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.
- 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.
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