Kyleigh Banks:

This week I went down the rabbit hole on all the videos I could find and the lectures that you've given on YouTube and on your blog, on your website and the rabbit hole can go on forever. I swear. There's a lot to learn.

Dr. Kirsten Small:

Yeah. There's still stuff that I feel that I haven't started to explore and write and I'm really looking forward to having a bit of space in my life right now to be able to do some of that. This morning I've been sitting and writing about why it's not a good idea to put oxygen on women's faces when their CTG's are normal, which I haven't actually, until now, had a chance to actually get across the literature or just had a sense that it was not a good idea. So yeah, it's quite nice to add a few extra bits of things that I can now say I'm well across.

Kyleigh Banks:

Yeah. Is that how it starts for you normally? Is you just get an inkling that like, "This isn't right." And then you go-

Dr. Kirsten Small:

There's something that comes up and I think, "Why do we do that?" And you get a sense that what you've been taught as a clinician comes from a position of dogma and this... If I don't actually know and have not been taught the research and you hear exactly the same phrases pop up repetitively, then it's a fairly good clue that whatever it is, is dogma, not science. And that's been a reliable indicator for me that it's worth going and having a deeper look at things and figuring out what we really do and don't know.

And so, when it comes to the CTG stuff, so much of everything is we actually don't know rather than we have evidence. And when we do have evidence, the evidence usually shows that it doesn't work and everyone just runs around going, "I don't want to know that. I'm just going to keep doing what I'm doing because it makes me feel better thinking that I'm making things better for people."

Kyleigh Banks:

Yeah. I thought about that. Do providers and nurses really not know? Are they not learning and reading the research?

Dr. Kirsten Small:

I think when it comes to anything related to fetal monitoring, I think that they don't know. And I think that we are actively discouraged from going down the rabbit hole. There was about a five year period leading into the PhD where I went, "I think it's going to be about CTG. So, I'm going to start reading everything I can get my hands on." And I've been practicing as a clinician for well over 20 years at that stage and thought that I knew the evidence. I got really angry because like, "Oh, my God. Grandma told me this." And the message that we were consistently getting was, CTG's don't work low risk women, but they do for women got risk factors. That was nonsense. Early deceleration's a head compression and variable deceleration is a cord compression and late deceleration's due to fetal hypoxia. That's all nonsense.

And the more I scratched the surface, the more I realized that the stuff that I thought that I knew that I had been taught, which is the stuff that everyone else is still being taught as well, is not true. And now, I look at the education programs, the Fetal Surveillance Education Program, it doesn't cover any of that. So, there's no active attempt on the part of the big groups that are teaching fetal monitoring to encourage clinicians to engage with the evidence that actually matters because they're just too busy teaching you that if the line wiggles in this direction, this is what you call it.

Kyleigh Banks:

Yeah. It's too much of a foundation of maternity care across the world, is that stupid white band, the bands that we hook on women. And in the states, I don't even know if providers believe that it's not beneficial for low risk women, because all of the hospital births I've attended as a support person... I mean, Low risk? Doesn't matter. First-time mom, head down baby, low risk, they strap that on first thing as soon as she walks into the hospital.

Dr. Kirsten Small:

It's part of it. The other thing is that what's considered to be at risk has expanded. And when I was a medical student it was 10 or 15% of the birthing population were considered to be at risk. Now, it's 90%.

Kyleigh Banks:

Wow.

Dr. Kirsten Small:

I mean, yes, there's been some shift in the population. Women are a little bit older and they are a little bit heavier. And so, we do see high incidents of things like gestational diabetes. But that is, in part, because we changed the diagnostic criteria and made it much easier to end up in that category. But the boundaries have been expanded and we've introduced things like low Papp-A levels, which the woman's got no way of knowing that she's at risk if we don't go doing the test. And then, we do the test and there's no external validation of whether that's real or not. And so, it's very difficult to argue against when you've got this pseudo-scientific, but my blood test results showed, and therefore I'm at high risk, which it's a different experience to, it's my fourth baby, but all of my other ones have been completely fine.

Parity is increasingly being recognized, quite rightly frankly, as a risk factor. So, the first time woman is no longer the healthy woman having her first baby, she's at high risk of stillbirth, and she'll probably be monitored because we're finding more and more reasons to induce people everywhere. And induction of labor is a risk factor, so they all end up monitored. Epidural's a risk factor, and yet, we quite like putting epidurals in left, right and center to people. So, if you're running an epidural rate of 85%, which is not unheard of in some of the places around Australia, 85% of women now have an indication for continuous CTG monitoring. So yeah, it's no longer the small end of the population of women who genuinely really are at risk with the old risk factors that we used to recognize in the past.

Kyleigh Banks:

Is there a point where continuous monitoring becomes evidence based?

Dr. Kirsten Small:

Not really. No. Most of the issue is the absence of evidence rather than evidence that isn't effective. So, the areas where we really would benefit from having some research, there just isn't any. And one of the questions that I repeatedly get asked is, "Well, what about feedback?" There's been one randomized control trial, it had 200 women and it's 100 in each group. All of them had one previous caesarean section, half had CTG monitoring, half in intermittent auscultation. Made no difference in any of the outcomes, but it was underpowered to detect a difference in any of those outcomes. So, we don't know, we just don't know. Meconium stained liquor you think might be a group of women who would probably benefit from CTG monitoring. No one's ever taken a group of women where that's the issue, and then randomized them to intermittent auscultation versus CTG monitoring to look at that.

Twins. No one's done that. Women who've had abnormalities in the fetal heart rate detected on intermittent auscultation. Now, that'd be a really good group to do because most of us, instinctively, go, "Well, if the heart rate's abnormal, the CTG probably will help us to sort out what's going on and might improve outcomes." But no one's looked at that as an independent population. They've been tossed in with the women who have the oxytocin infusion running and the ones with the epidural and the ones that are preterm and the ones that have all of the other risk factors smushed in together. And in those populations, what evidence we've got shows no benefit. But for any individual population, we don't really have data.

I suspect that women who have oxytocin running... And I think if I was supreme ruler of every maternity service, that'd be the population I'd probably want on CTGs, at the very least for the TOCO part of the equation so you can tell what's going on with contractions for people. And there's a bit of evidence hidden in the fine print of the McDonald to the Dublin paper, that there was a very, very big difference in the numbers of women with babies with seizures when oxytocin was being used with intermittent auscultation and when oxytocin was being used with CTG monitoring.

The study was not set up to actually answer that question, and it's just a little aside with a table where there's a little bit of data which suggests that if you use the CTG in women who had oxytocin running, that the babies do much better, which makes logical sense. The better argument is, of course, that oxytocin is a dangerous chemical and we should probably not use it anywhere near as often as we do, rather than let's keep blasting fetuses with this dreadful stuff but make it safer by adding in this technology.

Kyleigh Banks:

Yeah. So, electronic fetal monitoring was brought to the market because they assumed that knowing the heart rate would determine how baby was doing. That was just an assumption. And that's what's never been proven.

Dr. Kirsten Small:

No. And the history of it's really interesting. As soon as people invented the very first stethoscope, which was very Pinards like, somebody, a bloke, went, "I wonder what happens if you whack this on the belly of a pregnant person." And, "Look, you can hear the heartbeat." And they very quickly moved to, "Well, the normal heart rate is anywhere between 100 and 160." So, it was just counting. And it was much later that people started recognizing patterns which happens through about the 1950s. And the physiological underpinnings and the quality of the research that was being done during that period, they did their best under their circumstances, but it certainly doesn't come anywhere close to matching the requirements that we would have in this day and age for strong evidence.

But as I said, it's become part of the dogma that we teach, and the one that particularly gets underneath my skin is that early decelerations is due to head compression. And in fact, that's quite probably nonsense. And then, due to hypoxia, probably looking at the animal studies. So yeah, if we don't understand the physiology of it, well, then teaching people to interpret the wiggly lines on the basis of things that we've just made up, we can't possibly improve the outcomes.

Kyleigh Banks:

And I actually took a-

Dr. Kirsten Small:

[inaudible 00:13:02] Jesus in your toast and you found the picture of Jesus in your toast, you know you're going to win the lotto that day. We've got this huge brains that are so good at pattern recognition that we've just made up this really complicated story and then have spent 60 years trying to make it work.

Kyleigh Banks:

And still to this day, teaching that in schools. So, if someone wants to learn more specifically about the physiology of it, how the head compression thing is possibly nonsense. Do you have articles on that on your website?

Dr. Kirsten Small:

Yeah. I've got a couple about the head compression story. The people to watch, research wise, there's a group of researchers at the Liggins Institute in New Zealand and they're doing sheep research. Christopher Lear heads up the team, and they're really interested in actually establishing the physiology of what happens when you make a fetus hypoxic, what really happens to the heart rate changes, what happens when they're preterm, what happens when they're growth restricted, to try and give us some evidence to align with clinical practice. And they're turning everything up on its head at the moment, but it's not really being translated true into clinical practice as yet.

Kyleigh Banks:

For decades, probably, unfortunately.

Dr. Kirsten Small:

Yeah. Hopefully, we'll get there. But yeah, the system is so strongly built around all of these assumptions about how things work. It's really difficult to get people to step back from that when it requires a complete restructuring of the way that we run services and way that people think and our education programs. So yeah, it's not going to happen in a hurry. But just in the decade since I decided that I wanted to do CTGs as a thing for the PhD, I've certainly seen a shift that people are more willing to engage in conversations. And it's not just the doulas and the alternative birthing community who are questioning the medicalization of childbirth. There are now starting to be obstetricians and midwives who are doing the, "Yeah. That stuff probably doesn't work." Conversation, which it didn't feel like that was even imaginably possible 10 years ago. So, we're getting somewhere.

Kyleigh Banks:

Now, there is evidence that intermittent monitoring may be helpful?

Dr. Kirsten Small:

No, there is in fact no evidence that listening to the fetal heart in labor makes any difference in terms of outcomes. And even myself so desperately want to believe that that's true, because having a baby that dies during labor or soon after or is born in bad condition and has lifelong disability, it's so awful and you don't want to wish it on anyone. So, doing something that makes us feel like we're doing something useful is such a strong motivator. And I for years have asked myself the question of, is there enough evidence in terms of all of our observational data over many, many years of clinical practice to really argue that yes, every woman should have some form of fetal monitoring during labor or not? And what would happen if we suddenly stopped listening to babies and just monitor their mothers? I don't know the answer to that and it's such an uncomfortable question to ask. But yeah, I don't think any of us are willing to spend an awful lot of time even imagining what that might look like.

Kyleigh Banks:

Especially when that would include dismantling the entire system that's built on the use of it.

Dr. Kirsten Small:

Exactly.

Kyleigh Banks:

Yeah. That's fascinating, because even in the home birth communities, of course most women are using the intermittent handheld doppler and they assume that that's fantastic, just intermittent, every 30 minutes, it's great. But it's fascinating to hear that even that there's no evidence. It requires a lot of trust because we're taught that the machine that goes ping tells us everything we need to know. So, what is driving... I know the answer to this because I've listened to your lectures recently, but I want to hear it from you. What is driving the ongoing use? Who's benefiting? Who's profiting? Why is it like it is?

Dr. Kirsten Small:

It depends slightly on where you are in the world, but obviously there are capitalist forces that benefit because equipment gets sold and consumed. Every set of belly bands gets chucked out, and another set of belly bands used for the next woman. CTG monitoring equipment, particularly the new fancy central monitoring systems with computer analysis, they cost millions of dollars for health services to buy and they require regular software updates, which all costs money. So yeah, there's some big financial gains for people who sell that stuff and the people who invest in that stuff. And historically, the people who designed the systems and used the systems were also the ones profiting from them. So Paul.... No. Was it Paul? Anyway.

One of the original CTG researchers was one of the managing directors of Corometrics, who were a maker of CTG. So, the same time that he was going, "Everyone should have CTG monitoring, here's the evidence." He was also profiting from the use of it. So, there's been a bit of that through the history of it. It maintains obstetric power, and that was part of what I was looking at with my thesis. So, the domination of obstetrics over with birthing women over midwives and nurses, because the ultimate decision maker is always an obstetrician. And so, they, we, are allowed to run around going, "We know everything. And if I say so, then it must be true because I'm the final decision maker. And if there's a poor outcome, it's because you got the CTG interpretation wrong." So, it's easy to push the blame through to less senior members of the team and to other professional groups like midwives and nurses, or onto the woman herself as being the one who was responsible for the poor outcome rather than obstetrics taking responsibility for it.

Here in Australia, RANZCOG, the Royal Australia New Zealand College of Obstetrics and Gynecology runs the Field Surveillance Education Program, which is our national program. And in most jurisdictions in Australia, all people who work providing intrapartum care, midwives and obstetricians, are required to do the course at least every second year. And if you are in a senior role, you have to have at least 85% on the exam correct. And RANZCOG make money out of it. They're not doing it for free. So, this obstetric organization... And you got to remember there's something like, I don't know, eight midwives to every obstetrician in Australia. So, most of their income is coming from midwives paying to do the course that makes money for an obstetric organization who then uses that money to ensure that they stay in a position of power relative to the midwifery profession.

So, midwives are essentially investing in their own subjugation. That's not the case in other countries where the obstetric organization hasn't set up a course. But in Australia, that, quite effectively, keeps the balance of power in obstetrics.

Kyleigh Banks:

Does that course update with new evidence?

Dr. Kirsten Small:

According to their advertising, yes. But then, when you look through their reference list, it doesn't change from one update to another, it just gets fiddled around the edges a little bit. Yeah. The evidence that they're using is cherry picked and misrepresented. But they do make a big song and a dance about, "This is a physiological evidence based course." And I feel like the more bells and whistles and glitter you've got to fling around at the front end, the less evidence based things actually are. The ones that are really strongly evidence based speak for themselves, and you don't have to have a label on the front that says...

Kyleigh Banks:

"Yeah, believe me." Yeah. What kind of role does liability play? And of course, it's different for different countries, but...

Dr. Kirsten Small:

Yeah. It is different for different countries. In Australia, the issue is more about getting in trouble with the regulator. So, with the medical board or with APRA, rather than being sued by people, which is not the case in other countries. It's a complicated story because for the legal process to be successful, you need to have an expert witness who argues that if you had used the CTG or if you had interpreted the CTG differently, the outcome would be better. Those people tend to be obstetricians. So, it's not like the legal profession itself is out there driving the use of it. Again, it boils back to the fact that obstetrics maintains the use of it because we're the expert witnesses in these cases.

And if all major obstetric organizations issued a statement tomorrow saying that in fact CTG use doesn't improve outcomes, which would align with the evidence, and any expert witness who says so will be de-registered, that would get interesting really quickly in terms of legal circles. So yes, fear of litigation is a strong driver, but I think the story that sits underneath is still about obstetrics maintaining power.

Kyleigh Banks:

Yeah. It goes to show that the trust the science narrative is so subjective. Even when we're talking about science, it's subjective, because I'd ask you one thing, would I go talk to the head of ACOG, and I'm sure they'd say something completely different when you're looking at the same ocean of research. It's fascinating.

Dr. Kirsten Small:

The ability to critically read research is really important and it's very much a learned skill that needs practice to hone and a strong degree, a suspicion to ask the right questions of what it is that you are reading. So, I think it's really important to remember that all new knowledge is generated within a context and you have to know what the context was in order to be able to interpret what it is that you're seeing in terms of the results. So, where is it done? Who was it done by? What are the belief systems that underpin the way that the research was structured and the questions that are being asked?

And so, many of those belief systems are patriarchal. They're based on the idea that women are just a container that you put a fetus into, that they're not important, that the fetus is the thing that really matters and that you can slash your way through the body of the woman on the outside to rescue the fetus without great concern for what that might mean for her, women are not particularly good at being pregnant and giving birth and their bodies are dangerous places that need to be risk assessed and monitored and surveilled and managed, that midwives and nurses aren't very smart and that we need to manage and surveil and monitor and educate them. But obstetricians, they're fine. Just let them get on with their lives and do what they want.

Kyleigh Banks:

They're smart. They went to school for this, they know everything. They're the experts, not necessarily in women's bodies, definitely the experts in surgery, which is fantastic for some things. But yeah, not an expert of physiologic birth by any means.

Dr. Kirsten Small:

Yeah. So, you need to bear in mind, then, that when you bring those kind of belief systems in and you design equipment like CTG monitors or you design research around that equipment, that you bring those values into the research which tends to reinforce rather than challenge the beliefs that sit underneath the surface. And so, things like women's decision making, if you go back and read the fine print of the original research, the idea that women might actually choose to be part of the research or not, not always done well. And the idea that women might want to have somebody discuss what's being seen on the CTG and whether or not they should then have a caesarean birth really done poorly. And you read the research and it says, "In instances of abnormal CTG, caesarean section was performed." Well, hang on a minute...

Kyleigh Banks:

Yeah. It's up for debate.

Dr. Kirsten Small:

There's something that happens in between those two things, and that should be a conversation with the woman who then says, "Yes, I'm willing to have that surgery." Or not. It's not just an automatic thing.

Kyleigh Banks:

And women are put in very hard places, especially in the middle of their labor when an obstetrician comes in and says, "This is what I see, this is what's happening to your baby. We need to go now." And putting that decision on the mom in that minute, I've never had to make that decision, but I can imagine that it's a very hard decision to make even if you're briefed on this, even if someone's listening to this. If someone tells you that your baby's going to die unless we do a caesarean in the next 10 minutes, most women would say, "Let's go. Why are we even talking? Let's do it." So, it definitely puts us in a hard place.

Dr. Kirsten Small:

People are very vulnerable and you do need to trust that your care providers are knowledgeable and doing the right thing and making appropriate recommendations. You simply can't, during labor, continually fact check them to know that they're interpreting the CTG correctly and making appropriate recommendations.

Kyleigh Banks:

The most evidence based thing to do would be decline monitoring from the get go. Yeah. How many decades do you think it's going to take to get to a point where people are comfortable doing that?

Dr. Kirsten Small:

I have no idea, but I'm going to keep plugging away at what I can do to try and get us there. I do think that there's... One of the arguments that I hear is, we should just provide this information for women so that they can then make the decision. I hear it over and over again. It's very seductive, but it puts a huge amount of pressure on birthing women to get a doctoral degree in all of the individual things that they might encounter through pregnancy and birth about, should I be induced or not? What analgesia should I choose or not? What birth positions should I use? What kind of care provider? Which kind of healthcare service should I engage with and where? To make the many, many decisions that need to happen in labor. And we shouldn't demand that of women. That's why we train as healthcare professionals, is to get that knowledge to help support people making their decisions rather than just go, "Well, off you go. You decide. Come back and tell me."

We then load people up with information that says, "Actually, the care that you're about to receive probably isn't evidence based. Go and fight for your rights." In a system that is un-frankly and not good at recognizing women's decision making, and that undermines people's self confidence with that. And sometimes is just outrightly abusive if people make a choice that's outside of what is considered standard practice. Any clinician who's caring for a woman who makes a decision outside a standard practice risks some form of censure as well, even if it's quite clear that they had no part to play in that decision making. If you don't manage to fully harass or coerce the woman into having what the system says they should have, that's somehow your fault and you will be made to pay for it. So, it becomes really difficult for clinicians who do generally want to practice woman centered care that respects women's decision making to maintain their income and their professional registration over time.

And then, of course, if something goes wrong, the system turns around and blames the woman for the decision that she made because it was her fault even though what happened may have been a consequence of the poor care that happened because she was asking for something that the system was uncomfortable with. So, I do think we need to be careful with that whole idea that the way to fix this problem is to make birthing women responsible for making better decisions. It really requires a top down change so that we shift the balance of power in maternity care so that women are having a seat at the table and that what birthing women want for their birth is an important consideration in system design, which hasn't happened historically. And that clinicians who do practice in a woman centered way that honors women's decision making rewarded for that rather than punished for that. So, a system reform is what needs to happen rather than just expecting yet again that women are going to fix the problem.

Kyleigh Banks:

Yeah. Wow. It's a lot and it's very needed and I'm really excited that I'm entering this industry because I'm fairly new, just less than five years, that I have 50 years ahead of me to watch the transformation and see what happens. And my fingers are crossed that we move more towards trust and physiologic birth because we deserve it.

Dr. Kirsten Small:

And one of the things I argued in the thesis was that we need to be honest with people, and haven't been honest with people when it comes to fetal monitoring in the past. And that the professions that make up maternity care around the world need to start honest conversations within our own professions at the very least, and be able to admit that we've never done any research about no fetal monitoring versus fetal monitoring, we don't know if it works, as a starting point. And then, figure out what we're going to do about that. And then, start engaging in honest conversations with the people that we're providing a service for as well about the limitations about knowledge and our expertise, rather than, "Trust me and all will be well." When there's been repeated instances of people placing their trust in the profession and not being well.

I think we've undermined our trustworthiness over the years by having misrepresenting what we can and can't do for people and we need to rebuild all of that for people over time. And the only way we'll do that is by admitting that quite a lot of the time, we have no idea what we're doing, but we're doing our best and we're trying really hard because we don't want bad things to happen either.

Kyleigh Banks:

Yeah. What a weird place to be in. I imagine it's not easy being an obstetrician with your point of view in an industry like that. So, we appreciate it. From the moms and doulas, we appreciate it. If someone wants to read your thesis, learn more about your work, where can they do that?

Dr. Kirsten Small:

My website is birthsmalltalk.com and I publish most weeks, but not always, depending on what's going on in life. Somewhere in there is a link to the doctoral thesis and lots of other resources, mostly around fetal monitoring, but occasionally I get a bee in my bonnet about something else and I get to write about that as well.

Kyleigh Banks:

Yes. I'm very excited to hear about the oxygen when the fetal heart tones are strange. I'm excited. I'll be looking forward to that.

Dr. Kirsten Small:

Coming soon.

Kyleigh Banks:

Yeah. I hope you have a lot of time to write this coming season, winter for you. And I can't thank you enough for having this conversation.