A medical practitioners tribunal has heard the case of a consultant obstetrician who attempted to deliver a premature baby feet first through a tight cervix which ended in its decapitation, and has determined that the error in judgement did not amount to serious misconduct.
A report in the BMJ says the tribunal determined that a serious clinical error ultimately contributed to the baby’s decapitation, but not to his death as witnesses agreed that the infant was already dead.
Dr Vaishnavy Vilvanathan Laxman was nearing the end of a 24-hour split shift at Ninewells Hospital in Dundee in March 2014 when she was called to deal with a 30-year-old first time mother whose membranes had broken at 25 weeks’ gestation. The baby was breech, the placenta was low, the mother was bleeding from the vagina, and the cervix was no more than 4cm dilated and clamped around the baby’s calves. A prolapsed umbilical cord was causing foetal hypoxia. An ultrasound scan confirmed that cord compression had resulted in bradycardia.
“I remember thinking, should I try to deliver this baby. I still believe we had a very good chance of having the baby using other options than a C-section but we had to act fast,” Dr Laxman testified at the hearing.
As the baby moved forward, the cervix had gripped tightly around his neck. After traction failed, with the mother in extreme pain, general anaesthesia was administered and the team continued their efforts using incisions to widen the cervix. After an “increasingly desperate attempt” to deliver the head, the baby’s body came out with the head detached, separating due to traction, an autopsy found. All witnesses agreed that the baby was dead before decapitation.
Tribunal chair, Tim Bradbury, said “in the tribunal’s judgment, the magnitude of a doctor’s error of judgment should not be elevated to the status of serious professional misconduct simply by reference to the ultimate outcome”. “Even good doctors can make mistakes,” he said.
Dr Laxman will face no disciplinary sanction.