Case study resource
This case story is illustrative, based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself:
· Could this happen in my organisation?
· Who could I share this with?
· What can we learn from this?
Key learning points:
· Accurate diagnosis of labour allows appropriate interpretation of CTGs and more effective detection of fetal distress
· Antenatal CTGs should not be interpreted using intrapartum guidelines, as this may delay delivery of compromised fetuses leading to poorer outcomes
· When interpreting fetal monitoring, utilise a holistic approach and particularly consider the maternal risk factors