1. CTG Masterclass AVMA 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 Spastic Diplegic Hemiplegic Ataxic
Proportion CP
Spastic Diplegic
26%
Hemiplegic
35%
Ataxic 4%
Athetoid (Dyskinetic)
7-15%
Spastic Tetraplegic
18-20%

7. ..and Clinical Negligence
Proportion CP
Intrapartum
Spastic Diplegic
26%
<1%
Hemiplegic
35% 0%
Ataxic 4%
Athetoid (Dyskinetic)
7-15%
80%
Spastic Tetraplegic
18-20%
45% +

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
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 Abnormal CTG
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 !
Have a think about the references in the 2nd section – Why Mothers die was produced by CEMD which was superseded by CEMACH. How about this ?

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

43. National Results

44. Thankyou