Myth Monday: Electronic Fetal Monitoring
Many of the procedures and interventions that have become a
routine part of obstetrical care in America are not supported by evidence. Lack
of evidence-based care results in 9 out of 10 birthing people receiving care
that increases, rather than decreases, risks of harm to themselves and their
babies. One of these standard practices is routine Electronic Fetal Monitoring.
What are my options for fetal monitoring?
Fetal monitoring is performed in two ways: intermittent auscultation or electronic fetal monitoring. Intermittent auscultation (IA) is often referred to as "hands-on-listening" because it requires that the provider use a hand-held doppler or fetoscope to listen to fetal heart tones intermittently throughout labor. Electronic fetal monitoring (EFM) involves the use of doppler monitors that are placed on the abdomen to monitor fetal heart tones. EFM is most often continuous, but for low-risk birthing people, some hospitals "allow" intermittent monitoring for 20 minutes out of each hour
Is more information better?
The premise behind continuous EFM is to identify at-risk babies in hopes of improving outcomes. EFM was developed as an alternative to IA, with the goal of reducing fetal death and cerebral palsy. However, a 2006 Cochrane systematic review of electronic fetal monitoring vs. intermittent auscultation, which pooled data from 12 studies including more than 37,000 participants, showed that EFM failed to reduce ANY negative neonatal outcomes and babies of low-risk women monitored with EFM were 1/3 MORE likely to be admitted to the NICU. Continuous EFM increases the rate of operative vaginal delivery (forceps or vacuum), increases the risk of infection, reduces mobility in labor, and decreases birth satisfaction. Continuous EFM encourages a "hands-off" approach to managing labor, as nurses can view fetal heart tones and contractions from a central bank of monitors. It has also been shown to increase the rate of cesarean surgeries overall, as well as the cesarean rate for abnormal fetal heart tones. This may be due to a combination of interpreting the normal stress of labor as distress, and the fear of liability.
"These unnecessary surgeries harm the birthing person without benefiting the baby."
Interpretation of EFM readings is an art, not a science. When given the same set of readings one doctor may opt for an immediate cesarean, while another may recommend less invasive interventions, such as position changes or IV fluids and take a "wait and see" approach. So with this evidence, why is continuous electronic fetal monitoring still the "gold-standard" in most hospitals?
Why are doctors hooked on EFM?
One answer is the medical-model of care that is so engrained into many obstetricians' way of practice. Birth is viewed as a pathological process instead of a physiological one, of which babies often require rescue from a doctor. No matter the outcome, when a doctor performs a cesarean due to "non-reassuring fetal heart tones," the decision to continuously monitor the baby is confirmed. If the baby is truly in distress, then the continuous EFM saved the baby's life. If the baby is fine (which is the case 95% of the time), then the continuous EFM detected a problem and the baby was rescued before any harm was done. Another reason that hospitals continue to push for continuous EFM is because doctors aren't comfortable practicing without it. Intermittent auscultation is not routinely taught or practiced on the labor and delivery floor, even though in 2019, ACOG (American Congress of Obstetricians and Gynecologists) recommended that facilities adopt protocols and train staff in the use of a hand-held dopplers for low-risk women who desire it.
What's the bottom line?
So, what can you do with this information? First, seek out birthing places that practice intermittent auscultation. If you don't know which hospitals promote IA, ask your doula! If your chosen birthing place does not offer IA, ask why! You can also ask for intermittent monitoring while in the hospital and avoid the use of wireless monitors that encourage continuous monitoring.
Information in this blog should not be taken as medical advice. Any questions regarding your care during pregnancy, birth, or postpartum should be discussed with your provider.