The pattern of more than one emergency happening at once causing delay or deviation from standard practice was an emergent theme, particularly where more than one or two obstetric theatres were needed at once.
In the following instance, where a theatre was unavailable and a fetal bradycardia was being observed, there were multiple unsuccessful attempts at vaginal delivery. A possible cause of this is lack of situational awareness. A comprehensive review identified a possible cause as:
“Belief that a multiparous woman could deliver vaginally, hence persistence with an attempted instrumental delivery when the first attempt with [the] successfully placed instrument had failed.”
This was an emergent theme in the analysis with similar situations identified. One report outlined a situation where two obstetric emergency theatres were occupied, one with an ongoing operation and the other with preparation for a category 2 caesarean section, and a third emergency – a fetal bradycardia – occurred on the delivery suite. No action was taken at this point to stop the preparation for the category 2 caesarean section.
Rather than attempting to open a third theatre, the team waited for an obstetric theatre to become free. Once it did, they then made multiple attempts at instrumental delivery under pudendal block, despite lack of descent of the head, and an emergency caesarean was required.
An option to open a third theatre in the main theatre block was available, but was either not considered or the staff were unaware of this option.