EFM Response

Jackie says here:

"It turns out that there are indeed Prospective Randomized Controlled Trials done on EFM that go all the way back to the ’80s. By 1987 there were 8 or so of those “gold standard” trials published in authoritative journals in the US and Europe, including one from ‘86, in the British Medical Journal, comparing EFM with intermittent listening, and all the studies were summarized in the Lancet, December 12, 1987 (the intermittent listening was done with fetascope or Doppler, and differences between those two methods were not distinguished).

This meta-analysis showed unequivocal results, since all the studies came to the SAME CONCLUSION: EFM has only one constant and significant statistical effect: it increases the rate of cesarean section. The studies showed that there was no beneficial effect on fetal health, or on fetal outcomes. NONE. It does not identify more babies at risk than intermittent listening, or identify and save babies from CP, or turn compromised babies into healthy ones or save baby’s lives any more than simple intermittent listening. Therefore, the ratio of benefit-to-risk was negative in that it caused an increase in c-section without any benefit to mother or baby.

Yet today and every day, EFM machines churn away in every L&D, and no laboring mother is ever told that it’s just fine to have someone just listen to her baby’s heart rate every half-hour, or that she can request, and indeed insist, that she have intermittent monitoring. And of course, no one ever tells her that if she stays connected to the monitor, her chances of c-section go up. Even more distressing is the fact that no matter how ACOG re-analyzes and renames and re-categorizes FHR monitoring, as in the new practice bulletin, they will never come out and say.”Don’t use continuous monitoring because it has proven negative consequences”…that pesky increase in the rate of cesareans.

Here’s a really upsetting study published in the American Journal of Obstetrics and Gynecology that the Times will never mention: since obstetricians really couldn’t believe that observing every fetal heartbeat on a strip isn’t helping the health of babies, they thought that more training in interpretation of the monitor tracings would be the answer. So a study was done to find out if special training for obstetricians and perinatologists could reliably identify babies in trouble by using continuous monitoring. Here’s the citation in case you want to check it out: “Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: Interobserver variability”. American Journal of Obstetrics and Gynecology, doi 10.1016/j.ajog.2008.06.027[Abstract]. And here’s the conclusion of that study: even special extra training of experienced maternal-fetal medical professionals does not help predict or identify which babies would be compromised. It’s not just that they disagree because training is useless or because experts can disagree…it’s that they disagree because EFM is useless… or, as the researchers state: “intrapartum FHR (EFM) monitoring is not a useful diagnostic test…” If the effect of a procedure is neither neutral nor beneficial, if it has indeed been shown to have risk, i.e., lead to increased, and by implication, unnecessary c-section, how can the use of EFM on every woman every day in this country have any ethical justification.

ACOG says, in Practice Bulletin #76, “Despite its widespread use, there is controversy about the efficacy of EFM. Moreover, there is evidence that the use of EFM increases the rate of cesarean and operative vaginal deliveries. Given that the available data do not clearly support the use of EFM over intermittent ausculation, either option is acceptable in a patient without complications.” (Obstetrics and Gynecology, Intrapartum Fetal Heart-Rate Monitoring 106 (6), 1463-1561.) They can remove what they like from their own prior literature, but Amy is correct in that they cannot erase the studies already out there for years. Is it ethical for ACOG even to call EFM an “acceptable option”? ACOG wants everyone “to be on the same page”? Maybe intermittent listening is the page all should be on!! Let’s not even begin to talk about “defensive” medical practices!"