Episode 157 Monitoring the Fetus in Labour

How much trust are you placing on the CTG monitor as you welcome a new life into the world? Get ready to have your beliefs challenged as Dr. Kirsten Small and I dissect the language and implications surrounding fetal monitoring during labor. We dive beneath the surface to expose how CTG monitoring can become a source of moral panic, shifting the focus from the true essence of childbirth. 

Dr. Small, a critical voice in the field, and I navigate the complex world of CTG monitoring. We reveal how misleading language and beliefs can cloud our judgement about its effectiveness. Our conversation brings to light the dire need for a randomized controlled trial to evaluate physiology-based CTG interpretation conclusively. Together, we grapple with the challenge midwives and healthcare professionals face in reconciling evidence-based understanding with the stringent guidelines they are bound by. 

As our enlightening chat progresses, we unmask the complex nature of fetal monitoring during labor. From discussing Dr. Small's informative online courses to debating the implications of directly measuring oxygen levels in labor, we leave no stone unturned. We challenge the concept of central monitoring in labor, discussing its effectiveness and potential challenges. Whether you're a maternity professional, birth worker, or someone intrigued by fetal heart rate monitoring, this conversation offers insights and debates that will make you reconsider what you thought you knew. Tune in for a perspective-altering discussion that is sure to stimulate your thinking around fetal monitoring.

You can find Kirsten & her courses here on her website https://birthsmalltalk.com/
as well as on Instagram & Twitter @birthsmalltalk

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Florence: 0:01

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you. Episode 157 Monitoring the fetus in labour. I am overjoyed today to welcome Dr Kirsten Small, her of birth small talk, to the ObsPod, and I'm hoping this is going to be an incredible episode. A few listeners have actually asked if the two of us could get together and thankfully, despite being the other side of the world, she readily accepted by invitation to come on the ObsPod and discuss things CTG. So without further ado, kirsten, welcome. Perhaps you could tell us a little bit about yourself.

Kirsten: 1:40

Thank you. It's a pleasure to be here, and we obstetricians that are attempting to do education in the online space for people should definitely be backing one another. I've been interested in the question of why there's a difference between what the evidence is about approaches to monitoring the fetal heart rate in labour and what actually happens, since I was a trainee and I had the space in my life back in 2018 to start a PhD, so it seemed time to actually take a seriously, proper, deep dive and look at the evidence and find a research question that needed answering and focus on creating some new knowledge that would hopefully help shift us in the right direction in maternity service provision. When it comes to the issue of fetal heart rate monitoring, because it is an area that's been considerably controversial over the decades and is certainly room for improvement.

Florence: 2:48

Thank you. So I came across you on Twitter and blogs and things and it kind of pricked my interest because, rather than teaching, oh, this is how we interpret CTGs, it was very much more why are we doing them? What's the evidence for doing them? And I dipped into your taster course. So you run a course for professionals and I dipped into a taster course that you run last week and you started off with a very important thing of what should we call it. And I must admit, just even that was really interesting to me because I thought a lot about the language we use in the birth space and language that we use that is difficult in terms of labelling women like failure and sort of judgmental language. But I hadn't thought about the fact that electronic fetal heart rate monitoring might be in appropriate language. And you very much got us back to focusing on CTG Cardio Tokograph. Would you like to briefly explain why that is?

Kirsten: 4:15

Yeah, so CTG Cardio Tokograph. It does what it says on the tin Cardio heart rate monitoring, toco, uterine contractions, and it produces a graph showing how they change in relation to one another. So it is exactly what it says it is, and then you can add some kind of descriptor at the end of it so you can talk about CTG use or CTG recording or tracing or monitoring or whatever. Electronic fetal monitoring or EFM is the abbreviation that's often used to mean exactly the same thing, and it came into use really early in the history of CTG monitoring. But I spent a lot of time thinking about it when I was writing the 25 bazillion drafts of the PhD, thinking about what words are the best words to use, and it didn't sit well with me increasingly over time. Because the other alternative is to listen to the fetal heart rate intermittently, and while once upon a time that would have been done with a device like a pinard's stethoscope, which was not electronic in any way, in current practice in most parts of the world we use an electronic handheld Doppler device to listen to the fetal heart rate, which is a form of fetal monitoring. So intermittent auscultation is a form of electronic fetal monitoring, which then clouds the issue as to when you say electronic fetal monitoring, what exactly are we talking about? Are we talking about seasoning a CTG or are we talking about using a handheld Doppler to intermittently auscultate the fetal heart rate, and it doesn't really tell you what's going on.

Kirsten: 6:03

The other reason I decided not to go with it is the problem that happens when CTG monitoring becomes fetal monitoring is that then, if you're not doing CTG monitoring, it's very easy to say we are not doing fetal monitoring, when, in fact, if you're doing intermittent auscultation, you are doing fetal monitoring, and the evidence, which we'll probably get into in a moment, says that mostly it's actually equivalent in terms of the outcomes that you can expect for the baby with CTG monitoring.

Kirsten: 6:42

So it's so to try and keep the two separate. I always talk about CTG monitoring and intermittent auscultation, and I think electronic fetal monitoring just kind of clouds the issue and makes it complicated for people. Having said that, it is a personal choice and I don't criticise other people and so long as we can be clear about what it is that we're doing, but I do think it creates a sense of moral panic. When you say, well, I'm not going to use electronic fetal monitoring, people often assume that means that you are not going to do anything at all in the way of paying attention to the wellbeing of the fetus, and that worries people, which is it certainly is not what I'm proposing people do.

Florence: 7:26

Yeah, I very much. It really went into my head the idea that monitoring is actually us looking at the thing, not the thing itself. That definitely had a big impact on me.

Kirsten: 7:40

Certainly you can produce a magnificent CTG recording and unless somebody's looking at it, no monitoring is actually happening. And I've certainly heard stories and I heard it as well when I was doing my PhD of cases where a CTG machine had been attached to a woman and she'd been left alone. Nobody had come back and when somebody finally returned to the room the baby had died. That's just horrific. It might be electronic fetal monitoring, but there's actually no monitoring that's happening because no one's looking at it.

Kirsten: 8:16

So yeah you can't assume that just hopping a monitor on is actually going to solve the problem. It's about the people that are doing the process.

Florence: 8:27

Yeah, I also liked the fact you talked about that CTG includes the woman because of the toca graph, and it's interesting because I had, with women in mind, switched to calling it fetal monitoring because I thought that was more intelligible, understandable to a lay person than CTG, which you have to go. Oh, it's a cardio toca graph and that means this and that means you have to explain it all. But I hadn't thought about the fact that that was removing the woman and, yeah, that challenged my assumptions, definitely in a good way. So I'm not going to have to go back and go back to CTG, which is how I was brought up in the first place anyway, but think about how to make that intelligible to people.

Florence: 9:27

So, then we get to the kind of nitty gritty of well, why are we doing this? Because we use CTGs all the time. So I'm pleased to say we don't do admissions CTGs anymore, which was the thing that was present at the beginning of my career where you did 20 minutes when any woman walked through the door. So we don't do that. But anyone deemed an inverted commerce high risk is recommended to have continuous CTG in labour.

Florence: 10:02

And I don't know about Australia, but in the UK the number of women now deemed high risk seems to be increasing exponentially because we've got women who are deemed to have gestational diabetes don't get me started on that. Women who are older, over 40, women who actually might have a problem like growth restriction women, any woman having an induction, which the induction rates are very high. We mentioned before we started recording meconium. So the number of women that we're then default strapping onto our monitors is high and that has a massive impact on their labour. But instead of examining what are we doing? Strapping people onto monitors, we're making wireless monitors, which is good, that's beneficial, that's very helpful, but that's not looking at why we're using the monitors in the first place and on your mini course you had a really nice kind of comparison of data, so perhaps you could just once and for all say what you think in terms of the data shows us.

Kirsten: 11:38

Yeah, so the best evidence comes from randomized control trials where they select a group of women and then randomly assign them either to have CTG monitoring or intermittent oscultation. So you should end up with the same kind of factors going on in the background for both groups of women that might potentially explain a difference in outcomes. It should be the same. And then you do the monitoring and they have their babies and you come back and you measure the outcomes to see what went on. So there's been 11 trials where the comparison has been CTG monitoring versus intermittent oscultation and one other where the comparison was between having lots of CTG machines available so almost everyone had CTG monitoring versus locking most of the CTG machines away in a cupboard every second month so that only a handful of people can have them and it gets mixed in with the other ones, even though strictly speaking it's a slightly different approach. And the outcomes that interest me most are the long-term outcomes, while it matters whether a baby has a low-app gas score or not, if a baby has a low-app gas score and is then completely fine, it's not that important. So the biggest ticket item is obviously death. So there's two parts of that. There's the baby being alive at the start of labor but then being dying at some stage during the labor, so that it's still born or there's death in the first week of life related to low oxygen levels that have occurred during labor. And then when you combine, so that's early neonatal death and if you combine the two we call it perinatal mortality. Using CTG monitoring during labor, compared to intermittent oscultation, makes no difference to the still birth rate. It makes no difference to the early neonatal death rate, and when you add the two together and call it perinatal mortality, again there's no difference in terms of outcomes. So if anyone's attempted to say something like you have to have this because it'll stop your baby from dying, or CTG monitoring saves lives, there's no evidence to back that up at all.

Kirsten: 14:00

The next important long-term outcome is cerebral palsy. So that's damage to the developing brain of the fetus during labor due to low oxygen levels. That results in a permanent brain injury that turns up with things like movement disorders and sometimes intellectual impairment as well. That's life long and can't be fixed. And there's not an awful lot of research. Only two research groups did long-term follow-up to see what happened. So again, randomised people and as well as collecting data in the few days after the baby was born. They followed them up for 12 months, 18 months, two years to see what happened. No difference in cerebral palsy rates, except when you get to the fine print out of those two.

Kirsten: 14:49

One of the studies was done in an exclusively high-risk population and the specific risk factor was that all of the women were in preterm labor, so they were under 30, between 26 and 32 weeks pregnant when they were into labor, and the cerebral palsy rate was two and a half times higher when CTGs had been used, which the research was done in the 1980s and no one's kind of gone. Well, that's interesting. We should really go back and verify that and do it in some other populations and see what's going on here. But there's kind of been a collective sticking the fingers in the ears and saying la la, la, we'll just pretend it didn't happen, because no one has ever gone back and said well, that's really interesting. We should ask them more questions here.

Kirsten: 15:39

So there's the beginnings of a suggestion that CTG monitoring might actually be harmful in some groups of women and babies, and we've never really got to the bottom of that to know who is best served by CTG monitoring and who isn't the one area where CTGs seem to come out on top is with neonatal seizures that happen in the a day or two or up to a week after the birth of the baby.

Kirsten: 16:07

And if you mix low risk, high risk, everybody in together into the you know the maximum number of people that have ever been in a research trial then there's a statistically significant difference and the rate of neonatal seizures falls from 30 for every 10,000 births to 15 for every 10,000 births when intermittent hospitalizations used.

Kirsten: 16:32

So higher with intermittent hospitalization, lower with CTG monitoring and the difference is a difference of 15,000. So that does mean that you need to do an awful lot of CTG monitoring to prevent one baby from having an neonatal seizure. And those the trials where they did that two of those were the long-term trials where they then followed those babies through and despite the fact that the seizures were happening more often, it made no difference to long-term outcomes. So yes, jolly awful thing to have your baby have fits right after birth, but they're probably going to turn into a completely delightful three-year-old who's going to be able to climb trees and run around parks just like all the other three-year-olds. So you know for the really impactful long-term outcomes CTG monitoring seems to offer us no advantages over intermittent hospitalization.

Florence: 17:26

Yeah, I'm just going to let that sit there for a moment because that's mega and I kind of know that in the way I practice and I talk to women about that, because I'm fortunate that I see quite a lot of women that question what we're doing and ask for more personalized sort of bespoke planning. But I still have to say to them well, this is the guidance, but actually the evidence is debatable. But the fact that the evidence is there that it doesn't benefit, that's stronger than the evidence is a bit mixed. Or you know, we're recommending stuff in our national guidance which the evidence isn't great for the evidence is great.

Florence: 18:25

It just it doesn't back us up.

Kirsten: 18:29

Why do you think that's so hard for people to grasp sort of professionally I think midwives and obstetricians, like we, want to make things better for people, and stillbirth in particular. I mean it's a shockingly awful thing to happen and so if there's any glimmer of a suggestion, of a whisper, of a possibility that we might be able to improve that, when it's an uncommon outcome so reasonably healthy woman, one baby close to her due date the chance of intrapartum stillbirth is about three in 10,000. So you know it's really uncommon. So again, you know you need to have a supremely impactful intervention. If you're gonna make, if you're gonna reduce that to one, you need to have something that's a really, really powerful tool, and CTG monitoring just isn't that. But because those poor outcomes happen so infrequently and because CTG use is so common, it becomes really easy to start believing that well, the outcomes for the other 99,997 babies were great and so it must be working. Because every time I put a CTG on the baby's alive. So whoo-hoo. You know the technology must work and it's certainly.

Kirsten: 20:06

I think it's the same in the UK. It's certainly. My experience here in Australia is that if you go to a fetal monitoring course that's designed to teach you, mostly they teach you about CTGs. Occasionally they'll talk about intermittent oscultation instead, or as well, as it's almost always about the wiggly lines, it's about what the fetal heart rate patterns mean, and it's often also about who you should be advising CTG monitoring, for you know, memorising the big, long lists that it get increasingly long each year of all of these women that now are considered to have an indication for CTG monitoring, I've never apart from the courses that I run I've never seen a course that sits people down and goes through. There's a really important question that we need to ask first, and that is should we be doing this before we move on to the for, whom and how question?

Florence: 21:01

Yeah.

Kirsten: 21:02

And because we're not educating maternity professionals about the evidence, they just they kind of pick up the woolly fits. If the machine, if the technology exists and the guidelines says so, then that must be because there's evidence behind it, because that's the way it's supposed to work. Yeah, and so then you know, kirsten comes along, turns up and says these things that are considered really controversial when they shouldn't be, because it's just what the evidence says, yes, and it really creates some discomfort for people to be put into place with having to recognise that there's this big gap between what they're told is the best approach to saving babies' lives and what the research is actually telling us.

Florence: 21:53

Yeah, I think that's very true. I mean I have to attend an annual CTG update and competency and the focus is on can I interpret the CTG? Although we do physiological CTG interpretation, which I don't know if that well, there's no evidence for that either. But I do think I can understand the logic of trying to understand how the baby is actually physiologically coping with the situation it's in. So it makes slightly more sense than pattern recognition type interpretation.

Kirsten: 22:35

But I'd argue that that's just good branding. Yeah, yeah because, like all, like all, ctg interpretation is based on an understanding, or a misunderstanding, or accurately, of how fetal physiology works. So every single guideline is based in fetal physiology. And even in the physiology CTG interpretation guideline, you still have to be able to recognize a pattern. What does a baseline look like? It's still a pattern. Yeah, yeah, no, it's just that people are told that they're no longer looking for patterns.

Florence: 23:15

Yeah, I think it's just good.

Kirsten: 23:18

Yeah, yeah, I wait some evidence to see how their guideline matches up in terms of outcomes. There's a tiny little bit of research that's looked at that particular guideline compared with several others in terms of, you know, the ability of a tracing that's been categorized as normal to tell you that the baby actually is okay, and the ability of a tracing has been categorized as not normal to tell you that the baby is not okay and it does perform reasonably well in comparison to some other guidelines in that respect. That's not the same as saying that using it produces better outcomes for the baby, though.

Florence: 23:56

Yeah, what I was about to say is we need a new randomized control trial with physiology based interpretation to see if it makes a difference to outcomes. And my unit introducing it did seem to make a difference to outcomes. But we had a lot of intensive teaching, we had a lot, we had a fetal monitoring specialist midwife, we had two consultants spending a lot of time. So there's all sorts of confounding things that maybe cause the improvement in outcomes and of course, we're going to say, well, brilliant, we've had an improvement in outcomes and that's. That's fantastic, like you said, if we can save any single family from that desperately awful situation of their baby dying or being damaged.

Florence: 24:56

But cause and effect is not necessarily true. If we just take that, so one for the future, I look forward to a randomized control trial and then your analysis of it, which brings us a little bit to how. So, knowing that a lot of the audience that listen to my podcasts are midwives or student midwives, if we've just blown their minds by saying there's no evidence that it has a difference in terms of outcomes, ctg, how they're supposed to get up and go to work tomorrow and work in the confines of a system that has this belief, and I'm going to call it a belief, because it's that is what it is, isn't it?

Florence: 25:41

Essentially, it's a belief that CTGs make a difference. That's quite difficult for them to get their heads around. Do you have any advice for sort of how they might kind of reconcile?

Kirsten: 25:57

these two things in their heads.

Kirsten: 26:00

It's certainly something that I struggled with when I had the two hats of being both a clinically practicing obstetrician and being a researcher, and I would have conversations inside my own head as I was saying will you better put the CTG on with research? A kerstin saying you know that doesn't work. You've probably signed some kind of an employment contract that says you'll abide with the policies and guidelines of your institutions. So you know, if you would like to continue being employed, then you need to abide by the guidelines of your institution. What needs to happen is change. At a fundamentally different level, though, I really don't want to see midwives and obstetricians turning out with hammers and, you know, attacking CTG machines and tossing them off the backs of cliffs and, you know, being quite destructive and radical in the process. I think that the two things that really annoy me most about the current state that we found ourselves in with CTG monitoring are, firstly, that we're not honest with women in our counselling, and so that needs to change. We need to have honest conversations with women about the fact that we have these two options.

Kirsten: 27:22

The evidence would suggest that, in terms of outcomes for the baby, they're equivalent. In terms of the evidence for the outcomes for you. You're more likely to have a caesarean section or an instrumental birth or a sub-silver vacuum assisted birth if you choose to have CTG monitoring. Whether you are considered to be at low risk or considered to be at high risk, that's the same. So it's not that there's a whole body of evidence out there about women who've got risk factors that says no, no, ctg's actually work. For those women. That doesn't exist at all. So you know, even in situations where, for example, a woman's had a previous caesarean section and now plans to labour, she has a twin pregnancy, she's in pre-term labour, she's being induced, in all of those situations intermittent auscultation remains an evidence-based, valid choice. It may well make care providers jolly uncomfortable.

Kirsten: 28:20

There's been some good research looking at whether we actually enable women to have a choice, a decision about which approach to fetal heart rate monitoring they're going to use, and in most of the studies the number of women who said that they actively made a decision about yes, I want a CTG or yes, I want intermittent auscultation was less than 10%.

Kirsten: 28:46

So what happens mostly in practice is things like a midwife saying oh, I'm just going to pop you on the monitor now, or because of X you have to have, and so the idea that there's a decision to be made doesn't even enter the conversation, let alone a discussion about the evidence-based you know. He's the benefits, he's the risks, he's the potential consequences of this choice. This is what might change my advice at a later point in time and we might revisit it. If that happens, those conversations aren't happening, and I'd really like to see us having those conversations. There's still a risk that having those conversations might put you at odds with the guidelines, depending on the precise wording of them, and when I did my PhD, the hospital where I did my data collection had things. Words like women with risk factors will have CTG monitoring.

Kirsten: 29:44

Oh okay, which meant that the midwife was in a really difficult position, because if the woman chose not to have CTG monitoring, that was the midwife breaking the policy.

Florence: 29:57

Yes.

Kirsten: 29:58

And so that really discouraged them involving women in decision making. But even if that's the kind of policy structure you've got, I'm pretty sure that at most hospitals there will also be a policy about informed decision making. That says you have to give women a choice, you have to present the evidence, you have to explain the risks and the benefits and you have to respect women's decision making. So I think you can safely start, you know, get across the evidence base yourself so that you're confident about having those conversations and start having those conversations. The second thing that drives me really nuts about where we find ourselves is that because so many people are running around thinking that either we've already found the solution with CTG monitoring or we're just about to, because we've now got telemetry, we've now got central monitoring, we've now got computer interpretation, we've now got a new WISI guideline, and if you add them all up and put them in the blender, then we'll you know it'll work and we'll fix it. What it's doing is it's stopping us from doing research to go and find something radically different that actually will solve the problem for us. And so the other place we need to be having those honest conversations is within the professions. You know midwives talking to midwives, obstetricians talking to obstetricians, midwives and obstetricians talking to each other and talking to neonatologists. You know researchers having these conversations because there's, you know, there's a whole world of possibilities in terms of other ways other than just the heart rate that we might work out whether the fetus is doing okay or not.

Kirsten: 31:45

Because if you sit back and think about it, it's kind of nuts.

Kirsten: 31:49

If you went to an emergency department going, I'm really struggling to breathe and I think my oxygen levels are low and the only thing somebody did for you was take your pulse and then pat you on the head and say no, sweetie, you're fine, go home.

Kirsten: 32:04

You would not think that you had good care. No, and yet that is essentially all that we do with CTG monitoring. We try and guess oxygen levels on the basis of the heart rate pattern. We could, and we have previously had technology where you could directly measure oxygen levels. We could and we do already have some technology that means we can monitor changes in that electrical activity of the fetal heart that changes when oxygen levels are low. There's technology that's beginning to be used in adults in ICU, where you can measure oxygen levels in the brain directly with a monitor that sits on the head, that might be able to be shrunk down in size so that you could put it on the fetal head during labor. There's a whole world of opportunities, and it bothers me so much that babies continue to die and be damaged because we're still telling ourselves the lie that what we're doing is effective.

Florence: 33:10

Yeah, that's a very good point. We're not pushing things forward, because when I think about other things that have changed in my career for example prenatal testing for trisomies just you know the yes, you can debate whether that's a good or bad thing, but there have been massive technological developments in that. But in CTG, no, I mean I work in a unit where we do have STAN, so we do have ST analysis, but it doesn't make a massive difference, I'd say, although, to be fair, the main difference it makes to me is it gives me the impetus not to intervene. So you know, for me I think the main worry with monitoring is we're doing it's not just we're not doing any good, we're doing harm by increasing intervention, whether that's cesarean or assisted vaginal birth or whatever, because we get we intervene for obstetrical midwifery distress, really don't we? Yeah, but an ST analysis I think, in my small experience of it, has been valuable in perhaps being able to go no, that baby's not in trouble.

Kirsten: 34:37

Yeah, and it's interesting. There's some fairly good research that's been done and continues to be done. There's another Australian trial just coming out soon, if it hasn't already been published that when you're smoosh and ball together, we're not. We're not seeing benefits with the use of ST analysis. It doesn't seem to protect women against the increased cesarean section rate.

Kirsten: 35:01

But the research compares CTG on its own versus CTG with STAN and I just I just wonder, like knowing how obstetricians brains work, we all brought up with CTGs and then STAN came in later. When you're looking at a CTG that is just, you know, making the hair on the back of your neck stand up. You can ignore what the STAN says if it says it's reassuring. And I wonder if what we really need, and if anyone's brave enough to do it, is to do a trial where we do CTG versus just the STAN, not CTG plus STAN, take out the rest of the information and just have that. The number for the TQRS ratio is the only bit of data that people are basing decisions on, whether that would make a difference or not. I mean, as a researcher, it makes sense. But because people are so wedded to the idea that CTGs are the thing that stopping babies from dying.

Kirsten: 36:06

It terrifies people when you make a suggestion to stop doing them and use something radically different as a form of monitoring, but we'll never know whether it's a better option unless we do something like that. And the same when. When we did have fetal oxymetry, when we were directly measuring oxygen levels in labour, it was CTGs versus CTG plus oxymetry. It was never CTGs versus oxymetry, which is that's what the trial needs to look like to know whether it's a better technology, rather than considering it as an added extra.

Florence: 36:41

No, that's very true. Yeah, you're opening up all sorts of possibilities in my mind. That's great, and I definitely think if you're opening people's minds, listening, they need to dip into your blog, because you explore all sorts of interesting papers and topics like this in your blog and I'm not a very maths analytical person and so the way you've kind of gone through papers and discussed well, it could be this, it could be that, and this means this actually is really helpful for someone like me. That is, I'm not going to go and trawl through all the data myself, so I really would suggest people dip into that.

Kirsten: 37:25

Now wwwbirthsmalltalkcom. It's free. It's been running now for three years. I post most weeks, so there's over 150 blog posts. Mostly it's about fetal heart rate monitoring. Occasionally I feel the need to rant about something else that's caught my eye. There's a bit of stuff in there about perineal trauma and the perineal boundaries.

Kirsten: 37:51

Yeah, and you know feminism and you know whatever I feel drawn to write about. I mean, the prices are going back to some of the earlier blogs and making them easier for people to understand, because when I started writing it, I thought I was gonna be people you know met. Obstetricians and midwives would be the people who are reading it, and while they do, there are also a lot of people who aren't trained health professionals who are making use of the blog sign increasingly writing to try and make things easy for that audience as well. Yes, it's free resource. I have no plans to change it from being a free resource and I will keep posting for the foreseeable future.

Kirsten: 38:34

What I've added this year is online courses that are paid, and I currently have one specifically for maternity professionals, and it's a really, really deep dive. For instance, done my mini course, which is one-tenth of what's in the big course. Yeah, into the evidence, so that you know, no matter who then comes and tries to criticize your knowledge, you will be able to stand firmly on your two feet and say no, I know this in any conversation. There's a similar one that's for birth workers, so that's duelers and childbirth educators, and here are both instructors. You know all of the, all of the people who are working in and around maternity services but are not themselves registered maternity professionals. And there's a course coming next year that's for called fiddle monitoring the basics, which will be for both in women and just anybody who's interested, which will be, you know, really easy to understand, shorter and cheaper than the, than the other two options. So keep an eye out for that one, so those ones are paid.

Kirsten: 39:38

I do from time to time open the little free course that Florence has done and it's a bit of a promotion for one of the other courses. So subscribe and you'll find out when it's available and I'll let you know anyone can pop in and do that one and there's a certificate at the end of it and lot that you know it's actual information. That's in the professionals course. It's not just me, you know running it one hour long sales pitch out, you. You get to see literally some of the material that's in the full course and make use of it yeah, I really enjoyed it and it really got me thinking.

Florence: 40:12

So, yeah, I would definitely recommend that and I will put links to your website in the show notes from today before we wrap up.

Florence: 40:24

I wanted to touch briefly on central monitoring because we had a little bit of an exchange about that and I feel a bit torn about central monitoring. So I was always very anti-central monitoring because of this idea that, like you say, you could leave the woman in the room and the midwife could be out looking at the fetus but not seeing the whole picture of what's actually going on in the labor and not being with the women. Having introduced it in our unit, I don't find that happens, but it does give me an idea of what's going on. So at handover, or we've done the war and I've met the women, I've had a conversation, but then I can look at what's going on or one aspect of what's going on with her without going and constantly interrupting. But it does sit in a difficult place for me because there's that whole no decision about me without me. So tell me, because I think you've got some thoughts about some of the monitoring.

Kirsten: 41:44

This was the PhD. So, first of all, what is it? So, as we've gotten fancy with CTG technology, we've produced monitoring equipment that means that we can actually gather that data as a digital input and once it's the digital input, you can move the data somewhere else. So, yes, you can see it on a screen that sneaks to the bed or in the birthing room, but you can also then display it out on the call it central monitoring, because it's usually at a central location within the birthing service. And it's not just one CTG, it's every woman who has CTG monitoring on at that point in time is displayed up on a big screen in this central office. There's also a thing called remote fetal monitoring, which is when you know obstetrician can pull up their mobile phone at home and see a CTG trace for a woman that's in a hospital or in a one hospital can look at traces at a midwifery practice that's up the road or something along those lines.

Kirsten: 42:46

There has been a randomized control trial that's compared central fetal monitoring with standard CTG monitoring. So we just we don't have that level of quality research. There's only three trials, all of which involved a place where there was already central monitoring and then there wasn't, and so they then looked to see was there a difference in outcomes between when there was and when there wasn't? And there was no difference in terms of outcomes for the babies and in in two of the trials the caesarean section rate was higher when central monitoring was in use. You know, and we already know, that CTG use drives at higher than intermittent noscultation in one. Once they corrected for a change in the induction of labor rate, the difference disappeared. But you know it kind of. I think it depends on the context of what else goes on in your unit as to what effect it has.

Kirsten: 43:42

What I found and this was this was a hospital that had a very, very strong ethos of mid. The midwife stays in the room with the woman all of the time and that happened. You know, there was no even at two o'clock in the morning, because I took myself in to do observations at all random hours of the day and night and weekends and public holidays, just to see if I could catch people being naughty. And no, there was no like taking a cup of tea and biscuits and sitting out at the central monitoring station with your midwife mates at three o'clock in the morning and leaving the woman in the room on her own. It just didn't happen.

Kirsten: 44:17

What did happen was the thing that the midwives at this hospital called being K2'd after the name of the particular brand of monitoring equipment they had which was when the midwife was in the room with the woman who was having CTG monitoring and there was some change in the CTG pattern that caused alarm for people out at the central monitoring station and had them then come dashing into the birth room and sometimes it was really disrespectful and disres and disrupt. If you know it was literally slamming doors open and barging in and shoving the midwife out of the way with an elbow and flipping the woman on her side and, you know, pressing him in, you know pressing emergency buzzes and dashing up corridors to do caesarean sections, without really having a discussion about what was going on. That wasn't very common but it did happen. But even in situations where somebody did walk up the corridor and go, have a gentle tap on the door and say, you know, excuse me, can I, can I talk to you about your CTG?

Kirsten: 45:23

People weren't seeing what that looked like from the other side of the door and what was going on was the midwife had realized that there was a problem with the CTG. She was busy trying to fix the problem with the CTG. She was changing the woman's position, she was checking the woman's blood pressure, she was grabbing a vomit bowl or you know, the worm might have been in the shower and it might have been interference from hot water hitting the back of the telemetry monitor. So she was actively troubleshooting the situation and when somebody came to the door she had to stop. I say she most midwives, she's summer, he's the midwife had to stop what they were doing to fix the very problem that the people had come to the door to talk to her about, to talk to the people at the door about the problem.

Kirsten: 46:14

Yes so it slowed down the ability to actually respond in a timely way. It also meant that people weren't treating the midwife with respect in terms of recognizing that he's somebody who's quite capable of actually logically thinking through what is an issue. What's the issue? What are the 17 steps that I'm going to try? First to see if I can resolve the issue. Now I've reached a point where I actually need external input and I'm going to go get it, because the external input turned up before she got to number two or three on the list and so the midwives. It rubbed them up the wrong way and they felt really disrespected, which resulted in some challenges in terms of interprofessional relationships between staff. It kind of sent the message, particularly to newly qualified midwives, that you didn't really need to bother with CTG interpretation because somebody had come and knock on the door and tell you when there was a problem.

Florence: 47:18

Right.

Kirsten: 47:21

So it had the potential to de-skill people with CTG interpretation, because they just relied on someone who might not even be out there yeah, because it was not always somebody at the central monitoring station because they were busy to come and actually say, oh, you need to sort out what's going on. And the midwives spoke about they wanted to protect the birth room, to maintain privacy for the woman, which is a really respectful and appropriate thing for a midwife to be doing and so one of the ways that they could achieve that was that as soon as they recognized that there was a problem with the CTG, they'd get onto the computer and start making that would also appear on the CTG so that the person outside could see. You know, they can see that that's a problem. I can see what they're doing, but the problem was, while they're doing that, they're actually not doing all those things, because they can't be in two places at once.

Kirsten: 48:20

Yes, and so the midwives spoke about having to make a decision about am I with woman or am I with machine? Yes and I can either make her and her babies safety my first priority, but by risk and invasion of her privacy.

Florence: 48:37

Yeah.

Kirsten: 48:39

Or I can actively try and keep her room private. But then what's happening to?

Florence: 48:43

safety. Yeah, no, that's a really interesting way of thinking about it. From my perspective I feel that it could be good in the room because there's less interruption, but I hadn't thought about what you've just described so eloquently. But the other thing that I feel it does do away with is the awful situation that we used to sometimes being where the midwives worried about the CTG. The midwife calls the midwife in charge and all the doctor, everybody comes in, has a conversation about it. The woman is worried because the midwife was worried, and then the people that come in from the outside go nothing to see here it's all totally fine, and walk out again, or we're still have an argument about it in front of the woman, whereas those discussions and educational conversation can happen at the monitor outside and sometimes later on doesn't have to be at that moment in time if everything's going okay. So that's very thought provoking what you just described.

Kirsten: 50:00

Central monitoring didn't prevent that from happening. In where I was doing my data collection, the CTG, though, what happened is a woman had been vomiting. The tracer just slipped off the baby. It looked awful, but it was just loss of contact. And because it looked awful. Suddenly you've got the obstetric registrar, the resident, the team leader and another midwife all tripping in at high speed, Quickly, quickly. We need to put a scalp electrode on and then they leave again just as quickly. The woman would be left going. What's wrong?

Florence: 50:37

What just happened.

Kirsten: 50:39

These four people have just come in and told me that there's something wrong with my baby and you didn't recognise it. I can no longer trust you as my midwife, but in fact there was no problem and it didn't need intervention. If you've given the midwife five minutes to sort out the fact that this woman was vomiting and readjust the CTG, it would have been fine. There was no risk to the well-being of the baby at all and people still had the disrespectful conversations because they barge in and tell them in the wife that they didn't know what a baseline was.

Kirsten: 51:17

It was still happening, it didn't just shift outside the room, but what happened was that people were then, particularly on night duty, became a sport to critique CTGs out at the central monitoring station and the midwives often had, you know, they'd walk out to get a cup of tea and they'd kind of walk into the middle of this game that was being played of people being critical about their practice Right, which they found really disturbing. There were conversations about whether they were practicing good midwifery or not that were going on. They found their consent, their involvement, their awareness and ability to be able to defend themselves. So I think it's really important, particularly for us as obstetricians, because the view that we get is from outside the room yes, we tend to only be in when hopefully when we're invited in that we can lose sight of the fact that for the person in the room looking out, central fetal monitoring can be a very, very different experience to ours.

Florence: 52:25

That's been very educational and thought provoking. Thank you, I'm going to I'm going to mull that one over and think now about what I do next time. I'm on the Labour Ward with our central monitoring, so I normally end my episode with like a zesty bit, a kind of take home message, and I'm thinking the zesty bit needs to be being honest with women. Unless you think there's something different you want to add.

Kirsten: 53:02

No, I think that's the key. Everything that we do in maternity services should be about the women that we're serving and what we should recognise them as being capable women who, ultimately, the decision is theirs, because the consequences of the decision are theirs. So our job as care providers is to make sure we absolutely know the evidence back to front and we develop really good communication skills so that we can have conversations with people that inform and not terrify, and that open up rather than close down to choice for people, and that's a really difficult ask. I've spent many years of my career honing communication skills and evidence interpretation skills, so I think they're much harder to come by than working out how to interpret wiggly lines are.

Florence: 54:02

Yeah, yeah. Thank you very, very much for giving up some of your evening to join me. Thanks for the chance.

Kirsten: 54:10

It's always, you know it. Mostly I speak with midwifery audiences or with dole and childbirth educators, so it's an absolute delight to be able to have a bit of a chat within a fellow obstetrician about the issues and Well it's my pleasure and thank you so much.

Florence: 54:30

Like I couldn't believe you were like. Yes, I'm going to jump at the chance and and I hope that this episode is everything that people hoped for, but also that it makes people think, stop and think, what are we doing? And have those honest, really good conversations with women. I think that's the perfect place to leave it. Yes, bye, I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic If you could subscribe, rate and review, on whatever platform you find, your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting.

Florence: 55:22

There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the NHS more generally.

Florence: 55:35

I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Florence: 55:59

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links If you want to get in touch to suggest topics for future episodes. You can find me at theobspod, on Twitter and Instagram, and you can email me at theobspodcom. Finally, it's very important to me to keep the OBS pod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.