A Clinical Risk Case Study – Complications during a Caesarean Section

The Scene

A 30-year-old woman who had had a previous caesarean section brought a claim against her Obstetrician & Gynaecologist for damaging her bladder, during her 2nd caesarean section.

The caesarean section was carried out by a ST3 surgeon who was supervised by an ST6. During surgery, it was noted that the claimant had dense adhesions to anterior abdominal wall and the surgeons had difficulty in identifying the bladder. The surgeons noted acute bleeding which was presumed to be coming from the uterus, therefore, they decided to deliver the baby.

It later transpired that the acute bleeding was, in fact, coming from the bladder and the baby was essentially delivered through the bladder causing damage to the anterior and posterior walls.

Our Independent Clinical Findings

The female bladder overlies the cervix, and it is imperative that during a caesarean section the bladder is reflected in a downwards direction to ensure that there is no iatrogenic damage. When a patient has had previous caesarean sections the surgical planes can be lost and there may be significant adhesions (scar tissue), as was the case here. Because of the anatomy and tendency for scarring, bladder injury is a recognised complication of a caesarean section. Although bladder injury in itself does not automatically suggest negligence, it does raise questions over whether appropriate precautions were taken to avoid the complication arising.

The independent review, therefore, focused on precautions taken, specifically whether the surgeons acted within their own abilities. The ST3 who started the procedure was deemed to be appropriate, however, once adhesions were noted the procedure became substandard as the ST3 (and their supervising ST6) failed to request assistance from a more senior surgeon (i.e. a Consultant Surgeon) who should have taken over the surgery at this point.

Whilst it could be argued in some circumstances that the more senior ST6 was closely supervising the ST3, supervision is not the same as actually performing the operation. Furthermore, in this case, it was also highly questionable as to whether the operation was within the capabilities of an ST6 given the ST6’s specific experience. Evidence suggested in this case that the unit in question delivers thousands of babies a year, therefore, it would have been possible to seek assistance from a consultant as soon as the adhesions were recognised.

The independent review, therefore, concluded that that the complication was not negligent in isolation, however, there was evidence of substandard care due to the fact that once adhesions were identified, the surgeons acted beyond their abilities and failed to seek senior input.

How to prevent recurrence and improve patient safety

Prior to making any surgical incision, it is imperative that the anatomy is correctly identified, and the surgeon knows exactly what tissue they are about to incise. Due to the presence of scar tissue, the bladder can be difficult to identify, however, there are techniques that can be performed, such as feeling for the catheter balloon to demonstrate the bladder margins, or even filling the bladder with fluid.

Being able to correctly identify the anatomy frequently comes with experience, and whilst it is essential junior obstetric trainees are exposed to difficult cases, they should be aware of their limits and always seek senior assistance at the appropriate time.

To Conclude

In summary, whilst there is no guarantee that the presence of a consultant would have prevented the bladder injury, it's occurrence would have been less likely on the balance of probabilities.

Our independent findings consider that by not contacting a consultant when the adhesions were first identified, this caused the care to fall below a reasonable standard of care as a relatively inexperienced surgeon proceeded with a non-emergency case when it became challenging.

Had there been a significant risk of fetal compromise, then bladder injury is more understandable as delivery of the baby takes priority. In this case study, such urgency did not appear to be the case. Our independent findings suggest that there was no issue with an ST3 level trainee commencing the procedure, but concerns were raised regarding the lack of consultant input when the significant adhesions were identified.

 
Article co-written by TMLEP Clinical Risk and Patient Safety Publishing Team and Mr Jonathan Ash MBBS MRCOG FHEA, Consultant Obstetrician and Gynaecologist.
Important Notice: This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0)203 355 9796.
TMLEP Clinical Risk and Patient Safety Publishing Team and Mr Jonathan Ash MBBS MRCOG FHEA, Consultant Obstetrician and Gynaecologist. (2017). A Clinical Risk Case Study – Complications during a Caesarean Section. TMLEP Clinical Risk Case Studies. 1 (1), 1.