Introduction

Intrapartum fetal surveillance refers to the continuous or intermittent monitoring of the fetus during labour with the intent to assess fetal wellbeing and detect signs of distress or compromise [1]. There are two main methods of intrapartum fetal surveillance: continuous electronic fetal monitoring (CEFM) and intermittent auscultation (IA). CEFM involves the use of electronic devices to monitor the fetal heart rate and uterine contractions continuously throughout labour [1]. CEFM may be conducted via a cardiotocograph (CTG) either in wired, or wireless forms, internal scalp electrode (FSE) which involves a spiral electrode being inserted into the fetal scalp or breech [2, 3], or non-invasive fetal electrocardiogram (NIFECG), a wireless and beltless monitoring device which has more recently become available on the Australian market [4]. All forms of CEFM provide real-time information on the fetal heart rate pattern in conjunction with the measurement of uterine activity. Alternatively, intermittent auscultation involves listening to the fetal heart rate at specific intervals using a handheld Doppler device or Pinards’ stethoscope [5].

The aim of both CEFM and IA is to monitor the wellbeing of the fetus during labour and birth by providing fetal heart rate data to add to the overall clinical assessment of the woman or birthing person and their baby [1, 5]. Care involves excluding the suspicion of the presence of fetal hypoxia requiring further assessments and/or intervention to hasten the birth [2]. The choice of intrapartum fetal surveillance method depends on various factors, including the health status of the woman and her fetus, the stage of labour, the availability of monitoring equipment, and the preferences of the healthcare provider and the woman [3].

It is estimated that in Australia, more than half of the 300,000 women and birthing people who give birth each year are recommended to have CEFM in labour for indications such as induction or augmentation of labour, previous caesarean section, multiple pregnancy, use of epidural analgesia and/or delayed progress in labour [4]. Despite its widespread use, it is recognised that intrapartum fetal surveillance is not without limitations and challenges [6, 7]. Interpretation of fetal heart rate patterns can be subjective, and false-positive or false-negative results may occur, leading to unnecessary interventions or missed signs of fetal distress. According to the most recent Cochrane review, there is no evidence that continuous CTG monitoring improves maternal or neonatal outcomes, apart from a slight reduction in rates of neonatal seizures [1]. Furthermore, the review suggests that CTG may have deleterious effects, due to an association with increased caesarean section rates.

Literature about CTG monitoring often focuses on the safety of the fetus, as can be seen in key literature by authors including Chandraharan and Arulkumaran; Lamb and Heazell; Brocklehurst et al. [8–10]. This can overshadow the reality that the woman or birthing person, and the progress of labour, are impacted by the wearable or invasive medical device imposed upon them, often resulting in restriction of movement [11–14]. When labour is impeded, the potential for resulting intervention and surgical birth can result in negatively affecting the health of the neonate [15].

Since the introduction of wireless forms of continuous monitoring in 2003, qualitative literature describing women’s experiences of being monitored during labour and birth is limited [11, 14, 16, 17], and evidence of the experiences of women and birthing people in Australia remains scant [11]. To increase understanding of the experiences of women in the Australian maternity care system, we constructed a national survey with key questions about participants’ lived experiences of continuous fetal monitoring and/or intermittent auscultation. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia.

Methods

This paper is derived from a larger mixed methods study, ‘Women’s Experiences of Monitoring Baby (The WOMB Study)’ exploring the experiences of women and birthing people of fetal monitoring during labour, and the information they had received about fetal monitoring during pregnancy. Data were collected via a cross-sectional survey that was developed in the platform ‘Qualtrics’ [18] and distributed online via social media sites. The survey was developed by the research team, based on their expertise in the topic area, and findings from prior research on fetal monitoring [4, 11–13], humanising birth [19], ethics and informed consent [20], and childbirth and parenting education [21, 22]. The survey was piloted by three women who had recently given birth, which informed subsequent revisions made prior to recruitment.

The survey was open to participants from 30th May to 30th June 2022. Participants were eligible if they had given birth in Australia in the past five years and had experienced any form of fetal monitoring during labour, either intermittent auscultation or continuous electronic fetal monitoring. The analysis of quantitative survey data will be published elsewhere.

Approval to conduct the study was granted by the University of Technology Sydney Human Research Ethics Committee (approval no. ETH21-6563) and ratified by the University of Notre Dame Human Research Ethics Committee (approval no. 2022-063S). A detailed research data management plan was approved by both ethics committees and all data collection and analysis complied with the requirements for sourcing the data. Information about the study was provided to participants to read before they commenced the survey. Informed written consent was implied by completion of the survey, as advised in the participant information and as approved by the ethics committee.

For this paper, we extracted specific data on the perceived benefits and disadvantages of the monitoring that the participants received, including their answers to the following questions:

• What do you think are the benefits of being monitored?
• What do you think are the downsides of being monitored?
• If given the choice, would you choose the same form of monitoring?
• How would you prefer to be monitored?
• Now that you’ve had your baby, what do you wish you had been told about monitoring during labour?
• Do you have any other comments you want to share about your experience of monitoring during labour and birth?

The qualitative and inductive content analysis approach of Elo and Kyngas [23] was used to synthesise the data from the open-ended survey responses. According to Elo and Kyngas [23], their method can be applied qualitatively or quantitatively and in the former, used either deductively or inductively [23]. An inductive approach was taken as we aimed to derive concepts from the data, rather than deductively testing an extant theory or set of assumptions. Although quantitative forms of content analysis often include percentages or counts of codes and concepts, we felt it most appropriate to use a qualitative and inductive approach. Hence, no percentages or counting of data are included in our findings, as the analysis looked for relationships, patterns, and concepts in the data, rather than frequencies. We followed the three-stage process of content analysis espoused by Elo and Kyngas [23] that is, preparation, organising and reporting.

The preparation phase involved reviewing all survey questions with open-ended qualitative responses and allocating them to each researcher for coding and analysis, according to their area of expertise [23]. Authors, DF, RC and EN individually conducted open coding of the data pertaining to the questions described above which focused on participants’ intrapartum experiences.

The organising phase followed, in which conceptual categories were formulated [23]. To commence this process DF, RC and EN met for a full day workshop where codes were shared, reviewed, and discussed to make sense of the data. We then mapped codes into categories on a whiteboard, comparing our open codes and sharing interpretations, moving codes into different categories eventually agreeing on a conceptual framework. We continued to meet regularly by Zoom over the following six months, in an iterative process to confirm final categories and sub-categories. The categories and coded data were presented and discussed with the rest of the research team (co-authors KL, VS and KS). After deliberation on the various conventions of Content Analysis, we chose to structure the findings into categories and sub-categories, to align with the Elo and Kyngas [23] methodology which espoused that the term ‘concept’ is used when theory development is the goal of the analysis, or ‘category’ when theory is not anticipated [24, 25]. We chose ‘category’ accordingly, and the sections of each category ‘sub-categories’.

Reporting involved writing up the findings collaboratively and supporting our analysis with exemplar quotes. Categories were refined and consolidated [23]. Transcribed quotes from respondents’ survey responses were used to illustrate the categories.

Results

Valid responses to the survey were received from 861 participants. The average age of participants was 33 years, slightly higher than the most recently available Australian national average of 31.1 years [27], however, falling within the 30–34 year age range which accounted for the largest proportionate age range (38%) of all births in 2021. Responses were received from all states and territories of Australia, half from New South Wales and Victoria. More than 85% of respondents were born in Australia, higher than the national rate of 65.6% [27], which may be accounted for by the self-selection nature of the social media recruitment method used. Respondents identifying as Aboriginal or Torres Strait Islanders totalled 3.3%, lower than the proportion of First Nations women giving birth in Australia in 2021, reported as 5% [27]. Most participants were having their first baby (65%) and had completed tertiary level education (72%). In answer to the question, What kind of monitoring did you have in the birth you are describing now? 798 participants responded. Table 1 details the type of monitoring experienced by women in the survey, and where there was more than one type of monitoring (excluding admission trace), this was described as ‘multiple’ monitoring.

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Table 1. Type of monitoring experienced by survey participants.

https://doi.org/10.1371/journal.pone.0303072.t001

Two categories were constructed from the analysis of the data, Tending to the machine and Impressions of the machine. Each of these categories contained three sub-categories. Tending to the machine consisted of the sub-categories, Midwifing the monitor, Over-reliance on an unreliable machine and Bringing the baby into the room: a double-edged sword. The second category, Impressions of the machine, consisted of the sub-categories, Feeling uncomfortable and restricted, Taking me out of the zone, and Wishing I knew it was a choice.

Discussion

The findings of this study provide a comprehensive dataset on Australian women’s experiences of fetal monitoring in labour. The two categories constructed indicate the influence of fetal monitoring technologies on women and birthing people during their labour and birth experiences. The first category, Tending to the machine, outlines participants’ perceptions of the way clinicians interact with fetal monitoring technologies, indicating their sense that the technology and its associated data was privileged over their lived human experience. Although the survey was open to women who had experienced all forms of fetal monitoring, the majority of responses referred to experiences of CEFM. The presence of audible and visible continuous fetal heart rate data in the birth room was considered a ‘double-edged sword’, increasing anxiety for some who were not comfortable with the continual changes in fetal heart sounds and allaying the fears of others who felt reassured by the continuous trace.

The second category, Impressions of the machine, described the direct impact of fetal monitoring devices upon the labour and birth experiences of women and birthing people. These impressions included significant discomfort due to tight elastic belts of CTGs, restrictions to freedom of movement and the resultant inability to employ planned strategies for managing the pain of labour. This category also outlined the lack of information provided during pregnancy relating to their options for fetal monitoring in labour and a lack of informed consent which left women ‘Wishing they knew it was a choice’.

Using a care ethics lens [20, 28–31] to interpret these findings identifies an endemic lack of concern in maternity settings for genuine ethical care. Although technology can be useful in contributing to an overall clinical picture, it is not a replacement for attentive, human caring. Dutch philosopher Peter Paul Verbeek’s post phenomenologist theory of technological mediation [32] addresses the ways in which humans experience technology in the world, and the ways in which human experience is shaped by technologies. Verbeek [32] proposes that, as humans, we need to mediate our interactions with technology, rather than being locked into historical perspectives of seeing technology as either instrumentalist (under our control) or determinist (in control of us). By rejecting the notion of technology use in the birth space altogether, we minimise the opportunity to consider its impact in a nuanced manner.

When entering a hospital labour room, fetal monitoring technologies promote a notion of fetal personhood, by inviting us to listen to the fetal heart and watch its physiological patterns on a screen. In 2008, Verbeek wrote an analysis of the impact of routine antenatal ultrasound upon our understanding of fetal personhood, and parental-fetal relations [33]. His approach was reminiscent of the historical perspective presented in 1993 by Duden [34]. For example, the recognition of pregnancy was once a profoundly personal bodily sensation for a woman experiencing ‘quickening’, technology has brought about the anticipation of external, and often biomedical, confirmation of pregnancy [34]. Routine pregnancy ultrasound examinations may provide this confirmation prior to the woman’s own bodily experiences, whilst establishing the status of the fetus as a potentially independent being, separate from its mother [34]. We can observe fetal movements, make anatomical measurements, and share photographs of an unborn baby, months before they are born. Duden posits that technological transformations have strengthened the independent legal status of the fetus and the sense that pregnant women’s bodies need controlling, as we operate within what Duden refers to as ‘the age of the public fetus’ [34] (p.55).

We propose that the perspectives of care ethics [20, 28, 30, 31] and technological mediation [32] can equally be applied to fetal monitoring in the context of caring for women and birthing people during labour. By this, we mean that midwives and other health professionals should not simply comply with the demands of the fetal monitoring technology by midwifing the monitor instead of the person, which arguably increases the risk of physical and emotional harm. Instead, midwives and other health care professionals can mediate the impact of technologies upon the experiences of women and birthing people, while sustaining an ethics of care which keeps the individual at the centre by focusing on authentic engagement, attentiveness, and relationality [30, 31].

The first category of results, ‘Tending to the machine’, shows the propensity of continuous CTG monitoring in labour to shift the focus of care from the birthing woman or person to the machine. The presence of the machine in the room led to the experience of the technology having more importance than–or dominating—the lived human experience. The belief that CTG monitoring presents the safest form of monitoring an unborn baby, and that it can prevent an adverse fetal event, is an example of technorationalism. The concept of technorationalism includes the idea that ‘complex’ (e.g., technological) solutions are more suitable than simple (e.g., human care) ones, and views all technology as ‘progress’, whether or not it actually provides any benefit [19].

Preoccupation with the machine necessarily entails reduced interaction with the birthing woman, hindering midwives’ ability to be authentically ‘with woman’ [35]. Midwives have reported that CTG transducers require constant ‘fiddling’ to maintain connection and expressed that new technologies are urgently needed that better account for the needs of midwives and women in the birth room [12]. In our study, women sensed that their midwife was inconvenienced by their instinctive need to move and change positions in labour, sending a message that the fetal heart rate was the central focus of the midwife’s work, superseding the woman’s comfort and bodily autonomy, thereby reducing her choices.

In an institutional ethnography of the effects of a central monitoring system, where all CTG readings are available to all staff in a central location [36], midwives described being concerned by an emerging practice where, on seeing the reading, a clinician (doctor or senior midwife) would enter the labour room, having made interpretations and decisions, before consulting with the attending midwife or the woman herself. This provoked a sense of anxiety for midwives, and our findings align with this, from the perspective of birthing women and people. This shift in focus, from the woman–who is supposed to be at the centre of care–to the machine–was experienced as dehumanising. A resulting circumstance of the central monitoring system was the notion that clinical decision making was undertaken without a full clinical picture [36], and this was also shown in our subtheme, over-reliance on an unreliable machine. The women in our study described knowing that a non-reassuring trace was due to something happening in the room–an embodied and experiential knowledge—such as movement or loss of contact, but this information is not inherently embedded into the CTG data (though it can be added manually).

Perhaps more concerning is the second category, Impressions of the machine, which illustrates the way that fetal monitoring was experienced by women as a certainty. According to the four principles of biomedical ethics [37, 38], treatments and interventions in medical settings can only be given with full and informed consent. The context of pregnancy and birth carries no legal exemption [39]. Recent research identifies that in the maternity sector in particular, this does not always occur [29, 30, 40]. Knowledge and policy, skewed towards medicalised processes, shapes the way that choices are presented to pregnant and birthing women and people [41]. In addition, women have described feeling coerced and bullied in their interactions with perinatal medical professionals [42, 43]. Presenting any clinical intervention as a given necessity, or as routine rather than a choice, as described in the second category, Impressions of the machine, does not conform to current ethical standards. The idea that CTG monitoring can save a baby’s life is misleading, based on current evidence. And yet, this was an overwhelmingly common experience expressed by the women in this survey. Often, women who should have been eligible for IA were nevertheless continuously monitored with CTG. Women who declined monitoring, or particular forms of monitoring, had their wishes overridden [42, 43], which contravenes the ethical principle of respect for autonomy [37, 38], and is experienced as dehumanising and potentially as causing trauma.

Hospitals used information gathered from CTG as a way of gatekeeping particular practices. For example, some women described having to have a CTG trace before getting into the bath, even though a reassuring admission trace is not predictive of birth outcomes [44]. Interestingly, since 2003, continuous monitoring has been possible during water immersion with waterproof CTG (telemetry), but hospital policies are often prohibitive, or hospitals do not invest in the appropriate equipment for this to occur [13].

The strength of this study is that there is little research published on women’s experiences of intrapartum fetal monitoring in Australia, and to our knowledge, no survey data that has attracted such a large response such as the 800+ responses received. The rich data provided detailed hospital experiences from across all states and territories of Australia. Some respondents who were commenting about their experience of monitoring in their own labour and birth identified themselves as midwives, providing an interesting perspective from both sides of the lived experience.

Limitations include the nature of recruiting via social media, and we acknowledge there is a higher chance that the participants are self-selecting and may be more likely to have a negative interest in the topic. However, the rich data provided detailed hospital experiences from across all states and territories of Australia. It was also clear from scrutinising the data that some respondents who were commenting about their experience of monitoring in their own labour and birth, also identified themselves as midwives, providing an interesting perspective from both sides of the lived experience.

The principle of informed consent protects women and birthing people’s rights to voluntary consent or refusal of any medical treatment, procedure, or intervention based on the provision of sufficient, evidence-based information to make a decision that reflects self-determination, autonomy, and control [39, 45]. Our findings indicate that many women did not feel they had adequate information to make an informed decision relating to the method of fetal monitoring used throughout their labour. As such we strongly recommend that clinicians ensure they discuss fetal monitoring with women in the antenatal period, providing adequate verbal and written information outlining risks, benefits and alternatives. In addition, women need an opportunity to discuss this at the commencement of labour, with clinicians ensuring they gain continual consent rather than presuming consent once a form of fetal monitoring has been employed.

Other implications for practice include encouraging midwives to become more proactive in mediating the impact of fetal monitoring. Midwives need to take responsibility for the way in which they care for women and birthing people in the presence of technology, and for considering how the chosen form of monitoring technology may impact their experiences and ability to labour. For example, freedom of movement is an important aspect of supporting the physiology of labour and birth and managing pain. If freedom of movement is being prioritised, the restriction created by the use of wired CTG is clearly going to be inappropriate. Other options would need to be discussed. Keeping the birthing woman in mind and prioritising individual needs are key practices needed to provide high quality woman-centred (inclusive of all birthing people) intrapartum care. Future clinical guidelines and professional position statements need to address this issue, and many currently do not.

Future research implications include exploring ways to promote informed decision-making during pregnancy around options for intrapartum fetal monitoring, so that women and people have bodily self-determination as active participants in the assessment of their labour and the well-being of their baby. Additionally, a few women who have experienced sexual abuse self-identified in this survey that restriction of movement in labour and birth was re-traumatising. More in depth research is needed to explore this sensitively, to understand the full impact of restriction of movement for these women. The findings showed that clinicians’ shifting their attention away from the woman, who should be at the centre of her care, towards the machine, may contribute to suboptimal clinical decision-making and reduced options for women; something that needs to be explored in future research.

Conclusion

The findings of this research highlight serious issues which may be integral to current problems in maternity services, such as reliance on technology over human interaction, and overriding the right to bodily self-determination. These findings are concerning not only because they highlight how monitoring technologies can disturb the neurohormonal processes of labour, but, more alarmingly, the way such technologies are experienced as mandatory, leading to enforced physical restriction and therefore a denial of human rights. Midwives need to do better to uphold this right and to ensure that individualised information is given about types of intrapartum monitoring to ensure informed consent. This is important not only in the humanising of care, critical evaluation and mediation of technology is a key element in humanising birth. A crucial aspect of this is for midwives to take responsibility to mediate the impact of fetal surveillance on women and birthing people and to incorporate professional guidance on how to best do this. When using any technology, it is important for midwives to direct attention to the care, support and information needs of the birthing person, and use the information gained to support these needs.

Supporting information

Acknowledgments

We acknowledge Maridulu Budyari Gumal SPHERE and all the participants who responded to our survey.