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Ob-gyn questions use of fetal heart monitors in low-risk childbirths

Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates.
nasa.gov
Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates.

Over at KevinMd.com (a highly ranked medical blog that, as the Wall Street Journal puts it, “chronicles America’s often dysfunctional health care system through the prism of a primary care provider”), an ob-gyn physician asks, with considerable frustration, “Why do doctors cling to continuous fetal heart monitoring?”

The physician, Alexander Friedman, who currently occupies a maternal-fetal medicine fellowship at the University of Pennsylvania, points out what most pregnant women don’t know when they enter a hospital delivery room and are hooked up (via a belt) to a continuous ultrasound fetal heart monitor, which will follow and print out their baby’s heart rate during the labor and childbirth process:

Fetal heart monitoring has a high false-positive rate. In other words, it frequently misleads the doctor into believing — incorrectly — that a baby is in serious distress, a situation that then often leads to surgical intervention. Writes Friedman:

Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates. A recent report detailed the dizzying increases: Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available. That rate has grown by more than 50 percent in a decade.
I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips.

Fetal heart monitoring was originally developed to help doctors identify hypoxia, or lack of oxygen, during childbirth, a cause (but not the only one) of cerebral palsy. As Friedman writes in his essay, hypoxia is the complication that doctors fear most when they see a flat line in the baby’s heart rate after the mother’s contractions during labor.

But, as studies have shown, continuous fetal heart monitoring has not lowered the rate of children born with cerebral palsy. Nor has it lowered the rate of infant deaths.

Writes Friedman:

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.
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 expensive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.

Yet obstetricians continue to rely heavily on fetal heart monitors.

“An obstetrician will likely point to the fear of being sued,” explains Friedman, “but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don’t work and can cause harm.”

You can read Friedman’s entire essay, which includes a case example from his own practice of how fetal heart monitoring can mislead a physician, at the KevinMd site.

Comments (3)

  1. Submitted by Lois Garbisch on 09/26/2011 - 04:34 pm.

    My two daughters and my daughter-in-law all gave birth within the last couple of years, in different states. All were “pushed into” interventionist labor management and all suffered from complications that can be directly linked to the interventions, such as labor being slowed way down after being given the epidural anesthesia, infection due to having multiple internal monitors, excessive tearing, severe bladder complications. Why do I seem so judgmental? Because the doctor who delivered so many babies where I live never used these interventions and seldom had such complications. He actually became convinced that the interventions he learned in training cause many complications, so he learned to work without them.

    These young women were told about the wonderful labor and delivery rooms, where they’d be able to walk around, etc. But when they were actually there, they were given the interventions without any alternatives or complications being explained. That is why I use the word “pushed” in describing the administration of the interventions. The nurses were wonderful and hard working and concerned, but one has to wonder if they’ve ever seen a “natural childbirth.” The nurses are the labor managers, the doctor just does the delivery.

    It is no wonder that some women opt for out of hospital births, which of course, could mean other types of problems.

    I’m from the era when Natural Childbirth was much more of an option and many women sought information to make them able to cooperate with the birth process. I didn’t realize how much this had changes. My daughters report that their classes were much more slanted toward cooperating with the hospital process.
    I’m a former Childbirth Educator.

  2. Submitted by jana studelska on 09/26/2011 - 09:17 pm.

    The story is so much more than this. Follow the money…who makes these machines…how they allow one nurse to monitor several patients…how doctors can watch from their office while continuing to conduct appointments…

    Read the studies of how one strip is read so differently by different trained practitioners. So much for the value of the expensive machine and the expensive doctors.

    Consider how requiring women to be strapped into a fetal heart monitor is effectively tying her down with a four-foot leash. Not much different than a generation or two ago when women were literally and routinely tied to a bed.

    As a licensed midwife in MN and WI, I am proud to offer my clients evidence-based care standards, including fetal monitoring during labor according to standards laid out by the American Academy of Family Physicians and the World Health Organization. A far more accurate and sane way to monitor the well-being of a baby.

    Electronic fetal monitors are one of the main reasons I have a booming small business in this retched economy. I am turning customers away. Is there a trade-off for safety, as another comment suggested? Again, look to the evidence. Many people familiar with this situation say that midwives are the antidote to the crazy that is modern obstetrics.

    Kudos to the blogging MD who has the courage to call out his profession on baseless ritual and fraudulent medical practices. As long as he stays interested in obstetrics, he’ll have plenty of fodder.

  3. Submitted by Cathy McMahon on 10/04/2011 - 12:16 pm.

    I agree with Janna and Louis’ comments above, and would emphasize the burdens of being strapped to a short-tethered monitor for many hours at a time. It it contrary to the comfort of the mother in what is often a time of great pain. Better to able to move around, changing postures to relieve pressure.

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