Failure to Adequately Monitor Fetal Heart Rate
4th July 2018
Without significant delay after the onset of regular contractions, a full-term patient arrived at the maternity unit. There, at least one vaginal examination indicated that her labour had begun normally. However, the midwives on duty that afternoon had difficulty in determining the precise position of the foetus.
During the remainder of the afternoon, the midwife team recorded occasional deviations in the foetal heart rate as measured by a cardio tachograph machine (CTG) or electronic heart rate monitor (EHM). Nonetheless, with registrar advice, the duty medical team deemed the tachograph soundings to be within the normal range.
As the evening progressed, the duty staff noticed that the patient had gone into the full dilation stage. After an hour of passive descent, the delivery team advised the mother-to-be to begin pushing. During this active stage of labour, the quality of the indications of the baby’s heart rate rhythm (per the CTG output) reduced significantly, a fact that apparently and unfortunately went unnoticed at the time. A subsequent review by legal medical experts showed that foetal heart rhythm decelerated and the baseline readout wandered following some twenty minutes of pushing, thus rendering the recordings too complicated to classify.
During the second and final hour of labour leading up to the delivery, it was still not possible to evaluate the CTG trace, as there was little or no recording of the baby’s cardiac rate. Medical notes from the time recorded a heartbeat at the usual rhythm, though these writings seemed to be snapshots as distinct from an official classification.
In the twenty-seven minutes before the birth, the baby had begun crowning – but regrettably, no attempt was made to expedite the delivery until it became too late to do so. In fact, the duty medical team had considered an episiotomy to accelerate delivery – but in the end, they did not opt to carry out the procedure. In addition, it appeared that staff had voiced the possibility of an episiotomy due only to the slow progress of the labour, without any apparent reference to the problems experienced in determining the foetal heart rate.
In summary, the baby was born two and a half hours after the second stage of labour commenced, and not for some ninety minutes after the EHM trace had become unintelligible. Records showed that the baby was born in poor condition with an Apgar score of one after one minute and had the same low assessment after five minutes. The rating improved to five (out of ten) some ten minutes post-delivery. Following successful resuscitation, the baby received care in the hospital’s neonatal intensive care unit (NICU) and a subsequent diagnosis of cerebral palsy.
Independent Clinical Findings
In its review, Canterbury-based clinical and legal specialist organisation TMLEP* found three areas in which it considered patient care to have been substandard. In its view, each of these factors contributed to the resulting deprivation of oxygen supply to the baby and resulted in the cerebral palsy:
- Failure to monitor the heart rate of the foetus correctly.
- Poor quality CTG trace recording.
- Lack of informed decision-making on the part of the midwives.
Of the three above issues, the panel found the failure to check the heart rate adequately during the second stage of labour to be of the most concern in not detecting and preventing abnormalities.
Due to the poor quality CTG output during the pushing phase, the midwife team would not have been able to monitor the well being of the foetus; nor would it have been possible for them to make an informed decision regarding whether – and how – the baby was compromised. In such situations, delivery teams should secure an adequate cardio trace, such as with foetal scalp electrodes. When this is also not possible, staff should immediately refer the case to an obstetrician as an emergency, to expedite the birth.
In this case, if the team had questioned the poor quality traces and the decelerated heart rate, they might have been more aware of the need to increase the effort to obtain a reliable cardiac trace. Had reliable indications been achieved, the nursing staff could well have seen the necessity for expedited delivery via an episiotomy or an instrumental birth. In turn, such handling would probably have improved the outcome as the baby would not have suffered oxygen deprivation.
Recommendations for Prevention of Recurrence(s) and Improvement of Safety
If foetal cardiac traces fluctuate or are poor in quality, it is vitally important to obtain a better quality trace to check and detect possible compromise of the foetus, along with any need for expedited delivery.
When abdominal transducers do not detect the foetus cardiac rate with sufficient accuracy, the medical team ought to consider foetal scalp electrodes, unless contraindications exist.
Finally, when it is not possible to interpret a CTG trace, even with high-quality recording equipment, the patient should receive an urgent referral to an obstetrician.
Based on a recent medical report entitled A Clinical Risk Case Study – Failure to Adequately Monitor Foetal Heart Rate, published by the TMLEP Clinical Risk and Patient Safety Publishing Group* and co-authored by Mrs Jane Emily Ash RM BSc, Midwifery Practitioner. Reference: TMLEP Clinical Risk Case Studies 1 (10), 1.
*TMLEP has over a thousand professional clinical members and provides independent advice on healthcare practice.
Notice and disclaimer
This article is meant to raise awareness of clinical risk issues, reduce recurrence and improve patient safety. It is not medical advice. Details have been changed or omitted to guarantee anonymity, although clinical learning points remain unchanged.