Albert Einstein looked at the state of the world late in his career and said ‘It has become appallingly obvious that our technology has exceeded our humanity.’ A commonly held belief is that birth technology makes things safer, faster, and better, but this is not true – as is the case of fetal heart rate monitoring in labour.
Using technology just because we can often leads to unintended consequences, which is often the case in obstetrics. Continuous electronic fetal monitoring (EFM) certainly seems like a good idea- trained care providers use tools to monitor and interpret your baby’s heartbeat during labour and birth. An ultrasound device held against a mothers abdomen with a belt, and connected to a large machine that measures and records a baby’s response to contractions provides data about a particular woman’s labour. Logic says EFM would improve birth outcomes, right?
Three decades of research shows that continuous EFM doesn’t improve birth outcomes. When EFM is used during labour, no fewer babies die and no fewer babies have problems at birth. What has happened is that EFM use has caused more women to have caesareans then would have otherwise.
So if EFM doesn’t help babies, and puts mothers at a greater risk of surgical birth, it can’t be safer care.
Way back in 1988 a Harvard Medical School report described EFM as a ‘failed technology’, but also predicted that doctors wouldn’t stop using it because they were scared of being sued. Their prediction was correct. Fear of malpractice is pervasive in obstetrics, with doctors making decisions on care due to fear of being sued rather than on evidence-based standards of practice.
Devices used to monitor baby’s heart rates in labour:
- A fetoscope – a stethoscope with a large head designed for listening to fetal heartbeats
- A Doppler – a hand-held ultrasound device that transmits fetal heartbeats to a speaker
- External EFM – an ultrasound device held against a mother’s abdomen with a belt. The belt is connected to a large machine that measures and records fetal heartbeats and contractions. Confines you to a bed, offering very limited ability to move.
- Telemetry EFM – is a wireless version of external EFM, giving you ability to move around a little more and not be confined to a bed.
- Internal EFM – uses an electrode inserted in the baby’s scalp and a catheter inserted into the uterus.
(Image by Diana Hinek of ArtShaped Photography)
Why more information and monitoring does not lead to better outcomes:
Continuous fetal heart rate monitoring was introduced into hospitals in the 1970’s, without any evidence of its benefits from clinical trials. With a strong marketing push from the industry it was embraced by most obstetricians and nurses, but it was totally experimental.
The aim was to bring an end to cerebral palsy. However, the continued and widespread use of continuous EFM today still lacks evidence of its benefits, but it is one of the leading reasons for unnecessary caesareans.
Researchers have found that continuous EFM is a very poor test for detecting cerebral palsy- 99% of positive test results will be wrong (American College of Obstetricians and Gynaecologists, 2009). Not only this, the rate of cerebral palsy has remained the same over time because 70% of cases occur before labour even begins and cannot be prevented by EFM.
For most labours, more intensive monitoring increases obstetric intervention (episiotomy, vacuum delivery and caesareans) with no clear benefit for babies.
Difficulties associated with continuous EFM:
Being continuously monitored brings a number of difficulties for mum, baby and care providers.
- Most EFM machines will have you restricted to a bed with very limited ability to move around and change positions.
This is a problem because we know how important freedom of movement is during labour and birth (Lamaze Healthy Birth Practice #2- walk, move around and change positions during labour).
Freedom to move helps your labour to progress by allowing space for your baby to descend. Movement also provides natural pain relief and gives you a feeling of comfort and control.
- Continuous EFM means you won’t be able to utilise comfort measures such as a warm shower or bath.
- Read-outs from EFMs are ambiguous and often misinterpreted. Misinterpreted readouts, even by experienced care providers, often leads to them intervening unnecessarily when labour is actually progressing normally and baby is doing fine (hence the increased caesarean risk with continuous EFM).
You will find your care providers, and likely even your partner and yourself, focusing more on a monitor than on you. It can distract you from turning inward and being with your body and your baby. Anything that takes you out of your instinctive, primal brain and has you in your rational, thinking, frontal brain, is going to increase your stress, your pain and slow down labour.
The World Health Organisation (WHO) encourages intermittent listening with a stethoscope or Doppler device and warns that EFM is often used inappropriately.
You’ll need continuous EFM if:
- Your labour is induced or sped up with synthetic oxytocin
- You have an epidural
- You or your baby has a health problem
How to avoid unnecessary use:
- Remember that routine use of continuous EFM doesn’t make labour safer for you or your baby.
- Talk to your care provider in advance about intermittent fetal monitoring
- Find a care provider who doesn’t use continuous EFM routinely
- Let labour begin on it’s own (Lamaze Healthy Birth Practise #1)
- Stay home for as long as possible
- Remember that your body knows how to protect your baby during labour
- Use comfort measures and techniques to provide pain relief in order to avoid (or delay) use of an epidural
How to keep labour as safe as possible if you need EFM:
- Continue to move as much as possible both in and out of bed within the limits of your reach
- Have a peanut ball and birth ball with you (a few bucks from Kmart) for use on the bed or next to the bed to help with positioning. Avoid lying on your back supine or semi-supine for any length of time- this will slow labour and may increase the risk of abnormal fetal heart rates.
- Ask staff to turn off the monitor’s sound so as not to distract you
- Ask staff to turn the monitor away from you and your birth support partner/s
- Ask for a telemetry monitor (one that’s not attached by wires to the machine, allowing you greater freedom of movement)
Why do hospitals use continuous EFM routinely, when evidence shows it is not of benefit to mothers and babies?
- Doctors, nurses, midwives and hospitals still think that EFM protects them from cerebral palsy lawsuits. However, the introduction of EFM actually increased rates of medical malpractice lawsuits.
- Medical malpractice is based on something called standard of care. Standard of care does not mean best practice, or evidence-based practice, but if a baby had a poor health outcome, failure of an EFM printout as ‘proof’ of what went on for the court, would be seen as a failure to meet the standard of care. It increases the chance that a hospital would lose a lawsuit.
So basically, EFM is a great example of how care protects the interests of the care provider but does not always protect the interests of the mum or baby
- A lack of hospital resources may mean that a delivery unit may only have a few hand-held Dopplers, or none at all. They may not understand the value of purchasing small devices for hands-on listening.
- A busy delivery suite, and very stretched-for-time midwives, means it’s easier to read a computer screen then to spend time with a mother using hands-on listening to the baby’s heartbeat. This comes at a price, because it is well documented that a lack of continuous labour support increases caesareans risk on its own accord.
- Don’t forget that electronic fetal monitoring is big business. The fetal monitoring market is expected to reach $3.6 billion by 2022. The marketing behind it is huge. Hospitals may think that spending money on these machines will reduce hospital staff costs. And I’m sure they know that it increases caesarean rates, further increasing hospital revenue by massive amounts.
(Image by Diana Hinek of ArtShaped Photography)
The bottom line:
Electronic fetal monitoring was brought into labour rooms in the 1970’s for women with pregnancy and birth complications and was quickly used routinely for all women despite their low-risk status. There was never any research evidence to show it was safe or effective.
More recent evidence has shown that EFM has contributed to an increased caesarean rate, without making any improvements in cerebral palsy rates, Apgar scores, admission to the neonatal intensive care unit, low-oxygen brain damage, or stillbirth.
To make a fully informed choice for your labour and birth you need to understand the benefits, risks and alternatives to fetal monitoring (including your legal and human right to say no).
Evidence supports hands-on listening- a low-tech, high-touch approach- for people giving birth without known complications, a great evidence-based option for most mothers and babies.
(Featured image by Monet Nicole Birth Photographer )
- evidncebasedbirth.com/fetal-monitoring/ (2018)
- Giving Birth With Confidence 3rd Edition (2017) Lothian, J., DeVries, C.
- Optimal Care in Childbirth. The Case for a Physiologic Approach (2012) Goer, H., Romano, A.
Denise Georges is a Lamaze Certified Childbirth Educator working in Sydney. She is passionate about helping women find their innate birthing power through evidence-based education. She runs private and group classes that are interactive, fun and will get you primed and excited for your birthing and parenting journey ahead.