Arthur Brockett-Deakins
25 Feb 2014 · Coroner Andrew Harris · London (Inner South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed escalation of abnormal cardiotocography
“When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007, which advises that a 40 minutes bial SS before concluding if itis abnormal”
2. misinterpretation of maternal heart rate as fetal heart rate
“Display of MHR as FHR on CTGs: vs explained that if the foetus moves out of the range of the ultrasound field or the baby has sadly dies, the ultrasound transducer may then pick up the maternal pulse from the aorta, iliac or uterine artery and it is displayed as the FHR and can show reactivity and variability due to MHR changes and muscle contractions can be difficult to distinguish from the FHR”
3. inadequate documentation and support in private midwifery model
“Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the servicer to provide continuity of care. The midwifery service that was operating vher a cs pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court”
4. incorrect CTG interpretation due to signal artefact
“The only explanation that both expert midwife and expert obstetrician could reach for the unusual CTG trace after 1pm, in the context of the state of the baby at birth, was that the maternal puise rate was masquerading as the FHR but it had been multiplied by 1.5”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007”
Later report
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:”
Closely relatedConfidence 0.85 · high
This report
“The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same.”
Later report
“It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.”