66 Chapter 3 Table 4: Case descriptions of (potential) serious adverse events after antenatal CTG in midwife-led care (continued) 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 3 Emergency cesarean section Indication for aCTG: Reduced fetal movements. GA: 28+5. Conclusion of primary care midwife: Suboptimal aCTG. Care management: Referral to secondary care. Follow-up: Conclusion of secondary care: Suboptimal aCTG. Ultrasound: intrauterine growth restriction and brain sparing. ACTG reconnected and abnormal aCTG. An emergency cesarean section followed. AS 5/8/9. CPAP. Birthweight 840g (<p3). No (score 0) 4 Emergency cesarean section Indication for aCTG: Reduced fetal movements. GA: 38+2. Conclusion of primary care midwife: Suboptimal aCTG. Care management: Referral to secondary care. Follow-up: Conclusion secondary care: Suboptimal aCTG. Ultrasound: normal. ACTG reconnected and abnormal aCTG. A few hours after referral, an emergency cesarean section followed. AS 9/10. Birthweight 2363g (<p3). No (score 0)
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