Behind the Beeps: How Fetal Monitoring Shapes Your Birth Experience

Monday, December 1, 2025

We love when birth practices hit mainstream news. It doesn’t happen often—and when it does, it pulls the curtain back on the realities birthing families navigate every day. Recently, The New York Times published two major pieces: “The Worst Test in Medicine” and “These Hospitals Figured Out How to Slash C-Section Rates”. Both articles highlight something birth workers have known for decades: while we tend to focus on inductions or epidurals as the “big choices,” fetal monitoring may actually influence your birth more than anything else and yet, expectant parents and medical providers alike are left with very few choices.

And it makes sense. Childbirth is intense. Every parent wants to know their baby is safe. While a small number of people may trust their intuition completely, most expectant parents—and all providers—lean on fetal heart tones for reassurance. That reliance is understandable. It’s the tools we have and the system we’re inside that get complicated.

At Birthsmarter, we never assume there is one “right” way to give birth. Our work—our classes, our approach, our entire philosophy—is about helping families think critically, understand the landscape, and make confident decisions. To do that, we use The Birthsmarter Framework, which invites you to examine:

• What’s physiologically true
• What’s happening at a societal + systems level
• What’s true for you

What Fetal Monitoring Is Actually Checking

At the most basic level, medical providers monitor fetal heart tones to ensure the baby is tolerating labor. Every baby relies on a constant flow of oxygenated blood from the placenta, through the umbilical cord, into their body. When contractions intensify or the baby shifts position, that flow can change—creating normal fluctuations in heart rate.

A typical fetal heart rate runs 110–160 bpm with healthy “variability” of 5–25 bpm. Accelerations are reassuring, like exercise in adults. Small dips, called “decelerations,” during contractions are common, as contractions can cause minor and temporary cord compression.

Some decelerations can indicate something that needs attention—but in addition to monitoring fetal heart tones, providers will also take a birth parent's temperature and blood pressure to rule out additional complications. All of the quantitative data, alongside qualitative assessments, helps providers spot patterns and respond appropriately.

How Monitoring Is Done

Medical providers can monitor a baby’s heart rate in several ways, though when most people talk about fetal monitoring, they usually mean External (Electronic) Fetal Monitoring. From least invasive to most invasive:

• Intermittent Auscultation (IA): A nurse or midwife listens to the baby’s heartbeat with a handheld Doppler or stethoscope while feeling contractions. IA is done once every 15–30 minutes during active labor and once every 5–15 minutes during pushing.
• External Fetal Monitoring (EFM): Stretchy bands hold sensors on the belly to track the baby’s heart rate and contraction patterns. EFM can be wireless, allowing movement, or wired, which limits mobility. Monitoring can be intermittent or continuous (cEFM), often used with epidurals, Pitocin, or other interventions.
• Internal Monitoring:

  • Intrauterine Pressure Catheter (IUPC): Measures contraction strength from inside the uterus; only internal monitoring accurately assesses intensity.
  • Fetal Scalp Electrode: Attaches to the baby’s scalp to track heart rate directly.

  Internal monitors provide the most accurate information but require ruptured membranes and are only used when medically indicated.

Across all methods, we do not teach students to study or interpret fetal heart tracings. That’s your provider’s job, and where your choice of provider deeply matters. Even trained professionals can interpret the same tracing differently.

The Problem with Interpretation & Incentives

The NYT calls external fetal monitoring “the worst test in medicine” because it produces so many false alarms. The line between “normal” and “possible trouble” is not objective. How a provider interprets a tracing depends on training, experience, approach to care (trust vs. fear/defensive medicine), and unit context.

Fetal heart tones are classified into three subjective categories:

• Category I: Normal, no intervention needed
• Category II: Indeterminate—may require corrective measures (position changes, IV fluids, reducing Pitocin, intrauterine resuscitation)
• Category III: Abnormal—requires immediate intervention; ACOG recommends preparing for prompt delivery

Up to 80% of fetuses will have a Category II tracing at some point during labor. Despite research showing cEFM does not improve outcomes for healthy pregnancies, it remains the default. Financial incentives, inequitable reimbursement, liability fears, and staffing shortages push continuous monitoring into the norm, whether medically necessary or not.

Societal Context: What the Research Actually Shows

When EFM arrived in the 1970s–80s, it promised to prevent tragedies. Hospitals adopted it quickly, and parents assumed more monitoring meant safer births. But studies tell a different story. A massive Cochrane Review of 12 trials with 37,000+ births found continuous EFM did not reduce stillbirth, neonatal death, NICU admissions, cerebral palsy, or low Apgar scores, but it did increase the likelihood of cesareans and assisted deliveries. Today, “non-reassuring fetal heart tones” is the second most common reason for a first-time C-section.

Despite decades of evidence, continuous EFM use has risen—from 45% of labors in 1980 to around 90% today—as have cesarean rates. One review found cEFM increases the chance of a C-section by 63%. As Dr. Jon Hathaway told The New York Times, “It’s an ease-of-manpower issue over the science.” Monitors replace human presence and become tempting in understaffed systems. Legal liability further drives continuous use, sometimes at the expense of patient-centered care, contributing to closures like LifeCycle Birth Center in Bryn Mawr, PA.

We Already Know What Improves Outcomes

Proven strategies to reduce C-sections rely on human support, not technology. Access to midwives, nurses, and doulas—people who respond to what they see and hear—reduces unnecessary interventions. Evidence Based Birth also shows upright positions reduce abnormal fetal heart patterns by 54%, yet monitors often keep people on their backs, limiting movement.

Understanding this context doesn’t mean monitoring is inherently bad—but expectant parents deserve the full picture and need to understand how to work with monitors (like having a midwife, nurse, doula, or partner hold EFMs in place).

What You Can Do

Your most important pregnancy decision is where and with whom you give birth. If you’ll have continuous monitoring (hospital policy, induction, epidural), consider asking:

• Are midwives involved in my care?
• Do providers interpret the data with nuance?
• Do they prioritize movement and position changes?
• Do they offer wireless monitors?
• Are doulas welcomed or integrated?

If you prefer intermittent auscultation, are home birth or freestanding birth centers an option in your community? And if you’re in a hospital with EFM, you can turn down the volume, turn the screen away, or cover it to avoid distraction—helpful for partners too!

Why This Matters

Maternal health reform requires top-down and bottom-up pressure:

• Patients asking better questions
• Providers trained in physiologic birth
• Hospitals investing in midwifery care and nursing support
• Policymakers supporting doulas, midwives, and equitable care
• Transparency and public reporting (e.g., Leapfrog safety ratings)
• Increased access to high-quality childbirth education, like Birthsmarter classes

Birthsmarter classes give expectant parents the information, context, and agency that even excellent doula care or midwifery support can’t fully provide. Parents step into the role of informed consumers, understanding the system deeply enough to make confident, informed decisions—and advocate for themselves and for better care within their communities. Fetal monitoring isn’t just a medical tool. It’s a window into the values, structures, and priorities of our entire maternal health system.

Thank you to our medical advisor Tanya Tringali, CNM for contributing to this article.

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