The emotional costs of moving away from CTG use

When midwives and obstetricians raise their concerns with me about what it would mean if they moved from CTG use to intermittent auscultation, they often say something like – “I find CTG monitoring really useful. I feel safer when I can see the heart rate pattern and know the baby is okay.”

I think we don’t talk enough about the emotions maternity professionals attach to CTG use. If we are going to shift people away from CTG use, there’s needs to be an acknowledgement of these emotional benefits. I can see three categories of emotions that have been part of my life as an obstetrician and that I hear come up in conversations with other people on a regular basis. (If you recognise something else in yourself or people around you, let me know in the comments.)

They are comfort, competence, and control.

Comfort

CTG use can be anxiety reducing. Like the person in the quote above, it can generate a sense of safety. I hear people say things like “I feel happier when the CTG is on”, “I just feel better knowing…”, “I like being able to see / hear…” All these are essentially about feeling comfort rather than discomfort.

Messaging about the risk, the danger, of birth and of getting something wrong as a clinician is inescapable in current hospital environments. Seeking as sense of safety is understandable. A continuous recording of the heart rate has been promised to us as a way to achieve safety, both for that baby and for us as the care provider.

Competence

CTG monitoring provides plenty of opportunities to feel like a competent professional. This was a big one for me earlier in my career. Going to CTG education sessions and learning how to give the approved names to different parts of the trace helped me feel good about myself. Learning and being able to recite lists of risk factors for which CTG monitoring was meant to be used made me a useful source of information for others.

Control

Birth is messy and unpredictable, and if you provide direct care to one woman at a time in labour you never quite know how your day is going to pan out. If you are in a role where you are overseeing multiple women in labour, things have the potential to get really untidy. I can see why a digital journey board and central fetal monitoring system would generate a reassuring sense of control over the chaos. For the midwife in the birth room, control might look like a tidy partogram with all the heart rate data filled in at exactly the right times, no gaps in the fetal heart rate recording, tidy looking contractions, and an ever present maternal heart rate over the top of the trace.

As a midwife, if you know how to interpret a CTG back to front and upside down, it provides you with the potential to hold your ground against obstetric power. Using knowledge about what the guidelines really say, and having a detailed knowledge of the woman’s specific circumstances and goals, gives you power to resist when an obstetrician is pointing at the CTG recording and driving care in a particularly unhelpful direction.

The other control aspect is the sense of authority that CTG use offers professionals. Pointing at the CTG and saying “Your baby needs to be born RIGHT NOW” is practically guaranteed to generate the desired reaction from the woman, no matter what your profession is. As an obstetrician, the way maternity culture works meant that I got to be the final arbiter of decisions about whether the CTG was abnormal or not, and what to do about it. Not the woman, not their midwife.

Changing where the positive emotions come from

If our maternity systems are to move away from central fetal monitoring and CTG use, I believe we need to offer people alternate ways to feel comfortable, competent, and in control while providing care to women in labour. Here are my suggestions for how to make that shift.

Increased knowledge about the evidence for CTG use, intermittent auscultation, central fetal monitoring, and other aspects of fetal monitoring practice will first generate discomfort. I think of this as an example of the Gloria Steinem quote – “The truth will set you free. But first it will piss you off.” Once you settle into the knowledge and see the big picture, things begin to make more sense.

I sometimes jokingly offer to sell people an overpriced piece of quart crystal to put near the woman as a protective amulet, acting as a replacement for the CTG machine. There is just as much evidence for the effectiveness of this as there is for central fetal monitoring and CTG use. Once you shift into realising that the sense of comfort you were experiencing is a complete illusion, you can move beyond it.

Safety in maternity care comes from the quality of the relationships with women and with other care providers. It comes from an holistic approach to support health, recognise deviations from this, and making early and small readjustments to the course (and less often big dramatic responses). Let’s derive our sense of comfort from these instead.

Reconnecting with professional values, both at an organisational level as well as a personal level, helps to shift the ways we measure our sense of competence. Core values of woman-centredness and evidence-based practice are aspects of all the maternity professions. If we are brutally honest with ourselves, we need to acknowledge that we are putting women on CTGs (that make outcomes worse for women and no better for babies) so we can feel good about ourselves. And that’s not a demonstration of competent application of professional values. Focussing on delivering accurate information about fetal monitoring options, supporting women’s decision making, and providing their chosen method of fetal monitoring to a high standard provides a different path to feeling competent.

When it comes to control, I believe we are well overdue for a major period of professional reflection. Obstetrics in particular prefers to argue that power is the natural purview of the profession (see statements like – “every team needs a leader and that person should be an obstetrician”). When challenged, the standard approach is to shift blame onto midwives and women. Our current approaches to fetal monitoring both reflect the power of obstetrics and are also responsible for reproducing it.

At a personal level, I encourage you to reflect on what power / authority / control you have and how you are using it. Look for ways to feel powerful by working WITH rather than OVER people. Focus on self-control and put your emotions aside as you work to meet the woman’s needs for a sense of comfort, competence, and control during her birth.

Most maternity professionals spend a lot of time investing in their competence when it comes to CTG interpretation. If you want to learn to find comfort, competence, and a sense of control in your professional life, where do you go to engage in deeper conversations? Where can you find the knowledge you need to challenge your internalised beliefs and the support you need to practice differently?

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. The knowledge you need to think differently, to practice differently, to be someone different is there. And there’s support, with direct access to Dr Kirsten Small and to the other Academy members who are also committed to the same changes.

If you want to change yourself and to change maternity care – the Fetal Monitoring Academy offers a valuable path to and through that transformation.

Enrolments are open for only a few more days.