Pregnancy and Birth Injury Claims and Reporting.
Labour is, minute for minute, the most dangerous time of human life. Inadequate midwifery ratios, the rise in birth rate and lack of medical experience, training or communications all contribute to the rare but disastrous outcomes that we see. Failure of medical care is not more common but it is still cited as a major factor. For instance, in more than 50% of maternal deaths in the UK, ‘substandard care’ has occurred (CMACE RCOG 2011). With a rise in parental expectations, the result is that claims continue to increase significantly, with sometimes vast payouts.
The skills and experience of obstetricians varies enormously and contributes as much as demographic variables to the ‘postcode lottery’. At the same time the role of shortage of oxygen as a cause of damage is debated and establishing negligence and causation may require multiple experts. These experts need to be leaders in their field, but also aware of the normal standards and what these were at the time of the birth.
An increasing source of claims is the failure to diagnose, or adequately manage, fetal abnormalities or disease. Common examples include the failure to detect Down’s Syndrome, or a reduction in fetal growth, or complications among the increasing number of complex multiple pregnancies. Failure of medical care before labour is as (or more) important in long term childhood handicap as birth injury – the majority of cases of cerebral palsy are thought to originate long before labour. The ‘subspecialty’ of fetal medicine that covers fetal problems requires extra, specialised training beyond that of normal obstetricians and entry to the limited number of training places is highly competitive. This means expertise is relatively rare.
Although often used nearly synonymously with fetal medicine, possibly because subspecialty training in fetal medicine encompasses maternal medicine also (maternal fetal medicine), this area relates to medical disease either complicating or resulting from a pregnancy. This is a key area: more maternal deaths in the UK occur because pregnancy exacerbates pre-existing disease than occur from pregnancy complications; more than 50% still involve some form of substandard care. Most ‘maternal fetal medicine’ experts are in reality fetal medicine experts. In addition to those who concentrate more on the mother, there are a small number of highly sought after physicians who specialise only in pregnancy.
The specialty of obstetrics and gynaecology is wide and expertise in all areas is now impossible. Very few teaching hospital gynaecologists provide pregnancy care or deliver babies, let alone have expertise in maternal or fetal medicine. Even gynaecology itself is specialised, with urogynaecology, fertility, oncology as major branches. The role of surgery is lessening overall, and failure of medical care can occur not only with the standard of surgery or postoperative care, but also with the failure to offer non-surgical treatment.
TLA experts are leaders in these various fields of medicine.