Five questions you should ask about central fetal monitoring

Central fetal monitoring systems are becoming more and more common in maternity services in high-income countries. Once-upon-a-time heart rate and contraction data were printed directly to paper. Increasingly, these data are turned into a digital signal and shown on a computer screen. Digital data are easy to move to a place outside the birth room. With central fetal monitoring, data are moved to a central location in the maternity service, where it is displayed. The central fetal monitoring station typically consists of a bank of screens that display all the CTG traces, for all the women, in real time.

The idea behind central fetal monitoring is the belief that it is better to have many people looking at the one CTG, as it will prevent maternity professionals from not noticing the fetal heart rate pattern is not normal. The aim is to prevent poor outcomes for the fetus / baby. There has been very little research done to investigate whether central fetal monitoring achieves that goal. The research we do have shows central fetal monitoring does not help and it can push caesarean section and instrumental birth rates higher.

It is important to ask questions about central fetal monitoring systems BEFORE you arrive the hospital in labour, when there might be time for them to make different decisions about where you plan to give birth. Here are five questions I think you should ask:

1. Does this hospital have a central fetal monitoring system?

If you arrive in labour, and choose CTG monitoring, it won’t be immediately obvious to you whether or not the hospital has a central fetal monitoring system. In my research, some midwives but not all, explained that people outside the birth room could see the CTG trace. When I talk with maternity professionals and women who have given birth in many different settings – the same situation seems to apply in many places.

If you don’t specifically ask, you may not be told. Unless you start wandering around looking behind doors marked STAFF ONLY you probably won’t see the central monitoring station. You can’t make decisions that are right for you if you aren’t given information. The rest of the questions assume the answer to the question of whether there is a central fetal monitoring system is yes.

2. Who has access to my information and where?

If your CTG data is visible at the central monitoring station – who is going to be looking at it? Is it visible from the corridor where anyone walking past can see your personal information? (It was at the hospital where I did my research.) Who has access to the room where the CTGs are on display? Is the CTG the only thing on display or is other information also displayed (like your risk factors or the results of the last vaginal examination you had)?

Some central monitoring systems also allow remote access. That is, someone with a password and an internet connection can log into the system and can see the CTGs (and sometimes all electronic data). So, an obstetrician in their office at another site, or at home in bed, can look at your CTG trace. That has some advantages for the staff (the obstetrician doesn’t need to travel to the hospital to see the CTG and it is easier for staff to get an obstetric opinion on a trace). But it means that you have even less control over who might be looking at your information.

3. Can I control who has access to my information?

Do you have the option of using CTG monitoring and NOT having your data displayed at the central monitoring station? Can this be controlled from within the birth room? If it can be switched on or off but only at the central monitoring station, you will have no way of knowing whether your request has been honoured or not. The next person to walk into the central monitoring area might see the CTG isn’t being displayed and turn it back on, unaware your midwife turned it off for a reason.

If you choose intermittent auscultation, what difference does this make to the information available at the central monitoring station? What will be on display instead of the CTG?

It is my experience that you will usually not have any control over who sees your information, what information they can see, or when and where they can see it when central fetal monitoring is in use. You will have no way to find out later on who was looking at your information. Choosing intermittent auscultation instead can reduce the visibility of your information but doesn’t completely guarantee privacy of your health information.

4. What steps will you take to protect my privacy?

So far I have been talking about privacy in relation to your information. You might expect that when you are in your birth room, the door is kept shut and no one will come into the room unless your midwife asks them too. Many services have regular (often hourly) “rounds” conducted by a senior midwife and less frequently by the medical team. So there may be regular visits to your room. Ask what the policy about rounding is where you plan to give birth.

In addition to this, central fetal monitoring systems increase the chance that someone is going to come to your birth room in response to something they have seen at the central fetal monitoring station. This ranges from a gentle tap on the door and a request the midwife step out for a conversation about the CTG – to a group of agitated doctors charging in without knocking on the door first then taking over. This disruptive behaviour was a big issue at the place I did my research. As I have presented findings around the world, midwives come up to me and tell me that exactly the same thing happens where they work too. It might not happen everywhere, but it seems common.

Asking about whether you might suddenly have people in your room that you and your midwife didn’t ask to be there is therefore important. If this does happen at the hospital you give birth at and you don’t want it to happen, a good place to start is to request a copy of the hospital’s privacy policy. The hospital will have obligations under national privacy legislation to ensure your privacy. Ask how your maternity professional will meet their obligations under the relevant legislation. If you aren’t getting clear answers, you might find the best person to ask is high up in the organisation – like the Director of Nursing and/or Midwifery.

5. What steps will you take to protect my safety?

One thing I didn’t see happening when I was doing my research was women being left alone for extended periods of time, while their midwife sat at the central fetal monitoring station watching their CTG, or went to do work somewhere else while someone else watched CTGs from multiple rooms. This does happen in some places with central fetal monitoring and it makes your care in labour less safe. The fetal heart rate and your contractions are not the only form of information midwives use to check you are ok but if they aren’t in the room, they no longer have access to those other forms of information.

Ask whether you can expect your midwife to remain in the room at all times or not. You might value short periods of personal privacy, but being left alone for more than about 30 minutes at a time is not the best way to promote safety. Once again, hospital policies may come in useful here as they may say women should receive one – on – one care in labour. If this is the case you can insist they stay with you.

I saw other things that made me concerned about the safety of central fetal monitoring while I was doing my research. The first was obstetric staff making decisions about women’s care while standing at the central monitoring station, without having spoken to the woman’s midwife or the woman, and without having set eyes or hands on the woman. Decisions made without a comprehensive assessment of all relevant information are more likely to be poor decisions. Insist that medical staff explain why they have reached the decision to recommend a particular form of care so you can be confident they have the big picture, before you agree to the recommendation.

Another thing I saw that concerned me, was midwives doing things to speed up the birth process or to improve the quality of the CTG when these things were not going to make a difference to the outcome for the baby. This included things like cutting an episiotomy, putting a fetal spiral electrode on, or restricting a woman’s movements. These were not done because they were in the best interests of the woman and her baby, but to reduce criticism from people outside the room who were looking at the CTG. There are downsides to interventions like these. If they are being done when they aren’t going to make anything better, they can only make outcomes worse. Asking whether there is actually a problem for the baby or not will help you decide whether to agree to these interventions.

More about central fetal monitoring

Here are three blog posts I recommend that include more information about central fetal monitoring:

Central fetal monitoring: Time to deimplement? This post (written by Jyai Allen of the Transforming Maternity Care Collaborative) summarises part of my doctoral research and argues that central fetal monitoring should be removed from use.
Unintended consequences of using central fetal monitoring. In this post, I summarise one of my published papers. I explain how central fetal monitoring created disruptive and disrespectful behaviours.
Add central fetal monitoring and stir. This post asks whether you can safely reduce the number of midwives by introducing a central fetal monitoring system.

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