There’s not a lot of research about midwives’ experiences with intrapartum fetal heart rate monitoring with CTGs. (There’s even less about birthing women’s experiences.) So it is great to see new research from the Sydney based team of Deborah Fox, Rebecca Coddington, and Vanessa Scarf that sought to better understand midwives’ experiences relating to the care of women being monitored by CTG during labour.
How the research was done
For the research-minded, detail-oriented, folks out there – this research was part of a broader body of work which has been examining a new approach to intrapartum CTG monitoring which uses transabdominal monitoring of the electrical pattern from the fetal heart rate (called non-invasive fetal ECG or NIFECG in the paper). This is a “beltless” device which is stuck on to the front of the pregnant woman’s abdomen. In this particular part of the research project, midwives were interviewed either in person on in a focus group and asked about their experiences with CTG monitoring with new NIFECG system, and also with “wired” CTG monitoring (where the sensors are connected to the recording machine with a long cable) or with “wireless” telemetry CTG monitoring (where the sensors use radio frequency waves to communicate to the recording machine). Both the wired and wireless approaches are held in place by belts around the woman’s abdomen.
Twenty two midwives, all with experience of the three approaches to CTG monitoring, participated in the research. Thematic analysis of the interviews was used to make sense of the data and transform it into the published findings.
The take home messages
The researchers reported on three main themes: it becomes all about the machine, supporting women’s bodily autonomy, and being “with woman”, not with machine. Participants described how the CTG technology became the centre of attention in the birth room, drawing their focus, the focus of other clinicians, and also the woman to the output on the monitoring screen and the audible sound of the fetal heart rate in the room. The restrictive nature of wired CTG monitoring systems was described as limiting women’s bodily autonomy, while this was less the case with the wireless and NIFECG systems. Even with the telemetry systems, midwives however described the need to “fiddle” with the transducer to ensure a good quality output and reflected on how this prioritised the machine over the woman’s needs.
The authors concluded:
The ongoing challenge faced by midwives is the need to mediate the human-technology relationship when caring for women with complex pregnancies. As midwives, we have the capacity to choose how we practice and how we navigate our interactions with technology. It is evident that we can mediate the impacts on women by prioritising the woman’s needs over that of the technology. It is our intent that by critiquing the routinely accepted use of technology in childbirth we may better understand how to prioritise the woman and her innate physiological processes in order to facilitate safe and satisfying birth experiences.p. 6
Similar issues with the use of CTG monitoring equipment were visible in my doctoral research. I described the tension that arose for midwives who used additional documentation on the digital CTG as a way to keep people from entering the woman’s birth room in a disruptive manner. While this protected the birth space, it drew the midwife away from being mindfully present in the moment with the birthing woman. Being “with woman” is more than simply a nice touch – it is central to ensuring safety and supporting women’s physiological balance in labour. It really is well beyond time for us to critically question whether we do more harm than good with our attempts at fetal monitoring in labour.
I would have liked to see the research include data about midwives’ experiences using intermittent auscultation in labour. I suspect that intermittent auscultation would be experienced as enabling both the birthing woman’s bodily autonomy and the midwives’ ability to be more mindfully “with woman”. I look forward to seeing more evidence become available about trans-abdominal fetal ECG monitoring.
Fox, D., Coddington, R., & Scarf, V. (2021, Sep 20). Wanting to be ‘with woman’, not with machine: Midwives’ experiences of caring for women being continuously monitored in labour. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.09.002