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Lewisham and Greenwich NHS Trust

Below is one of the case studies written by contributors to the Each Baby Counts project.

Physiological Interpretation of Fetal Monitoring: The Picture Before and After

Mr Ahmed Zaima, Ms Dagmar Krueger, Ms Joanna Fuller, Sarah-Ann Evans, Sarah Skivens, Elizabeth Farrant, Linda Machakaire, Natasha Cullen, Sharon Elder

The Each Baby Counts initiative aims to reduce the incidence of stillbirth, early neonatal death and severe brain injury during term labour by 50% by 2020. At Lewisham and Greenwich NHS Trust, the ‘Sign Up To Safety’ team introduced physiological CTG interpretation for intrapartum fetal monitoring to improve outcomes.

Staff attended a CTG masterclass course introducing physiological interpretation of the CTG trace. The course emphasised how current CTG interpretation guidelines based on pattern recognition, have significant inter-and intra-observer variability, causing an increase in operative interventions with no reductions in hypoxic injuries and perinatal deaths. Units where physiological interpretation was embedded in practice had shown improvements in outcomes.

After reviewing the evidence presented at the masterclass, provided by the NICE and FIGO guidelines and performing further research within the subject, we used the existing weekly CTG discussions, junior doctors’ induction program and the midwifery mandatory training week to teach the approach to all maternity staff.

Funding was agreed for further CTG masterclasses, introducing central monitoring on labour ward and the appointment of band 7 midwives to provide individualised help and support to staff across both sites of the trust. The local intrapartum fetal monitoring guideline was rewritten to reflect the changes and unify practice. In addition, we reached an agreement that all staff caring for women in labour had to pass a competency assessment.

An audit of all deliveries occurring during the year before implementation, on both sites of our trust, compared to the year after the implementation of the physiological approach showed that we have achieved a 32% reduction in the number of babies admitted to NICU with hypoxic injuries, and a reduction in the number of babies transferred out for cooling. The results also showed that CS and assisted vaginal delivery rates remained unaltered.

During this episode, FBS was strongly discouraged, and only a couple were performed.

This achievement has encouraged us to collaborate with other units who have similarly demonstrated significant improvements in perinatal outcomes after implementing physiology based CTG interpretation.

Our plan is to develop an online educational package: www.physiological-ctg.com

This package will explain the principles of physiology based CTG interpretation and provide maternity staff with the scientific evidence to support their practice. It will include competency assessment tools and offer weekly CTG discussions to help embed the theoretical knowledge into clinical practice.