Women's Health Child Health Oxytocin Obstetrics and Gynaecology
Anna Shavilas first child was a bouncing baby boy. Her third, a healthy girl. But her second, Lara, died when she was just one day old. Was it because she was given a drug routinely used during childbirth?
In a corner of Brookwood cemetery in Surrey, two graves lie side by side. The headstone on one reads simply:
Lara Nadia Shavila. Born 15.3.1992. Died 16.3.92. With love. The second grave has only recently been dug and does not yet have a stone. It belongs to Laras grandmother, 61-year-old Yvonne Nicolaou.
Anna Shavila visits the graves on most Sundays and brings fresh flowers. Lara was her daughter, Yvonne her mother and she believes that, but for the grace of God, there would have been a third grave there bearing her name. She is convinced that the loss of Lara and Yvonne, and her own brush with death, are all related. The cause, she believes, was the bungling of Laras delivery by her local hospital and, in particular, the over-use of a drug called Syntocinon, which is routinely used to induce and speed up labour, despite the dangers having been known for years.
Lara was Annas second child. Her first, a healthy boy called Emil, was born in 1988 by Caesarean section. Lara was conceived in 1991. When Anna was admitted to the labour ward at the Royal Surrey County Hospital, Guildford, on March 13,1992, she bad had excruciating pains in her womb and vagina for 10 days. By lunchtime the following day, the pains were so bad, she was begging her consultant obstetrician for a Caesarean. The consultant, however, said that would not be necessary because her cervix had already dilated two centimetres and the baby would probably be born that night. It wasnt and Anna was then told that the birth would be induced.
At about 7am on March 15, Anna was connected to a Syntocinon drip and the dose was increased on a number of occasions. At about 11.3Oam, the baby began to show some quite serious heart-rate abnormalities generally a sign of distress but Anna claims that the staff did not seem too concerned and no doctor was called. The abnormalities then became more serious and, at 2.3Opm, the Syntocinon was switched off. By 2.4Opm, the babys heart-rate had begun to fluctuate wildly from the normal rate of about 150 beats per minute and a doctor was called urgently; within 10 minutes, the heart-rate bad plummeted to only 60 beats per minute and did not recover. It was decided to rush Anna through to theatre for a forceps delivery. But some time in that 10 minutes, as she was being transferred, Anna also felt a new, intense pain. It was like a bomb exploding, she says. I felt like I was burning from the inside. Her womb had ruptured. Her family was told she had only a 50-50 chance of pulling through. Yvonne, herself a midwife for more than 25 years, went into shock and was unable to speak.
Lara was delivered by Caesarean at 3.l9pm. The rupture had starved her of oxygen for at least half an hour and she was severely brain-damaged. The family knew she would die, so Yvonne called for a priest to christen her. Anna could scarcely bare to look at her, but Yvonne stayed with her in the Special Care Baby Unit, constantly talking to her and singing lullabies. Mum was a down-to-earth, no-nonsense kind of character, Anna says. But she was convinced that she had developed a bond with Lara. She said there was a piercing light that shone out of Laras eyes into her own. At 2.45pm the next day, Lara died in her arms.
Yvonne had always been healthy and had never spent a day of her adult life in hospital. But six weeks after Laras death she found a small lump in her breast. Soon after, it was diagnosed as cancer and she died on July 4 this year. Although it is impossible to prove, no one in the family is in any doubt that the cancer was brought on by the trauma of Laras death.
Yvonnes death exacerbated what had been a four-year nightmare for Anna. For 12 months after losing Lara, she hardly left her bed. Her depression made her over-eat and she put on four-and-a-half stone. On more than one occasion, she went to the cemetery in the early hours of the morning and tried to dig up Laras grave with her bare hands. Once, while driving home, she decided that life was no longer worth living and, momentarily, accelerated towards a lamppost. All that stopped her was the thought of the effect it might have on her family.
Coupled with the misery, Anna also felt anger against the hospital, so the local Community Health Council and the group Action for Victims of Medical Accidents put her in touch with Boyes, Turner and Burrows, a Reading law firm which specialises in medical negligence. Solicitor Adrian Desmond requested Annas records from the hospital and commissioned a number of distinguished professionals to examine the evidence.
One of these was Michael House, a consultant obstetrician and gynaecologist with more than 23 years experience and senior lecturer at the Charing Cross and Westminster Medical School. He couldnt explain the terrible pains that Anna suffered in the run-up to the labour, but was in little doubt what had caused the eventual rupture.
In a report, presented in October 1993, he wrote: It is absolutely essential that Syntocinon is used with great care and that the midwives concerned with its management are aware of the risk of uterine rupture if it is not used wisely... If the Syntocinon had been discontinued at around 11.30 when the more serious fetal heart abnormalities began to occur, then in my view, on the balance of probabilities, this labour would have progressed quite satisfactorily to a spontaneous vaginal delivery... In my view this uterine rupture was caused by the inappropriate administration of Syntocinon.
In February, the Royal Surrey County Hospital offered an out-of-court settlement. They agreed to pay Anna £20,000, without accepting liability. They say that independent legal advice was sought which confirmed -the following: the use of Syntocinon was entirely appropriate [and] there is no evidence whatsoever to indicate the cause of rupture, which was entirely unpredictable.
As her case had progressed, Anna had been taken aback to discover that other women had been through similar ordeals. She had been told that rupture of the womb was very rare. In the summer of 1992, she was contacted by Sally (not her real name), who had come to know about Anna through the Stillbirth and Neo-natal Death Society (SANDS). She, too, had lost a baby through a ruptured womb after being given Syntocinon and, like Anna, had previously had a Caesarean. She told Anna she had located other cases.
One of them was Joanne (not her real name), who had also had her first child by Caesarean. When pregnant with her second, she was told that the baby could be delivered normally and claims that the risk of rupture was never mentioned. Labour began on March 1, 1992, but it did not progress and she was put on a Syntocinon drip in the care of a student midwife. Her womb ruptured in the early hours of the following morning. Staff realised what was wrong at once and she had an emergency caesarean. After a month in the Special Care Baby Unit, baby Lisa survived, but with severe cerebral palsy. Now four years old, Lisa cannot talk or walk. Joannes misery was compounded when the hospital advised her that any future pregnancy might be life-threatening. She opted for sterilisation.
THE NUMBER OF CASES citing misuse of Syntocinon is alarming. In the past seven years, Professor Ron Taylor, who for 30 years was a consultant obstetrician at St Thomass Hospital in London, has given an expert opinion in more than 100 legal cases involving the death of a baby or cerebral palsy. Roger Clements, a consultant obstetrician and editor of Clinical Risk, the journal of risk management in healthcare, believes that he has seen a similar number.
In 1992, the Department of Health established a body called the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). Its latest report, which appeared last year, focused on the 388 deaths as a result of labour of normal weight babies during 1993. At Night & Days request, the clinical director, Ralph Settatree, examined the data that does not appear in the report, calculating that Syntocinon misuse claimed about 30 to 40 lives, which is about 10 per cent of all the years avoidable deaths. According to Professor Taylor, for every death caused by Syntocinon misuse, there may be up to three times as many cerebral palsy cases.
The drug is a synthetic form of oxytocin---the hormone produced by pregnant women which stimulates the contractions of the womb in labour and it is used when contractions do not start naturally or to speed up labour. It was introduced in the Fifties and was seen as a great step forward because previous non-synthetic oxytocin had been unpredictable in its effects. Induction of labour, coupled with forcibly breaking the waters, became routine with many obstetricians; shorter labours were seen as desirable because, in theory, they put less strain on the mother and reduced chances of infection. But alarm bells began ringing in the early Seventies.
One of the first to voice concern was Jean Robinson, former chairwoman and current vice-president of the Patients Association. She began to hear of hundreds of women who had suffered traumatic birth experiences. In an article for the British Journal of Midwifery last year, she said that the drug was pumped in to stimulate contractions, which were often of unphysiological frequency and intensity. The baby was being squeezed against a still tight cervix. Even the Jesuits never invented a more refined form of torture.
One of the standard obstetric text books, Munro Kerrs Operative Obstetrics, also observed back in the Seventies that widespread use of oxytocin... for the induction and the acceleration of labour has increased the risk of uterine rupture, particularly in the cases of women of high parity or with a previous Caesarean scar. A lamentable number of such ruptures are now on record. The drugs manufacturer, Sandoz, clearly warns that considerable caution should be shown when it is given to women who have had Caesareans.
When induction reached a peak in the early Eighties, technological advances, in particular the use of prostaglandins to prepare the cervix, meant that far fewer accidents occurred. But by then, another school of practice, known as the Active Management of Labour, was also in the ascendant. Pioneered by Dr Kieran ODriscoll at the National Maternity Hospital in Dublin in the late Sixties, it stated that labour should be allowed to start naturally, but be limited to 12 hours. Slow labours therefore tended to be accelerated using Syntocinon. ODriscoll claimed the 12-hour time limit benefited mothers and babies; critics argued that the main reason it was introduced was to enable hospitals to cope with large numbers of births.
Although few British hospitals have stuck rigidly to the Dublin principles, acceleration or augmentation of labour is still widely practised. But excess doses of Syntocinon can speed up contractions to a dangerous level, at or above one every two minutes, resulting in a condition known as hyperstimulation. if the birth is obstructed for example, by a narrow pelvis then the baby becomes trapped inside a womb which is in overdrive. In Professor Taylors experience, this is a far more common problem than rupture of the womb, but the consequences for the baby are equally devastating.
Nicole Dance is living proof. The nine year-old, who is also a client of Adrian Desmond, was awarded £1,075,000 last year by West Berkshire Health Authority, after it admitttd that the Royal Berkshire Hospital in Reading had been negligent in the way it had handled her birth.
Nicoles mother Julia went into labour on the afternoon of August 10, 1987. She claims to have been left with a midwife and that she was not checked regularly by a doctor. Within two hours, the monitor was showing that the babys heart-rate had become abnormal. Despite this, Syntocinon was administered at 6pm and the dose increased four times over the next 90 minutes. Her uterus rapidly became hyperstimulated, at one stage contracting every minute for at least 22 minutes. The heart-rate monitor continued to show abnormalities, which eventually became severe. Although the dose of Syntocinon was steadily reduced, the drug appears not to have been stopped.
Rather than delivering Nicole by Caesarean immediately, when it should havebeen obvious that she was in distress, the doctors waited until 130am the next day. By then, her brain had been deprived of oxygen and she was eventually diagnosed as having cerebral palsy. Her disability put a great strain on her parents marriage and they separated earlier this year.
Campaign groups such as the Association for Improvements in Maternity Services (AIMS), for which Jean Robinson is also a spokeswoman, believe that the use of drugs such as Syntocinon masks an underlying problem. Obstetrics, by and large, has a mechanistic mindset. It makes labour wards like factory production lines. She believes that Syntocinon has its place, but points out:
It often gets overlooked that the mechanistic approach can slow down labour, because it makes mothers tense and stressed. Unfortunately, the solution is not to create an environment that will make her more relaxed, but to give her Syntocinon or prostaglandins. And once she has been given those, she will almost certainly be given more drugs to take away the pain of the stronger contractions. The technology just takes over.
Such views underpin the ever-growing movement to promote natural birth, but obstetricians are generally sceptical of its benefits and some are openly hostile. By and large, the profession believes that technological innovations have solved far more problems than they have created. Nevertheless, on the specific question of whether Syntocinon should be given to women such as Anna, Sally and Joanne, who have previously had Caesareans, obstetricians are split.
Some believe it is safe to use the drug as long as the patient is closely monitored. This view is supported by the obstetricians bible, a massive volume called Effective Care in Pregnancy and Childbirth. It acknowledges that use of Syntocinon is thought by some to increase the risk of rupture in previous Caesarean cases, but concludes that this view is not universally
held, nor is it strongly supported by the available data... the increased risk of uterine rupture, if any, with oxytocin is extremely small. It recommends using the drug in such cases with the same precautions that should always attend its use.
Roger Clements is alarmed by this. The almost unqualified approval of the use of Syntocinon in previous Caesarean cases, which it appears to give, is extremely dangerous, he says. One has to consider why they havent got the data to show that there is an increased risk. If you were an obstetrician and you wanted to publish a study on the use of Syntocinon, you are only likely to do so if your disaster rate is low. Therefore such figures as exist come from units that do everything properly and consequently see hardly any ruptures.
The author of the quoted passage, Professor Murray Enkin of McMaster University in Canada, acknowledges this: What can I say, except that everyone should always be very careful with the drug.
The pioneers of Active Management of Labour at Dublins National Maternity Hospital laid down strict guidelines for the handling, not just of previous Caesarean cases, but of all labours back in the Seventies. Each patient was allocated an experienced midwife, who then closely monitored her throughout labour. This involved, crucially, progress being reassessed every two hours. A consultant obstetrician is on the ward at. all times, who can be called if problems arise
Prof Taylor studied the Dublin methods. If augmentation has failed to make the labour progress after two hours, the golden rule is, stop, and work out why, he says. In all probability, there is an obstruction and, if so, the last thing the mother needs is more Syntocinon. Unfortunately, some have not grasped the basic principle, if the labour is not progressing, they think that an increased dose will give the extra push that the baby needs.
The use of inexperienced staff by some hospitals is confirmed by a disturbing anecdote, related by a student midwife, who does not want herself, or the hospital, to be identified. My first ever experience on a labour ward was to look after a woman who was on a Syntocinon drip, she says, If I was in labour, knowing what I do about the drug, I would not expect to be looked after by a student with half an hours ward experience. Jean Robinson of AIMS says that in some of the cases brought to her attention in this country, doctors have ordered the use of Syntocinon over the telephone.
No one is suggesting that such situations will inevitably harm mother and baby, but, if things do go wrong, inexperienced staff generally compound the problem. For this reason, says Roger Clements, the misuse of Syntocinon should not be seen in isolation.
It is one part of the jigsaw, albeit a very important part, he says. The wider problem is that, in all too many instances, the overall care of the woman in labour is defective.
So how can improvements be made? A growing number of people believe that it will require a change in the overall approach to labour, away from the current, technology-driven methods. It is a view that does not cut much ice with obstetricians who would prefer the less radical solution of ensuring that labour wards are always properly staffed with doctors and midwives who have been appropriately trained.
Nearly all agree that lives would be saved, at no extra cost, if the cautious use of Syntocinon was made a priority. Some cite the need for the rigid application of Dublins golden rule of stopping the drug if it has not made labour progress within two hours.
It seems blindingly obvious that Britain requires a co-ordinated approach to the issue, but only now, after many years and hundreds of deaths and permanent injuries, are there signs of one emerging. Ralph Settatree expects that guidelines will be drawn up by next spring.
To my mind, they will be statements of the obvious, but unfortunately, for whatever reason, people can forget the obvious, he says. We cant go on observing things which we regard as substandard.
Positive change will also require patients to be vigilant. Like all the women contacted by Night & Day, Anna Shavila wants mothers, as well as doctors and midwives, to be aware of the dangers of Syntocinon misuse. I dont want pregnant women to panic, but staff should communicate with patients, she says. It was my body and my child that they were interfering with and I had a right to know what the consequences of that drug might have been.
Beverley Beech, chairwoman of AIMS, also emphasises that expectant mothers should not panic. She points out that all hospitals have labour-ward protocols, which state their policy on interventions such as Syntocinon. These should be available from the local Community Health Council. Hospitals also keep statistics on the numbers of inductions, Caesareans and augmented deliveries they carry out, and may make them available if you ask. The protocols and statistics can vary greatly, so you should be able to find a hospital that you feel comfortable with.
Although Anna survived her ordeal, she is still suffering from post-traumatic stress disorder and believes she has not yet properly grieved Laras loss. However, there has been one happy outcome. Annas doctors initially warned her that she should not have further children. But having learned through bitter experience that doctors may not always be right, she set about finding a consultant who could help her. She was put in touch with Professor Murdoch Elder at the Hammer-smith Hospital in London who told her that she could get pregnant, as long as she was carefully monitored. On January 18, 1994, baby Madelaine Lara duly arrived as a precaution, by Caesarean weighing six-and-a-half pounds and perfectly healthy.
The joy of having another child and the love and support of her family and church, all helped to bring Anna back from the brink. Her hope now is that other women will not have to suffer the same sadness and loss.