Fetal monitoring mistakes in birth injury claims

When families ask us to advise whether their child’s birth injury was caused by negligent maternity care, we check whether  fetal monitoring mistakes delayed the birth or increased the stress on the baby during labour, resulting in injury to the baby.

Midwives monitor the unborn baby’s heart rate during pregnancy and labour. This helps reassure them of the baby’s wellbeing. It also enables them to identify when a baby is not getting enough oxygen and requires urgent delivery to avoid brain injury from hypoxic ischaemic encephalopathy (HIE).

If your baby was born with HIE brain injury or needed neonatal intensive care after a delayed, prolonged or difficult birth, your fetal monitoring records and CTG traces can provide our specialist birth injury lawyers and medical experts with an important, contemporaneous account of the events which took place during the labour.

Our birth injury solicitors have helped countless families of children with birth injury disability claim the compensation and support that they need for their child. We are known for our outstanding expertise and success in complex cerebral palsy and birth injury claims, including those involving fetal monitoring misinterpretation and delayed delivery of babies who are suffering from fetal distress. If you would like to find out more about your baby’s birth injury, and what that means for your baby and family, or you have been contacted by MNSI or NHS Resolution, contact us to talk, free and confidentially, to one of our experienced birth injury solicitors.  

What is fetal monitoring?  

Fetal monitoring is one of the ways that midwives check on the unborn baby’s health and wellbeing during pregnancy and labour.

Midwives use fetal heart rate monitoring to record and track the baby’s heart rate and response to maternal contractions. They assess the baby’s condition by checking the baby’s heart rate and its variability, and whether (potentially harmful) decelerations or (reassuring) accelerations are present. A short period of fetal monitoring usually takes place when the mother attends maternity triage or is admitted to hospital in labour, and then again at regular intervals or continuously depending on the midwife’s assessment of the mother’s risk status and the baby’s condition. 

The midwife or obstetrician (childbirth doctor) interprets the fetal heart rate monitoring results and categorises them as ‘normal’, ‘suspicious’ or ‘pathological’. This interpretation and categorisation is important because it helps determine whether the labour should be allowed to continue or intervention is required to augment (boost) the mother’s uterine contractions with oxytocin (Syntocinon) or to deliver the baby urgently using ventouse suction, forceps or caesarean section.

Fetal monitoring is an important process in the provision of safe maternity care and should be carried out in accordance with national guidelines. Midwives and obstetricians are expected to be fully trained in the use and interpretation of fetal monitoring, and should know how to escalate and respond to signs of fetal distress. Fetal heart rate monitoring, including apparently normal results,  should always be considered in conjunction with an overall clinical assessment of  the mother’s health and risk factors, as well as the history of the current and previous pregnancies and any other concerns that she has expressed, such as unusually severe pain, unexpected vaginal bleeding or reduced fetal movements.

How is fetal heart rate monitoring performed during pregnancy and labour?

There are several standard methods that are used to monitor the baby’s heart rate during pregnancy and labour. The type of monitoring that is used depends on various factors, including the mode (vaginal delivery, VBAC, caesarean section) or place (hospital maternity department, midwifery-led setting) of birth, the mother’s risk status and informed preferences. The method and duration of fetal monitoring should be reviewed and adapted as necessary to provide safe care if complications or concerns arise during labour. 

Intermittent auscultation (IA)

During intermittent auscultation (IA) a midwife listens to the baby’s heartbeat, usually during and after contractions, through a hand-held Pinard stethoscope (ear trumpet) or a Doppler ultrasound (Sonicaid) device which is held against the mother’s abdomen.

The midwife must listen, count and record the number of fetal heartbeats heard over one minute, whilst simultaneously feeling the pregnant mother’s pulse (which should be different) to ensure that the mother’s heartbeat is not mistaken for the baby’s. Both types of IA rely on the midwife using the correct technique to pick up or hear, count and note the baby’s heartbeat accurately.  Intermittent auscultation is usually used in midwife-led maternity care where a mother’s labour is progressing well and the pregnancy is low risk with no reported or anticipated complications.  

Electronic fetal monitoring by cardiotocography (CTG)

During CTG monitoring, round transducer sensors are strapped to the mother’s abdomen via an elastic belt. These are connected to a monitor that shows the baby’s (fetal) heartbeat and the mother’s contractions. The CTG monitor produces an audible pulsing sound and a continuous graph (CTG trace) of the fetal heart rate in response to maternal contractions.  The CTG monitor can also be set to show the baby’s movements, which are recorded by the mother pressing a button each time she feels her baby move. 

CTG monitoring produces a clearer, more objective, continuous picture of the fetal heart rate, making it easier to track changes in baseline variability, accelerations and decelerations over time. National guidelines recommend that continuous electronic (CTG) fetal monitoring is used during labour where the mother has risk factors or there are complications or concerns, and when closer monitoring is required for the safety of mother and baby.

Continuous CTG monitoring is commonly used in labour where:

• the mother has an epidural;
• labour is not progressing;
• the uterine stimulant, Syntocinon, is used to boost contractions to speed up labour;
• the liquor contains significant meconium after rupture of the membranes (when the waters break);
• there are concerns about the baby’s heartbeat;
• the mother has high blood pressure, temperature, pulse rate, or an infection;
• the mother experiences new vaginal bleeding during labour;
• maternal contractions are abnormally long, frequent or painful;
• there are concerns about the baby’s unusual position or size;
• the mother is expecting twins.

Fetal scalp electrode (FSE)

A fetal scalp electrode (FSE) is an internal method of fetal heart monitoring which involves attaching a small electrode to the baby’s scalp during a vaginal examination. The FSE is connected to a monitor and once attached to the baby’s scalp, it picks up the baby’s heartbeat and provides a print-out of the fetal heart rate.

Internal monitoring with FSE is more invasive than CTG monitoring or IA but can be vitally important if external monitoring via CTG is thought to be unreliable, such as from loss of signal or where the CTG indicates that there may be a problem with the baby’s heart rate. Fetal scalp electrode monitoring is often used by maternity teams in deciding whether labour is safe to continue or whether the baby needs to be delivered urgently by forceps, ventouse suction or caesarean section. 

What types of fetal monitoring mistakes lead to birth injury?

Fetal monitoring is recommended as standard practise during pregnancy and labour as a way of checking and assessing the health of the unborn baby. External and internal methods of fetal heart rate monitoring are used routinely in hospitals and other maternity settings to assist midwives and obstetricians in making potentially life-saving decisions about labour and delivery of the baby.

Mistakes in the use, timing, technique and interpretation of fetal monitoring impair the maternity team’s ability to make safe clinical decisions based on an accurate assessment of the health of the unborn baby. This usually results in critical delays in delivering babies with fetal distress, causing (or worsening) injury to their brain and lifelong neurodevelopmental disability.

Numerous reports by national organisations, such as HSIB, MNSI, RCOG and NHS Resolution, have repeatedly confirmed our own experience that negligent fetal monitoring is a leading contributory factor in birth injury to babies or mothers and medical negligence birth injury claims.

We have successfully pursued birth injury negligence claims and secured life-changing compensation for countless children with cerebral palsy and neurodevelopmental disability whose injury was caused by negligent maternity care involving fetal monitoring errors.

Birth injury claims commonly involve delays arising from one or more of the following fetal monitoring mistakes:

• failure or delays in starting or continuing fetal monitoring;
• poor IA or CTG monitoring technique;
• mistaking the maternal pulse for the baby’s heart rate;
• misinterpreting or incorrectly categorising a ‘suspicious’ or ‘pathological’ CTG trace as ‘normal’;
• failing to recognise or act on signs of fetal distress (abnormal heart rate or baseline variability, decelerations);
• failing to escalate fetal heart rate abnormalities or call for senior or medical review;
• delayed decision or action to expedite delivery after a ‘pathological’ CTG trace;
• failing to monitor in accordance with national guidelines for IA, CTG and FBS;

• failing to transfer a mother from a midwifery-led setting to an obstetric-led unit after abnormal IA findings;
• system failures (e.g. failing to ensure midwives are skilled in IA, CTG interpretation etc).

How do maternal and fetal heart monitoring mix-ups occur?

We have handled many cases for injured babies whose birth was delayed when their midwives or doctors were falsely reassured about the baby’s health because they did not recognise that they were monitoring the mother’s heartbeat instead of the baby’s.

We usually see this fetal monitoring mistake in cases where an unborn baby became so unwell from oxygen deprivation during the labour that their heartbeat was too weak for the CTG transducer to pick up. During fetal monitoring in labour, the CTG uses low power ultrasound Doppler signal to detect the baby’s heartbeat, isolating it from the other movements within the mother’s abdomen, but if the transducer can’t detect a signal from the fetal heart, it will  respond instead to the signal produced by the mother’s abdominal and uterine blood vessels and reproduce the mother’s heart rate on the CTG trace instead of the baby’s. The mother’s heart rate would normally be slower than the baby’s but the stress of contractions during labour and delivery cause her heart rate to rise. Her tachycardia may then be misinterpreted as a reassuringly normal fetal heart rate by the midwife and other maternity staff.

Monitoring mix-ups between the maternal and fetal heart rate can also be the result of incorrect placement of the CTG transducer on the mother’s abdomen or a midwife or doctor’s lack of skill and experience in CTG interpretation resulting in failure to recognise the inconsistency of the unwell baby’s sudden improvement and apparently normal heart rate. Fetal monitoring mix-ups can also occur during intermittent auscultation (IA) where a midwife doesn’t realise that they are listening to the mother’s heartbeat instead of the baby’s because they have failed to feel simultaneously for the maternal pulse whilst listening for the fetal heartbeat.