A study published on February 19, 2020 in JAMA Network was designed “To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs [cardiotocography] during the penultimate hour before birth in infants with moderate to severe NE [neonatal encephalopathy] but no acute peripartum event.”
Neonatal encephalopathy is defined as disordered neonatal brain function within the first week of life in term infants (37 weeks or older). Approximately 30% of cerebral palsy occurs in infants diagnosed with NE, and NE is also a leading cause of medical litigation.
Cardiotocography in labor has been used for more than 3 decades to detect a stressed fetus so that delivery can be expedited in an attempt to reduce asphyxia leading to NE. Continuous CTG monitoring in labor has been shown to halve neonatal seizures.
Hypoxic peripartum injury is identified in more than 50% of instances of NE in New Zealand. Of the 149 NE cases reported in New Zealand from 2010 to 2011, 83 (55.7%) had no evidence of an acute peripartum event during labor and were reviewed in detail. Of these, 35 (42.2%) had at least 1 hour of CTG recording of adequate quality from 2 hours before birth.
The study was a case-control study that included ten practicing obstetricians and midwives at maternity hospitals in New Zealand who were masked to the perinatal outcome, were asked to assess tracings from 35 neonates with NE and evidence of birth hypoxia and 105 neonates without NE or birth hypoxia, all of whom were born in 2010 to 2011. The study’s participants were provided with brief clinical details and one hour of CTG tracings from the penultimate hour before birth for each baby. Clinicians assessed the CTG tracings and recommended a plan. The analysis of the study’s data was conducted from May 2017 to December 2017.
The study found that experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. “These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.”
The study’s authors concluded: “This study highlights the variability in interpretation of CTG readings, even among experienced clinicians who had recently completed a course in fetal surveillance education. It also raises concerns about the lack of competency assessment following fetal surveillance education. Pretesting and posttesting of competence has been shown to enhance the learning experience. However, most assessors only agreed with themselves 70% to 80% of the time. This point also highlights the lack of a criterion standard for interpretation of CTGs. Perhaps the only criterion standard is the correct assessment of a CTG and appropriate action plan when birth asphyxia was present and resulted in NE … We suggest that only those clinicians who attain a predefined level of competence in CTG interpretation should be able to provide secondary care in labor. The use of the CTG is firmly embedded in maternity practice. Our study highlights the need for further investment in and exploration of new approaches to fetal surveillance in labor. If this is as good as it gets, then we will continue to see rising intervention rates in women with no fetal hypoxia while continuing to fail some infants at risk.”
If you or a loved one have suffered serious harm as a result of a birth injury, such as a hypoxic injury, in the United States, you should promptly find a birth injury medical malpractice attorney in your state who may investigate your birth injury medical malpractice claim for you and represent you or your loved one in a birth injury medical malpractice case, if appropriate.
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