Summary
Region-wide collaboration between maternity services is leading to a standardised approach to fetal monitoring during labour, improving the safety of mothers and babies across the Local Maternity and Neonatal Systems (LMNS) in our region. A tool supporting clinical decision-making has been adopted and an innovative education programme developed incorporating learning from simulation and an animated video. Initial outcome data indicates a positive impact. Involving relevant stakeholders has been a critical part of the success of this ongoing improvement programme. A positive, open and transparent safety culture has been established enabling robust critical review of clinical incidents where there are safety concerns.
Background
In 2020/21 the regional LMNS safety forum expressed concern regarding increased referrals to the Healthcare Safety Investigation Branch (HSIB) – now the Maternity and Newborn Safety Investigation (MNSI) programme – where challenges with assessment of risk, cardiotocograph (CTG) interpretation and escalation were identified as contributory factors to poor neonatal outcomes, including intrapartum stillbirths, hypoxic ischemic encephalopathy (HIE) or neonatal deaths. The challenges were the disconnect between national guidance from the National Institute of Health and Care Excellence (NICE), and the ability to apply a physiological approach to CTG interpretation. Clinical teams were also frustrated in their efforts to use interpretation tools that were not fit for purpose and varied between maternity units.
Actions taken
The need to standardise the approach to CTG interpretation to ensure equity in clinical care and staff education was identified. Because midwives and obstetric trainees rotate within the LMNS, any variations in clinical guidelines, interpretation tools and terminology can cause stress for clinicians and potential safety concerns for women and babies. A thematic analysis of babies who had either died or had suffered a significant brain injury as a result of hypoxia was completed by Oxford University Hospitals NHS Foundation Trust to facilitate improvements in CTG interpretation and inform the development of a revised CTG decision-making tool and education and training programme.
A Quality Improvement team of the fetal monitoring obstetric and midwifery leads from each of the hospitals in the region was convened and met monthly. The group developed an intrapartum clinical decision-making tool informed by a physiology-based approach to CTG interpretation. They used an iterative approach using rapid Plan, Do, Study, Act (PDSA) cycles to agree a single Intrapartum Decision-Making Tool. Excellent working relationships have been established with Oxford Simulation Teaching and Research (OxSTaR) and NHS Creative. OxSTaR filmed a selection of scenarios addressing shared decision-making and communication during labour, challenges with hierarchy and escalation and the important role of human factors in everyday complex clinical situations NHS Creative produced an animation explaining fetal hypoxia in simple terms (see image above) and developed a training film to explain how metabolism occurs within the fetus.
A teaching programme offering a step-by-step approach to understanding fetal physiology and its application to intrapartum CTG interpretation was developed in collaboration with OxSTaR and NHS Creative. Fetal monitoring guidelines were updated to reflect changes in terminology, care planning and recommended interventions. A pool of assessment questions was designed, and the transition period for clinical teams supported with a series of clinical and educational expertise on the ‘shop floor’ coupled with 1:1 debriefs where concerns were identified. A poster was presented at the Maternity and Midwifery Festival in Birmingham earlier this year.
Achievements
This innovative approach to addressing a significant patient safety concern has improved safety and experience for patients and families, and the healthcare professionals who care for them. The primary aim was to improve neonatal outcomes without increasing unnecessary intervention. Data from Oxford University Hospitals NHS Foundation Trust’s initial service evaluation suggests significant improvement in neonatal outcomes in term births including significant reductions in HIE brain injury grades 2/3 and rates of unplanned term admissions to the neonatal unit and therapeutic hypothermia (cooling). There has been no significant increase in intervention for presumed fetal compromise overall, although there has been a significant increase in caesarean sections in line with the national picture. Despite this, the proportion of caesarean sections performed at term for presumed fetal compromise has not significantly increased.
Data from the second service evaluation demonstrates that while there has been a significant increase in expedited births there has been a significant and sustained improvement in neonatal outcomes. The proportion of caesarean sections performed for fetal compromise has not changed. Data from Buckinghamshire Healthcare NHS Trust from 2023 reflecting feedback from clinical teams 15 months after the implementation of the new tool and guideline is very positive. The revised decision tool combined with education has had a positive impact on patient care improving the safety of women and babies. There has been no significant increase in the proportion of caesarean sections performed for presumed fetal compromise and the number of babies born with poor cord blood gases has significantly decreased. There have been no investigations with fetal monitoring in the causal pathway in the Buckinghamshire, Oxfordshire and Berkshire West (BOB) LMNS for the past 12 months.
Avoidable brain injury at birth, whilst rare, costs the NHS billions of pounds in compensation payments and has lasting consequences for families and the staff involved. However, exact financial savings as a result of this initiative are not yet available. The educational programme is effective with evidence of increased engagement in continuous learning around fetal wellbeing. The intrapartum decision-making tool is being used correctly, is user friendly and clinicians report it enables them to consider the wider clinical picture.
Fetal monitoring leads report improvements in patient safety and improved experiences for families evidenced by fewer clinical incidents where issues with fetal monitoring were identified as contributory factors. Involving relevant stakeholders has been a critical part of the success of this ongoing improvement programme. A positive, open and transparent safety culture has been established enabling robust critical review of clinical incidents where there are safety concerns.
Feedback
“We want to make care safer to reduce the number of babies requiring treatment for possible encephalopathy in the newborn period. The team has developed a new way of interpreting CTG traces that includes both physiological assessment and includes the overall wellbeing of the mother in labour. It is also encouraging much more involvement of the labouring woman in her care and describes how to do that. They notice excellence and encourage people to offer the best care they can. There is an excellent new training package that is beautifully presented and very interesting and is likely to allow people to use the new system effectively. Their innovation is excellent and very timely for our maternity services.”
Feedback from a member of the Reporting Excellence service at Oxford University Hospitals
Peer review by a member of the Royal College of Midwives as external critical friends was extremely positive noting the high quality presentation and intuitive design of the online programme contents. The multimedia approach was welcomed.
Next steps
Service evaluations/audits of the impact of the revised clinical decision tool and education programme for each NHS organisation and LMNS in our region are almost complete. Current work is focused on transition to a digital version of the decision-making tool as the maternity services in Buckinghamshire and Oxfordshire move to an electronic healthcare system.