Improving electronic fetal heart monitoring


The stakes are high when a baby is born. Children harmed during labour can face lifelong consequences, and so avoiding preventable harm is a priority for healthcare providers around the world.

Cardiotocography (CTG) is used to monitor a baby’s heart rate during labour. A CTG machine listens to the baby’s heart rate through the mother’s abdomen and prints out an electronic “trace” of the baby’s heartbeat. By observing this trace and considering how the mother is progressing in labour, healthcare professionals aim to detect signs of fetal compromise and determine if action is needed.

Yet evidence shows that problems classifying and responding to CTG traces are among the most common causes of avoidable harm during labour. On top of the enormous impact for families, these errors are contributing to a growing litigation crisis, where spending on negligence claims in England is rising faster year-on-year than NHS funding.

The conventional wisdom has been that training midwives and doctors on how to interpret CTGs will reduce errors, but exactly how – and whether it makes a difference – remains unclear. To improve fetal heart rate monitoring in an effective, replicable and scalable way, we need to learn from healthcare professionals and better understand both the social and technical aspects affecting CTG classification and the actions taken in response.


We aim to develop and evaluate an intervention to improve fetal heart monitoring in the UK and make maternity care safer for babies and families. Toward that end, our multi-professional team of social scientists, researchers, midwives and obstetricians will look at how CTGs are classified, interpreted and responded to in UK maternity wards. We will identify hazards and work out how they can be addressed.

The project will begin with two systematic reviews of existing studies: one review investigating the effects of training healthcare professionals in CTG, and another review looking at the influences on safety of CTG in hospital-based maternity care settings. Next, we will observe the routine working practices of midwives and obstetricians in three maternity units across the UK – a method known as ethnography – and interview healthcare professionals so as to broaden our understanding of the social and cultural context that influences CTG classification. These findings will inform a framework of hazards in fetal heart rate monitoring.

We will then consult with healthcare professionals and the public to come up with an intervention. A follow-on project will evaluate its impact. Work on this project is expected to continue until 2021. Check back here for updates and research findings.

Funding and ethics

This study is funded by the Health Foundation’s grant to The Healthcare Improvement Studies Institute (THIS Institute). It is independently led by THIS Institute. The study was reviewed by West Midlands – South Birmingham Research Ethics Committee.