Women want to be involved in decisions about what kind of fetal monitoring to use in labour, but most describe not being given a choice (Hindley, Hinsliff, & Thomson, 2008). (More about that here.) When midwives felt pressured to ensure that CTG monitoring was put to use, they actively manipulated the information they shared (Hindley & Thomson, 2005). As one midwife said about discussing CTG monitoring –
I can get the woman to do exactly what I want. Nearly always. If I am just a bit.. a bit, sort of, clever and sympathetic, I can get her exactly where I want her. … I choose my words in a way so that she will not protest, it is the way I am asking her.
Blix & Öhlund, 2007, p. 55
I see three techniques maternity professionals (not just midwives) use when talking to women to ensure CTG monitoring is used. They are:
- Tell, don’t ask.
- Minimise.
- Provide limited information.
Let’s look at each of these in turn.
Tell, don’t ask
At the moment when a woman might be able to make a choice about fetal monitoring method, a choice is not offered. Instead a direct statement about what the professional is about to do is made. Things like:
- Let’s get this CTG started
- I’m going to put the monitor on now
- I need to get you on the CTG
Using statements like this make it difficult for women to see this is a moment when a decision is being made, and they aren’t being included in that decision (Scamell, 2011). Instead, using a question ensures women can recognise this as an opportunity for them to make a decision. A better language choices might be:
- The hospital guidelines recommend CTG monitoring. Have you thought about what type of monitoring you want to use?
- Is it OK with you if I put the CTG monitor on?
- Do you want to have CTG monitoring, or would you rather I listened to the baby intermittently?
Minimise
Minimising language implies that CTG use will have minimal impact, in a way that doesn’t reflect reality. Here are some examples:
- This’ll only take a moment
- We’ll do a quick trace first
- I’ll just pop this on
When minimising language is used, women are less able to see that the decision about fetal heart rate monitoring is of significance and they therefore might want to ask further questions or give the choice due consideration. Better options include providing accurate assessments about the time and significance of the decision:
- An antenatal CTG generally takes 20 to 30 minutes, but sometimes longer than this.
- Making a decision about fetal monitoring is important. Do you want some more time or information before you choose?
Provide limited information
Often there is no further information exchange beyond “let’s just pop you on a trace”, but when there is, this information is often non-specific, or inaccurate, or doesn’t provide sufficient detail to enable women to negotiate an informed choice. For example:
- This’ll tell us if your baby is happy
- CTGs save babies lives
- It’s perfectly safe
During observations for my doctoral research, the approach I saw most often was to tell women that because of (insert situation here) they needed to have CTG monitoring, followed by an explanation about what the equipment looked like and what the wiggles on the monitor were.
The decision about fetal monitoring method has significant consequences for women, and in line with other interventions, women should be supported to make an informed choice about the monitoring method they will use. This decision is best supported by providing accurate information about the benefits and harms of each approach to fetal monitoring, and personalising these to the specific woman. It has been my experience that many maternity professionals simply don’t know the research well enough to have an evidence based discussion about benefits and harms. That’s not entirely their fault, as fetal monitoring education rarely covers it.
For maternity professionals
If you read this and thought, hmm I’ve said those things, and you want to do better, where do you start? Here are my suggestions for you.
- Reflect. Imagine you are about to have a conversation with someone about fetal monitoring. You might want to grab your phone and record yourself saying the things you usually say. Spend some time reviewing what you just said and ask if it is clear there is a choice to be made, and whether you gave accurate, non-scary information about each option.
- Fill any knowledge gaps you might have about the benefits and harms of each different approach to fetal monitoring in labour. You are here reading this – so it’s probably no surprise that I have lots of free information you can use. I’d also love it if you came and did a course with me!
- Write a script, or say it out loud and record yourself. Practice different ways of having the fetal monitoring conversation so when you next need to put it into action, you feel confident you have this covered.
For pregnant women
I wish I could say that you can trust your maternity professional to get this right, but the research evidence is clear that it is far more common to not be given a choice and not be given correct information. Here are my three tips for you:
- Get informed. If you plan to labour, there’s a choice to be made about what fetal monitoring approaches you want to use, under what circumstances. Find out the pros and cons for each (there’s plenty of resources on the blog for you).
- Be proactive. Don’t wait for someone to ask you (or worse – to tell you) what fetal monitoring option you will use. Bring it up at an antenatal visit and ask them to make a note of the conversation in your notes.
- Insist on continuity of carer. Having one known care provider consistently will make it much easier for you to start, and then later continue, this conversation. As bonus, your risk of stillbirth and preterm labour will also fall!
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References
Blix, E., & Öhlund, L. S. (2007). Norwegian midwives’ perception of the labour admission test. Midwifery, 23(1), 48-58. doi:10.1016/j.midw.2005.10.003
Hindley, C., Hinsliff, S. W., & Thomson, A. M. (2008). Pregnant womens’ views about choice of intrapartum monitoring of the fetal heart rate: A questionnaire survey. International Journal of Nursing Studies, 45(2), 224-231. doi:10.1016/j.ijnurstu.2006.08.019
Hindley, C., & Thomson, A. M. (2005). The rhetoric of informed choice: perspectives from midwives on intrapartum fetal heart rate monitoring. Health expectations, 8(4), 306-314. doi:10.1111/j.1369-7625.2005.00355.x
Scamell, M. (2011). The swan effect in midwifery talk and practice: a tension between normality and the language of risk. Sociology of Health & Illness, 33(7), 987-1001. doi:10.1111/j.1467-9566.2011.01366.x
Categories: CTG, EFM, Language, Reflections
Tags: decision making, Language
Birth Small Talk 
I see parallels with other types of monitoring; my baby was in hospital for a week from the day after his birth, and we had a fight on our hands as wanted him intermittently monitored (4-hourly observations rather than continuous monitoring). Almost exactly the same in terms of language (no opportunity to make a decision given to us, talked about it being routine, and so on, then arguments when we wanted to not use it, “babies can die of sepsis” is one comment I remember). Eventually we were threatened with a Safeguarding referral (not only to do with the monitoring; there were other similar issues where we had audaciously attempted to have some say in our child’s care). We’re going through the complaints process now. But how to change a culture like that?
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I’m sorry you were not respected as a decision maker Ella. I have no easy solutions, but am committed to making space for conversations that challenge the status quo.
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I had no idea this topic of CFM and decission making was a subject of so many studies! Great text, thank you.
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Thanks Anna, I’m glad you are enjoying the posts.
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Thank you. Fascinating area of study, and sadly, one women probably aren’t conscious of till it’s too late.
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Thanks Claire, this is why it is important that maternity clinicians have appropriate conversations with women, and why continuity of carer is so important.
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What are the dangers of using a trace?
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It’s a great question Ellie, with a long answer. I’ll write a post about the risks of CTG monitoring sometime soon.
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