Electronic fetal monitoring should make a difference by picking up potential problems before they become serious. But rates of avoidable brain injury at birth have not decreased following the adoption of cardiotocography (CTG) trace monitoring in UK maternity units. The technology itself is not to blame – it is the processes around it, namely who reads the trace, how it is read, and whether or not a record is made of what has been read, that contribute to a preventable tragedy
CTG is widespread, but interpretation is not
Cardiotocography (CTG) is now routine practice in labour wards for women with low-risk pregnancies. It allows midwives and obstetricians to get a readout of the fetus’s heart rate relative to contractions, which in theory gives them advance warning of distress. But a CTG trace is only ever as good as the eyes which read it – the machine itself does not take action.
A CTG trace is only as good as the eyes which read it – the machine itself does not take action
A CTG trace in isolation cannot make a clinical decision – it can simply generate a pattern on a graph from which a clinician must determine what action, if any, is required. And then a record must be made that a clinician has correctly read and acted upon the information provided by the machine. These are three steps at which things can go wrong, and potentially cause a baby injury. The monitor may be producing an obvious warning pattern, but the midwife or doctor reviewing it may still fail to act upon what they have seen. And then if they do act upon it – if they do what they should do based on the information the trace has given them – it is only if they document that they have done this that they will be able to prove it later.
What the NICE guidelines actually say – and why it doesn’t happen
The updated NICE guideline NG229 provides clear advice on intrapartum fetal monitoring. It recommends a particular approach to CTG trace interpretation, by which the trace is divided into four categories: baseline fetal heart rate and its variability, accelerations, and decelerations. The baseline rate is then classified as normal, suspicious or pathological, as is the baseline variability. Accelerations are either present or not, while decelerations are classified as either non-pathological or pathological. If the baseline rate is normal, baseline variability is present, accelerations are present, and decelerations are non-pathological, the fetus is not in danger. If the baseline rate is suspicious or pathological, baseline variability is absent, accelerations are not present, or decelerations are pathological, then appropriate action should be taken to deliver the fetus. And ideally the trace should be classified according to all four categories.
It all sounds very logical on paper – on a whiteboard, perhaps, or in a courtroom – but in reality it is rarely followed. Most obstetricians and midwives work under significant pressure, and while they know what a normal CTG trace looks like, they may be willing to accept a normal baseline rate without taking the additional time required to make sure that it really is normal. Accelerations and decelerations can often be ignored without further thought. In the majority of cases, no attempt is made to measure baseline variability, only to write it down as normal once the trace has finished. And then, when it comes to classifying the trace, rarely is each category considered independently, let alone classified according to the criteria set out in NG229.
In many of the clinical negligence cases we have handled, particularly those concerning cerebral palsy, this has proved to be a particular issue. It is a matter for expert witnesses to testify on in court when it comes to analysing a CTG trace, including precisely what was visible when reviewing the circumstances of a child diagnosed with cerebral palsy months or years after birth. And in reviews of maternity services following disastrous outcomes for mother or baby, this has consistently been noted as a problem. Too often, variability is poorly recorded, as is the presence or absence of accelerations and decelerations. Decelerations are wrongly placed on the partogram, due to their association with the peak of a contraction. Baseline rate is wrongly averaged out or hidden by other marks on the trace. This lack of recording is frequently the reason why families turn to specialist solicitors when seeking redress for birth injuries, since a Cerebral Palsy Solicitor can begin the process of reviewing records to uncover what went wrong.
How can two clinicians reading the same trace reach different conclusions?
Variability between people is an issue for many diagnostic tests – CTG is no different. As a general rule, a clinician will become more experienced but less specific with advancing years. You might be looking at a fetal heart rate trace that reflects ordinary fetal movement rather than an emergency, or you might be in exactly the right place at exactly the right time to identify a trace indicating that a fetus is in serious distress. If there is any possibility that a trace has not been correctly interpreted, the recommendation is for a second independent trace to be taken and read by someone who is not privy to the patient’s condition and may not be employed in the same hospital. It is the only reliable way to combat the potential for human error.
What the major reviews say
The Ockenden Review into the care provided to Shrewsbury and Telford Hospital NHS Trust identified a number of recurring issues in the cases it examined. These included concern over the interpretation and recording of CTG traces. It is not uncommon for CTG traces to be poorly recorded, particularly in terms of timestamps, or left unlabelled. Nor is it unusual for there to be no record of when or if a senior clinician was contacted concerning a trace that was suspected to be abnormal.
The Healthcare Safety Investigation Branch (which investigates intrapartum brain injuries) has reported similar concerns in its own reviews of maternity services. Human factors and documentation around CTG trace interpretation are frequent contributory factors in the cases it reviews. The Royal College of Obstetricians and Gynaecologists’ Each Baby Counts programme (which aims to improve maternity services following term stillbirth, neonatal death, or neonatal encephalopathy) has also identified issues with CTG trace management in its own series of case reviews.
Three separate organisations, looking into separate areas of maternity care, came to similar conclusions concerning CTG trace recording and interpretation. It is arguably this consistency that means the issues raised by Each Baby Counts, the Ockenden Review, and the Healthcare Safety Investigation Branch have such far-reaching implications.
Establishing the timeline
When a baby is born with hypoxic-ischaemic encephalopathy and cerebral palsy is suspected, it is vital to establish whether the injury was sustained during labour, or antenatally. The reason for this is that no clinical negligence case will succeed on the grounds of purely bad luck – there must always be some element of failure in the standard of care provided to the claimant during their time in the care of the defendant. This is why evidence of antenatal care is so important to cases of cerebral palsy – if it can be proved that the injury could not have occurred during labour, the claim falls apart. But determining whether it did happen during labour is not always easy.
There are three broad areas of evidence which contribute to determining whether a baby has sustained an injury during labour – and therefore whether a claim for clinical negligence can proceed. The first is the umbilical cord blood gas at delivery, which is an objective indication of the state of the fetus at the time of birth. The second is the Apgar scores at one, five, and ten minutes after birth – these provide an indication of how the baby presented at birth. The final piece of evidence is the CTG trace itself, which should be time stamped at the start of each contraction and between them, as well as annotated and reviewed for changes in pattern. These pieces of evidence – the blood gas, the Apgar scores, and the CTG trace – should allow investigators to understand what was happening to the fetus, when it happened, and when it was noticed.
The decision to delivery window
Once it has been established that a fetus has sustained an injury during labour, establishing the decision-to-delivery window is the next priority. The decision-to-delivery window is the time between a decision being made to deliver the fetus and the actual delivery taking place. It is one of the most important pieces of information in a cerebral palsy claim, as it indicates how much time there was between a decision being made and it being acted upon. And it has to be established using the records concerning the trace.
It can be incredibly difficult to accurately determine the decision-to-delivery window, due to a lack of precise records. Clinicians must make a record of when the trace was suspected to be abnormal, when a senior doctor was notified, when a decision to deliver was made, and when delivery actually took place. These time stamps are necessary to determine whether the appropriate action was taken within a reasonable time frame, and whether or not failure to do so contributed to the injury sustained by the fetus. If they are missing, there is little the Trust can do to prevent a cerebral palsy claim from being made – the assumption will be that if the Trust’s documentation is so poor, they will not be able to prove that they acted correctly and promptly when faced with an emergency.
What happens if a poor outcome occurs?
For families who find themselves facing a cerebral palsy diagnosis, the maternity record is often where the investigation begins. Parents can request their notes from the Trust, as well as the CTG trace and any other tests that may have been performed. The information contained therein will form the basis of the claim – if there is no evidence in the notes to support it, a cerebral palsy claim will be difficult to bring. That is why a second opinion is so useful to families at this stage – most people do not have the expertise to understand a CTG trace or to spot inconsistencies or omissions in notes relating to fetal blood sampling. Specialist solicitors can instruct independent midwifery and obstetric experts to review the notes to determine whether there is a viable clinical negligence claim.
This is a time-consuming process for all those involved, but it is a necessary one. A review of the cord gas, Apgar scores, and CTG trace is essential to determining whether a fetus sustained an injury during labour, and if so, the role played by the maternity unit in that injury.
Why poor record keeping hurts the Trust
Claims for cerebral palsy are relatively uncommon, but when they do occur, the potential damages can be substantial. Maternity-related clinical negligence claims account for a disproportionately high number of the funds spent on all clinical negligence claims – it is not uncommon for cases to drag on for years at a time, putting huge strain on the individuals involved. Claims for cerebral palsy can put a huge burden on the NHS too – caring for a child with severe learning difficulties for the rest of their life can be incredibly expensive.
But the real cost is to the family who finds themselves having to care for a child with extensive needs. Their life – and their finances – will be irreversibly altered by the injury their child has sustained.
The importance of good record keeping
It is easy to think of good record keeping as little more than a bureaucratic hurdle – a box-ticking exercise designed to protect Trusts from litigation further down the line. But it serves another, more important, function – ensuring that staff take the time to do their jobs properly.
Doctors and midwives tasked with monitoring CTG traces may be required to review them under considerable time pressure, with night shifts, understaffed units, and the pace of modern healthcare all contributing to clinicians feeling as if they have little time to spare. Effective record keeping is designed to combat this – the very act of documenting a trace encourages a midwife or doctor to spend more time on it than they might otherwise. It serves as a reminder that the trace could indicate potential danger to the fetus, and that rushing through it will not allow them to pick up on subtle changes in the pattern that might indicate distress. By encouraging a thorough review, record keeping ultimately enhances patient safety.
When records are kept properly, everyone benefits – the patient, thanks to the extra care taken in reviewing the trace, and the Trust, which can demonstrate that it took all reasonable precautions in the event of an emergency.
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