This post was originally written in 2020 and I have freshened it up a bit. The argument that technology will fix the shortcomings of CTGs continues to be used.
If we just tried harder…
In the years leading into my PhD I started reading everything ever published about CTG monitoring. (It may come as no surprise there’s quite a lot!) I attempted to do it roughly chronologically, starting with the earliest research and working to the present time. Approaching it that way meant I could see patterns in the way researchers were discussing CTG use.
At first, people were very excited and convinced CTG monitoring was the solution they had been waiting for! In the late 1970s, results from randomised controlled trials started appearing, showing CTG monitoring wasn’t making outcomes better for the fetus, and it was increasing the caesarean section rate. Pretty soon after that I started seeing a repeated message running strongly through the literature. That message was the belief that if people just tried a bit harder, then CTG monitoring would actually do what it has been designed to do. Often the suggestion was that if people were just a bit smarter then CTG monitoring would work properly, like this one:
There is little doubt that bad monitoring is worse than none at all, and that ominous patterns may be overlooked. This litany of deficiencies is a problem of education, not of the potential usefulness of the monitor.
Schifrin, 1984, p. 464
There is of course, no convincing research showing the CTG education leads to better outcomes. This is an area I have published about (and this post is about that paper).
Just add tech!
In more recent years the argument has shifted slightly. Now the addition of more technology is suggested as the means to ensure CTG monitoring can at last blossom as it was meant to all along. This was essentially the line of argument taken by authors Knupp, Andrews and Tita in their 2020 review on the future of CTG monitoring. They examined the following approaches:
- Standardised interpretation guidelines, noting that “any improvements as a result of these standardisations remain to be demonstrated”.
- Fetal stimulation. This is used to provide reassurance of normal fetal oxygenation but has never been assessed with respect to whether this improves outcomes.
- Fetal scalp blood sampling which “has not been effectively demonstrated to reduce operative deliveries or long-term perinatal outcomes”.
- Fetal echocardiogram ST segment analysis – which has showed no benefit in perinatal outcomes in meta-analysis of randomised controlled trials, and
- Fetal pulse oximetry- which “did not reduce the caesarean section rate or improve perinatal outcomes” when it was assessed either.
So far the argument that technology will save the day isn’t doing so well…
The authors went on to describe two new monitoring systems:
- the Monica Novii (and similar systems) that detect the electrical activity from the fetal heart from a sensor placed on the woman’s abdomen, and records electrical activity from the uterus to detect contractions rather than using an external or internal pressure sensor, and
- the Moyo – a wearable fetal heart rate monitor that uses Doppler to record the fetal heart. No uterine tone measurement is incorporated.
Neither system has yet been investigated to determine if it produces better outcomes for the woman and / or her baby than either intermittent auscultation or “standard” CTG monitoring. I am starting to see some research about both these systems (like this and this, and this paper from Nepal), where the focus is on answering questions other than “does it work?”.
Knupp’s team also explored the evidence for computerised interpretation of the CTG. This gets back to the “if people were just smarter” issue, as it assumes a computer will consistently and accurately interpret the CTG every time, eliminating the problem of variable or incorrect CTG interpretation. To date no computer interpretation systems have been able to improve outcomes either. This undermines the argument that eliminating interpretation errors by making people smarter will suddenly make CTG monitoring work.
Perhaps one day I’ll be proven wrong, but I simply can’t see how after 60 years of proof that the CTG can’t save babies from harm that a doo-dad to plug into the monitor, an education course, or a standardised guideline will now make CTG monitoring effective. Perhaps it is time we acknowledge the thinking that led to the creation of CTG technology was fundamentally flawed. If we had abandoned CTGs in the mid 80s when the bulk of the randomised controlled trials were available, we would have had 40 years to come up with a solution that actually works. Let’s not waste more decades before getting started.
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References
Knupp, R. J., Andrews, W. W., & Tita, A. T. N. (2020). The future of electronic fetal monitoring. Best Practice & Research Clinical Obstetrics & Gynaecology. https://doi.org/10.1016/j.bpobgyn.2020.02.004
Schifrin, B. S. (1984). Letter to the editor. Journal of Law and Medicine, 10(4), 464.
Categories: CTG, EFM, New research, Perinatal mortality
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