The Case of a Precious Pregnancy: Medico-legal Dilemma
Balancing Life and Law: The Challenges of a Precious Pregnancy
Pregnancy is not a disease, but when it becomes one it is sudden and life threatening, to the mother and the child, and since Consumer Protection Act the obstetrician

Now and then, every obstetrician has to deal with women who fail to conceive after years of trying, or who repeatedly lose their babies in pregnancy. When a pregnancy finally occurs it is termed a "precious pregnancy" and the baby born thereof is termed a "precious baby". While the joy of the happy parents on such a successful outcome is, I am sure, immeasurable, I can't help but feel that the adjective "precious" seems to imply that uneventful pregnancies or all other babies are not!

Motherhood is the ultimate fulfillment of womanhood. To achieve it, a woman will go to great lengths if required and even risk her life subjecting herself to all kinds of fertility treatments if need be. Every, I repeat, every, child is precious for a pregnant mother. But my obstetrician colleagues beg to differ on choice of syntax. To them, delayed or difficult conceptions and risky pregnancies are the ones that medically constitute precious pregnancies, and the babies so born are 'precious' babies. Such pregnancies are watched over with extra care by the obstetrician, and an elective caesarean section is very often resorted to, simply to pre-empt any complications that might arise from a vaginal delivery.

But, I digress. Let me tell you about a lady whom I will call Snehalata (that's not her real name, of course). She was already 30 when she decided to marry. She badly wanted to become a mother soon but the first two years after marriage saw her barren. I understand that her husband had a low sperm count for which he was successfully treated, leaving the way now clear for her to conceive. Unfortunately, just around that time, she developed epilepsy for which treatment was started and which would continue indefinitely.

This posed a dilemma: her physician cautioned her that these drugs were teratogenic, which is to say that they had the potential to cause serious birth defects in the baby. Obviously, she could not stop the drugs and yet, if she became pregnant, the baby was at risk. What could she do? She ached for a child while at the same time she could not avoid the drugs. Should she or should she not try for a baby?

After a great deal of painful and prayerful consideration with her husband and with her obstetrician, she decided to take a calculated risk. Her obstetrician, Dr. A, fully supportive of her decision, detailed the kind of defects a baby could develop. The chief among these affected the neural tube which is the structure that ultimately develops into the brain and spinal cord. One way to prevent neural tube defects would be to take large doses of folic acid concurrently. There was enough evidence to support this theory.

Dr. A chalked out a plan: start folic acid before wishing to conceive and continue the drug thereafter. A screening would be done early during the pregnancy to assess the developing baby and, if a neural tube defect was found, the pregnancy would be terminated. If not, the pregnancy would continue. This was more than acceptable to the woman.

As good fortune would have it, she missed her period and a pregnancy was duly confirmed. Her joy knew no bounds but, soon, apprehension crept in. What if the folic acid didn't work? Days of agony followed until, finally, an ultrasound examination and some blood tests showed that the baby seemed defect-free. Further screening followed at regular intervals, each of which she dreaded until, by the sixth month, the satisfactory progress of pregnancy and development of the child with no detectable defects finally assured her that her baby, her precious baby, was normal.

The road ahead was clear but her progress was not. In her seventh month of pregnancy, she developed pre-eclampsia, a dangerous, pregnancy-related condition that could adversely affect both her and her baby. Left unchecked, it could progress to the far worse condition called eclampsia. Snehalata's obstetrician, always available, skillfully treated her and guided her to a full term without further mishap. She did not develop eclampsia.
When her labour pains began, she was admitted into hospital and Dr. A checked on her periodically.

Her progress was satisfactory and her baby began it's slow descent down her pelvis and birth canal. The first-time labours were always the longest unlike second or third-time mothers who would come and pop out their babies effortlessly. Through the background hum in the labour suite Snehalata could hear the beep-beep of the foetal monitor, assuring her that her baby was in fine fettle, slowly working it's way to the outside world. Snehalata's powerful uterine muscles contracted and relaxed steadily as the labour progressed. Her nurses kept a close watch, while Dr. A, who was in the theatre suite working on another patient, made frequent enquiries.

Finally, the time came. The baby's head could be visualised. Dr. A was there, and gently encouraged Snehalata to push, relax, push, relax. The head began to emerge. There seemed to be a problem with the baby's shoulder. was it stuck?. This was immediately recognised by Dr. A as shoulder dystocia, an emergency. Dr. A lost no time. She acutely flexed Snehalata hips so that her thighs rested on her abdomen, and then manipulated the baby to eventually deliver it. It was a beautiful baby girl and her cry was music to an exhausted Snehalata's ears. An attending paediatrician examined the baby and found no neural tube defect on a preliminary examination.

The baby was pink and looking quite comfortable. But wait...why wasn't she moving one arm? The paediatrician, very much concerned, made a detailed evaluation and concluded that the arm was paralysed. But how? A hasty, whispered consultation with the obstetrician followed. Yes, the shoulder was stuck and had to be disengaged. That was all the paediatrician needed to diagnose a condition called Erb's palsy or paralysis. Because the shoulder got stuck while the head was being delivered, the angle between the neck and shoulder was increased causing the nerves to the arm getting stretched and injured. Maybe they were even torn; only time would tell.

The problem that caused this is called shoulder dystocia. Dystocia essentially means a difficult labour and one of the causes is impingement of the shoulder in the birth canal during delivery, impeding further progress of the baby. It can lead to compression of the umbilical cord and consequent asphyxiation of the baby unless it is rapidly reversed. It is a true obstetric emergency and the obstetrician has to work quickly to save the baby. A protocol to deal with this condition has been described and was followed by Dr. A.

Not surprisingly, Snehalata's family was upset. The beautiful baby they had all been waiting to receive was born with a paralysed arm. The weeks that followed saw consultations with various specialists. There were plenty of suggestions but, in the end, the common message was: right now we can only wait and see. A pall of uncertainty and gloom descended on the household. And Snehalata? What about her? Her life was now her little baby girl. She doted on her. Despite the paralysis, her baby was otherwise well. Snehalata savoured her motherhood. Did she blame anyone for what had happened? Who could she blame? Surely not her obstetrician who had been more than supportive all along, and had seen her through a difficult period of pre-eclampsia. Indeed, it was Dr. A who made her motherhood possible in the first place! She was there when Snehalata arrived in the birthing suite and had attended on her and conducted the delivery efficiently and with due care. How could she possibly blame her? Oh, no. Recrimination was the last thing on her mind. She had far too much to thank Dr. A for. So, Snehalata simply decided it was fate and left it at that.

While Snehalata chose not to press the matter further or lodge a complaint, the hospital authorities placed the case before the Peer Review Committee.

A Peer Review Committee is a body of chosen specialists that sits periodically to review adverse medical outcomes such as the paralysis of Snehalata's baby following delivery. The Committee's brief is to look for any deficiencies in the medical management of the case under review. Once the case records are studied, a preliminary report is prepared together with a list of queries for the clinician involved who has to appear before the Committee. Based on the replies received, a final report is prepared which can sometimes have far reaching consequences such as mandating specific treatment guidelines in situations such as the one that confronted Snehalata's obstetrician, Dr. A. So, in due course, the obstetrician was summoned before the Committee. The questions were specific and many.

Was the management of the shoulder dystocia proper?

Could the nerve injury have been prevented?

Was it proper to give this high risk pregnancy a trial of vaginal delivery ? Should not a cesarean section have been done instead?

Dr. A presented the case in detail, highlighting the "precious child" aspect of the pregnancy of a patient on antiepileptic drugs. A trial of normal labour was allowed. The labour had progressed normally. She was under constant observation and close monitoring. There was nothing to interrupt the trial and intervene (as it is, obstetricians are accused of performing unnecessary caesarean sections). There were no risk factors that could have prompted her to anticipate a shoulder dystocia. It simply occurred as an obstetric emergency at that moment in time when the baby was emerging. It was immediately recognized and corrected by the standard and accepted technique of acutely flexing the mother's thighs on her abdomen and disengaging the shoulder manually. As a result, the baby was quickly delivered. At no time could Dr. A recall having applied excessive traction to the baby's emerging head. It was regrettable that the injury to the nerves occurred. Dr. A added that if she had to manage this labour again, she would have done it in exactly in the same way.

The Peer Committee was now faced with the painful question: Was there any evidence of medical negligence? Medical negligence is defined as "failure to follow medical norms." In the case of Snehalata's labour, an emergency in the form of shoulder dystocia. It constituted an emergency as it had to be resolved within minutes else the child was in a danger of dying of suffocation. The obstetrician diagnosed the condition correctly as per the clinical norms. Having done so she applied the correct therapeutic norm of thigh flexing maneuver and manual disengagement of shoulder and delivered the child safely. There was no failure to follow the accepted norm in the case and thus there was no negligence.

Yet, the injury to the child was iatrogenic that is, caused by the treatment, caused by an act of doctor. True, it was not due to negligence on part of the obstetrician and the obstetrician cannot be prosecuted for it. As lawyers would put it, it did not constitute an "actionable wrong". On the contrary, in the practice of medicine, the patient has to pay for the injury that the physician has caused and pay to treat the injury that has been caused! Suffering, mental agony and everything that goes with it are additional burdens. Should not there be some provision in the law to compensate a patient in such cases on purely compassionate grounds? The Chairman of the Peer Committee put this question to Dr. A.

"Well, sure", agreed Dr. A. "The poor lady has suffered badly. But how can she be compensated in this manner?
"Very simple. In the form of a 'No Fault Compensation', much like the kind that is provided in accident cases," replied the Chairman.
Dr. A was aghast. " I beg your pardon? Are you actually saying that we pay in this manner? I am sorry but my response would be a clear, big, 'NO'. Do you know that this will be in the papers the next day and do you know what will be the public reaction? That so-and-so and the hospital messed up a simple delivery and this is what they had to pay out. What will be the hospital's image? What will be my department's image? My image? I, my residents and the labour room staff gave this lady our everything. And, you know what? The patient thinks so too. Before she left, she told me in a hushed but broken voice, 'Thank you for taking care of me.' My resident almost started crying. Sure, it's all very well to pay out this no fault thing in a road accident. But in this case? No. No. No."

There ended the Peer Committee meeting.

As I write, I reflect and find that I am inclined to agree with Dr. A. Knowing her for many years, I am quite sure that she would have emptied her own purse to help Snehalata's baby, not because she believed in a "no fault compensation" but because of her compassionate nature.

The case report underscores the duality of pregnancy as a natural yet potentially risky process. It sheds light on the challenges obstetricians face, particularly in high-stakes situations where outcomes can be unpredictable despite diligent care. Pregnancy management is a multistage management, intervention at any stage could be faulted for adverse out come. The Consumer Protection Act, while empowering patients, places immense pressure on healthcare professionals like obstetricians who may become vulnerable to litigation due to adverse outcomes that are sometimes beyond their control.

Delicate Decisions: Medico-legal Perspectives on High-stakes Pregnancy

Written By: Dr. Shri Gopal Kabra - 15, Vijay Nagar, D-block, Malviya Nagar, Jaipur-302017
Email: kabrasg@hotmail.com, Ph no: 8003516198