Way back in 2017, as I was in the first year of my PhD, I put together this short piece and sent it to a friend. I asked that she keep it safe and in the event that I died before the PhD was done, that she publish it on her blog. Fortunately, that didn’t come to pass! I rediscovered it in my hard drive recently and am pleased to be able to share it at last.
#1 CTGs don’t save baby’s lives
Women monitored by continuous cardiotocograph (CTG) monitoring during labour were no less likely to experience a stillbirth or a neonatal death than women monitored by intermittent auscultation (IA). Three women in 1000 experienced perinatal loss if they had CTG monitoring, and 3 in 1000 women experienced this outcome if they had IA (Alfirevic, et al., 2017).
Women who had a CTG performed on admission to hospital in labour had the same risk of experiencing the death of their baby (0.8 in 1000) as women who had IA only (0.9/1000) (Devane, et al., 2017).
Women who had a CTG performed in the antenatal period because of concerns about the wellbeing of their baby had a 23 in 1000 chance of experiencing the death of their baby. Women with the same concerns who had IA only had 11 chances in 1000 of experiencing this outcome (Grivell, et al., 2015). While the death rate was higher for women who had a CTG, it narrowly missed being statistically significant (95% confidence interval 0.95 to 4.42).
#2 CTGs don’t protect baby’s brains
Women monitored by continuous CTG monitoring during labour had 4 chances in 1000 that their baby would develop cerebral palsy. Women who had IA in labour had 2 chances in 1000 of the same diagnosis. While this rate was higher for women who had a CTG, it wasn’t a statistically significant outcome (95% confidence interval 0.84 – 3.63) (Alfirevic, et al., 2017).
While cerebral palsy has not been studied as an outcome of admission CTGs, there are no differences in any other outcome that indicate possible damage from low oxygen levels (Apgar scores, admission to neonatal intensive care, hypoxic ischaemic encephalopathy, or neonatal seizures) (Devane, et al., 2017).
Likewise, cerebral palsy has not been studied as an outcome for women having antenatal CTGs, but there were no difference in the rates of outcomes that might suggest possible brain injury (Apgar scores, admission to neonatal intensive care) (Grivell, et al., 2015).
#3 CTG use harms women
There is a tendency to see caesarean section as simply an alternate way to have a baby. If we view it as a complication of maternity care, one that exposes women to short term discomforts and complications and several long term risks (including stillbirth in the next pregnancy), then it becomes clear that the use of CTGs harms women.
The use of continuous CTG monitoring during labour increased the chance of caesarean section by 63%. The rate rose from 3.6% with IA to 5.4% in women with continuous CTG monitoring during labour (Alfirevic, et al., 2017). Note that the rate of caesarean section has increased significantly in the years since the research was conducted, so this is likely to under-represent the probability of caesarean section for women giving birth in hospitals with much higher rates.
The use of admission CTGs increased the chance of caesarean section by 22%, from 3.6% to 4.4% (Devane, et al., 2017).
The use of antenatal CTGs doesn’t alter the chance of caesarean section significantly (rate of 18.5% for IA and 19.7% for CTG use) (Grivell, et al., 2015).
#4 There is a lack of evidence to support the use of CTG monitoring during labour for women with risk factors
Five trials have assessed the usefulness of continuous CTG monitoring during labour for women with risk factors, with only 1,974 women were included (compared to 16,049 women without risk factors). This means that it is difficult to be sure whether continuous CTG monitoring during labour is of use for uncommon outcomes such as death or cerebral palsy. The Cochrane review (Alfirevic, et al., 2017) noted that there was no reduction in death rates, a statistically significant increase in cerebral palsy rates and a statistically significant increase in the caesarean section rates in women with risk factors who had CTG monitoring rather than IA.
(I have written more about this since the original version of this was written.)
In summary
The evidence suggests that the use of CTGs antenatally, at admission, or during labour doesn’t help babies, and it harms women. There is insufficient evidence to know whether there is a specific population of women who might benefit from the use of CTG monitoring.
References
Alfirevic, Z., Devane, D., Gyte, G. M., & Cuthbert, A. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews (Online), 2, CD006066. http://doi.org/10.1002/14651858.CD006066.pub3
Devane, D., Lalor, J. G., Daly, S., McGuire, W., Cuthbert, A., & Smith, V. (2017). Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews (Online), 1, CD005122. http://doi.org/10.1002/14651858.CD005122.pub5
Grivell, R. M., Alfirevic, Z., Gyte, G. M. L., & Devane, D. (2015). Antenatal cardiotocography for fetal assessment. Cochrane Database of Systematic Reviews, 9(9), CD007863. http://doi.org/10.1002/14651858.CD007863.pub4
- Being with woman, not with machine
- New horizons for fetal monitoring: Photoacoustic assessment of the fetal brain and placenta
Categories: antenatal CTG, CTG, EFM, IA, Perinatal brain injury, Perinatal mortality, Stillbirth
Tags: Admission CTG, antenatal CTG, caesarean section, Cerebral palsy, Continuous antenatal fetal monitoring, Evidence, Stillbirth
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- Comparing intrapartum CTG monitoring guidelines – Birth Small Talk
- Does CTG monitoring during labour work? – Birth Small Talk
- Admission CTGs: Do they improve outcomes? – Birth Small Talk
Birth Small Talk 
Hi KirstenThanks for sending this. I love itDid you intentionally title it four things…needs to NOW?Daisy
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Thanks Daisy – I have fixed it.
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How extraordinary that their use, and annual re-training still seems to be an absolute requirement!
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now I’ve read my last comment back, it could sound like I’m suggesting that your information is not correct, it’s quite the opposite, what I find extraordinary is that CTGs are still in use and seemingly so fundamental to the policies and procedures of maternity units.
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I do too, which is what prompted my PhD.
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Hospital from home birth transfer. BRILLIANT! They agreed to use a hand held doppler to monitor baby after one 20 minute initial strip. Excellent birth! Due in no “small” part to sharing your information with them! Thanks!
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Thank you – it’s always lovely to hear that people are using evidence in practice.
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So good to see evidence so clearly articulated.
So difficult to change practice in high risk settings.
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Great article Kirsten, thanks for sharing it.
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Thank you Kirsten for your brilliant work on this issue. As a CBE I do my best to inform couples about how to navigate the highly interventionist birth culture … I’ll be sharing this post far and wide – it distills the depth of your research in such a clear way!!! Thank you Rhea xx
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Thanks Rhea. I’m glad it’s useful.
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Thank you. I have just finished my second week of midwifery training as a second year student and on Friday the staff received their results form the previous weeks FSEP exam. From all reports it is very stress-full and the results dictated whether they can work as midwives in birth suite, depending on being a level 1,2 or 3 score. On the same day of placement, the hospital lactation consultant generously took close to 2 hours from her day to spontaneously offer both myself and another student, breastfeeding education, focusing on tips, tricks and communication with women, birthing people and families when they are experiencing challenges and how we as students can learn his knowledge and support well, so families can leave the hospital and be confident in themselves, their capacity and their baby. Another thing she shared is that she felt many midwives did not have the knowledge or confidence to support breastfeeding challenges and often will directly refer them onto the lactation consultant quickly, who she feels is for more challenging difficulties such as tongue ties etc. And with this she highlighted how governing bodies placed much more importance upon the CTG exams for midwives, and very little but on ongoing education of breastfeeding for parents and families on the ongoing sustenance of their growing families. Your article has pricked up my ears and I am eager for further discussion around the meanings of CTG information, especially around the evidence. Great Work Kirsten, really appreciate it. Huge Blessings Stephanie Jane
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Thanks Stephanie. Your lactation consultant’s observation is very insightful. It would be a great starting point for further research!
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Brilliant, thank you. You have provided a much needed report. Have you sent a copy to NICE and the RCOG with a request that they reconsider their advice on EFM?
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NICE and the RCOG are aware of the evidence, as are all the major obstetric organisations that provide guidance for clinicians about fetal monitoring.
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Yet still they have pushed through IOL for all at 41 weeks despite the evidence being very poor quality, thus turning all my low risk women who consent to IOL at 41 weeks from low risk to high, meaning CtG compulsory. I love this blog post we need more obs like you!
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Thank you. I feel the need to point out that CTGs are never compulsory – even for women with risk factors. Having said that, the population where there is the strongest suggestion of benefit (though still not great data) are women using oxytocin during labour. A discussion of pros and cons and an active decision about heart rate monitoring method(s) should still happen for women planning induction of labour.
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And yet this research and knowledge does not inform policy/ guidelines in big institution’s 🤷♀️
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