Women’s Psychosocial Outcomes Following Cardiotocography (CTG) and ST-Analysis (STan) Fetal Surveillance during Labour: An Australian Randomised Controlled Trial

Abstract

The STan Australian Randomised Controlled Trial (START) has been designed to compare two techniques of intrapartum fetal surveillance: cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram (STan+CTG) versus CTG alone. The aim of START, the first trial of its kind in Australia, is to determine if STan+CTG reduces Emergency Caesarean Section (EmCS) rates. It is also the first comprehensive intrapartum fetal surveillance trial worldwide to include the examination of clinical, economic, and psychosocial outcomes. This thesis encompasses four studies (presented as self-contained papers, two of which are published), undertaken alongside the randomised controlled trial (RCT), to integrate the perspectives of women who participated in the study and add important contextual value to the clinical results. The aim of Study One was to identify, collate and examine the evidence surrounding women’s psychosocial outcomes of EmCS worldwide. The systematic review included a large number of studies (n=66) from 22 different countries. Key psychosocial outcomes found to be negatively impacted by EmCS included post-traumatic stress, health-related quality of life, overall experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the most examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptoms and diagnosis. The aim of Study Two was to examine women's experiences with the type of monitoring they received in the RCT. Using a qualitative research design, a sample of thirty-two women were interviewed about their experiences with the fetal monitoring. Six themes emerged from analysis: reassurance, mobility, discomfort, perception of the fetal Scalp Electrode (FSE), and overall positive experiences. The primary difference between the two techniques was whether or not women had an FSE (an FSE is always used with STan+CTG and when necessary with CTG alone). In general, it was found that women were very accepting of STan+CTG as it was perceived as a more accurate form of monitoring than CTG alone. Study Three examined women’s psychosocial outcomes alongside the RCT. A cohort of consecutively recruited women who had participated in the RCT from its initiation were invited to complete a mixed-method psychosocial questionnaire approximately eight weeks after giving birth to explore numerous outcomes including; postnatal depression, quality of life, psychological distress, infant feeding practices, and satisfaction. Of the 527 women invited to participate, 207 women completed the questionnaire (n=113/263, STan+CTG; n=94/264, CTG alone). Analysis was by intention to treat. This questionnaire provided necessary data for two subsequent papers. The first paper presents the findings in relation to women’s satisfaction with birth and monitoring and the second presents findings on women’s psychological and health outcomes. In terms of birth satisfaction, while there were no clear statistically significant differences between the two groups in satisfaction with the overall birth, responses about experiences with fetal monitoring tended to favour women randomised to the STan+CTG arm. Women in the STan+CTG arm reported higher average satisfaction with staff competency associated with the monitoring and were more likely to disagree with the statement that they would prefer a different type of monitoring in future labours compared to CTG alone. The qualitative component of this study provides further insight into the key positive and negative aspects of both forms of fetal surveillance and interestingly shows that women in the CTG arm who had an FSE, reported very similar experiences to women in the STan arm, findings that are in line with Study Two. In terms of psychological and health outcomes, both monitoring types appeared to produce comparable results in terms of postnatal depression, quality of life, distress, and infant feeding. Results of this research firstly highlight the diverse and significant impact EmCS can have on women’s psychosocial outcomes, particularly in relation to traumatic stress. These findings underscore the requirement for evidence-based strategies to provide appropriate psychosocial support and information about EmCS in the context of routine antenatal and postnatal care. Furthermore, against a backdrop of several RCTs worldwide examining the clinical outcomes of STan, this is the first comprehensive trial to include women’s perspectives. Overall, policy makers can be assured that STan results in, at the very least, comparable psychosocial outcomes relative to CTG alone. Findings from this trial should be incorporated when developing consumer-based information about intrapartum fetal surveillance, regarding common misconceptions by women and care providers about the potential use of an FSE.