65 Clinical outcomes of aCTG in primary midwife-led care Table 4: Case descriptions of (potential) serious adverse events after antenatal CTG in midwifeled care Total aCTGs n=5736 Case no. Outcome Case description aCTG SAEs (causality score 4-6) Cause SAE Human factors Organisational factors Patient- related factors Other factors 1 Stillbirth Indication for aCTG: Reduced fetal movements. GA: 31+0. Conclusion of primary care midwife: normal aCTG, normal ultrasound, normal blood pressure. Care management: regular care. Follow-up: After a few days, extra consultation because of pre- eclampsia symptoms. Fetal death diagnosed. Yes (score 6) Incorrect aCTG- assessment. 2 Stillbirth Indication for aCTG: Reduced fetal movements. GA: 37+6. Conclusion of primary care midwife: suboptimal aCTG. Care management: Immediate referral to secondary care. Follow up: 30 minutes later, aCTG/ultrasound in secondary care bradycardia and emergency cesarean section followed. AS 0/0, 3240g. 20 minutes resuscitation. No (score 3) Incorrect aCTG- assessment; classified as suboptimal but later assessed as preterminal. This is not likely to be the cause of the SAE. Cause stillbirth: Hb 1.5 mmol/l, major feto- maternal transfusion. 3
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