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Skåne University Hospital reports five cases according to lex Maria in which it is believed that there were deficiencies in fetal monitoring during pregnancy or delivery. In three of the cases, the children’s lives could not be saved.
Birth in Sus – Skåne University Hospital in Malmö.
The incidents took place during the period September 2019 to February 2020 and have been reported to the Swedish Health and Care Inspectorate (Ivo).
– This is extremely tragic for couples who have been through this and have suffered these losses, we are well aware of that. We work to be as safe as possible and to be as transparent as possible, says Pia Teleman, gynecology operations manager at Skåne University Hospital.
The first incident concerns a woman who rushed to Sus’s maternity ward in Lund due to reduced fetal movements and contractions. When examined, staff found weak fetal movements and abnormal CTG patterns. CTG (cardiotocography) is an electronic fetal monitoring that measures the fetal heart rate. A new check-up was decided two days later, but by then the fetus had died.
The second incident concerns a woman who came to Sus’s maternity ward in Malmö due to abdominal pain and contractions. The woman had abnormal CTG. The staff felt that a longer CTG recording was needed to be able to make a decision on measurements, but at one point the CTG went offline and when it was turned back on a moment later, the CTG curve drifted further and further. Doctors performed an emergency cesarean section, but the baby’s life could not be saved.
The third incident occurred when a woman visited Sus in Lund due to reduced fetal movements. She had visited the hospital several times before. Staff discovered deviant CTG patterns, but “did not handle it correctly,” Region Skåne writes in a press release. When the woman delivered by emergency caesarean section, the fetus suffered severe brain damage and died a few days later.
Sus does not rule out that the lives of the three children would have been saved if they had acted differently. But the internal investigation work does not show anything that indicates a system error, such as staffing or workload.
– We know how many served in the respective work shift. Everyone who has been involved in the case writes opinions, the person doing the investigation talks to those involved, and there they discuss whether they have been unusually accused. But we haven’t been able to see such a pattern, says Pia Teleman.
The other two incidents that took place at Sus in Lund and in Malmö are reported because they could have resulted in serious medical injuries. Even there, Sus assesses that there is a connection to the way one has acted on the basis of deviated CTG curves.
All doctors and midwives receive more training and certification on an ongoing basis, and according to Pia Teleman, this work will be further intensified. Randomized controls have also been introduced to ensure routines for interpreting and signing fetal follow-up curves.
