Reducing risk by improving standards of intrapartum fetal care

Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a distric t hospital labour ward-guidelines, cyclical audit, monthly feedback meeting s and training sessions in cardiotocography (CTG), The effects of these int erventions on quality of care was assessed by use of the CESDI system in al l babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gest ational age differed significantly between audit periods. In the baseline a udit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, an d in the next four periods it was 23%, 27%, 27% and 32%, In the latest audi t period, after further educational interventions, it was 9%, Many of the f ailures to recognize or act on abnormal events were related to CTG interpre tation. After the interventions there was a significant increase in cord bl ood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapar tum care can be achieved by a programme of clinical risk management.