Last week I wrote about the concept of the CTG as a “midwife by proxy” – when women are left alone attached to a CTG monitor. (You can read that post here.) In it, I mentioned that the work midwives and nurses who provide intrapartum care actually do is under-researched and under-acknowledged. I was delighted to see recently published research that sought to capture details of the work that labour nurses in one state in the USA did in relation to CTG monitoring during labour.
About the research
Fox, Glasofer, and Long (2022) surveyed nurses currently providing intrapartum care, asking about the time spent working to achieve a continuous recording of the fetal heart rate with the CTG monitor and the equipment they used to facilitate this. 134 nurses contributed to the study. Almost 50% of respondents reported spending 1-2 hours per 12-hour shift manipulating the ultrasound transducer to achieve a continuous recording. A similar proportion of respondents spent 1-2 hours per shift repositioning women to facilitate CTG monitoring. The authors noted “approximately half of participants spend up to one third of their shifts in efforts to achieve fetal monitoring” (p. 4).
In addition to the fetal monitoring straps provided to secure transducers to the maternal abdomen, nurses reported to using an array of other equipment. This included: washcloths, peri-pads, pillows, intravenous fluid bags, alcohol pads, gauze, belly bands, stockinet, sand bags, towels, specimen containers and adhesive tape. These additional items of equipment were used in 22 – 37% of shifts. All but one of the respondents reporting using some form of additional equipment to achieve continuous monitoring.
The take home messages
The thoughts that stayed with me as I read this paper were:
- CTG monitoring equipment is clearly inadequately designed if the use of additional aids is this routine. The information relating to the use of additional equipment to ensure a continuous recording is not one that I have seen reported in literature previously. I suspect that until recently there has been little interest in the embodied work of nurses and midwives (feminised professions) and birthing women. When there is difficulty attaining a good trace, it has been easy to blame the woman or the clinician, rather than to demand better equipment design.
- When calculating the cost of CTG monitoring in future research, it is important that the cost of additional equipment be factored in. This is particularly the case when the equipment is single use only. Failure to do so risks underestimating the true cost to the healthcare budget.
- The use of continuous CTG monitoring to free up midwifery time (see last week’s post) is likely a false economy. Up to 4 hours in each 12-hour shift were consumed by the need to fiddle with equipment or to wiggle women’s bodies. While there is no research (yet) examining the time required to perform intermittent auscultation, it is likely that intermittent auscultation takes up far less than one third of the work completed by midwives and nurses as they provide labour care.
- There is an opportunity cost involved when continuous CTG monitoring is in use. That is, when the nurse or midwife spends hours mucking about focussed on getting a nice-looking wiggly line on the CTG monitor, there are other things they simply cannot do. Other safeguarding work doesn’t get done, so any (theoretical) gains in safety that might come from CTG use are offset by failure to attend to other signs of concern. Additionally, attending to women’s social, psychological, and spiritual needs inevitably falls far down the list of priorities.
Where to next?
This research opened a new window into the work done by midwives and nurses to make CTG monitoring happen and raises new questions. Qualitative work, in particular ethnographic observations of people at work, would help to further identify what it is that both birthing women and those providing care in labour do to ensure an interpretable CTG recording is generated. No research has yet made direct comparisons regarding the time commitment required of clinicians and the equipment costs of intermittent auscultation with CTG monitoring. This would be useful information to inform healthcare funding priorities.
Fox, A., Glasofer, A., & Long, D. (2022, Jan 13). Time and effort by labor nurses to achieve and maintain a continuous recording of the fetal heart rate via external monitoring. Nursing for Women’s Health, in press. https://doi.org/10.1016/j.nwh.2021.12.001