Preventable Harm

Women, their families and insurers value safety in labour highest. However, in 2008 the UK-based Kings Fund report ‘Safe Births: everybody’s business’ observed that while the overwhelming majority of births in England are safe, some births are less safe than they could and should be. This observation accurately summarizes almost the last century of obstetric care in the UK.

In 1917 the UK Medical Research Committee reported that ‘52% of infant deaths were avoidable’ and in 1924 the author of a national UK Maternal Mortality Report described maternal deaths as a ‘burden of avoidable suffering’.

Although perinatal outcomes have improved over the last century, the proportion of ‘avoidable suffering’ has remained depressingly static since these early reports: > 50% of intrapartum stillbirths were deemed avoidable with better care in the 4th CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) report, published in 1997 and the most recent CMACE (Centre for Maternal and Child Enquiries) report ‘Saving Mothers’ Lives’, published in 2011, still identified substandard care in 70% of Direct deaths and 55% of Indirect deaths.

The investigation of the root cause of these maternal and perinatal deaths reveals a consistent set of themes related to substandard care, including failure to recognize problems; failure to seek senior input; poor or non-existent team working; and the requirement to improve skills, with emphasis on teams and not individuals.

Improving maternal and perinatal care is also a global priority; the World Health Organization (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. Worldwide, there are approximately four million neonatal deaths each year, with a similar number of stillbirths and these have become the focus for two of the Millennium Development Goals.

Finally, this preventable harm is extraordinarily expensive. Substandard care and its sequelae cost the NHS £3.1 billion in the decade 2000−2010; individual, family and societal costs notwithstanding.

Skills Training

Improved multiprofessional training appears to be one of the most promising strategies to improve perinatal outcomes across the world, localized for best fit, with a parallel evaluation of outcomes to ensure a positive effect.

Training has been recommended almost annually since the 1990s; as early as 1996, the 5th Confidential Enquiry into Stillbirths and Deaths in Infancy recommended a ‘high level of awareness and training for all birth attendants’. Annual ‘Skill Drills’ have been recommended by both the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG), as well as national bodies on both sides of the Atlantic; the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the USA and the maternity Clinical Negligence Scheme for Trusts (CNST) whose Risk Management standards have mandated training in the UK since 2000. Moreover, teamwork training has also been recommended.

Training is not magic, nor is it automatically effective; therefore we must ensure that training improves outcomes. There are now numerous studies evaluating the effectiveness of skills training for obstetric emergencies, with increasing evidence that practical training is associated with improvements in clinical outcomes. However, not all training has been associated with such positive effects and there are a number of studies where training either did not improve clinical outcome or was associated with an increase in perinatal morbidity. Where training has been demonstrated to be effective it should be widely implemented and can be included in national guidance.

Intrapartum care demands sensitivity, clinical skill and acumen from a multiprofessional team of carers. Training should address all of these elements, and this is likely to require a broad range of training techniques and tools. The Kings Fund recognized that: “maternity units could easily provide their own simulation-based training … Any such training should include clinical skills, communication, team working, and awareness of roles within the team”.

I will review some different elements of intrapartum training, particularly training for electronic fetal heart rate monitoring (EFM), the use of simulation for technical skills training and also some new evidence for teamwork training.

Electronic Fetal Heart Rate Monitoring

‘Make the right way the easiest way’.

All practitioners involved in intrapartum care should ensure that they have the knowledge and skills to interpret the cardiotocograph (CTG) and act appropriately, with the aim of providing high-quality, defensible care. However, this does not appear to be the case for some carers at least.

The evidence linking brain injury to intrapartum care is inconsistent but it is a major source of litigation. The recent NHS Litigation Authority (NHSLA) report concluded that the most effective way to reduce the financial and human cost of maternity claims is to continue to improve the management of risks associated with maternity care, focusing on preventing incidents involving the management of women in labour, including the interpretation of CTG traces.

A Swedish study reviewed the outcomes of infants (> 33 weeks) born in Stockholm County between 2004 and 2006 and found that there was substandard care during labour in two-thirds of infants with a 5-minute Apgar score of < 7. The main reasons for the substandard care were related to misinterpretation of the CTG and not acting on a pathological CTG in a timely fashion. These findings were almost exactly replicated in Norway over a similar time period.

A recent systematic review concluded that training can improve CTG competence and clinical practice, but further research is needed to evaluate the type and content of training that is most effective.

One of the problems with CTG interpretation is that it is difficult and requires a holistic assessment of the woman, her labour and appropriate action as well as the fetal heart rate pattern itself. Improving outcomes in labour when EFM is used is dependent on more than just CTG interpretation alone. The National Institute of Clinical Excellence (NICE) in the UK have produced two guidelines that helpfully standardize the interpretation of intrapartum CTGs; however, they are each > 100 pages long, which makes them difficult to implement at the coalface of care.

CTG stickers that summarize the guidelines into a simple stick-on format ( Fig 4-1 ) have been successfully introduced into practice with an associated 50% reduction in 5-minute Apgar scores of < 7 minutes and hypoxic ischaemic encephalopathy in a UK unit. However, the sticker itself does not magically improve outcomes; all staff in the unit should be trained annually to use the sticker, its use should be mandated for all staff whenever a CTG is reviewed and other contrary tools and systems should be stopped. Finally, the use of stickers should be ‘policed’ using notes audits and the effect on outcomes such as low Apgar scores.

CTG sticker consistent with NICE 2007 Intrapartum Guideline.

Stickers have been recommended in Sweden and, where they have been introduced as part of a multiprofessional training programme there have been significant improvements in infants born in poor condition in both the USA and Australia.

Multiprofessional training for CTG interpretation, using standardized tools can be effective and both the tools and the training should be implemented more widely.

Simulation and Obstetric Skills Training

Obstetric emergencies are rare and it is axiomatic that they should be managed by experienced staff; indeed, this is almost ubiquitously recommended. However, experience is difficult to acquire because of their rarity, but may be gained in part through simulation.

Simulation permits individual health professionals and teams to inculcate skills and cultures in preparation for safe, effective clinical care, whilst gaining confidence and becoming more efficient. Simulation is an educational device, not a place or a technology: it can be as simple as trousers with red material to reproduce some of the visual clues for postpartum haemorrhage (PPH) or as complex as a high-technology simulation centre.

We should not overestimate the effect of simulation; a recent review of simulation-based medical education (SMBE) recognized that some but not all SMBE was associated with improvements in clinical outcome. There is an important need to test whether obstetric simulation training programmes are effective, sustainable and cost-effective.

Eclampsia

One of the first published descriptions of obstetric simulation was an eclampsia drill. Simulating eclampsia enabled departmental staff to develop and ‘road test’ an eclampsia box containing the equipment, drugs and guidelines required to manage the clinical condition.

Subsequently a randomized-controlled trial comparing effectiveness of different methods and sites for multiprofessional training for eclampsia across a whole region demonstrated marked improvement in care after training. Following training, there were significant improvements in completion of basic tasks (87% pre vs. 100% post) and the administration of magnesium sulphate (61% pre vs. 92% post) in simulated eclampsia. Time taken to commence administration of magnesium sulphate was on average nearly 2 minutes quicker following training.

Simulation training for eclampsia is gaining in importance as the rate of eclampsia is falling in the UK, whereas substandard care appears to be increasing, particularly for pre-eclampsia and eclampsia, where > 90% of deaths were associated with substandard care in the last triennial enquiry. The introduction of simple tools like the eclampsia box described above and regular rehearsal using local drills appears to be the most effective and sustainable method of training for eclampsia.

Shoulder Dystocia

Shoulder dystocia, including training, is covered in Chapter 12 .

Vaginal Breech Delivery

Planned vaginal breech birth has become increasingly uncommon since the publication of the Term Breech Trial, but competence in assisted vaginal breech delivery remains an important skill for accoucheurs to care for women who choose vaginal breech birth, and also for those women who present very late in labour (see Chapter 16 ).

As with shoulder dystocia, practical simulation using high-fidelity models provides an opportunity for staff to practise management. There is a report of significant improvement in residents’ ability to perform simulated breech deliveries following training on a birth simulator including a patient-actor.

Instrumental Delivery

There is good evidence that when delivery needs to be expedited, a single instrument application is the safest method of delivery, followed by caesarean section and then two instrument applications (ventouse and forceps), with failed instrumental delivery and caesarean as the most dangerous.

Therefore, appropriate and safe use of forceps and vacuum remains an essential obstetric skill, but UK obstetric trainees have identified that training for operative birth, particularly rotational deliveries, can be difficult to acquire. Simulation and virtual reality models may offer more training opportunities.

Dupius and colleagues developed a high-fidelity model that allows the trajectory of the application of forceps blades to be tracked using spatial sensors. Senior obstetricians demonstrated a superior technique, but after training the abilities of junior staff improved. Other models have been developed to simulate appropriate traction. After practical training both the correct forces and successful delivery were achieved more often in simulated instrumental births.

Maternal Collapse

Maternal cardiac arrest is rare, complicating approximately 1 in 30 000 pregnancies in the UK and it is therefore imperative that all healthcare professionals can provide basic resuscitation. In the 2007 CEMACH Report resuscitation skills were considered poor in an unacceptably high number of maternal deaths. This and the most recent report both recommend that all clinical staff should undertake regular training to improve basic, intermediate and advanced life support skills.

Perimortem caesarean section is an essential part of Advanced Cardiac Life Support for cardiac arrest/collapse in pregnancy. Simulation provides an opportunity to practise skills for this very rare problem and improved care after cardiac arrest has been described after simulation training in a general hospital setting. A small US study also found improved outcome in an obstetric setting.

However, results of training in an obstetric setting across a whole health system have been disappointing: a recent retrospective cohort study investigated the use of perimortem caesarean section in the Netherlands between 1993 and 2008 following the introduction of obstetric training in 2004. The rate of perimortem caesarean increased from 12% to 35% after the introduction of training. However, maternal outcomes remained poor, most likely due to delay in performing the caesarean as none were carried out within 5 minutes of the cardiac arrest.

Neonatal Resuscitation

A systematic review concluded that perinatal mortality might be reduced if birth attendants receive practical neonatal resuscitation training, but the evidence of effect is weak. More recent studies have evaluated the effect of the World Health Organization Essential Newborn Care course, a neonatal rather than obstetric training course. One study using a before-and-after implementation design was associated with improvements in midwives’ skills and know­ledge. There was also a reduction in early neonatal deaths among low-risk women who delivered in first-level clinics in Zambia. A cluster randomized-controlled trial to assess this neonatal resuscitation intervention could not replicate the original results.

Following the introduction of the 3-day Essential Newborn Care course in six countries there was neither a significant reduction in the rate of early neonatal deaths, nor in the rate of perinatal death. Interestingly, there was an unexpected reduction in the rate of stillbirth. It is plausible that the observed reduction in stillbirths might have been the result of training because before training infants born without obvious signs of life may have been misclassified as stillbirths. After training, resuscitation was more likely to be attempted, with a possible reduction in those births previously misclassified as stillbirths.

Promising preliminary observations of the effect of the Helping Babies Breathe programme have recently been published. This is an educational training programme for low-resource countries that aims to improve neonatal resuscitation using basic simulation scenarios.