Ivy Morris

the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. : (1) Foetal heart monitoring: Ivy's foetal heart rate ought to have been monitored and was not monitored. In the second stage of labour the maternal heart rate was recorded on the aged The the During external CTG machine for the majority of (if not all) the time when the intent was to monitor the foetal heart rate. The confounding factor was the similarity of the heart rates at the commencement of the second stage: There were opportunities and methodologies available to resolve this issue that were not taken: There was evidence of potential error of this kind in the interpretation of CTG traces being a known phenomenon: (2) Failure to follow midwifery guidelines: To confirm assessment of the CTG using the agreed assessment tool: The need to request an obstetric review after 1 hour of active pushing: The need to request an obstetric review for maternal tachycardia.

(3) Episiotomy Infiltration took place which could have led to an episiotomy and delivery within minutes_ There was unresolved evidence as to whether an episiotomy was a planned event or a contingency which did not arise. There was though evidence that the midwife who performed the infiltration had not performed an episiotomy since qualification and wished to have support and supervision should one become necessary Whilst such support and supervision may have been available in this case, in other this could lead to delay: