A paper published in the BMJ today looking at data from Scottish national registers shows a higher incidence of perinatal mortality for births occurring during the out-of-hours period (17.01 – 08.59hrs and on weekends). Researchers found 26% of neonatal deaths from intrapartum anoxia (lack of oxygen) were associated with delivery during this time of the day. The increase in risk of neonatal death ascribed to anoxia, excluding planned caesarean delivery, was found to be 45%.
The authors identified a number of variables which may account for this higher incidence of perinatal mortality, such as the lack of the immediate availability of senior clinicians. They suggest that an improvement in the level of clinical care for women delivering out-of-normal working hours may reduce overall rates of perinatal death.
Doctors are aware of the times during the day that are associated with higher risks and when these deaths are likely to occur. Previous data from the National Patient Safety Agency shows that most severe fetal compromise incidents occur between 20.00 to 04.00hrs1.
Much of the obstetric care is undertaken by junior doctors during this time of the day. This does not mean that junior doctors do not provide a safe service, instead it relates to the experience and skills needed to deal with emergencies. Doctors in training may not be fully trained to interpret subtle changes in fetal heart rate tracings (CTG) which are the early signs of a baby being at risk. This research shows that the higher mortality rate during the out-of-hours period corresponds directly to those periods when care is mainly provided by the doctors in training. Currently, in a majority of maternity units, consultants are on-call from home and not resident in the hospital.
The Royal College of Obstetricians and Gynaecologists (RCOG) has mentioned over and over again that for maternity services to be safe there must be increased consultant presence. Senior staff provide supervision and training for junior doctors and our maternity services need to move towards a consultant-led model, rather than one that is dependent on trainees.
Dr Tahir Mahmood, RCOG Vice President (Standards) said “All women admitted to the maternity unit irrespective of the risk factors should be provided with one-to-one care in labour by a midwife and an experienced obstetrician.
“The interpretation of a baby’s heart rate tracings requires special knowledge and experience. Quite often subtle changes in the CTG as early warning signs of asphyxia can only be interpreted by experienced doctors and junior doctors need to be supported and educated to acquire this skill. It is therefore crucial to have experienced obstetricians (consultants) working in labour ward during the out-of-hours period. Previous research has shown that increased consultant presence in the labour ward has many benefits, including reduced c-section rates2.
“It is important that midwives and obstetricians should remain skilled in the interpretation of early changes in the CTG during labour. The RCOG has been working on the development of an e-learning package on intrapartum fetal monitoring which was meant to be made freely available to all midwives and obstetricians. The development of this educational programme has been recently suspended. Based on the findings of this research, we urge upon the Department of Health to reconsider its decision to resurrect this much needed educational tool.”
Mr Mahmood continued, “The European Working Time Directive (EWTD) has limited the amount of training time for junior doctors and the Temple report has stated that working patterns for consultants need to change. Increasing the presence of consultants in the labour ward around the clock would not only improve training opportunities for the junior doctors but would also improve standards of care for all women in labour3.”
The RCOG has advocated for the past ten years that the care during labour in hospitals should be consultant delivered. We are aware of the present financial pressures. Therefore, as an interim solution, a Good Practice guide4 was published. The RCOG looks forward to working with the Department of Health, across all four nations, to develop robust plans for workforce and continuing professional development (CPD) programmes for the midwives and the obstetricians to improve the care of women during labour.
Notes
1. RCOG, Safer Childbirth. Minimum Standards for the Organisation and Delivery of Care in Labour (Oct 2007). To view this document, please click here http://www.rcog.org.uk/files/rcog-corp/uploaded-files/WPRSaferChildbirthReport2007.pdf
2. Spencer et al. Editorial: ‘Caesarean delivery in the second stage of labour’, BMJ 2006;333:613-614 (23 September), doi:10.1136/bmj.38971.466979.DE
3. Mahmood et al. ‘Should hospitals be designated as training or service only?’ Obstetrics, Gynaecology and Reproductive Medicine; 20: 3, pp. 93-96 (March 2010)
4. RCOG Good Practice No. 8 ‘Responsibility of Consultant On Call’ (Mar 2009). To view this document, click here http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GoodPractice8ResponsibilityConsultant.pdf
To see the RCOG statement on the Temple report, please click here http://www.rcog.org.uk/what-we-do/campaigning-and-opinions/statement/rcog-statement-publication-temple-report-ewtd .