The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report[i] published in 1997 found suboptimal care in three-quarters of babies who died from an intrapartum-related cause. Most of the criticism focused on electronic fetal monitoring.
The report highlighted failure to initiate CTG when indicated, failure to ensure good-quality CTG, inadequate CTG interpretation and failure to communicate the findings to senior staff in a timely manner. The conclusions resulting from these findings included recommendations for:
- a regular/rolling programme of training in the use of electronic fetal monitoring
- simple guidelines on the interpretation of electronic fetal monitoring
- guidelines on appropriate management in situations where the CTG is abnormal and clear lines of communication when an abnormal CTG is suspected.
Medical and midwifery staff have responded and now there are NICE intrapartum guidelines and several structured training programmes. However, the themes identified in the present Each Baby Counts report remain remarkably similar to those in the CESDI report 20 years ago. It was anticipated that computer-assisted CTG assessment and management alerts would revolutionise fetal monitoring, but a recent large randomised control trial, the INFANT study, did not demonstrate this. INFANT found no evidence that using computer assisted decision support software in conjunction with CTG reduced the occurrence of poor outcomes for babies at birth or developmental issues at 2 years when compared with CTG alone.[ii] Therefore, reinforcement of the recommendations from CESDI 1997 remains essential if the aspirations of the Each Baby Counts project are to be realised.
It is also crucial to challenge the research community to continue to search for more robust methods for intrapartum assessments of fetal well-being. The continued reliance on fetal heart rate changes to inform maternity staff about fetal health in often complex, high-risk situations is inadequate. The maternity profession urgently requires a more holistic approach to well-being assessment and training to achieve improved outcomes for babies.
Staff tasked with CTG interpretation must have documented evidence of annual training.
The RCOG recommends formal documented evidence of regular continuous CTG training and competency assessment through such means as e-Learning for Healthcare (e-LfH) electronic fetal monitoring training,[iii] Advanced Life Support in Obstetrics (ALSO®) Provider Course,[iv] Managing Medical and Obstetric Emergencies and Trauma (mMOET)[v] and locally developed CTG training sessions for all intrapartum care providers. ‘Fresh eyes’ reviews or a buddy system should be part of the culture of CTG assessment in order to minimise misinterpretation of CTGs. In England, these recommendations comprise element 4 of the Saving Babies’ Lives care bundle.[vi]
Key management decisions should not be based on CTG interpretation alone.
When reviewing a continuous CTG, healthcare professionals must take into account the full picture, including the mother’s history, stage and progress in labour, any antenatal risk factors and any other signs the baby may not be coping with labour.A CTG should not be reviewed as a stand-alone investigation.
[i] Maternal and Child Health Research Consortium. Confidential Enquiry into Stillbirths and Deaths in Infancy: 4th Annual Report, 1 January–31 December 1995. London: Maternal and Child Health Research Consortium; 1997.
[ii] INFANT Collaborative Group. Computerised interpretation of fetal heart rate during labour (INFANT): a randomised controlled trial. Lancet 2017;389(10080):1719–29.
[iii] e-learning for Healthcare: About the Fetal Monitoring Programme[http://www.e-lfh.org.uk/programmes/electronic-fetal-monitoring].
[iv] Advanced Life Support in Obstetrics [http://www.also-uk.com].
[v] Advanced Life Support Group: Managing Medical and Obstetric Emergencies and Trauma (mMOET) [http://www.alsg.org/uk/MOET].
[vi] O’Connor D. Saving Babies’ Lives: A Care Bundle for Reducing Stillbirth. London: NHS England; 2016 [https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf].