False assumptions about continuous EFM & liberal use of Cesarean surgery

by faithgibson on June 15, 2013

in Cesarean Politics, Contemporary Childbirth Politics, Economic Issue$

Scientifically documenting the common but false associations between:

  • the routine continuous use of electronic fetal monitoring (EFM) as a strategy to prevent Cerebral Palsy & other neurological damage in newborns and
  • high rates of Cesarean Section as a method to prevent pelvic problems and incontinence in childbearing women 

by faith gibson — all rights reserved June 2008


[a) Am. College of Obstetrician & Gynecologists (ACOG) Task Force on Neonatal Encephalopathy & Cerebral Palsy, 2003
 September 15, 2003 edition of Ob.Gyn.News;  [c] and August 15, 2002 report in Ob.Gyn.News

[c] “EFM as a Public Health Screening Program: The Arithmetic of Failure”  by Dr David Grimes; VOL. 116, NO. 6, DECEMBER 2010 OBSTETRICS & GYNECOLOGY

There is a strong but wrong assumption in the US that normal birth is dangerous for babies and damaging to the pelvis floor of childbearing women. As a result, most Americans equate safety in childbirth to the routine use of EFM, which is assumed to save the unborn babies from brain damage and a C-Section to save the mother from ‘female troubles’.

Almost everyone, from the lay public to the government policy makers, believes that anything less than the current aggressive use of technology and obstetrical interventions is thought of as foolish and irresponsible if requested by the childbearing family and medical malpractice if offered by an obstetrician or other medically-trained birth attendant.

We must ask — are such conclusions born out by the scientific literature? Does research identify EFM and liberal use of Cesarean surgery as able to eliminate or substantially reduces neurological problems in newborns and maternal pelvic dysfunction or incontinence?

Nobody wants babies to be born with preventable neurological disabilities or for mothers to become incontinent as a result of childbirth. The big question is whether or not elective Cesarean surgery a reliable method to prevent problems sometimes associated with childbearing?

Interestingly enough, the obstetrical profession’s research says “no” to both of these proposed fixes. More specifically, research also identifies that many routine obstetrical practices actually make matters worse.

The History and Economics of Electronic Fetal Monitoring:

Since 1975 there has been a 6-fold increase in the routine use of EFM on low-risk mothers. This reflects the obstetrical profession’s century-long search for something that would dependably eliminate cerebral palsy and other neurological problems for babies associated with birth.

Obstetricians hoped and fervently believed the expanded use of EFM, combined with cesarean section whenever the data indicated a possible problem, was the modern answer to an ancient and heartbreaking problem.

EFM is now the most frequently used medical procedure in the US – official estimates are that 85 to 93 percent of all childbearing women are continuously hooked up to continuous EFM equipment during labor. [citation Listening to Mothers Survey 2002 & 2006; Martin et al 2003]

Many health insurance carriers reimburse hospitals $400 an hour for continuous electronic monitoring in labor. How is this economic incentive contributing to the nearly universal policy of EFM as a routine procedure for health women with normal labor?

I must point out that the consensus of the scientific literature has never supported the routine use EFM for this purpose.

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 did identify a decided increase in Cesarean section rates and operative deliveries. Its only positive finding was a small reduction in neonatal seizures, but this doesn’t seem to result in any over-all improvement in infant well being.

Another recent study noted that the ability of continuous EFM to detected 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 EFM during labor.

Only about 8% of all neurological complications for newborns have any possible association with events of labor or birth.

When EFM is routinely used on a low and moderate risk population with normal pregnancies, it introduces unnatural and unnecessary risks. In spite of these well-known problems, the universal use of EFM during normal labor has continued unabated and resulted in a sky-rocketing Cesareans section rate that is not associated with better outcomes. Unfortunately, the delayed and downstream complications associated with the liberal use of Cesarean surgery makes this policy counterproductive in the extreme.

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”. [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.

Additional tools and techniques must be used to determine the significance of any abnormal data. Those 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 as to proper guidelines for their use and the validity of the information they provide. “When in doubt, cut it out” is still the operative obstetrical motto.

In 2003, 1.2 million Cesarean surgeries were performed in the US (27.5% cesarean rate) at a cost of $14.6 billion. Rounded off to whole numbers, the Cesarean rate for 2014 was 33%. It’s predicted to be over 50% by the beginning of the next decade. And yet, the public and the press never seem to question the unproven notion that normal childbirth is somehow made safer and better by turning it into an expensive and risky operation.

Yet this policy of ‘pre-emptive strike’ has not made the tiniest bit of difference in the incidence of CP and similar neurological conditions. This verifiable fact is now gratefully used in malpractice cases in the defense of obstetricians. Otherwise, these well-recognized facts have made no difference in the continuous use of EFM on low and moderate risk mothers-to-be.

A failed experiment — the routine use of continuous EFM: Thirty years of continuous electronic fetal monitoring of all laboring women, combined with the liberal use of cesarean section at the slightest suspicion of fetal distress, has failed to reduce the rate of cerebral palsy and other neurological disabilities. This well-documented fact is widely acknowledged in the scientific world. In July of 2003, a report by the American College of Obstetrician and Gynecologists (ACOG) Task Force on Neonatal Encephalopathy & Cerebral Palsy 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.” [emphasis added]

This ACOG task force report has the endorsement of 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”.

The September 15, 2003 edition of Ob.Gyn.News stated that:

“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 [cerebral palsy] 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].

The idea that infection might play an important role in [CP] development evolved over the years as it became apparent that in most cases the condition cannot be linked with the birth process.  ” [emphasis added]

An August 15, 2002 report in Ob.Gyn.News stated that:

“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, professor and vice chair of ob.gyn at the University of Texas, Galveston.

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.” [emphasis added]

*Placenta accreta is when the placenta grows abnormally into the uterus; ‘percreta’ is when it grows through the uterine wall and attaches to the bladder or bowel.

These are life threatening complications that frequently require an emergency hysterectomy to stop the bleeding. Percreta has a 7 to 10% maternal mortality rate.

Link to  “EFM as a Public Health Screening Program: The Arithmetic of Failure
~ by Dr David Grimes

Electronic fetal monitoring has failed as a public health screening program.
Nevertheless, most of the four million low-risk women giving birth in the United States
each year continue to undergo this screening.

faith gibson — all rights reserved June 2008

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