Failure to recognise non-reassuring CTG

The Health and Disability Commissioner investigated a complaint from a 22-year-old woman about the care provided by her midwife and lead maternity carer during labour. Her baby was delivered by urgent Caesarean section and was born underweight with respiratory distress.

The woman began experiencing pain around 39 weeks into her pregnancy. She contacted her midwife who told her that what she was experiencing was normal and instructed her to take paracetamol and to rest.

On her due date, the woman contacted the midwife because she believed she was having contractions. The midwife examined her and told her she was not in labour. Two days later, the midwife examined her again and told the woman that she was in early labour.

The following day, the woman contacted the midwife, and they met at hospital for a further examination. The midwife started a CTG to monitor the fetal heart rate, which she did not interpret as significantly abnormal. After noting a small amount of yellow-green discharge, the midwife sought the advice of the charge midwife. The charge midwife confirmed that the discharge was meconium and noted that the CTG had been abnormal from the beginning. An obstetric registrar also identified the CTG to be abnormal.

Health and Disability Commissioner Anthony Hill found that the midwife breached the Code of Health and Disability Services Consumers’ Rights in several respects. She failed at the outset to recognise that the CTG was abnormal and, for the next hour, did not recognise that the CTG was abnormal. The woman had continued to smoke throughout her pregnancy and consequently was at higher than normal risk of having an underweight baby.  Accordingly, the midwife should have monitored the fetal growth more closely. The woman also had a long period of latent labour, and given that the fetal head had not descended into her pelvis, the midwife should have assessed her more thoroughly.

The midwife also failed to document her antenatal care adequately.–case-notes/commissioner’s-decisions/2013/11hdc00098–case-notes/case-notes/failure-to-recognise-non-reassuring-ctg-(11hdc00098)


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