Researchers have found that birthing women want to be involved in decisions about intrapartum fetal monitoring, but most birthing women describe not being given a choice (Hindley, Hinsliff, & Thomson, 2008). When midwives felt pressured to ensure that CTG monitoring was put to use, they actively manipulated the information they shared in order to achieve this goal (Hindley & Thomson, 2005). As one midwife said about discussing CTG monitoring with a birthing woman –
I can get the woman to do exactly what I want. Nearly always. If I am just a bit.. a bit, sort of, clever and sympathetic, I can get her exactly where I want her. … I choose my words in a way so that she will not protest, it is the way I am asking her.
Blix & Öhlund, 2007, p. 55
When I reflect on my experience as a clinician, I recognise three techniques that clinicians (not just midwives) use to ensure that CTG monitoring is commenced. They are:
- Tell, don’t ask.
- Minimize.
- Provide limited information.
At the moment when birthing women might be able to make a choice about fetal monitoring method, direct statements about the clinician’s intended action are made:
- Let’s get this CTG started
- I’m going to put the monitor on
- I need to get you on the CTG
Using statements like this make it difficult for birthing women to see that this is a moment when a decision is required (Scamell, 2011). Couching this as a question ensures that birthing women can recognise this as an opportunity to participate in decision making. A better language choice might be:
- The hospital guidelines recommend CTG monitoring. Have you thought about what type of monitoring you want to use?
- Is it OK with you if I put the CTG monitor on?
- Do you want to have CTG monitoring, or would you rather I listened to the baby intermittently?
Minimising language implies that the planned intervention will have minimal impact, in a way that often doesn’t reflect reality. Here are some examples:
- This’ll only take a moment
- We’ll do a quick trace first
- I’ll just pop this on
When minimising language is used, birthing women are less able to see that their decision about fetal heart rate monitoring is of significance and that they therefore might want to ask further questions or give the choice due consideration. Better options include providing accurate assessments about the time and significance of the decision:
- An antenatal CTG generally takes 20 to 30 minutes, but sometimes longer than this.
- Making a decision about fetal monitoring is important. Do you want some more time or information before you choose?
Often there is no further information exchange beyond “let’s just pop you on a trace”, but when there is, this information is often non-specific, or inaccurate, or doesn’t provide sufficient detail to enable women to negotiate an informed choice. For example:
- This’ll tell us if your baby is happy
- CTGs save babies lives
- It’s perfectly safe
The decision about fetal monitoring method has significant consequences for birthing women, and in line with other interventions, women should be assisted to make an informed choice about monitoring method. This decision is best supported by providing accurate information about the benefits and risks of each approach to fetal monitoring, and personalising these to the specific woman. This is not a quick discussion, and such decision making is best supported within a therapeutic relationship that starts early in the pregnancy and continues through labour and birth.
References
Blix, E., & Öhlund, L. S. (2007). Norwegian midwives’ perception of the labour admission test. Midwifery, 23(1), 48-58. doi:10.1016/j.midw.2005.10.003
Hindley, C., Hinsliff, S. W., & Thomson, A. M. (2008). Pregnant womens’ views about choice of intrapartum monitoring of the fetal heart rate: A questionnaire survey. International Journal of Nursing Studies, 45(2), 224-231. doi:10.1016/j.ijnurstu.2006.08.019
Hindley, C., & Thomson, A. M. (2005). The rhetoric of informed choice: perspectives from midwives on intrapartum fetal heart rate monitoring. Health expectations, 8(4), 306-314. doi:10.1111/j.1369-7625.2005.00355.x
Scamell, M. (2011). The swan effect in midwifery talk and practice: a tension between normality and the language of risk. Sociology of Health & Illness, 33(7), 987-1001. doi:10.1111/j.1467-9566.2011.01366.x
- What stops clinicians from using intermittent auscultation?
- If fetal movement monitoring on its own doesn’t work, will adding a blood test to it improve outcomes?
Categories: CTG, EFM, Language, Reflections
Birth Small Talk 
I see parallels with other types of monitoring; my baby was in hospital for a week from the day after his birth, and we had a fight on our hands as wanted him intermittently monitored (4-hourly observations rather than continuous monitoring). Almost exactly the same in terms of language (no opportunity to make a decision given to us, talked about it being routine, and so on, then arguments when we wanted to not use it, “babies can die of sepsis” is one comment I remember). Eventually we were threatened with a Safeguarding referral (not only to do with the monitoring; there were other similar issues where we had audaciously attempted to have some say in our child’s care). We’re going through the complaints process now. But how to change a culture like that?
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I’m sorry you were not respected as a decision maker Ella. I have no easy solutions, but am committed to making space for conversations that challenge the status quo.
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I had no idea this topic of CFM and decission making was a subject of so many studies! Great text, thank you.
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Thanks Anna, I’m glad you are enjoying the posts.
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Thank you. Fascinating area of study, and sadly, one women probably aren’t conscious of till it’s too late.
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Thanks Claire, this is why it is important that maternity clinicians have appropriate conversations with women, and why continuity of carer is so important.
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What are the dangers of using a trace?
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It’s a great question Ellie, with a long answer. I’ll write a post about the risks of CTG monitoring sometime soon.
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