Mrs N was admitted for induction of labour at a gestation of 38 weeks. Mrs N had requested induction as she was feeling very tired. Antenatally, there had been no concerns over mother or baby. A cardiotocograph (CTG) was normal. As the cervix was unfavourable, Dr L inserted 1mg prostaglandin gel into the vagina. Dr L asked the midwife to commence continuous fetal heart rate monitoring. However recordings were not documented at regular or consistent intervals.
Six hours later, Mrs N was not in labour and the cervix was still unfavourable. Dr L inserted a second prostaglandin gel. Two hours later, Mrs N was in labour with the cervix 3cm dilated. The membranes were artificially ruptured after five hours, after which labour progressed rapidly, resulting in a normal delivery within two hours. During the induction process and labour, the fetal heart was monitored electronically using a CTG.
The baby was born in poor condition with low Apgar scores and transferred to the neonatal intensive care unit.
Mrs N developed a primary postpartum haemorrhage due to an atonic uterus, which failed to respond to medical intervention. The bleeding was so severe that Mrs N needed a laparotomy and ligation of the internal iliac arteries, which successfully arrested the uterine bleeding.
Analysis of the baby’s blood shortly after birth revealed metabolic acidosis consistent with intrapartum hypoxia. Unfortunately, the baby developed seizures and investigations revealed hypoxic ischaemic encephalopathy. The child now has severe spastic cerebral palsy.
A claim was brought by Mrs N. The experts were critical of the monitoring of the fetal heart rate both during the induction phase with prostaglandin, as well as during labour. There was a combination of inadequate fetal heart rate documentation and inaccurate interpretation by the midwife. The CTGs were incorrectly interpreted as normal when they were actually pathological. Allowing labour to continue, rather than performing a caesarean section, led to intrapartum asphyxia and the resultant brain injury. The obstetric expert was also critical of the poor documentation on the CTGs, with a failure to record the date and time, or contractions in some instances.
There was no criticism of the management of the postpartum haemorrhage.
The case was settled for a high sum.
- It is important to have a valid indication for induction.
- A CTG is a tool to monitor the fetal heart rate both during the antenatal period and during labour. In labour it is also used to monitor uterine contractions. The fetal heart rate (FHR) has a number of features that must be examined to allow proper interpretation. There are different levels of abnormality of the FHR. An intrapartum CTG classified as pathological requires urgent intervention.
- Training in CTG interpretation and regular updates should be mandatory for all healthcare professionals working in obstetric units.
- Misinterpretation of CTGs and failure to act on abnormal CTGs are cited as major factors in maternity claims in the United Kingdom. Between 2000 and 2010, “CTG interpretation” was the second most expensive category in terms of claims by value at over £466 million – Ten Years of Maternity Claims – An Analysis of the NHS Litigation Authority Data (October 2012).
- The NICE Clinical Guideline on induction of labour, published in 2008, recommends continuous CTG monitoring of labour which, if normal, can be reduced to intermittent monitoring.