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Why is safety in intrapartum electronic fetal monitoring so hard?

Why it matters

Problems with intrapartum electronic fetal monitoring (EFM) during labour have repeatedly been identified as a major area of preventable harm in maternity care. But improvement has been difficult and slow. One possible reason is that efforts to improve fetal monitoring may have focused too much on the training and competency of individual professionals, rather than looking at the wider systems, processes, decisions, and actions that come into play.

To understand the range of influences on the safety of electronic fetal monitoring, we conducted a multidisciplinary study using human factors/ergonomics and social science perspectives.

Our approach

The study involved a combination of observations and interviews in three UK maternity units, and looked at clinical situations where EFM had already started, and up to the point of escalation.

We carried out 325 hours of observation and 23 interviews across the three units. Researchers spent up to seven eight-hour days in each maternity unit, particularly on the labour ward.

What we found

The study found that electronic fetal monitoring should be understood not as a simple set of individual behaviours and decisions, but instead as a collective process taking place within complex clinical microsystems and involving multiple interactions between people, tasks, tools, technology, organisation, culture, and behaviour.

Though high quality work systems are essential to safety, they may be sub-optimally designed or function poorly. Structural challenges, including staffing and equipment, buildings, and facilities were all identified as key influences on safety. But also highly influential are variations in clinical competence, issues with teamwork and situation awareness, and lack of standardisation of criteria for assessing deterioration. The ability to communicate concerns may be influenced by how well supported people feel and how well the systems for escalation are designed and function. Fatigue, cognitive load, and problems in making sound decisions in highly pressurised situations further contribute to the challenges – and may not be fully addressed by current systems for seeking second opinions from colleagues.

This study is very useful in showing that effective improvement in electronic fetal monitoring is likely to require going beyond revising guidelines or providing more individual training. It is a practice fraught with sociotechnical complexity and interdependencies, and is profoundly collective in character. Improvement efforts must address the need for the range of influences on safety to be addressed, including purposefully designed work systems, improved guidance and processes, enhanced tools and technologies, and a deeper understanding of people, their roles, and their skills. While some of these problems can be managed at a local level, others will demand extensive and large-scale coordination.

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