Electronic fetal monitoring
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7300.1436 (Published 16 June 2001) Cite this as: BMJ 2001;322:1436All rapid responses
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Ros Goddard's article mentions three recent Confidential Enquiries
into Stillbirths and Deaths in Infancy, which she says have consistently
recognised inadequate interpretation of the cardiotocograph as a prime
cause of adverse events and then goes on to say that 'To prevent
litigation trusts should act on this recommendation and ensure that such
training is available free for all relevant staff'.
Hospital trusts should be providing the necessary training not to
prevent litigation if they get it wrong but to ensure that no baby dies
needlessly. Ros Goddard does not appear to understand the utter
devestation to a family that occurs when 'inadequate interpretation'
occurs and a much loved baby dies as a result.
The majority of patients do not want financial compensation when
something goes wrong. What we want is honesty..what went wrong and why,
for mistakes to be admitted and assurances that preventative measures will
be taken to ensure that it doesn't happen again to somebody else.
Competing interests: No competing interests
While Dr Goddard, in her editorial of June 15 [1], appeared to
acknowledge the fact that trials of routine electronic fetal monitoring
are underpowered, she did not appear to draw the logical conclusion. Using
her figures for intrapartum stillbirth and cerebral palsy of intrapartum
origin, a trial powered (80% power, alpha 5%, two-sided) to show a 50%
decrease in intrapartum stillbirth would need to recruit approximately
83,500 women to each arm and a trial powered to detect a 50% decrease in
cerebral palsy due to intra-partum causes would require approximately
670,000 women in each arm. The current meta-analysis has less than 19,000
cases in total [2]. The evidence is not, as she states, "strongly against
the routine use of electronic fetal monitoring". The evidence simply does
not exist and, given the numbers required, it probably never will.
Routine electronic fetal monitoring halves the risk of neonatal
seizures even when applied to a low risk population [2]. Statements to the
effect that electronic fetal monitoring has not been shown to reduce the
risk of intra-partum stillbirth and cerebral palsy have the same
fundamental weaknesses as statements associated with some previous public
health disasters, such as "there is no evidence to suggest that blood
products can transmit HIV" or that "there is no evidence that BSE can be
transmitted to humans". Falsely equating "absence of evidence" with
"evidence of absence" does not have a glorious history and should be
avoided.
1. Goddard R. Electronic fetal monitoring is not necessary for low
risk labours. BMJ 2001;322:1436-1437.
2. Thaker SB, Stroup DF, Chang M. Continuous electronic heart rate
monitoring for fetal assessment during labor (Cochrane Review). Cochrane
Database Syst Rev 2001;2:CD000063.
Competing interests: No competing interests
A wonderful resource of natural childbirth educators
Finally! This editorial article is a wonderful resource for natural
childbirth educators that sums up the known research about the lack of
evidence to support routine, continual EFM during labor.
As a teacher of natural childbirth, I know from the research and from
common sense that EFM does little for the majority of unmedicated, low-
risk mothers except restrict their movement during labor and lead to more
medication and intervention. It also has the unfortunate side-effect of
leading those present during labor who are supposed to be supporting the
mother to 'coach' the monitor instead.
Bravo to the BMJ for recommending the elimination of continual EFM in
favor of more hands-on, one-on-one care by a nurse, midwife or other
medically trained person who can check for distress in normal labors of
low-risk mothers using the much more comfortable and just as effective
(based on the research cited in your editoral) method of ascultation.
This method is already used routinely in the midwifery model of care.
I am putting this article on my must-read list for all my students
desiring natural birth. I can only hope that the ACOG here in the US
takes a similar stand. Unfortunatly in the medical climate here in the
states, I am afraid that such a low-tech and cheap, effective and natural
way to monitor labors will not be quickly embraced over the higher-tech,
more expensive, less-effective EFM.
Competing interests: No competing interests