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

CTG Masterclass

AVMA Annual Clinical Negligence Conference 2012

Professor Tim Draycott, Consultant ObstetricianHealth 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

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% 0%

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

Reassuring Non- reassuring AbnormalBaseline rate(bpm)

110 – 160 100 – 109161 - 180

<100>180

Comments:-

Variability(bpm)

5 bpm or more <5 for 40 mins ormore but <90 min

< 5 for 90 mins ormore

Comments:- CTG onfor 60 mins so far

Accelerations Present None Comments:-

Decelerations None EarlyVariableSingle prolongeddeceleration up to 3mins

Atypical variableLateSingle prolongeddeceleration > 3mins

Comments:-Unprovokeddecelerations

Opinion Normal CTG(All f our f eaturesreassuring)

Suspicious CTG(One non-reassuringfeature)

Pathological CTG(two or more non-reassuring or one ormore abnormal f eatures)

Dilatation Not assessed Comments:- Not contracting Contractions ….:10

Action Urgent transfer to tertiary unit and review by senior obstetrician

Date ……………………… Time………………… Signature………………………………………………. Status………………………….

Classification

Actions - Suspicious

Action - Pathological

NICE IP ‘Guide’line

New Sticker

Antenatal Sticker

Dr C BRAVADO

• Discuss risk• Contractions

• Baseline Rate• Accelerations• Variability• Accelerations• 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• 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. 1997CEMD – 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 !

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

• [email protected]