Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis

Intrapartum fetal monitoring practices in Norway: A population-based study

OBJECTIVE

To describe intrapartum fetal monitoring methods used in all births in Norway in 2019-2020, assess adherence to national guidelines, investigate variation by women's risk status, and explore associations influencing monitoring practices.

METHODS

A nationwide population-based study. We collected data about all pregnancies with a gestational age ≥ 22 weeks during 2019-2020 from the Medical Birth Registry of Norway. We used descriptive analyses, stratified for risk status, to examine fetal monitoring methods used in all deliveries. Univariable and multivariable logistic regression models were used to determine factors associated with monitoring with cardiotocography (CTG) in low-risk, straightforward births.

RESULTS

In total, 14 285 (14%) deliveries were monitored with only intermittent auscultation (IA), 46214 (46%) with only CTG, and 33417 (34%) with IA and CTG combined. Four percent (2 067/50 533) of women with risk factors were monitored with IA only. Half (10589/21 282) of the low-risk women with straightforward births were monitored with CTG. Maternal and fetal characteristics, size of the birth unit and regional practices influenced use of CTG monitoring in this group.

CONCLUSIONS

Most births are monitored with CTG only, or combined with IA. Half the women with low-risk pregnancies and straightforward births were monitored with CTG although national guidelines recommending IA.

Midwives' attitudes toward the use of cardiotocograph (CTG) machines in labor units: A study in Jordan

BACKGROUND

The purpose of cardiotocograph (CTG) usage is to detect any alterations in fetal heart rate (FHR) early before they are prolonged and profound. However, the use of CTG machines on a routine basis is not an evidence-supported practice. There is no Jordanian study that assesses the midwives' attitudes toward this machine. This study aimed to identify Jordanian midwives' attitudes towards the use of cardiotocograph (CTG) machines in labor units, alongside examining the relationships between midwives' personal sociodemographic characteristics and such attitudes.

METHODS

A descriptive research design was used to identify Jordanian midwives' attitudes towards the use of CTG machines in both public and private labor units in Jordan. Data were collected using the valid and reliable tool designed by Sinclair (2001), and these were used to identify midwives' attitudes towards CTG usage. A total of 329 midwives working in the labor units of governmental and private hospitals in the center and north of Jordan participated in the study from May to July 2022.

RESULTS

The total mean score for the attitude scale was M = 3.14 (SD = 0.83). More than half of the sample (N = 187, 58.4 %) demonstrated a mean score greater than 3.14, however, which indicates generally positive attitudes toward CTG usage in labor units. Midwives working in private hospitals and those holding Bachelor's degrees had more positive attitudes toward the use of CTG machines.

CONCLUSION

This study provides new insights into the attitudes of Jordanian midwives towards CTG use in labor units. These suggest that it is critical to conduct training courses for registered midwives to help them develop and/or regain confidence and competence with respect to various key aspects of intrapartum care, including intermittent auscultation and the appropriate use of CTG.

Labor management and neonatal outcomes in cardiotocography categories II and III (Review)

The safe care of both mothers and fetuses during labor is a primary goal of all health professionals. The assessment of fetal oxygenation and well-being is a key aspect of perinatal care provided. Fetal heart rate (FHR) auscultation became part of daily obstetric practice in a number of countries during the 20th century and remains a key method of fetal monitoring, particularly in low-risk pregnancies. Cardiotocography (CTG) is the continuous monitoring and recording of the FHR and uterine myometrial activity, making it possible to assess the fetal condition. It therefore plays a critical role in the detection of fetal hypoxia during labor, a condition directly related to short- and long-term complications in the newborn. Herein, particular reference is made to the management of CTG category II and III standards, as well as to the handling of childbirth. In addition, specific FHR patterns are associated with immediate neonatal outcomes based on updated studies conducted worldwide. Finally, the prognostic significance of CTG and its potential as a prospective avenue for further investigation are also highlighted herein. Given that the misinterpretation of CTG findings is the most common cause of medical-legal responsibility, this knowledge field requires more emphasis and attention. The aim of the present review was to further deepen the knowledge on issues that mainly concern the safety and monitoring of pregnant women and fetuses during childbirth.

Changes in mental health services in response to the COVID-19 pandemic in high-income countries: a rapid review

BACKGROUND

Severe deterioration in mental health and disrupted care provision during the COVID-19 increased unmet needs for mental health. This review aimed to identify changes in mental health services for patients in response to the pandemic and understand the impact of the changes on patients and providers.

METHODS

Following the Cochrane guidance for rapid reviews, Cochrane CENTRAL, MEDLINE, Embase and PsycInfo were searched for empirical studies that investigated models of care, services, initiatives or programmes developed/evolved for patients receiving mental health care during COVID-19, published in English and undertaken in high-income countries. Thematic analysis was conducted to describe the changes and an effect direction plot was used to show impact on outcomes.

RESULTS

33 of 6969 records identified were included reporting on patients' experiences (n = 24), care providers' experiences (n = 7) and mixed of both (n = 2). Changes reported included technology-based care delivery, accessibility, flexibility, remote diagnostics and evaluation, privacy, safety and operating hours of service provision. These changes had impacts on: (1) care access; (2) satisfaction with telehealth; (3) comparability of telehealth with face-to-face care; (4) treatment effectiveness; (5) continuity of care; (6) relationships between patients and care providers; (7) remote detection and diagnostics in patients; (8) privacy; (9) treatment length and (10) work-life balance.

CONCLUSIONS

A shift to telecommunication technologies had a significant impact on patients and care providers' experiences of mental health care. Improvements to care access, flexibility, remote forms of care delivery and lengths of operating service hours emerged as crucial changes, which supported accessibility to mental health services, increased attendance and reduced dropouts from care. The relationships between patients and care providers were influenced by service changes and were vastly depending on technological literacy and context of patients and availability and care access ranging from regular contact to a loss of in-person contact. The review also identified an increase in care inequality and a feeling of being disconnected among marginalised groups including homeless people, veterans and ethic minority groups. Telehealth in mental care could be a viable alternative to face-to-face service delivery with effective treatment outcomes. Further research is needed to better understand the impact of the changes identified particularly on underserved populations.

Cardiotocography in practice: a qualitative study to explore obstetrical care professionals' experiences with using cardiotocography information in Dutch practice

OBJECTIVE

This study aimed to explore obstetric care professionals' experiences with using cardiotocograph (CTG) information and how they employ this tool in their practice.

DESIGN

Qualitative study, involving 30 semi-structured interviews and two focus group sessions. Conventional content analysis was used for data analysis.

SETTING

Amsterdam University Medical Centers in the Netherlands.

PARTICIPANTS

In total, 43 care professionals participated. The respondents included obstetricians, residents in obstetrics and gynaecology, junior physicians, clinical midwives and nurses.

FINDINGS

Three main categories were identified that influenced the use of cardiotocography in practice; (1) individual characteristics involving knowledge, experience and personal beliefs; (2) teams involving collaboration in and between shifts and (3) work environment involving equipment, culture and continuing development.

CONCLUSION

This study underlines the importance of teamwork when working with cardiotocography in practice. There is a particular need to create shared responsibility among team members for cardiotocography interpretation and appropriate management, which should be addressed in educational programmes and regular multidisciplinary meetings, to allow learning from colleagues' perspectives.

Can social capital play a role in contracting services of family doctors in China? Reflections based on an integrative review

BACKGROUND

The family doctors' contract service problem is not about government management alone, but an interaction of a complex social environment. Consequently, the effect of contracted services of family doctors not only depends on policy incentives but also needs to win the participation, acknowledgement, and confidence of community residents. The purpose of this integrative review is to examine whether there is any significant evidence that social capital in the form of social networking groups and other forms of social groups have any positive impact on the acceptance and the effectiveness of family doctors' contractual services.

METHOD

Research on qualitative, quantitative and hybrid methods published in peer-reviewed journals on the social capital role in the process of contract service of family doctors were eligible for inclusion. In view of the increasing attention paid to the contract service effect of family doctors during this period, a 10-year time scale was selected to ensure full coverage of relevant literature in the same period. In total, 809 articles were determined in the database retrieval results which were downloaded and transferred to the Mendeley reference application software.

RESULTS

Twelve articles met the inclusion criteria for this integrative review and the quality of the included studies were assessed using the published criteria for the critical appraisal of quantitative and qualitative research methods. Majority of the articles assessed reported that there was evidence of a positive link between social support, especially a sense of belonging and the presence of regular family doctors. The influencing factors of patients' contract behavior of studies conducted in China were social interaction of social capital, acceptance of the first contact in the community, year of investigation, and exposure to the public.

CONCLUSION

The study affirms previous studies that suggest that social resources have the propensity to improve relationship between patients and clients and between doctors and peers for the benefit of the patients and the stability of the overall healthcare system. Through the integration of various social resources family doctor systems accelerate the development of community construction. These social capital (social network groups) can guide residents to use family doctor services to maintain health. Social capital can also help residents have a regular and reliable family doctor.

Shared decision-making and maternity care in the deep learning age: Acknowledging and overcoming inherited defeaters

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision-making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub-kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI-enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision-making.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice

BACKGROUND

The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring.

AIM

To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring.

METHODS

Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed.

FINDINGS

Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible.

DISCUSSION AND CONCLUSION

Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.

Perceptions and Opinions of Patients About Mental Health Chatbots: Scoping Review

BACKGROUND

Chatbots have been used in the last decade to improve access to mental health care services. Perceptions and opinions of patients influence the adoption of chatbots for health care. Many studies have been conducted to assess the perceptions and opinions of patients about mental health chatbots. To the best of our knowledge, there has been no review of the evidence surrounding perceptions and opinions of patients about mental health chatbots.

OBJECTIVE

This study aims to conduct a scoping review of the perceptions and opinions of patients about chatbots for mental health.

METHODS

The scoping review was carried out in line with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews guidelines. Studies were identified by searching 8 electronic databases (eg, MEDLINE and Embase) in addition to conducting backward and forward reference list checking of the included studies and relevant reviews. In total, 2 reviewers independently selected studies and extracted data from the included studies. Data were synthesized using thematic analysis.

RESULTS

Of 1072 citations retrieved, 37 unique studies were included in the review. The thematic analysis generated 10 themes from the findings of the studies: usefulness, ease of use, responsiveness, understandability, acceptability, attractiveness, trustworthiness, enjoyability, content, and comparisons.

CONCLUSIONS

The results demonstrated overall positive perceptions and opinions of patients about chatbots for mental health. Important issues to be addressed in the future are the linguistic capabilities of the chatbots: they have to be able to deal adequately with unexpected user input, provide high-quality responses, and have to show high variability in responses. To be useful for clinical practice, we have to find ways to harmonize chatbot content with individual treatment recommendations, that is, a personalization of chatbot conversations is required.

[Normal childbirth: Physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Initial assessment on admission and fetal monitoring during labor]

OBJECTIVES

The purpose of this literature's review is to provide recommendations for measures to assess fetal "well-being" at admission and during labor in order to identify a non-reassuring fetal condition.

METHODS

Consultation of the Medline database, and of national and international guidelines.

RESULTS

Two fetal heart rate monitoring techniques are available at admission and during labor. In comparison with intermittent auscultation (AI), continuous cardiotocography (CTG) monitoring was associated, in a meta-analysis involving 13 trials including more than 37,000 women, with a reduction in RR neonatal seizures by half. Relative risk (RR)=0.50 with a 95% CI [0.31-0.80] without significant difference objectified with respect to cerebral palsy RR=1.75 95% CI [0.84-3.63]. In contrast, a significant increase in cesarean sections was associated with continuous CTG RR=1.63 95% CI [1.29-2.07] and women were also at greater risk for operative vaginal delivery RR=1.15 95% CI [1.01-1.33]. Current results are insufficient to demonstrate the actual impact of surveillance methods (continuous or discontinuous) on the overall perinatal mortality rate. Larger randomized trials remain to be conducted.

CONCLUSION

The systematic search for the confirmation of the reassuring character of the fetal state at admission and during labor makes it possible to identify intrapartum hypoxic events.

Breastfeeding experiences and support for women who are overweight or obese: A mixed-methods systematic review

Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence-based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Clinical Validation of Mobile Cardiotocograph Device for Intrapartum and Antepartum Monitoring Compared to Standard Cardiotocograph: An Inter-Rater Agreement Study

Objective: Electronic fetal monitoring (EFM) using cardiotocograph (CTG) is commonly used both to assess fetal wellbeing in late antepartum and for intervention during intrapartum period. We validated the performance of indigenously developed mobile cardiotocograph (CTG) device with wireless probes compared to standard CTG device. Materials and methods: We sequentially used mobile and standard CTG devices in 495 pregnant women in labour and 359 pregnant women with gestation > 32 weeks. The CTG interpreted by two independent obstetricians in a blinded manner were compared to estimate the agreement by kappa (k) statistic. Results: High level of agreements between mobile and standard CTG devices for both intrapartum (87.9%; kappa 0.61) and antepartum monitoring (91.2%; kappa 0.60) were observed. Most of the pregnant women (80% in intrapartum and 70% in antepartum groups) and all nurses and obstetricians preferred the mobile CTG device over standard CTG device. Conclusion: The mobile CTG device can reliably be used for both intrapartum and antepartum monitoring instead of the standard CTG devices. The smaller size, portability and ability to transmit the recordings for second opinion make it suitable for use by midwives for appropriate triaging and referral. Wider availability of CTG and interpretation support at the peripheral facilities would assist identifying at-risk pregnancies and foetuses for timely referral and appropriate action to reduce perinatal deaths, stillbirths and birth asphyxi.

Experiences and views of midwives performing antenatal cardiotocography in Dutch primary care: A qualitative study

OBJECTIVE

In the current Dutch maternity care system, pregnant women who have an indication for an antenatal cardiotocography (CTG) to be undertaken need to be referred from primary midwife-led care to secondary obstetric-led care. Within three different regions in the Netherlands independent primary care midwives perform antenatal CTG in primary care, introduced as a pilot project. The aim of this study was to evaluate the experiences and views of primary care midwives who perform antenatal CTG in primary care.

DESIGN

Using a qualitative approach data were collected by seventeen in depth semi-structured interviews. The interview recordings were transcribed verbatim and analysed using thematic coding.

SETTING

Three regions in the Netherlands where midwives carry out antenatal CTG in primary care during this pilot project.

PARTICIPANTS

Seventeen primary care midwives were interviewed between July and November 2017.

FINDINGS

In general, midwives were satisfied with performing antenatal CTG and felt it contributed positively towards the midwife-client relationship. However, midwives experienced an increased workload, partly due to time-consuming technical difficulties. Furthermore, mixed feelings existed on whether antenatal CTG contributes to a more physiological or to a more pathological approach in midwifery practice. Most midwives believed that performing antenatal CTG contributes to the physiological process: strengthening of their gate-keeper role, increased confidence of their clients and improved midwife-client relationship. In contrast, some midwives believed it contributes to a pathological process: medicalization and relying too much on technical devices.

KEY CONCLUSIONS

This study showed an overall positive attitude of primary care midwives towards performing antenatal CTG when required, in primary midwife-led care. However, performing the antenatal CTG can be a challenge for midwives, as midwifery care within this setting is often for healthy women who have a straightforward pregnancy. For some midwives, providing antenatal CTG monitoring in the primary care setting may be seen as using a pathological approach to midwifery care.

IMPLICATIONS FOR PRACTICE

There seems to be a place for antenatal CTG in primary midwife-led care. However, further research is needed before this practice can be implemented widely.

Admission cardiotocography versus intermittent auscultation of the fetal heart in low-risk pregnancy during evaluation for possible labour admission - a multicentre randomised trial: the ADCAR trial

OBJECTIVE

To assess the effect of admission cardiotocography (ACTG) versus intermittent auscultation (IA) of the fetal heart (FH) in low-risk pregnancy during assessment for possible labour on caesarean section rates.

DESIGN

A parallel multicentre randomised trial.

SETTING

Three maternity units in the Republic of Ireland.

POPULATION

Healthy, low-risk pregnant women, at term and ≥ 18 years old, who provided written informed consent.

METHODS

Women were randomised to receive IA of the FH or 20 minutes ACTG on admission for possible labour onset, using remote telephone randomisation. Both groups received IA during labour, with conversion to continuous CTG as clinically indicated.

MAIN OUTCOME MEASURES

Caesarean section (primary outcome), obstetric interventions (e.g. continuous CTG during labour, fetal blood sampling, augmentation of labour) and neonatal morbidity (e.g. metabolic acidosis, admission to the neonatal intensive care unit, neonatal death).

RESULTS

Based on 3034 women (1513 and 1521 randomised to IA and ACTG, respectively), there was no statistical difference between the groups in caesarean section [130 (8.6%) and 105 (6.9%) for IA and ACTG groups, respectively; relative risk (RR) 1.24; 95% CI 0.97-1.58], or in any other outcome except for use of continuous CTG during labour, which was lower in the IA group (RR 0.90, 95% CI 0.86-0.93).

CONCLUSION

Our study demonstrates no differences in obstetric or neonatal outcomes between IA and ACTG for women with possible labour onset, other than an increased risk for continuous CTG in women receiving ACTG.

TWEETABLE ABSTRACT

No differences in outcomes between intermittent auscultation and admission cardiotocography for women with possible labour onset.

Does it get better with age? Women's experience of communication in maternity care

BACKGROUND

Communication with maternity care providers is one of the strongest predictors of the perceived quality of maternity care. There is evidence that older mothers experience better communication than younger mothers, but no evidence for why this occurs.

AIM

To identify differences between younger (<35 years) and older (35+ years) mother's perceived quality of communication and any apparent age-related differences.

METHODS

We analysed cross-sectional data from 2504 first-time mothers in the Having a Baby in Queensland Survey 2012. Binary logistic regression assessed associations between maternal age and perceived optimal communication (information, participation, and connection) from care providers during women's most recent pregnancy and birth. Multivariable logistic regression modelling determined the effect of potential confounders (model of care, mode of birth, maternal age, and risk perceptions) on associations between age and communication quality.

FINDINGS

After adjustment for confounders, older mothers were more likely to report experiencing optimal information (e.g., not receiving conflicting information) and connection with caregivers (e.g., comfortable asking questions) in both pregnancy and birth. There were no age-related differences in the perception of participation. Model of care and mode of birth were more influential than maternal age in predicting communication perceptions. Women who used midwifery or private obstetric models and had unassisted vaginal births were more likely to perceive optimal communication.

CONCLUSION

Given the benefits of communication on maternity care, redressing these age-related differences should be a focus of future communication training for care providers to ensure that women receive optimal communication, regardless of their age.

Family physicians perceived role in perinatal mental health: an integrative review

Background

Responding to and caring for women who experience mental health problems during the perinatal period, from pregnancy up to one year after birth, is complex and requires a multidisciplinary response. Family physicians are ideally placed to provide an effective response as it is recognised that they are responsible for organising care and supports for women and their families. This paper reports an integrative review undertaken to examine family physicians’ perceived role in perinatal mental health care and concludes with recommendations for health policy, research and practice.

Method

A systematic search of literature in seven databases from January 2000 to March 2016 identified a total of 1125 articles. Qualitative, quantitative and mixed-method studies were eligible for inclusion if they explored family physicians’ experiences of caring for women who experience perinatal mental health problems.

Results

Thirteen articles reporting 11 studies met the inclusion criteria for this review and quality of included studies were assessed using published criteria for the critical appraisal of qualitative and quantitative research methods. Cross-study narrative syntheses of quantitative and qualitative findings are presented under three themes: identification of perinatal mental health problems, management of perinatal mental health problems and barriers to care provision. While family physicians recognise their role in relation to perinatal mental health the collective interpretation revealed that; they receive variable levels of preparation for this role, no consistent approach to screening exists, pharmacological management of mood disorders is the main treatment modality and limited access to specialist perinatal mental health services exists which impacts on pharmacology decisions.

Conclusion

Family physicians require timely access to local integrated care pathways that provide a wide range of services that are culturally sensitive, perinatal mental health specific, support psychological well-being and infant/family mental health. Family physicians are open to incorporating a brief validated screening tool into primary practice supported by succinct guidelines. Research that examines training needs in relation to perinatal mental health could be used to inform family physician training programmes and curriculum development around perinatal mental health.

Midwives' perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania

Background

The Doppler is thought to be more comfortable and effective compared to the fetoscope for assessing the fetal heart rate (FHR) during labor. However, in a rural Tanzanian hospital, midwives who had easy access to both devices mostly used fetoscope. This study explored midwives’ perception of factors influencing their preference for using either a Pinard fetoscope or a FreePlay wind-up Doppler for intermittent FHR monitoring.

Methods

Midwives who had worked for at least 6 months in the labor ward were recruited. Focus group discussion (FGD) was used to collect data. Five FGDs were conducted between December 2015 and February 2016. Qualitative content analysis was employed using NVivo 11.0.

Results

Three main themes emerged as factors perceived by midwives as influencing their preference; 1) Sufficient training and experience with using a device; Midwives had been using fetoscopes since their midwifery training, and they had vast experience using it. The Doppler was recently introduced in the maternity ward, and midwives had insufficient training in how to use it. 2) Ability of the device to produce reliable measurements; Using a fetoscope, one must listen for the heartbeat, count using a watch, and calculate, the Doppler provides both a display and sound of the FHR. Fetoscope measurements are prone to human errors, and Doppler measurements are prone to instrumental errors. 3) Convenience of use and comfort of a device; Fetoscopes do not need charging, and while it is possible to “personalize/hide” the measurements, and may be painful for mothers. Dopplers need charging and do not cause pain, but provide limited privacy.

Conclusion

Midwives’ preferences of FHR monitoring devices are influenced by the level of device training, experience with using a device, reliable measurements, and convenience and comfort during use. Fetoscopes and Dopplers should be equally available during midwifery training and in clinical practice.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1736-y) contains supplementary material, which is available to authorized users.

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

BACKGROUND

Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

OBJECTIVES

To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

MAIN RESULTS

We included 13 trials involving over 37,000 women. No new studies were included in this update.One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

AUTHORS' CONCLUSIONS

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Patient Advocacy in an Obstetric Setting

A correlation study design was used to examine the interrelatedness of power, attitudes regarding intermittent fetal monitoring, and perceived barriers to research utilization with a labor and delivery nurse’s attitude toward patient advocacy using the conceptual framework of the science of unitary human beings. The linear combination of the three independent variables was significantly correlated to attitude toward patient advocacy and power as knowing participation in change had the greatest impact on patient advocacy.

Fetal heart rate monitoring: from Doppler to computerized analysis

The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.

An Exploration of the Views and Experiences of Midwives Using Intermittent Auscultation of the Fetal Heart in Labor

OBJECTIVES: To identify the experiences of midwives using intermittent auscultation of the fetal heart rate in labor.

DESIGN: A qualitative descriptive study with a sample of 8 midwives, 3 from a DOMINO scheme and 5 from the labor ward at an Irish urban maternity unit. Data collection was through tape-recorded semistructured interviews. Data analysis involved transcription of the interviews verbatim and thematic analysis.

FINDINGS: Three core themes were identified: vulnerability, the culture of the organization, and walking the tightrope. The findings suggest that the main challenges which inhibit midwives using intermittent auscultation is the lack of professional guidelines, inconsistency in documentation, and working in a biomedical model of care. The participants also identified that midwives practicing in a midwifery social model of care have more confidence and use midwifery skills to support the use of intermittent auscultation.

CONCLUSIONS: The findings suggest working within a midwifery social model of care facilitates the use of intermittent auscultation. Guidelines and education on the explicit use of intermittent auscultation need to be made accessible to midwives. Midwives believed that women could promote the use of intermittent auscultation through their own education on monitoring fetal heart rate options in labor.

Service users' experiences and views of aggressive situations in mental health care: a systematic review and thematic synthesis of qualitative studies

BACKGROUND

Aggressive situations occurring within mental health services can harm service users, staff, and the therapeutic environment. There is a consensus that the aggression phenomenon is multidimensional, but the picture is still unclear concerning the complex interplay of causal variables and their respective impact. To date, only a small number of empirical studies include users' views of relevant factors. The main objective of this review is to identify and synthesize evidence relating to service users' experiences and views of aggressive situations in mental health settings.

METHODS

We included qualitative studies of any design reporting on service users' own experiences of conditions contributing to aggressive situations in mental health care and their views on preventative strategies. Eligible articles were identified through an electronic database search (PsycINFO, PubMed, Ovid Nursing Database, Embase, and CINAHL), hand search, and cross-referencing. Extracted data were combined and interpreted using aspects of thematic synthesis.

RESULTS

We reviewed 5,566 records and included 13 studies (ten qualitative and three mixed methods). Service users recognized that both their own mental state and negative aspects of the treatment environment affected the development of aggressive situations. Themes were derived from experiential knowledge and included calls to be involved in questions regarding how to define aggression and relevant triggers, and how to prevent aggressive encounters effectively. The findings suggest that incidents are triggered when users experience staff behavior as custodial rather than caring and when they feel ignored.

CONCLUSION

The findings highlight the importance of staffs' knowledge and skills in communication for developing relationships based on sensitivity, respect, and collaboration with service users in order to prevent aggressive situations. An important factor is a treatment environment with opportunities for meaningful activities and a preponderance of trained staff who work continuously on the development of conditions and skills for collaborative interaction with users.

Patient and public attitudes to and awareness of clinical practice guidelines: a systematic review with thematic and narrative syntheses

Background

Clinical practice guidelines are typically written for healthcare providers but there is increasing interest in producing versions for the public, patients and carers. The main objective of this review is to identify and synthesise evidence of the public’s attitudes towards clinical practice guidelines and evidence-based recommendations written for providers or the public, together with their awareness of guidelines.

Methods

We included quantitative and qualitative studies of any design reporting on public, patient (and their carers) attitudes and awareness of guidelines written for providers or patients/public. We searched electronic databases including MEDLINE, PSYCHINFO, ERIC, ASSIA and the Cochrane Library from 2000 to 2012. We also searched relevant websites, reviewed citations and contacted experts in the field. At least two authors independently screened, abstracted data and assessed the quality of studies. We conducted a thematic analysis of first and second order themes and performed a separate narrative synthesis of patient and public awareness of guidelines.

Results

We reviewed 5415 records and included 26 studies (10 qualitative studies, 13 cross sectional and 3 randomised controlled trials) involving 24 887 individuals. Studies were mostly good to fair quality. The thematic analysis resulted in four overarching themes: Applicability of guidelines; Purpose of guidelines for patient; Purpose of guidelines for health care system and physician; and Properties of guidelines. Overall, participants had mixed attitudes towards guidelines; some participants found them empowering but many saw them as a way of rationing care. Patients were also concerned that the information may not apply to their own health care situations. Awareness of guidelines ranged from 0-79%, with greater awareness in participants surveyed on national guideline websites.

Conclusion

There are many factors, not only formatting, that may affect the uptake and use of guideline-derived material by the public. Producers need to make clear how the information is relevant to the reader and how it can be used to make healthcare improvements although there were problems with data quality. Awareness of guidelines is generally low and guideline producers cannot assume that the public has a more positive perception of their material than of alternative sources of health information.

Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women

Background

Research-informed fetal monitoring guidelines recommend intermittent auscultation (IA) for fetal heart monitoring for low-risk women. However, the use of cardiotocography (CTG) continues to dominate many institutional maternity settings.

Methods

A mixed methods intervention study with before and after measurement was undertaken in one secondary level health service to facilitate the implementation of an initiative to encourage the use of IA. The intervention initiative was a decision-making framework called Intelligent Structured Intermittent Auscultation (ISIA) introduced through an education session.

Results

Following the intervention, medical records review revealed an increase in the use of IA during labour represented by a relative change of 12%, with improved documentation of clinical findings from assessments, and a significant reduction in the risk of receiving an admission CTG (RR 0.75, 95% CI, 0.60 – 0.95, p = 0.016).

Conclusion

The ISIA informed decision-making framework transformed the practice of IA and provided a mechanism for knowledge translation that enabled midwives to implement evidence-based fetal heart monitoring for low risk women.

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

BACKGROUND

Cardiotocography (known also as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth.

OBJECTIVES

To evaluate the effectiveness of continuous cardiotocography during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 December 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with (a) no fetal monitoring, (b) intermittent auscultation (c) intermittent cardiotocography.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, quality and extracted data from included studies.

MAIN RESULTS

Thirteen trials were included with over 37,000 women; only two were judged to be of high quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials). There was no significant difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.63, 95% CI 1.29 to 2.07, n = 18,861, 11 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.15, 95% CI 1.01 to 1.33, n = 18,615, 10 trials).Data for subgroups of low-risk, high-risk, preterm pregnancies and high-quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome.

AUTHORS' CONCLUSIONS

Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed choice without compromising the normality of labour.