Although the concepts of periodic fetal heart rate and fetal heart rate patterns are new to most obstetricians, with a little instruction they apparently have little difficulty in recognising the various types of fetal heart rate patterns and classifying them into innocuous and ominous groups.
(Paul & Hon, 1970, p. 168)
Since Paul and Hon’s overly optimistic paper promised that CTGs would make maternity care better and required little instruction, CTG education has become a big business in high income countries. Here in Australia, most but not all state health departments require clinicians to have attended the Royal Australian and New Zealand College of Obstetricians and Gynaecologists RANZCOG fetal surveillance education course (known as FSEP) in the past one or two years, and to have achieved a high score. This generates a significant income for RANZCOG, who also make policy saying that institutions should support maternity staff to access education (including their own educational product) (RANZCOG, 2025).
In the UK, the Okenden report (2020) recommended investment in fetal monitoring education. This has lead to the creation of a new cadre of midwife: the fetal monitoring midwife. Again, this is a significant financial investment. It is therefore reasonable to expect there is good evidence that investing in CTG education produces better outcomes for women and babies.
Does FSEP improve outcomes?
It has been a few years since I last attended an FSEP day. The last time I did, the presenter made the claim that there had been research proving that the program led to better outcomes. The evidence for this was a paper by Brown et al., published in 2017. The paper concludes with:
We have shown that a national multidisciplinary education program targeting interpretation and management of intra- partum fetal monitoring may be associated with improved neonatal outcomes.
p. 5
… and then recommends that the program should be mandatory for all maternity care providers.
On the face of it, they reported that national perinatal outcomes were better in the years after FSEP was introduced (they looked at outcomes from 2005 – 2010), compared to before (outcomes from 1998 to 2004). In table 2, they provided a list of before and after outcomes for Apgar scores, intubation, hypoxic ischaemic encephalopathy, and transient tachypnoea of the newborn – all with a statistically significant reduction.
Being a details person, I looked at the fine print and immediately went, huh? The raw numbers told a different story. Apgar scores of <5 at 5 mins went up from the first period to the second. Use of intubation increased; hypoxic ischaemic encephalopathy rates increased; and transient tachypnoea also rose. How was this “improved neonatal outcomes”? (See the table below for the numbers in the before and after columns.)
I eventually worked out what they had done. The denominator they used was not the total number of births during that time period, but the number of babies admitted to the neonatal nursery. And the number of babies admitted was much higher during the second period than the first.
Sure, that’s one way to analyse the data. But I suspect that the vast majority of parents want to know whether they can expect good outcomes when their baby is born, and are not only interested in whether the outcome will be good in the event their baby is admitted to the nursery. The authors didn’t provide a justification for this choice of analysis in the paper.
So I have reanalysed their data, using the number of births in both periods as provided by the authors of the paper. And the story is the VERY different. Here’s the new table:
| Outcome | Before FSEP | per 10,000 births | After FSEP | per 10,000 births | Relative risk | 95% confidence intervals |
| Apgar 0 at 1 min | 203 | 1.2 | 265 | 1.5 | 1.34 | 1.11-1.61 |
| Apgar <5 at 5 min | 948 | 5.4 | 1264 | 7.4 | 1.37 | 1.26-1.49 |
| Intubation and ventilator support | 938 | 5.3 | 1275 | 7.4 | 1.39 | 1.28-1.52 |
| Hypoxic ischaemic encephalopathy | 615 | 3.5 | 827 | 4.8 | 1.38 | 1.24-1.53 |
| Transient tachypnoea of the newborn | 119 | 0.7 | 444 | 2.6 | 3.83 | 3.13-4.69 |
For each of the outcomes listed, there was a statistically significant increase in how often they occurred AFTER the FSEP program was introduced. So the answer to the question of whether there is proof that the introduction of FSEP led to better outcomes is a resolute NO!
What about other research?
If there’s no proof of better outcomes from the Australian experience, what about research from other parts of the world? In 2020, Kelly et al. published a systematic literature review that set out to answer the question of whether training in CTG monitoring improves outcomes. They reviewed 64 studies (including the Brown paper). Their take home message was that “evidence for the impact of CTG training on neonatal and maternal outcomes is limited, shows inconsistent effects, and is of low overall quality”. The Kelly et al paper should be compulsory reading for all people who design, run, and fund CTG education. The authors have done the science well and argue their position competently.
There is therefore no compelling evidence that education, and frequent reeducation on CTG monitoring, can improve outcomes.
What does this mean?
Back in 2021, Professor David Ellwood and I have published a mini-commentary reflecting on the findings of the Kelly et al., 2020 review (Small & Ellwood, 2021). Based on the current evidence set out by Kelly and colleagues we argued that stand alone CTG education should not be considered mandatory for maternity clinicians. I still stand by this. I’d rather see the money that is currently put towards this being shifted to other purposes. Like skills training for dealing with birth emergencies, or workshops aimed at improving inter professional communication and collaboration.
The absence of evidence that CTG monitoring education improves outcomes doesn’t surprise me in the least. Nor should it surprise anyone who knows the evidence about CTG monitoring. Given that the evidence base doesn’t show better outcome when CTGs are used rather than intermittent auscultation, then teaching people more about how to do CTG monitoring can’t ever be expected to make anything better!
The really important question to ask here is – who benefits from continuing to mandate regular CTG education for the vast majority of the maternity professional workforce?
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References
Brown, L. D., Permezel, M., Holberton, J. R., & Whitehead, C. L. (2017, Aug). Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study. Journal of Maternal-Fetal and Neonatal Medicine, 30(15), 1777-1781. https://doi.org/10.1080/14767058.2016.1224839
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
Paul, R. H., & Hon, E. H. (1970, Feb). A clinical fetal monitor. Obstetrics & Gynecology, 35(2), 161-169.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2025). Intrapartum fetal surveillance clinical guideline. 5th Edn. https://ranzcog.edu.au/statements-guidelines
Small, K., & Ellwood, D. (2021, Aug). Does training in intrapartum fetal monitoring actually work? British Journal of Obstetrics & Gynaecology, 128(9), 1420. https://doi.org/10.1111/1471-0528.16725
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Tags: Education
7 replies ›
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- Giving oxygen when the CTG is abnormal – Birth Small Talk
- Adding something extra to make the CTG work – Birth Small Talk
- Is more technology the solution to fetal monitoring? – Birth Small Talk
- Education isn’t the solution – Birth Small Talk
Birth Small Talk 
FSEP mandatory here in Victoria and seems a conflict of interest to me as the only acceptable course is run by RANZCOG who would seem to have a financial interest in maintaining the status quo. Would be good to see independent review whether it has made a difference
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I concur with the concerns that you have raised , however because CTG monitoring is concreted in to clinical care , quality reviews and case reviews , they are here to stay. The main challenge for institutions is to minimise the chaos that CTGs generate because of their intrinsic limitations. One approach to this is to agree on the language and intepretation as best we can and therefore some form of training I do see as necessary . It will not make a noticeable clinical difference however it could help reduce the angst and mayhem caused by CTGs.
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I’d love to see a focus on the evidence base routinely incorporated into fetal monitoring education options.
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