Kingston Hospital Foundation Trust – Physiological CTG and human factors training to reduce early neonatal deaths and intrapartum brain damage

In 2015 in the UK, 1,136 babies either died in labour, soon after birth, or sustained severe brain injury. In three quarters of those cases, different care might have led to a different outcome.

When staff at Kingston Hospital’s maternity department reviewed serious incidents from 2009 to 2014, misinterpretation of cardiotocography emerged as a common theme. CTG is an important means of recording a baby’s heartbeat and the contractions of the womb. If it indicates abnormalities in the baby’s heart rate, the decision may be taken to perform an emergency caesarean section or an assisted delivery. But it was clear that staff at the trust would benefit from further education in its use.

And so a learning and development programme was created. It focused on improving fetal surveillance and wellbeing by bolstering clinicians’ knowledge, and their competence in CTG interpretation. The training included human factors awareness.

Since its introduction in 2015, there has been a 60 per cent reduction in severe hypoxic-ischaemic encephalopathy – HIE; brain damage which results when an infant’s brain doesn’t receive enough blood and oxygen – with no cases of HIE attributed to CTG misinterpretation in 2016-17.

The percentage of cases of early neonatal deaths due to CTG misinterpretation has also fallen, from 50 per cent in 2015-16 to 40 per cent in 2016-17. In 2017-18, CTG misinterpretation was not identified as a contributor to any early neonatal death.

An e-learning tool has now been developed to help other hospitals teams increase their CTG knowledge.

Read a detailed case study about this project at HSJ Solutions


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