Saturday, September 13, 2008

Understanding fetal monitoring

An article, 'Mother's plea after death of newborn' on p3 of the Saturday Age today has a sad tale, from which I have excerpted a couple of lines:
"[Jane] (the mother) said CTG machines, which monitor an unborn baby's heart rate, were not working properly and her partner had to alert staff when the heart rate dropped well below normal.
"Jane said it seemed obvious that 'our little girl wasn't coping', but she kept being told everything was OK. Shortly after the birth by caesarean, Jane's baby girl died."

I feel great sympathy for these parents. They were isolated in a hospital room, with monitor straps around Jane's belly and the machine that goes 'ping'. The alarm on the monitor would have started sounding when the baby's heart rate dropped - or was it just loss of contact [ie not working properly]? Why was the partner the one who had to alert staff? How did the partner know what was OK or what was not? Jane says it seemed obvious that 'our little girl wasn't coping', so where was the midwife?

The answer seems to be that the midwife was not in the room. It seems that the hospital did not have enough staff to keep a midwife in that room at that time.

Cardio Tocograph (CTG) machines are used consistently and often continuously in hospital births. As with any test, the information provided by the machine needs interpretation - not at some time in the future, but as it happens. That interpretation should not be the job of the partner, or the alarm function on the machine. It should be the work of the midwife who is in the room continuously with the woman.

I would encourage anyone who agrees to electronic fetal monitoring (EFM); having a CTG trace, that you agree ONLY if a person who is able to take responsible action on the results of the trace is present at the time.

Continuous EFM, or any other type of fetal monitoring, including doppler or pinard stethoscope, does not ensure the safety and wellbeing of the baby. It is useful only when appropriate action can be taken on the information that is provided, and the person who receives the information understands its meaning.

Continuous EFM can give a false sense of security, as well as a false sense of doom. The usual response to a non-reassuring CTG trace in today's maternity services is to rush to the operating theatre and have an emergency caesarean birth. In the case highlighted in this story, that did not happen soon enough, with tragic consequences.

The protection of the wellbeing and safety of mother and baby are the guiding principles in all midwifery. A midwife working in a hospital should not leave the room if she considers that a mother requires continuous EFM.

You might say that's unreasonable.
Midwives have to leave the room, to do paperwork, to go to the toilet, to have meal breaks, or whatever.
That's true. So turn off the CTG machine, and take the belts off the woman, before leaving the room. It's unreasonable to expect the mother and her partner to become defacto watchers of the EFM in the absence of a midwife. They are not able to understand what they are hearing and seeing. That's a professional act, and if there is truly a reason to keep the machine running, there must be a person in attendance and an intention to intervene.

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