Obstetrics' Dark Underbelly: Electronic Fetal Monitoring in Labor Fails to Help
March 01, 2017
I am the mother of four children and married to a perinatologist (high-risk obstetrician). Together, we share a passion for childbirth and for staying up-to-date on what works best in labor. Because we know what the evidence says about using continuous electronic fetal monitoring in labor (EFM), we’ve chosen to avoid it completely for our own children’s deliveries. While inconvenient to the hospital system, I encourage all expectant mothers to consider refusing constant monitoring and to request intermittent monitoring instead.In order to achieve this goal, we made several choices that aided our desire. First, and when available, take advantage of using alternative birthing environments. I had my children in three different states, so I didn’t always have options, but when I did, I gave birth at a free standing birth center and an alternative space within a hospital. EFM is generally not used in these settings, which makes intermittent monitoring the default. Second, hire the appropriate care provider. I sought out midwifery care because they typically use intermittent monitoring instead of EFM, even in the hospital setting. In addition to this, employ a doula to help you navigate both the labor and hospital system. She can not only improve your chances of having a positive, vaginal delivery but also make your desire for intermittent monitoring known and help mitigate this request to hospital staff.Third, if these things are not available or reasonable for you, be sure to confirm the use of intermittent monitoring at your clinic visits. If your provider is not eager to accommodate this request, switch to someone else. Finally, fill out a birth plan that clearly states your desire for intermittent monitoring and give it to your doctor, both at the clinic and upon arrival in labor. Some hospitals might “require” EFM, but you always have the option of saying, “No!” to this and any other intervention. Refusing EFM can be contentious, so be prepared by having your support person advocate for you. The expectant mother should avoid negotiating this for herself so she can concentrate on laboring.Here’s why we said, “No!” to EFM:1 | Wearing EFM will not protect your baby. Large, randomized controlled studies have shown its use does not improve APGAR scores (newborn health assessment), admission to a neonatal intensive care unit (NICU), the length of time spent in a NICU or prevent fetal death. It can reduce the extraordinarily rare incidence of infant seizure, but otherwise, it fails to help2| EFM does not reduce rates of cerebral palsy (CP), the very thing it was implemented to do over 50 years ago. The levels are the same today as they were before widespread EFM use.
3 | The American Congress of Obstetrics and Gynecologists does not endorse EFM for low-risk pregnancies (which is about 85% of all births.)
4 | Women are often subjected to this ineffectual intervention without informed consent, which takes away a mother’s right to refuse care. Lawyer Thomas P. Sartwelle calls this an “egregious failure.”
5 | When EFM is used, the focus often becomes constantly interpreting its readings rather than meeting the needs of the laboring woman. It reduces a woman’s ability to change positions or take a bath for comfort.
6 | Wearing an EFM will increase your risk of having an instrumental (forceps, vacuum or episiotomy) or a cesarean section. The use of EFM in labor has been shown to increase cesarean delivery by as much as 63% and is the second most common indication for the primary cesarean.
7 | We are currently at an all-time high for cesarean delivery in the United States (about 33%). This is up 500% from the 1970s. Despite the uptick in cesarean birth, outcomes have not improved. In fact, the United States has a rising maternal and infant mortality rate.
8 | Cesarean birth incurs a three-fold increased risk for complications such as hemorrhage, organ damage, infection, and death when compared to vaginal delivery. Simply put, the more clinicians use EFM, the more they operate. The more that doctors perform cesarean sections, the more women who will die or have serious complications from childbirth. It’s time to give women true informed consent. No one should be wearing EFM unless they know the facts. I also believe using EFM contributes to making labor a technological event rather than a natural process. In additional to the above reasons, I avoided its use because I wanted a more personal, humane experience, which of course, is paramount to preserving the complexity of a woman’s morale and dignity while giving birth.