Comments on: ACOG Issues New Practice Bulletin on Continuous Electronic Fetal Monitoring

By: jennifer

jennifer — Mon, 14 Nov 2011 21:05:04 +0000

Hello, I am a seasoned labor and delivery nurse as well as a certified childbirth educator. I am proud to say I invented a soft disposable pad that is used directly on the external monitor. I believe that if we are monitoring pregnant woman we should at least make it a comfortable experience. the-addition is a soft latex free pad that provides a more comfortable experience as well as less adjustment for the provider, Please visit the website. Thank you

By: Donna

Donna — Mon, 17 May 2010 16:40:08 +0000

After reading the link above re malpractice, I was shocked to see the author tout monitoring as “risk free” (what have we all been talking about here…increased risk of Cesarean without increased benefit, which ain’t small potatoes) and non-invasive. He also states that Cesarean surgery is one of the safest surgeries around (so safe that our MMR is going up as the Cesarean rate goes up). All spoken like a true man who isn’t the one under the knife. I was at a conference the other day and the comment was made that any surgery which isn’t lifesaving is lifethreatening…radical but true if you read the tiny numbers in the stats.

I agree with the poster above that getting the nurses to cooperate with intermittent auscultation is a huge hurdle. At my hospital, if there are doughnuts and pizza in the nurses’ station kitchen, nobody is going to forego that to sit on a patient’s bed and listen to heart tones.

By: Henry Dorn MD

Henry Dorn MD — Fri, 26 Feb 2010 14:10:54 +0000

I think its telling to see who is really upset about the changing guidelines for EFM –
the trial lawyers.

See link for an example
http://www.chicagomedicalmalpracticelawyersblog.com/2009/07/cerebral-palsy-and-the-new-aco.html

By: mrs spock

mrs spock — Sun, 19 Jul 2009 19:50:52 +0000

Until hospitals are willing to provide staffing that allows for 1:1 nursing care during labor, with nurses trained to use intermittent manual monitoring, we will have EFM. I’ve worked L & D, and I’ve never even seen a fetoscope. It was normal to be assigned 2-3 laboring patients to monitor. And since most labors were inductions, or had Pitocin enhancement, it was hospital policy to monitor the heartbeat every 15 minutes minimum. With 2-3 patients, it would be well nigh impossible to to do this without EFM, as well as to complete the other nursing duties required. Until many of the hospital practices are changed- staffing ratios, inductions, pain management, use of Pitocin- EFM will simply not be going away.

By: Amy Romano

Amy Romano — Mon, 13 Jul 2009 00:07:27 +0000

Interesting conversation and hello Jackie from Amy!

Rachel, I agree that we need to publicize the fact that ACOG’s own clinical guidelines say that cEFM is an overused, harmful intervention and that a low-tech alternative is safe and effective. But ACOG has been saying these things for years and years now, and cEFM rates continue to rise (BTW, the 2005 rate of cEFM is 94% according to Listening to Mothers II). Looking at the guideline and press release give a sense of why this is true. The fact that intermittent auscultation is the safer method for the mother and just as safe for babies (barring significant complications in the labor) is given a few lines lip service, while the intricacies of how to interpret cEFM sprawls across multiple pages of the document. This leaves the reader believing that they’ve unlocked the key to making cEFM effective, which is utterly untrue.

Thanks MomsTFH for the link. I had seen that once upon a time but forgot it was out there.

By: Jackie

Jackie — Sun, 12 Jul 2009 22:55:05 +0000

Well, thanks for the link to that article. I’ve spent many an hour in L&D’s on Long Island, NY, as a doula, and the consequences of cEFM are all too evident for some of the mother’s I support, but as a Lamaze educator, I make sure that every doula client of mine has abstracts and quotes and citations to bolster her refusals of cEFM, and the article you linked has some really juicy ones that I can use! And ACOG has a “Committee Opinion, #108″ from 1992 on Informed Refusal which I found in a 2001 “Compendium of Selected Publications” on the “ethical dimensions of informed consent”. I’ll quote form it: “Once a patient has been informed of the material risks and benefits involved with a treatment, test, or a procdedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure, or whether to make a choice among a variety of treatments, tests, and procedures”, and ” the informed patient has the right to refuse to undergo any of these treatments, tests or procedures.” Armed with information, our friends, our sisters, daughters and clients are beginning to refuse. The link you told us about is valuable in that light. So thanks.

By: MomTFH

MomTFH — Fri, 10 Jul 2009 22:46:27 +0000

Here is a good article and bibliography from the U.S. Preventative Services Task Force for anyone who is interested.

By: Jackie Levine

Jackie Levine — Fri, 10 Jul 2009 22:34:20 +0000

I was at a Michelle Odent lecture several years ago and I’ve resurrected my notes, which are not complete for this topic, because this info came from a Q&A portion of the lecture. He said that the best results for baby’s health came from the hand-held “pocket doppler”, and he cited what he called a “very good” triangular study from Zimbabwe published in the BMJ, which was done to identfify the least expensive way of three, fetascope, cEFM or pocket doppler, to acheive the best results…in other words, did they have to buy those big expensive machines if the little ones were effective? I didn’t note the year of that study, but he went on to talk about a study from 1990 in the New England Journal of Medicine that was done on preemies, and even in this high-risk population, intermittant listening by pocket doppler had the best outcomes, and a follow-up on the babies at 18 months showed the most CP in the continuous EFM group. This is all just fyi, because as Amy and Rachel say, EFM rates have only risen, and practices are difficult/impossible to change unless, like thalidamide, there is glaring harm. How many organizations have grown up just to support and protect women’s bodies and their babies, and their rights to normal birth? All the private and public voices, and the people doing research and teaching best-evidence care must keep talking to each other and supporting each other, because gloom about the state of maternity care in our country lurks very near by. Anyway, Hi Amy from Jackie Levine.

By: Gloria Lemay

Gloria Lemay — Fri, 10 Jul 2009 19:31:54 +0000

The trick would be to
a) find a fetoscope in the hospital
b) find a nurse who knew how to use it
As long as there are nurses who have never used a non-electrical, non u/s listening device, ACOG won’t have an easy time changing back to the old ways. Even intermittent electronic monitoring is harmful to babies and has never been proven to improve birth outcomes.

By: Rachel

Rachel — Fri, 10 Jul 2009 13:58:45 +0000

Amy, no worries – I never post on a topic like this without expecting some potential discussion and disagreement. My first instinct was also to pull a copy of the old version and compare line by line – unfortunately that was not possible, and I agree with you that this is a problem. I have seen other org guidelines that are not completely pulled, but are just edited with a prominent note that the guideline has been superseded by a new version – which I think is a much more appropriate and transparent strategy.

As to the reason I was personally interested in posting on this topic (and I try not to speak for OBOS when responding to this type of question, but just for myself) – I was aware that there was already research out there suggesting cEFM is not all it was cracked up to be, including the research the ACOG document cites. As the document reminds us, though, despite that research existing for some time, use of EFM has gone from 45% 30 years ago (before some of the research Jackie cites) to 85% now (and by “now” I mean 2002, but after research has been published questioning the benefits). Clearly, use has gone up and providers are not getting or internalizing the message that this practice and its ubiquity need to be questioned. That, I think, makes it important to publicize the ACOG statement, to inform and notify these providers that their practice is not necessarily consistent with the evidence or with their professional org (for many of them, anyway) – but more importantly to inform readers that this statement exists so they are armed with information if needed when encountering their own birth providers.

Side note: I do think the three categories are somewhat important as well, at the very least as a reminder to clinicians that not every blip warrants an immediate c-section, and to try to apply some consistency for those who are going to persist in using cEFM, considering the poor interobserver reliability in interpreting the tracings that the bulletin authors note. If they’re going to do it, I hope they could at least agree on what it means at some rudimentary level. But I’m a medical librarian by day, so I have an unusual appreciation for categories and definitions.