IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth (the IMMO programme): protocol for a qualitative study

International audience; Introduction: Sub-optimal electronic fetal heart rate monitoring (EFM) in labour using CardioTocoGraphy (CTG) has been identified as one of the most common causes of avoidable harm in maternity care. Training staff is a frequently proposed solution to reduce harm. However, current approaches to training are heterogeneous in content and format, making it difficult to assess effectiveness. Technological solutions, such as digital decision support, have not yet demonstrated improved outcomes. Effective improvement strategies require in-depth understanding of the technical and social mechanisms underpinning the EFM process. The aim of this study is to advance current knowledge of the types of errors, hazards and failure modes in the process of classifying, interpreting, and responding to, CTG traces. This study is part of a broader research programme aimed at developing and testing an intervention to improve intrapartum EFM.Methods and analysis: The study is organised into two workstreams. First, we will conduct observations and interviews in three UK maternity units to gain an in-depth understanding of how intrapartum EFM is performed in routine clinical practice. Data analysis will combine the insights of an ethnographic approach (focused on the social norms and interactions, values and meanings that appear to be linked with the process of EFM) with a systems thinking approach (focused on modelling processes, actors and their interactions). Second, we will use risk analysis techniques to develop a framework of the errors, hazards and failure modes that affect intrapartum EFM. Ethics and dissemination: This study has been approved by the West Midlands - South Birmingham Research Ethics Committee, reference number: 18/WM/0292. Dissemination will take the form of academic articles in peer-reviewed journals and conferences, along with tailored communication with various stakeholders in maternity care. Strengths and limitations of this study:•A multidisciplinary team of obstetricians, social scientists, midwives and engineers will collaborate to characterise the technical and social mechanisms that may affect the safety of EFM in labour.•The study combines the strengths of ethnographic research and engineering approaches to systems analysis and risk assessment.•This project will generate a detailed characterisation of the errors, hazards and failure modes in intrapartum EFM and will help to inform the development of an intervention that will directly target the reasons for problems in interpretation and response to CTG traces.•Three maternity units across the UK will be selected; the generalisability of the findings will require careful assessment.