Five questions to ask yourself when deciding about fetal monitoring in labour

During pregnancy there are a LOT of decisions to be made. What you plan to do during labour (if that is part of your plan!) when it comes to fetal monitoring is an important decision. The type of fetal monitoring you decide to use can potentially have a big impact on your experience of giving birth, how you give birth, and the health of your baby.

Let’s assume you have all the information you need. Perhaps you have just done my brand new course – Fetal Monitoring: The Basics! What then? How do you take that information and turn it into a decision?

In module 5 of Fetal Monitoring: The Basics, I step you through the decision making process. One of the steps is to ask yourself some questions. These help you to get clearer about what you want so you can make a decision that really works for you. Here are those questions.

What are your personal risk factors?

The advice you’ll get from a maternity professional about which type of fetal monitoring they recommend will be strongly influenced by whether there is something in your personal story that might increase the chance of your baby experiencing a complication during labour that is due to low oxygen levels. I won’t run through the list here as it is HUGE, and this is something that is best done with your personal care provider.

Let’s assume you have had that conversation and have been told that because of thing A, you are “high risk”. That isn’t the end of the story, and there are some more questions that you might want to think about on your own, or in conversation with your care provider. About 90% of women will be told they are high risk – yet the chance of a poor outcome for the baby is typically lower than 1%. It’s very common to end up in the high risk category and the label itself doesn’t mean you don’t have a choice about what type of fetal monitoring to use, or that there aren’t more things to consider in your decision making.

Here are some things to think about:

How big is that risk, really? Is this like the difference between driving your well serviced car carefully to the local shopping centre on a sunny day and doing the same thing when there is light rain? Or is it more like standing on the roof of a clapped out car with faulty brakes, with a drunk driver behind the wheel doing 120 km/hr in a 60 km/hr zone? Asking how big the chance of a poor outcome is when you have thing A or don’t have thing A will make this clearer.
Do you have any protective factors? You might have thing A that increases your risk – but do you also have things B and C that reduce your risk? Maternity care guidelines typically have long lists of risk factors, but they rarely take into consideration the presence of factors that reduce risk. Looking to see where the balance is can make decisions clearer.
How accurate is that risk number? You might be told your risk of a bad outcome for the baby is one in 1000. Finding accurate numbers for each different risk on the long list of risk factors is hard. I know because I have tried to do that when writing up my research and when writing blog posts. As a busy maternity professional, it is simply impossible to have them all memorised and to stay up to date. So you are likely to be given a best guess rather than a really accurate number. Google Scholar can be helpful. Look for research papers that will tell you what that risk really is – for example by searching “risk of stillbirth with twin pregnancy”.
Get risk literate. Knowing things like the difference between relative risk and absolute risk can be really helpful to understanding what your risk profile actually is. Sara Wickham has some great blog posts about risk that you might want to check out.

What are your priorities?

The original definition of “evidence based practice” emphasised that choosing options in healthcare should always include the priorities of the person on the receiving end of that care. You. If you get clear in your own mind about what is important to you first – then you can stand up for yourself when you are discussing your choices and your decision with your care provider.

What level of risk are you comfortable with? Would you still head to the shops on a rainy day, or would you wait for another time? Perhaps you would ALWAYS order a grocery delivery as you don’t feel safe even on a sunny day? The line in the sand for risk is different for different people.
What is it you want most from your birth? To keep it as pain-free as possible? To keep it as physiological as possible? To have the option to shift to caesarean section whenever you reach your risk line? Different people want different things – and your care provider’s assumptions about what you want might not be anywhere near what you actually want!

What are you fearful about?

Making a decision when you are terrified about something usually doesn’t lead to great decision making. Identifying and naming the things that scare you, then holding them up to the light to see if they really should be scary is an important process. Going back to the question about risk can help here – just how likely is that thing you are scared about will happen? Knocking it into an accurate size helps reduce emotional overload and leave room for good decisions.

Another useful approach here is to make “what if” decisions early. By that I mean, sit down and run through a bunch of possible scenarios, including the ones you are most scared of. If it comes to pass – what would you want to do? If your care provider is having trouble hearing your baby’s heart with a Doppler – what do you want to happen? Pre-deciding this in advance takes the heat out of the emotion. Compare this with trying to make a decision when your brain is screaming at you saying “they can’t hear her – what if it is too late!”.

What do or don’t you have access to?

The “real” world provides some limits for decision making. You might want to have CTG monitoring with computer interpretation of the recording – but if that isn’t available anywhere near where you live and plan to give birth, deciding that you want it isn’t going to mean you get it! Ask your care provider about what is and is not available in relation to fetal heart rate monitoring where you plan to give birth (and your back up facility if that is relevant) so you aren’t deciding on something that is unachievable.

The other part of this question is about your personal energy, time, and money. If you make a decision that doesn’t match up with the policies of the facility you plan to give birth in, you are likely to encounter some degree of push back. In the ideal world, that would be minimal. It can be difficult to predict whether someone is going to get really up in your face aggressively or just say OK let’s do it. While some will feel like Wonder Woman and be ready to pull out their shield and their golden whip and go into battle, you might not. And that’s OK too. Doing the best you can, given the less than ideal circumstances you find yourself in, is still giving your best!

What is your backup plan?

This idea ties back in with the idea of having those “what if” conversations well ahead of time. Birth is unpredictable. The people you encounter during your birth are also to a degree going to be unpredictable. Making a decision that you will have fetal monitoring method A – no matter what! – is an unrealistic expectation. You might get your chosen option after all, but not having a backup plan (or several back up plans) means you might be blind-sided when things don’t turn out the way you anticipated. Here are some possible scenarios where you want to have a backup plan about whether a change in the approach to fetal monitoring would work for you:

You weren’t originally planning on an epidural, but you change your mind during labour
Your labour is taking a long time and you have decided to have an oxytocin drip to see if that makes a difference
Some kind of worrying sign has cropped up – like vaginal bleeding, or meconium stained liquor (the baby do a poo before birth)
There’s been a change in the heart rate pattern and it isn’t normal any more
You care provider is finding it really difficult to get reliable information about your baby’s heart rate using your preferred method.

As I said in the section about fearful decision making, having this mapped out well in advance can make life much easier for everyone. Then when your care provider is having trouble hearing the baby’s heart beat, they can say “hey you remember we talked about this and you said you wanted (this option), are you still OK with that?” – rather than starting a longer conversation about each option and the pros and cons when a quick decision is best.

What to know more?

Good decision making happens best with good information. That’s why I wrote Fetal Monitoring: The Basics. The course has all the information you need to make good decisions about fetal monitoring in one easy to access place. The course opens on March 20, 2024 and pre-enrolments at an early bird price are available now and for a short time only! You can find more details about the course HERE.

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