Title: Using telemetry to monitor the fetal heart in labour: a mixed methods study.
Funder: Health Education England

Abstract: Background Continuous electronic fetal monitoring (EFM) in labour is recommended for high-risk' women, whose fetuses may be at greater risk of fetal hypoxia. Conventional EFM involves the use of two transducers (one for the fetal heart and one for uterine activity) that are attached to a woman's abdomen via leads and connected to a larger machine. A continuous record of the fetal heart and uterine activity is recorded. Movement of the woman in labour is restricted to the length of the leads; many women tend to stay on the bed. EFM by telemetry also employs two transducers on the abdomen but information is sent to the main machine wirelessly; the woman is able to mobilise freely and is able to be immersed in water. Recent intrapartum guidelines have been published (NICE, 20014) and made a recommendation that all women having continuous EFM in labour should be offered telemetry and further research should be undertaken. A recent survey of UK maternity units (Watson, 2014) found that 64% of units that responded (n = 104) had at least one telemetry machine. There is no contemporary evidence regarding what influences the use of telemetry within maternity units, any possible impact telemetry may have on labour outcomes or the experience of women for whom it is used, including any difference it may make to control or satisfaction in labour. Further investigation is warranted. Aims To gain a deeper understanding of social processes influencing different ways of continuously monitoring the baby's heart in labour. To gain a greater knowledge and understanding of telemetry use (including outcomes, costs, advantages and disadvantages) and contribute to improving women's experiences and outcomes when continuous monitoring of the fetal heart is required. To contribute to; the provision of information about telemetry for women, health professionals and commissioning stakeholders; the development of guidelines for fetal monitoring in labour; and training for health professionals and students. Plan of investigation Phase 1.An integrative review of existing literature (Whittlemore and Knaff, 2005). Phase 2. Qualitative data collection Using grounded theory (Charmaz, 2000): Participant and non-participant observations of women using telemetry being admitted and during their labour. In depth interviews following birth with women who have used telemetry and midwives caring for them. Phase 3. Quantitative data collection Prospective observational cohort Data will be collected on a cohort of women using telemetry and compared to a cohort of women not using telemetry. Both clinical outcome data and perceived control, and satisfaction data will be collected. Phase 4. Data from both the qualitative and quantitative phase will be synthesised and contribute to: provision of information about telemetry for women, health professionals and commissioning stakeholders; development of guidelines for fetal monitoring in labour; and training for health professionals and students. Findings will also contribute to future work on development of a new tool to measure and capture any effects that telemetry has on labour outcomes and experiences. Summary of potential benefits to patients and NHS The provision of safe, high quality, personalised care for women experiencing high-risk' labours is a priority for all maternity units. Telemetry has the potential to ensure women can enjoy some of the freedoms in labour and positive birth outcomes experienced by their more low risk' peers; however this has not been evaluated. This will be the first contemporary study of use of telemetry in labour and is likely to broaden the understanding of and capture any effects of using telemetry to monitor the fetal heart in labour. It will also contribute to the provision of information for women, guidelines for fetal monitoring in labour, and training for health professionals and students.

Lay abstract: Over 800,000 babies are born in the United Kingdom (UK) every year and the majority will be monitored in some way during the labour. Monitoring of the baby's heartbeat, during labour, aims to identify those babies who may be coping less well; steps can therefore be taken to reduce the likelihood of any problems. Continuous monitoring of the baby's heartbeat involves the use of two flat discs (one to monitor the baby's heart and one to monitor the contractions) which are attached to the woman's stomach via leads and connected to a larger machine (see Figure 1). A continuous record of the heartbeat and contractions is printed out. Continuous monitoring (rather than intermittent monitoring every fifteen minutes) is recommended for women who enter labour with an underlying medical or fetal condition that may cause the baby to be at an increased risk of problems. It is also recommended if complications develop during labour such as bleeding or the passing of meconium (the baby's stools). In the UK approximately 60% of women will have continuous monitoring at some stage of their labour. Some of the advantages of continuous monitoring are that the baby's heartbeat can be continuously recorded showing trends over time. Disadvantages are that midwives and doctors may focus on the recording and interpretation of the monitoring rather than the woman, and there are likely to be more interventions such as forceps births. It also prevents the woman from moving freely or changing position (which is important to encourage progress in labour), as the leads are a hindrance. The woman is also unable to use the bath or pool. Telemetry Monitoring by telemetry also uses two discs on the abdomen but information about the baby's heartrate and contractions is sent to the main machine wirelessly; the woman is able to mobilise freely and as the discs are waterproof, is able to be immersed in water. Using telemetry enables the woman to adopt whatever position she may choose (including use of the birthing pool if appropriate) and may promote increased mobility and upright positions. Guidelines for the care of healthy women in labour have recently been published (NICE, 2014). The guideline has made a formal recommendation that all women having continuous monitoring in labour should be offered telemetry. The guideline also recommends that further research should be undertaken on the use of telemetry. A recent survey of UK maternity units (Watson, 2014) found that 64% of units had at least one telemetry machine. Despite this, there is no contemporary evidence regarding what influences the use of telemetry within maternity units or any possible impact telemetry may have on labour outcomes (including use of different types of pain relief). There is a lack of evidence investigating the experience of women for whom it is used, including any difference it may make to control or satisfaction in labour. Exploration of both advantages and disadvantages (including increased cost) is warranted. This study has three main aims: To gain a deeper understanding of social processes influencing different ways of continuously monitoring the baby's heart in labour. To gain a greater knowledge and understanding of telemetry use (including outcomes, costs, advantages and disadvantages) and contribute to improving women's experiences and outcomes when continuous monitoring of the fetal heart is required. To contribute to the provision of information about telemetry for women, health professionals and commissioning stakeholders; the development of guidelines for fetal monitoring in labour; and training for health professionals and students. The main objectives of the study are to Collect and analyse interview and observation data from women using telemetry to monitor the baby's heart beat in labour and midwives caring for them. Collect clinical data such as length of labour, use of pain relief and perceived control and satisfaction from a group of women using telemetry and compare this to a group of women not using telemetry. Synthesise both sets of data to draw conclusions on the use of telemetry in labour and contribute to future work developing a new tool that can be used on a larger population evaluating the impacts of telemetry use. This will be the first contemporary study of telemetry in labour and is likely to broaden the understanding of using telemetry to monitor the baby's heart in labour. It will contribute to capturing any effects that telemetry has on labour experiences and outcomes for women giving birth within a UK setting and contribute to the use and development of guidelines and training for health professionals.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH