Evidence-based care is a topic that comes up often in obstetrics. Every year, countless studies are done to examine the way birth is managed in the hospital. Some changes and technological advancements are based on evidence: what is the best practice, and does it improve outcomes for moms and babies? Others are not evidence-based, and are based on risk management, financial planning, ease for the practitioner, or other reasons that may not be in the best interest of the client/patient.
Continuous electronic fetal monitoring is one of the latter. When having a baby in the hospital, this is standard procedure unless you’ve requested otherwise: a stretchy strap is wrapped around the laboring woman’s belly with a monitor positioned over the baby’s heartbeat. Another monitor and strap are attached up nearer to the top of the uterus to monitor contractions. The picture above is of a typical strip. The top shows the baby’s heartbeat, and the bottom shows contractions.
The hope was that by continuously monitoring babies and their response to contractions, more babies could be saved– and cerebral palsy (at that time, thought to be linked to lack of oxygen during birth) would be prevented. Those of you reading may already know the downside to this, in terms of physiologic birth. Getting up, changing position, and moving around, are all incompatible with continuous monitoring–it can confuse the reading. If a laboring woman can’t move during contractions, those contractions can be exponentially harder to handle, and thus begins the cascade of interventions. And if a baby is positioned in a way that makes it challenging to hear the heartbeat, or a mama is obese–or any number of other things that can make continuous monitoring impossible–a fetal scalp monitor is introduced: more interventions.
Even so, one might argue that these interventions were worthwhile if they kept babies healthy and alive. Unfortunately, over the years since this has been commonplace, continuous electronic fetal monitoring has not reduced infant mortality or cerebral palsy. The only number that has significantly changed since its introduction are the number of cesarean sections.
In the Philadelphia Inquirer last month, Alex Friedman, a fellow in maternal-fetal medicine wrote about his experiences with this, and his feelings when performing an “emergency” surgery based on the strip, only to find a vital, screaming baby inside. “No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry,” he writes.
Dr. Friedman also cites several studies in the past few years, all supporting the evidence that continuous fetal monitoring is not a foolproof screening tool.
“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.”
Read Dr. Friedman’s article (and the inflamed comments below it) to learn more about what he has found. It’s always nice to find someone from the medical model questioning the status quo and trying to practice in an evidence-based way.
Here is the full article.