Part 2 — (a) Efficacy; (b) Barriers to Laboring Woman’s Informed Consent
EFFICACY OF EFM
In 2004, 28,014 neonates died, reflecting 0.68% of all U.S. births that year (U.S. Department of Health and Human Services [USDHHS], 2004).
Chen et al. (2011) compared EFM to no EFM in labor using data from U.S. birth certificates from 2004. **
{**Editor’s note: Birth certificate data in the US does not record any information about methods for monitoring the fetal heart rate except for EFM. There is no way to know if these babies had any monitoring via auscultation or if they delivered precipitously without the usual care during labor. }
The primary finding was that EFM during labor significantly lowered early neonatal (within the first 6 days of birth) and infant mortality (deaths within the first year) (RR 0.50, p < .001), with the greatest benefit observed in preterm births: 24–27 weeks’ gestation (128.1 vs. 207.7, p < .001); 28–31 weeks’ gestation (14.9 vs. 28.6, p < .001); 32–33 weeks’ gestation (2.4 vs. 6.3, p = .001); and 34–36 weeks’ gestation (0.5 vs. 1.3, p < .001).
There was no benefit of EFM on newborn mortality in the late neonatal period (7–27 days after birth) (0.5 vs. 0.6, p = .402) and postneonatal period (28–364 days after birth) (1.7 vs. 1.8, p = .296).
Although continuous EFM did have a beneficial effect on preventing neonatal mortality in preterm births, the benefit decreased as the fetus got closer to a term birth.
In the same study, Chen et al. (2011) reported a very small benefit to newborns born ≥37 weeks if EFM was used (0.2 vs. 0.3, p < .001); however, this category reflected a wide range of gestational ages from 37 to 44 weeks. Data from the National Vital Statistics System obtained for this study are categorized as follows: 37–39 weeks, 40 weeks, 41 weeks, and 42 weeks or more (USDHHS, 2004).
By grouping all newborns born after 37 weeks into one category, 7.1% of the newborns included in this one category were postterm (USDHHS, 2004). This finding is consistent with previous reports which reflect 7% of all U.S. births as postterm (Martin et al., 2003).
Postterm birth is associated with increased perinatal mortality (stillbirths and early neonatal deaths), which is twice that of term births, and increases sixfold and higher at 43 weeks of gestation or beyond (ACOG, 2004).
Because this study did not have separate categories for term (38–42 weeks) and postterm births (42–44 weeks), and there was lack of clarity of whether the data represented completed weeks of gestation, Chen et al.’s study (2011) cannot suggest that EFM has reduced the incidence of early neonatal mortality and morbidity in healthy women with uncomplicated pregnancies at term.
BARRIERS TO INFORMED CHOICE
Knowing what is known, consumers have to wonder why EFM is a standard of care for healthy women with uncomplicated pregnancies. In addition to the initial cost of purchasing an EFM machine, there are the hidden costs of EFM when it is overused.
It costs money to keep nurses and doctors certified to read EFM strips, maintain EFM machines, buy the supplies that go with EFM machines, store EFM strips, and pay for the increased costs of electricity to continuously operate the EFM machines; and if documentation is not done well, or is inaccurate, it sets the hospital and staff up for possible malpractice (Romano & Lothian, 2008). Spending money is warranted if it improves outcomes, but in healthy women with low-risk pregnancies, money is being spent on EFM, and outcomes are worsening.
Malpractice
Fear of litigation is often mentioned as a reason for EFM (Chalmers et al., 2009; Lewis & Rowe, 2004); however, in reality, obstetric malpractice claims have risen as cesarean surgeries have gone up (Clark, Belfort, Byrum, Meyers, & Perlin, 2008).
When detailed and highly specific protocols with effective peer review were initiated at the Hospital Corporation of America, cesarean surgeries fell and malpractice claims plummeted (Clark et al., 2008). Murray and Huelsmann (2007) reported that common areas for litigation involve claims related to oxytocin (Pitocin) misuse that led to perinatal death and injury.
Kesselheim et al. (2010) evaluated malpractice claims of infants with neurological impairment who had a non-reassuring FHR pattern during labor. Pregnancies where the laboring woman reported prenatal vaginal bleeding (p = .004, OR = 27.1), a long labor during the first stage (p = .030, OR = 4.0), or minimal variability on EFM in the first stage (p = .020, OR = 4.3) were more likely to have an infant with neurological complications when compared to fetuses with nonreassuring patterns who were born healthy.
When those caring for pregnant women express concern about malpractice, one has to evaluate what the evidence shows, and then use this information as an opportunity to change the way care is provided. Women who present in labor with a history of prenatal bleeding, or have a very long labor during the first stage, or minimal variability on EFM during the first stage of labor, need special attention—not to avoid malpractice but to have a healthy baby and mother.
Institutional Barriers
Nurses want to provide optimal care during labor but feel that birth today is hastened and controlled, which leads to medical interventions that are not necessary (Sleutel et al., 2007).
Nurses, physicians, administrators, and patients are viewed by nurses as all contributing toward a culture where the focus is on the technology, and the patient is forgotten (Sleutel et al., 2007).
A facility culture that supports implementing evidence-based change is more likely to institute IA policies for healthy women with uncomplicated pregnancies than one that doesn’t (Graham et al., 2004; Sleutel et al., 2007).
Although change can occur from the administration, change is more likely to be implemented if nursing staff have input into creating and supporting the change prior to the initiation of the new policy (Graham et al., 2004). Nursing leadership also needs to get the support of obstetricians and the anesthesiology department if the guidelines are to be endorsed as a unit policy (Graham et al., 2004).
In one of the hospitals identified in Graham et al.’s (2004) study, change occurred as a direct response to consumer pressure for IA.
Although the policy changed at the three hospitals identified in Graham et al.’s (2004) study, additional barriers were identified by nurses that prevented the IA policy from being fully embraced.
The barriers included lack of dopplers; concerns about the legal ramification if no paper strip was present; anesthesiology wanting EFM on women receiving epidurals (although this practice was eventually changed at one of the hospitals);
- auscultation skills and labor support had to be learned or relearned;
- a 1:1 nurse-to-patient staffing ratio was not always maintained;
- nurses liked central monitoring to chart and monitor the FHR from outside the labor room;
- nurses trusted EFM, and felt it provided security;
- and women who had previously received EFM viewed the technology as providing them with quality care (Graham et al., 2004).
Nurses
Midwives make a decision to use EFM at two critical times: the initial assessment (which is ineffective in improving neonatal outcomes in healthy women with uncomplicated pregnancies [Devane, Lalor, Daly, McGuire, & Smith, 2012]) and when the midwife categorizes the woman as high-risk or low-risk based on the midwife’s personal clinical risk schema and not evidenced-based clinical guidelines (Rattray et al., 2011).
The way a nurse views childbirth influences cesarean surgery rates (Regan & Liaschenko, 2007), and could influence the adherence to IA protocols.
In Regan and Liaschenko’s study (2007), three cognitive frameworks of childbirth were identified:
- birth as a natural process;
- birth as a lurking risk;
- and birth as a risky process.
Nurses who viewed birth as a natural physiologic process supported the laboring woman as a “credible knower” who was competent to perform birth. The role of the nurse was as an expert guide. Nurses with this cognitive frame of reference viewed the laboring woman and fetus as an inseparable whole.
Nurses who viewed birth as a lurking risk believed that the nurses were the expert knowers, not the laboring woman.
And the nurses who viewed birth as risky viewed the fetus as the focus of care, and the birth process as inevitably filled with risk. The nurses who viewed birth as risky were more likely to use EFM continuously, and to offer epidurals. The authors hypothesized that for the nurses who viewed birth as risky, cesarean surgeries would be higher.
Translating theory into practice is a challenge, with many midwives being supportive of IA, yet feeling powerless to go against a system favoring an interventionist approach in childbirth (Hindley & Thomson, 2005).
Barriers to informed choice include a midwife’s belief that technology enhanced her professional status and was of higher value than her intuitive knowledge and skills; the labor unit being too busy to have conversations about EFM; and fear of litigation (Hindley & Thomson, 2005; Lewis & Rowe, 2004).
Childbirth Education
Childbirth education, like birth in the United States, is now predominantly conducted in hospital settings and not in the home (DeVries & DeVries, 2007). This shift from the home to the hospital has contributed to childbirth educators being employed by hospitals, thereby setting up a potential conflict of interest and ethical distress (Ondeck, 2009).
Although the Code of Ethics for Childbirth Educators expects childbirth educators to promote normal physiologic birth (Lamaze International, 2006), many pregnant women are instead being acculturated to hospital routines and policies, including EFM, during childbirth education classes.
Nurses who viewed birth as a natural physiologic process supported the laboring woman as a “credible knower” who was competent to perform birth.
One of the goals of Healthy People 2020 is to increase the proportion of women attending childbirth classes (USDHHS, 2011). In the Listening to Mothers Survey II, the percentage of first-time mothers attending childbirth classes was about 56%, and 9% for experienced mothers (Lothian, 2007a). These figures are nowhere near the greater than 90% goal a previous Healthy People strove for.
To assess if mothers who had attended childbirth classes had increased knowledge to make informed decisions, Lothian (2007a)analyzed the data from the Listening to Mothers II survey and compared the different groups of mothers. Almost all of the mothers, including the mothers who had never attended a childbirth class, wanted to know the risks associated with cesarean surgeries, epidurals, and inductions that have become routine in childbirth.
In addition, most women, even the women who had attended childbirth classes, did not know the complications associated with induction of labor or cesarean surgeries. This data strongly suggests that the way childbearing women are currently being educated is not working and that women may not have the necessary information to give informed consent.
INFORMED CHOICE
Informed choice was perceived as being highest for a blood test to screen for Down syndrome (75%, p < .001) and lowest for EFM (31%, p < .001; O’Cathain et al., 2002). Although midwifery practice places value in advocating for women and babies and providing informed choice, the reality is that women in labor choose what the midwife thinks is best, which isn’t always based on evidence (Hindley & Thomson, 2005).
Using the theoretical framework of Barrett’s Theory of Power (Barrett, 1990), a laboring woman cannot give informed consent for fetal monitoring without first making an informed choice. An informed choice occurs after the woman has been made aware of her evidenced-based options.
The role of the nurse is to enhance the power of the laboring woman by thoroughly responding to questions related to fetal monitoring while at the same time demystifying the benefits of EFM in pregnancies that are low risk. The nurse supports the woman’s decision regarding the type of fetal monitoring chosen without having a vested interest in what the woman freely chooses.
Creating a culture of safety starts during the prenatal period and requires childbirth educators and maternity nurses to recognize the power within each woman to make an informed choice based on evidence.
Discussions about fetal monitoring ideally need to take place prior to the onset of labor, with the understanding that if the woman’s condition changes, ongoing discussions need to take place; knowledge through education is thought to empower women.
However, in Machin and Scamell’s (1997) study, women who entered the labor unit wanting a nonmedicalized birth ended up feeling disempowered and dissatisfied with their birth experience, which was a different outcome from the women who were willing to go along with the medical system culture. In the end, regardless of what the women wanted for their personal labor and birth experience, the final outcome for all of the women in this study was the same: Personal autonomy was relinquished to the dominant medical culture, with the full participation of nursing (Machin & Scamell, 1997).
PUTTING THEORY INTO PRACTICE
Childbirth educators want pregnant women to make an informed choice based on evidence, and at the same time, want to support a woman regardless of her decision. Unlike 30 years ago, women now have access to books, videos, and online media to tell them about the birth process. As a result, many pregnant women arrive to childbirth classes already having made decisions about what they want for their birth experience.
The way information is conveyed during childbirth classes needs to be evaluated because information overload has been reported. Lothian (2007b) suggests that childbirth education classes need to have less content focused on hospital policies and the different stages and phases of labor.
In its place, Lothian recommends more emphasis be placed on practical ways of having an easier and less complicated birth. Lothian suggests storytelling as a way of sharing information.
Examples of laboring women having more mobility and control when Auscultation is used can be shared during group discussions. James (2010) and Abe (2010) advocate childbirth classes being a forum to practice making informed choices through role playing.
Pregnant women and their partners can learn during a class how to advocate for IA instead of EFM, so that the words and the scenarios have been rehearsed prior to being in labor.
To provide content that is evidenced-based and not viewed as biased, Tumblin (2007) has integrated the word “choice” throughout every childbirth class. Tumblin also reported that prior to her class on interventions, she has each class member choose an intervention and research the topic. Using this teaching strategy, the class member who selects EFM would then lead the group in a discussion by being knowledgeable in the risks and benefits of EFM and IA.
This teaching strategy changes the dynamics of childbirth education by shifting the locus of control onto the pregnant woman. Opportunities to teach also provide a venue for the group to share thoughts and feelings regarding EFM and IA, and to own the knowledge (Nolan, 2009).
Regardless of which teaching strategy is used, the most important ingredient for success is to keep the pregnant woman and her partner as the focus. Nolan (2009) believes a childbirth education class should be based on what women most want to learn, not a routine curriculum format.
This strategy is also supported by James (2010) who recommends contacting group members before the first class, and midway through the course, to see what they are interested in learning more about. Using some of these strategies provides an opportunity for pregnant women and their partners to learn how to communicate their needs (Nolan, 2009).
IMPLICATIONS FOR PRACTICE
The overarching goal of childbirth education is to have a healthy birth. Childbirth practices should not constitute a one-size-fits-all approach. Nurses and childbirth educators need to focus their attention on the patient, and not a machine.
The indiscriminate use of EFM in the labor room is not improving outcomes and is actually causing harm to healthy women with uncomplicated pregnancies. Employing a low-tech, high-touch approach needs to be the main philosophy while providing nursing care to most laboring women.
Creating a culture of safety starts during the prenatal period and requires childbirth educators and maternity nurses to recognize the power within each woman to make an informed choice based on evidence. Childbirth classes envisioned in a new light provide an educational forum for pregnant women and their partners to learn how to communicate their needs, share their wisdom, and develop skills of advocacy so that a healthy birth can be achieved.
LISA HEELAN is a Robert Wood Johnson New Jersey Nurse Scholar and a PhD nursing student at Seton Hall University.
