Two papers I read recently have been asking me to turn them into a blog post and the day has finally arrived for the post to take shape. The first was a chapter from medical historian Jacqueline Wolf’s 2020 book exploring the historical context shaping the rise, rise, and rise of caesarean section rates around the world. In chapter five, titled Inflating Risk, she focused on the 1960s to 1980s with a section of the chapter exploring the role CTG technology played in driving up the caesarean section rate during that period, and it is this that I focus on here. The second paper was the work of midwife Anna Melamed, who recently published (2023) a feminist post-structuralist critique exploring the role of the CTG and what it has come to mean in maternity care.
Learning about, and from, history
In becoming the norm, electronic [CTG] monitoring thwarted one of the main demands of [birth] reformers – intervention-free birth as the default. Instead, the monitoring became a constant presence that often led to cesarean section.
Wolf, 2020, p. 151.
As CTG machines were being developed and deployed in clinical practice in the 1960s, they were promoted as a means to reduce the use of caesarean section, which had a rate of around 4.5% in the USA at the time. There was little evidence on which to base this assumption of falling rates. It was believed the near continuous provision of fetal heart rate data would overcome the problem of performing an urgent caesarean section for fetal concerns only to discover the fetus had been fine all along. Current maternity professionals will recognise the error in these assumptions. Compared with intermittent auscultation, CTG use is associated with an increase in the use of caesarean section, and the rate of false positives (deciding the fetus is in trouble but it isn’t) is significant.
On major drawback to CTG technology soon became apparent, and that was the challenge of making sense of the heart rate pattern. An obstetrician quoted in the chapter described this as like interpreting a piece of modern art – everyone sees something different. The complexity of CTG interpretation ultimately favours obstetric authority and undermines that of birthing women. Once an obstetrician decided the pattern was proof that the fetus was in harm’s way, the CTG recording could be used to force women to agree to caesarean section. It is almost impossible for a labouring woman to know whether to trust their assessment. Carol, a woman who described her birth in 1976 in the chapter said:
That’s something I guess I’ll never forget, that the baby would die, or I could die, or both of us … what they were saying, it just didn’t seem right. Since then, of course, I’ve read these books that say that half of [physicians] … don’t know how to read the monitors”.
p. 134
Rising in parallel with the increasing use of CTG machines and caesarean section, were complaints from women about the brutality and rigidity of birth practices. The 1970s saw the publication of Spiritual Midwifery (Ina May Gaskin) and Immaculate Deception (Suzanne Arms), and the emergence of birth reform organisations. Reformers argued against medical controls over birth, the use of technology, and inappropriately high rates of caesarean section.
CTG monitoring provided a means for obstetrics to reject reform efforts. In a population convinced that continuous recording of the fetal heart rate would prevent harm to the baby, women had (and continue to have) little choice other than to rely on the judgement of the person interpreting the CTG recording and their recommendation for intervention. Media stories about the (presumed) benefits of CTG use functioned to generate anxiety that “bad things” might happen to the fetus without using CTGs and solidified the technological and mechanical approaches to labour management that birth reform efforts sought to mitigate.
Disturbing the mother-fetus connection
When using the cardiotocograph, the fetus appears as an electronic reading, apart from and outside of the woman… The expert can read its complicated coding, and has knowledge about the fetus that can then be translated to the mother by attributing selfhood [to the fetus], such as the baby is ‘not happy’ or ‘getting tired’.
Melamed, 2023, p. 167.
Melamed begins by arguing the inseparable relationship between woman – placenta – fetus, and then through birth, the emergence of the also inseparable mother – baby dyad. Historically speaking, the pregnant woman was the best (and only) person to know the state of the fetus and her body through pregnancy and birth. This way of thinking aligns with the holistic paradigm (as defined by Davis-Floyd, 2001) that holds that the body and mind are not separate, and neither are the woman and fetus.
The CTG is the product of an entirely different way of thinking, speaking, and knowing about women, fetuses, babies, and birth: the technocratic paradigm (Davis-Floyd, 2001). In this world view the mind and body, and the woman and her fetus are distinctly separate entities, with the body viewed as a machine. When a CTG recording is generated, a representation of the fetus exists outside the woman’s body. With central fetal monitoring, that fetal representation shifts and can appear in sites where the woman is no longer present.
CTG use, and particularly central fetal monitoring, disturbs the fetal connection with the woman as maternity professionals “see” the fetus independent of the woman. The woman’s mechanical body is more of a focus than women’s minds. For example, cervical dilatation and maternal observations are often displayed overlaid on the CTG recording where it is readily seen at the central monitoring feed, without professionals needing to encounter the “real” body or the mind attached to it. Women’s priorities for their birth and their role as decision maker become very easy to overlook when this happens.
Melamed argues that intermittent auscultation (which offers similar effectiveness to CTG use) doesn’t have the same impact on the body-mind and mother-fetus connections. She wrote, intermittent auscultation:
does not try to symbolically remove the fetus from the context of its mother’s womb, but honours the mother – placenta – fetus in its wholeness and its unknowable-ness.
p. 169
Thinking differently about fetal monitoring methods
Technocratic ways of thinking about maternity care dominant much of the research about fetal heart rate monitoring. Writers like Wolf and Melamed give us an opportunity to step outside of that world view and reflect on the values, roles, and meaning socially embedded in different fetal monitoring approaches. We can then ask – is this what we want?
References
Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynaecology & Obstetrics, 75, S5-S23. https://doi.org/10.1016/S0020-7292(01)00510-0
Melamed, A. (2023). A post-strucutralist feminist analysis of electronic fetal monitoring in labour. British Journal of Midwifery, 31, 165-171. https://www.britishjournalofmidwifery.com/content/professional/a-post-structuralist-feminist-analysis-of-electronic-fetal-monitoring-in-labour
Wolf, J. (2020). Inflating risk (Chapter 5). In Cesarean Section: An American History of Risk, Technology, and Consequence. https://doi.org/10.1353/book.58899
Categories: CTG, EFM, Feminism, IA
Tags: caesarean section, central fetal monitoring, Holistic, Technocratic
Birth Small Talk 
I absolutely love this blog, its everything i think , witness and feel furious about. IA is unobtrusive and small , its reliable and promotes freedom to move, spontaneity and confidence. the ctg is a monster and ruins every birth . midwives ate taught yearly on how to interpret it. there is no space to discuss its infallibility or lies . it creates a power dynamic and babies are reported as lazy as well as tired or happy as mentioned above. its very destructive emotionally , physically and psychologically.
LikeLike
Glad you can relate to it Ellen!
LikeLike