When an expectant mother begins the process of childbirth, the outcome of a healthy baby takes precedence over any birth plan. Continuous Fetal Monitoring (CFM) using cardiotocography is a practice designed to ensure such a positive outcome. Could there be any harm from CFM?

“Many of our problems in US maternity care stem from the fact that we leave no room for recognizing when nature is smarter than we are.” 

Ina May Gaskin, Birth Matters: A Midwife’s Manifesta

Both of my children were delivered by midwives. Fetal monitoring occurred in labor after almost every contraction using a doppler, fetoscope, or a Pinard (one of my midwives was Danish) depending on whether I was in the birthing tub or not and what stage of labor I was in. This method is called Auscultation.

In contrast to my experience, CFM uses an electronic fetal monitor (EFM). This monitor is made of two large stretchy belts wrapped around your abdomen in order to monitor the baby’s heartbeat and your contractions. It is used continuously. This can also be done internally with an electrode. [note]https://www.acog.org/Patients/FAQs/Fetal-Heart-Rate-Monitoring-During-Labor?IsMobileSet=false[/note][note]http://www.omama.com/en/labour-and-birth/intermittent-and-continuous-fetal-monitoring.asp[/note]

The decision to use intermittent auscultation or CFM is often dictated by your doctor, hospital, or insurance company’s preference. Research has found; however, that continuous fetal monitoring is not necessary in most pregnancies and often leads to unnecessary interventions.

“The techno-medical model of maternity care, unlike the midwifery model, is comparatively new on the world scene, having existed for barely two centuries. This male-derived framework for care is a product of the industrial revolution. As anthropologist Robbie Davis-Floyd has described in detail, underlying the technocratic mode of care of our own time is an assumption that the human body is a machine and that the female body in particular is a machine full of shortcomings and defects. Pregnancy and labor are seen as illnesses, which, in order not to be harmful to mother or baby, must be treated with drugs and medical equipment. Within the techno-medical model of birth, some medical intervention is considered necessary for every birth, and birth is safe only in retrospect.” 

Ina May Gaskin, Ina May’s Guide to Childbirth

The purpose of monitoring fetal heartbeat is to detect if it should become abnormal during labor. Sometimes an abnormal fetal heartbeat recovers or is not a sign of any complications. Sometimes it signifies further testing should be done and that the baby is in distress. The normal heart rate is 110-160 beats per minute. If this number slows for a prolonged period to below 110, it can indicate a heart problem or oxygen depravity. [note]https://www.acog.org/Patients/FAQs/Fetal-Heart-Rate-Monitoring-During-Labor?IsMobileSet=false[/note][note]https://www.cochrane.org/CD006066/PREG_continuous-cardiotocography-ctg-form-electronic-fetal-monitoring-efm-fetal-assessment-during-labour[/note][note]https://www.aboutkidshealth.ca/Article?contentid=402&language=English[/note]

“Only rarely do doctors in training have the opportunity to sit continuously with laboring women for hours. Most are taught to intervene in the normal process so often and so early that they have never witnessed a normal labor and birth.” 

Ina May Gaskin

Several studies have compared the results of continuous versus intermittent fetal monitoring. One study published in 2017 titled “Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour” found there was no difference in outcome for the baby’s health between the two practices; however, there was an increase in the number or surgical births and use of instruments for vaginal births from constant monitoring.

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.

Cochrane

One problem with the practice of continuous fetal monitoring during childbirth is that often the results are inaccurate leading to unnecessary interventions.

In childbirth, the use of continuous fetal monitoring is controversial. This is because the accuracy of the technology is still quite limited. Fetal monitors can be misread, and they can sometimes register a problem with the baby’s heart rate when none really exists. The high false-positive rate of continuous fetal monitoring during childbirth has led to an increased incidence of unnecessary caesarean section. For this reason, it is recommended that continuous fetal monitoring only be used in high-risk births. 

Regardless, continuous external fetal monitoring throughout labour
is still used in many births in North America. A number of health-care providers see this as a useful tool for assessing the baby’s heart rate and the mother’s contractions.

About Kids Health

Mothers need to be informed of their options and discuss them with their health care providers. Intermittent or continuous fetal monitoring can be used in combination. Some practitioners start with continuous and move to intermittent if the heart rate remains normal. Others do it in reverse only using CFM if the need arises.

Even using CFM for the first 20 to 30 minutes of labor creates a false need for intervention. Dr. Marc Ringel explains the history of the practice and why it should be changed in Scientific American:

By the 1960s, monitoring technology had progressed to an ultrasonic gizmo, held against the mom’s belly with an elastic band, that could pick up the fetal pulse continuously and record it as a squiggle on a long strip of paper. Paired with a tocometer, which measures uterine contractions (and is also held against the mother’s abdomen and outputted to that same strip of paper), this gave health care workers a powerful way to track fetal well-being from moment to moment. Continuous fetal monitoring quickly became de rigueur. I spent a good deal of my medical school obstetrics rotation adjusting ultrasound and tocometer heads that had lost the signal.

Trouble is, when you compare the labors of women with low-risk pregnancies who have been monitored continuously to labors of women who have not, the babies come out about the same. But the continuously monitored mothers are subjected to significantly more interventions—oxytocin stimulation, forceps deliveries, episiotomies, C-sections, etc.—with their attendant expenses and complications. The critical phrase here is “low-risk pregnancies,” which is what most pregnancies are. For uncomplicated patients, fetal well-being can be assessed more than adequately by intermittently measuring babies’ heart rate with a handheld ultrasound device. There are still plenty of good reasons to monitor some labors continuously—just not most.

Moreover, despite reams of studies and guidelines about CFM, diagnosis of fetal distress based on monitor data is still dismayingly imprecise. Two doctors can look at the same strip and draw opposite conclusions. So far, artificial intelligence hasn’t helped much to distinguish reassuring from nonreassuring monitor tracings.

If there is any doubt about a baby’s well-being, professionals reflexively want to do something. Anything but a reassuring tracing heightens vigilance, steering the birth process down a path that may well lead to more intervention.

Mammals, including humans, move about a good deal in labor. Women naturally change position. They may thrash or pace. Making them stay still so that finicky electronic monitors can remain in position is unnatural. It inhibits a laboring mother’s instinctual movements that help her fetus find an optimal lie for its journey down the tight birth canal. Restricting her freedom of movement may cause a mother to experience more anxiety and pain, making it likely that she will require more labor-slowing pain medications.

Many labor and delivery units have now changed their protocols for low-risk pregnant women. Instead of automatically resorting to CFM, on admission staff obtain a “baseline strip” of about a half hour, just to reassure themselves that the baby is starting out okay. Once again, studies have shown that such strips too often nudge normal women with normal pregnancies who will deliver normal babies in the direction of instrumented or operative deliveries, with no better outcomes for their babies and more complications for themselves.

Many a doctor has acceded to routine CFM for her patients because she has asked herself, “What am I going to say in court, with the plaintiff sitting there before the jury, her pitiful ‘damaged’ child in her arms, when her attorney asks me, ‘So, in the absence of monitoring her continuously during labor, how did you know, Doctor, this poor baby was okay?’” Never mind that the vast majority of newborn problems have nothing to do with what happens during labor and delivery, nor that a fetal monitor strip is equally likely to hurt as to help a malpractice defense.

Ob-Gyns Do Too Much Fetal Monitoring

In the United States, 80% of childbirth labors are assisted by continuous fetal monitoring!

Fetal distress is a common reason for surgical intervention. What mother wouldn’t agree to stop the process of natural labor and proceed with a cesarean when informed there are “nonreassuring fetal heart rate tones”. This is the second most common reason for cesarean surgery. The number one reason is “failing to progress“. [note]https://blogs.scientificamerican.com/observations/ob-gyns-do-too-much-fetal-monitoring/?fbclid=IwAR1gFD9H_22gO7hgJfWDBhGVAQVufBreCGknl4R-RZqOZDSNKF8O9Ur0LkM[/note]

C-section rates in the US far exceed recommendations by the World Health Organization of 10 to 15 percent. In fact, nearly 1 in every 3 births is delivered surgically in North America. [note]https://www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising-at-an-alarming-rate[/note]. There are many risks associated with surgical births for both mother and child:

• Increase the risk of maternal death by 60%[note]https://www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising-at-an-alarming-rate[/note]
• Childhood obesity
• 5 times increased risk of “maternal bleeding, uterine rupture, hysterectomy and cardiac arrest” [note]https://www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising-at-an-alarming-rate[/note]
• Infant respiratory issues[note]https://www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising-at-an-alarming-rate[/note]
• Autoimmune disorders [note]https://www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising-at-an-alarming-rate[/note]

“The problem is that doctors today often assume that something mysterious and unidentified has gone wrong with labor or that the woman’s body is somehow “inadequate” – what I call the “woman’s body as a lemon” assumption. For a variety of reasons, a lot of women have also come to believe that nature made a serious mistake with their bodies. This belief has become so strong in many that they give in to pharmaceutical or surgical treatments when patience and recognition of the normality and harmlessness of the situation would make for better health for them and their babies and less surgery and technological intervention in birth. Most women need encouragement and companionship more than they need drugs.” 

Ina May Gaskin

Continuous fetal monitoring during low-risk pregnancies is unnecessary. This common practice leads to increased risks for mother and child when surgical interventions result in false results. This practice needs to be reviewed and discussed in order for women to take back their strength and wisdom in childbirth, no matter where they choose to deliver.

Image: Sabrina Weiwei Yao on Flikr  Some rights reserved