"Every case of asphyxia can be used as a learning example". Conclusions from an analysis of substandard obstetrical care.

Aim: To propose suggestions for improvements in care based on conclusions from studies on low Apgar scores and substandard care during labor. Setting and patients: Studies on infants with low Apgar scores in a general obstetric population 2004-2006 and claims for financial compensation on the behalf of infants, based on the suspicion that substandard care in conjunction with childbirth has caused severe asphyxia or neonatal death in Sweden 1990-2005. Results: The most common flaws were related to insufficient fetal surveillance, defective interpretation of cardiotocography (CTG) tracings, not acting in a timely fashion on abnormal CTG, and the incautious use of oxytocin. Besides, in half of the infants a suboptimal mode of delivery added further trauma to the already asphyxiated infant. Additionally, resuscitation was unsatisfactory in many of these infants. The most critical flaw was defective compliance with the guidelines concerning ventilation and the early paging of skilled personnel in cases of imminent asphyxia or known complications during labor. In many case reports, the documentation of the neonatal resuscitation was insufficient to enable accurate and reliable evaluation. Conclusions: Examples of proposed improvements in care during labor are the introduction of a permanent educational atmosphere with aside time for daily educational rounds and discussion, cooperation around the use of standardized terminology in CTG interpretation, the cautious use of oxytocin, and the routine paging of a pediatrician before birth in cases of complicated delivery or imminent asphyxia. The proposed interventions need to be evaluated in clinical trials in the future.