Smith v Sheridan

In a breech caesarean delivery, the obstetrician must create an opening large enough to deliver the whole baby safely. If gentle traction does not deliver the after-coming head, the practitioner must stop and enlarge the uterine incision, including by a relieving vertical incision where appropriate. Excessive traction causing mechanical injury to the baby is negligent. A clotting disorder may exacerbate bleeding, but it does not explain the initial tearing of intracranial veins or provide a plausible alternative without evidential support. Causation is determined on the balance of probabilities by evaluating the whole clinical and expert evidence.

The claimant, a child, suffered severe permanent brain damage following his breech birth by caesarean section. The defendant consultant obstetrician encountered difficulty delivering the after-coming head, enlarged the uterine incision laterally, applied Wrigley’s forceps and recorded using a hard pull. The claimant developed a sudden intracranial haemorrhage, profound collapse, prolonged resuscitation and subsequent disseminated intravascular coagulation.

The claim concerned whether the defendant had breached the appropriate obstetric standard and whether that breach caused the claimant’s injuries. The defendant relied on non-negligent explanations, principally pre-existing disseminated intravascular coagulation or neonatal alloimmune thrombocytopenia.

1. Liability and causation. Judgment was given for the claimant on liability and causation. The defendant had used excessive force to deliver the after-coming head and had failed to enlarge the uterine opening further when gentle traction proved unsuccessful.
2. In a breech caesarean section, the practitioner must create sufficient space for safe delivery of the head. Wrigley’s forceps should ordinarily assist a gentle lifting movement. When resistance is encountered, the practitioner must stop and take stock, then enlarge the incision laterally or by an inverted T incision, where appropriate, rather than increase traction.
3. The claimant’s injuries were caused by trauma during delivery. Mechanical distortion of the head produced shearing forces between the skull and brain, tearing intracranial veins and causing a sudden and massive subdural haemorrhage. The absence of external bruising did not exclude that mechanism because the traction was brief and the injury resulted from internal shearing forces.
4. The claimant had no pre-existing disseminated intravascular coagulation or neonatal alloimmune thrombocytopenia. The low platelet count developed in the context of the massive haemorrhage, hypoxia, resuscitation and subsequent disseminated intravascular coagulation. That coagulation disorder exacerbated the bleeding but did not initiate the venous tearing.
5. The case was not treated as one of res ipsa loquitur. The court reached its conclusion from the evidence, including the operative note, the clinical course and the expert evidence. The defendant’s reliance on the rarity of comparable reported cases did not displace the balance of probabilities.
6. The claim succeeded on the preliminary issues of liability and causation. A further hearing or directions by a Master was required for assessment of damages and consequential matters.

First instance decision. The judgment records that the trial concerned liability and causation only. Assessment of damages and consequential directions were left for a further hearing.