Birth Small Talk

Talking about birth

Adding something extra to make the CTG work

Photo by Jordan Whitfield on Unsplash

In order to overcome the inability of CTG use to achieve the goals that it was designed to achieve, it is common for people to add another something or other. I call this the CTG+ approach. There is research that examines whether these additions are effective or not and I have written about much of this research in the past. In this post, I signpost these previous posts for you so you can take a look at the evidence for yourself.

Additions to the CTG I have previously written about:

  • “If people were just smarter, then CTGs would work.” This statement, or similar ones, crops up quite often in discussions about CTG use. Along with Professor David Elwood, I have published a mini-commentary about whether education improves outcomes with CTG use. We wrote the commentary in response to a systematic literature review. You can read about that literature review, and our commentary on it, here.
  • Central fetal monitoring: Evidence about central fetal monitoring was of particular interest to me when I did my doctoral research. There isn’t much unfortunately. You can access my doctoral thesis via this post. Along with my supervisors we have published about our concerns that central fetal monitoring systems may have unintended consequences when introduced to maternity services (read about that here) and that central fetal monitoring systems might undermine, rather than improve, safety (read about that here).
  • More tech will fix it! This post reports on an evidence summary that looked at fetal oximetry, ST segment analysis of the fetal electrocardiogram, fetal blood sampling, computer interpretation of the CTG, changes to professional guidelines, and fetal stimulation. (Spoiler – none of this works).
  • I have written more about computer interpretation of the CTG here. This post looked at the costs of introducing computer analysis of the CTG in the INFANT trial.
  • There’s also more about ST segment analysis here.
  • Fetal blood sampling is addressed in this post. It turns out that we should probably pay more attention to the equipment we use when assessing fetal lactate levels during labour.
  • Fetal stimulation is sometimes used as a way to decide whether an abnormal CTG pattern actually reflects low oxygen levels in the fetus or not. This post looked at research examining whether fetal stimulation improved outcomes when used in addition to CTG monitoring.
  • New technological approaches are on the horizon as an alternative or adjunct to CTG monitoring and I’m keeping my eyes peeled for research about them. This post is about recording fetal oxygen levels by using a device placed on the woman’s abdomen, and this one is about another non-invasive approach that aims to measure oxygen levels in both the placenta and the fetal brain.

I remain sceptical that we will find a way to get CTGs monitoring to improve perinatal outcomes. I would really love it if we can find a better technology that helps us to reliably identify fetuses that will benefit from surgical birth and those who won’t. I suspect that measuring oxygen levels directly in a non-invasive way might be the answer. I worry that, once again, we might jump the gun and introduce new technologies before properly assessing them.

Categories: Basics, CTG, EFM

Tags: , , , , , , , , ,

11 replies

  1. Thank you so much for your blog, it is really interesting. I look forward to listen to your lecture at the Normal birth conference in Århus, Denmark!


  2. Dear dr Small, thank you for all your work.

    I have a question for you: how do we act to change practice?

    I keep seeing posts on Social Media showing CTG as standard, safe procedure, offered routinely in pregnancy and when I bring up that there is no evidence do use it in this way people won’t listen to me, attack me etc. I am “just” a birth activist so not a midwife involved in direct care but it beaks my heart that so much time and recources is invested in CTG and c-section rate increases dramaticly in my country. It is frustrating to know what I know from you and seeing practice so different…

    Any advice or reflection? Maybe you already have a post on this topic and I just haven’t read it yet?


    • Keep having quiet gentle conversations about the research. We need high level policy change before individual practitioners will be able to change their practice. And that will only happen when there’s a shift in attitude that reaches tipping point.


      • Thank you for this ❤

        Can you see this shift happening? In Poland where I live there is very strong obstetric lobby and not much happening to put midwifery back on it's place, midwives embrace CTG as a service they can offer.


      • I remain quietly hopeful that it will. It will take time and it won’t happen without challenging obstetric authority. Midwives talking to one another about the evidence and their experiences is the first step in developing a strong united voice.


      • Also is advocating for more modern CTG machines that make it easier to move is a right thing to do if we canno’t kick the CTG out right now?


      • It depends on what you mean by more modern machines. Focus on technology that makes the experience of being monitored better for women (waterproof telemetry for example), rather than technology designed to make life easier for clinicians but has evidence of higher CS rates (central monitoring systems).


  3. I mean the first thing: technology that makes being monitored better experience for women, telemetry is a gamechanger, but it is still based on false asumption that contrinous fetal monitoring is beneficial.


  4. Loved your view on unintended consequences of centralised CTG monitoring. I am now seeing that first hand. Not many positives.


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