Editor’s Note: The Canadian Medical Protective Association (CMPA), which is a mutual medical defense organization for Canadian physicians, protects the professional integrity of physicians and promotes safe medical care in Canada. This article is based on a CMPA study and was published originally on the CMPA website in June 2025.
At the end of 2024, CMPA membership included 2,901 family physicians whose practice included obstetric care. Figure 1 compares the 10-year trends of medical legal experiences between these family physicians and all CMPA members. The cases include all civil legal actions or provincial/territorial medical regulatory authority (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?
Figure 1
Between 2015 and 2024, family physicians providing obstetric care had significantly higher rates of college complaints (p<0.0001) when compared to all CMPA members.1
What are the risk levels regarding medico-legal cases, compared to other family physicians providing obstetric care?
In a 5-year period (2020–2024), 23% of family physicians providing obstetrics care were named in at least one medical-legal case. 5% had two or more cases in this period.2
Annually, 7% of family physicians providing obstetric care were named in at least one case per year. 1% had an average of two cases or more per year.
Between 2020 and 2024, 151 obstetrics-related cases, including civil legal actions and College and hospital complaints, closed by 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 638 obstetric cases closed by CMPA between 2020 and 2024, involving any physician who provided obstetric care.
What are the most common patient complaints and peer expert criticisms?3
Complaints reflect a 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?
Intervention frequencies among medical 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, such as a Caesarean section, or an inappropriate use of these interventions, such as augmentation of labor with an abnormal fetal heart rate or 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 such as in the case of a 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 situation where a fetus is smaller than expected for its gestational age.
- A patient underwent a late medical termination of a 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 labor.
- 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 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 with second trimester bleeding.
- Inadequate documentation
- Peer experts were critical of a family physician’s lack of contemporaneous documentation of a patient’s labor 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 harm in medico-legal cases?4
- Patient factors5
- ASA status 3+6
- Maternal age >35
- Multiple gestation
- Pre-eclampsia, eclampsia and HELLP syndrome
- Maternal infection such as sepsis or an obstetric wound infection
- Abnormal bleeding and hemorrhage such as a placental abruption or immediate postpartum hemorrhage
- Uterine rupture
- Provider factors7
- Deficient assessment
- Failure to refer, such as a situation in which a family physician failed to consult OBS for a patient with risk factors
- Failure to admit, such as following atypical fetal heart rate findings
- Failure to read medical records, which indicated biophysical profile or fetal heart rate tracings
- Issues with intrapartum fetal monitoring
- Misinterpretation of fetal heart rate
- Failure to initiate internal fetal monitoring
- Deviation from clinical practice guidelines such as the Society of Obstetricians and Gynecologists of Canada (SOGC) guidelines for fetal health surveillance and induction of labor
- Team factors8
- Poor team communication related to an abnormal fetal heart rate
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 labor 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 such as the 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 tracing.
- 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 in situations such as shoulder dystocia or 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.
Limitations
The numbers provided in this report are based on CMPA medico-legal data. CMPA medical legal cases represent a small portion of patient safety incidents. Many factors influence a person’s decision to pursue a case or file a complaint, and those factors vary greatly by context. Thus, while medico-legal cases can be a rich source of important themes, they cannot be considered representative of patient safety incidents overall.