Birth Small Talk

Talking about birth

Just try harder, then it will work! An allegorical tale.

Photo by Markus Spiske on Unsplash

Chris was brimming with anticipation. A few months ago, he saw an advertisement for a crash prevention system that could be retrofitted to any car. Known as the Collision Triage Gauge (CTG) it promised to reduce serious car accidents by half. He had done his background research – several prominent celebrities had been using the CTG system and they repeated the same messages that this made car travel safer and, as an added bonus, reduced car insurance premiums. The CTG had finally been fitted to his car and Chris was keen to hop in and test it out.

Sliding into the driver’s seat, he turned on the car’s ignition, pushed the glowing blue START button and was delighted by what followed. The heads-up display from the CTG lit up with many pleasing colours. Some of the information presented was recognisable (he could see kilometres per hour with a zero next to it). Other bits confused him, and he assumed they related to the fancy technology that made it work.

That’s when he realised that he was stuck. He didn’t actually know how to make sense of the array of data readouts. Disappointed, he pulled the CTG manual from the glove box and headed back to the warmth of his kitchen to read it. This didn’t provide him with the answers he needed, as it seemed to assume that the driver already knew how to interpret the information the car presented and what to do in response to it. He opened a web browser and began searching for a CTG training course.

There were several on offer to choose from. Some were online, some required him to travel to a city nearby, some had an exam at the end, while others offered simply a certificate of attendance. It was difficult to choose. He finally settled on one that promoted itself as being an engineering-based course, taught by someone who seemed to have plenty of experience. They had even published a research paper about how their CTG course improved knowledge. The next study day was this coming weekend, so he paid the fee and booked in.

Sunday afternoon found Chris back in the driver’s seat. He had made lots of notes at the course and learned a lot. His post test score was much higher than his pre-test score, so he was confident that the course was worth his investment of time and money. He pressed the START button again, checked the readout from the CTG, and released the handbrake. He headed up the road towards the bridge, watching the data roll across the display. Chris was concentrating intently, making sure he interpreted the information correctly.

That’s when the tractor pulled out of the side lane. Chris didn’t notice it until the last minute. He stamped on the brake, only just avoiding a collision. The farmer on the tractor shook his head as he drove past. Chris ran through the course checklist again – everything was still in the “normal” range, so he couldn’t see any reason for the lack of forewarning. He drove carefully back home and considered his next steps.

As soon as their office opened on Monday, Chris called the manufacturers of the CTG, looking for advice. They pointed out that even people who have attended training often found it hard to correctly interpret the CTG data. They had just released a software upgrade that provided computer interpretation of all the information from the car’s sensors so that pretty much anyone could get it right. All you had to do was look for the colour green (safe), orange (possible problem), or red (pull up now!). As an added bonus, it included a monitor that could stay in the kitchen so family members could check on where the car was and what speed it was doing whenever they liked. You could even install an app on your phone to get the same information!

Chris was a bit disgruntled about having to spend more money to get the CTG to work but considered that he had little choice, now that he had already invested so much. The software update was scheduled to occur overnight. He spent the afternoon searching online for other owner’s experiences. He found lots of stories that reassured him that other people had found their CTGs lived up to expectation, and several heart-breaking stories of fatal car accidents. When he read these closely, it was clear that the drivers weren’t following the manual or hadn’t been to the same training program as him. Some people had even been charged with criminal negligence when they crashed and caused an injury, and it became clear during the investigation that they hadn’t been to a recent CTG training program. Chris recognised that you can’t expect the CTG to work if you don’t try hard enough!

On Tuesday morning, we find a despondent Chris on the bus for his commute to work. The software update seemed to make things worse. His cat had wandered idly past the passenger side of the car as he was pulling out, immediately causing the CTG to turn red, even though there was quite clearly no risk of a crash. He didn’t have time to figure out what to do, so he abandoned the idea of driving the car entirely. Over morning tea, his workmates asked how he found the new CTG. Too embarrassed to admit that he wasn’t able to make it work, he lied and told them that it was wonderful and that his wife had asked to take the car that day. Discussion turned to a recent news story where the local mayor had suggested that they make CTGs compulsory in order to improve the motorway traffic accident problem that seemed to defy all previous attempts to fix it. He opened the app on his phone and sighed at the signal showing the car still stationary in his drive.

The car remained in the drive for the rest of the week, while Chris pondered what to do next. On Saturday a friend popped by for a few drinks and showed Chris a series of research papers that he hadn’t seen before. These suggested that the CTG had not actually been proven to work before it was released for sale. Chris dismissed this idea – his friend was known to be a bit of an oddball after all. He couldn’t imagine that with all the regulation in place around technology manufacturing and the news stories about CTGs that it might be true that the device would never work. Putting his glass back on the table, he said to no one in particular – I just have to try harder – then it will work!

This post arose from a conversation between Sara Wickham and myself, as we tossed about suitable analogies to explain the current misperceptions about intrapartum fetal heart rate monitoring. If you have been reading my posts for a while, you’ll be aware that research doesn’t provide clear evidence that intrapartum CTG monitoring prevents poor outcomes. (If you are new to Birth Small Talk then you might like to start here). When I have presented this information in the past, some people have responded by telling me that the research evidence is no longer relevant because 1. the technology we now use for CTG monitoring (such as computer interpretation of the CTG or central monitoring) means that CTG monitoring now works; and / or 2. our knowledge about how to interpret CTGs is so much better and clinicians are better educated than they ever have been, so CTG monitoring now works.

I call this the “if we just tried harder” argument, because it suggests that if we just tried harder then CTG monitoring would work. This idea has actually been with us right from the start of research into CTG monitoring. Kelso, et al., in 1978 questioned whether better education might have lead to a different outcome in their randomised controlled trial (which showed no benefit). What I have tried to make clear in this tale about Chris and his car, is that if the first bit of technology doesn’t work, then reading manuals, attending training courses, trying really hard to interpret the CTG, and adding more technology won’t change the fact that the technology never worked in the first place. The reality that the technology was never going to work doesn’t stop people from imagining that the technology does work, blaming people who use the technology when the technology doesn’t work, setting up financial incentives that favour the use of the ineffective technology, or attempting to make the use of the technology routine. All of these practices are commonplace in our application of CTG monitoring to clinical practice.

We can either, like Chris, keep pursuing new ways to attempt to make technology do the thing that we paid for it to do; or accept that it was simply a bad idea in the first place, uninstall it, and look for other ways to build safety. I’m not at all sure which option will win out when it comes to CTG use in maternity care!


Kelso, I. M., Parsons, R. J., Lawrence, G. F., Arora, S. S., Edmonds, D. K., & Cooke, I. D. (1978). An assessment of continuous fetal heart rate monitoring in labor. A randomized trial. American Journal of Obstetrics and Gynecology, 131(5), 526-532. 

Categories: CTG, EFM, Reflections

3 replies

  1. Brilliant, constantly pointing out that CTG does not work, cannot be interpreted and should be ditched has failed for years. Perhaps your brilliant analogy will finally expose the fact that the Emperor has no clothes.


  2. Wonderful. Thanks so much. Particularly the near miss with the tractor. CTGs ignore so much relevant information that could be gained by keeping your eyes on the road – being with the person not the machine.


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