For this critique we have focused on Chapter 8 of the final Ockenden report1, which covered findings about intrapartum care.
This chapter is a qualitative analysis of themes identified in the case reviews, illustrated by short summaries of selected cases and in some cases quotes from families or staff. It is a pity that it does not include any quantitative information to show how frequently the problems were seen in the cases reviewed, or how often better practice in these areas might have or was likely to have led to a better outcome. This would have enabled a better understanding of the scale of the problems.
Included in the body of the report are a number of ‘Local Actions for Learning’ (LAfLs) which are summarised in Chapter 14. Chapter 15 has a list of ‘Immediate and Essential Actions (IEAs) to improve care and safety in maternity services across England.’ These “complement and expand upon” the IEAs identified in the interim report published in December 2020
Paragraphs 8.4, 8.5 and 8.10 detail cases where a junior obstetrician failed to call a consultant. We wonder what is stopping junior staff escalating issues and feel that the report might have usefully explored this issue further. Elsewhere there is mention of midwives being reluctant to raise concerns for fear of bullying. It would have been helpful to know whether for junior doctors the issue is likewise fear of bullying, or whether it is a lack of training and/or guidance on when they should escalate concerns.
From the cases discussed, the issue seems to be less about consultant ‘presence’ than about failure of junior staff to escalate concerns (in paragraphs 8.7, 8.8 and 8.10) and failure of consultants to respond appropriately even when concerns were raised (paragraph 8.11). A recommendation of a twice-daily ward round is made, but we are concerned that this is not necessarily going to help with such cases if consultants are not called or do not respond when an issue arises at other times of day. Neither does it seem appropriate for consultants to be reviewing straightforward labours where there is no cause for concern - especially not as this seems to mean three strange people entering and disturbing the atmosphere of the labour room. Given the comments about shortage of obstetricians, would it not make more sense to ensure that consultants are focused on reviewing complex labours and standing by to step in promptly if a previously straightforward labour becomes problematic?
Comments in paragraphs 8.16 to 8.21 illustrate serious issues of bullying of midwives, and an ‘us and them’ attitude from labour ward midwives towards those working in the MLUs. This toxic attitude appears to lie behind a number of the failures of midwives to escalate concerns, or to have concerns taken seriously when they did escalate them. It is therefore disappointing that the Local Actions for Learning (LAfLs) relating to these issues only refer to the Labour Ward coordinator modelling values and of “All clinicians” needing “to work towards establishing a compassionate culture”, without addressing the apparently widespread bullying culture amongst midwives. Instead, a recommendation for anti-bullying training for all staff, and actions to foster team-working between labour ward and MLU midwives might have been expected.
There is an interesting comment in paragraph 8.38 that “FHR abnormalities during labour rarely correlate with fetal compromise because the FHR is highly sensitive to hypoxaemia/hypoxia (both common during labour), but lacks specificity for fetal acidosis, the end point of intrapartum hypoxia.” (In other words, it doesn’t tell you which babies really are in trouble.)
In paragraph 8.39 the report authors say that “current guidelines remain silent on the adverse role played by intrapartum factors, which impair fetal adaptation to the challenges of labour such as fever, chorioamnionitis, meconium, abnormal fetal behavioural states, and excessive head moulding.” In fact the NICE guidelines on Intrapartum Care do advise “thinking about the whole clinical picture”, though without going into such detail. The NICE guideline is due to be updated so hopefully this will be clarified.
This section details a number of cases which don’t seem to relate to failure to recognise or escalate an abnormal CTG (cardio-tocographic monitoring), but rather to failure to act on other concerning signs. Similar concerns are raised in a later section ‘Delay in escalation and taking appropriate action’ - see below. The cases in the section on early labour are as follows:
Paragraph 8.41 “Intermittent auscultation (IA) showed a significant drop in the baseline fetal heart rate (FHR) although remaining within normal parameters. The FHR was not auscultated for 1 full minute following a contraction. The FHR was auscultated prior to the lady entering the pool and found to be 90bpm. There was a delay in escalation.” This seems to be about failure to act on the findings of intermittent auscultation, not failure to recognise an abnormal CTG, and it doesn’t explain what caused the delay in escalation.
Paragraph 8.43 reports a case where it took two hours to transfer a woman who presented at the MLU “with a temperature of 37.70C, maternal heart rate (MHR) 120bpm” Again, this seems to be nothing to do with recognising an abnormal CTG and it is not explained why it took 2 hours to transfer this mother.
In paragraph 8.45, “a woman in labour had meconium stained liquor and fetal tachycardia” but “The CTG was not considered pathological by the maternity review team and therefore to give the woman ‘an option’ to have a category 1 caesarean is not the standard practice. There is also no evidence that a further vaginal examination was performed prior to the caesarean to exclude or confirm full dilatation, in which case an emergency caesarean may not have been necessary.” This seems to be a case where a potentially unnecessary intervention was offered - so the opposite of a failure to recognise a problem.
It is not clear why these examples would lead to a LAfL that: “Obstetricians must not assess fetal wellbeing with fetal blood sampling (FBS) in the presence of suspected fetal infection.”
The current NICE guidelines say not to use FBS if there is a risk of infection passing from mother to baby, but nothing about when there is a suspected infection in the baby. And the draft update to the Intrapartum care guideline section on fetal monitoring recommends not doing fetal blood sampling in any case.
It is good to see the issue of “injudicious use of oxytocin” highlighted (paragraph 8.49) but concerning that the team found continuing “inappropriate commencement and continuation of oxytocin despite evidence of deterioration of the baby’s condition.” Given this we might have expected an LAfL relating specifically to the need for training and guidelines on the appropriate use of oxytocin, and yet there is no mention of this. This seems to be a serious omission.
Paragraphs 8.59 and 8.60 refer to “an expectation for midwives working on the MLU to manage with reduced staffing” and to incidents where the second midwife was told to leave the unit. It is therefore odd that the LAfLs do not include ensuring adequate staffing at MLUs.
Delay in escalation and taking appropriate action
This section talks about failure to “undertake continuous electronic fetal monitoring” and details several cases where CTG was not started in an MLU when abnormal fetal heart rate changes were detected. However, it is not clear whether in these cases, if intermittent auscultation had already identified a concern, the best action was to start CTG in the MLU (with a consequent further delay in transfer to the obstetric unit) or to escalate the case immediately.
Paragraph 8.65 refers to an abnormal fetal heartrate seen with intermittent auscultation but “This was not acted upon, a CTG was not performed nor was the case escalated.”
Paragraph 8.66 says that “Intermittent auscultation was started, however there was a delay in starting CEFM {continuous electronic fetal monitoring} when this became abnormal. Eventually the CTG was started and a further examination was undertaken which revealed a cord prolapse.”
Paragraph 8.67 sets out a case where “there was a failure to appropriately document intermittent auscultation of the fetal heart and commence CTG monitoring for a woman labouring in the pool with meconium.” However, there were a series of other problems including a “significant delay” between the decision to transfer and calling for an ambulance. An abnormal CTG was found on the labour ward, but it appears that there was delay in carrying out a caesarean birth due to the registrar being called away for a twin birth and the on-call consultant not being called. It is not at all clear in this sorry tale how doing CTG at the MLU would have helped.
As paragraph 8.68 notes, these cases seem to be about “the wider issues found on the labour ward relating to failures in appropriate escalation and consultant obstetric review once transfer to the consultant-unit was achieved” rather than anything specific to the use of CTG in the MLUs. There are several cases (paragraphs 8.68-8.71) of failure of proper risk assessment at MLUs of mothers experiencing reduced fetal movements, with concerns being dismissed. This sounds like an important training issue but there is no LAfL that specifically mentions this - just a general call for “multidisciplinary team skills drills.” It also seems that this may not be an issue solely for staff at MLUs as paragraph 8.85 also describes a mother of twins whose report of reduced movements was not acted on.
It is encouraging to see the report recognising the importance of psychological birth trauma, and that “pain, lack of attention, vulnerability, unkind words, swearing, sarcasm and bullying towards women as well as unkind treatment of colleagues, amongst midwives and obstetricians” as well as physical trauma can all contribute to this.
Another interesting comment is that “Sometimes, despite documented good quality care and reassurances, the woman’s recollection is terror, guilt, suspicion and feelings of Trust cover up.” The review team appear to have taken on trust the documented “good quality care and reassurance.” It is not clear whether they compared the women’s accounts with what was recorded in the notes. In any case, this points to women not having had appropriate support postnatally to deal with their birth trauma. Paragraph 8.108 recognises that “a debrief with a midwife is often not enough.” So why is there no recommendation about the support that should be offered?
We hope that this page is of interest, especially to our colleagues in the maternity services improvement community.
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