Local anaesthetic toxicity via epidural during c-section - do I have a valid medical negligence claim?

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I had a bit of a scary labour/birth with dd 11 weeks ago and wondered if anyone could shed any light on whether I might have a valid medical negligence claim? Has anyone come across this situation before?

I was in latent phase of labour for 4 days. Was having strong contractions every 1 - 5ish minutes for the whole time, but only got to 2cm dilated. MLU kept telling me to stay at home but on the fourth day, because it had been going on for so long, they eventually said I could go to the labour ward to be assessed.

Labour ward assessed me and discovered that my hindwaters had broken. Because I thought they had gone more than 24 hours previously they said that I needed to be induced asap. I said that I wanted an epidural before the induction process was started and they agreed.

So, I had the epidural put in and induction was started. I was a bit concerned that one side of my body felt more numb than the other and dh said that one of my pupils was more dilated than the other. We asked the anaesthetist to check but she said she thought it was all normal.

Induction started off well, but after a while my contractions started getting really erratic. They would up the drip and my uterus would go crazy contracting all over the place uncontrollably, so they’d reduce the drip and my contractions would tail off. They kept the drip going though and we finally got to 10cm dilated and they started me pushing. After about 20 minutes or so, I was examined and told that actually I still had a lip of cervix that was in the way of baby’s head. They tried to hook it over her head while I was pushing but she was well and truly stuck. By now baby was getting distressed so I was rushed to theatre for either forceps or emcs.

Surgeon said forceps would be too dangerous because of the risk of cervical prolapse, so I had to go for emcs. No problem. I gave consent and was prepped very quickly. They injected the spinal block into my epidural thingy in my back. However, within a few seconds I started to feel my face going numb. Then my eyes and, scarily, my throat. I was finding it hard to breathe. I told the midwife, who told the anaesthetist, and everyone started panicking.

It turns out that the spinal block anaesthetic had leaked into my bloodstream. They kept telling me to keep talking to them and to definitely not go to sleep. They told me that they had to get a reversal drug into me quickly. I heard dd's first cries as she was lifted out and I saw dh go over to where they were weighing her.

Meanwhile the reversal drug was being pumped in which meant that the anaesthetic was wearing off and I could feel the cesarean procedure being carried out. At that point they discovered that my uterus wouldn't contract and they couldn't get it back into me and stitch it up. It felt like it was taking forever, and the anaesthetic was really wearing off. The pain became unbearable and I told them screamed that I couldn't cope with it, so they put me under general anaesthetic. I lost 2 litres of blood while they wrestled my uterus back in.

Next thing I know I was having hallucinations that I was in the jungle. I finally woke up about 12 or so hours after the emcs and hadn’t the faintest idea why I was in hospital. I remember asking dh if I had been in a car accident.

After he and the nurses filled me in on some of the details, I got to hold dd for the first time and start breastfeeding. They told me that during the first 24 hours after the procedure I was at high risk of heart failure. I also later found out that while I was unconscious I had been in very real danger of slipping into a coma. Dh told me that the whole time I was unconscious I had a nurse constantly checking all the machines I was hooked up to so that if I went into cardiac arrest they could act immediately.

I was kept in the high dependency/intensive care unit for 4 days while they monitored me. The anaesthetic and the reversal drug had caused havoc with my internal organs – my liver was badly affected, my bp was all over the place and my heartrate was 150bpm for about 3 days solid. I was on oxygen, iv antibiotics, fluids, iv magnesium and potassium, and I was on half hourly obs.

But it did all gradually start getting better, and they started taking me off all the machines. Eventually, I was taken to the postnatal ward, and finally discharged as an outpatient. I’ve been having regular blood tests and my liver function finally went back to normal 2 weeks ago.

The anaesthetist told me that local anaesthetic toxicity only happens to 1 in 100,000 people and that I was just the really unlucky 1 person. She said that they’d never had it happen before and it was so rare that she had her colleagues and her boss and her boss's boss all turn up to the theatre to see it all happening. She did a talk on it at the hospital a few days later and is now writing a journal article about it to further the research into it and teach other anaesthetists how to deal with it if it happens to other women again in the future.

I've asked to be sent a copy of the journal article. I've also been offered a "Birth Reflections" session to have a de-brief and the opportunity to ask questions, which I'm planning to do in a few weeks' time.

I’ve done a tiny bit of research and it seems very unusual for it to just be “bad luck” and that it most often occurs because the epidural is administered incorrectly. Of course, the hospital have told me that the epidural was administered correctly and that I must have dislodged it when I was pushing during the induction . I just don’t know what to think.

Has anyone else out there come across this situation? Is it genuinely "bad luck" or is it more likely that the epidural was administered incorrectly? Is it possible to dislodge an epidural while in the pushing stage of labour? And dislodge it to the point of it leaking into the bloodstream?

Sorry for the epic post - there’s loads I haven’t even included, but aware that this is already a majorly long story!

Sorry for the awful experience.

It is not unreasonable for you to wonder if there is something that could have been done to prevent this happening to you. However based on your description, I'd say not.

Your case for medical negligence would centre around the supposition that medical staff i.e. the anaesthetists in question failed to provide a reasonable standard of care to you in relation to the a) insertion b) care c) top-up of the epidural.

1. Was the epidural inserted correctly? I know you've said it was one-sided but that certainly doesn't mean it was inserted incorrectly, unfortunately some of them are unilateral. The fact that it was an inadequate block means that it is very likely that it certainly started off in the epidural space (being in the subarachnoid or 'spinal' space from the start would have meant you were very very comfortable, and probably with a low blood pressure).

1. Is there anything that could have been done to stop it shifting from epidural to subarachnoid space or into a blood vessel? Nope. Unfortunately. Rare, but it happens. I don't love using other anaesthetist's epidurals for this reason - if I put it in I'm more sure about it. I've certainly aspirated blood from another's epidural that had no suggestion in insertion documentation that it was inserted into a blood vessel. There is a rich vascular bed of criss-crossing blood vessels in the epidural space into which an epi catheter can slip.

1. Is there any way your anaesthetist could have detected early that it was a spinal catheter rather than an epidural one when you proceeded for section? Difficult one - you can aspirate these catheters (if you get CSF - cerebrospinal fluid - back, you're spinal not epidural, if you get blood back you're in a blood vessel and you don't use it) but it's terribly difficult and not reliable. Did she give you a 'test' dose before giving you the full whack? Maybe, maybe not. If you were an emergency, there may not have been time. This is defendable.

I note the comment previously about the local anaesthetic being mistakenly injected into an IV cannula. Not likely - your first symptoms in this case would have been cardiac or seizures, rather than the 'high spinal' symptoms you appear to have experienced.

1. Management of the situation. Did they react quickly enough when you began to complain of difficulty breathing? The management of this is to tilt the table upwards and then to proceed to general anaesthetic if this does not work. The "reversal drug" - Intralipid - is only usually given in response to cardiac arrhythmias or seizures. By the by, it doesn't reverse the analgesic effect of the local so wouldn't have accounted for your sensation.

Without seeing your medical notes/being present, I cannot know for sure, but everything you have described is suggestive of a high spinal (i.e. an 'epidural' dose being delivered into the subarachnoid space) rather than 'local anaesthetic toxicity' where local anaesthetic is a) delivered directly into the bloodstream or b) exceeds the maximum local anaesthetic dose per kg of body weight. You would have gotten tingling/numbness around your mouth and fingers, and very quickly afterwards had seizures/cardiac arrhythmias etc.
The intralipid will have caused your liver problems postoperatively and it might be an idea to ask the rationale for it being given as I'm not sure - based purely on what you are saying - you had the symptoms of local anaesthetic toxicity. However, be aware, they will say they did it to save your life and they won't be wrong.

To be honest, it sounds like you had a known complication of anaesthesia and were managed safely and appropriately, intralipid being strictly necessary or not. I don't think there are grounds for medical malpractice. I think you're entitled to know more about the situation should you wish.

DOI: anaesthetist.