Constant electronic fetal monitoring in the form of the cardiotocograph has become a ubiquitous part of birth management in most high-income countries, profoundly affecting birth and often leading to interventions (Miller et al, 2016). Like any intervention in birth, it both reflects and creates its social context. This article uses a poststructuralist feminist critique to interrogate the role and meaning of the cardiotocograph. It argues that use of the cardiotocograph in birth reinforces and reflects the logic of the separate sovereign self (Irigaray and Whitford, 1991; Jones, 2016) and reveals an enactment of the symbolic ‘matricide’ (Irigaray, 1993a; Green, 2012) and the creation of fetal selfhood (Barad, 2007). The mother–fetus and the mother–midwife are fundamentally relational dynamics on a philosophical and physiological level. The cardiotocograph creates a false rupture in these relations. The author suggests that intermittent auscultation of the fetal heart in labour is better able to centre the mother–placenta–fetus relation and the midwife–mother relation.
The relationality of birth
Young (1984) describes a pregnant woman experiencing birth as a dialectic state, a fluid and changing relationality as the woman–placenta–fetus becomes mother–baby. The woman neither controls the birth as a conscious doing nor does it happen to her as a passive being; the birthing woman is the process. The holistic conception of birth articulated by Davis-Floyd (2001) centres a woman’s own embodied knowledge and the dynamic processes between the woman and her fetus, and between the woman and her midwife (Kirkham, 2010). However, with the rise in hospital birth, this holistic midwifery understanding of the intrinsic relationality of birth has been steadily undermined by the authoritative knowledge of patriarchal obstetric thinking (Jordan, 1997).
Martin (1987) highlighted how in hospital births, labour progression and fetal wellbeing become not a relational process, but rather a mechanistic process or task to be achieved. She drew the analogy of the mother’s body as machine, the baby as product and the midwife as machine operative. Privileged knowledge becomes not the mother’s own sense of labour, but quantifiable and disassociated measurements and observations, including the cardiotocograph outputs.
The cardiotocograph: what’s the problem?
In the UK, approximately 90% of women give birth in obstetric-led hospital settings (NHS Digital, 2021), many monitored by cardiotocograph. However, there is scant evidence of the efficacy of constant electronic fetal monitoring. The most recent Cochrane review concluded that there were ‘no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being’ and there was a 63% rise in the risk of caesarean section (Alfirevic et al, 2017). In her work on centralised cardiotocograph, Small (2020) criticised the ‘fetal distress meta-narrative’ rationale for fetal monitoring in labour. Other critics have focused on the high number of false positives (Grimes and Peipert, 2010), poor predictive value (Graham et al, 2014), lack of observer agreement (Sabiani et al, 2015), rise in iatrogenic effects (Small, 2020), litigation issues (Sartwelle and Johnston, 2014) and a principle of ‘first do no harm’ (Jansen et al, 2013). The rise in interventions resulting from cardiotocograph monitoring is correlated with higher rates of birth trauma (Perez-Botella et al, 2019) and postnatal depression (Bell and Andersson, 2016), lower breastfeeding rates (Brown and Jordan, 2012) and high costs (Birthplace in England Collaborative Group, 2011).
Cardiotocograph use abounds and although women can decline, hardly any do (Hindley et al, 2008). The decision is principally made by professionals using clinical guidelines written in an obstetric paradigm seeking technological, quantifiable solutions to improving neonatal outcomes (Hindley et al, 2006; Rattray et al, 2011; Small, 2020). Although cardiotocograph use in ‘low-risk’ labour is not recommended by the National Institute for Health and Care Excellence (2017), increasing numbers of women are on ‘high-risk’ pathways with cardiotocograph monitoring. Reasons for this include the proliferation of antenatal screening for risk factors (Cuckle and Maymon, 2016), rising acuity (Sandall et al, 2011) and increased induction of labour rates (NHS Digital, 2021). Hospital guidelines tend to recommend cardiotocograph for all high-risk births, regardless of evidence or rationale for improved neonatal outcomes, for example for vaginal births after caesarean (Small, 2022a). Additionally, where guidelines are open to interpretation, there is often a culture of defaulting to cardiotocograph. Habitual use by midwives is partly the result of cultural norms regarding routine procedures (Wagner, 2001; Davis-Floyd, 2003; Greer, 2010; Odent, 2016), and partly the dominant risk narrative, including fear of litigation (Lyerly et al, 2009; Sartwelle and Johnston, 2014; Coxon et al, 2016).
The cardiotocograph as a rupture of the mother–fetus relation
The interjection of the cardiotocograph into birth both alters and reflects not only the perception and process of birth, but also how both the mother and the fetus/baby are conceived. To further understand the significance of this, poststructuralist feminist analyses of the concept of self (Irigaray, 1974; Jones, 2016), and specifically of the impact of technology in pregnancy and birth (Young, 1984; Mitchell, 2001; Barad, 2007) can be examined.
Western philosophical thought is based on the premise of an individuated and unified self that interacts with another one (or many ones); ie is bound by a membrane, and inside that membrane is the same throughout (Jones, 2016). Irigaray (1985) counteracted this by highlighting the inherently relational nature of humans and of all living beings. She explained that to have the idea of the self-originating subject in the world, there has to be symbolic matricide (Irigaray, 1993b; Green, 2012; Jones, 2014). The male subject denies his interdependency, but still needs a mother for his original existence, and carries on needing other people all his life. Meeting his needs while denying dependency requires appropriation and exploitation. Therefore, imagining the subject as sovereign requires erasing the mother, while exploiting her labour (Jones, 2016). Irigaray (1974) deconstructed Western metaphysics that form the basis of current ‘phallic imaginary’. For example, she examined the matricide present in the Greek myth of Athena issuing forth from the head of Zeus, in Plato’s lack of acknowledgement of the cave as the womb and in Lacan’s account of the mirror stage of human development (Irigaray, 1974). She theorised that Lacan’s ‘mirror’ is not a flat object that the lone (boy) child gazes into, but the living, relating, loving mother (Jones, 2014). It is the mother’s body, work and engagement in the relation of mother–child, that makes the child a human.
The corporal reality of the living, feeling mother, on whom life depends, is an inherent philosophical challenge to the idea of the sovereign (male) individual. In the mother–fetus–placental unit, it is possible to see the fallacy of the idea of the sovereign self (Young, 1984; Irigaray and Whitford, 1991; Green, 2012). Experiencing pregnancy and birth gives women a corporeal understanding of relationality. Pregnant or breastfeeding women can create life and nourish it from their bodies; there is a traffic of gases and nutrients across the membrane of their bodies, and their baby is dependent on them. In this situation, the idea of the self as being boundaried and self-sufficient seems absurd (Jones, 2016). In her essay on pregnant embodiment, Young (1984) examined how the subjective experience of pregnancy dissolves the idea of the unity of self; the pregnant woman’s self is not the same throughout, but contains elements of the ‘other’. The fetus and mother are neither one, nor two ones, but a relational dynamic made up of the mother–fetal unit, containing and transcending them both. This is not only true philosophically, but also physiologically.
The fetus as simply ‘contained’ in the maternal body does not sufficiently describe biological reality (Kingma, 2019). The physiological relation of the mother–fetus is evident in the role of the placenta, in chimeric cells and in the work of midwives. The placenta typifies this fundamentally relational not-one-nor-two state and challenges the concept of a sovereign unified self (Irigaray, 1993b; Green, 2012). It is a mediator, a temporary dynamic organ that exists only because of the relation between the mother and fetus, not aimed at fusing or subsuming one into the other.
Lynch-Lawler (2020) described the mutual exchange of ‘placental-chimeric-maternal relations’. Chimerism is the transfer of cells and DNA between the mother and fetus during pregnancy, to the benefit of both fetal and maternal health. Kelly (2012) claimed these findings challenge the idea of the placental barrier as maintaining the identity integrity of the two separate subjects. Chimerism illustrates the semi-permeable membrane of self in relation to the other and disproves the classic understanding of a separate self in opposition to other selves. We are all part of our mothers, and mothers are part of their children (Kingma, 2019).
The cardiotocograph as a rupture of the mother–midwife relation
Midwives working in the biopsychosocial model (Walsh and Newburn, 2002) demonstrate a tacit knowledge of the maternal–utero–fetal unit. If there are concerns for the fetus or the progress of the labour, they work with the woman, encouraging movement or a left lateral position, ensuring she is hydrated or using reassuring touch or words. The relationality of the mother–fetus and the mother–midwife are both implicitly understood (Kirkham, 2010). The introduction of the cardiotocograph into birth represents a rupture to these relational states to the detriment of the birthing women.
When using the cardiotocograph, the fetus appears as an electronic reading, apart from and outside of the woman, as with an ultrasound scan. The expert can read its complicated coding, and has knowledge about that fetus that can then be translated to the mother by attributing selfhood, such as the baby is ‘not happy’ or ‘getting tired’. Mitchell (2001) pointed to the ultrasound as a causal factor in the attribution of selfhood to the fetus, with sonographers attributing characteristics such as ‘shy’ or ‘cooperative’. Barad (2007) maintained that technologies emerge co-currently with, and in relation to, any contemporary discourse or social understanding. She showed how the effective materialisation of the fetus opened the way for fetal selfhood to be exploited by the pro-life movement or sex-selective abortion (Taylor and Nicky, 2019).
When a cardiotocograph machine is used, the fetus is symbolically removed from the context of the mother–placenta and represented in the form of its heartbeat on the screen. The cardiotocograph attempts to represent the fetus as an individual human separate from its relation to its mother. As with Mitchell’s (2001) understanding of the ultrasound scan, it is an empirical instantiation of Irigaray’s matricide. Illustrated cardiotocograph training manuals often show the fetus as a lone floating subject without a mother (Gauge, 2011; Schmidt and Kopf-Löchel, 2014; East Midlands Maternity Clinical Network and Senate, 2019). Similarly, a list of ‘inappropriate uses of cardiotocographs’ in a training course (Small, 2020) did not include the woman declining, concerns about the iatrogenic risks to the women of the cascade of interventions (Kitzinger et al, 2006; Alfirevic et al, 2017), or the detrimental effect on labour of the mother feeling observed and anxious (Anderson, 2002).
Qualitative research into women’s and midwives’ experiences of the cardiotocograph in labour reveals alienation and erasure of the mother. In Davis-Floyd’s (2003) ‘birth as an American rite of passage’, a labouring woman, Diana, stated ‘as soon as I got hooked up to the monitor, all everyone did was stare at it…I got the weirdest feeling that it was having the baby, not me’. Davis-Floyd goes on to describe ‘the sound of the galloping and the vision of the needle travelling across the paper, [give] the illusion that the machines are keeping the baby’s heart beating...Many nurses have told me so powerful is this illusion that they can’t help but feel that unhooking the woman from the monitor will cause the baby’s heart to stop’.
Fox et al’s (2021) qualitative research into cardiotocograph use revealed how it disrupts the corporeal experience of birth as a process from within. They found that women themselves focused on the machine, which then externalised their experience of labour. It broke the focus of ‘doing the work’ of labour, and they reported women watching the digits on the screen to determine if they were having a contraction (although they did not specify how many of those women had an epidural, which would hamper them from sensing their own labour). The women seemed to internalise the container view (Kingma, 2019) by changing their behaviour for the benefit of the cardiotocograph itself. They reported women focusing on maintaining constant monitoring (a ‘good trace’), to the extent that they limited their own movement in labour, saying ‘I might as well just stay here [be]cause I can see my baby is monitoring well’. It seems in the descriptions almost as if the loss of representation of the fetus on the machine might somehow endanger the fetus itself. Symbolically moving the fetus from the mother–placenta–fetus relationality into the machine gives the illusion its existence is dependent on that machine.
Numerous studies confirm what can seem obvious to someone who has been in a birth room with a cardiotocograph: the machine takes attention away from the labouring woman (Hindley, et al, 2006; Fleming et al, 2011; Fox et al, 2021; Small et al, 2021). This is a far cry from the ‘watchful attendance’ of a midwife being with-woman, attentive and attuned to her clinical, emotional and spiritual needs and responsive to any subtle changes (de Jonge et al, 2021). Medical professionals, partners and women themselves cannot help but look at the machine and relate to it as if it is the centre of care. Fox et al (2021) described doctors and midwives entering a room and going straight to the cardiotocograph, looking at it even if they were talking to the woman. They quoted the mother of a labouring woman berating her daughter’s caregivers: ‘Are you looking at my daughter’s face, seeing her squinting? Breathing heavy? Tossing and turning? Are you watching this? You are watching the monitor but you are not watching her’ (Fleming et al, 2011).
The cardiotocograph also gives the midwife significant tasks of adjusting the transducer on the woman’s abdomen to ensure a constant trace, and of analysing and documenting the trace. Fox et al (2021) quoted a midwife referring to adjusting a cardiotocograph: ‘[I’m] interrupting her focus, interrupting her flow, interrupting her endorphins that are happening…It’s interrupting her labour if not stopping labour’.
Needing to keep a good trace has its roots partly in the illusion that the machine is keeping the baby alive, but also in understanding the monitor as a tool of measurement and the authoritative source of information about fetal wellbeing. Any ‘loss of contact’ is taken to mean possible fetal distress (Hindley et al, 2006; Small, 2020), leading to a shift of labour care to the obstetric team and starting the ‘cascade of intervention’ (Kitzinger et al, 2006). Small (2020) reported that cardiotocograph technology is based on an ideology that regards the birthing women as passive and risky and the fetus as precious and at risk. Giving the fetus selfhood, as a unit separate from (and possibly in danger from) its mother, allows the doctor to come in as the rescuer of the fetus. The mother is reduced to an organic incubator, rather than intrinsically related to, and inseparable from, the fetus (Kingma, 2019; Small, 2022b). This ideology is implicated in the ongoing rise in birth interventions, often starting with the cardiotocograph. This introduces iatrogenic health problems for mother and baby (Birthplace in England Collaborative Group, 2011), low rates of satisfaction with birth (Keedle et al, 2022) and a negative effect on the postnatal period and bonding, which is ultimately a public health problem (Bell and Andersson, 2016).
Implications
Based on a premise that it is possible to quantify, predict and therefore prevent or treat any problems for the mother and the fetus (Downe et al, 2019), hospital guidelines invariably prioritise the ‘objective’ data from the cardiotocograph over the multi-layered, relational knowledge of the mother or midwife. Her subjective knowing and doing of the pregnancy and the birth, the intimate sense she has of the labour, is relegated to ‘acknowledging her wishes’ or ‘gaining consent’ for medical professionals’ actions upon her (Dove et al, 2017). The women’s own complex subjective relational knowledge is devalued in place of medical objective measurements. The interpretation and responsibility for the labour are transferred from the birthing woman and her midwife to the cardiotocograph data and the obstetrician, from the biopsychosocial model of care that can incorporate relationality, to the medical model that cannot. However, the baby and mother’s physical, psychological and emotional safety are bound together. The best improvements in neonatal outcomes are shown to be from high-quality relational care. For example, continuity of carer promotes both midwife–mother and fetus–mother relations, supporting the mother’s overall wellbeing (Sandall, 2017).
Every maternity report in the last 10 years from Kirkup (2015), through Ockenden (2022) to East Kent (Kirkup, 2022), via Five X More (Peter and Wheeler, 2022), reports not listening to women as a central theme. Giving women the chance to express themselves means little if there is a lack of acknowledgement of women’s feelings and senses as useful knowledge. The obstetric paradigm, exemplified by the cardiotocograph, excludes other ways of knowing; women’s own knowing, midwife knowing, the fetus-in-relation-to-mother knowing. But birth is dialectic; the fetal–placental–maternal unit is in a dynamic moment of transformation and partition, ‘the most extreme suspension of the bodily distinction between inner and outer’ (Young, 1984).
The cardiotocograph ruptures mother–fetus and mother–midwife relationalities and impacts birth and understanding of mothers and babies. It undermines women’s subjective knowledge, constrains a woman through wires and the imperative to ‘keep the trace’, takes everyone’s attention and gives the midwives tasks other than attending to the woman. It externalises the fetus, gives it selfhood separate from the mother, and encourages deference to the authoritative knowledge of the medical model. The primacy of the cardiotocograph relies on and amplifies the ideal of the sovereign unified self, and the symbolic matricide woven into this phallic imaginary. This in turn relegates women to organic containers and ultimately damages the birth process and therefore women’s physical, emotional and spiritual health.
Recommendations
Irigaray (1985), Young (1984) and others suggested an understanding of the world based on relational thought, imaginaries and logic structures. A reimagining of birth that centres relationality would start by acknowledging the nature of the self as semi-permeable and the ‘being/doing’, ‘both/and’ nature of the mother–placenta–fetus in pregnancy and birth, acknowledging a state of health that includes such dramatic dynamic change (Young, 1984). Specifically, this could be better facilitated using intermittent auscultation in place of cardiotocograph in many instances.
Intermittent auscultation offers comparable neonatal and maternal outcomes to cardiotocograph, with reduced caesarean rates across risk categories (Small et al, 2019; Al Wattar et al, 2021). It allows reassurance that the fetus is coping with labour with a beating heart, and can alert caregivers to fetal stress or demise (National Institute for Health and Care Excellence, 2017; World Health Organization, 2018). It allows the mother to move freely and stay in ‘labour-land’ or reach out to others without hindrance. The midwife and other birth attendants can give full attention to the mother and the messages she is giving, acknowledging information gleaned from the midwife–mother relation itself and the mother’s knowledge of herself in the process of birth. It does not try to symbolically remove the fetus from the context of its mothers’ womb, but honours the mother–placenta–fetus in its wholeness and its unknowable-ness. Counting is only one way of measuring value, and intermittent auscultation allows for integrating information about the fetal heart rate into a wider range of empirical information for assessing labour.
Guidelines on fetal monitoring use should be revised based on evidence and rationale, and should recommend intermittent auscultation over cardiotocograph in most cases (Al Wattar et al, 2021; Small, 2022b). Offering a cardiotocograph to a woman should be discussed as an intervention with the statistics of risks and benefits clearly presented and genuine supported choice given. Challenging the habitual use on labour wards requires midwives to rekindle their respect and openness for the relational, dynamic nature of birth.
Key points
- Philosophically and physiologically, the mother and fetus are a relational dynamic containing and transcending them both.
- The introduction of the cardiotocograph to birth represents a rupture to the mother–fetus relation and the mother–midwife relation, to the detriment of birthing women.
- When a cardiotocograph is used, the fetus is symbolically removed from the context of the mother–placenta and the focus shifts from the woman to the machine.
- Symbolically, moving the fetus from the mother–placenta–fetus relationality into the machine devalues the mother and gives the fetus (false) selfhood.
- Hospital guidelines prioritise ‘objective’ data from the cardiotocograph over the relational knowledge of the mother or midwife.
- The best improvements in maternal and neonatal outcomes are shown to be from high-quality relational care, which is more possible with intermittent auscultation than with cardiotocography.