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The value of reviewing the ‘whole picture’

The most common theme, and one that runs through all of the above vignettes, is the lack of appreciation for the whole picture when assessing continuous CTG.

 

By focusing solely on the CTG, maternity providers miss the other warning signs a baby or mother may be demonstrating that intervention is required.

 

Situation

A low-risk mother attended with painful contractions and reduced fetal movements. Initially, there were no accelerations on the CTG and the mother was admitted for observation with a plan to repeat the CTG in 4 hours. However, after 1 hour the mother still complained of reduced fetal movements and increased abdominal pain. The midwife commenced the CTG and decelerations were noted. The mother was transferred to the labour ward, and on recommencing the CTG the fetal heart rate was less than 80 beats/minute. The membranes were ruptured and thick meconium was present. A decision for a category 1 caesarean section was made and the baby was born within 15 minutes of the mother’s arrival on the labour ward, but died despite resuscitation.

Commentary

This vignette highlights the multiple signs that the mother and baby were demonstrating that were not drawn together to identify how at risk this baby was. Although a plan was made for admission and observation, the significance of the CTG was not appreciated in the context of the reduced movements and maternal abdominal pain.

 

Situation

A mother attended in labour and was found to be 4 cm dilated. After 4 hours, there was no progress and she was transferred to the antenatal ward to await events. When the CTG was repeated, it was considered to be suspicious, but after review by a doctor the woman was allowed home.

When the mother reattended a few hours later, the CTG was abnormal. This was discussed with the on-call consultant obstetrician, who recommended the doctor perform fetal blood sampling. When the obstetric registrar performed the vaginal examination prior to fetal blood sampling, the cervix was fully dilated. This was not fed back to the consultant and the registrar persisted with the fetal blood sampling despite the evidence that an assisted vaginal delivery could have been attempted. The consultant attended and reviewed the mother 30 minutes later. A ventouse delivery was performed promptly.

The baby was born in poor condition and died in the early neonatal period.

Commentary

The local reviewers commented that when the consultant was asked to review the situation, the whole team was not fully appreciative of the complete picture. The background of the prolonged latent phase and the nonreassuring CTG prior to discharge, attendance with an abnormal CTG and persistence with a fetal blood sampling at full dilatation when assisted delivery was achievable should have been assessed as a whole to prompt earlier delivery of this baby.

 

Things you can do

A holistic approach that takes into account the risk factors for both the mother and the baby as well as the stage and progress in labour should be adopted when making any management decisions.

The identification and consideration of risk factors such as persistently reduced fetal movements before labour, fetal growth restriction, previous caesarean section, thick meconium, suspected infection, vaginal bleeding or prolonged labour must become standard practice when reviewing a CTG.