The study, first published in 2003, looks at the root causes of adverse events and near misses in obstetrics at seven

hospital maternity units by interviewing 93 members of staff, identifying the areas of mismanagement in each

case and thematically analysing them

Ashcroft, B

English

Brenda Ashcroft

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Failures in Childbirth Care

The study, first published in 2003, looks at the root causes of adverse events and near misses in obstetrics at sevenhospital maternity units by interviewing 93 members of staff, identifying the areas of mismanagement in eachcase and thematically analysing them

University of Salford Institutional Repository

BriefingFailures in childbirth careBrenda AshcroftSchool of Nursing and Midwifery, University of Salford, SalfordThe study, first published in 2003, looks at the root causes of adverse events and near misses in obstetrics at sevenhospital maternity units by interviewing 93 members of staff, identifying the areas of mismanagement in eachcase and thematically analysing them.Journal of Health Services Research & Policy Vol 15 Suppl 1, 2010: 52–55 # The Royal Society of Medicine Press Ltd 2010BackgroundObstetric claims account for half of all NHS litigationbills with the cost of cerebral palsy cases being between£1.5 and £8 million.Aims of the studyThe aims of the project were to identify the underlyingroot causes of 37 cases of severe birth asphyxia in obste-trics likely to result in cerebral palsy claims, using asystems approach rather than a person approach.About the studyThe researcher studied 37 cases selected from sevenmaternity units within the north-west of England. Theunits studied covered a range of available facilities,including three large inner-city units with a highnumber of deliveries and significant obstetrical compli-cations. Four of the seven units practised a team midwif-ery system in line with that recommended by thegovernment in its Changing Childbirth guidance wheremost of the midwives there worked on a labour wardfor a day at a time. Their experience, therefore wasinfrequent and patchy.The other three units adopted the traditionalapproach of using block allocations to the labour wardwhich meant the midwives there had more consolidatedexperience. The researcher interviewed 93 members ofstaff altogether, of which 81 were midwives, two wereconsultants, 8 were registrars, one was a senior SHO(senior house officer) who had been acting in the roleof registrar, and one was a junior SHO. A panel ofexpert witnesses was used to identify the areas of mis-management in each case and these were thematicallyanalysed.Practical findingsFor this work, the researcher used findings from anearlier study by the author to provide background infor-mation about latent failures within the system of care onthe labour ward. In the 37 cases studied, all involved achild with severe birth asphyxia – where the child hadproblems receiving enough oxygen before, during orjust after the birth process – and these children weretaken to a neonatal unit. Many were considered tohave a poor prognosis. Staff were interviewed to sup-plement information gathered from case records andrecordings from cardiotocography (CTG) – the techni-cal means of recording fetal heartbeat and contractionsduring childbirth.An ‘expert’ assessment board then identified areas ofmismanagement in each case where it was clear thatdifferent acts or omissions should have happened. Thisteam included two consultant obstetricians, a consultantmidwife, a midwifery risk manager, a consultant neona-tologist, a neonatal midwife and the researcher. A rootcase analysis then took place, using accepted methods.Of the 37 cases, 32 were adverse events and five werenear misses, but all involved inappropriate action, afailure to take action or a delay in taking action. Theresearchers found that overall, at least 15 infants werelikely to develop cerebral palsy due to a poor prognosisand the cases were often complicated. Less than half ofthe cases (16) were reported in trusts’ incident reportingschemes, meaning 21 went unreported because either:† there was a lack of recognition that an adverse eventhad just happened (some saw it as a near miss); or† the case was not considered to be serious enough; or† or in one case a midwife felt the consultant had actedinappropriately and contributed to the cause of theevent, but did not want to openly criticize him.52 J Health Serv Res Policy Vol 15 Suppl 1 January 2010 DOI: 10.1258/jhsrp.2009.09s106The largest amount of adverse events (20 out of 37)happened during a night shift.Type of failuresAlthough human error was associated with every caselooked at, this was linked to many factors such as alack of clinical experience, lack of labour ward skillsand knowledge, lack of training and lack of supervisionfor inexperienced members of staff.In all cases, there were failures to identify obstetriccomplications and either a failure to act appropriately,a delay in doing so, or else inappropriate action wastaken due to the above reasons. Various types ofhuman failures happened including:† not taking appropriate action at signs of fetalhypoxia (distress);† the fetus not being monitored adequately;† not recognizing an obstruction during labour;† inappropriate use of Syntocinon – a drug given tohelp induce or continue labour;† inappropriately failing to provide adequate supervi-sion, support and guidance for junior and inexperi-enced staff;† delays in providing adequate resuscitation for anewborn baby having breathing difficulties.From the 37 cases, there were 13 emergency Caesareansections, two deliveries by forceps, 10 by ventouse and12 normal deliveries.System failuresThe researchers found there were 34 cases in whichthere were no guidelines or protocols to advise regard-ing clinical practice or organizational issues.Unsupported junior staff/inexperienced staffThe seniority and experience of staff in these cases wasalso noted by the researchers as an issue. In morethan half of the cases (19) the lead midwife providingcare was either junior or inexperienced and many saidthey felt less confident in their labour ward skills.In nine of the 15 cases of babies with the poorest prog-nosis, the main caregiver was a junior or inexperiencedmidwife. Similarly with medical staff, in 31 cases,problems arose due to the use of unsupervised juniormedical staff who were in the first ‘on-call’ position forcomplications. In eight of the 15 cases involvinginfants with the poorest prognosis, the obstetriciansinvolved were inexperienced. Problems also intensifiedwhen in 19 of the 37 cases, a paediatric registrar hadto be ‘crash called’ quickly when the junior paediatricianattending lacked sufficient skill and experience to resus-citate the infants adequately.Communication and cultural issuesFailures in communication were a problem in all thecases studied by the researchers, and were oftenrelated to culture on the labour ward – a system thatis hierarchically-led and historically-based. When mid-wives and obstetricians had differences of opinion, themidwives often failed to seek assistance from the con-sultant because they feared criticism or that it woulddamage their working relationship with registrars.There were failures to provide assistance to junior orinexperienced members of staff, and a failure for themto seek it when needed (29 cases). The culture of thelabour ward seems to mean less experienced membersof staff are expected to get on with the job and notseek help even when they want or need it because todo so would be considered as a lack of their ability orthat they were unable to cope.In 31 cases, problems arose when junior or inexperi-enced medical staff members were used in a ‘first on-call’position for complications, also a cultural issue. In 19cases it involving delayed infant resuscitation, thepaediatric senior house officer (SHO) attended unsu-pervised, and the registrar had to be called in anemergency to assist. In 15 cases there was a differenceof opinion between midwives and obstetricians regard-ing how and when to act, but no mechanism in placeto support resolution.Heavy workloads and reducedmidwifery staffing levelsWorkload was identified as an important factor and theresearchers found that in 26 out of 37 cases, the adverseevent or near miss happened during a very busy time onthe labour ward when there were not enough midwivesto manage cases safely.In 10 of these 26 cases, there was a reduction of atleast one midwife from the established number requiredon duty and in 10 other cases a poor skill-mix (too manyjunior midwives) put additional pressure on the alreadyheavy workload.The researchers found in 19 cases there was inap-propriate use of high-risk procedures, involving theuse of Syntocinon – a drug given to help induce or con-tinue labour – and epidural blockades during busytimes on the wards. There were also no guidelines orprotocols to highlight the risks and special precautionswith using Syntocinon.In nine cases, there were high-risk or elective pro-cedures (such as induction of labour and plannedCaesarean sections) with inadequate midwifery staffinglevels. All of these were evidence of latent errors in theJ Health Serv Res Policy Vol 15 Suppl 1 January 2010 53Failures in childbirth care Briefingsystem, said the researcher, creating an environment inwhich accidents were waiting to happen. There werealso problems related to changeover of medical andmidwifery staff in seven cases.Seven cases involved midwives taking time away fromclinical duties to perform other duties including clericalduties, domestic duties when other support was unavail-able, and porter’s duties, transferring clients to thewards following delivery.Training needsTraining needs were apparent from interviewing thestaff for the research. In more than half of cases (21),midwives and obstetricians lacked consistent updatingin cardiotocography (CTG) interpretation, with mid-wives often lacking opportunities to do so because ofworkload, with no opportunities for time-out training.In 18 cases, members of staff were unfamiliar withlabour ward protocols and failed to follow them whilein 11 cases, there were inadequate labour ward induc-tion programmes for new members of staff. In 17cases, paediatricians (SHOs) appeared to lack trainingin infant resuscitation.In 13 cases staff lacked awareness of the signs ofcephalopelvic disproportion (when the baby is toolarge to fit through the pelvis) and failed to identifythe problem and take action.Lack of equipment and equipment failureEquipment problems also played a part and in 14 casesthere was a lack of, or a failure of equipment, i.e. infantresuscitation apparatus and fetal blood sampling analy-sis machines.Only one of the labour wards in the maternity unitsstudied had resuscitation apparatus in every roomwhere deliveries might happen.Summary of main findings† Of 37 cases studied, at least 15 of the children had apoor prognosis and were likely to go on to developcerebral palsy;† More than half (56%) of adverse event cases were notreported to the trust’s critical incident reportingscheme;† Three-quarters of cases of adverse events happenedin intensely busy periods with inadequate numbersof midwives and most (20 out of 37) happenedduring night shifts;† In almost all the cases (32) there were inexperiencedmidwives and obstetricians lacking labour wardskills, who were left unsupported and unsupervisedwith complicated cases;† In three-quarters of cases, junior or inexperiencedmembers of staff failed to seek help they neededbecause the culture of the labour ward discouragedthem from doing so;† In one-third of cases there was a failure to recognizecephalopelvic disproportion (when the baby is toolarge to fit through the pelvis) as an underlyingcause of failure to progress in labour;† In almost half of all cases there was an excessive orinappropriate use of Syntocinon;† Inexperienced and unsupported clinicians who lackthe necessary skills in infant resuscitation were oftenpresent at deliveries of babies with breathing difficul-ties at greatest risk of developing cerebral palsy.Conclusions, recommendations andimplications for practice and policy† Midwives returning to work in the labour ward aftera prolonged period need help and support frommore experienced midwives because their knowl-edge, skills and confidence will have lessened whilethey were away;† Mandatory multidisciplinary training for cardiotoco-graphy (CTG) interpretation and managing life-threatening complications such as shoulder dystociashould be provided on a time-out basis;† Consultants should be seen as a part of the labourward team and not only as an advisor, so they needto maintain their clinical skills in this environment;† The profile of cephalopelvic disproportion asan underlying cause of failure to progress in labour,Syntocinon, and labour complications should beraised among staff to increase their knowledge;† Efforts should be made to change the existing hier-archical culture in the labour ward by encouragingKey messages† Staff are reluctant to carry out an unplanned Caesarean sectiononce labour has begun and take too long before deciding tointervene in this way;† Not all adverse events are recorded in hospital trusts’ criticalincident reporting scheme but should be;† There is a worrying lack of knowledge underpinning practiceespecially relating to the signs of obstruction during labour dueto cephalopelvic disproportion (when the baby is too large to fitthrough the pelvis);† Staff inexperience and lack of adequate supervision and gui-dance is involved in almost all cases of adverse events inchildbirth;† The culture of the labour ward means less experiencedmembers of staff are expected to get on with the job and do notseek help even when they are unsure of what to do;† Staff have become too casual about the use of Syntocinon (drugto help induce and continue labour) and underestimate the risksof using it;† There is a need for training on a time-out basis for midwives andobstetricians so they can accurately interpret fetal heart record-ings and practice emergency scenarios.54 J Health Serv Res Policy Vol 15 Suppl 1 January 2010Briefing Failures in childbirth caremore goodwill, cooperation and team work betweendifferent professional groups;† Members of the medical team need to provide juniorand more inexperienced practitioners with moresupervision and support;† Trusts need to set realistic minimum midwifery staff-ing levels for labour wards as this is a high-risk areaprone to significant medical accidents and highfinancial litigation.AcknowledgementsThis briefing paper is based on work undertaken by Brenda Ashcroft,midwifery lecturer in the School of Nursing and Midwifery,University of Salford. We thank Adrian O’Dowd who helpedcompile the paper.The full report, this research summary and details of other PatientSafety Research Portfolio work can be seen at http://www.pcpoh.bham.ac.uk/publichealth/psrp/commissioned.shtmlConflict of interest: None.J Health Serv Res Policy Vol 15 Suppl 1 January 2010 55Failures in childbirth care Briefing

Failures in childbirth care

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