I use a Google Scholar alert to notify me of the latest publications about CTG monitoring. Every day or so I get an email with about ten papers and I flick through them to see what they are about. It makes it easy for me to stay on top of the trends in conversations about CTG monitoring. One of the repeated patterns I encounter is the edict regularly issued by authors writing in peer reviewed publications that women should not be given a choice of fetal heart rate monitoring method in labour. They don’t say it quite like that though. Instead the writer will say things like:
- “Constant intrapartum electronic fetal monitoring is necessary”
- “When any condition thought to increase the risk of hypoxia is present, continuous electronic fetal monitoring is mandatory”
- “When continuous electronic fetal monitoring is required…”
- “Consider whether CTG monitoring needs to continue”
[I have gently edited the original quotes from published literature and I choose not to name sources here. My aim is not to shame the people who wrote these things, but to encourage reflection on language choices.]
This is my regular reminder that women have a choice about any and all interventions during labour. That includes a choice about fetal heart rate monitoring. CTG monitoring is never “necessary”, “needed”, or “required” and it should NEVER be mandated.
More subtle (but still a source of frustration for me) are the writers who say things like:
- “Intermittent auscultation is an appropriate method of monitoring the baby’s heartbeat for women without risk factors”
- “Using CTG monitoring in low risk pregnancy is a non-evidence based intervention”
- “The absence of risk factors means the woman can receive intermittent auscultation”
- “Experts emphasise that without suitable indications, CTGs are potentially harmful”
You might be thinking – hang on Kirsten. Have you lost your mind?
All those statements are true. Or at least they are close to it – there is some (though flawed in my opinion) evidence that CTG use in low risk populations reduces the incidence of neonatal seizures. CTG use in the low risk population is therefore arguably not strictly speaking “non-evidence based”. That’s not the issue though.
Let me make the problem visible to you by changing the emphasis. We NEVER see authors (other than me perhaps) write:
- “Intermittent auscultation is an appropriate method of monitoring the baby’s heartbeat for women with risk factors”
- “Using CTG monitoring in high risk pregnancy is a non-evidence based intervention”
- “The presence of risk factors means the woman can choose intermittent auscultation”
- “Experts emphasise that even when used for accepted indications, CTGs are potentially harmful”
All these statements are also accurate. You could argue they are even more accurate than those about low risk women, as the apparent benefit in neonatal seizures disappears and is replaced by a higher rate of cerebral palsy when we look at CTG use in high risk women. But you won’t ever see sentences like these appear in peer reviewed literature.
Why? Because deep down, the assumption in maternity professional circles is that CTG monitoring works. And some maternity professionals believe that when they think the fetus is at risk, the woman no longer gets a choice. Therefore, we see written statements that support women having a choice only when they are considered low risk. But we never see statements that support women having a choice in the presence of risk factors. This creates the impression that there is no choice for women perceived to be at higher risk. Now can you see the problem?
Dear fellow writers,
I request that you reflect on your language choices. All women who labour, regardless of their risk assessment, get to choose whether they want intermittent auscultation or CTG monitoring. Write in a way that shows you believe this to be true.
Please and with much love,
Kirsten
Categories: CTG, EFM, Feminism, IA, Language, Reflections, Writing
Tags: decision making
Birth Small Talk 
So good to see your own thoughts written down the way this should be approached.
Thank you Kirsten for summing it up perfectly!
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Thanks Anita!
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Bang on the nail Kirsten! Reframing language is an essential element in shifting the discourse. Conversations in childbirth have been stuck on a merry go round that causes more harm than good, obscuring fact from fiction.
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