CTG Masterclass AVMA Annual Clinical Negligence Conference 2012 Professor Tim Draycott, Consultant Obstetrician Health Foundation Improvement Science Fellow

Birth care not always easy

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

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

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

Cerebral Palsy Spastic Diplegic Hemiplegic Ataxic Proportion CP Spastic Diplegic 26% Hemiplegic 35% Ataxic 4% Athetoid (Dyskinetic) 7-15% Spastic Tetraplegic 18-20%

..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% +

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

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

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

Hypoxia Oxygen sensitive parts of body Kidneys Heart Brain

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

MRI

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

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

MRI Findings

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

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

When to change to EFM ?

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

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

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

NICE EFM

Coalface

Classification

Actions - Suspicious

Action - Pathological

NICE IP ‘Guide’line

New Sticker

Antenatal Sticker

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

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

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

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

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.

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

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)

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

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

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

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 ?

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

National Results

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