oct ewj 24 online - Flipbook - Page 14
The Changing Landscape of
Cardiotocography (CTG) and the
Impact on Midwifery Expert Witnesses
by Gemma McIntyre - Somek & Associates
The monitoring of a baby using a cardiotocograph (or
CTG as it is more commonly known) during the intrapartum period first became usual practice in the
1970’s (Gauge and Henerson, 2004) and has developed over time to become a tool, which is now commonplace on every labour ward. Student midwives
are taught about CTG interpretation throughout
their undergraduate degree programmes, midwives
have a yearly update and most Trusts hold regular
CTG teaching sessions, yet CTG interpretation and
escalation continues to be one of the top themes in
cases reported to NHS Resolution Early Notification
Scheme (NHS Resolution, 2019), Royal College of
Obstetricians and Gynaecologists (RCOG) Each Baby
Counts Scheme (RCOG, 2020) and Maternity and
Newborn Safety Investigations (MNSI) (Healthcare
Safety Investigation Branch, 2023). In response to this
there have been changes to national guidance, developments in education, three safety bundles which include fetal monitoring as an element and a focus on
achieving these ambitions as part of the Maternity Incentive Scheme. This changing landscape must be
considered by all midwifery expert witnesses when reviewing cases and providing expert witness reports
and testimony, as to what was current practice for a
reasonable and responsible midwife at the time of the
incident. This article will explore some of the key
changes.
would sometimes be used on the antenatal ward depending on how confident the midwife felt about
using it. There was limited training and guidance on
how to use it and I remember some midwives did not
trust it and preferred their own interpretation.
By 2019 national guidance (NHS England, 2019) was
recommending its usage to reduce the risk of human
error when interpreting antenatal CTG traces. The
use of computerised CTG analysis then became used
regularly on the antenatal ward, particularly during
induction of labour. The use of DRC is very specific in
that it can only be used when there is no uterine activity. The tool is not designed to be used in labour; of
course the difficulty comes in defining when labour
begins. Many midwives interpreted this to mean when
a woman was identified as being in established labour,
with regular contractions and with her cervix being
4cm or more dilated.
MNSI reports began to highlight this to Trusts and in
2023 the Dawes Redman education site provided a
statement on the use of computerised CTG analysis,
which clearly set out that DRC can be used prior to
the administration of the first vaginal prostaglandin
in induction of labour, providing there is no uterine
activity (Nuffield Department of Women's & Reproductive Health, 2023). It can also be used after a
stretch and sweep and when a mechanical method to
induce labour is used, again providing there is no
uterine activity. NHS Resolution (2023) shared a case
story based on a case when antenatal computerised
CTG monitoring contributed to the outcome. The
aim of this was to raise awareness of the dangers of
using DRC when uterine contractions are present.
For the expert witness this means considering what
the accepted practice was at the time of the incident
when considering if performing or not performing
DRC met the standard of the reasonable and responsible midwife.
Antenatal fetal monitoring and use of computerised
CTGs.
When I first qualified in 2012 there was very limited
guidance on how to interpret antenatal CTG traces.
National Institute for Health and Clinical Excellence
[NICE], (2007) guidance on intrapartum care and
NICE (2008) guidance on antenatal care made no reference to interpretation of antenatal CTG traces and
it was dependant on the Trust in which a midwife was
working to produce local guidance. In the Trust
where I first worked we were fortunate to have clear
guidance for interpreting and categorising antenatal
CTG traces as either normal or abnormal, but this was
not always commonplace. One tool used to overcome
this was the use of computerised CTG analysis, also
known as Dawes Redman Criteria (DRC). This is a
software tool which has a bank of over 100,000 CTG
traces at various gestations and once some baseline
data is entered it uses this to perform a numeric analysis and robust interpretation of the CTG trace.
When to perform a CTG?
Making the decision to commence continuous CTG
monitoring in labour is often the role of the midwife.
In order to determine which women are suitable for
intermittent auscultation and which require continuous monitoring is based on a thorough and continuous risk assessment. The risk assessment for labour
includes a consideration of any risk factors during
pregnancy and the current presentation of the
woman. Midwives who qualified before me may remember how an admission CTG would be performed
on every woman attending in labour; NICE (2007)
In my experience, in the Trust where I worked, in
2012 the use of computerised CTG analysis was well
embedded in the antenatal day assessment unit and
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