External Fetal Monitoring

Fact or fiction? External Fetal Monitoring allows us to rescue babies from death or brain damage.

The reality: "[More than 40] years after EFMs became part of intrapartum care...it is yet to be proved of value in predicting or preventing neurologic morbidity." (Rosen & Dickson)

What is an electronic fetal monitor?

An electronic fetal monitor also known as:

an EFM

an external fetal monitor

an electronic heart fetal monitor

It is an instrument used to record the heartbeat of your unborn baby, as well as your contractions. It can be internal or external. The thought was that EFMs could monitor difficult and high risk labors to ensure the delivery of a healthy baby...so the development of this device stemmed from something very good don't you think? However has this proven to be true?

Unfortunately, the answer is no.

The External Fetal Monitor

Using an external fetal monitor is simple and painless - however uncomfortable and restricting to you! Two elastic belts are placed around your abdomen. One belt holds a listening device in place while the other belt holds the contraction monitor. The nurse - or midwife - adjusts the belts to get the best readings from each device.

Sometimes, it is difficult to hear the baby's heartbeat with the external monitoring device. Often, the monitor may show subtle signs of a developing problem - often times these assumptions are incorrect and there is no real threat to you or your baby.

In some cases, the doctor - or midwife - may recommend that the external belt be replaced with an internal fetal monitor - IFM.

The Internal Fetal Monitor

The internal fetal monitor - or IFM - is an electronic wire that is screwed in the skin of your baby's head after your membranes have been ruptured. The provider will place it in the baby's head during an internal vaginal exam.

The internal monitor can only be used when your cervix is already open.

The IFM provides a more accurate record of your baby's heart rate. HOWEVER, it is NOT without risks!

The risks of the internal fetal monitor device are severe:

The electrode itself provides a convenient route for the entry of bacteria and viruses into the amniotic fluid and/or your baby's scalp (Cunningham et al. 1989:301).

With an internal fetal monitor, the rate of infection doubles in comparison to external fetal monitoring.

"If it were not for antibiotics, the death rate from monitor-produced infections would be staggering."

Your baby is also at risk of infection from the electrodes. Remember, they are in his scalp!

Of all monitored babies - with an internal fetal monitor - 4 to 5% will suffer from scalp abscesses, lacerations, hematomas and hemorrhages (Brackbill et al 1984:11).

However, all the risk of infection is not the greatest risk to your baby...the risk of cord prolapse is. A cord prolapse which is a direct result from your bag of water being artificially broken - AROM (Cunningham et al. 1989:301).

"Many mothers leave the hospital firmly convinced that electronic fetal monitoring saved their babies from otherwise certain death caused by cord prolapse when in fact it was the monitoring (and prerequisite amniotomy) that caused the prolapse in the first place" (Brackbill et al. 1984:11).

We won't even go into what something this painful (have an electrode inserted in your scalp) might do to your baby's psyche! Will he wonder about this new world which is welcoming him this such pain?

Here is another fact: More babies have abnormal fetal heart rate - FHR - patterns with external fetal monitoring than with auscultation...

External Fetal Monitoring

So why use something that is inaccurate?

The reasoning behind external fetal monitoring is this:

Asphyxia - inadequate oxygen - during labor can cause many perinatal death and cases of mental retardation and cerebral palsy (CP). Listening to your baby's heart rate picks up abnormal patterns before anything bad happens therefore avoiding a negative outcome...however the fact is that intervening rarely averts them.

The problem must be too little information too late.

You may think: "Surely a machine that continuously monitors the fetal heart rate of my baby - and traces analysis - will give my doctors a reliable means of diagnosing fetal distress and preventing damage..."

Unfortunately, this is not exactly true.

As studies show, the belief that abnormal fetal heart rate patterns are reliable predictors of asphyxia is a grave error. Even when asphyxia precedes brain damage, it may be a result, not the cause.

External fetal monitors have a high false-positive rate and a very low false-negatives rate. The high false-positive rates give a sense of truth...we want to believe that we are doing everything we can to make sure your labor has the best outcome, right!?

But if the link between abnormal fetal heart tones and asphyxia symptoms is weak and the tie between asphyxia and brain damage is weak, then the link between fetal distress and damages is weak indeed!

As will all measures of fetal well-being, good news reassures, but bad news does not unequivocally confirm problems. Another mistake is the belief that information from a machine is more reliable than information from people. For example: sometimes the transducer picks up the maternal pulse instead of your baby's resulting in a false diagnosis of bradycardia - abnormally slow heart rate - and a possible emergency c-section, unless someone compares the monitor with your pulse.

External Fetal Monitoring: What the Studies Show

Out of 10 randomized controlled trials, only 3 proved to be beneficial...but those weren't without issues:

So what if we told you that external fetal monitoring actually does harm?

From 1980 to 1989, c-section rates for external fetal monitoring groups with diagnosis of "fetal distress" increased nearly 10 fold - from 1.2% to 9.9% respectively.

Several studies have shown that personal contact - auscultation vs. EFM - reduces complication and intervention rates.

In the United States, the external fetal monitoring rate was 45% in 1980, up to 73% in 1999 and as some reports show, it was up to 93% in 2007. This increase however, was greater among low-risk women, who were least likely to benefit, than high-risk women.

External Fetal Monitoring: What Doctors Tell Us

Doctors tell us that external fetal monitoring protects them against malpractice suits or that hospitals have too few nurses to auscultate often enough (Ob Gyn News).

The malpractice argument rests on the belief that tracings are valuable courtroom evidence and that not using electronic fetal monitors renders doctors liable because it is "standard practice."

As to malpractice suits, H.F. Sandmire observes that a tracing "leaves a permanent record for hindsight interpretation by expert witnesses" who will claim that mild deviations indicate fetal distress.

As to the liability issue, M.G. Gilfix reviewed the law pertaining to electronic fetal monitoring and informed consent and he concluded that [using auscultation over an electronic fetal monitor] did not render a doctor liable because of the abundant evidence that auscultation is equally good.

Furthermore, Gilfix says informed consent demands that women be informed of risks and benefits of proposed tests and treatments, which would mean a duty to inform women that electronic fetal monitors have not been shown to improve outcomes, but rather increases c-section delivery rates.

And finally, about too few nurses to auscultate... it really means too few nurses provide optimum care.

Henci Goer in her book "Obstetric Myths versus Research Realities" ends with this:

External Fetal Monitoring: More Facts

H.L. Mencken is supposed to have said:

Electronic fetal monitoring is a perfect example of this!

The profound message of the external and internal fetal monitors is that your body is so defective and in danger from potential malfunction that it is necessary to apply a special machine to more exactly monitor your baby to protect him from potential harm caused by you. And that even justifies screwing an electrode in your baby's head without the benefit of pain medication if need be!

Internal and External Fetal Monitoring: Reviews

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