Interpretation of fetal heart rate monitoring
Tuesday 28 January 2020
Deputy Health and Disability Commissioner Rose Wall today released two reports finding Hutt Valley District Health Board (the DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to two women during labour.
Ms Wall noted that since these events the DHB had commissioned an external review of its maternity services. The review identified several areas of risk that threatened the safety of the service, including a severe staff shortage, and made a number of recommendations.
In both her reports the Deputy Commissioner was concerned about the failures with monitoring the babies’ heart rates, and was critical of the DHB’s systems and processes, noting the systemic failures identified in the external review of its maternity services. HDC will be closely following up with the DHB to ensure that these external recommendations are implemented along with the recommendations made by HDC in each of these cases.
Inadequate fetal heart rate monitoring and interpretation is a recurring theme across complaints to HDC about maternity care nationally across all DHBs and Ms Wall said she is concerned that training on fetal heart rate monitoring is not currently mandatory for all practitioners. HDC has raised this issue previously and intends to follow-up with the Neonatal Encephalopathy Taskforce about the development of a national fetal surveillance education programme.
Report One (17HDC01547)
The first report concerns a woman who went into labour when she was at term with her first baby. The baby was lying in an occipital posterior position which means the back of the baby’s head faced towards the mother’s spine. This is common and can cause a slower or obstructed labour.
Staff started cardiotocography (CTG) monitoring of the baby’s heart but this was discontinued for three hours while the woman laboured in a birthing pool. When the midwife became concerned about the fetal heart rate in the second stage of labour CTG monitoring was restarted. The CTG was difficult to interpret, but showed a hypervariable fetal heart rate (fetal heart beat-to-beat variability above the normal range) and uterine hyperstimulation.
An obstetrician was consulted and the possibility of a Caesarean section discussed, but the CTG appeared to improve and it was agreed to allow the woman more time to push. Following that assessment the CTG deteriorated significantly and the baby required urgent delivery by emergency Caesarean section. The baby suffered severe brain damage due to oxygen deprivation and, tragically, passed away at six days of age.
Ms Wall found that a number of failings by the DHB and its staff represented a pattern of poor care.
"The DHB must ensure that it has in place appropriate staffing levels, policies that provide sufficient guidance, and equipment in good working order, so that staff are supported adequately to provide safe care," Rose Wall said.
Ms Wall also found the obstetrician in breach of the Code, criticising her for not adopting a more cautious approach and proceeding to a Caesarean section when she first reviewed the woman.
Ms Wall recommended that the DHB apologise to the parents; consider amending its procedure to ensure that a clinician capable of performing a fetal scalp blood lactate test is rostered on for every shift, and ensure that the lactate testing machine is functioning; and provide HDC with evidence that it has made certain amendments to its clinical practice guidelines and policies.
In addition, she required the DHB to provide HDC with a detailed update report on the steps taken to carry out the external reviewers’ recommendations, including in particular recommendations regarding staffing, clinical guidance and training.
Ms Wall recommended that the obstetrician apologise to the parents, and provide HDC with a reflective statement on what she has learnt from this case and how she has used that to educate other staff.
The full report for case 17HDC01547 is available on the HDC website.
Report Two (17HDC01376)
The second report concerns the care provided to a woman during her pregnancy, induction of labour, and birth. Her lead maternity carer was a self-employed obstetrician and gynaecologist. The obstetrician carried out ultrasound scans in his office to monitor the fetal growth, but he did not record the outcomes in the clinical notes and did not detect that there was asymmetrical intrauterine growth restriction (IUGR).
At 38 weeks’ gestation the obstetrician diagnosed the woman with pre-eclampsia and she was admitted to hospital for an induction of labour.
Throughout the induction the woman experienced excessively frequent contractions (tachysystole), and although this was a high-risk birth, fetal heart rate monitoring was not carried out continuously by cardiotocography (CTG). The obstetrician and the DHB staff involved in the woman’s care failed to recognise and address the potential accumulative significance of the tachysystole. As labour progressed the fetal heart rate was not recognised as significantly abnormal and the baby was born with a brain injury consistent with hypoxic ischaemic injury.
Rose Wall was critical of systemic failures at the DHB, including a lack of clarity in policies/procedures.
"These failures left staff without clear instructions and support, and resulted in a failure to monitor the woman and her baby adequately during the induction process, and to recognise the significance of the ongoing tachysystole, or, where it was recognised, to escalate the abnormal CTG by requiring the obstetrician’s earlier attendance," Rose Wall said.
Rose Wall was also critical of several aspects of the care provided by the obstetrician, including carrying out suboptimal growth assessment resulting in asymmetrical IUGR not being detected; not recognising the cumulative risk of the ongoing tachysystole, and not acting urgently enough on the CTG abnormalities. She found him in breach of the Code and recommended that the Medical Council of New Zealand consider undertaking a further competence review, and that he provide an apology to the woman and undertake further training.
Rose Wall made a number of recommendations to the DHB regarding staff training, policies for inductions involving private obstetricians, a review of its equipment, and reporting back to HDC on its progress implementing the recommendations made in the 2018 external review of maternity services. She also recommended that the DHB apologise to the parents.
The full report for case 17HDC01376 is available on the HDC website.