Labour ward incidents and potential claims – lessons learned from research

Clin Risk 2008;14:235-238
doi:10.1258/cr.2008.080081
© 2008 Royal Society of Medicine Press

 

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AvMA Medical & Legal Journal


Dr Brenda Ashcroft

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 = 93) providingcare during critical periods were interviewed by the authorusing the cognitive interviewing technique. These included 81midwives, two consultant obstetricians, eight registrars andtwo senior house officers. An expert panel consisting of consultantobstetricians, midwives, a consultant neonatologist and theresearcher applied the Bolam test to identify instances wherecare had been substandard and injury caused as a result. Althoughthe cases were often complex, covering more than one shift andover more than one stage of labour, the most dangerous timeappeared to be during the night shift (19 cases, 51%), followedby the evening shift (13 cases, 35%) and then the day shift(five cases, 14%). The main problems include: failure to respondappropriately to signs of fetal hypoxia (26 cases, 70%); undiagnosedobstruction (22 cases, 59%), which was broken down into failureto identify cephalopelvic disproportion (13 cases, 35%); andshoulder dystocia (nine cases, 24%). Delayed resuscitation ofthe infant occurred in 26 cases (80%), and in 18 cases (49%)there was excessive and inappropriate use of Syntocinon. Allcases involved human error, either through a delay or failureto take action, or taking inappropriate action. However, thesewere all underpinned and perpetuated by system and culturalerrors present in the labour wards, such as allowing unsupportedand inexperienced personnel to work in a position for whichthey lacked the necessary skill and experience. This was perpetuatedby the customary practice of using unsupervised junior medicalstaff in a first on-call position for complications, and alsoof failing to sustain safe midwifery staffing levels. This inturn prevented support for more inexperienced staff. Consequently,when inexperienced midwives and obstetricians were left unsupervisedin charge of complicated cases, it created accidents waitingto happen. When unsupervised and inexperienced paediatriciansattended the birth of an asphyxiated infant, the child’s conditiondeteriorated 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.

Labour ward incidents and potential claims – lessons learned from research
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