How Will You Monitor The Baby and I?

Know How You and Your Baby Will Be Monitored

The likelihood of the "cascade of medical interventions" that lead to unnecessary cesarean births can be gauged by asking your care provider how you will be monitored during active labor.


How will the baby and I be monitored during active labor (6-10 cm)?


Unfortunately, most women who deliver in busy hospitals where the nurses primarily care for you during labor and report your progress to your OBGYN care provider are monitored with Continuous Fetal Monitoring (CFM) for low risk births, even though this has been proven to unequivocally increase the C/S rates, with no better outcomes for babies and mothers compared to Intermittent Fetal Monitoring (IFM) that is safer and more appropriate for low risk births (Alfirevic Z;, et al, 2006, Bix E., 2005). [As per the World Health Organization: These two methods of fetal surveillance have been compared in a number of trials (Haverkamp et al 1976, 1979, Kelso et al 1978, MacDonald et al 1985, Wood et al 1981,Neldam et al 1986). Cesarean section rate and operative vaginal delivery rates were both higher in all the electronically monitored groups. There is little evidence that the increased number of interventions in the electronically monitored groups led to substantive benefits for the infants. Perinatal deaths and low Apgar scores were not reduced in the groups with electronic monitoring. Only one measure of neonatal outcome was improved by electronic monitoring, in the largest trial: neonatal seizures (MacDonald et al 1985). A further analysis of this trial suggested that the excess risk of neonatal seizures in the auscultation group was mainly limited to labors that were induced or augmented with oxytocin. The follow-up data of the infants with seizures showed an equal incidence of major neurological disabilities in the groups monitored electronically and by auscultation.]

Therefore routine use of CFM on low risk birthing women necessarily introduces more risks that are associated with surgical Cesarean births.

First, what is Continuous Fetal Monitoring?

CFM consists of a birthing woman wearing two tight belts around her belly, the top one toward the top of her uterus using a tocometer to monitor the frequency and length of each contraction (not intensity), and the lower belt near the lower part of her uterus recording the baby’s heart beat with an electronic ultrasound doppler transducer or by an internal electrode screwed into the baby’s scalp (which requires the “bag of waters” broken and can lead to an infection ascending into the uterus/baby) moment to moment in real time. In order to “get a good reading” on the monitor strip,  CFM requires continuous and constant contact of these two “probes” which is achieved by tightening the belts on the pregnant woman’s abdomen. 

Why is this a problem?

In order to maintain adequate contact with both probes to obtain an adequate reading on the monitor, the mobility of the birthing woman is often restricted. The instinctive, most comfortable positions that laboring women naturally assume when unencumbered and which are the best positions to promote optimal fetal positioning to help their baby through the pelvis to have a vaginal birth (i.e. leaning forward, standing, walking, squatting, lunging, laboring on hands on knees, or in the tub) are prevented.  The adequate contact of the probes is hard to maintain when women are in these positions, and it is more difficult for the nurses to keep the monitoring strips on tight enough to “get a good reading for the strip.”  Even when trying to accommodate different positions and ambulation, most often the patient eventually needs to resort back to the supine position (lying on your back) of the woman semi-sitting or lying on the bed (which closes the pelvic outlet, making less room for the baby to come out). This position encourages babies to rotate to the more problematic posterior position, and closes the pelvis instead of allowing the pelvis to naturally open to help the baby come out (refer to How Will I be Born by Jean Sutton, and www.spinningbabies.com for more information about Optimal Fetal Positioning).  In addition, the birthing surges are more painful lying on the bed on your back, side or semi sitting than in the more natural positions mentioned above (the minute you start having contractions you will immediately appreciate this!!).  

Removing that ability of ambulation by confining the birthing woman to the bed in an unnatural and more painful position to get a “good reading” for the CFM removes one of her greatest coping skills to deal with the power of labor and to help the labor progress normally. This positional restriction and routine CFM monitoring begins the “cascade of medical interventions”  that lead to increased pain of labor and the mal-positioned babies that these positional restrictions can create, the increased need to have an epidural due to this unnecessary increased pain, the subsequent risks of epidurals (see True Informed Consent For Epidurals) including low blood pressure in the mom and fetal distress in the baby, and the further sequela that includes slowing or arrest of labor, use of Pitocin to augment the arrested or slow labor (which is not addressing the true etiology of the arrest or slow progress of labor, namely a mal-positioned fetus, which would not have been created with natural laboring positions, adequate ambulation, and timely correction of mal-positioned babies), etc.  Managing a low risk birth with CFM creates scenarios that create a “Necessary” Unnecessary Cesarean.  This CFM method has a high sensitivity (picks up a problem if it really exists), but has a low specificity (Grant, 1989), meaning that it has a high rate of false positive signals of assessments of fetal distress in low risk births and a concomitant high number of (unnecessary) interventions including C/S that  may ultimately reveal a healthy, un-compromised fetus, especially if used in a group of low-risk pregnant women (Curzen et al 1984, Borthen et al 1989).

What is Intermittent Fetal Monitoring? and How does it differ from CFM?

For low risk births, Intermittent Fetal Monitoring (IFM) is the safest way to monitor the wellbeing of the fetus during labor (as per the most recent ACOG and ACNM standards).  To adequately and safely perform IFM, a nurse (or midwife)  must listen at the bedside with the patient between and during contractions once every hour for latent (early labor), every half hour to 15 mins during active labor (6cm to 10 cm), and every 5 mins or after each push during the pushing stage. Each assessment consists of establishing a baseline between contractions, then listening through a whole contraction to detect any periodic changes in the heart rate during the contraction, and for a whole minute after the contraction has passed, to pick up any periodic decelerations that could signify that CFM would be required to more carefully investigate the status of the baby instead of IFM.

So why is CFM done instead of IFM in hospitals for low risk births, if it has been shown through high quality studies accepted by ACOG’s Standards of Practice for low risk women that IFM is so much safer than CFM?

The answer is two-fold:

  1. IFM does require a higher nurse/patient ratio (more time per patient) than most hospitals can afford.  Due to budgetary restrictions that limit the number of nurses that can be hired, most women, regardless of risk, are put on CFM, because there are just not enough nurses on the floor to adequately perform IFM with the frequent level of direct patient contact that would be required for low risk women. It is easier for the nurses to assess all the babies on CFM on the unit from the TV screens in the nursing station (regardless of the increase in medical interventions and higher C/S rates that result.)
  2. The nurses are responsible for monitoring all the babies’s heart rates and tolerances to labor on the busy labor unit, not the OBGYN (most of whom are not present with you at the bedside during your whole labor because he/she may be doing office hours or seeing other patients until they are notified by the nurses about your status regarding the “fetal strip” generated by the CFM and the cervical dilation status assessed by the nurses). The OBGYN will then make certain labor management decisions from afar over the phone. It is not the responsibility nor within the scope of practice of a Registered Nurse to diagnosis and correct mal-positioned babies as the labor progresses: they can only report the cervical progress and the status of the patient. It is only the responsibly of the obstetrical care provider (OBGYN or Midwife) to diagnose and treat this condition. If the baby’s head is mal-positioned (with the baby’s head either in the posterior position            —baby looking in front of you with his /her back on your back, or extended and not flexed, or asynclitic— meaning tipped), the baby’s head is wider in those positions and may have difficulty fitting through the narrow part of the mid pelvis. This can cause a much longer and more painful “back labor,” a slowing of labor, or an arrest of labor because the baby literally may just not fit out in that position (unless the mal-position is corrected by a practitioner who is familiar with how and when to diagnose and treat this deviation from normal labor).

On average, in NY and NJ where the use of CFM is extremely high for low risk women, 60% of women will become fully dilated and be ready to push, and their OBGYN will then be summoned to attend the birth.

If, due to the sequela of CFM stated above, a mal-positioned baby is not diagnosed and corrected at the correct time during labor —when it can make a difference due to the birth attendant not being present during the whole labor as the baby’s position is   dynamically changing,—and this mal-position creates a “failure to progress or descend” diagnosis, the current statistics in NY and NJ indicate that 30-40% of these low risk women (who were inappropriately placed on CFM due to their risk status and became subjected to the negative sequela that cascade from it) ultimately will need to birth their babies by Cesarean Section.  If the average primary C/S rate should be no higher than 15% in an average risk population, and if in fact the actual primary C/S rate approaches 30%, then 15% of these C/S could have been avoided by using a more physiological approach to birth, incorporating IFM as appropriate instead of automatically resorting to CFM as a mode for monitoring the babies in labor.

If that same woman would have been supported to have a physiological birth with their birth attendant present for the entire labor, IFM used as appropriate for evaluation of fetal wellbeing,  the ability to freely ambulate and and have full mobility, the use of hydrotherapy, and techniques such as Rebozzo, positional changes specific to fetal position to encourage optimal fetal position in labor,  utilizing gravity and upright laboring and birthing positioning, she will have a lower need and use for analgesia and anesthesia, and she may not have needed to end with a birth that needed to be a Cesarean birth.  In fact, Intermittent monitoring (IFM) is most appropriate for low risk women as per ACOG guidelines.

If your care provider tells you that you will be monitored by CFM instead of IFM for a low risk birth, you may want to ask your care provider that  “If it has been definitively proven through high quality scientific studies that CFM for low risk births creates more harm than good, why is this harmful practice still used for low risk births?”

Sources:

  • Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006 ;(3):CD006066.,
  • Bix E, Reiner LM, Klovning A, Oian P. Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review. BJOG. 2005; 112(12):1595–1604.]
  • Curzen P, Bekir JS, McLintock DG, Patel M. Reliability of cardiotocography in predicting baby's condition at birth. Br Med J 1984; 289:1345-1347.
  • Grant A. Monitoring the fetus during labour. In: Chalmers I et al (eds). Effective care in pregnancy and childbirth. Oxford, Oxford University Press 1989
  • Haverkamp AD, Thompson HE, McFee JG, Cetrulo C. The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy. Am J Obstet Gynecol 1976; 125:310-320.
  • Haverkamp AD, Orleans M, Langendoerfer S, McFee J, Murphy J, Thompson HE. A controlled trial of the differential effects of intrapartum fetal monitoring. Am J Obstet Gynecol1979; 134:399-412
  • Kelso IM, Parsons RJ, Lawrence GF, Arora SS, Edmonds DK, Cooke ID. An assessment of continuous fetal heart rate monitoring in labor. Am J Obstet Gynecol 1978; 131:526-532.
  • MacDonald D, Grant A, Sheridan-Pereira M, Boylan P, Chalmers I. The Dublin randomized trial of intrapartum fetal heart monitoring. Am J Obstet Gynecol 1985; 152:524-539.
  • Neldam S, Osler M, Hansen PK, Nim J, Smith SF, Hertel J. Intrapartum fetal heart rate monitoring in a combined low- and high-risk population: a controlled clinical trial. Eur J Obstet Gynecol Reprod Biol 1986; 23:1-11.
  • Wood C, Renou P, Oats J, Farrell E, Beischer N, Anderson I. A controlled trial of fetal heart rate monitoring in a low-risk population. Am J Obstet Gynecol 1981; 141:527-534.