Push from England to reduce routine EFM use

Here’s a very interesting article from England which questions the use of routine electronic fetal monitoring.

    [Gillian] Smith [Scottish national officer of the Royal College of Midwives] is heading a campaign by the RCM Scotland to reduce the number of unnecessary interventions women in labour are subjected to. She said: “Is routine electronic foetal monitoring required in every single woman? Perhaps they do not need it. Does that then start a string of interventions because the woman is strapped down and can’t move about?”There is research to prove that a woman who is up and about will labour better.

    Our campaign is about trying to encourage midwives not to give in too quickly. Research tells us that women who receive one-to-one care are less likely to need analgesia and Caesareans. There is a tendency to perhaps intervene a little earlier than is actually required.”

According to the article, the cesarean rate in England has doubled in the past 20 years, and is now close to the 25% mark (which is still lower than the cesarean rate here in the US). Many studies have demonstrated that intermittent auscultation in low-risk women with healthy pregnancies is just as effective as continous electronic fetal monitoring, with the added benefit of allowing the woman to move around and not be confined to her bed during labor.

From further down in the article (the naysayers point of view, if you will):

    Dr David Farquharson, clinical director for women’s reproductive health at the Edinburgh Royal Infirmary, said the practice of electronic foetal monitoring was standard in his hospital to reassure doctors and patients.He said: “This is a very controversial area. A lot of obstetricians do not feel comfortable not having a record of foetal heart rate when the woman comes into hospital.

    “The alternative is the midwife listening with a hand-held device, and that depends on her being confident on hearing it.

    “The problem with that is knowing what they are listening to, then counting the beats with a watch. There is always the risk you could be taking the mother’s pulse. That’s a worry to obstetricians.”

That last sentence is the kicker there. I ask you this: would a midwife who is well trained in fetal auscultation, and who probably does it on a daily basis, really be so simple as to confuse a maternal heart rate with a fetal heart rate, or be unable to find the fetal heart rate in the first place? Is their trust in the clinical skills of their midwives so low? Is this really the worry that’s keeping Scottish obstetricians up at night?? Please. Distinguishing the maternal heart rate from the fetal heart rate is often a very simple matter of taking the woman’s pulse at the same time while listening to the baby’s heart—if what you’re feeling in the pulse is matching what you’re hearing in the heart rate, then obviously you’re listening to the mother’s pulse and not the fetal pulse.

Fetoscopes can be just as sensitive as electronic monitors, and in some situations are actually better than EFMs for the simple reason that they don’t produce artifact, and there’s actually a living, breathing, thinking clinician on the other end of the fetoscope. Electronic monitors often have built in computer logic buttons which will try to make sense of a fetal heart pattern that the machine doesn’t understand (for example, if there is extreme tachycardia, some EFMs, not being able to understand a heart rate over 200 beats per minute, will automatically halve the heart rate, and the only way to tell for sure is to actually listen to the heart rate itself, i.e. auscultation.) Fetoscopes are also supposed to be used to confirm the presence of supraventricular tachycardia, to make sure that missed and skipped beats are not artifact appearing on the EFM—we were just taught this in class during our lecture on fetal heart rate monitoring. I think the worry really stems from the fact that more and more trust is being placed in machines, while the skills and critical thinking of experienced clinicans is being devalued in the face of technology. Very few clinicians are even trained to use a fetoscope any more, just like doctors are no longer being trained to deliver breech presentations. Sensitive, important skills are being lost to newer generations of practitioners, so that now the standard has become cesarean cesearean cesarean, sometimes because doctors no longer have the skills to do anything but.

I wonder if England can begin to limit the use of EFM, will America follow it’s lead? In our litigious society, part of me seriously doubts it, but I’ll keep my fingers crossed anyway. Go RCM! We’re rooting for you.

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One Comment

  1. Yehudit
    Posted March 17, 2008 at 10:49 am | Permalink

    The discussion here is a bit odd, because continuous CTG in labour is not routine in most UK hospitals. The controversial bit is defining “high risk” labours, because CTG is used for those (unless the woman declines, and knows that she can decline). The other controversial bit is admission CTGs (20-30 minute trace on admission) which about half of hospitals still seem to do, despite recommendations that this practice stop from NICE (National Institute of Clinical Excellence) and RCOG (Royal College of Obstetricians and Gynaecologists). But it is rare in the UK to find an obstetrician who would be prepared to defend routine use of CTG throughout labour – they must have really dug that one up.

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