Fetal Monitoring—A Risky Business for the Unborn and for Clinicians

Abstract

describe the clinical application ofthe ST-analysis of fetal EG technology as an additional sourceof information in fetal monitoring. The title of their articleand the conclusion imply that the method contributed to theadverse outcomes. However, closer reading gives quite a dif-ferent picture. In relation to case 1 the authors say:..‘.guidelines were not followed because they indicate immediatedelivery in the case of a (pre)terminal CTG. This case illustratesthe difficulty of classification of the CTG.’ (p. 1199). Aboutcase 2 they say ‘A preterminal CTG pattern. which shouldhave been acted upon at an earlier stage.’ (p. 1200) and aboutcase 3: ‘Perhaps the most important lesson from this case isthat one should continue to assess the CTG’ (p. 1200).What is described in the three cases is thus either a situationwith preterminal cardiotocogram (CTG) where no action wastaken or misinterpretation of CTG and/or the staff passivelyawaiting an ST event.The authors’ conclusion should come as no surprise: ‘Themost important limitation of ST analysis is deviation fromSTAN clinical guidelines by labor ward personnel rather thana fault in the technology’ (p. 1199).Who then should be blamed? The monitoring technology?The guidelines? The obstetrician? The midwife? What are thereasons for inaction when action is called for and when boththe technology and the guidelines recommend action? Withhindsight it all seems illogical, and anyone who was not therefinds it difficult to understand what happened. We fail toappreciate that difficult trade-offs are necessary when theclinicians have to make their decisions in a busy, uncertainand ‘noisy’ setting. The easiest way out is to blame technologyor the human involved. However, it is more interesting andproductive to start asking why, instead of who. Accidents oradverse events are seldom the result of one single mistake, butemerge from a host of factors.How can we explain why the personnel did not apply themethods of CTG interpretation that they and their seniorcolleagues have practised since CTG was introduced in the1960s. Why does the arrival of a technical device adding STanalysis to CTG, make us behave like the onlookers who sawtheir first automobile? It is likely, of course, that problemswith CTG interpretation have always existed and that a bal-anced, evidence-based assessment of its risks has not been ableto compete with our tendency to stick with established cus-tomary practices. One wonders whether our resistance toalternative technologies and practices and our overconfidencein the effectiveness of traditional techniques (‘this is howwe’ve always done it’) may perhaps benefit powerful regula-tory, academic and industry interests at the heart of the devel-opment of medical technology, which tend to inhibitinnovation.Comparing what is going on in the delivery room toanother risky activity such as flying immediately reveals thehuge difference between the amount of attention and resour-ces put into the two. A whole science has developed aroundrisk and safety in aviation and it pays off. It is obvious thatadverse outcomes related to errors occur far more often in thedelivery rooms than in the air. Why is it so? Risk and safety arenot areas of high priority in the delivery room even if riskanalysis and mitigation systems have been successfully andsystematically introduced in various local settings, for exam-ple, in the UK (http://www.msnpsa.nhs.uk). Four decades of