Birth Small Talk

Talking about birth

Does training in intrapartum fetal monitoring actually work?

Photo by Ivan Aleksic on Unsplash

Although the concepts of periodic fetal heart rate and fetal heart rate patterns are new to most obstetricians, with a little instruction they apparently have little difficulty in recognising the various types of fetal heart rate patterns and classifying them into innocuous and ominous groups.

(Paul & Hon, 1970, p. 168)

Since Paul and Hon’s overly optimistic paper promised that CTGs would make maternity care better and required little instruction, CTG education has become a big business. It is reasonable to apply a research focus to CTG education and see whether it is a good investment or not. Late last year Kelly et al. (2020) published a systematic literature review which set out to answer the question of whether training in intrapartum CTG monitoring achieves the goal that it promises. Their take home message was that “evidence for the impact of CTG training on neonatal and maternal outcomes is limited, shows inconsistent effects, and is of low overall quality”. The Kelly et al paper should be compulsory reading for all people who design, run, and fund CTG education. The authors have done the science well and argue their position competently.

Professor David Ellwood and I have just published a mini-commentary reflecting on their findings (Small & Ellwood, 2021). Based on the current evidence set out by Kelly and colleagues we argued that stand alone CTG education should not be considered mandatory for maternity clinicians. 

Here in Australia, most but not all state health departments require clinicians to have attended the Royal Australian and New Zealand College of Obstetricians and Gynaecologists fetal surveillance education course (known as FSEP) in the past one or two years, and to have achieved a high score (level three). I’m curious to know what happens in other parts of the world. Is CTG education mandated? Who offers the courses? How long are the courses? Is there an exam and what form does it take? How much do you pay to attend? Please add your comment below so we can see what is happening around the world. 


Kelly, S., Redmond, P., King, S., Oliver-Williams, C., Lame´, G., Liberati, E. G., Kuhn, I., Winter, C., Draycott, T., Dixon-Woods, M., & Burt, J. (2020). Training in the use of intrapartum electronic fetal monitoring with cardiotocography: Systematic review and meta-analysis. BJOG, in press

Paul, R. H., & Hon, E. H. (1970, Feb). A clinical fetal monitor. Obstetrics & Gynecology, 35(2), 161-169. 

Small, K., & Ellwood, D. (2021). Does training in intrapartum fetal monitoring actually work? BJOG: An International Journal of Obstetrics & Gynaecology, in press

Categories: CTG, EFM, New research


5 replies

  1. FSEP mandatory here in Victoria and seems a conflict of interest to me as the only acceptable course is run by RANZCOG who would seem to have a financial interest in maintaining the status quo. Would be good to see independent review whether it has made a difference


  2. I concur with the concerns that you have raised , however because CTG monitoring is concreted in to clinical care , quality reviews and case reviews , they are here to stay. The main challenge for institutions is to minimise the chaos that CTGs generate because of their intrinsic limitations. One approach to this is to agree on the language and intepretation as best we can and therefore some form of training I do see as necessary . It will not make a noticeable clinical difference however it could help reduce the angst and mayhem caused by CTGs.



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