Intrapartum fetal monitoring and the spectre of litigation

Abstract

Purpose -The routine use of intrapartum electronic fetal monitoring (EFM) has resulted in an increased burden of operative and vaginal instrumental deliveries for women at low obstetric risk. Such modes of delivery increase maternal mortality and morbidity risks. This study aims to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice. Design/methodology/approach -A total of 58 registered midwives across two NHS Trusts in one region in the north of England were interviewed using a qualitative approach. Findings -Midwives attempted to manage the psychological burden of the threat from clinical negligence by using EFM. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of EFM to accurately detect fetal compromise but are aware that the visual monitoring record is recognised as a valuable piece of legal evidence. The midwives' perceptions of professional self-efficacy in seeking to avoid a claim in clinical negligence contributed to defensive practice.Research limitations/implications -The study was conducted in only two hospitals in one region of England; however the Trust demographics were similar and midwifery practice within the unit reflects national maternity standards of care. Practical implications -Multidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines where intrapartum fetal monitoring is concerned and Trust audit departments must undertake regular audit cycles in order to ascertain practice compliance with best evidence. Originality/value -The paper provides information so that midwives' knowledge regarding the limitations of EFM can be improved.

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

“…Following this, a further 5 were excluded; one explored midwives’ perceptions of the use of technology and was not explicitly about monitoring the FHR [15], one was a duplicate publication [16], one explored views on decision-making and was not explicitly about monitoring the FHR [17] and two were either non-comparable in design or it was impossible to extract themes from the data [18,19]. In total, 13 papers, detailing 11 studies (1,194 professionals), are included in our review (Figure 1); the findings of one study [20] are reported across two additional publications [21,22]. Details of the studies included are outlined in Table 1 and Table 2.…”

“…Reassurance emerged as a prominent theme in 9 [15,22-24,27-31] of the 11 included studies. EFM offered reassurance because professionals believed the cardiotocograph (CTG) trace provided hard copy ‘proof’ that the baby was not compromised whilst in their care [22-24,26,27,31].…”

“…EFM offered reassurance because professionals believed the cardiotocograph (CTG) trace provided hard copy ‘proof’ that the baby was not compromised whilst in their care [22-24,26,27,31]. When an adverse outcome occurred, this ‘proof’, not achievable through IA, was perceived as potentially minimising the exposure of clinical staff to criticism and litigation [22,26,27].…”

“…EFM offered reassurance because professionals believed the cardiotocograph (CTG) trace provided hard copy ‘proof’ that the baby was not compromised whilst in their care [22-24,26,27,31]. When an adverse outcome occurred, this ‘proof’, not achievable through IA, was perceived as potentially minimising the exposure of clinical staff to criticism and litigation [22,26,27]. From the data, it appeared that a principal reason for using EFM was the perceived reassurance (‘ the ability to hear the fetal heart in the background ’ [30]) and perceived protection against legal action afforded by the hard copy CTG trace [21-23,26,27,31];…”

“…*The results of this study are reported across three publications; references for additional papers include Hindley and Thomson [21] and Hindley & Thompson [22]. …”