Safety and the CTG

A team of researchers from The Healthcare Improvement Studies (THIS) Institute (and elsewhere) in the UK pulled together a comprehensive review of the literature late last year (Kelly et al., 2024). The aim of their literature review was to identify the range of influences on the safety of CTG monitoring in clinical practice. Here is a summary of what they found, and my thoughts about what this means for maternity services.

What they did

The authors searched for research, investigations, and reports that related to safety concerns in maternity care and the use of CTG monitoring in labour, published between January 2001 and when the searches were done in August 2024. 142 journal articles and 14 reports were included, most coming from the US, and UK, and the rest from a very wide range of countries, including 18 from Australia.

To make sense of what they were seeing in the literature, the authors used the Yorkshire Contributory Factors framework that sets out 19 different domains that contribute to the safety of healthcare in hospital settings. These domains are set out in the paper, and include things like policy and procedures, the physical environment, and staff workload. There are advantages in using a framework, particularly when dealing with such a large body of literature and trying to work out what to focus on. Frameworks also introduce the risk that you might not see something important in the literature, if there is no place for it in the framework.

What did they find?

Given the large number of articles and reports, and the number of domains in the framework, much of the detail of their findings is tucked away as supplementary material, with a summary provided in the body of the paper. Both the paper and the supplements are free to access if you want to see the detail.

What stood out for me, and the authors also choose to focus on in their summary, were the large number of factors that are best considered as system level issues rather than being the responsibility of the individual maternity professional. These included (but are not limited to):

Unsafe organisational cultures with strong hierarchies of power generating fear of speaking up
High staff workload (their term – I would call this understaffing to highlight that safe healthcare systems should provide sufficient staffing for the workload experienced – workload is only “high” if you have planned for less staff than are required for safety)
Equipment not being available, or poorly maintained
Inadequate systems and resources to support access to higher level care when required
Inconsistent and unclear fetal monitoring guidelines, with lack of consistent terminology hampering communication about fetal heart rate patterns

Things to be cautious about when applying these findings

Some of the safety factors identified, particularly those derived from investigations and reports, are things that people believe will improve outcomes, rather than being proven. For example, the supplement includes the following factors:

not instituting CTG monitoring in the presence of risk factors, or when the fetal heart rate was heard to be abnormal with intermittent auscultation
not using the “Fresh Eyes” second check system
intermittent use of CTG monitoring
Insufficient education in CTG interpretation

There is no evidence that addressing any of these factors leads to improved outcomes. Including them in the findings reinforces the unproven belief that they are effective interventions.

I see this as a problem for two reasons. First, organisations committing to improved safety are likely to encourage CTG use, “Fresh Eyes” checks, prevent intermittent CTG use, and mandate more education – despite no evidence that this works. All this costs time, money, and effort that would be better directed at solving understaffing, organisational culture, and access to appropriate care – factors that really do make a difference, and that will also improve outcomes when women decide to use intermittent auscultation.

Second, by reinforcing the message that these factors improve safety, the pressure to do research to demonstrate whether they are effective interventions, or not, is reduced. This maintains the current state of practice, with increasing and uncritical use of unproven fetal monitoring interventions.

What should maternity services focus on in light of this evidence?

Having adequate numbers of staff, with the right skills and experience, and who have access to functioning equipment that permits them to do their work to high standard is important. Not only will this improve outcomes relating to fetal heart rate monitoring, the flow on effects for other aspects of safety, quality of care, women’s experiences of that care, and professional satisfaction are significant. This is not consistently achieved in high-income countries and the situation is even more fragile in low and middle-income countries, where the consequences of this are clearly visible in outcome data.

Workplace culture, driven by governance structures such as the policy environment, is fundamentally important. You can have the right people and the right equipment, but if it is accepted practice for requests for assistance to be ignored or for people to be disrespected, then safety will not happen. Senior leadership must set the tone here, with hiring and firing decisions made to encourage alignment with organisational cultural priorities. We must put a stop to the practice of promoting aggressive and disrespectful people into positions of authority in healthcare systems.

These then make up my 2025 wish list: That all women have access to safely staffed and resourced maternity care and that they will encounter respectful care delivered by people who are nurtured and supported and who love where they work and what they do.

What is on your wish list?

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References

Kelly, S., Lamé, G., Dixon-Woods, M., Liberati, E., Kyriacou, H., Dunn, H., Egerton, A., Kok, Z. K., Jones, K., Zheng, X. N., Kuhn, I., Draycott, T. J., Winter, C., & Burt, J. (2024). Influences on safety of intrapartum electronic fetal heart rate monitoring practices: a scoping review. BMJ Open, 14(12). https://doi.org/10.1136/bmjopen-2024-085827