Does Electronic Fetal Monitoring Increase the Rate of Unnecessary Cesareans?
Monday, June 7, 2010 at 8:30PM
By Jill—Unnecesarean
Or perhaps the bigger question is whether Dr. Alex Friedman should prepare for an angry backlash for criticizing such precious tenets?
Dr. Friedman was interviewed for the June 7 Associated Press article, Overtreated: More medical care isn’t always better.
There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother’s abdomen fearing the worst, only to pull out a pink, screaming bundle.
“Everyone knows it’s a bad test,” said Friedman of the Hospital of the University of Pennsylvania. “You haven’t done the patient a big service by doing an unnecessary surgery.”
Electronic fetal monitors record changes in the baby’s heart rate, a possible sign of too little oxygen. They became a tradition — now used in 85 percent of births — years before research could prove how well they work.
Guidelines issued last summer, aiming to help doctors better interpret which tests are worrisome, acknowledge the monitors haven’t reduced deaths or cerebral palsy. But they do increase the chances of a C-section. While they should be used in high-risk women, the guidelines say the low-risk could fare as well if a nurse regularly checked the baby’s heart rate.
Later this year, the National Institutes of Health will begin a major study to see if adding a newer technology — a type of fetal EKG already used in Europe — to the heart-rate monitor would better identify which babies really are struggling and need rapid delivery.
On May 31, Dr. Friedman wrote an op-ed piece for the Philadephia Inquirer entitled, “Dangerous delivery shows peril of multiple C-sections”
The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.
More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.
At the same time, it’s becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.
[…]
Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut.
The surgery is simple: the surgeon cuts, spreads, and pokes, layer by layer, until reaching the baby. The surgeon first opens the skin a few centimeters above the pubic bone. The fat underneath easily gives way until the connecting fascia is reached. The tough, fibrous fascia, which holds the intestines in the abdomen, is cut at the midline and opened in either direction. The beefy abdominal muscles beneath are spread.
Finally, the glossy peritoneum, the last layer of the abdomen, is entered, and only the uterus lies between the doctor and the baby. In a term patient, the maroon, swollen uterus, flanked by finger-size veins, fills almost the whole abdomen, pushing the intestines up. The surgeon moves the bladder out of the way, cuts the lower uterus open, and is met by a baby’s foot, face, elbow, or behind, depending on how the baby is positioned.
The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm’s way the next time surgery is performed.
[…]
With a first cesarean, the up-front costs - a few more days in the hospital, a longer recovery - may seem reasonable. Only in retrospect can the true costs become apparent.
Good luck, Dr. Friedman.
More Friedman:
Beyond Medicine, a Doctor’s Urge to Save a Patient From Herself (December 12, 2006, New York Times). Friedman was criticized for his attitude toward female sterilization.
Wanted: Workaholics to Become Obstetricians (August 9,2005, New York Times)
Reader Comments (32)
Eeew, I didn't know about the layers...I mean, I knew they were effected, but not exactly like he described!! That's awful!
I am SO GLAD the continuous monitoring is being questioned. And that doctors are actually seeing pretty pink babies that proves the monitor wrong. I wish it didn't come to that...but I am glad SOME doctor somewhere is going, "This isn't a baby I should have taken out!"
I wish everyone who was thinking about cesarean as an easy alternative to vaginal birth would read that description of the surgery- it's chilling to me!!! If that doesn't scare you... then you might have seen too many horror movies.
I've thought a lot about this, since I am preparing for a VBAC this summer and CFM is often recommended as a "good" way of detecting UR. If it has high sensitivity but low specificity, I wonder how it could be improved. Like, if a laboring woman had sudden scar pain, could EFM be helpful as a back-up method? Or if there was no scar pain but the fetal monitor showed distress, could it be confirmed by auscultation with a fetoscope? And what about the fetal EKG noted in the AP publication?
Presumably, a lot of normal babies have heart decelerations and such, but no one ever looked for it using this method until the past couple of decades, so distress is probably the wrong word anyway. I had a previous vaginal delivery in which my son was "in distress" per the monitor for a short period of time, so I was asked to lie on my left side while wearing an oxygen mask. He was perfectly fine when born. Luckily, it happened close to "pushin' time" so no one suggested a C-section. I was a FTM, and it was a long labor, so I might have given up if scare tactics were applied and then been very angry to find out he was actually fine in there.
The cesarean section and electronic fetal monitoring (overtreatment) are THE safety net of U.S. maternity care. It's what is drilled into medical students and is now accepted on a societal level as women's safety net. They can be, of course, but not to the extent to which they are utilized, which was Friedman's point in the AP interview.
I'm ready to watch the predicatble missiles to be fired back from people who do not want this mythology challenged. Should be interesting.
I am so totally rooting for this guy, I really am. He's local to me, too, maybe I'll send him some lunch!
Interesting what Jill said about Cesarean section as a safety net. When I could not get my previous provider to perform a vaginal breech delivery, he told me it was because if my baby got stuck with body delivered and head still inside, a C-section would be "impossible" at that time, and my baby would die and that "OBs don't do any procedure in which they can't fall back on a C-section." I kind of wondered if it was even true that he could not attempt a C-section at that point.
Heck, I had worsening decels throughout labor AND an occult prolapse AND my baby was born -- vaginally -- healthy and pink. The OB reduced the prolapse and did an antepartum cordotomy, and my daughter's Apgar's were 9/9. I will be grateful to the end of my days that the hospital didn't hustle me off to a C-section.
Wow Kathryn, what an amazing OB! I hope you filled out the Birth Survey for him/her!
"With a first cesarean, the up-front costs - a few more days in the hospital, a longer recovery - may seem reasonable. Only in retrospect can the true costs become apparent."
So true. If the decision to perform a primary cesarean only resulted in a primary cesarean, it wouldn't be so bad (at least the risk would be manageable). But when a primary cesarean usually means 2, 3, even 4 more subsequent surgeries, each time increasing risk, well...that's what made me a VBACtivist.
Yes, it will probably only be a matter of time before this doctor gets some serious crap from his "colleagues" at ACOG. I read the article and almost peed my pants when I read the portion about maternity care. It's not often you see an MD openly talking about the problems in maternity care. At least, not a doctor which ACOG doesn't write off as a crunchy crackpot or something.
I was pre-med in college and during my stint shadowing physicians, I saw (up close and personal) two c-sections while they were being preformed. They let me scrub in to the surgery room and stand at the side of the surgical table. I tell you, watching those two c-sections pretty much cured me for life of ever, ever, ever wanting one unless absolutely necessary. The layers thing is what got me, too. They had to cut through so many layers to get to the baby, then stitch each one back up. It took a really long time and looked horrendous and painful afterwards when they stapled the mom closed. One of the moms was asleep from the pre-surgery sedative and missed the birth. I just remember thinking, "NO thanks!" The medical community makes it sound like all women have a zipper across their abdomens and you just unzip it, get the baby, and zip it shut again. Nothing could be farther from the truth.
Foxy.Kate - from all I know about birth, what the doctor said is true. Babies *can* be wedged into the vagina and need to be pushed back out of the pelvis, but once half the baby is out, it would probably kill the baby if they tried to grab one half and shove the other. There is a maneuver called Zavanelli's Maneuver (http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm) - is the last ditch effort to get a live baby out during a shoulder dystocia, but can only be done at the same time as a crash cesarean. I have never heard of anyone using Zavanelli's M. during an impacted breech delivery.
Question (and perhaps it should go somewhere else): Why don't docs do a scalp PH before every cesarean? Why isn't there a PH machine in every single labor room? I understand the membranes need to be ruptured and it can be somewhat invasive, but compared to the invasiveness of a cesarean, I'd choose the scalp PH all day long. I know I can't be the only one wondering this. I will tell you, unless someone can show me why NOT, I am encouraging my clients to insist on it before an "emergency" cesarean (versus a crash section). Thoughts?
NavelgazingMidwife, I'm not sure if this is the same as what you are saying, but my third child did get stuck with her body out and her head in. She had turned to footling breech (both feet down!) in the middle of the night before her birth, and then was born in a 45 minute labor that included cord prolapse and getting stuck with only her head and shoulders inside. The paramedic who assisted in her delivery reached in with both hands and carefully pulled her out. It hurt like hell, but obviously a c-section was not an option in my bedroom. Her only real injury was a minor stretched nerve that healed on its own in a few days, and I didn't have so much as a tear.
I have a question. Is a pink and healthy baby a sure sign that a c-section was unnecessary? My youngest was born by c-section due to distress. I do not know what his Apgar scores were, but I assumed that he would only be in poor condition if we waited too long for the c-section. Is that not correct?
The only thing that I wish he addressed in his article was unnecessary inductions and overuse/misuse of Pit that can cause those 'unreassuring heart tones' that cause "bad strips." But then again, that would be TWO big cans of worms to open instead of just one ...
NM, isn't not breaking the water too soon a big deal? As in it speeds up labor, perhaps helping baby get stuck? And introduces infection risk, of course. And keeps mom tethered. All of which seem like big turnoffs to me.
"Is a pink and healthy baby a sure sign that a c-section was unnecessary?"
It seems to me that if the fetal monitoring indicated distress/decelerations, and the C-section happened some number of minutes later )sometimes a lot of minutes) and the baby looked great, then how severe could the distress have been? It must have been temporary at best, and wouldn't it be gone already if the mother were still in the delivery suite and not the OR? I am just speculating here, though.
While I was pregnant I read a couple of studies that concluded that fetal monitoring didn't reduce deaths or complications and it increases c-section rates, so I initially turned down the monitor that was offered, mostly because I didn't want to be stuck in bed. You should have seen the eyerolling this produced. I allowed them to strap it on later, when I was in the mood to sit on the bed anyway, and I think the strong steady heartbeat they could hear helped support my rejection of any interventions offered. So maybe it can go both ways.
Also, I've heard that the fetal monitor may be more of a problem for those going the epidural-pit route because the mother's adrenaline level is not heightened as it would normally be, so the baby's oxygen levels aren't raised by the adrenaline, etc. and it results in a more scary monitor reading. But I don't remember off the top of my head where I read this, so I can't vouch for the accuracy of this account.
The EFM belts may cause unnecessary sections, but they do pick up info that can be used in a court of law to win millions in damages for failure to diagnose fetal distress and failure to act in a timely manner. I'm too old at this point to believe that the push to discard EFM is entirely to prevent cesareans. With all of the issues surrounding defensive medicine, it is likely that one of the aims is to reduce monitoring which helps families win lawsuits. No EFM strip, less hard evidence of negligence. Just sayin'
"...I think the strong steady heartbeat they could hear helped support my rejection of any interventions offered. So maybe it can go both ways." (Rachel_in_WY)
"With all of the issues surrounding defensive medicine, it is likely that one of the aims is to reduce monitoring which helps families win lawsuits. No EFM strip, less hard evidence of negligence. Just sayin'" (Sherry)
Very interesting comments. I'd never thought of it that way.
The evidence showing that EFM does nothing but increase incident of c/s has been out there for a while -
However, jurys do not know this and the lawyers leave this oh so small point out of their arguments..........
eastcoastmama- The meta-analysis on it (Prentice, Lind) was published in 1987, which was right near the first big peak in the national c/s rate. Graph