Literature review ~ Intrapartum cardiotocograph monitoring (EFM) & perinatal outcomes for women at risk for complications

by faithgibson on September 29, 2023

in Cesarean Politics, Electronic Fetal Monitoring, Women's Reproductive Rights

Note-2-self ~ copied to AI project on CALM auscultation incl. providing background info on EFM (last edited 10-25-2023)

Review article from Australia posted

Editor’s Preliminary Notes:

In UK and Australia, what we “Yanks” describe as an “electronic fetal monitoring” (EFM for short) is called “CTG“, which is an abbreviation used for cardio – toco – graphy or “cardiotocography“.

So every time you see the initials ‘CTG’ in the following article, think “EFM” for electronic fetal monitoring as a verb, and electronic fetal monitors as a noun.

The Most Common Childbirth Practice in America — EFM — is both unnecessary and dangerous


In spite of the expense of EFM (about $15,000 per unit), this product does not provide any benefit or better “outcomes” for babies or their mothers.

This is a well-established scientific fact, proven over and over again for more than 50 years.

Unfortunately, EFM is routinely used on healthy women in more than 90% of all hospital labors.

The unnecessary and inappropriate use of EFM is directly responsible for a three-fold increase in Cesarean surgeries and indirectly responsible for a subsequent increase in maternal mortality (death) and morbidity (serious complications, often with long-term consequences). {see references at the end of this article}

However, electronic fetal monitoring is a very expensive technology, which means it is especially profitable for the companies that manufacture fetal monitors.

This helps explain why electronic fetal monitoring technology has been found, again and again over the course of 47 years. While it provides NO benefit, EFM has always been associated with both direct and indirect harm to childbearing women.

This has been an established fact since Havenkamp‘s clinical trial comparing the outcomes of EFM to auscultation was published in 1976. This was followed by hundreds of other scientific papers that confirmed their 1976 finding — while EFM had no benefit for babies, it tripled the C-section rate (16%) compared to auscultation (only 6%).

This is a predictable consequence of medically unnecessary Cesarean surgeries and delayed and downstream harm in post-Cesarean pregnancies and mandated repeat C-sections.

Politically-effective Action — Mandatory Product Disclosure

Many other posts on this site call for legislation that would legally require the manufacturers of EFM equipment to include the scientifically established, irrefutable fact that their EFM technology provides NO benefit to the unborn baby, either before or after its birth, while its routine use increases the rate of surgical deliveries and post-cesarean maternal deaths.

Mandatory Product Disclosure (MPD), as is legally required for virtually every other type of medical technology, would establish a legal obligation for obstetrical providers (hospitals and physicians) to inform pregnant and laboring women that intermittent auscultation (IA) has been scientifically established as the most effective method for monitoring fetal well-being during labor and that using continuous EFM during the labor of healthy women with normal pregnancies is associated with three-fold increase in Cesarean deliveries and an elevated level of post-Cesaean maternal mortality.

We must keep in mind that a Cesarean section is major abdominal surgery, which always is accompanied by known and unknown risks and often includes unexpected problems.

Hospitals began replacing auscultation with continuous EFM during labor in the 1970s. At that time, no scientific studies had established that EFM was safer or better than IA. But starting in 1976, multiple comparison studies of EFM vs. IA found that EFM did not benefit the fetus, while at the same time being associated with an increased rate of Cesarean deliveries and multiple intra- and post-op complications, as well as delayed and downstream problem with fertility and future pregnancies.

But most egregious of all is the significant increase in maternal mortality rate following complications of Cesarean surgery and  longer hospitalization and re-hospitalization that increases their exposure to iatrogenic (i.e. medical mistakes) and nosocomial harm (i.e. hospital-acquired drug-resistant infections, medication errors, etc).

Women and Birth

Volume 33, Issue 5, September 2020, Pages 411-418
Women and Birth
Review article

Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review

Volume 33, Issue 5, September 2020, Pages 411-418

Women and Birth

Literature review for:

Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk rights and content



Caesarean section rates have risen in high-income countries.

One of the potential drivers for this is the widespread use of CTG monitoring.


Intrapartum cardiotocograph monitoring is considered to be indicated for women at risk for poor perinatal outcomes.


This systematic literature review with meta-analysis examined randomised controlled trials and non-experimental research to determine whether cardiotocograph monitoring rather than intermittent auscultation during labour was associated with changes in perinatal mortality or cerebral palsy rates for high-risk women.


A systematic search for research published up to 2019 was conducted using PubMed, CINAHL, Cochrane, and Web of Science databases. Non-experimental and randomised controlled trial research in populations of women at risk which compared intrapartum cardiotocography with intermittent auscultation and reported on stillbirthneonatal mortalityperinatal mortality and/or cerebral palsy were included. Relative risks were calculated from extracted data, and meta-analysis of randomised controlled trials was undertaken.


Nine randomized controlled trials and 26 non-experimental studies were included.

Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates.

The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy.


Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome.


There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits.


Intrapartum cardiotocograph (CTG) monitoring was introduced in the 1970s.1 The CTG records and displays the fetal heart rate and uterine tone over time making it possible to examine relationships between heart rate and uterine activity. Fetal heart rate patterns are considered to provide physiological information regarding oxygenation of the fetus.2

During labour a reduction in placental blood flow occurs during uterine contractions.3 This reduction may place the fetus at risk for low oxygenation.4 Hypoxia is presumed to be responsible for a proportion of perinatal deaths and cases of cerebral palsy (CP).5, 6

CTG monitoring was introduced as a screening tool in order to detect fetal hypoxia so that corrective action could be taken.7 The goals of intrapartum CTG monitoring include reducing perinatal mortality and CP. CTG monitoring confers no benefits over intermittent auscultation (IA) for women considered to be at low risk for poor perinatal outcome.8

Most professional guidelines regarding intrapartum fetal monitoring therefore consider that IA is appropriate for women at low risk.

Continuous intrapartum CTG monitoring for women at risk is universally recommended within professional guidelines.9, 10, 11, 12, 13 Caesarean section rates have increased over the past two decades,14 with clear evidence that use of CTG monitoring contributes to increases in the use of cesarean section.15

Rates of maternal mortality and significant maternal morbidity appear to be increasing in some high-income countries16 and are associated with rising cesarean section rates.17, 18

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Intrapartum Fetal Surveillance guideline acknowledges that evidence from randomized controlled trials (RCTs) do not demonstrate a perinatal benefit from intrapartum CTG monitoring for infants born to women with risk factors but suggests that non-experimental evidence supports this practice and therefore justifies the guideline’s recommendations for CTG use.9

No systematic review of non-experimental research regarding intrapartum CTG use in high-risk women has previously been undertaken. The Cochrane review of RCTs investigating intrapartum CTG monitoring included subgroup analyses for high and mixed-risk populations of women, but this information was not foregrounded within the review making it easy to overlook.

Given that CTG monitoring is associated with surgical risks for women, it is important to revisit the evidence regarding intrapartum CTG monitoring to ensure that current efforts to reduce perinatal hypoxic injury and death are effective and balance this risk.

The research question underpinning this systematic literature review and meta-analysis was: does continuous intrapartum CTG monitoring modify the risk for fetal or neonatal mortality, or cerebral palsy, for infants born to women who are considered to be at increased risk of experiencing perinatal mortality or CP? In order to address this question evidence from both RCTs and non-experimental research was examined.

Section snippets

Literature search

This systematic literature review was registered prospectively with PROSPERO (CRD42018114637). The PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and Web of Science databases were searched in November 2018 and updated in July 2019. The search string used was (“Cardiotocography” OR “Fetal Monitoring” OR “Monitoring, Physiologic”) AND (“Labor, Obstetric” OR “Delivery, Obstetric”). The search was limited to English language publications, humans and no date

Non-experimental research

Twenty-seven non-experimental papers reported data between 1972 and 2018. Data from Fleet et al.24 and Hopkins et al.25 were merged, as the earlier paper provided data prior to and the latter provided data after CTG monitoring was introduced.

Most research (n = 16) was undertaken in the United States of America (USA). The remainder was conducted in Canada (n = 3), Denmark (n = 2), the United Kingdom (UK) (n = 1), Africa (n = 1), Germany (n = 1), Israel (n = 1), Norway (n = 1), and Switzerland (n = 1).


Only non-experimental studies at critical risk of bias showed reductions in perinatal mortality related to intrapartum CTG monitoring. During the 1970s and 1980s significant advances occurred in neonatal care.62, 63 Contraception and pregnancy termination became increasingly available, and there was a reduction in preterm birth, which is known to be a strong determinant of perinatal mortality.64 These changes occurred contemporaneously with the introduction and expansion of CTG use and may well ????? (no further text available on their website)


Evidence from quality non-experimental research and RCTs shows no difference in the rates of stillbirth, neonatal mortality or perinatal mortality between the use of IA or CTG monitoring during labour in populations that include or consist of women considered to be at increased risk for poor perinatal outcome. Intrapartum fetal surveillance guidelines which recommend CTG monitoring for women considered to be at risk are not consistent with the evidence base. Clinicians and professional bodies

Ethics statement

None declared.


None declared.

Conflict of interest

None declared.

CRediT authorship contribution statement

Kirsten A. Small: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Mary Sidebotham: Supervision, Validation, Writing – review & editing. Jennifer Fenwick: Supervision, Writing – review & editing. Jenny Gamble: Supervision, Validation, Writing – review & editing.


The authors would like to acknowledge the assistance of Ms Bonnie Dixon, Health Librarian, Griffith University who assisted in structuring the search terms, and Professor Rob Ware, Menzies Health Institute, for statistical advice.

References (66)

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