Editorials ajog.

org

Electronic fetal monitoring or

cardiotocography, 50 years later:
what’s in a name?
Diogo Ayres-de-Campos, MD, PhD

lmost 350 years ago, fetal heart sounds were first

A described by the French physician Marsac, but it took
another 150 years before fetal auscultation using mechanical
FIGURE
The Hewlett-Packard 8020A, the first commercially
available fetal monitor, released in 1968 (author’s
stethoscopes entered routine clinical practice in western
photograph)
Europe and North America.1
The use of electronic methods for acquiring and recording
fetal heart rate (FHR) and uterine contraction (UC) signals is
a much more recent event. Consistent methods for acquiring
FHR and UC signals were first described by Edward Hon,2
Roberto Caldeyro-Barcia,3 and Konrad Hammacher4
in the 1950s and early 1960s, and this eventually led to the
development of the first commercial fetal monitor in
19685 (Figure).
Electronics is a branch of physics that deals with the
emission, behavior, and effects of electrons (as in electron tubes
and transistors).6 It was mostly developed in the 20th century
and allowed the invention and refinement of appliances that
have markedly changed our society, such as radio, television,
Ayres-de-Campos. Electronic fetal monitoring or cardiotocography. Am J Obstet Gynecol
telephones, and computers. Integrated circuits appeared in the 2018.
early 1960s and opened up a whole new era for electronic
development.
Electronic fetal monitoring (usually shortened to EFM) it was indeed the only form of electronically monitoring the
was the natural name given in the 1960s and 1970s to fetus, several other technologies for fetal surveillance
describe the new technology of continuously monitoring involving electronics were subsequently developed: ultra-
fetal heart rate and uterine contraction signals. The age of sound, handheld Doppler, fetal electrocardiography, fetal
electronics was at its peak, and it was important to pulse oximetry, etc. The terms electronic fetal monitoring and
differentiate this technology from previously existing fetal heart rate monitoring also have the limitation of not
mechanical methods. fully describing the signals that are acquired, leaving out
The term gained popularity in many English-speaking maternal uterine contractions.
countries, particularly in the United States. In other parts In 2015, the International Federation of Gynecology and
of the world, the technology became known as cardiotocog- Obstetrics promoted the largest international consensus to
raphy (usually shortened to CTG), from the Greek words date on intrapartum fetal monitoring, with the objective of
kardia meaning heart and tokos meaning labor and standardizing terminology, interpretation, and clinical
childbirth. In the United Kingdom, both names were used management.7 A total of 50 experts from all over the world
interchangeably. participated, including many leading figures from the
With the passage of time, the term electronic fetal United States, such as Lawrence Devoe, Richard Paul,
monitoring has become a misnomer. While in the early days Barry Schifrin, Julian Parer, Vincenzo Berghella, and
Catherine Spong. The panel agreed that
From the Department of Obstetrics, Gynecology and Reproductive cardiotocography is the term that best describes the
Medicine, Santa Maria Hospital, University of Lisbon Medical School, continuous monitoring of fetal heart rate and uterine
Lisbon, Portugal.
contraction signals.
Received March 1, 2018; accepted March 6, 2018.
In 2018, we celebrate the 50th anniversary of the clinical
The author reports no conflict of interest. use of FHR and UC signal monitoring, a respectable age for
Corresponding author: Diogo Ayres-de-Campos, MD, PhD. any technology and a sign that it has passed the test of time
dayresdecampos@gmail.com
and gained a solid place in obstetric care. It remains at the
0002-9378/free
center of the decision process in the important goal of
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.03.011 avoiding intrapartum fetal hypoxia, and it is likely to main-
tain that role in the coming years.
JUNE 2018 American Journal of Obstetrics & Gynecology 545
Editorials
We owe it to the next generations of physicians entering
our speciality to agree on a common terminology for
obstetric techniques and procedures. In this era of global-
ization and easier access to medical information, the use of
common terminology promotes better communication
among health care professionals and easier transmission of
knowledge.
Harmonization of language is a particularly important task
for English-language countries that have assumed a leading
role in medical progress and dissemination. Agreeing on
common terminology requires an effort to question the
significance of deeply enrooted terms and to look beyond
national borders, evaluating their impact on the whole
international community.
The term electronic fetal monitoring is of important
historic significance, but it has now become outdated
because it does not adequately describe nor fully represent
the signals acquired by this technology. Cardiotocography is
the most accurate term to replace it, and it has the advan-
tage of already being used by a large part of the international
community.
546 American Journal of Obstetrics & Gynecology JUNE 2018
ajog.org
Let us make an effort in 2018 to homogenize the way we
call this important technology for obstetricians and in
this way contribute to the celebration of its 50th
anniversary. -
REFERENCES
1. Gultekin-Zootzmann B. The history of monitoring the human fetus.
J Perinat Med 1975;3:135-44.
2. Hon E. Apparatus for continuous monitoring of the fetal heart rate. Yale
J Biol Med 1960;32:397-9.
3. Alvarez H, Caldeyro-Barcia R. The normal and abnormal contractile
waves of the uterus during labour. Gynaecologia 1954;138:190-212.
4. Hammacher K. New method for the selective registration of the fetal
heart beat. Geburtshilfe Frauenheilkd 1962;22:1542-3.
5. Freeman RK, Garite TJ. History of fetal monitoring. In: Freeman RK,
Garite TJ, eds. Fetal heart rate monitoring. Baltimore: William & Wilkins;
1981. p. 1-6.
6. Merriam-Webster Dictionary. Available at: https://www.merriam-
webster.com/dictionary/electronics. Accessed Feb. 25, 2018.
7. Ayres-de-Campos D, Arulkumaran S; for the FIGO Intrapartum Fetal
Monitoring Expert Consensus Panel. FIGO consensus guidelines
on intrapartum fetal monitoring: introduction. Int J Gynecol Obstet
2015;131:3-4.