By Laura Johnson Dahlke, MFA
Upon arrival and in the transition phase of labor, contractions coming strong and fast, I sat on the hospital bed—eyes closed. Rushes erupted in quick waves, and I had to remain focused to ride with the intensity. A few minutes later, on a break from the tightening sensations, I looked down to discover a continuous monitor (or what medical professionals call an electronic fetal monitor or EFM) that had been strapped around my bulging midsection. The belt, held together with Velcro, felt tight and uncomfortable. The nurses had lifted up my gown and without asking, put on the EFM. I managed to make eye contact with my husband and he understood what I wanted to say.
“We don’t want continuous monitoring. We’d like intermittent monitoring,” he said. “Take it off her.”
The nurses had many excuses, mostly about assuring my baby’s safety, but eventually, albeit reluctantly, removed the monitor.
This situation transpired despite the fact we discussed my preferences for unmediated childbirth several weeks before labor began. “Intermittent monitoring will be no problem,” my Ob/Gyn told me at one of my clinic appointments nearing the end of my pregnancy. Intermittent monitoring, versus continuous monitoring, provided me with the ability to move about freely and generally find any position that made me comfortable. This is usually done with a handheld doppler, like ones used at clinic visits, and I preferred the personal experience of human monitoring as opposed to being hooked up to a machine. My previous three drug-free births had been monitored this way.
My desire, while inconvenient to the hospital system, is based on sound evidence. EFM was introduced in the 1960s having never been studied before its widespread use. Now that this intervention has been appropriately investigated, large, randomized controlled studies have shown it doesn’t improve outcomes for babies. EFM has not reduced the rates of cerebral palsy (CP), the very thing it was implemented to do. In addition, it fails to improve APGAR (newborn health assessment) scores; admissions to the neonatal intensive care unit (NICU); length of time spent in the NICU; or prevent fetal death. In extraordinarily rare, high-risk cases, it can reduce neonatal seizures but otherwise is a poor tool to predict or identify much of anything. To summarize, in over a half century, EFM has been an experiment that has failed.
EFM does not reduce rates of CP or generally improve outcomes for babies. Let me repeat that. EFM does not reduce CP or generally improve outcomes for babies. I’ll say it once more. EFM does not reduce rates of CP or generally improve outcomes for babies. This bears repeating because it goes against the standard of care in nearly all US hospitals. Women are subjected to this intervention, often without their consent, despite its lack of improved outcomes, and falsely told it is in the best interest of their baby. This practice remains despite the fact that the American Congress of Obstetrics and Gynecology doesn’t endorse it for low-risk pregnancies and that for most women, EFM isn’t necessary or recommended.
What EFM does increase, however, is cesarean delivery (it also increases a mother’s risk of vacuum/forceps delivery and episiotomy). It is the second most common indication for a primary cesarean after arrest of labor. Continuous monitoring increases a woman’s chance of having a major abdominal surgery that comes with a two to four-fold greater risk of complications compared to vaginal birth. It is estimated by Ob/Gyn Neel Shah, MD, that the overuse of cesarean birth (currently at 33 percent, a 500 percent increase since the 1970s) results in about 20,000 major surgical complications annually such as hemorrhage, organ damage, infection and even death.
EFM has also been shown to increase the number of lawsuits filed against providers for cases of CP or other maladies. Some argue women wear EFM not to protect their babies against harm but to protect a doctor or midwife in court. Lawyer Thomas P. Sartwelle et. al say EFM is an “egregious failure,” and is “ineffectual, used without informed consent, and harmful to mothers and newborns alike.” MacLennan et al believe its readings should be inadmissible in court.
The time has come for expectant mothers to question routine EFM, especially for low-risk pregnancies which happens to be the vast majority of moms.
Because of a woman’s increased risk of cesarean section when EFM is used, I believe more laboring mothers should refuse it and request intermittent monitoring instead. In turn, healthcare professionals should be morally compelled, if not legally bound, to fully inform mothers of what the research says about EFM. Providers should tell women, before they arrive in labor, that EFM does not protect babies against cerebral palsy and that by wearing the device they are at an increased risk of having surgery and thereby more complications. Hospitals should promote evidence-based care and provide an environment where it can be accomplished.
Women—not hospital administrators, nurses, or providers—should have full autonomy in making medical decisions for themselves and must be given correct and current information about any intervention they may be exposed to during labor.
EFM is an intervention to be sure, and it is not without consequence.
Laura Johnson Dahlke, MFA, studied creative writing at Antioch University Los Angeles and also has an MA in English from The University of Nebraska at Omaha. Laura’s work appears in publications such as The Explicator, The McGraw-Hill Reader: Issues Across the Disciplines, Women’s Studies: An Interdisciplinary Journal, Hippocampus Magazine and Momaha.com. She lives in Omaha with her husband and four children.
Caughey, Aaron B., MD, PhD, Alison G. Cahill, MD, MSCI, Jeanne-Marie Guise, MD, MPH, and Dwight J. Rouse, MD, MSPH. “Safe Prevention of the Primary Cesarean Delivery.” America Journal of Obstetrics and Gynecology 210:3 (2014): 179-93.
Greene, Michael F. MD. “Obstetricians Still Await A Deus ex Machina.” The New England Journal of Medicine 355:21 (2006): 2247-48.
MacLennan, Alastair H., MD, Suzanna C. Thompson, MD, and Jozef Gecz, PhD. “Cerebral Palsy: Causes, Pathways, and the Role of Genetic Variants.” American Journal of Obstetrics and Gynecology Dec. (2015): 779-788.
Oster, Emily. Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—and What You Really Need to Know. London: Orion, 2013.
Sartwelle, Thomas P., James C. Johnston and Berna Arda. “Perpetuating Myths, Fables, and Fairy Tales: A Half Century of Electronic Fetal Monitoring,” The Surgery Journal 1.1 (2015): e28-e34.
Shah, Neel. MD “A Different Approach to Improving Childbirth” Maternal Health Task Force, Harvard School of Public Health Blog 9 Nov. 2015. Web. 14 April 2016. http://www.mhtf.org/2015/11/09/a-different-approach-to-improving-childbirth/