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Ella Lee

Vivian Li

Health officials are taking a second look at a new rule requiring a doctor to be present when ordering a medical procedure, such as inducing labour, for a pregnant woman.
In Hong Kong, it is common for an obstetrician not to appear in the delivery room until the midwives tell the doctor the baby is 'ready'. 
But in recent years there has been an influx of expectant mothers from the mainland, who usually have fewer pre-natal checks, giving rise to concern about increasing maternal deaths and complications.
The Department of Health introduced the new requirement, aimed at improving maternal safety, in April in a revision to its code of practice for private hospitals. 
For the first time, it requires a doctor to be present to assess the mother-to-be before ordering labour to be induced or medication for the delivery. The code says: 'Before a decision is made to perform an intervention, e.g. labour induction, the patient should be assessed on-site by a medical practitioner with appropriate qualifications and experience.' 
The department says 'intervention' covers both medical procedures and medication. 
The code was revised after a Shenzhen woman died of a rare condition at the private Baptist Hospital  in October last year. Her attending doctor was not present during an emergency Caesarean section. 
The rule has sparked  heated debate among medical professionals. 
Some are frustrated that the requirement was imposed without wide consultation. They also worry that it could have a far-reaching effect on their private practices. 
Complaints from doctors have prompted the department to ask  the College of Obstetricians and Gynaecologists, the top training body for specialists in the field,  whether the new rule should be relaxed and, if so, how. 
Director of Health Dr Lam Ping-yan  told the Post his team was having discussions with various parties, including private hospitals, doctors and the college. 'Ideally, doctors should examine the mothers before ordering any intervention, but [in practice], a doctor may have already conducted a check-up on a woman a day before she is admitted to hospital,' Lam said. 'So should we still require a doctor to come on-site before starting the induction of labour? We are listening to doctors' concerns.
'We want to discuss with the college in what situations a doctor's presence is absolutely necessary and on what occasions only midwives' presence is needed,' he said.
 Most private hospitals rely on visiting doctors who run their own clinics to bring them patients. In emergencies, those doctors have to travel to the hospital. In some cases, they may give instructions over the phone to midwives to induce labour.
The department's code of practice for private hospitals, nursing homes and maternity homes contains guidelines for the city's 13 private hospitals. Operators that breach the code face suspension of their licences, although such a severe punishment is highly unlikely. 
Principal medical officer Dr Tina Mok  said the new requirement was only a guideline, so it could not define when exactly doctors should be on-site. 
Tim Pang Hung-cheong,  spokesman for the Patients' Rights Association,  said it was quite common that doctors appear rather late at deliveries, and this should be changed. 
'A private hospital should also have its own back-up medical team if the attending doctor cannot respond in time,' Pang said.
The Private Hospitals Association supports the safety measure as a 'general principle', but its president, Dr Alan Lau Kwok-lam, said hospitals should have autonomy in designing their in-house safety rules. 
'There should not be a rigid rule; an individual hospital has its own culture and contingency plans,' he said. Lau said the rule did not include the word 'on-site' when the department consulted the association about the revision earlier this year.
Dr Robert Law Chi-lim,  an obstetrician and gynaecologist, said the new requirement was unnecessary. 
'Doctors and midwives work as a team. It is a doctor's clinical decision when he should be attending the patient; we should trust this decision,' Law said. 
Dr Ares Leung Kwok-ling, senior vice-president of the college, said it had not yet formed a position. 
Leung, who is also the deputy medical director at Union Hospital in Sha Tin, said he respected the rationale for enhancing safety but was worried that strictly requiring doctors to be on-site might backfire. 
'Sometimes it will be much quicker for a doctor to instruct a midwife over the phone to start a procedure while he's on his way, rushing to the hospital,' Leung said.
He said that if an obstetrician failed to respond to an emergency, the hospital's administrators should be alerted and should send its own team to help.
Chan Wing-yan, a schoolteacher who gave birth at a private hospital a few days ago, said: 'Midwives in Hong Kong are very experienced and professional. It is acceptable for doctors to be off-site as long as they can attend the mothers during critical moments.'
Lawrence Wong Wah-tak, whose wife recently gave birth to their first baby, also said it was reasonable for doctors to delegate duties to well-trained midwives.
 'Our attending doctor runs a clinic near the hospital; he came on time, and we never worried about this,' Wong said.
On October 10 last year, a Shenzhen woman died at Baptist Hospital after an emergency caesarean section to deliver a boy. The hospital said the 33-year-old woman suffered an amniotic fluid embolism, a very rare condition seen once in about 20,000 cases. The woman's husband said no doctor had visited his wife during the 10 hours before she had the emergency surgery. 
In an interview with the Post in October, the woman's attending doctor, Dr James Lam How-kit,  said it was usual for the attending doctor not to be present during the early stages of labour. 
Lam also said he had done his best, arriving 15 minutes after he received the news that his patient had become unresponsive. 
Mok said the department's investigation found that the hospital had not breached the code of practice in that case.
 'The hospital responded to the emergency in that case. We do not find any persistent errors or system failure with the hospital.'




Rule brings doctors to delivery room earlier