The case against electronic fetal monitoring

medium_324806416Just weeks after the publication of two articles in the BJOG that questioned electronic fetal heart monitoring, a freely available article in the Journal of Child Neurology does an absolutely stellar job of bringing together the case against the use of this technology.  The authors begin their paper – Cerebral Palsy Litigation: Change Course or Abandon Ship – by explaining that, in the last half-century, the response to the frequency of litigation and the increasing value of damages relating to birth-related cerebral palsy ‘was abandonment of the venerable ‘‘first do no harm’’ principle, replacing it with the expedient self-serving ethics of ‘‘do whatever is necessary to keep trial lawyers at bay.’’’ (Sartwelle and Johnston 2014)

The paper then goes on to describe the effects of this litigation and the way in which it is based on erroneous beliefs about electronic fetal monitoring:

“Electronic fetal monitoring precipitated, nurtured, and continues to be the primary cudgel against defendant physicians in the world’s courtrooms. But electronic fetal monitoring is based on 19th-century childbirth myths. Its scientific foundation is almost nonexistent. Its false positive rate exceeds 99%. It does not predict cerebral palsy.  After 40 years of continuous use and supposed improvements, electronic fetal monitoring has not reduced the cerebral palsy risk. It has, however, increased the cesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike.” (Sartwelle and Johnston 2014)

It gets even better, as the authors explain how a courtroom evidence rule could be used to turn this situation around.  I thoroughly recommend reading this article, as it brings together a number of key areas of evidence, and is one of the clearest and most quotable pieces I have ever read on this topic.

“It is far past time for birth-related professional organizations to confront electronic fetal monitoring reality, abandon the electronic fetal monitoring ship, and start over. Birth-related professional organizations must come to grips with the undeniable evidence that electronic fetal monitoring is an epic medical ethical dichotomy—it harms mothers and babies in direct opposition to the long-made promise not to do so. The time to act is now. If not now, when?”  (Sartwelle and Johnston 2014).

 

Sartwelle TP and Johnston JC (2014). Cerebral Palsy Litigation: Change Course or Abandon Ship.  Journal of Child Neurology.  DOI: 10.1177/0883073814543306

The cardinal driver of cerebral palsy litigation is electronic fetal monitoring, which has continued unabated for 40 years. Electronic fetal monitoring, however, is based on 19th-century childbirth myths, a virtually nonexistent scientific foundation, and has a false positive rate exceeding 99%. It has not affected the incidence of cerebral palsy. Electronic fetal monitoring has, however, increased the cesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike. This article explains why electronic fetal monitoring remains endorsed as efficacious in the worlds’ labor rooms and courtrooms despite being such a feeble medical modality. It also reviews the reasons professional organizations have failed to condemn the use of electronic fetal monitoring in courtrooms. The failures of tort reform, special cerebral palsy courts, and damage limits to stem the escalating litigation are discussed. Finally, the authors propose using a currently available evidence rule—the Daubert doctrine that excludes ‘‘junk science’’ from the courtroom—as the beginning of the end to cerebral palsy litigation and electronic fetal monitoring’s 40-year masquerade as science.
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