ACOG refines guidelines for fetal monitoring in labor

ACOG recently updated guidelines for fetal monitoring in labor.  They call it a refinement.  Very interesting.

Directly from the press release “Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.” That is an increase in use by 89% with what benefit to mothers and babies? More cesarean?  More interventions and managed labors? Perinatal mortality hasn’t decreased.  Shocking really.   So for the needs and most likely benefit of the truly high-risk moms and babies all women have been subjected to more and more electronic monitoring in labor resulting in more morbidity for mothers and babies.

Apparently a big issue is that there are huge discrepancies in interpretation when assessing the FHT strips by physicians. There was a group of 4 physicians who initially assessed 50 FHT tracings and only agreed 22% of the time. Then two months later the same 4 physicians were asked to re-assess the same 50 tracings and their own evaluations varied nearly 1 in 5.   I have heard this over and over anecdotally from labor and delivery nurses through the years.  That no one can agree.  That the variance is so great.  Better to treat just in case whether by interventions or a cesarean.  I have been told that even a 40 hour course on FHT assessment leaves one without any clear advancement of skill or knowledge. The training actually left one individual less inclined to trust assessment.  So how does this comfort the expecting woman? Knowing that the machine that rules so much of labor and delivery in combination with the human element is so fallible.  Now that is non-reassuring in real life application.

So what can be done?  Unless there is a real high-risk situation that needs to be addressed, ask for intermittent auscultation with a handheld doppler or even better with a fetascope.  When a nurse, midwife or doctor actually listens personally to a baby with a fetascope there is no machine interpreting sound. It is with their own ear and skill assessing your baby.

The other thing to remember is keeping away from routine use of  induction, narcotic use, and epidural use in labor can greatly improve the opportunity to remain low-risk and healthy.  Thus not requiring continuous fetal monitoring.

I only touched on a few aspects of the new guidelines.  For a more complete breakdown of the refined guidelines, the NY Times did a nice piece.

4 Responses to “ACOG refines guidelines for fetal monitoring in labor”

  1. Ironica says:

    Nicholas,

    You say “Fetal heart rate tracings do have a lot of meaning. They do tell us about intrapartum events such as cord compresssion, head compression, fetal hypoxia, and fetal acid/base status. Whether this information is useful in a low risk labor is up to some debate, but that information is present in the strip.”

    No, there’s really no debate: there’s actually a mountain of evidence that routine continuous monitoring has NO salutary effect on birthing moms and their babies. The only effect, in study after study, is an increase in c-sections. Given that a c-section carries many risks that a normal vaginal birth does not, this can explain some of the increase in maternal mortality and morbidity we’re seeing in the United States.

    That information may well be unambiguously present in the strip; I’ve never learned to read one. But if it is, then that information is *not* helping doctors determine which babies need to be “rescued” through their mother’s stomachs. What seems more likely is that we have misidentified the range of normal for those readings.

    Now, the merits of direct listening via fetoscope are not so clear-cut, as you rightly point out; a doctor *still* has to be trained to interpret such monitoring properly, and right now, few of them are. But as a passive method, it cannot possibly cause harm to the baby, at least. It also seems less likely to mislead doctors into unnecessary c-sections. But, whatever method used to monitor, it’s clear that continuous EFM is at best of no use for the majority of pregnancies.

  2. Brigette says:

    I just wish women had the right to refuse… I haven’t found a single hospital that will allow a woman to labor without one, which means that you will be forced to stay in bed, which is not the ideal way for me to labor, I know that. My choices should be respected and if I choose to “risk” only using a Doppler or what not, that is my families decision. Also the notion that somehow EFM is accurate is ridiculous, how many times have women been rushed off to have a c-section because their baby is showing non-reassuring heart tones, and the doctor pulls out a happy healthy pink baby, not a blue not breathing one… ( a great article published http://www.philly.com/inquirer/health_science/weekly/20100426_Test_leads_to_needless_C-sections.html) Drs should be doing what their patient and themselves have decided is the best way to proceed with their care, not what is mandated by insurance companies as a way to have “proof” that they did or didn’t do something they were supposed to… I think initially EMF was supposed to be intermittent, with women being able to walk around and move, with 1 on 1 nursing care, not the way it is being implemented now.

  3. >> When a nurse, midwife or doctor actually listens personally to a baby with a fetascope there is no machine interpreting sound. It is with their own ear and skill assessing your baby.

    This is psueodoscience nonsense. We can argue about the meaning of the fetal heart rate tracing, but saying that listening with a fetoscope is somehow better than using a doppler is just ridiculous. The “skill” involved is being able to interpret the strip, not being able to count the heart rate. The EFM machine actually does that better than any human could do.

    Fetal heart rate tracings do have a lot of meaning. They do tell us about intrapartum events such as cord compresssion, head compression, fetal hypoxia, and fetal acid/base status. Whether this information is useful in a low risk labor is up to some debate, but that information is present in the strip.

  4. Kathy says:

    Desirre,

    I can see EFM as a way to increase lawsuits in at least a few ways — not only does the strip guarantee that there will be evidence to be used against the hospital in a court of law (because as the above points out, there will always be plenty of people who will attest that the doctor should’ve performed a C-section at *this* point on the strip; I don’t have a link, but I remember reading about a study done in which doctors analyzed EFM strips, and when they were told that the labor ended negatively they were more likely to say they’d have done a C-section than doctors who were told that the labor ended positively — even though it was the same strip). But of course, if you have no EFM strip, then you have a lawyer indicating that that was beneath the “standard of care” since “everybody” does EFMs. [And if everybody jumped off a bridge…?]

    Also, EFM by its very use and existence is a constant signal to the laboring parents that “this machine keeps your baby safe and guarantees a live birth and healthy outcome.” Then, when that apparent promise doesn’t materialize — i.e., the baby has cerebral palsy or some other condition — they feel defrauded or cheated out of the healthy baby they expected. And more likely to sue.