Influences on safety of intrapartum electronic fetal heartrate monitoring practices

Why it matters

Electronic fetal monitoring with cardiotocography (EFM-CTG) is used during labour and delivery to track how the baby is doing and to spot possible signs of deterioration. In England and many other countries, it’s recommended as a way to monitor fetal heart rate during high-risk births.

Failures relating to electronic fetal monitoring have been repeatedly identified in reports into the safety of maternity care. While improving individual training in EFM-CTG has been a focus of improvement efforts in the past, there may be many other influences on safety of electronic fetal monitoring. More needs to be understood about the range of factors that could influence EFM-CTG, but the evidence hasn’t been systematically collated or organised yet.

To address this, we conducted a scoping review (a type of research that aims to map out the key concepts, evidence, and gaps in a particular field or topic) with the aim of identifying influences on the safety of EFM-CTG practices. We structured our findings using an evidence-based framework used for classifying the causes of patient safety incidents, called the Yorkshire Contributory Factors framework (the ‘YCF framework’).

What we found

We did find a body of evidence describing influences on the safety of EFM-CTG practices, but it had some limitations. For example, it wasn’t always clear what type of fetal monitoring was being described. Opinions on best practice varied across studies. The views of maternity service users were not prominent: most studies reported from a clinical or professional viewpoint, with very little information about whether the people giving birth had been consulted.

We used the YCF framework to help us organise the evidence. To accurately reflect evidence as a whole, we identified the full range of factors reported in the literature, even when the findings contradicted each other.

Many studies reported structural issues such as high staff workload and staff shortages, which can lead to cognitive overload – when the brain is overwhelmed with too much information or too many tasks to process at once. Equipment problems were also common.

Inconsistent guidelines and local procedures were identified as challenges in the literature. Some studies stressed the importance of training staff in interpreting a CTG, but lack of standardisation in training and procedures between units led to inconsistencies. The evidence also pointed to the need for training in specific areas related to fetal monitoring, such as escalation procedures.

In the context of the YCF, ‘active failures’ are mistakes or errors made by people at the ‘sharp end’ of healthcare – the healthcare professionals. They include mistakes like misinterpreting CTG or problems in responding to abnormal traces. Although many studies highlighted these types of error, they often didn’t fully investigate why they happened. However, the available literature suggests that potential influences on active failures include things like the working conditions of the healthcare staff involved, communication and organisational issues, and equipment problems.

Two important influences on EFM-CTG found in the literature may not be fully captured by the framework. One is the fear of litigation, which may encourage defensive practices and excessive use of CTG. The second is that ‘active failures’ can occur at different stages of labour.

Our review confirms that detecting and responding to fetal deterioration using EFM-CTG requires structures, systems, culture and processes that support a reliable and safe care pathway that is personalised and responsive to individuals.

Given the significant harm and legal claims linked to fetal monitoring during labour, improvement efforts need to address all the factors highlighted in this review. Solving these issues will require new thinking about the problems to be solved, the targets for intervention, and the design of solutions.