The TRUTH about Fetal Distress

(Article from FitPregnancy's May 2010 issue)

By: Jeanne Faulkner, R.N.

 Monitoring babies during labor is supposed to ensure their safety, but it hasn't worked that way.  New guidelines should help.

ELECTRONIC RETAL HEART monitoring (EFM) is the most common obstetric procedure performed in the United States.  Intended to determine the baby's well-being during labor, it's now a routine element in at least 85 percent of labors, up from 45 percent in the 1980's.  But it has proved to be a very imprecise tool.

Introduced in the 1970's, EFM was supposed to decrease  perinatal mortality and cerebral palsy (CP) by detecting fetal heart rate patterns that indicate oxygen deprivation during labor.  Doctors could then deliver quickly, usually by Cesarean section.  Problem is, EFM's false-positive rate for predicting CP is greater than 99 percent.  "EFM hasn't reduced perinatal mortality or CP at all", says George Macones, M.D., vice chairman of the Committe on Obstetric Practice at the American College of Obstetricians and Gynecologists.  CP rates have essentially remained the same since World War II despite advancements in treatments and inteventions.

"EFM isn't currently a good indicator when babies are in trouble," Macones explains.  "What we've done is increase the number of C-sections in response to highly subjective EFM interpretations."  In one experiment, four obstetricians examined 50 EFM tracings (printouts of the fetal heart rate).  Their interpretations were the same in only 22 percent of the cases.  Two months later, the OBs re-evaluated the traccing and changed their minds in 1 out of 5 cases.

Making a dull tool sharper

Imperfect as it is, EFM is the standard of care in modern obstetrics.  "EFM is currently the best map for a healthy birth, though sometimes it steers us in the wrong direction," says Marc Jackson, M.D., a maternal-fetal medicine specialist at Salt Lake City-based Intermountain Healthcare (IH), whose 22 percent C-section rate is among the lowest in the U.S. "Our goal is to improve interpretation by creating a better map."

Macones and Jackson believe new guidelines will reduce subjectivity and more accurately identify the need for intervention.  The new classifications:

CATEGORY 1 - tracings are normal; monitoring may be intermittent.
(Women with preeclampsia, type I diabetes or suspected fetal growth restriction require continuous monitoring.)

CATEGORY 2 - tracings are indeterminate; further continuous monitoring and evaluation are needed.

CATEGORY 3 - tracings are abnormal, and prompt evaluation and interventions, such as giving the mother oxygen, are required.  IF there's no improvement, the baby should be delivered ASAP.

An IH-designed pilot program in which third-party nurse-experts review EFM tracings to objective consultations has shown promising results.  In the meantime, try to stay healthy during pregnancy and, most importantly, be flexible.  "Directions change fast in labor," Jackson says.  "Every doctor wants the best outcome.  This is the map we're following now."

Here's what I think...

I was surprised to find this article in fit pregnancy. Its small but shows that the interventions topic and how they lead to unnecessary cesarean sections is starting to reach the mainstream.  I was impressed by that.  I was also impressed with the quotes from ACOG recognizing that EFM is subjective and imperfect and has not in any way proven to improve outcomes.  Seriously, 99 percent false-positive readings??? Seriously?  

So how is a woman supposed to feel about this article?  Here we have a real issue with women birthing in hospitals.  They go there seeking "safety" and find out that the "safety monitors" are not accurate.  And even if they were, the person reading the tracing may not read it properly.  As a matter of fact the only thing guaranteed in all this is that the nurse/doctor WILL MOST DEFINITELY read the tracing wrong and send this same women for an unnecessary cesarean section!

I have often wondered if a doctor, shown that same tracing several months later, would still recommend the cesarean section. Well this article gives me the answer.  Yep, he'd probably change his mind!  How comforting.  

What got me upset is the writers "advice" at the end.  So basically these new "categories" are still in infancy and so is the program to educate healthcare providers on them.  (I won't even touch how labeling them "categories" reminds me of hurricane catastrophes...so I digress.)  She offers that women "stay healthy" and "be flexible".  What kind of advice is that???

Well, what if I am one of their "FitPregnancy-Yoga-Organic-Exercise-Healthy-Preggo-Moms"???  This writer is saying to me that none of that matters...I am still to stay "flexible" because I have to realize that my birth outcome is determined in how the person who is working that day during their shift PERCEIVES my EFM tracing.  Oh, I feel much better now.

So what is this doula's advice?  BE SMART! Educate yourself.  Trust your body and your baby! If you feel like you MUST birth in a hospital setting realize that intermittent monitoring is the best choice for you and may decrease your risk of cesarean section! Be mobile during your labor so that you can progress faster and not be "tied down" by monitors.  Labor at home for as long as possible with support partners who REALLY know the flow of labor so that you can feel safe and confident while laboring there until it is time to go to the hospital!  Educate your healthcare provider on what you KNOW to be true.  Yes, I said EDUCATE them...not ask them, not beg them, not "see if its ok with you" them.  But educate them. 

Lisi Grullon, CBE, CD, LE

After reading this article....what do you think?