Fetal Monitoring in Labor & Delivery

Trials show that both forms of electronic fetal monitoring (intermittent CTG and continuous CTG) are both associated with higher rates of cesarean & instrument-assisted vaginal births when compared to auscultation (doppler) monitoring.

Trials show that the use of either form of electronic fetal monitoring (intermittent CTG and continuous CTG) did not improve fatal or severe outcomes in babies, when compared with auscultation (doppler 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, ACOG , WHO, and the ACNM (American College of Nurse-Midwives) encourage or 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. An umbrella term Including both continuous EFM (below) and Intermittent Fetal Monitoring (also below) (NICE, 2022).

Continuous Electronic Fetal Monitoring (or Continuous CTG)
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 (or Intermittent CTG)
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.).

Pinard Fetal Stethoscope
A simple, trumpet-shaped listening device, typically made of wood, plastic, or metal, that allows a healthcare provider to hear a baby's heartbeat through the mother's abdomen without using electricity or ultrasound. It is used for intermittent fetal heart monitoring during pregnancy and labor (MARTIS ET AL., 2017).

RCT (Randomized Controlled Trial)
A randomized controlled trial (RCT) is a study in which participants are randomly assigned to different groups so researchers can fairly compare an intervention with standard care, another intervention, or no intervention (NCI, N.D.).

Intrapartum Hypoxia
Intrapartum fetal hypoxia is a reduction in the baby’s oxygen supply during labor. If sufficiently severe or prolonged, it can cause acid to accumulate in the baby’s blood—but hypoxia does not automatically mean injury occurred (DI PASQUO ET AL., 2022).

There are three dominant forms of fetal monitoring used in US births. Continuous Electronic Fetal Monitoring, Intermittent Electronic Fetal Monitoring and Intermittent Auscultating (normally done with a handheld doppler).

Parents planning a hospital birth and planning a spontaneous, unmedicated labor should have two options available to them. First intermittent electronic fetal monitoring and second, intermittent auscultation. Below we will discuss the evidence behind each one. Electronic monitoring will always be the default in American hospitals so parents should speak with their provider first if they desire to use intermittent auscultation instead to make sure this preference can be safely implemented within the hospital they plan to use.

Parents planning a hospital birth that will involve prostaglandins, Pitocin or other means of induction and or augmentation will be required to use continuous fetal monitoring. The use of epidural pain management will also warrant the need for continuous fetal monitoring.

For those planning an out of hospital birth, you will receive intermittent auscultation. Most out of hospital providers use a handheld doppler but some may utilize other tools like pinard fetal stethoscopes.

The Cochrane review 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 (ALFIREVIC ET AL., 2017).

Compared with intermittent auscultation, continuous and 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." - Cochrane Review (ALFIREVIC ET AL., 2017)

Newer research has found that not all newborn seizures are related to labor. Most are caused by conditions that begin before or after birth, meaning continuous fetal monitoring would not be expected to prevent them (CHAKKARAPANI ET AL., 2025).

When continuous electronic fetal monitoring was first introduced, cerebral palsy was widely believed to result from oxygen deprivation during labor. Researchers therefore expected that earlier detection of fetal distress would reduce the incidence. We now know that most cases of cerebral palsy originate before labor, with only a small proportion resulting from acute intrapartum hypoxia. This helps explain why the Cochrane review found that, despite reducing neonatal seizures, continuous electronic fetal monitoring does not reduce the incidence of cerebral palsy (ALFIREVIC ET AL., 2017; ACOG & AAP, 2014).

"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)

“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)

“IA is the preferred method for monitoring the FHR during labor at term where the risk of fetal acidemia is rare.” - ACNM (ACNM, 2026)

“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.” - WHO (WHO, 2018)

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 intermittent 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).

(NICE, 2026; ACOG, 2025B)

Norway: For low-risk labor, intermittent auscultation is recommended. Routine admission CTG and continuous CTG are not recommended unless there is a clinical indication. (Moderate-confidence finding for intermittent auscultation; high-confidence finding against routine CTG.)

Japan: After a reassuring 20-minute CTG, the fetal heart rate may be monitored using intermittent auscultation every 15–90 minutes, followed by another CTG within six hours. Continuous CTG during latent labor is permitted but not required. (Moderate-confidence finding.)

Sweden: During the first stage of low-risk labor, either intermittent auscultation or intermittent CTG may be used. During the second stage, monitoring may consist of auscultation or continuous CTG. Admission CTG is recommended for all women, but continuous CTG is not required throughout low-risk labor (Moderate-confidence finding.)

(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-confidence findings of fetal-monitoring guidance (OECD, 2025; UN IGME, 2025; WHO ET AL., 2025).

Intermittent auscultation is the primary or only form of monitoring used in out of hospital births.

In hospitals in the US, electronic fetal monitoring (intermittent or continuous) remains the predominant form of fetal monitoring, despite recommendations and supporting evidence for auscultation monitoring (ARNOLD & GAWRYS, 2020).

Author Inference: Increasing integration of intermittent auscultation (doppler monitoring) for eligible labors, may help the US to reduce our cesarean rate; currently 32.5%.

In 2015, WHO evaluated nationally representative data from 159 countries (representing 98% of global births, and adjusted for national development. Mortality declined as cesarean rates increased towards 10%. But above 10%, the relationship flattened- with no additional reduction in maternal or newborn mortality (WHO, 2015).

The US cesarean rate (CDC, 2026) is 117% higher (relative increase) than the upper end of the range historically considered ideal by WHO (10-15%) (WHO, 2015).

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.