Medico-legal risk: What family physicians providing obstetric care need to know

At the end of 2024, CMPA membership included 2,901 family physicians whose practice included obstetric care (Type of Work 78).

The graph below compares the 10-year trends of medico-legal experiences between these family physicians and all CMPA members. The cases include all civil legal actions or College complaints that the members were involved in and are not limited to obstetric cases.

What are the relative risks of a medico-legal case for family physicians providing obstetric care?

Between 2015 and 2024, family physicians providing obstetric care had significantly higher rates of College complaints¹ (p<0.0001) when compared to all CMPA members.

What are your risk levels regarding medico-legal cases, compared to other family physicians providing obstetric care?

Percentage of family physicians providing obstetric care, 5-year case frequency

	%, Medico-legal case frequency, 5 years
No case	77.5
1 case	17.5
2 cases or more ( 2020 - 2024)	5.0

Percentage of family physicians providing obstetric care, 1-year case frequency

	%, Medico-legal case frequency, 1 year
No case	92.8
1 case	6.4
2 cases or more	0.8

In a 5-year period (2020 – 2024)², 23% of family physicians providing obstetrics care were named in at least 1 medico-legal case. 5% had 2 or more cases in this period.

Annually, 7% of family physicians providing obstetric care were named in at least 1 case per year. 1% had an average of 2 or more cases per year.

Between 2020 and 2024, 151 obstetrics-related cases, including civil legal actions, College and hospital complaints, closed in CMPA involved a family physician. In many of these cases, physicians in other specialties such as obstetricians and anesthesiologists were also involved.

Because obstetric care often requires collaboration among many healthcare providers, the following sections present findings from 639 obstetric cases closed by the CMPA between 2020 and 2024, involving any physician who provided obstetric care.

What are the most common patient complaints and peer expert³ criticisms? (n=639)

Complaints are a reflection of the patient’s perception that an issue occurred during care. These complaints are not always supported by peer expert opinion. Peer experts may not be critical of the care provided or may have criticisms that are not part of the patient’s allegation.

What are the most frequent interventions with peer expert criticism? (n=639)

Intervention frequencies among medico-legal cases are likely representative of physicians’ practice patterns and do not necessarily reflect high-risk interventions. In addition to criticism related to the performance of the above interventions, peer experts may be critical of a delay in performing an intervention (e.g. Caesarean section) or an inappropriate use of these interventions (e.g. augmentation of labour with an abnormal fetal heart rate, forceps with a high head).

Diagnostic error occurred in 193 cases. This resource is focused on family physicians providing obstetric care. The following examples of peer expert criticism demonstrate issues and circumstances family physicians encountered that contributed to a diagnostic error.

• Delay or failure to perform an intervention
  • Peer experts were critical of a family physician’s failure to take steps to ensure fetal well-being (e.g fetal scalp electrode) indicated by a prolonged abnormal fetal heart tracing.
  • A physician failed to order regular biophysical profiles for a fetus with known growth restriction.
  • A patient underwent a late medical termination of pregnancy for a fetus with chromosomal abnormalities after a family physician failed to order maternal serum screening.
  • A family physician failed to perform a fetal fibronectin test for a patient in preterm labour.
• Inadequate communication with other healthcare providers
  • An infant suffered a brachial plexus injury when a family physician failed to consult obstetrics for assistance in managing shoulder dystocia.
  • An infant died when a family physician failed to consult obstetrics for a Caesarean section for uterine tachysystole and repetitive late decelerations of the fetal heart rate.
  • Peer experts were critical of a family physician for failing to perform an instrumental vaginal delivery with a double set-up and for failing to consult the obstetrician prior to attempting the delivery.
  • A lack of clear communication between the nurse and the physician about concerns around the fetal heart rate led to a delayed delivery causing neurological injury to the infant.
• Misinterpretation of a test
  • An infant died when a family physician failed to recognize deep variable decelerations of the fetal heart rate as abnormal.
  • An infant was born with a neurological injury when an atypical fetal heart rate pattern was allowed to continue beyond the recommended guidelines.
• Deficient clinical assessment
  • A family physician failed to assess a patient for cephalopelvic disproportion, which led to a patient requiring an emergency Caesarean section for maternal exhaustion and an abnormal fetal heart tracing.
  • A physician failed to perform adequate prenatal assessments for a patient with a history of miscarriage.
  • A family physician failed to diagnose uterine tachysystole in a patient receiving oxytocin.
  • Peer experts were critical of a family physician’s failure to perform an ultrasound prior to performing a vaginal exam on a patient presenting with second trimester bleeding.
• Inadequate documentation
  • Peer experts were critical of a family physician’s lack of contemporaneous documentation of a patient’s labour and post-partum course in hospital.
  • A family physician failed to document fundal heights during a patient’s antenatal visits.

What are the top factors associated with severe patient harm⁴ in medico-legal cases? (n=639)

Risk reduction reminders

The following risk management considerations have been identified for physicians providing obstetric care based on peer expert feedback:

Antepartum

• Discuss each patient's individual labour and delivery options in the antepartum period and consider the possibility of unanticipated events requiring urgent or emergent interventions.
• Consider early referral to an obstetrician or maternal fetal medicine specialist for high-risk patients.

Intrapartum

• Clearly communicate persistent fetal heart rate concerns and clinical concerns to appropriate team members (e.g. surgical team) and emphasize timely attendance of appropriate staff or delivery.
• Reinforce the need for regular training in fetal assessment and situational awareness for all obstetrics clinicians. Have clear policies for the interpretation and management of atypical or abnormal fetal heart rate tracings.
• Incorporate clinical pathways, clinical practice guidelines, or decision tools as appropriate.
• Determine if a back-up plan is required prior to attempting a trial of instrumental vaginal delivery.
• Be mindful of a change in patient condition when using high-alert medications such as oxytocin.
• Consider using a standardized template for situations in which timelines are important (e.g. shoulder dystocia, assisted vaginal deliveries).

Postpartum

• Be alert to potential postpartum complications when a patient repeatedly returns with the same or worsening symptoms. Reevaluate the diagnostic assumptions and repeat the physical examination. Consider whether to consult with a colleague.
• Following an obstetrical emergency, discuss the circumstances and outcomes with the patient and their family. Consult the CMPA handbook Disclosing harm from healthcare delivery or contact the Association for individual advice on disclosure.
• Debrief with the team following an urgent delivery or patient safety incident to evaluate the effectiveness of team communication; document the care provided.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA resources.

• CMPA Research:
• Implementing obstetrics quality improvement is associated with improved workplace culture
• CMPA workshops
• Effective team interactions
• Advanced diagnostic reasoning
• Theatre arts
• CMPA eLearning activities
• Competing priorities and team situational awareness in obstetrics
• Interprofessional communication in obstetrics
• Fostering a culture of psychological safety in healthcare teams
• Hospital policies: when healthcare providers have different opinions in obstetrics

Looking for more?

For any data request, please contact [email protected]

Notes

1. 1. 
   Physicians voluntarily report College matters to the CMPA. Therefore, these cases do not represent a complete picture of all such cases in Canada.
2. 2. 
   It takes an average of 2-3 years for a patient safety incident to progress into a medico-legal case. As a result, newly opened cases may reflect incidents that occurred in previous years.
3. 3. 
   Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
4. 4. 
   Referring to both maternal and neonatal harm. In CMPA Research glossary, severe patient harm is defined as symptomatic, requiring life-saving intervention or major medical/surgical intervention, or resulting in a shortened life expectancy, or causing major permanent or temporary harm or loss of function.
5. 5. 
   Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
6. 6. 
   The American Society of Anesthesiologists (ASA) Physical Status Classification System is used by physicians to predict a patient’s risks ahead of surgery. ASA status 3 indicates severe systemic disease.
7. 7. 
   Based on peer expert opinions. These include factors at provider, team and system levels. For obstetric cases, there is no evidence for any system level factors in the data.