New research from an international team sought to identify why midwives used CTG monitoring in labour for women considered to be at low risk, despite guidelines advising against CTG use for this population (Jepsen, et al., 2022). Research like this is useful as it can help to understand the barriers to changing practice. Actor-network theory was used as the conceptual framework – prompting the research team to consider the role(s) the CTG plays during labour and how it connects people and equipment in networks of action. 31 midwives and three midwifery students working in New Zealand, Australia, Denmark, and Norway participated in five focus groups to generate data for the research.
The authors described six key roles that the CTG machine might play:
1. The CTG as a “babysitter”. The term “babysitting” was used to describe the practice of initiating CTG monitoring so the midwife could leave the birth room and attend to other priorities. Midwives both described this and also recognised the inappropriateness of this practice: one midwife was quoted as saying “Everyone knows that they CTG can only register the state of the fetus but not act. If used alone as a babysitter, we can have a perfect registration of a dying fetus” (p. 5).
2. The CTG as the midwife’s partner. The CTG was considered as an essential tool in midwifery practice, particularly in high-tech maternity units. The presence of the CTG machine in the birth room encouraged its use, particularly when it was difficult to find alternate monitoring equipment (like a Pinard or fetal Doppler).
3. The CTG machine as an agent of shared responsibility. The CTG sat within a network that provided a sense of connection and shared responsibility between the midwife, the parents, and when central monitoring was in use, with midwives and obstetricians outside the room.
4. The CTG as a protector that “covers your back”. The CTG acted as a form of proof of the care provided. In doing so, it operated in an expanded network that included regulatory bodies and courts of law. The CTG was both a source of anxiety and provided relief from anxiety when used in this way.
5. The CTG as a disturber of normal birth. Midwives described the CTG machine becoming the centre of focus for people in the birth room and restricted the woman’s movements. Starting CTG monitoring with the intention of using it for only a brief time could lead to the continued use of CTG monitoring for the duration of labour and might drive other interventions.
6. The CTG as a requested guest. Midwives were typically the initiators of CTG use but did so in response to an expectation that medical staff would ask for CTG monitoring to be instituted if the midwife had not already done so.
Including midwives from four different countries was a real strength of this research. What struck me were the similarities in the roles the CTG was found to play in all four locations. This suggests that the networked relations around CTG monitoring (such as professional guidelines, professional regulatory processes, legal processes and so on) are similar in all four locations. These shared similarities offer hope that if change can occur in one location, then it should be possible to reproduce it more universally.
The authors concluded with the following advice about how to reduce over-reliance on CTG monitoring:
We must ensure that midwives regain confidence and competence in using, interpreting, and communicating their intermittent auscultation practices and do not need the security, the proof, the defence that the CTG trace offers. We must look at staffing levels in our maternity units, how midwives are supported and cared for, and the birthing unit’s culture more broadly. We also recognise that we need to focus on intermittent auscultation if all midwives can provide this practice.p. 8
Jepsen, I., Blix, E., Cooke, H., Adrian, S. W., & Maude, R. (2022, Jan 22). The overuse of intrapartum cardiotocography (CTG) for low-risk women: An actor-network theory analysis of data from focus groups. Women & Birth, in press. https://doi.org/10.1016/j.wombi.2022.01.003