Shoulder dystocia: Updating some medico-legal issues.

Shoulder dystocia, or shoulder entrapment at birth, is an obstetrician's nightmare, which not infrequently leads to court litigation with complaints of serious foetal and/or maternal damage. Increasingly, retrospective management scrutiny is extending well beyond second stage birth mechanics and involving all case file entries, history taking, ultrasound scan measurements and haematology profile results, etc. The article highlights some medico-legal issues including the influence of the Montgomery ruling on patient disclosure and subsequent management.

Implications of the Pharmacovigilance Risk Assessment Committee recommendations for the treatment of genitourinary syndrome.

The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has issued statements regarding limiting the use of high-dose oestradiol creams by women experiencing the genitourinary syndrome of menopause, and such statements carry much medicolegal weight. Although a low dose is most often used, some clinicians opt to use higher dose creams with close monitoring of the patient. The committee should publish the evidence behind these statements or amend its official position.

Labour ward negligence.

No amount of symposia and clinical meetings and formal management will make a clinical difference unless obstetric units regularly and ruthlessly self-assess to curb medical negligence. Court case, which represent a small portion of substandard outcomes, not infrequently reveal a serious lack of obstetric judgment as well as paucity of knowledge which are compatible with unsupervised responsibility of labour ward duties. One UK court case ACF 32(2): 09/2019 presents a factual picture of obstetric practice which is difficult to reconcile with modern UK practice. This article limits itself to a number of facts as presented to court by the claimant, and the comments are directed purely at the resulting implications. These facts as stated are seriously worrying in themselves as they reflect practice well below the minimum care to be expected in a modern country and are far from what is recommended by the Royal College of Obstetricians and Gynaecologists and indeed every day standards. The article recommends the shifting of focus from individual to collective or unit responsibility to achieve better care. In any case where gross mismanagement is found, there should be a wider check on practices within the whole obstetric unit.

Montgomery and its impact on current medical practice - good or bad?

Patient autonomy requires full disclosure prior to a valid consent. The 2015 UK Supreme Court ruling in Montgomery has displaced Bolam on this issue and is inducing a disquieting sense of angst in some medico-legally conscious clinicians. For the time being, the Bolam test still applies for treatment and/or diagnosis claims. The very grossness of the defendant in Montgomery's withholding of information to the patient (remarkably not thought negligent by the lower courts) prompted the judges of the Supreme Court to dispense with the long-standing Bolam test. (The Editor considers the case should have been won using Bolam in any event.) The foreseeable shoulder dystocia that caused catastrophic injury to the claimant's baby would (and should) have been avoided by a planned caesarean section. The claimant's damage award of £5.25 million as a result of the defendant's obstetrician's failure to provide full disclosure seems to have induced clinicians to over-watch their step, at times to a ridiculous extent. On the one hand, many clinicians' anxiety may result in a defensive/protective approach: 'These are the facts, now you choose', thus leaving a sense of hurtful abandonment in patients. Much harm may be done within Medicine if the facts underlying the decision in Montgomery are not properly considered and evaluated.

Re-visiting Bolam and Bolitho in the light of Montgomery v Lanarkshire Health Board.

This article considers the potentially untapped significance of the Bolitho test, while the Bolam test looks to be facing a challenging twilight. It re-examines the landmark House of Lords case of Nadyne Montgomery v Lanarkshire Health Board, having regard for Bolam as modified by Bolitho. Although further jurisprudential Bolam challenge is likely in the wake of the Montgomery ruling, there are grounds for re-examining Bolitho, on its own merits.

Submitting medico-legal intra-partum CTG (I-P CTG) monitoring to the Bolam and Bolitho principles.

The article analyses some of the seeming weaknesses of the Bolam and Bolitho tests as applied to electronic foetal monitoring in labour, in the form of intra-partum CTG monitoring. Homing on to such aspects as confirmation of foetal hypoxia/acidosis, it evaluates the Bolam and Bolitho tests in the context of evidence-based medicine versus traditionally held views, which still hold their own in medical jurisprudence. Case law examples are quoted to illustrate various points. The discussion is of practical relevance both to the individual obstetrician as well as to national budgetary implications, bearing in mind, that, for example, in 2011, 'birth asphyxia' comprised 50% of the UK NHS litigation costs, and in the 2000-2010 decade, the same NHS forked out £3.1 billion for maternity medico-legal claims (the highest of any speciality), mostly involving cerebral palsy and CTG misinterpretation. The article concludes with suggestions to help level the potential extant equivocity between legal principle and medical practice. It also looks at the ruling in Montgomery v Lanarkshire Health Board, UK Supreme Court, and its challenge to Bolam. The implications pose a serious and overdue challenge to a test, born in 1957 and lacking the necessary qualities to serve many 21st century medical quandaries, including the ones raised here.

The shifting sands of medico-legal intra-partum Ctg (I-P Ctg) monitoring.

Intra-partum (IP) surveillance of the unborn child by cardiotacography (CTG) monitoring is the commonest obstetric procedure in the developed world.(1) It is also the most medico-legally contested obstetric procedure in labour. In 2011, 'birth asphyxia' comprised 50% of the UK National Health Service (NHS) litigation costs,(2) and in the 2000-2010 decade, the same NHS paid out £3.1 billion for maternity medico-legal claims (the highest of any speciality), mostly involving cerebral palsy and CTG misinterpretation.(3) This article looks at a number of characteristics of IP CTG monitoring which argue for its questionable solidity of base in court proceedings.

Pre-operative pain sensitivity: A prediction of post-operative outcome in the obstetric population.

CONTEXT: Experimental assessments can determine pain threshold and tolerance, which mirror sensitivity to pain. This, in turn, influences the post-operative experience. AIMS: The study intended to evaluate whether the pre-operative pressure and electrical pain tests can predict pain and opioid requirement following cesarean delivery. SETTINGS AND DESIGN: Research was conducted on females scheduled for cesarean section at a tertiary care hospital of the state. Twenty women were enrolled, after obtaining written informed consent. MATERIALS AND METHODS: PAIN ASSESSMENT WAS PERFORMED ON THE EVE OF CESAREAN SECTIONS USING THREE DEVICES: PainMatcher(;) determined electrical pain threshold while the algometers PainTest(™) FPN100 (manual) and PainTest(™) FPX 25 (digital) evaluated pressure pain threshold and tolerance. Post-operative pain relief included intravenous morphine administered by patient-controlled analgesia, diclofenac (100 mg, every 12 h, rectally, enforced) and paracetamol (1000 mg, every 4-6 h, orally, on patient request). Pain scores were reported on numerical rating scales at specified time intervals. STATISTICAL ANALYSIS USED: Correlational and regression statistics were computed using IBM SPSS Statistics 21 software (IBM Corporation, USA). RESULTS: A SIGNIFICANT CORRELATION WAS OBSERVED BETWEEN MORPHINE REQUIREMENT AND: (1) electrical pain threshold (r = -0.45, P = 0.025), (2) pressure pain threshold (r = -0.41 P = 0.036) and (3) pressure pain tolerance (r = -0.44, P = 0.026) measured by the digital algometer. The parsimonious regression model for morphine requirement consisted of electrical pain threshold (r(2)= 0.20, P = 0.049). The dose of morphine consumed within 48 h of surgery decreases by 0.9 mg for every unit increment in electrical pain threshold. CONCLUSIONS: The predictive power of pain sensitivity assessments, particularly electrical pain threshold, may portend post-cesarean outcomes, including opioid requirements.

Predictors of post-caesarean section pain and analgesic consumption.

BACKGROUND: Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. The objective of this study was to investigate whether preoperative electrical and pressure pain assessment can predict post-caesarean section pain and analgesic requirement. MATERIALS AND METHODS: A total of 65 subjects scheduled for elective caesarean section, who gave written informed consent, were studied. Preoperatively, PainMatcher(®) was used to evaluate electrical pain threshold, while manual PainTest™ FPN 100 Algometer and digital PainTest™ FPX 25 Algometer determined pressure pain threshold and tolerance. Postoperatively, numerical rating scales were used to assess pain at regular time intervals. Patients received intramuscular pethidine (100mg, 6 hourly), rectal diclofenac (100mg, 12 hourly), and oral paracetamol (1g, p.r.n.) for pain relief. Statistical analysis was conducted using PASW Statistics 18 software. RESULTS: Preoperative electrical pain threshold correlated significantly with post-caesarean pain scores at 6 and 24 hours (r = -0.26, P < 0.02; r = -0.23, P < 0.04, respectively), and with the quantity of paracetamol consumed by the patient within 48 hours of surgery (r = -0.33, P < 0.005). Preoperative pressure pain tolerance measured by PainTest™ FPX 25 Algometer was significantly correlated with pain scores 6 hours postsurgery (r = -0.21, P < 0.05). Pain scores 6 hours post-caesarean section correlated significantly with anesthesia-general or spinal (F = 4.22, v(1) = 1, v(2) = 63, P < 0.05). CONCLUSIONS: The predictive methods proposed may aid in identifying patients at greater risk for postoperative pain. Electrical pain threshold could be useful in personalizing the postoperative analgesic protocol.

Hb Valletta [beta87(F3)Thr-->Pro] and Hb Marseille/Long Island [beta2(NA2)His-->Pro; (-1)Met-(+1)Val-(+2)Pro-Leu], in a unique compound heterozygote with a normal hemoglobin phenotype.

This study refers to the quantitative hemoglobin (Hb) phenotype of a 19-year-old female with Hb Valletta [beta87(F3)Thr-->Pro] in association with Hb Marseille/Long Island [beta2(NA2)His-->Pro; (-1)Met-(+1)Val-(+2)Pro-Leu] and a normal Hb electrophoretogram. The data serve to alert investigators to the possibility that relatives with apparently normal Hb phenotypes may be transmitting mutant alleles and suggest methods for identification.

Reproductive health in Malta.

OBJECTIVES: The Maltese population traditionally harbours Roman Catholic beliefs that have been gradually secularised. The present study sets out to quantify the consequences of more liberal sexual attitudes in this community. METHODS: We reviewed the reproductive and sexual health indicators reported from Malta and from other selected European countries. We then analysed the findings of a questionnaire study which was carried out among 200 Maltese and 2200 other European individuals to investigate various aspects of their sexual history. RESULTS: A greater proportion of Maltese births occur in teenagers but the out-of-wedlock maternity rate in Malta appears to be the third lowest in Europe. However, the rate appears to have nearly trebled over seven years. Sexually transmitted infections rates in Maltese are either similar to or lower than those reported from the other European countries. The Maltese reported a higher mean age at first intercourse and a lower mean number of sexual partners mainly in women aged over 35 years. They received an earlier sexual education but they still predominantly resorted to unreliable contraception methods at their first sexual encounter. CONCLUSIONS: The study confirms that sexual behaviour has changed. The educational support to deal with these altered practices is in place but still needs to be reinforced.