Midwives and medical staff must receive better training in how to interpret measures of baby heart rates and contractions to reduce the risk of stillbirth or injury, experts have warned.
On the back of new data, they have raised fears that some clinicians lack key skills to interpret foetal heart rates and are not receiving adequate training to help them recognise when babies are at risk.
“If you are not able to provide one-to-one care there is more scope for error”
In addition, they called on trusts to also invest in multi-disciplinary training to improve workplace culture and enable midwives and doctors to learn from mistakes.
The issue relates to the ability of NHS staff to properly understand cardiotocograph, or CTG, readings of a baby’s heart rate and mother’s contractions.
According to analysis by Health Service Journal, there are hundreds of NHS negligence claims each year showing a failure to properly monitor and respond to warning signs in foetal heart rates.
Data from NHS Resolution – formally the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.
This is despite multiple reports warning about the extent of the problem stretching back eight years. A 2009 study of 100 stillbirth claims by the NHS Litigation Authority found “the most frequent example of negligence was in misinterpretation of CTG traces (34%) with 25 cases identified as midwife error”.
In 2012, the authority looked at a decade of maternity claims, identifying 300 cases where abnormal CTG traces were not recognised or acted on, with midwives often not seeking help.
“Midwives and obstetricians lack the core skills to interpret CTG tracings”
It found 49 of the 50 midwifery-related error claims needed obstetric assistance, but help was only sought in 16 cases. In 33 claims, the midwife thought the CTG was normal when it was not. The report urged trusts to invest in training, simulation, staffing levels and technology.
In 2013, a study of perinatal mortality for NHS Cumbria concluded one of the common themes was “a failure to act on a suspicious CTG” and a report by the West Midlands Perinatal Institute found 18 out of 25 baby deaths it examined in 2010 involved a failure to recognise an abnormal CTG reading.
In recent months, significant concerns have been raised by coroners about the standards of education and training for midwives after the deaths of babies who were starved of oxygen when warning signs were missed.
In March, coroner David Hinchliff demanded changes to midwifery training after finding “significant failings” in the death of Billy Wilson who was born at Pinderfields Hospital in November 2013.
His mother was given increasingly stronger medication to induce labour over six days despite the fact the CTG was warning Billy was suffering stress. A newly qualified midwife increased the dose on the night Billy was born despite a “pathological” change in the CTG.
He died three days after being born. The midwife admitted at the inquest that she did not understand the CTG and claimed not to have been properly trained to interpret it at university. She had also yet to complete online training about CTG interpretation.
“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery”
Expert obstetrics witness Professor Philip Steer told the inquest such problems were “commonplace and that student midwives can qualify and become registered without this essential training”.
In February, Mr Hinchliff highlighted similar issues around the death of Maxim Karpovich, who died after an emergency caesarean in March 2015.
He said: “It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions.
“This inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings,” he said.
Meanwhile, health secretary Jeremy Hunt launched an investigation into baby deaths at Shrewsbury and Telford Hospitals NHS Trust in April, with five deaths linked to failures to monitor foetal heart rates.
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The Nursing and Midwifery Council said student midwives must be able to demonstrate they were competent to monitor mothers and babies during labour.
However, a spokeswoman noted that the regulator recognised that “concerns have been raised around the type and consistency of specific training in CTG tracing interpretation”.
“We have recently commenced a wholesale review of our pre-registration midwifery standards and will be developing new standards of competence for future graduate registered midwives,” she said.
“We will be carefully considering all the concerns that have been raised and will be looking at all available evidence, including the recommendations made by [Mr Hinchliff], to ensure our standards are appropriate for future midwifery care,” she added.
“We will be carefully considering all the concerns that have been raised”
But Mandy Forrester, head of quality and standards at the Royal College of Midwives, warned that the health service’s 3,500 midwives shortage meant some staff would be under significant pressure.
“If you are not able to provide one-to-one care there is more scope for error,” she said, adding that RCM members had expressed concerns about outdated equipment and the increasing complexity of births.
“Trust leaders need to look at their maternity services, their outputs and statistics and reassure themselves that their trust is up to date with its training and to make sure that it is multidisciplinary. That is key,” she said.
“They should check processes that are in place are actually happening, that those are audited and that the audit loop is closed and evaluated,” she told Health Service Journal.
She also questioned the validity of the CTG as a tool, but stressed that midwives must also refer concerns about a birth to doctors when issues beyond their scope of practice emerge.
Call to boost midwife training in vital foetal monitoring
Eddie Morris, vice president for clinical quality at the Royal College of Obstetricians and Gynaecologists, accepted CTG mistakes were an issue and argued that trusts needed to focus on multi-disciplinary training to reduce errors.
“If we can get a team to function better, then a lot of what we see in terms of CTG misinterpretations would be significantly reduced,” he said. “It is about inter-professional trust and valuing other people.
“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery,” he stated.
He also said maternity departments should have regular simulations, drills and skills, and weekly CTG meetings where staff can discuss cases within a no blame culture.
Next month the RCOG will publish its Each Baby Counts report covering all 169 UK hospitals delivering babies.
Mr Morris said the report would be “concentrating very hard on CTG interpretation and situational awareness as well as how the team functions”.
Case study: Success story on CTG errors
Call to boost midwife training in vital foetal monitoring
One NHS trust has reduced its CTG errors to zero for almost an entire year, after devoting more resources to the problem in the past year.
“We have put in place quite a rigorous process”
Barking, Havering and Redbridge University Hospitals NHS Trust delivers more than 8,000 babies a year and has turned around its rate of CTG errors following investment in staff training, equipment and culture.
Wendy Matthews, the trust’s director of midwifery, said 75% of maternity incidents included some form of CTG error in 2015-16, but in the last 11 months the trust has not had a single CTG error.
She said: “We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multi-disciplinary team.
“I’m not sure how many trusts really do that,” she told Health Service Journal.
- Changes the trust has introduced include:
- A dedicated CTG midwife to lead training for staff, including one to one
- Central CTG monitoring and review by different staff every hour
- An eight-hour e-learning programme with staff given a day off to complete it. Doctors and midwives are not allowed on the labour ward until they complete the training
- Weekly multi-disciplinary CTG meetings for staff to discuss cases
- Annual mandatory training on CTG that staff must pass
- Replacing four different types of equipment with one single system
- Multi-disciplinary simulation training