Signal ambiguity resulting in unexpected outcome with external fetal heart rate monitoring.
We report cases of unexpected adverse fetal outcome from monitored labors in which the fetal heart rate tracing was interpreted as reassuring. In these cases, portions from another signal source, usually maternal, were imperceptibly substituted into the fetal tracing in a way that masked the evidence of fetal compromise.
Neilson
Duncan R
DR
Legacy Health System, Portland, Oregon, USA.
Freeman
Roger K
RK
Mangan
Shelora
S
D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D005260:Female; D005316:Fetal Distress / Q000175:diagnosis*; D005318:Fetal Heart / Q000502:physiology*; D005323:Fetal Monitoring / Q000379:methods; D006801:Humans; D008297:Male; D011247:Pregnancy; D011256:Pregnancy Outcome; D012680:Sensitivity and Specificity