Improving fetal monitoring

October 27, 2011 at 7:04 pm

My sister emailed me a link to an article about electronic fetal monitoring this morning: “Unnecessary C-sections performed due to fetal heart rate system” from KSL.com. The article explains: “Maternal-fetal medicine specialists believe fetal heart rate patterns may not be a good indicator of a baby’s health, and may lead to . . . unnecessary interventions and higher health care costs.”

I’ve heard this many times before in my own research, so I was glad to see it getting more attention in the mainstream media. While it’s definitely important to ensure our babies are weathering labor well, the current system of monitoring and interpreting eletronic fetal monitor tracings has proven itself unreliable. I blogged about this issue in July of 2009 on my old blog.  Here’s a re-post:

Emily passed along a link to a NY Times article: “Updating a Standard: Fetal Monitoring,” by Jane E. Brody.

Electronic fetal monitoring (EFM), rolled-out in the 70’s, hasn’t done what doctors thought it would do–“reduce the risk of cerebral palsy and death resulting from inadequate oxygen to the fetal brain.” In fact, EFM has had some negative consequences. The NY Times article reports:

¶Electronic monitoring has led to a significant increase in both Caesarean deliveries and forceps vaginal deliveries.

¶Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit, which has led to soaring costs for malpractice insurance and, in turn, prompted many obstetricians to stop delivering babies.

¶Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths.(source)

I wish it were possible for hospital staff to implement intermittent monitoring by human beings. Through my research, I’ve come to strongly believe that the best “monitor” for childbirth is a trained person, not a machine. With the presence of a skilled labor attendant, subtle indicators of maternal and fetal well-being (some of which an electronic fetal monitor couldn’t catch) can be recognized more readily. Unfortunately, most nurses are too busy to spend the necessary time personally listening to fetal heart tones on multiple patients, and few doctors are present before pushing time. So EFM isn’t likely to be replaced by person-al monitoring anytime soon (or ever).

So improving the use of this technology is definitely in order. I’m heartened by the efforts of the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Dr. George A. Macones who are encouraging obstetricians to refine and improve the way they interpret electronic fetal monitor tracings. Especially considering the somewhat frightening inconsistency of doctors’ interpretations of EFM tracings, as the NY Times article reports:

In a study in which four obstetricians examined 50 fetal heart rate tracings, they agreed in 22 percent of the cases. Two months later, the same four doctors re-evaluated the same 50 tracings and changed their interpretations on nearly one of every five.

And in more than 99 percent of cases, predictions based on the tracings that the baby would have cerebral palsy have proved wrong.(source)

These new EFM recommendations sound like a step in the right direction. I love that OBs are being encouraged try “giving the mother oxygen, changing her position, treating her low blood pressure and stopping stimulation of labor if that is being done” before jumping to a cesarean for abnormal fetal heart tones.

It’s so easy to get caught up in villainizing OBs and the medical establishment. It’s too bad a few “bad eggs” can taint our view of the profession. So I’m always grateful to be reminded that there are docs and medical researchers working hard to protect women and babies. I hope to see the day when MDs, midwives, researchers, nurses, doulas, and parents can come together for the betterment of maternity care. I really hope to see that.