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Assigning risk status at the onset of labour

 

The first theme that emerged on reviewing the reports was the quality of assessment of risk for mothers and their babies at the start of labour.

 

By incorrectly assigning a mother to a low-risk pathway, maternity providers limit the intensity of fetal monitoring that the baby receives and may be caring for a mother and her baby without access to all the necessary resources.

 

Situation

A mother attended in labour with a history of no fetal movements that day, mildly raised blood pressure and a maternal tachycardia. The fetal heart rate was monitored with intermittent auscultation.

When she ruptured her membranes at full dilatation, thin meconium was evident. There was a prolonged deceleration.

Help was summoned but the baby was born quickly with maternal effort only, while the doctor was preparing for an instrumental delivery.

The baby was born in poor condition and underwent therapeutic cooling. The baby was subsequently was diagnosed with Grade 3 HIE.

Commentary

The use of intermittent auscultation for fetal monitoring was inappropriate as the mother had multiple risk factors including a history of reduced fetal movements, raised blood pressure and maternal tachycardia.  

Current national guidance is that such women should be offered continuous CTG for fetal monitoring and be cared for in an obstetric-led unit.[i]

 

Situation

A mother arrived in labour at full term. Her previous baby was small for gestational age. Symphysal fundal height measurements had not been performed since 36 weeks and she had not had serial fetal growth scans.

Intermittent auscultation was performed throughout labour and was reported as normal. After spontaneous rupture of membranes the fetal heart could not be located, however, the baby was born several minutes later in poor condition.

The baby was small for gestational age (<1st centile) and was transferred for active therapeutic cooling with a diagnosis of grade 2 HIE.

Commentary

Although the missed opportunity to assess the growth of this baby began in the antenatal period, this baby’s story highlights the importance of performing a fresh risk assessment when a mother presents in labour. Had it been noted that this baby was at risk of being small for gestational age (because of the previous baby’s birth weight) and that this baby had not had sufficient growth assessment in this pregnancy, the high-risk nature of this pregnancy may have been anticipated and CTG monitoring considered.

 

Things you can do

A local IT system to facilitate adequate risk assessment at the onset of labour should be designed, to ensure that mothers are giving birth in the most appropriate setting with the appropriate monitoring.

 

 

 


[i] National Institute of Clinical Excellence (NICE). Intrapartum Care for Healthy Women and Babies. NICE Clinical Guideline 190. London: NICE; 2014 (update 2017). Available from: https://www.nice.org.uk/guidance/cg190 [accessed on 6th October 2017].