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.