Lindsey Cool was nearing the end of labor at the St. Alphonsus Regional Medical Center in Boise, Idaho, in 2003 when her doctor decided to use internal electronic fetal monitoring. An electrode was attached to the baby's scalp to monitor his heart rate. Everything was fine during contractions; the heart rate was within normal limits. "After I began pushing, the monitor fell off," Cool said. "My doctor panicked." Without Cool's consent, he ordered a vacuum extraction—a procedure in which a cup is attached to the baby's head and a vacuum pump is used to pull the child from the birth canal. He "ripped my son out," Cool said. She required stitches, and she "almost lost my right labia." After that dramatic intervention, there was no sign that the baby had any heart or breathing trouble.
Electronic fetal monitoring—which also includes external monitoring, in which an ultrasound transducer is placed on the mother's stomach—is supposed to prevent deaths by alerting the doctor to complications that would require an emergency Cesarean or vacuum extraction. Which sounds logical enough: The more you monitor the baby, the more likely you are to catch problems instantly. But study after study has proven that EFM is not logical at all, as it provides no benefit to most patients and creates more problems than it catches.
A federal Centers for Disease Control and Prevention review of controlled studies of EFM found "that routine use of the procedure had no measurable effect on death or illness of infants or mothers," The New York Times reported. "But they said electronic monitoring was associated with a higher rate of Caesarean deliveries, which increases surgical risks to mothers." That's from an article published 20 years ago. Fast forward to a 2013 review of 13 studies, involving more than 37,000 participating women, by the independent Cochrane Pregnancy and Childbirth Group. It found no correlation between EFM and reductions in fetal death.
And yet, EFM is more popular than ever. It's used on 85 percent of pregnant women, up from 45 percent in 1980. In fact, it's the single most widely used obstetric practice in the United States.
So why, despite decades of overwhelming evidence, do doctors and patient alike continue to insist on this largely useless and sometimes dangerous procedure?
Electronic fetal monitoring was introduced in the 1960s and 1970s without much clinical trial. Still, early studies suggested positive outcomes, and in particular led doctors to believe that the EFM could prevent fetal asphyxia, or interruptions of oxygen to the fetus. Since asphyxia was thought to cause cerebral palsy, doctors were eager to use the new technology, which seemed to promise them greater control over birth than ever before. By the late 1980s however, large-scale trials demonstrated no benefit from EFM. Further research confirmed that consensus, and it has been well-established science for more than 20 years that EFM does not improve obstetric outcomes.
But if the science has been against EFM, cultural prejudices have been on its side—and that's proved decisive. Over the course of the twentieth century, and into the twenty-first, birth in the United States has been increasingly medicalized. In part that means there have been more interventions available, including drugs, Cesareans, monitoring, episiotomies, and other surgical options. But it also means that pregnancy has been reconceptualized "as a disruption to health that necessarily requires expert medical intervention, and thinking of pregnancy as primarily about health and illness," according to Amy Mullin, author of Reconceiving Pregnancy and Childcare. Medical technology is seen as necessary, and the more medical technology that's employed, the safer the birth is thought to be. So doctors are reluctant to put aside any tools, even if those tools have been shown not to work.
There's another reason for retaining EFM: fear of malpractice. Doctors worry that if they stop using fetal monitors, they'll be held liable for anything that goes wrong. "[M]any professionals believe that their risk of liability is reduced if they have the paper printouts as a record of fetal heart patterns," Carol Sakala, director of programs at Childbirth Connection, told me. But even that excuse doesn't hold up. According to Thomas P. Sartwelle, a partner at Beirne, Maynard & Parsons in Houston, EFM consistently exposes doctors to unnecessary and costly malpractice suits. Doctors frequently disagree about the meaning of EFM print-outs; one study found that four doctors agreed on EFM interpretation in only 22 percent of cases. And yet, Sartwelle told me, EFM print-outs are used in court to claim that the baby did not get enough oxygen during birth, and that a C-section would have prevented cerebral palsy. This, despite the fact that there is no evidence that continuous EFM reduces cerebral palsy (and the link between asphyxia and cerebral palsy is itself largely discredited). "The very thing that [obstetricians are] relying on to protect themselves is the very thing plaintiffs lawyers rely on to prosecute them," Sartwelle said, adding, "Its ubiquity probably gives everyone comfort."
It shouldn't, as there's evidence that continuous electronic fetal monitoring causes harm. Consider Lindsey Cool's disturbing childbirth story: A false indication of a problem, or even a failure of the equipment, can cause doctor to order dramatic interventions. In particular, as the American Academy of Nursing has stated, continuous EFM "has been associated with an increase in cesarean and instrumental births," which increases health risks for mothers and babies alike.
Continuous EFM can also make labor less comfortable. "Most of the time, continuous electronic fetal monitoring keeps a woman in bed, tethered to the machine," Sakala said. Being unable to move during labor can be annoying and inconvenient, but worse, it can increase the likelihood of unnecessary and potentially dangerous interventions. "Being up and about has been shown to reduce the need for epidural analgesia, shorten the length of labor, and help avoid a cesarean," she said.
There are simple, proven alternatives to EFM. "Midwives have used a variety of tools to listen to fetal heart beat for generations, for pregnancy and labor," Amanda Huber, a certified nurse midwife at Hennepin County Medical Center in Minneapolis, Minnesota, told me. Often a stethoscope or fetoscope is used "intermittently, so we can listen to the fetal heartbeat at recommended intervals during labor and birth." In some high-risk pregnancies, as when labor has to be induced, continuous EFM can be helpful, she said. Otherwise, intermittent monitoring is safer.
Huber's suggestions may sound odd or risky to Americans who have grown used to EFM over the last four decades. But they're not innovative. Even 25 years ago, the American College of Obstetricians and Gynecologists stopped recommending continuous EFM. Others have followed suit. In 2009, ACOG refined its guidelines further; the head of the drafting committee said that EFM "hasn't reduced perinatal mortality or the risk of cerebral palsy." This year, the American Academy of Nursing advised against routine use of EFM.
Even Britain's National Health Service has come around, issuing guidelines last year stating that most women are safer giving birth at home, without drugs or surgery or medical interventions. But in the U.S., labor and childbirth revolve around hospital medicine rather than home midwives. Midwives deliver only about 8 percent of babies in the U.S., and direct-entry midwives—those without nursing certification—are even criminalized in some U.S. states.
Electronic fetal monitoring has been causing gratuitous harm for more than 40 years now, with no scientific rationale except for inertia and obstetric gullibility in the face of a pretty print-out. Still, that inertia and gullibility are awfully hard to overcome. One solution, Sartwelle suggests, is for courts to follow the scientific consensus and reject EFM readings as junk science; once doctors realize that the readings are unacceptable in court, they might stop clinging to them. Professional medical organizations also need to take a stronger stand: Even though ACOG has acknowledged that there is no evidence that EFM conveys any benefit, the organization still says, unbelievably, that all women in labor should be monitored with EFM. But perhaps the best way to effect change is to inform pregnant women of the facts: For most women, when the doctor attaches an electronic monitor to your belly, the chances of complications go up, not down.