During the summer between my second and third year, I explored the subject of fetal wellbeing, from how cardiotocography (CTG) training is delivered, to the legal implications of issues of interpretation.
As part of the Midwifery course, students learn about intermittent and continuous fetal monitoring guidelines, and how and when to use each method. However, although I learnt that I should do these things, I did not necessarily know why. It wasn't until I attended Edwin Chanadrahan's ‘CTG masterclass’, and it was spelled out to me that I was listening and looking for signs of fetal hypoxia (or chemoreceptor decelerations), that I made the link from theory to practice.
Reading a CTG confidently is a skill gained through experience and exposure. Obstetricians must pass an exam on CTG interpretation (Royal College of Obstetricians and Gynaecologists (RCOG), 2017), yet no such standard exists for midwives, and it is down to each Trust to set their own guidelines on fetal monitoring and assessment (RCOG, 2017).
In May 2017, there were reports that lack of continuous fetal monitoring training for midwives led to mistakes and a failure to spot early warning signs of fetal hypoxia (Donnelly, 2017). The effects fetal hypoxia can be devastating: no family expects their baby to have a potentially life-altering brain injury. These events often lead to litigation, costing the NHS millions every year and altering families' lives unimaginably.
The NHS Litigation Authority (soon to be NHS Resolution) handles claims made against the NHS for breeches in duty of care. It provides a range of services, from indemnity cover to legal and professional advise. It also endorses the ‘Sign up to Safety’ initiative, supporting teams to make care safer (NHS England, 2017).
Within the criminal justice system, in order for the Crown Prosecution Service (CPS) to prosecute, it has to be satisfied that it is in the public interest, and that there is a realistic prospect that the jury will find the defendant guilty beyond reasonable doubt (CPS, 2017). In a civil court, the process is slightly different: the court assesses whether harm was caused based on the balance of probabilities (Kaplan et al, 2012).
The ‘Every Baby Counts’ report is a response to the UK's static stillbirth rate. It is an ambitious project that seeks to halve the stillbirth rate by 2020 (NHS England, 2016) by collecting and analysing data from cases of perinatal mortality and brain injury during labour. It is this kind of shared learning that the Clinical Human Factors Group (CHFG) seeks in order for the NHS to model a system of investigation similar to that of the aviation industry. It is hoped that this overarching view and the search for commonalities will raise standards and safety (CHFG, 2017).
Where there is a culture of safety and multidisciplinary team working, standards improve. This is shown through the results of the PROMPT training in Bristol (North Bristol NHS Trust, 2013), and the CTG masterclasses in Lewisham and Greenwich. The data shows that where a multidisciplinary team is engaged, involved and held to the same standards, there is reductions in serious incidents. The Fetal Monitoring Team at St George's University Hospitals NHS Foundation Trust won an award for clinical leadership for their reduction in serious incident and caesarean section rates, through the use of CTG with echocardiogram (ECG) analysis (also known as ST analysis, or STAN) technologies, and standard training for all obstetric staff (British Medical Journal, 2017). This is also beginning to show at Lewisham and Greenwich, where fetal wellbeing midwives work to improve outcomes through masterclasses and weekly case reviews. If we are to halve the stillbirth rate by 2020, a systematic, standardised approach should be considered.