by Heidi Green
July 29, 2009

Electronic fetal monitoring (EFM) seems to make sense. Childbirth seems like a volatile time for both mother and child. While we can get a general sense how the mother is doing by looking at her, we don’t know how the child is doing until the moment of birth. By then (so goes the case for EFM) it may be too late to help the ailing baby.

That’s why 85 percent of childbirths occur with EFM in place. (Keep in mind that this may be an underestimate. The most recent year for which figures are available is 2002, but the data show a consistent upward trend since 1980, when fewer than half of births (45 percent) received EFM.)

Unfortunately, the popularity of electronic fetal monitoring really proves nothing. It doesn’t mean that it is necessary. It doesn’t mean that it prevents poor birth outcomes for the child. It doesn’t mean that it leads to positive outcomes for the mother, either.

In fact, the latest clinical management guidelines about the topic from the leading national medical organization of obstetricians and gynecologists (ACOG) recognize that the practice is highly controversial and may have serious consequences, including “increases [in] the rate of cesarean deliveries and operative vaginal deliveries.”

Background
EFM during labor looks not only at the fetal heart rate (FHR), but also variations that occur during uterine contractions, such as accelerations and decelerations in heart rate over time. Fetal heart rate (FHR) monitoring is used to determine “if a fetus is well oxygenated.” It may be performed externally or internally. Externally, a Doppler device is strapped to the laboring woman’s abdomen; internally, a spiral wire is typically twisted into the baby’s scalp.

EFM also collects data on uterine contractions, including the number of contractions present in a 10-minute period averaged over a 30-minute period. It also reports duration of contractions, intensity of contractions, and relaxation time between contractions.

Recommendations for EFM
In its new guidelines, ACOG is not calling for the abandonment of electronic fetal monitoring. Rather, they state that “when EFM is used during labor, the nurses or physicians should review it frequently. In a patient without complications, the FHR tracing should be reviewed approximately every 30 minutes in the first stage of labor and every 15 minutes during the second stage.” For a patient with complications “(e.g., fetal growth restriction, preeclampsia) [ACOG calls for EFM] approximately every 15 minutes in the first stage of labor and every 5 minutes during the second stage.”

Problems with EFM
The efficacy of EFM during labor “is judged by its ability to decrease complications, such as neonatal seizures, cerebral palsy, or fetal death, while minimizing the need for unnecessary obstetric interventions, such as operative vaginal delivery or cesarean delivery.” ACOG’s meta-analysis of EFM studies shows that the procedure fails miserably to meet these goals.

In fact:

• Compared with intermittent ausculation to check fetal heart rate, the use of EFM increased the overall cesarean delivery rate.

• The use of EFM also increased the risk of both vacuum and forceps operative vaginal delivery.

• The use of EFM did not reduce mortality for monitored babies.

• The use of EFM also did not reduce the risk of cerebral palsy.

• EFM was noted as reducing only one risk, that of neonatal seizures.

Do you need EFM?
Expectant parents, here’s my recommendation: Don’t wait until you’re in the labor and delivery room to discuss this topic with your health care provider. Find out your doctor’s perspective on intermittent monitoring versus EFM. Ask questions that give you an idea of how your provider is likely to handle this aspect of your labor care and how familiar they are with ACOG’s new guidelines.

Frankly, as one who has found activities such as walking, bouncing, and rocking to be critically important to my own comfort and the advancement of labor during childbirth, I’m not sure that I fully agree with ACOG’s tentative position on this topic. For example, the guidelines read that “when EFM is used during labor [it should be] review[ed] frequently,” even in patients “without complications.” Why should patients without complications be monitored frequently? What impact does such monitoring have on a woman’s ability to labor successfully, physically, and without undo intervention?

Anecdotally, when an external monitor slipped off of my abdomen during childbirth with my firstborn, the obstetrician ordered an internal monitor and required me to remain in bed for the remainder of labor. I didn’t know to question this decision; surely, I should have. Mine had been a healthy, low-risk pregnancy, and the FHR tracings that had been obtained up to that point gave no cause for concern. Staying in bed for the remainder of the labor was unpleasant, uncomfortable, and unnecessary.

As always, parents, we need to be informed… be aware… and be unafraid of asking questions.