68 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 7 Emergency cesarean section Indication for aCTG: Reduced fetal movements. GA: 40+1. Conclusion of primary care midwife: reassuring aCTG. Care management: regular care. Follow-up: A few hours after aCTG, assessment by a member of the quality committee; conclusion non-reassuring aCTG and advice directly referral to secondary care. Conclusion of secondary care: sinusoidal aCTG pattern. Emergency cesarean section followed. AS 1/8/9. Birthweight 3088g (p40). Severe anaemia. No (score 0) aCTG=antenatal cardiotocography
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