English Midwives' Views and Experiences of Intrapartum Fetal Heart Rate Monitoring in Women at Low Obstetric Risk: Conflicts and Compromises

Abstract

Over the last 20 years in the United Kingdom, midwives have implemented the routine use of intrapartum fetal monitoring regardless of the risk status of laboring women. This practice is at odds with the published research. The discrepancy between practice and best evidence merits further investigation. A qualitative study was conducted to evaluate midwives' attitudes and experiences about the use of fetal monitoring for women at low obstetric risk. Fifty-eight midwives working in two hospitals in the north of England were interviewed by using a semistructured approach. The taped interviews were transcribed and analyzed by using a general thematic approach. Issues included midwives' perceptions of low-risk status, the socialization of midwives, and the loss of woman-centered care. Midwives subscribed to the notion of woman-centered care, but because of a complexity of factors experienced in their daily working lives, they felt vulnerable when attempting to implement evidence-based fetal monitoring practices. Midwives regretted the loss of a woman-centered approach to care when technologic methods of intrapartum fetal heart rate monitoring were used indiscriminately. An appreciation of the complex factors affecting the ability of midwives to implement evidence-based practice is important when attempting to facilitate the development of appropriate fetal monitoring practices for women at low obstetric risk.

Foetal monitoring: A woman-centred decision-making pathway

“…This study confirms concerns that clinical guidelines on electronic foetal monitoring are not always followed 14,27,28 and illuminates midwives' decision-making processes that lead to this outcome. The two key CEFM decision points during labour care are significant findings in explaining the processes and informing strategies to address the risks of not following clinical guidelines.…”

“…30 The second decision point is when the woman was categorised according to the midwife's judgment of risk, which was not always consistent with clinical guidelines. Consistent with other studies, a range of factors influencing the midwives' judgment included the presence of technology, pressure from medical colleagues 14 fear of adverse events and litigation 28 and women's expectations. 31 However despite the women's expectation, similar to other studies 31 the midwives in this study did not give the women a choice of the foetal monitoring method.…”

“…This study showed that the admission CTG for women without antenatal history risk factors can lead to CEFM, sometimes with no further decision on behalf of the midwife, as the CTG remained in place simply because the midwife was too busy to remove it, identified in this study as the CTG as 'babysitter', similar to the 'midwife by proxy' described in Hindley's study. 28 However, the admission CTG is a poor predictor of adverse outcomes, tests poorly in preventing adverse outcomes and does not improve neonatal outcomes. 29 The use and interpretation of the admission CTG remains controversial for both low and risk labours and its routine use for all women has the potential to diminish traditional midwifery skills.…”

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

“…It may confer no benefit, can generate both non-medical and medical anxiety, and through subtle effects may cause significant harm” [6] (p.vii). Further, the CTG monitor becomes the centre of attention for family and caregivers rather than the woman herself [3,7] and presents a physical barrier to the provision of ‘hands-on’ support to the labouring woman. Additionally, the woman’s confidence in her ability to give birth safely without the use of technology is diminished.…”

“…These include a lack of knowledge or skills with IA [8] and being reassured by the sound of the fetal heart in the background [9]. The most often cited reason is fear of medico-legal consequences offset by a perception of continuous CTG as being a protective measure because of the hard copy evidence of monitoring [9] despite midwives’ lack of confidence in its reliability to detect fetal compromise [7,10]. …”