Gloria
A few months ago I posed a similar question to the list, and we had a couple
of weeks of hot debate over the ether about the evils etc of CTG but more
specifically the use of centralised computerised decision support and
monitoring. It's clear there are three issues, one being the "bank of
monitors" in order for someone "out there" to keep an eye on what's going on
in the room, second the use of the computer to assist in decision support
and thirdly the ability to archive CTG traces electronically.
It's difficult to separate these three issues as sometimes such systems are
installed for one purpose and used for another. Also midwives are often not
consulted when such systems are introduced but then become the main users of
them.
The discussion was published in full in the last journal of the ARM
"Midwifery Matters" but I suppose it can be found in the archives of this
list as well. However, below is a summary of what people said.
Incidentally, as a result of the discussion on this list, we have thus far
avoided the purchase of such a system at Maidstone.
Happy reading
Joy Kemp
1. Electronic archiving of CTGs
“There is a need to keep CTG records, so electronic archiving is a good
idea. Trying to write a report when the trace has walked is not easy!
Whether it's of value for any other purpose, I know of no research. “
Ann M Thomson, Professor of Midwifery, University of Manchester
“The question of storage or archiving is separate: for those women who need
CTG monitoring, there is a corresponding need to store this recording for
medico-legal purposes. Whether this is paper storage or digital archiving is
irrelevant to this argument, since neither method requires a centralised
bank of monitors.
Andrew Symon, University of Dundee, Scotland
“The K2 package builds confidence in those that do not already have
biological confidence in the process of labour and the normal adaptation of
the fetus in response to labour. It is balanced....it puts biological
logic into a situation to help a more healthy and appropriate interpretation
of events
Marjorie, a midwife
“Joy, “For your info, the K2 address is: { HYPERLINK http://www.k2ms.com }
www.k2ms.com “
Andrew Symon
“I am only aware of one study looking at centralised monitoring. Weiss et
al (1997) did a retrospective study comparing centralised monitoring (n=805)
to non-centralised monitoring (n=817) in regard to perinatal outcome.
Acknowledging the weaknesses in such a design, the results suggested that
'centralised monitoring may be associated with an increase in the overall
caesarean section rate and operative vaginal delivery rate.
Alternatively you could have a look at the following references which
already present false positive value for the CTG in predicting adverse fetal
outcomes:
Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic
fetal monitoring in predicting cerebral palsy. The New England Journal of
Medicine 1996;334:613-618.
Nelson KB. The neurologically impaired child and alleged malpractice at
birth. Neurologic Clinics 1999;17(2):283.
MacLennan A. A template for defining a causal relation between acute
intrapartum events and cerbral palsy: international consensus statement.
British Medical Journal 1999;319:1054-1059.
Declan Devane, Doctoral Student / Midwifery Research Assistant, University
of Dublin
“I'm deeply opposed to central bank monitoring because at best it gives
tacit support a flawed technology, at worst it replaces a human presence
with a machine.”
Denis Walsh, Midwifery Lecturer, University of Central Lancashire
It seems, from those who have experience of a centralised system, that what
happens in practice is that staff do not stay in the room if there is a
central monitor. This denies the labouring woman individualised care, and I
can't think of a good reason for this practice.”
Andrew Symon, University of Dundee, Scotland
“Derby have had it for years. It often got to the point where the monitors
were bleeping all the time at the midwife station. Midwives just assumed
that there was loss of contact, since they were so fed up of having to keep
getting up and resetting the @@@*** things. when it was busy, they alarmed
away with no-one listening to them. What happens to evidence based
practice when these toys are introduced?”
Soo Downe, Principal Midwifery Lecturer, university of Central Lancashire
“My view of (centralised monitoring) is that the use of fetal scalp clips
has increased to prevent loss of contact as this of course sets off the
alarm bell, which is very annoying for those at the desk. This is also very
distressing for those in the room as people who are watching the trace at
the desk keep checking on what is happening in the room, this disturbs the
room even more than having a CTG in progress.”
Christine Halliday, Midwife at a birth centre, Australia
“I wonder how women will feel knowing that they are being monitored beyond
the walls of the room within which they labour. It seems to be a trend that
women are exposed to technological interventions, which do not necessarily
demonstrate a benefit for the majority of women experiencing normal birth,
yet it is the majority of the women that then become exposed to this
intervention. “
Amanda Mansfield, Midwifery Lecturer, Kings College London
Here in the United States… centralized fetal monitors… were installed before
their ineffectiveness was proven. They are used in place of a hands-on
maternal/fetal assessment. installing continuous monitoring now is not
evidence based and a real step back for the care of mothers.”
Cecilia Jevitt, Assistant Professor of Midwifery and Nursing, University of
South Florida, Tampa
My experience also has been that doctors walk in to a birthing room
uninvited due to what they see on the computer screen - and I would also
suggest that this screen exaggerates the features on the trace. More
disappointingly, I have had student midwives report to me that they have
been told by the midwife that they are working with, that they don't have to
remain in the room as the labour can be watched from the desk!! I believe
that these monitoring systems disempower midwives using their midwifery
skills and …do not believe that they improve outcomes.”
Clare Capito, Consultant Midwife, Barking, Havering and Redbridge NHS Trust
“Central monitoring is decidedly the slippery slope, be warned.”
Helen Shallow - midwife consultant Derby
“A retrograde and, arguably, misguided step!”
Cathy Walton, Albany Practice, Kings College Hospital
“Risk management incorporates the application of current best evidence.
There is enough research that casts doubt on the efficacy of continuous CTG
even for women with a compromised or potentially compromised
pregnancy/labour. “
Jenny Cameron, Midwife Lecturer & Practitioner
“How this would assist normal birthing? …It must be extraordinarily
distressing for women (and their partners) for women to be strapped up to a
machine with no one to interpret the results and even worse if alarms are
going off. “
Maggie Banks, New Zealand College of Midwives
“Read Ellen Blix' s article in the latest issue of BJOG before spending any
money on such a system….In our unit no midwives at all were involved in the
purchasing decision…the quality of the transmission from the rooms to the
central monitoring station was so poor that it was impossible to know what
was going on without being in the labour room. Also, the system was so
noisy that it was unbearable to be at the station if it was on, so either
everyone fled to the labour rooms, or it was turned off. We never, not in
1990 nor anytime since, had any instruction in how to make use of the
electronic archiving system in our set-up, so that capability has never been
used, though that was the rationale for purchasing it.”
Rachel Myr, Hammerfest, Norway
“They have this system at St George's Hospital in London. It may be worth
contacting Liz Stephens, the consultant midwife there. St George's has also
stopped doing routine admission traces.”
Miranda, BirthChoice UK
“There are issues to do with incompetent technology itself as well as
incompetent interpretation of the technology by professionals as well as
fear of litigation… Role change is an important aspect of technological
advancement and patterns of assimilation by professionals have been the
subject of much discourse. Some writers have examined the underlying
philosophy of integrating technology into the work environment and have
identified important aspects worthy of discussion.
Dr. Marlene Sinclair Senior Lecturer in Midwifery, University of Ulster
----- Original Message -----
From: "Gloria Lankshear" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, May 09, 2003 10:52 AM
Subject: Re: Computerised Decision support systems/intelligent systems
> Dear members,
>
> Thanks very much for the reply from Chris Hendry.
> Really helpful discussion of some of the concerns that will arise from
such systems. If anyone else has comments for the group or directly to
myself, I would be grateful.
>
> I, of course, have to be objective!! (lets not go there!) As I am
researching how labour ward staff react to such a system, how it affects
decision-making, staff teamwork, and whether it aids staff and avoids risk
situations, or whether it may even add to their anxiety. The reaction of the
birthing woman and her partner will also be interesting and of course should
be a central factor in its use.
>
> In my literature searches on the CTG itself, I have found much literature
on the questionable nature of the CTG itself; on what it can actually
reliably measure and how it has become widely used in spite of the fact that
it was never clinically piloted or proved. Also on the difficulty of
interpretation, and how experts differ between themselves and even give
different interpretations when given the same CTG at another time.
>
> Nevertheless, the CTG is used on the majority of high risk cases, and in
some hospital on all women who have an epidural. Though I see that the
latest recommendations are not to use it on 'normal' labourers, it is used
in a high number of cases. The designers of the decision support system
consider that if the interpretation (given all the provisos) could be made
more reliable, this would be beneficial.
>
> However, back to decision support systems and intelligent systems in
general, has anyone any experience of such systems, and comments to make?
>
> Thanks again, Gloria
>
>
>
> -----Original Message-----
> From: hendry [mailto:[log in to unmask]]
> Sent: Thu 08/05/2003 21:51
> To: [log in to unmask]
> Cc:
> Subject: Re: Computerised Decision support systems/intelligent systems
>
>
>
> Hi to you all from the wintry south.
> I really appreciate the interesting conversations and information on this
> list. I am a regular lurker, but could not hold myself back on this one!
>
> I am really concerned about the potential application of an intelligent
> electronic CTG system. Firstly, how reliable are CTGs in actually telling
> the story. If the woman is at an odd angle, the baby sleeping, the mother
> anxious etc, all, in my experience, impact on the CTG tracing. How are you
> going to get it right for the computer. Place women in a moulded bed (I
hope
> I am not giving anyone ideas), in a specifically simulated environment? No
> matter how hard you will not replicate the 'normal' environment for that
> women, so how can you determine the 'cause' of an 'irregular' CTG tracing?
>
> What about the human dimension. Pregnancy and birthing are generally
anxiety
> provoking for most women. I could not imagine anything worse than being
> lined up, placed in an artificial position (most pregnant women do not lie
> still all day) and being told by someone else how your baby is. Are we
> taking away from women their ability to judge their bodies and from
midwives
> the skills of knowing the subtle changes that occur in pregnancy and birth
> and the 'symptoms' displayed by mother and baby as a result? What about
the
> effect of environment?
>
> I really think we need to step back and think about the long term effects
> for both us and women of the belief that we can safely electronically
> observe pregnancy and childbirth. This has the potential to further create
a
> dependence on technology in pregnancy and childbirth which leads to a loss
> of skills. What about the routine use of scans to determine DOB even when
> the woman can pin point the date of conception!!
>
> I am not anti technology, but I think we need to include a philosophical
> critique of the potential for such technology to guide development.
>
>
> Chris Hendry
> (03-3489-347) or
> (021-655-355)
> ----- Original Message -----
> From: Gloria Lankshear <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Friday, May 09, 2003 4:07 AM
> Subject: Computerised Decision support systems/intelligent systems
>
>
> > Dear list members,
> >
> > I am studying a computerised decision support system which is going to
be
> implemented into a NHS delivery suite shortly. It is a system that will
> assist in interpreting the CTG reading of the fetal heart rate.
> >
> > In my literature searches I have come across many papers on the design
of
> expert systems and intelligent systems but no papers except the following
> asking the users what they think of such systems and whether they are
indeed
> helpful.
> >
> > Hartland, J. (1993), 'The use of intelligent machines for
> electrocardiograph interpretation', in Button, G. (ed.), Technology in
> Working Order.
> >
> > Have any members had any experience of such systems themselves? Or do
they
> know of such systems in actual use, rather than in the design stage. I
have
> read about MYCIN.
> >
> >
> >
> > Thanks
> >
> >
>
>
>
