Fetal monitoring training guideline

This guideline provides a framework in relation to training and assessment of competency of staff including intermittent auscultation (IA) and cardiotocography (CTG) as this is an area where evidence suggests performance can be improved. Clinicians should have sufficient knowledge and expertise to recognise ‘patterns’, to have an understanding of the pathophysiology of fetal heart rate control and hypoxia, as well as knowledge of associated clinical circumstances to correctly interpret the traces and to institute appropriate management.

The Chief Medical Officer's (CMO) report ‘Intrapartum related deaths: 500 Missed Opportunities’ in 2007 (Department of Health 2007) has highlighted issues relating to lack of knowledge to interpret traces, failure to incorporate the clinical picture, incorrect or delayed action and communication / common sense issues. Recent serious untoward incident reports have also highlighted a variety of concerns relating to cardiotocograph (CTG) interpretation and subsequent clinical management.

The NHS Litigation Authority’s 'Ten years of maternity claims' highlighted that from 1st April 2000 to 31 March 2010, there were 300 claims relating to CTG interpretation at a value of 466 million. The main allegations focused on failure of the healthcare professionals to recognise an abnormal CTG and act on it, and the failure to refer appropriately and document sufficiently.

This guideline represents a consistent approach to fetal monitoring training, competency and assessment. To support training staff will have access to on line K2MS perinatal training package which can be accessed from work or home to encourage learning and updating of knowledge. The following is applicable to all staff caring for women ensuring:

• ALL staff who interpret CTG traces are competent to do so.
• Midwives and obstetric staff continuously update their knowledge and skills in fetal monitoring.
• Competency in CTG interpretation by providing training as well as conducting an assessment process.
• Support is given to staff, who do not achieve 80% competency in assessment too.

The On-Call Obstetric Consultant is responsible for the overall care of the “high risk” woman on the delivery suite and is available to give an opinion to an obstetrician/midwife.

Obstetricians and midwives are responsible for giving an opinion on a CTG as part of the ‘Fresh Eyes’ system and can escalate their concern/s to the on-call Obstetric Consultant for an opinion.

The Patient Safety Team are responsible for reviewing poor outcomes of infants and mothers following delivery, conducting root cause analyses, and identifying areas of concern in which a review of the CTG is a component. They can also recommend further training/review via the obstetric/midwifery lead. The team liaises with the midwife and SCM to advise, review and make recommendations if required.

The Senior Charge Midwives (SCM) in each area are responsible for ensuring staff complete the K2 training package and assessment tool on an bi-annual basis.

The Midwife is responsible for keeping updated in CTG analysis, completing the K2 package and assessment tools and to discuss a CTG case review on an bi-annual basis.

1. New Staff

All new staff (including Bank staff) will be provided with CTG training. This will include access to:

• online K2 training package
• copy of the Fetal Monitoring Policy
• copy of the Fetal Monitoring Training Guideline
• PDF NICE Guideline CG190 Intrapartum Care (updated 2017)
• training record.

2. Existing Staff

Staff who have been trained and assessed competent in Fetal Monitoring will be required to:

• Complete K2 package as a minimum every 2 years:
  • Fetal Physiology
  • Intrapartum Cardiology
  • Intermittent Auscultation.
• Complete the on line CTG assessment tool (K2) as a minimum every 2 years, obtaining 80% pass mark.
• Staff who are returning to work from maternity leave or long term sickness are required to complete the recommended K2 packages and pass the appropriate assessment tools, prior to interpreting CTG’s.
• In addition it is recommended that staff attend an adverse event meeting once a year. All staff need to evidence ongoing competence as part of the requirements for revalidation. Staff should use TURAS to record evidence of ongoing competence.
• All staff are required to attend yearly, a 2 hour Fetal Monitoring update (to include intermittent auscultation  (in-house).

3. CTG Assessment

The training and assessment process for CTG interpretation has been based upon that designed and developed by the core intrapartum fetal monitoring group at St Georges Maternity Unit London. Provision of feedback and support to the clinician who fails to demonstrate competencies will be facilitated by:

• Lead Obstetric Consultant
• Senior Charge Midwife

4. The Process to be followed when a midwife or obstetrician does not obtain 80% Competency in CTG Assessment tool.

A midwife or obstetrician who does not achieve 80% competency in CTG Assessments shall:

• Have an individual discussion with the SCM on the pathophysiology of CTG
  and NICE guidelines as soon as possible.
• Have a ‘one to one’ CTG training to discuss various case scenarios as soon
  as possible.
• Revisit K2 training package and simulator.
• On completion of the above, to re-sit the CTG Assessment tool as soon as
  possible.

5. Interim measures (until the obstetrician or midwife achieves 80% competency).

Confidentiality will be respected if a clinician does not achieve 80% competency in the CTG Assessment. However, this has to be balanced against patient safety and interim measures may be necessary to maintain the quality of intrapartum care.

The midwife / obstetrician will:

• Be unable to act as 2nd signatory on the ‘Fresh Eyes’ system.
• Ensure they do not interpret CTG’s unsupervised.

In the event of an obstetrician or midwife passing the assessment but continuing to demonstrate difficulty in analysis, interpretation or actioning of abnormal CTG’s the steps in 4/5 must be revisited and an action plan put in place by the Lead Obstetric Consultant/SCM to address the learning needs.

The Senior Charge Midwives will maintain a database of all staff working within the maternity unit and record completion of the K2 package and assessment tool on a 2 yearly basis. Individuals are responsible for forwarding their completion certificate to their line manager for inclusion in their personal file. There will be regular audit of the percentage of staff who has undertaken the training on IA and CTG interpretation.

MCQIC

CTG’s are also reviewed on a monthly basis as part of the Scottish Maternity Patient Safety Programme (MCQIC).

Matters relating to non-compliance will be discussed with the SCM and in the event of continued non-compliance will be referred to the Service Lead or Head of Midwifery as appropriate

The guideline will be circulated to staff by email and can be accessed at any time.

Following an initial review after 6 months to identify any practical / resourcing issues, it is anticipated that the review process will be in line with the NHS Borders Policy on Management and Development of Procedural Documents, for which the standard length of time for review is 3 years.

However, changes within the organisation affecting this process, together with any changes in the legislation or the requirements of external regulators/accreditation organisations may prompt the need for revision before the 3 year natural expiry date.

Department of Heath. On the State of Public Health: Annual Report of the Chief Medical Officer 2006. Chapter 6: Intrapartum-related deaths: 500 missed opportunities. London: The Stationery Office; 2007

National Institute for Health and Care Excellence. CG190 (2014)(updated 2017) Intrapartum care: Care of healthy women and their babies during childbirth. London: NICE 

NHS Litigation Authority (2012). Ten years of maternity claims: An analysis of NHS Litigation Authority data.