Setting the Scene
The Patient attended the delivery suite with her fourth episode of reduced fetal movements in three weeks. The Patient was admitted for an induction of labour; however, this was delayed over a period of days. Whilst awaiting transfer to the delivery suite, a CTG was performed which was unable to locate the fetal heart rate. Sadly, the Patient’s baby was stillborn, with evidence of intrauterine growth restriction.
The main learning points from this review stem from the following events:
Generating an imprecise GROW chart based on an inaccurate delivery date.
Not identifying the baby’s intrauterine growth restriction during the Patient’s third trimester scans.
Discharging the Patient without reviewing the corrected GROW chart or performing an ultrasound scan, despite returning to the hospital with reduced fetal movement.
Not acting upon the Patient’s reports of reduced fetal movements, resulting in a failure to record all episodes of reduced movements.
Not putting in place a management plan regardless of the Patient’s complaints of reduced fetal movement over a 3-week period.
Not referring the Patient for further assessment when the 40-week symphysis fundal height was suggestive of static growth.
- Waiting for over 24 hours for transfer to the delivery suite once found to be suitable for artificial rupture of membranes despite the availability of on-call staff who could have facilitated transfer.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
When generating a GROW chart, it is essential that the accurate due date is entered, as otherwise it can skew the monitoring of fetal growth for the entire pregnancy and inhibit the clinician’s abilities to identify any issues.
If the production of an inaccurate GROW chart is recognised, it is imperative to generate a new chart with the correct details urgently, and to replot all previously documented measurements in order for an accurate curve to be monitored.
If, based on symphysis fundal height measurements, growth restriction is suspected, patients should be referred urgently for further assessment, which usually consists of a growth scan and clinical review. Depending of the availability of ultrasound scans and clinic appointments, there can be differences in referral to assessment times however, within 72 hours is reasonable. If however, there are additional risk factors, including reduced fetal movements, or a recent history of reduced fetal movements, consideration should be given to expediting an assessment of fetal growth and wellbeing within twenty-four hours.
Episodes of reduced fetal movement should be acted upon and appropriate referrals made for further investigation. Significance should be given to recurrent reduced movements at advanced gestations and/or within a short space of time.
Where activity and acuity prevent timely transfers of inductions to the delivery suite, there must be clear evidence of effective escalation with individualised management plans instigated. The senior midwife coordinating the maternity unit and the on-call consultant obstetrician should be made specifically aware of individual patients who are ‘breaching’ reasonable transfer times. The patient should be reviewed, with a clear management plan made for her care whilst awaiting transfer. There should also be evidence of a staffing review to ensure that all possible opportunities for facilitating transfer have been exhausted.
- It is imperative that clinicians and midwives receive up to date and regular training on identifying fetal growth trajectories, and what actions need to be implemented should slowing or static growth be identified. The Perinatal Institute recommend annual face to face lectures, hands on assessment and online training in the theory and practice of monitoring fetal growth for all staff who are involved in the measuring, plotting and management of fetal growth. This allows for a clear understanding of the issues involved in monitoring fetal growth and facilitates standardisation of practice and management.
It is of vital importance that patients are reviewed holistically at every contact, in order to identify and act upon deviations from the norm. When assessing fetal wellbeing in the antenatal period, fetal movements should be discussed at every appointment, and fetal growth should be appropriately monitored at regular intervals.
When a patient reports reduced fetal movements, these reports should be acknowledged and acted upon, with further assessment of fetal wellbeing offered in a timely manner. Each episode of reduced movements should be clearly recorded in order that future caregivers are aware of the full history. In cases of recurrently perceived reduced fetal movements, additional investigation and review should be instigated, including ultrasound assessment of fetal growth and a management plan for timing of birth.
Where fetal growth is shown to be slowing or static, a full clinical review should be performed in order that all relevant details form part of an ongoing management plan. When estimated fetal weight as determined by ultrasound scan shows a slowing of growth, the patient should be reviewed by an obstetrician prior to leaving the clinic. Where symphysis fundal height is shown to be slowing, an urgent referral for further assessment of fetal growth should be made. Annual training in the theory and practice of monitoring fetal growth is recommended so that care can be standardised across practitioners, with clear guidance on management of at risk patients.
During induction of labour, once a patient is deemed suitable for artificial rupture of membranes, transfer to the delivery suite should be facilitated as soon as possible. Where there is a delay due to activity and/or acuity on delivery suite, the patient awaiting transfer should have a multidisciplinary review and clear management plan documented. A staffing review should be undertaken and evidenced to ensure that all possibilities for transfer have been considered and exhausted.