Continuous fetal monitoring – is it right for you?

The evidence shows that intervening in the normal physiological process of labor carries a host of risks that, in a healthy woman carrying a healthy baby, are not justified by the  benefits.  (It should also be noted that many of these “benefits” are for the caregivers and not the laboring woman, but that’s another post altogether.)

By far the most common labor intervention is the use of continuous fetal monitoring.  According to Childbirth Connection’s Listening to Mothers Survey II, 2006, 94% of mothers were given EFM and of those, 93% were monitored continuously (76%) or most of the time (17%).  If you will be giving birth in a hospital, the chances are that you will be offered continuous monitoring in your labor.  Sounds great, right?  You can make sure that your baby is doing well every second of your labor!

But there’s something you should know: the evidence shows that continuous monitoring does not improve outcomes for mothers and babies.  In fact, for a low-risk woman, it can increase risk of an unnecessary c-section or instrumental delivery. It is estimated that continuous monitoring results in 1 additional c-section for every 58 women monitored.  I’m thinking of one local hospital that does probably 60 deliveries a day.  That’s something like 1 extra cesarean every single day.   Think about that.

We’ve known for at least 20 years that intermittent auscultation, where fetal heart rates are monitored with a fetoscope or handheld doppler for a few minutes every hour, is at least as safe as continuous monitoring with EFM. There are no differences in newborn mortality, admission to the NICU, Apgar scores, or cerebral palsy between women who are monitored intermittently and those who are monitored continuously.  Nearly every professional birth-related medical organization (the American College of Obstetrics and Gynecologists, The Association of Women’s Health, Obstetric, and Neonatal Nurses, The American College of Nurse-Midwives, the American Academy of Family Physicians, as well as the US Preventative Services Task Force) recommends intermittent auscultation over continuous monitoring and publishes guidelines for its use. (See the references for links that you can print out and take to your care provider.)

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One main drawback to EFM use is that it severely restricts mobility.  The internal version uses a monitor screwed into the baby’s scalp and a catheter placed in the uterus to measure the strength of the contractions, and requires artificial rupture of membranes and mom staying in bed.  The external version fastens around the mother’s abdomen with wide elastic belts and in theory allows mom to get up and move around (at least as far as her “leash” allows.)  The information from both internal and external EFM is fed to video screens and a strip recorder at the bedside.

In practice, what normally happens is that (being a large elastic belt, heavy monitors, and trailing wires) EFM is bothersome to many moms, like having a scratchy tag or a rock in your shoe.  That’s if it stays in place, which often it doesn’t if the woman is laboring normally and is moving around.  Sometimes they’re very fiddly and slip at the slightest movement.  Then the monitor starts squawking and the nurse comes in with varying degrees of frustration and disapproval to adjust it.  The laboring mother feels chastened or guilty for having to make her nurse stop what she was doing to come in and fix the monitor. Because the nurse has to make the adjustments, she’s not in charge of what she’s wearing on her own body.  (How empowered would you feel in your daily life if you couldn’t zip your own pants or tie your own shoes?)  The monitor is most accurate when she doesn’t move, and so to avoid making problems for others she finally gets back in bed. Lack of movement leads to more pain, a willingness to receive more interventions, and increased likelihood of a cesarean.  Not good.

The other big pitfall with EFM (and this might just be a function of the medical model of care) is that it is looking for problems – and makes it more likely to find them.  Interpretation of the strips varies widely from caregiver to caregiver and even reading to reading.  Check out this quote from George A. Macones, MD, who headed the development of the ACOG Practice Bulletin on EFM.

“One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.”

Whoa.  The natural conclusion to many is that, since we can’t be 100% accurate in our readings, anything that looks “nonreassuring” should be treated as an emergency just in case it really is.  This is a great way to avoid a hefty malpractice suit but not so good for mothers and babies.  One Cochrane systematic review even found in increase in perinatal deaths when CFM was used – definitely not what we are all going for.

From a support professional’s experience, I can also say that there is a definite tendency to watch the monitor instead of the laboring woman.  And a laboring woman needs and deserves to be the focus of everyone’s attention.  Women are not simply a thing in the corner to be ignored while her loved ones are caregivers are fascinated with the thing that goes “beep”.

As with any intervention, there are times when CFM is indicated.  These situations may include, but are not limited to, previous c-section, fetal growth restriction, induced or augmented labor (Pitocin is a strong risk factor for fetal distress), and pre-eclampsia.  In the absence of risk factors, intermittent auscultation is the better choice for most women.  I recommend you discuss monitoring with your care provider.  If CFM is recommended, ask why, and be wary if the answer is not that you have a condition requiring CFM, but “so we can keep an eye on your baby.”

 

References:

Lamaze for Parents – guide to EFM

ACOG announces new fetal monitoring guidelines

ACOG guidelines for fetal monitoring

practice guidelines for fetal monitoring from the American Academy of Family Physicians

Association of Women’s Health, Obstetric, and Neonatal Nurses fetal monitoring guidelines

American College of Nurse-Midwives fetal monitoring guidelines

US Preventative Services Task Force on EFM

Cochrane summary on CTG/EFM

Alfirivic, Z. et al. (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.

Grivell, R. et al. Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007863

Evidence Based Birth

Goer H, Leslie M. S, Romano A. The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. The Journal of Perinatal Education. 2007;16(Suppl. 1):32S–64S.

Thacker S. B, Stroup D. F. Continuous electronic heart rate monitoring for fetal assessment during labor. 2001. Cochrane Database Systematic Review (2): CD000063.

 

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