Medico-Legal Issues with CTG Interpretation
Vikram Sinai Talaulikar and Sabaratnam ArulkumaranAffiliation:
Department of Obstetrics and Gynaecology, St. George’s Hospital and University of London, Tooting - London, SW17 0RE, UK.
Electronic fetal monitoring is the recommended method of intrapartum fetal surveillance in high risk pregnancies and the cardiotocography (CTG) forms an integral part of intrapartum care on most modern labour wards. Despite the questions about its efficacy and controversy regarding increased rates of operative delivery associated with its use, continuous CTG remains the predominant method of intrapartum fetal monitoring. Although CTG is sensitive in detecting abnormalities of fetal heart rate (FHR), its specificity for detection of fetal hypoxia is low and therefore confirmatory tests such as fetal scalp blood sampling or analysis of fetal electrocardiography (ECG) become necessary.
The intrapartum CTG trace forms a central piece of documentary evidence in litigations related to adverse perinatal outcomes which are alleged to have arisen due to events that took place during the labour and/or delivery of the baby. The main reasons for litigation are not just for recovery of costs determined by injury, pain, loss and future care of a brain damaged child; but the parents also want to know what happened and why, and expect the healthcare staff to be held accountable for their actions.
Majority of medico-legal cases have similar problems which can be laid down to a few factors such as - a) inability to interpret FHR trace, b) inappropriate action, c) technical aspects and d) record keeping.
Not only can litigations have long-term consequences for the working lives of midwives or obstetricians but they have been influential in changing practice trends such as rising caesarean rates. Unfortunately obstetric litigation with its huge costs is a growing problem and for the foreseeable future, the CTG is here to stay. The best defence against litigation is good clinical practice with adherence to evidence based guidelines and regular mandatory training in the interpretation of CTG for all labour ward staff. There should be a mechanism for the rapid review of adverse obstetric events and dissemination of key learning points to all staff.
CTG, fetal, hypoxia, intrapartum, medico-legal, monitoring, surveillance.
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