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Trust delivers training to clinicians for improving their fetal monitoring skills and reducing serious incidents attributing to CTG misinterpretation,preventing severe hypoxic encephalopathy and early neonatal deaths

Challenge

    • In UK, 1136 babies either died in labour or soon after birth or sustained severe brain injury (2015)
    • Review of all serious incidents from 2009 to 2014 highlighted Cardiotocography (CTG) misinterpretation as a common theme within the trust
    • Reduce the number of cases of hypoxic-ischaemic encephalopathy (HIE) and early neonatal deaths due to CTG misinterpretation to zero

Action

    • Introduced Physiological CTG and Human Factors training to reduce early neonatal deaths and intrapartum brain damage
    • Developed an e-learning tool to facilitate learning and case discussions
    • Created an online group of fetal monitoring midwives and held regular meetings, establishing a network between different hospitals running similar projects
    • Facilitated patient involvement through the Maternity Service Liaison Committee

Result

    • 60% reduction of severe HIE since the introduction of the project in 2015
    • Resulted in no cases of HIE attributed to CTG misinterpretation in the 2017-18
    • Percentage of cases of early neonatal deaths (>24 weeks) due to CTG misinterpretation dropped from 50% to 40%
    • No cases of CTG misinterpretation were identified as contributors to the early neonatal deaths in 2017-18

Outline:

The Secretary of State announced the Sign Up to Safety initiative in 2014 in which NHS trusts were invited to commit to a new ambition to reduce avoidable harm, and halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries in babies by 2030, with a 20% reduction by 2020.

Our unit carried out a review of all serious incidents from 2009 to 2014 which highlighted Cardiotocography (CTG) misinterpretation as a common theme, and a successful proposal was put forward to NHSLA Sign Up to Safety. The program set to address and improve fetal surveillance and wellbeing through enhancing clinicians level of knowledge, and competence in interpretation of CTG using fetal physiology based approach and human factors awareness.

There has been a 60% reduction of severe HIE since the introduction of the project in 2015 (0.15% in 2015-16, 0.07% in 2016-17, and 0.055 in 2017-18) with no cases of HIE attributed to CTG misinterpretation in the 2017-18. The percentage of cases of early neonatal deaths (>24 weeks) due to CTG misinterpretation dropped from 50% in 2015-16 to 40% in 2016-17 and no cases of CTG misinterpretation were identified as contributors to the early neonatal deaths in 2017-18.

Ambition:

In 2015 in the UK, 1136 babies either died in labour or soon after birth or sustained severe brain injury and 76% of those babies might have had a different outcome with different care.

Various contributory factors were identified and improving fetal monitoring skills alongside with ability to work as a team, maintain oversight of the full clinical picture and communicate effectively were major recommendations of “Each baby counts report 2015”.

The ambition at Kingston Maternity is to reduce to zero the number of cases of hypoxic-ischaemic encephalopathy and early neonatal deaths due to CTG misinterpretation.

Outcome:

There has been a 60% reduction of severe HIE since the introduction of the project in 2015 (0.15% in 2015- 16, 0.07% in 2016-17, and 0.055 in 2017-18) with no cases of HIE attributed to CTG misinterpretation in the 2017-18.

The percentage of cases of early neonatal deaths (>24 weeks) due to CTG misinterpretation dropped from 50% in 2015-16 to 40% in 2016-17 and no cases of CTG misinterpretation were identified as contributors to the early neonatal deaths in 2017-18.

Spread:

- An e-learning tool was developed in collaboration with other experts to facilitate learning and case discussions (https://www.physiological-ctg.com) and has been increasingly used by different hospital teams.

- The Project Lead Midwife participates in the Intrapartum Monitoring sub group of the European Congress of Perinatal Medicine. This group’s aim is to improve the standards of electronic fetal monitoring.

- The Project lead Obstetrician participates as a faculty member to external CTG masterclasses both in the region as well as abroad, including honorary work with Babylife training CTG masterclass

- The project’s impact and methodology has been shared in multiple national and international meetings (3rd European Congress on Intrapartum Care 2017 Sweden, British intrapartum care society Meeting 2018 London, Perinatal Congress 2018 St Petersburg).

- A network between different hospitals running similar projects has been created with an online group of fetal monitoring midwives as well as regular meetings. Most recent meeting occurred at Kingston Hospital on the 11th of June 2018 with fetal monitoring midwives from different hospitals in the UK.

- Patient involvement has been achieved through the Maternity Service Liaison Committee (MSLC).

Value:

Reducing avoidable harm - HIE and early neonatal deaths due to CTG misinterpretation- has primarily a huge impact on babies and their families. We feel that even if only one baby a year could be saved from long term disability such severe as cerebral palsy, or one single family could take a newborn baby home instead of going through bereavement, our work was already worthwhile.

Reducing avoidable harm represents also a huge financial saving to the Hospital and the NHS in general, as one baby with brain damage costs over 10 million pounds in long term multidisciplinary care and litigation. The impact of the health care staff cannot also be underestimated - no doctor or midwife goes through so many years of training to be defeated by systemic errors or lack of knowledge in CTG and Human factors.

Involvement:

The project successfully involved a multidisciplinary team across different disciplines (midwives, obstetricians, neonatologists, anaesthetists). It was presented at a meeting with Maternity Service Liaison Committee (MSLC) and the participation and feedback from the public was encouraged.

Patients were invited to the clinical governance meeting dedicated to the project to share their experience. All members of the staff are encouraged to make suggestions for improvement and raise concerns if necessary.

For example, in the staff survey the SUTS team was rated easily accessible by 100% of the repliers. Also concerns were raised regarding the time of the CTG meetings (clashing with other meetings, always the same day so not appropriate for part timers) that have been acknowledged and improved.

A network of professionals from different hospitals with interest in intrapartum fetal monitoring was created and shared learning occurred through social media and scientific meetings. This network resulted also in the creation on an e-learning tool for on going learning and support of other units aiming for the same improvement.

Key individuals

Susana Pereira