Customer Success Story. Interview with Dr. Edwin Chandraharan, St. George’s Hospital London.

Edwin Chandraharan (MBBS, MS (Obs&Gyn), DFFP, DCRM, MRCOG) is the Lead Consultant Labour Ward & Lead Clinical Governance in Obstetrics and Gynaecology at St. George’s University Hospital in London, UK and has been working with ST Analysis since 2002.

Can you tell us about your first experiences of STAN and ST Analysis?

ST Analysis was introduced to St. George’s Hospital by my predecessor Mr. Austin Ugwumadu and Professor Sir Sabaratnam Arulkumaran in 2002. Initially we had only four STAN ST machines and hence had to prioritise its use for specific clinical situations (e.g. meconium stained liquor, previous caesarean sections etc.). We soon realized that in order to benefit from the technology, we needed to train our staff appropriately and use the device more often to gain experience and expertise. This was the beginning of our learning curve. In 2004 a midwife, who was experienced in ST Analysis was hired to work halftime with research and education and halftime clinically on the labour ward. This immensely helped obstetricians and midwives to develop the knowledge and skills to use and interpret this technology.

You published the results of your first 1500 cases1. Can you tell us about the experience you describe in the article?

We identified 14 babies who were monitored using ST Analysis but had poor outcomes. On analysis, the poor outcomes were all related to human factors. The human errors included lack of knowledge (e.g. failure to recognise a pre-terminal CTG trace), failure to incorporate the clinical picture (such as intrapartum pyrexia, fresh thick meconium, and sentinel hypoxic events during labour) and failure to follow STAN Guidelines including failure to take appropriate action and delays in action.

Once we had looked at the outcomes and realised the cause of these poor results, we instituted several measures to reduce human error. These included intensive training for all midwives and doctors, training and assessment of competencies for all new staff joining our department, instituting a central monitor for ‘fresh eyes approach’. The STAN-specialist midwife was employed, and arranged mandatory training and study days for all staff, including certification for both midwives and doctors. We set up a database for all cases so we could easily keep track of our results and follow up all cases that had a poor outcome in weekly case discussions.

Now we are in 2011 and you have gained a lot more experience. Can you describe how you work with the STAN-method today?

We have 19 STAN ST monitors in the labour ward and we have continued to work very actively with this technology. There is greater interaction between obstetricians and midwives to continuously improve knowledge and outcomes.

An Intrapartum Fetal Monitoring Group at St. George’s has been established, and it constitutes of Prof. Sir Arulkumaran, Mr. Ugwumadu, midwife Gini Lowe and myself. We were the first hospital in the UK to have implemented a Policy on Competency in Electronic Fetal Monitoring in Labour to achieve a minimum 85% competency in the Assessment and to have a support system for those who do not achieve this level of competency.

We strongly believe that unlike fetal blood sampling (either for pH or lactate) and fetal pulse oximetry which look for peripheral acidosis, ST Analysis looks at a central organ, i.e. the fetal heart. It is therefore the best technology currently available for intrapartum fetal heart rate monitoring.

Our caesarean section rates (19-23%) are the lowest among all teaching hospitals in London (average 28-32%) and we believe STAN ST has immensely contributed to our lower caesarean section rate. In 2010 we only performed seven fetal blood sampling in 5500 deliveries.

Our team continuously organise education and training course in fetal monitoring during labour, both in our own hospital and in other hospitals in the UK.

1. Doria V, Papageorghiou AT, Gustavsson A, Ugwumadu A, Arulkumaran S Review of the first 1502 cases of ECG-ST waveform analysis during labour in a teaching hospital. BJOG 2007;114:1202-1207.

# #