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Central fetal monitoring – time to de-implement?

Investment in fetal monitoring technology

Maternity services in high-income countries have invested heavily in medical technologies. However, some technologies have been implemented without clear evidence of clinical benefit or safety. Cardiotocograph (CTG) is commonly used to monitor the fetal heart rate in labour. Professional position statements and clinical guidelines recommend the use of CTG, despite highest-level evidence that it does not improve perinatal outcomes, even for women with risk factors (Small et al., 2020). See more here does-intrapartum-ctg-monitoring-save-lives. Furthermore, one of the unintended consequences of CTG has been escalating rates of caesarean section (Small et al., 2020).

Impact of fetal monitoring technology

Central  monitoring systems (CMS) transmit data from the CTG to a central site where it can be interpreted outside the room. CMS are being rolled out as a valuable add-on to CTGs, yet there have been no randomised trials of CMS. Indeed, the only evidence available is from three small studies that demonstrated CMS do not impact perinatal outcomes (Small et al., 2021). Furthermore, two of the studies measured an increase rates of instrumental birth and caesarean section after CMS was introduced (Brown et al., 2016; Weiss et al., 1997). Additional concerns include that midwives spend less time in the room with labouring women when these are CMS (Brown et al., 2016).

New research with clinicians in a setting with CMS

Obstetrician Dr Kirsten Small (PhD), project lead with Transforming Maternity Care Collaborative, conducted doctoral research about how CMS organise the work of maternity clinicians. Her PhD was supervised by Emeritus Professors Mary Sidebotham and Jenny Gamble, and Professor Jennifer Fenwick. Their latest publication describes how CMS affect maternity care providers clinical behaviours (Small et al., 2021). The setting for this qualitative study was a maternity hospital where 90% of women had a CTG in labour (all connected to a CMS). Thirty-six midwives (including midwifery students), and 16 doctors (including obstetric residents, registrars, and consultants) participated in the study. Dr Small interviewed (individually and in groups) and/or observed (e.g., when interacting with the CMS) participants and then led analysis of the data.

Undermining midwifery autonomy and compromising maternity care

The study found that clinicians outside the room made clinical decisions without all the relevant information, which potentially compromises safety (Small et al., 2021). Informants described how decisions were made, before engaging with the birthing woman and her midwife. Team leaders were perceived to check-in less with individual midwives (i.e., to get updated about the woman’s labour), if they could see that the CTG was normal.

Some midwives felt professionally disrespected by obstetricians, who would see the CMS and enter a room without invitation or permission (Small et al., 2021). This behaviour required midwives to de-escalate concerns, sometimes in a context of forceful obstetric communication. Importantly, this is the opposite of the usual process where midwives escalate concerns based on the midwife’s professional judgement. Taken together, making decisions outside the room, and coming into the room to then bypass or contradict the midwife’s interpretation of the CTG, was perceived to undermine women’s confidence in their midwife (Small et al., 2021).

Midwives lamented they were spending more time documenting on the CMS rather than being with woman. To limit disruptions to the birth space, midwives described changing their practice. For example, midwives limited women’s positions to ensure good contact for a CTG and directed women’s pushing efforts to speed up second stage labour. Informants described obstetricians acting on normal second stage decelerations (seen on the CMS), by performing surgical/instrumental birth.

Time to pause and consider next steps

Maternity services who are considering installation of CMS should pause – further research that demonstrates clinical benefit is required. Maternity services that have installed CMS, should rigorously evaluate the risks and benefits of these systems. Next steps may include the decision to de-implement CMS. De-implementation is the “process of identifying and removing harmful, non-cost-effective, or ineffective practices” (Upvall & Bourgault, 2018, p.495). Unlike implementation research, however, little is known about the process of de-implementation (van Bodegom-Vos et al., 2017). Three criteria have been suggested to help services identify which interventions are appropriate for de-implementation (McKay et al., 2018):

1) not effective or harmful; or

2) not the most effective or efficient to provide; or

3) no longer necessary.

Managers and service leaders have a responsibility to disinvest from technologies that meet any of these criteria.

Highlighted research

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2021). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women and Birth. https://doi.org/10.1016/j.wombi.2021.05.006

References

Brown, J., McIntyre, A., Gasparotto, R., & McGee, T. M. (2016). Birth outcomes, intervention frequency, and the disappearing Midwife—Potential hazards of central fetal monitoring: A single center review. Birth43(2), 100-107.

Burton, C., Williams, L., Bucknall, T. et al. (2019). Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Systematic Reviews, 8(194). https://doi.org/10.1186/s13643-019-1111-8

McKay, V. R., Morshed, A. B., Brownson, R. C., Proctor, E. K., & Prusaczyk, B. (2018). Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. American Journal of Community Psychology62(1-2), 189–202. https://doi.org/10.1002/ajcp.12258

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and birth : journal of the Australian College of Midwives33(5), 411–418. https://doi.org/10.1016/j.wombi.2019.10.002

Upvall, M. J., & Bourgault, A. M. (2018). De-implementation: A concept analysis. Nursing forum, 10.1111/nuf.12256. Advance online publication. https://doi.org/10.1111/nuf.12256

van Bodegom-Vos L, Davidoff F, Marang-van de Mheen PJ. (2017). Implementation and de-implementation: two sides of the same coin? BMJ Quality & Safety, 26, 495-501.

Weiss, P. M., Balducci, J., Reed, J., Klasko, S. K., & Rust, O. A. (1997). Does centralized monitoring affect perinatal outcome?. The Journal of Maternal‐Fetal Medicine6(6), 317-319.

Withiam-Leitch, M., Shelton, J., & Fleming, E. (2007). Central fetal monitoring: Effect on perinatal outcomes and cesarean section rate. Obstetrical & gynecological survey62(4), 232-233.