miércoles, 21 de enero de 2015

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Monitoring Fetal Health Spotlight Case Commentary by Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

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Monitoring Fetal Health Spotlight Case
Commentary by Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD

The Case

A 29-year-old woman had an uncomplicated pregnancy with a healthy fetus and presented to the hospital at term (40 weeks) in early labor. She progressed slowly over the first night. By the next morning, she had a completely dilated cervix and was ready to push. She pushed for approximately 2 hours without any difficulty or any sign of problems with the fetus. Unfortunately, when the infant was born, he was cyanotic and flaccid with very low Apgar scores. An arterial blood gas at the time showed a pH of 6.70 (normal: 7.25–7.35), a profound acidosis. The infant required extensive resuscitation but survived and was transferred to the neonatal intensive care unit.

The infant subsequently had multiple seizures typical of hypoxic-ischemic encephalopathy (brain injury from inadequate oxygenation of the brain that occurred during childbirth) and other problems related to the complicated delivery. He spent a month in the neonatal intensive care unit before being transferred to a neuro-rehabilitation unit. He is likely to be severely disabled for the remainder of his life.

A root cause analysis of the case found that the mother had been appropriately monitored and had not shown any evidence of distress. The fetus had been monitored using the standard fetal heart rate tracings throughout the time of labor. The fetal heart rate tracings had shown evidence of Category 2 and 3 abnormalities (moderate-to-severe fetal distress) for at least 90 minutes prior to the delivery. These abnormalities, which likely would have prompted an urgent cesarean delivery, had not been recognized by any of the physicians or nursing staff.

In this institution, continuous fetal heart monitoring of all of the women in labor was displayed centrally on a large 40-inch monitor at the nurses' station. On this screen, the individual fetal heart monitoring strips for the 16 rooms were displayed continuously in small windows. Two nurses at the nursing station were assigned to watch the monitor at the time of the concerning abnormalities. When asked about the incident, they both replied that they "just didn't see the bad tracings" and commented how difficult it can be sometimes to identify abnormalities and to continuously watch all 16 small windows. The responsible obstetrician was busy throughout the period of abnormal tracings with another complicated childbirth.

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