What to Know About Fetal Monitoring Errors

Fetal monitoring helps care teams evaluate how a baby is tolerating pregnancy and labor by tracking the heart rate and, in many cases, uterine contractions. When monitoring is not performed, interpreted, or acted on appropriately, families may be left with questions about whether warning signs were missed and whether an injury could have been prevented.

What are fetal monitoring errors?

During labor, clinicians may periodically listen to the fetal heart rate or use electronic fetal monitoring to continuously record the baby’s heart rate and the mother’s contractions. Monitoring may be external, using sensors placed on the abdomen, or internal in certain circumstances.

A fetal monitoring error is not a medical diagnosis. It is a potential breakdown in how monitoring was selected, performed, interpreted, communicated, or acted upon. Fetal heart rate patterns can change for many reasons, and an abnormal tracing does not automatically mean a baby has been injured. The care team must consider the tracing together with the mother’s condition, the progress of labor, medications, and other clinical information.

When a pattern suggests that a baby may not be tolerating labor, the care team may need to evaluate the cause, take steps to improve fetal oxygenation, increase surveillance, or move toward delivery when clinically appropriate.

Signs a baby may have been affected

Fetal monitoring errors do not create one specific set of symptoms. Concerns may arise when the labor record shows concerning or worsening fetal heart rate patterns followed by signs that a newborn may have experienced reduced oxygen or blood flow.

• A low or unstable heart rate, breathing difficulty, or poor color after birth
• The need for resuscitation, respiratory support, or neonatal intensive care
• Low muscle tone, weak reflexes, or unusual sleepiness
• Seizures or unusual movements
• Acidosis on cord blood testing or findings consistent with hypoxic-ischemic encephalopathy (HIE)
• Feeding difficulties or developmental delays identified as the child grows

These findings can have many causes and do not, by themselves, prove that a monitoring error occurred. A careful review of the fetal heart rate tracing, delivery records, newborn evaluations, and subsequent medical care is often needed to understand what happened.

How fetal monitoring errors happen

Fetal monitoring can involve equipment, clinical judgment, communication, and time-sensitive decisions. Potential breakdowns may include:

• Failing to begin appropriate monitoring or increase surveillance when maternal, fetal, or labor conditions change
• Allowing a poor-quality or interrupted tracing to continue without correcting sensor placement or using another monitoring method when appropriate
• Confusing the mother’s heart rate with the baby’s heart rate
• Failing to recognize concerning changes or a pattern that is becoming more serious
• Not communicating changes in the tracing to the obstetrician or other responsible clinicians
• Delaying evaluation, intrauterine resuscitative measures, or delivery when the clinical circumstances call for prompt action
• Using malfunctioning equipment without addressing the problem or obtaining a reliable alternative tracing
• Inadequate training, supervision, staffing, or handoff communication that contributes to missed information

When fetal monitoring errors may be medical malpractice

Not every abnormal fetal heart rate pattern, difficult delivery, or birth injury is the result of medical malpractice. A malpractice claim generally requires evidence that the care fell below the acceptable standard and that the failure caused or contributed to an injury.

Circumstances that may point to negligence include:

• The care team did not use appropriate monitoring despite known risk factors or a meaningful change in the mother’s or baby’s condition
• A persistently unreliable tracing was not corrected or replaced with a more dependable method when appropriate
• Clinicians failed to distinguish the maternal heart rate from the fetal heart rate
• Concerning fetal heart rate changes were not recognized, documented, communicated, or escalated
• The team did not respond appropriately to a pattern suggesting the baby might not be tolerating labor
• A cesarean delivery or other necessary intervention was delayed despite clinical indications for urgent action
• Equipment problems, staffing gaps, or communication failures were allowed to interfere with timely care

Wais, Vogelstein, Forman, Koch & Norman, LLC works with qualified medical experts to review fetal monitoring strips, labor and delivery records, and the timing of clinical decisions to determine whether the standard of care may have been breached.

Treatment and long-term outlook

Treatment depends on whether the baby experienced an injury and how severe it may be. A newborn who shows signs of oxygen deprivation may need immediate resuscitation, breathing or cardiovascular support, blood testing, neurologic monitoring, imaging, and treatment for seizures or other complications.

Eligible newborns with moderate to severe HIE may be considered for therapeutic hypothermia, sometimes called brain cooling. Because this treatment is time-sensitive, the neonatal team must evaluate the baby promptly and determine whether the medical criteria are met.

Long-term care may include follow-up with neurology, developmental pediatrics, physical therapy, occupational therapy, speech or feeding therapy, and early intervention services. The outlook varies widely and depends on whether an injury occurred, the area and severity of any injury, and the child’s response to treatment. An abnormal fetal heart rate tracing alone cannot predict a child’s future.