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Healthcare risk assessment

Obstetrics and Maternal-Fetal Medicine Risk Assessment: Monitoring, Escalation and Safe Birth Controls

A worked example showing how a birth unit finds, scores and controls risks to mother and baby, from fetal monitoring and haemorrhage to handovers, records and infection control.

Updated November 2026 8 hazards assessed Review every 3 months Highest risk: Critical to High
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Executive summary

This assessment shows how a hospital birth unit can find, rate and control the risks that most threaten mothers and babies. Eight hazards were chosen because they are plausible in everyday obstetric and maternal-fetal care, from delayed recognition of fetal distress and severe bleeding to handover errors, medicine dosing, equipment faults, record privacy and infection spread. Each hazard is scored before controls and again after the existing and added controls. Haemorrhage recognition is the most serious inherent risk because delay can be fatal within minutes. After the proposed controls, most hazards fall to Medium or Low, but serious obstetric emergencies stay at Medium because the impact remains high. Early actions are a simulated haemorrhage drill, a standard handover tool, a monitoring equipment check and a rule for escalating abnormal traces. Every score illustrates method, and specialist clinical review is needed before any real change.

Focus area
Obstetrics and maternal-fetal medicine
Setting
Labour ward, antenatal clinic and postnatal care within a hospital obstetric unit
Method
Five by five likelihood and impact risk register with clinical governance review

Scope

This assessment covers antenatal, intrapartum and immediate postnatal care on a hospital obstetric unit, including fetal monitoring, emergency response, medicines, records, staffing and infection control. It looks at risks to the mother, the baby, staff and the service. It does not replace a formal site-specific assessment, and jurisdiction, unit size, staffing model and equipment are assumptions made for teaching.

Context

The unit has midwives, obstetricians, anaesthetic staff, neonatal support, healthcare assistants and a clinical lead. Care is delivered on a labour ward with birth rooms, theatre, an antenatal clinic and a postnatal ward. Monitoring uses cardiotocography, ultrasound, blood pressure devices and electronic records. Each hazard is scored before controls to show its natural level, then again after existing controls and the additional controls proposed. Clinical judgement and specialist review remain central to every decision.

Objectives, assets and stakeholders

The objective is to give safe, respectful and timely care to every woman and baby, prevent avoidable harm, protect privacy and keep staff able to act in an emergency. Assets include the lives and wellbeing of mothers and babies, monitoring and resuscitation equipment, medicines and blood products, clinical records, staff skills and the reputation of the unit. Stakeholders include women and their families, midwives, obstetricians, anaesthetists, neonatal teams, managers, the clinical governance committee, regulators and partner services. Every hazard has one owner role, and the clinical lead reviews the register with the governance committee each quarter.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 2, score 8, medium: H07 Likelihood 4, impact 3, score 12, high: H03 H06 Likelihood 4, impact 4, score 16, high: H01 Likelihood 4, impact 5, score 20, critical: H04
3 Possible Likelihood 3, impact 4, score 12, high: H05 Likelihood 3, impact 5, score 15, high: H02
2 Unlikely Likelihood 2, impact 4, score 8, medium: H08
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible
2 Unlikely Likelihood 2, impact 2, score 4, low: H06 H07 Likelihood 2, impact 3, score 6, medium: H02 H03 H05 Likelihood 2, impact 4, score 8, medium: H01 Likelihood 2, impact 5, score 10, high: H04
1 Rare Likelihood 1, impact 4, score 4, low: H08
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Delayed recognition of abnormal fetal heart rate traces 16 High 8 Medium Clinical lead for intrapartum care
H02 Failure of monitoring, ultrasound or resuscitation equipment 15 High 6 Medium Biomedical engineer
H03 Handover errors at shift change and transfer of care 12 High 6 Medium Ward manager
H04 Delayed recognition and treatment of postpartum haemorrhage 20 Critical 10 High Clinical lead for obstetrics
H05 Medicine and infusion dosing errors 12 High 6 Medium Pharmacy lead
H06 Privacy breach and incomplete consent documentation 12 High 4 Low Information governance lead
H07 Staffing shortage and gaps in competence 8 Medium 4 Low Head of midwifery
H08 Infection and exposure spread on the unit 8 Medium 4 Low Infection prevention lead
H01

Delayed recognition of abnormal fetal heart rate traces

Safety Before 16 After 8

Abnormal cardiotocography patterns are misread, not reported, or not acted on in time, so fetal hypoxia develops before the team intervenes.

Who or what is affected: Babies, mothers, midwives and obstetricians

Causes

Fatigue, competing demands, varied interpretation and high workload during labour.

Consequences

Hypoxic brain injury, emergency birth, long term harm and complaints.

Existing controls

  • Midwives document fetal traces at set intervals.
  • Flagged traces are reviewed by a senior clinician.

Control gaps

Traces are reviewed on paper, and escalation depends on individual judgement.

Additional controls

  • Prevent: Provide regular training on trace interpretation using a shared classification language.
  • Detect: Audit a sample of traces each month and compare findings with outcomes.
  • Respond: Use a standard escalation pathway with a set time limit for senior review.
Likelihood 4 x impact 4 before; 2 x 4 after Owner: Clinical lead for intrapartum care Target: Within 30 days Early warning: Abnormal traces that remain unreviewed for more than 30 minutes.
H02

Failure of monitoring, ultrasound or resuscitation equipment

Operational Before 15 After 6

Cardiotocography machines, ultrasound units, infusion pumps or resuscitaires fail, give wrong readings or run out of battery during a birth.

Who or what is affected: Women, babies and the birth team

Causes

Ageing devices, missed service dates and damaged batteries or cables.

Consequences

Missed warning signs, inaccurate readings and unsafe delay in care.

Existing controls

  • Devices are serviced under a maintenance schedule.
  • Staff complete a short start up check at each shift.

Control gaps

Start up checks are recorded on paper and not reviewed centrally.

Additional controls

  • Prevent: Replace units overdue for service and hold a spare monitor on each labour ward.
  • Detect: Log daily checks and flag any device with a fault or missing check.
  • Respond: Keep a backup plan for moving a woman quickly to a working room.
Likelihood 3 x impact 5 before; 2 x 3 after Owner: Biomedical engineer Target: Within 14 days Early warning: Any device check missing or fault logged on a labour ward.
H03

Handover errors at shift change and transfer of care

People Before 12 After 6

Information about a woman's risks, medicines, plan or fetal status is lost or misunderstood when staff change, so the next team acts on incomplete facts.

Who or what is affected: Women, babies and the incoming team

Causes

Busy periods, interruptions, unclear documents and staff new to the unit.

Consequences

Missed doses, delayed reviews, repeated tests and avoidable harm.

Existing controls

  • Verbal handover takes place at the bedside each shift.
  • A written care plan is kept in the notes.

Control gaps

Handover content is not standardised and is rarely audited.

Additional controls

  • Prevent: Introduce a structured handover tool with fixed fields for risks and pending actions.
  • Detect: Sample handover records each month and check that key risks are carried forward.
  • Respond: Require a senior check when a woman moves between teams.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Ward manager Target: Within 45 days Early warning: Handover entries missing a named clinician or a structured summary.
H04

Delayed recognition and treatment of postpartum haemorrhage

Safety Before 20 After 10

Blood loss after birth is underestimated or the response is slow, so the woman becomes critically unwell before treatment and blood products arrive.

Who or what is affected: Mothers, babies, midwives, anaesthetists and blood bank staff

Causes

Underestimated blood loss, uterine atony, retained tissue and a delayed call for help.

Consequences

Shock, organ failure, transfusion reactions, emergency hysterectomy or death.

Existing controls

  • Blood loss is estimated and recorded after each birth.
  • A major haemorrhage protocol is displayed in each birth room.

Control gaps

Drills are not held across all shifts, and blood product access is not tested.

Additional controls

  • Prevent: Keep a haemorrhage trolley checked and sealed at the start of each shift.
  • Detect: Measure blood loss by weighing where possible and total it at set times.
  • Respond: Run a timed simulation drill twice a year with a structured debrief.
Likelihood 4 x impact 5 before; 2 x 5 after Owner: Clinical lead for obstetrics Target: Within 30 days Early warning: Estimated blood loss rising while pulse and blood pressure change.
H05

Medicine and infusion dosing errors

Safety Before 12 After 6

Oxytocin, magnesium sulphate, antibiotics or analgesia are prescribed, prepared or given at the wrong dose, rate or route, or to the wrong woman.

Who or what is affected: Women, babies and nursing staff

Causes

Look alike packaging, rushed preparation, dosing by weight and unclear orders.

Consequences

Uterine overstimulation, fluid overload, toxicity, allergic reaction or neonatal depression.

Existing controls

  • Prescriptions are checked by a pharmacist before supply.
  • Infusion pumps have dose limits set for high alert medicines.

Control gaps

Double checks are skipped during busy periods, and pump limits can be overridden.

Additional controls

  • Prevent: Use standard concentrations and pre-filled options for high alert medicines.
  • Detect: Hold a documented double check at the bedside for every high alert infusion.
  • Respond: Keep antidotes and a clear incident reporting route on each ward.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Pharmacy lead Target: Within 60 days Early warning: A high alert infusion started without a documented second check.
H06

Privacy breach and incomplete consent documentation

Technology and data Before 12 After 4

Records are viewed without a care reason, shared on unsecured devices, or lack documented consent for tests, procedures or sharing of information.

Who or what is affected: Women, partners, staff and the information governance team

Causes

Shared logins, personal devices, busy wards and unclear consent forms.

Consequences

Loss of trust, complaints, unlawful disclosure and harm to dignity.

Existing controls

  • Staff sign confidentiality terms and complete annual training.
  • Electronic records need a login, and access is logged.

Control gaps

Consent for sharing is recorded in several places and is hard to find.

Additional controls

  • Prevent: Restrict record access by role and require a stated care reason for each view.
  • Detect: Review access logs each month and investigate unusual patterns.
  • Respond: Maintain a clear breach notification route and a standard letter for affected women.
Likelihood 4 x impact 3 before; 2 x 2 after Owner: Information governance lead Target: Within 45 days Early warning: Access to a record by staff with no current involvement in the woman's care.
H07

Staffing shortage and gaps in competence

People Before 8 After 4

Too few midwives or doctors, or staff without current emergency skills, leave the unit unable to meet demand safely during peak or sickness periods.

Who or what is affected: Women, babies, existing staff and managers

Causes

Recruitment gaps, sickness, high turnover and reliance on agency cover.

Consequences

Delays in care, fatigue, errors and staff burnout.

Existing controls

  • A rota sets minimum safe numbers for each shift.
  • Bank staff are used when rota gaps arise.

Control gaps

Competency is checked annually, not when staff change roles or return from leave.

Additional controls

  • Prevent: Set competency checks for emergency skills and record them on a central list.
  • Respond: Use a safe staffing escalation to the on call manager when numbers fall below the minimum.
Likelihood 4 x impact 2 before; 2 x 2 after Owner: Head of midwifery Target: Within 90 days Early warning: Shifts running below the minimum safe staffing level.
H08

Infection and exposure spread on the unit

Safety Before 8 After 4

Pathogens spread between women, babies and staff through poor hand hygiene, contaminated equipment, unsafe injections or exposure to blood and body fluids.

Who or what is affected: Women, babies, staff and visitors

Causes

Busy shifts, shared equipment, crowded bays and gaps in cleaning routines.

Consequences

Sepsis, neonatal infection, staff illness and a wider outbreak.

Existing controls

  • Hand hygiene gel is placed at each bedside.
  • Staff are vaccinated against relevant infections on joining.

Control gaps

Audit results reach staff too slowly to change practice.

Additional controls

  • Prevent: Use single use equipment where possible and follow cleaning schedules.
  • Detect: Audit hand hygiene and equipment cleaning each month.
  • Recover: Keep a sharps and exposure procedure with rapid testing and follow up.
Likelihood 2 x impact 4 before; 1 x 4 after Owner: Infection prevention lead Target: Within 60 days Early warning: Repeated audit failures in hand hygiene or equipment cleaning.

Rating method and evaluation

Each risk is rated on two five-point scales. Likelihood runs from Rare to Almost certain, and impact runs from Insignificant to Catastrophic, with harm to a mother or baby weighted most heavily. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. The score guides priority and is not a precise measurement. Inherent risk is the score before any controls, and residual risk is the score after existing and added controls are working. Controls are rated only when they are in use and tested, not when they are written. Anything Critical needs immediate senior action, anything High needs a dated plan and a named owner, anything Medium needs routine controls and checks, and anything Low is accepted and monitored. Midwives, obstetricians and women's representatives challenge ratings at governance meetings, and any score is reviewed after a serious event, a near miss or when an indicator reaches its threshold.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 3 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Time from a reported major bleed or an abnormal fetal trace to senior review.Escalate to the clinical lead when review exceeds the agreed target in any case, and to the governance committee if it happens more than once a month.
Handover entries missing a named clinician or a structured summary.Escalate to the ward manager on any missed handover, and review the trend at each governance meeting.
Equipment checks not signed off or devices overdue for service.Remove the device from use at once and escalate to the biomedical engineer, then to the clinical lead if the gap persists for a week.
Access to clinical records outside a care relationship or unusual bulk downloads.Escalate to the information governance lead at once, and to the privacy officer if access is confirmed.
Infection control audit findings, such as missed hand hygiene or unclean equipment.Escalate to the infection prevention lead within one working day, and to the clinical lead if the same finding repeats.

Contingency arrangements

If a serious event occurs, such as a major haemorrhage, cardiac arrest or a baby needing urgent neonatal resuscitation, the clinical lead activates the emergency response and the on call consultant attends. Staff follow local emergency protocols and call for additional help without delay. Records are preserved, and the service informs the woman and her family openly. Affected equipment is removed from use, and the incident is reported through the governance process. Specialist and legal contacts are made through the risk lead as required in the relevant jurisdiction.

Prioritized action plan

  1. Run a simulated haemorrhage drill with a timed response, owner clinical lead, within 30 days.
  2. Set a rule for escalating abnormal fetal traces to a senior clinician, owner obstetric consultant, within 30 days.
  3. Check monitoring and resuscitation equipment daily with a logged sign off, owner biomedical engineer, within 14 days.
  4. Introduce a structured handover tool at every shift change, owner ward manager, within 45 days.
  5. Confirm double checks for high alert medicines during busy periods, owner pharmacy lead, within 60 days.

Conclusion

Safe obstetric care depends on steady habits: recognising deterioration early, escalating without hesitation, practising emergencies, handing over clearly, checking equipment and medicines, and protecting privacy. The highest scores sit with haemorrhage, fetal monitoring and medicine errors, and each has controls that bring the residual score down. Treat the register as a living record, review it on the stated cycle, and seek qualified clinical and legal advice for any real decision.

Assumptions and limitations

Assumptions

  • The unit provides round the clock obstetric and neonatal cover, with a named consultant on call.
  • Jurisdiction and national guidance are not specified, so duties are described in general terms only.
  • Equipment is serviced under a maintenance contract, and staff are trained on the devices they use.

Limitations

  • The scores are teaching examples and do not describe any real unit.
  • Clinical guidance changes over time, so specialist review is needed.
  • This is educational content and is not clinical, legal or medical advice.

Related frameworks to study

  • Structured escalation tool such as SBAR
  • Hierarchy of controls
  • Three lines model of risk ownership
  • Failure mode and effects analysis
  • Root cause analysis for serious incidents

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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