Medico-Legal Issues related to Intrapartum CTG

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Medico-Legal Issues related toIntrapartum CTG

• S.Arulkumaran
• Professor Head
• Obstetrics Gynaecology
• St.Georges Hospital Medical School University of
  London

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Should we use EFM? CTG is the key in most
obstetric litigation

• RCTs No reduction in PN deaths or CP
• - Increase in CS rate
• - Reduction in NN convulsions (?HIE)
• Inadequate numbers to show these end
  points
• CESDI IP deaths due to hypoxia
• - Inability to interpret, failure to incorporate
  clinical picture, inappropriate action, delay in
  intervention
  

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Litigation Liability Causation

• Abnormal CTG, low Apgar score, low cord arterial
  pH, assisted ventilation, admission to SCBU, HIE
  gt Neurological damage
• Several intrinsic fetal disorders cause
  neurological disability abnormal CTG
  inappropriate management may be coincidental.
• Mismanagement of labour may not be relevant to
  the outcome

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Acute IP events cerebral palsy

• ESSENTIAL CRITERIA
• Evidence of metabolic acidosis in cord UA or
  early NN samples pHlt7.0 BD gt12 mmol/l
• Early onset of severe or moderate neonatal
  encephalopathy in infants gt34wk
• Cerebral palsy of a spastic quadriplegic or
  dyskinetic type

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Acute IP events Cerebral palsy

• ADDITIONAL CRITERIA
• A sentinel hypoxic event occurring immediately
  before or during labour
• A sudden rapid sustained deterioration in FHR
  pattern
• Apgar scores of lt7 for more than 5 mins
• Early evidence of multisystem involvement
• Early imaging evidence of acute cerebral
  involvement

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Liability

• Abnormal CTG poor outcome causation is not in
  doubt gt ?Liability
• ? Appropriate action taken in the presence of
  abnormal CTG
• Expert opinion Care given fell short of what
  was expected by a responsible body of medical
  opinion (BOLAM PRINCIPLE)

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• Bolam Principle The test is the standard of
  the ordinary skilled man exercising and
  professing to have the specialist skill. A man
  need not possess the highest expert skill at risk
  of being found negligent .
• BOLITHO PRINCIPLE It can be demonstrated that
  the professional opinion is not capable of
  withstanding logical analysis, the judge is
  entitled to hold that the body of opinion is not
  reasonable or responsible.

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Timing Severity of Injury

• Timing of injury is not always possible based on
  the CTG
• Grossly abnormal CTG may suggest possible injury
  but cannot predict the severity of the injury
• In the presence of abnormal CTG how long can one
  wait before intervention? Does the delay worsen
  the injury without changes in the CTG?

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Review of cases with CP or IP - SB

• Acute hypoxia Prolonged bradycardia
• Sub-acute hypoxia Prolonged decelerations
• The above two patterns usually present with acute
  clinical events or in late first or second stage
  of labour/ at times cause unknown
• Gradually developing hypoxia
• Long standing hypoxia reduced variability /-
  shallow decelerations

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ACUTE HYPOXIA

• PRESENTS WITH PROLONGED BRADYCARDIA
• ABRUPTION, CORD PROLAPSE, SCAR RUPTURE
• UTERINE HYPERSTIMULATION / TOCOLYSIS
• Important considerations - CTG PRIOR TO
  BRADYCARDIA CLINICAL PICTURE- TMS, IUGR,
  infection, APH etc

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Long standing hypoxic pattern

• No accelerations
• Markedly reduced baseline variability
• Shallow decelerations lt15 beats
• May have a normal baseline rate

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Subacute hyoxia

• Prolonged decelerations More time below the
  baseline rate (e.g.gt90 secs) and shorter
  duration at the baseline rate (lt30 secs)
• Less than optimal circulation through the placenta

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GRADUALLY DEVELOPING HYPOXIA

• Accelerations do not appear
• BASELINE RATE increases and VARIABILITY reduces
• CONSIDER THE CLINICAL PICTURE (parity, cervical
  dilatation, rate of progress, high risk factors)
• IF REQUIRED PERFORM FBS X 2

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Xxx xxxxx
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Fetal behavioural state - Cycling

• Cycling with a reactive followed by a sleep
  pattern suggests that the baby is neurologically
  normal
• Absence of cycling may be due to drugs,
  infection, cerebral haemorrhage, chromosomal or
  congenital malformation, previous brain damage
• Previously brain damaged baby may or may not show
  cycling but cord pH may be normal such babies
  may not show evidence of HIE but may exhibit
  signs of neurological damage that manifests later

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Perfusion injury ? Timing of injury ?
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HOW TO REDUCE HYPOXIC EVENTS/ LITIGATION
Education Risk management

• Regular knowledge update at CTG courses
• Review of CTGs with poor outcome in hospital
  training two weekly?
• Availability of learning materials- books/CDs
• Incidence reporting and risk management

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How to reduce hypoxic events/ LITIGATION Good
clinical practice Good communication

• Establish and encourage accepted lines of command
  communication
• Appropriate action. e.g. change of position,
  hydration, stop oxytocin infusion, intrauterine
  resuscitation with tocolytics, FBS,
  amnio-infusion, Oxygen to mother ?
• Consider obtaining additional information pH,
  pulse oximetry, STAN, Computer analysis/ neural
  network
• Good communication

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Evidence to help defend a case- Cord pH good
records

• Selective or routine cord blood sampling two
  vessels/ arterial?
• Potential for poor outcome two vessels. E.g.
  Operative delivery for fetal distress, low Apgar
  scores, TMS, pre-term, abnormal CTG/FBS, cases of
  infection, IUGR, APH.
• Consider online electronic archival of CTG and
  notes (WORM disks)

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Obstetric accidents a review of 64 cases. Ennis
Vincent .BMJ 19903001365-7

• 11 cases CTG was omitted
• 19 cases CTG was missing
• 6 cases - CTG was unreadable
• 14 of the remaining 28 cases signs of fetal
  distress went unnoticed or were ignored

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Overview of functions
Possible to export data
Can integrate with3rd-party Software
Statistics
Generate Forms
Flow sheets
Surveillance and Alerting
ADT Interface to HIS
Data Storage CTG (8 hrs) notes of 4000 women in
one WORM disk (25y)
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Record Keeping

• When CTG is not up to the time of delivery or the
  CTG is not technically satisfactory auscultate
  record
• In cases with abnormal CTG and poor outcome
  describe the CTG in the notes
• ??Photocopy the CTG notes certify separate
  copy with risk manager Confidentiality issues??
• Avoids fading of the CTG, missing pages or notes
  introduction of additional notes

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THANKYOU