Theresa Fitzpatrick and Louise Holt, labour ward coordinators at Leeds Teaching Hospitals NHS Trust (LTH), describe how they have implemented a ‘buddy system’ to make cardiotocograph (CTG) interpretation a more reliable method of assessing fetal wellbeing in labour.
We know that misinterpretation of CTGs, poor documentation and failure to refer to a doctor are key trends in adverse neonatal outcomes. Some trusts have implemented a 'fresh eyes' approach to CTG interpretation ensuring that CTG traces are interpreted by more than one person. A fresh eyes approach recognises that factors such as fatigue, familiarity and limited knowledge can lead to lack of objectivity and this can impede accurate interpretation of a CTG. We decided to take this a stage further and implement a CTG categorisation buddy system where midwives on the delivery suite are paired together to make assessments of each other’s CTG traces.
Most hospitals use a pre-printed sticker that sets out the NICE criteria to determine if a CTG is to be categorised as normal, suspicious or pathological. The CTG classification is made at least every hour and a sticker is placed in the notes but at our trust the buddy independently assesses the CTG categorisation and countersigns the sticker if they agree. If there is a disagreement the midwife and buddy will immediately refer the CTG to the midwifery coordinator and/or the registrar for their clarification. If agreement still cannot be reached, the CTG is referred to the consultant. Once categorisation has been agreed, our guidelines set out an action plan based on NICE recommendations for CTGs found to be suspicious or pathological.
With the buddy system, it is the same two colleagues for each shift who make an assessment of the CTG trace. We recognise there’s a risk they will perpetuate each other’s mistakes - the margin for error may be greater than with a true fresh eyes approach. But being paired with a named buddy is more likely to remind and motivate midwives to review categorisation of their CTG tracings. It also maintains continuity of care and privacy for the woman.
Pairing buddies
The labour ward coordinator allocates buddies at the start of each shift and ensures the system is managed properly – clearly displaying buddy allocations on the board and in notes. When pairing buddies the coordinator takes into account the experience and capability of staff. We don’t pair midwives of the same band. So, band five midwives are paired with band six, band six with band five, six or seven and band seven with band six. It’s important that junior staff know they can challenge the categorisation of a more senior midwife. The buddy system enshrines this ability to query a colleague’s judgement.
Positive response
An important factor in the success of our system has been the tremendous support from staff. People have adapted really well in taking it on board. The buddy system has been part of the LTH intrapartum guidelines since 2008 but we know that even if it wasn’t a formal procedure the midwives would still do it as they are so enthusiastic about it. It has provided a mechanism for midwives to support each other. This is contrast to previously when some midwives would look at CTG traces behind closed doors and be frightened to ask for a second opinion.
Successful implementation
Our message to other units thinking of implementing a buddy system is get the labour ward coordinators on board as they are instrumental in driving its success. A positive approach is also important, with the emphasis not on policing or checking midwives but rather about supporting midwives and making that support an integral part of clinical procedures. The system also has other benefits – it provides a good learning opportunity to improve CTG categorisation skills and complements formal CTG training.
Actively involving midwives and obstetricians at the development stage and enabling them to take ownership of the change in practice has also been important to successful implementation.
Conclusion
Within the LTH's maternity units, the buddy system has become an integrated part of everyday practice and has been extend to antenatal fetal monitoring. We still have work to do on evaluating effects on neonatal outcomes - as time goes we will have more valid data on this.
Even without formal evaluation the buddy system has made a huge difference to the way we work together. It provides a valuable learning opportunity and encourages a more open culture where midwives can freely challenge each other’s judgement.
For further information email theresa.fitzpatrick@leedsth.nhs.uk or louise.holt@leedsth.nhs.uk