A Clinical Risk Case Study- Failure to Adequately Monitor Fetal Heart Rate

A Clinical Risk Case Study- Failure to Adequately Monitor Fetal Heart Rate

The Scene

The Patient, who was full term, went into labour and soon after arrived on the maternity unit. Subsequent vaginal examinations showed that progress was normal however, the midwives struggled to determine fetal position. During the rest of the afternoon, the midwives noted occasional deviations from the norm in the fetal heart rate however, with Registrar input, the CTG’s were deemed normal.

Later that evening, the midwives noted that the Patient was fully dilated, and after an hour of passive descent, the Patient was advised to start pushing. From the onset of the active second stage of labour, the quality of the fetal heart rate recording diminished significantly however, this was not acknowledged by the midwives. Our review identified that within twenty minutes of pushing, fetal heart rate decelerations were recorded and a ‘wandering’ baseline was present, which made the CTG difficult to classify. After an hour of pushing there was virtually no recording of the fetal heart rate, and for the next and final hour of the labour, the trace was completely uninterpretable. The fetal heart was noted occasionally in the contemporaneous records as being audible at a normal rate, but these appear to have been brief snapshots of fetal heart rate, rather than a formal review and classification.

The baby was noted to be crowning twenty-seven minutes prior to birth however, no attempt was made to expedite delivery, until it was too late to do so. Consideration had been given to performing an earlier episiotomy however, this was not performed. The rationale for considering an episiotomy appeared to have been in view of slow progress, rather than in response to the fetal heart rate trace. The baby was born two and a half hours after the onset of the active second stage of labour, and over an hour and a half after the trace became uninterpretable. The baby was born in poor condition, with an Apgar score of one at one minute, one at five minutes and five at ten minutes of age. Resuscitation was successful, and the baby was transferred to NICU for ongoing care. The baby was later diagnosed with cerebral palsy.

TMLEP’s Independent Clinical Findings

The TMLEP review identified three main findings of sub-standard care that was afforded to the Patient during labour. These failures contributed to the baby being starved of oxygen and later being diagnosed with cerebral palsy;

  • Failing to monitor the fetal heart rate
  • Poor quality CTG recording
  • Lack of informed decision making by the midwives
  • The most concerning issue that the independent review identified, was the failure to adequately monitor the fetal heart rate during the second stage of labour, the purpose being to detect for fetal heart rate abnormalities.

Unfortunately, as the quality of the CTG was poor during pushing it would have been almost impossible for the treating midwifery team to determine the baby’s wellbeing and make any informed decision as to whether or not the baby was compromised. In situations such as this, the team should have obtained a better-quality trace (i.e. with a fetal scalp electrode), or in the absence of being able to do this, the Patient should have been referred to an obstetrician and birth expedited.

Had the team questioned the poor-quality traces along with the continuing decelerations in the fetal heart rate, they should have made every effort to obtain a high-quality trace. If this had been obtained, the midwifery team would have expedited the delivery (ie through an episiotomy or referral for an instrumental birth), which would have lessened the time the baby was starved of oxygen and ultimately, on balance, improved the baby’s outcome.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

Where poor quality traces are obtained showing fluctuating fetal heart rate every effort should be made to obtain a better-quality trace to determine whether the baby is compromised and whether delivery should be expedited.

Unless contraindications are present, a fetal scalp electrode should be considered where abdominal transducers are not effectively recording the fetal heart rate.

Where a CTG trace is uninterpretable despite all efforts to obtain a better-quality recording, an urgent referral to an obstetrician should be made, as fetal wellbeing cannot be demonstrated.

To Conclude

It is imperative that decision making during labour is fully informed, and that all aspects of both maternal and fetal wellbeing are taken into consideration. TMLEP’s independent review concluded that fetal wellbeing was not fully considered, with a loss of situational awareness resulting in an inappropriate focus on progress in labour and a lack of action to remedy the poor quality CTG trace. This therefore, compromised the second stages of labour resulting in the failure to expedite delivery. The baby was subsequently exposed to a hypoxic intrauterine environment for a prolonged period of time, which resulted in hypoxic ischemic encephalopathy and a subsequent diagnosis of cerebral palsy.

Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Mrs Jane Emily Ash RM BSc BSc Midwifery Practitioner.

References

  • The TMLEP Clinical Risk and Patient Safety Publishing Group and Mrs Jane Emily Ash RM BSc BSc Midwifery Practitioner. (2018). A Clinical Risk Case Study- Failure to Adequately Monitor Fetal Heart Rate. TMLEP Clinical Risk Case Studies. 1 (10), 1.