Mayday, Mayday, Mayday! A Call to all Americans to fix a problem wasting millions of healthcare dollars & results in preventable maternal deaths ~ Part 1 of 2

by faithgibson on May 1, 2019

in Electronic Fetal Monitoring, OB Interventions: Dubious or Detrimental

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Chapter 1

A call to all Americans:

We need to fix a simple problem that wastes many millions of healthcare dollars every year on an ineffective technology that is very expensive and results in preventable maternal deaths from an artificial increase in Cesarean surgeries.

These needless tragedies for childbearing women and their families are a direct result of routinely use this technology on healthy women with normal low-risk pregnancies who do not need or benefit from it. Electronic fetal monitoring was originally developed and is  designed for use in very high-risk pregnancies; when applied to a healthy population of women with normal pregnancies, EFM not only does not provide any benefit but actually introduces harm.

For the last 50 years, manufactures of EFM have promoted their product as a dependably effective method to prevent cerebral palsy, newborn neurological disorders and also reduce the risk to hospitals and doctors of being sued. Unfortunately, EFM does not perform as advertised and its use is not neutral.

But the routine use of EFM over the last 5 decades has not reduced the CP rate all, not even by a teeny tiny 1/10th of 1 percent — zip, zero, zilch, nada! All that routine EFM does for women with low-risk pregnancies is to send their C-section rate through the roof. The second most frequent reason given for performing a C-section on a first-time mother is “non-reassuring fetal heart rate” as defined by the EFM strip.

In low-risk pregnancies, this intervention — EFM — is iatrogenic (detrimental), as its routine use is associated with a significant increase in Cesarean surgeries. This, in turn, increases maternal mortality due to complications during and after the surgery and in subsequent pregnancies. In post-cesarean pregnancies, there is an increase in the incidence of unexpected fetal demise due to placental abnormalities.

Ethical Contradictions for EFM manufactures and Hospitals

There is an ethical contradiction inherent in the current practice of obstetrics in the United States, a unique ethical dilemma that affects all Americans. It concerns all of us, even if we, or one of our own family members, is not expecting a baby any time soon.

What we are & what are NOT saying

This plea for common sense is not an indiscriminate rant about the obstetrical profession. No one, least of all me as a former labor and delivery room nurse for 15 years, is questioning the life-saving ability of modern obstetric medicine for women with high-risk pregnancies or those who develop serious complications during labor.

In fact, we all are uniformly grateful that skilled obstetricians and high-tech obstetrical services are readily available to those lives depend on such interventions.

But currently, the noble humanitarian goals of obstetrics are not being realized for the healthy 70 to 85% of the childbearing population. This is not an inconsequential issue, either in the number of families affected (approx. 3 million every year), the expense in scarce healthcare dollars, or the impacts on the lives of women, their babies, their families, and society.

In the United States, healthy low-risk laboring women are being subjected to the routine use of an obstetrical intervention that does not improve the outcomes for themselves or their babies when compared to the traditional method of routinely monitoring the well-being of a fetus during labor with either a special stethoscope (fetoscope) or a hand-held Doppler.

Rigorous scientific research has repeatedly documented that the low-tech, high-touch, one-on-one method known as auscultation is as effective an electronic monitoring machine, with the added benefits that auscultation does NOT increase the C-section ratewhile c-EFM does.

The facts are crystal clear — the routine use of continuous Electronic Fetal Monitoring (c-EFM) on healthy, low-risk women does not prevent cerebral palsy or similar neurological problems in newborns.

A pivotal Supreme Court ruling by Justice Brennen made a legal distinction that is helpful in understanding this issue. The ruling noted that it was illogical to treat two different things as if they were the same, and equally illogical is to treat two of the same things as if they were the different.

Based on this distinction, the current use of c-EFM is illogical, in that it treats two very different groups — generally, healthy childbearing women with normal low-risk pregnancies are being treated the same as women with high-risk pregnancies that put their fetus at high-risk.

Because c-EFM is appropriate in high-risk situation does NOT make it appropriate for women who are not suffering from these complications.

EFM is not the “Buckle-up for Safety” devise that its promoters claim

Hospitals and the obstetrical profession treat c-EFM as the central source of safety in childbirth, the way seat belts are seen as the universal answer to automobile safety. From this buckle up for safety perspective, the two EFM straps that go around the mother’s abdomen and plug into a computerized EFM machine is the obstetrical version of mothers-to-be wearing their seatbelt during labor. Just as we expect new parents to put their newborn in an infant car seat for the trip home from the hospital and buckle their own seat belts, we likewise see EFM belts as able to keep healthy baby safe during labor and birth.

But give the indisputable facts communicated in hundreds of studies and randomized controlled trials, the idea that 2 EFM straps encircling the pregnant abdomen of low-risk women ever minute of their labor is the height of craziness!

The facts are immutable and 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.

That hospital corporations and individual obstetricians believe continuous EFM will help to defend them in case of a malpractice suit also does not make its use appropriate, unless institutions or practitioners first obtain informed consent identifying the purpose of EFM as a risk-management strategy for protecting the hospital or birth attendant.

Laboring woman lying in bed while her unborn baby is being continuously monitored by EFM

C-EFM: The Crux of the Obstetrical Profession’s Ethical Dilemma

The crux of the ethical contradiction I referred to earlier is obstetrical profession’s practice of using an expensive technology designed to help the unborn babies of women with high risk pregnancies and applying this technology universally to women who are low-risk. While there are many health and safety aspect of this ethical dilemma, one the most important to society is an economic issue known “value added”.

The Economic Principle of Value Added

The economic principle of  ‘value-added’ describes paying an additional amount of money in order to get goods or services that are substantially BETTER (and definitely NOT worse) than it would been without the added goods or services.

Unfortunately for healthy women with normal low-risk pregnancies, c-EFM is value subtracted!

The logical step to take in this instance is to end all obstetrical protocols in American hospitals that make the universal use of c-EFM the standard of care for all laboring women, including the 70-80% of healthy women with normal, low-risk pregnancies. In the place of this ineffective and often harmful policy, this new standard calls for two major chances.

First, all healthy women with normal pregnancies need to be fully informed about the ineffectiveness of c-EFM when used on a low-risk population and the clear and present danger associated with the routine use of c-EFM due to an associated increase in the rate of Cesarean surgeries when c-EFM is used by the bedside and even greater increase in C-sections when central monitoring systems are used.

This preparation for fully-informed consent prior to the use of c-EFM must also identify the mother’s heightened expose to serious complications during and following Cesarean surgery, which includes an increased rate of serious morbidity (disability) and maternal mortality.

Here is an sample of this clear language published professional journal in 2011

“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 … ”

Fetal Heart Rate Monitoring Update; The Female Patient, April 2011

Secondly, full information must be provided to healthy childbearing women that identifies the routine use of auscultation as the appropriate standard of care for healthy women with normal low-risk pregnancies. Protocols for auscultation require one-on-one care as provided by an L&D nurse, midwife or physician throughout the active stages of labor and birth.

Auscultation ~ the conventional and scientifically-proven way to effectively monitor fetal wellbeing in low-risk pregnancies

Auscultation (also known as hands-on listening) is a non-continuous method used since the early 20th century to monitor fetal well-being (i.e. the verb, not the machine) during active labor.  A physician, midwife or L&D nurse uses a fetoscope or hand-held Doppler to regularly listens to the fetal heart rate and rhythm and record the information on the mother’s chart.

Studies on the efficacy of electronic fetal monitoring are always contrasted to the outcomes of auscultation. While the word ‘auscultation’ often does not appear in the same sentence as the study’s conclusion, nonetheless the comparison is always between EFM and auscultation, not between monitoring with EFM versus no monitoring

The Science-based Standard for Healthy Women with low-risk pregnancies is not EFM

Auscultation with a DeLee fetoscope

Hands-on auscultation is the “control” against which all studies on the efficacy and effectiveness is EFM is measured.  When reading studies that found no benefit to c-EFM, that finding validated auscultation as having equal or better outcomes.

Based on this scientific evidence, auscultation is the preferred standard of care during the active stages of labor for women with normal pregnancies. Auscultation, or ‘hands-on’ monitoring, is already is a routine part of the care provided by midwives and some family physician birth attendants.

Using a fetoscope or hand-held Doppler, the L&D nurse or other professional birth attendant regularly listens to the fetal heart every 30, 15 or 5 minutes, a frequency that depends on the stage of labor and baby’s response to long and strong contractions.

By counting the heart rate for one full minute (or longer, but never shorter), the ‘beats per minute’ heart rate (bpm) and its rhythm (regular, irregular, with or w/o accelerations and with or w/o decelerations) are identified and recorded on the mother’s labor chart.

Auscultation uses the same four parameters of information for determining fetal well-being first taught by Dr. Joseph DeLee in the 1920s and still used today for interpreting c-EFM strips.

The standard for fetal wellbeing is determined by the presence of:

    • a normal baseline
    • normal variability
    • normal accelerations
    • no pathological decelerations
  • The normalcy of the FH rate and rhythm  relative to these four factors is used to determine if a ‘reassuring’ pattern is, or isn’t, present.

This same auscultation criteria is consistent with the current systematic approach to interpreting the electronic fetal monitor tracing. In 2008, the National Institute of Child Health and Human Development (NICHHD) convened a workshop to revise the accepted definitions for electronic fetal monitor tracing and introduce a new classification scheme for decision-making with regard to EFM tracings. However, this on-going assessment model both reflects and applies to auscultation as well.

The NICHHD task force identified the key elements for assessing fetal wellbeing in EFM to be the same ones used in auscultation:

(1) baseline heart rate
(2) presence or absence of variability
(3) interpretation of periodic changes

This system also conforms to the Advanced Life Support in Obstetrics course mnemonic: DR C BRAVADO as a memory tool for the systematic interpretation of fetal monitoring data.

DR = Determine Risk, which refers to the ongoing assessment of both maternal and fetal risk factors each time the FHR is monitored. 

C = Maternal Contractions, the status of which is constantly factored into the birth attendant’s on-going determination of risk. For example, a modest FHR deceleration during a long, strong pushing contraction would be considered normal, whereas the same type of deceleration during latent labor would not be considered normal.   

Fetal monitor strip/FHR via auscultation: BRAVD
B = baseline rate, V = variability, A = accelerations, and D = decelerations

O = overall assessment and interpretation of fetal wellbeing (or lack thereof) 

Continued ~Chapter 1 ~ Part 2



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