Continuous Foetal HR Monitoring, with Dr Kirsten Small

Continuous Foetal Monitoring can be uncomfortable, anxiety-inducing or misleading, but there’s plenty of evidence for its use, right? That’s the question Dr. Kirsten Small set out to answer after her long career in obstetrics. Her research led her to question everything about trace monitoring, from the case for low and high risk differentials to how centralised monitoring changes care in the birth room.

In this episode, I’m speaking to Kirsten about her findings, and how you can make an informed choice about whether to use CTG monitoring during your birth.

Kirsten Small is a retired specialist obstetrician and gynaecologist, working as an educator, writer, and researcher.

Her vision is to promote and protect respectful maternity care for women, babies, families, and their care providers through education and research. 
She is a feminist and is critical of the patriarchal values embedded within healthcare systems, and particularly within obstetrics and gynaecology. 

Kirsten is mother to two lovely grown up people. When she’s not writing or teaching, she’s probably reading, sewing, gardening, or cooking. 

Find more from Kirsten on her blog - www.birthsmalltalk.com or follow her on Instagram, Facebook or X @birthsmalltalk

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Transcript

Megan Rossiter  00:00

Ad - This episode is brought to you in partnership with iCandy. I've been using our iCandy peach pushchair almost daily for the last seven years and counting. And I've really put their five year warranty to the test using it for both my boys on muddy walks in aeroplane holes in and out of my car boot and aside from being completely filthy, my fault not theirs. It's still going strong. I can't wait to tell you more about my experience with eye candy later in the show. 

Megan Rossiter  00:24

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Megan Rossiter  00:49

You're listening to the Birth-ed podcast. I'm your host and founder of Birth-ed, Megan Rossiter. If you're looking for the evidence, the nuance the detail that's missing from your antenatal appointment, then I've got your back. The Birth-ed podcast is here to help you sort the facts from the advertising the instinct from the influences and the information you're looking for from the white noise of the internet. I hope you've got a cup of tea in hand and a notepad at the ready. Let's dive in. 

Megan Rossiter  01:15

Hi, everybody. Welcome back to the Birth-ed podcast. I am really excited today to be having a conversation about something that is in the UK certainly impacting more and more women as they are preparing for their birth, whether this is something that they've kind of offered and understand about before they go into labour, or whether it's something that's kind of sprung upon them at some stage in labour that they suddenly have to find themselves making a decision about and the conversation that we're having today is about continuous electronic foetal heart rate monitoring with Dr. Kirsten Small. So Kirsten is a retired specialist obstetrician and gynaecologist now working as an educator, writer and researcher. Her vision is to promote and protect respectful maternity care for women, babies, families and their care providers through education and research. Kirsten's main approach to achieving respectful maternity care includes promotion of physiological birth, ensuring access to timely, appropriate and proven interventions when pathology arises, supporting women's decisional capacity and the expansion of midwifery continuity of care and models of care. Kirsten describes herself as a feminist and therefore critical of the patriarchal values embedded within healthcare systems, particularly obstetrics and gynaecology. So we are going to get on it like a house on fire. Kirsten is also a mum to two lovely grown up people of her own caston welcome, thank you so much for joining me.

Dr Kirsten Small  02:48

Thank you for having me. You know, I'm really looking forward to it. 

Megan Rossiter  02:51

So this is your what would almost lifelong area of expertise what was it that led you to being so interested in kind of unpicking the research and the evidence behind continuous electronic foetal heart rate monitoring in labour? How did you get here?

Dr Kirsten Small  03:10

When I first qualified as a specialist way back in 2000, I moved into private practice here in Australia and went to a private hospital was previously I'd only worked in the public system. So the government funded hospital system and the approach to CTG foetal monitoring in labour was different. And people were that I'd worked in the public sector were quite convinced that this was the correct and right way. And in the private sector, people were quite convinced that this was the correct and right way. And I was curious about the fact that that is the seem to be this interesting reinterpretation of the evidence base to kind of suit the culture of the organisation and a kind of parts that didn't think too much about it and got on with raising children and building a career and being busy and tried to catch some sleep. And eventually thought, you know, it'd be really interesting to write a book about this to help women make decisions, but always busy having a career and raising children and trying to get some sleep. So it just never happened. And then eventually, life changed and the kids grew up and I became increasingly attracted into academic spaces. A couple of days before that happened. I had a consultation with a couple who she was pregnant with twins and I had given what I thought was really standard advice, according to our College of Obstetricians and Gynaecologists guidelines here in Australia, and that was that CTG monitoring and labour would be her best option. And her partner challenged me to find some evidence to prove that that was the case. And I thought, this will be easy or as we say an Australian Hold my beer and said, I don't have anything on hand, give me a couple of days, and I'll email you something. And I thought, you know, this will be a quick trip through the University Library, download a couple of papers, and we'll be done. Well, I couldn't find anything. And in fact, there was nothing. And now that I've spent decades looking at the literature, there is nothing there is no research that actually says that outcomes are better in the case of a woman with a twin pregnancy, if she uses CTG monitoring during labour rather than the alternative of intermittent auscultation. So I had to kind of go back and go, Well, good. I think this is just one of those things that everyone thinks is a good idea, but we can't actually prove it. And I was, I was really shocked that I didn't know that. I'd been practising for about 20 years at that point. And you think that he's this technology that I use on a daily basis. I didn't actually know what the research evidence said. And so, I mean, I've had multiple various interests during my life, but CTG has really gone underneath my skin. And so when it came time to do a PhD, it was the one idea that kept floating back up to the top, and I just, I just couldn't get rid of it. And despite, despite my lovely supervisors, suggesting, you know, at least half a dozen alternative options, coast and off the bloody CTG is again, it was the one that stuck. And so yeah, ultimately my doctoral research was, was actually central foetal monitoring a particular kind of approach to foetal monitoring. But that required me to actually go and get across all of the evidence in great detail that ever been written, and turned into a couple of research papers. And then once once the thesis was written, because I read all this stuff, it didn't actually quite make it into the thesis. And there were still things I wanted to get quite chatty and tell the world about. So what do you do? Well, you start a blog. So that happened. And I'm pleased to say that there is actually a book, it is currently still hiding in the hard drive of my computer. But I do have a publisher looking at it at the moment. And depending on the outcome of that conversation, either, they'll take it forward, or the next thing I'll be teaching myself is how to self publish a Book. So it will finally eventually actually emerge in the world. But in the meantime, I have some online courses for folks to do to update their knowledge as well.

Megan Rossiter  07:35

Yeah, I mean, I think we're gonna need to take it all the way back in a minute. But I just think it's really interesting to hear that perspective, particularly when you're saying, you know, you're practising for 20 years, and you'd never even kind of questioned what it was that you were actually practising. So it is incredible that finally somebody is kind of shouting about this stuff. And hopefully we can get this message across not just to kind of healthcare providers, but it's women, that families that are accessing services as well, so that when they are making decisions about how their baby is monitored and labour, they are able to do that from a kind of truly informed place. So let's take it right right right back to basics. Some people might have listened to everything you just said man like, What on earth are you talking about? So what is it that we are told these words talking about CTG, intimacy, and auscultation? What started as a very, very, I know nothing. Imagine that that stage.

Dr Kirsten Small  08:33

One of the key questions that a maternity professional is going to be asking themselves when they're looking after you during labour is is this baby features? Okay? Can it stay where it is? And we wait for labour to unfold? Or do we need to make some changes to improve the situation or possibly get it out but they really quick and be dashing off to do zerion sections or instrumental birthlight forceps or vacuum extraction? And the main way that we get that question answered, is to pay attention to patterns of the foetal heart rate and how they change in relation to contractions. And originally, the first technology that was designed to achieve that was to use something like a stethoscope and to listen to the foetal heart rate. And you'd listen for long enough to be sure about what it was that you were hearing and happy or not happy about what was going on. And then you stop and you do some other stuff and then some time later you go back and listen again. So that's called intermittent auscultation. auscultation just comes from I think it's French or Latin or something, all of those things, and it means listening. And there are various different ways that we do that in current practice and the most common one is going to be a handheld Doppler device, which uses you know, it's got batteries in it, they're often have a water Have handset on so you can use it in the shower or the bath, a little dab of gel on the end, pop it on over where you expect to find the heart where it's close, and listen to the sound. And it comes out through a speaker. So everyone here and it often has a little inbuilt computer, that'll actually calculate the heart rate and display it on a screen so that you don't have to be looking at your watch and listening to the sound and trying to do maps inside your head at three o'clock in the morning, when it's your third night Judy shifted. To make life a little bit easier. That obviously didn't have the high tech versions of that we had the low tech versions of it which which came into practice that 1830s So almost 200 years have been around for a long time. But then by the early 1960s, as computerization and technology developed further, people started to think okay, we could we can do better than this. And they came up with what we now know as the CTG or cardio Toko graph. So cardio refers to the heart Toko refers to contractions and graph refers to the fact that you're generating a graph of that information. So the heart rate and the strength of the contractions are plotted over time, one on top of each other so that you can watch how the heart rate changes, as the contractions come and go. It's used continuously usually. So when a woman first presents interprofessional care at a hospital or a birth centre, or wherever she is, and that equipments being used, then the monitoring equipment goes on, and it stays on until the baby's born. And so depending on where you are in the world, it might be control called continuous electronic foetal monitoring CFM, which is a bit of a rant about it in one of my courses. Yes, because the machine actually isn't monitoring anything, it's just generating a graph, the monitoring happens because a health professional comes and looks at the thing determines, you know, is there enough information to even begin to make sense of this, and then make sense of it and decides that what what this is telling me is that, you know, things are okay, things are not okay. And then so they need to understand how to interpret it, they also need to have the authority to do something about it. So you know, you could, you could have, you know, a woman's husband, who's an information technology engineer, who did his master's thesis about, you know, how to design a computer to interpret CTG, but he's not allowed to say, quick bullets theatre team went, you know, it requires a particular person with a particular skill set and that authority, and then you can call it monitoring, the machine doesn't actually do that. And the process of monitoring is never continuous. People look at the trace, make that determination, then they do something else. So it's actually continuous recording, but it's not really continuous monitoring. And of course, now that we've got modern Doppler technology for intimate and auscultation Well, that's electronic, and it's the foetus and the purpose of it is also to monitor so it's also electronic foetal monitoring. So, so you'll, you'll hear me, bullet CTG, and when I write I call it CTG. Because the CTD is only one thing. It's the CDG. It's nothing else and it's you're not going to get confused using electronic foetal monitoring has also created this kind of bizarre situation, which you see appearing in the research literature by about 1970s, where people are talking about comparing, monitored and unmonitored Labor's Because suddenly, intermittent auscultation, which is the form of monitoring that had existed for about 150 years, was seen as an monitoring, even though it's actually a form of foetal monitoring, it creates this impression that it's not enough, or it's nothing. And I think, you know, that language is a bit worrying when, particularly when we're going to cover the research in a minute, we're particularly when you know what the research says when you compare the two in terms of how well they work against each other.

Megan Rossiter  14:10

When that was introduced, and what research was it based on to introduce the CTG monitoring in the hospital?

Dr Kirsten Small  14:20

Not, not much in the first five years or so people would tend to publish, you know, we're at this hospital, and we have X number of births each year, and two years ago, where we didn't have CTG machines, you know, the death rate for babies was such and such. And then we introduced it, and now we've had it for two years, and now the death rate is this and it's less and so we're who they must work. And there's a really good example of this in a paper from I think it was 1973 where they did precisely that, but then they actually happened to mention that at the same time I found that they introduced the new whiz bang CDJs into this hospital. The other thing that happened was, they also introduced a neonatal intensive care unit. Now, just think that might have had a difference on whether babies survived or not. You know, unless you do really well designed research that removes other things that might possibly explain what you're seeing from the picture, then you can get tricked into thinking that something's working better than it might actually be the case. So it wasn't until 1976 that somebody did what we call a randomised control trial, which is considered the best way to answer these kind of questions. They actually had quite a lot of trouble getting it started, because people were already so convinced that CCGs were the bee's knees, that it was considered unethical to not have all women monitored by CTG at the time. So they did a really interesting thing that the only trial that ever use this particular approach. And it once women had agreed that they were part of the research, everyone got CTG monitoring, and they used internal monitoring. So they used an electrode attached to the baby's head to monitor the heart rate, the electrical signal, baby. And they also put a pressure catheter inside the uterus to measure the strength of the contractions. And then they randomly chose which people were going to get intermittent auscultation or not. And the ones who got intermittent auscultation, had the city's EEG machine locked in a box and pushed out into the corridor. So it was in use, and a tracing was being recorded. So you could look back at it afterwards. But you weren't allowed to look at it until the baby was born. And those women then also had a study nurse that was called was in America, who came and do intermittent auscultation. And they much to their surprise, and you can kind of judge the tone of it when you read through the original paper in the discussion section, much to the surprise, didn't actually prove anything when you were allowed to look at the CTG, it was just as good when you did the intermittent auscultation and didn't look at the CTG. And there was a slightly higher rate of abnormal heart rate patterns in labour when people were looking at the CTG machine. And the only way that came up was because of this particular approach to doing the race where everyone had a CTG, but you only get towards got to look at them afterwards, so that you can actually compare the two. And the authors wondered whether it was the reassuring presence of the study nurse on a regular basis going in and physically laying hands on the woman that somehow calmed her down and made her less anxious. And that improved blood flow to the foetus and therefore reduced the incidence of heart rate, abnormal heart rate patterns. And we don't have the end of that story because it was 1976. And nobody's ever thought to do anything that looks like that ever again to try and answer that question. And that's kind of been my experience when I've read through the literature that you see these aha kind of moments going on. That's an interesting thing. But then no one really follows up on it, because they're already so convinced that they know the answer. And the answer that they've convinced themselves is that CTG is a fabulous Sunday work and we should do it for everyone, which is not the case.

Megan Rossiter  18:30

Yeah, and in the UK, it it isn't for everyone in the same way that it is in some countries like the US where it's quite standard. In the UK, suppose we take like a risk approach to whether or not to offer somebody CTG monitoring in labour. So if you're listening to this, and you're in the UK, the kind of situations where this might come up would be if you had an epidural or basically if you had any reason to be on a labour ward other than choice. So sort of, if you were having a VBAC, if you were over four weeks of pregnancy twins, like the list is quite endless and seems to be getting longer and longer. Or if a concern arose in labour through intermittent auscultation. And you have been hadn't had continuous monitoring up until that point, say the list of reasons why it can feel quite endless.

Dr Kirsten Small  19:28

It is the Australian guideline is of all of the international guidelines. Ours has the longest written list of reasons why people should end up on a CTG and it's actually really hard to get good quality data about how often CTG is in use in Australia. So one of the one of the things I did when I was collecting data for the PhD was every time I went into Burp suite were doing observations. They had to lots of information in that room. They had what was called the journey board which was the list of everybody who was in labour And then there was the central foetal monitoring bank with the the actual CTG traces. Or there would be what we call the party gramme. So you know, record of the cervical dilatation, over time when CTG monitoring wasn't new. So I made note of how many women there were, how many CDJs, there were, so that then over the course of the nine month period, I was collecting data, I could work out how many people had CTG monitoring was 90%. So the vast majority of people in Australia and I believe this is the same pretty much everywhere actually get popped into this high risk category. So you're actually not that special if someone calls your high risk, because it's most people, yeah, a bit of a unicorn to manage to, you know, have all of the stars aligned correctly for you to not end up in a high risk category, which is kind of a bit nuts because the things that we're trying to prevent through foetal heart rate monitoring, whichever type we're using, is still based during labour. So the baby's alive when labour starts, but isn't by the time it's born, deaf in the first week of life due to low oxygen levels, or brain damage due to low oxygen levels, measured either in the short term through things like seizures, or in the long term, because it causes cerebral palsy and other causes of neurodevelopmental delay. And when you add all of those things up in a modern data sets are like the birthplace data that both both Australia and the UK had a birthplace study. And if you look across all places of birth, across both low risk and high risk, and admittedly, they still excluded multiple pregnancies, and a few other things, that would have increased the number slightly, the chance of you having one of those outcomes is 0.41%. So 90% of women are at risk for an outcome that actually happens less than one half of a percent of the time. So, you know, there's a bit of weirdness goes on around that whole risk assessment thing. There's been 12 randomised control trials that have been added together that form the evidence base about intermittent auscultation versus CCGs. And they started being done that first one in 1976, and the most recent one was 2006. So it's now coming up to 20 years since we've had any new research. And the world's changed, obviously. And so you've got to wonder whether any of it actually applies anymore. Some of the trials were done in exclusively low risk populations, some were done and exclusively high risk populations, several were done in what they call mixed risk. So a mixture of both low and high risk, and sometimes they report the data separately for those two, so that they ended up, you know, analysed in one or the other, or they don't, and you've got them all smushed up. If you look at all of the trials all squished in at once, regardless of the risk category, whether you use CT G's or intermittent auscultation, the death rates, and death rates during labour and the death rate in the first week of life, there's no difference at all. There's a slight increase in neonatal seizures, seizures of fits in the first couple of days after birth, when intermittent auscultation is used rather than CTG monitoring. There is no difference in the long term brain injury stuff though cerebral palsy, neurodevelopmental delays the same regardless of which method you use. There are higher rates of zerion section and instrumental birth when you have CTG monitoring, rather than intermittent auscultation. So that's when you lump all of them in together. And there's kind of a myth that floats around maternity services that that's the evidence for low risk women and that there's somehow there's this magical pile of research somewhere else, that people kind of wave their hands and go, Oh, but there's all this other research that women that are having credit risk that shows that it actually works. So if you actually go to the Cochrane Review, and you split it down by risk, and there, they actually do this in the Cochrane Library, which in your country, and mine is free to access so people can just go in Google, the name of the first author is l fear avec ALFIEV. I see it was 2017. If you put in CTG labour, you'll, you'll find that you could read the entire 100 page thing yourself, knock yourself out. It has been in the fine print a bit but it is there. So if you split it down by risk category, if you're low risk, there still is that benefit in terms of fewer neonatal seizures, but you need to, you need to do an awful lot of CDJs to prevent one seizure. And the trade off for that is that a whole bunch of extra women again, and they end up with zero infections or instrumental birth forceps or vacuums that they would not have otherwise had if they'd used intermittent auscultation. And again, no no difference in terms of death rates or and that no once looked at the cerebral palsy data at all in the low risk population, so we just we just don't know the answer to that question. If you look at the high risk population, surprise, surprise, there is no difference in death rates at all. The statistical difference in the United stages disappears. So there's no difference in the seizure rate at all. And if you look at the high risk stuff around cerebral palsy, there's only been one trial that looked in a in an exclusively high risk population, and that population were all women who were in preterm labour. So this doesn't apply to, you know, the couple with the twins or the woman who's got diabetes, or whatever this was women who were in labour between 26 and 32 weeks of pregnancy. And in that group, if you were monitored my CTG the chance of your baby ending up with cerebral palsy was 2.5 times higher than if you're monitored by intermittent auscultation. And it was statistically significant. That's another one of those things that you kind of go. But that's interesting. And that was 1983, in your six, if I remember correctly, and again, no one's kind of gone, we should really look into that. And so we're still going around recommending CTG is for women in preterm labour, without really being honest about the fact that we don't know whether it might make the weight things worse. Which, which worries me a little bit. Yeah, so this, this practice of splitting people up into these two lumps and this letter called Low risk, and this letter called high risk, and if you're low risk, what happens is, you might not get much of a choice, you're going to be told, Well, we just need to listen in with the Doppler every 15 minutes or, you know, whatever the local guidelines says that's, that's all you need. And someone isn't necessarily going to sit down and have a talk to you about CTG use. But if you went in and said, I'd really rather have a CTG, you're probably not going to get any pushback, and people will just do it. On the other hand, if you have a risk factor, having the bag, you're overdue, you know, you've got meconium stained fluid, you've had the epidural, then you're gonna be told that you quote unquote, need a CTG. And if you said, I'm not having one, you're gonna get some resistance against that idea. And yet that that practice of splitting people up into the two groups, first of all has a whole pile of stuff that's wrong with that, we won't go into that. But that offering people a completely different approach to monitoring, which, you know, if there was really good evidence behind it, you could justify it, well, there just isn't really good evidence behind it to be able to justify this really radically different approach to the two groups. So, you know, I really think and this is why the blog exists to mind doing courses and why I've written the book, I really think that we should, we should treat women like the intelligent, sensible decision making human beings that they actually are, and tell them the pros and cons of each of the options. And let them make up their own mind about it. Instead of telling them that they need to have a CTG because of insert risk factor here, in the middle of actually telling them it won't actually make any difference that I have to do it because that's what the rules are at my hospital.

Megan Rossiter  28:27

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Megan Rossiter  29:41

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Megan Rossiter  30:55

In your opinion, what lace if any, does CTG monitoring have in modern maternity care?

Dr Kirsten Small  31:04

I think Well, I think women are women are entitled to choose to use it if they want. And, you know, many women will find the constant audio track of the heart rate or in the background, they find it reassuring, and then it can reduce their anxiety. And you know, that's fabulous. Some women find that being poked at every 15 minutes and possibly, you know, if you're in a birth pool, having to rearrange yourself so that somebody can get to you to poke at you might find that actually quite disturbing and might prefer, you know, if you can get a good quality trace with straps or with a scalpel electrode or whatever in place, to just to be left around line and have continuous monitoring. And, and that's one so, you know, women women who choose to use the CTG should be entitled to use a CTG I'm not, I'm not trying to ban CTG use, despite what people might say about me. That one, what will we have some maybe evidence and again, it's one of those following up on this, because it's quite interesting came from the really big research trials, which was done in bubble and it's quite, it's quite famous in obstetrics circles, it's known bad Dublin trial. And Dublin had this thing going on at the time called the active management of labour, which is very different to active labour, which involved using lots and lots of oxytocin drips to speed labour up, basically, because they wanted to guarantee that women would be in and out of their birth rooms fast enough that they could get another lot in before the sun went down. And so they have, they've got a table in the paper, where they break the data down according to who had an oxytocin infusion, and who didn't, what kind of monitoring they had, whether it was seated any monitoring and intermittent auscultation. And they split the data up for neonatal seizures. And the Dublin trial was really it was the one that found the biggest benefit from CTG use with neonatal seizures of all of the trials. So you know, it's a good place to go to try and understand what's happening around seizures. If you look at the data where oxytocin Towson was in use, you don't even need to be able to do much in the way of statistics that numb the number of seizures in the group who had oxytocin and who had intermittent auscultation. It's really high. just eyeballing the numbers, it's enough to tell you that this is, you know, not great. When it's oxytocin use and and city monitoring is in use, then the rate is much, much lower, it does actually reach statistically significance. But also you don't really need the stats to tell you it's just completely blindingly obvious looking at it. If you look at the next line, where women were not on oxytocin, though, the rate of seizures is actually identical between CTG use and intermittent auscultation. And it's much much lower than even the group were safe. EEG monitoring was used with oxytocin so that you know, keep take home number one, oxytocin dangerous stuff, don't use it unless it's a really jolly good reason to not just because you want to get people three birth weight faster. And secondly, while this was not a study that was designed specifically to answer that question, it does imply that possibly if oxytocin is in use, then CGG monitoring might actually be effective at reducing seizures for you. But if oxytocin isn't in use, it's probably not going to make a difference. Amazing. Yeah. So whether it's just speed up labour or because labour is being induced, you know, if I was still wearing my I'm practising a lot as an obstetrician and somebody's now made me supreme, your ruler of the universe, and I can rewrite the guidelines. That's the one that I'd still keep. 

Megan Rossiter  34:57

Okay, that's really I think that's really helpful for people. to kind of hear, because when we hear, when you get this high risk label, you're just kind of jumbled in with everybody, even though that the potential risk factors might be absolutely nothing to do with each other. And when we just get this kind of blanket, well, you're high risk now so, and when research doesn't break things down into, actually, the health condition.

Dr Kirsten Small  35:22

And again, that's the problem with the trials that we've got most of them like, like the Dublin trial smooshed everybody up together. So there were women with pre-eclampsia, or women in preterm labour or women who are overdue women who had oxytocin running, women have had it be journals, women who had meconium stained like or women who had bleeding, you name it. And so it might, you know, maybe, maybe CPG monitoring is like fabulous for women with diabetes. But it's really dangerous for women with preeclampsia. And when you put them both into the same research trial, maybe it cancels itself out, we just, we just don't know, because no one's ever done that stuff. There's only three trials that have looked around a single risk factor. One was the preterm birth trial, and I just mentioned, the 2000. And sixth trial, and most recent one was women who'd had one previous Caesarean section, it was a tiny trial over 50 Women in both arms of the study, and like, you know, given that the risk of uterine rupture is probably no more than one in 1000. If you've got a child, it's only got 50, women having CPGs and 50, women having intermittent auscultation, it's just too small to be useful. And not surprisingly, they found it made no difference. And there was a slight tendency towards highest as their infection rate when CCGs were used. But again, the trial was too small to actually reach statistical significance for that. The remaining of one of what I called the single risk trial, so you know, just one risk factor was done in Pakistan, and it was women who had meconium stained, like or during labour, again, quite small, and no statistically significant differences between the groups in terms of outcomes for the babies. So one of the questions that I get asked all the time, is I'm having a VBAC. What is the evidence say, and there is there really, apart from that one, pretty ordinary trial, it doesn't actually help all that much. There's actually no evidence that anyone can pull out to go, you will do so much better. While you're attempting your vaginal birth after Caesarean section, if you have ECG monitoring, and not having it would represent a material risk to you or your baby, there's just there is no evidence at all to be able to back that statement up.

Megan Rossiter  37:40

I mean, this is going to be mind blowing for people that has been told they have to continue throwing in labour,

Dr Kirsten Small  37:47

we really need a revolution around language when it comes to all things related to foetal monitoring, you know, like, care in general, you know, on maternity care, you know, like, is she being monitored? Well No

Megan Rossiter  38:02

No there's no one in there, we're all standing outside having a cup of tea! 

Dr Kirsten Small  38:05

Exactly. I mean, she's got a midwife who is physically present the entire time. He's doing intermittent auscultation. He's also, you know, monitoring her blood pressure and the rest of her vital signs, and noticing the changes in the sounds that she's making. And whether she looks hot and flustered or whether there's bleeding on her pet, you know, there's constant monitoring going on. But because the CTG is not on No, no, she's not being monitored. And I hear nonsense with people, you know, let's just pop this CTG on, it'll tell us if your baby's happy. It's not like the Edinburgh depression score, you know, it's not designed

Megan Rossiter  38:38

Please choose a smiley face to see how you're feeling! 

Dr Kirsten Small  38:42

It's designed to tell us whether the heart rate is giving us some clues that the oxygen levels might be low. And could we like, actually, please tell people that and then to tell people that or use language that implies that people don't have a choice, just it really gets my goat, you know, the whole you need to you require? Because you're having you will have it's not just the midwives, obstetricians or obstetric nurses, if you're in the UK that are working directly with women, it's in the guidelines as well. And this was when I did the PhD. I was looking at how is it happening, that women are being excluded from this decision making process, when, you know, everyone knows what informed decision making means, and they go around sprouting the fact that it's important that we should be doing it in the professional colleges, you know, the hospital had had a policy about it. And yet when it comes to foetal heart rate monitoring, no one was actually being given a choice and they weren't being given information about the evidence they were being told what it was and what would happen if it was abnormal, but not whether it worked. So I went and looked at local hospitals, state and national guidelines and the language comes from there. So you know the hospital guy And Lyons said that it was the care providers responsibility to decide that when there are risk factors that the woman would have a CCG. If you're operating under a mandatory hospital policy, which if you don't follow you risk losing your job. And it says, this woman will have a CTG, you're not going to say, right, so we've got these two options. Which one would you like? It's just professional and safer for you to direct people down a particular path. And as a clinician, this impacted on me as well, you know, even going back into clinical practice, having finished the PhD, knowing everything that I knew, my options as an obstetrician were limited. And if people think that obstetricians that kind of, you know, they can we can do whatever we want, but it's actually not true, we're held to the same policies as everybody else. And so you have these bizarre moments, I'd be on the phone to a big bluff going, so he put the CTG on? Well, Kirsten, the researcher is sitting in my other shoulder going, Really, what are we really going to be having this conversation, right? But what we really need is we need structural change we need we need change at the level of national guidance, we need change in the way that researchers think about this, because it's it's even, it pops up in research papers all the time. I see, you know, intelligent researchers who should know better saying making statements that intimate not quotation is appropriate for women with no risk factors. Yeah, and you know, what, it's also appropriate for women who've got risk factors who make an informed choice to use it, we don't get to say that bit out loud. Yeah. And, and so it creates this impression that there really is no option. And it's got to stop. But it's, you know, I want I want people to get the understanding that blaming your midwife is not appropriate, because it's not their fault. You know, they're operating under a system of policies and guidelines, and quality improvement, and you know, lots, lots of eyes on their work to make sure that they're dotting the I's and crossing the t's. And doing as they're told, they don't really have a lot of power to be able to do anything different.

Megan Rossiter  42:21

And it is also that this sort of culture, isn't it that you, you said that even 20 years of practice, you just didn't know. And, you know, we can't, we cannot expect every midwife and every doctor to have read every research paper about absolutely everything there is to it, maternity care. So if that has been the way that you've trained, and then the way that you've practised, you can see how you get to a point of being like, well, of course, it's safe, and you gotta be doing

Dr Kirsten Small  42:46

CTG education is typically mandatory, when other bits of the work that we do isn't like, no one's ever made me go to a mandatory course on how to perform us as a safe Caesarean section. But every year, I had to go to a CCG training course. And they just don't teach the evidence base. It's all about the big long list of these are the reasons why you should use it. And then it's about how to read the wiggly lines and make sense of them that the question of whether we should be generated in the wiggly line in the first place just isn't covered, which is why it was such a surprise for me after 20 years of practice to realise that there wasn't any actual evidence behind so many of the recommendations at all. The first paper that I published out of the PhD was an answer to the kind of conversations I was having with other obstetricians and blissing in the literature as well, which was, you know, well, that's what the randomised control trials say. But there's this big body of evidence that isn't randomised controlled trials, it's research that's been done in other ways, and it's really convincing, and it really proves that session cheese work at dawn read all I did, there was a bit quite a lot. In fact, most of it was pretty awful. And so we we scratched through, you know, with the first paper being 1973. And through till 2019, which is when I published it, the most recent paper was actually in 2018. Of all of the research that was not a randomised control trial that was done in a population that included women with risk factors. And we then quality assessed it started. And so there's this thing that's called the Robin's AI tool that researchers used to know whether the kind of research approach that was used can reasonably be expected to tell you something useful or not. And out of the 26 papers that we started with five made the cut. And of that five, do you want to know how many of them showed that CTG monitoring is better than intermittent? auscultation? Zero that'd be zero. None of them showed any difference between intermittent auscultation and CTG monitoring. So, you know, the, the idea that there's this big body of convincing research out there that shows that it works. When you actually go looking for it. It's just not true. And as I said, you know, me, the clinician in that moment with that, has been asking me for evidence about using it for twins would have been really, really shocked to discover that all three of my training, nobody had actually thought to mention it. And I think, you know, a lot of the focus in my PhD was about understanding kind of high level social forces that are responsible for that, and obstetrics. And I don't mean, obstetricians, I mean, obstetrics as a way of knowing about the world about thinking about pregnant women and about birth and about babies and about midwives, and therefore of how you act in the world. When you an obstetrician or when you're working within obstetric ways of knowing and doing it creates the situations where the foetus is seen as really, really special and precious, and it always perfect even if it's not, and it has to be protected at all costs. And women who are pregnant, they're actually the problem. They're the ones that the foetus is at risk from. They can't really be trusted to tell you whether the foetus is okay or not somebody smart outside of the woman has to do that. And when it really is, you know, obstetrics says you can't trust midwives because the they'll try and run you out of town. And obstetricians are the ones that have to be in charge. So CTG monitoring just it really works really effectively to reinforce obstetric dominance in maternity services because it provides this system where you know obstetricians are the expert if there's a problem with the CTG, and there's a midwife and an obstetrician, talking about it, whose opinion counts was always going to be the obstetrician. Unless the obstetrician isn't a first year obstetric registrar and the midwife is somebody who has been doing it for 35 years. And that obstetric registrar recognises that the chances are that the obstetrician will just put their hands on the same go, because I said so. And therefore, my interpretations the valid one. So there's really good reasons why obstetrics doesn't really want obstetricians to know the truth about it either, or midwives or women. Because, you know, it risks upsetting the whole balance of the authority that obstetrics has within maternity services in high income countries around the world.

Megan Rossiter  47:52

There's something that you just said there that I know we have kind of mentioned, but I've realised we might have mentioned it with the kind of understanding that both you and I understand what CTG monitoring as and if you're listening, you might not quite understand, when you're talking about two people having a conversation about interpreting the CTG, it doesn't print out with like a little alert on it being like, ah, issue performaces Areum section, it is for somebody to look at, and to interpret and decide what they think that it means

Dr Kirsten Small  48:26

kind of like reading tea leaves. So you know, two different people can look at the same pattern and one can go on, this is fine. It's okay. The other one can go Oh, no, it's more than Okay, quick. Call theatre I'm coming. And it's well recognised in the research that people have looked at Inter observer variability. So they were given 50 ct G's out to four different people to interpret. And all four of them agreed with the that, you know, this particular one CTG was the same thing, less than 50% of the time. They've also, interestingly looked at intra observer variability where you give somebody a CTG. And three months later, you give them the CTG again, you know, he gave him 300, so that they don't know which one, you know, there's too many of them to just remember the CTG. And the chances that you'll call it the same thing the next time. They're not 100%. They're far lower than that. And I've had personal experience of that where I've done necessary instruction at three o'clock in the morning for an awful looking heart rate tracing. And then in the booth review, meeting, the following Monday, someone's pulled out the CTG and I've gone well, that's fine. Who did that? Well, that was you? Yeah.

Megan Rossiter  49:44

Yeah. So I just think that that's really important to kind of communicate to people because I think sometimes this reliance that we have on machinery makes us go like I said, the machine is going to tell us and it's not it's not it's not that clever yet.

Dr Kirsten Small  49:58

It's an inexact science. It's a little bit lying on your back on a field on a summer's day and looking at clouds and working out whether it's a giraffe or a VW.

Megan Rossiter  50:06

Yeah. So the final thing that I'd really like to cover that I know is certainly something that's kind of bandied about is to do with the different types of CTG monitoring. So just to kind of loosely cover that is this sort of the CTG way to hang on it from the outside. So listening through the kind of, I suppose ultrasound waves, or one that you've already mentioned, which is the foetal scalp electrode, which is a sort of like screw hook that goes just under baby's scalp. Now, frequently, women will be told that the foetal scalp electrode is more reliable. Have you got anything to share on if somebody has decided despite all of the conversation that we've had, that they've decided, yes, I'm going to accept continuous electronic monitoring in labour,

Dr Kirsten Small  50:58

compared to CTG monitoring using external Dopplers. It is true that foetal alcohol and foetal spiral electrodes so that people are aware of the fact that it screws into the baby's head, the tracing is more complete, there are fewer periods where the woman's moved and the straps slipped, or where the baby's moved and is no longer underneath the sensor. And so you have a period where it's not being recorded. There's there are far fewer gaps. So is it more reliable? Well, yes, there is. Does that translate into better outcomes? Well, let me summarise the evidence from randomised control trials that have compared foetal spiral electrodes with standard CTG monitoring. There are none. No one's ever looked at that. And again, this is you know, there's just big holes in what we should know. So we don't know whether that more continuous monitoring translates through into better outcomes or not, there's no doubt that increases in infection rates for both mothers and for babies. And there are some other risks as well. You know, there's some really awful stories of electrodes being screwed into places where there shouldn't be like an umbilical cord with breech baby or into an eye, you should feel where you're putting the thing and not whacking on somewhere that you're not supposed to. But of course, if you don't use it at all, it's never going to have that, that risk. So, like the rest of the CTG street, they have they have pros and cons. And I think it's important that we're upfront with people. And so the whole, let's just pop a clip on telling people that didn't actually it was actually punctures the skin for starters is not okay. And that there are some risks associated with it. It does, particularly for bigger bodied women, where it can be really tricky to get a reliable tracing, if you've chosen to use a CTG and then somebody is having to, you know, physically wrangle the equipment on your body for eight hours, it's uncomfortable for you, it's challenging for them, it can just be a whole lot less awful to have internal monitoring used instead. So you know, that might be a risk benefit equation that you're happy to make use of. But you know, it's not so much that they're in use that bothers me. It's the fact that they're in use without people actually being honest with people, and sharing the pros and cons, and then supporting them to make their decision about whether they want to use them or not.

Megan Rossiter  53:34

Yeah, I think that's just a really important thing to cover, because sometimes it's sort of sold as the better version of CTG. But as you said, with not any research at all, in terms of outcomes for the babies, whether that is more helpful or not. I think I could keep talking to you for the next three hours. But we're sort of coming to the end of our hour, is there anything that you would really like? 

Dr Kirsten Small  54:01

See if this gets the chop when you get to the editing or not. There's another hidden conversation that again, I don't think is happening in maternity services anywhere near as often as it should, and that's around this thing called Central foetal monitoring at which was the main focus of my PhD. So now that we've moved away from the original CT G's machines just printed directly onto a piece of paper. And as we got better with technology, then out they generate a digital signal, and they send it to, you know, a machine that's basically computer. And so the trace now appears as an electronic signal on a computer screen, which also means you can move the data it doesn't have to stay beside the woman side in the room that she's in. And so central foetal monitoring takes the data from individual birth rooms into a central log. patient in the maternity service, hence the name. And so every woman who used to be having CTG monitoring at the time, her CD will appear on a bank of monitors. So you know, if you've got 10 rooms in your birth suite, and every one of them is full and 10, women have CCGs, there'll be 10 traces on display, so that people can sit out at the central monitoring station, and keep an eye on what's happening with the CCGs. Across the service. At face value, that seems like a really good idea, you know, it's an extra set of eyes. And if the midwives busy doing something else, and our backs turn to doesn't notice a problem, somebody at the central monitoring station might pick it up. And, you know, if you need to feel the midwife and you need to pop out for a way, somebody else can be looking over your trace while you're not in the room. But again, no one's actually done any randomised control trials to see whether that versus standard CPGs where if you want to see the trace, you have to actually go walk into the room to see it, whether it makes a difference in terms of outcomes. What we do have is three small trials where there had been a central foetal monitoring system in use at a hospital. And then the blue smoke got wet out and they stopped working. And it was too expensive for them to be replaced immediately. And so there was an a period where they didn't have central foetal monitoring, and then some clever clogs, decided this would make a good research paper and so they compare the outcomes between the two periods. And what they found is that there's no difference in outcomes for baby. Some of the trials showed that the Syrian section instrumental birth rates were higher when there was central foetal monitoring in USAC. You know, this is on top of the rights that we see when we move away from intermittent auscultation. And one of the trials which was in Australia asked midwives and obstetricians. When did you spend more time in the room? Was it when we had the central monitoring station active or was it without and they they all said they spent more time in the room when there was not central foetal monitoring, which has important safety implications, because there's all sorts of stuff at than the CTG that people are gathering information about to tell us whether things are okay for this woman and this baby, other than just the heart rate pattern. And if you're not in the room, can I kind of notice them, unless you're specifically asking about it, because this is it's a hospital wide initiative. You know, if you walk into a birth room and you go, actually I'd really like CTG monitoring, unless you have specifically asked about it, you have no way of knowing whether your data is visible outside of that birth room. To him, it's visible, some of these systems will let obstetricians log in from at home on their mobile phones so that they can check traces at the hospital without having to go in. So you know, who's watching it, where they are, how they're making use of that information. And I think that raises some genuine concerns about privacy. You know, that person can wander past and have a bit of a squizzy, your personal CTG tracing and any other information that happens to be written on it. My research was interested in understanding an event that was happening at a particular hospital where it was in use and that the midwives they call it being catered, which was the name of their central foetal monitoring system, which was when they were in a room with a woman in labour who had a CCG on and then did some kind of a wiggle on the CCG. That was not what you would expect to see and then suddenly, slam the doors would fly open and ended come a barrage of people who are all completely wired going, oh my god, your CCG Oh my god. And sometimes it was really disrespectful. And you know, I had stories about midwives ending up in tears and women who was scared and thinking that their baby was about to die. Sometimes it was really gentle and it just be a little gentle block at the door. And he is everything I kind of just noticed the CTG is not a right, that even when it's just a little gentle knock at the door, that midwife who was quite probably in the middle of trying to figure out what's going on What do I need to make this better as to stop what they're doing to go and sort out this other person who now is demanding their attention. So it's pulling them away from actually addressing the situation. People would then adjusted their practice to try and protect women's privacy and to stop this from happening. And in order to do that, they learned that the best way was to add lots of notes to the CDT G and so they sit there in front of the computer furiously typing and want your woman vomiting woman on toilet straps readjusted you know whatever so that whoever's outside looking at that going God like the look of that didn't get out I was okay she's on the toilet and they you know, they've they've clearly seen it because they're adjusting the straps, that's okay I don't need to go in. But it then meant that midwife and a back turn to the woman and as busy furiously typing into a computer, and people talking about, well, I have a choice I can be with women, or I can be with CTG, I can be both. So it really, you know, kind of put the idea of protecting the woman's birth space and maintaining her privacy and being physically present and mindful of her at odds with one another in a way that we've never really seen before because of the introduction of the technology. So if you're if you're expecting and you're going to a hospital, then ask your midwife Do you have central foetal monitoring? Is there the option for me to have control over whether my information is visible or not? At the central monitoring station? You know, what are you going to do to make sure that my privacy which is in slot enshrined in legislation is being protected and that I'm not going to end up with, you know, disrespectful care? You know, there were situations where women were sitting on the toilet, having a poo when suddenly six people have wandered in barged into the bathroom. And I'll go up data, because they wanted to see what was going on with the CCG. I messed with some of it was really awful.

Megan Rossiter  1:01:30

Yeah. And that actually leads me to probably one of the most important conversations about CTG. Is has there been and I will be surprised if there has been because this isn't the kind of thing but obstetrics likes to research? Has there been any research into women's experience of having CTG? Like, what do they feel about it? Do they like having it? Do they find it helpful? Do they find it annoying? It restricts their movement? Does that exist?

Dr Kirsten Small  1:01:58

There's there's been a little bit but most of it is before 1980s? So it's really, really old.

Megan Rossiter  1:02:05

I wasn't I wasn't even born in the 1980s. So this is this is like my mum having even earlier than that, like, this is not recent, is it? 

Dr Kirsten Small  1:02:16

Yeah. And some of it was done in the context of randomised control trials. And it was really about, you can tell from the flavour of the writing that what they were after, was information that they could use to help talk women into having CTG monitoring, rather than a genuine appreciation of what the experience was like or not. And so, you know, for some women, they did describe anxiety about, you know, is it going to electrocute me or the baby being anxious every time they could hear the heart rate decelerating, and not knowing whether that meant, you know, the next beat was just not going to be there in the baby, it'd be dead and they would have heard this baby die in front of them. They did talk about a change in the atmosphere in the birth from becoming quite technical and how people would walk into the room and ignore them and look at the machine and even their husbands partners would spend a lot of time looking at the lines on the machine and seductive with them. There's yeah, there's not there's not a lot of recent stuff. There's been a little bit just in the last few years, but all around New technological additions to the CTG. So telemetry, so the wireless version of CTG monitoring, we've got a bit of stuff about women's experiences, and yes, they are more mobile and spend less time on the bed. When that's in use, whether that actually translates into a difference in terms of loads zero infection rates, we don't know. And the other one is a new whiz bang thing called non invasive foetal ECG which gets the same information that you're getting from A foetal spiral electrode, but with stick on monitors that go on the woman's abdomen, so it's been particularly marketed for bigger bodied women, and it avoids having to you know, rupture their membranes and stick things into their vagina in order to be able to tell what's going on both for contractions and for the foetal heart rate. And so there's a bit of Australian research about women's experiences of that and often those women had had regular common garden variety CTG and previous Labour and had something to compare with. But yeah, that's that's about it. Really. There's there's none on women's experiences in relation to central foetal monitoring,

Megan Rossiter  1:04:33

which I suppose just goes away to show that what the focus is that when we're researching CTG, we're not interested in whether you like it or not. And so, but certainly some of the things that you've said I know will like resonate with women that have had CTG monitoring that suddenly it feels like the focus has gone to the machine even from the person that is in labour, we stare at these numbers, bearing in mind it takes obstetricians in requires years and years and years of mandatory training to be able to even vaguely interpret them. And we kind of switch our focus to them as they they're going to tell us more about what's going on in our labours than actually the sensations that we are actually physically experiencing. And it can limit mobility, you can find yourself kind of end up on a bed. And then the kind of loss of contact and stuff that we've mentioned, that can mean that you're kind of put into positions that might be positions that you wouldn't otherwise have adopted. So it says that those are certainly the kind of...

Dr Kirsten Small  1:05:30

And told, Don't move. Because if you move I lose the heartrate. Yeah. And so you know, you end up kind of cramped on your left hand side with your knees tucked up in an awkward direction for 17 hours. Yeah, cuz you just can't get up. You know, I also saw when I was doing data collection, again, is this trying to keep the doctors from coming into the room business of women being told to hurry up and push their baby out harder and faster, because if the midwives get the boat, the baby born quickly, then there wouldn't be time for the obstetricians out at the central monitoring station to look at the CTG and think gee, that's been going on for a while I should go to that room, or they'd cut an episiotomy to get the baby born faster, not because they were concerned about the baby, but simply to stop obstetricians from coming into the birth room. Which, you know, on the list of reasons to do an episiotomy to stop an obstetrician coming into your birth room. It's not on there.

Megan Rossiter  1:06:25

No, it's not. Oh, my God. We should do a whole episode on maternity politics. I could go on and on. Thank you so so, so much for your huge, enormous insight there. If people still have questions, or this has really piqued their interest, and they want to learn more, where can people find you? Where can they find your work?

Dr Kirsten Small  1:06:51

Birthsmalltalk.com is the name of my blog, and I post something most Wednesdays and it's mostly about foetal monitoring. Sometimes I decided to have a rant about something else that's caught my eye. I'm on Instagram and Facebook and Twitter as @birthsmalltalk. So people can catch me they're most I'm pretty, I'm pretty lazy on social media, they mostly it's just me posting blog posts and then promoting my courses. The link to the courses is on the the blog page as well. And there's a course for maternity professionals. So for midwives and obstetricians who are who are now having a moment going, Oh, I didn't realise I didn't know this stuff, I should probably go and learn something, I have a course for you. There's a course called foetal monitoring for birth workers, which is for, you know, the doulas and the childbirth educators and the maternity activists and all of the people who are working with pregnant and postpartum women to make decisions or understand what happens that goes through the evidence. But they don't necessarily have all the lingo that the medical people have, where I can talk about, you know, intrapartum this and, you know, gotta use more common playing language in that setting. And also, you know, those are people who don't have access to a university library or the skills to be able to research into evidence I do all of the hard work for you. I also have a course which is currently in the hands of 20, very, very thorough and enthusiastic testers, I have to say they're really impressing people, they've found every single typo that I made in this course, it's just quite magnificent, which is called foetal monitoring the basics. And it will be for women who want the information for themselves for their own decision making. So all going well, and how many more mistakes these guys find and how much tidying up I need to do. I'm hoping that maybe by the end of March that that one will be available for release, and it'll be a lower price course than the other two, because I want it to be accessible to people. And it'll be you know, what we're in the online world called an evergreen course. So you'll sign up, you'll get instant access to it, there won't be any, like class start or finish times, there won't be any webinars at a particular time, it'll be just come learn. And when you're done, you go again, and you'll have access to it for I haven't decided yet probably a month to be able to go and learn all the stuff that you need to learn. So yeah, options, plenty of places to get education, because you can't necessarily rely that you're going to get it in the healthcare system. And the key takeaway message that I want to really want to leave people with is the idea that it is a choice and it's your decision if you're the one who's pregnant. It's your decision to make you never need or require or have to have CTG monitoring. It's a choice.

Megan Rossiter  1:09:55

Amazing. Thank you so, so much.

Megan Rossiter  1:10:04

Thank you so much for listening to today's episode of the Birth-ed podcast. It's my actual life mission to get these conversations in front of as many expensive families as possible and you can be a part of this mission. Don't worry, I'm not recruiting you into my cult. But if you leave a five star rating and review of the podcast then we creep up the charts getting more ears change more births, change more lives and come on, you know you want to be a part of that change.