CMPA Report on Obstetrical Risks
Obstetrics is a complex and high risk area of medicine, involving various healthcare providers across a number of phases of care. Unfortunately, the consequences of patient safety incidents in obstetrics, including those resulting from medical negligence, can be catastrophic. As a result, obstetrical incidents account for a significant portion of costs to medical liability insurers, and compensation payments to patients.
The Canadian Medical Protection Association (CMPA) and the Healthcare Insurance Reciprocal of Canada (HIROC) are the largest providers in Canada of medical liability insurance to physicians and to healthcare organizations and their employees, respectively. Due to the cost of obstetrical incidents to these organizations, and the consequence of such incidents to patients, the CMPA and HIROC released a report in 2018 analyzing hundreds of medico-legal cases involving in-hospital obstetrical incidents between 2004 and 2013 1.
Injuries to patients can occur in many different contexts, and at any stage of obstetrical care. Most commonly, however, issues arise during intrapartum care – labour and delivery – and can result in injuries to both mothers and children. Maternal complications include hemorrhage and infection. Neonatal complications include brain injuries resulting from anoxia (lack of oxygen), and injuries relating to the mismanagement of shoulder dystocia, a situation that can occur when the baby’s shoulder becomes lodged in the mother’s pelvis during delivery. Among the cases reviewed, the method of delivery most commonly implicated was caesarian sections (C-sections), particularly those done on an emergent or urgent basis.
As all cases reviewed in the study involved a legal element, the majority involved some harm to a patient. The child was most often the victim of the severest types of harm – death, or catastrophic or major injury.
While obstetrical incidents can vary widely in terms of the type and severity of outcome, the CMPA and HIROC have identified a number of common contributing factors. The two major themes among these factors are:
- Failures related to the clinical decision-making and situational awareness of individual healthcare providers, including physicians and nurses; and
Shortcomings related to the situational awareness of both individuals and obstetrical teams often lead to delays in the detection of problems, resulting in failures to appreciate the severity of those problems and the urgency with which they require attention. These issues often arise from, or are exacerbated by, inadequate communication between members of the obstetrical team. Various issues related to the systems in place, such as inadequate processes and protocols, resource issues, and administrative problems, are also common contributing factors to obstetrical incidents.
While the above factors can lead to problems at any stage of obstetrical care, the CMPA and HIROC have identified a number of specific high-risk areas for patient harm:
- Intrapartum fetal surveillance
- Induction and augmentation of labour with oxytocin
- Assisted vaginal delivery
- Timing of the decision to perform a C-section, and
- Management of shoulder dystocia
The most significant among these risk areas, based on the number of cases in which they are involved, are intrapartum fetal surveillance and the induction and augmentation of labour with oxytocin.
Intrapartum fetal surveillance
Intrapartum fetal surveillance is a central component of obstetrical care, and essential to assessing fetal well-being during labour and delivery. There are two main issues that can arise during this process. The first is a failure by the obstetrical team, most commonly nurses, to promptly notify a physician of an abnormal fetal heart rate (FHR) patterns. The second is the misinterpretation of those patterns by both physicians and nurses. These failures can occur in concert with, or lead to, additional issues including inadequate attention to patients during critical periods of care, such as when evidence of fetal compromise is present. Problems can also arise from the insufficient capacity of the obstetrical team to respond to emergencies, or even a lack of compliance with, or awareness of, hospital fetal surveillance protocols.
Induction and augmentation of labour with oxytocin
Oxytocin is often administered to expectant mothers to induce the uterus to begin labour, or during labour to increase the frequency, duration and strength of contractions. This can be a delicate process, however, the mismanagement of which is a common factor in obstetrical incidents. The most common problems are failure to reduce the rate of oxytocin infusion – or discontinue it altogether – when clinically indicated; and, delays in notifying physicians of abnormal findings. Communication issues can lead to additional problems in this context, such as failures to challenge questionable induction and augmentation orders, or to appropriately escalate concerns about patient care.
The study conducted by HIROC and the CMPA reveals a number of factors that can be shown to give rise to a risk of harm to patients during obstetrical care. Common themes include decision-making, situational awareness, and communication during obstetrical care, often contributed to by factors arising from the systems put in place by healthcare facilities and organizations. While no single deficiency may alone result in injury to a patient, their cumulative effect can mean delayed responses to fetal distress, prevention of a timely delivery, and severe, but preventable, harm to patients.
By Luke Young