Monitoring babies during labour: what are the issues for pregnant women and their health professionals? A study day report

AIMS Journal, 2017, Vol 29 No 3

Jo Dagustun reports on the INFANT trial study day in October 2017

This national (central Birmingham based) free-to-attend study day on the 17th October 2017 was organised by the NCT. I wasn’t sure what to expect, but I was keen to go along and listen (and to catch up with fellow birth activists). I know from my own doctoral research that this is a really important topic in the context of women’s accounts of their maternity-service experiences and that it also plays a key role in debates about service improvement.

A key focus of the morning was a briefing on the INFANT trial ¹, a study that the NCT had collaborated on (a review of the trial is available in this journal). Commencing the day’s presentations, the lead academic on the project, Professor Peter Brocklehurst (University of Birmingham), presented the background to this research, its key findings, the team’s conclusions and an interesting perspective on the politics of publication (all a little too quickly for me, I will admit, but Peter’s presentation was certainly engaging and his main points clear enough). The burning research question, in particular, was clearly communicated: does CEFM (Continuous Electronic Fetal heart rate Monitoring) have the potential to improve outcomes if traces are interpreted more accurately and consistently, and if more effective action is taken based on those interpretations (or, in other words, if human error is significantly reduced). The hope was that complementary technology might help to better identify which babies might benefit from an early c-section as well as reduce intervention where CEFM interpretation has previously been over-cautious. Key to Peter’s presentation was the finding that the ‘…use of computerised interpretation of cardiotocographs in women who have continuous electronic fetal monitoring (CEFM) in labour does not improve clinical outcomes for mothers or babies’. As such, the results of the INFANT trial laid the ground for one of Peter’s key challenges: perhaps it is our belief in the power of the technology of CEFM (which is, at its core, simply a sophisticated machine to measure pulse) that is deficient, and perhaps therefore we need, as a community of researchers, practitioners and service-users, to be far more creative in how we seek to reduce adverse maternity outcomes. It was also suggested that we still know very little about whether changes in pulse in labour (as measured by CEFM) represent impending or existing damage: this is surely key to how we approach service development in this area.

A wide variety of speakers had been invited to talk after Peter’s keynote presentation. First up was Rhona Hughes (NHS Lothian), representing the NICE guideline development team tasked with taking such research into account in updating the relevant guidance. It was interesting to hear Rhona discuss the process of drafting guidelines on the usage of CEFM, reflecting the scientific evidence at the same time as seeking to respect the principle of choice: to what extent should birthing women’s choices be facilitated when these choices are not supported by the evidence on what makes for effective care? Rhona also discussed the technique of fetal scalp stimulation ², which is now recommended as an interim step before fetal blood is taken from the scalp in certain circumstances. Next we heard from Louise Robertson (RCOG), who focussed on the need to improve teamwork and situational awareness in emergency obstetric situations, as identified in the Each Baby Counts initiative. The last of the morning’s speakers was Milli Hill (Positive Birth Movement), who offered an important service-user informed perspective on the role of monitoring in labour. Milli highlighted, for example, how women’s experiences of monitoring in labour were so often associated with major restrictions on their mobilisation and choice of positions, whilst the seemingly mythical technology of telemetry – which could presumably lessen this impact - lurked in the shadows of women’s accounts.

In the afternoon, there were further presentations (from an antenatal teacher, obstetrician, midwife and neonatologist), each shifting the focus to practice implications. During this session, the issue of labour ward understaffing was highlighted, and it was claimed - rather worryingly given their key responsibility for safety - that the vast majority of labour ward co-ordinators were not allocated specific times to carry out their role. From an AIMS perspective, I would hope that this staffing issue will be scrutinised carefully by the CQC during provider inspections going forward. There was also an interesting, but inconclusive, discussion about the role of specialist monitoring midwives, and a call for the improvement of intermittent monitoring skills.

But the day was so much more than a series of presentations. For the last session of the day, all participants were invited to contribute to the proceedings, with each table discussing a series of questions related to the topic of the day. For me, this was perhaps the most fascinating part of the day, as the tables of obstetricians, midwives, service-users and others started to talk, with participants often coming from very different perspectives on any given issue. I was particularly pleased to witness the robust discussions going on around me, not least to try and shift the discussion away from work designed to simply improve our utilisation of existing electronic foetal monitoring techniques to many broader questions, including the wider impact of CEFM on the social practice of birth.

So was it worth travelling from Manchester to Birmingham to attend this event? For me it certainly was, and I would recommend that all AIMS activists look out for similar events to attend. (Birth activists, just as much as practitioners, benefit from continuous professional development opportunities!) For me, the main benefit of the day was the way the organisers had thoughtfully created an important discursive space in which service-user representatives, academic researchers and healthcare professionals could come together to start to explore the many issues surrounding foetal monitoring for women, babies and families. Although I came away from the day convinced that EFM was perhaps even more of a problem than I had previously thought, I was also inspired by the meeting. In particular, I felt that it was a really good example of researchers engaging well with service-users, in the presence of healthcare professionals, in a respectful way. Breaking down barriers between academic researcher, practitioners and service-users can only be a good thing, for therein lies a future in which the research agenda is truly informed by the research priorities of women. Many thanks to the NCT for organising the day, and - via the very experienced birth activist Mary Newburn - for providing a thought-provoking last word: in 2017, a maternity service that assigns labouring women to a bed for lengthy periods, because of the constraints of outdated CEFM technology, is simply not good enough.

References

1) The INFANT trial http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30568-8/abstract

2) Fetal Scalp Stimulation https://medical-dictionary.thefreedictionary.com/fetal+scalp+stimulation