ABSTRACT
Continuous cardiotocography (CTG) en cap sul ates many of the issues that distinguish the social model from the biomedical model of care: our relationship with birth technologies, the in ter pretation of equivocal evid ence, notions of risk and the significance of the birth envir on ment. All of these need ex plor ing in the con text of fetal monitoring. As I practise in a large maternity hos pital I ex peri ence exactly the same concerns re gard ing fetal monitoring now as I did when I was first prompted to write on this area in 1998. Since then I have had the oppor tun ity to ex peri ence more births at home and in birth centres and these have informed my present views. One thing that is striking about envir on ments where intermittent auscultation is used is how rarely fetal distress is diagnosed, when on large labour wards it is a common occurrence. This is not explained solely by the different case mixes of each setting. In this chapter I will ex plore the evid ence base of different types of fetal monitoring. I will engage with the risk/bene fit ratio in attempting to apply the research findings. This requires us to examine the iatrogenic effects of con tinu ous CTG. The discussion needs to scope the issue of perinatal death and injury and their relationship to intrapartum events. We will briefly examine competing or adjunct technologies to see whether they help our deliberations. The role of tech no logy in modern birth practice will be discussed and how that impacts on childbirth attendants and birthing women. Finally, the ubi quity of risk needs addressing if we are to challenge power ful discourses that shape attitudes and practices towards fetal monitoring on the ground. Continuous CTG has always been a provocative area of intrapartum practice to examine because strong custom and practice routines preceded robust evid ence. The tech no logy was widespread and embedded in practice before the ran dom ised controlled trials (RCTs) appeared. The RCTs, summar ised in Alfirevic et al.’s (2006) review, challenge the embedded practice, not only casting doubt over its use for low-risk women but failing to show any perinatal mor tal ity bene fit for high-risk women as well. Over the past couple of years, critiques of evidence-based health care have exposed the pos sib il ity of biases in research reporting and implantation, with techno lo gical in nova tions receiving favour able evalu ations (de Vries and Lemmens 2006). It is therefore fascinating to observe the impact of negat ive findings from the evalu ation of a tech no logy. Authoritative voices like the National Institute for Clinical Excellence (NICE) in the UK and the national colleges of obstetricians in the USA and Australia have thrown their weight behind judicious applica tion of con tinu ous CTG so that more maternity ser vices are now complying with evid ence recommendations.
