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Does Electronic Fetal Monitoring Increase the Rate of Unnecessary Cesareans?

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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)


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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!"

June 8, 2010 | Unregistered CommenterMaegan

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.

June 8, 2010 | Unregistered CommenterSara

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.

June 8, 2010 | Unregistered CommenterKK

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.

June 8, 2010 | Registered CommenterJill

I am so totally rooting for this guy, I really am. He's local to me, too, maybe I'll send him some lunch!

June 8, 2010 | Unregistered Commenterfoxy.kate

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.

June 8, 2010 | Unregistered CommenterKK

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.

June 8, 2010 | Unregistered CommenterKathryn T.

Wow Kathryn, what an amazing OB! I hope you filled out the Birth Survey for him/her!

June 8, 2010 | Unregistered CommenterVanessa Manz

"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.

June 8, 2010 | Unregistered CommenterHeather

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.

June 8, 2010 | Unregistered CommenterAugusta
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