oct ewj 24 online - Flipbook - Page 15
discouraged the use of this and today it would be very
unusual to see this practice.
occur time and again. How could I support women
to use the toilet and so promote independence, mobilisation and preservation of dignity, not to mention
reduce the risk of bladder damage, when I needed to
continuously monitor their baby?
NICE (2022) currently provides a list of antenatal
maternal and fetal risk factors as a guide to determine
which clinical situations indicate continuous CTG monitoring in labour should be offered. This also includes
a caveat that if other concerns not listed are present
then, following a multi-disciplinary review, the offer
of continuous CTG monitoring can be considered.
As a student midwife I was shown how to unplug the
transducers, wrap them up and hand them to the
woman and leave the CTG running whilst I assisted
her to the toilet. Once she returned to the bed (freshly
made with a clean inco sheet and a fluffed up pillow,
of course) I would dutifully plug the transducers back
into the machine and write in the gap on the CTG
paper ‘up to toilet’. I would think nothing of this and,
along with my colleagues, continued this practice with
no real concerns about what could be happening to
the fetal heart rate whilst there was no monitoring on.
There were always situations where I would consider
that the risk of disconnecting the CTG for a toilet
break were too great, this would usually be when there
were concerns about the CTG trace or when the
woman had epidural anaesthesia in place. In this instance I would offer intermittent catheterisation and
on the whole women accepted this. It was very unusual to offer a bedpan and there was no commode on
the unit. As telemetry became more available this
could be used, however there was initially only 1 machine on the unit which was big and heavy and didn’t
always work very well, so myself and most colleagues
tended to use this only when necessary.
As labour progresses the role of the midwife is to
continue reviewing the risk assessment and consider
any risk factors which have developed in the intrapartum period. NICE Intrapartum care guidance in
2014 and 2017 both recommended a documented
systematic assessment of the mother and baby at a minimum of hourly and more frequently if there are concerns (NICE, 2014, 2017). In 2022 NICE published
‘Fetal Monitoring in Labour’ guideline, which is a
stand-alone guideline separate from intrapartum care
guideline (NICE, 2022). This also includes recommendation of an hourly assessment of the mother and baby
during labour and specifies what should be taken into
account as part of the assessment and which conditions
indicate a move to continuous CTG monitoring.
In my experience, although the latest guidance may
provide written direction on what to cover, the ordinary midwife would have been expected to perform a
comprehensive risk assessment encompassing all of
the elements listed prior to publication of this guideline. The midwifery expert witness must therefore
consider what the actions would have been for the reasonable and responsible midwife when considering
cases prior to 2022.
In 2019 I became aware of a case where a midwife had
done exactly as I did and disconnected the CTG whilst
a woman she was providing care for used the toilet.
On her return she plugged back in the CTG and the
fetal heart rate was no longer recording. Initially this
did not cause concern as the transducer does sometimes need to be moved to accurately record the heart
rate, especially following reposition of the woman.
When the fetal heart rate was located there was an ongoing fetal bradycardia. The emergency bell was
pulled and the baby’s birth was expediated. When reviewing the case it became apparent that no one could
determine how long the fetal bradycardia had been
ongoing and this impacted on the decision making of
the obstetric team. This changed my practice and for
me now ‘continuous means continuous’, after all if a
woman is being monitored using a continuous CTG
this is because increased risk factors are present.
There are some exceptions to this rule and one which
I have observed in several cases is the assessment of
blood stained liquor. NICE (2007, 2014, 2014, 2022)
all indicate that fresh bleeding in labour or any vaginal blood loss other than a show is considered an intrapartum risk factor and continuous CTG
monitoring would be required. In my experience
midwives often have the tendency to describe ‘pinky
liquor’ or to document ‘show evident’ on multiple occasions. In this way the language used has normalised
a risk factor and does not always allow for consideration of the significance of multiple small amounts of
blood loss. Healthcare Safety Investigations Branch
(2023) highlights this as a theme in risk assessment in
the intrapartum period of care. This needs careful
consideration as an expert witness and the question I
ask of myself is ‘when did I alter my practice to reflect
this?’ It can be difficult to determine how effectively
engrained ways of working such as this are challenged
and new learning disseminated to embed new practice. As an expert I think back to a situation where I
experienced this and consider my actions. I then use
this to determine what was current expected practice
at that time.
The changes in interpretation and importance of
categorisation
Further challenges in CTG landscape include the
various changes made to how CTG traces are assessed,
interpreted, categorised and what, if any, escalation is
required. Although there have been other methods
used for CTG interpretation the majority of my experience is in using the NICE guidelines and I will
focus on some of the key changes within this.
As a midwife, CTG assessment is a continuous process
throughout caring for a woman in labour. A formal
assessment may be documented at least hourly in the
records but in reality the midwife is continually observing the CTG and making notes, adjustments or
acting if there are concerns. Until the updated NICE
Continuous means continuous
As a clinical midwife caring for a woman having
continuous CTG monitoring, usually using a wired
machine and encouraging fluids, the same issue would
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