31 Ensuring Competency in Intrapartum Fetal Monitoring. Handbook CTG

 31

Ensuring Competency in Intrapartum

Fetal Monitoring

◈

The Role of GIMS

Virginia Lowe and Edwin Chandraharan

Handbook of CTG Interpretation: From Patterns to Physiology, ed. Edwin Chandraharan.

Published by Cambridge University Press. © Cambridge University Press 2017.

Background

St George’s Maternity Unit employs CTG and fetal ECG (ST-Analyser or STAN) to

assess fetal well-being during labour. Both these tests require clinicians to have

sufficient knowledge and expertise in order to recognize and correctly interpret common

CTG changes. To understand the importance of these changes requires an understanding

of the pathophysiology of FHR control and hypoxia, and, additionally, the knowledge of

associated clinical circumstances is essential in order to ensure appropriate

management. The ‘Confidential Enquiry into Stillbirths and Deaths in Infancy’ report in

the mid-1990s concluded that 50 per cent of intrapartum-related deaths could have been

prevented if the clinicians involved had instituted alternative management. Lack of

knowledge regarding CTG interpretation was identified as a significant factor within the

report, as well as failure to incorporate the whole clinical picture, incorrect or delayed

action and communication/common sense issues. The Chief Medical Officer’s report

‘Intrapartum-Related Deaths: 500 Missed Opportunities’ in 2007 has also highlighted

the above issues as recurring themes in obstetric care.St George’s Intrapartum Monitoring Strategy (GIMS) comprises intensive,

physiology-based CTG training, use of fetal ECG (STAN) to reduce the false-positive

rate of CTG and a mandatory competency testing for all midwives and obstetricians.

This combination aims to deepen the appreciation clinicians have for the intricacies of

fetal monitoring and promotes consistency across the service.

Objectives

1. To ensure that all staff (midwives and obstetricians – trainees, middle-grade

doctors and consultants) who interpret CTG/STAN traces are comprehensively

trained.

2. To ensure that all staff continuously update their knowledge and skills in fetal

monitoring.

3. To ensure competency in CTG/STAN interpretation by providing training as well

as conducting an assessment process.

4. To provide support to staff who do not perform up to 85 per cent competency in

CTG/STAN interpretation to maintain a high standard of care.

Strategies

Intense Physiology-Based CTG Training

This involves a deeper understanding of fetal pathophysiology: instead of

morphologically classifying decelerations as ‘early’, ‘variable’ and ‘late’, the

underlying mechanism is explored (e.g. baroreceptor- or chemoreceptor-mediated) as

well as the fetal response to ongoing hypoxic or mechanical stresses. In addition,

education focusses on the consideration of the features of the type of intrapartum (acute,

subacute or a gradually evolving) or chronic (long-standing) fetal hypoxia on the CTG

trace and encourages differentiation of a compensatory fetal response from

decompensation. Case scenarios are discussed in depth to reinforce the importance of

considering the whole clinical picture and to embed learning points.Use of Fetal ECG (STAN)

Fetal ECG is used to determine the energy balance within a central organ (myocardium)

so as to identify the onset of myocardial glycogenolysis as a mechanism to maintain

energy balance with the onset of anaerobic metabolism. This may help reduce the falsepositive rate of CTG while improving perinatal outcomes. See Chapter 22.

Competency Testing

The assessment tool comprises questions on ‘pattern recognition’ as determined by

current guidelines on intrapartum FHR monitoring; knowledge of fetal pathophysiology

including the types of hypoxia; questions on situational awareness and considering the

wider clinical picture (e.g. recognition of features of MHR, injudicious use of

syntocinon etc.). There is an agreed policy within the unit which summarizes the

expectations, an extract of which is shown below:

Training and Assessment

a. New Staff

All new staff (midwives and all grades of obstetricians involved in intrapartum fetal

monitoring) will be provided CTG/STAN training as part of their induction. After their

training, they will be required to obtain 85 per cent competency in assessment in both

CTG as well as STAN to demonstrate their knowledge in intrapartum fetal monitoring.

Obstetricians are required to attend weekly CTG meetings, which are held on

Tuesdays and Fridays, to update their knowledge and skills in CTG/STAN

int

erpretation. It is recommended that they attend at least two such meetings every

month. Minimum requirements would be to attend CTG Meetings at least once a month

and to attend at least 12 meetings in 6 months or to complete the online CTG

Assessment Tool at least twice in 6 months. Midwives are strongly encouraged to attend

as often as shift pattern permits.

b. Existing Staff

All staff are expected to undergo a formal CTG Training (minimum 3 hours) once every

12 months, in addition to attending the CTG Meetings as stated earlier.All staff who have passed the assessments in CTG/STAN will be required to re-sit the

test at least once every two years, or earlier, if required (for example if they are involved

in

two or more adverse incidents which involved failures in CTG/STAN interpretation or

they have been involved with an SI where failure to interpret CTG/STAN by the clinician

concerned contributed to the poor outcome).

Outcomes

The approach to intrapartum FHR monitoring has resulted in a significant reduction in

intrapartum emergency section rate from 15 per cent in 2008 to 8 per cent in 2012

(Figure 31.1). Despite commencing a regional service for morbidly adherent placentae

and a regional bariatric service, both of which may increase the total caesarean section

rate, currently the emergency caesarean section rate remains between 6.1 and 8.2 per

cent. The neonatal metabolic acidosis rate as well as the HIE rates have also halved

during this period (Figure 31.2), and currently, the maternity unit has half the nationally

reported HIE rate in the United Kingdom.

Figure 31.1 Trends in total and emergency caesarean section rates.Figure 31.2 Rates of neonatal metabolic acidosis rate and HIE rate.

Discussion

CTG interpretation that relies on ‘pattern recognition’ is fraught with inter- and intraobserver variability, leading to overdiagnosis as well as failure to recognize features of

ongoing intrapartum hypoxia. These errors may lead to unnecessary intrapartum

operative interventions and hypoxic-ischaemic injury, respectively. The St George’s

approach to intrapartum FHR monitoring focusses on fetal physiology and a deeper

understanding of the features observed on the CTG trace so as to avoid flaws of ‘pattern

recognition’ and has resulted in halving of intrapartum caesarean section and adverse

perinatal outcome rates. This training is facilitated by a group of clinicians with a

particular interest in fetal monitoring, including midwives employed as CTG specialists

who maintain competency records and can be available for one-to-one support.

Introducing mandatory competency testing is not without its challenges: there can be a

level of anxiety around the formal assessment process, and a clear pathway is required

where competency is not achieved in order to maintain patient safety. These issues are

mitigated by ensuring all clinicians involved in CTG training maintain a strong clinical

presence and, therefore, are in a position to take advantage of educational opportunities

in practice and provide consistent support while also maintaining credibility and anappreciation of the challenges faced by frontline staff. Where clinically appropriate,

STAN is routinely employed as a ‘central organ test’ to reduce the false-positive rate of

CTG. Although meta-analysis has not reported any significant decrease in caesarean

section rates and gives conflicting information about reduction in neonatal metabolic

acidosis, data from St George shows that the use of STAN in combination with an

intensive physiology-based CTG training and mandatory competency testing may result

in significant improvement in perinatal outcomes while reducing unnecessary

intrapartum operative interventions.

Conclusion

All maternity units should consider training midwives and obstetricians in fetal

physiology so as to critically analyse the pathophysiological mechanisms behind the

features observed on the CTG trace. This may avoid errors due to inter- and intraobserver variations secondary to merely relying on ‘pattern recognition’ based on

existing guidelines. This training should be followed up by mandatory competency

testing on CTG interpretation. Once the staff are fully trained in fetal pathophysiology,

the use of STAN appears to significantly reduce intrapartum emergency caesarean

section rates and improve perinatal outcomes (neonatal metabolic acidosis and HIE

rates).

Further Reading

1. Ayres-de-Campos D, Arteiro D, Costa-Santos C, et al. Knowledge of adverse neonatal

outcome alters clinicians’ interpretation of the intrapartum cardiotocograph. BJOG

2011;118(8):978e84.

2. Nurani R, Chandraharan E, Lowe V, et al. Misidentification of maternal heart rate as fetal

on cardiotocography during the second stage of labor: the role of the fetal electrocardiograph.

Acta Obstet Gynecol Scan 2012;91(12):1428e32.

3. McDonnell S, Chandraharan E. The pathophysiology of CTGs and types of intrapartumhypoxia. Curr Wom Health Rev 2013;9:158e68.

4. Chandraharan E, Lowe V, Arulkumaran S. Pathological decelerations on CTG: time for

FPS or FBS? Int J Obstet Gynecol 2012:S309.

5. Chandraharan E, Arulkumaran S. Prevention of birth asphyxia: responding appropriately

to cardiotocograph (CTG) traces. Best Pract Res Clin Obstet Gynaecol 2007;21(4):609e24.

6. Chandraharan E, Lowe V, Ugwumadu A, Arulkumaran S. Impact of fetal ECG (STAN)

and competency based training on intrapartum interventions and perinatal outcomes at a

teaching hospital in London: 5 year analysis. BJOG 2013;120(s1):428–429.

7. Pinas A, Chandraharan E. Continuous cardiotocography during labour: analysis,

classification and management. Best Pract Res Clin Obstet Gynaecol 2015;25:S1521-6934.

8. Chandraharan E, Lowe V, Penna L, Ugwumadu A, Arulkumaran S. Does ‘process based’

training in fetal monitoring improve knowledge of cardiotocograph (CTG) among midwives

and obstetricians? Book of Abstracts. Ninth RCOG International Scientific Meeting, Athens,

2011. www.rcog.org.uk/events/rcog-congresses/athens-2011