It was time to update this post from August 2022 and share it again. Understaffing is an increasingly common issue in the maternity care systems of high-income countries so this remains an important issue.
Using central monitoring to replace midwives
The makers of central fetal monitoring technology don’t market their systems as a means to solve staffing issues. But there is evidence that central fetal monitoring systems are sometimes used in an attempt to maintain safety when staffing levels are less than ideal. Researchers describe midwives using central fetal monitoring systems in this way:
It can be convenient to be able to say, “I’ve got two patients,” or “I’ve got to help with this other birth, I’m going to leave this one on the monitor.” At least I have some sort of clue watching the central monitor of what is going on there. (RN 5)
(Chuey et al., 2020, p. 49)
Smith and colleagues (2012) used the term “midwife by proxy” to describe the use of CTG monitoring, including central fetal monitoring, as a substitute for midwifery care in their review of midwives’ experiences with CTG monitoring in labour. For example, in one of the included studies, midwife Alice explained watching multiple CTGs from one location:
It was easier for me to sit down at the desk, and I watched because it was easier to do that . . . the CMM2 [senior clinical midwife manager] had to go and help assist with an FBS [fetal blood sample], and she said to me, “Would you mind looking after, watching Room 1 and 7 as well?” So, I was watching Room 1, 4, 7, and 9.
(Hill, 2016, p. 72)
In Alice’s situation, we see one midwife tasked with watching four women’s CTG recordings simultaneously. It is physically impossible for one person to respond in a timely and clinically appropriate way to more than one abnormal CTG at a time. It might seem that as long as one person is watching multiple CTGs that all will be well, but if that one person leaves the central monitoring area to attend to one of those women, then three woman are not having their CTGs monitored.
Simply installing a central fetal monitoring system is not enough. There are no guarantees that because a CTG is visible at the central fetal monitoring station then someone will be present in that area. Even if there is someone in the room, they may not be attending to the CTG recording that requires attention or understand important contextual information that changes how to interpret the trace. One of the midwives I interviewed for my research told me about the challenge of getting outside help when they had interpreted the CTG as abnormal but the midwife at the central fetal monitoring station disagreed with their assessment. The midwife said:
I had come out of the room and asked them to assess my trace, and they looked at it [on the central monitor]. There were four or five traces on the board. I was concerned about my trace, but there was someone else who had a trace that was more concerning. They looked at my trace, saying no this is fine. . . . They didn’t consider the clinical context. It might be fine for a baby that is term, well grown, and got resilience, but not with a little pretermer.
(Small, et al., 2022, p. 196)
This was described as “not being able to see the wood for the trees”, because without specific knowledge of the birthing woman and her clinical context, the CTG cannot be interpreted appropriately. While in this instance, the woman had a midwife who was actively advocating for her, if the woman’s midwife were absent from the picture due to short staffing, then there would have been a risk to safe care provision.
Fixing understaffing without adding more staff doesn’t work
In her Master’s research thesis (Griggs, 2012), American labour and delivery nurse Kelly Griggs related the case of a woman whose baby developed irreversible neurological injury while continuous CTG recording on a central fetal monitoring system was in use. At several key points in time, the nurse caring for the woman had to leave the woman’s room to attend to the care of others as there were not enough staff. No one was at the central fetal monitoring station as all nurses were providing clinical care. Consequently, no one recognised the CTG was abnormal and appropriate action was not taken in a timely manner.
Because of this event, the hospital instituted a new position, the “perinatal safety nurse”. Their role was to remain at the central fetal monitoring station, constantly interpreting all CTGs, and communicating with other clinical staff to ensure timely responses when the pattern was abnormal. In her thesis, Griggs described improvements in several outcomes during the first two years of this initiative, highlighting the value of having someone in a dedicated perinatal safety role.
Griggs later approached staff at the unit to better understand what had changed in the unit after the introduction of the new role, finding that all was not as positive as it seemed from her initial data (Griggs & Woodard, 2019). Nurses completed surveys before and after the introduction of the new role; and were invited to attend focus groups once the new nursing role had been embedded in the organisation. The only statistically significant difference in the before and after surveys was a very concerning reduction in nurses’ confidence that they would be approached if someone had concerns about the CTG recording of a woman in their care. At both time points, nurses indicated low support for the statement that staffing levels were adequate to support the perinatal safety nurse role.
Griggs and Woodard explained that when the unit was busy, the perinatal safety nurse was “often pulled away from their station” to assist with other nursing cares (p. 275). The task of watching the CTGs then fell to nurses from the senior management team who observed from a remote location. While not commented on in the paper, this raises concerns for me about further loss of contextual information, competing demands on the nurse’s attention, and diminished ability to mount a timely response.
So – what happens when you introduce a central fetal monitoring system into a maternity service who are struggling to provide adequate staffing to maintain safety? You end up with an expensive central fetal monitoring system in a maternity service that still struggles to provide adequate staffing to maintain safety. Along with this, you now have a large hole in the budget that might have been directed to hiring staff. You cannot fix an unsafe maternity system by adding a sprinkle of central fetal monitoring and stirring.
A plea for appropriate language use
From time to time I hear something like “Oh but our unit is so busy!” as the reason why intermittent auscultation is rarely in use, or why central fetal monitoring is considered to be the bees knees. The concern I have about this language is how it implies birthing women should be responsible for turning up in a nicely staggered and ordered line that is proportional to the number of staff rostered on for the shift. It takes the responsibility off the organisation to design care delivery systems that work, and to employ the right number of professionals, with the right knowledge and skills, in order to provide quality care.
If we want maternity services that flexibly provide services that can meet birthing women’s needs for safety (in the broad sense of that word – not just “not dead”) then we need to start saying it like it is. The unit isn’t busy – it is understaffed and not designed to provide safety!
References
Chuey, M., De Vries, R., Dal Cin, S., & Low, L. K. (2020, Jan/Mar). Maternity providers’ perspectives on barriers to utilization of intermittent fetal monitoring: A qualitative study. Journal of Perinatal and Neonatal Nursing, 34(1), 46-55. https://doi.org/10.1097/JPN.0000000000000453
Griggs, K. M. (2012). Implications of Perinatal Safety Nurse Fetal Monitoring Surveillance in the Labor and Delivery Setting [Masters, Gardner-Webb University]. School of Nursing.
Griggs, K. M., & Woodard, E. K. (2019). Implementation of the Fetal Monitor Safety Nurse Role: Lessons Learned. American Journal of Maternal & Child Nursing, 44(5), 269-276. https://doi.org/DOI:10.1097/NMC.0000000000000558
Hill, K. (2016). An exploration of the views and experiences of midwives using intermittent auscultation of the fetal heart in labor. International Journal of Childbirth, 6(2), 68-77. https://doi.org/10.1891/2156-5287.6.2.68
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022, Mar). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women & Birth, 35(2), 193-200. https://doi.org/10.1016/j.wombi.2021.05.006
Smith, V., Begley, C. M., Clarke, M., & Devane, D. (2012). Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. BMC Pregnancy and Childbirth, 12(1), 166. https://doi.org/10.1186/1471-2393-12-166
Categories: CTG, EFM, Perinatal brain injury
Tags: central fetal monitoring, Fetal Safety Nurse, Midwife by proxy, safety, Staffing
Birth Small Talk 
Thank you Kirsten- this is one decision I have been strongly opposing. Your blog tells it all-simply and plainly.
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Thanks for holding the line Evita. We need research before introducing new technologies to the birth space.
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