CTG Masterclass A V MA Annual Clinical Negligence Conference 2012

1. CTG MasterclassAVMA Annual Clinical Negligence Conference 2012 Professor Tim Draycott, Consultant Obstetrician Health Foundation Improvement Science Fellow

2. Birth care not always easy

3. Introduction • Cerebral Palsy • Pattern of injury • Relationship with low Apgar score • Standard of care • Intermittent Auscultation • Electronic Fetal Monitoring • Interpretation • Action required • Cases

4. Low Apgars and CP • Base Excess ≤12 likely to be normal • Apgar score <7 • Odds ratio for CP after low (<7) Apgar scores at 5 minutes in tern infants is 3.72 • Proportion of CP in the population that could be attributed to a low Apgar score (<7) at 5 minutes is 10.9% • At least 50% of Low Apgar scores could be prevented with better care

5. Recurring Themes • Failure to perform EFM • Failure to recognise CTG abnormalities • Failure to respond to CTG abnormalities: • Fetal blood sampling • Expedite delivery

6. Cerebral Palsy

7. ..and Clinical Negligence

8. Clinical Negligence • Standard of care • Breach in duty of care • Midwives • Obstetricians • Paediatricians • Did that breach cause the injury ?

9. Causation • Athetoid Dyskinetic Cerebral Palsy • Acute profound hypoxia • Spastic Tetraplegic Cerebral Palsy • Chronic partial ischaemia

10. Athetoid CP • Profound acute hypoxia - ‘lack of oxygen’ • Uterine Rupture • VBAC • Cord Prolapse • Abruption

11. Hypoxia • Oxygen sensitive parts of body • Kidneys • Heart • Brain

12. MRI findings • Areas of brain with high metabolic rate • Deep grey matter • Posterior parts of lentiform nuclei • Ventro-lateral nuclei of thalami • Hippocampus

13. MRI

14. Spastic Tetraplegic CP • Mechanism of injury less established • Prolonged period of mild – moderate hypotension • Cord Compression • Head Compression • Watershed areas of brain

15. Chronic Partial Ischaemia • Low blood pressure in cerebral arteries • Perfusion at peripheries reduced • Lawn Sprinkler

16. MRI Findings

17. Intrapartum • Monitoring fetal heart rate in labour • Intermittent Auscultation • Cardiotocograph • Baseline rate • Baseline variability • Accelerations • Decelerations • Introduction only

18. Intermittent Auscultation • Normal Labour • The RCOG EFM guideline recommends: • In the active stages of labour, intermittent auscultation (IA) should occur after a contraction, for a minimum of 60 seconds, and at least. • every 15 minutes in the first stage • every 5 minutes in the second stage • Failure to perform IA as above is substandard care

19. When to change to EFM ?

20. Cardio-tocography • Abdominal palpation • Maternal pulse • Name/number/time/paper speed • Technically adequate • Documentation (actions & opinion) • Interpret in light of clinical setting

21. Reassuring CTG • 4 Features: • Baseline rate 110-160 • Baseline variability - 5bpm or more • Accelerations • No decelerations

22. Intrapartum • Standard of care • NICE EFM May 2001 • NICE Intrapartum Guideline Sept 2007 • Pre 2001 – FIGO guidance published in 1987

23. NICE EFM

24. Coalface

25. Classification

26. Actions - Suspicious

27. Action - Pathological

28. NICE IP ‘Guide’line

29. New Sticker

30. Antenatal Sticker

31. Dr C BRAVADO • Discuss risk • Contractions • Baseline Rate • Accelerations • Variability • Accelerations • Decelerations • Outcome

32. However………. • DrCBravado not consistent with: • Electronic Fetal Monitoring Guideline, published in 2001 • NICE Intrapartum Guideline in 2007 • Therefore its use is substandard care

33. Breach of Duty • Assessment of CTG • Classification into NICE category • Documentation, each hour • Appropriate action for CTG category

34. Causation – CP Template • Fetal, umbilical arterial cord, or very early neonatal blood: pH <7.00 & base deficit >12 mmol/l • Severe or moderate neonatal encephalopathy in infants >34 weeks • Spastic quadriplegic or dyskinetic CP • Exclusion of other identifiable causes

35. CP Template contd • Sentinel hypoxic event • Sustained fetal bradycardia or poor variability in the presence of late or variable decelerations • Apgar scores of 0-3 beyond 5 minutes (previously <7). • Onset of multi-system involvement within 72 hours of birth.

36. Causation and timing • Paediatric expert • Use of umbilical artery base excess: Algorithm for the timing of hypoxic injury Ross and Gala. Am JOG. 2002 • >10% infants born with Base Excess ≥16 will have cognitive defects at 1 yr • Almost all infants born with base excess ≤ 12 are normal

37. Timing of Injury • Normal Labour • Fetus enters labor with a base excess of –2 mmol/L • 1 mmol/L per 3 to 6 hours in normal first stage of labour • 1 mmol/L per hour of second stage • Abnormal CTG • 1 mmol/L per 30 minutes with repetitive typical severe variable decelerations • 1 mmol/L per 6 to 15 minutes in subacute fetal compromise • 1 mmol/L per 2 to 3 minutes with acute, severe compromise (eg, terminal bradycardia)

38. Timing • A guide, not an exact science • At what time would delivery have avoided injury ? • Work backwards through trace • Intermittent Auscultation

39. Pitfalls • Cord Gas better than expected • Venous sample • Complete cord compression • MRI • Other causes • Chronic Partial • May not have sentinel event

40. Conclusion • Breach of duty of care • Use NICE EFM & IP Template • Action also defined by national guidance • Causation • ACOG & International consensus template

41. Problem ? • 50% adverse outcomes preventable with better care CESDI – 4th Annual Report. 1997 CEMD – Why Mothers Die. 1998 CEMACH – Saving Mothers Lives 2007 • UK Apgar <7 at 5 mins • Ranges from 0.4% of term infants to 1.96% • 5 fold variation !

42. Neonatal Outcomes 5’ Apgar p=0.00042 (Chi2 test for trend) HIE p=0.0176 (Chi2 test for trend)

43. National Results

44. Thankyou www.prompt-course.org tdraycott@gmail.com