This article refers to a recent legal case raising concerns about Patient Safety in the context of a standard midwifery practice for positioning a patient in labour. In a Judgment handed down in December 2007, the High Court held that the 45° 'semi-supine' position with a lateral wedge or pillow(s) falls below an acceptable standard of care in that it exposes women to an increased risk of ACC. It is our understanding that this has long been recognised as standard for labouring women in lithotomy by many if not most midwives in the UK (or so we are widely informed) and we shall be interested in the views from readers. At trial, the Judge accepted the evidence of the Claimant's expert obstetrician (a very senior gynaecologist) that it was not permitted in his own hospital and is inherently unsafe. He argued that even in 1999 only a fully supine (ie flat) position with a 15° degree left lateral tilt using a dedicated wedge (not pillows) or a modern tilting delivery bed was acceptable care. By contrast the Defendant's expert obstetrician argued that it was the practice in all but one hospital he knew of in Europe or America, the exception being Cork in Ireland. We have done our best to verify this out of concern for Patient Safety and so far we think that he may be correct, although it is right to acknowledge the old aphorism that 'Bad Practice does not become Good Practice by Long Practice'.

The problem with the Claimant's argument is that labour can last for many hours and a fully supine position with a large wooden or rubber wedge permanently in situ behind the mother's back may be excruciatingly uncomfortable and difficult to enforce. The semi-supine position does not lead to ACC or recognised problems in any other cases we have heard or read about. However, there is no midwifery or obstetric textbook or literature we have found identifying it (ie either accepting it or advising against it) and it may be that this has simply been handed down by mouth during midwifery training without any empirical data about efficacy. Whilst common sense and basic physics suggest to us that the semi-supine position should be at least partially beneficial in diverting the weight of the gravid uterus away from the vena cava, the relative risks and benefits compared to a fully supine tilted position are not quantifiable (or at least they have not been quantified yet to our knowledge) and on a retrospective analysis one can understand the Judge's conclusion where this child was born with Cerebral Palsy. As in so many legal cases, it will be the 'performance' of one obstetric or midwifery expert witness against another that counts at trial, or the persuasion of one barrister against another, should there be a similar ACC case arising in this standard position. It seems to the writer that something apparently so standard in midwifery practice cannot and should not be left to anecdotal evidence or expert witness performance at trial.

We will be advising the Defendant concerned about Risk Management and would be interested to hear about any readers' views, similar cases or experiences; or to learn about any midwifery or obstetric textbook or literature we have not seen. This is just one example of a decision that troubles members of the profession we have spoken to. There are bound to be a number of decisions by Judges every year that the profession would (if aware of them) regard as troubling and we use this case as an example in support of our argument that it is the responsibility of the profession as well as lawyers to oppose the spread of defensive medicine. Our invitation is for the RCOG and UKCC, for instance, to monitor clinical negligence litigation even more closely and to be proactive by responding on behalf of the profession. If it is indeed correct that the semi-supine position apparently being taught to and adopted by so many midwives in the UK is not effective in reducing the risk of ACC then it must be changed whereas if the position is safe then there ought to be some evidence-base for it from the profession itself and not from Judges.

Matthew Trinder Partner matthew.trinder@bevanbrittan.com