Recurring concern

Unreliable management of abnormal antenatal CTG

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First reported 24 Oct 2014•Latest report 18 Mar 2025

Definition

What this concern includes

Includes failures in the dedicated antenatal or antepartum CTG process, including guidance and classification, interpretation, assessment of fetal wellbeing, consultant involvement, escalation, decisions about intervention or delivery, and the timing of those actions.

Not included

  • Excludes intrapartum CTG monitoring and interpretation unless the assertion explicitly concerns the same antenatal or antepartum CTG process.
  • Excludes generic maternity staffing, training, communication or clinical-judgment deficiencies unless they directly impair management of abnormal antenatal CTG.
  • Excludes failures in fetal monitoring after labour has begun and non-CTG maternity risks such as GBS, mode-of-delivery planning or neonatal care.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

National Institute for Health and Care Excellence2
Royal College of Obstetricians and Gynaecologists2
Department of Health and Social Care1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Alonzo Christopher Andrew Wood · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alonzo Christopher Andrew Wood was born on 23 September 2023 and died on 26 September 2023 from multi-organ failure associated with a significant hepatic congenital haemangioma. A spontaneous bleed occurred between 21 September and his birth, leaving him critically unwell at delivery. The report also identified insufficient guidance on management actions following an abnormal antenatal CTG, including whether and when delivery should occur.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient guidance on management actions for abnormal antenatal CTG

    Wider context from the report

    “During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG. In particular, the clinicians indicated that there was no guidance where there has been an abnormal CTG antenatally as to whether delivery should occur and, if so, in what period. As such, the decision making is reliant on individual clinical judgment. ”

    Source location

    Alonzo Christopher Andrew Wood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider reviewing evidence on antenatal CTG interpretation and resulting actions.

    Verbatim wording from the response

    “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.”

    Source location

    Response from NICE
    Page 1 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with others to assess whether a practice guide can be produced for practitioners.

    Verbatim wording from the response

    “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.”

    Source location

    Response from NICE
    Page 1 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Insufficient high-quality evidence is likely to prevent NICE producing guidance on antenatal CTG interpretation and resulting actions.

    Verbatim wording from the response

    “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.”

    Source location

    Response from NICE
    Page 1 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clinical variability means strict antenatal CTG protocols cannot cover every situation; individualised care and experienced clinicians’ judgment remain necessary.

    Verbatim wording from the response

    “The variability in clinical scenarios in the antenatal period means that strict protocols or exhaustive guidelines, may not cover every situation, underscoring the importance of individualised care plans developed by experienced clinicians. It cannot be emphasised enough that the complexity and variability inherent in clinical practice necessitate reliance on professional judgment to ensure optimal outcomes for both mother and baby.”

    Source location

    Response from Royal College of Obstetricians and Gynaecologists
    Page 2 · response
    Published 26 March 2025

    Open published response

  2. Manchester (City)

    AI-generated summary

    Isa Riaz Mushtaq · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Isa Riaz Mushtaq was delivered by emergency caesarean section after reduced fetal movement, a suspicious antenatal CTG and fetal bradycardia. He did not recover from the bradycardia/asystole episode, developed severe hypoxic ischaemic encephalopathy and died on the third neonatal day. The principal concern was the absence of detailed national guidance for interpreting and managing abnormal antenatal CTGs, including when urgent delivery is required.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of fetal blood sampling for antenatal CTG assessment

    Wider context from the report

    “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance. Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery. For example, the following problems with antenatal CTG interpretation may arise:- (i) Should change of position or intravenous fluids be used in the same way as in labour (ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes (iii) At what stage should intervention should be made and with what urgency in the absence of decelerations. (iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations (v) What significance should be attached to the absence of accelerations where there is reduced variability. Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because: (i) It is not intended for such use and therefore such practice is arguably not evidence based (ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally. (iii) Only a very small percentage of antenatal CTG’s are not normal. (iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance. St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG. There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases. ”

    Source location

    Isa Riaz Mushtaq · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of detailed national guidance on antepartum CTG assessment and management

    Wider context from the report

    “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance. Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery. For example, the following problems with antenatal CTG interpretation may arise:- (i) Should change of position or intravenous fluids be used in the same way as in labour (ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes (iii) At what stage should intervention should be made and with what urgency in the absence of decelerations. (iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations (v) What significance should be attached to the absence of accelerations where there is reduced variability. Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because: (i) It is not intended for such use and therefore such practice is arguably not evidence based (ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally. (iii) Only a very small percentage of antenatal CTG’s are not normal. (iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance. St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG. There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases. ”

    Source location

    Isa Riaz Mushtaq · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026