oct ewj 24 online - Flipbook - Page 16
guidance in 2022, assessment was of four key features;
baseline rate, variability, accelerations and decelerations. Each feature was considered individually, assessed and scored as either reassuring, non-reassuring
or abnormal with the scores added up to determine
what the overall categorisation was. The three overall
categorisations have not altered since the 2007 guidance (NICE, 2007), and are ‘Normal, Suspicious or
Pathological’. Changes between the guidance in 2007,
2014 and 2017 included the acceptance of a baseline
heart rate of between 100-160bpm as a reassuring feature rather than non-reassuring, and then back to
110-160bpm in 2017 (NICE, 2007, 2014, 2017).
There were also changes to the assessment of decelerations with more detail given and some of the language used changing. There was more detailed
guidance about what actions to take with each categorisation, including who to escalate to and actions for
other clinicians following this such as fetal blood sampling, conservative measures or expediting the birth
of the baby (NICE, 2017).
Whilst the knowledge and understanding of CTG
traces is growing there will be continued changes to
guidelines. There are now an increased amount of
things for midwives to consider when caring for a
woman on continuous CTG monitoring. Overall, I
find the emphasis the new guidance places on the
CTG as a tool to be used in conjunction with a holistic
assessment of the woman, including involving the
woman in the process and allowing for concerns not
mentioned in the guideline to be taken into consideration, very much needed. Almost every midwife can
recount a time when they have been in the room and
something just doesn’t feel quite right but the CTG
doesn’t quite meet the criteria for escalation. This updated guideline provides some first steps in supporting midwives to escalate these concerns.
What does this mean for the midwifery expert
witness?
When thinking about what the key takeaways are for
the expert witness, it’s helpful to remember that CTG
interpretation is not an exact science; very pathological CTG traces are generally easy to spot but it’s the
ones that could be interpreted either way that cause
more differences in opinion between clinicians. My
five top tips are;
The standalone intrapartum fetal monitoring
guidance introduced in 2022 (NICE, 2022) made several changes to both language and parameters for
each feature and overall categorisation. The assessment of the features became colour coded as white,
amber or red, rather than reassuring, non-reassuring
or abnormal. The overall categorisations of normal,
suspicious and pathological have remained the same.
• Look at the CTG and consider it based on the
national guidance that was current at the time. I
now find it more difficult to remember the parameters
for the difference features for a case in 2013 than I do
for a case in 2021 or 2023. To assist with this I created
a quick glance guide with the different parameters for
each feature so I can assess the trace based on what I
knew at that time. This has proved invaluable.
A significant change was that assessment of the rate of
contractions was included in the systematic assessment
as a feature, which had not previously been the case.
The parameters included the presence of 5 or more
contractions in a ten minute period an amber feature
(NICE, 2022) whereas this had previously been considered the aim when using oxytocin to stimulate contractions (NICE, 2007, 2014, 2017).
• Consider not just local guidance but also what was
usual practice at that time - for an example, my
above point about use of the toilet when performing
continuous CTG monitoring. Local guidance can
sometimes be very helpful here, like in the case of use
of Dawes Redman criteria during induction of labour.
A further change to the parameters was a change to
what constitutes a normal baseline. Previously a baseline of 110-160pm was considered reassuring, with
160-180bpm non-reassuring and above 180bpm abnormal (NICE, 2017). In the 2022 guidance a baseline rate above 160bpm is considered a red feature
and makes the overall categorisation of the CTG
pathological (NICE, 2022).
• Remember what the role of the midwife is. It’s easy
to look at a CTG and think “we would have had that
baby delivered in my workplace.” The role of the midwife is to perform an initial risk assessment, commence
CTG monitoring effectively, perform an ongoing
holistic risk assessment, ensure fresh eyes occurs
hourly, categorise the CTG trace and escalate concerns
to a senior midwife and/or the obstetric team. It isn’t
to determine if the decision for a caesarean birth or
an assisted vaginal birth should have been performed
- that is outside of the scope of practice for a standard
midwife and you will need to defer to an expert
obstetrician.
In clinical practice, in the Trust where I work, these
changes, along with others from the updated guidance, have now been incorporated into the electronic
records system, which has allowed me and my colleagues to embed them into practice easily. When reviewing cases I take into account what the guideline
was at the time, my understanding of it and when my
practice altered. My Trust’s electronic system was not
updated until May 2023, however this change was disseminated during clinical shifts, newsletter and on
training days, not to mention that a midwife has a responsibility to remain up to date on changes to local
and national guidance, so I consider that a reasonable
and responsible midwife should have embedded this
into their clinical practice by mid-2023, as I did.
EXPERT WITNESS JOURNAL
• Look at when you think escalation should have occurred when looking at timings. Use the actual timings to assist with working backwards from when the
baby was born. For example, if the baby was born at
03:30 and the obstetric team made the decision at
03:20 after it was escalated to them at 03:15 but you
consider no reasonable and responsible midwife
would have failed to have escalated at 02:45 (30 minutes earlier), then in conclusion the time of birth, in
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