How does the use of continuous electronic fetal monitoring influence women's experiences of labour? A systematic integrative review of the literature from high income countries

BACKGROUND

A variety of technologies are used to monitor fetal wellbeing in labour. Different types of fetal monitoring devices impact women's experiences of labour and birth.

AIM

This review aims to understand how continuous electronic fetal monitoring (CEFM) influences women's experiences, with a focus on sense of control, active decision-making and mobility.

METHODS

A systematic search of the literature was conducted. Findings from qualitative, quantitative and mixed methods studies were analysed to provide a review of current evidence.

FINDINGS

Eighteen publications were included. The findings were synthesised into three themes: 'Feeling reassured versus anxious about the welfare of their baby', 'Feeling comfortable and free to be mobile versus feeling uncomfortable and restricted', and 'Feeling respected and empowered to make decisions versus feeling depersonalised with minimal control '. Women experienced discomfort and a lack of mobility as a result of some CEFM technologies. They often felt anxious and had mixed feelings about their baby's welfare whilst these were in use. Some women valued the data produced by CEFM technologies about the welfare of their baby. Many women experienced a sense of depersonalisation and lack of control whilst CEFM technologies were used.

DISCUSSION

Fetal monitoring technologies influence women's experiences of labour both positively and negatively. Wireless devices were associated with the most positive response as they enabled greater freedom of movement.

CONCLUSION

The design of emerging fetal monitoring technologies should incorporate elements which foster freedom of movement, are comfortable and provide women with a sense of choice and control. The implementation of fetal monitoring that enables these elements should be prioritised by health professionals.

Tending to the machine: The impact of intrapartum fetal surveillance on women in Australia

Qualitative research about women and birthing people's experiences of fetal monitoring during labour and birth is scant. Labour and birth is often impacted by wearable or invasive monitoring devices, however, most published research about fetal monitoring is focused on the wellbeing of the fetus. This manuscript is derived from a larger mixed methods study, 'WOmen's Experiences of Monitoring Baby (The WOMB Study)', aiming to increase understanding of the experiences of women and birthing people in Australia, of being monitored; and about the information they received about fetal monitoring devices during pregnancy. We constructed a national cross-sectional survey that was distributed via social media in May and June, 2022. Responses were received from 861 participants. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia. This paper comprises the analysis of the free text survey responses, using qualitative and inductive content analysis. Two categories were constructed, Tending to the machine, which explores participants' perceptions of the way in which clinicians interacted with fetal monitoring technologies; and Impressions of the machine, which explores the direct impact of fetal monitoring devices upon the labour and birth experience of women and birthing people. The findings suggest that some clinicians need to reflect upon the information they provide to women and birthing people about monitoring. For example, freedom of movement is an important aspect of supporting the physiology of labour and managing pain. If freedom of movement is important, the physical restriction created by a wired cardiotocograph is inappropriate. Many participants noticed that clinicians focused their attention primarily on the technology. Prioritising the individual needs of the woman or birthing person is key to providing high quality woman-centred intrapartum care. Women should be provided with adequate information regarding the risks and benefits of different forms of fetal monitoring including how the form of monitoring might impact her labour experience.

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.

A qualitative study of a sample of women participating in an Australian randomised controlled trial of intrapartum fetal surveillance

BACKGROUND

The STan Australian Randomised controlled Trial (START), the first of its kind in Australia, compares two techniques of intrapartum fetal surveillance (cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram (STan+CTG) with CTG alone) with the aim of reducing unnecessary obstetric intervention. It is also the first comprehensive intrapartum fetal surveillance (IFS) trial worldwide, including qualitative examination of psychosocial outcomes and cost-effectiveness. In evaluating and implementing healthcare interventions, the perspectives and experiences of individuals directly receiving them is an integral part of a comprehensive assessment. Furthermore, the added value of using qualitative research alongside randomised controlled trials (RCTs) is becoming widely acknowledged.

OBJECTIVE

This study aimed to examine women's experiences with the type of IFS they received in the START trial.

METHODS

Using a qualitative research design, a sample of thirty-two women were interviewed about their experiences with the fetal monitoring they received. Data were analysed using thematic analysis.

FINDINGS

Six themes emerged from analysis: reassurance, mobility, discomfort, perception of the fetal Scalp Electrode (FSE), and overall positive experience.

CONCLUSION

Interestingly, it was found that women who had an FSE in the CTG alone arm of the trial reported very similar experiences to women in the STan+CTG arm of the trial. Despite STan and CTG differing clinically, from women's perspectives, the primary difference between the two techniques was the utilisation (or not) of the FSE. Women were very accepting of STan+CTG as it was perceived and experienced as a more accurate form of monitoring than CTG alone. Findings from this study have significant implications for health professionals including midwives and obstetricians and implications for standard practice and care. The study has demonstrated the importance and significance of incorporating qualitative enquiry within RCTs.

Computerised interpretation of the fetal heart rate during labour: a randomised controlled trial (INFANT)

BACKGROUND

Continuous electronic fetal monitoring (EFM) in labour is widely used and computerised interpretation has the potential to increase its utility.

OBJECTIVES

This trial aimed to find out whether or not the addition of decision support software to assist in the interpretation of the cardiotocograph (CTG) reduced the number of poor neonatal outcomes, and whether or not it was cost-effective.

DESIGN

Two-arm individually randomised controlled trial. The allocations were computer generated using stratified block randomisation employing variable block sizes. The trial was not masked.

SETTING

Labour wards in England, Scotland and the Republic of Ireland.

PARTICIPANTS

Women in labour having EFM, with a singleton or twin pregnancy, at ≥ 35 weeks' gestation.

INTERVENTIONS

Decision support or no decision support.

MAIN OUTCOME MEASURES

The primary outcomes were (1) a composite of poor neonatal outcome {intrapartum stillbirth or early neonatal death (excluding lethal congenital anomalies), or neonatal morbidity [defined as neonatal encephalopathy (NNE)], or admission to a neonatal unit within 48 hours for ≥ 48 hours (with evidence of feeding difficulties, respiratory illness or NNE when there was evidence of compromise at birth)}; and (2) developmental assessment at the age of 2 years in a subset of surviving children.

RESULTS

Between 6 January 2010 and 31 August 2013, 47,062 women were randomised and 46,042 were included in the primary analysis (22,987 in the decision support group and 23,055 in the no decision support group). The short-term primary outcome event rate was higher than anticipated. There was no evidence of a difference in the incidence of poor neonatal outcome between the groups: 0.7% (n = 172) of babies in the decision support group compared with 0.7% (n = 171) of babies in the no decision support group [adjusted risk ratio 1.01, 95% confidence interval (CI) 0.82 to 1.25]. There was no evidence of a difference in the long-term primary outcome of the Parent Report of Children's Abilities-Revised with a mean score of 98.0 points [standard deviation (SD) 33.8 points] in the decision support group and 97.2 points (SD 33.4 points) in the no decision support group (mean difference 0.63 points, 95% CI -0.98 to 2.25 points). No evidence of a difference was found for health resource use and total costs. There was evidence that decision support did change practice (with increased fetal blood sampling and a lower rate of repeated alerts).

LIMITATIONS

Staff in the control group may learn from exposure to the decision support arm of the trial, resulting in improved outcomes in the control arm. This was identified in the planning stage and felt to be unlikely to have a significant effect on the results. As this was a pragmatic trial, the response to CTG alerts was left to the attending clinicians.

CONCLUSIONS

This trial does not support the hypothesis that the use of computerised interpretation of the CTG in women who have EFM in labour improves the clinical outcomes for mothers or babies.

FUTURE WORK

There continues to be an urgent need to improve knowledge and training about the appropriate response to CTG abnormalities, including timely intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98680152.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) HTA programme and will be published in full in Health Technology Assessment; Vol. 22, No. 9. See the NIHR Journals Library website for further project information. Sara Kenyon was part funded by the NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands.

A pilot exploratory investigation on pregnant women's views regarding STan fetal monitoring technology

BACKGROUND

Women's views are critical for informing the planning and delivery of maternity care services. ST segment analysis (STan) is a promising method to more accurately detect when unborn babies are at risk of brain damage or death during labour that is being trialled for the first time in Australia. This is the first study to examine women's views about STan monitoring in this context.

METHODS

Semi-structured interviews were conducted with pregnant women recruited across a range of clinical locations at the study hospital. The interviews included hypothetical scenarios to assess women's prospective views about STan monitoring (as an adjunct to cardiotocography, (CTG)) compared to the existing fetal monitoring method of CTG alone. This article describes findings from an inductive and descriptive thematic analysis.

RESULTS

Most women preferred the existing fetal monitoring method compared to STan monitoring; women's decision-making was multifaceted. Analysis yielded four themes relating to women's views towards fetal monitoring in labour: a) risk and labour b) mobility in labour c) autonomy and choice in labour d) trust in maternity care providers.

CONCLUSIONS

Findings suggest that women's views towards CTG and STan monitoring are multifaceted, and appear to be influenced by individual labour preferences and the information being received and understood. This underlies the importance of clear communication between maternity care providers and women about technology use in intrapartum care. This research is now being used to inform the implementation of the first properly powered Australian randomised trial comparing STan and CTG monitoring.

Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women's experiences of self-monitoring

BACKGROUND

Hypertensive disorders in pregnancy are a leading cause of maternal and fetal morbidity worldwide. Raised blood pressure (BP) affects 10% of pregnancies worldwide, of which almost half develop pre-eclampsia. The proportion of pregnant women who have risk factors for pre-eclampsia (such as pre-existing hypertension, obesity and advanced maternal age) is increasing. Pre-eclampsia can manifest itself before women experience symptoms and can develop between antenatal visits. Incentives to improve early detection of gestational hypertensive disorders are therefore strong and self-monitoring of blood pressure (SMBP) in pregnancy might be one means to achieve this, whilst improving women's involvement in antenatal care. The Blood Pressure Self-Monitoring in Pregnancy (BuMP) study aimed to evaluate the feasibility and acceptability of SMBP in pregnancy.

METHODS

To understand women's experiences of SMBP during pregnancy, we undertook a qualitative study embedded within the BuMP observational feasibility study. Women who were at higher risk of developing hypertension and/or pre-eclampsia were invited to take part in a study using SMBP and also invited to take part in an interview. Semi-structured interviews were conducted at the women's homes in Oxfordshire and Birmingham with women who were self-monitoring their BP as part of the BuMP feasibility study in 2014. Interviews were conducted by a qualitative researcher and transcribed verbatim. A framework approach was used for analysis.

RESULTS

Fifteen women agreed to be interviewed. Respondents reported general willingness to engage with monitoring their own BP, feeling that it could reduce anxiety around their health during pregnancy, particularly if they had previous experience of raised BP or pre-eclampsia. They felt able to incorporate self-monitoring into their weekly routines, although this was harder post-partum. Self-monitoring of BP made them more aware of the risks of hypertension and pre-eclampsia in pregnancy. Feelings of reassurance and empowerment were commonly reported by the women in our sample.

CONCLUSIONS

SMBP in pregnancy was both acceptable and feasible to women in this small pilot study.

Central Fetal Monitoring With and Without Computer Analysis: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether intrapartum fetal monitoring with computer analysis and real-time alerts decreases the rate of newborn metabolic acidosis or obstetric intervention when compared with visual analysis.

METHODS

A randomized clinical trial carried out in five hospitals in the United Kingdom evaluated women with singleton, vertex fetuses of 36 weeks of gestation or greater during labor. Continuous central fetal monitoring by computer analysis and online alerts (experimental arm) was compared with visual analysis (control arm). Fetal blood sampling and electrocardiographic ST waveform analysis were available in both arms. The primary outcome was incidence of newborn metabolic acidosis (pH less than 7.05 and base deficit greater than 12 mmol/L). Prespecified secondary outcomes included operative delivery, use of fetal blood sampling, low 5-minute Apgar score, neonatal intensive care unit admission, hypoxic-ischemic encephalopathy, and perinatal death. A sample size of 3,660 per group (N=7,320) was planned to be able to detect a reduction in the rate of metabolic acidosis from 2.8% to 1.8% (two-tailed α of 0.05 with 80% power).

RESULTS

From August 2011 through July 2014, 32,306 women were assessed for eligibility and 7,730 were randomized: 3,961 to computer analysis and online alerts, and 3,769 to visual analysis. Baseline characteristics were similar in both groups. Metabolic acidosis occurred in 16 participants (0.40%) in the experimental arm and 22 participants (0.58%) in the control arm (relative risk 0.69 [0.36-1.31]). No statistically significant differences were found in the incidence of secondary outcomes.

CONCLUSION

Compared with visual analysis, computer analysis of fetal monitoring signals with real-time alerts did not significantly reduce the rate of metabolic acidosis or obstetric intervention. A lower-than-expected rate of newborn metabolic acidosis was observed in both arms of the trial.

CLINICAL TRIAL REGISTRATION

ISRCTN Registry, http://www.isrctn.com, ISRCTN42314164.

Informing the development of NICE (National Institute for Health and Care Excellence) quality standards through secondary analysis of qualitative narrative interviews on patients’ experiences

Background

We set out to explore if, and how, an archive of qualitative, narrative interviews covering over 60 health issues could be used to inform the development of National Institute for Health and Care Excellence (NICE) quality standards. We also sought to identify which aspects of health care are important to people facing different health conditions and to test a set of ‘core components’ in focus groups with people who tend to be less well represented in interview research studies.

Objectives

(1) To conduct qualitative secondary analysis (of collections of narrative interviews) to identify common, core components of patients’ experiences of the NHS. (2) To test these candidate components with (i) further purposive sampling of the interview collections and (ii) a series of focus groups with users. (3) To embed the project alongside the development of NICE clinical guidelines and quality standards. (4) To inform the development of measurement tools on patients’ experiences. (5) To develop and share resources and skills for secondary analysis of qualitative health research.

Methods and data sources

We used qualitative methods including qualitative secondary analysis, interviews with team members and focus groups. We also ran a workshop on secondary analysis practice and a dissemination seminar. The secondary analysis used narrative interviews from the archive held by the Health Experiences Research Group in Oxford. These interviews have been collected over a 12-year period, number over 3500 and are copyrighted to the University of Oxford for research publications and broadcasting. Other data were digital recordings of interviews and observations at meetings. We prepared reports intended to contribute to NICE clinical guidelines and quality standards development.

Results

We identified eight consistently important aspects of care: involving the patient in decisions; a friendly and caring attitude; an understanding of how life is affected; seeing the same health professional; guiding through difficult conversations; taking time to explain; pointing towards further support; and efficiently sharing health information across services. Expectations varied but we found few differences in what is valued, even when we tested the reach of these ideas with groups who rarely take part in mainstream health research. The asthma report for NICE highlighted several issues, but only the importance of proper inhaler training contributed to a quality statement. Several barriers were identified to using (unpublished) tailor-made analyses in NICE product development.

Conclusions

We compared the perspectives about what is most valued in health care between people with different health conditions. They were in agreement, even though their experiences of health-care relationships varied enormously. With regard to the NICE clinical guideline and quality standard development process, the usual source of evidence is published qualitative or quantitative research. Unpublished secondary analysis of qualitative data did not fit the usual criteria for evidence. We suggest that targeted secondary analysis of qualitative data has more potential when the qualitative literature is sparse, unclear or contradictory. Further work might include further testing of the identified core components in other patient groups and health conditions, and collaboration with NICE technical teams to establish whether or not it is possible to identify areas of patient experience research where targeted secondary analyses have potential to add to a qualitative literature synthesis.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.