This is part two of a series of posts about the risks that flow from the use of intrapartum monitoring. Last week, I examined evidence of short and long-term physical harms to birthing women relating to higher rates of surgical birth when intrapartum CTG monitoring is used. This week I focus on possible psychological harms which have been reported relating to CTG use.
There has been limited exploration of women’s experiences of intrapartum fetal heart rate monitoring throughout the history of the technology, with most of the research occurring prior to 1988, when the evidence up to this point was summarised in a literature review (Snydal, 1988). Thirteen studies, which varied in design, quality, timing and country, were analysed. Women reported that CTG monitoring limited their mobility during labour and that the belts used for external monitoring were restrictive and uncomfortable. CTG monitoring was described as producing a technical atmosphere in the birth room which women said led to partners and health practitioners being focused on the machine, rather than on themselves.
Women often reported anxiety, and this arose for two reasons. Firstly, women lacked understanding about how the technology worked (for example women feared that they might be electrocuted by it), and secondly, changes in the fetal heart rate led to anxiety about the wellbeing of their fetus. While many women included in the research reported positive experiences with CTG monitoring, this was not the case for all women.
One of the papers reviewed by Snydal was noteworthy. Shalev et al. (1985) compared blood levels of hormones associated with stress in a group of women exposed to CTG monitoring during the antenatal period, and a group without CTG monitoring. A significant rise in insulin, cortisol, growth hormone, and catecholamines was found to commence 10 minutes after CTG monitoring was initiated, with the rise being sustained over an hour. This mirrors the findings of Mancuso et al. (2008), who used validated psychometric texts for anxiety and documented a significant increase in anxiety scores after antenatal CTG monitoring.
Such research has not been repeated for the use of CTG monitoring during labour. Elevated levels of stress hormones have the potential to impact labour progress and safety, for example slowing labour progress by reducing oxytocin production, a hormone which is also known to have neuroprotective effects on the fetal brain (Buckley, 2015). This might go some way to explaining why the rate of caesarean section for reasons other than fetal heart rate abnormalities is higher when CTG monitoring is in use.
The only other research into birthing women’s experiences regarding intrapartum fetal monitoring undertaken since Syndal’s review was that of Killien and Shy (1989) who surveyed women enrolled in an randomised controlled trial examining the use of either CTG or IA monitoring in premature labour. Women randomised to IA were slightly more likely to rate their experience of monitoring and the “nursing” support provided during labour more favourably.
What strikes me most about the research regarding women’s experiences of intrapartum fetal heart rate monitoring is the absence of it. In the past thirty years there has been no research examining how women experience intrapartum CTG monitoring, what they prefer, and the meaning they assign to fetal monitoring. In the past 20 years, only one study has investigated anxiety in relation to antenatal CTG use and no one has since taken this up and replicated or expanded on their findings. The use of CTG monitoring has become close to universal, and there have been significant changes in the technology used for CTG monitoring during this period.
I am not surprised by the paucity of research however. The drive to use continuous intrapartum CTG monitoring has always been about maintaining the authority of obstetric ideology (Arney, 1988) rather than being focussed on meeting the needs of birthing women. Given the ubiquity of CTG use, it is well past time that researchers began asking birthing women about what they want.
Arney, W. R. (1982). Power and the profession of obstetrics. University of Chicago Press.
Buckley, S. J. (2015). Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. https://www.nationalpartnership.org/our-work/resources/health-care/maternity/hormonal-physiology-of-childbearing.pdf
Killien, M. G., & Shy, K. K. (1989). A randomized trial of electronic fetal monitoring in preterm labor: mothers’ views. Birth, 16(1), 7-12. http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=2662982&retmode=ref&cmd=prlinks
Mancuso, A., De Vivo, A., Fanara, G., Denaro, A., Laganà, D., & Maria Accardo, F. (2008, Jan). Effects of antepartum electronic fetal monitoring on maternal emotional state. Acta Obstetricia et Gynecologica Scandinavica, 87(2), 184-189. https://doi.org/10.1080/00016340701823892
Shalev, E., Eran, A., Harpaz-kerpel, S., & Zuckerman, H. (1985). Psychogenic stress in women during fetal monitoring (hormonal profile). Acta Obstetricia et Gynecologica Scandinavica, 64(5), 417-420. https://doi.org/10.3109/00016348509155159
Snydal, S. H. (1988). Responses of laboring women to fetal heart rate monitoring. A critical review of the literature. Journal of Nurse-Midwifery, 33(5), 208-216. http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=3065468&retmode=ref&cmd=prlinks