5. Miss F complains the Trust was not concerned by the reduction in her daughter’s movement and the drop in her estimated growth. She says that if staff had noted the placenta had stopped growing at 34 weeks, they could have intervened to prevent her the sad death of her daughter. She says she has been devastated by her loss.
6. As a result of her complaint, Miss F would like to see service improvements, and compensation.
7. Miss F became pregnant with her first baby in January 2022.
8. She reported a feeling of reduced movements to the maternity team at the Trust at 25+4, 32+4 and 35+3 weeks. She presented again at the Trust at 36+5 weeks with no reported movements for two days and she was told there was no fetal heartbeat. She was induced and gave birth to her daughter two days later. Her daughter was sadly dead on delivery. We extend our sincere condolences to Miss F.
12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We understand this may be difficult for Miss F to read.
Reduced movements
13. Guideline 57 from the RCOG is the guideline on reduced foetal movements. In cases of recurrent episodes of reduced movement, it recommends a cardiotocography (CTG) assessment for each episode of reduced movement. CTG is a continuous recording of the fetal heart rate and is widely used in pregnancy as a method of assessing fetal wellbeing. It also suggests that induction of labour at term could be considered when there are recurrent episodes of reduced movements but emphasises that there is not enough evidence to make an actual recommendation on this. Sadly, Miss F had not reached her pregnancy’s full term at the time she lost her baby, so staff were not able to make this consideration.
14. Miss F first noticed reduced movement her baby on 21 June 2022. She assessed by staff and as seen by the community midwife the following day for additional reassurance. As this was the first episode of reduced movement, in line with Guideline 57, staff were not required to complete a CTG assessment. During her pregnancy, she reported two additional episodes of reduced movement. On each of these occasions the Trust completed CTG traces. The first carried out on 9 August and the second on 29 August 2022 (9 days before identifying no foetal heartbeat).
15. CTG traces are only able to assess the baby’s condition at the time which they are run. Our adviser has confirmed that each of the CTG traces completed on Miss F were subject to the Dawes-Redman analysis, a computerised assessment in antenatal (non-labouring) CTGs. They note that in both cases, the Dawes-Redman analysis met the criteria, that the computerised analysis suggests the CTGs are reassuring and show no concerns. Drawing on their experience, and from their own visual analysis, our adviser’s interpretation of both CTG traces is that they appear to be normal, indicating an active baby with no evidence of hypoxia (low levels of oxygen).
16. We understand it must have been extremely worrying for Miss F when she attended the Trust with reduced foetal movements. We hope we have been able to reassure her that the evidence indicates that on each occasion she the feeling of reduced movements, staff acted in line with appropriate guidance.
Drop in growth
17. Green Top guideline 57 recommends scanning to check for growth restrictions when there are episodes of reduced foetal movement. Maternity staff track the expected growth of a baby on a chart with the centile lines showing how the baby’s growth compares with other babies of the same age and sex. Miss F complains there was a drop in her baby’s centile measurement between 63% and 52%.
18. Green Top guideline 31 outlines what staff should do if there are concerns about the growth of the baby. In cases where there is concern, the only realistic management is to deliver the baby. Our adviser says this would never be undertaken before 37 weeks unless a significant concern existed, because of the risks of prematurity. Delivery is sometimes undertaken prior to 37 weeks’ gestation, usually where the growth is below the 10th centile and slowing down, or if the doppler measurement (a scan that measures blood flow through the umbilical cord and around the different part of the baby’s body) in such cases is abnormal, or the CTG is abnormal.
19. Our adviser confirms that normal growth parameters lie between the 10th and 90th centile. The percentile chart is the most common type of growth chart, for example, if a baby on the 50th percentile for weight would mean that half babies their age are lighter, and half are heavier. In late pregnancy the estimation of the weight of the baby from ultrasound measurement carries a significant margin of error of 20% either way.
20. At the start of the pregnancy, Miss F was told to take aspirin to reduce the risk of pre-eclampsia (a condition that causes high blood pressure in pregnancy), which our adviser says can be associated with growth restriction. Staff also arranged for growth scans to be completed early in the pregnancy, which is in keeping with guidance, Green Top 31, Appendix 2 which says that each risk assessment should be individualised taking in to amount previous medical history, obstetric history and current pregnancy history. If risk is identified, this may necessitate monitoring with serial scanning.
21. At the time of birth, the baby was slightly smaller than indicated by the last scan, although was still well within normal parameters. The scans undertaken at 32 and 35 weeks’ gestation showed steady and consistent growth of the baby which was between the 60th and 70th centiles estimated weight. The GROW chart also shows the birthweight of the baby, and our adviser says that this does not indicate any concern about the baby’s weight which is within the 20% margin of error.
22. It is understandable that Miss F was worried when she found out her baby was smaller than was indicated from the growth scans. We hope we have been able to provide some reassurance that staff did not dismiss the drop in her baby’s growth and managed this in-line with guidelines, and her baby’s growth was not a cause for concern.
Placenta not growing
23. Miss F says the Trust has given her conflicting information about why her baby died. The cause of death was recorded as placental abruption with cord accident (this is where the placenta separates from the uterus before childbirth).
24. Miss F says she was told over the phone that the placenta stopped growing at 34 weeks but when she met with the Trust as part of the complaint process, she was told her baby’s cause of death was unknown. Miss F says that there is evidence the placenta stopped growing at 34 weeks as the umbilical archery blood flow through the placenta reduced from 42% in July to 15% in August 2022. We understand how the drop in percentages would be alarming to Miss F.
The Trust says that the during the conversation the consultant had Miss F, they tried to explain in non-medical terminology that her baby was average size, and the placenta was average size for around 34 weeks, not that the baby had stopped growing. The Trust apologised for any confusion that may have resulted from this conversation.
The General Medical Council, Good Medical Practice says that ‘[doctors] must make sure the information [they] give to patients is clear, accurate and up to date, based on the best available evidence’.
25. Our adviser explains that resistance to the flow of arterial blood in the umbilical cord normally lessens as the pregnancy advances, so the resistance index (RI), as represented by the percentages, tends to fall in later pregnancy, which is what occurred in this case. Unless there are concerns about the baby’s growth restriction, which we earlier established there were none, the Green Top Guidance 57 says the Doppler measurement in the umbilical cord is of limited value.
26. Having considered the information given to Miss F in the Trust’s investigation report about the cause of death, and having considered her recollection of the conversation, there is nothing to suggest within the records why staff would have shared information about the placenta having stopped growing and that it shared accurate information about what happened in line with GMC Good Medical Practice. We have not seen evidence the placenta stopped growing and we hope we have been able to explain why the drop in blood flow is not a concern.
27. We understand that having a conversation about why Miss F’s baby was stillborn will have been deeply upsetting for her.
28. We are deeply sorry to hear about the upset Miss F has suffered and of how she and her family have been affected. We understand how much this complaint means to her and thank her for sharing the details. We hope this statement clearly explains the reasons why we will not be considering the complaint further and we regret any further distress this decision may cause.
1. We have carefully considered Miss F’s complaint about University Hospitals of North Midlands NHS Trust.
2. We have seen no indication the Trust dismissed the drop in her baby’s movements and measurements and consider staff acted in line with the relevant standards.
3. We have also seen no indication the placenta had stopped growing at 34 weeks.
4. We are very sorry to hear about the circumstances of Miss F’s complaint and understandably, how she has been affected. We recognise how much this complaint means to her and thank her for sharing this with us. We hope this statement clearly explains the reasons why we will not be considering the complaint further.