The BMJ Awards 2017: Clinical leadershipBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1360 (Published 22 March 2017) Cite this as: BMJ 2017;356:j1360
- Nigel Hawkes, freelance journalist, London, UK
St George’s fetal monitoring
Oxygen deprivation during labour is universally recognised as a disaster in the making, but is enough done to prevent it? At St George’s University Hospitals NHS Trust in London, the answer was no. Edwin Chandraharan, consultant obstetrician and gynaecologist at the trust says: “Our rate of hypoxic ischaemic encephalopathy (HIE, the brain injury caused by oxygen deprivation) was above the national average. Our neonatal metabolic acidosis rate (a measure of oxygen deprivation) was 2.6%, and our emergency caesarean section rate was 15-17%. We reflected on our results and accepted they were worse than national data.”
The response was uncompromising and included mandatory retraining and testing on the interpretation of fetal heart monitoring (cardiotocography, CTG) for all midwives and obstetricians who worked in the labour wards. “CTG was introduced in 1968 with no clinical trials,” Chandraharan says. “Interpretation was based on recognising certain patterns, and it got into the culture that ‘this is good’ or ‘this is bad’ without real knowledge.”
The answer was to change the way CTG was interpreted, retrain staff, and then oblige them to achieve an 85% pass mark before being allowed to work in the labour wards. Since this was introduced in 2010, emergency caesareans have fallen to 6-8%, the acidosis rate to 0.6%, and the HIE rate to half the national average.
Since every baby with brain damage costs the NHS £8m-£10m, Chandraharan estimates that the measures have saved £30m—three fewer babies damaged at birth than would have happened had there been no improvement. “And the indirect social costs to parents having to lose their jobs to look after a brain damaged baby for life are immeasurable,” he adds.
Pilot of doctors’ assistants
Junior doctors work very hard, but not everything they do is really doctoring. At East …