs A’s waters had broken and sent her to hospital for induction of labour.

11. Mrs A’s baby was delivered safely by emergency caesarean section on 15 September.

12 September 2023

15. Mrs A says the Trust did not listen to her concerns her waters had broken on 12 September 2023. Mrs A says the midwives should have kept her in for monitoring.

16. The records show Mrs A attended the maternity unit on 12 September 2023 with concerns her water had broken. Mrs A reported wetness in her underwear at 11.30am and more fluid at 1pm but there had been no fluid since wearing a pad.

17. The midwife noted no fluid was seen on the pad and was unable to diagnose broken waters from the pad. Mrs A declined a speculum examination. The midwife offered an amnisure test to check for broken waters. The amnisure test was negative.

18. The midwife took Mrs A’s obstetric observations including, position of the baby, fetal heart rate, Mrs A’s temperature and heart rate.

19. The midwife advised Mrs A to call the maternity unit again should she be concerned her waters had broken.

20. We reviewed Mrs A’s medical records with the help of a midwife adviser.

21. Assessment guidance states ‘advise women with suspected rupture of membranes (SROM) after 37+0 weeks to contact their midwife or maternity unit to have an initial triage assessment over the phone with a midwife. This should include when the membranes ruptured and an assessment of any risk factors such as:

• meconium-stained liquor • vaginal bleeding • blood-stained liquor • reduced fetal movements • continuous abdominal pain • unpleasant smelling liquor • the woman feeling unwell • group B streptococcus carriage • the baby has an abnormal presentation • fetal growth restriction • low-lying placenta

22. If any of these factors are present or if there is any uncertainty, the woman should be advised to immediately attend the maternity unit for an urgent in-person review’.

23. SROM guidance states if a woman presents with potential pre-labour SROM with no contractions at 37+0 weeks gestation, the midwife should undertake the following examinations:

• stable, normal fetal position • normal fetal heart rate • normal maternal pulse rate, temperature or other early warning score markers of sepsis • exclude group B strep by checking in notes

24. The admission records document the correct observations were undertaken including confirmation the baby was in the correct position for labour and had a normal fetal heart rate. Mrs A’s observations were taken and recorded on an Obstetric Early Warning Chart and all observations were within normal limits. A normal temperature and pulse rate confirmed Mrs A was not showing any clinical signs of sepsis.

25. In the absence of any signs of infection or complications the SROM guidance says all low-risk women may be invited to go home to await events. This was the case with Mrs A which was the correct and appropriate course of action.

26. Having been unable to confirm Mrs A’s waters had broken, the midwife checked the baby’s position and heartrate which were both normal. The midwife took Mrs A’s observations which were also normal and ruled out any infection. Mrs A was sent home with safety netting advice to call back should her waters break. This is in line with the guidelines highlighted above.

13 September 2023

27. Mrs A says she called the maternity unit on 13 September as she was still concerned about the watery loss she was experiencing. She says she expected to be asked to go straight back to the maternity unit to be reviewed again, but a midwife advised her to wait at home and come in the following day for a planned stretch and sweep appointment.

28. Mrs A has provided a call log to show she made a five minute call to the maternity unit on 13 September at 11.32am. The Trust has no record of this call except for a note in the system at 11.50am made by the duty midwife booking a stretch and sweep appointment for Mrs A the following day.

29. Based on this, the Trust agrees Mrs A called the maternity unit on 13 September. The Trust interviewed the midwife who was on duty that day. The duty midwife cannot remember the call and does not know why she would have booked a stretch and sweep appointment for a woman who’s waters had broken. The midwife said their usual practice would be to invite the woman in for review as had happened the day before.

30. The Trust apologised for not keeping a record of the call and explained since October 2023 it has made significant changes to its telephone triage system and now a record is kept of every call.

31. On 14 September 2023 Mrs A attended the maternity unit for a stretch and sweep. An amnisure test showed positive this time.

32. The Trust said as Mrs A had reported watery loss for two days they decided to treat her as if her waters had broken on 12 September. It said this was not because they thought the test was incorrect on 12 September but because the midwife felt it safer to assume the waters had been broken for longer.

33. We reviewed Mrs A’s medical records with the help of an obstetrician adviser.

34. At 1.15pm on 14 September the midwife at the maternity unit recommended Mrs A go to the hospital for induction of labour after confirming her waters had broken.

35. At 3.15pm Mrs A arrived at the hospital for induction of labour. On admission to the unit Mrs A was fit and well, and her observations were within normal limits. The pregnancy was full term, and the fetal heart rate had been documented as normal on admission. As a precaution, the midwife documented Mrs A’s waters had broken on 12 September.

36. At 6.15pm Mrs A had not yet been taken to the labour ward and a midwife apologised to Mrs A for the delay caused by high demand on the unit. The midwife carried out a cardiotocography (CTG) to measure the baby’s heartrate. The midwife carried out a blood test to check for signs of infection and took observations including temperature, blood pressure and heart rate which were all within normal parameters.

37. At 9pm the obstetrician assessed Mrs A and started her on antibiotics as a precaution to potential infection due to the ruptured membranes which may increase the risk of infection to the baby.

38. At 4.40am and 5.15am on 15 September a midwife noted there was no capacity to start induction of labour due to high demand on the labour ward.

39. At 9am a midwife escalated concerns about the CTG reading to the obstetrician and took Mrs A to the delivery suite.

40. At 1.50pm, induction of labour still not having been commenced, the obstetrician noted the CTG could be reflective of fetal infection and recommended delivery by caesarean section. The plan was discussed with Mr and Mrs A who were both in agreement. The obstetrician noted ‘I have acknowledged the delay in commencing induction of labour have contributed to possibility of infection’. It is not clear whether the obstetrician meant ‘may have’ or ‘has’.

41. Mrs A had a category two caesarean section. A category two caesarean section means there is fetal compromise which is not immediately life threatening.

42. The decision to carry out an emergency caesarean section was made at 1.50pm and Mrs A’s baby girl was delivered at 2.40pm not requiring any resuscitation with an Apgar score of 10 at 1 minute of life and 10 at 5 minutes of life.

43. The Apgar score relates to observations which are made of the baby’s heart rate, breathing, colour, muscle tone and response to stimulation soon after birth. Mrs A’s baby’s Apgar Score was as high as it could be.

44. Mrs A was well post-delivery and was discharged on 17 September with no concerns.

45. NHS website ‘Maternity Matters’ states, ‘an emergency caesarean section is one that is not planned in advance. The word ‘emergency’ sounds very scary but most emergency caesareans are not life-threatening for the mother or baby. It just means the team need to deliver the baby soon’.

46. NHS website for caesarean section states, ‘around 1 in 4 pregnant women in the UK has a caesarean birth, a caesarean may be carried out because:

• your baby is in the breech position • you have a low-lying placenta • you have pregnancy-related high blood pressure • you have certain infections • your baby is not getting enough oxygen and nutrients • your labour is not progressing or there's excessive vaginal bleeding

47. An article by the Royal College of Obstetricians and Gynaecologists discusses the rate of caesarean births citing data published by NHS England. In September 2023, 23% of births in England were by emergency caesarean section.

48. Caesarean guidance states, ‘Category 1 caesarean birth is when there is immediate threat to the life of the woman or foetus, and category 2 caesarean birth is when there is maternal or fetal compromise which is not immediately life-threatening’.

49. Our obstetrician adviser said it could be argued various delays (including the decision to induce, delays in admitting to the labour ward and failure to be asked to attend on 13 September) increased the risk of fetal infection.

50. However, had Mrs A been invited to the maternity unit on 13 September and received confirmation her waters had broken, there may still have been a significant delay in commencing induction of labour due to the high demand on the ward. Induction itself may have taken many hours and concerns about infection may still have developed.

51. We have no way of knowing for sure if Mrs A’s waters had actually broken on 13 September and in what way her experience may have been different had she been invited back to the maternity unit that day.

52. Given there are a such a wide range of possible scenarios, and unknown contributing factors, it cannot be said whether the initial suspected delay in confirming Mrs A’s waters had broken had definite bearing on the eventual means of delivery.

53. Due to the unknown elements highlighted above, we are unable to strongly link the events of 13 September to Mrs A delivering her baby by emergency caesarean section and will therefore take no further action.

54. We understand Mrs A’s delivery did not happen as she expected it to, and we do not wish to diminish Mrs A’s account of how she was impacted. As highlighted above, giving birth by emergency caesarean section occurs in around one in four births and is an accepted and safe mode of delivery which can happen for many different reasons.

55. We were pleased to learn Mrs A delivered a healthy baby girl. We hope our investigation has given Mrs A some reassurance about the care she received. Mrs A may also be reassured to know we have received no other similar complaints about the Trust.

1. We have carefully considered Mrs A’s complaint about Oxford University Hospitals NHS Foundation Trust (the Trust).

2. We were sorry to hear about Mrs A’s experience and thank her for bringing her complaint to us for our consideration.

3. We reviewed aspects of Mrs A’s care and treatment. We have seen the midwives provided the correct care in line with the relevant guidelines on 12 September. We have decided we cannot link the events of 13 September 2023 to Mrs A delivering her baby by emergency caesarean section.

4. We have therefore decided we do not need to take any further action on the complaint. We understand our decision may be disappointing to Mrs A and we are sorry if this adds any further distress.