My doctoral research focussed around the impact a central fetal monitoring system was having on maternity professionals who worked with it. When I started planning my research, I had never personally worked as an obstetrician in a place where central fetal monitoring was in use. So I entered into the research with a curious mind about what I would find.

Now well on the other side of it, my position is clear. I’m very worried that central fetal monitoring, like CTG use itself, has been introduced prematurely and without evidence that it works. I think central fetal monitoring systems are probably overall a bad idea.

What does the evidence say?

I’ll only touch on this briefly as it is something I have already posted quite recently (you can read the most recent research here). The best way to know if central fetal monitoring systems work would be to select two or more hospital sites where central monitoring is not in use, then randomly decide who gets a system and who doesn’t. Outcomes for women, babies, and staff, and systems would be measured before, during, and after implementation, making sure that fetal monitoring policies are otherwise the same at all sites and they all get the same amount of education and attention to the importance of fetal monitoring. Then the outcomes would be compared between sites with and those without central fetal monitoring. In other words, a randomised controlled trial.

That has never happened.

Instead, there have been four “natural experiments” where what happened before is compared with what happened after. In some, the before was central fetal monitoring and the after was when the system failed and was no longer available. In others, the before was prior to implementation and the after was after the central fetal monitoring system was in place.

None show any benefits for babies. Some show more intervention for women – others don’t. The evidence doesn’t provide a compelling reason to introduce expensive technology to maternity environments.

What hasn’t been properly assessed in research?

When I designed my research, my interest was in the social forces that maintain and expand fetal monitoring technology in clinical practice. I used an approach called Institutional Ethnography that helps researchers to find out how things happen the way they do. It doesn’t measure whether something is safe or harmful – and I therefore can’t make claims that I have proven that central fetal monitoring is one or the other.

What I did do was spend many hours watching midwives and obstetricians working with the central fetal monitoring system at one hospital, and more hours talking to midwives and obstetricians about their experiences of working with central fetal monitoring. Since I started presenting and publishing findings, I have had more conversations with maternity professionals who work with central fetal monitoring systems about their experiences. Here are some of my thoughts…

Central fetal monitoring as a technology of power

Central fetal monitoring systems mirror Bentham’s panopticon – a designed environment that allows one or a few people to observe a large number of people, without those people knowing when they are, and are not, being observed. French philosopher Michel Foucault added to this design the understanding that surveillance coupled with social expectations about behaviour is a technology of power – a way to get people to do what you want without having to use force.

This was definitely something I saw pan out as I was collecting data. A midwife told me that you wouldn’t get away with intermittent auscultation for long as people could see that the woman was labelled high-risk and they could see there was no CTG trace. Rather than collectively resisting the pressure to use CTGs, it felt safer to comply in advance – even if no one was actually going to notice and criticise.

It wasn’t just that central fetal monitoring provided an effective tool to promote CTG use while barely having to do anything to promote CTG use. Any other aspect of midwives work that could be “seen” at the central monitoring station and where there were cultural expectations about what that midwife should be doing was impacted by central fetal monitoring. Haven’t done a vaginal examination in the last 4 hours? No observations done in over an hour? Haven’t told the team leader about those late decelerations? All now highly visible.

That’s not an entirely negative thing. Foucault’s writings on power remind us that power is not alway oppression and harm. Power is also a way to get people to do or not do things so there is a positive outcome. Like not speeding through a school zone at pick up time, or driving while intoxicated, or killing your neighbour for mowing the lawn early on Sunday. Central fetal monitoring might improve safety by making sure midwives are doing things that make safety better.

However, the values and beliefs of the people who designed and introduced central fetal monitoring are hardwired into the technology. Using central fetal monitoring reinforces and plays out those beliefs. These include the belief that midwives are a bit stupid and need someone clever to keep an eye on them, that women are risky and that the fetus is inherently fragile and precious. It’s then no wonder that many midwives feel something is off kilter when they bring their best professional self into an environment with central fetal monitoring. They notice the loss of authority, respect, and autonomy (Gottfreeðsdottir et al., 2025).

Women become an iPatient

Verghese (2008) wrote of the way that users of healthcare are reduced to “an icon for another entity clothed in binary garments” – naming this representation of the real embodied person as the “iPatient”. He went on to describe how clinicians now meet the iPatient, forming assessments and an approach to their care, before they encounter the real person.

Central fetal monitoring systems reduce women to digital data points – G1P0, 37 weeks, 6 cm dilated, trace reassuring. While these may be accurate descriptions (mostly, not always) they fail to capture the entirety of that woman. The messy reality of a real woman with social, emotional, and physical needs – and opinions – remains neatly shut behind a door. Only the parts of her that are considered to be useful information for obstetric decision making get to exist at the central monitoring station.

I saw an example of this when I was sitting at the central monitoring station during a period of observation for my doctoral research. I had arrived in time for the midwifery handover. In one birth room was a woman with a high BMI. The midwife handing over was careful to remind the oncoming team that this woman did not want her BMI to become the focus of clinical decision making and to be constantly reminded that “well because of your size you should…”. A short time later, medical handover happened in the same space. Looking at the CTG trace, the registrar started with “and in room six we have a woman with a BMI of 48…” and made no mention of the way this women wanted to be known and considered while in the care of the hospital team that day.

Women repeatedly describe wanting to be heard and to be seen as part of their maternity care experience (Faktor, et al., 2024). Investigations into poor outcomes repeatedly bring up the problem of women feeling unheard and unseen. Yet this is precisely what central fetal monitoring technology does. It turns the territory into a map – and people are convinced the map is the only reality they need to see.

Everyone is responsible so no one takes responsibility

The lines of responsibility for CTG interpretation are clear when paper-based monitoring is being used. The person who is the primary care provider (midwife in most places, nurse in some) and who stays in the room (ideally the vast majority of the time), is the person responsible for looking at the trace, interpreting the trace, communicating with the woman about the trace, and when required coordinating an appropriate response from the rest of the healthcare team in response to the trace. Once the data from the CTG are visible in multiple places and to multiple places, things get muddy.

Technically everyone who can see the CTG is now responsible. The midwife in room six who is a new grad who doesn’t yet feel confident with CTG interpretation but knows the team leader will come in if there’s a problem. Meanwhile, the team leader is trying to get two more midwives for the evening shift in between finding postnatal beds for the three women who gave birth a few hours ago. The registrar has been away for the past hour and is just back from theatre and trying to catch up on what the next priority is. A consultant just wandered in looking for a free computer to check pathology results, but they aren’t the one on call for birth suite so while they see the trace it’s not their problem. A midwife from the antenatal floor just transferred a woman down and is talking to the registrar about her test results, while glancing at the big decelerations in room six wondering what the story is, says nothing.

Each of these people reasonably assumes that someone else is doing something already. Not long before I started data collection at my field site, there had been a stillbirth to a woman who was on a CTG with the trace visible at the central monitoring station. She was in the triage area, concerned about reduced movements. Everyone was busy that day, so no one spent very long sitting at the desk to look at someone else’s trace. Over a two hour period the trace became increasingly abnormal before there was no heart rate any more.

Shifting data outside of the building is even more problematic. Sure you can pay someone to watch CTGs in a data monitoring centre. But what happens when no one has the time to answer the phone when that person flags an issue? They can’t walk into the room and talk to the woman themselves.

What is the appropriate use of central fetal monitoring?

I think the only place for central fetal monitoring should be in a randomised controlled trial to determine its effectiveness and safety. There’s no logical ethical barrier to prevent such research. Sure it would be a complex intervention requiring good research design, but all that can be managed with the right funding and an experienced and capable research team. And then, we would know if central fetal monitoring is a blessing or a beast.

If you have worked through the introduction of central fetal monitoring in a maternity service – what are your observations about the impact it had? What other things have you noticed?

One way to minimise the impact of central fetal monitoring is to use intermittent auscultation more often

There’s plenty of research showing that a lack of knowledge and confidence in using intermittent auscultation is a common problem for midwives. I’m running a workshop next month that is designed to build your confidence so you can offer intermittent auscultation to more women, and do it in a way that is safe for you and safe for them and their baby.

References

If you like a challenge – you can read my full thesis here.

These are the papers I published from the thesis:

Small, K., Sidebotham, M., Gamble, J., & Fenwick, J. (2021). “My whole room went into chaos because of that thing in the corner”: Unintended consequences of a central fetal monitoring system. Midwifery, 102, 103074. https://doi.org/10.1016/j.midw.2021.103074

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women & Birth, 35(2), 193-200. https://doi.org/10.1016/j.wombi.2021.05.006

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022). Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice. Women & Birth, 35(2), e188-e197. https://doi.org/10.1016/j.wombi.2021.05.001

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2023). The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography. Women & Birth, 36(3), 281-289. https://doi.org/10.1016/j.wombi.2022.09.004

And a more recent publication I was involved in:

Gottfreeðsdottir, H., Small, K., Helgadottir, B. P., & Gamble, J. (2025). Who is in the centre? A qualitative study on midwives’ experience of working with central fetal monitoring system. Women & Birth, 38(2), 101891. https://doi.org/10.1016/j.wombi.2025.101891

Other papers cited here:

Faktor, L., Small, K., Bradfield, Z., Baird, K., Fenwick, J., Gray, J. E., Robinson, M., Warton, C., Cusack, S., & Homer, C. S. (2024). What do women in Australia want from their maternity care: A scoping review. Women & Birth, 37(2), 278-287. https://doi.org/10.1016/j.wombi.2023.12.003

Verghese, A. (2008). Culture shock–patient as icon, icon as patient. New England Journal of Medicine, 359(26), 2748-2751. https://doi.org/10.1056/NEJMp0807461