By Elke Bachmann, RN, MSN, CNM
Electronic Fetal Monitoring: Evidence vs. Practice
Here’s a story: One morning, just before dawn, a man in a little village started running around its perimeter blasting a trumpet as loud as he could. He did it every day after that, making a ton of awful noise. The neighbors were patient with him for a while. They thought he had to have a reason. He might be mentally ill and needing their indulgence or maybe trying to learn the trumpet with no other time to practice. They put up with it, put in ear plugs, went to bed a little earlier. Finally, it got to be too much for one of the villagers. He went up to the man as he was making all that noise and said “For heaven’s sake, what are you doing? Why are you going around blasting this trumpet every single morning?” and the man said “I do it to keep the elephants away.” The neighbor was stunned. He said “But there are no elephants in America.” And the man replied “See how well it’s working?”
This bad joke is sadly analogous to much of American health care. The staggering costs and burden of suffering from excess vigilance and intervention are beginning to receive some attention but one of the reasons we have this problem is the time it takes us health care professionals to stop doing something once we begin to suspect it doesn’t need to be done. Policies unsupported by evidence become fossilized in the “standard of care”. Routine continuous electronic fetal monitoring (EFM) is one of these things. Chances are, in your education, much will be made of EFM while you hear of monitoring fetal well-being with intermittent auscultation (IA) of the fetal heart rate (FHR) in passing, if at all.
Continuous EFM in labor is not indicated when there is no reason to suspect impaired blood flow through the placenta. There is no reason to ever put a fetal monitor on a normal mother and baby in labor. Not on admission to “see if everything’s ok”. Not once a shift. Not after rupture of membranes. Never. We started monitoring babies in labor because it seemed harmless, like it might help us predict problems, and intervene more appropriately. We continue to do it in 97% of labors because of convenience, habit, unfamiliarity with alternatives, and most egregiously to give the lawyers something to look at in the event of unexpected outcomes. However, decades of in vivo experience and scientific inquiry have thoroughly demonstrated that the only impact of continuous monitoring on well women in labor is a skyrocketing rate of cesarean delivery without concurrent improvements in neonatal outcomes. If nurses had a nickel for every time they heard “You’ll never get sued for going ahead and doing a cesarean.” they could afford to lobby for a nurse midwife driven maternity care system. This does not mean you shouldn’t learn about EFM or that it’s entirely useless. The non-stress test, as part of pre-labor testing, is a very good screening test for fetal well-being. When there are risk factors for or evidence of circulatory impairment in labor, some FHR patterns seen with continuous monitoring are reliably reassuring and others point to problems. Nonetheless, for a healthy mother and baby, without risk factors for uteroplacental insufficiency, the only thing EFM does is increase the risk for cesarean by generating false suspicion, by restricting the mother’s mobility, and by turning our attention from the mother to the machine. The advent of central displays, which enable nurses to watch EFM strips from the desk, takes us farther yet from the bedside even as evidence supports continuous, face-to-face, care for improved maternal outcomes.
While we know continuous monitoring doesn't help maternal or neonatal outcomes, another thing we know is that ignoring fetal well-being in labor is potentially harmful. Intermittent auscultation is the approach that provides us with the information we need while shielding us from the extraneous and putting us back at the bedside. IA protocols are approved by the American Congress of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), and the American College of Nurse Midwives (ACNM). They consist of establishing FHR baseline by listening with a Doppler between contractions, while the baby is not moving. Once a baseline has been determined, we listen from the peak of or through a contraction, until 30 -60 seconds after the contraction every 30 minutes in active labor. During pushing, the frequency increases to every 5-15 minutes. Decelerations in the FHR that start after the peak of contractions and persist after the contraction, significant decelerations from the beginning to the end of more than 50% of contractions, and bradycardia are FHR patterns that require closer assessment and intervention. If you hear these with IA, apply continuous EFM. If you don’t, relax and have a beautiful birth.
Nurses have to be ready for self-examination and scrutiny of other elements in the health system to prevent habits and skewed priorities from replacing evidence based, patient centered care. Students and new nurses, stewards of the future, should always be asking their instructors and preceptors why they do what they do and listening for the tone of the answers. Are they about science and support for adaptive physiologic processes? Or are they about work-flow, staffing, reimbursement, or what is arguably the biggest generator of unnecessary screening and intervention: butt covering? If facts are presented to you, poke around in the literature to see if they have a positive impact or just for scaring elephants. That way at least you won’t be covering your butt with something insubstantial. Cover it with science and strong nurse/ patient relationships instead. Get inspired to build the future of health care on those values and support monitoring of normal babies with IA .
For more information, check out the ACNM Healthy Birth Initiative at http://www.midwife.org/ACNM-Healthy-Birth-Initiative and the UCSF CME on IA at www.ucsfcme.com/2010/slides/MOB10003/19KingIntermittentAuscultation.pdf and in Evidence Based Birth at http://evidencebasedbirth.com/evidence-based-fetal-monitoring/
By Elke Bachmann, RN, MSN, CNM