The FDA issued a “Dear Healthcare Provider Letter” recently to warn healthcare professionals and facilities about inaccurate readings in certain models of fetal monitors. The manufacturer, Philips, warned that the inaccurate readings may lead to unnecessary interventions, failure to identify the need for interventions, and failure to identify fetal distress. The devise manufacturer recommends that users reduce risks by confirming fetal life before using the monitor and also by using an obstetric stethoscope, Doppler, and ultrasound imaging.
In the United States, nurses are way ahead of physicians when it comes to the issue of fetal monitoring. In the second edition of Fetal Heart Rate Monitoring published by AWHONN in 2008, the authors state,
“Birthing units striving toward evidence-based practice should develop a philosophy of care that promotes the presence of the nurse to provide close support of women in labor and the use of auscultation for low-risk laboring women.”
The American College of Obstetricians and Gynecologists (ACOG) acknowledges the problems associated with EFM. In their most recent Practice Bulletin (#106, July 2009) they say once again,
“Despite its widespread use, there is controversy about the efficacy of EFM….Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative deliveries….Given that the available data do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications.”
Although ACOG states (above) that intermittent auscultation is acceptable, they also state that there is no evidence to support the optimal frequency at which intermittent auscultation should be performed. They recommend that providers review EFM strips at least every 30 minutes during the active phase of Stage I and every 15 minutes during Stage II. In contrast, the only method for intermittent auscultation that they identify (but not recommend) is every 15 minutes during Stage I and every 5 minutes during Stage II. ACOG says that it may not be feasible to keep to such a schedule.
Maybe its time to request that AHRQ (Agency for Healthcare Research and Quality) or the NIH (National Institutes for Health) issue a report and recommended guidelines for fetal monitoring during labor. The evidence is overwhelmingly clear that support during labor has significant benefits. Continuous EFM has significant risks for cesarean surgery and operative vaginal delivery, both of which have their own lists of possible complications. Our health care dollars would be better spent by providing enough nurses so that intermittent auscultation can be the standard of care for low-risk laboring women. A benefit would be the increased support provided by having the nurses in the labor room frequently. We could stop spending so much money and time on trying to make continuous EFM “work,” and we could stop worrying about machines that don’t work!