Abstract
To explore the effect of introducing 24/7 resident labour ward consultant presence on neonatal and maternal outcomes in a large obstetric unit in England. Retrospective time sequence analysis of routinely collected data. Obstetric unit of large teaching hospital in England. Women and babies delivered between1 July 2011 and 30 June 2017. Births <24 weeks gestation or by planned caesarean section were excluded. The primary composite outcome comprised intrapartum stillbirth, neonatal death, babies requiring therapeutic hypothermia, or admission to neonatal intensive care within three hours of birth. Secondary outcomes included markers of neonatal and maternal morbidity. Planned subgroup analyses investigated gestation (<34 weeks; 34-36 weeks; ≥37 weeks) and time of day. 17324 babies delivered before and 16110 after 24/7 consultant presence. The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant presence began (OR 1.09 p.a.; CI 1.04 to 1.13). Overall, there was no change in this trend associated with the transition to 24/7. However, in babies born ≥37 weeks gestation, the upward trend was reversed after implementation of 24/7 (OR 0.67 p.a.; CI 0.49 to 0.93; P = 0.017). No substantial differences were shown in other outcomes or subgroups. Overall, resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes. However, 24/7 presence was associated with a reversal in increasing adverse outcomes for term babies.
Highlights
The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant
Resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes
The UK triennial national enquiries into maternal and perinatal deaths from the 1990s and early 2000s all highlighted suboptimal care associated with intra-partum fetal deaths and maternal deaths; and the late input of an obstetric consultant was cited as a contributory factor to these outcomes [1, 2]
Summary
The UK triennial national enquiries into maternal and perinatal deaths from the 1990s and early 2000s all highlighted suboptimal care associated with intra-partum fetal deaths and maternal deaths; and the late input of an obstetric consultant was cited as a contributory factor to these outcomes [1, 2]. National Patient Safety Agency data suggested that adverse incidents were more likely to occur at night when a consultant was unlikely to be present [3]; and an association between adverse perinatal outcomes, including mortality, and births at night was shown in a seven year registry-based cohort study including all hospitals in the Netherlands [4, 5]. Studies of units in the United States where there was 24/7 specialist obstetric presence did not detect associations between outcomes and time of birth [7, 8]. In 2005 the UK Royal College of Obstetricians and Gynaecologists (RCOG) recommended that by 2010 all maternity units with >5000 births per year should have resident obstetric consultant presence 168 hours per week (i.e. 24/7 consultant presence) [9]. In 2016 and 2017 the UK RCOG changed their recommendations, suggesting that alternatives to 24/7 consultant presence should be explored [15, 16]
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