We have launched a national patient safety investigation into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.

Multiple methods and types of equipment are used to continuously monitor fetal wellbeing during labour and birth. This can cause complexity and safety issues. Common safety issues have been identified with equipment availability and functionality, inability to interpret the fetal heart rate, and staff understanding of equipment and its purpose.

Identification of issue

A review of HSIB maternity investigations into stillbirths, neonatal deaths and babies born with suspected brain injury identified issues with the suitability of equipment and technology used to monitor the baby’s heart rate in labour.

Investigation summary

The investigation will:

  • Identify the factors that influence the choice of continuous fetal heart rate monitoring equipment.
  • Identify the variations of continuous fetal heart rate monitoring equipment found in clinical practice.
  • Identify barriers to reliable continuous heart rate monitoring and escalation of concerns noted when using technology.
  • Review the factors that need to be considered when using continuous electronic fetal heart rate monitoring equipment. These factors include training, equipment support and engineering usability, with a focus on centralised monitoring.

Intermittent auscultation (IA) and clinical interpretation of continuous cardiotocography (CTG) are outside the scope of this investigation but may be the focus of a future investigation. IA is a technique of listening to and counting the fetal heart rate for short periods during labour using a handheld device. Continuous CTG uses a machine to produce a continuous written record of the fetal heart rate during labour and clinicians use a tool to interpret and categorise the CTG trace.

Safety recommendations

As part of our final investigation report we’ll make safety recommendations to the appropriate national bodies in order to improve patient safety.

Investigation updates

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