In our last bulletin we looked at general surgical and A&E cases; two of three areas that the NHS Litigation Authority are focussing on, to analyse what lessons can be learned from clinical negligence claims to reduce harm and improve patient safety.   

At our patient safety forum, which took place on 3 December 2014 in our Manchester office, we examined the third area - maternity claims. This is an area of medicine which generates very high value claims and, most importantly, life-changing injuries to children and mothers. Improving patient safety in this area is a priority.

The discussion started with the acknowledgment that deprivation of oxygen during delivery, leading to stillbirth, neonatal death or cerebral palsy is the key point of concern. Other areas of risk include placental abruption/foetal bleed, foetal trauma at delivery and shoulder dystocia (where the baby's anterior shoulder gets stuck behind the mother's pubic bone). 

In this article, with advice and guidance provided by Dr Mike Maresh, Consultant Obstetrician and Gynaecologist, we will focus on two issues which were discussed during the forum, as areas where improvements can be made: the importance of properly interpreting CTG traces; and how to minimise risk in shoulder dystocia cases. 

The interpretation of CTG traces

In 2009 the NHS LA carried out a study of stillbirth claims in which it was identified that one of the key areas leading to stillbirth was the misinterpretation of CTG traces. This was the most significant example of negligence encountered in the study.

A number of pitfalls in CTG interpretation have been identified and it has been found that it is possible to reduce CTG interpretation errors by:

  • Ensuring a technically satisfactory foetal heart rate tracing and if necessary using a scalp electrode. 
  • Ensuring contractions are being recorded clearly and checking maternal pulse rate regularly.
  • Using a pro-forma/standard document (eg a pre-printed label)  in the notes, setting out  whether various characteristic of the foetal heart  rate pattern are reassuring or not.
  • Setting out an action plan after each CTG assessment. 
  • Regular review of CTGs, with checking by another person (a ‘fresh pair of eyes’).
  • Regular and documented medical/midwifery/anaesthetic ward rounds.
  • Central CTG monitoring may also be helpful in so far as the CTG can be monitored independently and objectively by other members of staff, albeit this comes at a cost. 
  • Regular, mandatory training/use of standard guidelines.

The management of shoulder dystocia

Shoulder dystocia, whilst relatively uncommon, has potentially devastating effects on a baby. There are some predictive signs both antenatally and in labour, although many cases have no such warning signs. 

Antenatally, a previous large baby, a mother with diabetes, a suspected large baby and a labour going post-term are all indicative of a baby being at greater risk of shoulder dystocia. 

Predictive signs in labour include secondary arrest of cervical dilation (for example, after six centimetres), slow descent of the head through the pelvis and slow progress in the second stage of labour. 

A protocol has been created, with the mnemomic HELPERR, as a guide for midwives and doctors alike when dealing with a case of shoulder dystocia:

H – Call for Help
E – Evaluate the Episiotomy
L – Legs – McRoberts Manoeuvre
P – Suprapubic Pressure
E – Enter rotations manoeuvres
R – Remove the posterior arm
R – Roll the patient to her hands and knees

Once a baby has been delivered following a diagnosis of shoulder dystocia, it is important that details of the incident are recorded within the notes, including:

  • the names of the midwives and doctors in attendance;
  • details of when the obstetric and/or neonatal staff were called; and
  • confirmation as to which specific manoeuvres were performed with  timings.

Again a specific form including all such details assists this process.

Conclusion

Whilst maternity claims continue to be a concern for NHS trusts and private midwifery organisations, the NHS LA hope that, with patient safety improvement plans, and good SUI reporting and lesson learning when things do go wrong, the harm caused to babies and mothers during delivery will be minimised and, as a consequence, there will be a reduction in the high levels of compensation presently paid out on annual basis.