When I gave birth to my first child in 2003, I was as prepared as I could be: positions, breathing, birth plan. What I hadn’t accounted for was an uninvited, domineering presence in a corner of the room that would so dictate proceedings that no one dared act without referring to it. The cardiotocography (CTG) machine, the silent birth partner.
CTG machines measure fetal heart rate and uterine contractions and are now omnipresent in labour wards, but it was never meant to be this way. When they were first developed, in a partnership between Konrad Hammacher and Hewlett Packard in 1968, they were to save lives by detecting the early stages of hypoxia – babies starving of oxygen in the womb. Following their introduction in hospitals from the early 1970s, perinatal deaths went down (although this also coincided with better antenatal screening), but for the last 10 years this figure has remained static. And the number of babies born with cerebral palsy has not decreased in the last 100 years (it’s still not known if cerebral palsy is absolutely a birth injury, or happens at another time).
Meanwhile, there is increasing litigation against the NHS directly related to the misinterpretation of cardiotocograms (CTGs) resulting in babies born dead or damaged. The cost of these lawsuits has risen sevenfold in four years: from £11.8m in 2006 to £85.8m last year.
Without question that CTGs save lives, but there is a big problem – like all equipment they are only as good as the people operating them, and results can be difficult to interpret. Trials show they can lead to false positives, which can lead to unnecessary intervention. And because CTGs are a monitoring, not a diagnostic tool, the results should never be read in isolation but as part of a jigsaw.
My first labour, in 2003, resulted in various interventions – induction, forceps, emergency C-section, lumbar puncture for my baby, IV antibiotics (the side effects of which could have been profound deafness) – many triggered by the CTGs on which we all, slavishly, started to rely. Looking back, I can only compare parts of it to otherwise rational, intelligent people over-relying on satnav and driving up one-way streets, simply because a machine told them to. There were times when the midwives attending paid more attention to the machine’s spewing paper tongue than me. Look at me, I wanted to say, look up.
With CTGs, one midwife can sit in front of a central monitor and keep track of several women in one go. “CTGs are the only way,” one senior member of maternity staff told me, “to stretch one midwife over more than one woman.” Contrary to popular belief, things don’t go wrong in labour from one minute to another, there are warning signs – signs a CTG can pick up, but there has to be someone there to interpret the data and get appropriate help quickly. Otherwise CTGs are not just useless but dangerous, providing a false sense of security.
With hindsight and after much analysis of all the data of my own first birth, (which took many years) there was no real evidence to show my daughter was indeed ever in distress, so I’ll never know if the C-section saved her life or if I took up unnecessary medical time and resources. But at least I had the luxury of musing with a live, healthy baby. About 500 babies die each year as a result of misinterpretation of CTGs.
After the birth I became highly involved with maternity services, acting as a lay representative at a large teaching hospital. The most harrowing case I ever sat in on was that of a woman whose baby showed obvious signs of distress, but the medical staff attending only looked at the last few sheets of the printout (which concertinas into a neat pile as it prints out, I often wonder if part of the answer would be to simply not perforate the paper). In other words, instead of flinging their arms wide and looking at data that would have given them a good overview, their hands did no more flicking than if they’d been reading a paperback book.
There is another major problem, which has nothing to do with CTGs per se, but which their use flags up. Remember those unnecessary interventions mentioned earlier? With increasing C-sections, some senior staff are in theatre at a time when they should be on the ward. When staff suspect something is not right they are often scared of getting help. “If you suspect something is wrong,” more than one labour ward professional told me, “you need to get a doctor with experience, and if they’re in theatre performing a C-section, which they increasingly are, it takes a lot of courage to make a fuss.” So you have situations where doctors are performing C-sections that may or may not be necessary and have often been decided on by the (mis)reading of a CTG, and there are other women whose babies desperately need C-sections, but are not getting them at all, or in time. Some babies are being monitored to death.
This is not a problem that is going to go away. We have a shortage of midwives that is entirely cash-led, with more cuts threatened, despite a pre-election promise to increase the number. The more continuous the care a woman receives, the less chance of a breakdown in communication. There will now be much talk of retraining staff in the reading of CTGs (more money spent, more staff away from the labour ward), and certainly that’s important. But, yet again, it’s a misreading of the situation. The CTG machine was never meant to be the labouring women’s default companion: an experienced midwife was.