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Clinical decision-making in obstetrics sits at the heart of many high-value birth injury claims. Intrapartum choices - from CTG interpretation to escalation timing - often determine whether cases of cerebral palsy or stillbirth are preventable, defensible, or indefensible. Understanding how these decisions unfold, and where systems fail, is essential for any solicitor building or defending an obstetric negligence claim.

Intrapartum Decision-Making: Clinical Risks

Labour is dynamic - what begins as a low-risk physiological process can become pathological in minutes. According to Dr Phelan, the key clinical challenges often arise from “the grey zone” - situations where CTG traces are suspicious but not overtly pathological.

Common pitfalls include:

• CTG misinterpretation and delayed escalation. Despite years of national guidance (NICE, FIGO, Physiological), CTG remains an imperfect and subjective tool, with high false-positive rates and variability between reviewers.

• Failure to contextualise. Staff shortages and increasing consultant frontline workload have eroded the “helicopter view” needed to interpret labour contextually.

• Inadequate consent and documentation. True informed consent is often unachievable during acute obstetric emergencies, where distressed patients cannot process complex risks.

• Continuity of care breakdown. Women may encounter dozens of clinicians during pregnancy, undermining trust and consistent advice - particularly in cases involving declining intervention or where complex risks such as bleeding, clotting disorders, or transfusion decisions require specialist input from haematology expert witnesses.

Together, these factors create fertile ground for misjudged escalation, poor record-keeping, and ultimately, medico-legal exposure.

Medico-Legal Considerations

Dr Phelan emphasised that most birth injury litigation hinges on breach and causation within this “grey zone.”

Claims frequently centre on:

• Failure to deliver earlier by caesarean section

• Failure to interpret or escalate a suspicious CTG

• Inadequate or absent consent for instrumental delivery

For solicitors, understanding how clinicians balance context and timing is key. Breach often arises not from a single misread CTG, but from systemic issues - poor staffing, communication breakdowns, or failure to act on red flags like meconium plus oxytocin use, which Dr Phelan identified as “a lethal combination”.

Causation analysis should therefore consider whether earlier intervention would have altered the outcome - particularly where evidence shows prolonged foetal bradycardia, delayed theatre access, or loss of situational awareness.

Case Examples & Outcomes

Case 1: Delay in Caesarean Section (BMI 51, Induction of Labour)

A first-time mother with morbid obesity was committed to a vaginal birth despite emerging hypertension and a large baby. When labour failed to progress, she requested a C-section at 8 p.m., but the team - occupied with emergencies - deferred the procedure overnight. She laboured rapidly, ultimately sustaining a fourth-degree tear during an instrumental delivery.

• Breach Allegation: Failure to review and proceed to caesarean at 8 p.m.

• Outcome: Breach denied. The team acted within reasonable clinical limits given high surgical risk, unavailability of theatre staff, and the absence of immediate indication for emergency section.

Case 2 – Consent and Instrumental Delivery

This case involved a 42-year-old woman who conceived after 13 years of failed IVF. She had gestational diabetes and was counselled antenatally for an elective caesarean section due to her high-risk profile - but declined the offer, opting for a vaginal birth.

During labour, she reached full dilation but the CTG became suspicious. The consultant proceeded to theatre for a trial of instrumental delivery. Three pulls with the ventouse were unsuccessful, followed by an attempted forceps application that failed to lock. The decision was made to proceed to an emergency C-section. Tragically, the baby suffered a massive intracranial haemorrhage secondary to the ventouse attempt and died shortly after birth.

Allegations centred on two key issues:

• Failure to perform an elective C-section antenatally, despite her risk profile.
• Failure to obtain valid consent for the instrumental delivery attempted in theatre.

Dr Phelan noted that the documentation of antenatal counselling was strong - the patient had clearly declined the planned C-section - so breach was denied on that point. However, breach was accepted regarding the lack of detailed consent for forceps delivery.

Despite this, causation was weak. Post-mortem findings showed the fatal intracranial bleed was directly caused by the ventouse and not the abandoned forceps, meaning earlier or different consent would not have changed the outcome.

This case underscores the medico-legal weight of robust antenatal documentation and nuanced consent discussions, particularly when patients decline recommended interventions or when multiple instrumental methods are considered.

Key Takeaways for Solicitors

• Scrutinise escalation timelines in CTG-related cases.
  Pathological CTGs are rarely missed - but suspicious traces often fall into a “grey zone.” Understanding when escalation should have occurred is crucial to determining breach.

• Correlate fetal heart trace findings with decision-to-delivery intervals.
  Even small delays can alter neurological outcomes. Claims involving hypoxic-ischaemic encephalopathy (HIE) often hinge on whether clinicians acted within the 30-minute standard - and whether that timing was clinically appropriate in context.

• Review antenatal documentation and consent evidence closely.
  Many obstetric claims turn on whether a woman’s choices were properly documented and contextualised. Strong antenatal notes and contemporaneous consent records can make or break breach arguments.

• Consider human factors and governance failures alongside clinical errors.
  Staffing shortages, fatigue, and poor oversight often underpin systemic breach. Understanding these wider governance issues helps build more defensible and evidence-based expert reports.

• Evaluate causation pragmatically.
  As Dr Phelan highlighted, not every breach alters the outcome. Where delivery timing or decision-making would not reasonably have changed prognosis, causation arguments weaken - and recognising this early can save significant litigation cost.

The Four C's

• Choice: "In maternity, women will choose their seat and they'll also choose not to wear their seat belt, and we still have to fly the plane. And then when we hit turbulence and there's a head injury, somehow they will take it back and say, well, you should have insisted I wore the seat belt."

• Context: "Every risk report or MNSI report in the country talks about maintaining a global helicopter view of women's labour..."

• Consent: "Fully informed consent, the way it currently sits nationally is something that I don't think is achievable."

• Continuity: "Continuity of care one to one care with midwives, continuity of care with clinicians or consultants is a dream in the NHS that we've never achieved."

Watch the full webinar here >