The Savage case. Week four: Mrs. Savage's expert witnesses.

Continuing her evidence last week to the Tower Hamlets District Health Authority inquiry into her competence, Mrs Wendy Savage was closely questioned by the obstetrician members of the panel about her management of the AU case, in which the baby died eight days after birth. Professor Howie asked Mrs Savage whether she felt she was justified in using oxytocin to stimulate labour in view of the risk, with a small pelvis and a breech presentation, that the head might become stuck after the breech was delivered. Mrs Savage replied that she did not think AU was in effective established labour and if she and her husband, who were pressing for a vaginal delivery, were to be shown that she could not deliver vaginally she had to experience some effective contractions which would make the cervix dilate. Mrs Savage said she believed it was very unlikely that the baby could be delivered vaginally. Her feeling was that the baby was too big to come into the pelvis. She did not believe that by giving two hours of oxytocin she was going to drive down a baby of the same size as AU's last baby to the extent that she was well into the second stage and the head was going to get trapped. If one gave oxytocin to a multigravid woman most would deliver within six hours but would not be fully dilated in two hours. Mrs Savage said she had asked Mr Nysenbaum, the senior registrar, to examine AU and if she had not progressed to put up some oxytocin so she could have adequate contractions and report to Mrs Savage in theatre. When she went to the theatre Mr Nysenbaum had not yet done a vaginal examination. She was not aware there was thick, fresh meconium. If she had known she would not have put up the oxytocin but would have done a caesarean section straight away. She said she found it inexplicable that, having found thick, fresh meconium, he put up the oxytocin. She would have expected him to walk down to the theatre, report that he had ruptured the membranes and found thick, fresh meconium, and ask whether a caesarean section should be done. Mrs Savage said that she would have replied "yes." She said that with the breech high, the baby passing meconium, and the woman having dysfunctional labour she would have done a caesarean section, leaving aside the scar on the uterus and the small pelvis. Mrs Savage said she was absolutely furious with Mr Nysenbaum. She had asked him to put up oxytocin and report back to her in two hours, and he had ruptured the membranes and apparently ordered an epidural. She said she had not read all through Mr Nysenbaum's notes. When she saw "artificial rupture ofmembranes" and "unable to reach buttocks," she was so amazed that anyone could rupture the membranes when they could not reach the buttocks that she turned the page over and threw up her hands in horror, so that she did not see the words "very thick, fresh meconium." In this particular woman with the information she had, Mrs Savage said she did not think this was a risky labour. She admitted she should have had the information about the meconium. In retrospect, however, she believed she should have been much harder with Mr U. Instead of saying, "I don't think this baby is going to deliver soon," she should have said, "I don't think this baby is going to come out of the vagina." In the fifth case, which the inquiry has now decided to call "X," a caesarean section in which there were difficulties in delivering the baby's head, Mrs Savage said that the vaginal examination at 1 25 showed cessation of progress. That was the time at which she would have intervened, had she been aware of the vaginal examination. The hospital should have been able to provide a caesarean section within 15 minutes of that vaginal examination. Mrs Savage had not expected that it would take an hour to get X to the theatre. She thought that in that hourX probably found it impossible not to push and may well have driven the head a bit further down. The inquiry heard evidence from two of Mrs Savage's expert witnesses. Dr Marion Hall, consultant obstetrician and gynaecologist with Aberdeen Teaching Hospitals and honorary senior lecturer at the University of Aberdeen, told the panel that in her view the management of the AU case was within the limits of acceptable practice because all the factors were considered. She agreed that the risk of entrapment of the after coming head was much greater in a breech than in the average pregnancy, but the decision to use oxytocin for two hours had been taken on rational criteria. In the SP case she said she did not think there were any risks to mother or child. It was certainly within the broad limits of acceptable medical practice; she herself would have used oxytocin earlier. In the DL case, since it was a high breech, there was a risk of cord prolapse, but in a teaching hospital with close monitoring one did not expect to lose babies from cord prolapse. The X case, she said, was quite correctly managed. Dr Hall described Mrs Savage's management, taken as a whole, as of high quality, albeit showing her to be at one end of the spectrum of acceptable practice, yet firmly within it. She said there was no evidence on which she should have been suspended and, if asked for an opinion, would recommend her immediate reinstatement. Mr John McGarny, senior consultant in obstetrics and gynaecology at the North Devon Hospital, Barnstaple, and former council member of the Royal College of Obstetricians and Gynaecologists, told the inquiry that when he first read the notes in the AU case he thought the decision to have a trial of labour was unreasonable, but having gained more information about the reasons he thought the decision was a reasonable one. Provided close observation was kept of the labour, as it was here, he thought the risks were quite small. In the X case, labour was carried out exactly as he would have done it. In the case of DL there was no inadequacy in the treatment of the anaemia, he would not criticise the decision to induce, and he believed there was nothing in the management of the delivery which was outside the bounds of acceptable medical practice. Nor was the management of SP outside those bounds. Mr McGarny said he thought it would be very easy to go through the notes of any working obstetrician in the country to find his five so called worst cases and bring an event such as this inquiry into being.