repost from Fall 2010)
While doing my daily ‘tour’ of birth-related blogs, this April 2010 headline caught my eye: “Common Intervention Leads To Needless C-Sections”
What the author Alex Friedman is referring to, is continuous electronic fetal monitoring (efm).
For the record, SOGC’s position on fetal monitoring/surveillance can be found here. They recommend intermittent monitoring in low risk women, and specify what situations might warrant a move to continuous monitoring instead. I have been unable to find Canadian statistics on efm use. In the 2006 Listening to Mothers Survery, 94% of (US) women reported that they had continuous efm. In 2001, 20% of labours in Canada were induced, and as of 2008-2009 the epidural rate in Ontario was 60%, and the caesarean rate was about 25% (27.7% in Canada). www.cihi.ca
While continuous monitoring is considered necessary during inductions, epidurals, and in other ‘high-risk’ situations, this necessity does not change the risk of the mother having a caesarean section as a result of the data obtained through continuous efm.
When you check in to the hospital to give birth, they generally hook you up to “the monitors”. To hook up the monitors, a stretchy band is wrapped around your contracting belly, which holds two round discs in place – the disc at the top of your belly (a tocometer) measures the frequency (how often they come) and duration (how long they last) of your contractions, and the disc lower down on your belly is an ultrasound device that measures the baby’s heart rate. It’s important to know that the “Tocometer” (aka tocodynamometer) measures how much force your belly puts against the toco disc as a way of measuring your uterine contractions – so if you carry extra weight around your mid-section, the toco might not pick up the real strength of your contractions. If you sneeze, shift, bend etc - all that movement is picked up by the toco too.
If for some reason your caregivers feel like the external devices aren’t recording accurately enough, they may want to place an internal monitor instead. A thin wire is passed through Mom’s opening cervix, and threaded into babies scalp. This gives doctors a direct reading of the fetal heart rate, and if they have placed an IUPC (intra-uterine pressure catheter) at the same time, they’ll have a more accurate reading of contraction pressure too. If they don’t place an IUPC, you might find yourself with both an internal monitor for baby AND an external monitor for you (I’ve seen it happen).
Once you’re all hooked up and ready to go, the monitors will give a printout of what they are recording – you’ll see this as two squiggly lines either on a long piece of paper, or on a computer monitor. Generally the top line is baby’s heart rate, and the bottom line is your contractions. Interpreting what these squiggly lines mean, and then interpreting what to DO about it, is as much art and personal judgement, as it is science. What one caregiver sees as an emergency, another caregiver may very well see as normal. (I’ve seen this happen too)
Which brings me to the article by Alex Friedman. I’ve interspersed key portions of the article with my own thoughts.
“Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.”
I would also add that in my opinion, a good screening test has an appropriate risk-benefit ratio. If the risks are high but the benefits are low, and even if the risks are low but the results aren’t reliable (false positives and/or false negatives), that doesn’t seem like a very good screening tool to me – why go through a procedure that isn’t going to give you meaningful information for your decision-making process?
“The Pap smear is an excellent screening test: By examining a few cells brushed from the cervix - where the vagina opens into the uterus - doctors catch precancerous changes - or even early cancer - when it is easy to treat.
But fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and invasive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.
… A study in the New England Journal of Medicine found that only 1 of 500 babies with a bad strip had cerebral palsy. Moreover, it remained unclear if the condition had developed before labor, in which case cesarean couldn't prevent it.
A 2006 analysis by the British Cochrane Collaboration, evaluating all available research, found that fetal heart monitoring failed to reduce perinatal mortality - the risk of a baby's dying late in pregnancy, during birth, or shortly after birth - and increased cesarean section rates and forceps deliveries, compared with listening to a baby's heart rate intermittently.”
Yep, you read that last sentence correctly.
Continuous electronic fetal monitoring does NOT reduce the risk of your baby dying, and does NOT catch the very condition it was designed to prevent (cerebral palsy) but it DOES increase your risk of having a surgical birth.
Everyone wants a healthy baby and a healthy mother. You might hear caregivers tell you that they have to monitor continuously for the safety of baby. Some will go so far as to say that Mom is being selfish when she doesn’t want to be continuously monitored, and they say this isn’t about her comfort, or her ‘nice experience’, but about making sure her baby is born alive and healthy. Just remember, if you are a healthy low-risk woman with a normal pregnancy, the evidence says that continuous efm isn’t ‘safer’ at all! “Even for high-risk fetuses, evidence of the benefit of electronic monitoring… is lacking.” - quoted in “The Thinking Woman’s Guide To Birth” by H. Goer
“Steven Clark and Gary Hankins, two prominent obstetricians, voiced my (the author Alex Friedman’s) frustration. “A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” they wrote in the American Journal of Obstetrics and Gynecology. "Electronic fetal heart rate monitoring has probably done more harm than good."
So why do doctors still use continuous fetal monitoring, if the research shows that it probably does more harm than good? Most often you’ll hear an answer along the lines of “better safe than sorry.” Whether it is expressed as a fear of being sued, as insurance company requirements, or as a genuine belief on the part of obstetricians that it is in the baby’s best interest for the mother to undergo major abdominal surgery, these are all variations on the “better safe than sorry” theme. (I won’t get into the whole discussion here about how we currently weigh out baby’s best interest versus mother’s best interest)
I think there might be more to it than “better safe than sorry”. Obstetricians in North America must have malpractice insurance. If they get sued, their insurance rates go up, and this has the potential to force them out of practice. Their livelihood, and the wellbeing of their families is at stake. How motivated would YOU be to change the way you work, if you knew that doing so might result in you losing your job? Try not to forget that OB’s have to pay the bills just like the rest of us.
So let’s put some pieces together:
Research shows that continuous efm in low-risk situations does more harm than good.
Doctors, who are rarely in medicine ‘just for the money’, but are there because they want to somehow help people, are worried about being sued because it puts both their livelihood and their ability to help people, on the line.
IF doctors make the switch from continuous to intermittent efm on the grounds that continuous efm is harmful, suddenly the door swings wide open for women who underwent caesarean surgery due to “a bad strip”, to sue doctors for causing them harm.
The OB is now damned if they “do” AND doomed if they “don’t”. What’s an obstetrician to do?
I’m not making excuses, and I’m not trying to downplay the pain of women who underwent cesarean surgery, I’m just trying to walk a mile in the OB’s shoes. You have to know where people are coming from, before you have a chance at making a change.
Aside from the money issue, obstetrics has a history of being slow to make changes based on available research. Doctors knew that hand-washing would slow the spread of infection and decrease maternal mortality rates foryears, before they finally started washing their hands. DES continued to be prescribed even after it was shown to doat best, nothing beneficial. Cytotec is still in use on L&D units, even though its own manufacturer says that use is off-label. Why should we be surprised that - in an age where we want a paper-trail for everything; where science trumps intuition; where the one with the best lawyer wins – doctors continue to require continuous efm for low-risk women? I don’t think we should be surprised at all… but we should be motivated to protect ourselves; we should be prepared to work for change.
The Bottom Line:
If you are a healthy and low-risk pregnant woman (which is the vast majority of you), one of the best things you can do to protect yourself against an unnecessary cesarean, is to NOT CONSENT to continuous efm in your healthy low-risk labour.
Intermittent efm gives the caregiver just as much useful data as continuous efm, but without an increased surgical risk for Mom. And there is risk for Mom. Cesarean surgery is major abdominal surgery and the more of them you have, the higher the risks become. Visit Childbirth Connection to learn more about caesarean surgery risks.
If your doctor and hospital include continuous efm in their low-risk birth policies, saying no to continuous efm the day you arrive at the hospital is not usually enough. If you want to protect yourself against an unnecessary surgery,talk to your doctor in advance of your labour day, about your monitoring options. If you’re lucky, your doctor and hospital use intermittent monitoring whenever possible and so you are already one step closer to a safe vaginal birth. Either way, have them write in your file that as long as you remain low-risk (and have your doctor be specific about how they define low-risk) you can have intermittent rather than continuous monitoring. That way if a different doctor is on-call or your nurse doesn’t agree, you can refer them to the written orders in your file.
Please know that if your labour is induced (20% of Canadian women), or if you have an epidural (60% of Ontario women), these interventions both move you into a category which SOGC says require continuous monitoring, and come with their own substantial list of risks and benefits that will need to be weighed out.
To learn more about common practices in birth, and how they affect you, and your baby, please see:
Mothers Advocate – If you want to make informed choices about your pregnancy and birth, but are concerned that you might get overwhelmed by too much information, or don’t want to read, start here. Mothers Advocate gives you the bottom line on the most important things you need to know, in short video clips.
Science & Sensibility - A Research Blog About Healthy Pregnancy, Birth & Beyond from Lamaze International.
Thinking Woman’s Guide To A Better Birth by Henci Goer. This book “puts the power of the latest scientific research on childbirth into the hands of women to help them discern the facts from the myths and make informed decisions about their maternity care."
Gentle Birth, Gentle Mothering by Dr. Sarah J. Buckley. “This book gives you the WHOLE story to help you with your most important decisions in birth and mothering.”
A Guide to Effective Care in Pregnancy and Childbirth - This is an online overview of results of the best available research about effects of specific maternity practices today.
repost from Fall 2010)