The clinical factors behind UK’s soaring maternity liability payments

Past and Future

Yesterday I wrote about the single most important reason for the UK’s massive maternity payouts: the failure to properly investigate bad outcomes and the resulting failure to learn from them. That was the finding of a just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data.

The author of the report proceeded to investigate the poorly investigated claims and found recurring clinical reasons for massive liability payments:

Nearly every error was a failure of omission and all involved failure to inform women of the risks of vaginal birth.

The 50 claims were clinically varied but by reviewing them all together to get a national picture it was possible to identify common themes:

1) Errors with fetal heart rate monitoring
2) Breech birth
3) Inadequate quality assurances around staff competency and training
4) Patient autonomy and informed decision making

Nearly every error was a failure of omission. Nearly every error was a failure to undertake clinically indicated interventions. It’s not hard to see the impact of the Royal College of Midwives’ Campaign for Normal Birth at work here; in an effort to “achieve” vaginal birth, important warning signs were ignored and babies were grievously harmed as a result. Moreover, mothers were unable to make informed choices because they were not informed of the very real risks of vaginal births.

The most glaring errors occurred with fetal heart rate monitoring including failure to monitor, failure to properly interpret monitoring and failure to act on abnormal results.

Enlight129

Who made the errors?

Twenty four claims involved a midwife but only one involved a consultant.

Why did midwives repeatedly make serious errors? I suspect it is because UK midwives fundamentally misunderstand the value of fetal heart rate monitoring.

The report notes:

The most recent Cochrane review demonstrates that, compared to intermittent auscultation, continuous fetal monitoring using a CTG, is associated with a 50% reduction in neonatal seizures (RR 0.50 95% CI 0.31-0.80). However, it does not reduce the risk of developing CP and is not associated with any other benefits in fetal wellbeing. These finnings were consistent in high and low risk pregnancies and in preterm births …

Many midwives have looked at this data and concluded that fetal monitoring is worthless and therefore should be avoided or ignored. But the scientific evidence doesn’t show that fetal monitoring is worthless; it shows that continuous electronic fetal monitoring is no better than rigorously performed intermittent auscultation. Monitoring itself can provide critical information.

The other caveat about fetal monitoring is that it has a high false positive rate. That means that fetal monitoring may show an abnormal result for a normal baby, but that is not a reason to ignore abnormal results.

To put it in terms that may be easier to understand, finding a breast lump also has a high false positive rate. Most breast lumps are not cancer but that doesn’t mean that doctors should ignore breast lumps because most of them are not cancer. Some of them are cancer and it is only by investigating further and intervening (breast biopsy) that the correct determination can be made. Yes, if we wait long enough, the cancer will eventually progress and become obvious but that’s not an argument for watchful waiting.

Similarly, only some of the abnormal fetal heart rate tracings are due to fetal oxygen deprivation. Yes, if we wait long enough, the lack of oxygen will eventually become obvious by leading to fetal collapse, but that’s not an argument for watchful waiting. It’s an argument for investigating further and intervening (childbirth interventions).

UK midwives are fundamentally wrong about the value of fetal monitoring and that’s part of an even larger error: they’re fundamentally wrong about the value of vaginal birth because they confuse cause and effect.

Sure, scientific evidence shows that those who have easy, uncomplicated vaginal births fare better than those who have complicated C-section births but the C-sections don’t cause the complications; the complications cause the C-sections. Scientific evidence also shows that people who were never admitted to the ICU during their hospitalizations fare better than those admitted to the ICU, but that’s not because the ICU causes complications; it’s because people with complications are admitted to the ICU. Refusing to use childbirth interventions for those who develop complications in pregnancy is like refusing ICU admission to who develop complications during hospitalization. It’s a deadly mistake.

And that mistake is compounded by the most unforgivable clinical error identified by the report, the failure to obtain informed consent.

Evidence of a lack of informed consent was evident throughout the 50 claims reviewed.

That’s pretty damning.

An example was a woman who opted to have a vaginal birth after caesarean section (VBAC) but her initial caesarean was complicated by a difficult delivery that involved making a J-shaped incision on the uterus. This is not an absolute contraindication to VBAC but there is “insufficient evidence to support the safety for VBAC in women with previous T or J incisions” and there should have been a documented discussion by a consultant which made an individualised assessment around the suitability for VBAC and the possible increased risk of uterine rupture. The issue here is not that the woman was offered a VBAC but that she was not adequately given the information on which to make an informed decision.

In other words, the mother was not offered accurate information about the risks of vaginal birth. The same thing happened with breech births, history of shoulder dystocia and twins. There is a word for that type of behavior; the word is “paternalistic.” This paternalism is a direct violation of medical ethics.

… The practice of autonomy and patient consent revolves around the key feature of informed decision making, whereby the healthcare professional and the patient engage in dialogue about treatment options, their benefits, risks, consequences and alternatives… [T]his information must be clear, accurate, balanced without bias, take into consideration the individual patient, the nature of their condition and in a language that they understand.

Promotion of normal birth is bias pure and simple. It isn’t merely unethical; it’s a critical clinical factor behind the soaring UK maternity liability payments.

The promotion of normal birth doesn’t merely hurt babies and families. It is an extroardinarily expensive mistake.

  • Eater of Worlds

    I remember reading when someone’s baby died, they did EFM, but the midvwives had no idea how to read the results. Turns out, these midwives were not taught this in school and they were hired by the hospital assuming they knew how to use it so they weren’t asked and were not tested to see if they could do it. I simply don’t understand why they would prefer IA to this. If it’s properly placed and competently read, it is so much better than trying to listen to heartbeats accurately as well as being able to do it at the exact right time for, well, hours I guess. The latter uses up labor that could otherwise be better engaged, and as mentioned it’s extremely difficult to be accurate and be able to tell the difference when the rate changes by just a few heartbeats. Sure, the equipment is more expensive, but not compared to the millions in lawsuits.

  • Zornorph

    I remember when Boy-O was being born. Not only were there all these monitors hooked up, every now and then a nurse had to come by and sign the paper to show that she had looked at it and if a wire came undone and the signal stopped, she had to write why the record was interrupted and sign that as well. I felt very happy knowing that he was being so closely monitored. I cannot imagine not wanting that information.

    • EmbraceYourInnerCrone

      I completely agree. I had 2 miscarriages so was completely paranoid by the time I was ready to deliver my daughter. I had constant EFM and everything went fine. Until it didn’t: meconium stained waters, they decided to go for internal monitoring which means an electrode attached to the baby;s head, late decels and the doctor decided to use the vacuum to get her out fast. They had to suction her and had the NICU team standing by for that before she even was out. They got her lungs cleared and got her breathing. I don’t want to imagine what the outcome might have been if there had been no monitoring and if the meconium had just been seen as “a variation of normal”

    • Kerlyssa

      i worked as a practical nurse for a while, we basically had no medical training beyond how to take blood pressure and basic hygeine stuff, and even we knew to sign off on record taking, including interruptions. hell, i think i’ve seen this in fast food record keeping, too. this is atrocious.

    • MaineJen

      I had wireless monitors on me the whole time, because I was being induced/augmented. I could get up and walk around, get in the tub, etc, and the monitors sent all the info back to the main nurses station and to the readout at bedside. It wasn’t a flawless system, the monitors seemed to lose the signal every time I moved and a nurse would have to come in and adjust them. Annoying, right? I was still glad they were watching me and baby so closely. Modern technology rocks. 🙂

      • Azuran

        I had wired monitors but the lines where very long and I had the right to move around as much as I wanted, they offered birthing balls and stuff like that. So I was not in any way glued to my bed or stuck in any particular position.
        Not that I wanted any of that. I got the epidural as soon as possible and couldn’t be happier about it XD

  • RudyTooty

    “Many midwives have looked at this data and concluded that fetal monitoring is worthless and therefore should be avoided or ignored.”

    So. Tired. Of. This.

    I hear it from CPMs **and** CNMs and it is a dangerous and reckless opinion.

  • Empress of the Iguana People

    Paternalism is okay if it’s midwives doing it! Sometimes it seems as if these midwives are blinder than my blindbard.

    • Lilly de Lure

      Maternalism?

      • MaineJen

        MommyDearest-ism

        • Russell Jones

          “When I told you to believe that fetal monitoring is worthless and therefore should be avoided or ignored, I wanted you to MEAN IT.”

  • CSN0116

    So UK midwives have become the very thing they were designed to be in contradiction to: paternalistic health care providers who rob women of their autonomy and force birth environments. Sounds a lot like those “dick male OB’s” I hear so much about…

    • kilda

      yep, Except instead of golf, they like knitting.

      • CSN0116

        Haha!

      • Charybdis

        And “holding space”.

    • Mac Sherbert

      Nothing worse than catty women.

  • Madtowngirl

    Wow. Despite the many problems in the US healthcare system, it does make me feel glad to be getting care under providers that are diligent about informed consent. When I had my c-section, the doctor was very thorough about the risks, and when I was pregnant last year (ended in miscarriage), the doctor informed me about the risks of VBAC in my situation. I feel very fortunate to currently have access to providers who are more interested in my health than their own egos.

    • CSN0116

      I am for US prenatal healthcare standards for ALL American women. I will never compromise and accept a midwife-led system such as this.

      • My time in the UK was so long ago that I hesitate to write this, but the antenatal care there that I was taught to give was superior in many respects to what I saw in the US during the same period. And it can’t be forgotten that a significant number of US women get no prenatal care at all, or only one or two visits.

        • Kerlyssa

          yep. us has the best medical care in the world… it’s just not accessible to many.

        • Anj Fabian

          I’d have to disagree with the antenatal care being superior.

          From the stories I hear coming from the UK, their maternity system is awesome for (midwife led care) low risk women who stay low risk and also for the really high risk women who start and end in consultant led care.

          Where the gaps show up is when low risk women are no longer low risk, but they are treated like they are low risk. Women who are at elevated risk but don’t have any risk factors that get them the care they need. Say they have a second trimester miscarriage without a known cause. That’s concerning, but it won’t get them bumped up until complications are noticed in a later pregnancy.

          • Eater of Worlds

            What would you consider someone who suddenly has a problem during labor but isn’t having regular external monitoring done, which is done in the US but not in the UK until they notice an issue, from what I understand. Once they do notice an issue and put on the gizmo so it’s on constantly, then they see a problem but dismiss it or they don’t know how to read the output and miss it totally. This situation is one I’ve heard happening multiple times, and apparently the midwives were not taught to read the output and were hired without being able to use the system at all.

            Any woman can have sudden issues in labor and all the midwives should be prepared for it. I’m often shocked at how few doctors are actually there to deal with problems that crop up The whole system seems fucked.

          • Hannah

            This is spot on re the UK system ^^.

            My concern recently is that the criteria for high risk seem to be being constantly eroded.

  • Mel

    I am so grateful for the time my OB and the resident OB took to talk with me about options when Spawn was born.

    I knew enough from this website and other reputable sites that my chances of being induced successfully as a FTM with an unfavorable cervix was less than half, that breech micropreemies do better when born through C-section, and that I had a medical condition that could rapidly worsen causing uncontrolled bleeding and cardiovascular accidents.

    I was more than happy to get a C-section before anyone had talked to me, but these two doctors spent the time explaining my options and the potential issues with each option. (To be fair, my OB made it clear an induction was off the table in terms of options – but she explained why I was unlikely to deliver vaginally before having very serious medical complications. I chimed in with “Look, Spawn doesn’t need the added pressure on vessels in his brain. I have no interest in trying to push a baby out while keeping my blood pressure low without an epidural. Because, yeah, that’s not going to happen.”)

    Plus, I have the added bonus of having a classic vertical incision so I get repeat CS for any future babies! (That was the only thing that threw my OB; apparently she’s not had a patient explain that she’d prefer not to need pelvic floor reconstructive surgery after uncomplicated vaginal births like most of her maternal female relatives. )

  • Roadstergal

    “it shows that continuous electronic fetal monitoring is no better than rigorously performed intermittent auscultation”

    I have a question about this. Is continuous EFM more automated/easier to do than ‘rigorously performed intermittent auscultation’? Those first two words make me think so…
    Because if so, the fact that it takes some aspects of human error and skill differentials out of the equation would seem to make it preferable?

    • kilda

      that’s my impression too – that rigorously performed intermittent auscultation is not easy to do right and has a lot more room for operator error. But undertrained midwives are apt to take it to mean that “listen to the baby now and then” is as good as continuous monitoring.

    • Squillo

      Not a clinician, so I can’t answer that, but I would think IA is more labor intensive and thus less likely to be done as frequently as necessary. Also, there’s no strip for someone more experienced (or a court) to review.

    • fiftyfifty1

      “Is continuous EFM more automated/easier to do than ‘rigorously performed intermittent auscultation’? ”

      Absolutely. Properly performed intermittent auscultation has to be done on a set schedule which is frequent enough that it basically keeps the provider from doing much else. And if you are doing it by ear (not by visual tracing) it is extremely variable in quality depending on the person. Fetal heart rate decelerations can be very subtle (e.g. a HR of 135 rather than 140) and yet very important. I know that I myself couldn’t tell the difference!

    • Azuran

      Indeed it does.
      In a perfect world, they are the same. But it the real world, it’s a lot easier to have EFM equipment for every single bed (which costs you nothing if they are not in use and don’t need supervision) than it is having properly trained nurses/midwives doing it. You can’t predict how many women are going to show up in labour, so you can’t know how many midwives you’ll need doing IA full time. If too many women show up or if there’s an emergency, you might not have enough people to do it correctly.
      And that’s without even considering individual skills.

      • Lilly de Lure

        In an NHS hospital then this would be completely impractical – the staff are stretched to the limit as it is with the financial squeezes, they simply wouldn’t have the time to do this correctly.

        • Azuran

          Even where I gave birth (In Canada) this would have been a problem.
          The day I gave birth, we were only two women in the entire labour ward. So we both could have had 2 nurses and 2 nurse student doing constant monitoring on us. (Somehow we still managed to need emergency c-section at exactly the same time)
          The next day, all hell had broken lose and EVERYONE was having a baby. There’s no way they could have done it correctly for everyone.

    • RudyTooty

      My issue with IA, is that no matter how “rigorously” I perform it, or how much midwives INSIST that they can hear it (because of their magical superpowers), there is NO WAY I can hear baseline variability with auscultation.

      When was the most recent IA vs continuous EFM RCT conducted? It also seems (I know I could look this up myself) that this is rather dated information.

      No one does exclusive IA any more. Oh, why, oh why would you do this? Midwives do this. CPMs do this. This is foolishness. This is how you get a dead, limp, white newborn plopping out in your hands at a homebirth.

    • Totally. At least, at my Hospital. I mean they don’t call them “SpaceLabs” for nothing. They’re based on the tech NASA uses to monitor astronaut vitals.

  • Roadstergal

    “Evidence of a lack of informed consent was evident throughout the 50 claims reviewed.”

    That’s horrifying, but from everything I’ve heard from the posters on this site, and the crazy stuff my friend in the UK parrots back to me that she got from the midwives – it’s not surprising at all. Their business model seems to be misinformed consent.

  • moto_librarian

    Jesus. I am stunned that they did not explain the specific risks that a J incision present to a VBAC attempt. That is just unconscionable.

    And it’s very clear from the Twitter discussions by some of the supposed leadership of UK midwifery that they think that EFM (CTG) is worthless. Given that seizures are a symptom of oxygen deprivation, their willingness to ignore a 50% reduction associated with intermittent monitoring is pure negligence.

    • fiftyfifty1

      Yeah, smothering my kid until he seizes. Why would any mom have a problem with that?

    • Kelly

      Seizures are completely fine when having a “natural” birth and when breastfeeding. /sarcasm