Three things to stop saying about fetal monitoring

There are three terms I often hear maternity professionals say in their conversations with women around fetal monitoring that I want them to stop using. Each of these terms is used as a euphemism for what is really going on and they have the potential to confuse or mislead. I’ll provide examples of how each term is often used and what it wrong with these statements. I’ll also tell you what to replace these terms with. The terms are:

Happy
Tired
Distressed

Happy

“So this is your baby’s heart rate showing up on the monitor – and this tells us if they are happy or not.”

“Baby looks happy at the moment!”

“Your baby is not happy about this, so I think we should…”

Fetal heart rate monitoring – whether by intermittent auscultation or CTG monitoring – is not a kind of Edinburgh Depression Screening Test for mood. There is no way to tell whether a fetus is feeling happy, pleased, content, or satisfied, or some other emotional state. If someone were unhappy, we would suggest things like a hug, a cup to tea, a chat with a loved one, or perhaps taking part in an activity they usually enjoy. We would not suggest ongoing surveillance of their mood or surgery to improve it.

Tired

“We use the monitor to tell us if baby is getting tired during your labour.”

“Your baby is starting to show signs of being tired. I think it is time we got them out.”

We do know that there are states of fetal behaviour that appear to resemble sleep, and a fetus with low oxygen levels tends to spend more time in fetal sleep as it reduces the use of oxygen. But we have no idea about whether fetuses perceive tiredness in the same way babies and adults of. If someone were feeling tired, a nap, or a good long sleep, or perhaps a strong cup of coffee if those were not possible right now would be suggested. Again, being tired isn’t managed by more monitoring of tiredness or by surgery.

Distressed

“There are no signs of fetal distress right now so we can keep watching the heart rate for a bit longer.”

“Your baby is clearly distressed so I want to…”

“Your caesarean section was needed due to fetal distress.”

The term fetal distress is very firmly embedded in clinical practice and has a long history of use. So you might be thinking I am being very weird to suggest that it be dropped. I’m far from the first person to suggest this. Obstetrician Phillip Steer suggested abandoning it back in 1982.

One of the problems I have with the term is it’s slipperiness. That is, there’s actually no measurable fetal state that can prove that fetal distress is present or absent. Fetal heart rate patterns are meant to indicate that fetal distress is probable or suspected but how do you prove that this undefinable quality known as fetal distress is the cause of the heart rate pattern in the first place?

The other problem is the emotional intensity of the term distress. Unlike “unhappy” or “tired” – common states that are short-lived and easy to fix – distress is a subjectively unpleasant experience that most of us would very much like to avoid, please and thank you. Again, we have no way of knowing what the fetal experience of having dangerously and harmful low oxygen levels is like. Maybe it feels like the warm fuzzy feeling of impending sleep? But telling someone their fetus is distressed implies they are experiencing something like an impending feeling of doom. This fear generating language doesn’t support rational decision making.

Here’s what to say instead

The fetal state that causes harm is low oxygen levels. The fetal heart rate changes when oxygen levels fall in an attempt to prevent harm. Mostly these adjustments are successful, sometimes they are insufficient. Because there’s no way to tell between fetal coping and no longer coping using heart rate alone, other information is (or should be) factored into decisions about whether and when to recommend intervention.

So – how do you explain this factually, in an easy to comprehend way, and without fear-mongering? Try some of these versions of what appears above:

When we listen to your baby’s heart or look at the rate on the screen, we are looking for hints that the baby is working hard to cope with low oxygen levels.
Right now the heart rate pattern is normal so that tells me that baby’s oxygen levels are fine.
Baby’s heart rate pattern is a little bit abnormal. This suggests that baby is adjusting to low oxygen levels and is coping with them. I want to keep a close eye on the heart rate to see if baby continues to cope okay.
I haven’t seen a normal heart rate pattern for a while now. Along with (these other things that raise concern), I’m no longer confident that baby is coping with what is happening for them. Here’s what I recommend happens next …

Given how simple it is to shift language here (it takes no extra time), I’m not sure why the terms happy, tired, and distressed have hung about so long in maternity care circles. Perhaps we don’t believe women have the capacity to understand the truth? Perhaps professionals don’t know the truth themselves? Start shifting your language and be a model for others to also change.

If someone around you is talking about happy, tired, or distressed babies, ask them what they mean. See if you can gently nudge them towards a better informed understanding of the evidence of fetal heart rate monitoring and the adoption of more factual language.

Planning an VBAC? Been told you “need” to have CTG monitoring?

Maybe your last birth involved one or more of these?

You were told you HAD to have CTG monitoring
Someone “popped a little clip on the baby’s head” without bothering to get your informed consent
The CTG monitoring equipment was uncomfortable and limiting for your freedom to move
People wandered in and out of the birth room to look at the monitor without talking to you
Everything suddenly turned to chaos because of some change on the monitor and you felt you had no control over what happened next

It’s no wonder you are looking for a better birth experience this time, while not making compromises on safety. My course I’m having a VBAC. Do I need fetal monitoring? is your solution to feeling powerless and uncertain about what to do to prevent a repeat of your previous experiences. It’s a short course but big on evidence, with easy to understand summaries of what researchers have show about different types of fetal monitoring during VBAC. You’ll also find practical and effective communication strategies that help make sure you get the type of fetal monitoring you want for your birth.

Enrol now and start learning today!

Access the course instantly!

Learn more

References

Steer, P. J. (1982). Has the expression “fetal distress” outlived its usefulness? BJOG: An International Journal of Obstetrics and Gynaecology, 89(9), 690-693. https://doi.org/10.1111/j.1471-0528.1982.tb05091.x 