Confidence in Irish maternity services has again been shaken by the news that the deliveries of nine babies in the past year or so at Portiuncula University Hospital are to be investigated by senior consultant obstetricians. Seven of these cases relate to babies with hypoxic ischaemic encephalopathy (HIE) at birth, six of whom received neonatal hypothermic treatment known as neonatal cooling. Two cases relate to stillbirths.
Neonatal cooling is a process whereby a baby’s body temperature is lowered significantly for 72 hours to facilitate recovery of brain tissue that may have been damaged by a lack of oxygen and/or blood supply around the time of birth, ie HIE. Depending on the severity, the baby may die or suffer from long-term outcomes, ranging from cerebral palsy with or without intellectual disability, epilepsy, developmental delay. In mild cases there might be no effect at all.
Therapeutic cooling is applied in cases of moderate to severe HIE and reduces the rate of death, severe disability and cerebral palsy. The treatment was fully established nationally in 2012 and is now the standard of care. The expected rate of HIE is about 1.5 per 1,000 births. The Portiuncula investigation has been precipitated by the clear anomaly of six babies being referred for therapeutic cooling in 2024 and an additional case already this year, significantly more than the expected number of one or two based on the 1,300 or so deliveries at Portiuncula in 2024.
It is a matter of considerable concern that this is happening less than seven years since the publication of the Walker report in 2018, which investigated the referral of another six babies at Portiuncula for therapeutic cooling in 2014. That report made a number of recommendations, most or all of which were apparently implemented at the hospital in subsequent years. Significantly however, it presciently warned that the “incidents described in this report have been highlighted in previous reports in other hospitals in Ireland and abroad and, without fundamental changes in process and training, will happen again”.
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It is for the investigators to determine whether or not HIE could have been avoided in any of the latest cases. It would be a mistake, and unfair to the parents of the babies and staff at Portiuncula, to prejudge the issue without detailed knowledge of the clinical
circumstances surrounding each of the cases. However, it is concerning that the HSE has felt the need to appoint “a highly experienced management team to oversee maternity services in the hospital over the coming months”. The clear implication is that the HSE is not satisfied with the current state of maternity services at the hospital.
Portiuncula is not unique in experiencing problems in the delivery of maternity care. My experience of investigating adverse outcomes of pregnancies (including maternal deaths), not least in my 2017 report on Portlaoise Hospital and eight other hospitals in Ireland, has led me to conclude that three key factors lie at the heart of problems that result in adverse outcomes: management structures, clinical governance and staffing levels.
In relation to the first two points, I have for many years flagged issues with maternity units in Ireland that are integrated into general hospital management structures. In my view, doctor-managed maternity hospitals and units such as the Rotunda, Holles Street and the Coombe hospitals in Dublin provide better outcomes for women and infants.
My key point is that in obstetric services, a doctor needs to be at the heart of management. The three Dublin maternity hospitals have the highly effective mastership system, whereby a consultant obstetrician has clear overall corporate responsibility. It is a position imbued with both authority and accountability. While the master works in a collegial manner with midwifery and lay management, he or she is in overall charge. No matter how well-intentioned, there is no way that a lay manager can fully understand the intricacies of obstetric care, with the 24 hours a day, 365 days a year, relentless nature of the delivery of safe care to women where unexpected emergencies can arise at any hour.
Day to day on a labour ward, there must always be a consultant who has ultimate responsibility for outcomes. In practice this means regular rounds of the labour ward several times a day, seven days a week, where each woman is visited in person by the responsible consultant accompanied by the senior midwife and nonconsultant doctor on duty. This allows the early identification and timely resolution of potential problems such as lack of satisfactory progress in labour. Critically, it enhances the lines of communication between medical and midwifery staff and women in labour.
We know from a series of investigations into obstetric catastrophes in the UK that conflict between doctors and midwives is a potent cause of problems, of the kind that cause mothers and babies to suffer the most. Harmonious working relationships between medical and midwifery staff are essential for the delivery of safe care, and there must be no place for clinical care silos.
Overly long duration of labour, especially in first-time mothers, is a significant factor in the development of HIE. In too many cases I have reviewed, there has been a reluctance to diagnose labour and transfer a woman to the labour ward in a timely fashion. It is not possible to conduct comprehensive foetal monitoring in an antenatal ward. Education regarding the diagnosis of labour needs to be enhanced so that long labours are prevented.
Continuous audit of the outcome of every pregnancy is another critical part of clinical governance. In this way, problems can be identified early and solutions applied. Of course, the vast majority of pregnancies are uncomplicated, with the safe delivery of a healthy baby to a healthy mother under the primary care of midwives.
Without fundamental reform of management and clinical governance, tragic outcomes will remain an unacceptable, recurring but avoidable feature of Irish maternity services.
Dr Peter Boylan is former master of the National Maternity Hospital and former chairman of the Institute of Obstetricians and Gynaecologists
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