I have been so super busy with lots of reading and writing assignments for midwifery school.
This week in intrapartum, we're reading, discussing and synthesizing multiple aspects of fetal monitoring in labor. Did you know that in low risk women, continuous EFM is no better than intermittent auscultation in labor, as it relates to reducing rates of cerebral palsy? In fact, rates of CP have been unchanged since EFM was first introduced in the early 1970's? Continuous EFM in low risk women actually increases the likelihood of a cesarean section.
Does this mean that I am an uber crunchy granola student midwife who has been brainwashed into believing that continuous EFM (or any EFM!) has no place in birth? WRONG-O!
I have had a belief for many years now that EFM has a time and a place in birth. I feel it's more than appropriate, for a low risk laboring woman to have a baseline fetal monitor strip on admission to labor and delivery to determine adequate fetal oxygenation AT THAT MOMENT IN TIME (admission). After that, I feel that intermittent auscultation, at the appropriate intervals during labor, is best for the low risk pregnant woman and her fetus. If, however, at any point in time that things change from low risk to potentially a higher risk, I don't hesitate to put the fetal monitor back on to reassess the fetus. And yes (GULP!) I believe that interventions are sometimes needed. All on a case by case, moment by moment basis.
Labor and birth is not a cookie cutter process, nor is it an assembly line.
17 comments:
I'm so glad to hear you say that. It seems as though you either have to to be completely non intervention or super high intervention. Every woman needs to be evaluated on a case by case basis.
On another note....are you enjoying Frontier? I'm trying to narrow down the school I want to apply to and decide where I want to go. So many decisions!
I hear that Georgetown has an online nures-midwifery school, too. I haven't heard anyone talk about it, though.
As I understand, EFM can spot problems in a "normal" labor with a low-risk mom that wouldn't as easily have been detected, like rare cord issues. I'd really like to see more "cordless" efm's on L & D units, but I'm sure they are quite expensive.
@Theresa: I'm loving Frontier! I absolutely recommend this school for anyone looking to become a CNM, FNP, or WHNP.
I HATE the EMF. First reason being the one you stated, second being staff tends to look right at the EFM readings upon entering instead of the mother. It's a total disconnect between the staff and the patient. But on the other hand, this means I have a job as a doula ;)
As a former midwife and now L&D RN, I really hate continuous EFM. I think it is a major contributor to the need for epidurals as women need to be in positions that allow for the monitoring.
But the biggest problem and the reason most docs want continuous EFM is juries. When juries stop mandating healthcare we'll all be better off.
"This week in intrapartum, we're reading, discussing and synthesizing multiple aspects of fetal monitoring in labor. Did you know that in low risk women, continuous EFM is no better than intermittent auscultation in labor, as it relates to reducing rates of cerebral palsy?"
Yes, I did know that, and I find it incredibly frustrating. So much time, effort, and angst goes into putting people on the monitors, taking them on and off monitors, collecting and agonizing over the meaning of the little strips, and the evidence says it DOES NOTHING except to increase C-section rates, and yet we will NEVER STOP, for the same reason you will never stop taking off your shoes at the airport: because somebody says "safety" and all rational thought stops (meanwhile we have increased the level of CO2 in our atmosphere to levels not seen in 15 million years, on the road to temperatures warmer than the last time the global was completely free of ice -- hey, we don't know that's unsafe).
Speaking as an evidence-based-medicine guy, pour me a bowl of that granola. I took half my Step 3 today and one thing I do not need is more crap to learn and remember that is known not to won't -- a selfish perspective, but there you are.
Thanks for you honesty Anonymous! (I'm guessing that you are a physician?)
As a low-risk mom with a living baby, now a grown adult, who is alive today ONLY because the corpsman wanted to play with his new EFM and asked if he could try it out on me----EFM spots trends and problems that might well not show up with intermittent ascultation---15 minutes, during contractions? Yeah right that would happen!---and during that contraction, you will spot the late decel or failure of variability that indicates troubles?
A pink squalling infant after section is not a failure of EFM, when a false negative is a dead or injured baby. If we section before acute fetal distress, that isn't a problem unless your goal ranks the experience over the infant.
"Thanks for you honesty Anonymous! (I'm guessing that you are a physician?)"
So they tell me! We actually had a nice conversation while I was going through a difficult off-service rotation as an EM resident. This was a while back.
"Yeah right that would happen!---and during that contraction, you will spot the late decel or failure of variability that indicates troubles?"
The problem is that a lot of the trouble we think we see on the strip is not real trouble, just minute-to-minute weirdness that we would be better off not knowing about.
C-sections have their own troubles. Not just for mothers, but for babies, too. Babies are meant to squeeze their way out, not be cut out, and the lungs, for example, take a hit with the c-section.
These issues are really complicated, which is why the ultimate test is to monitor some people, do intermittent ausculatation on others, and see how the two groups do.
People did that. The groups did about the same. Monitoring didn't help anything. It didn't reduce the number of dead babies, or handicapped babies, or babies in the NICU. It just didn't help.
Nice article, thanks for the information.
Well Anonymous physician - it sure is nice chatting with you again! Are you a full fledged Emergency Attending now? Do ya have a blog? :-))))
Question from a NICU nurse:
Is it possible the rates of CP are unchanged due to increased number of premature babies being born and surviving vs. the use of EFM that would detect issues early?
@Heather - super question.
Heather - that is a very valid question!
And further to Heather's comment let's not forget how many babies are being born premature now because of routine elective induction of labour. March of Dimes is sounding the alarm on this one.
Yes, I love the 36 weeks induction for TOBP (Tired of Being Pregnant). Will get you a NICU stay almost every time. Fortunately, most of our docs will not induce until at least 38 weeks.
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