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Failure to recognise non-reassuring CTG (11HDC00098)
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(11HDC00098, 22 March
Midwife ~ LMC ~ Meconium ~ Respiratory distress ~
Non-reassuring CTG ~ Rights 4(1), 4(2)
A 22-year-old woman complained about the care provided during
labour. She began experiencing pain around 39 weeks into her
pregnancy. She contacted her independent midwife and lead maternity
carer. The midwife 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 her that she was in early labour.
The following day, the woman contacted the midwife, as her
contractions were closer together. The midwife agreed to meet her
at hospital to conduct a further examination. She started a
cardiotocograph (CTG) trace, which she did not interpret as
significantly abnormal. A small amount of yellow-green discharge
was noted and 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 attended and also identified the CTG to be
abnormal and requested an urgent Caesarean section. The baby was
born underweight, diagnosed with respiratory distress and
transferred to the neonatal intensive care unit.
It was held that the midwife breached Right 4(1) for failing at
the outset to recognise that the CTG was non-reassuring and, for
the next hour, continuing to fail to recognise that the CTG was
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 the fetal head had not descended into her
pelvis, which should have prompted a more thorough assessment once
she was in latent labour. In light of these failings, the midwife
was found in breach of Right 4(1).
It was also held that the midwife's antenatal documentation was
sparse and not recorded sequentially, and some entries were written
retrospectively without being identified as such. By failing to
document antenatal care in accordance with professional standards,
the midwife breached Right 4(2).