Letter to the Editor,
Title: ESMiE confidential enquiry: Broader view besides focus on errors by birth-attendants.
Re:Rowe R, Draper ES, Kenyon S, Bevan C, Dickens J, Forrester M, Scanlan R, Tuffnell D, Kurinczuk JJ. Intrapartum-related perinatal deaths in births planned in midwifery-led settings in Great Britain: findings and recommendations from the ESMiE confidential enquiry. BJOG 2020;127:1665–1675.
Dear Editor,
The important ESMiE study1 highlights many well-known issues. Its conclusions bolster a view that birth-attendants are not learning from mistakes perpetuating preventable serious events. ESMiE1 is highly important but methodologically equivalent to a retrospective uncontrolled unblinded study, hence caution required regarding the weight of conclusions. Therefore, the conspicuous shortcomings especially the prevalence of logistical errors (common in normal-outcome-group as well) may not be the uppermost underlying reasons. Does validity/weakness of science of intermittent auscultation (IA) and cardiotocography (CTG) need a mention? With imperfect science, limited resources, ever-higher standards and non-eradicable human factors; would similar proportion (50 -75%) of adverse events may often/always appear ‘avoidable’ in retrospect, but not necessarily prevented in practice?2
The messiness of CTG is well-known.2 This letter focuses on IA, especially relevant to ESMiE1 which criticises non-compliance (61%) to national guideline.3 It does not critique science or guidelines but only clinical practice. It illustrates a case having IA despite a risk-factor. But why didn’t the IA diagnose the likely progressively abnormal fetal heart rate (FHR) pattern? An optimal scientific IA should hedge risk-stratification-errors because it should detect occurrence of abnormal FHR even in “low-risk” cases (some call the “new high-risk”). ESMiE1 recommends auditing frequency of IA despite no logical/scientific rationale for IA every 15 minutes3 (unnecessary arduous burden / recipe for non-compliance), against 15-30 minutes recommended by most developed countries.4 Contrastingly, it is the recommendation of “1 minute auscultation”3 that has been shown to miss seriously abnormal FHR patterns.4 Moreover, NICE3 took a retrogressive step enforcing that the FHR read-outs on Doppler-device be ignored and the audible FHR tones be counted over a minute documenting as a single figure (presumably the baseline FHR). Notwithstanding, the observation of Doppler-device read-outs (not counting) reveals reliable instantaneous FHR, allows better recognition of baseline and important FHR variations.4 Contrarily, in the presence of acceleration/deceleration, the actual counting over 1 minute gives a meaningless random number (not the true baseline) thereby misleading judgement of decelerations.4 The culprit is not midwives mentioning baseline FHR as a narrow range (which it actually is).1,4 More importantly, the unwarranted effort of actually counting to 120 -160 over 1 minute compromises attention span and also precludes flexible/longer extension of auscultation which is crucial for fetal safety.4
Thus, it is important to recognise that flawed regimes and unscientific FHR pattern-recognitions enforced on grassroots birth-attendants2,4 account for perinatal adverse events whether risk-categorisation etc. was optimal or not. ESMiE1 enquiry suggests solutions as shared commitment to agreed plan, openness, mutual respect and development of yet another new standardised risk assessment tool1 (to be fully exercised at every patient-interaction?) which cannot compensate for bad science.2 The proportion of avoidable factors seems to have increased from 47% in 2015 to 75% despite similar measures.1 Ever-escalating logistical/organisational standards are resource-intensive and can even be distracting.2 Recruiting more staff who then spend increasing time on bureaucracy and lesser time individually on actual clinical exposure may create its own problems. A broader perspective correcting flawed science seems crucial together with reverberation of old solutions.
Disclosure of interests: The author has no conflict of interest to declare.