16. Maternity clinical incident report Events that could result in important short- or long-term adverse effects for the mother or baby should be based on local consensus but would probably include: Maternal/delivery incident loss >1500 ml Cord accident Deep venous thrombosis Duration 2nd stage >3hrs (prim) Duration 2nd stage >1hr (parous) Duration established labour >18 hrs Eclampsia Hb <8g/dl postpartum Hysterectomy/laparotomy Fetal/neonatal incident APGAR <7 at 5 minutes Birth trauma Cord pH <7.2 Neonatal death Neonatal seizures Stillbirth >500g Shoulder dystocia Small for gestational age Term baby admitted to paediatric unit Unsuspected fetal anomaly Organisational incident Blood-Anaesthetic complications ITU admission Maternal death Pulmonary embolism Third degree tear Unsuccessful forceps/ventouse Uterine rupture Delay >30mins for emergency CS Delay following call for assistance Delivery outwith labour suite Faulty equipment Interpersonal conflict over case management Potential service user complaint Prescribing/administration error Retained swab/instrument Violation of local protocol/guideline