INTRODUCTION

 Cardiotocography (CTG) has been integrated into routine assessment of fetal wellbeing, used on admission to identify cases for continuous electronic fetal monitoring for risk of intrapartum asphyxia. A case-based approach is recommended to justify the application of CTG  and develop customized management plans. Efficient CTG application, interpretation, documentation, and communication are essential for effective patient management and correct escalation procedures where necessary, to minimize iatrogenic causes of poor outcome .

 

The purpose of this clinical audit is to assess current clinical practice of CTG by doctors on patients at the major hospitals in Bahrain: King Hamad University Hospital (KHUH),  Bahrain Defense Force Hospital (BDF), Salmanyia Medical Complex (SMC) & American Mission Hospital (AMH). Current practice on CTG application, interpretation, documentation and communication are compared to international standards of best practice outlined in NHS,  NICE, ACOG and RANZCOG national guidelines, as well as FIGO international recommendations. 

 

OBJECTIVE

 To assess the current clinical intrapartum application of cardiotocography (CTG) in 4 major hospitals in Bahrain. Compliance with international evidence-based recommendations set by the NHS, NICE, ACOG, RANZCOG and FIGO guidelines was analysed. It is hypothesised the hospitals are meeting international standards for evidence-based, patient-centred CTG application.

 

METHODS

A prospective design was adopted. The audit was segmented into three stages: stage 1 (pre-intervention) stage 2 (intervention and education) and stage 3 (post-intervention). A referenced audit tool adapted from international recommendations. Convenience sampling was used, and intrapartum CTG application to 230 cases was assessed. Inclusion criteria was restricted to clinicians who directly manage and interpret CTG tracings and communicate findings with patients, family and staff. Midwives were trained to objectively observe blinded subject doctors during routine practice and complete the audit-tool. Data was analysed and results were compared to international standards of care for CTG use in intrapartum foetal monitoring. 100% compliance indicates satisfactory adherence to reference guidelines.Random collected CTG samples target hospitals were analysed to ensure data validity. Following Stage 1, target hospitals will be given customised recom 

 

 

 

RESULTS

 

 Average compliance to recommendations for risk factor assessment ranged from (57%-93.33%) with highest variation in case-based identification of risk-factors to indicate CTG application. Hospitals were (44%-71.88%) compliant with recommendations on proper CTG interpretation and appropriate response escalations. Application of the “fresh-eyes” approach for interpretation varied from 28% to 90% across target hospitals.  Case-based documentation was achieved (46%-77.28%) of the time. 65.38% of the time, the patient’s refusal of CTG monitoring was not recorded in one of the 4 major hospitals. Recommendations for standardised communication achieved (41%-81.67%) compliance. Significant variance across criteria and hospitals was noted. Clear recommendations were customized for each target hospital to achieve satisfactory compliance.

 

 

CONCLUSION

 Areas of improvement were discussed and recommendations on relevant points of care were made in adherence with international standards of CTG application, followed by a final re-audit to assess post-intervention clinical application of CTG in Bahrain compared to set international guidelines. National-based guidelines to standardise practice and adhere to international standards are recommended. Results of this audit will be shared with Bahrain NHRA for consideration into national guidelines.