Originally published September 2014
The role of fetal surveillance in the antepartum and intrapartum periods is to monitor fetal well-being, as well as to help recognize potential fetal compromise and the need for further intervention or delivery. Identifying the areas of risk associated with fetal heart rate monitoring may reduce adverse perinatal outcomes and medico-legal problems for members who provide antepartum and intrapartum care.
The CMPA reviewed its medico-legal cases that opened between 2002 and 2013 and involved issues with fetal heart rate (FHR) monitoring; 199 cases were identified, of which 162 were closed. The majority of cases were legal actions (82%), followed by complaints to a medical regulatory authority (College) (15%), a hospital (2%), or an inquest (1%). Seventy-three per cent of the cases had an unfavourable outcome for the member. Obstetricians represented 63% of the physicians involved in the cases, while family physicians represented 31%. Other involved physicians included pediatricians, residents, and anesthesiologists.
The cases were grouped into intrapartum and antepartum periods, allowing the FHR monitoring issues to be presented for each period; in 4% of the cases, issues were found in both periods. Common problems in assessment, interpretation, and management are presented for each period.
The antepartum period, consisting of care provided before labour commenced, represented 14% of the cases. Most babies in these cases were stillborn. The mothers were primarily at term or post-term.
Assessment and interpretation
Two main issues were found in the assessment step. The first was a failure or delay in performing specific diagnostic tests, particularly a non-stress test (NST) or a biophysical profile (BPP), when risk factors for adverse perinatal outcomes were identified. Significant risk factors included gestational hypertension, intrauterine growth restriction (IUGR), post-term, and decreased fetal movement. The second issue was not continuing the NST for a longer period of time or repeating the test when an atypical or abnormal NST was present or once risk factors were identified.
In the interpretation step, the NST was misinterpreted as normal. In some cases, the mother complained of decreased fetal movement. The following case demonstrates what could happen when tests are misinterpreted.
Case example: Misinterpretation of non-stress test
A morbidly obese primiparous woman at 38 weeks arrives at a high-risk unit and reports decreased fetal movement for 24 hours. This is her second visit in 3 days. A non-stress test is interpreted as normal. The on-call obstetrician reassures the patient and tells her to follow-up with her regular obstetrician at her next appointment in 4 days. At that appointment, no FHR is found and an ultrasound confirms intrauterine fetal death. The patient is admitted for induction.
A College complaint is initiated and the committee cautions the obstetrician for misinterpreting the NST as normal. The committee, with the assistance of an expert, states that he should have either continued the NST until improvement was seen or performed a biophysical profile (BPP).
There were indications from the antenatal fetal testing that further intervention was required. In many of these cases, the experts were of the opinion that the patient should have been admitted, referred to a specialist, or transferred to a high-risk unit or tertiary centre. In other cases, the delivery should have been expedited.
The intrapartum period, care during labour and delivery, represented 82% of the cases in this review. The majority of the babies had catastrophic clinical outcomes (e.g. spastic quadriplegic cerebral palsy, developmental disorders). The mothers were predominantly at term. Cases which involved medical induction or augmentation were excluded, since these were included in the article "Medico-legal risks with induction of labour."
Assessment and interpretation
Inadequate fetal surveillance was the main problem in the assessment step and included a delay or failure to order continuous fetal heart monitoring, insert a fetal scalp electrode (FSE) when external tracing was difficult to interpret, or obtain a fetal scalp pH in the presence of abnormal tracings. Delays in recognizing the fetal heart rate tracing abnormalities were also issues in the interpretation step.
Timely attendance was one of the issues in this phase, particularly after being informed of an atypical or abnormal FHR tracing, prolonged second stage of labour, or diagnosis of breech presentation. Another significant issue was a delayed intervention, either by Caesarean section or by instrumental delivery. The next case illustrates the importance of timely attendance and early intervention.
Case example: Delay in attending and performing C-section
A primiparous woman is admitted in early labour at 39 weeks and 4 days gestation; contractions are 5 minutes apart. Electronic fetal monitoring (EFM) shows minimal variability. Two hours later, the family physician (FP) artificially ruptures the patient's membranes revealing thick meconium. He places a FSE one hour later and notes no improvement in the tracing. Looking for a second opinion on the minimal variability and the thick meconium, the FP consults the on-call obstetrician. The obstetrician orders an epidural, assesses the patient 2 hours later, and orders an urgent Caesarean section for fetal distress. The infant is delivered approximately one hour later and requires active resuscitation. The child has spastic quadriplegic cerebral palsy and severe global developmental delay.
A legal action ensues. Experts are critical of the obstetrician for ordering an epidural without first assessing the patient, taking two hours to arrive to assess the patient, and delaying performing an emergency Caesarean section. Experts also comment that the physician's interpretation of the tracing may not have taken into consideration the paper speed of 1 cm/min.; more worrisome was the absence of fetal monitoring in the 50-minute period prior to the delivery. A settlement was paid to the patient by the CMPA on behalf of the member obstetrician.
In two-thirds of the cases, other members of the care team or system-related issues played a part in delaying the diagnosis of potential fetal compromise.
Monitoring issues for nurses and midwives were identified. These included not appreciating the severity of the fetal heart tracing, not contacting the physician when having difficulty monitoring or obtaining the FHR, and not instituting continuous electronic fetal monitoring. Communication problems between the physicians and nurses also contributed. Frequently a nurse did not provide accurate information about significant changes in the FHR tracing, and the physician did not ask enough questions to be satisfied about the clinical condition and EFM interpretation.
Problems in the hospital were system-related and most often due to inadequate staffing or equipment. In one case, elective surgical cases were in progress when an urgent Caesarean section was called and there was no available operating room.
Other contributing factors were related to the maternal obesity, as identified in a case where the mother and the fetal heart rate may have been confused. The FHR tracing (i.e. quality and speed, of 1, 2 or 3, centimetres per minute) may also have been a factor in another.
Risk management considerations
Based on the review of the expert opinions in the medico-legal cases involving issues with fetal heart monitoring, the following risk management considerations were identified.
Assessment and interpretation
- If the fetal heart rate is difficult to obtain in the antepartum period, consider other fetal evaluation methods such as ultrasound and BPP.
- When there is an atypical or abnormal non-stress test consider further testing, continued monitoring, or consultation with another physician.
Assessment and interpretation
- Policies and procedures should be in place to guide the level of monitoring required for women with risk factors.
- Clear policies and procedures should be in place to guide the interpretation and management of atypical or abnormal fetal heart rate tracings.
- Consider the speed of EFM tracing when interpreting the tracing.
- Consider applying a fetal scalp electrode if the external monitoring is inadequate or difficult to interpret.
- When consulting another physician or specialist:
- clearly communicate the clinical situation
- provide the reason for the consultation
- convey the urgency of the consultation, as appropriate
- Provide sufficient and clear communication with the members of the team during assessments and handovers.
- Clearly communicate the urgency when delivery is required in the presence of a persistently abnormal fetal heart rate. Adequately disseminate the urgency to other members of the team.
- Document all aspects of the care provided in the antepartum and intrapartum periods accurately and in a timely manner.
- In cases of adverse outcomes and events, discuss the circumstances and outcomes with the patient and her family, and document the discussion in the record.