Reviewing maternity records: six issues that may warrant closer scrutiny

Dr Argyro Syngelaki, Specialist Consultant Midwife in Fetal Medicine, highlights some of the issues that can be important when considering the chronology and standard of midwifery care in a maternity claim. 

When reviewing maternity records, the significance of an individual observation, presentation or investigation may not always be immediately apparent. 

A maternal observation may have been recorded. A woman may have presented with a concern that was assessed at the time. An ultrasound finding may have been documented. Viewed individually, these events may not necessarily indicate a problem with the care provided. 

However, when the chronology is considered as a whole, a different picture can sometimes emerge. 

With nearly two decades of experience across midwifery, maternity care and tertiary fetal medicine, I consider the overall maternity pathway when reviewing a case, including whether changing risks were recognised, concerns were appropriately investigated and acted upon, and escalation occurred when required. 

Here are six areas that may warrant particular consideration when reviewing maternity records. 

1. Do repeated concerns reveal a developing pattern? 

Repeated presentations or clinical concerns can be important when considering the chronology of maternity care. 

Individual events or findings may not always appear particularly concerning in isolation. However, when considered together, they may reveal a developing pattern of maternal or fetal concern that warranted further assessment, closer surveillance or escalation. 

This might include changes in maternal observations or symptoms, concerns about fetal wellbeing or growth, or repeated presentations during pregnancy. 

An important consideration is therefore not only what happened at each individual contact, but whether the developing clinical picture was recognised across the maternity pathway. 

2. Was an abnormal finding acted upon, rather than simply recorded? 

The presence of an abnormal observation or investigation result within the records does not necessarily demonstrate that it was appropriately managed. 

It is also important to consider whether its significance was recognised, whether appropriate action was taken and whether the woman's condition and response were subsequently followed up. 

Depending on the concern, this may include escalation to a senior midwife, obstetrician or another member of the multidisciplinary team. 

Areas that may warrant closer scrutiny include abnormal maternal observations, concerns regarding fetal wellbeing, abnormal fetal growth and abnormal ultrasound or Doppler findings where there is no clear evidence of appropriate referral, escalation or follow up. 

3. Did the plan of care respond to changing risk? 

Risk can change throughout pregnancy, labour and the postnatal period. 

Good midwifery care involves not only identifying relevant risk factors during the initial assessment, but recognising changes in the clinical picture and responding appropriately. 

When reviewing a case, it may therefore be important to consider whether new symptoms, observations, investigation results or concerns prompted appropriate reassessment. 

This can include whether additional monitoring or surveillance was required, whether referral was appropriate and whether concerns were escalated at the right time. 

4. Were there gaps in monitoring, referral or follow up? 

The chronology may also identify gaps or delays that warrant further consideration. 

These can include inadequate maternal or fetal monitoring, gaps in antenatal surveillance or follow up, delayed review or referral, failure to respond appropriately to abnormal fetal growth, or delays in treatment or transfer of care. 

Cases involving antenatal screening, fetal growth, ultrasound surveillance and Doppler findings may require particular consideration of whether the appropriate pathway was followed and whether findings resulted in timely action. 

5. What do the records show about communication and handover? 

Communication is an important part of maternity care and extends beyond what was communicated between healthcare professionals. 

Women should understand the nature of a concern, what is being recommended and why, and what symptoms or changes should prompt them to seek further assessment. 

Communication between professionals is also important, particularly during handover, referral and transfer of care. 

When reviewing the records, relevant considerations may include whether important clinical information was communicated, whether discussions and decisions were appropriately documented and whether adequate safety netting was provided. 

6. Is additional expert evidence required? 

Maternity cases can involve several different areas of professional responsibility, and the issues in dispute will determine which expert disciplines are required. 

As a Consultant Midwife, I can provide an opinion within my expertise across antenatal, intrapartum and postnatal midwifery care. This can include assessment and monitoring, recognition of risk and deterioration, escalation, communication, documentation, multidisciplinary working, referral pathways, follow up and safety netting. 

My specialist experience in fetal medicine also allows me to consider relevant aspects of antenatal screening, fetal growth assessment, ultrasound and Doppler. 

However, where an opinion is required specifically on obstetric medical decision making, such as medical treatment, operative management or a decision that sits within an obstetrician's responsibility, an obstetric expert may also be required. 

Depending on the issues involved, evidence may also be required from a neonatologist, radiologist, fetal cardiologist, anaesthetist, geneticist or pathologist. 

Identifying the appropriate areas of expertise at an early stage can help establish which aspects of the care require specialist opinion. 

Looking at the chronology as a whole 

Ultimately, reviewing maternity records should involve more than identifying isolated entries within the notes. 

The chronology can be particularly important. A series of findings that may appear relatively unremarkable individually can sometimes demonstrate a developing pattern when considered together. 

The question is not simply whether a concern was recorded, but whether its significance was recognised, whether the response was appropriate and whether the subsequent care reflected the changing clinical picture.