Why do CTG and escalation failures keep recurring?
Most babies cope well with labour. A small number develop hypoxia, which can lead to acidosis and brain injury if it is not recognised and acted on. Fetal heart rate monitoring is one of the main ways of spotting babies who may be becoming compromised, and it is one of the areas most often criticised when maternity care goes wrong.
National reviews, including Morecambe Bay (2015), the Ockenden review (2022), the East Kent investigation 'Reading the signals' (2022) and the National Maternity and Neonatal Investigation led by Baroness Amos (final report 2026), have found similar themes again and again. Women were not listened to. Traces were read in isolation. Concerns were raised but not escalated, or escalated but not acted on. Hierarchy and poor teamworking discouraged challenge.
How do you decide between intermittent auscultation and CTG?
Choosing the method starts with a risk assessment at the onset of labour, repeated at least hourly and whenever anything changes. NICE recommends intermittent auscultation for women at low risk, and offering continuous CTG where there are antenatal or intrapartum risk factors, always respecting the woman's informed choice.
| Situation | Usual recommendation | Examples (not a full list) |
|---|---|---|
| Low risk at onset of labour | Intermittent auscultation | Uncomplicated pregnancy, spontaneous labour at term |
| Antenatal risk factors | Offer continuous CTG | Previous caesarean birth, pre-eclampsia, fetal growth restriction, diabetes, reduced fetal movements |
| Intrapartum risk factors | Offer continuous CTG | Maternal pyrexia, significant meconium, fresh bleeding, oxytocin, delay in labour, abnormality heard on auscultation |
Risk changes. A woman who started at low risk may develop a temperature or meconium-stained liquor, and her monitoring and place of care should change with it. A woman with capacity can decline any monitoring. If she declines a recommended CTG, explain the reasons, document the discussion, offer the method she prefers and keep it under review.
How often should you listen in with intermittent auscultation?
Intermittent auscultation is a skilled clinical assessment, not a quick check. NICE NG229 sets the minimum standard below. Follow your local guideline for detail.
| Stage | Fetal heart | Maternal pulse |
|---|---|---|
| First stage | Listen for at least one minute immediately after a contraction, at least every 15 minutes, and record as a single rate | Palpate and record hourly, or more often if there is concern |
| Second stage | Listen for at least one minute immediately after a contraction, at least every 5 minutes | Palpate at the same time as listening, to differentiate the two at least every 5 minutes |
How should a CTG be reviewed?
Before reading the trace, check the basics: the woman's identity, date and time, paper speed, and that the fetal and maternal rates are distinct. NICE NG229 then expects a full, systematic assessment of the woman and baby at least every hour, or more often if there are concerns.
- Context: Antenatal and intrapartum risk factors, stage and progress of labour, and whether oxytocin is running.
- Maternal condition: Temperature, pulse, blood pressure, signs of infection, bleeding, pain out of proportion, and what the woman tells you about how she feels and the baby's movements.
- Contractions: Frequency, duration and strength. Too-frequent contractions reduce the baby's recovery time.
- Fetal heart features: Baseline rate, variability, accelerations and decelerations, classified using the NG229 approach and your local tool.
- Change over time: Compare with earlier parts of the trace. Is the baseline rising? Is variability falling? Are decelerations deeper, longer or slower to recover?
- Plan: Decide whether the overall picture is reassuring or concerning, what action is needed, who needs to know and when you will review next. Record it.
In NG229, a stable baseline of 110 to 160 beats per minute and variability of 5 to 25 beats per minute are normal features. A rise in baseline of 20 beats per minute or more is a concerning feature even if the rate is still within the normal range. Prolonged reduced variability, and especially absent variability, needs urgent attention.
At 02:00 the baseline is 135 with normal variability. At 04:00 it is 150 with occasional decelerations that recover quickly. At 05:30 it is 165, variability has dropped to around 4 and the woman's temperature is 37.9. Glancing at the last ten minutes might suggest a slightly fast trace. Looking at the trend shows a rising baseline, falling variability and possible infection, which needs an urgent obstetric review.
What is a fresh eyes CTG review?
A fresh eyes (or buddy) review is when a second midwife or doctor assesses the CTG and the clinical picture in person, at regular intervals. NG229 expects it for women on CTG before each next hourly assessment, and it is part of NHS England's Saving Babies' Lives Care Bundle. Its purpose is to counter tunnel vision and the gradual acceptance of a slowly worsening trace.
How do you escalate a CTG concern?
National reports have repeatedly found that midwives and junior doctors recognised something was wrong but did not escalate clearly, did not feel heard, or did not escalate further. SBAR (Situation, Background, Assessment, Recommendation) helps make the message clear and specific.
Hi, it's the midwife in room 4. Just letting you know the CTG is a bit funny. Could you have a look when you get a chance?
This is the midwife in room 4 about Amina, 39 weeks, first labour, 7 cm. I am worried about the CTG. Oxytocin started two hours ago and her temperature is now 38.2. Over the last hour the baseline has risen from 140 to 165, variability is under 5, and there are late decelerations with every contraction. Contractions are 5 in 10. I have stopped the oxytocin, moved her onto her left side and given fluids. I need you to review her now, within the next few minutes, and please let the consultant know.
- If the response does not match your concern, say so plainly and ask for a specific action, such as 'I need you to come now'.
- If you are still not satisfied, go to the labour ward coordinator, the registrar or the consultant. Your unit's escalation policy supports this.
- Use any agreed safety phrase your unit has for raising urgent concerns.
- Record who you told, when, what you said and the response.
For the doctor receiving the call
Listen, review in the time the situation needs, and if you cannot attend because you are in theatre, say so and help the caller reach someone who can. The coordinator and registrar need a view of every woman on the unit. Regular safety huddles and board rounds help keep that situational awareness, which is easily lost when several women need review at once.
What should a reflection after a fetal monitoring incident include?
If a baby or mother has been harmed, the family must be told honestly what happened, offered an apology and involved in the investigation. This is a professional duty of candour and, for notifiable safety incidents in England, a statutory duty for the organisation. If you are under investigation, contact your defence organisation, trade union or legal representative before writing statements.
The CTG looked normal to me and there were accelerations with pushing. It is very hard to tell the difference in the second stage, my colleague signed the fresh eyes review, and the unit was busy. I will be more careful.
In the second stage I documented the CTG as reassuring when it was recording the mother's heart rate. I did not palpate her pulse alongside it, and I did not recognise that accelerations with every push and a rate near the maternal pulse are warning signs. I also did not reconsider the trace against her previous caesarean and a long second stage. The baby's deterioration was not recognised in time. I was open with the family. I have since passed my unit's fetal monitoring competency assessment, I now palpate and record the maternal pulse throughout the second stage, and a practice development midwife has audited my CTG documentation over four months.
The strong version names the specific failure and the missed warning signs, links them to the wider clinical picture, accepts responsibility without blaming the colleague, shows candour and describes changes verified by someone else over time.
Further learning
Our course Maternity Care and Fetal Monitoring Concerns covers risk assessment, intermittent auscultation, structured CTG review, fresh eyes, SBAR escalation and the lessons from national maternity investigations, with a guided reflection and remediation plan. It is educational and sits alongside, not in place of, your unit's training. Related courses cover paramedic assessment decisions and restrictive practice for colleagues working in those areas.
Frequently asked questions
How often should a CTG be reviewed in labour?
NICE NG229 expects a full systematic assessment of the woman and baby at least every hour, or more often if there are concerns. For women on continuous CTG, a fresh eyes review by another clinician should be done in person before the next hourly assessment. Follow your unit's guideline and review tool.
What is a normal CTG baseline?
Under NICE NG229, a stable baseline fetal heart rate of 110 to 160 beats per minute is a normal feature, and variability of 5 to 25 beats per minute is normal. A rise in baseline of 20 beats per minute or more is a concerning feature even if the rate remains within the normal range.
How often do you listen to the fetal heart in the second stage?
With intermittent auscultation, NICE recommends listening for at least one minute immediately after a contraction at least every 5 minutes in the second stage, palpating the maternal pulse at the same time so the two rates are clearly differentiated. Record each auscultation with the time and both rates.
How can you tell if the CTG is picking up the maternal heart rate?
Warning signs include accelerations with every push, a rate close to the mother's pulse, or a sudden change in the pattern, especially in the second stage. Palpate the maternal pulse at the same time as the fetal heart. If there is doubt, consider a fetal scalp electrode or ultrasound to confirm fetal heart activity.
What should a midwife do if the doctor does not come to review a CTG?
Repeat the concern clearly and ask for a specific action and time. If the response is still not adequate, escalate to the labour ward coordinator, registrar or consultant in line with your unit's policy, keep the woman and baby under close review, and record each call and response.
Can a woman decline continuous CTG monitoring?
Yes. A woman with capacity can choose or decline any form of monitoring. Explain why CTG is recommended, the risks, benefits and alternatives, document the discussion, offer the method she prefers, and continue to review the situation with her as labour progresses.
Related courses
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
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Restrictive Practice and Use of Force in Mental Health
This course explains the legal and professional framework for restrictive practices in mental health settings in England, including physical…
Sources and further reading
- Fetal monitoring in labour (NG229). National Institute for Health and Care Excellence.
- Intrapartum care (NG235). National Institute for Health and Care Excellence.
- Saving Babies' Lives Care Bundle. NHS England.
- Final report of the Ockenden review. Department of Health and Social Care.
- Reading the signals: maternity and neonatal services in East Kent. Department of Health and Social Care.
- National Maternity and Neonatal Investigation. Department of Health and Social Care.
- Standards of proficiency for midwives. Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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