As people come to recognise that current fetal heart rate monitoring practices have little relationship to the evidence about their effectiveness, it is common for them to ask “how did this happen?”. Historian Jacqueline Wolf has set out answers to this nicely in her 2021 paper. This post explores and expands on what she has written.
What is the problem, exactly?
CTG monitoring was introduced into practice in the late 1960s. By the 1970s it was widely accepted as an “essential” tool for maternity care (Banta & Thacker, 1979). CTGs fundamentally changed the work and roles of obstetricians, midwives, nurses, and the role expectations and experiences for birthing women. CTG recordings were, and remain, a major driver of decisions for caesarean section and other birth interventions. The beliefs and assumptions inherent in the technology set the scene for expensive litigation when the monitoring failed to produce the benefits promised.
When evidence that CTG monitoring was pointless and harmful started to arrive in the late 1970s and was well established by the mid 1980s, no-one backed away from its use.
Fertile soil
CTGs didn’t arrive into a vacuum. Understanding what was going on in maternity care in the USA (where they were first introduced and rapidly took hold) helps us to understand why CTG monitoring promised to be the perfect antidote.
Obstetrics had not long emerged from a struggle for relevance. In the 1910s, US medical schools did not teach any obstetrics, on the belief that birth was an ordinary physiological process that did not require medical input. Obstetrician Joseph De Lee wrote in the very first issue of the American Journal of Obstetrics and Gynecology in 1920 that a systematic approach to medicalised childbirth would both improve outcomes and increase recognition for the profession. Heavy sedation, episiotomy, forceps birth, and manual removal of the placenta were recommended as routine practices for all women.
Research done by Friedman in the 1950s led to the establishment of standardised curves of labour progress. This broadened obstetric definitions of “abnormal” labour to include anything that sat outside of the idealised labour progress curve he created. Intervention to return progress back to the norm was the logical next step. CTG monitoring would provide a convenient way to track the frequency, duration, and strength of contractions, and how this changed when interventions to alter progress were introduced.
There had also been a series of well-publicised birth complications that created a public acceptance of CTG monitoring as a solution. Thalidomide was revealed as the cause of multiple birth defects in 1962. President Kennedy’s prematurely born son died two days after birth in 1963, followed two years later a rubella epidemic that lead to a fresh round of concern about fetal abnormalities for infected women. In public health campaigns, women were advised that good outcomes could be assured but it was their responsibility to take the required precautions. Accepting CTG use was simply one more of the obligations for women to ensure the birth of a healthy child.
The late 1960s saw ultrasound introduced to maternity practice. This made the fetus visible and therefore more “real” than ever before. Ultrasound imaging sparked a major shift towards seeing the fetus as the primary patient. Obstetricians were seen as the logical profession to protect and rescue the fetus, and women’s primary role was permitting the obstetrician to do so.
Feminist concerns calling for birth reform were also active at the time. This was the era of Grantly Dick-Read and Lamaze – both offering pathways to “painless” birth. Partners began to enter birth rooms, and coaching by husbands was recommended by many in the birth reform movement. Being able to see the onset of a contraction on the CTG machine so husbands could start to encourage the recommended breathing patterns was seen as a benefit from CTG use (Syndal, 1988).
This post war period was a boom time for technology development more generally. Many advances genuinely did make people’s lives better. Washing clothes, vacuuming, ironing, and other domestic work typically performed by women was simplified by new electronic technology. “Electronic fetal monitoring” fit with this. As Hon (the inventor of the CTG machine) claimed in 1969 in a Life magazine article “We can talk to an astronaut who is hundreds of thousands of miles above the earth but without modern electronics, a doctor had little or no idea what was happening to the fetus just inches from his ear.” The same July 25 edition that featured this article on the wonders of CTG monitoring, also celebrated the Apollo moon mission launch.
The logical solution
CTG monitoring offered great promise for many. It was a way for obstetrics to increase its authority and relevance. Some women welcomed it as it seemed to offer a promise for a less medicalised birth. Society embraced it as a technological advancement that would inevitably make the world a better place. CTG monitoring was simply the logical solution – so its rise to near universal application is not all that surprising.
We now know that CTG monitoring failed to deliver on most of these promises. It doesn’t prevent death or brain injury of the fetus. It doesn’t reduce the medicalisation of birth. What it did then and continues to do now, is to maintain obstetric dominance in maternity care. As the dominant profession, it is therefore no surprise that obstetrics continues to place unwarranted faith in the use of CTG monitoring.
Where to next?
Wolf offered no suggestions about what we should now do. What she makes clear is that CTGs rose to prominence and stayed there for reasons other than proven effectiveness. Indeed, CTG monitoring is where it is in spite of evidence proving its ineffectiveness.
While I continue to believe there is some value in continuing to put the evidence of the inadequacy of CTG monitoring in front of people (otherwise I wouldn’t be doing it), this approach it isn’t going to change the situation on it’s own. Broader scale social change is needed to create the perfect setting for CTG monitoring to be abandoned. Women’s right to bodily autonomy must replace the focus on the fetus in maternity care.
That change is coming… I spoke about it at last week’s first ever consumer led maternity care conference. It’s time for users of maternity care to lead the way. Ask questions. Know your rights. Expect better. Demand better from maternity care systems and from the professionals who work in them.
Decisions about fetal monitoring are for YOU to make. This is true whether you are considered “high risk” or not. It remains true even when someone tells you that you don’t have a choice and that CTG monitoring is mandatory. My recently published book Monitoring your baby in labour: An evidence-based guide to help you plan your birth supports you to make these decisions.
Buy your copy today
References
Banta, H. D., & Thacker, S. B. (1979). Assessing the costs and benefits of electronic fetal monitoring. Obstetrical & Gynecological Survey, 34(8), 627-642. https://doi.org/10.1097/00006254-197908000-00026
Snydal, S. H. (1988). Reponses of labouring women to fetal heart rate monitoring: A critical review of the literature. Journal of Nurse Midwifery, 33(5), 208-216.
Wolf, J. (2021). “They said her heart was in distress”: The electronic fetal monitoring and the experience of birth in the USA, 1960s to the present. Journal of the International Committee for the History of Technology, 26(2), 33-61. http://www.icohtec.org/wp-content/uploads/2022/03/26-2-33.pdf
Categories: CTG, EFM, History, Obstetrics, Feminism
Tags: technology, Hon, Apollo, 1969, USA, De Lee, Lamaze, Dick-Read
Birth Small Talk 
This is the page I get sent to regarding your book and I can’t see any information about how to purchase it.Â
Vivienne Hill MidwifeNew Zealand
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Thanks for pointing that out ! I’ve updated the link. This is the correct one – https://education.birthsmalltalk.com/monitoring-your-baby-in-labour
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