Fetal Monitoring in Labor - Guidelines, Evidence & a Global Perspective

Trials show that doppler monitoring, compared with both continuous electronic fetal monitoring as well as intermittent fetal monitoring, has been associated with lower rates of cesarean birth and instrument-assisted vaginal births. Additionally, doppler monitoring is not associated with worse outcomes than both forms of electronic fetal monitoring.

These conclusions are based on trials that included both low- and higher-risk labors. Analysis of the high-risk subgroup did not show that continuous fetal monitoring improved outcomes and was consistent with overall results of the full Cochrane review.

For a low-risk healthy spontaneous labor, both ACOG & WHO recommend the use of doppler monitoring and do not recommend continuous fetal monitoring.

Current recommendations favoring continuous fetal monitoring for many higher-risk labors are based primarily on observational evidence, physiologic reasoning, pharmacological understandings, and expert consensus rather than randomized clinical trials demonstrating improved major birth outcomes.

Cardiotocography (CTG)
Electronic monitoring that records the fetal heart rate and uterine contractions on a tracing used to assess fetal well-being during labor (NICE, 2022)

Continuous Electronic Fetal Monitoring
A method of continuously recording the baby's heart rate and the mother's uterine contractions using external or internal electronic sensors throughout labor (ACOG, 2019).

Intermittent Fetal Monitoring
Periodic assessment of the fetal heart rate at recommended intervals during labor rather than continuous monitoring. This may be performed using intermittent auscultation or intermittent electronic monitoring, depending on the clinical situation (ACOG, 2019).

Intermittent Auscultation (IA) (AKA Doppler Monitoring)
A method of fetal monitoring in which a healthcare provider listens to the baby's heart rate at regular intervals using a handheld Doppler device or fetoscope rather than continuously recording the heart rate (ACOG, 2019).

Pitocin (Synthetic Oxytocin)
A synthetic form of the hormone oxytocin that is administered intravenously to induce labor (start labor) or augment labor (strengthen labor after it has already begun) (ACOG, N.D.).

The Cochrane review (and meta-analysis) is considered to be the highest level of evidence on continuous electronic fetal monitoring. It includes 13 randomized trials and 37,000 women. Across the 13 trials, there was a mix of risk levels, with some trials including low and high risk, and others looking at specifically low- or high-risk labors. This review was funded by The Cochrane Pregnancy and Childbirth Group with no industry funding reported.

Compared with intermittent auscultation, continuous intermittent fetal monitoring was associated with:

An often-overlooked finding is that the lower rates of cesarean birth and instrument-assisted vaginal birth were associated with intermittent auscultation—not intermittent electronic monitoring (ALFIREVIC ET AL., 2017).

The reviewers also noted that while neonatal seizures were reduced, there was no clear evidence that this translated into improved long-term neurological outcomes, including cerebral palsy.

"Data for low-risk, high-risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results." (ALFIREVIC ET AL., 2017)

"A Cochrane review of 13 RCTs... found that continuous EFM was associated with an increase in cesarean deliveries and an increase in instrumental vaginal birth rate. However... the authors found no significant difference in the rates of perinatal death or cerebral palsy when compared with intermittent auscultation." - ACOG (ACOG, 2019)

The Cochrane authors concluded that continuous electronic fetal monitoring and intermittent fetal monitoring increased the rates of cesarean birth and instrument-assisted vaginal birth but did not reduce the risk of perinatal death or cerebral palsy. Although continuous monitoring was associated with an approximately 50% lower relative risk of neonatal seizures, there is no evidence that this reduction translated into improved long-term neurological outcomes (ALFIREVIC ET AL., 2017).

“For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.” - (ACOG, 2019)

“Obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device” - ACOG (ACOG, 2019)

“Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labour.”

Intermittent auscultation (doppler) is generally appropriate for women entering labor with a healthy, term, low-risk pregnancy, when labor begins spontaneously, and no maternal, fetal, or labor complications are present. ACOG states that either intermittent auscultation or electronic monitoring may be used when no complications or risk factors exist (ACOG, 2025A), while NICE and WHO specifically recommend intermittent auscultation for healthy, low-risk women in labor (NICE, 2026; WHO, 2018)

(BLIX ET AL., 2019; JSOG & JAOG, 2011; JSOG & JAOG, 2023; NORWEGIAN MIDWIVES ASSOCIATION, 2025)

These countries were selected for their strong maternal and neonatal outcomes and the availability of clear, moderate- to high-quality fetal-monitoring guidance (OECD, 2025; UN IGME, 2025; WHO ET AL., 2025).

This article is provided for general educational and informational purposes only and does not constitute individualized medical advice, diagnosis, or treatment. Research findings and professional guidelines may not apply to every person or clinical circumstance. Discuss decisions about your care with a qualified healthcare professional who understands your individual history and needs. Although The Birth Review makes reasonable efforts to represent sources accurately, information may become outdated, studies may contain limitations, and qualified experts may interpret the same evidence differently.