If you have been hanging around Birth Small Talk for more than a moment, you’ll know I’m very focussed on putting the evidence about fetal heart rate monitoring in front of as many people as possible. And you’ll know that this position puts me at odds with a lot of what most people will hear in mainstream maternity services. So I get some pushback from time to time. And even when I don’t, I worry about getting pushback… Or even worse – I worry I’ll end up being completely ineffective.
So why bother?
There are days when it starts to feel like it is too far between wins and I consider “chucking it all in”. It might be nice to slide off into obscurity and turn my neurospicy brain to another hyperfocus. Learning the names of all the bird species on my property maybe.
I’m writing this post as a reminder to me about my “why” and sharing it with you. Maybe it’ll help you to tap into your “why” too – and keep you in the good fight for a bit longer as well. Whatever that fight is for you.
The back story
As a 12 year old, I won a student scholarship for academic excellence – the Walter T. Weaver Bursary (weird that I can still remember the name of that all this years later but I still don’t know what to call that bird I hear most days at sunrise!). I was interviewed for the local newspaper and told them I planned to become a doctor one day. As I remember it, it was not that long after I had switched from planning to be a ballet dancer, so I doubt anyone took me all that seriously.
At some point during my high school years, a guidance counsellor once suggested medicine was not a suitable job for a young woman. Well…. That galvanised the decision! Off to med school it was.
By the time I entered University I was already an ardent feminist, having been raised by an educated woman who ran a successful business and left a copy of the Female Eunuch lying around where I might find it. I was interested in making women’s health care better. Despite my young age, I could already see there were huge problems there. So I set my sights on Obstetrics and Gynaecology very early.
My medical school years covered the late 80s and early 90s. It was the dawn of the Evidence-Based Medicine movement. As a bookish introvert this suited me perfectly. I loved heading to the library to look up the research about what to do to solve a clinical problem. It seemed an easier and more effective pathway to good practice than to spend a decade or two learning by trial and error or guesswork.
Becoming an obstetrician / gynaecologist
By the time I entered specialist training, I already had an obsession with my future profession, research skills, and the belief that using good evidence was the only ethical way to practice. I also knew that women got a raw deal in many aspects of life, including their healthcare, and wanted to be part of solving that rather than taking part in it. You might think that I would have quickly spotted the problem with fetal heart rate monitoring early on in my training. But, no…
The sheer volume of knowledge that must be amassed to successfully practice in obstetrics and gynaecology and to pass exams is VAST. It is larger now than it was then, but current trainees have significant advantages due to the greater accessibility of information online than I had access to. Not having to find time to sneak off to the library to see if this month’s copy of the British Journal of Obstetrics and Gynaecology was out on display yet would have made my life easier!
When it came to fetal monitoring, I can’t recall EVER looking at the evidence myself, and none of the people who were responsible for educating me suggest that or shared the details in their teaching. Instead, I learned lists of who should have CTG monitoring, how to make sense of the heart rate patterns, acid-base physiology, the technical skills of putting on fetal spiral electrodes and taking fetal blood samples, and of course – how to do caesarean sections and vacuum assisted births. I was so busy feeling pleasure at the increasing sense of mastery I was developing, that it never occurred to me to ask if any of it was evidence-based. Or to consider looking at it through a feminist lens.
And then…
I became a specialist and set up my own private practice. I built relationships with the women who sought my services over an extended period of time. I got to see the downstream effects of my recommendations. They asked me good questions, and I realised I had to listen and learn from them, and to provide care that met their needs. Feminist Kirsten was determined to share good information so the women I was caring for would be well positioned to make their decisions.
And still the penny hadn’t dropped that CTG monitoring wasn’t evidence-based. That happened after a consultation I once had with a woman who was in the process of planning her vaginal birth for her twins. I recommended continuous CTG use, as that was what the guidelines said. Her partner challenged me and asked for evidence to back up that recommendation. I didn’t have it at my fingertips, but I remember feeling extremely confident that I would locate it with one quick library search. I offered to email copies of the evidence to them a few days later.
But there was no research. None. And there is still none specifically asking the question of whether CTGs or intermittent auscultation is the better option for twins.
I was really angry about it too. Angry that I didn’t already know this. Angry to have spent so much time telling people this worked when I should have been better informed about something that was an absolutely fundamental and day-to-day part of my practice. Angry that the information about the lack of evidence was not something that any of the people I had learned from had ever pointed out to me.
So I started to do better…
I started to read the evidence base about fetal heart rate monitoring. And I started to explain to women in my care in my private practice that they had a decision to make and that I would honour that decision. And many women decided to have intermittent auscultation.
Can you guess what happened next?
Yup.
I ended up in all sorts of hot water with the management team at the hospital where I had admitting rights. My obstetric “colleagues” not only didn’t support me, they were actively awful about it. It was a very painful learning experience, but it made it completely crystal clear that obstetrics isn’t an evidence-based profession. Obstetrics is fundamentally about maintaining control over women by providing the illusion of safety.
So the idea for a PhD research was born. It took me several more years to get to it, but I did. What I learned was transformative. I forgave myself for not trying hard enough to get the local hospital to change their policy, and for not working harder to get those other obstetricians on board. The powers that maintain CTG use are SO much bigger than any one of us – it is no wonder that as one individual practitioner I was unable to do very much to shift the dial. (And it’s no wonder you find it hard to do so as well…)
I still want to change maternity care
17 year old feminist me, who wanted to make healthcare better for women, is still here. But I know more now about the work that needs to be done. Both my mother and my maternal grandmother were rendered non-functional by dementia in their mid 70s, so my best guess is I have 20 years of productive working life left in me.
Over the past decade my focus has been on making the evidence-based accessible and visible so that anyone who wants to know what it says can readily find it with a quick Google search. I’ve made a good start, and I’m starting to see signs of it paying off. Researchers and policy makers are starting to acknowledge the limitations about what we do and don’t know about fetal monitoring.
But it isn’t enough. Before I die (or lose my mental faculties) I want to see policy and culture shift in maternity services around the world. And I want that shift to mean that women will routinely be given HONEST information about their fetal monitoring choices. And that the professionals sharing that information will get a pat on the back for doing it, not threats of unemployment and deregistration. And I want all maternity professionals to work together, with women, to build systems of care that really do make outcomes better, rather than pretending that the new CTG training program will finally make CTG monitoring work…
That’s a big job. I’ll need YOU to get on board and help me with that. I’ll need time and money and right now both are in short supply. Right now, it feels like maybe it would be less heart breaking to give up than to not finish the job. Which is why I wanted to tap into my WHY once again today and attempt to put some oomph back into my life.
What can you do to help – right now?
First: Send me a DM, or an email, or post a comment about how my work has had a positive impact on you. At present, it often feels like I am screaming pointlessly into the void. It would really help to know that something is working.
Second: put your name down on my newsletter list so I can connect with you and share more opportunities to get on board with the things I have planned for 2026. (BIG THINGS.)
And finally: invest in the paid offers I have out at present. That money makes a huge difference and will fund my ability to keep going. It doesn’t need to be much. You could head to my Free Stuff course and make a $5 donation and I promise it will make me smile for days!
You’ve read the blog posts, but still want more? Wish you could find details summaries of all the evidence in the one place? Want to connect with a growing tribe of people working to solve the fetal monitoring problem?
The Fetal Monitoring Academy is a HUGE resource library covering just about every aspect of fetal monitoring research, with expert analysis and critique so it is easy to understand. New content is added regularly in response to requests from Academy members – so you will find exactly what you are looking for. You also get:
- Ready access to leading expert Dr Kirsten Small to have your questions answered
- Monthly live Meetups to discuss aspects of fetal monitoring practice, with a view to promoting and supporting practice change
- A secure online community space where like-minded people hang out. It’s place to be supported and to support others as we work together to stop the nonsense
- Downloadable resources
- Certificates you can use to claim professional development hours
If you are a maternity professional, doula, educator, researcher, or simply a birth nerd who wants to know more – the Fetal Monitoring Academy is perfect for you.
Enrolments are open for a short time only each February and August. Add your name to the list to make sure you hear about it when the doors are open again
Register to learn more!
Categories: CTG, EFM, Obstetrics, Reflections
Tags: Why?
Birth Small Talk 
Oh Kirsten, thank you for telling the story of your obstetrics journey so openly, with honesty and resolve to continue examining the evidence base (or lack of) for CTG monitoring. When I began my journey transitioning from hospital midwife to home birth midwife with the Community Midwifery Program in Fremantle WA the first skill I was required to demonstrate was abdominal palpation and auscultation with a pinnard. I believe these essential basic Midwifery skills are now lost or disregarded, as midwives rely on ultrasound technology to determine fetal position and presentation, and Doppler for fetal sounds. I learned how to listen to fetal heart sounds using a Doppler underwater which was a very new birth environment in the early 2000’s. I presented many educational sessions to WA hospital midwives keen to embrace the option of waterbirth for labouring women. I am proud to have conducted the first VBAC waterbith in Beverley Hospital with GP support, for parents whose first baby died during a breech hospital caesarian birth at KEMH. Kirsten, we are (unrecognised) trailblazers for Australian Birthing families. It takes courage, commitment and dedication to effect meaningful change, while banging our heads against walls and being shot down in flames along the way. I’m with you. 100% And don’t get me started about effective evidence based breastfeeding support and tongue-tie treatments when indicated. Love your work! Lois Wattis
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Thanks Lois. I heard a talk once where the speaker’s key message was “if you can’t see it, you can’t be it.” My response was that’s total bollocks. If you and I had needed to see someone else stepping up to solve problems, nothing would ever change. Here’s the trailblazers!
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Hi Kirsten,
I’m not sure this even counts as a proper email, but I felt I had to write. I think we met once, walking along the seafront at Grange-over-Sands with Lesley Page. At the time, I didn’t realise who you were.
I just wanted to say: please don’t give up. I know it can feel disheartening when logic and evidence don’t seem to move people, but that doesn’t mean your voice isn’t making a difference. Your emails are incredibly helpful, and they matter.
I work in NHS England, and even here, money is still being spent on all sorts of things without the evidence or scholarship to back them up. So your clarity, your persistence, and your expertise are more important than ever.
Please keep going. We need people like you.
Warmest wishes,
Trixie
Would you like me to help you format this in Outlook or add a signature block?
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Thanks Trixie – I remember that walk, and hearing part of Lesley’s life story, and talking with you. That conference was a great coming together of people. I’m pleased it continues, even if they are no longer able to say the word “normal” out loud anymore…
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Loved hearing (well, actually reading 😁) your story, Kirsten! I so recognise the feeling of being alone in it all. Just got my midwives degree last month and currently thinking about what I’m gonna do with it: join a midwifery practice or venture out on my own – which seems a bit scary and a tat irresponsible as I’m just out of school…
But knowing I have a trusted source of information and can back women’s choices with it really helps. Not that I’ll be having a lot of CTG monitoring in a private practice, but it would be great to be able to support women who’d “risk out of care”.
Please keep doing what you do! Been interning a lot (and than working a lot to compensate lost wages during internships) but hope to have the opportunity to join a meeting again.
Kind regards, Bertine
P.S. Any luck locating the French article?
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Thanks Bertine. I’m pleased to hear you have crossed the finish line! And simultaneously the start line. I’m confident you’ll make a good decision about the path forwards. No matter what you choose, you will have to learn as you go. If you can gather a network of people to learn from, then I’d suggest going where your heart calls you strongest.
I let the trail of the French paper go cold – one day when there’s time I’ll hunt it down!
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Hi Kirsten,
Love your work. Replying because you said you would value it. There are
people out here in the void!
It was really good to read about your journey to a critical stance on
EFM. Wanted to say how much I appreciate the work you are doing. I’m a
burnt out ex midwife in the UK, having realised that I can’t change the
system, am causing trauma to women and babies, the system is only
interested in maintaining itself, and I need to prioritise my sanity and
physical wellbeing. Also caring for a mum with dementia – surely the NHS
practice on fetal monitoring shouldn’t make less sense than someone with
dementia.
In addition to the many concerns you raise about the lack of evidence
for benefits of EFM to women or babies, and because of your explanation
of how you were taught lots about how to interpret and when to do, but
no critical exploration of risk/benefits about EFM, I wonder if you have
considered the effects of ultrasound exposure during EFM on the fetal
brain? In particular the phenomenon of microcavitation and streaming.
And the whole lack of evidence of safety of ultrasound for babies? But I
expect there isn’t any room for another crusade in you.
Sorry got no spare cash to buy anything, but imagine me cheering you on.
Viv
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Thanks Viv – your message warms my soul. I haven’t made that particular deep dive – but Caroline Rodgers has. There’s a blog post back a few years ago about her paper about the possible impact of prolonged Doppler exposure on brain development. She keeps me updated as she continues to publish. It is worth looking at her work on ResearchGate if you have access to it.
It’s yet another aspect of fetal monitoring that has been underinvestigated, making it easier to presume there are few downsides. But who really knows!
Kirsten
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What a great post, Kirsten! Of course I knew some of your story, loved working with you at Griffith and was so pleased to see your progress with the PhD; SO DESPERATELY NEEDED in the extremely non-evidence-based world of maternity care. Being retired I can’t do much other than send people to your publications but when I can, I do. You are a pathfinder for birthing women and midwives and maybe a few ‘good’ ob-gyns out there.
Stay strong and keep going (and maybe it’ll help stave off the dementia too!)
Hugs from over here in Trumplandia,
Maryann maryann.long@gmail.com
Find activism resources for Cville at https://tinyurl.com/56edfw3c
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Thanks Maryann – staying sane in Trumplandia is quite the challenge too!
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Hey! I’m a reader in Bloomfield, NJ. I had a primary section for a “huge” 8lb2oz baby at 41 weeks – elective, scheduled, not permitted to even try to labor, my OB said I’d regret an induction and that I was irresponsible to even wait as long as I had – and then a VBAC with a larger baby. I now volunteer with a birth nonprofit and have your website on my list of trusted resources.
I was so broken by my birth that I did consider freebirth in the woods rather than let a surgeon touch me again – not actually something I felt called to, or wanted, but an impulse borne out of trauma. People like you- your willingness to tell the truth, subject available evidence to rigorous inquiry, trust pregnant women to have the capacity to make their own medical decisions, your feminism, and your HUMANISM – made a difference for me.
I can imagine it is hard to post into the void of the internet and wonder if anyone is on the other side. Black and white messaging gets clicks. Simple stories about villains and heroes get clicks – whether it’s the surgeon saying the midwife is the villain (very common in the US) or the doula saying the surgeon is the villain, or what have you. Easy stories about something complicated and powerful and terrible – in the old meaning of the world, beautiful and dangerous at once – these stories sell, but they are not the truth. Thank you for your dedication to truth.
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Thank you Kate 💜 So good to see you standing in your power and showing others the way too!
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Hi Kirsten
I wanted to thank you for what you do, while I am fortunate to be a midwife in the NZ continuity of care system, this is slowly being overtaken by obstetric led care that is not evidence based, CTG’s are done here for everything and anything especially where I work which is remote rural, 2 hours away from a secondary level unit, and four hours to a tertiary level unit.
Obstetricians are hard to argue with when things are done “just because” or because someone tells you thats what they want done. Women centred care is becoming eroded slowly with guidelines and recommendations that are not evidence based and care providers who pick and choose what they follow and then what they don’t. Short staffing, time restraints also impacting factors as well in decision making and care provided with women.
Your emails, academy and study are a little ray of sunshine in the somewhat murky waters of midwifery, keep on keeping on, you do make a difference and you give us all the courage to keep asking the hard questions and challenging those around us who do things just because “that is what we do”
Nicci Fahey RM BMid PgCertMid LMC Midwife Whakatipu Midwives Queenstown PH 027 353 7980 PH 022 506 7347 Oncall Midwife – Urgent pregnancy concerns for you or your baby
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Thank you 💖😘
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Dear Kirsten
I am a Dutch independent midwife and your course has been very important to me.
This is because I knew already about the lack of evidence, but it felt like I was in a weird world because so many people around me behaved as if a CTG was a very beneficial thing and I was the one being crazy by doubting its use and pointing to the dangers of it to the mother.
So thank you thank you for being a reasonable and scientifically backed voice out there.
It made a huge difference in counseling women and discussing the whole thing with colleagues
Pauline Doedens
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Thank you Pauline 🥰
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Dear Kirsten
please don’t stop what you are doing. I’m sorry that it can seem like shouting into a void. I love your posts and courses and I share your blog posts with everyone of my classes when I am encouraging them to ask for IA. I love that your blog is so accessible and I know that at least some of the parents read it and it helps them to decline CTG in our highly medicalised Irish hospitals.
Thanks you for doing what you do, and for doing it so well
Sarah
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Thank you! 💖
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Kirsten, thank you so much for all that you do. I regularly read your blog and social media posts. I find them so valuable and informative, and as a journalist and a qualified doula, I also share these with anyone who will listen. You are making a huge difference, and this change is going to be bottom up – not top down. Every single woman who exercises her right to evidenced-based care, who demands IA and refuses CTG is forcing change. It might feel like a trickle but soon it will be a deluge. Keep the faith ❤️
Warm regards,
Simone
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Thank you Simone xxx
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