AIMS IrelandWhat you need to know about: Electronic Foetal Monitoring (CTG)
Electronic Foetal Monitoring
Electronic foetal monitoring is a commonly used practice in Irish maternity units.
Electronic foetal monitoring (EFM or CTG) measures your baby’s heartbeat in frequency and strength and measures your contractions.
Electronic Foetal Monitoring can be either:
1.) external – by a belt which is known as cardiotocography (CTG) which goes around your tummy
2.) internal – Foetal scalp monitoring, which is a monitor that is attached to your baby through the top layer of your baby’s scalp.
Electronic Foetal monitoring provides health care professionals with a print out graph of your baby’s heart rate during contractions. The graph is then used to determine how your labour is progressing and if your baby is tolerating labour well or is becoming distressed.
You may be asked to have electronic monitoring in one of two ways:
1.) Admission trace, which is essentially a ‘snapshot’ over a short duration (usually about 20 minutes)
2.) Continuous electronic foetal monitoring, which means that your baby is monitored over your entire labour
The intention of the use of continuous monitoring is that health care providers hope it will show if your baby’s oxygen levels are low or your baby is not tolerating labour well – to prevent cerebral palsy, brain damage, newborn seizures, or death or possibly prevent a uterine rupture.
The following are some of the benefits (advantages) and risks (disadvantages) of using electronic foetal monitoring in labour
Advantages of Electronic Foetal Monitoring:
* Evidence has shown that there was less instances of newborn seizures when continuous monitoring was used.
Disadvantages of Electronic Foetal Monitoring:
* EFM has been shown to be less accurate than internal foetal scalp monitoring or intermittent monitoring.
* EFM has a high rate of ‘false positives’ which has implications on your labour
* EFM can be difficult to get an accurate reading due to design; the belt can slip or be hard to access heart rate due to your baby’s position
* EFM has been shown to increase your chances of interventions, including Caesarean section and assisted delivery
* EFM restricts your options in labour – you cannot use water for pain relief or move about freely
* Many women feel EFM is uncomfortable
* Many women feel EFM makes contractions more difficult
* Many women feel EFM makes them ‘tied to the bed’
* Some women do not like being hooked up to a machine
* Women report that EFM increases anxiety “at one point the CTG lost my baby’s heart rate as the belt slipped, I was scared something was really wrong”
* Women report in some instances labour support from health care professionals is disturbed when EFM is used – time and attention is given to reading the results of EFM, rather than supporting women.
Intermittent Monitoring
Monitoring in labour is important to ensure that your baby is happy and healthy and that your labour is progressing normally. An alternative to Electronic Foetal Monitoring is Intermittent Monitoring.
Intermittent Monitoring is a way of measuring your baby’s heart rate using a hand held Doppler (an electronic device used to hear your baby’s heartrate, sometimes referred to as a Sonicaid) or by using a Pinard stethoscope (a trumpet shaped device). If using a Sonicaid, you will be able to hear your baby’s heartbeat each time your baby is monitored. Your baby’s heart rate is much faster than yours and will sound like a horse galloping or a train. If using a Pinard, only your health care professional will be able to hear your baby’s heart rate.
With intermittent monitoring, your health care professional will listen to your baby’s heart rate at designated times throughout your labour to ensure your baby is happy and healthy. Intermittent Monitoring can be used in water and does not restrict movements.
Advantages of Intermittent Monitoring:
* intermittent monitoring can be used in water and does not restrict movements
* Evidence has shown that there is no difference between intermittent monitoring and continuous monitoring for “perinatal mortality, cerebral palsy, Apgar scores, cord blood gases, admission to the neonatal intensive care unit, or low-oxygen brain damage” Cochrane Review 2006
* intermittent monitoring does not increase your risks of assisted delivery or Caesarean section
Disadvantages of Intermittent Monitoring:
* Evidence has shown that there was less instances of newborn seizures when continuous monitoring was used as compared with intermittent monitoring.
* Women report difficulties in accessing intermittent monitoring in some obstetric led maternity units due to routine policy and the individual beliefs or perceptions of risk from health care providers. This practice is not based on evidence and contradicts Irish National Guidelines for clinical practice in Maternity Care.
Recommendations
Evidence has shown, that with the exception of newborn seizures, intermittent monitoring has more benefits to electronic foetal monitoring with no additional risks in low risk women. Much evidence has also shown that the benefits of intermittent monitoring, over electronic foetal monitoring, extend to women in moderate-high risk groups. For this reason, intermittent monitoring is recommended over electronic foetal monitoring
What women say about Electronic Foetal Monitoring – excerpts from 42 weeks.ie birth stories:
“All that lying around getting the trace on the heartbeat and being scanned threw out my focus”
And:
“I forced myself to lay down for another trace in order to receive more pain relief. I couldn’t stay lying down but held the CTG myself as I stood and swayed”
And:
“I find negotiating in labour very distressing and the CTG is something that seems to always been an issue of contention. I wanted to avoid all of this by birthing at home with a midwife”
And:
“She asked me to lie back on the bed so that she could put me on a trace. I explained that the contractions were too much and I couldn’t do that. “Well if I can’t examine you, I can’t admit you,” she said. I am not ashamed to say that I hated her at the moment. I felt so helpless and vulnerable. What choice did I have but to do what she said.”
And:
“As far as I am concerned, forcing a woman to lie on her back for an admittance trace is nothing short of pure torture”
And:
“Midwife we got was nice but said no to pool as it was against VBAC protocol as I would need continuous trace. I said I would agree to this as long as it didn’t stop me moving about as no way I could be lying in bed constantly. I knew that if that happened it would be end of my VBAC. She was supportive of this and got me a gymball so I was on that with the Entenox, on the trace and managing well.”
National Irish Guidelines on Foetal Monitoring in Labour
The HSE has created a National Clinical Strategy and Programmes in many realms of health. The purpose of this is to provide standardised care to benefit people using the services and providing them. A part of this strategy is the creation of guidelines to be used for clinical practice in the Irish health service. Guidelines have been created in many areas of health, including obstetrics and gynaecology.
The National Guidelines for Obstetrics and Gynaecology are national guidelines for obstetric practice in Ireland. These guidelines are meant to provide guidance to the local policy of units in Ireland.
Recommendations in The National Guideline provides a starting point for women to open communication with care providers on various practice and to aide informed decision making. Recommendations are not compulsory. Your care provider can advise you, but it’s your decision on the day.
In June 2012, the HSE launched a guideline called “Intrapartum Fetal Heart Rate Monitoring (issued June 2012)”. This guideline looks at the topic of foetal heart monitoring and recommends for low risk women:
* admission trace is not recommended
* electronic foetal heart monitoring is not recommended
* intermittent monitoring in labour is recommended
The Guideline is available to read in full at this link.
All National Clinical Guidelines for Obstetrics and Gynaecology are available to read here:
The majority of maternity units in Ireland are yet to implement these recommendations into their policy and many women report admission trace and electronic foetal monitoring is routine everyday practice for all women in obstetric led units. Midwife-Led and homebirth care options do not use electronic foetal monitoring; they use intermittent monitoring.
Regardless of routine policy in obstetric led units, women do negotiate intermittent monitoring following discussions with health care providers.
“I was considered ‘high risk’ but intermittent monitoring was very important to me and I discussed it at every appointment. I attended the consultant led unit as a public patient in OLOL. In labour I got mixed reactions to my request to avoid the CTG. First midwife wasn’t happy but another midwife was fantastic and supported my choice. I laboured upright on the ball or standing/swaying and she would occasionally monitor the baby intermittently. Made all the difference for me.”
In order for you to make an informed choice on foetal monitoring, your care team should provide you with information which will help you make the best choice for you and your baby. This should include:
* the benefits – the advantages of intermittent monitoring vs electronic foetal monitoring
* the risks – the disadvantages of intermittent monitoring vs electronic foetal monitoring
* implications – associated risks of intermittent monitoring and electronic foetal monitoring
* possible future consequences of intermittent monitoring vs electronic foetal monitoring
Labour is not necessarily the best time to hear this information for the first time, so it is recommended you discuss your options on monitoring, and other care options, with your care team at your antenatal appointments. A birth plan can be an excellent way to initiate this discussion.
For tips on informed decision making please read 42 weeks article “No Thank You” – A Guide to Informed Decision Making.
To read more on the evidence for intermittent vs continuous monitoring for low and high risk women please see here: Evidence Based Birth
Helpful and Related Reading:
10 Tips for Preparing for a Positive and Healthy Birth