The False Association btw the routine use of continuous electronic fetal monitoring (c-EFM) to prevent Cerebral Palsy, Maternal Pelvic Floor Damage & Protect OBs from Lawsuits ~ Part 1 (of 3)

by faithgibson on March 3, 2019

in Cesarean Politics, OB Interventions: Dubious or Detrimental

Part 1 (of 3)

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  • Revealing the false association between routinely using continuous electronic fetal monitoring (EFM) as a strategy to prevent Cerebral Palsy and other neurological damage in newborns

  • Well-documented increase in Cesarean surgery associated with the routine use of continuous EFM in healthy (low-risk) women with normal pregnancies

  • The well-documented INABILITY of Cesarean surgery to prevent pelvic floor damage in childbearing women

There is a strong but wrong assumption in the United States that normal childbirth inevitably risks the life of unborn babies and regularly leaves the pelvic floor of childbearing women permanently damaged.

For more than a century, the obstetrical profession has searched intensely for ways to dependably eliminate cerebral palsy (CP) and similar neurological pathologies, while also looking for ways to prevents malpractice lawsuits.

American obstetricians believed the invention of electronic fetal monitoring in 1958 gave them a near-perfect tool for preventing these birth-related tragedies.

EFM is formally described as a medical procedure that uses electronic instruments to continuously record both the heartbeat of the fetus and its laboring mother’s contractions. These two streams of data are displayed on the monitor’s screen as well as being recorded on a moving graph paper that creates a permanent legal record of the minute-by-minute status of the unborn baby’s health throughout the hours of labor and birth.

The obstetrical protocol for its use is to monitor every laboring woman continuously during the entire length of the labor and birth, no matter how healthy the mother or normal the pregnancy.

However, electronic fetal monitoring by itself was only half of the answer. The other and equally critical part of this “obstetrical miracle” was immediate operative delivery — forceps, vacuum extraction, or Cesarean surgery — to rescue the unborn baby at the slightest indication of fetal distress as indicated by the EFM tracing.

Continuous EFM, with its ability to gather critical information about the wellbeing of the fetus, combined with the ability to almost instantly remove the baby from the mother’s body, was considered by the obstetrical profess to be a marriage made in heaven.

Educating the Public to Embrace this “brave new world”

Under these circumstances, it’s no surprise that the obstetrical profession aggressively and quite successfully promoted the use of these two obstetrical procedures. Obstetricians repeatedly assured the American public that the routine use of EFM, combined with the liberal use of Cesarean surgery at the slightest indication of fetal distress, would to universally prevent babies from becoming brain-damaged during childbirth.

In a historical context, these obstetrical interventions were seen as making up for the design flaws that were a normal facet of female reproductive biology. For more than a century, obstetrical textbooks had described childbirth as a ‘patho-physiology‘ — that is, a natural physiological process that was fundamentally defective (i.e. pathological).

Biology as “destiny” — historical gender bias as it influenced the thinking of obstetricians

In the early 1900s, obstetricians described pregnancy as a nine-month disease that required a surgical cure. Doctors were referring to the physical damage to both mother and baby they frequently saw as a result of childbirth.

The mother’s perineum was often bruised and sometimes damaged so badly that stitches were required to put the mother’s tissue back together. In addition to the pain, it was believe that this assault on the mother’s pelvic floor was the origin of the ‘female troubles’ many women experienced later in life.

Fig.661 “An injury to the anterior position of the Levator ani due to crushing from the blade of the obstetric forceps and the ramus pubis. Very difficult to repair”. 1924 edition of DeLee’s “Principles & Practice of Obstetrics”

At that time, no one realized that many of the ”troubles” ascribed to biological weakness of the female gender were actually a direct result of the routine use of obstetrical forceps that damaged nerves, tore supporting ligaments and otherwise harmed the mother’s pelvic floor.

But from the perspective of a late 19th and early 20th century male physician, it seemed that a woman’s reproductive biology was God’s mistake when compared to the biology of a man. For the male of the species, sexual reproduction never resulted in his death or physical damage, whereas women could be harmed or died from the complications of pregnancy and childbirth.

This supposed biological inequality was just one more brick in the wall that divided the sexes and resulted in an assumption that men were the ‘perfected’ half of the human species, while the female gender was biologically and psychologically inferior.

As for the  newborn baby, doctors saw the patho-physiology of the female gender as making childbirth so hard on the fetus that newborn babies were often too tired to breathe and so they died or suffered a variety of birth injuries that might leave them physically or mentally handicapped for life.

Given the facts of this obstetrical perspective, the much higher C-section rate associated with EFM is was seen an unexpected benefit for women, as Cesarean delivery was the only sure way to save new mothers from developing ‘female troubles’.

Failure to use EFM seen as Medical Malpractice

As expert witnesses, obstetricians frequently testified in court cases and provided information to the news media about the role of EFM.

In the opinion of many obstetrical spokesmen, any failure to utilize this potent new combination of continuous EFM and nearly-instant access to Cesarean delivery constituted medical malpractice, the “earliest form of child abuse”, or criminal neglect, depending on whether the culprit (as defined by the obstetrical profession) was a hospital or doctor, the parents or a midwife.

21st Century Interventionist Obstetrics seen as “normal” by the public 

At this point in our history, the American public generally accepts our highly medicalized childbirth system as a welcome status quo — a wonderful use of the most modern and cutting edge technology to make life better for everyone. People don’t question our highly-medicalized obstetrical system any more than they wonder if telephones, personal computers and air travel are a ‘good’ thing.

Are these assumptions about c-EFM & liberal use of C-section born out by the scientific literature?

  • Does the research identify the routine use of continuous EFM and liberal use of Cesarean surgery as substantially reducing neurological problems in newborns when compared to simpler methods of intrapartum monitoring?
  • Has medical science discovered reasons other than the management of the labor and birth that explain why some apparently normal birth result in CP and similar problems?
  • As for preventing ‘female problems’, no one wants new mothers to become incontinent or suffer pelvic damage as a result of childbirth, but does the high rate of Cesarean surgery in the US reliably prevent those problems?

Since c-EFM and elective Cesarean delivery were both incorporated into the American standard of obstetrical care decades ago, one world assume the answer is “yes”.

Interestingly enough, the obstetrical profession’s own research, as published in its own peer-reviewed journals in the US and other developed countries, says “no” to both of the supposed fixes of c-EFM and liberal use of Cesarean.

In fact, scientific studies identify many of the routine obstetrical practices associated with our highly medicalized model of childbirth to make matters worse for families and society when the unproductive expense and the increase in medically-unnecessary operative deliveries are taken into account.

  • ACOG Task Force on Neonatal Encephalopathy & Cerebral Palsy; Am. College of Obstetrician & Gynecologists 2003
  • Ob.Gyn.News; September 15, 2003 edition
  • Ob.Gyn.News; August 15, 2002 edition
  • Heart Rate Monitoring Update; The Female Patient, April 2011
  • Medscape Ob/Gyn & Women’s Health; 9/16/02
  • Ob.Gyn.News; August 1, 2002, Vol 36, No 15

The seductive idea that c-EFM & Cesareans would eliminate CP AND protecting obstetricians from lawsuits

When the electronic technology of fetal monitors first became available, obstetricians all across America genuinely believed they finally had a permanent solution to an ancient and heartbreaking problem. Historically and in contemporary times, some apparently healthy babies of healthy mothers do not survive an apparently normal labor and birth for inexplicable reasons, while other newborns suffer unexpected but nonetheless permanent mental and/or physical disabilities.

Members of the obstetrical profession were convinced that continuous EFM for all laboring women was the new and improved standard of care and would, when combined with cesarean delivery whenever the monitor tracing indicated even a small problem, be the long-awaited answer to their prayers.

But in modern America (post-medical malpractice crisis of 1975), the family’s personal and financial tragedy was often compounded by a professional tragedy — the high likelihood that parents will file a lawsuit against the hospital, and all the doctors and nurses involved in the labor and birth. Since 1975, there has been a 6-fold increase in the routine use of c-EFM on low-risk mothers.

There was (and is) nothing wrong with hospitals and obstetricians hoping that continuous electronic monitoring of all laboring women would prevent both the personal tragedy and the malpractice risk to the obstetrician.

The problem is not the hopes and dreams of the obstetrical profession, but what the scientific evidence says — or in this case, what it does NOT say. All the studies done in the last 50 years on the use of continuous electronic fetal monitoring on low and moderate risk mothers found that EFM combined with increased Cesarean delivery did not make any statistically-significant difference in perinatal outcomes (i.e. no reduced rate of death, cerebral palsy or encephalopathies).

The right use of EFM: High-risk pregnancies

The one and ONLY area that c-EFM outperforms simpler methods is when used to monitor the labors of pregnant women with extremely high-risk pregnancies. However, this is only 15% of total labors. Women with low-risk pregnancies are the huge majority of all labor patients; 70% to 85%.

If the obstetrical profession had limited its routine use of c-EFM to the demographic that actually needed and benefited from it — extremely high-risk labors — I wouldn’t be writing about this discordant obstetrical practice and you, the reader, wouldn’t be reading about an expensive medical misadventure directly associated with increased levels of iatrogenic mortality and morbidity.

But the facts are indisputable:  The current system treats all healthy women with normal pregnancies as if they were high-risk. More to the point, it does this without improving outcomes for babies and while increasing medically-unnecessary surgical deliveries, and its many complications, including increased maternal mortality and morbidity.

For example, a paper titled “Fetal Heart Rate Monitoring Update” [The Female Patient, April 2011] makes this crystal clear. It begins by saying:

“Intrapartum fetal heart rate monitoring is the most common obstetric procedure performed in the United States”

The authors immediately admit that:

“Despite the widespread use of EFM, there has been no decrease in cerebral palsy. … meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity.2

However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.1”

Although intermittent fetal auscultation {IA} may be a theoretical option in low-risk patients, nursing staffing limitations makes this impractical … ”

A 2006 meta-analysis aggregated the data from randomized controlled trials done during the 1980s and 1990s and found no change in perinatal mortality or cerebral palsy rate when electronic fetal monitoring was used during labor.

It also identified a decided increase in Cesarean section rates and operative deliveries. It’s only positive finding was a small reduction in neonatal seizures, but this did NOT seem to make an overall difference in infant well being.

  • Another recent study noted that the ability of continuous EFM to detect potential cases of cerebral palsy during labor is only 00.2%

This is not because the electronic circuitry of the equipment is flawed, but because the premise is incorrect – cerebral palsy can neither be reliably detected nor prevented based on the routine use of c-EFM during labor of healthy women with normal pregnancies.

The reason is simple enough:

  • Only about 8% of neurological complications in newborns have any possible association with events of labor or birth
  • Of that small percentage, intermittent auscultation (a simpler and non-continuous form of fetal monitoring known as IA) would have either picked up or missed the very same data but without introducing the added expense and all the other potential complications of c-EFM
  • When c-EFM is routinely used on a low and moderate risk populations with normal pregnancies, it introduces unnatural and unnecessary risks that include a substantial increase in episiotomy, forceps delivery, vacuum extraction, Cesarean surgery and maternal mortality.

A report in the September 15, 2003 edition of Ob.Gyn.News stated:

  • “The increasing cesarean delivery rate that occurred in conjunction with fetal monitoring has not been shown to be associated with any reduction in the CP rate
  • … Only 0.19% of all those in the study [diagnosed with CP] had a non-reassuring fetal heart rate pattern…..
  • If used for identifying CP risk, a non-reassuring heart rate pattern would have had a 99.8% false positive rate   N.Engl. J. Med 334[10:613-19, 1996
  • Evidence leads us to believe that maternal infections during pregnancy might play an important role in [CP] development . . . and that in most cases the condition cannot be linked with the birth process.”

An even more authoritative study, one that is the equivalent of a blue-ribbon panel, is the report issued in 2003 by the American College of Obstetrician and Gynecologists (ACOG) known as the Task Force on Neonatal Encephalopathy & Cerebral Palsy

It stated:

  • Since the advent of fetal heart rate monitoring, there has been no change in the incidence of cerebral palsy. . . .
  • The majority of newborn brain injury does not occur during labor and delivery
  • …. most instances of neonatal encephalopathy and cerebral palsy are attributed to events that occur prior to the onset of labor . . . 

This ACOG report was endorsed by six major federal agencies and professional organizations, including the CDC, the March of Dimes and the obstetrical profession in Australia, New Zealand and Canada and is widely regarded as the:

most extensive peer-reviewed document on the subject published to date”.

A report in Ob.Gyn.News in August 15, 2002, Dr. Hankins, professor and vice chair of Ob-Gyn at the University of Texas, Galveston.  stated:

“Performing cesarean section for abnormal fetal heart rate pattern in an effort to prevent cerebral palsy is likely to cause as least as many bad outcomes as it prevents.

… A physician would have to perform 500 C-sections for multiple late decelerations or reduced beat-to-beat variability to prevent a single case of cerebral palsy.

But since Cesarean section carries a roughly 0.5% risk of future uterine rupture, those 500 C-sections would result on average in 2.5 uterine ruptures. This in turn would cause one case of neonatal death or cerebral palsy….

So I’ve prevented one case of cerebral palsy and I’ve caused one, concluded Dr. Hankins

Moreover, those 500 women who underwent C-section because of an abnormal fetal heart rate pattern face substantial morbidity related to their surgery, including a 5 to 10 fold increase in relative risk of infection, a 5-fold increase in [blood clots] as well as a 10- to 20-fold increase in future risk of placenta previa and accreta, he added.”

A current EFM textbook for L&D nurses and midwives notes that:

“the greatest misconception about EFM is the belief that it is a diagnostic tool. EFM is useful only as a screening tool”.

[Ref: EFM-Concepts and Applications, Menihan & Kopel, 2nd ed, p. xii, 2008]
  • The value of EFM lies in using the information as a question, and not as an answer. Over 90% of fetuses with ‘non-reassuring’ FHR patterns are healthy.

To properly evaluate an abnormal EFM strip, additional medical procedures are needed to determine the significance of this non-reassuring data. These methods include fetal scalp sampling (taking blood from small blood vessels on the unborn baby’s scalp) and fetal scalp stimulation.

However, these additional methods also suffer from serious disagreements between professionals who frequently disagree over the guidelines for use and the validity of the information they provide.

Lack of agreement btw obstetricians on EFM data & whether an emergent C-section is needed

The other ‘elephant’ in the room when interpreting c-EFM data is the incredible lack of agreement between obstetricians over the data being streamed to fetal monitor screens and printed out on reams of graph paper.

All the professional insiders — OBs, L&D nurses, obstetrical department heads, hospital administrators and their attorneys and lobbying groups such as the American College of Obstetricians & Gynecologists ACOG — are each and everyone aware of the “slips twixt cup and lip” when it come to the interpretations EFM data by different obstetricians.

Here is another excerpt from the “Female Patient” April 2011 quoted earlier that reports on studies of this issue that the public is never privy to:

“There is considerable inter- and intra-variability in the interpretation of EFM. Clinicians disagree with each other in their evaluation of FHR about 80% of the time.

Even when reviewing the same FHR pattern several months later, a clinician disagrees with his or her own initial interpretation about 20% of the time.1

One study by Chauhan et al had 5 clinical obstetricians evaluate the FHR patterns of 100 parturients using the traditional intrapartum evaluation (reassuring vs. nonreassuring). Forty-six percent of these patients had an emergent cesarean delivery, and 2% had a fetal pH less than 7.0.

The study found that not only was there poor agreement among clinicians, but they could not even predict which parturients had an emergent cesarean delivery or low fetal pH. [3]

Fetal metabolic acidosis and hypoxic-ischemic encephalopathy are also associated with significant increases in EFM abnormalities, but EFM predictive ability to identify these conditions is low.” [4]

Simply put, the scientific literature has never supported the routine use c-EFM and one of the reasons may well be that the obstetrical profession has never been able to agree on the data.

If they did, the C-section rate would drop like a stone, but instead, the obstetrical profession and the American news media are neither one talking about the big blue elephant that is smack in the middle of the room. And so, the operative motto for American obstetrics is remains: “When in doubt, cut it out

         In 2003, 1.2 million Cesarean surgeries were performed in the US (27.5% cesarean rate) at a cost of $14.6 billion. The Cesarean rate for 2006 was over 31% and for the most recently available stats (2017)  it’s a whooping 32.8 % (i.e. 33%) or one out of every three women who gave birth in 2017. This is equivalent to the number of people that graduate from college every year.

However, C-section stats are wildly different, depending on what state the mother gives birth. For example, stats for first-time mothers in New Mexico, South Dakota and Iowa in 2017 were just 17%, but 31 percent  of first time moms in West Virginia were delivered by Cesarean. Obviously the high Cesarean in the US is not the result of a universal failure of female reproductive biology

The use of Cesarean surgery as‘pre-emptive strike’ has not made the tiniest bit of difference in the incidence of CP and similar neurological conditions. And yet, the public and the press never seem to question how unlikely it is that normal childbirth in healthy women is somehow made safer and better by turning it into an expensive and risky operation.

Obstetricians use research documenting the ineffectiveness of c-EFM to defend themselves against lawsuits

Even more oximornic is the obstetrical profession’s newly inverted relationship with c-EFm when it comes to malpractice cases claiming negligence in the use of EFM (or not using it every minute the mother was in the hospital) or mistakes interpreting EFM tracings. When OBs are on the other end of the stick, they acknowledge the information in this large body of research (examples of which I quoted earlier) and use it to defend themselves.

Since the publication of ACOG’s task force report in 2003, attorneys for obstetricians and hospitals who got sued because a baby developed CP trot out the studies that identify c-EFM as being unable to detect or prevent cerebral palsy, regardless of how much or little the mother was electronically monitored or how the EFM data was or wasn’t the interpretation by their OB or the L&D nurses.

Personally I say ‘good for them’; obstetricians and hospitals shouldn’t sued for a bad outcomes they were NOT responsible for. But why is this recognition not used up-front, why not honestly tell low risk women that the use of c-EFM make no difference in outcomes for healthy women with normal pregnancies. Why not quote the conclusions in the April 2011 report Fetal Heart Rate Monitoring Update:

“Despite the widespread use of EFM, there has been no decrease in cerebral palsy. … meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity.2

However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.1”

Although intermittent fetal auscultation {IA} may be a theoretical option in low-risk patients, nursing staffing limitations makes this impractical … ”   

But in real life, the well-documented lack of evidence for the use c-EFM has made absolutely no difference when it come to the policies of hospital obstetrical units, as they continue to insist that low and moderate risk women must be hooked up to continuous fetal monitor for the entire length of their labors.

Continue to Part 2 (of 3) ~ The False Association  btw routine use of c-EFM) to prevent Cerebral Palsy in babies, pelvic floor damage in mothers & protect OBs from lawsuits

Originally posted June 2008, updates March 2019

Reference on ObGyn liability insurance:

C-section rate for first time mothers – 2017

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