Labour ward incidents and potential claims – lessons learned from research

Abstract

This paper provides an insight into the underlying factors involved in potential cerebral palsy and/or shoulder dystocia claims. The research was undertaken to identify the root causes of 37 cases of birth asphyxia in term infants severe enough to warrant admission to neonatal care units in the north-west of England between 2001 and 2002. All available staff (n ¼ 93) providing care during critical periods were interviewed by the author using the cognitive interviewing technique. These included 81 midwives, two consultant obstetricians, eight registrars and two senior house officers. An expert panel consisting of consultant obstetricians, midwives, a consultant neonatologist and the researcher applied the Bolam test to identify instances where care had been substandard and injury caused as a result. Although the cases were often complex, covering more than one shift and over more than one stage of labour, the most dangerous time appeared to be during the night shift (19 cases, 51%), followed by the evening shift (13 cases, 35%) and then the day shift (five cases, 14%). The main problems include: failure to respond appropriately to signs of fetal hypoxia (26 cases, 70%); undiagnosed obstruction (22 cases, 59%), which was broken down into failure to identify cephalopelvic disproportion (13 cases, 35%); and shoulder dystocia (nine cases, 24%). Delayed resuscitation of the infant occurred in 26 cases (80%), and in 18 cases (49%) there was excessive and inappropriate use of Syntocinon. All cases involved human error, either through a delay or failure to take action, or taking inappropriate action. However, these were all underpinned and perpetuated by system and cultural errors present in the labour wards, such as allowing unsupported and inexperienced personnel to work in a position for which they lacked the necessary skill and experience. This was perpetuated by the customary practice of using unsupervised junior medical staff in a first on-call position for complications, and also of failing to sustain safe midwifery staffing levels. This in turn prevented support for more inexperienced staff. Consequently, when inexperienced midwives and obstetricians were left unsupervised in charge of complicated cases, it created accidents waiting to happen. When unsupervised and inexperienced paediatricians attended the birth of an asphyxiated infant, the child's condition deteriorated further when they were unable to resuscitate it. If such system and cultural errors as these are not rectified, the current high rate of damaged babies is likely to continue.

Shoulder dystocia: analysis from a risk management perspective

“…A study by Ashcroft 13 highlighted the issues predisposing to negligent cases of SD currently in the UK. Mismanaged SD cases were found to be directly linked to system failures including allowing unsupported staff to work in a position for which they lacked sufficient skills, training knowledge or experience.…”

Systematic review of medical literature for medicolegal claims and complaints involving neonates

“…They identified that in 78% of the cases, senior clinicians did not provide assistance to inexperienced clinicians (including junior paediatricians), and that the juniors often felt unable to ask for help for fear of being labelled as 'unable to cope'. 17 Issues relating to suboptimal communication were highlighted as a significant category of complaints, as noted above and in tables 1 and 2. However, we could also consider poor communication as contributary to errors resulting in malpractice claims.…”

“…11 18 19 21 Factors implicated Some of the studies included did investigate contributing factors to errors resulting in complaints (see table 3). Ashcroft 17 undertook a cognitive interview of clinicians, exploring various factors implicated in serious incidents and outstanding claims on the Labour ward. This paper Open access that failing to take action, making the wrong decision or a delayed decision were implicated as human errors in all the cases of malpractice they presented.…”

Every Woman Needs a Midwife, and Some Women Need a Doctor Too

“…Not only are actual staffing levels important but so also are the ranges of expertise within the workforce across a 24‐hour period, with out‐of‐hour periods creating particular safety issues . This problem was exacerbated by the customary practice of using unsupervised junior medical staff in a first on‐call position for complications . With respect to task shifting, some evidence has been reported of improved outcomes and cost savings when midwives take on tasks previously within the remit of obstetric staff, for example, examination of the healthy newborn, which is usually carried out by junior doctors , and the role of advanced neonatal practitioners .…”