Intrapartum fetal surveillance

Abstract

Electronic fetal monitoring (EFM) is the recommended method of intrapartum fetal surveillance for high-risk pregnancies. The cardiotocogram (CTG) trace forms a central piece of documentary evidence in medico-legal cases related to intrapartum hypoxia and birth asphyxia. Cardiotocography was introduced in 1960s as a screening tool with the view to reduce fetal hypoxic brain injury and cerebral palsy rates. However, its positive predictive value for intrapartum fetal hypoxia is as low as 30%, with false positive rate of around 60%. Since its introduction in obstetric practice there has been an increase in intrapartum caesarean section and operative delivery rates, but there has been no demonstrable reduction in occurrence of cerebral palsy or intrapartum fetal deaths. The low specificity of CTG for detection of fetal hypoxia therefore necessitates confirmatory tests such as fetal scalp blood sampling (FBS) or analysis of fetal electrocardiography. The National Institute for Health and Clinical Excellence (NICE) recommends continuous intrapartum fetal monitoring with CTG for high-risk pregnancies and storing the CTG electronically for at least 25 years for medicolegal purposes.It is mandatory that all healthcare professionals who are responsible for the care of women in labour are adequately trained and assessed on pathophysiology of fetal heart rate (FHR) changes in labour to improve interpretation of CTG and avoid adverse maternal and/or fetal outcomes.Confidential enquiries into intrapartum morbidity and deaths have shown that the four main contributors to poor perinatal outcomes are – an inability to interpret CTG by the health professionals, a failure to incorporate the overall clinical condition, a failure to communicate or escalate, and delay in taking appropriate action. In this article we discuss three cases, two of which led to adverse perinatal outcomes. The key learning points and risk management issues relevant to the cases are also discussed.