Alarm bells should be ringing throughout the Westminster offices of the health minister and his staff today, and they should not stop until urgent action is taken.
The Times reported yesterday that during the inquest of baby Billy Wilson, who died at three-days old, the midwife in charge of Billy's mother, Carla, at Pinderfields Hospital in Wakefield did not know how to use the CTG machine.
Giving evidence at the inquest at West Yorkshire coroner's court, the newly qualified midwife explained that she had not received appropriate CTG training during her midwifery course at Bradford University, a three-year BSc degree course for people with no previous health care experience.
Because she missed what the machine was telling her – that Billy was being starved of oxygen and was in acute distress – rather than urgently moving mother and baby into obstetric care and likely a C-section – she simply increased the dose of labour-inducing drugs, which made the situation worse.
Billy was eventually delivered using forceps but had already suffered the catastrophic brain damage that led to his tragic death three days later.
Even more worrying was a statement from one of the expert witnesses that such lack of training was 'commonplace', with student midwives allowed to qualify and become registered without completing it. Not surprisingly, following evidence, the senior coroner issued a 'Preventing Future Deaths Notice', warning that more deaths will occur unless there are changes.
Cardiotocography, or CTG, is fundamental to the care of a woman in labour and of her baby. It quite simply measures the fetal heartbeat, providing medical staff with vital information about the health of a baby. If a baby is in distress, its heart rate will increase or decrease for a period of time, outside the measurements considered normal.
Medical guidelines issued by the National Institute for Health and Care Excellence (NICE), the independent organisation, set up by the government in 1999 to oversee standards, clearly indicate the parameters of when fetal readings should be considered suspicious, and then pathological, meaning urgent intervention is needed by an obstetric team.
The principles for CTG trace interpretation specifically state:
- When reviewing the CTG trace, assess and document contractions and all four features of fetal heart rate: baseline rate; baseline variability; presence or absence of decelerations (and concerning characteristics of variable decelerations if present); presence of accelerations.
- If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low.
- If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician.
Too many of my negligence cases that have resulted in a baby dying or being born severely disabled centre on mistakes by midwives either reading CTGs or not acting quickly enough to alert the Obstetric team that something is wrong.
Inexperienced or non-trained staff all too often misinterpret readings, or mix-up the mother's heartbeat with the baby's or position the transducer wrongly resulting in a poor and indecipherable trace.
When lawyers get involved with such cases, often to try to get answers for distraught parents, we very often find that the CTGs are poor quality, faded or even lost. Building a case requires considerable forensic analysis with CTGs being enhanced or reconstructed and experts spending considerable time analysing the traces.
In one such case, we were forced to rely on a faded CTG and enhancement did not provide the answers we were seeking. After a roller coaster of a case and a trial only a few weeks away, the NHS Trust suddenly 'found' a contemporaneous copy of the CTG that had been taken at the time (presumably in case litigation might follow). This proved to be the best evidence available to show that the baby was being damaged and that the midwives should have acted to deliver him urgently. The severely disabled child's damages are now being assessed.
Families experiencing the tragedy of birth injury or the death of a baby need medical answers as to what went wrong. Most then hope that their experience will, at the very least, feed into and impact on how midwives deliver care and go on to generate better procedures and outcomes.
If midwives are not even learning how to use the basic equipment which underpins maternity care before they're allowed out on the wards and are responsible for patient care, the whole maternity system is in jeopardy.