Intrapartum cardiotocography and the pathway to cesarean section: Interpretation, decision-making, and system-level translation – A systematic review

Intrapartum cardiotocography (CTG) has been embedded in modern obstetric practice for more than 5 decades, yet its relationship with cesarean section remains paradoxical and unresolved. Despite widespread use, uncertainty persists regarding how CTG interpretation translates into operative decision-making and whether this translation reliably reflects fetal physiology. We conducted a systematic review to examine intrapartum CTG not simply as a monitoring modality, but as a decision-generating system that shapes the pathway to cesarean delivery. A systematic search of PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library was undertaken from database inception to March 2025, using combined controlled vocabulary and free-text terms related to intrapartum CTG, fetal heart rate interpretation, decision-making, and cesarean section. Eligible studies included randomized trials, observational studies, systematic reviews, guideline analyses, and interpretive reliability studies examining intrapartum CTG and its association with operative delivery; studies limited to antenatal monitoring or postpartum outcomes without intrapartum relevance were excluded. A total of 1247 records were identified, of which 31 studies met the inclusion criteria following the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 screening. The included literature encompassed randomized trials, cohort studies, systematic reviews, guideline evaluations, and interpretive reliability analyses. Given substantial heterogeneity in study design and outcomes, data were synthesized narratively using a qualitative, theory-informed approach rather than meta-analysis. Methodological limitations were appraised qualitatively, with no formal risk-of-bias scoring tool applied. Across study designs and clinical settings, CTG use was consistently associated with increased cesarean section rates, while demonstrating limited specificity for fetal acidemia, hypoxic–ischemic injury, or long-term neurological outcomes. Interpretation variability, guideline discordance, and indeterminate trace categorization – particularly Category II patterns – emerged as dominant drivers of escalation. Adjunct technologies and computerized interpretation altered clinician confidence but did not reliably recalibrate intervention thresholds. System-level factors, including medicolegal pressure, institutional protocols, and risk-averse clinical cultures, further amplified uncertainty-driven operative delivery. This review was not registered. No external funding was received. These findings suggest that intrapartum CTG functions less as a diagnostic test and more as a sociotechnical decision system that prioritizes risk avoidance. Reframing CTG within a physiological and system-based interpretive model may be essential to reducing unnecessary cesarean sections while preserving fetal safety.