Midwives matter more than monitors.
I had only been a midwifery student for a few months when I first heard the late, great Marsden Wagner speak about the lack of evidence for electronic fetal heart monitoring (EFM). At the time, he told us, more than 80 randomised controlled trials had been carried out and they had all failed to show that EFM was an effective intervention. ‘There has never,’ he would say, ‘been any scientific evidence that high-tech interventions such as the routine use of electronic fetal monitoring during labor decrease the mortality rate of babies’ (Wagner 2000: 1).
Since then, there has been a steady stream of research telling us the same thing, although this seems to have had little effect in changing practice. One team in the USA – led by a trial lawyer whose interest stemmed from trying lawsuits and wondering why the medical profession didn’t get rid of EFM as the evidence against it accumulated (Thomas Sartwelle, personal correspondence 2015) – has produced a number of recent papers challenging obstetricians to consider this practice (Sartwelle and Johnston 2015; 2016; Sartwelle et al 2015). These papers do not simply point out the lack of evidence to support the use of EFM; they also consider the ethical dimension of the use of EFM and raise questions about informed consent.
From EFM to CFM
But even though the arguments against EFM accumulate, the technology continues to be used and elaborated upon, with central fetal monitoring (CFM) now being used in some areas. For anyone who hasn’t encountered this term, CFM describes a set-up whereby the cardiotocograph (CTG) machines in labour and delivery rooms are wired to send their output to a central computer. Usually, there is a set of screens at the midwives’ station or in another staff-only area, and midwives and doctors can see the CTG traces of all the women who are being monitored, at the click of a mouse.
I first encountered one of these systems in the USA. One of the local hospitals had installed a CFM set up, and there are no prizes for guessing that it was the hospital to which the women who were planning home and birth centre births least wanted to be transferred, if they needed medical intervention during labour. I discovered that the goal of some of the staff on the labour ward (which did not include midwives) was to get every labouring woman connected up to the CFM system, an epidural and an electronic blood pressure machine which was set to alarm if an unusually high or low reading was taken.
The combination of these technologies meant that the staff could sit together in the staff room and watch the screens. They could rest assured that the women were pain-free and spending their labours watching TV with their families and that alarms would go off if they were needed. It was a curious state of affairs, which contrasted strongly with my own experiences of being with labouring women as a midwife. I remember being completely at a loss as to how to respond when I was shown this fabulous and shiny new system by a couple of staff members who clearly thought it was a brilliant innovation which would benefit both them and the women and babies they cared for.
Women, midwives and CFM
Many units have adopted CFM since then, and many midwives (and a good few obstetricians of my acquaintance) lament the negative ways in which it affects women’s experiences. I’ve heard midwives share their concerns that CFM systems have played a part in reducing (or at least justifying the reduction of) midwife-to-woman ratios on the labour ward and, if I had a pound for every story I’ve heard about a member of staff barging into a woman’s room because they had seen something on the CFM that gave them cause for concern, but later turned out to be artefact, then I could start a charity which offered free doorstops to all women opting for hospital birth. There are also concerns that the existence of such systems means that people feel obliged to use them and still the research shows that these don’t make a positive difference to outcomes.
Making the wrong kind of difference
One recent study, however, has shown that CFM can make a difference, albeit not in the way some women want it to. In one hospital, the unexpected loss of the CFM system was turned into an opportunity to compare the outcomes of women and babies and the attitudes of labour ward staff before and after the change (Brown et al 2016). If you’ve been following along from the beginning, you probably won’t be surprised to hear that there was no difference in the perinatal outcomes with or without CFM. The raw data seemed to suggest that women who used CFM were less likely to have a normal birth than women who were electronically monitored but without the use of CFM. However, adjusting the data to account for the use of prostaglandin as a cervical ripening agent seemed to remove that difference.
The significant difference between the two groups was related to staffing. More than half of the staff (56 per cent of midwives and 54 per cent of obstetricians) reported that they spent more time with the woman during the time when the CFM wasn’t available than when they were able to use CFM (Brown et al 2016). So CFM has now been clearly shown in research to reduce the time that midwives spend with women; an outcome that the authors of this study describe in the title of their paper as a hazard.
The value of midwifery
Of course CFM constitutes a hazard. Women aren’t meant to be cared for by televisions and monitors. Monitors can’t tell when the quality of a woman’s sensations changes. Televisions don’t know when a woman needs her pillows plumping up or turning over to the cool side. Neither can they read the subtle signs that tell a midwife when a labouring woman needs a drink, a trip to the loo or some quiet words of encouragement or reassurance. But happily, for every paper or review that says that EFM or CFM doesn’t make a difference, there’s another one showing that midwives do.
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Brown J, McIntyre A, Gasparatto R et al (2016). ‘Birth outcomes, intervention frequency, and the disappearing midwife’potential hazards of central fetal monitoring: a single center review’. Birth, Online ahead of print. DOI: 10.1111/birt.12222
Sartwelle TP and Johnston JC (2015). ‘Cerebral palsy litigation: change course or abandon ship’. Journal of Child Neurology, 30(7): 828-841.
Sartwelle TP, Johnston JC and Arda B (2015). ‘Perpetuating myths, fables, and fairy tales: a half century of electronic fetal monitoring’. The Surgery Journal, online ahead of print. DOI https://www.thieme-connect.de/DOI/DOI?10.1055/s-0035-1567880
Sartwelle TP and Johnston JC (2016). ‘Neonatal encephalopathy 2015: opportunity lost and words unspoken’. The Journal of Maternal-Fetal and Neonatal Medicine, 29(9): 1372-1375.
Wagner M (2000). Technology in birth: first do no harm, Oregon: Midwifery Today. https://www.midwiferytoday.com/articles/technologyinbirth.asp