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Intrapartum electronic fetal monitoring: imperfect technologies and clinical uncertainties—what can a human factors and social science approach add?
  1. Jane Sandall
  1. King's College London, London, UK
  1. Correspondence to Professor Jane Sandall, King's College London, London WC2R 2LS, UK; jane.sandall{at}

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For many women, fetal well-being in labour is assessed using continuous electronic fetal monitoring with cardiotocography (CTG), a technique used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour.1 However, problems in the assessment of fetal well-being in labour and delays in escalation and response have been consistently highlighted in maternity care safety inquiries, both in the UK and internationally, causing untold distress to parents and families.2–6

Taking an interdisciplinary perspective, drawing on both human factors/ergonomics and social science, the study from Lamé and colleagues,7 published in this issue of BMJ Quality and Safety, aims to understand the everyday practice of electronic fetal monitoring with CTG and the organisational and work context within which this takes place. Findings are based on ethnographic observations and interviews with midwives and doctors at different levels of seniority in three UK maternity units over a 12-month period during 2019 and 2020. The authors focused on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of the work settings concerned, with the aim of identifying potential sources of risk.

Combining human factors and social science perspectives is a novel approach and promises new insights. A human factors approach aims to understand how tasks are conducted in practice (work ‘as done’), rather than how they are documented or prescribed (work ‘as imagined’).8 Lamé and colleagues’ analysis was based on the System Engineering Initiative for Patient Safety 2.0 model to describe the work systems, the interactions of people, tasks, technology, organisational structures, environment and external influences on CTG monitoring. In addition, a social science theoretical perspective can deepen knowledge of wider social, cultural and political factors, and asks critical questions about the role of social inequality, power and control in the framing and enactment of safety policies and practices.9 For example, this approach has been used to provide insight into problems with the lack of timely recognition, and treatment response of women and patients whose condition is deteriorating while receiving care in acute maternity and medical settings.10 Specifically, ethnography is a research methodology that can show what happens routinely in healthcare, and reveal the what and how of improving patient care.11

By combining these two approaches, the authors highlight how electronic fetal monitoring is not a simple process but a complex sociotechnical activity involving multiple interdependent elements (people, tasks, technology and tools, environment and organisation) that may interact in complex ways. They highlight how success depends on multiple actors who must coordinate activity, achieve shared understanding, make sound decisions in the face of uncertainty and competing considerations, demonstrate respect for those in labour and their partners and take appropriate actions at the right time.

The findings in the paper suggest that improving the safety of electronic fetal monitoring will require accounting for these complex system interdependencies, rather than focusing solely on areas such as individuals’ proficiency in interpreting CTG traces. For example, the paper highlights variation in monitoring guidance and practice both between and within maternity units. This includes different guidance from The International Federation of Gynecology and Obstetrics and the UK’s National Institute for Health and Care Excellence, likely due to the contested nature of the evidence underpinning practice. The authors identify rationalisation and standardisation of such guidance as one area for intervention, while emphasising that updated guidelines are unlikely, on their own, to improve processes and outcomes as a much more multifaceted approach will be required.

In addition to the above, continuous electronic fetal monitoring promises greater diagnostic certainty, which should inform decision-making on management; however, it is important to note that an underlying issue contributing to delays is that midwives and doctors are limited in their interpretation and decision-making due to uncertainties in the accuracy and validity of CTG measurement,12 even when computerised interpretation is used,13 and that these issues remain problematic in other areas of measurement of patient deterioration in healthcare.14 Social science analyses of medical uncertainty are a substantive area of research in the social sciences and health technologies,15 and further research in this area would be fruitful.

Lamé and colleagues highlight uncertainties expressed by clinical staff in making a decision to escalate. Although not raised in this paper, timely and appropriate detection, escalation and response processes are also problematic in other hierarchical organisations with relationships of power, which require the ability of those lower in the hierarchy to raise concerns,16 or by those who are considered by staff not to have a legitimate voice.17 In a national NHS survey in 2022, women were asked, ‘If you raised a concern during labour and birth, did you feel that it was taken seriously?’. The proportion to say ‘yes’ decreased from 80% in 2013 to 77% in 2022, with women from the poorest deciles and ethnic minority groups reporting lower levels of confidence.18 These issues have also been raised in the USA19 and Australia6 in relation to women’s safety concerns not being responded to, and an inequalities lens would be valuable in future research. Research in other areas of healthcare has highlighted the potential contribution of ‘patient and family concern’ in escalation of a patient’s deteriorating condition,20 in addition to a campaign (Martha’s rule) for the legal right to seek a second opinion from another specialist doctor based in the same hospital who is independent of the team treating the patient, or alternatively, the right to seek a rapid review by a separate clinical team.

Lamé and colleagues’ study is an output of the IMMO (IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth) programme which aims to advance current knowledge of the types of errors, hazards and failure modes in the process of classifying, interpreting and responding to CTG traces. This particular paper’s focus was up to the point of escalation but did not examine timely response and ongoing management in detail. These latter areas have also been identified as issues contributing to delays in an adequate response in maternity inquiries and reports. The research team’s insights into this aspect, particularly organisational culture and organisational behaviours, would have been helpful, because as the authors themselves point out, this is a strength of a social science approach.

To improve outcomes for women and babies, further research on how to structure escalation management and response practices which take into account clinical uncertainty and intentionally address hierarchies of power are required, and seem fruitful areas for future focus and investigation to improve quality and safety of maternity care. Bringing together a human factors and social sciences theoretical and methodological approach will likely result in richer data and insights than either alone through bringing two complementary ‘outsider’ perspectives, and how such approaches can address gaps in knowledge related to the practice of electronic fetal monitoring.

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  • Contributors JS drafted the work and revised it critically for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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