DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD

Dated this the 31^st day of July 2014 

Present:  Smt.Seena.H.  President

              Smt.Shiny.P.R. Member

                                                                          Date of filing :   11/02/2013

           CC No.37/2013

1.Reshmi,

  W/o.Prajesh,

  Rakkanathodi House,

  Perur (PO),

  Ottapalam.

2.Baby Reshmi,

   D/o.Prajesh,

   Rakkanathodi House,

   Perur (PO),

   Ottapalam.

(Rep.by 1st complainant)                               -                  Complainant

(by Adv.E.Muraleedharan)

        Vs 

1.Dr.Lekhanarayanan

   New Ashwini Hospital,

   Ottapalam (PO),

   Palakkad

(By Adv.V.K.Venugopalan)

2.Manager,

  New Ashwini Hospital,

  Ottapalam (PO),

  Palakkad                                                     -                  Opposite parties

 (By Adv.V.K.Venugopalan)

 O R D E R

Order by Smt.SEENA.H, PRESIDENT

Brief case of the complainant as detailed in complaint is as follows:

Complainant was under the treatment of opposite party No.1 in connection with her pregnancy for ante–natal care and delivery.  Regular check ups & tests were done by the complainant.  Scan was done in the 7^th month.  Nothing abnormal was noted and it was informed that the complainant was expecting a normal delivery. On 24/07/2012 complainant approached opposite party No.1 with mild labour pain & opposite party No.1 advised to take admission in opposite party No.2 hospital where she was working.  Accordingly complainant was admitted to opposite party No.2 hospital at 6.30 p.m.  On the next day she was taken to the labour room at about 11.a.m.  Opposite party No.1 examined the complainant at the labour room and there after left the room entrusting her with the nurses.  Complainant had unbearable pain and when only the condition became dangerous opposite party No.1 attended the complainant.  Then only opposite party No.1 informed that the child is over weight and natural delivery is not possible as the head was delivered.  Opposite party No.1 has taken out the child recklessly using force and forceps. The child has not cried  after delivery.  Complainant has also suffered     serious health problems due to the act of opposite party No.1.  After delivery the left hand of the baby was found to be functionless.  Also she could not open her left eye completely.  The act of opposite party has resulted in injuries to the brain and other  organs of the body of the baby.  Opposite party no.1 instead of attending the complainant through out the labour and opt for  caesarian section  if necessary, entrusted the complainant with the nurses and went away.  According to the  complainant the said act prevented 1^st opposite party from taking timely decision and action.  The act of opposite party has resulted in lifelong misery and permanent disablement of the girl child. The child was under treatment in Thrissur Elite Mission Hospital and treatment is still going on.  Complainant’s husband also died due to the problems developed due to the shock.  Complainant incurred huge amount as expense for treatment of herself and the child. According to the complainant the act of opposite parties amounts to gross deficiency of service on their part.  2^nd opposite party is also vicariously  liable for the acts of the 1^st opposite party. Hence the complaint.  Complainant prays for an order directing the  opposite parties to pay complainant an amount of Rs19,99,900/-. as compensation.

Contentions put forward by the opposite parties are as follows.

The complainant a second gravida  was under the ante-natal care of the 1^st opposite party since 20/1/2012.  She was a well built lady with a history of 1^st full term normal non instrumental vaginal delivery of a baby being 3.5 kg.  The 1^st complainant’s expected date of delivery was on 8/8/2012 and investigations including GCT (Glucose Challenge Test) and USG  at 20^th week of gestation were normal.  She was found to have mild pregnancy induced hypertension (PIH) at 26^th week and was put on ante hypertensive drugs. 

The 1^st   complainant came to consult the 1^st opposite party in her clinic on 27/4/2012 with complaints of mild occasional pain.  On examination she had signs of early labour with per vaginal findings and as cervix 50% effaced, two finger loose, membrane present vertex at 3 stations and with normal pelvis.  Since she was also found to be hyper-tesnsive the 1^st OP advised admission to the 2^nd OP hospital.  The 1^st complainant got admitted to the hospital on the same day at 7.30 p.m. and anti hypertensive drugs were stepped up and prepared for labour.  BP was maintained well within normal limits and foetal heart sound was good.  Being a 2^nd gravida with previous normal vaginal delivery, the 1^st opposite party had decided to accelerate labour for the reason that there was no contra-indication for vaginal delivery.  This plan for trial vaginal delivery and cesarean section if indicated during trial was well informed to the patient as well as her bystanders and they were also favouring trial vaginal delivery.  Hence the patient had been kept under close observation and monitoring. All vital parameters were checked and assessed periodically.

On 25/7/2012 labour acceleration was started at 7 a.m. with pitocin and close monitoring continued.  At 10.a.m. her vaginal examination showed cervix 75% effaced, 3 c.m. dialated and membrane present.  The 1^st opposite party had done Artificial Rupture of Membrane(ARM) and clear liquor drained.  The labour progressed well and baby’s head delivered normally with mediolateral episiotomy. But there was difficulty in delivering the shoulder and it was managed as per Mac Robert Maneuver with supra pubic pressure and delivered a female baby weighing 4.1 kg at 11.30a.m. The patient developed a complication called shoulder dystocia which was managed as per accepted medical practice by resorting to Mac Roberts Maneuver.  No vacuum or forceps were used in her case.  The baby was immediately handed over to pediatrician present in the labour room and immediately resuscitated and shifted to Neonatal Intensive Care Unit (NICU).  Placenta and membrane expelled completely and episiotomy sutured in layers.  Uterus well contracted and bleeding within normal limits. Her post natal period was uneventful except for the complaint of hip and leg pain for which she underwent orthopedic consultation. The 1^st complainant was discharged on 27/7/2012 and on her 1^st post natal check up uterine involution was found to be good and episiotomy wound healed well. 

The baby was resuscitated in the NICU with utmost care and caution and oxygen saturation was well maintained.  On the 2^nd day, milk feeds were started and RBS was maintained.  The baby was diagnosed to have developed Erb’s Palsy which was properly managed by limb in neutral position.  Since the baby had persistent tachyponea (High breathing rate ) and in view of Erb’s palsy the baby was referred to Neonatology higher centre with IV fluids and under oxygen support.

Shoulder dystocia is an unpredictable event and the same is not caused due to any act or omission on the part of gynecologist who attended the delivery and in such cases the 1^st step is MacRobert’s maneure and the 1^st complainant easily delivered with it and supra pubic pressure.  There was no requirement for using vacuum or forceps in the process of delivery.  Since the 1^st complainant had an uneventful vaginal delivery of a baby having 3.5 kg,       4½ years back and on examination there was no cephalo pelvic disproportion(CPD), there was no contra indication for trial vaginal delivery in her case.  Moreover there was no prolonged labour and clear liquor drained on ARM and all vitals were within normal limits. The occurrence of brachial plexus palsy is a reported non complication in difficult delivery due to shoulder dystocia.  In the treatment of the complainants, standard and medically accepted procedure was adopted in strict regard to accepted medical protocol.  There was no negligence or carelessness on the part of the 1^st opposite party in the above matter and hence she is not liable to compensate the complainants.

Both Opposite parties denied the entire allegations of the complainant.  Following labour induction, the 1^st opposite party had assessed the progress through out the labor attending the patient and her progress of labour was satisfactory with favorable cervix and head delivered without difficulty but shoulder got stuck in maternal symphosis  pubis and caused difficulty which was managed according to MacRoberts Maneure.  Shoulder dystocia was an unexpected event and there was no reasonable ground or cause to anticipate the same and in the 1^st complainant’s case,  she had an earlier uneventful vaginal delivery.  Opposite party denied that she was informed that the child is overweight and natural delivery is not possible only when the head is engaged and stuck – in and through forced delivery the baby should be pulled out by forceps is falsely stated for undue advantage.  Further allegations that the 1^st opposite party had taken the child out by using forceps is highly ill motivated.   1^st opposite party had resorted to Mac Robert's Manure which is the standard and accepted procedure for the management of shoulder dystocia and no instrument was used in the said procedure.  The 1^st opposite party had adopted the procedure with utmost care and expertise as per standard protocol and the statement that the 1^st complainant came to know that due to negligence, responsibility and lack of expertise and pulling the child by hand and forceps, the baby sustained severe injuries and caused trauma to organs and brain is unfounded and unsustainable. Further allegation that by the reckless and primitive way of extraction of baby by pulling body parts, the 1^st complainant had also sustained trauma and health problems is purposely stated for undue gain and hence denied.  The allegation that trauma was caused to the 1^st  complainant’s pelvic bone and bones were prolapsed and her body was incised extensively than required are not true.  Mac Roberts Manure is the standard and medically accepted procedure a reasonable gynecologist is expected to adopt in a situation of difficult labour caused by shoulder dystocia in trial vaginal delivery.  Further allegations that the 1^st opposite party had irresponsibly and lazily left the labour room after entrusting the 1^st complainant to the care of nurses having no expertise and experience is falsely and purposefully alleged with ulterior motives.  The nursing staff was well experienced and the delivery was progress in under constant supervision of this opposite party.  The allegation that the 1^st opposite party had not cared to watch the condition of mother and baby and problems at the time of delivery for taking timely decision for following obstetric procedures is unfounded and unsustainable. Further allegation that by the time the 1^st opposite party reached the labour room things had gone beyond her control and in her negligence, improper and unskilled attempt to extract the baby the 1^st complainant and her baby sustained severe injuries is highly ill motivated.    There was no negligence or deficiency in service on the part of 1^st opposite party rather she had acted with due care and caution as per accepted medical practice. 

In the post natal period the 1^st complainant had complained of pain at hip and leg for which orthopedic consultation was taken.  The clinical findings of the orthopedician was L4-L5 Inter Vertebral Disc(IVD) bulge/Lumbs sacral strain.  She was relieved of the symptoms by treatment and she was discharged perfectly well.  When she had come up for post natal review she did not have any complaint of persistence of earlier symptoms.  Regarding the management of the baby the treatment decisions were taken by the pediatrician attached to the 2^nd opposite party hospital and reference to higher centre was also made as per his decision. 

The further averments in the complaint regarding treatment of the baby at Elite Mission Hospital and the decease of the husband of the complainant is not within the knowledge of the opposite parties.  Opposite party 1 is a person having qualification of MBBS, DGO and DC(AP) with experience of 11 years   as a consultant gynecologist.  According to opposite parties there is no deficiency in service on the part of opposite parties and the complaint is liable to be dismissed. 

The evidence adduced by the parties consists of their respective chief affidavit Ext.A1and A2 marked on the side of complainant and Ext.B1 marked on the side of 1^st opposite party.  Witnesses examined on the side of complainant as PW1 and PW2. 

Now the issues for considerations are

1.  Whether there is any negligence on the side of opposite parties?
2. If so what is the relief and cost entitled to the complainant?

Issue No.1:  Complaint rests mainly upon three allegations.

          Firstly 1^st opposite party failed to remain in the labour room through out the period of labour there by timely decision and action could not be taken by her at the time of complication.

          Secondly 1^st opposite party has pulled out the baby by forceps and by using force which has resulted in all the latter complications developed to the baby.

          Thirdly the reckless and careless handling of the complainant by 1^st opposite party has resulted in serious health problems to the complainant.

          According to the 1^st opposite party following labour induction she has assessed the progress through out the labour attending the patient and her progress of labour was satisfactory.  Labour accelerations was started at  7a.m. with pitocin and close monitoring continued.  At 10 a.m. her vaginal examination showed cervix 75% effaced 3 c.m. dialated and membrane present.  She has done artificial  rupture of membrane and clear liquid drained.  The labour progress well and baby’s head delivered normally.  But there was difficulty in deliver in the shoulder and it was managed by Mac.Roberts maneuver.  According to opposite parties no forceps or vacuum was used at the time of delivery.   The complication of shoulder distorcia was managed as per Mac.Roberts maneuver with supra pubic pressure which is the accepted medical practice. Further shoulder distorcia being an unpredictable event is not caused due to any act or omission on the part of the gynaecologist who attended the delivery.  There was no requirement for using vacuum or forceps as the complainant  easily delivered. 

          Opposite parties denied the allegation of the complainant that she suffered trauma and health problems due to reckless act of 1^st opposite party.  It is also not correct to say that the complainant No.1, pelvic bone were prolapsed and her body was incised extensively than required.  1^st opposite party has managed the situation as per Mac.Roberts maneuver which is the standard and medically accepted procedure a reasonable gyanacologist is expected to adopt in a situation of difficult labour caused by shoulder distorcia in trial virginal delivery. In the post natal period the 1^st complainant had pain at hip and leg for which orthopedic consultation was taken.  The clinical findings of ortho paedician was L-4, L-5, Inter Vertebral Disk(IVD) bulge/Lumbo Sacral Strain.  She was relieved of the symptoms of treatment and she was discharged perfectly well.   No complaints were made at the time of review also. 

          Heard both parties and has gone thoroughly through the evidence on record as well as the authoritative texts placed before the Forum.

          Ext.B1 is the case records pertaining to complainant No.1 at New Aswini Hospital, Ottapalam.  Ext.B1 Doctor’s order sheet reveals the act that as  submitted by 1^st opposite party, pitocin was ordered to be administered by the order of 1^st opposite party at 10.a.m.  ARM done noted and physical examination result was also seen recorded which implies the doctor was present at the hospital at 10.a.m.  As per the delivery notes prepared by 1^st opposite party (Ext.B1) it is seen that at 11.25 a.m. the head delivered normally.  Further stated that shoulder struck behind symphysis.  Anaesthesist and Pediatrician called for help, Mac.Roberts position given legs abducted and forced to maternal abdomn and staff gave supra pubic pressure and the shoulder was delivered with difficulty.  1 minute time interval between delivery of head and shoulder. Baby was seen by the Pediatrician.  Uterus contracted and bleeding was within limits.  Ext.B1 case sheet was marked without any objection.  As per Ext.B1 child was delivered on 11.30 a.m.  There is no contra evidence to the effect that the doctor was not present at the labour room.

The authoritative text on (21^st edition of William’s Obstetrics) has stated that shoulder  dystorcia is an unpredictable medical complication in child birth.

          It is understood that the shoulder distorcia is a non complication in labour and the 1^st maneuver to be followed in Mac.Robert maneuver.  Hence the 1^st opposite party Doctor has adopted the same for managing the situation.  As per the settled position, the doctor cannot be made liable if she has followed   an accepted medical practice followed by persons of the same profession.  It is true that the baby has suffered damage due to shoulder distorcia.  Ext.A2 has clearly stated so also.  But the question herein whether the resultant damage was due to any breach of duty or negligence on the part of the doctors.  To attribute negligence there should always be nexus between the breach of duty and resultant damage.  As far as the nexus is absent no liability can be fastened.  DW1 and DW2, the doctors who has treated the child has examined before the forum.  Both has deposed the gravity of injury caused to the baby, but nothing was forthcoming regarding the negligence on the part of the opposite parties.  No gynecologist expert was examined.  Complainant has not even taken the pain to cross examine the opposite parties  which would have revealed what actually transpired in the labour room and other aspects also.  It is seen that the complainant has given more important to the injury caused to the baby and regarding the evidence to prove that aspect, but failed to establish the fact that the injury sustained was due to the negligence on the part of the opposite parties.  Further there is no evidence on record to show that the reckless act of the 1^st opposite party has caused trauma to the complainant.  The harm if any caused to the complainant and the baby may be due to the application of Mac.Roberts Manuevar which is the first steps to be followed in such a situation.  Since 1^st opposite party has followed the standard accepted pracitce, no negligence can be attributed to her.

          In view of the above discussions, we are of the view that complainant failed to establish medical negligence on the part of the opposite parties.  In the result complaint dismissed.

Pronounced in the open court on this the 31^st   day of  July 2014. 

     Sd/-  

  Seena H

  President   

     Sd/-

 Shiny.P.R.

  Member

APPENDIX

Exhibits marked on the on side of complainant

Ext.A1 series                 - Medical bill(Original)

Ext.A2                        - Patient record issued by Elite Mission Hospital,

                          Thrissur(Original)

Exhibits marked on the side of opposite party

Ext.B1-                Case sheet of the complainant issued by opposite party

                          (Original)

Witnesses examined on the side of complainant

PW1                       -Dr.Aloke.V.R

PW2                       -Dr.Pradeep

Ext.C1 -  Medical Report of the complainant issued by special medical board,

             District Hospital, Palakkad.

Cost

No cost allowed