This systematic review and thematic analysis has identified themes related to professionals’ views of monitoring the FHR during labour through a synthesis of 11 studies on this topic. Four prominent themes (reassurance and safety, technology, communication/education and midwife by proxy), which might be considered influential when attempting to implement evidence-based FHR monitoring practices during labour, emerged from the data.
EFM offered professionals reassurance because they perceived it as providing the hard copy ‘proof’ of an uncompromised baby. This ‘proof’ was perceived to minimise exposure to criticism and potential litigation. However, professionals also recognised the false sense of security offered by EFM and not all professionals relied on the CTG to ensure a good neonatal outcome. The view that EFM offered reassurance of an uncompromised baby appeared to change over time. The earlier studies, for example, Cranston , and Birch and Thompson , demonstrated more faith, by professionals, in EFM assuring a good outcome than later studies [26, 30, 32]. This may reflect the lack of evidence of benefit on the safety and efficacy of EFM over IA that has emerged from randomised trials  during this period of time. In addition, evidence reporting variations in inter- and intra-observer agreement in CTG interpretation has emerged [33, 34] since the publication of the earlier studies and this may have affected some professionals’ confidence in EFM use.
Determining choice for or differentiating between types of FHR surveillance based on perceptions of risk as influenced by feelings of safety and reassurance can pose challenges for professionals in clinical practice. This is because the notion of risk in maternity care remains ill-defined and ambiguous and is often made more complex by professionals interpreting risk in very different ways depending on knowledge and past experiences . The identified need by professionals, to have hard-copy proof of FHR surveillance, as a perceived safety mechanism and as a potential protector against possible litigation, might be overcome by recent developments in FHR monitoring technology. These developments include the ability of hand-held Doppler devices to sequentially store information on FHR auscultations and in some instances produce paper print-outs of intermittent FHR recordings. This ‘paper-proof’ could potentially facilitate the choice of IA over EFM as it addresses the concern, to some extent, of safety and reassurance when performing FHR monitoring in clinical practice.
Professionals reported a preference for IA, yet also reported difficulty in using IA due to poor staffing levels, busy clinical environments and the increased medicalisation or industrialisation of childbirth. Contrary to this, and although we have found no evidence in the literature supporting this view, it might be plausible to assume that EFM itself is increasing professionals’ time requirements and requires more time than when using IA in practice. For example, the time taken to maintain EFM equipment, respond to alarms and interpret the CTG trace, could, in practice, take much longer than the time required to record the FHR by IA. Furthermore, if EFM causes increased discomfort leading to an increased need for regional analgesia, then this will require increased observation by clinical staff and ultimately a greater commitment of time by professionals. The perceived benefits of using EFM when staffing levels are low or when the clinical environment is busy should not, however, supersede best practice guidance which recommends the use of IA for low risk women during labour [36
]. In addition, professionals describe using EFM as a protector against potential litigation and as a midwife by proxy. However, applying a CTG because a professional cannot be with a labouring woman implies that a professional cannot watch the monitor, therefore reducing any protector effect potentially offered by EFM. In addition, IA allows for close proximity and engagement with women, a view highlighted by women as being very important [37
]. This might allow for increased communication and afford professionals a greater view of the overall clinical picture. As Shearer [39
‘intrapartum fetal death is not prevented by monitors; it is prevented by an alert doctor [midwife] at the bedside of a laboring woman’ (p.127)
Of interest in this review is the finding, in two of the included studies [30, 32], of a strong agreement that CTGs are used unnecessarily (74% and 70% in these two studies, respectively) and that they can lead to unnecessary routine intervention (61% and 82.5%, respectively), compared to, in the same two studies, a reported strong disagreement that using any technology in childbirth is undesirable (75% and 82.5%, respectively). This could be interpreted as professionals experiencing conflicting attitudes, demonstrating, potentially, that consideration of the use of EFM in practice is no longer viewed as a form of intervention in childbirth, rather as a routine aspect of modern, ‘normal’ maternity care.
This review highlights some of the barriers to and facilitators for the use of IA and EFM during labour, and offers some insight and understanding of professionals’ views. These will be useful for clinical decision-makers to consider or target when implementing policy and practice change. The need to educate professionals on the most appropriate, evidence-based means of FHR monitoring for individual women, ensuring availability of FHR monitoring guidelines and policies for staff and by using a collaborative approach to fetal monitoring and CTG interpretation to ensure best practice, have been highlighted in this review. This may be assisted by highlighting that EFM has not, to date, offered any increased evidence of benefit for improved maternal and neonatal outcomes over IA for low risk women [1, 2].
The availability of regular study days on fetal monitoring for all staff would provide an opportunity to discuss some of the barriers, as identified in this review, (for example, protection against and fear of litigation, poor staffing levels and busy clinical environments, increased resource requirements that can potentially result from use of EFM), to effecting evidence-based practice change.