Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-030271 on 28 June 2019. Downloaded from IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth (the IMMO programme): protocol for a qualitative study Guillaume Lamé, 1 Elisa Liberati,1 Jenni Burt,1 Tim Draycott,2,3 Cathy Winter,2,3 James Ward,4 Mary Dixon-Woods1 To cite: Lamé G, Liberati E, ABSTRACT Strengths and limitations of this study Burt J, et al. IMproving Introduction Suboptimal electronic fetal heart rate the practice of intrapartum monitoring (EFM) in labour using cardiotocography (CTG) ► A multidisciplinary team of obstetricians, social sci- electronic fetal heart has been identified as one of the most common causes rate MOnitoring with entists, midwives and engineers will collaborate to of avoidable harm in maternity care. Training staff is a cardiotocography for characterise the technical and social mechanisms frequently proposed solution to reduce harm. However, safer childbirth (the IMMO that may affect the safety of electronic fetal heart current approaches to training are heterogeneous in content programme): protocol for a rate monitoring (EFM) in labour. qualitative study. and format, making it difficult to assess effectiveness. BMJ Open ► The study combines the strengths of ethnographic Technological solutions, such as digital decision support, 2019;9:e030271. doi:10.1136/ research and engineering approaches to systems bmjopen-2019-030271 have not yet demonstrated improved outcomes. Effective analysis and risk assessment. improvement strategies require in-depth understanding ► Prepublication history for ► This project will generate a detailed characterisation of the technical and social mechanisms underpinning the this paper is available online. of the errors, hazards and failure modes in intrapar- EFM process. The aim of this study is to advance current To view these files please visit tum EFM and will help to inform the development of knowledge of the types of errors, hazards and failure modes the journal online (http:// dx. doi. an intervention that will directly target the reasons in the process of classifying, interpreting and responding org/ 10. 1136/ bmjopen- 2019- for problems in interpretation and response to car- 030271). to CTG traces. This study is part of a broader research http://bmjopen.bmj.com/ diotocography traces. programme aimed at developing and testing an intervention ► Three maternity units across the UK will be selected; Received 6 March 2019 to improve intrapartum EFM. the generalisability of the findings will require care- Revised 22 May 2019 Methods and analysis The study is organised into two Accepted 10 June 2019 ful assessment. workstreams. First, we will conduct observations and interviews in three UK maternity units to gain an in-depth understanding of how intrapartum EFM is performed in from sub-optimal fetal heart rate monitoring, routine clinical practice. Data analysis will combine the insights of an ethnographic approach (focused on the social particularly electronic fetal heart rate moni- © Author(s) (or their toring (EFM) using cardiotocography (CTG) on September 27, 2021 by guest. Protected copyright. norms and interactions, values and meanings that appear to 3 employer(s)) 2019. Re-use be linked with the process of EFM) with a systems thinking in labour. Effective interventions to improve permitted under CC BY. approach (focused on modelling processes, actors and their the practice of EFM have remained elusive, Published by BMJ. perhaps in part because of a lack of sound 1 interactions). Second, we will use risk analysis techniques The Healthcare Improvement to develop a framework of the errors, hazards and failure understanding of its range of influences on Studies Institute (THIS Institute), modes that affect intrapartum EFM. University of Cambridge, safety. We aim to generate a comprehensive Cambridge, UK Ethics and dissemination This study has been approved characterisation of the technical and social 2School of Social and by the West Midlands—South Birmingham Research Ethics mechanisms that may affect the safety of Community Medicine, University Committee, reference number: 18/WM/0292. Dissemination EFM in labour with the goal of informing the will take the form of academic articles in peer-reviewed of Bristol, Bristol, UK development of a targeted intervention for 3Women and Children’s Health, journals and conferences, along with tailored communication North Bristol NHS Trust, with various stakeholders in maternity care. improvement. Westbury on Trym, UK 4Engineering Design Centre, Fetal monitoring in labour University of Cambridge, INTRODUCTION Two principal methods can be used to Cambridge, UK Preventable harm related to childbirth can monitor the fetal heart rate in labour: inter- be catastrophic for women, children and mittent auscultation and EFM with CTG. Correspondence to 1 Guillaume Lamé; families, as well as causing high costs for National Institute for Health and Care 2 guillaume. lame@ thisinstitute. health systems. One important source of Excellence (NICE) guidelines recommend cam. ac. uk preventable harm in maternity care arises offering intermittent auscultation to women Lamé G, et al. BMJ Open 2019;9:e030271. doi:10.1136/bmjopen-2019-030271 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-030271 on 28 June 2019. Downloaded from at low risk of complication during labour4; EFM is the should be trained in both the review system and the esca- recommended option in the presence of certain signs lation protocol,12 with mandatory yearly training and or conditions specified in the guidelines (such as fresh competency assessment. Implementation of this bundle vaginal bleeding, hypertension or high temperature or is measured as the percentage of staff who have received when oxytocin is used).4 Our study focuses on the use of training in fetal monitoring; the percentage deemed CTG, where the baby’s heart rate is monitored through competent in fetal monitoring and the percentage whom a Doppler ultrasound transducer and the woman’s have successfully completed mandatory annual updates. contractions are monitored through a uterine pressure It is clearly important that such training be supported transducer. Both signals are monitored continuously and by high quality evidence. A 2011 systematic review recorded and/or printed as a CTG trace.5 These traces concluded that training for CTG interpretation in labour are then used to detect fetal heart rate abnormalities and can lead to improvements in individuals’ interpretation trigger appropriate action. skills, interobserver agreement and management of intrapartum CTGs.13 However, the training interventions Interpretation included in the systematic review were highly heteroge- Interpretation and response to intrapartum CTG traces neous in format and content (including e-learning, case involve a series of complex sociotechnical processes with reviews, monthly audit with feedback, voluntary review many potential points of failure. Interpretation of CTG sessions and clinical supervision through tele-didactics), traces requires healthcare professionals to consider the making it difficult to draw definitive conclusions on what classification of the trace in the context of the clinical features and mechanisms of the training were linked with circumstances of the mother, the fetus and the status of practice improvement. The authors of the systematic labour, in order to formulate a response and take action. review also noted that the generally poor quality of the The initial classification involves review of four features reviewed studies warrants caution with the findings.13 on the CTG trace: the baseline heart rate, baseline vari- Perhaps because so little evidence exists, training ability, the presence of accelerations and the presence or programmes are not standardised14 and where absence of decelerations, as well as characteristics of vari- programmes are implemented there are difficulties able decelerations if present. NICE guidelines provide in demonstrating positive impacts. For example, in criteria to classify each feature as ‘reassuring’, ‘non-reas- Denmark, all midwives and physicians in maternity suring’ or ‘abnormal’.4 The trace itself is then classified units were required to take part in a CTG education in one of four ways: (1) ‘normal’ (all features are reas- programme consisting of e-learning, a 1-day course suring), (2) ‘suspicious’ (one non-reassuring feature and and a final written assessment.15 The evaluation of this all other features are reassuring), (3) ‘pathological’ (one programme suggested that it did not decrease the risk 16 abnormal feature or two or more non-reassuring features) of birth hypoxia. A national intervention in Sweden http://bmjopen.bmj.com/ or (4) ‘need for urgent intervention’ (acute bradycardia yielded similar results.17 18 or a single prolonged deceleration for 3 min or more). One challenge in moving the field forward is that In determining responses to non-normal traces, NICE most of the effort so far is based on the assumption that guidelines provide management indications to be consid- improvement requires targeting deficits in individuals’ ered in context with the clinical circumstances. The knowledge.19 20 Improving each staff member’s knowl- guidelines also recommend documenting any maternal edge and skill is clearly important, but insufficient atten- or fetal risk factors, the woman’s and the unborn baby’s tion has