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Improving electronic fetal heart monitoring


The stakes are high when a baby is being born. Monitoring the fetal heart rate can help in assessing the baby’s wellbeing during labour and in determining whether action is needed.

Cardiotocography (CTG) is a method of electronic fetal monitoring using a machine that can print out a “trace” of the baby’s heartbeat. But problems in interpreting and responding to CTG traces are among the most common causes of avoidable harm during labour. When harm occurs, the consequences may be lifelong and have enormous impacts on families – and  also contributes to growing spend on clinical negligence claims.

Training midwives and doctors on how to interpret CTG traces has been the dominant strategy for improving safety so far, but evidence that it works remains unclear. To improve fetal heart rate monitoring, we need to better understand the whole range of influences on risk, and not just individual competence.


This study was conducted by a multidisciplinary team of social scientists, human factors/ergonomics experts, midwives, and obstetricians.

First, we carried out a systematic review investigating the effects of training healthcare professionals in CTG. Published in BJOG, it showed that many of the studies in this area are of low quality. There is only limited evidence of the impact of CTG training on maternal and neonatal outcomes. Robust evidence on the optimal content and delivery for CTG training is lacking. You can read more about this study here.

Second, a team of human factors experts and social scientists studied CTG practices in three maternity units across the UK. Using observations and interviews to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, the study found that electronic fetal monitoring can be understood as a complex sociotechnical activity. Tasks, people, tools, and technology, and organisational and external factors all exert important influences on safety. This study is published in BMJ Quality and Safety, and you can read a summary here.

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.

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