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Monday
Jun062011

Whether beneficial or not

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By Jill Arnold

 

Here is the first and last paragraph of an editorial by a physician and consultant for Neoventa Medical in the current AJOG (June 2011).

 

First:

As an obstetrician, present at the dawn of intrapartum electronic fetal monitoring (EFM), I had every expectation that EFM would improve perinatal outcomes and that these effects would be validated by robust clinical trials. However, metaanalysis of the randomized controlled trials (RCTs) comparing EFM with fetal heart tone auscultation failed to show that EFM decreases the most adverse perinatal events, mortality and hypoxic neurologic injury. Whether taken individually or collectively, the published trials were simply not adequately powered for these tragic outcomes which, fortunately, are quite rare. Consequently, 4 decades after its introduction into intrapartum care, the benefits, if any, that may be attributable to EFM remain to be conclusively established.

EDIT 6/11/2011: Criticism was received that not enough of the original editorial was included in the post. Here are the next two paragraphs. 

This current situation makes the study by Chen et al, potentially quite important. First, its sheer size far exceeds the preceding RCTs in aggregate. Second, unlike the earlier RCTs, this study did find that EFM use was associated with significantly reduced rates of neonatal mortality and low Apgar scores. Third, the improved survivorship of preterm fetuses receiving EFM is noteworthy because most of the previous trials focused on term or near term infants. Fourth, fewer neonatal seizures were observed in the “high-risk” group who received EFM. Finally, like the previous RCTS, EFM was associated with increased rates of operative vaginal deliveries, and cesarean section for “fetal distress.”

The authors opine that these encouraging results reflect the ability of EFM to provide “accurate and early detection of fetal acidemia” and to encourage appropriate interventions. As a retrospective cohort study rather than a prospective clinical usage trial, a post hoc, propter hoc relationship between the use of EFM and the neonatal outcomes observed cannot be absolutely determined. One could also argue that Apgar scores and/or neonatal seizures may not be adequate surrogate markers for hypoxic neurologic injury, because they can stem from numerous causes other than intrapartum oxygen deprivation. Further, birth certificates as data sources have some significant limitations. Unlike complete medical records, they do not afford a glimpse into the actual fetal heart rate (FHR) tracings to determine whether they were properly interpreted or acted on. Other possibly relevant and important details of medical care and decision making that might have affected neonatal outcomes were not available to the investigators.

 

Last:

Returning to the central question implicit in this study, should every parturient, regardless of risk status, and with a pregnancy of any viable gestational age, receive continuous EFM? Chen et al do not have the definitive answer and neither do I. Given the enormity of undertaking the adequately powered RCT that should been done when EFM was introduced, it is unlikely that the desired level I evidence will be available any time soon. Even if such a study were considered, that is, comparing EFM with fetal heart tone auscultation, would there be sufficient bed side work force to make it feasible? Lacking this study, and if we provisionally accept the hypothesis that EFM does improve perinatal outcomes, then the obvious corollary is to address the more frequent, possibly excessive number of obstetric interventions that accompany EFM and place many mothers at risk. Whether such interventions can be made more appropriately by making our fetal monitors more “intelligent” or by using well-studied adjunctive screening methods, or both, it behooves all who care for laboring patients to encourage work on this side of the equation as the overwhelming majority of laboring patients will continue to receive EFM, beneficial or not, in the foreseeable future.

 

The editorial is online, so feel free to read and comment here.

 

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Reader Comments (30)

One step forward…two steps back. How maddening. I was checked routinely by a doppler and didn’t have to be moved from whatever position I was laboring in that felt best. If I was forced to labor in bed, hooked up to EFM, I can only imagine how quickly I would’ve been begging for pain medication and then sent down a road that often leads to a c-section.

June 6, 2011 | Unregistered CommenterJen

This is not the first article criticizing continuous EFM, but perhaps one of the most straightforward physician muttered words I've heard on the subject. In my lit review for my dissertation proposal I found that the research was overwhelmingly in favor of the judicious use of EFM for all labors regardless of risk level. In nearly all of the research that I came across, the cascade effect of interventions (usually ending in an unnecessarean) due to ambiguous readings coupled with the subjective nature of reading strips from EFM far outweighed the benefits in terms of reductions of infant morbidity and mortality.
Don't get me wrong, I firmly believe in the technologies that help to alleviate poor birth outcomes, but in this case, the data stands that EFM has a place, simply not in all labors and deliveries and certainly not to be used continuously. Just my 2cents and for anyone interested, I'd be more than happy to share many, many journal articles on the topic.

June 6, 2011 | Unregistered CommenterAlissa

What is there to say? Except maybe, dear doctors, when you continually choose your beloved interventions over our health, don't be surprised when we become not only defensive, but reluctant to use your services unless we have no other option. As far as I am concerned, you can place all the impetus for the rise in homebirths and especially unassisted births squarely in the hands of the medical profession and their insistence on using their machines that go "ping!" come hell, high water, or increased maternal mortality.

June 6, 2011 | Unregistered Commenteremjaybee

I fell victim to a C Section because the EFM malfuncioned, failed to show any heartbeat. The Obs reminded me later that 'it wasn´t worth taking chances'. My friend with a CP child said how lucky I was. I felt I had been cheated and mistreated. Could I have had a normal birth? I think so, it was my second child (first was a normal vaginal delivery) and I had an easy pregnancy. We will never know. Another statistic.

June 6, 2011 | Unregistered Commenterjengam

Emjaybee, couldn't have said it better!

June 6, 2011 | Unregistered CommenterAnne

Nice post, emjaybee!! While Big Obstetrics is busy shifting the blame for intervention-overkill onto women (we're obese, we're having babies when we're older, we frivolously sue doctors), maybe it's time for them to have a look in the mirror...

June 6, 2011 | Unregistered CommenterWendy

My husband and I had our first baby in the hospital and while I was laboring alone the baby's heartrate plummeted unbeknownst to us (or apparently anyone)...long story short, when the nurse finally came in to check the EFM strip and saw the decel, I was rushed in for an emergency CS. I delivered our son vaginally while being prepped but because of a fluke cord accident during my labor he suffered severe hypoxia and our little guy died the next day. I fully believe there was nothing that could have been done to save him, but EFM certainly didn't prevent the tragedy. And I do honestly wonder if a midwife with a Doppler, in constant attendance, might not have caught it sooner. (Our next baby was a high-tech hospital birth but the last two were amazings with some fabulous midwives in attendance.)

June 6, 2011 | Unregistered Commentermel

I'm a NCB supporter, a doula (in my before kids life), a homebirthing Mom and (gasp!) a L&D RN. I want the moms I care for to have the birth they desire. But above all, I want the baby to come out of their vagina. If that happens in the tub, wonderful. If that happens at home, awesome. If that happens with Pitocin and an epidural, great. So we watch and wait and let labor take it's course, but if I know that an intervention will make the difference between a section and a vaginal birth, you'd better believe I'll reccomend the intervention. Tonight I cared for a mom who had been actively laboring with ruptured membranes for 36 hours. She was 6cm and had been 6cm for 12 of those hours. She had an awesome doula and an awesome midwife and a fabulous partner. But she needed to relax and the baby needed to rotate. So she chose an epidural and five hours later pushed out her son. I don't think it would have worked out without the epidural. Do I think they are HIGHLY overused? Absolutely. But do they have a place? Definitely.

June 6, 2011 | Unregistered CommenterMaria

Mel, thanks for your comment. I'm so sorry for your loss.

June 7, 2011 | Registered CommenterJill

*amazing HOMEBIRTHS* I meant. =]

June 7, 2011 | Unregistered Commentermel
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