Last week I published a post about why I’m not on a guideline writing group. I mentioned that I sometimes provide anonymous gentle suggestions for people who are working on fetal monitoring guidelines about how to make theirs better. You might like to get a copy of the fetal monitoring guideline where you work / where you support women to birth / where you plan to birth and read the fine print to see whether the guideline needs some polishing. Here are the five things I suggest I you look out for.
1. Does the guideline support women’s decision making?
In most parts of the world, women have legal rights to determine their healthcare. Professional guidelines are supposed to provide guidance for professionals about what they (the professional) should do – yet often the wording of the guidelines implies that women must make certain healthcare decisions. Look out for language that suggests that women “need” or “require” a particular form of fetal heart rate monitoring, or that maternity professionals “should” or “must” use a particular form of fetal heart rate monitoring.
Instead, a good guideline would use language that is clear about what the role of the maternity professional is in relation to women’s decision making. For example:
- Explain the options of intermittent auscultation and CTG monitoring, including evidence for each, during the antenatal period.
- When risk factors are present, recommend the use of continuous CTG monitoring in labour. Record the woman’s decision in the electronic record.
As much as I would love for a guideline to recommend intermittent auscultation to all women, regardless of the presence of risk factors (as this would align with the evidence base), this is a long way away from current approaches. Suggesting that particular change in wording is likely to be met with a solid wall of refusal. Making it clear that women are the decision makers when it comes to fetal monitoring is a step in the right direction.
Want to know more about how the wording of guidelines leads to maternity professionals limiting women’s choices? You can read about my research in that area here.
2. Does the guideline contain a statement accurately summarising research comparing IA with CTGs?
Most of the guidelines I have seen don’t meet this standard. Either there is no mention at all about the evidence base, or it is inaccurately presented as providing proof that outcomes for women with risk factors are better with CTG use. At the very least a good guideline should include the 2017 Alfirevic Cochrane review on the reference list. It would drive me wild with delight if a guideline included my systematic review of the evidence for women with risk factors on the reference list too!
Here’s some suggested wording to include that summarises the evidence accurately:
Evidence from randomised controlled trials has shown CTG use was associated with higher rates of caesarean section and instrumental birth than intermittent auscultation across all risk categories (Alfirevic et al., 2017). The only perinatal outcome where CTG performed better than intermittent auscultation was for the prevention of neonatal seizures, with 15 fewer babies having seizures per 10,000 births. This finding only reached statistical significance for women considered at low risk. CTG use performed no better than intermittent auscultation for the prevention of mortality, cerebral palsy, neonatal acidosis, low Apgar scores, or rates of admission to the neonatal nursery. This was true across all risk categories.
The evidence from randomised controlled trials is old and may not be generalisable to current maternity services. More recent evidence using different methodologies has also found no perinatal benefit from CTG use in either low (Heelan-Fancher et al., 2019) or high risk populations (Small et al., 2020).
3. Does the guideline contain factual inaccuracies?
One of the common fallacies I continue to see in fetal monitoring guidelines (and their associated education packages) is the statement that early decelerations are due to head compression and are not a sign of hypoxia (low oxygen levels). This has been refuted by fetal physiology researchers over the past decade. Early decelerations are a response to hypoxia.
Also look out for incorrect claims that:
- CTG use improves perinatal outcomes, particularly for women with risk factors (there’s no evidence that supports this);
- Certain CTG patterns are a sign of fetal compromise (they are a physiological coping mechanism that works to reduce damage from low oxygen – signs of compromise include things like low blood pressure and are not measured by the CTG);
- Admission CTGs improve perinatal outcomes (Devane et al, 2017).
A good guideline would not contain factual inaccuracies and when new evidence comes to light, would be updated to include this.
4. Do the guidelines impact the practice of midwives differently to the practice of obstetricians?
This one is trickier to spot. I have published research on how I read guidelines to look for this (Small et al., 2022). It requires some insider information so you know who is usually doing what in maternity services, as the guidelines don’t typically split the job responsibilities up according to profession.
What do I mean by this? Take the example of a common recommendation that when the CTG is significantly abnormal, care should be “escalated”. In other words, the person interpreting the CTG should communicate with someone who can assist in taking appropriate action. If you are the senior obstetrician on call – you are not the person doing the escalating, you are the one on the receiving end of this. Escalation is typically a task for midwives providing direct clinical care to women. Guidelines are typically clear about when to escalate but usually have nothing to say about what the person being escalated to should do and when.
My research showed that guidelines were worded in a way that really strongly dictated what midwives should and should not be doing, when, and how. For obstetricians the same guidelines were gentle suggestions at best. (You can read more about how to understand what you might be seeing in this blog post.)
Does your guideline reinforce medicalisation in your service in ways that don’t really have anything to do with safety and quality of care? If so, play about with the wording to balance the power differently. Give midwives more autonomy, and include clear instructions about what the responsibilities and roles of obstetric staff are. Notice what the response is when you suggest these changes.
5. When is the guideline due for revision?
In addition to telling you when it was published, most guidelines also tell you when they are meant to be revised next. This is worth looking at for two reasons. One is to make sure the guideline is up to date and keeping pace with changes in the evidence base. If it is more than five years old, it is almost certainly time for a do-over.
The other reason it is worth taking a look at the revision date, is that it is much easy to change a guideline during a scheduled revision than to get it changed not long after an update has happened. If the revision date is close or has passed, you have a window of opportunity!
If you are working in a maternity service and are looking for a great quality improvement activity to participate in, you might like to check the list of guidelines to pick one that is due for revision. Offer to lead, or at least play an active role in, the revision process. It looks great on your CV and it helps build your knowledge of how change happens (or doesn’t) in maternity care systems. You might want to start with something a little less controversial than the fetal monitoring guideline if you are new at this and work your way up from there!
If you are a user of maternity services rather than a professional, there are roles for you in guideline writing too. Many places are required to have healthcare user input into quality management processes. You might like to approach the Director of Midwifery and enquire about the pathway to participating in guideline development and redevelopment.
Did you find this useful?
If you do decide to analyse your local guideline(s) – let me know what you found! If you decide to take a role in updating the guideline, let me know how that played out, what you learned from the process, and whether you were successful in making the guideline better.
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References
Alfirevic, Z., Devane, D., Gyte, G. M. L., & Cuthbert, A. (2017, Feb 03). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 2(CD006066), 1-137. https://doi.org/10.1002/14651858.CD006066.pub3
Devane, D., Lalor, J. G., Daly, S., McGuire, W., Cuthbert, A., & Smith, V. (2017, Jan 26). Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews, 1(1), CD005122. https://doi.org/10.1002/14651858.CD005122.pub5
Heelan-Fancher, L. M., Shi, L., Zhang, Y., Cai, Y., Nawai, A., & Leveille, S. (2019, Feb 27). Impact of continuous electronic fetal monitoring on birth outcomes in low-risk pregnancies. Birth, 46(2), 311-317. https://doi.org/10.1111/birt.12422
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020, Sept). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and Birth, 33(5), 411-418. https://doi.org/10.1016/j.wombi.2019.10.002
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022, Mar). Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice. Women & Birth, 35(2), e188-e197. https://doi.org/10.1016/j.wombi.2021.05.001
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2023, May). The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography. Women & Birth, 36(3), 281-289. https://doi.org/10.1016/j.wombi.2022.09.004
Tags: decision making, Evidence, guidelines
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