The False Association btw Continuous Electronic Fetal Monitoring & increased use of Cesarean surgery as a strategy for preventing cerebral palsy & reducing malpractice lawsuits against doctors & hospitals ~ Intro & Overview

by faithgibson on August 1, 2019

in Electronic Fetal Monitoring, OB Interventions: Dubious or Detrimental

Originally published March 2100 ~ New Intro & Overview

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Identifying the false association (and failed strategy) between the routine use of continuous electronic fetal monitoring (EFM) and associated increase in Cesarean surgery based on ‘non-reassuring’ EFM tracing.

The purpose of this medical and legal strategy was to:

  • Prevent cerebral palsy and other permanent neurological damage in newborn babies

  • Protect hospitals and obstetrical professionals from childbirth-related malpractice suits

 


Intro & Overview  

This is a series of posts on the safety, expense, social consequences and ethical considerations of the current policies and protocols for fetal monitoring in the US.

The ‘what’ and ‘why’ of fetal monitoring

Listening regularly to the rate and rhythm of the unborn baby’s heart during the labor and birth is a standard protocol used routinely by doctors, midwives and nurses during the active labor and birth of babies born in developed countries. It’s clearly appropriate to monitor the unborn baby during the biological stress of labor.

The question is how exactly that goal should be accomplished and what are the criteria for deciding?

Fetal Monitoring Protocols, beginning with the verbs of Auscultation

The standard of care during childbirth in the first three-quarters of the 20th century required professional birth attendants to use of a special type of stethoscope known as ‘fetoscope’ to regularly listen to the fetal heart. Monitoring also requires the use of a wristwatch or a wall clock with a second hand in order to count the number of heartbeats per minute and note the presence (or absence) of other heart-related characteristics of fetal health.

This protocol is called auscultation. This strange and unfamiliar word — pronounced aws – cul – ta – tion — simply describes the act of listening to the biological sounds of human and animal bodies, usually from hollow organs such as heart, lung, or bowel using a device such as a stethoscope, fetoscope or hand-held electronic doppler.

You can also use your ear placed directly against the patient’s body or a tube made by rolling up a piece of paper. This led to the invention of the stethoscope in 1816 by a Parisian physician (René Laennec) because he was not comfortable placing his ear directly onto a woman’s chest to listen to her heart.

For healthy women with normal term pregnancies, the protocol for auscultation requires labor or birth attendants to listen with a fetoscope or hand-held Doppler for one full minute, sometimes longer as indicated. In addition to counting the baby’s heart rate per minute (BPM), labor and birth attendants note its rhythm (regular or irregular), listen for normal variability and any significant or prolonged increase or decrease in the rate (accelerations or decels).

While the mother-to-be is in early (latent or ‘warm-up) labor, the unborn baby is routinely monitored every hour. During the first stage of active labor, the protocol is to listen every 30 minutes, or more frequently if indicated.

After full dilation, the second or pushing stage begins and it generally includes two distinct phases, with the frequency depending on the phase. As the mother pushes the baby’s down into the birth canal (the descent phase), birth attendants listen every 15 minutes or so.

During the perineal phase, when the baby is being pushed out of the birth canal, the fetal heart is listened to after every other contraction — approximately every 5 minutes or more frequently if indicated.

Each time information is collected on the unborn baby’s heart rate and rhythm it is recorded on the mother’s chart. This data is carefully tracked and used to confirm the continuing well-being of the unborn baby or alert the birth attendants of a potentially serious problem. If a serious abnormality is detected, the situation is evaluated and when needed, medical or surgical interventions are used.

The protocol for auscultation also requires a labor room nurse, midwife or physician to be consistently present in the room during the active phases of the woman’s labor. In addition to listening and keeping track of significant changes in the fetal heart tones, auscultation includes direct observation of the mother’s physical and mental well-being and the nature and progress of her labor as it affects her and her fetus.

Usually, the mother-to-be requires and greatly benefits from the support and assistance provided by labor and birth attendants. On-going one-on-one care helps her cope more effectively with the normal anxiety, pain, and physical stress of her labor, which helps reduce the need for medical and surgical interventions.

Studies over the last half-century that compared auscultation to electronic fetal monitoring show no difference in outcome (neither better or worse) for the newborn babies of healthy women with normal pregnancies.

The nouns of Electronic Fetal Monitoring

Development of Fetal Monitoring Machines

In the late 1960s, electronic equipment was developed that made it possible for a machine to continuously listen and record the activity of the fetal heart, as well as tracking the frequency and length of labor contractions.

EFM was originally designed to monitor the unborn babies of women with very serious medical diseases, high-risk pregnancies, and women who developed serious complications during labor.

The malpractice crisis of the mid-1970s changes everything

An unexpected, and in many ways irrelevant event — the malpractice crisis of 1975 — changed the way this technology was used in the US. Due to several unexpectedly large malpractice settlements, the companies that sold professional liability insurance dramatically increased their premiums. This provided a great hue and cry from the medical community and made the costs associated with malpractice insurance the topic of newspaper headlines for several weeks. Following this focus on litigation, there was a 6-fold increase in the use of continuous EFM in hospitals all across the country.

As more and more hospitals routinely used continuous EFM for all their labor patients, EFM was formally adopted as the standard of care in American hospitals. No long a special protocol reserved for women with serious medical complications and/or a very high-risk pregnancy, continuous EFM was used on all laboring women, no matter how healthy the mother or low risk her pregnancy.

The routine use of

The No 1 obstetrical procedure in the US is continuous Electronic Fetal Monitoring

 

According to an article published in April of 2011 by a practicing obstetrician:

“ . . . intrapartum fetal heart rate monitoring is the most common obstetric procedure performed in the United States.

Despite the widespread use of EFM, there has been no decrease in cerebral palsy. … trials show that EFM has no effect in perinatal mortality or pediatric neurologic morbidity. {1}

Citation #1. “Heart Rate Monitoring Update” The Female Patient, April 2011

In hospitals, the hourly reimbursement rate for continuous electronic fetal monitoring by many health insurance companies is several hundred dollars an hour, in some cases as much as $400. The routine use of this expensive technology, along with a significant increase in Cesarean surgeries associated with the routine use of c-EFM, is an economic double whammy that has contributed significantly to the high and continuously rising cost of childbirth services in the US over the last 50 years.

This is particularly an issue for larger hospitals that have central monitoring systems. In these hospitals, L&D nurses and obstetricians sit at the Nurses’ Station in the hallway and watch banks of computer screens simultaneously displaying the EFM tracing from several different labor rooms. Hospitals with central monitoring have an even higher C-section rate than those where monitoring the electronic monitor display is the direct responsibility of the L&D nurse assigned to that patient.

The universal use of c-EFM continues to make childbirth services disproportionately expensive in the US. In parts of the country, hospitalization for childbirth is approaching, and in some cases equals the cost of an organ transplant (over $100,000).

The obstetrical profession’s mistaken belief that not using continuous EFM equates to malpractice

As expert witnesses, obstetricians are frequently called on to testify in legal cases about electronic monitoring. As spokesmen for the obstetrical profession, they also funnel information to the news media about the role of EFM.

A majority of obstetricians spokesmen believe that any failure to utilize this potent combination of continuous EFM and nearly-instant access to Cesarean delivery for all childbearing women, no matter how healthy the mother or normal the pregnancy constitutes substandard or negligent care.

In the opinion of these individuals, this constitutes medical malpractice if the provider is a hospital or physician, and criminal neglect or the “earliest form of child abuse” if the decision to not be electronically monitored during labor is made by the parents or a midwife. While these opinions come from highly regarded professionals, they are nonetheless devoid of scientific support, untrue, and misleading in the extreme.

Based on a consensus of the scientific literature, the truly informative statement — the type of information legally required as part of the “informed consent” process, is that continuous EFM is NOT recommended when the mother-to-be is healthy and her pregnancy is normal. Furthermore, a professionally licensed maternity care provider would be legally obliged to inform healthy childbearing women that auscultation protocols are the science-based ‘best’ choice, and that c-EFM is actually contra-indicated, that provide no benefit while introduces unnecessary risks and unproductive expense. 

The Future of Maternity Care in the United States

A new vocabulary, a new perspective, a new way to provide care during pregnancy and childbirth

The basic purpose of maternity care for healthy women with normal pregnancies is to protect and preserve the health of these already healthy women. The needs of healthy women are fundamentally different than those of women with serious complications and high-risk pregnancies. Maternity care is a different discipline, with a perspective very different from that of obstetrics, which is a surgical specialty.

It would be enormously helpful if we used a different vocabulary to distinguish and discuss this functional distinction, identifying maternity care as professional discipline focused on healthy childbearing, while obstetrics would continue to be recognized as the surgical specialty that it is, a discipline that focuses on the diseases and abnormal conditions of female reproductive biology, complications of pregnancy and management childbirth in women who have high-risk pregnancies or develop complications during labor, birth or postpartum period.

Relative to this 70-85% childbearing population, the goal for our healthcare system must be a cost-effective model that is able to preserve health of already healthy women and effectively prevent, or successfully treat, minor complications that arise during pregnancy and childbirth and in case of a serious complication, consult with, refer or transfer of care to high-risk obstetrical specialists.

What we need as individuals, as childbearing families and as a society is to be certain that all customary childbirth practices are scientifically sound, including the protocols for fetal monitoring used when providing childbirth services to healthy women with low-risk pregnancies. This means safe, cost-effective, and also meets the physical, social and emotional needs of childbearing families and their newborn babies.

Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.

The ideal maternity care system seeks out the point of balance where the skillful use of physiologically-based care, and adroit use medical interventions whenever necessary, results in the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

Ultimately, the quality of maternity care must be is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.

As the #1 obstetrical procedure in the United States — one that is uniquely expensive for those who pays these bills (including federal MediCaid program — we need to be sure that EFM does what its manufacturers say it does.

Based on the current consensus of the scientific literature amassed over the last 40-plus years, the “best practices” as defined by best outcomes for mothers and babies and least expense to the society both in money and human terms must be scientifically identified and implemented as the legal and ethical standard of care for healthy women with normal pregnancies who decline routine interventions during labor unless they become medically necessary.

Providing maternity care to healthy childbearing families 

If obstetrics, for whatever reason, is not configured to meet the real needs of childbearing women, then it must systematically reform itself. If unwilling or unable to do this, its can and should change its focus by reclaiming its historic role as a doctor trained in a speciality to meet the needs of women suffering from diseases and pathological conditions associated with their reproductive biology, including hormonal issues, infertility, cysts, tumors, and complications of pregnancy, childbirth and the postpartum period.

In this context, it’s appropriate to stress how obstetrics as a surgical discipline differs from the basic purpose of maternity care — to protect and preserve the health of already healthy women.

Its a function of the health care system to create a cost-effective model of maternity care that is able to preserve health and effectively prevent or successfully treat non-surgical complications during pregnancy and childbirth.

This factors in the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life, including delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and the overall cost of care to individuals and society.

It is for this reason that continued routine use of EFM on healthy women with normal low-risk pregnancies cannot be permitted to continue.

The scientific evidence is overwhelming — routine EFM resulting in a sharply elevated Cesarean rate without any benefit to the mother or baby. Cesarean deliveries needlessly expose childbearing women to all the intra-operative complications of major surgery, a 13-fold increase in emergency hysterectomies within 14 days of the Cesarean birth, secondary infertility, and potentially fatal complication for both mothers and unborn/newborn babies in subsequent pregnancies.

The following series will address the why, when, how of both EFM and auscultation, including the diverse circumstances of their use and their cost in financial and human terms, the scientific literature and Action Plan to correct one of its most serious problems, which is the routine use of an obstetrical procedure — continuous EFM — which was designed to be used in very high risk pregnancies  but instead has been allowed by the medical profession and the public to become a universal standard of care used during the normal labors of healthy women with low-risk pregnancies.

faith gibson, LM ^O^

ContFormer L&D nurse, California licensed professional midwife #41, author-editor of the California College of Midwives’ Standard of Care (2004); appointed to the Medical Board of California’s Midwifery Advisory Counsel, served 6 years, 3 as its first Chair (2007-2013)

 


 

Continue to Part 1A ~ Fetal Monitoring ~21st-century Conundrum for the US

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