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Midwives’ and doctors’ attitudes towards the use of the cardiotocograph machine
Midwifery 27 (2011) e279–e285
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Midwives’ and doctors’ attitudes towards the use of the cardiotocograph machine Sarah McKevitt, MSc, BSc (Hons), RGN, RM (Clinical Team Leader, Labour Ward)a,, Patricia Gillen, PhD, PG Dip Nurs Ed, MSc, BSc, RM, RGN (Lecturer)b, Marlene Sinclair, PhD, Med, DASE, BSc RNT, RM, RN (Professor of Midwifery Research)c a
South Eastern Health and Social Care Trust, Upper Newtownards Road, Dundonald BT16 1RH, UK School of Nursing, University of Ulster, Shore Road, Newtownabbey BT37 0QB, UK c Institute of Nursing Research, University of Ulster, Shore Road, Newtownabbey BT37 0QB, UK b
a r t i c l e in f o
abstract
Article history: Received 26 October 2009 Received in revised form 23 September 2010 Accepted 13 November 2010
The appropriate use of the cardiotocograph (CTG) machine in the clinical setting is an issue of concern for midwives and doctors. Objective: to examine midwives and doctors attitudes towards the use of the CTG machine in labour ward practice. Background: this small study provides new insight into the attitudes of doctor and midwives towards the use of CTG. Design: an exploratory descriptive design that used a combination of qualitative and quantitative approaches. A valid and reliable tool designed by Sinclair (2001) was used to measure the attitudes of doctors and midwives towards CTG usage. In addition, follow-up semi-structured interviews with doctors and midwives were conducted. Setting: a maternity unit in Northern Ireland. Participants: participants selected had worked in the labour ward within the last year (n ¼ 56 midwives; n ¼ 19 doctors). Six midwives and two doctors were randomly selected to participate in the interviews. Findings: the study demonstrated a favourable disposition towards the use of CTG machines with 72.5% (n ¼29) of respondents indicating that they viewed CTG technology positively and 87.5% (n ¼ 25) indicating they were confident about their skill in interpreting CTG tracings. The majority of the respondents (60.0%, n ¼ 24) felt that their training adequately prepared them for using CTGs. The illustrative accounts provided by the respondents demonstrated a predominant belief that CTG technology continues to have a role in monitoring and detecting abnormalities in the fetal heart rate but this role is limited by how well the CTG is used and interpreted. The interviews confirmed the data obtained from the questionnaires and revealed a number of professional needs and concerns relating to CTG usage. Implications for practice: the implication of this study may be focused on addressing the training needs of students, newly qualified staff and regular updates for employed staff. There was some concern that this technology may be deskilling staff and therefore there is a need to improve confidence levels in using alternatives to this type of fetal monitoring. & 2010 Elsevier Ltd. All rights reserved.
Keywords: Fetal monitoring Cardiotocograph monitoring Birth technology
Introduction Cardiotocograph monitoring (CTG) is one of the most commonly used technologies in labour ward practice. The safe use of this technology is of prime concern to midwives and obstetricians but studies frequently show that the levels of agreement in the usage
Corresponding author.
E-mail addresses: [email protected] (S. McKevitt), [email protected] (P. Gillen), [email protected] (M. Sinclair). 0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2010.11.003
and interpretation of CTG fetal heart tracings is poor among professionals (Strong and Jarles, 1993; Bracero et al, 2000; Freeman, 2002; Devane and Lalor, 2005). These difficulties will affect the manner in which midwives and obstetricians respond to the challenges posed by variations in CTG fetal heart patterns, which in turn will impact on the indications and timings of subsequent interventions. This has implications for multidisciplinary collaboration in labour ward practice. The need for consensus regarding the use and interpretation of CTG is essential to safe and collaborative practice and will ultimately improve multidisciplinary relations between midwives
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and obstetricians (Fox et al., 2000). However, the Confidential Enquiry into Maternal and Child Health (2009) has attributed poor communication and interprofessional collaboration to maternal and infant mortality and morbidity. It is important for midwives and obstetricians to develop more understanding of each other’s attitudes toward the use of CTG in labour ward practice so that development of evidence informed guidelines and implementation of these is a multidisciplinary collaboration. This paper will present the main findings from a study on the practice of using CTG technology in labour ward practice and will build on previous research reported by Sinclair (2001). Many aspects of practice have changed in the past 10 years and some of this is due to the implementation of the National Institute for Health and Clinical Excellence (2007) Guidelines on Fetal Monitoring which provided clear guidelines on how cardiotocograph monitoring should be used. Therefore, research reporting data from both midwives’ and doctors’ attitudes towards the CTG are both timely and relevant.
Literature search A literature search was initiated using the following terms: technology, health technology, birth technology, fetal monitoring, electronic fetal monitoring and cardiotocograph (CTG) monitoring using the following databases CINHAL, Pubmed and MIDIRS. The search was limited to the English Language with a time span 1999–2009, although some seminal pieces prior to this date were reviewed. The search strategy also involved consultation with experts in this field.
Literature review Within labour wards the use of the CTG has become widely used to assess fetal well-being in labour but subsequent randomised controlled trials have failed to find any benefit of CTG monitoring over intermittent auscultation (Vintzileos et al., 1993; Thacker et al., 2001; Larma et al., 2007). In fact the use of the CTG has been shown to increase the rate of interventions used in labour (Grant, 1993; Mires et al., 2001; Alfirevic et al., 2006). These increasing levels of interventions have altered the manner in which midwives and obstetricians now care for all women in labour. In response to this, the World Health Organisation has raised concerns that due to this increasing medicalisation of childbirth there has been an erosion of midwifery and obstetric skills and confidence (World Health Organisation, 1997). However, some professionals have embraced health technology and according to Barnard and Gerber (1999) this association with technical knowledge and skill has been a source of increased prestige and power for nurses and midwives. Sandelowski (2000) found that the introduction of the CTG was seen as improving communication and reducing tensions between the nurse and clinician as it produced visual evidence of events that had occurred when the doctor was not present. However, this can be difficult if there is poor consensus of opinion on how these CTG traces are interpreted. Differences among providers in fetal heart rate interpretation and management have been cited by Symonds (1994) as a factor in morbid outcomes and costly litigation. Vincent et al. (2004) state that obstetric claims account for over 70% of all NHS litigation expenses with an average cost of cerebral palsy cases of £1.5 million. Over 85% of these cerebral palsy cases are associated with abnormalities of fetal heart monitoring (Vincent et al., 2004). However, Hindley and Thompson (2007) found that midwives’ knowledge of the evidence relating to CTG monitoring was superimposed by a perception that by using this type of monitoring it would provide a legal defence in the event of litigation.
Cowie and Floyd (1998) argue that this may be at the expense of women-centred care as the use of technology removes professionals from the naturalness and human dimensions of childbirth. Indeed studies have shown that the use of technology can impede care by alienating and dehumanising both nurse and patient (Cooper 1993; Davis-Floyd, 1994; Hindley et al., 2006). Barclay and Jones (1996) have argued that technology has been employed to regain power and control over women. Alternatively not all women view interventions as a negative aspect of labour and some women and their partners expect to see technology and are comforted by its presence (Williams and Umberson 1999; Sinclair, 2000; Hindley et al., 2008). The literature review revealed that there is a lack of empirical knowledge relating to attitudes towards the use of CTG in labour ward practice. Dover and Gauge (1995) carried out a descriptive correlational study to survey midwives’ attitudes and practices related to intrapartum fetal monitoring and findings indicated that midwives’ preferred methods of monitoring varied with the clients risk category. However, the study demonstrated that midwife preference did not necessarily match the actual choice of method. Many factors influenced choice in particular confidence in the equipment and confidence in one’s own ability to choose the correct method of fetal monitoring. In a later study, Sinclair (2001) examined the attitudes of midwives who had worked in labour ward. The results show that midwives rejected the notion that they were becoming too dependent on the use of CTG machines in their practice. However, midwives who trust the machines are more predisposed to their use and trust is affected by perceived competence. Reime et al. (2004) examined maternity care provider group’s attitudes towards birth and found that obstetricians were the most attached to technology and interventions, midwives the least and family clinicians fell in the middle. When asked about continuous CTG monitoring the study showed that midwives and family clinicians had attitudes/beliefs more in line with current evidence than obstetricians. The accessed literature draws attention to the fact that there is a wide range of perspectives to the use of CTG technology in labour ward practice. It highlights factors that may contribute to midwives and doctors forming certain attitudes towards this technology which may ultimately affect the manner in which that individual responds to it in practice. The numbers of studies that specifically attempt to examine attitudes to CTG are relatively few in number. Thus, it is evident that there is a need to build on the data obtained by Sinclair (2001) and generate new knowledge by involving doctors.
Design and method This was an exploratory descriptive study undertaken as part of a Masters degree in Midwifery by the first author. The design combined qualitative and quantitative approaches and used a validated questionnaire with a Cronbach’s a of 0.78% designed by Sinclair (2001) to measure attitudes towards the CTG. This questionnaire was adapted to collect new information related to incidents where the use of CTG involved collaboration between doctors and midwives. Semi-structured interviews were conducted with midwives and doctors to allow the researcher to further explore and understand the issues for practitioners using the CTG in labour ward practice.
Pilot work A pilot study was conducted because the questionnaire was adapted to include obstetricians from a previously validated
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questionnaire by Sinclair (2001). A sample of four midwives and two doctors was obtained for the pilot study and the response rate was 100%. These participants were not included in the main study. Feedback from these participants was positive but the participants reported difficulties in understanding question 20. These difficulties were noted and the wording of the question was altered to ensure the question was more easily understood. In order to detect any potential for researcher bias in the interview process a small pilot study with three volunteers was performed. It is also important to take steps to ensure that the questions were open and exploratory so that the responses were not guided in a particular direction.
Ethical issues The ethical issues involved in this study were subject to internal review by the University of Ulster Student Research Ethics Filter Committee. The study also underwent ethical review by the Office for Research Ethics Committees Northern Ireland (ORECNI) and a favourable ethical opinion was obtained. Permission was also sought from the Hospital Research Committee and access was granted. Implied consent was assumed for the questionnaire when participants completed and returned it. Consent to participate in the one to one interviews was sought by asking willing participants to complete a section on the questionnaire seeking their support and requesting their contact details. Confidentiality of all data including that obtained from the interviews was guaranteed and all data was annonymised and stored under lock and key. Permission to use quotes for reporting was obtained at interview. Transcripts were reviewed by the research team only.
Sample The sampling strategy utilised in this study was purposive sampling. The total population of midwives and doctors who had worked in the labour ward during the past 12 months in a consultant-led NHS Trust Hospital (with an annual childbirth rate of approximately 3500) were accessed (n ¼56 midwives and n ¼19 doctors). A response rate of 53% was achieved (n ¼29 midwives, 51.8% of the midwives group and 11 doctors, 57.9% of the doctors group). Table 1 provides demographic details of the participants. 70% (n ¼20 midwives and eight doctors) of the participants who completed the questionnaire gave their consent to being interviewed at a later date. Purposive sampling was also used to obtain the sample for the qualitative aspect of this research. The researcher selected two participants from each of the age ranges, 20–29, 30–39, 40–49 and 50–59 years. The selected participants were thought to best represent the research area and be typical of the total population (Fain, 2004). Their length of working experience in the labour ward environment ranged from five months to 15 years. A total of six midwives and two doctors were interviewed.
Data collection and analysis Using the hospital internal post, a questionnaire was posted out to the total sample of midwives and doctors. Participants were asked to complete and return the questionnaire to the researcher within two weeks. After two weeks a reminder letter was sent to all participants. After a further two weeks the researcher conducted a descriptive statistical analysis of the quantitative data using Statistical Package for the Social Sciences (SPSS v 11). Simple descriptive statistics that included the use of frequency distributions, frequency counts and percentages were used to elucidate the
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Table 1 Demogrphic profile of the participants. Demographics Age
Grade
Years of labour ward experience
Midwives n¼ 29
Doctors n ¼ 11
20–29 years n ¼4 30–39 years n ¼11 40–49 years n ¼12 50–59 years n ¼2 60+ years n¼ 0
20–29 years n¼3 30–39 years n¼3 40–49 years n¼2 50–59 years n¼2 60+ years n¼ 1
Band 5 n ¼3 Band 6 n¼ 22 Band 7 n ¼4
Consultant n¼ 6 Registrar n ¼2 SHO n¼ 2 GP trainee n¼ 1
0–5 years n¼ 5 5–10 years n ¼2 10–15 years n ¼6 15–20 years n ¼4 20–25 years n ¼8 25–30 years n ¼4
0–5 years n ¼2 5–10 years n¼3 10–15 years n¼2 15–20 years n¼1 20–25 years n¼1 25–30 years n¼2
findings from within the data. The researcher also used measures of variability in the form of standard deviations to describe how spread apart values are in a distribution of values (Nieswiadomy, 2008). Four weeks after the questionnaires were collected the researcher conducted eight taped semi-structured interviews in a private office in the workplace. The interview format was structured around the responses to the questionnaire and issues identified from the current literature relating to CTG monitoring. The interview process lasted on average 20–30 minutes and took place over two weeks. Before the interview commenced, written consent was obtained. Due to the exploratory nature of this study the participants were made aware from the start that they could withdraw from the study at any stage. Participants had an opportunity to review the transcripts at a later date enabling the researcher to gain agreement that the transcripts provided a true reflection on what had been discussed. A thematic analysis was carried out on the interviews transcripts and illustrative written accounts in order to identify themes, patterns and concepts. Expert opinion was also obtained to verify analysis.
Findings from the questionnaire The overall sample was 29 (72.5%) midwives and 11 (27.5%) doctors. The results indicated a largely positive attitude towards CTG usage with 72.5% (n¼29) of the respondents totalling a score of 75 and over (maximum score being 115) (see Table 2). An independent t-test failed to reject the null hypothesis that there are no differences between doctors’ and midwives’ attitudes towards CTG in labour ward practice (t¼ 3.9 at p¼0.05, CV¼2.02). A number of items had substantial majority responses of 65% or more. These substantial majorities represent definitive positions being taken by the doctors and midwives who participated in the study. In particular, 90% (n ¼36) disagreed that CTG was essential for ensuring successful deliveries, while 82.5% (n ¼33) of the population agreed that CTG can lead to unnecessary intervention. It is interesting to note that the majority of doctors (n¼ 7, 63.6%) disagreed with this statement. This disagreement between the two professional groups indicates differing opinions on some of the benefits of CTG. Interestingly a majority (72.5% n¼29) of the respondents disagreed that CTG undermined their skills. The large majority of the respondents (87.5% (n¼35) felt confident about interpreting cardiotocograph (n ¼26, 89.6% of midwives, n¼9, 81.8% of doctors). However, while 60.0% (n ¼24) of the respondents felt that their training adequately prepared them for CTG usage, almost half of the population of midwives (n ¼14, 48.3%) felt unprepared for CTG usage following their training.
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Table 2 Attitudes towards CTG usage. Item statements
D (%)
U (%)
A (%)
1. I believe CTGs can lead to unnecessary medical intervention 2. I could not imagine working without a CTG being available in case an emergency arises 3. I feel CTGs are so routine, they are virtually invisible during a birth 4. I do not like using CTGs 5. I think using any technology in childbirth is undesirable 6. I think CTGs undermine my own skills 7. I like using CTGs 8. I believe that using a CTG increases a mother’s anxiety 9. I feel I can routinely monitor the CTG signals without being distracted from the mother 10. I think CTGs are a major benefit to midwives 11. I believe CTGs can give rise to the wrong decisions being made 12. I only use a CTG when it is absolutely necessary 13. I think the CTG distracts attention away from the mother 14. I always trust the CTG’s readouts over my own observations 15. I think medical/midwifery colleagues rely too much on CTGs 16. I believe midwives’/doctors skills are undermined by over-reliance on CTGs 17. I think CTGs are vital in helping a midwife/doctor to decide when medical intervention is needed 18. I feel vulnerable if a CTG is not available 19. I rely on the CTG when I am not sure what is happening 20. I think CTGs spoil the beauty of a birth 21. I don’t feel entirely confident in my ability to use a CTG 22. I believe CTGs are essential for ensuring successful deliveries 23. I always trust my own judgement even when the CTG gives contrary indications 24. I believe CTGs are essential when labour is being induced 25. I feel that CTGs are often used unnecessarily
10 45 82.5 67.5 82.5 72.5 30 20 30 37.5 12.5 30 45 80 20 25 35 67.5 60 57.5 87.5 90 52.5 37.5 15
7.5 20 7.5 17.5 12.5 10 35 30 10 22.5 17.5 5 10 12.5 17.5 12.5 15 15 7.5 7.5 2.5 5 32.5 25 15
82.5 35 10 15 5 17.5 35 50 60 40 70 65 45 7.5 62.5 62.5 50 17.5 32.5 35 10 5 15 37.5 70
D ¼% disagree and strongly disagree, U ¼% undecided, A ¼% agree and strongly agree.
Responses from open ended questions At the end of the questionnaire, the participants were given the opportunity to recall an incident where the use of CTG monitoring involved collaboration between doctors and midwives. There were 32 responses to this question (28%, n ¼9 doctors and 72%, n ¼23 midwives). Of those, 22 (68.8%) respondents (n ¼9 doctors and 13 midwives) felt that the involvement of the multidisciplinary team had a positive influence on the incident. The following themes were identified:
multidisciplinary team ‘yhad a positive influence as the midwives’ concerns and clinical judgment backed with CTG abnormalities lead to the medical decision for caesarean section’ (Respondent number 10 (doctor)). Impact of CTG on the mother It was generally thought that the use of CTG ‘yshould be done with the mother and infant as the focus of care’ (Respondent number seven (doctor)). One respondent considered the mothers opinion of CTG to be: ‘‘yinitially intrusive and worrying when interpretation showed the possibility of fetal distress. However, it is reassuring when normal patterns are present.’’ (Respondent number 27 (midwife)).
1. The role of CTG in monitoring and detecting abnormalities. 2. Importance of effective teamwork. 3. Impact of CTG on the mother.
The role of CTG in monitoring and detecting abnormalities The role that CTG plays appears to be primarily: ‘‘y to reassure midwifery and medical staff that all is well with the baby’’ (Respondent number 2 (midwife)). However, this is limited to how well the information obtained from the CTG is interpreted by the professionals. CTG was viewed in a positive light when clinicians ‘‘y did not trust the CTG tracing alone but as part of the clinical information available’’ (Respondent number 7 (doctor)). Importance of effective teamwork The respondents who responded negatively reported examples of poor teamwork and poor levels of agreement between doctors and midwives. Respondent number four (midwife) stated ‘I feel the outcome was poor because appropriate action was not taken despite the midwives being unhappy with the trace’. However, reassuringly in the majority of cases there appeared to be good levels of agreement between the professionals. Indeed, in one case where there was a presence of a number of risk factors and a nonreassuring fetal heart tracing the respondent involved felt that the
CTG was frequently seen as increasing mother’s anxiety levels particularly when there were poor levels of agreement with staff ‘ymothers and partners may be aware of your concerns and as a midwife you have to reassure them even though the doctor is not concerned’ (Respondent number, 33 (midwife)). On the other hand in an instance were there was good levels of agreement and the CTG was used in conjunction with fetal blood sampling ‘ymother and father were aware of why the decision for caesarean was made and they were happy with the decisions and outcomes’ (Respondent number 13 (doctor)).
Findings from the interviews A sample of six midwives and two doctors participated in the interviews. The common themes which were identified from the participant’s responses are as follows: 1. 2. 3. 4.
Determining appropriate usage. Reaching a decision. Professional concerns. The way forward.
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Determining appropriate usage
Professional concerns
The use of CTG monitoring was considered to be appropriate for mothers who had identified risk factors and it emerged that participants practice was guided by local policy and guidelines. However, these policies and guidelines were generally viewed more positively by the more junior staff ‘I would rely on the policies and guidelines of this unit to help me decided if the CTG is required (Interviewee seven (midwife))’. One more experienced midwife recalled how she would ‘yuse my (her) judgment, it all depends on the timing if I felt she was going to deliver quickly I would give it a miss’ (Interviewee 2). The participants reported that CTG monitoring was also used to provide reassurance. The ‘yability to hear the fetal heart in the background’ (Interviewee 7(midwife)) seemed to provide reassurance for the labouring mother and staff members attending to her. This may result in CTG monitoring being used too frequently. However, there was a general feeling that they are not used ‘yas inappropriately as they used to be, there seems to be more awareness now for not using them for low risk mothers’ (Interviewee two (midwife)).
All the respondents expressed concern that there is limited evidence to support the use of CTG and it was reported that ‘ythey (CTG’s) are necessary because we don’t have a superior tool’ (Interviewee four (doctor)). Furthermore, Interviewee four (doctor) stated that ‘ythey often indicate a problem when in fact there isn’t one’. An illustration is provided by the following commentary:
Reaching a decision Respondents acknowledged that specialised skills are required to interpret CTG with all but one of the participants acknowledging that they had the necessary skills and knowledge to effectively interpret these CTG tracings. Practice was seen as an important way to develop skills in CTG interpretation and use: ‘ywe learn every day we use a CTG and we develop our skills from that experience’ (Interviewee eight (midwife)). One respondent who was aware of a knowledge deficit in CTG interpretation compensated for this by relying ‘y heavily on the more experienced members of the team’ (Interviewee seven (midwife)). The use of joint multidisciplinary policies and guidelines and a fetal heart scoring system was seen as a way in which to ensure that ‘yeveryone is interpreting CTG in the same way so hopefully there will be less variation in what the midwife says and what the doctor says’ (Interviewee two (midwife)). The midwives in particular felt that this scoring system enabled them to discuss their concerns about a fetal heart tracing in a systematic manner. Interviewees felt that concerns must be directed through the appropriate lines of communication: ‘‘If a midwife has concerns about a CTG she will discuss it with the sister, if the sister is unhappy she will discuss it with the SHO or the registrar who then makes a decision whether to do something or discuss it with the consultant.’’ (Interviewee 4 (doctor)). Therefore it would appear that CTG interpretation requires effective communication and collaboration at every level. Fortunately the participants agreed that conflict and disagreements were not a regular occurrence but they had developed different strategies to overcome it: ‘‘You may suggest performing a fetal blood sample but even if they don’t want to do that you can suggest stopping the syntocinon or changing the mother’s position.’’ (Interviewee 8 (midwife)). In keeping with the finding from the questionnaire it is clear that the interviewees are aware that the ability to reach a decision on a fetal heart tracing is limited to how well the information is interpreted by the professional. Tools such as fetal heart scoring systems will assist professionals in the interpretation of CTG tracing. However, how individuals communicate the concerns regarding a CTG tracing can ultimately determine the outcome.
‘‘I definitely think a lot of women end up with forceps or vacuums because of CTG concerns that wouldn’t necessarily have warranted it’’ (Interviewee 8 (midwife)). This was seen as having an impact on maternal choices as: ‘‘yoften women are disappointed because they have not achieved the birthing experience that they may of wished for’’ (Interviewee 7 (midwife)). The interviewees also commented on the fact that this increase in intervention could have a negative impact on their professional skills: ‘‘I think midwives end up in situations were an instrumental delivery could have been a normal delivery and I think that reduces midwives skills’’ (Interviewee 6 (midwife)). All the interviewees agreed that ‘inappropriate use and being used on low risk women when there is no indication’ (Interviewee two (midwife)) continues to be a big concern. The interviewees felt that this stemmed from inexperience and lack of knowledge which was another concern relating to CTG usage. This lack of knowledge was also seen to be a problem when abnormalities in the fetal heart are identified: ‘‘Staff need adequate training so when they do identify a problem they know to inform senior staff’’ (Interviewee 2 (midwife)). This concern is worrying in that it can result in a delay in intervention which may put the fetal well-being at risk. The way forward The interviewees called for more training in CTG usage particularly for junior members of staff. All of the participants agreed that doctors and midwives should be educated together in CTG interpretation ‘so that everyone is singing from the same hymn sheet’(Interviewee four (doctor)). There was also a call for professionals to ‘ytrust their skills more and be more confident using intermittent auscultation’ (Interviewee one (midwife)). This was seen as providing an alternative to CTG monitoring. There was also a call to increase the knowledge base on CTG: ‘‘your practice regarding CTG could be improved by increasing our knowledge through auditing our practices and conducting more research in this area’’ (Interviewee 5 (midwife)). It was believed that more research ‘will improve our technology to monitor the fetus in labour ‘(Interviewee four (doctor)).
Discussion of findings The objective of this study was to identify midwives’ and doctors’ attitudes towards the use of CTG technology in labour
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ward practice. In order to synthesise and provide a deeper understanding the main findings of this study will be discussed with the relevant literature. While 60.0% (n ¼24) of the respondents felt that their training adequately prepared them for CTG usage under half of the population of midwives (n¼14, 48.3%) felt unprepared for CTG usage following their training. This corresponds with studies conducted by Pelletier (1995) and Clarke and Holmes (2007). The majority of participants who were interviewed felt that they had obtained the skill to effectively use this equipment through experience and not through their training. It is interesting to note that while the majority of midwives and doctors felt confident in their skills at interpreting CTG it emerged from the interviews that there were times that midwives needed reassurance from doctors and other colleagues when reaching a decision regarding a CTG tracing. Sinclair (2000) argues that competence increases confidence which in turn promotes autonomy. Multiprofessional education and training for doctors and midwives to use CTG technology was one of the recommendations from Sinclair’s original study in 2001 and nine years later it was evident that this recommendation still has validity and relevance. In order to assist staff in making decisions, employers devise policies and guidelines in order to guide staff. It emerged from the interviews that practice relating to CTG usage was guided by policy and guidelines. However, in a survey of guidelines for intrapartum electronic fetal monitoring in low risk mothers the majority of these guidelines were poorly appraised by the reviewer which has implications for the delivery of evidence based care (Hinsliff et al., 2004). It is also seen that sometimes these policies can conflict with the professional’s ability to be an autonomous practitioner. Benner (1984) explains that expert midwives and nurses have almost an intuitive grasp of each patient situation and a certain level of experience enables practitioners to make decisions on an intuitive basis. There were times when the participants based their decisions regarding fetal monitoring on their experiences and intuition. Therefore, while standardising guidelines and policies may be viewed as restrictive and an obstacle to individualised care the aim is to provide parameters and guideposts which will enable safe and competent practice (Buckley and Dunn, 2000). Responses to the attitude scale indicated a largely positive attitude toward CTG technology. Despite differences in training and philosophies an independent t-test demonstrated that there were no differences between midwives’ and doctors’ attitudes towards CTG technology. There may be a couple of explanations for this. Most of the doctor respondents were consultants and registrars and their familiarity of CTG technology may have influenced the responses. One other possible explanation is that the policies relating to CTG monitoring in this unit involved an input from both doctors and midwives and all the professionals used a common scoring system when interpreting the fetal heart rate patterns. This may allow for a more unified practice however, more research is required in this area. It is interesting to note that midwives and doctors differed on their opinions relating to the statement CTG can lead to unnecessary intervention. This disagreement between the two professional groups may indicate differing perspectives on birth technologies such as CTG monitoring (Davis-Floyd, 1994). The illustrative incidents demonstrated that generally communication and collaboration between the two professions was effective. However, those incidents which were viewed as negative displayed examples of poor teamwork and poor levels of agreement. This concurs with previous studies which concluded that the effectiveness of CTG technology continues to be hampered by inconsistencies in interpretation of the fetal heart tracings (Zain et al., 1998; Ayres-de-Campos et al., 1999; Bracero et al., 2000). The interviewees believed that the use of the scoring system did go
some way to providing a uniformity in interpretation. It is interesting to note that Bracero et al. (2000) found that when clinicians used a fetal heart rate scoring system to classify the tracings the agreement was poor. Hindley et al. (2005) also noted that a multidisciplinary group had a low level of agreement when using a newly designed tool to appraise fetal monitoring guidelines. This may indicate as stated by Ullman et al. (2004) that practitioners from different background vary in their interpretation of such tools. However, the midwives felt that this scoring system provided them with a systematic tool for voicing any concerns they may have regarding a fetal heart tracing thereby improving communications with doctors. Sometimes these disagreements did give rise to situations of conflict. The interviews revealed that this situation was viewed by the interviewees as undesirable and interventions were often introduced by the midwives in order to resolve the situation. It was hoped that if doctors and midwives received more training together in CTG usage and interpretation it would reduce the incidence of these situations. Crowe and Smith (2003) found that this type of education can enhance shared understanding and interprofessional collaboration. The participants also felt that joint training in cardiotocograph monitoring will result in a more uniform practice and interpretation of fetal heart tracings. Those who were interviewed demonstrated awareness and expressed concern that the use of CTG has not been shown to be more effective than intermittent auscultation in lowering perinatal mortality rates (MacDonald et al., 1985; Haggarty, 1999; Thacker et al., 2001) and thus its use in labour ward practice was frequently questioned. While it was generally accepted that CTG had a role in monitoring the labours of women who were considered to be in the high obstetric risk category none of the participants felt that its use was appropriate for low risk mothers. The respondents felt that by conducting more research on cardiotocograph it may improve practice and knowledge on fetal monitoring. Analysis of the multidisciplinary incidents revealed that the use of CTG should be done with the mother and infant as the focus of care. Also, CTG monitoring was sometimes viewed as dehumanising and depersonalising patient care. This has been viewed as a criticism of the use of technology in health care (Cooper, 1993; Barnard and Sandelowski, 2001). The respondents in the interviews argued that this often had an adverse effect on the birthing atmosphere and in how relationships evolved between the mother and the professionals. The interviewees had observed in their practice that CTG monitoring generally resulted in an increase in interventions in labour which echoes findings by Tracey and Tracy (2003). This increase in intervention was viewed by the respondents as limiting the mother’s choice in labour and altering her birthing experiences. It also emerged during the interviews that this increase in intervention may result in an erosion of their professional skills. Barnard and Gerber (1999) argued that while technology stimulates the need to acquire new skills it will alter and de-emphasise certain existing skills. In order to prevent this erosion of skills the interviewees suggested that skills are updated in other methods of fetal monitoring especially intermittent auscultation so practitioners can be confident performing it.
Limitations The sampling strategy and the sample size used in this study are acknowledged by the researcher as one of the limitations of this study. As is the case with any purposive sample, the sample chosen may not be representative of the population. Purposive sampling was used to obtain the sample for the interviews and the researcher selected these individuals from a group of volunteers. It could be argued that these volunteers may have a specific interest in the
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topic under discussion and therefore may not necessarily represent the views of the general population. Another limitation to this study was that the researcher was a midwife who worked in this unit and therefore was known to the participants. This may have created a form of bias and the participants may have felt inclined to mould their responses to an already known criterion.
Conclusion The study highlighted a number of issues relating to CTG usage. The findings from this study indicated that both the midwives and the doctors who participated in this study would benefit from attending joint training on fetal heart rate monitoring and interpretation. This could be facilitated by providing workshops on CTG usage and interpretation in order to update staff thereby improving communication and collaboration. This may also improve midwives’ confidence levels in using and interpreting CTG tracings. The respondents also called for more in-depth training for student midwives and doctors. Although this study has certain limitations the findings of this study do present insights into midwives’ and doctors’ perceptions and attitudes towards CTG usage in labour ward practice. The objective of this study was achieved and the findings were substantially supported by previous studies identified in the literature. This adds weight to the findings of this study. As a result of carrying out this study a number of recommendations have become apparent which can only serve to improve and enhance current practice. Information obtained from this study could provide a useful base for studies with a wider remit that would be more representative of the general population.
Acknowledgements The authors would like to thank the hospital management who facilitated access for the study. We also thank the midwives and doctors who despite the demands of their personal and working lives found the time to participate in this study. References Alfirevic, Z., Devane, D., Gyte, G.M., 2006. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews. Ayres-de-Campos, D., Bernardos, J., Costa-Pereira-Leite, L., 1999. Inconsistencies in classification by experts of cardiotocogram subsequent clinical decision. British Journal of Obstetrics and Gynaecology 106, 1307–1310. Barclay, L., Jones, L., 1996. Midwifery Trends and Practice in Austrailia. Churchill Livingstone, London. Barnard, A., Gerber, R., 1999. Understanding technology in contemporary surgical nursing: a phenomenographic examination. Nursing Inquiry 6, 157–166. Barnard, A., Sandelowski, M., 2001. Technology and humane nursing care: (ir) reconcilable or invented difference? Journal of Advanced Nursing 34, 367–375. Benner, P., 1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Wokingham. Bracero, L.A., Roshanfekr, D., Byrne, D.W., 2000. Analysis of antepartum fetal heart tracing by physician and computer. Journal of Maternal Fetal Medicine 9, 181–185. Buckley, E.R., Dunn, N.J., 2000. Delivering quality in midwifery practice and education. In: Fraser, D. (Ed.), Professional Studies for Midwifery Practice. Churchill Livingstone, Edinburgh, pp. 179–197. Clarke, T., Holmes, S., 2007. Fit for practice? An exploration of the development of newly qualified nurses using focus groups. International Journal of Nursing Studies 44, 1210–1220. Confidential Enquiry into Maternal and Child Health, CEMACH, 2009. Perinatal Mortality 2007, United Kingdom. CEMACH, London. Cooper, M.C., 1993. The intersection of technology and care in the ICU. Advances in Nursing Science 15, 23–32. Cowie, J.L., Floyd, S.R., 1998. The art of midwifery: lost to technology? Australian College of Midwives Incorporated Journal 11, 20–24. Crowe, J., Smith, L., 2003. Using co-teaching as a means of facilitating interprofessional collaboration in health and social care. Journal of Interprofessional Care 17, 45–55.
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(Eds.), Cochrane Pregnancy and Childbirth Database. Update Software, Oxford. Haggarty, L.A., 1999. Continuous electronic fetal monitoring: contradictions between practice and research. Journal of Obstetric, Gynecologic, and Neonatal Nursing 28, 409–416. Hindley, C., Hinsliff, S.W., Thomson, A.M., 2005. Developing a tool to appraise fetal monitoring guidelines for women at low obstetric risk. Journal of Advanced Nursing 52, 307–314. Hindley, C., Hinsliff, S.W., Thomson, A.M., 2006. English midwives views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: conflicts and compromises. Journal of Womens Health 51, 354–360. Hindley, C., Hinsliff, S.W., Thomson, A.M., 2008. Pregnant women’s views about choice of intrapartum monitoring of the fetal heart rate: a questionnaire survey. International Journal of Nursing Studies 45, 224–231. Hindley, C., Thompson, A.M., 2007. Intrapartum fetal monitoring and the spectre of litigation. 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Intrapartum auscultation of the fetal heart rate. American Journal of Obstetric and Gynaecology 3, 935–936. Symonds, E.M., 1994. Fetal monitoring: medical and legal implications for the practitioner. Current Opinion in Obstetrics and Gynaecology 6, 430–433. Thacker, S.B., Strong, D., Chang, M., 2001. Continuous electronic heart rate monitoring for fetal assessment during labour (Cochrane Review). /http://www.update-soft ware.com/publications/CochraneS (last accessed 13 February 2005). Tracey, S.K., Tracey, M.B., 2003. Costing the cascade: estimating the cost of increased obstetric interventions using the population data. British Journal of Obstetrics and Gynaecology 110, 717–724. Ullman, R.M., Yiannouzis, K., Gomme, C.G., 2004. Testing a tool to assess perineal trauma. British Journal of Midwifery 12, 93–100. Vincent, C., Davey, C., Esmail, A., et al., 2004. Learning from Litigation: An Analysis of Claims for Clinical Negligence. University of Manchester, Manchester. Vintzileos, A.M., Antsaklis, A., Varvarigos, I., et al., 1993. A randomised trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation. Obstetrics and Gynaecology 81, 899–907. Williams, K., Umberson, D., 1999. Medical technology and childbirth: experiences of expectant mothers and fathers. Sex Roles 41, 147–168. World Health Organisation, 1997. Care in Normal Birth: Report of a Technical Working Group. WHO, Geneva. Zain, H.A., Wright, J.W., Parrish, G.E., et al., 1998. Interpreting the fetal heart tracing. Effect of knowledge and neonatal outcome. Journal of Reproductive Medicine 43, 337–367.
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Midwifery journal homepage: www.elsevier.com/midw
Midwives’ and doctors’ attitudes towards the use of the cardiotocograph machine Sarah McKevitt, MSc, BSc (Hons), RGN, RM (Clinical Team Leader, Labour Ward)a,, Patricia Gillen, PhD, PG Dip Nurs Ed, MSc, BSc, RM, RGN (Lecturer)b, Marlene Sinclair, PhD, Med, DASE, BSc RNT, RM, RN (Professor of Midwifery Research)c a
South Eastern Health and Social Care Trust, Upper Newtownards Road, Dundonald BT16 1RH, UK School of Nursing, University of Ulster, Shore Road, Newtownabbey BT37 0QB, UK c Institute of Nursing Research, University of Ulster, Shore Road, Newtownabbey BT37 0QB, UK b
a r t i c l e in f o
abstract
Article history: Received 26 October 2009 Received in revised form 23 September 2010 Accepted 13 November 2010
The appropriate use of the cardiotocograph (CTG) machine in the clinical setting is an issue of concern for midwives and doctors. Objective: to examine midwives and doctors attitudes towards the use of the CTG machine in labour ward practice. Background: this small study provides new insight into the attitudes of doctor and midwives towards the use of CTG. Design: an exploratory descriptive design that used a combination of qualitative and quantitative approaches. A valid and reliable tool designed by Sinclair (2001) was used to measure the attitudes of doctors and midwives towards CTG usage. In addition, follow-up semi-structured interviews with doctors and midwives were conducted. Setting: a maternity unit in Northern Ireland. Participants: participants selected had worked in the labour ward within the last year (n ¼ 56 midwives; n ¼ 19 doctors). Six midwives and two doctors were randomly selected to participate in the interviews. Findings: the study demonstrated a favourable disposition towards the use of CTG machines with 72.5% (n ¼29) of respondents indicating that they viewed CTG technology positively and 87.5% (n ¼ 25) indicating they were confident about their skill in interpreting CTG tracings. The majority of the respondents (60.0%, n ¼ 24) felt that their training adequately prepared them for using CTGs. The illustrative accounts provided by the respondents demonstrated a predominant belief that CTG technology continues to have a role in monitoring and detecting abnormalities in the fetal heart rate but this role is limited by how well the CTG is used and interpreted. The interviews confirmed the data obtained from the questionnaires and revealed a number of professional needs and concerns relating to CTG usage. Implications for practice: the implication of this study may be focused on addressing the training needs of students, newly qualified staff and regular updates for employed staff. There was some concern that this technology may be deskilling staff and therefore there is a need to improve confidence levels in using alternatives to this type of fetal monitoring. & 2010 Elsevier Ltd. All rights reserved.
Keywords: Fetal monitoring Cardiotocograph monitoring Birth technology
Introduction Cardiotocograph monitoring (CTG) is one of the most commonly used technologies in labour ward practice. The safe use of this technology is of prime concern to midwives and obstetricians but studies frequently show that the levels of agreement in the usage
Corresponding author.
E-mail addresses: [email protected] (S. McKevitt), [email protected] (P. Gillen), [email protected] (M. Sinclair). 0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2010.11.003
and interpretation of CTG fetal heart tracings is poor among professionals (Strong and Jarles, 1993; Bracero et al, 2000; Freeman, 2002; Devane and Lalor, 2005). These difficulties will affect the manner in which midwives and obstetricians respond to the challenges posed by variations in CTG fetal heart patterns, which in turn will impact on the indications and timings of subsequent interventions. This has implications for multidisciplinary collaboration in labour ward practice. The need for consensus regarding the use and interpretation of CTG is essential to safe and collaborative practice and will ultimately improve multidisciplinary relations between midwives
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and obstetricians (Fox et al., 2000). However, the Confidential Enquiry into Maternal and Child Health (2009) has attributed poor communication and interprofessional collaboration to maternal and infant mortality and morbidity. It is important for midwives and obstetricians to develop more understanding of each other’s attitudes toward the use of CTG in labour ward practice so that development of evidence informed guidelines and implementation of these is a multidisciplinary collaboration. This paper will present the main findings from a study on the practice of using CTG technology in labour ward practice and will build on previous research reported by Sinclair (2001). Many aspects of practice have changed in the past 10 years and some of this is due to the implementation of the National Institute for Health and Clinical Excellence (2007) Guidelines on Fetal Monitoring which provided clear guidelines on how cardiotocograph monitoring should be used. Therefore, research reporting data from both midwives’ and doctors’ attitudes towards the CTG are both timely and relevant.
Literature search A literature search was initiated using the following terms: technology, health technology, birth technology, fetal monitoring, electronic fetal monitoring and cardiotocograph (CTG) monitoring using the following databases CINHAL, Pubmed and MIDIRS. The search was limited to the English Language with a time span 1999–2009, although some seminal pieces prior to this date were reviewed. The search strategy also involved consultation with experts in this field.
Literature review Within labour wards the use of the CTG has become widely used to assess fetal well-being in labour but subsequent randomised controlled trials have failed to find any benefit of CTG monitoring over intermittent auscultation (Vintzileos et al., 1993; Thacker et al., 2001; Larma et al., 2007). In fact the use of the CTG has been shown to increase the rate of interventions used in labour (Grant, 1993; Mires et al., 2001; Alfirevic et al., 2006). These increasing levels of interventions have altered the manner in which midwives and obstetricians now care for all women in labour. In response to this, the World Health Organisation has raised concerns that due to this increasing medicalisation of childbirth there has been an erosion of midwifery and obstetric skills and confidence (World Health Organisation, 1997). However, some professionals have embraced health technology and according to Barnard and Gerber (1999) this association with technical knowledge and skill has been a source of increased prestige and power for nurses and midwives. Sandelowski (2000) found that the introduction of the CTG was seen as improving communication and reducing tensions between the nurse and clinician as it produced visual evidence of events that had occurred when the doctor was not present. However, this can be difficult if there is poor consensus of opinion on how these CTG traces are interpreted. Differences among providers in fetal heart rate interpretation and management have been cited by Symonds (1994) as a factor in morbid outcomes and costly litigation. Vincent et al. (2004) state that obstetric claims account for over 70% of all NHS litigation expenses with an average cost of cerebral palsy cases of £1.5 million. Over 85% of these cerebral palsy cases are associated with abnormalities of fetal heart monitoring (Vincent et al., 2004). However, Hindley and Thompson (2007) found that midwives’ knowledge of the evidence relating to CTG monitoring was superimposed by a perception that by using this type of monitoring it would provide a legal defence in the event of litigation.
Cowie and Floyd (1998) argue that this may be at the expense of women-centred care as the use of technology removes professionals from the naturalness and human dimensions of childbirth. Indeed studies have shown that the use of technology can impede care by alienating and dehumanising both nurse and patient (Cooper 1993; Davis-Floyd, 1994; Hindley et al., 2006). Barclay and Jones (1996) have argued that technology has been employed to regain power and control over women. Alternatively not all women view interventions as a negative aspect of labour and some women and their partners expect to see technology and are comforted by its presence (Williams and Umberson 1999; Sinclair, 2000; Hindley et al., 2008). The literature review revealed that there is a lack of empirical knowledge relating to attitudes towards the use of CTG in labour ward practice. Dover and Gauge (1995) carried out a descriptive correlational study to survey midwives’ attitudes and practices related to intrapartum fetal monitoring and findings indicated that midwives’ preferred methods of monitoring varied with the clients risk category. However, the study demonstrated that midwife preference did not necessarily match the actual choice of method. Many factors influenced choice in particular confidence in the equipment and confidence in one’s own ability to choose the correct method of fetal monitoring. In a later study, Sinclair (2001) examined the attitudes of midwives who had worked in labour ward. The results show that midwives rejected the notion that they were becoming too dependent on the use of CTG machines in their practice. However, midwives who trust the machines are more predisposed to their use and trust is affected by perceived competence. Reime et al. (2004) examined maternity care provider group’s attitudes towards birth and found that obstetricians were the most attached to technology and interventions, midwives the least and family clinicians fell in the middle. When asked about continuous CTG monitoring the study showed that midwives and family clinicians had attitudes/beliefs more in line with current evidence than obstetricians. The accessed literature draws attention to the fact that there is a wide range of perspectives to the use of CTG technology in labour ward practice. It highlights factors that may contribute to midwives and doctors forming certain attitudes towards this technology which may ultimately affect the manner in which that individual responds to it in practice. The numbers of studies that specifically attempt to examine attitudes to CTG are relatively few in number. Thus, it is evident that there is a need to build on the data obtained by Sinclair (2001) and generate new knowledge by involving doctors.
Design and method This was an exploratory descriptive study undertaken as part of a Masters degree in Midwifery by the first author. The design combined qualitative and quantitative approaches and used a validated questionnaire with a Cronbach’s a of 0.78% designed by Sinclair (2001) to measure attitudes towards the CTG. This questionnaire was adapted to collect new information related to incidents where the use of CTG involved collaboration between doctors and midwives. Semi-structured interviews were conducted with midwives and doctors to allow the researcher to further explore and understand the issues for practitioners using the CTG in labour ward practice.
Pilot work A pilot study was conducted because the questionnaire was adapted to include obstetricians from a previously validated
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questionnaire by Sinclair (2001). A sample of four midwives and two doctors was obtained for the pilot study and the response rate was 100%. These participants were not included in the main study. Feedback from these participants was positive but the participants reported difficulties in understanding question 20. These difficulties were noted and the wording of the question was altered to ensure the question was more easily understood. In order to detect any potential for researcher bias in the interview process a small pilot study with three volunteers was performed. It is also important to take steps to ensure that the questions were open and exploratory so that the responses were not guided in a particular direction.
Ethical issues The ethical issues involved in this study were subject to internal review by the University of Ulster Student Research Ethics Filter Committee. The study also underwent ethical review by the Office for Research Ethics Committees Northern Ireland (ORECNI) and a favourable ethical opinion was obtained. Permission was also sought from the Hospital Research Committee and access was granted. Implied consent was assumed for the questionnaire when participants completed and returned it. Consent to participate in the one to one interviews was sought by asking willing participants to complete a section on the questionnaire seeking their support and requesting their contact details. Confidentiality of all data including that obtained from the interviews was guaranteed and all data was annonymised and stored under lock and key. Permission to use quotes for reporting was obtained at interview. Transcripts were reviewed by the research team only.
Sample The sampling strategy utilised in this study was purposive sampling. The total population of midwives and doctors who had worked in the labour ward during the past 12 months in a consultant-led NHS Trust Hospital (with an annual childbirth rate of approximately 3500) were accessed (n ¼56 midwives and n ¼19 doctors). A response rate of 53% was achieved (n ¼29 midwives, 51.8% of the midwives group and 11 doctors, 57.9% of the doctors group). Table 1 provides demographic details of the participants. 70% (n ¼20 midwives and eight doctors) of the participants who completed the questionnaire gave their consent to being interviewed at a later date. Purposive sampling was also used to obtain the sample for the qualitative aspect of this research. The researcher selected two participants from each of the age ranges, 20–29, 30–39, 40–49 and 50–59 years. The selected participants were thought to best represent the research area and be typical of the total population (Fain, 2004). Their length of working experience in the labour ward environment ranged from five months to 15 years. A total of six midwives and two doctors were interviewed.
Data collection and analysis Using the hospital internal post, a questionnaire was posted out to the total sample of midwives and doctors. Participants were asked to complete and return the questionnaire to the researcher within two weeks. After two weeks a reminder letter was sent to all participants. After a further two weeks the researcher conducted a descriptive statistical analysis of the quantitative data using Statistical Package for the Social Sciences (SPSS v 11). Simple descriptive statistics that included the use of frequency distributions, frequency counts and percentages were used to elucidate the
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Table 1 Demogrphic profile of the participants. Demographics Age
Grade
Years of labour ward experience
Midwives n¼ 29
Doctors n ¼ 11
20–29 years n ¼4 30–39 years n ¼11 40–49 years n ¼12 50–59 years n ¼2 60+ years n¼ 0
20–29 years n¼3 30–39 years n¼3 40–49 years n¼2 50–59 years n¼2 60+ years n¼ 1
Band 5 n ¼3 Band 6 n¼ 22 Band 7 n ¼4
Consultant n¼ 6 Registrar n ¼2 SHO n¼ 2 GP trainee n¼ 1
0–5 years n¼ 5 5–10 years n ¼2 10–15 years n ¼6 15–20 years n ¼4 20–25 years n ¼8 25–30 years n ¼4
0–5 years n ¼2 5–10 years n¼3 10–15 years n¼2 15–20 years n¼1 20–25 years n¼1 25–30 years n¼2
findings from within the data. The researcher also used measures of variability in the form of standard deviations to describe how spread apart values are in a distribution of values (Nieswiadomy, 2008). Four weeks after the questionnaires were collected the researcher conducted eight taped semi-structured interviews in a private office in the workplace. The interview format was structured around the responses to the questionnaire and issues identified from the current literature relating to CTG monitoring. The interview process lasted on average 20–30 minutes and took place over two weeks. Before the interview commenced, written consent was obtained. Due to the exploratory nature of this study the participants were made aware from the start that they could withdraw from the study at any stage. Participants had an opportunity to review the transcripts at a later date enabling the researcher to gain agreement that the transcripts provided a true reflection on what had been discussed. A thematic analysis was carried out on the interviews transcripts and illustrative written accounts in order to identify themes, patterns and concepts. Expert opinion was also obtained to verify analysis.
Findings from the questionnaire The overall sample was 29 (72.5%) midwives and 11 (27.5%) doctors. The results indicated a largely positive attitude towards CTG usage with 72.5% (n¼29) of the respondents totalling a score of 75 and over (maximum score being 115) (see Table 2). An independent t-test failed to reject the null hypothesis that there are no differences between doctors’ and midwives’ attitudes towards CTG in labour ward practice (t¼ 3.9 at p¼0.05, CV¼2.02). A number of items had substantial majority responses of 65% or more. These substantial majorities represent definitive positions being taken by the doctors and midwives who participated in the study. In particular, 90% (n ¼36) disagreed that CTG was essential for ensuring successful deliveries, while 82.5% (n ¼33) of the population agreed that CTG can lead to unnecessary intervention. It is interesting to note that the majority of doctors (n¼ 7, 63.6%) disagreed with this statement. This disagreement between the two professional groups indicates differing opinions on some of the benefits of CTG. Interestingly a majority (72.5% n¼29) of the respondents disagreed that CTG undermined their skills. The large majority of the respondents (87.5% (n¼35) felt confident about interpreting cardiotocograph (n ¼26, 89.6% of midwives, n¼9, 81.8% of doctors). However, while 60.0% (n ¼24) of the respondents felt that their training adequately prepared them for CTG usage, almost half of the population of midwives (n ¼14, 48.3%) felt unprepared for CTG usage following their training.
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Table 2 Attitudes towards CTG usage. Item statements
D (%)
U (%)
A (%)
1. I believe CTGs can lead to unnecessary medical intervention 2. I could not imagine working without a CTG being available in case an emergency arises 3. I feel CTGs are so routine, they are virtually invisible during a birth 4. I do not like using CTGs 5. I think using any technology in childbirth is undesirable 6. I think CTGs undermine my own skills 7. I like using CTGs 8. I believe that using a CTG increases a mother’s anxiety 9. I feel I can routinely monitor the CTG signals without being distracted from the mother 10. I think CTGs are a major benefit to midwives 11. I believe CTGs can give rise to the wrong decisions being made 12. I only use a CTG when it is absolutely necessary 13. I think the CTG distracts attention away from the mother 14. I always trust the CTG’s readouts over my own observations 15. I think medical/midwifery colleagues rely too much on CTGs 16. I believe midwives’/doctors skills are undermined by over-reliance on CTGs 17. I think CTGs are vital in helping a midwife/doctor to decide when medical intervention is needed 18. I feel vulnerable if a CTG is not available 19. I rely on the CTG when I am not sure what is happening 20. I think CTGs spoil the beauty of a birth 21. I don’t feel entirely confident in my ability to use a CTG 22. I believe CTGs are essential for ensuring successful deliveries 23. I always trust my own judgement even when the CTG gives contrary indications 24. I believe CTGs are essential when labour is being induced 25. I feel that CTGs are often used unnecessarily
10 45 82.5 67.5 82.5 72.5 30 20 30 37.5 12.5 30 45 80 20 25 35 67.5 60 57.5 87.5 90 52.5 37.5 15
7.5 20 7.5 17.5 12.5 10 35 30 10 22.5 17.5 5 10 12.5 17.5 12.5 15 15 7.5 7.5 2.5 5 32.5 25 15
82.5 35 10 15 5 17.5 35 50 60 40 70 65 45 7.5 62.5 62.5 50 17.5 32.5 35 10 5 15 37.5 70
D ¼% disagree and strongly disagree, U ¼% undecided, A ¼% agree and strongly agree.
Responses from open ended questions At the end of the questionnaire, the participants were given the opportunity to recall an incident where the use of CTG monitoring involved collaboration between doctors and midwives. There were 32 responses to this question (28%, n ¼9 doctors and 72%, n ¼23 midwives). Of those, 22 (68.8%) respondents (n ¼9 doctors and 13 midwives) felt that the involvement of the multidisciplinary team had a positive influence on the incident. The following themes were identified:
multidisciplinary team ‘yhad a positive influence as the midwives’ concerns and clinical judgment backed with CTG abnormalities lead to the medical decision for caesarean section’ (Respondent number 10 (doctor)). Impact of CTG on the mother It was generally thought that the use of CTG ‘yshould be done with the mother and infant as the focus of care’ (Respondent number seven (doctor)). One respondent considered the mothers opinion of CTG to be: ‘‘yinitially intrusive and worrying when interpretation showed the possibility of fetal distress. However, it is reassuring when normal patterns are present.’’ (Respondent number 27 (midwife)).
1. The role of CTG in monitoring and detecting abnormalities. 2. Importance of effective teamwork. 3. Impact of CTG on the mother.
The role of CTG in monitoring and detecting abnormalities The role that CTG plays appears to be primarily: ‘‘y to reassure midwifery and medical staff that all is well with the baby’’ (Respondent number 2 (midwife)). However, this is limited to how well the information obtained from the CTG is interpreted by the professionals. CTG was viewed in a positive light when clinicians ‘‘y did not trust the CTG tracing alone but as part of the clinical information available’’ (Respondent number 7 (doctor)). Importance of effective teamwork The respondents who responded negatively reported examples of poor teamwork and poor levels of agreement between doctors and midwives. Respondent number four (midwife) stated ‘I feel the outcome was poor because appropriate action was not taken despite the midwives being unhappy with the trace’. However, reassuringly in the majority of cases there appeared to be good levels of agreement between the professionals. Indeed, in one case where there was a presence of a number of risk factors and a nonreassuring fetal heart tracing the respondent involved felt that the
CTG was frequently seen as increasing mother’s anxiety levels particularly when there were poor levels of agreement with staff ‘ymothers and partners may be aware of your concerns and as a midwife you have to reassure them even though the doctor is not concerned’ (Respondent number, 33 (midwife)). On the other hand in an instance were there was good levels of agreement and the CTG was used in conjunction with fetal blood sampling ‘ymother and father were aware of why the decision for caesarean was made and they were happy with the decisions and outcomes’ (Respondent number 13 (doctor)).
Findings from the interviews A sample of six midwives and two doctors participated in the interviews. The common themes which were identified from the participant’s responses are as follows: 1. 2. 3. 4.
Determining appropriate usage. Reaching a decision. Professional concerns. The way forward.
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Determining appropriate usage
Professional concerns
The use of CTG monitoring was considered to be appropriate for mothers who had identified risk factors and it emerged that participants practice was guided by local policy and guidelines. However, these policies and guidelines were generally viewed more positively by the more junior staff ‘I would rely on the policies and guidelines of this unit to help me decided if the CTG is required (Interviewee seven (midwife))’. One more experienced midwife recalled how she would ‘yuse my (her) judgment, it all depends on the timing if I felt she was going to deliver quickly I would give it a miss’ (Interviewee 2). The participants reported that CTG monitoring was also used to provide reassurance. The ‘yability to hear the fetal heart in the background’ (Interviewee 7(midwife)) seemed to provide reassurance for the labouring mother and staff members attending to her. This may result in CTG monitoring being used too frequently. However, there was a general feeling that they are not used ‘yas inappropriately as they used to be, there seems to be more awareness now for not using them for low risk mothers’ (Interviewee two (midwife)).
All the respondents expressed concern that there is limited evidence to support the use of CTG and it was reported that ‘ythey (CTG’s) are necessary because we don’t have a superior tool’ (Interviewee four (doctor)). Furthermore, Interviewee four (doctor) stated that ‘ythey often indicate a problem when in fact there isn’t one’. An illustration is provided by the following commentary:
Reaching a decision Respondents acknowledged that specialised skills are required to interpret CTG with all but one of the participants acknowledging that they had the necessary skills and knowledge to effectively interpret these CTG tracings. Practice was seen as an important way to develop skills in CTG interpretation and use: ‘ywe learn every day we use a CTG and we develop our skills from that experience’ (Interviewee eight (midwife)). One respondent who was aware of a knowledge deficit in CTG interpretation compensated for this by relying ‘y heavily on the more experienced members of the team’ (Interviewee seven (midwife)). The use of joint multidisciplinary policies and guidelines and a fetal heart scoring system was seen as a way in which to ensure that ‘yeveryone is interpreting CTG in the same way so hopefully there will be less variation in what the midwife says and what the doctor says’ (Interviewee two (midwife)). The midwives in particular felt that this scoring system enabled them to discuss their concerns about a fetal heart tracing in a systematic manner. Interviewees felt that concerns must be directed through the appropriate lines of communication: ‘‘If a midwife has concerns about a CTG she will discuss it with the sister, if the sister is unhappy she will discuss it with the SHO or the registrar who then makes a decision whether to do something or discuss it with the consultant.’’ (Interviewee 4 (doctor)). Therefore it would appear that CTG interpretation requires effective communication and collaboration at every level. Fortunately the participants agreed that conflict and disagreements were not a regular occurrence but they had developed different strategies to overcome it: ‘‘You may suggest performing a fetal blood sample but even if they don’t want to do that you can suggest stopping the syntocinon or changing the mother’s position.’’ (Interviewee 8 (midwife)). In keeping with the finding from the questionnaire it is clear that the interviewees are aware that the ability to reach a decision on a fetal heart tracing is limited to how well the information is interpreted by the professional. Tools such as fetal heart scoring systems will assist professionals in the interpretation of CTG tracing. However, how individuals communicate the concerns regarding a CTG tracing can ultimately determine the outcome.
‘‘I definitely think a lot of women end up with forceps or vacuums because of CTG concerns that wouldn’t necessarily have warranted it’’ (Interviewee 8 (midwife)). This was seen as having an impact on maternal choices as: ‘‘yoften women are disappointed because they have not achieved the birthing experience that they may of wished for’’ (Interviewee 7 (midwife)). The interviewees also commented on the fact that this increase in intervention could have a negative impact on their professional skills: ‘‘I think midwives end up in situations were an instrumental delivery could have been a normal delivery and I think that reduces midwives skills’’ (Interviewee 6 (midwife)). All the interviewees agreed that ‘inappropriate use and being used on low risk women when there is no indication’ (Interviewee two (midwife)) continues to be a big concern. The interviewees felt that this stemmed from inexperience and lack of knowledge which was another concern relating to CTG usage. This lack of knowledge was also seen to be a problem when abnormalities in the fetal heart are identified: ‘‘Staff need adequate training so when they do identify a problem they know to inform senior staff’’ (Interviewee 2 (midwife)). This concern is worrying in that it can result in a delay in intervention which may put the fetal well-being at risk. The way forward The interviewees called for more training in CTG usage particularly for junior members of staff. All of the participants agreed that doctors and midwives should be educated together in CTG interpretation ‘so that everyone is singing from the same hymn sheet’(Interviewee four (doctor)). There was also a call for professionals to ‘ytrust their skills more and be more confident using intermittent auscultation’ (Interviewee one (midwife)). This was seen as providing an alternative to CTG monitoring. There was also a call to increase the knowledge base on CTG: ‘‘your practice regarding CTG could be improved by increasing our knowledge through auditing our practices and conducting more research in this area’’ (Interviewee 5 (midwife)). It was believed that more research ‘will improve our technology to monitor the fetus in labour ‘(Interviewee four (doctor)).
Discussion of findings The objective of this study was to identify midwives’ and doctors’ attitudes towards the use of CTG technology in labour
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ward practice. In order to synthesise and provide a deeper understanding the main findings of this study will be discussed with the relevant literature. While 60.0% (n ¼24) of the respondents felt that their training adequately prepared them for CTG usage under half of the population of midwives (n¼14, 48.3%) felt unprepared for CTG usage following their training. This corresponds with studies conducted by Pelletier (1995) and Clarke and Holmes (2007). The majority of participants who were interviewed felt that they had obtained the skill to effectively use this equipment through experience and not through their training. It is interesting to note that while the majority of midwives and doctors felt confident in their skills at interpreting CTG it emerged from the interviews that there were times that midwives needed reassurance from doctors and other colleagues when reaching a decision regarding a CTG tracing. Sinclair (2000) argues that competence increases confidence which in turn promotes autonomy. Multiprofessional education and training for doctors and midwives to use CTG technology was one of the recommendations from Sinclair’s original study in 2001 and nine years later it was evident that this recommendation still has validity and relevance. In order to assist staff in making decisions, employers devise policies and guidelines in order to guide staff. It emerged from the interviews that practice relating to CTG usage was guided by policy and guidelines. However, in a survey of guidelines for intrapartum electronic fetal monitoring in low risk mothers the majority of these guidelines were poorly appraised by the reviewer which has implications for the delivery of evidence based care (Hinsliff et al., 2004). It is also seen that sometimes these policies can conflict with the professional’s ability to be an autonomous practitioner. Benner (1984) explains that expert midwives and nurses have almost an intuitive grasp of each patient situation and a certain level of experience enables practitioners to make decisions on an intuitive basis. There were times when the participants based their decisions regarding fetal monitoring on their experiences and intuition. Therefore, while standardising guidelines and policies may be viewed as restrictive and an obstacle to individualised care the aim is to provide parameters and guideposts which will enable safe and competent practice (Buckley and Dunn, 2000). Responses to the attitude scale indicated a largely positive attitude toward CTG technology. Despite differences in training and philosophies an independent t-test demonstrated that there were no differences between midwives’ and doctors’ attitudes towards CTG technology. There may be a couple of explanations for this. Most of the doctor respondents were consultants and registrars and their familiarity of CTG technology may have influenced the responses. One other possible explanation is that the policies relating to CTG monitoring in this unit involved an input from both doctors and midwives and all the professionals used a common scoring system when interpreting the fetal heart rate patterns. This may allow for a more unified practice however, more research is required in this area. It is interesting to note that midwives and doctors differed on their opinions relating to the statement CTG can lead to unnecessary intervention. This disagreement between the two professional groups may indicate differing perspectives on birth technologies such as CTG monitoring (Davis-Floyd, 1994). The illustrative incidents demonstrated that generally communication and collaboration between the two professions was effective. However, those incidents which were viewed as negative displayed examples of poor teamwork and poor levels of agreement. This concurs with previous studies which concluded that the effectiveness of CTG technology continues to be hampered by inconsistencies in interpretation of the fetal heart tracings (Zain et al., 1998; Ayres-de-Campos et al., 1999; Bracero et al., 2000). The interviewees believed that the use of the scoring system did go
some way to providing a uniformity in interpretation. It is interesting to note that Bracero et al. (2000) found that when clinicians used a fetal heart rate scoring system to classify the tracings the agreement was poor. Hindley et al. (2005) also noted that a multidisciplinary group had a low level of agreement when using a newly designed tool to appraise fetal monitoring guidelines. This may indicate as stated by Ullman et al. (2004) that practitioners from different background vary in their interpretation of such tools. However, the midwives felt that this scoring system provided them with a systematic tool for voicing any concerns they may have regarding a fetal heart tracing thereby improving communications with doctors. Sometimes these disagreements did give rise to situations of conflict. The interviews revealed that this situation was viewed by the interviewees as undesirable and interventions were often introduced by the midwives in order to resolve the situation. It was hoped that if doctors and midwives received more training together in CTG usage and interpretation it would reduce the incidence of these situations. Crowe and Smith (2003) found that this type of education can enhance shared understanding and interprofessional collaboration. The participants also felt that joint training in cardiotocograph monitoring will result in a more uniform practice and interpretation of fetal heart tracings. Those who were interviewed demonstrated awareness and expressed concern that the use of CTG has not been shown to be more effective than intermittent auscultation in lowering perinatal mortality rates (MacDonald et al., 1985; Haggarty, 1999; Thacker et al., 2001) and thus its use in labour ward practice was frequently questioned. While it was generally accepted that CTG had a role in monitoring the labours of women who were considered to be in the high obstetric risk category none of the participants felt that its use was appropriate for low risk mothers. The respondents felt that by conducting more research on cardiotocograph it may improve practice and knowledge on fetal monitoring. Analysis of the multidisciplinary incidents revealed that the use of CTG should be done with the mother and infant as the focus of care. Also, CTG monitoring was sometimes viewed as dehumanising and depersonalising patient care. This has been viewed as a criticism of the use of technology in health care (Cooper, 1993; Barnard and Sandelowski, 2001). The respondents in the interviews argued that this often had an adverse effect on the birthing atmosphere and in how relationships evolved between the mother and the professionals. The interviewees had observed in their practice that CTG monitoring generally resulted in an increase in interventions in labour which echoes findings by Tracey and Tracy (2003). This increase in intervention was viewed by the respondents as limiting the mother’s choice in labour and altering her birthing experiences. It also emerged during the interviews that this increase in intervention may result in an erosion of their professional skills. Barnard and Gerber (1999) argued that while technology stimulates the need to acquire new skills it will alter and de-emphasise certain existing skills. In order to prevent this erosion of skills the interviewees suggested that skills are updated in other methods of fetal monitoring especially intermittent auscultation so practitioners can be confident performing it.
Limitations The sampling strategy and the sample size used in this study are acknowledged by the researcher as one of the limitations of this study. As is the case with any purposive sample, the sample chosen may not be representative of the population. Purposive sampling was used to obtain the sample for the interviews and the researcher selected these individuals from a group of volunteers. It could be argued that these volunteers may have a specific interest in the
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topic under discussion and therefore may not necessarily represent the views of the general population. Another limitation to this study was that the researcher was a midwife who worked in this unit and therefore was known to the participants. This may have created a form of bias and the participants may have felt inclined to mould their responses to an already known criterion.
Conclusion The study highlighted a number of issues relating to CTG usage. The findings from this study indicated that both the midwives and the doctors who participated in this study would benefit from attending joint training on fetal heart rate monitoring and interpretation. This could be facilitated by providing workshops on CTG usage and interpretation in order to update staff thereby improving communication and collaboration. This may also improve midwives’ confidence levels in using and interpreting CTG tracings. The respondents also called for more in-depth training for student midwives and doctors. Although this study has certain limitations the findings of this study do present insights into midwives’ and doctors’ perceptions and attitudes towards CTG usage in labour ward practice. The objective of this study was achieved and the findings were substantially supported by previous studies identified in the literature. This adds weight to the findings of this study. As a result of carrying out this study a number of recommendations have become apparent which can only serve to improve and enhance current practice. Information obtained from this study could provide a useful base for studies with a wider remit that would be more representative of the general population.
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