Wired CTG and Labour Mobility

Introduction and Background

Considering the importance of mothers’ positioning during labour, concerns have been raised over wired CTG and how the wiring limits the ability of women to change their positions during labour) (Cluett et al, 2009). Likewise, according to Jokkhan et al (2015), the limiting nature of wired CTG triggered the development of telemetry, a similar electronic device used to monitor foetal heart contractions, only that it uses wireless transmitters, thereby enhancing mothers’ mobility during labour. Particularly, mobility is considered useful during labour because when women freely move during labour, they psychologically develop a sense of control over the situation and this may reduce the need for pain relief interventions (Center for Maternal and Child Enquiries and Royal College of Obstetricians and Gynaecologists, 2010). In fact, this advantage (i.e. wirelesses) of telemetry over wired CTG has been acknowledged by various health authorities in the UK including the National Institute for Health and Care Excellence (NICE). For instance, according to NICE (2014), practitioners must avail telemetry to any woman who may be in need of constant foetal monitoring during labour. Besides, NICE discourages the limitation of women to the supine position but rather encourage that women should adopt any position that they would feel comfortable with (NICE, 2014). But, even with the non-limiting nature of telemetry, NICE (2014) guidelines require that practitioners should ensure that telemetry does not impede this free movement. However, despite the superiority of telemetry over wired CTG in enhancing mobility, it has several limitations that are inherent with it. For instance, Mangesi et al (2009) contend that telemetry machines are more expensive to acquire set up and maintain. Hence, there may be a need for an alternative, which is the wired CTG. That said, to the best of the researcher’s knowledge, there is a paucity of research evidence highlighting the use of CTG and its effects on patient mobility during labour. In fact, the researcher assumes that this lack of evidence may be part of the reasons why it is not used in their practice setting. Hence, the main focus of this review is to evaluate the use of cardiotocography monitoring (CTG) and how it influences a woman’s mobility during labour. Besides, the study will also examine how mobility impacts on the foetal or maternal outcome. This topic is of particular interest to the researcher because, in the researcher’s practice setting, CTG is rarely used.

Research Objectives

i. To evaluate the use of CTG in labour setting

ii. To identify the impact of wired CTG on women’s mobility during labour

iii. To explore the impact of mobility on foetal outcome

Research Methodology

The Critical Literature Review Methodology

First, a literature review is defined by Wood et al. (2006) as the process of conducting an overview of existing and published research materials with the aim of identifying the current theoretical issues related to the current problem or topic of study, and the current state of knowledge about these problems. Hence, Critical literature review methodology is a research method that critically examines the currently existing research evidence and highlighting the current state of knowledge about the research topic at hand. The current study aims to explore the evidence that exists on the use of CTG and how it affects the mobility of women during labour. Therefore, the critical literature review methodology was chosen for this particular study based on the reason that it will enable the researcher to identify the existing body of knowledge and evidence on the use of CTG and its impact on the mobility of women during labour. Moreover, this choice is based on the assertions by Russell (2005) that the methodology not only summaries these pieces of evidence but also evaluate the issues and key themes that run through them. This justifies the use of a critical literature review in the current study.

Search Strategy

The researcher conducted a bibliographic search of literary materials that were related to CTG influences on mobility during labour. The search was conducted in three major online journal articles, namely: EBSCO, MEDLINE and CINAHL, and only the research articles that were retrievable in full text and published in the English language were selected for review. The researcher used various search terms; including labour, foetal heart rate, telemetry, and mobility to complete the search.

Study Selection

During the literature search, the researcher first looked at the abstracts of each journal article to identify any piece of literary material that could be of relevance to the research topic. Based on the above-mentioned inclusion/exclusion criteria, the researcher was predominantly focused on primary studies to retrieve the most available data. While the researcher was first determined to find articles within five years of publication, some articles did not meet this criterion but were found to be of high relevance to the study. Nonetheless, the primary focus of the search process was to get relevant literature with evidence and adequate information on the research topic that could be implemented in evidence-based practice.

Search Results

When the researcher applied the search terms to EBSCO, 16,788 citations emerged. However, when the researcher added a different criterion, no relevant pieces of literature emerged, and therefore, no journal articles from this database were selected. When the search terms were used on CINAHL, 15,976 journal articles appeared, and the use of inclusion/exclusion criteria narrowed down the journal articles to 1231, yet only one article was relevant to the topic. The same procedure was followed in MEDLINE, yielding 4772, in the first search, and 463 in the second search after narrowing down the search process using the inclusion/exclusion criteria. Only two journal articles were found to be relevant to the research topic. Appendix 3 shows the search results. Appendix 1 illustrates the search process.

Results

The use of telemetry has been highlighted by many studies (i.e., Siristatidis 2012) to be more effective in enhancing mobility and change in position during labour, mainly because it entails a wireless transmission of foetal heart rate transmissions. Against this backdrop, Watson et al. (2018) conducted an online survey to explore that use of telemetry and its impact on the quality of maternity outcomes. As part of the objectives, the researchers intended to understand how telemetry influenced the birth process, with mobility being one of the aspects evaluated. Here, answers from a total of 166 participants from 59 maternity facilities, 31% of the respondents agreed that telemetry enables proper mobility during birth, and consequently delivering some level of satisfaction with the labour experience.

The study by Watson et al. (2018) is published in the British Journal of Midwifery, which is an established journal article focused on academic research on the topic are of gynaecology and related practices. The main researchers in this study: Watson, Mills, and Lavender all have the qualifications to conduct research in the subject of mobility during maternal labour. For instance, Watson is a senior midwife, and a Ph.D. student at the University of Manchester, Mills is a lecturer in midwifery at the University of Manchester, while Lavender is also a professor at the University of Manchester. Being academicians in a renowned university and practitioners in midwifery, the researchers have the credibility and qualification to conduct such as study and were at a better position to effectively interact with the target population in a manner that would help them gather the most relevant data for the research. Also, the researchers have clearly indicated that their study was funded by the Research and Innovation Division at the University of Manchester’s Foundation Trust. Whereas there is a possibility that the funding might have made it easier for the Trust to influence on the study results, the ethical considerations made by the researchers could have minimised this influence. Nonetheless, the researchers failed to indicate who initiated the study, and this makes it difficult to infer the extent to which the initiator could have influenced the findings (Woods et al., 2006). Above all, the study tittle gives a clear theme of the study, which is indicated as ‘the use of telemetry in labour.’ It is easier to infer from the tittle what the researchers were interested in, and how they would achieve their objectives (i.e., by conducting an online survey). Furthermore, the researchers have also given a clear overview of the study through an abstract, which provides a background, the methods, summary research findings, and a conclusion. An abstract enables an easier search and retrieval of research articles and therefore contributes to the process of conducting future research in the same topic (Ormston et al. 2014). In regards to the introduction section of this study, the researchers have presented background and justified the importance of undertaking their research. In doing so, they have examined the significance of foetal heart rate monitoring, the vital role of telemetry in conducting foetal heart rate monitoring, and the reason why they were interested in reviewing the use of telemetry within maternity facilities in the UK. This clear introduction and justification of the study presents the reader with interesting information about the topic and helps them develop an interest in the study. However, the researchers failed to justify why they chose the qualitative research design, even though it comes out clearly to be the best methodology to achieve their objectives (Palinkas et al., 2015).

Notably, there are several limitations to the study by Watson et al. that limits the generalizability of its findings. For instance, the study experienced a low response rate, as only 104 maternity institutions participated. According to Ormston et al. (2014), a low response rate translates to a small sample, which affects the extent to which the study findings can be generalized. As a survey, the qualitative study design applied by Watson et al. (2018) influenced the results in terms of subjecting the findings to the researcher’s bias. However, an advantage of the qualitative methodology, especially in this study, is that the researcher reveals the subjective perception of the respondents on mobility, and therefore the data gives a personal experience of the respondents (Palinkas et al., 2015). Lawrence et al. (2013) aimed to investigate how encouraging women to take different positions, i.e., sitting, standing, kneeling and walking – versus encouraging them to take supine positions would affect the duration of labour, the volume of placental blood flow, and the general progress of labour. The study, published in the Wiley Journals and peer-reviewed, was conducted by Lawrence A, Styles C, Hofmeyr J, and Lewis L. Commendably, there is a precise detail of who the researchers are, where they work and their educational background. For instance, a majority of the authors are both academicians and gynaecologists in prominent universities and hospitals respectively, and this gives them the credibility to conduct academic research on positions and mobility during maternal labour. However, the researchers have neither indicated who funded the study nor the existence of any individual and organization that might have influenced the study outcomes. This affects the interrogation of the credibility of the study findings. It is, however commendable that the researchers have used the study title to properly introduce the study themes, which are the positions and mobility during maternal labour. Palinkas et al. (2015) contend that an adequately stated research title and research themes contributes to clarity and accuracy of intended study objectives. Furthermore, the researchers have used an abstract to provide a concise overview of the study findings. The abstract provides a background of the study, the research aim, methodology, and a summary of results. Interestingly, the abstract has been written in a manner that intrigues and triggers the interest of any reader to read the whole paper. The researchers reviewed existing randomized control trials from the Cochrane research database. According to Savin-Baden & Major (2013), this methodology (i.e., review of evidence), is useful in determining the current state of the art in nursing practice and are thus helpful in the development of practical practice guidelines. This choice of methodology was, therefore, an appropriate one for the researcher’s objective of examining and developing useful practice guidelines in on how to achieve the most effective mobility and positions during maternal labour. Nonetheless, a quick search of the Cochrane database revealed no similar study done before, and therefore, it could concluded that the research was a replication of a previous one.

The study drew evidence from randomized control trials on pregnancy and labour and found that women who gave birth while in upright and recumbent positions took 1 hour and 22 minutes shorter to give birth than those who were in upright positions. Besides, the study found that women who were in an upright position were less predisposed to caesarean section compared to those who were lying in bed or lateral position. Ultimately, the study concludes by acknowledging the importance of upright and walking positions in reducing the duration of the labour process, in reducing the need for a cesarean birth. Interestingly, the findings of this study corroborate with the results of other studies (e.g., Chen et al. 2011), whereby it was found that taking different positions such as kneeling, sitting, walking and standing has a positive effect on placental blood flow during labour. But there are several limitations on the results by Lawrence et al. (2013). For example, the study combined several studies with diverse methodologies, and this exposed the study to bias, inaccuracy, and lack of rigour (Ragin, 2014). Besides, the study combined several empirical and theoretical pieces of evidence, and this contributes to complexity in establishing the validity and relevance of the study (Savin-Baden & Major, 2013). Additionally, due to the complex nature of labour (i.e., characterized by several emotional and physical variables), most of the studies reviewed by Lawrence et al. (2013) did not blind the women as well as their accomplices when allocating them to both the control and intervention groups. This contributes to several inconsistencies and difficulties in interpreting the much heterogenic RCTs reviewed by Lawrence et al. (2013), and therefore, the results of the study should be interpreted and generalized with caution. In the backdrop, CTG involves an electronic recording of the baby’s heart rate as well as the monitoring the contractions in the uterine, both of which are transmitted through wires to a recording machine. Against this backdrop, Alfirevic et al. (2013) evaluated CTG as an electronic technology used in the assessment of foetal heart rate, its advantages, and disadvantages. The researcher selected a total of 13 RCTs that covered sample population 37,000 women participants. Besides, Alfirevic et al. (2013) only included RCTs that compared different forms of CTG application, including intermittent cardiotocography and intermittent auscultation. From the onset, the researchers acknowledge that CTG involves the wearing of a belt across the mother’s abdomen during the entire monitoring process, and this limits the mother’s mobility. Besides, the researchers treat their audience to the knowledge of internal CTG, which they claim to involve the attachment of an electrode to any presenting part of the baby – usually the head. They claim that even the internal CTG limits the mother’s mobility when the wire is attached to the baby’s head. Some studies reviewed by Alfirevic et al. (2013) were qualitative and revealed the views of women as well as the opinions of professionals on the impact of CTG on mobility during maternal labour. For instance, the researchers reviewed a study by Munro et al. (2004), where women expressed their misgivings on continuous CTG, citing that it limited their mobility. More interestingly, Alfirevic et al. (2013) found that women tend to report more pain when they lay on their back during labour and this is attributable to not being able to change positions to cope with the pain.

A critical evaluation of the study by Alfirevic et al. (2013) reveals several methodological issues that are worth noting. First, it is commendable that the researchers have conducted a comprehensive exploration of the research question, especially in the introduction section. In doing so, the researchers have defined the concept of foetal heart rate monitoring, described the concept of cardiotocography and the different forms of CTG (i.e., either internal or external CTG) that can be conducted during maternal labour. The researchers have then gone ahead to describe the research question, namely: what is the effectiveness of continuous CTG during labour? According to Ragin (2014), this exploration of research question not only orients the readers to the underlying problem under investigation but also enables a quick determination of the usefulness of the research study in regards to how its findings can practically be applied. Secondly, an examination of the study’s discussion section indicates that the researchers have somewhat achieved their objective of identifying the effectiveness of CTG. For instance, they found an association between continuous CTG and a reduction in neonatal seizures, even though no significant differences were found between intermittent and constant cardiotocography with respect to infant mortality or cerebral palsy. On the flipside, the researchers found that CTG was associated with increased risk of caesarean section. Finally, the researcher concluded that it is important to inform women of these results so they can make informed decisions upon considering the benefits and limitations of CTG. However, it is unfortunate that the researchers failed to indicate who funded the study, or who initiated the study to be undertaken. This makes it challenging to establish the influence of any third party on the research findings (Savin-Baden & Major, 2013). Furthermore, the researchers did not mention any ethical considerations they made in the study, and therefore, it is difficult to ascertain whether the study was based on any ethical background. Wood et al. (2006) contend that ethical considerations are essential in ensuring that the data collected are not falsified or fabricated in the process of seeking truth and knowledge. Worryingly, without mentioning any ethical considerations made by the researcher, it is difficult to determine whether the data were falsified or not.

Discussion

Mobility and Patient Satisfaction

The first theme that emerges from the reviewed study is that CTG affects mobility and patient satisfaction during maternal labour. For instance, Watson et al. (2018) highlight several circumstances under which telemetry is used and finds that telemetry had a positive influence on satisfaction and mobility during labour. Whereas this study fails to compare the impact of telemetry and CTG on the mobility of women during the birth process, its emphasis on the influence that telemetry has on mobility, argued together with the fact that CTG does not enable a wireless foetal heart rate transmission, warrants the extrapolation that to some extent, wired CTG limits the mothers’ ability to take different position during the birth process. The particular mentioning of mobility as an aspect of labour that is improved by telemetry raises the question as to whether CTG, which uses a coded transmission of foetal heart rate, can yield the same satisfaction of the labour process among women at birth – yet one of the assumptions about CTG is that women find it challenging to take an upright position and change into several positions during labour. On the contrary, as highlighted in the free-text responses received by Watson et al. (2018), telemetry enables women to be more mobile and take an upright position during labour. That said, considering the critical role of mobility in reducing the length of labour and its contribution to the reduced use of analgesia (Lawrence et al., 2013), CTG, a limiter of mobility, can, therefore, be associated with longer labour duration and may necessitate the use of pharmacological analgesia. It is also possible to extrapolate from the discussions by Watson et al. that the leads in wired CTG enforce discomfort and immobility, thereby preventing the patient from using the pool or changing position. Interestingly though, while telemetry has been assumed to enhance better mobility and pool birthing compared to wired CTG (Lawrence et al. 2013), research by Watson et al. does not give conclusive evidence to warrant the assumption that telemetry enables women to be more mobile or sit in an upright position. The inconclusive results regarding the role of telemetry in enhancing mobility and satisfaction in labour, therefore, call for further research on this topic area.

Effects on the Labour Process and Progress

In most countries, it is a common practice that women give birth in labour beds (Alfrevic et al., 2017). However, various observational studies have revealed that the position that women take while lying in bed affects uterine contractions, thereby affecting the labour process. Interestingly, this review has found that mobility is an essential aspect of maternal delivery and that in any progressive delivery session, there is no single or universal position. These results are especially relevant and intriguing, considering that the CTG makes it difficult for women to take a standing, kneeling, or walking position (Chen et al. 2011). Instead, the wired transmission of foetal heart rate in CTG limits the mother to bed care; thus the mother cannot walk, kneel, or stand. This ultimately affects the general progress of the process, prolongs the process and may contribute to negative labour outcome in terms of placental blood flow. Hence, even though the research by Lawrence et al. (2013) does not focus in the impact of CTG on mobility during maternal labour, the evidence it produces enables an evaluation of the extent to which immobility caused by wired CTG may affect the progress of maternal labour. There are a series of complex physiological changes that occur during the first stage of labour that leads up to the opening of the cervix in preparation for the birth of the baby. But the physiological processes involved in this stage of labour are influenced by several factors such as the intensity of uterus contraction, the occurrence or non-occurrence of the membranes, the size of the baby, whether the placenta is functioning or not, and whether the pelvis is adequate or not (Lawrence et al. 2013). Consequently, from time immemorial, women have been encouraged to stay mobile and take different positions by walking, sitting, or standing, especially in moments just before being ready to give birth. Whereas there are many variations in achieving an upright and mobile position, women are fundamentally encouraged to stay in a mobile and upright position, a phenomenon that can be achieved through the use of various props such as birthing balls, recliner chairs or taking a shower. However, from the reviewed studies, it emerges women would not find it easier to take these positions when they are under coded CTG. Sometimes the codes are strapped around the uterus, and this limits them from taking an upright position. Even if they could take an upright position, it would be difficult for them to alternate these positions or also use the recommended props (e.g., birthing balls).

Effects on Pain Management Strategies

It also emerges from the review that wired CTG would also limit the application of other comfort measures. In external CTG, the patient is required to wear a belt across their abdomen while being monitored, and this restricts their mobility. Similarly, in internal CTG, an electrode is attached to the baby’s presenting part (mostly the head), and this also limits the mother’s mobility. Therefore, both internal and external CTG has an impact on the mother’s mobility, and this consequently impedes the application of several other essential procedures and comforting measures. For instance, Lawrence et al. (2013) reveal that sometimes it may be necessary to rock the mother on the hips or conduct a lower back massage, but this may be difficult or impossible to achieve if the mother is strapped all around with the CTG transmission codes. Reviewed literature has also shown that CTG inhibits immersion in water and makes it challenging to employ other comforting strategies. Hence, it is possible to conclude that wired CTG not only affects the mother’s mobility but also inhibits the implementation of several other comforting procedures that may be useful during the delivery process. For purposes of effective practice, these findings reveal the need for proper sensitizations among women to enable them understand the limiting nature of CTG and to ensure that they make informed choices of the clinical procedures they subscribe to during maternal labour.

Conclusion

In summary, the main aim of this study was to explore the impact of CTG on mobility during maternal labour. Alongside this aim, the researcher had the objective of understanding the use of CTG and the impact of mobility on foetal outcome. To achieve these objectives, the researcher relied on a literature review methodology, whereby relevant journal articles were reviewed to for evidence. In doing so, the researcher identified three key sources of research evidence, one being a randomised control trial while the other two being meta-analyses. In regards to the first objective, the study has found that CTG is a clinical procedure which involves monitoring and recording the baby’s heart rate. The procedure can either be internal or external but in both cases, the measuring machine (cardiotocograph) uses a pair of wired codes attached to a monitor transmit the uterine contractions that enable the measurement of the baby’s heart rate. The study found that these pair of codes attached to the monitor inhibits the mother’s ability to move or sit upright. Besides, it has been found that when the belt is tied around the mother’s uterus, they are less likely to change position or use other pain relieving props such as birthing ball. Additionally, the study has found that wired CTG inhibits the application of various pain management strategies such as lower back massage and immersion in water. The impact of this immobility is serious. When the mother is unable to change positions or undergo the various procedures involved in the process, the physiological processes occurring during the labour process are interfered with, and this may affect patient satisfaction. A key practice point that this study presents is that women should be informed of the advantages and disadvantages of CTG before they are subjected to the procedure so that they can make an informed decision in the process. All in all, there are several limitations of this study that may affect its findings. For instance, due to a paucity of primary research on this area of practice, the researcher included only one primary research and two secondary (meta-analyses) in the review. Thence, the findings of this study are subject to the limitation of secondary data including the biases of the original authors. Besides, a large volume of data was retrieved during the review, and this created complications in regards to the selection and use of relevant data. In the process, the researcher only selected the data that were deemed to be relevant in answering the research questions, while leaving out those that never seemed to be relevant. The findings may therefore be subject to selection bias. Nevertheless, this study has drawn evidence from a variety of data sources, thus contributing to the validity of the study findings.

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