When there’s a string of poor outcomes in a maternity service, and issues around fetal heart rate monitoring in labour are found to part of the problem, what invariably happens next is a recommendation for more and better education. It seems logical to believe that people who know more about the indications for CTG monitoring, how to interpret fetal heart rate patterns, and how and when to intervene in labour on the basis of those patterns, will make better decisions and outcomes will improve.
New research adds to what we know about the effectiveness of CTG education in improving outcomes.
What does the latest research say?
A research team based in France (Slaoui et al., 2024) aimed to assess the impact of an online training program about CTG interpretation on the rate of perinatal asphyxia (having low oxygen levels around the time of birth) at a group of five maternity hospitals in Paris. They defined perinatal asphyxia as a pH of less than 7.0 at birth or in the first hour of life, plus at least one of the following: Apgar score of less than seven at five minutes of age, the use of resuscitation measures at birth, or a sign of hypoxic ischaemic encephalopathy. Outcomes were first assessed in a population of infants born between July and December 2014. A mandatory online training was conducted from January to June 2016, and included an assessment with a pass mark of 80%. The “after” population were infants born between July and December 2017. At both time points, only term, singleton births with a head-first baby where included. Women who gave birth by scheduled caesarean section prior to labour were excluded as were infants known to have a congenital abnormality.
What happened?
83% of obstetricians, and 65% of midwives, providing birth care at the hospitals completed the training and achieved the required pass mark. There was one notable difference in the population of women giving birth in the later time period – they were significantly less likely to be giving birth for the first time (the rate fell from 79% of births to 46% of births being first births). First births are associated with higher rates of perinatal asphyxia, so you would expect that even without an educational intervention, the rate of perinatal asphyxia would be lower in the second time period. The authors didn’t adjust their findings to correct for this. There were no differences in caesarean section, instrumental birth, or non-instrumental vaginal birth between the two periods.
Perinatal asphyxia before the educational intervention occurred at a rate of 0.45% and 0.54% after – the difference was not statistically significant. Further analysis found that there were no differences in the number of cases of asphyxia that were considered avoidable (0.3% vs 0.28%). Among infants with perinatal asphyxia there were no deaths in the earlier time period and three in the later period – again the difference was not statistically significant but the study was not designed to be large enough to explore this outcome. There were no differences in the number of “suboptimal cares” per case of asphyxia. While the types of suboptimal care remained broadly the same between the two time periods – with delayed response to an abnormal CTG being the most common – there was a significant increase in the number of cases with errors in CTG interpretation in the later time period.
Wait, what?
So in summary, this particular education program didn’t make outcomes better, and might have actually made things a tiny bit worse. That actually comes as no surprise to me, as it fits with the larger body of previous research that has looked at whether CTG education helps or not (I have written about that before if you want to know more). The other reason I am not surprised is that there is no convincing evidence that CTG monitoring, even when done right, can make outcomes better. So going to a course about it isn’t going to suddenly, magically, make everything better.
Every time I read the outcomes of another investigation where there was a poor outcome in labour related to fetal heart rate monitoring, I see the recommendation to improve education about CTG use. I really wish the people making these recommendations would take moment to consider whether this is a good idea. All the evidence suggests that these types of recommendations are just window dressing to make it look like they care about the problem, without actually doing anything meaningful. It’s well past time we started getting serious about making birth safer, without pretending that CTG monitoring is going to achieve this.
Sign Up for the BirthSmallTalk Newsletter and Stay Informed!
Want to stay up-to-date with the latest research and course offers? Our monthly newsletter is here to keep you in the loop.
By subscribing to the newsletter, you’ll gain exclusive access to:
- Exciting Announcements: Be the first to know about upcoming courses. Stay ahead of the curve and grab your spot before anyone else!
- Exclusive Offers and Discounts: As a valued subscriber, you’ll receive special discounts and offers on courses. Don’t miss the chance to save money while investing in your professional growth.
Join the growing community of birth folks by signing up for the newsletter today!
References
Slaoui, A., Cordier, C., Lefevre-Morane, E., Tessier, V., Goffinet, F., Le Ray, C., Bourgeois-Moine, A., Sibiude, J., Laurent, A. C., & Azria, E. (2024, Mar). Impact of an e-learning training for interpreting intrapartum fetal heart rate monitoring to avoid perinatal asphyxia: A before-after multicenter observational study. Journal of Gynecology Obstetrics & Human Reproduction, 53(3), 102736. https://doi.org/10.1016/j.jogoh.2024.102736
- High risk obstetrics and high risk women: a wee rant about language
- Just try harder, then it will work! An allegorical tale.
Categories: CTG, EFM, New research
Tags: Education
Birth Small Talk 