Negligent nurses at a rural Eastern Cape hospital likely caused a baby's severe brain damage, an Eastern Cape judge has ruled, saying the child would have been delivered without harm, but for the staff’s inadequate monitoring, lack of clinical knowledge and skills, and non-compliance with the maternity guidelines.
MedicalBrief reports that the nurses, at the Isilimela Hospital, in the Port St John’s District, used oxytocin to induce birth after a prolonged labour, but failed to monitor the foetal heart rate or for excessive uterine contractions, which can starve the baby of oxygen, according to the judgment handed down on 29 July in the Eastern Cape High Court (Bhisho).
The plaintiff, Ms V, is seeking damages from the provincial Health Department arising from the troubled birth of her son, Baby M.
V, who was 25 at the time, testified that on 3 July 2012, when her waters broke, nurses at the Isilimela Hospital examined her but with no doctor’s assessment.
Nurses monitored the foetal heart rate; the baby was far from delivery. Oxytocin was administered by drip. Soon V’s contractions intensified and she was instructed to lie on her side. Eventually, she succeeded in pushing the baby’s head out and called the nurses for assistance. M was delivered in a compromised condition. A doctor arrived, turned the baby upside down, and slapped his feet. M did not cry and the doctor took the baby away for resuscitation, according to the judgment.
V pleaded the failure of the medical staff to perform a Caesarean led to a hypoxic incident, which damaged her son’s brain and resulted in spastic quadriplegic cerebral palsy. The court heard the baby failed to achieve the usual growth milestones. M does not talk, but points to what he wants. He cannot wash or dress himself. He can feed himself but is a messy eater. He is unable to walk properly.
At the start of trial, the court ordered the question of liability be decided separately from the quantum of damages.
Judge JGA Laing said the department eventually conceded there had been negligence. The focus of the trial switched to establishing causation: whether the negligence led to the brain damage.
The judge noted that medical specialists agreed on a number of points in joint minutes which the court felt bound to accept.
Radiologists Dr Andre MacDonald and Dr Bates Alheit both felt a magnetic resonance imaging (MRI) scan displayed the features of a peripartum hypoxic ischaemic injury (HII). In the absence of a sentinel event, the injury resulted from intermittent or prolonged hypoxia, with a severe, final episode during labour. The radiologists agreed it was unlikely a genetic disorder or an infective disease caused M’s brain damage.
Obstetricians and gynaecologists Dr Krzysztof Janowski and Dr Michael Wright agreed that with her labour failing to progress, the plaintiff had been a high-risk patient on admission, requiring continuous electronic foetal monitoring.
At 7pm her dilation was 6cm. Nurses administered oxytocin to stimulate uterine contractions, but failed to perform cardiotocographic (CTG) monitoring to detect tachysystole. By 8pm, M was fully dilated. This, said the specialists, suggested hyperstimulation and inadequate monitoring. At 8.30pm, V gave birth. M presented with low Apgar scores, required resuscitation and developed hypoxic ischaemic encephalopathy (HIE).
The experts agreed it was “very likely” a sub-acute hypoxic process began after the administration of oxytocin. It was probable, too, there had been an obstructed labour because of M’s cephalopelvic disproportion.
In the absence of proper medical records, the experts could not rule out the possibility of undetected over-stimulation, leading to foetal distress; this, in turn, led to sub-acute hypoxia after the administration of oxytocin, which rapidly became acute. The MRI scan confirmed the presence of an HII.
They agreed that the available records indicated the onset of moderate to severe neonatal encephalopathy (NE) within 24 hours of delivery. There were several examples of sub-standard care, including inadequate monitoring, lack of clinical knowledge and skills, and non-compliance with the maternity guidelines.
“Neurodevelopment delay most probably was preventable had expedited delivery by Caesarean section, after detecting cephalopelvic disproportion,” said Janowski and Wright . The use of oxytocin had been “injudicious” in the face of clear contraindications.
Unlike the other experts, the paediatricians disagreed strongly on numerous points.
Dr Yatish Kara (for the plaintiff) was adamant M had cerebral palsy with gross motor developmental delay; there were no indications of a genetic, metabolic, or chromosomal cause for the brain injury. The MRI scan, the nature of the plaintiff’s labour, and M’s presentation at birth suggested the cause was an HII during labour.
He had interviewed V for his report, and learnt it had been her second pregnancy, with no problems during the first. There was no family history of epilepsy or mental illness, and she had not taken herbal medicines or drugs.
There was significant encephalopathy at birth, with two convulsions during the first two days of life. Mother and child were transferred to the Nelson Mandela Academic Hospital, which recorded birth asphyxia and HIE.
By contrast, Dr Amith Keshave (for the defence) believed M had an autistic spectrum disorder (ASD); an underlying genetic condition and not cerebral palsy. The child’s clinical presentation was not what would have been expected from the nature and timing of the injury described by the remaining experts, said Keshave.
M’s language delay, with selective mutism, as well as echolalia, was common for a child with ASD, he said. So, too, was M’s preference for playing by himself, poor eye contact, and aggression towards himself and others. He presented with a sensory processing disorder; was a picky eater; was hypersensitive to his ears or head being touched, was fearful of haircuts; and had a high pain threshold, among features Keshave felt confirmed an underlying ASD.
Regarding the MRI scan, Keshave referred to the literature, that the abnormal results could be associated with ASD.
Under cross-examination, Kara admitted some of M’s features matched those of a child with ASD, but insisted this was a secondary issue. Keshavave, for his part, accepted it was possible for a child with cerebral palsy to have ASD.
Laing felt neither Kara nor Dr Keshave was a poor witness: each based his opinions on a sound premise and reached through logical reasoning.
However, the judge said Keshave’s ultimate acceptance of the views of the remaining experts in the unrepudiated joint minutes, his concession that the probable cause of M’s brain injury was intrapartum and that features of an HII were present, as well as his admission that he could not dispute that sub-standard care on the part of the medical staff had been the cause of the brain injury, persuade the court that the other experts’ opinion was to be preferred.
Judgement: https://www.saflii.org/za/cases/ZAECBHC/2025/16.html