It is always tricky to find evidence about what maternity professionals’ practice looks like when it comes to CTG monitoring. It has become like the floor covering in the birth suite – no one comments on it, it’s just there. So it’s always a joy when someone publishes research that gives us a glimpse into practice. New research from the Netherlands asked midwives and doctors about what goes on in their hospital and what their own practice looked like (Hbraken, et al., 2022). Their findings are interesting.

The researchers used an online survey sent to all “secondary care” midwives (I’m not quite sure what this description refers to) and all “gynaecologists” (I presume they mean obstetricians so this is what I am going to call them) in training and qualified, in the Netherlands. Of the 510 people who responded, 155 were midwives, 105 were obstetric trainees, and 250 were obstetricians.

Fetal spiral electrode use

All but one person reported that fetal spiral electrodes were in use at their hospital. 25% of people said that a fetal spiral electrode was used routinely after membrane rupture as soon as it was technically possible to put one on and another 20% said they were used routinely after membrane rupture once the woman was in active labour. One third said they were used when there was an indication, with the most common being when the quality of the external heart rate trace was poor, or when the CTG was abnormal. People responding to the survey estimated that 71% of women in their care would have a fetal spiral electrode used in labour. Midwives reported slightly more use of a fetal spiral electrode at 75% than trainees did at 70%.

Worryingly, when asked “do you ask for informed consent before place a fetal spiral electrode?”, 26% said no. When asked “do you discuss possible complications of fetal spiral electrode placement?” 72% said they did not. There was no breakdown provided for these questions according to the professional group.

Intrauterine pressure catheter use

54% of people reported that intrauterine pressure catheters were used to monitor contractions at their hospital. People estimated that they were used for about 5% of births, and this was the same across the professional groups. The most common reason given for the use of an intrauterine pressure catheter was because the external contraction monitor wasn’t producing a reliable recording.

ST segment analysis

25% of people said ST segment analysis of the CTG was available at their hospital and they estimated that it was used for about 60% of births. Midwives were a bit less likely to use it at 54% compared to trainees at 65%.

Fetal blood sampling

All but 4 people reported that fetal blood sampling was available at their hospital. Fetal blood sampling was reported to be used for about 15% of births. Midwives reported using it less often at 10% of births. 77% of respondents who had access to fetal blood sampling said they tested for pH, 9% for lactate, 13% for both, and 1% were unsure what was being tested. Some hospitals set an upper limit for the number of samplings performed for the one woman, with three or four being the most common cut off points.

Should everyone have CTG monitoring?

The survey asked “Do you think that continuous CTG monitoring should be performed during all deliveries?” 94% of people said no. They didn’t provide information about how often CTG monitoring was being used, which is a pity as that is difficult data to find.

My thoughts

I’m pleased to see that universal CTG use was not a widely held attitude in the Netherlands. But I am really shocked at the persistent practice of using a fetal spiral electrode without consent and without adequate information sharing. The authors also commented on this in the discussion, saying

National law in the Netherlands states that with informed consent, the complications that have a 1% or higher change of occurring must be discussed. If a complication is known to be severe but has a less than 1% chance of occurring, it must also be discussed. The most common complications of the fetal spiral electrode are a superficial wound (incidence 41.6%) and abscess formation (incidence 0.2 – 4.5%). … We advise obstetric care providers to give patients information about potential risks and benefits of fetal spiral electrodes to enable them to make an informed decision.

p. 162

I’m curious. How do these numbers measure up with what you are seeing (or doing) in practice where you live?

Reference

Habraken, V., Spanjers, M. J. M., van der Woude, D. A. A., Oei, S. G., & van Laar, J. (2022, Sep 30). Experiences with intrapartum fetal monitoring in the Netherlands: A survey study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 278, 159-165. https://doi.org/10.1016/j.ejogrb.2022.09.028

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Categories: CTG, EFM, New research

Tags: Consent, decision making, fetal blood sampling, Fetal spiral electrode, Intrauterine pressure catheter, lactate, pH, STAN analysis