A Case Example
The pregnant patient had an antenatal check with her GP on three occasions when notable discrepancies between the gestational age and the fundal height measurement were evident. Fundal height measurement is correlated with gestational age and in line with NICE guidelines for antenatal care, any discrepancy above or below 3 cm requires a referral for an ultrasound assessment to rule out a small or large for gestational age fetus. The woman’s subsequent antenatal check was with a midwife who assessed the fundal height consistent with the gestational age. At this appointment, the midwife noted the findings from the GP checks in previous appointments and understood that no referral for an ultrasound or an obstetric referral was arranged.
The patient was admitted to the hospital in labour and gave birth to an Intrauterine Growth Retarded baby that was born in poor condition and subsequently passed away.
The main learning points from this review stem from the following events:
- The patient was not referred to an obstetrician by her GP when a discrepancy between gestational age and fundal height was noted.
- Although the midwifery team assessed the fundal height consistent with the gestational age, they did not refer the patient to an obstetrician despite being aware of the abnormalities recorded by the GP.
- An investigation to exclude intrauterine growth retardation(IUGR) was not considered.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance Patient safety are as follows:
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NICE Guidelines should be followed to trigger a further investigation if a fundal height is +/-3cm from gestational age. In this case, the discrepancy found by the GP on various occasions warranted further investigation to rule out an IUGR baby.
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All healthcare professionals involved in antenatal care must consider a holistic assessment of pregnancy at each antenatal appointment. This is to ensure consistency and consideration of every event that has occurred during pregnancy that may have an impact on the overall assessment. This is particularly important when antenatal care is shared. Professional updates for all GPs and Midwives involved in the provision of antenatal care must include an understanding of accurate the fundal height measurement at every antenatal assessment to assess for an IUGR baby. Review of the entire antenatal history and contemporaneous record of findings at each assessment must be maintained at each antenatal appointment to provide a holistic assessment. This would ensure that any deviations from the norm are identified and appropriate actions are taken to minimise any risks associated with failure to act on abnormal findings.
- In cases which trigger further investigation, a referral to a specialist should be made. In this case, failure to refer the paint for an ultrasound by her GP was a missed opportunity to validate normal fetal growth and confirmation of intrauterine growth restriction. It is likely that the outcome, in this case, would have been different if the baby was diagnosed in pregnancy.
Conclusions
In summary, it is important that all clinicians that conduct antenatal care should be aware of the NICE guidelines, clinicians should be mindful that antenatal patients will see a number of clinicians and are unlikely to be aware of complications if not previously discussed. The missed opportunity for the disparity to be investigated in this case could be seen to have contributed to the baby that was born in poor condition and its subsequent death.
TMLEP would like to highlight the importance of recognising red flags and triggers in pregnant patients and undertaking investigations either themselves, or referring the patient to an obstetrician to investigate further.