Do Patients Benefit From Routine Electronic Fetal Monitoring?

FRANK H. BOEHM, M.D. Professor of Obstetrics and Gynecology, Vanderbilt       YES In today’s managed-care, cost-cutting environment, electronic fetal monitoring is a must. It is the cheapest and most feasible way to monitor fetal well-being during labor.   Studies show that intermittent auscultation with stringent evaluation of recording frequency is not feasible under normal labor and delivery-room conditions without one-on-one nursing care. But that is costly and rarely possible.   Studies also show that electronic fetal monitoring is associated with reduced neonatal seizure rates and lower perinatal mortality from hypoxia.   Anecdotally, fetal monitoring also saves lives. It can detect a heartbeat that suddenly drops to levels that require an immediate lifesaving cesarean. Intermittent auscultation misses that. Anecdotes don’t impress epidemiologists, but they’ve convinced doctors and nurses on the firing line that fetal monitoring is useful.   Most of the studies that show continuous monitoring no more beneficial than intermittent auscultation are flawed. Many were done with one-on-one nursing in the auscultation group. And interpretation of fetal monitoring was inconsistent. One study found electronic fetal monitoring did not prevent cases of cerebral palsy, but 90% of the time CP is from brain damage before labor and delivery, not during it.   Unfortunately, doctors don’t interpret fetal-monitor strips consistently. What is fetal distress to one doctor is not to the next. So the National Institute of Child Health and Human Development will soon publish hard-core definitions.   Another problem is the common concept that a fetus is either normal or in distress. But there is a middle ground for about 30% that requires no immediate action. Doctors need to learn not to overreact.

DAVID GRIMES, M.D. Professor and Vice-Chair, Department of Obstetrics and Gynecology, University of California, San Francisco; Chief, Ob-Gyn, San Francisco General Hospital       NO Studies show the only benefit of routine electronic fetal monitoring is to lower risks of neonatal seizures. These seizures are not desirable, but there’s no evidence they translate into a greater risk of cerebral palsy or other neurological impairments.   Yet fetal monitoring affects the mother by dramatically increasing her risk of having a cesarean delivery. This increases her mortality risk and gives her a more painful and longer recovery. Electronic fetal monitoring has saved babies’ lives. Balancing that are cases where it has cost mothers’ lives.   It leads us to practice a lower standard of obstetric care because the concerned maternity nurse has been replaced by an unthinking machine in the corner, spitting out paper.   Several studies show that a concerned person by the bedside makes labor less dysfunctional; women require less oxytocin and analgesia and have a lower cesarean rate. Nursing care is more expensive, but you get what you pay for.   When we use electronic fetal monitoring, we also tend to put women in inappropriate positions for labor. Women tend to labor more comfortably and efficiently in a semi-upright position or while walking around. But we commonly strap them on their backs with elaborate girdles so that the machine works better, not so the uterus works better.   Electronic fetal monitoring has a poor positive predictive value-false positives outweighing true positives. Among experts, the interpretation of fetal-monitoring strips isn’t consistent. Even perinatologists, with their advanced training in maternal and fetal medicine, don’t agree.   If perinatologists can’t agree on interpretations or on patient management based on tracings, I suspect there may be little hope for generalists like me.