From time to time, a team of authors write an article summarising information about a single topic. These articles are often intended for medical students and doctors in training. One such summary relating to fetal monitoring during labour was recently published (Richmond et al., 2025). Authored by a team from the UK, I thought it would be interesting to fact check the piece and see how they did…
What sources did they use?
The first thing I looked at was the reference list, to see what sources they used to inform their writing. I was a bit surprised to find there was no reference list! Instead there was a short list of “Further reading” with the NICE and “Physiological” guidelines mentioned, along with the Each Baby Counts and Avoiding Brain injury in Children (ABC) projects, and finally, a link to the Baby Lifeline CTG Masterclass training course. (A strong UK focus is therefore evident.) The only other sources directly referred to in the paper were the 2022 NHS Resolution report on the Early Notification Scheme (regarding maternity litigation cases), and the Kelly et al., 2021 paper that reviewed the evidence for fetal monitoring education.
This is disappointing for an educational resource as there is no trail of breadcrumbs that a reader could follow if they wanted to double check or learn more about something that was mentioned in the paper.
What topics did they cover?
The vast majority of education about fetal monitoring in labour I have encountered generally includes two things: A list of people who are meant to be better off with CTG use, and instructions on how to make sense of the wiggly lines on the CTG. I wanted to see if these authors followed suit, or stepped out of this and included any discussion of the evidence about whether CTG monitoring makes a difference to outcomes for women or their babies. After the introduction, the headings in this paper were:
- How should the fetus be monitored in labour?
- Normal fetal physiology and associated features of fetal heart rate on the CTG
- Mechanisms of intrapartum fetal compromise
- Patterns of fetal hypoxia
- Improving intrapartum fetal surveillance: contributory factors to adverse outcomes
The introduction does include the statement that:
CTG was introduced for fetal monitoring in the 1970s with the hope it would reduce perinatal morbidity and mortality. Unfortunately, no study to date has shown CTG use to reduce mortality, only a reduction in seizures. Conversely, the rates of clinical intervention have increased significantly.
p. 73
So there was at least some acknowledgement of the shortcomings of CTG use in the paper. The authors then went on to propose that the solution was “physiological interpretation”, while acknowledging that there is no evidence to back this up either. Nonetheless, the rest of the paper was clearly based around the belief that if people knew how to make sense of the wiggly lines better and acted appropriately, then lives would be saved, brain injury avoided, and there would not be inappropriate use of surgical birth. Sigh.
What did they get right?
The definitions for different parts of the fetal heart rate trace were consistent with accepted wisdom. They correctly made the point that decelerations are a sign of compensation designed to protect the fetus from harm, not “distress”. The potential for harm associated with injudicious use of oxytocin was correctly identified. They didn’t make the error of including a section on head compression as a cause of decelerations. The failure of the Each Baby Counts program to improve outcomes was acknowledged. They also correctly identified that more and “better” fetal monitoring education is an unproven intervention.
What did they get wrong?
They repeated the standard advice to split women into low risk and high risk categories, offering intermittent auscultation (with explicit mention of the need for consent) only to women in the low risk category. The wording of the heading (“how should the fetus be monitored…?”) and the text within it (“development of complications … should prompt continuous fetal monitoring”) implied that women in the high risk category should not be offered a choice of fetal monitoring method, and no specific need for consent for CTG use was mentioned at any point in the paper. It is no wonder there continues to be high rates of women reporting the unconsented use of CTG monitoring.
The now discredited idea that variable decelerations are due to cord compression, mediated by activation of baroreceptors was presented as a fact. The “Patterns of fetal hypoxia” section repeated what is taught in the “Physiological” guideline, without attribution, or acknowledgement that other frameworks for CTG monitoring also exist. No evidence was offered that this particular framework does better or worse than any other.
Take home thoughts
The primary purpose for the paper seems to be to inform people about, and promote, the ABC project as it is being introduced across all UK maternity units. In my opinion, this paper serves more as advertising than as quality educational content. When maternity professionals read these sorts of papers, they might feel they are engaging with evidence, but it really is Evidence-Lite™ whitewashed to maintain current (problematic) practice standards.
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References
Kelly, S., Redmond, P., King, S., Oliver-Williams, C., Lame´, G., Liberati, E. G., Kuhn, I., Winter, C., Draycott, T., Dixon-Woods, M., & Burt, J. (2021). Training in the use of intrapartum electronic fetal monitoring with cardiotocography: Systematic review and meta-analysis. British Journal of Obstetrics and Gynaecology, 128, 1408-1419. https://doi.org/https://doi.org/10.1111/1471-0528.16619
Richmond, A. K., Dewick, L., & Breslin, E. J. (2025). Intrapartum fetal monitoring. Obstetrics, Gynaecology & Reproductive Medicine, 35(3), 73-81. https://doi.org/10.1016/j.ogrm.2024.12.003
Categories: CTG, EFM, IA, Obstetrics, Reflections
Tags: ABC, Each Baby Counts, Education, Myths, UK
Birth Small Talk 
Hi! I love your work, keep it up! Will you be selling your merchandise in Ireland at all? I’m a midwife in Dublin and we have to do the K2 CTG programme every second year as part of CPD. What’s your thoughts on this programme? I noticed they have removed FBS from the programme in the last couple of years and added chapters on antenatal CTGs. Thanks Nadia
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Thanks Nadia. I’ll need to find a Europe based print on demand supplier who can deliver and that’s quite a long way down the to do list at present, I’m afraid. I’m not a fan of the K2 Perinatal Training Programme – though admittedly the last time I saw inside it was in 2019. I analysed it as part of my PhD work and showed how it functioned to maintain obstetric power. There’s a link to my thesis on the Publications page if you are particularly keen to read it!
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