A team of researchers in Denmark recently published research about how often, and why, CTG monitoring was used rather than intermittent auscultation among women considered low risk (Muusmann et al., 2026). I’m going to take you through what they found, before considering how they have missed the point entirely. Note that this isn’t a criticism of the quality of their research – and they are not the only team of researchers I have seen missing this point.
What did they do?
The research team reviewed birth records from 2023 at one hospital, to identify a group of women considered low-risk. They excluded women giving birth before 37 or at / after 42 weeks of gestation, whose labour was induced or who gave birth by planned caesarean section, those with an existing uterine scar, or a breech presentation. They then applied the Danish Society of Obstetrics and Gynaecology criteria for low risk pregnancy, also excluding women with a BMI of 30 mg/m2, chronic medical conditions, mental health disorders, gestational diabetes, cholestasis, hypertensive disorders, low of high levels of amniotic fluid, or stillbirth. They identified 411 women who met these criteria.
They pulled information from their records about the type of fetal heart rate monitoring first used and the reason provided for its use. This was compared with the Danish guideline and with the NICE guideline, and classed as “compliant” with each guideline or not.
What did they find?
50% of this low-risk group of women used intermittent auscultation. The remaining women mostly used continuous CTG monitoring (44%), a handful used intermittent CTG monitoring, and the remainder (5%) had what the authors defined as “epiCTG” – 30 minutes of CTG monitoring after the initiation of epidural analgesia, repeated again each time a bolus was given, with intermittent auscultation for the remainder of the time. Fetal scalp electrode use was very common (64% of women using continuous CTG monitoring).
An admission CTG was recorded for 18% of women, with 55% of women remaining on the CTG and 45% using intermittent auscultation after this.
Consistent with the risk category, the majority of births (93%) were achieved without surgical intervention, with a caesarean section rate of 1% and instrumental births at 6%. Fetal blood sampling was performed in 11% of labours. The only outcome reported for babies were Apgar scores, with only one baby have a score of under seven at five minutes. The authors did not provide a breakdown of mode of birth or Apgar scores by mode of monitoring.
Among the women for whom CTG monitoring had been initiated at the start of professional labour care, the most common recorded indications were fetal heart rate abnormalities (35%), epidural analgesia (32%), and meconium stained amniotic fluid (17%).
When audited against the NICE guideline, 9% of women were monitored in a way that was not in compliance with the guideline, with two thirds of these relating to not using CTG monitoring when an indication was present. Assessing against the Danish guideline the rate of non-compliance was 14% with almost all (95%) of these relating to the use of CTG monitoring when not indicated in the guideline. The biggest difference was accounted for by differing guidance relating to the use of continuous CTG monitoring following epidural insertion, recommended by NICE and not recommended in the Danish guideline.
Did the researchers miss the point?
There is a problem with the logic line in this paper. The authors have failed to understand that women, not midwives, and not guidelines, determine which fetal heart rate monitoring approach is used. The authors of this study have assumed that when a guideline recommends a particular approach to fetal heart rate monitoring then this must happen.
I don’t have access to the Danish guideline, but I do have a copy of the NICE guideline (2025). What the NICE guideline says is that women considered to be at low risk should be offered intermittent auscultation (1.2.9) and when risk factors are present, to offer CTG monitoring (1.2.14). It also says to support the woman’s decision about fetal monitoring (1.1.3). It doesn’t say that women at low risk MUST have intermittent auscultation. I suspect the Danish guideline says something similar. (Can anyone who has access to it please confirm?)
To accurately measure guideline compliance would have required the research team to ask women which fetal monitoring approach they were offered. If a woman at low risk is offered intermittent auscultation and chooses CTG monitoring – this is compliant with the NICE guideline. It’s also an ethical approach to care.
Why this is a bigger problem than it might first look
The authors didn’t consider fetal monitoring to be a decision made by women rather than by midwives. The peer reviewers and editors of the journal didn’t appear to see fetal monitoring as a decision made by women either – as they approved publication of the paper without requesting a reframing of the terminology used. I also suspect that most readers of this paper won’t see the problem here because they too believe that guidelines and midwives decide fetal monitoring methods, not the women who use them.
Which means we have a huge human rights issue on our hands that no one is paying enough attention to.
Consider also how it seems logical to ask whether CTG monitoring is “overused” in women considered to be a low risk, but asking the same question for a population of women with risk factors seems unthinkable. The authors of this paper made the argument in their introduction that CTG use has not been found to improve cerebral palsy rates or neonatal mortality but is associated with higher rates of caesarean section and instrumental birth.
This is an accurate reflection of the evidence. For women with risk factors. The difference in cerebral palsy rates between women allocated to CTG use and those allocated to intermittent auscultation has never been studied in a low risk population. I am yet to see anyone frame CTG use in a high risk population as “overuse” or study this as a problem, though we have plenty of evidence for high rates of CTG use without consent.
Let’s all push for a big shift in mindset. Women decide on the fetal monitoring method that will be used in their labour. Not guidelines. Not maternity professionals. It is the only ethical possibility.
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References
Muusmann, F. B., Gommesen, D., Nathan, N. O., Nordentoft, A. C., Hegaard, H. K., & Backhausen, M. (2026). Use of intrapartum cardiotocography in low-risk pregnancies: A cross-sectional study. Sexual & Reproductive Healthcare, 48, 101236. https://doi.org/10.1016/j.srhc.2026.101236
Categories: CTG, EFM, IA, New research
Tags: decision making, Denmark, guidelines, Human rights, low risk, NICE
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