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Timely actions when an abnormality is identified

 

Another theme that emerged on reviewing these babies was the potential to improve the outcome had the abnormality identified through intermittent auscultation been recognised and/or acted upon in a more timely manner.

 

Situation

A low risk mother was booked for a home delivery. Her community midwife attended and performed vaginal examination which revealed her cervix was fully dilated. Membranes had ruptured earlier in the day and pink liquor was now draining.

Despite a deceleration being heard on intermittent auscultation, 80 minutes of pushing with slow descent of the head and further persistent audible decelerations, an ambulance was not requested.

The baby showed no signs of life when born and an ambulance was called. Resuscitation was successful and the baby was transferred for active therapeutic cooling. Grade 3 HIE was diagnosed.

Commentary

It is not always clear from a review why a health professional acted in a certain way; they may not have realised that the change in the fetal heart rate represented a deceleration, they may have noted decelerations but not considered them to be significant enough to prompt action or they may not have appreciated the wider picture in the given situation.

Situation

A mother attended in the latent phase of labour and decided to use the birthing pool to help with pain relief. A few hours later, the mother reported rectal pressure and was examined out of the birthing pool. Her cervix was fully dilated. The fetal heart rate was around 105 beats/minute on intermittent auscultation, having previously been around 140 beats/minute, and the mother was encouraged to push. The mother wished to go back into the birthing pool and, despite the decelerations persisting, she had a further 10-minute trial of pushing in the birthing pool.

After another 15 minutes, delivery had still not occurred and the decelerations were still audible. The mother was transferred to a trolley in preparation to transfer to the obstetric-led labour ward. As the vertex was advancing, an episiotomy was performed and the baby was born. This was approximately 1 hour after the initial deceleration was heard.

The baby was born in poor condition and was transferred for active therapeutic cooling.

Commentary

This baby’s story highlights the need to act when an abnormal fetal heart rate is identified rather than continuing with a plan that is no longer appropriate for the clinical situation. There were missed opportunities to call for assistance and expedite delivery by performing artificial rupture of the membranes. Despite abnormalities being detected on intermittent auscultation, fetal monitoring was not escalated to continuous CTG as is recommended in national guidance.[i]

Things you can do

When labour deviates from a low-risk pathway, for example, when decelerations, a rising baseline rate, presence of meconium or vaginal bleeding are detected, the mother’s care should be reassessed in a holistic manner. Care should be escalated through the use of continuous CTG monitoring including, if necessary, transfer to a unit with access to obstetric and neonatal support.

Employing a ‘fresh ears’ approach to intermittent auscultation, whereby a second midwife confirms the fetal heart rate pattern every hour, may reduce interpretation errors.

 

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[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].