I just love the title of this new research paper: When evidence fails to change practice: Examining the persistence of continuous fetal monitoring (De Vries et al., 2025). When I was planning my PhD topic, the question that kept burning a hole in my brain was “Why are we still using CTGs?“. I ultimately went with a research question that was adjacent to that rather than tackling this one head on. But De Vries and colleagues have tackled this question head on, and it isn’t the first time they have explored this area. Their previous paper (Chuey et al., 2020) looked at the related question of why maternity professionals don’t use intermittent auscultation more often. (I have blogged about this other paper before.)
The authors do a fabulous job of explaining why the question is a valid one to ask. They set out the evidence and the current situation (particularly in the USA) very clearly. The paper is worth reading simply for the introduction alone.
How did they go about answering this question?
Three members of the team spent 121 hours observing practice in the labour and delivery unit of a tertiary academic medical centre. They shadowed nurses, midwives, and doctors and had informal conversations with them during that time. They also had six formal interviews with key informants. They generated themes from the data and presented these as their findings.
What did they find?
There was a strong (but not evidence-based) belief in the clinical value of CTG monitoring in labour, primarily for women considered to be a high risk. The permeability of the definition of what constituted “high risk” meant that it was easy for women to be fitted into this category.
Non-clinical factors acted as a strong driver for CTG use. These included:
- Fear of litigation (even though several participants pointed out that CTG use is probably not protective)
- Insufficient training in intermittent auscultation, and loss of knowledge over time among experienced clinicians, coupled with a very strong focus on education and competence assessment for CTG monitoring
- Hospital policy and documentation procedures. At this hospital, the electronic health record made it difficult to offer and / or use intermittent auscultation when risk factors were present.
- Women had little knowledge and therefore influence on the choice of fetal monitoring method, and many women defaulted to “whatever you think is best”. It was also clear that professionals did not inform women of their options nor provide education to support decision making.
- The absence of stable interprofessional relationships to generate trust. With 40 doctors and 200 nurses, and frequent changes in who was caring for a woman during the course of her labour, professionals were unable to build trust and confidence in one another.
- Convenience and workflow. It was simply easier for professionals to default to CTG use. Intermittent auscultation was considered to be too time consuming, requiring the professional to spend more time at the “bedside”. Central fetal monitoring intensified the difference in labour effort required to keep track of fetal wellbeing when intermittent auscultation was in use.
The authors went on to explore the relationships between each of the factors, showing how this created a complex network that made it hugely challenging to change practice.
What did they recommend?
Four recommendations were made.
- Provide education about fetal monitoring options for expectant families, informed by research on the benefits and risks of CTG use and intermittent auscultation.
- Rethink hospital policies, both those specifically addressing fetal monitoring, and also those that relate to how monitoring is deployed (for example requiring the ongoing one-on-one presence of a professional in the birth room when CTG monitoring is in use).
- Challenge the assumption that central fetal monitoring is cost effective and safe.
- Require formal and ongoing training on intermittent auscultation for physicians, nurses and midwives.
I agree with each of these, and have been making one-woman-with-no-funding efforts to drive this change myself. How?
- I have a course that steps through the evidence about CTGs and intermittent auscultation for anyone planning their birth.
- Members of my Fetal Monitoring Academy have been working on building skills in policy analysis over the past few months, an essential first step to tackle policy change. (Enrolments will open soon, pop your name on the waiting list if you are interested).
- My PhD focussed on central fetal monitoring, with multiple academic publications from this and a new paper about central fetal monitoring published this year. (You can find them all on my publications page).
- I have provided education for members of the Fetal Monitoring Academy, and a handful of groups of midwives, specifically about intermittent auscultation. And, I’m about to run a brand new workshop on intermittent auscultation for anyone who is interested.
I want to ramp up my efforts to achieve change this year. Why? Because 40 years of ignoring the evidence and continuing to be complicit in a system that misleads and harms birthing women is about 39 years too long. If you are also ready to put an end to the nonsense, come and join me!
Are you ready to tackle your lack of confidence with intermittent auscultation?
It’s time to fix this problem and shift practice in a direction that aligns with evidence. If you are a maternity professional and the thought of offering intermittent auscultation to more women (including some considered “high-risk”) gives you a tight uncomfortable feeling in your chest – let me fix that for you.
On Saturday August 2nd, 2025 at 2 pm AEST (Brisbane time – that’s GMT+10) I’ll be hosting a LIVE online 2 hour long workshop, called Confident Intermittent Auscultation. Join me and address each of the fear points that is holding you back. I’ll take you through the evidence and provide my eight top tips for how to do intermittent auscultation in a way that keeps you, the woman, and her baby safe.
Register by clicking the link below for more information about the workshop
Want to know more?
References
Chuey, M., De Vries, R., Dal Cin, S., & Low, L. K. (2020, Jan/Mar). Maternity providers’ perspectives on barriers to utilization of intermittent fetal monitoring: A qualitative study. Journal of Perinatal and Neonatal Nursing, 34(1), 46-55. https://doi.org/10.1097/JPN.0000000000000453
De Vries, R. G., Low, L. K., Chuey, M., Abdelnabi, S., & Lewallen, M. (2025, Jun 9). When evidence fails to change practice: Examining the persistence of continuous fetal monitoring. Qualitative Health Research, 10497323251347137. https://doi.org/10.1177/10497323251347137
Categories: CTG, EFM, New research
Birth Small Talk 
Thanks for the information re the workshop. Unfortunately the link to register wont let me input my details – is there any other option? Thanks kindly Heather
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Hi Heather – try this link instead. It’ll get you directly to the checkout. Kirsten
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