Continuous Cardiotocography (CTG)

Cardiotocography (CTG) has been recognized for decades by midwifery specialists as an effective for diagnosis during the intrapartum phase. The primary objective during intrapartum fetal monitoring is to avoid any adverse fetal outcomes, and therefore, midwives and doctors use CTC for diagnostic purposes during the critical time of the laboring period. (Alfirevic, Gyte, Cuthbert & Devane 2017). As such, midwives remain constant caregivers during the laboring process, and they must possess adequate knowledge about CTG and the competencies needed to interpret cardiotocographs accurately. However, even though CTG has been used in healthcare diagnosis for a long time, there is still a call for the midwives to be given rigorous training on the interpretation of cardiotocographs (James, Maduna & Morton, 2019) as most of the beginning practitioners face a challenge in linking theories and practices. The present paper is a systemic review of the study by (Alfirevic, Gyte, Cuthbert, & Devane 2017) on the application of Cardiotocography (CTG) for fetal assessment during labor and how the results of the study might inform midwifery practice in Australia. In addition, the review includes a reflation on competency-based education midwifery outcomes of CTG care in maternity hospitals.

CASP Systemic Review: Cardiotocography (CTG) Fetal Monitoring during Labor

The article by (Alfirevic, Gyte, Cuthbert, & Devane 2017) explores the application of Cardiotocography (CTG) as one of the approaches to assess fetus electronically during labor.  Continuous CTG was associated to the authors is linked to a growth in caesarean sections and influential vaginal births. The challenge however, remains on the best approaches to convey the same results to women to help them make informed decision without compromising the normality of labor (Alfirevic, Gyte, Cuthbert, & Devane 2017), Continuous CTG comes in to bridge this gap. The primary reason for the introduction of Continuous CTG in clinical practice was to help manage the devastating outcomes—recurrent death and neonatal hypoxic brain injuries, and ensure that the baby is born healthy.

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CTG during labor is linked to a reduction in the rates of seizures neonatal seizures, though no clear differences in cerebral palsy, infant monitoring and related measures of neonatal wellbeing. Alfirevic, Gyte, Cuthbert, & Devane (2017) argues that the seizures linked to continuous CTG monitoring is significant, but must be interested with caution in the absence of good excellence long‐term and follow‐up data. The result of the study indicates that continuous CTG monitoring translate to an increase in caesarean sections (Alfirevic, Gyte, Cuthbert & Devane 2017). The effect is clinically reasonable since CTG assessments leads to more intervention such as fetal blood sampling and amniotomy, plus several other diagnosis that are presumed fetal and for which emergency caesarean section is considered the only safer management option.

Most research detail the diverse benefits to maternal and newborn health results attainable because of expanding access to a skilled and competent birth attendant that includes midwifery services. However, these benefits are often established on the hypothesis that the midwifery workforce shares a common identity and definition. Unfortunately, a clear description of midwifery competencies is seldom talked about. A set of competency for professional midwives is essential to providing up to standard healthcare services that translate into a desirable outcome.  Competency-based education entails an approach to preparing healthcare professionals for practice. The approach is nearly concerned with graduate outcome capabilities and revolves around the competencies derived from the scrutiny of the social and needs of the patient. It reduces the emphasis on time-based teaching and promises greater flexibility, accountability, and learner centeredness.

CBE for the midwifery discipline is a program or curriculum of study that has its primary learning outcomes revolving on the International Confederation of Midwives (ICM)’s “Essential Competencies for Basic Midwifery Practice” (Saleem, Jan, McInytre, Rattani & Sikandar 2015). Crucial characteristics of competency-based education collected from a wide variety of published literature are outlined below. The inter-relationships among the various mechanisms are based on four fundamental facets: (1) approaches to support and promote active learner involvement; (2) adult learning theories; (3) knowledge of the areas of learning and approaches required to be successful; (4) a coherent sequencing of the anticipated outcome (Hawkins, Welcher, Holmboe, Kirk, Norcini, Simons, & Skochelak,  2015). Success is attained through collaborative efforts and partnerships between the educators and the learners.  

Gravina (2017), on the one hand, argues that competency-based teaching for healthcare professionals, in his case midwifery, requires a shift from the traditional focus of learning as gaining of knowledge of the topic taught to focus on performance. The emphasis should be on the ability of the learners to demonstrate critical thinking and essential professional skills Gravina (, 2017). Translation of knowledge acquired into practice is the primary focus of CBE. The time taken to master the competencies does not matter (Fan, Wang, Chao, Jane, & Hsu, 2015). The program provides inherent flexibility for the learners to study the subject area in greater depth. 

Discussion: Reflecting On How the Results of the Study Might Inform Midwifery Practice

            There is a significant leap in tasks from obstetric SHO to register, including making decisions about when an intervention is necessary intrapartum care. Majority of physicians and the patients prefer a normal virginal delivery, and the need for a healthy baby and the mother override everything. Such key decisions are directed with the help of an intrapartum CTG (Mullins, Lees & Brocklehurst, 2017). As such, the finding of this study is important in ensuring successful maternal delivery and reducing the rate of fetal mortalities in Australia. Any physician or nurse who has worked in the labor room understands norm CTGs where delivery has taken place in a horrible condition dreadful looking CTGs that have caused in a category 1 caesarean.

Cardiotocography (CTG) is a complex technology for monitoring fetuses during pregnancy, labor, and delivery. The technology requires expertise to interpret, just like any sophisticated tool used in areas like surgery. Competency based-education enables graduate midwives to effectively learn to apply sophisticated technologies such as CTG to deliver quality care. In one study conducted by Bewley & Braillon (2018), midwifery graduates required more training in addition to formal education to understand and use CTG compared to medical students. The scores of the latter improved after few times of exposure to CTG programs  The disparity in the time taken to master the CTG application between the two groups is caused by the different abilities to connect the theoretical and practical aspects of nursing education. CBE can bridge the gap.

The World Health Report of 2006 recommended that “in preparing the workforce, the curriculum is expected to meet standards that are often defined as core competencies” (World Health Organization 2006). The curriculum must be responsive to the evolving knowledge and state of healthcare and the need to meet the expectations of the clients. The competency-based education (CBE) approach to learning and teaching healthcare professionals has resulted in many benefits midwifery education across the world. The most cited benefit for CBE is that it helps the learners connect the theoretical and practical/clinical aspects of education before graduation, resulting into learners that not only have knowledge in their subject of study but can translate the knowledge into practice (Fullerton, Thompson, & Johnson, 2013). The graduates can appreciate the competencies developed during their period of pre-service education and continue to apply the same approach as they attempt to maintain and learn new skills required during the course of their professional careers.



Midwives remain constant caregivers during the laboring process, and they must have sufficient knowledge about CTG and the competencies needed to interpret cardiotocographs accurately. The knowledge and skills to analyze the outcomes of the CTG are essential for critical decision-making during intrapartum care activities. It is evident from the systemic literature review that competency-based education for midwifery can enhance access to a qualified competent midwife during pregnancy and birth to prevent the high rate of maternal mortality rates. The ability of graduate midwives to translate the knowledge learned during the pre-service period to actual practice increases with the adoption of competency-based education.


Alfirevic, Z., Gyte, G. M., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane database of systematic reviews, (2).

Fan, J. Y., Wang, Y. H., Chao, L. F., Jane, S. W., & Hsu, L. L. (2015). Performance evaluation of nursing students following competency-based education. Nurse education today35(1), 97-103.

Gravina, E. W. (2017). Competency-based education and its effect on nursing education: A literature review. Teaching and Learning in Nursing12(2), 117-121.

James, S., Maduna, N. E., & Morton, D. G. (2019). Knowledge levels of midwives regarding the interpretation of cardiotocographs at labour units in KwaZulu-Natal public hospitals. Curationis42(1).

Nehrir, B., Vanaki, Z., Mokhtari Nouri, J., Khademolhosseini, S. M., & Ebadi, A. (2016). Competency in nursing students: a systematic review. International Journal of Travel Medicine and Global Health4(1), 3-11.

Mullins, E., Lees, C., & Brocklehurst, P. (2017). Is continuous electronic fetal monitoring useful for all women in labour?. Bmj359.

Bewley, S., & Braillon, A. (2018). Electronic fetal heart rate monitoring: we need new research approaches. Bmj360, k658.

Saleem, Z., Jan, R., McInytre, H., Rattani, S. A., & Sikandar, R. (2015).Midwive”’ perception about their practice in a midwifery-led care model in Karachi, Pakistan. British Journal of Midwifery23(3), 200-207.

Hawkins, R. E., Welcher, C. M., Holmboe, E. S., Kirk, L. M., Norcini, J. J., Simons, K. B., & Skochelak, S. E. (2015). Implementation of competency‐based medical education: are we addressing the concerns and challenges?. Medical Education49(11), 1086-1102.