I am an NHS obstetrician hoping to share some thoughts and experiences about my working life. Maybe you enjoy call the midwife, perhaps birth fascinates, or you are simply curious about what exactly an obstetrician is? You might be pregnant and preparing for birth right now. Perhaps you work in maternity care and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case TheObsPod is for you. Each episode contains 'the zesty bit' the essence of what I hope you will take away from listening. I do hope you will subscribe and enjoy joining me. Find me on Twitter @FWmaternity & @TheObsPod & explore #MatExp matexp.org.uk to find out more about women and staff working together to improve maternity services. With thanks to Anna Geyer www.newpossibilities.co.uk for my beautiful artwork
You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod please check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider. If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth. Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small. Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor. If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience. My bea...
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Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the obspod is for you. Episode forty eight. As I mentioned last week, this is not going to be a comprehensive review of fetal heartbeat monitoring because it's a very wide and complicated topic. It almost feels as I record this episode as if I'm stepping into a field of buried landmines. I know this is a very emotive topic on which many people have very strong opinions, and so recording this episode it might well all blow up in my face. However, I think it's an important topic to consider. So this is a collection of my thoughts about intrapartum, that is labour monitoring of the baby's heartbeat. To start with, I'm going to talk about why we're monitoring. There's quite a common saying that birth is the most dangerous journey of your life. Indeed, this is stated in obstetric textbooks, some of which are sitting on my shelf behind me. It stands to reason if this is so dangerous that it would make sense in some way to monitor the health of the baby during the process of birth. Given the relative inaccessibility of the baby when it's within the womb, we have to rely on relatively few indicators. It's quite difficult to monitor the baby, and therefore inevitably we focus on the things we can look at, the indicators we can measure, one of which is the baby's heartbeat. We can actually detect that and measure it. What are we aiming to achieve by listening to it? Well, we're using the baby's heartbeat to try and tell us about the oxygenation of the baby, so how much oxygen the baby is receiving, and in that way how it's affecting its internal organs. Changes in the heart rate might signal the normal process and progress of the labour, but some changes may signal hypoxia, a shortage of oxygen. Ultimately our aim is to prevent damage to the baby or worse still, death. So we're using heartbeat monitoring as a screening test. Remember when I've talked about screening tests in a previous episode, one of the criteria that we need to use is that we should be able to detect a change and that there should be an intervention that can be taken early enough to prevent deterioration into a more serious situation. In this case we might be expediting the birth of the baby, trying to prevent damage from the lack of oxygen. This is not a new idea. In the 19th century there is documentation of the indication for forceps in favourable situations, I'm assuming that means when the cervix is fully dilated, if the fetal heartbeat is heard below 100 or above 180. Those are parameters that I would recognise today. Some of you who listen regularly will know I have a 1930s obstetric textbook that I enjoy looking back at. And in that book there are similar observations that distress or impending death are associated with first an increase in the fetal heart rate and then a steady decline. Interestingly, it does however note that temporary slowing of the fetal heartbeat during a contraction is normal, but that pronounced slowing with a tardy return to the usual rhythm is an indication of the child's life being in danger. Listening to the baby's heartbeat during labour is therefore not a new concept. In practical terms, these practitioners would have listened with a stethoscope or pinard, the sort of trumpet I mentioned previously. And the action they could take was a forceps, an assisted vaginal birth if they heard things that were concerning to them. But now let's add in technology. I've talked previously about the advent of ultrasound in the 1970s. Ultrasound Dopplers meant the introduction of electronic fetal heartbeat monitoring. We could now use a machine to continuously listen in to the baby's heartbeat during labour. Surely that would be a good thing, wouldn't it? Or is it any machine is only as good as the people using it? We may now have achieved a continuous record of the baby's heartbeat, but now we have to consider what it actually means. What sensitivity or specificity does it have? In other words, does it correctly identify the babies that are in difficulty or in trouble from those babies that are not? And if we think a baby's in trouble and we do a cesarean, for example, and the baby is fine, was that good because we prevented a problem or was that we were performing an unnecessary intervention? How are we going to test this new technology and decide if it's worth implementation or not? And what are the downsides of monitoring the baby's heartbeat? Unfortunately, a lot of these questions are unanswered. Continuous electronic fetal heartbeat monitoring was introduced in a quite widespread way without much recourse to evidence, firm evidence that it made a difference. It was more a question of we now have the technology to measure it. We now can monitor the baby's heartbeat. It's a given that that would be a good thing. To think about this a bit more, I'd like to turn to where our knowledge of how a baby behaves in labour comes from. In actual fact, a lot of our understanding of how a baby's heartbeat behaves and how a labour and contractions affect a baby come from experimental physiology work done on sheep on the sheep fetus. Much of our understanding of asphyxia and hypoxia was on this basis, again performed back in the sixties and seventies. So what is the evidence for electronic continuous CTG in labour? Well, the evidence is there, but it's quite old. So I've attached in the program notes a Cochrane review. Remember that's where they group together different studies. They looked at twelve trials to look at the benefit of continuous CTG monitoring over intermittent listening in. Together the trials did involve thirty seven thousand women, but no trial compared continuous heartbeat monitoring with no monitoring at all. Most of the studies are old, and the review was dominated by one large trial from nineteen eighty five involving thirteen thousand women. The trials do show that there is a reduction in neonatal seizures. So babies that have a fit shortly after labour, which we know can be a sign of hypoxic damage. But there was no difference in the number of babies who died during or shortly after labour, and no difference in the rate of cerebral palsy. And cerebral palsy is the long-term damage that we're trying to prevent. It did conclude, however, that other possible long-term effects have not been fully assessed, and that we need more studies. And it did demonstrate a possible rise in the cesarean section rate. So in other words, our intervention. Any trial looking at the use of continuous electronic fetal heartbeat monitoring and labour would also need to have very consistent approaches in interpretation and also consistent approaches in terms of staffing, equipment, and recourse to action if a decision to intervene was required. This immediately introduces tremendous complexity. You've got to educate the healthcare staff in a standard approach to interpretation and action. There'll be many confounding variables. And there will also be lots of side effects. Side effect of a woman perhaps being less active in labour because she's attached to a monitor. Perhaps a side effect of a shift in prioritization from support of a woman to attempting to capture the baby's heartbeat continuously. So undertaking a trial to look at the success or otherwise of electronic fetal heart rate monitoring is difficult. Then we need to come on to who should be monitored. I'm going to talk now about something called the admission test or admission CTG. Obviously this is a good plan. Every woman admitted in labour should have a 20 minute CTG to check on the well being of the baby. Great plan. This way we can easily pick up babies that are at risk or already stressed by the start of contractions. My 1990s textbook on fetal monitoring has a whole chapter on the admission test. There are obvious advantages over a midwife intermittently listening in for a minute after contraction every 15 minutes, because you'll be picking up the baby's heartbeat a much larger percentage of the time. Stands to reason, good idea. But then again maybe not. We're back to screening test categorization. The first point of a screening test is the prevalence in the population of the problem you're trying to detect. If the complication is of low prevalence, for example, this is a healthy baby at the end of a healthy pregnancy, the prevalence of hypoxia will be low, very low, and therefore false positives will be higher. False positives will be babies that are actually fine, but that we think are demonstrating signs of distress. In view of this, women with a healthy pregnancy we shouldn't be using electronic cardiotocograph CTG. We should be using intermittent or sometimes called intelligent auscultation. That's the listening in I mentioned. Listening in for a minute after a contraction, every fifteen minutes in the first stage of labour and every five minutes in the second stage of labour. Listening in this way will be much less restrictive for the mother and will hopefully not lead to us intervening excessively as a false positive. But it will enable the midwife to pick up on key changes. Remember that we talked about a low heartbeat or a raised heartbeat. The midwife will be able to record what that baby's normal heart rate is like, but she'll be able to detect over the course of the labour if that's changing. Is there a rising baseline? Is the baby's heartbeat dropping and taking a prolonged time to come back up to the baseline after a contraction? She will still be able to pick up on the key salient features that are important in the baby's heartbeat, but we will not be monitoring continuously. If she detects these problems, then she will be able to start a continuous electronic record of the baby's heartbeat in response to those changes. The fact that women with a healthy pregnancy do not need continuous electronic fetal heartbeat monitoring in labour takes us back to attempting to stratify risk. I've talked in the language episode about not liking high risk or low risk. So in reality what we're trying to do is think what is the chance that this baby is likely to have a problem during its journey down the birth canal? Is this baby at a high chance in a high prevalence group for intrapartum hypoxia distress or is it in a low chance, low prevalence group? I would argue that one of the key determinants as to whether or not this baby should be monitored is actually the action we're taking ourselves. If we're introducing artificial hormones, prostaglandins or syntocinon to induce a labour, then yes, we're putting this baby under potential additional stress, a situation that it perhaps wasn't prepared for. And therefore one of the reasons we stick to monitoring despite the controversies is the interventions we undertake ourselves. So when I think about some of the controversy about fetal heartbeat monitoring and continuous CTG, I think we sometimes miss the point and need to come back to is this a natural labour? Is this a physiological labour? As well as how is the baby? Is this a baby that we think can tolerate the journey? So the first step in our heartbeat interpretation that I mentioned last week, Dr. CQ Bravado, DR defining risk is key to if we should use an intrapartum continuous electronic CTG or not in the first place. Having decided that for this woman and this baby we should be using it, the next problem is interpretation. Interpretation is not straightforward, partly because there are a multitude of guidelines, and the guidelines are constantly being changed and updated. At the moment we have NICE, the National Institute of Clinical Excellence, we have Physiological CTG, and we have FIGA, the International Federation of Obstetrics and Gynecology. Each of these uses different language, different nomenclature, when to act, what time frame to review the CTG over how we should describe things. It's no wonder that each baby counts. The project by the Royal College of Obstetricians and Gynecologists trying to improve outcomes for babies flags CTG interpretation issues as a problem. Women might look at the statistics and think we're incompetent. How can we possibly accept that we make so many mistakes in inverticomas? But the reality is there's much more complexity to the situation. It is disheartening when you look at the each baby count's recommendations that some of the recommendations on fetal heart rate monitoring are essentially the same as from the KESD report in 1997, KESD being the old confidential inquiry into stillbirths. That means we haven't come anywhere in twenty four years. At that point I was in my first year as a registrar. In that time, we have talked about early and late decelerations, type one and type two decelerations, variable decelerations, complicated and uncomplicated tachycardia, normal, suspicious and pathological normal, intermediary and pathological normal, intermediary and abnormal chronic hypoxia, acute hypoxia, gradually evolving hypoxia compensated and gradually evolving hypoxia decompensated. Is it any wonder that maternity staff are getting confused? And as with every aspect of obstetrics, we're trying to find that balance, balance between the safety of the mother and the baby intervening or not intervening. One late intervention can be incredibly costly for that mother and that baby if there's a poor outcome. One intervention too soon? Well that's a cost too, in terms of perhaps the woman having an unnecessary caesarean, and the repercussions that may have for her health or for her future births. But it's generally more likely as maternity care professionals that we're going to err on the side of caution. Not all the changes in how we describe baby's heartbeats are negative. We definitely have gained insight over the years. I find it disheartening when I have a woman in clinic who's perhaps had a cesarean before and she comes to discuss her birth choices, her birth options with me in the antenatal clinic. She will describe to me the life-saving procedure that was done to save her baby's life last time because her baby was an extremis. The baby was very distressed. I will pull out the heartbeat tracing. And sometimes that will be the case, and I'll look at it and think, excellent decision. Sometimes it breaks my heart. I pull out the heartbeat tracing, I look at it and I think I wouldn't have done that operation. I wouldn't have taken that action. With the knowledge I have now. And I know that differing consultants, differing obstetricians have different thresholds for when they will or won't intervene. And that variety of interpretation and threshold for risk is where the problem really lies. We need to work to women receiving a better standard of care, not dependent on who is on or what they're currently thinking. We've tried to overcome these issues with initiatives such as fresh eyes. That's the idea that the midwife in the room once an hour comes out and gets a midwife or doctor to have a fresh look, make sure she's not missing something. Or with having central monitoring. So at the hospital I work at, we have a screen where we can view all the heartbeat traces of the women in labour outside the room. That can be good, less interruptions for the woman after all. But at the same time, we're then looking at the fetal heart rate in isolation, not with her in front of us, using our clinical skills to assess what's actually happening with her and her baby, and most importantly, talking to her about what we're thinking. Last week I talked about computerized analysis of antenatal CTGs with Dawes Redman criteria. Could we not use computerized heartbeat traces for labour care? Well, unfortunately, large trials have shown that this doesn't work. Tested in forty six thousand labouring women, the results were very disappointing. So although humans are fallible, it appears that we cannot be bettered by computers in this situation. Another way of looking at improving our detection of problems with the baby's heartbeat trace is to add adjuvant tests, tests that might, when we have a concern, try and confirm or refute that diagnosis. In the past we used to do fetal blood samples, taking a drop of blood from the top of the baby's head from the scalp and looking at the pH, the acidity of that baby, to try and determine how well that baby was coping with labour. And although this remains in national guidance, there is quite a lot of evidence that actually a test from the top of the baby's scalp does not indicate the well being of the baby. It doesn't equate to what may be happening in its central blood system for a start. And secondly, that sample can easily be contaminated by amniotic fluid and vaginal fluid. So it's not an accurate way of assessing what's happening with the baby. The alternative is something called STAN or ST analysis. This is an actual electrical recording of the baby's heartbeat. Similar to if an adult came into hospital with chest pain, they would have an ECG and we would see changes in that ECG showing myocardial or heart muscle hypoxia. Stan works on that assumption. If the baby is stressed and if the baby is becoming hypoxic, it will show this in its ECG. And then knowing that those changes are happening in that baby that tells us actually, yes, there's something going on with this baby more than what we're just seeing in the heart rate alone. Some places have found the introduction of StAN extremely beneficial. It's reduced the emergency cesarean section rate and improved the outcome for babies. However, it's been difficult to replicate these results. Outside of research conditions, implementing StAN. Many hospitals have not been able to find the same success. With the focus on reducing stillbirth and improving safety in maternity services, there has been a lot of focus at national level, including in the Saving Babies Lives Care Bundle on fetal heartbeat monitoring in labour. We've introduced rules about the frequency of education. The need to take a competency test. Individually we take a test every year interpreting the CTG that's marked and deemed whether we've passed or failed. If we don't pass, we'll have a set of individual one-to-one teaching sessions until we're back up to speed. We've looked at human factors, how teams interact, things like escalation, workload, staffing. We have a fetal heartbeat monitoring specialist senior midwife, so when we have a query on the labour ward, we can go to her and get advice and support. And this is not just for the midwives, this is for the doctors too. We have annual masterclasses, regular meetings for all grades of staff. And through this project that started with the Sign Up to Safety Initiative, we've dramatically reduced both our perinatal mortality and the babies affected with HIE, hypoxic ischemic encephalopathy or hypoxic brain damage. It's taken enormously hard work by some of my colleagues, but it's also taken a massive amount of collaboration from us all. All these different things come into play. Nothing is as simple as just looking at the heartbeat tracing in isolation. So from all this, what is my zesty bit? What is my essence? My nugget this week that I want you to remember. I think as healthcare professionals I'd like you to take a step back. Let's stop arguing about which guidance we're following. If we cannot agree ourselves as a profession, how will this invoke confidence and trust in the women we care for? We need to be more honest about the issues and the complexity around fetal monitoring. In preparing for this episode, I've searched for and found almost no information for women on fetal monitoring, either its success or its failings, or what to expect. I'm wondering if despite our best intentions we may have lost sight of what we're trying to achieve. Anytime I think about fetal heart rate monitoring, I think about the Monty Python hospital sketch, or in my mind the machine that goes Bing. I have put a YouTube link to this in the programme notes. This is a sketch in which a woman in labour comes in to birth her baby, and the staff are obsessed with the number of machines, the latest technology, and most importantly, what it cost, which is the most expensive, and what do the hospital administrators think? For me, whilst it's absolutely hilarious, it can prove slightly uncomfortable watching. We are more and more invested in fetal monitoring technology, trying to use computers, central monitoring systems and ST analysis. Perhaps we need to take a step back, educate ourselves on the basics, and look at our decision making. Something that one of my colleagues is attempting to pioneer. Thinking through this episode, I thought of a few steps we should be taking. Step one should we offer monitoring to this woman? What is the relevance of it for her and her baby? Step two have we given her sufficient information in advance for her to decide if she wants this monitoring? Step three are we competent? Do we have sufficient education, understanding, and a regular competence assessment to use this monitoring? Step four do we have common language and teamwork and a good decision making process? Step five Do we monitor the impact of using the fetal heartbeat technology? Yes, the perinatal outcomes, the outcomes of the baby, but also our cesarean rates and women's experience of care. As a pregnant woman, understand the limitations of the test. Yes, it may be beneficial for you and your baby. For some babies, of course, monitoring will be beneficial, possibly even life saving. These babies that are at risk of hypoxia during labour as very small growth restricted babies, or premature babies, or twin pregnancies. An important situation in which continuous heartbeat monitoring is absolutely essential is when we're using syntocinone, synthetic hormone to make the womb contract. Whilst its use can be very beneficial, there are lots of associations with its use and increasing the chance of the baby getting distressed. So use of heartbeat monitoring in this situation I would say is essential. Don't be afraid when more than one person comes in to look at the baby's heartbeat, to give their opinion and discuss things with the midwife caring for you and yourself. Know that that teamwork, fresh eyes, and the decision of what is the right treatment for you and your baby is a very complex process, and that for your midwife asking the views of other members of the team is something she's doing not only to keep you and your baby safe, but to try and minimise unnecessary intervention. So I'm not at all saying that monitoring is not the right thing to do. But understand its limitations, understand its benefits, understand the impact it will have on you, and your experience of maternity care, and make an informed choice about what you wish to do. In the absence of any properly designed information for women, I've enclosed a couple of articles which debate the pros and cons of fetal heartbeat monitoring that you may find interesting to read and think about as you plan your birth. I do hope you've enjoyed listening to this episode of The Obspod. Feel free to contact me on Twitter at fwmaternity or at the Obspod to ask me questions, give me topics for future episodes, or let me know what you think. It's absolutely fantastic when you get in touch. I really enjoy reading your comments. As usual, I've tried to include in the programme notes some extra reading about this particular topic, both for professionals working in maternity care and for pregnant women using services. I'd like to reassure you that although I'm talking about my experiences working in maternity care, I take confidentiality very seriously and do not give any personal information about any of my patients. If you've enjoyed listening, I'd love you to recommend the OBSPod to friends or colleagues, and please do leave me a review on whichever podcast directory you find my episodes. Many thanks for listening.
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