If you've ever seen a woman labouring in hospital with two straps around her belly and a machine displaying her baby's heartbeat, you've likely seen a cardiotocograph, more commonly known as a CTG.
Continuous fetal monitoring is a familiar part of modern maternity care. For many women, it's introduced as a routine precaution, particularly if they've had a previous caesarean, are being induced, have an epidural or develop complications during labour. The explanation is often fairly straightforward: we need to keep an eye on your baby to make sure they're coping with labour.
And, of course, that's something every mother wants. We all want to know our babies are safe.
But what many women aren't told is that there are different ways to monitor a baby's heartbeat during labour, and the research comparing these approaches is more complex than you might expect. In fact, continuous monitoring doesn't necessarily lead to better outcomes for babies, and it can affect how women experience birth.
This area of maternity care deserves more attention, especially given how often these decisions are made without women being fully informed about their options.
What Are the Different Types of Fetal Monitoring?
During labour, contractions temporarily reduce blood flow through the placenta. This is a normal part of the birth process, and most babies tolerate these changes well. However, changes in a baby's heart rate can sometimes suggest they're having difficulty coping or aren't receiving enough oxygen. Monitoring the fetal heart rate is one way healthcare professionals assess how a baby is responding to labour.
There are two main approaches.
Intermittent auscultation involves a midwife regularly listening to your baby's heartbeat using a handheld Doppler or a traditional Pinard stethoscope. Instead of recording the heartbeat continuously, the midwife checks it at intervals throughout labour, assesses the heart rate, and listens for concerning changes.
Continuous cardiotocography (CTG) uses electronic equipment to record your baby's heart rate alongside your contractions. Usually, two sensors are held against your abdomen with elastic straps, producing a continuous tracing that healthcare professionals interpret.
Both approaches are forms of fetal monitoring, which is an important distinction. Sometimes the language used in maternity care can create the impression that women who don't have a CTG are somehow unmonitored, even though intermittent auscultation is an established and recommended method of assessing fetal wellbeing.
According to Queensland Health, intermittent auscultation is recommended for women with uncomplicated pregnancies and straightforward labours, while continuous CTG monitoring is generally recommended when additional risk factors are present.
However, the recommendations themselves are only part of the story.
What Does the Research Actually Tell Us?
One person doing particularly interesting work in this area is Dr Kirsten Small, a retired obstetrician and gynaecologist who now works as a researcher, educator, and writer. Through her research, including doctoral work examining central fetal monitoring systems, Dr Small has explored the evidence supporting routine CTG use and the ways fetal monitoring influences clinical decision-making and women's experiences of birth. One central question she raises is whether greater use of monitoring technology necessarily leads to safer births.
A major Cochrane systematic review published in 2017 examined research comparing continuous CTG monitoring with intermittent auscultation during labour. The findings were interesting. Continuous CTG monitoring was associated with a reduction in neonatal seizures, which are uncommon but potentially serious. However, the review did not identify a clear reduction in deaths around the time of birth or in cerebral palsy. At the same time, women receiving continuous CTG monitoring were more likely to have a caesarean section or an instrumental vaginal birth involving forceps or vacuum assistance.
These findings don't mean that continuous monitoring is unnecessary or that it cannot benefit individual babies. Reducing neonatal seizures is a meaningful consideration, but the available research has limitations, including the age and quality of some studies. What the findings do suggest, however, is that more monitoring doesn't automatically mean better outcomes, and any potential benefits need to be considered alongside the possibility of additional interventions.
I think that's an important conversation to have, particularly when continuous monitoring is sometimes presented as the obvious or safest choice without much explanation about what the research actually shows.
What If You're Considered High Risk?
This is where things become particularly interesting. In Australian maternity services, continuous CTG monitoring is commonly recommended for women who have certain risk factors. These might include a previous caesarean birth, pre-eclampsia, an epidural, an induction involving oxytocin or concerns about the baby's wellbeing.
These recommendations are not without clinical reasoning. Some circumstances increase the likelihood of complications, and identifying changes in a baby's heart rate can help healthcare professionals recognise when further assessment or intervention may be necessary. However, one of the limitations highlighted by Dr Small's research is that studies frequently group women with very different clinical circumstances together under the broad description of high risk.
A woman attempting a vaginal birth after caesarean (VBAC), for example, has a very different clinical history and risk profile from a woman experiencing pre-eclampsia or having her contractions stimulated with synthetic oxytocin. Yet the evidence doesn't always show how much continuous CTG monitoring benefits women with each individual risk factor.
Interestingly, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has acknowledged this limitation in its updated Intrapartum Fetal Surveillance Clinical Guideline. The guideline recommends that continuous CTG be offered when risk factors are identified, but also recognises that the evidence is generally insufficient to establish its benefit for every individual risk factor. Importantly, it emphasises informed consent and discussions about monitoring options throughout pregnancy and labour.
That doesn't mean women should disregard clinical recommendations. It means we should ask more thoughtful questions about why a particular recommendation is being made, what benefits are anticipated, and whether reasonable alternatives exist. For women planning a VBAC, in particular, this can be a really valuable conversation to have during pregnancy rather than waiting until labour begins.
When the Machine Becomes the Focus
Something else I find interesting about fetal monitoring is the way technology can influence the atmosphere in the birth room. A CTG machine produces a continuous stream of information, but that information still needs to be interpreted by a healthcare professional. The machine itself cannot determine with certainty whether a baby is experiencing oxygen deprivation or whether an intervention is required.
Interpreting CTG traces isn't always straightforward, either. Research has demonstrated that clinicians can interpret the same tracing differently, even when they have considerable experience. Dr Small makes an important distinction between continuously recording a baby's heartbeat and continuously monitoring their wellbeing. While a CTG produces an ongoing record, meaningful monitoring still depends on appropriate clinical interpretation, timely action and consideration of the broader circumstances.
Sometimes, though, the presence of the machine can shift everyone's attention to the screen. Midwives, obstetricians, birth partners and even labouring women themselves can become focused on the numbers and patterns on the monitor. This isn't necessarily a bad thing, particularly when there are genuine concerns about the baby's wellbeing, but it can change the experience of labour.
A woman who was previously moving instinctively, focusing on her contractions and responding to her body's sensations, may suddenly find herself watching a screen, worrying about changes in the heartbeat, or being asked to stay in a particular position to keep the recording reliable.
For some women, hearing their baby's heartbeat provides reassurance. For others, it can create anxiety, discomfort or a sense that their birth has become more clinical. Neither experience is wrong, and I think both deserve to be acknowledged.
Does Continuous Monitoring Mean You Have to Stay in Bed?
Not necessarily, though it depends on the equipment available and your individual circumstances. Traditional CTG systems often involve cables connecting the abdominal sensors to a bedside monitor. These can restrict movement or make changing positions harder, especially when the equipment struggles to maintain a reliable recording. However, some hospitals have wireless CTG systems, sometimes called telemetry, which can allow women greater freedom to move around during labour.
Even when continuous monitoring is recommended, it may still be possible to stand, sway, lean forward, use a birth ball or adopt different labouring positions while maintaining an adequate tracing. Women who have epidurals can also be supported to change positions with appropriate assistance from their healthcare team. Having a doula who is knowledgeable about maternal positioning can be especially valuable in these circumstances, helping women explore comfortable and potentially beneficial positions while working within the practical limitations of their care.
Another option may be an internal fetal scalp electrode, attached to the baby's scalp after the membranes rupture. This can provide a more consistent heart rate recording when external monitoring is difficult, but it is an invasive procedure involving a small puncture to the baby's skin and carries additional risks, including infection. As with any intervention, women should understand what is being proposed, why it is being recommended and what alternatives might be available.
The key is that continuous monitoring shouldn't automatically mean abandoning every preference you had for movement, positioning, or comfort during labour.
Who Else Is Watching Your Baby's Heartbeat?
There's another aspect of fetal monitoring that many women may never have considered. In some hospitals, CTG tracings aren't only visible on the monitor beside the labouring woman. They can also be transmitted to a central monitoring station, where healthcare professionals can view recordings from multiple birth rooms simultaneously.
At first glance, this sounds reassuring. Additional clinicians can identify potentially concerning changes, adding another layer of oversight. However, Dr Small's research on central fetal monitoring has raised questions about how these systems shape maternity care, particularly how they affect communication between clinicians, relationships between midwives and labouring women, and the overall atmosphere of the birth room.
For example, a clinician viewing a tracing remotely may identify something concerning without knowing the full circumstances of what's happening in the room. This can sometimes lead to unexpected interruptions or additional staff entering the birth space. There are also questions about whether central monitoring changes how much time healthcare professionals spend physically present with women. After all, a screen can tell us something about a baby's heart rate, but it cannot replace the broader assessment, reassurance, and individualised care a midwife provides at the bedside.
Research has not yet established that central fetal monitoring improves important outcomes for babies compared with CTG monitoring viewed within the birth room alone. This doesn't mean central monitoring cannot be helpful. It simply raises another important question: does introducing additional technology always deliver the benefits we expect?
And given that these systems may allow information to be viewed outside the birth room, women should also be able to ask who can access their monitoring information and how their privacy is protected.
What Does Informed Choice Actually Look Like?
I think one of the greatest challenges in maternity care is that women are often told what will happen without being given a meaningful opportunity to consider alternatives. There's an important difference between being told that continuous monitoring is recommended and being supported to understand why that recommendation has been made.
If continuous CTG monitoring is suggested during your labour, it's entirely reasonable to ask what specific concern has prompted the recommendation, what the monitoring is expected to achieve, what the evidence says about its benefits and limitations, and whether intermittent monitoring remains an appropriate option in your circumstances. You might also want to ask whether wireless monitoring is available, how you can keep moving during labour, or what would happen if you initially choose intermittent monitoring and a concern develops later.
Importantly, these conversations don't need to happen for the first time when you're already in established labour. The latest RANZCOG guidance encourages discussion of fetal monitoring options during the third trimester, when women arrive in labour, and as circumstances change throughout the birth. I think this is a positive step toward recognising that informed consent isn't simply agreeing to a recommendation. It's about understanding the available options and being actively involved in decisions about your care.
And, of course, decisions can change. You might begin labour planning to use intermittent auscultation and later decide that continuous monitoring is more appropriate. Alternatively, you might want to discuss your options again if your circumstances change. The goal isn't to make every decision before labour begins. It's to feel informed enough to participate in those decisions as they arise.
It's Not About Rejecting Technology
I want to be clear that none of this is about suggesting women should refuse continuous fetal monitoring or disregard the advice of their healthcare providers. Modern obstetric care plays an important role in identifying and managing complications, and in some cases, closer surveillance and timely medical intervention can be incredibly valuable.
Women also have different preferences. Some find continuous monitoring reassuring and actively want it. Others prefer intermittent monitoring because it allows them greater freedom and fewer interruptions. What matters is that women understand their options and can make decisions that reflect both their clinical circumstances and their personal preferences.
One thing I appreciate about Dr Kirsten Small's work is her willingness to critically examine long-established practices and ask whether the evidence supports the assumptions we've come to accept. That kind of questioning is essential to improving healthcart have to come at the’ to come at the expense of respecting the professionals who provide it.
If you'd like to explore the research further, I recommend visiting Dr Kirsten Small's Birth Small Talk website, where she shares accessible, evidence-based articles and educational resources about fetal monitoring and maternity care.
At Redland Doula Co, I provide personalised birth and postpartum support to families across Redland City, Brisbane and surrounding areas. If you're preparing for birth and would value someone by your side to support informed decision-making, continuity of care, and a positive birth experience, I'd love to hear from you.
