The purpose of intrapartum surveillance is a timely detection of babies who may be hypoxic, so that additional assessments of fetal wellbeing may be used or the baby be delivered by caesarean section or instrumental vaginal birth, to prevent perinatal/neonatal morbidity or mortality.
Currently, CTG traces are being interpreted by using guidelines which are purely based on 'Pattern-Recognition' and the same guidelines are applied to every fetus, irrespective of the gestational age and wider clinical picture such as ongoing chorioamnionitis, fetal reserve etc. This has resulted in significant inter-and intra-observer variability leading to an increase in unnecessary operative interventions and hypoxic injuries and perinatal deaths. The Still Births Report published by the NHS Litigation Authority in 2009 confirmed that 34% of stillbirths were due to CTG Misinterpretaiton and the recent Each Baby Counts Report published by the RCOG (2017) has highlighted that 1136 babies either died during labour or in the early neonatal period or had sustained severe brain damage in 2015 and 76% of these cases could have been avoided by an alternative management.
Having achieved a significant improvement in neonatal outcomes since the adoption of physiological CTG interpretation, our team of dedicated maternity staff felt that we owe it to our women and children to do as much as we can to keep them safe.
We submitted our initiative to the RCOG Each Baby Counts forum 2017, which won first prize.
Encouraged by the RCOG Award and the urgent need to improve perinatal outcomes based on the Each Baby Counts Report, we collaborated with other units who have demonstrated significant improvements in perinatal outcomes after implementing physiology based CTG interpretation and have received National Awards.
We aspire to improve the outcome for mothers and babies all over the world. For this reason we promise to dedicate 10% of gains made from this project to go to charities supporting patients suffering from cerebral palsy and to the improvement of CTG interpretation worldwide.
A fetus is exposed to both mechanical (head and umbilcial cord compression) and hypoxic (utero-placental insufficiency and sustained compression of the umbilcial cord) stresses during labour. Physiology-Based CTG Interpretation involves understanding these stresses during labour and determining the fetal response to ongoing stress. Therefore, it is all about individualising care instead of blindly applying the same CTG Guideline for all fetuses during labour. It is about asking the question "How is the Fetus"?
Our tutorials encompass a pathophysiological approach to explain how a fetus defends itself against intrapartum hypoxic/ischaemic insults and the signs that suggest the progressive loss of compensation.
With greater understanding, and incorporation of fetal pathophysiology whilst interpreting CTG traces, our aim is to achieve a reduction in unnecessary intrapartum operative interventions and their resultant complications such as postpartum haemorrhage, perineal tears and abnormal invasion of placenta to women, whilst at the same time to reduce the incidence of fetal hypoxic-ischaemic encepahlopathy (HIE) and reduction in perinatal deaths.
Our team, who has an extensive experience in physiological-based CTG interpretaiton in daily clinical practice and have had several publications in this area, has worked very hard to ensure that delegates are provided with knowledge-based sessions and lectures, interactive tutorials to re-enforce knowledge, interactive CTG cases to promote deeper understanding of different types of intrapartum hypoxia and non-hypoxic causes of fetal injury as well as a competency test to ensure that knowedge is deeply embedded. In additon, compared to other exisitng training packages on CTG, we have ensured that the delegates will have access to weekly interactive cases involving CTG Interpretation and intrapartum management so as to continuously update their knowledge. We strongly believe that promoting such continuous professional development (CPD) is key to reducing maternal and perinatal complications secondary to CTG misinterpretation.
Our educational materials are based on current scientific evidence and where the evidence is weak or unavailable, we have recommended good medical practice based on expert opinion and clinical experience.
In our lectures we have attempted to simulate real-life teaching and have endeavoured to make the lectures as exciting and interactive as possible, whilst emphasising the principles of fetal physiology. Our teaching aims to provide the rationale behind recommendations made, and the reference to the relevant research and evidence behind the explanations.
Each tutorial provides the opportunity to take notes and to provide feedback. Your feedback is always welcome and we hope to keep this work as updated and as authentic as we can.
We provide an assessment tool based upon a question bank that is approved and updated by several experts in the field of physiological interpretation of CTG, who use the physiological approach to interpret CTGs in their daily clinical practice.
The appraisal tool provides a certifcate of competence that is valid for 1 year. This will be based on completion of an annual assessment. In addition, there will be a certificate of competency in continuous professional development for those delegates who have completed at least 10 weekly CTG update sessions in a year.
The weekly CTG session is designed to simulate the real-life intrapartum monitonig of a fetus under different clinical scenarios (e.g. presence of meconium, temperature, chorioamnionitis, poor fetal reserve etc) where the delegates will be able to provide their management input as the case evolves. Only the first attempt is logged in the user's assessment log. However, the user can replay the scenario for learning and review the recommendations by the Expert Panel.
It is envisaged that the users will be able to upload their anonymised CTG traces directly to our designated online portal so that this can be discussed by the wider user group every week, based on fetal physiology to learn lessons. Input will be provided by our Expert Panel on the interpretation of these user-uploaded CTG traces every week to enhance the learning experience.
We recognise that due to variation in clinical practice with regard to intrapartum management and reported high inter and intra-observer variaiblity in 'pattern-based' CTG interpetation, there may be disagreement amongst the users. However, based on the experience of maternity units which have implemented 'physiologcal CTG Interpretation', it is envisaged that by asking the question 'How is the Fetus?', these disagreements will diminish over time. If there are disagreements between users, the Expert Panel will provide an input based on scientific evidence and experience on physiological CTG interpretation.
All users are invited to submit CTG cases for presentations. Cases will be selected for weekly discussion based on their demonstration of the evolution of fetal pathophysiology and not based on outcomes. "Benefit of hindsight", which is a significant drawback of CTG intepretation based on 'pattern-recognition' will be eliminated by the users being trained to predict the next change on the CTG trace by the application of fetal pathophysiology.