“Every case of asphyxia can be used as a learning example”. Conclusions from an analysis of substandard obstetrical care

ObjectiveTo increase our knowledge of the occurrence of substandard care during labour.DesignA population-based case–control study.SettingStockholm County.PopulationInfants born in the period 2004–2006 in Stockholm County.MethodsCases and controls were identified from the Swedish Medical Birth Register, had a gestational age of ≥33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of <7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth.Main outcome measureSubstandard care during labour.ResultsWe found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for ≥45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated. Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care.ConclusionsThere was substandard care during labour of two-thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

To identify maternal, pregnancy, delivery and infants characteristics related to neonatal asphyxia and associated with substandard care. A nation-wide case-control study in Sweden. Infants born between 1990 and 2005 with a gestational age > or = 33 weeks and a spontaneous or induced onset of labor. Cases were 177 previously identified infants suffering from encephalopathy caused by asphyxia where there was suspected substandard care during labor, and where claims for financial compensation were filed. Controls were identified from the population-based Swedish Medical Birth Register, had an Apgar score of 10 at five minutes, and were alive at 28 days of age. Severe asphyxia associated with substandard care during childbirth. Maternal and delivery factors associated with asphyxia included maternal age > or = 30 years, short maternal stature (< or =159 cm), previous cesarean delivery, insulin-dependent diabetes before pregnancy and gestational diabetes, induced deliveries and delivery at night, with adjusted odds ratios (ORs) ranging from a two- to fourfold increase in risk. Compared with non-dystocic deliveries, the OR for dystocic deliveries was fivefold higher, and was further increased if epidural anesthesia or opioids were used. Small- and large-for-gestational age infants, post-term (> or =42 weeks) births, twins and breech deliveries had a three- to eightfold increase in risk of asphyxia when there was substandard care during labor. Dystocia of labor, especially if epidurals and/or opioids are used, is the strongest risk factor associated with substandard care causing severe asphyxia during labor.

Background: Elaborate Cardiotocography (CTG) is the most commonly used test for antepartum and intrapartum fetal surveillance because it gives information via the cerebro-cardiac response of fetal cerebral activity, which is modified by the hypoxia. Objective: This study was designed to compare the perinatal outcomes among the normal and abnormal CTG groups. Method: It was a prospective observational study carried out in the Department of obstetrics, BSMMU during the period July 2006 to July 2008. Hundred consecutive normal and hundred consecutive abnormal CTC tracings were collected from patients who were advised to perform CTG after admission. Both labour and non-labour patients were included. Interpretation of CTG was done based on FlGO recommendation (1987). Pregnancy and neonatal data were obtained and the findings were correlated with the FHR tracing. Statistical analysis was carried out by student's unpaired t-test, X 2 and Z-test. Level of significance was set at P value < 0.05. Results: Out of 100 abnormal CTG, 30% had tachycardia, 42% had deceleration, 38% was non reactive, 4% had absence beat-to-beat variability and 4% had fetal bradycardia. There was significantly higher caesarean delivery, lower apgar score, higher requirement of neonatal resuscitation and admission at neonatal unit and higher perinatal death among the abnormal CTG group. The abnormal fetal outcome was found highest in heart rate deceleration group. Conclusion: CTG can be continued as a good screening test of fetal surveillance but it is not the sole criteria to influence the management of high-risk pregnancies. Abnormal CTG should be supplemented with other test before intervention. Key words: CTG; Perinatal outcome. DOI: 10.3329/bsmmuj.v2i1.3706 BSMMU J 2009; 2(1): 18-24

Asphyxia is a major cause of neonatal mortality, often linked to inadequate perinatal care, especially misinterpretation of cardiotocography. In Finland, the Patient Insurance Centre manages medical claims, offering a no-fault compensation model. Utilizing these claims could enhance obstetric safety and newborn health. The aim of this study was to analyze the compensated patient claims and identify the substandard care leading to asphyxia. A nationwide retrospective registry-based study was conducted. Data included all compensated patient insurance claims for neonatal asphyxia (N = 77) reported to the PIC between 2012 and 2022 Claims involving compensated fetal or neonatal asphyxia were analyzed. Data from the PIC electronic database, including obstetric and neonatal characteristics, severity of asphyxia, interventions, and long-term outcomes, were reviewed, and the substandard care was categorized and analyzed. Neonatal outcomes were categorized as follows: no permanent injury (n=26), permanent injury (n=28), and death (n=23). All neonates met the criteria for asphyxia, and most required extensive intensive care. Permanent injuries included cerebral palsy, other physical disabilities, and epilepsy. All deaths resulted from severe asphyxia. Substandard care was most often attributed to inadequate monitoring of fetal well-being (n=69), particularly in using and interpreting cardiotocographs and responding to pathological fetal heart rate changes. Other issues included delayed delivery (n=64) and inadequate management of the birth (n=28). These findings highlight substandard care as a key contributor to asphyxia and emphasize the need for improved clinical practice. Enhancing training, protocols, and quality care standards is crucial to prevent adverse neonatal outcomes.

Background: The purpose of intrapartum fetal monitoring by cardiotocograph (CTG) is to identify early signs of developing hypoxia so that appropriate action can be taken to improve the perinatal outcome. Although CTG findings are well known to monitor the progress of the labor due to the paucity of recommendations, there has always been a clinical dilemma as the term fetuses respond differently than a preterm fetus. However, umbilical cord blood pH can distinguish the infant at high risk for asphyxia and related sequel. Therefore, because of differences in fetal physiology in term and preterm fetuses, CTG findings vary, and hence the validity of CTG to determine fetal acidosis should be different. Aims and Objectives: This study aimed to correlate abnormal intrapartum CTG findings with umbilical cord blood pH in term and preterm labor and thus evaluate the success of CTG in predicting fetal acidosis during labor. Methods: The present study included 210 women in labor (70 preterm and 140 term) with abnormal intrapartum CTG that was classified as per 2015 revised International Federation of Gynecologists and Obstetrician (FIGO) guidelines. Immediately after delivery, 2 ml Umbilical artery cord blood sample was taken in a pre-heparinized syringe for analysis, pH &lt;=7.2 was taken as acidosis and pH &gt;7.2 was taken as normal. The measured data were general maternal characteristics which included gravida status, associated comorbidities, method of induction and character of liquor, the intrapartum CTG tracings recorded, the cord arterial blood pH and the neonatal characteristics such as APGAR score and neonatal outcome. Results: Data from 70 preterm labor was compared with 140 term labor. In this study, 20.9% of the babies had acidosis. Suspicious CTG due to decreased variability were more common in the preterm group than in the term group (21.4% vs. 8.6% p&lt;0.05). Positive predictive value (PPV) of abnormal CTG for fetal acidosis in the preterm group was found to be higher than that in the term group, PPV of pathological CTG being even higher than suspicious CTG. Women with suspicious CTG had 82% less risk of fetal acidosis as compared to pathological CTG. Women with Bradycardia had 5.9 times the risk of fetal acidosis as compared with normal and tachycardia. Conclusion: Abnormal CTG should be managed appropriately without any delay to prevent acidosis and cord blood pH should be done in all labors with abnormal CTG. However, our findings of a higher incidence of lower cord blood pH and suspicious CTG due to decreased variability alone highlight the limitation of criteria currently used for interpretation of CTG in preterm labors.

Development and pilot test of a CTG skills test for midwives.

Background: An important function of cardiotocography (CTG) is to promptly identify non-reassuring fetal status during delivery, as these deviations often prompt primigravidae to undergo a caesarean section. However, these abnormal CTG traces may or may not correspond to intraoperative findings such as meconium-stained liquor or low APGAR scores at birth. It's worth noting that not all abnormal CTG changes result in poor outcomes. Therefore, there is a pressing need for research to explore their correlation, demonstrating the benefits of CTG in accurately detecting non-reassuring fetal status and how it correlates with subsequent intraoperative findings. Aim: To demonstrate the correlation of intra operative findings and fetal outcome in primigravida undergoing caesarean section for non reassuring cardiotocography. Methods: A prospective study of 50 cases of primigravida undergoing emergency caesarean section for non reassuring CTG was taken at the department of Obstetrics and Gynaecology Lalla Ded hospital Srinagar was taken. Their CTG traces were correlated with their intraoperative findings such as meconium stained liquor, cord around neck, oligohydramnios, placental abruption and apgar score at birth. Results: Out of these 50 primigravida who underwent emergency caesarean section,62% had CTG with decelerations-Non reactive, 30% had a CTG trace with persistent decreased variability while 8% had a persistent low baseline on CTG . Among patients with CTG trace showing decelerations 58% had meconium stained liquor, 16.5% had cord around the neck and 25.8 % had low APGAR scores at birth . Among the group of patients with decreased variability 42.1% had meconium stained liquor, 10.5% had cord around the neck and 21% had low APGAR scores at birth. Among the group with low baseline, 51% had meconium stained liquor, 23% had cord around neck and 39 % had low birth apgar. Conclusion: Cardiotocography shows a positive correlation with meconium-stained liquor and APGAR scores at birth, but not with cord entanglements. Therefore, it's crucial to use CTG judiciously and consider employing other non-invasive, cost-effective tests to detect non-reassuring fetal status, aiming to reduce unnecessary caesarean sections.

Background: Cardiotocography (CTG) is used on a regular basis to check on fetal health, but it remains a topic of investigation for fetal-neonatal outcome correlation and low Apgar scores. Abnormal CTG patterns like fetal tachycardia, fetal bradycardia, and decelerations can signify fetal distress and are correlated with poor neonatal health. Objective: To determine the frequency of Low Apgar score in patient having abnormal cardiotocography. Study Design: Descriptive study. Duration and Place of Study: The study was conducted from March 2023 to September 2023 at the Department of Obstetrics and Gynaecology, Saidu Group of Teaching Hospital Swat. Methodology: 107 pregnant women aged between 18 and 40 with singleton gestations and abnormal CTG were selected using a non-probability consecutive sampling. Demographic data such as maternal age, gestation age, parity and Apgar scores at 5 minutes of delivery were collected. Descriptive statistics and Chi-square tests were employed to associate low Apgar scores (≤5) with demographic parameters with a p-value of ≤0.05 considered to be statistically significant. Results: The mean age of the participants was 28.37 ± 3.08 years, the mean gestational age was 37.11 ± 1.95 weeks, and the mean parity was 1.71 ± 1.47. Of the 107 participants, 76 (71%) had a low Apgar score, while 31 (29%) had a normal score. No significant association was found between low Apgar scores and age, gestational age, or parity (p-values of 0.847, 0.688, and 0.993, respectively). Conclusion: Abnormal CTG is associated with a high frequency of low Apgar scores.

ST Analysis of the Fetal ECG, as an Adjunct to Fetal Heart Rate Monitoring in Labour: A Review.

Background: Cardiotocography(CTG) is a widely used intrapartum tool for assessing fetal well being by monitoring fetal heart rate patterns in relation to uterine contractions. However, CTG interpretation is subject to high inter-observer variability and false-positive rates leading to potentially unnecessary interventions. umbilical cord arterial blood gas analysis, particularly pH measurement, offers a more objective evaluation of fetal acid-base status at birth and may improve perinatal outcome prediction. Aim: To assess the association between CTG patterns and umbilical cord arterial blood pH and to evaluate their combined predictive value for neonatal outcomes in term pregnancies. Methods: A prospective observational study was conducted over 18 months at Dr RMLIMS. A total of 160 term pregnant women in labor were enrolled. CTG was classified using FIGO guidelines into Normal, suspicious, pathological categories following delivery, umbilical cord arterial blood was analyzed for pH. Results: A significant association was observed between pathological CTG findings and low umbilical cord arterial pH(&lt;7.2),indicating metabolic acidosis. Neonates born with abnormal CTG patterns and low pH had higher rates of NICU admissions and low APGAR scores. Conclusion: While CTG remains a valuable intrapartum monitoring tools. Its predictive accuracy improves when combined with objective parameters like umbilical cord blood pH.

To compare the rates of abnormal ST segment patterns of the ECG and cardiotocographic (CTG) abnormalities in fetuses with metabolic acidaemia at birth and controls. To evaluate the inter-observer agreement in interpretation of ST analysis and CTG. Case-control study. Three University hospitals in southern Sweden. Cases and controls were selected from the Swedish randomised controlled trial on intrapartum monitoring, including 4966 fetuses monitored with a scalp electrode. Two obstetricians independently assessed the CTG and ST traces of 41 fetuses with metabolic acidaemia at birth and 101 controls, blinded to group, outcome and all clinical data. They classified each CTG trace and ST analysis as abnormal or not abnormal, and whether there was indication to intervene according to the CTG or to the CTG + ST guidelines. If their classification differed, assessment by a third obstetrician determined the final classification. Rates of CTG and ST abnormalities and decisions to intervene. Rates of inter-observer agreement. CTG was classified as abnormal in 50% and ST in 63% of cases with acidaemia, and in 20% and 34% of controls, respectively. CTG abnormalities were judged to be indication for intervention in 45% and CTG + ST abnormalities in 56% of cases with acidaemia, and in 15% and 8% of controls, respectively. The proportion of agreement between the two initial observers was significantly higher for ST abnormalities (94%) than for CTG abnormalities (73%), and for indication to intervene according to CTG + ST (89%) than according to CTG alone (76%). The inter-observer agreement rate was higher for a decision to intervene based on CTG + ST than on CTG alone.

Background: Cardiotocography (CTG) is a cornerstone of intrapartum fetal monitoring and plays a vital role in assessing fetal well-being during labor. Abnormal CTG patterns—such as elevated baseline fetal heart rate, reduced variability, and decelerations—are commonly linked to adverse neonatal outcomes, including low birth weight, decreased 5-minute APGAR scores, increased neonatal intensive care unit (NICU) admissions, and perinatal mortality. Despite its widespread use in tertiary care, the effectiveness of CTG relies heavily on accurate and timely interpretation to reduce unnecessary interventions and improve perinatal outcomes. Objective: To evaluate fetal outcomes associated with pathological intrapartum CTG among term pregnant women at Abbasi Shaheed Hospital, Karachi. Methods: A descriptive cross-sectional study was conducted over six months and included 133 laboring women at term (gestational age ≥37 weeks) with singleton pregnancies and maternal age ranging from 20 to 45 years. CTG was defined as pathological when the baseline fetal heart rate exceeded 170 bpm, variability was less than 5 bpm, or early, prolonged, or late decelerations were observed. All participants underwent standardized corrective interventions, including maternal repositioning and oxygen therapy. Data were collected using structured forms and analyzed using SPSS version 20. Associations between CTG patterns and fetal outcomes were assessed using Chi-square and Fisher’s exact tests, with statistical significance set at p ≤ 0.05. Results: Among 133 patients, 24 (18%) neonates had low birth weight, 33 (25%) had low 5-minute APGAR scores, 13 (10%) required NICU admission, and 4 (3%) experienced in-hospital mortality. The presence of late decelerations was significantly associated with low APGAR scores (p=0.004) and NICU admissions (p=0.012). Conclusion: Pathological CTG patterns strongly predict adverse neonatal outcomes. Timely recognition and standardized responses can enhance perinatal safety in resource-constrained tertiary care settings.

This paper reports an examination of intra- and inter-observer agreement in midwives' visual interpretation of intrapartum cardiotocographs (CTGs). The issue of intra- and inter-observer agreement in the interpretation of CTG interpretation has serious implications for the validity of electronic fetal heart rate monitoring and subsequent decisions on intrapartum management. However, no studies were found that assessed intra- and inter-observer agreement in midwives' interpretations of CTG tracings. Twenty-eight midwives independently interpreted three intrapartum CTG tracings on two separate occasions using a self-administered Cardiotocograph Interpretation Skills Test. Inter-rater agreement in interpretation was assessed by cross-tabulating the two sets of raw data obtained at time 1 and time 2 and computing Cohen's Kappa (kappa). Intra-rater agreement was assessed by computing kappa for each rater with the two sets of raw data (time 1 and time 2) obtained from each individual. The data were collected in 2000. Overall intra-rater agreement ranged from 'fair to good' (kappa = 0.48) to 'excellent' (kappa = 0.92). Raters' classifications altered in 18% (n = 5) of cases for the normal tracing, in 29% (n = 8) for the suspicious tracing and in 11% (n = 3) for the pathological tracing. Inter-rater agreement was fair to good, with kappa statistics ranging from 0.65 to 0.74, respectively. Agreement was highest in the classification of decelerations (kappa = 0.79) and lowest in the assessment of baseline variability (kappa = 0.50). Overall inter-rater agreement was highest in the suspicious tracing (kappa = 0.77, excellent) and lowest in the normal tracing (kappa = 0.54, fair to good). Inter- and intra-observer variability are intrinsic characteristics of the interpretation of intrapartum CTGs. Levels of agreement revealed degrees of variation that expose room for improvement. Efforts are needed to reduce inter- and intra-observer variation in interpretation of intrapartum CTG tracings. In addition, research should focus on the development and evaluation of non-invasive, low observer variability methods of intrapartum assessment of fetal well-being. The subjectivity of CTG interpretation and inconsistencies in interpretation should also be considered in intrapartum management, clinical audit and in medico-legal settings.

A study was made of 112 cases of imminent foetal asphyxia, delivered by Caesarean section at the Sabbatsberg Hospital 1.1.1966–31.12.1968. As controls 84 cases on which Caesarean section was performed for reasons other than asphyxia were chosen from the same period. A follow-up was made of the children in both groups in order to clarify whether the diagnosis of imminent asphyxia was correct, and if foetuses delivered by Caesarean section for imminent asphyxia developed normally. Of the 112 children with imminent foetal asphyxia 23 had an Apgar score of less than 7 after 1 min. 29 had the umbilical cord wound around the neck in such a way that it could explain the imminent asphyxia. At the follow up 25 out of 112 children in the asphyxia group were not normally developed or had physical malformations of some kind. Only 4 infants in the control group had the same signs.

Background: Cardiotocography (CTG) records changes in fetal heart rate and their temporal relation with uterine contractions. Its aim is to diagnose the hypoxia and prioritize the babies who need urgent delivery. Objective: The aim of the study is to assess the role and effectiveness of admission CTG and compare the abnormal and normal CTG regarding fetal outcomes. Methods: It is a prospective observational study held in Z.H. Sikder Women’s Medical College &amp; Hospital for the period of 1 year (July 2020 to June 2021). 500 pregnant women were studied in this period. Admission and intermittent CTG was done according to need. Statistical level of significance was set at p &lt;0.05. Result: Total 500 cases were taken as study population according to inclusion criteria and divided into two groups, normal and abnormal CTG. Abnormal CTG includes both suspicious and pathological varieties. Difference in Apgar score, NICU admission and perinatal asphyxia was statistically significant (p&lt;0.05). Conclusion: A CTG is a non-invasive, reliable and cost-effective screening method to evaluate the fetal condition and to predict perinatal outcome in high risk and also in low-risk pregnancies. Caesarean section rates may be dramatically reduced by appropriate use of CTG.