Evaluation of a fetal monitoring education program

Impact of an e-learning training for interpreting intrapartum fetal heart rate monitoring to avoid perinatal asphyxia: A before-after multicenter observational study

INTRODUCTION

Perinatal asphyxia, a condition that results from compromised placental or pulmonary gas exchange during the birth process, is rare but can lead to serious neonatal and long-term consequences. The visual analysis of cardiotocography (CTG) is designed to avoid perinatal asphyxia, but its interpretation can be difficult. Our aim was to test the impact of an e-learning training program for interpreting CTG on the rate of avoidable perinatal asphyxia at term.

METHOD

We conducted a retrospective multicenter before-after study comparing two periods, before and after the implementation of e-learning training program from July 1, 2016 to December 31, 2016, in CTG interpretation for midwives and obstetricians in five maternity hospitals in the Paris area, France. The training involved theoretical aspects such as fetal physiology and heart rhythm abnormalities, followed by practical exercises using real case studies to enhance skills in interpreting CTG. We included all term births that occurred between the "before" period (July 1 to December 31, 2014) and the "after period (January 1 to June 30, 2017). We excluded multiple pregnancies, antenatal detection of congenital abnormalities, breech births and all scheduled caesarean sections. Perinatal asphyxia cases were analyzed by a pair of experts consisting of midwives and obstetricians, and avoidability of perinatal asphyxia was estimated. The main criterion was the prevalence of avoidable perinatal asphyxia.

RESULTS

The e-learning program was performed by 83 % of the obstetrician-gynecologists and 65 % of the midwives working in the delivery rooms of the five centers. The prevalence of perinatal asphyxia was 0.45 % (29/7902 births) before the training and 0.54 % (35/7722) after. The rate of perinatal asphyxia rated as avoidable was 0.30 % of live births before the training and 0.28 % after (p = 0.870). The main causes of perinatal asphyxia deemed avoidable were delay in reactions to severe CTG anomalies and errors in the analysis and interpretation of the CTG. These causes did not differ between the two periods.

CONCLUSION

One session of e-learning training to analyze CTG was not associated with a reduction in avoidable perinatal asphyxia. Other types of e-learning, repeated and implemented over a longer period should be evaluated.

Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis

Background

Sub‐optimal classification, interpretation and response to intrapartum electronic fetal monitoring using cardiotocography are known problems. Training is often recommended as a solution, but there is lack of clarity about the effects of training and which type of training works best.

Objectives

Systematic review of the effects of training healthcare professionals in intrapartum cardiotocography (PROSPERO protocol: CRD42017064525).

Search strategy

CENTRAL, Cochrane Library, MEDLINE, EMBASE, PsycINFO, British Nursing Database, CINAHL, ERIC, Scopus, Web of Science, ProQuest, grey literature and ongoing clinical trials were searched.

Selection criteria

Primary studies that reported impact of training healthcare professionals in intrapartum cardiotocography. Title/abstract, full‐text screening and quality assessment were conducted in duplicate.

Data collection and analysis

Data were synthesised both narratively and using meta‐analysis. Risk of bias and overall quality were assessed with the Mixed Methods Appraisal Tool and GRADE.

Main results

Sixty‐four studies were included. Overall, training and reporting were heterogeneous, the outcomes evaluated varied widely and study quality was low. Five randomised controlled trials reported that training improved knowledge of maternity professionals compared with no training, but evidence was of low quality. Evidence for the impact of cardiotocography training on neonatal and maternal outcomes was limited, showed inconsistent effects, and was of low overall quality. Evidence for the optimal content and method of delivery of training was very limited.

Conclusions

Given the scale of harm and litigation claims associated with electronic fetal monitoring, the evidence‐base for training requires improvement. It should address intervention design, evaluation of clinical outcomes and system‐wide contexts of sub‐optimal practice.

Tweetable abstract

Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.

Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.

Formal training in cardiotocograph interpretation of healthcare practitioners improves interpretation: A prospective descriptive analytical study in a resource constrained setting

OBJECTIVE

To evaluate the effect of structured training on the cardiotocograph (CTG) interpretation skills of healthcare workers (HCWs) involved in obstetric care in a recourse constrained setting.

METHOD

In all, 218 HCWs completed pre- and post-intervention questionnaires. The intervention involved structured teaching on technical aspects of CTG monitoring, fetal physiology, and adaptation to stress, and a holistic approach to interpretation. Descriptive statistics were used to summarize demographic characteristics, frequencies, and percentages for categorical data.

RESULTS

Only 26.2% of participants felt that their pre-graduate training was adequate; this was reflected by the poor baseline knowledge in CTG interpretation (56% misinterpreted) and lack of knowledge regarding technical aspects of CTG monitoring in 48.8% of participants. The training session led to a 65% improvement in technical aspects and interpretation. Those HCWs not receiving continuous training showed a more significant improvement (P  < 0.001) and there was a 100% improvement in knowledge regarding the required documentation before commencing monitoring. Most (99.5%) HCWs acknowledged an improvement in knowledge, and 96.2% would participate in similar mandatory education sessions.

CONCLUSION

These findings highlight the fact that training in CTG monitoring is warranted and desired by HCWs. It also supports the implementation of structured CTG education in resource-constrained settings.

The effect of electronic fetal monitoring (EFM) education program on EFM interpretation skills

Purpose: The aim of this study is to train midwifery students on electronic fetal monitoring (EFM) within the scope of the course and then to evaluate their pre- and post-course EFM knowledge and EFM interpreting skills.Methods: This interventional study was carried out at the Department of Midwifery, Faculty of Health Sciences. The study population comprised of the senior (last-year, 4th-year) students who attended the Midwifery Department of the Faculty of Health Sciences during the academic years 2015-2016 and 2016-2017. Of the 4th year students in the midwifery department, 42 who attended the school during the academic year 2015-16 and 61 who attended the school during the academic year 2016-2017 and accepted to participate in the study comprised the study sample.Results: The difference between the pre- and post-EFM course scores was statistically significant (p<.05). While the mean score obtained by the students before the EFM course was 55.29 ± 11.17, it was 76.15 ± 6.72 after the EFM course. Analysis of the success rates of the midwifery students in the EFM/NST course demonstrated that 80.6% of the students were successful.Conclusions: The findings of the study demonstrated that the participants' postcourse EFM knowledge and trace interpretation skills were better than their precourse EFM knowledge and trace interpretation skills.

A randomised-controlled trial evaluating a fetal monitoring education programme

OBJECTIVE

to evaluate the effectiveness of a fetal monitoring education programme on midwives' fetal monitoring knowledge and intrapartum cardiotocograph interpretation skills.

DESIGN

two group, before-after, randomised-controlled trial.

SETTING

two maternity hospitals in the Republic of Ireland.

PARTICIPANTS

55 midwives were randomly assigned to either the experimental group (n=27) or the control group (n=28).

INTERVENTIONS

the experimental group participated in a 1.5 hr fetal monitoring education programme, whereas the control group attended an alternative education programme consisting of a non-fetal-monitoring-related video presentation.

MEASUREMENTS

the primary outcomes of interest were fetal monitoring knowledge and intrapartum cardiotocograph interpretation skills test.

FINDINGS

in the fetal monitoring knowledge post-test, the median percentage correct responses for the control and experimental groups were 56% (IQR 18.75) and 88% (IQR 12.5), respectively. This difference, 31.2%, was statistically significant (U=78.5, 95.1% CI -31.25 to -18.75, p<0.001). In the intrapartum cardiotocograph interpretation skills post-test, the median percentage correct responses for the control and experimental groups were 55.6% (IQR 16.7) and 66.7% (IQR 22.2), respectively. This difference, of 11.1%, was statistically significant (U=186, 95.2% CI -16.67 to -5.56, p<0.001).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

attendance at a short (1.5 hr), in-service fetal monitoring education programme can increase midwives' fetal monitoring knowledge and cardiotocograph interpretation skills. The availability of in-service fetal monitoring education programmes is sporadic, often less than recommended, and is a cause for concern.

Midwives' visual interpretation of intrapartum cardiotocographs: intra- and inter-observer agreement

AIM

This paper reports an examination of intra- and inter-observer agreement in midwives' visual interpretation of intrapartum cardiotocographs (CTGs).

BACKGROUND

The issue of intra- and inter-observer agreement in the interpretation of CTG interpretation has serious implications for the validity of electronic fetal heart rate monitoring and subsequent decisions on intrapartum management. However, no studies were found that assessed intra- and inter-observer agreement in midwives' interpretations of CTG tracings.

METHODS

Twenty-eight midwives independently interpreted three intrapartum CTG tracings on two separate occasions using a self-administered Cardiotocograph Interpretation Skills Test. Inter-rater agreement in interpretation was assessed by cross-tabulating the two sets of raw data obtained at time 1 and time 2 and computing Cohen's Kappa (kappa). Intra-rater agreement was assessed by computing kappa for each rater with the two sets of raw data (time 1 and time 2) obtained from each individual. The data were collected in 2000.

RESULTS

Overall intra-rater agreement ranged from 'fair to good' (kappa = 0.48) to 'excellent' (kappa = 0.92). Raters' classifications altered in 18% (n = 5) of cases for the normal tracing, in 29% (n = 8) for the suspicious tracing and in 11% (n = 3) for the pathological tracing. Inter-rater agreement was fair to good, with kappa statistics ranging from 0.65 to 0.74, respectively. Agreement was highest in the classification of decelerations (kappa = 0.79) and lowest in the assessment of baseline variability (kappa = 0.50). Overall inter-rater agreement was highest in the suspicious tracing (kappa = 0.77, excellent) and lowest in the normal tracing (kappa = 0.54, fair to good).

CONCLUSION

Inter- and intra-observer variability are intrinsic characteristics of the interpretation of intrapartum CTGs. Levels of agreement revealed degrees of variation that expose room for improvement. Efforts are needed to reduce inter- and intra-observer variation in interpretation of intrapartum CTG tracings. In addition, research should focus on the development and evaluation of non-invasive, low observer variability methods of intrapartum assessment of fetal well-being. The subjectivity of CTG interpretation and inconsistencies in interpretation should also be considered in intrapartum management, clinical audit and in medico-legal settings.

Interobserver agreements in assessing 549 labor admission tests after a standardized training program

BACKGROUND

The labor admission test is a short cardiotocography (CTG) performed upon admission to the maternity ward. The aim of the present study is to examine interobserver agreements when the labor admission tests were assessed by midwives and obstetricians who had received training in interpreting CTG.

METHODS

Five hundred forty-nine high- and low-risk women who delivered at Hammer-fest Hospital were included. The tests were assessed by three midwives and three obstetricians who had completed a standardized training program. The traces were assessed as normal, intermediary, or abnormal. Weighted kappa (kappaw), proportion of agreement (Pa), and predictive values were calculated.

RESULTS

Between the pairs of observers, kappaw varied between 0.57 and 0.75; Pa for a normal test between 0.78 and 0.88, and Pa for an intermediary/abnormal test between 0.56 and 0.69. At a cutoff intermediary test, mean sensitivity was 0.43 (range=0.39 -- 0.48), specificity 0.75 (range=0.69 - 0.81, positive predictive value 0.13 (range=0.12 -- 0.15), negative predictive value 0.94 (range=0.94 -- 0.94), likelihood ratio (LR) for a positive test result 1.73 (range=1.53--1.99), and LR for a negative test result 0.76 (range=0.75--0.77).

CONCLUSIONS

Midwives and obstetricians who had completed the training program achieved good levels of agreements in assessing labor admission tests. The agreements in normal tests were better than those in intermediary/abnormal tests. Obstetric staff should be aware that there are disagreements in assessing labor admission tests; especially in tests assessed as intermediary/abnormal.

History and development of fetal heart assessment: a composite

Methods of assessing the fetal heart remained unchanged for approximately 150 years until the first commercial monitor suitable for clinical practice was sold in 1968. The impact and events of the last 30 to 40 years surrounding fetal heart assessment are revealed in perspectives of the past, present, and near future. Assessment practices have been shaped by the development of biotechnology, unrealistic expectations, interpretation disagreement, consumer response, and the practice and educational resources written by nursing and medicine.

Teaching nursing students to critically evaluate electronic fetal monitor tracings

Evaluation of electronic fetal monitor (EFM) tracings is challenging for nursing students and novice perinatal nurses. Use of a standardized nursing process tool facilitates recognition of electronic fetal monitoring patterns and application of appropriate nursing interventions. Feedback from expert nurses and nursing instructors validates students' critical thinking skills.

The art of midwifery: lost to technology?

This paper looks at how the art of midwifery is affected by the increasing availability and use of sophisticated technology. The use of the cardiotocograph is an example of how overuse of such technology can have detrimental affects, not only for the midwife but also for the woman in labour. While this technology has made a great impact in obstetric nursing, the effects on the low-risk pregnancy need to be evaluated. Midwives need to be research-based in their clinical practice and question the overuse of technology, such as the cardiotocograph, in cases where it is not warranted.