Medico-Legal Issues with CTG Interpretation
Vikram Sinai Talaulikar and Sabaratnam Arulkumaran
Affiliation: Department of Obstetrics and Gynaecology, St. George’s Hospital and University of London, Tooting - London, SW17 0RE, UK.
Electronic fetal monitoring is the recommended method of intrapartum fetal surveillance in high risk
pregnancies and the cardiotocography (CTG) forms an integral part of intrapartum care on most modern labour wards.
Despite the questions about its efficacy and controversy regarding increased rates of operative delivery associated with its
use, continuous CTG remains the predominant method of intrapartum fetal monitoring. Although CTG is sensitive in
detecting abnormalities of fetal heart rate (FHR), its specificity for detection of fetal hypoxia is low and therefore
confirmatory tests such as fetal scalp blood sampling or analysis of fetal electrocardiography (ECG) become necessary.
The intrapartum CTG trace forms a central piece of documentary evidence in litigations related to adverse perinatal
outcomes which are alleged to have arisen due to events that took place during the labour and/or delivery of the baby. The
main reasons for litigation are not just for recovery of costs determined by injury, pain, loss and future care of a brain
damaged child; but the parents also want to know what happened and why, and expect the healthcare staff to be held
accountable for their actions.
Majority of medico-legal cases have similar problems which can be laid down to a few factors such as - a) inability to
interpret FHR trace, b) inappropriate action, c) technical aspects and d) record keeping.
Not only can litigations have long-term consequences for the working lives of midwives or obstetricians but they have
been influential in changing practice trends such as rising caesarean rates. Unfortunately obstetric litigation with its huge
costs is a growing problem and for the foreseeable future, the CTG is here to stay. The best defence against litigation is
good clinical practice with adherence to evidence based guidelines and regular mandatory training in the interpretation of
CTG for all labour ward staff. There should be a mechanism for the rapid review of adverse obstetric events and
dissemination of key learning points to all staff.
Keywords: CTG, fetal, hypoxia, intrapartum, medico-legal, monitoring, surveillance.
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