Litigation related to intrapartum fetal surveillance

The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention (“rescue”) predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of “rescue”, but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.