32 Physiology-Based CTG Training. Handbook CTG

 32

Physiology-Based CTG Training

◈

Does It Really Matter?

Sara Ledger and Edwin Chandraharan

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

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

Key Facts

Baby Lifeline’s Role in CTG Training

Baby Lifeline is a unique, UK-based mother-and-baby charity that was established in

1981 after its founder tragically lost three premature babies successively. Its mission is

to ensure the healthiest outcome possible in pregnancy and birth; it does this by

developing evidence-based, highly relevant, vital training for multidisciplinary teams

working in the maternity sector. Course topics and content are chosen based on

recommendations from confidential enquiries and pertinent reports highlighting key

areas of suboptimal care within the maternity sector. The Charity was established in

1981 and started its important relationship with multidisciplinary training in 1999,

following on from recommendations from the Confidential Enquiry into Stillbirths and

Deaths’ (CESDI) fourth annual report.1

Centres and DelegatesBaby Lifeline staged its first CTG masterclass in 2005, and demand has increased each

year, with a total of 10 one-day courses and one two-day course being held in 2015 at

multiple centres across the United Kingdom and Channel Islands. Baby Lifeline has

staged a total of 42 physiology-based CTG study-days since 2005 in 27 different

centres. Over 1,840 multiprofessional delegates (79 per cent midwives, 16 per cent

obstetricians, 5 per cent legal professionals) have attended masterclasses from a diverse

range of maternity units and organizations within the United Kingdom and

internationally.

Structure and Aim of Masterclass

The structure of the courses consists of 1-day (‘CTG Master Class: Fundamentals of

Fetal Monitoring’) and two-day courses (‘CTG Master Class: A Deeper

Understanding’) with postcourse materials to cement knowledge and enable delegates to

carry out vital, evidence-based modifications to practice.

The aim of the masterclass is to provide evidence-based training on CTG

interpretation based on fetal physiology and pathophysiology of intrapartum hypoxic

injury so as to reduce hypoxic-ischaemic encephalopathy while reducing unnecessary

operative interventions. Delegates are invited to engage with CTG traces and thoughtprovoking research and look reflectively at their own practice, centred on logical

physiology-based reasoning.

Key Outcomes

Delegate Feedback

Structural feedback has been excellent, with 98 per cent of delegates reporting that the

quality of education was ‘Very Good’ (20 per cent) or ‘Excellent’ (78 per cent) (Figure

32.1). Interestingly, Figure 32.2 illustrates that, of the 914 delegates that responded

following the course, only 10 (1 per cent) felt that the study-day confirmed that there

was no need to modify their practice. The remaining 99 per cent reported that they

intended to modify practice in a minor or major way (88 per cent), or they would

consider modifying their practice after seeking more information (11 per cent). Themajority of respondent delegates (51 per cent) intended to modify their practice in a

major way following the course.

Figure 32.1 A graph to show postcourse delegates’ responses regarding overall quality of

education of both 1-day and 2-day CTG masterclass (2005–2015).

Figure 32.2 A graph to show postcourse delegates’ responses regarding the effectiveness

of 1-day and 2-day CTG masterclasses at influencing practice.

Anonymised delegate responses to statements relating to key course objectives also

infer that the CTG masterclass would have an effective influence on practice. Delegate

confidence in knowledge was quantitatively measured by using a five-point Likert scale

ranging from ‘Strongly Disagree’ to ‘Strongly Agree’ to the statements below:

I understand the control of fetal heart rate and the factors that affect the features

observed on the Cardiotocograph (CTG).

I understand the types of intrapartum hypoxia and resultant features observed on the

CTG Trace.I appreciate the wider clinical picture; such as, inflammation, infection and meconium

whilst interpreting CTG Traces.

I feel confident in my application of National Guidelines and additional tests of fetal

well-being.

I feel confident in my recognition of processes whilst interpreting CTG Traces.

The variance in responses pre- and postcourse showed an increase in confidence

postcourse. On average, across all statements and delegates that completed the tests, an

increase of 35 per cent delegates reportedly ‘agreed’ or ‘strongly agreed’ with the

preceding statements than prior to the course. A total of 94 per cent ‘agreed’ or ‘strongly

agreed’ that they were confident and understood the key knowledge points postcourse,

as opposed to 59 per cent prior to the course (Figure 32.3).

Figure 32.3 A graph to show how many delegates agreed or disagreed with statements

relating to how confident they felt about course objectives precourse and postcourse.

Increased confidence in technical skills inevitably promotes shared learning of

evidence-based practice on labour wards and could lead to increased patient safety.

“This has been an excellent day. I feel totally inspired. I hope to instigate positive

changes to my practice and, as a team leader, that of others.”

“This is an excellent course. I have learned more today than in 16 years of training. I

will try and constitute this management in my unit.”

One of the best study days I have attended. Qualified in 1977! (2014)

I found the course extremely interesting, motivating and empowering … I now feel far

more confident in my knowledge of physiology, therefore more confident in my

int

erpretation. (2014)Impact of Training: Pre- and Post-Tests

Eight hundred and ten midwives and obstetricians underwent 10 questions on NICE

guidelines, type of intrapartum hypoxia, fetal response to stress as well as decision

making (e.g. performing fetal blood sampling or operative interventions) before the

commencement of the CTG masterclass (the ‘Pre-Test’). They answered the same

questions after 8 hours of intense, physiology-based CTG training (the ‘Post-Test’).

Figure 32.4 shows significant improvement in the knowledge of NICE guidelines,

understanding of the types of hypoxia, fetal response as well as on decision making.

This illustrates the positive impact of physiology-based CTG training on improving

knowledge and decision making among midwives and obstetricians.

Figure 32.4 Pre- and post-test results of 810 delegates. Note the significant improvement

in

all parameters tested after training.

Key Challenges to Multiprofessional Training

in Physiology-Based CTG Interpretation

Many reports and national bodies have recommended that improvements to training

would lead to improvements in safety and outcomes.1–4 However, despite these

recommendations, investment in external CPD (continuous professional development)

courses appears to be insufficient. A recent survey was completed by delegates that

attended Baby Lifeline’s training in the first half of 2014; it showed that 59 per cent of

delegates had to self-fund the cost of attending courses, including travel andaccommodation, or were given a fully funded or part-funded place by Baby Lifeline

(Figure 32.5). An additional 5 per cent of delegates conveyed that places were paid for

by Royal Colleges or unions (‘other’). Just 38 per cent of delegates reported that they

were supported by their organization to attend the training, 2 per cent of which were

legal professionals.

These findings support a report published by The King’s Fund in 2008, which

investigated healthcare professionals’ views about safety in maternity services. In the

short questionnaire, clinicians reported a ‘general feeling that there are insufficient

funds for CPD’,5 with many of the direct quotes communicating a great degree of

familiarity:

Midwives should have paid time away from their work environment to reflect on practice

and learn from difficult situations. They should not be expected to study in their annual

le

ave and to pay for this study time. (Midwife/independent midwife, 3–10 years’

experience)

(p.15)

Figure 32.5 A graph to show how delegates self-reportedly paid for Baby Lifeline studyday places in the first half of 2014. The graph shows the percentage of responses for each

answer.

In order to alleviate some of the financial pressures on both self-funding delegates

and financially crippled NHS organizations, Baby Lifeline gained support from

sympathetic law firms, leading training equipment manufacturers and voluntary expert

faculty; this enabled Baby Lifeline to offer study-days at subsidized rates to all

delegates, which is in fact 75 per cent less than the course fee of some professionalbodies that conduct CTG courses in the United Kingdom. Despite low costs for training

and some fully funded places, delegate attendance was lower than anticipated in 2014.

CTG masterclasses with delegate numbers as low as 18 were delivered in some regions

of the United Kingdom. This is likely to reflect the staffing pressures experienced by

many maternity units and the inability of staff to get time off to attend training.

Patterns in the structural differences of Baby Lifeline’s CTG courses (1 day and 2

days) may also reflect an adjusted culture due to underresourced maternity units and,

consequently, limited study leave. From 2011 to 2012, 80 per cent of CTG

masterclasses staged by Baby Lifeline were the 2-day masterclasses; however, this fell

to 17 per cent from 2013 to 2015.

Another key challenge for physiology-based CTG training is the current guideline

on CTG interpretation which has been published by the National Institute of Health and

Care Excellence (NICE), is based on pattern recognition. It is quite alarming that even 5

years after the publication of NICE guidelines on CTG interpretation in 2007,6 <50 per

cent of delegates answered questions on NICE guidelines correctly (Figure 32.4). This

illustrates the flaws of using ‘pattern recognition’ as it causes confusion among

midwives and obstetricians and leads to errors in the classification of CTG traces.

The most recent updated version of this guideline (December 2014) not only had

used even more confusing terminology, very unfortunately, several of its

recommendations were not based on robust scientific evidence but on the personal

clinical experience of three obstetricians on the Guideline Development Group.7 This is

likely to create confusion and worsen outcomes for women and their babies in the future.

In fact, a National Survey of Labour Ward Lead Obstetricians in the United Kingdom,

which was presented at the National Labour Ward Leads’ Meeting in March 2015 at the

Royal College of Obstetricians and Gynaecologists, confirmed that more than half of the

consultant obstetricians (labour ward leads) surveyed felt that the updated NICE

guidelines on CTG interpretation would worsen communication in the labour ward,

increase operative interventions and also may increase the incidence of hypoxicischaemic encephalopathy. Therefore, clinicians should be cautious in implementing

non–evidence-based guidelines on CTG interpretation, if it is felt that they may in fact

worsen perinatal outcomes and make communication in the labour ward difficult.Instead, a physiology-based CTG interpretation may help improve neonatal outcomes

while avoiding unnecessary operative interventions.8,9

Conclusion

Baby Lifeline has conducted a total of 42 physiology-based CTG study-days since 2005

in 27 different centres, and over 1,840 multiprofessional delegates (79 per cent

midwives, 16 per cent obstetricians, 5 per cent legal professionals) have attended these

‘CTG masterclasses’ so far. However, despite these courses being subsidized, funding

by cash-strapped NHS maternity units and staffing issues pose a major challenge.

However, it has been clearly shown that the use of ‘physiology-based CTG training’,

mandatory competency and a test of central organ oxygenation (fetal ECG or STAN)

reduces intrapartum emergency caesarean sections and rates of hypoxic-ischaemic

encephalopathy.8,9 Therefore, continued investment in physiology-based CTG

interpretation is essential to avoid hypoxic-ischaemic brain injury and its sequelae as

well as unnecessary intrapartum operative interventions.

References

1. Maternal and Child Health Research Consortium. (1997). Confidential Enquiry into

Stillbirths and Deaths in Infancy: 4th Annual Report. London: Maternal and Child Health

Research Consortium.

2. NHS Litigation Authority. (2012). Ten Years of Maternity Claims: An Analysis of NHS

Litigation Authority Data. London: NHS Litigation Authority.

3. Royal College of Gynaecologists. (1999). Towards Safer Childbirth: Minimum Standards

for the Organisation of Labour Wards. London: RCOG Press.

4. Royal College of Obstetricians and Gynaecologists (2007). Safer Childbirth: Minimum

Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press.

5. Smith, A., Dixon, A. (2008). Health care professionals’ views about safety in maternity

services. The King’s Fund.6. Intrapartum care: care of healthy women and their babies during childbirth. NICE

guideline number 55. 2007.

7. Intrapartum care: care of healthy women and their babies during childbirth. NICE

guideline number CG 190. December 2014.

8. 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.

9. 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.