21 Mar New recommendations highlight the need for standardised fetal monitoring training to Save Babies’ Lives
Investigations into neonatal death and injury occurring during labour have consistently highlighted the urgent need for improvements in initiation, interpretation, escalation and decision-making surrounding fetal monitoring, particularly relating to continuous electronic fetal monitoring/cardiotocography (CEFM/CTG) [1,2, 3].
Most recently, the latest MBRRACE confidential enquiry into babies who died during or shortly after birth again found issues with fetal monitoring to be a recurring theme . For example, assessors found that for those babies who received continuous electronic fetal monitoring during labour, a delay in escalation to medical staff was noted in almost half of cases and a delay in medical review, decision-making or in achieving expedited delivery was identified in the care of a quarter of babies .
Similarly, the RCOG’s Each Baby Counts report  identified 1136 babies born in the UK in 2015 who died during term labour or in the first 7 days of life, or who sustained a severe brain injury. It found that 76% of these babies may have had a different outcome had there been improvements to their care. In almost three-quarters of these cases, sub-standard care relating to fetal monitoring was identified as having contributed to the outcome . An NHS Resolution review of themes arising in legal claims where alleged clinical negligence had resulted in a child suffering from cerebral palsy, yet again found errors in fetal heart rate monitoring to be the most commonly occurring theme .
These reports have consistently called for effective, multi professional training and subsequent assessment of staff competency in areas including use and interpretation of fetal monitoring.
Saving Babies’ Lives
The Saving Babies’ Lives Care Bundle (SBLCB) was first released in 2016 by NHS England ; this guidance to maternity services contained evidenced-based interventions to reduce the rates of stillbirth. A key element of this care bundle is effective fetal monitoring during labour. As in previous reports, SBLCB highlighted the importance of regular training: “All staff who care for women in labour are required to undertake an annual training and competency assessment on CTG interpretation and use of auscultation.”
Last week, NHS England released an update to this guidance, which expands the bundle’s remit to include perinatal mortality, and responds to the findings of an evaluation of the bundle’s impact in 19 early adopter trusts [5,6]. Saving Babies’ Lives Version Two (SBLCBv2) reinforces and includes expanded recommendations for the delivery, duration and content of staff training in fetal monitoring .
The need for a national standard for training
In 2018, Baby Lifeline’s Mind the Gap report  found variation nationally in the provision, evaluation and funding of maternity staff training. This included variation in the content and duration of training topics provided. For example, data was collected from trusts about mandatory training provided on electronic fetal monitoring/CTG and specifically, how often and for how long this training was mandated for staff. Annual duration of mandatory training varied significantly: by region, an average of 3.35 hours per year were mandated in South West England, compared to 8.25 hours in Wales .
A key recommendation of the Mind the Gap report, therefore, was that, “Maternity-specific national training guidance must be developed… The guidance should cover the content of training for different professional groups, how often they should attend, and the minimum assessment standards.” 
It is encouraging to see that the SBLCBv2 contains specific and expanded guidance on the frequency, and minimum duration of training and some guidance on requirements for competency assessment in relation to training on fetal monitoring. In particular, we welcome recommendations that fetal monitoring training should be delivered in a multi-professional setting, and guidance on specific content; including teaching on the physiology underlying changes in the fetal heart rate, fetal response to hypoxaemia, as well as the pathophysiology of fetal brain injury .
The training gap
Importantly, SBLCBv2 states that, “trusts must be able to demonstrate that all qualified staff who care for women in labour are competent to interpret CTG” . Baby Lifeline’s Mind the Gap 2018 reported that staff competency in CTG interpretation was not assessed in one-third of UK trusts. Furthermore, 1 in 10 trusts reported that they were not currently recording staff attendance rates on mandatory training .
Positively, 84% of trusts reported that their mandatory training in electronic fetal monitoring was provided in a multi professional environment. 99% of trusts indicated that they provided training in electronic fetal monitoring to their maternity staff. In contrast, training in intermittent auscultation was provided less frequently, in 83% of trusts; only around a third of trusts mandated training in intermittent auscultation for obstetricians .
In total, only 20% of trusts responding to Baby Lifeline’s Mind the Gap project, provided all training elements recommended by SBLCB in relation to effective fetal monitoring during labour . This starkly demonstrates that guidelines alone are not enough to save lives; there must be investment in the dissemination of best-practice, and subsequent support for trusts to implement evidenced-based recommendations.
What are we doing to help?
Baby Lifeline’s highly evaluated courses, CTG Masterclass and Advanced CTG Masterclass, have for many years been advocating the holistic assessment of mother and baby in relation to the CTG trace, taking into account fetal physiology and the wider clinical picture. As recommended in SBLCBv2, CTG Masterclass teaches “fetal physiological responses to hypoxaemia, the pathophysiology of
fetal brain injury, and the physiology underlying changes in fetal heart rate ,” it also includes discussion of other clinical factors such as fetal growth restriction, and encourages delegates to provide individualised care, and maintain situational awareness, rather than interpreting a CTG trace in isolation.
These courses are always taught in a multi-professional, and often multi-organisational environment. Courses can alternatively be commissioned for whole maternity teams; empowering units to change practice and improve outcomes.
“Our aim as intrapartum care providers should be to ensure a healthy baby and a healthy mother at the end of labour without increasing unnecessary operative interventions. Physiological interpretation of CTG by individualising care, instead of using one CTG-guideline sticker with predetermined arbitrary time limits on all babies with different physiological reserves and risk factors in labour, is crucial to avoid hypoxic and traumatic birth injuries to babies and to reduce unnecessary operative interventions and resultant complications to the mother. It is no longer acceptable…when 34% of poor perinatal outcomes are due to CTG Misinterpretation.”
Mr Edwin Chandraharan
Course Director, Baby Lifeline’s CTG Masterclass; Lead Clinician for Labour Ward; Lead Clinician for Clinical Governance in Obstetrics & Gynaecology, St Georges Hospital, London.
 Draper, E., Kurinczuk, J., and Kenyon, S. (Eds.) on behalf of MBRRACE-UK. (2017). MBRRACE-UK 2017 Perinatal Confidential Enquiry: Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester.
 The Royal College of Obstetricians and Gynaecologists. (2015). Each Baby Counts: 2015 full report. London: The Royal College of Obstetricians and Gynaecologists.
 Magro, M. (2017). Five Years of Cerebral Palsy Claims; A thematic review of NHS Resolution data. London: NHS Resolution.
 O’Connor, D. (2016). Saving Babies’ Lives: A care bundle for reducing stillbirths. Retrieved 21 March, 2019.
 NHS England. (2019). Saving Babies’ Lives Version Two: A Care Bundle for Reducing Perinatal Mortality. Retrieved 21 March 2019.
 Widdows, K., Roberts, S., Camacho, E., and Heazell, A. (2018). Evaluation of the implementation of the Saving Babies’ Lives Care Bundle in early adopter NHS Trusts in England. Manchester: Maternal and Fetal Health Research Centre, University of Manchester.
 Ledger, S., Hindle, G. and Smith, T. (2018). Mind the Gap, An Investigation into Maternity Training for Frontline Professionals Across the UK (2017/18). Retrieved 21 March 2019.