First published in November 2020, this post has been revised and updated.
The language people are exposed to, and make use of, in healthcare is important. Language is the way in which we come to understand and share our knowledge of the world. Carried within the words we use are values and assumptions, sometimes visible, but often hidden below the surface. Critically reflecting on our use of language is an important part of transforming maternity care to provide safe and respectful care. This is no less important when it comes to fetal heart rate monitoring than it is for any other aspect of healthcare.
What is “fetal monitoring”?
Very soon after the introduction of CTG monitoring in the late 1960s, the use of the CTG during labour became described as “fetal monitoring”. For example, Paul and Hon (1970) reported on the introduction of CTG monitoring during labour in Connecticut, USA. Their paper included a table which lists a number of “indications for fetal monitoring” that describes the circumstances under which CTG monitoring, rather than intermittent auscultation, was initiated in their population they studied.
Once CTG use was defined as “fetal monitoring”, the use of other methods to assess the fetal heart rate were no longer consistently described as a form of fetal monitoring. For example, Chan and co-authors (1973) described how out of 6,533 “deliveries”, the “number monitored” was 1,150. Whilst not explicitly described in this paper, it is highly likely that intermittent auscultation was used for the majority of the remaining women. Weinraub et al. (1978) took this one step further in their paper “Perinatal outcome in monitored and unmonitored high-risk deliveries” specifically describing women who received intermittent auscultation as being “unmonitored”.
These examples demonstrate how the addition of CTG monitoring as an option for fetal monitoring during labour resulted in the alternate choice – intermittent auscultation – being diminished through the use of language which transformed it into “not monitoring”. This issue persists into present day language use in maternity care. For example, Theodoridou et al. (2020) recently provided a summary of non-invasive options for fetal heart rate monitoring, without once including intermittent auscultation in the paper.
Why “not monitoring” matters
Transforming the language describing intermittent auscultation to “not monitoring” generates psychological discomfort when women seek to use intermittent auscultation for fetal heart rate monitoring in their labour. Linguistically speaking, CTG monitoring occupies the place of the proper way to monitor, and intermittent auscultation becomes clearly inadequate. The portrayal of intermittent auscultation as inferior is clearly at odds with the research evidence.
I have seen this language playing out in clinical practice. The answer to the question “is she being monitored?” is only yes when a CTG is in use. Not only does this misrepresent the usefulness of intermittent auscultation for fetal monitoring, a statement like this underestimates the work that midwives do in monitoring ALL aspects of the wellbeing of the woman, her fetus, and the unfolding of her labour. Ensuring that the two wiggly lines of the fetal heart rate and the woman’s uterine activity are plotted on graph paper has come to represent the main thing that is required for quality care. In reality, they are simply two wiggly lines on a chart with little meaning when viewed in isolation from all the other information gathered when monitoring (in its broadest sense) the woman and her baby.
What can you do?
Notice yourself talking about monitoring in labour and reflect on the language you are using. Are you using words that makes the work of monitoring the woman, her fetus, and her labour disappear? Does your language imply that CTG monitoring is the only form of fetal monitoring? Practice using different ways of talking about monitoring in labour and explain why you have changed your language to the people around.
Language is powerful. It constitutes the ways in which we know the world and shapes how we take action in the world. Make use of the power of language to generate the changes you want to see in maternity care.
Are you planning a vaginal birth after caesarean section and are looking for information about the fetal monitoring options available to you? You can find what you are looking for here!
References
Chan, W. H., Paul, R. H., & Toews, J. (1973). Intrapartum fetal monitoring. Maternal and fetal morbidity and perinatal mortality. Obstetrics and Gynecology, 41(1), 7-13.
Paul, R. H., & Hon, E. H. (1970). A clinical fetal monitor. Obstetrics and Gynecology, 35(2), 161-169.
Theodoridou, A., Athanasiadis, A., Tsakmakidis, G., Tsakiridis, I., Pilavidi, A., Vosnakis, C., Dagklis, T., Mavromatidis, G., & Mamopoulos, A. (2020). Current methods of non-invasive fetal heart rate surveillance. Clinical and Experimental Obstetrics & Gynecology, 47(4), 459-464. https://doi.org/10.31083/j.ceog.2020.04.5422
Weinraub, Z., Caspi, E., Brook, I., Rahmani, P., Bukovsky, I., & Schreyer, P. (1978). Perinatal outcome in monitored and unmonitored high-risk deliveries. Israel Journal of Medical Sciences, 14(2), 249-255.
- Perinatal outcomes in the UK: Update from the MBRRACE-UK report
- Can CTG monitoring prevent HIE? The problem of prevalence.
Categories: CTG, EFM, Language, Reflections
Tags: Language
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- Language matters – Birth Small Talk
- Smart surveillance and the caesarean section rate: Have they cracked the code? – Birth Small Talk
- Myth Busting #3: Fetal monitoring is essential – Birth Small Talk
Birth Small Talk 
You have outdone yourself this time Kirsten- Congratulations. Thank you for your clarity of thought, your candour and your courage to challenge what is considered “quality care and standards”. You took me back to the time when as a young obstetrician, I thought the CTG was the most powerful tool, spent hours learning terminology, classification, application of knowledge in decision making etc. Today as a strong advocate of professional midwifery and natural birth, I see clearly the negative impact of CTG in low-risk uncomplicated pregnant women in labour. It is an intervention we can do without…I shared your blog with many obstetric colleagues. I am delighted you are speaking at the NLBC 2020.
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Thanks Evita. We have shared experiences – I was keen to achieve mastery of the CTG as a young doctor too, but with time came to see that it didn’t live up to expectations. I’m looking forward to the conference, but wishing we could meet in person instead. Maybe 2021 will see us both back on the train platform in Grange-over-Sands again?
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