ļ»æEpisode 194 - Monitoring your baby during labour
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome everybody to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today I have Dr. Kirsten Small with me here, who has been on the podcast before, great friend of mine, love her work. She works through birth small talk is where she puts out all of her good juicy stuff, but she's also put out a book recently called, I'm holding it up, Monitoring Your Baby in Labor, an evidence-based guide to help you plan your birth. And I want to talk to Kirsten about this because this is a one-of-a-kind, first-of-its-kind book. And Kirsten is the queen and expert on monitoring your baby in labor. And we want to particularly talk about the culture of it, the safety and benefits, some of the possible side effects of monitoring your baby in labor. I know people don't think about that as a possible downside of monitoring your baby in labor, and we're going to go deep into this topic. Welcome, Kirsten, to the Great Birth Rebellion podcast.
Kirsten:
[1:27] It's lovely to be back again. Thank you so much.
Mel:
[1:30] And this episode is sponsored by my dear friend and birth prep extraordinaire, Poppy Child from Pop That Mama. She's a doula and hypnobirthing practitioner, and her online hypnobirthing course called The Birth Box has already helped thousands of women get ready for labor. Listen to this recent review of The Birth Box. The woman says, I'm a first-time mom and I gave birth to my beautiful baby boy yesterday. I've been listening to The Birth Box on repeat for the past few months, including the day in which I went into labor, and I had the most empowering birth experience, and I can honestly say that listening to The Birth Box was a huge part of this success.
Mel:
[2:12] Reframing the pain that you experience during labor can be a purposeful pain instead of a harmful pain and that really helped me to know that and just being able to surrender to the wild ride that birth is and let my body take over was the most incredible thing
Mel:
[2:31] And this is coming from a pelvic floor physiotherapist based here in Australia. She says, I will recommend it to all my patients. And you know me, I'm so picky about what I will endorse, but I do get behind the work that Poppy is doing. And in the birth box, you'll learn tools to help you manage pain and how to stay steady when labor gets intense. It's all about giving you knowledge, confidence, and a mindset that actually works when the big day comes and for the big days that will follow. BirthBox is rated five stars across the board. And with my code, Melanie, you'll get 25% off. So if you're preparing for birth, go to the checkout.
Mel:
[3:13] You'll be so glad you did. The link is in the show notes. Use the code Melanie to get your 25% off. Right. So first question, Kirsten, what is currently done during labour and birth to monitor the wellbeing of a baby because they're on the inside. We can't really tell how they're going, but we have a good red hot crack at it. So what can women expect when they go into labour to be the strategy around monitoring their baby?
Kirsten:
[3:45] The most common approach is that, without necessarily you even being aware about it, is that midwife, nurse, obstetrician, whoever's the primary care provider, will be running through a list of risk factors in the back of their mind and risk assessing you to put you into either a low-risk category or a high-risk category. And if you're low-risk, then you will probably end up with intermittent auscultation, which involves listening from time to time and it varies a bit from place to place but it's usually 60 seconds every 15 minutes and a bit more often as your labour progresses with something like a Doppler or a pinard listening to the baby's heart rate. If you end up in the high risk category then you will almost certainly end up with CTG monitoring. So usually that involves straps around your belly, two senses, one to measure how strong the contractions are and the other one to pick up the baby's heart rate, and those then get plotted on a graph on a machine over time so that you can actually see the changes in the baby's heart rate pattern. There's some slight variations on how CTGs are done. You know, there's wireless options. There are wires that attach directly to the baby's head. There are beltless options in some hospitals as well, but that's the basic approach that most people are going to encounter.
Mel:
[5:07] So essentially, when you go into hospital for labor and birth, or if you're planning a home birth or birth center birth, one of the main strategies for monitoring the well-being of the baby is to be checking and plotting the baby's heart rate as some kind of proxy measurement for if your baby is okay. There's another thing that some hospitals do, not all hospitals, and that's the admission CTG where you walk into the hospital and in some places it's regardless of your risk factor. Everybody has this introduction to the hospital. We'd like to check your cervical dilation and, you know, a baseline CTG sometimes for all women. So can you just briefly touch on the idea and culture around this admission CTG?
Kirsten:
[6:02] Yeah, and they have slightly different names in different places. In India, when I visited last year, they were calling them non-stress tests, which the terminology I learned that only applies to using it during pregnancy. So it might pop up with a different name somewhere where you are. The only research that we have about those comes from exclusively low-risk populations. And the belief system that sits behind it is that, well, if you're high-risk, you're going to get a CTG put on from the start of your labour anyway.
Kirsten:
[6:31] But if you're low risk, then we're going to use intermittent auscultation. So let's do a CTG because it might detect another risk factor, an abnormal heart rate pattern that will then put you into a high risk category. So then we can justify using continuous CTG monitoring throughout your labour. You know, we'll probably get onto the evidence base in a moment. But one of the main problems with that, and it was the answer to the question of does Does fetal monitoring during labour improve outcomes?
Kirsten:
[7:03] It was already known at the time that the researchers started investigating admission CTGs. And of course, if you don't improve outcomes by putting women on continuous CTG monitoring for the rest of their labour, then you're never going to improve outcomes by doing admission CTGs so that you can find more women to offer a continuous CTG monitoring to. So it was kind of doomed to fail from the start, but it's a real measure of the bright optimism that people had and continue to have that if we just try a little bit harder, this CTG monitoring thing will actually work.
Mel:
[7:37] So I'm sensing a little bit of condescension in your voice there about the place of admission CTGs and the vague hope that maybe we just need to monitor more babies in order to finally find the beneficial impact of CTG monitoring. So CTGs are culturally embedded into maternity care. They're in every room. I feel as though clinicians have a preference for CTG monitoring over the intermittent auscultation option. And for women who are wondering what intermittent auscultation is, as Kirsten alluded to, you know, it's a Doppler, it's handheld, it doesn't make a printout, it's a handheld Doppler and you put it on the woman's belly, on your belly, and you can hear the heartbeat and the midwife or anybody who's in the room makes assumptions about if that's a good, healthy heartbeat or if there's something wrong.
Mel:
[8:32] And certainly for low-risk women that's what's recommended is the intermittent auscultation but the CTG monitoring is embedded into maternity care culture and that was part of what you studied for your PhD was the use of CTG central feeder monitoring where basically women in various rooms in the hospital are attached to CTG monitors and all that information is being beamed back to a central place with somebody watching all the screens and determining which babies are okay and which babies are not. Can you give us a story basically of how did CTG become embedded into the culture of of maternity care, and we'll learn in a minute that it's not, because there was a stack of evidence to support it.
Kirsten:
[9:21] I'm going to blame the 1950s. So it's post-war America. There's this fantastic optimism that we now have this boom in knowledge and in technology development, and so we can now put our minds to it because we're great, clever people, and we can solve all of the problems that society faces. So that was generally going on in the 1950s. And so obstetricians got caught up in that as well and went, we can solve the problems of babies dying during labour, babies ending up with brain injury by inventing a technology that allows us to monitor the heart rate. Because the only thing that was available at the time was intermittent and auscultation, using some kind of direct method of listening to the baby, like, she says, reaching up for her shelf, a pinnard stethoscope or, you know, an adult stethoscope that you use for listening to parts and doing blood pressures. And so the machine was invented and people started doing some research to understand the patterns. A lot of that was actually already based on assumptions that people had come to in, like, By the mid-1850s, the same messages about what constitutes a normal heart rate and an abnormal heart rate were already in place prior to this. And they were really just kind of doing a bit of light, gentle fact-checking rather than vigorous research at that point in time.
Kirsten:
[10:49] And very, you know, it's technology, it solves a problem that had been really difficult to solve. And it worked particularly nicely because it positioned obstetricians as the expert and the problem solver and the rescuer of women. So culturally it worked because, you know, they were the dominant and powerful profession within maternity services at the time and continue to be. The belief system that it is built on really captured people's attention. And so by the mid-1970s, basically every hospital, maternity hospital in the US, had some form of CTG monitoring. And you start seeing publications coming out where people saying, oh, we're using 85% of the women in our hospital now.
Kirsten:
[11:35] It took off really quickly before the first ever randomized control trial was done. And that was published in 1976. and it showed that it did not work. It was done in a high-risk population and the response to that was, oh, we must have done the research wrong. Well, let's do it again.
Kirsten:
[11:55] So the same group did another body of research, published in 1979. Other people started publishing about the same time. And everyone came up with the same result. It's not working. It's not saving babies' lives. It's not improving outcomes. It's pushing up the cesarean section rate, which at the time was like 5%. It was ridiculously low. And they kept saying, no, the problem is the research. The problem is the research. It's not the technology not working. And so by the early to mid-1980s, the idea was we just need one really, really big study because then we'll finally be able to prove that this works. And that was what's called the Dublin trial. So it continues to be the largest of the direct comparisons between CTG use and intermittent auscultation. It's a randomised controlled trial. It was done fairly well by research standards of the time. It's not perfect. And it showed that CTG monitoring doesn't prevent death during labour. It doesn't prevent death in the days after the baby's born. And they also were one of the first groups to do any long-term follow-up. So they followed babies out until they were about two years of age and looked at cerebral palsy rates. It didn't make a difference to cerebral palsy rates at all. So, you know, we've had about 40 years now of knowing that.
Kirsten:
[13:20] Randomised controlled trial evidence shows that CTG monitoring doesn't save baby's lives, doesn't prevent long-term brain injury. There's been other kinds of research, and that was the first of the papers I published out of the PhD, was to look at all of the other sorts of research that are not randomised controlled trials. Because I kept hearing this story where people that, I called it the hand wave, oh, but there's all this other research that shows that they do work. And I went, hold my beer, and I went and found it all. And no, no, no, it does. There's none of that research looked at long-term brain injury outcomes. We don't know the answer to that question. Of the studies that were of reasonable quality, none of them showed an improvement in mortality rates for the babies in a high-risk population. And there's been another researcher published about the same time as me who looked at 1.2 million women giving birth in the US who were low risk at the onset of labour. And again, no benefits from using CTG monitoring other, but an increase in the caesarean section rate. So the horse has bolted and it's too late to shut the gate, though I'm desperately trying to go and find the horse and bring it back into the paddock.
Kirsten:
[14:31] And it was all based on some really seductive beliefs, like women want their babies to do well. Obstetricians want to be the people who rescue these babies. Nurses and midwives want to be part of this as well in terms of making sure that good outcomes happen. It's bright, shiny technology, and in the years since it was invented in the late 1960s, it's got brighter and shinier because we've now got the central fetal monitoring systems you were just talking about, and computer interpretation, and they're pretty, and it goes ping, and it makes all sorts of sounds, and woohoo, being able to go wireless, and the newest beltless stick-on, non-invasive fetal ECG systems, again, it's more bright, shiny, sparkly stuff that has people thinking that we've somehow fixed the problems that it was having, and it will now work, and all of the evidence that has accrued to date for each of the new rounds of additions to it also show it isn't any better than what we were doing before.
Mel:
[15:36] So we've gone ahead and adopted CTG into mainstream maternity care. Under the guise, under the messaging, told the story, hey, if we can listen to your baby, we can keep it more safe. However, none of the researchers proved that. So we kept it because we want it to work. We want to believe that this is the thing. We want to do something. This is the thing that we can do, not because it actually works. So we haven't found any benefit, but have they found a disadvantage? So I just feel like an intervention like this can't be neutral. Is there a disadvantage to having CTG monitoring during labour and birth?
Kirsten:
[16:23] Yeah, there are two things to talk about here. One is what we know to be true from research, and one is about the fact that there's a whole bunch of unanswered questions that no one's brave enough to go and actually ask in research.
Kirsten:
[16:37] So we know it drives up the use of caesarean section and of instrumental births,
Kirsten:
[16:42] so forceps, births, vacuum, births. And you can see those as, oh, it's just another way to have a baby. It's no big deal. But if it wasn't the way that you planned to have a baby, Each of those is associated with its own specific set of additional risk factors.
Kirsten:
[16:57] So, for example, women who give birth by forceps are much more likely to have a postpartum hemorrhage and they're more likely to have severe perineal trauma damage to their pelvic floor muscles. Caesarean section, you're more likely to have infections, bleeding, blood clotting problems, pain, a longer recovery phase, more challenges with breastfeeding. And the same is true for the babies, that babies who are born by either of those methods are more likely to have things like jaundice, a stay in the nursery, breathing issues. So, you know, while the rate of complications from both procedures is relatively small, it is higher than having a spontaneous vaginal birth without the assistance of instruments. There's also some, it depends on exactly the approach to fetal monitoring. So if you're using a fetal spiral electrode, the little wire thing that screws into the baby's scalp, there's some risks specific to that around increased risks of infection for the baby, increased risks of bleeding, trauma to the scalp. And then there's not so well-researched areas, there's a tiny bit of stuff looking at the.
Kirsten:
[18:08] For some women, it induces more anxiety. For some women, it is anxiety-relieving because they believe that it works and so they feel reassured by the comforting presence of the machine. I'm mindful of the fact that me bursting into their room going, you do realise that's nonsense actually kind of undermines that sense of security. And it can be a bit upsetting for people, both professionals and for birthing women. But, you know, there's no point in this having faith in myth. You know, I might as well tell you a crystal to stick in the corner of your birth room to keep you safe rather than tell you to have a CTG.
Kirsten:
[18:51] There are some changes in the way that care providers interact with women. So lots of women talk about how doctors and midwives, you know, they'd walk into the room and the first thing that they would do is walk straight over to the CTG machine and look at that. And then eventually they might turn around and look at the woman and say, hello. With central fetal monitoring, which was the specific focus of my PhD, it's introduced a whole nother new round of issues for people because what was happening was that, you know, the midwife would be alone in the room with the woman and the CTGs on and the midwives, probably most of the time had noticed that something's not quite right with this heart rate tracing. And so they were going through their own mental checklists, you know, what's going on? What's the contraction pattern? What's the colour of the lycord? Does the woman need to change position? Is her blood pressure okay? Do I need to do a vaginal examination? And in the midst of trying to work through all of that to decide whether or not it was appropriate to ask for somebody else to come and look in or whether this was just a solvable problem, you know, you just needed to adjust the strap because it had slipped off the baby. Somebody from outside the room would have come bursting in in a state of high anxiety because they'd seen something on the CTG out at the central fetal monitoring system, which then meant that the midwife had to stop what she was doing, meet the communication needs of this other person who did not know what was going on.
Mel:
[20:19] In the room
Kirsten:
[20:19] And didn't know the woman as well as this person, whilst at the same time still continuing to figure out what the issue is and what needs to be done. You know, sometimes those were just a gentle knock on the door. Hello, is everything okay in there? You know, we still pulled the midwife away, but at least it wasn't over the top. Other times people would come into the room and literally push the midwife into the back corner and take over. And before they knew it, five minutes later, an emergency cesarean section is happening and the woman's being rolled out and the midwife's going, what the heck just happened? And in order to stop those intrusive arrivals of people into the room,
Kirsten:
[21:01] midwives were changing their practice in subtle little ways. And the first thing that they did was do a whole lot more documentation so that if somebody saw an abnormal heart rate on the CTG, they would also see a bunch of notes overlaid over the top of the CTG, which basically was intended to communicate, hang on, I've got this, I'm sorting this out, you don't need to come running in. But of course, if the midwife's at the computer entering those notes.
Kirsten:
[21:28] She can't be doing all the things. So she's, you know, less sorting out is actually happening while she's trying to communicate with the people outside of the room to say, I'm sorting it out, it's okay. And they were doing things like insisting that women stay in a particular position because that was the only place where they could actually get a good heart rate tracing, or cutting an episiotomy and yelling at the woman to push harder, not necessarily because they believed that there was a problem with the baby and the baby needed to be born sooner, but because they were trying to get the baby out fast enough that nobody out at the central monitoring station would have a moment to look at the heart rate tracing and decide that they needed to come into the room. So the kind of research I did didn't count things like changes in instrumental birth rates or episiotomy. So I can't tell you what the numbers looked like, but this is just what people were telling me about the impact of it. And that's one of the problems is we don't have research about that because no one's done it. No one ever has done any studies that have looked at the impact of using CTGs on postpartum hemorrhage rates, perineal trauma rates, breastfeeding rates, birth trauma rates, psychological outcomes, PTSD.
Kirsten:
[22:48] How long it takes for women to be able to return to paid employment or to non-parenting duties, impact on sexual function you know they're just there's so many areas that are left untouched.
Kirsten:
[23:01] Because why would you fund and do research that might undermine your favorite toy.
Kirsten:
[23:08] It's just easier to say there's very little evidence to suggest that it's causing these problems when the issue is that no one's done the research in the first place.
Mel:
[23:17] I had a dilemma last night and I knew we were talking today. One of my clients, because I'm still a clinical midwife, one of my clients contacted me and said, Mel, I'm a little bit concerned about my baby's movements.
Mel:
[23:30] What can we do? I could hear she was distressed on the other end of the phone and I knew my only strategy would be to go and listen to the heartbeat. But also, if her intuition was telling her that something wasn't right, then we need to be wise to that. And so I said to look up my recommendation is that we go into hospital and we need to check the baby out the way that they're going to do that is to do a ctg monitor like to put a ctg monitor on and in my head I'm going well yeah but for what purpose because actually the truth of it is is there's actually not even any research about what a normal fetal heart rate pattern is for us to even compare and say, hey, this is what an abnormal heart rate is because we know what a normal heart rate is. So I said to her, look, that's the best we've got. The only way we can give you any information right now is an ultrasound, but I knew that that hospital wouldn't have that facility on the weekend. But I was like, they'll do a CTG. And then they did. And they said, this looks good, this looks normal, we can't see any problems. And all the time I'm having this debate in my head going, well, that's nice.
Mel:
[24:47] I assumed that the baby would be well, but we've used this normal CTG to confirm that. But do we even really know what a normal fetal heart rate pattern is anyway?
Kirsten:
[25:02] Actually, we do. There's been quite a lot of studies, and some of them quite continuing to be done quite recently. There was one that came out of Ireland in the last five years, where people look at how strong the link is between a particular fetal heart rate pattern and a poor outcome for the baby. And in that Irish one, they were looking at a thing called hypoxic ischemic encephalopathy, so signs of brain injury for the baby. So they can identify that if you have things like if you have accelerations on the CTG, then the risk of having a baby who has HID is lower than if you don't. And if you have decelerations on the CTG, then the risk is higher. So we do have some evidence about that. What we don't have is proof that detecting those particular patterns and doing the interventions that currently happen when we see those patterns actually translates into a better outcome for the baby. Because the problem is that things like hypoxic ischemic and cephalopathy are rare. So moderate to severe disease is about five babies out of 1,000.
Kirsten:
[26:19] But about 26% of women who have completely healthy, normal babies without any problems at all will have an abnormal heart rate pattern during the last part of their labour, 26% of them. So if you've got 1,000 women having babies...
Kirsten:
[26:38] And five of them are going to have a baby that has a problem. And probably about three of those will have an abnormal heart rate pattern. But you've got 260 women having an abnormal heart rate pattern who are destined to have a completely normal baby.
Kirsten:
[26:53] That's three babies out of 263 where the pattern is abnormal and it means something. How do you tell the difference? Well, you can't. And so that's why we see this big pushing up of the cesarean section rate and the instrumental birth rate because people have to try and guess which ones are the ones who might actually benefit from having their baby earlier. And sometimes they get that wrong and babies are still born in poor condition. And sometimes they get it wrong and babies who were going to be completely fine end up being born earlier by cesarean section or instrumental birth when it isn't actually going to improve the outcome. And that's what we see in the research. So we're still missing babies who end up with a poor outcome. But in the meantime, we're pulling a whole bunch of babies who were never destined to have a problem out far too early as a consequence of the fact that the relationship between heart rate patterns and outcomes, while there is one, it's not particularly strong. And there's no heart rate pattern that says this baby definitely needs to be born, and this baby definitely does not need to be. It's all a lot of guesswork and a lot of vibes, you know, flying by the seat of the pants thing. Now, coming back to the problem of what do you do with a woman with reduced fetal movements or some other concern during pregnancy.
Kirsten:
[28:18] We actually have very little research. There's only been four studies that have looked at CTG monitoring during pregnancy and labour. It's decades ago that the last of the studies were done. I haven't got the number off the top of my head, but I think it's something like only 2,000 women were ever randomised to the trial. So the size of the studies is too small to be useful to anyone. And what they found was that when you look at the raw numbers, women who had, the studies were between having a CTG and somebody gave you the doctor the results to look at, or having a CTG and the results were hidden in an envelope and nobody could look at it until after the baby was born. And in the group where the results were revealed, they were twice as likely to have a baby who died as the women where the results were hidden. Now, it just fails to reach statistical significance. So, the difference is
Kirsten:
[29:10] not statistically significant. So, you will see that reported as there was no difference. But the raw data suggests that maybe if you'd had 10,000 women in the study instead of 2,000, it might have achieved statistical significance. So I think we do need to be a bit cautious. But I know that when you and that woman went to that hospital and talked to another midwife, that CTG monitoring was not the only thing that was done.
Kirsten:
[29:37] Yeah, somebody will have felt her tummy. They will have felt her baby. They will have felt to see if they could feel the baby moving. They will have done a clinical assessment of the amount of fluid that was around that baby. They will have checked her blood pressure and maybe her urine and a whole bunch of other methods to see whether there was signs of some underlying problem developing in the woman's pregnancy. So she will have had a comprehensive midwifery assessment done, not just a CTG. And I think that's the thing that helps in terms of the care.
Kirsten:
[30:15] And I'm not an ultrasound expert. I have not done a deep dive into the evidence around ultrasounds. I know it's taken me more than a decade to get to the point where I have the depth of knowledge I have about CTGs. And I do not want to spend another decade getting across ultrasounds. But it's my impression that they do better. And so when there are concerns about babies antenatally, a scan is probably a better idea than a CTG. And if you're having a CTG and it's normal, it's probably not enough on its own without... A comprehensive midwifery assessment and maybe an ultrasound scan to be able to go, no, things are actually fine and we can just continue as planned with this pregnancy.
Mel:
[31:04] So what you're saying then is we currently, it's embedded into the culture, but the research is cloudy as to the benefits. But what they do know is that because of a deficiency in how good we are at interpreting the results of a CTG, we're erring on the side of caution and intervening in births,
Mel:
[31:27] what appears to be unnecessarily, just to try and pick out the ones that intervention would save and help. But the flip side of it is that we're giving a lot of women and babies interventions that they didn't need out of clinicians' uncertainty and fear. And I think the other thing is that because CTGs are documented on paper, they can be used as, I guess, a tool, a bargaining tool or an assessment tool later when they're reviewing births and outcomes. I wonder if clinicians are a bit concerned that because CTGs are documented, that somehow they're going to be brought back up if there is a poor outcome and maybe, I don't know, it seems to be safer for a clinician to intervene when it wasn't needed than to be a bit more judicious with interventions.
Kirsten:
[32:25] That is probably true in today's medico-legal climate that the saying for all of my profession as an obstetrician is that no one sees you for doing a cesarean section, but they might see you for not doing one, which is a bit of a sad state of affairs really to be in. I just want to go back. You said that because people have an issue with interpreting the CTG, that's not the problem. Exactly the same heart rate pattern, correctly identified by somebody as, you know, the baseline is 120, there's reduced variability and there are complicated variable deceleration. Can mean a baby that is destined to be born with a problem. It can mean a baby that is destined to be born healthy. They are exactly the same. So it's not that the interpretation is wrong. It's that we're assigning a meaning to the heart rate pattern that doesn't necessarily predict the outcome with enough strength for it to be actually useful in clinical practice is the issue. Right, right.
Mel:
[33:27] So that's not...
Kirsten:
[33:29] Yeah, because there's a lot of myths out there that the reason that we haven't made CTG monitoring work properly is that midwives are stupid and I really, really strongly reject that. We've spent decades now. When I was training in the 1990s, we had weekly CTG education sessions. This is not new. We've spent a long time investing on upskilling, educating, re-educating, reminding, reinforcing people about how to make sense of the wiggly lines. And it doesn't work. What evidence we have in studies about education shows no benefit. And again, most of that research is poor quality. All it does is it shows that mostly that if you ask people to sit a test at the beginning and at the end of their education session, they learn something. All that proves is that education works. Who knew? But it doesn't necessarily translate to better clinical outcomes. And in the few studies that have actually looked at clinical outcomes, there's either been no difference or in some of them, things have actually gotten worse.
Mel:
[34:37] Right. So are there any circumstances? under which a CTG is a good idea.
Kirsten:
[34:45] Yes, when the woman wants one. And we did a podcast episode on this previously, so I won't go into detail with it because people can go and have a look at that. But what I do want to focus on is the idea that the kind of fetal monitoring that gets used, whether it's in pregnancy at the time the woman first arrives for care or throughout the rest of her labour and birth, someone is making a decision. You know, you don't walk into a room and, you know, Harry Potter-like, the equipment magically wraps itself around you and attaches you. You know, someone has to make a conscious choice to turn the machine on the wall, grab the equipment out, put some ultrasound gel on the ultrasound, place the sensors in the right place and make it all work.
Kirsten:
[35:34] And I think that that decision should be made by the woman whose body it is being attached to and not by one of her care providers or by hospital policy. And I presented just over the weekend at the Respectful Maternity Care Conference about how we have this huge human rights abuse happening in front of us. And that's the unconsented use of CTG monitoring in labour but because people are not given adequate information to be able to make a decision for themselves and they're often told that they do not have a choice. Because you're high risk, you'll have to have a CTG, which is ethically completely no, no, no, not okay, but it's happening all over the place. Because there's a lot of decisions to be made and some women might be happy to delegate that decision to somebody else and that's fine, but it should be an active decision making process to go, you know, you just do whatever if that's what the woman wants to do. One of the things that really gets underneath my skin is when I see people who.
Kirsten:
[36:41] When they talk about birth plans, they talk about birth preferences and birth wishes instead of decisions. And I really like the term decisions because it's much clearer. If we start talking about, well, the woman wishes that she has intermittent auscultation or her preference is for CTG use, rather than saying the woman has decided, then somebody else just takes over the decision making at that point in time. And can just steamroll through all of that. So for those of you who are planning to have a baby, I would encourage you that when it gets to the point where you're having conversations with a care provider that you also use the right language. And so that's to say things like, I have decided I will have X during my labour. Can you please make a note of that in my records? I will let you know if my decision changes. Not would it be okay if or I'd really rather if where it comes across as a wish or a preference, it just makes it really easy for somebody else to step in and do the decision making and push you to one side at that particular point in time.
Mel:
[37:55] So this is a strategy for women then if you have made a decision that you don't want continuous CTG in your labour and birth don't pitch it as hey, I really didn't want that. I actually want this instead. I hope that's okay. It's go in there, steamroll, own the decision. I have made this decision. This is actually not up for discussion and, you know, you will facilitate that. I do have a question about there's two circumstances under which I see clinicians really insistent upon using CTG The first is during an induction, and the second is if the baby does a poo, so if there's meconium stained licor. These are the times in particular where clinicians are like, we really, really need to put this on. Can we first start about talking about meconium? If there's meconium, is a CTG going to help with that outcome?
Kirsten:
[39:03] And I'm going to add one more to the list, and that is when you're doing intermittent auscultation and the heart rate is not normal. In one way or another. There has never been, oh, no, that's not quite true. There has been one randomised control trial where all of the women who entered that study had meconium staining of the lycol. It was done in Pakistan. It's never been published. But the Cochrane Review, which is Al-Firavik et al. 2017, has the unpublished data and they include it in their meta-analysis of the results.
Kirsten:
[39:36] A hundred women, far too small to detect an outcome. And the mortality rate in that particular study was astronomically high. It was about 10 times what we see in developed countries because it was Pakistan at a particular point in its history where everyone had, you know, the chance of a poor outcome was universally high for lots of reasons. And it showed no benefit from CTG use compared to intermittent auscultation. So the tiny bit of research that we have is not actually really all that useful, and that's all we've got.
Kirsten:
[40:10] Induction of labour, again, there's never been a study that's taken a group of women who are being induced and have said, what happens if we ask you guys to have a CTG and ask you guys to have intermittent auscultation, then follow through to see what the outcomes are. No one's done that research. The best that I've been able to come up with, which again is in that podcast recording that we did once before, is if you dig about in the fine print inside the Dublin trial, that was the biggest one of the studies, they did some subgroup analyses about whether women had oxytocin infusions or not. And the rate of neonatal seizures was less for women who had an oxytocin infusion and had CTG monitoring than it was for women who had an oxytocin infusion and had intermittent and auscultation, and it did reach statistical significance. While for women who did not have an oxytocin infusion, there was no difference in the seizure rate between CTG use and intermittent auscultation. Now, I don't know whether that applies in practice anymore because the way that oxytocin was being given in the early 1980s in Dublin is not the way that we do it anymore in clinical practice. And the rate of seizures in the CTG monitored group who had oxytocin in that study was 36 per 10,000.
Kirsten:
[41:29] If you look at the, I forget the name of it now, the ARRIVE trial, the inducing labour at 39 weeks in PRIMIP study from America, the rate of seizures in that study, where I'm assuming everyone had CTG monitoring and was being induced, was 9 per 10,000 because the way that induction is now being done is different. So whether or not that applies anymore, I don't know. We really don't have any strong evidence. In clinical practice, the issue is that if you're a pregnant woman and you've decided that you don't want a CTG but you do want to be induced, you are not going to have somebody agree to proceeding with the induction unless you agree to having CTG monitoring.
Kirsten:
[42:14] It is considered part of the package deal. The other one that I see pop up a lot is midwives tell me, oh, I only ever use the CTGs when there's a really good reason to do it. And that's when if I hear a problem with the heart rate with intermittent auscultation, then I'll put it on. Again, there has never, ever been a study that looks specifically at that one particular thing. Though one of the criteria that made people high risk and that got them into a high risk study like the Dublin trial was that there had been an abnormal heart rate pattern on intermittent auscultation. So women with that particular issue were included, along with women with diabetes and preeclampsia and twins and overdue and preterm and a whole pile of other things so that it potentially disappears into the mix. But there's no studies that show that putting a CTG on under those circumstances will improve outcomes. What we need to be careful of, particularly here in Australia, is that the wording in the RANS-COG guideline, which has improved dramatically in the last year, I have to say, still says if you hear an abnormal heart rate pattern, the woman must have a CTG.
Kirsten:
[43:25] It doesn't say have a conversation with the woman about her options and advise that CTG monitoring is a good idea. It says that you've got to get the CTG on this woman, which again, we're back to the fact that we have an ethics issue going on here where women are not considered to be the decision maker about things that happen to their body, which is not okay.
Mel:
[43:49] Well, and there's nothing to say that if you continued with the intermittent auscultation, that that wouldn't create just the same outcome for the woman versus CTG because we haven't really checked that, have we? So if you hear an abnormal fetal heart rate on the Doppler with intermittent auscultation and you just keep using intermittent auscultation as opposed to putting a CTG on, that could very well create the same sort of level of monitoring and outcomes as a CTG, but we just haven't checked it yet.
Kirsten:
[44:21] Yeah, correct. It should trigger all of the same, you know, a comprehensive assessment of the overall situation that's going on here. It should trigger more frequent listening with intermittent auscultation. You don't just want to go, heard of deceleration, I'll wait another 14 and a half minutes before I listen again. No, you need to keep listening until you understand the rest of the information that you would be trying to get from a CTG. And it's the same heart, doing the same pattern. The physiology changes are the same, whether you are hearing it or seeing it. So you should respond exactly the same way. If the response that you would get to that particular pattern with a CTG was on would be, quick, we've got to do a cesarean section, you should be doing the same thing with intermittent auscultation. The problem we have is one of trust in maternity services, and that is that obstetricians, unless they can see it on a piece of paper, they're not going to trust trust. The midwife who says, we've had a fetal bradycardia now and it's been going on for nine minutes. You need to get this baby born. And then we get this bizarre situation where people will want to hit the reset button on the timer and put a CTG on and pretend that there hasn't already been nine minutes of fetal bradycardia. And then they'll wait nine minutes on the CTG before they go,
Kirsten:
[45:43] oh yeah, there really is, before they'll take action. And you can see why that would be a huge problem.
Mel:
[45:49] That has happened to me very occasionally. We would transfer from home to hospital because of an alteration in the fetal heart rate. And I walk in and at times I've even phoned the hospital, I'm like, get everything ready.
Mel:
[46:04] We need to just like, it's all, it's action stations. And you walk in and as you said, it's this reset of like, well, we know you said there's a problem, but we need to go through our process to ascertain that there most definitely is a problem and then we will act and I'm sitting there dancing around like I just listened to this many minutes of decelerations and you're not going to believe me until exactly as you said you can see that for yourself you don't believe that there's you know sometimes I've arrived and they just have not even called the on-call staff because they're like well we need to ascertain if there's an emergency actually before we do any of the calling so then there's I want you to first tell us about the book that you wrote this book monitoring your baby in labor and evidence based I'm reading it backwards an evidence-based guide to help you plan your birth and then I want to ask you about some recent news stories about this you know amazing new lactate monitor that's being developed that we can clip onto the baby's head that's going to give us real-time information about the baby's well-being and solve this problem of the inefficiency of CTGs.
Mel:
[47:20] So if you're coming to this episode going, what about that new research that's all over the news? I would like to talk about that. But first, Kirsten, can you tell us why you felt like you needed to write this book?
Kirsten:
[47:35] There are still so many myths and chunks of misinformation that float around maternity services. One of the big myths that I was having a warm discussion with an obstetric nurse in the US over the weekend on Facebook about this is this belief that refuses to go away, that for women with risk factors, using a CTG really does improve outcomes. And we have no evidence to prove that that's the case. Theoretically, it could actually be true. I would be surprised knowing what I know about the physiology behind all of it. But we don't have hard proof that using a CTG improves outcomes for women with any specific risk factor or who are considered high risk in general. And I know from my own research and that of others that women are not consistently asked to give consent before any form of fetal monitoring. And there's an issue with not enough consent for intermittent auscultation just as much as there is with not enough consent for CTG use in clinical practice, neither of which is acceptable. We need to ask women for permission before we do something to their body, and fetal monitoring is doing something to a woman's body. And so it's not enough for me to say, well, go and talk to your care provider, because I know that there's a fairly good chance that your care provider doesn't know the information.
Kirsten:
[49:04] And will not offer you a choice of fetal monitoring method. And, you know, I say that with a great deal of love and respect for people who are in clinical practice. That was me. That's what started this story. That was me as an obstetrician in private practice thinking I was shit hot and at the top of my game and it was really important to me. Like I marketed myself as somebody who listened to women, who was really woman-centred, who made sure that they used the evidence. And one day I was seeing a woman who had a twin pregnancy and we were having the usual chat about planning her birth and I said, and I would recommend that you have CTG monitoring and it'll look like this. And her partner said to me, can you share some research about that that shows that that actually will benefit us? And I went, sure, no problem, thinking this would be super easy because, you know, there would have to be evidence for this because it's in all of the guidelines. I said, look, give me a few days, I'll email you something and I went hunting for it. I'm an academic. I have multiple research degrees. I know how to find stuff. Nothing. There was nothing. That's when I realised that I was also spreading misinformation about CTG use. I had to do a big about face and start educating myself because I had not been taught that. I'm not saying that there's a bunch of.
Kirsten:
[50:24] Professionals out there who are deliberately being bad practitioners, it's a system-wide problem that we are not teaching this to people. So if you can't get it from your healthcare provider, and obviously I spend a lot of time and effort working with healthcare providers to try and improve that situation by educating them, but I can't get to everyone by Tuesday. So the book is there for any woman who is now having to make a decision about CTG use or intermittent auscultation or neither for her upcoming birth or even during her pregnancy. So it gets the book right into the hands of the people so that they know what's going on. And I'm hoping that they'll go and smack it on the desk of their obstetrician or their midwife and go, have you read this thing? And then, you know, both with me trying to get at the professionals from my end and if women are turning up going, you need to update your knowledge of the evidence base, then we may start to, as I said, we might at least get the horse back into the paddock and start seeing that, you know, more honest conversations are happening around fetal monitoring practice.
Mel:
[51:32] So what you're saying is this is a decision that women can make, but you can only make an informed decision if you have the information and not the information that's just been given to you by somebody who wants you to choose the CTG because that's what that's what their policy says, that's what the hospital does.
Kirsten:
[51:50] And if you know that you are allowed to make the decision, there was a recent study in Ireland that showed that 37% of women did not know that they had a choice when it came to the way that their baby was monitored during labour.
Mel:
[52:06] And so if a woman doesn't choose a CTG, because so then that's the next step. Okay, so let's say we just do away with CTGs and, you know, maybe we focus on intermittent auscultation maybe. How can we work out which babies are okay during labor and which babies are not? How would we determine that? Because there's things like fetal blood sampling that can give a little bit more information. But is there currently a way to work out which babies are not doing well and need to be born and which are not? Or which and which are, I mean.
Kirsten:
[52:48] The terrifying answer to that question is no, we have no idea. We've spent 60 years pretending that there's an answer to that question, which I think is profoundly disrespectful, and it has really prevented researchers and technology developers from actually going and finding a thing that might actually solve that problem, because everybody's busy trying to tweak the CTG machine and make it work the way that people believe that it is destined to actually work to fix the problem.
Kirsten:
[53:19] I think, and I'm working with a PhD student at the moment on a decision-supporting technology tool, which is an interesting place to find myself in because I'm openly critical of these, but here we are. Because I think at the moment, the risk assessment stuff happens at the front. So people risk assess to decide which kind of fetal monitoring approach should be used. And we've gone through this. That's nonsense because it assumes that as your risk goes up, so does the benefit of using a CTG machine, and that's not true. I think the place for risk assessment is, as I said, there are some studies that show that if you have a particular heart rate pattern, there is a slightly higher risk of you having a baby with a poor outcome. I think if we then layer on a comprehensive risk assessment around that time, there's, then we might get closer to being able to say, actually, the chance, given this heart rate pattern and given that you're 36 weeks and this is a growth restricted baby and you have pre-eclampsia and you're from this particular ethnic group and whatever, whatever, the risk of this baby developing a problem if we don't intervene at this time is actually 10%. And because of that, And I think we should do a cesarean section.
Kirsten:
[54:35] Whereas for another woman, this is your third baby. The Lycor is clear. You're 39 and a half weeks pregnant. You've never had a problem before. The baby's a normal size. You know, same heart rate pattern. The risk assessment is the chance of there being a real problem here is less than one in 10,000. I think we continue with your labour. I think that's probably where we're going in terms of technology development is to keep the CTG. But do the stuff like, as a clinician, this is the kind of stuff that, you know, you and I are used to doing inside of our head, which is kind of a, you know, I've got a gut feeling that this one might be all right, but it's a really imprecise thing. But this would provide an individualised risk assessment. And the challenge then is to do it in a way that still values woman as the decision maker rather than getting to a, well, the computer says no situation where people have no idea why that particular recommendation for intervention is coming out of the computer system. So whether that can be achieved or not, I don't know, but we're working on that. I think ultimately we need to look for things that are not the heart rate.
Kirsten:
[55:42] That tell us about how the baby's going. If you go to the emergency department as an adult saying, I feel awful. I think there's something seriously wrong with me. I'm not sure if I'm having a heart attack or maybe I've got a lung infection. I just feel terrible. If the only thing that they did for you was to take your pulse, even if they took your pulse for an hour and then patted you on the head and sent you home, you would think you did not have great care. And that is essentially what we are doing for fetuses, is we're taking their pulse and then either intervening or patting their mothers on the head and going, it's fine. We're not looking for other channels of information from the fetus other than just their heart rate. And we need to start looking for those. And we need to pick something that tells us not how the baby is not coping or compensating is the scientific version of it, but that is showing us that this is a baby that's now moved out of.
Kirsten:
[56:48] Sure, there's a problem, but I'm actually managing just fine and I've made all of these adjustments so that I am not being injured, that picks up something just on the cusp of when the baby is starting to actually be damaged from low oxygen levels so that we can do something about it. And with a big enough window period that there's time to organise a cesarean
Kirsten:
[57:08] section or an instrumental birth. I see some kind of across-the-horizon developments for that, but there's certainly nothing that's going to be coming into clinical practice anytime soon. Which brings us to the lactate question. So there's a group based in Western Australia that have been loud and proud on the media recently, and they're trying to sell a product, much respect, marketing is important. And what they're doing is they're measuring a thing called lactate or lactic acid.
Kirsten:
[57:41] And I suspect this is not going to work. I am very willing to be proven wrong, but I am concerned that they are going to introduce this into clinical practice, just like CTGs were on the basis of, well, we think this is a fabulous idea without actually evaluating to see whether it works or not. The problem that I have with lactate monitoring is basically the same that I have with fetal heart rate monitoring, is that it measures coping. So when oxygen levels fall low, there are a whole bunch of biochemical processes that the body needs to do in order to stay healthy, and they require energy. At its most basic level, energy in the body requires the production of a chemical called adenosine triphosphate, or ATP. And when there's lots and lots of oxygen around, glucose is converted into quite a generous amount of ATP. Now, if your oxygen levels fall, you still need ATP for all of your cells to do all of the things that your cells do. So our bodies have an alternate pathway. Isn't that a fabulous and clever thing to have? And so there's this thing called anaerobic respiration that breaks the glucose down into not quite as much, but still makes ATP molecules. But as a byproduct, it now produces a thing called lactic acid or lactate.
Kirsten:
[59:06] Which can then be recycled back into that system to convert it back into substrates that are then used to make more ATP molecules. So that's a really handy thing. Because it's an acid, it makes the blood more acidic. And so people, for a very long time, it actually predates the invention of the CTG machine. People were testing baby's blood to see what their pH level was, and in more recent levels, directly measuring lactate levels to see what's going on. Now, while there, again, there is a link, but it's not a hugely strong link between as your lactate levels rise, the chance of you having a baby who has a health problem after birth goes up. But most of the babies who have a high lactate level or a low pH are, in fact, completely fine because what we're seeing is a baby that's going, it's okay, I've got this girlfriend, I've got my plan B in action and I'm doing a lot of it. And because of that, my cells are able to continue functioning completely normal. But inside that subset of babies that have a lot of lactate and a lot of acid is also a group of babies who are going, I don't got this. I have tried everything I possibly can and I have now reached the point where I have nothing else to give. And we can't tell the difference between those two. The same is true of the heart rate patterns.
Kirsten:
[1:00:28] The heart rate patterns like decelerations are an attempt on the part of the baby to reduce the amount of work that the heart has to do. In the face of low oxygen levels because you need oxygen to make muscles contract and the heart's a muscle. So if your heart's contracting at 60 beats per minute rather than 120, that's half as much oxygen. It's very handy. It's a very sensible, functional way to protect your heart tissue from damage is to lower your heart rate. But when people see a deceleration, they go, oh, my Lord, this fetal just gets quick. Let's do a cesarean section. When, in fact, what they're seeing is fetal coping. It doesn't have quite the same ring to it. And again within that subset of babies who are having decelerations will be some who've gone I've done all the coping I can and I need to get out of here right now because I haven't got anything left in me so as I said what we need instead is a test that will tell us not there's a lot of coping going on but this baby is now reaching the point where it's running out of coping and is heading into the something seriously bad's about to happen situation we're not there yet.
Mel:
[1:01:35] So we don't know, we can't determine which babies are no longer coping. We just know the ones that are starting to compensate for whatever's happening in their labour and birth. Is it possible that the heart rate could be normal and the lactate could be normal, but the baby is still struggling?
Kirsten:
[1:01:55] In theory, yes, but the chances of that are very, very, very small.
Mel:
[1:02:04] In a real life example, so once a week, so I play netball, have done since I was a teenager, and I am definitely a Division 2 player, not a Division 1 player. However, our team was placed in Division 1, so now I've been forced into the scenario of fighting for my life every Saturday against other Division 1 teams. I can guarantee for the entirety of that game that I am working at full capacity, my heart rate is higher than it should be, my lactate is higher than it should be, and I'm on the verge of vomiting and or passing out by the end of four quarters. Is that what we're talking about when a baby is laboring and under the stress and intensity of that adventure Is their heart rate going up and their lactate going up because they are also working hard as their mother is? And that's what we're measuring. We're measuring the activity and the stress that the baby's body is under. I mean, I'm not being injured during the game. It's just that's what happens when you work really hard. Is that the same thing that's happening to a baby in labour?
Kirsten:
[1:03:23] Yes, it is. The difference is that nobody's rushing onto the field halfway through the second quarter as you're about to try and shoot for a goal, to push you down onto a trolley and drag you out of the middle of it because, Mel, your lactate's 6.7. Quick, we've got to get you to an ICU.
Mel:
[1:03:43] Right. Okay, I just want to give a, just check a real-life example of, you know, is it just, you know, they're working really hard but they're not sick yet?
Kirsten:
[1:03:54] Correct. So, you know, we know that oxygen levels drop, The transfer of oxygen across the placenta drops each time there's a contraction. And, you know, women have been producing babies for a very long time. There's been evolutionary pressures to make sure that we can make labour and birth be safe for babies as a way to arrive in the world. And so we've developed all of these mechanisms that mean that babies do okay on their own. Because, like, until 1830, nobody was listening to heart rates.
Kirsten:
[1:04:26] And, you know, humans have been around for quite a long time before that. So babies have had to figure out how to survive on their own without us deciding that it's time for them to come out of the uterus early and have really good systems to be able to do that. And so the changes that we're seeing in heart rates are about...
Kirsten:
[1:04:48] Protecting themselves in the face of low oxygen in order to avoid being damaged. The changes that we're seeing in lactate levels are part of that picture as well. Though, you know, when acid levels get very, very high, the acid itself can start to cause damage to the tissue. So, you know, in both situations, there is a point at which it gets to be too much and it is not going to solve the problem for all of the babies. And we do know babies sometimes die during labour and babies sometimes die in the days after their labour or end up with brain injuries. You know, I'm not some magical thinker who believes that all babies have fabulous outcomes. You know, it's a problem. And I'm here not because I want to chuck out all of the tools that we have, but because I want us to transition to something that actually works. One of the stories that's in my back collection of experiences that I've had as a clinician is caring for a woman who was 39 weeks, first baby, completely uncomplicated pregnancy, had had all of the tests and the scans and, you know, didn't have anything that was out of the ordinary range.
Kirsten:
[1:06:04] Had ruptured the membranes with clear lycor, wasn't yet contracting, lived on a farm two hours drive away from this country hospital where I was working at the time. And so she hopped in the car and came in, which was a very sensible choice. And somebody put a CTG machine on, completely normal, upside down, back to front, no doubt about it, normal tracing. Not in labour. Obviously, we're not sending her home because it's a four-hour round trip. So we said, why don't you go into town, go for a walk, have dinner with your husband, come back in a few hours. So she did that, came back later that evening. Somebody put the CTG back on. Completely, completely normal. Tucked her up into bed and said, buzz when you start having some contractions, which she did at about one o'clock in the morning.
Kirsten:
[1:06:51] Baby was dead.
Kirsten:
[1:06:55] And so the CTG didn't protect her from that. And I would really like a technology that we could have used at an earlier stage during that day that would have gone klaxons ringing. There's something going on here and you need to do something differently. And CDG monitoring did not produce that alert for us. And, you know, if it had been left on continuously, maybe it would. But, you know, in most parts of the world, that woman would not have been inside a hospital. She would have been at home and would have presented back to hospital when the contractions increased in intensity. So, you know, possibly at 2 a.m. Before we were, you know, starting to pay more attention to what was going on with her. So, yeah, that's why I'm here doing the things that I do, not because I just want to mess people's lives around and destroy all CTG machines. You know, we won't get to the point where we have researchers and tech developers and academics working and government bodies and people who fund research working together to find something that works. If they keep thinking that if we just sent people to another education day or if we just upgraded our CTG monitoring system and made it more comfortable for women, then the problem would go away because that's not working.
Mel:
[1:08:23] So the horse that bolted is probably actually dead in the paddock and we are trying to thrash it. And what you're saying is stop focusing on the dead CTG horse. Move on and find a strategy that will work.
Kirsten:
[1:08:44] Yeah. Maybe the goat is what we should be. And it's been there all along, But because we've been so busy flogging the horse for 150 years, we've completely overlooked the fact that the goat was the solution all along.
Mel:
[1:09:00] Imagine if goats were the solution. Wow. Okay. Kirsten, I think, I feel like you've answered all of my questions, but is there anything else you would want listeners to know about monitoring their baby in labour?
Kirsten:
[1:09:18] Well, the answers are in the book, basically. It is a comprehensive but easy to understand review of all of the evidence and the background behind how the evidence was done so you can see whether to trust any of it or not.
Kirsten:
[1:09:34] Obviously, it's designed for women who are making these decisions for themselves. But if you are one of the people who has conversations with women about fetal monitoring discussions, so you're a doula, you're a childbirth educator, you're a midwife, an obstetric nurse, you're a doctor, then you should be reading this as well. Researchers and policy writers who are not yet across the evidence base, Yes, it's a great entry point because it is simple and easy to read. But as you've seen, if you flick to the back of the book, the reference list is extensive. So you can then go and fact check everything. Like, don't believe me, go and look at the research. It's all laid out in the back of the book so you can actually see that I have not misquoted or misrepresented somebody's research studies.
Kirsten:
[1:10:19] And the more people we have who know the truth of the matter, the more likely it is we'll get to a tipping point where the change that needs to happen will actually happen. So the book's currently available in all of the usual places where you'd expect to find a book. It's available as an e-book. It's available as the paperback version. I've also done a rather nice hardcover version which has color inside of it and the paper's better quality in it. It's lovely and it's particularly handy for those of you who maintain some kind of a lending library. You know, if you're a midwife or a doula, often they will buy a bunch of books and lend them out to people that are their clients. So, you know, if that's what you're doing, you might want to grab the hardcover version of it. And Mel's going to share a link in the show notes to a webpage that has all of the Amazon listings so that no matter which part of the world you're in, you'll end up on the right one for where you are. And the non-Amazon places, you can buy the book for those of you that have issues with Amazon, understandably. And there's also the option, if you want, you can have a personally autographed copy from me as well. So, where to go to buy that is on the list there as well.
Mel:
[1:11:33] Fabulous. And one thing that I know that maternity care providers don't have is a stack of time to actually educate women about their options often. That's something that this is why this podcast exists as well. I know that lots of clinicians will say, look, we need you to have a think about and make decisions about this particular topic. I've got 10 minutes to give you a little bit of information. But if you want a bigger discussion, people often recommend these podcast episodes. But the book is something that you can recommend to women who have more questions, who want to make an informed decision. You can say, look, actually, the best place to get all the information that you might need to make this decision is in this book. And I will say, I do think it's pitched at a really nice level in terms of it's not too academic, although the research papers are academic. It's not so academic that a regular person, anybody out there who can interpret and listen to this podcast could easily understand this book. So don't be frightened. And just remember, this is a decision for you to make. It's not innocuous. Choosing CTG monitoring has some risks and benefits. Not choosing it has some risks and benefits too. So it's up to you to decide what you want to do.
Kirsten:
[1:12:51] Towards the end of the book, it's not just the evidence. There's also a whole chapter in there about how to make the decision, how to communicate that decision to your care provider and what to do if you encounter resistance to the decision so that, you know, it's not just like, here's the evidence, off you go. You know, I'm going to hold your hand in terms of actually giving yourself the best chance of making it happen the way that you have decided that you want it to happen.
Mel:
[1:13:21] Perfection. We've done it. Thank you so much for being here, Kirsten. Kirsten has been on the podcast before and we've had a lot of robust discussions about CTG during pregnancy, labour and birth. So I'm going to tag all of those episodes in the show notes below. Click below if you want to get Kirsten's book, Super Easy Access, and I'll also link to Kirsten's blog and all of the things she does online. Thanks, everybody, for being with us for this episode of the Great Birth Rebellion podcast, and we will see you next time. To get access to the resources for each podcast episode, join the mailing list at melanithemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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