A common obstetrical intervention used inappropriately
By Doula Delight From bahama islandsinfo
The most common obstetrical intervention during labor and birth is fetal heart rate monitoring even though fetal heart rate patterns are poor predictors of the baby’s well-being.1 When first begun, electrical heart rate monitoring (EFM) of the fetus during labor and birth was expected to alert physicians of pending fetal distress thereby enabling obstetricians to rescue the baby before lasting harm occurred. The “inventor” of EFM predicted that EFM could save as many as 20,000 babies a year and cut the number of brain injured babies by 50%.2 The obstetrical community was quick to buy into the theory of
EFM and by 1976 many hospitals had fetal monitors and most used them continuously during labor even though EFM was not improving birth and neonatal outcomes as predicted.3
What continuous EFM did do was to increase the likelihood of unnecessary Cesarean birth and/or the use of forceps or vacuum assisted births.4, 5, 6, 8, 9 Continuous EFM confines mothers to bed, often restricting the mother’s position so the fetal heart rate can be more easily monitored. The focus of labor becomes the machine and the printed strip of the baby’s heart rate pattern relative to maternal uterine activity rather than the mother and the labor she is experiencing. Interpretation of fetal and maternal well-bring based totally on the EFM strip tracing is inappropriate and a practice some mothers find irksome.10
Some EFM advocates claim that continuous EFM is staff-sparing and is an inexpensive way to monitor laboring clients in poorly staffed maternity units.11 Indeed, “since the advent of EFM, EFM tracings and the debate surrounding their interpretation have proved more valuable to plaintiff’s lawyers than to physicians seeking potential patterns of fetal distress” (p. 834).12 It was only after obstetricians began promulgating the extravagant claims about the compelling evidence of the fetal rescue made possible by the use of EFM that litigation became the obstetrical nightmare it has become.3 Indeed today, no professional maternity care organization recommends routine use of EFM.4 In fact, many professional maternity care organizations now have policies that speak directly against continuous EFM.13
Intermittent fetal heart rate auscultation (IA) is just as effective as continuous fetal heart rate monitoring4, 5, 6, 8, 9 for low-risk women. When comparing the outcomes of continuous EFM with IA, there was no difference in newborn Apgar scores under 7, birth related mortality, or the incidence of cerebral palsy.4, 9, 11 IA requires the auscultation of the FHR at regular intervals specified by agency protocols. New research suggests that “a multiple-count strategy” that includes listening to the FHR both between and during contractions is a reliable way to access the baseline FHR, the presence of accelerations (periodic increase in the FHR and an indicator of fetal well-being) and the presence of FHR decelerations (a potential predictor of fetal compromise and distress).9
Viable alternatives to continuous EFM are the old-fashioned, low tech auscultation using a fetoscope (pregnancy-specific stethoscope) or the hand-held dopplar device to periodically monitor fetal well-being and his response to uterine contractions.14 Intermittent auscultation promotes the progression of labor by facilitating upright positions and movement in labor and enhancing maternal
comfort and satisfaction. Birth outcomes are no different with this less restrictive intermittent monitoring and are a more labor and maternal friendly means of assessing fetal status.15
And yet, routine use of continuous EFM continues to be the norm despite evidence that both challenges and contradicts this practice. In 2007, six years ago, Nageotte wrote, “While there’s little evidence that EFM during labor improves outcomes when compared with intermittent auscultation, …[a]s a labor-saving device for nursing care and as a way to generate a permanent record of FHR patterns, it would appear that EFM is here to stay.”16 So, despite the research outcomes or the detriment to the mother and baby of EFM, the practice of continuous EFM of low-risk mothers and babies prevails.
Go to following link to view references (PDF): http://www.bahamaislandsinfo.com/images/stories/2013/wk-07-12-13/DoulaReference-swk-07-12-13.pdf
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