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.