I was interested to see a newly published paper from Namibia reporting on midwives’ perceptions about the use of intrapartum CTG monitoring (Uusiku, et al., 2022). There are several papers that have previously explored midwives’ experiences with CTG monitoring, but all the ones in my collection have so far come from high-income countries. I was curious to see if the findings from Namibia were similar or not to these previous studies.
The short answer is that Namibian midwives reported the same sort of things that have been published in studies from high-income countries previously. Namely:
- They perceived both advantages and disadvantages to CTG use in labour
- They expressed a desire for more education in relation to interpreting heart rate patterns, and
- They had very little discussion with women regarding fetal monitoring.
Nope, nope, nope!!!
While their research itself is great and adds to our knowledge, this statement made me cross (let me be clear I was not cross with the research team, I was cross that this is a “thing” in maternity care):
The participants also appreciated the use of the cardiotocograph machine as it saved them time and allowed them to attend to other patients while the machine was running. One midwife commented “So, I feel that the CTG is really helpful and, sometimes, it is like you do other things while the CTG is monitoring once you have attached the woman to a CTG.”
p. 19
This approach (putting the CTG on and leaving the woman alone while attending to other tasks) was termed “midwife by proxy” by Smith and colleagues (2012) in their review of the literature regarding health professional’s views about fetal monitoring. It is really important to not be fooled into thinking that CTG machines have agency and are monitoring the fetus so the midwife doesn’t have to. All the CTG machine is doing is generating a recording of the fetal heart rate in relation to uterine activity plotted over time. Monitoring requires that a suitably trained person is interpreting the recording the machine is producing and making a determination of whether the pattern is normal or not. If CTG use is to improve perinatal outcome (and that remains to be proven) it is vital that someone can take immediate action in relation to the evolving pattern, interpreted in the light of the overall clinical context.
Returning to the CTG recording after a period of time away to see a perfect recording of the death of the fetus is fortunately rare, but it does happen. We need to stop considering the practice of using of the CTG as a “midwife by proxy” as advantageous and instead see it for what it really is: a gross abrogation of professional care. Any manager in a maternity setting who chooses to purchase more CTG machines in order to overcome (or enable) reductions in staffing should be held accountable for this nonsense.
What gets me most heated about the idea that you can replace a midwife with a CTG machine is the way that this reflects on peoples’ perceptions of what midwifery is and what midwives do. A midwife providing intrapartum care does SO much more than simply take note of the frequency and duration of the woman’s contractions and how the fetal heart rate responds to them. For starters, midwives are also paying attention to the woman and noting how she is responding to the challenge of labour over time. Midwives provide a stable presence that permits the woman to regulate her autonomic nervous system and endocrine system ideally achieving the high parasympathetic / low sympathetic, high oxytocin / low adrenaline balance that maximises uterine blood flow and therefore supports fetal wellbeing in labour.
Many of the tasks performed by midwives as they provide care in labour have been under-researched, are poorly understood, and go largely undocumented in hospital records. The CTG machine does not in any way begin to approximate what midwifery care looks like. Midwifery care requires expertise, intuition, attention, patience and looks a bit like magic when it is done well. There is clear evidence that midwifery care is what makes maternity systems safe (Nove, et al., 2021), not machines that go ping.
Please, please, please… if you start CTG monitoring on a woman in labour, never leave her unattended (unless she specifically requests this) with the assumption that the CTG machine will do your job. And if you are a manager making decisions about how to spend money in your maternity system, employ more midwives and buy fewer CTG machines. That is how you fund safety.
References
Nove, A., Friberg, I. K., de Bernis, L., McConville, F., Moran, A. C., Najjemba, M., Ten Hoope-Bender, P., Tracy, S., & Homer, C. S. E. (2021). Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Global Health, 9(1), e24-e32.
Smith, V., Begley, C. M., Clarke, M., & Devane, D. (2012). Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. BMC Pregnancy and Childbirth, 12(1), 166.
Uusiku, L., James, S., Sonti, I., & Tuhadeleni, O. (2022). Midwives’ perceptions regarding the use of the cardiotocograph machine as an intrapartum monitoring tool in Namibia: A qualitative research study. Global Journal of Health Science, 14(1),16-22.
Categories: CTG, EFM, New research
Tags: midwife, Midwife by proxy, safety
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Birth Small Talk 
What a fantastic article.
I would like to think all NHS managers would read it and take note of the last bit!
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Thanks you Kirsten for recognising and acknowledging what midwives do. It is in deed magic to watch when it is done well.
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Thank you, Kirsten, for describing what midwives truly do – I have shared this blog with both my obstetric and midwifery colleagues. We have all resorted to this, especially in high-volume settings and I suspect continue to do so…While our midwives are being taught “intelligent intermittent ausculation” I was excited when our former head of obstetrics shared an e-learning certificate course on “Intermittent ausculation” – which she enjoyed doing herself and encouraged other colleagues to do the same. Change is happening- we are beginning to reflect-review our practices.
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That’s great news Evita!
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