One of the problems I see over and over again is the over simplification of complexities in relation to fetal heart rate monitoring in labour. Education and clinical guidelines tend to produce what appear to be logical and straightforward explanations and advice when there is a lot of mud in the pond. Here are two examples:
- Rising lactate levels are a reliable sign of fetal compromise and indicate a clinical need for birth to be expedited.
- Central fetal monitoring systems ensure multi-professional oversight of all CTGs, so abnormal patterns will not be missed.
In both of these cases the situations are much more complicated (like this and this).
When I see investigations into poor outcomes relating to fetal monitoring in labour (whether they relate to an isolated case or an entire health service), I often see blanket recommendations for more education for maternity professionals about CTG interpretation. The idea that better education leads to better outcomes is seductively simple and many people never think to go beyond this. So it was a great pleasure to read a new research paper that specifically set out to delve into the muddy pond and report on the realities of clinical practice.
Their paper (Lamé et al., 2023) is open access and it is well worth the time taken in reading it. Why not grab a copy and email it to the quality improvement / patient safety officer at your local hospital and ask for their opinion on it too.
What did they do?
The research team selected three maternity services in the United Kingdom, one small (< 2000 births a year), one medium-sized (2000 – 5000 births), and one large unit (>5000 births). In each hospital they spent time observing people at work (325 hours in total) and also interviewed people with diverse roles and responsibilities relating to fetal monitoring in labour (23 interviews). They used a systems engineering approach that looked at how the work was actually done, rather than how it was imagined as done.
Notably, the focus was on the situation where: “the decision to initiate EFM [CTG monitoring] had already taken place, and up to the point of escalation, without examining clinical interventions in response to possible fetal deterioration” (p. 2). This was the “business as usual” zone rather than an exploration of the complexity of work that arises once the CTG is interpreted as abnormal.
What did they find?
Well – it was complicated…
Staffing levels were recognised as critical for safe practice, yet all three services had issues with understaffing or a lack of experienced staff in roles where this was required. All sites had suboptimal fetal monitoring equipment with poor maintenance and two had insufficient numbers of monitors. Three different guidelines were used across all three sites, generating issues relation to a lack of consistent terminology and criteria for defining normality. Record keeping, particularly by medical staff was an issue. Midwives typically used stickers specifically designed to support consistency in interpretation and response, while medical staff wrote in the notes or directly on the trace and some made no notes at all.
“Fresh eyes” approaches were in place but a second person who had not already seen the trace was not consistently available, and examples of inappropriate agreement with an incorrectly interpreted CTG were seen. While all sites conducted regular CTG education sessions, workloads often prevented attendance, particularly for midwives. Issues with communication for escalation were identified. Disagreements over appropriate courses of action were common.
What does this mean?
The authors have done an excellent job of highlighting the complexity of work related to CTG monitoring in labour. This feels much like my clinical experience everywhere I have worked. Remember, their focus was on the “business as usual” situation – not what to do when the CTG is abnormal. If services aren’t getting things right when the CTG pattern is fine – I think we can easily guess just how messy things get when that is no longer the case. The research team do have plans to consider this in future research.
The paper makes clear why the well-intended advice to send staff to more, or better, CTG education sessions is probably entirely pointless. They focus on the issues that require a big systems level approach – such as educating, recruiting, and retaining staff; policies about purchasing and maintaining fetal monitoring equipment; and the need for a single standardised national approach to CTG interpretation. They concluded:
Improving EFM [CTG monitoring] is not simply a matter of producing better guidelines or more rigorous individual training. Instead, it requires understanding that CTG is a practice fraught with sociotechnical complexity and inter-dependencies, and is profoundly collective in character, underpinned by relationships, expertise and skill. … While some issues may be tractable to local action, other will require large scale coordination.
p. 9
The authors also suggested their findings contribute to the debate about whether the lack of research evidence showing a benefit from CTG use is due to the inherent limitations in the technology or due to the way it is implemented. They don’t say which of these arguments their findings supports but I suspect they believe it is the second option. I would point out that most of the problems they identified are embedded in the technology itself: the additional work hours required to perform CTG monitoring increases demand for staff; the equipment is complex, expensive, and difficult to operate reliably; and the interpretation and communication of fetal heart rate patterns lacks clarity (imagine if it were this difficult to communicate a haemoglobin result).
Now is a great time to ask funders of maternity care if they are prepared to seriously invest in staffing, equipment, quality guideline development, and education at the level required to improve outcomes. Or will they instead choose to continue the charade of blaming the overworked midwife struggling with a half functional CTG machine rather than accept responsibility?
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References
Lamé, G., Liberati, E. G., Canham, A., Burt, J., Hinton, L., Draycott, T., Winter, C., Dakin, F. H., Richards, N., Miller, L., Willars, J., & Dixon-Woods, M. (2023). Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis. BMJ Quality & Safety, in press. https://doi.org/10.1136/bmjqs-2023-016144
Categories: CTG, EFM, New research
Tags: documentation, Education, Fresh eyes, guidelines, safety, Staffing
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