Today Andie talks about fetal monitoring during labor and answers questions from her followers.

Points from the video:

Learn about the actual evidence for different types of fetal monitoring and how we got to where we are now.

What is electronic fetal monitoring?

Electronic fetal monitoring is when the baby’s heart rate is followed with an ultrasound machine while contractions are monitored with a pressure sensor. Simply put, we are looking to see if baby is happily and normally beating along, and if they are responding to the mother’s contractions. It picks up any increases in the fetal heart rate (accelerations) and any decreases (decelerations), as well as how often surges are coming and for how long they are lasting.

Where is fetal monitoring done?

Traditionally we see continuous electronic fetal monitoring in a hospital setting, which usually means you have to stay on or near the bed.

Out of hospital birth tends to lean towards a midwifery model of care.  Generally that looks like low tech, high touch with minimal intervention. One of the first interventions seen in hospitals is usually “Here’s your green gown, get in bed and let’s monitor baby”.  And that starts a cascade of intervetions.

Another fetal monitoring option is intermittent, which we call hands-on listening. With hands-on listening, your midwife listens to the baby’s heart rate for short periods of time at regular intervals. With a trained ear we can hear all the details seen on the computer screen. In addition to listening to baby, we are also either feeling with our hands or watching mom to know the details of her contractions.

There are a few different devices that can be used for hands-on listening during labor like a horn or fetal stethoscope, but most commonly you will see a Doppler. It’s such a lovely option because its

  • Comfortable for mom
  • Everyone in the room can hear the heart beat
  • Can be used in many different laboring positions
  • Can be used underwater
  • Allows for more personal space
  • Does not require wearing uncomfortable belt

What Is the Evidence on Fetal Monitoring?

Continuous vs. hands-on listening

Looking at 12 randomized controlled trials including more than 37,000 participants, the researchers found no differences between the continuous EFM group and the hands-on listening group in Apgar scores or cord blood gases, rates of low-oxygen brain damage, admission to NICU, or perinatal death. They also found no difference between groups in the percentage of people using medication for pain relief during labor.

One concerning finding was that people in the continuous electronic fetal monitoring group were 63% more likely to have a Cesarean and 15% more likely to experience the use of vacuum or forceps when compared to those in the hands-on listening group.

There was not a difference in the rate of cerebral palsy between the 2 groups.

Evidence on Intermittent monitoring.

People have asked us if there is any evidence that “putting someone on the monitor” for a set time (e.g., 20 minutes of every hour) is any better than hands on.

They found that intermittent EFM detected more abnormal fetal heart rates (54%). As a result, more people who used intermittent received Cesareans (28%), however, the Doppler ultrasound group had the best newborn health outcomes overall. So,they concluded that the use of a handheld Doppler is a more reliable test for abnormal fetal heart rates than intermittent.

Potential Drawbacks of Electronic Fetal Monitoring

Electronic Fetal Monitoring usually requires that a mother wear two monitoring belts around her abdomen during labor, which restricts movement and may even require staying in bed. Most people in hospital settings give birth in a lying or semi-sitting position. One of the reasons for this is that it is easier for caregivers to access the mother’s abdomen to monitor the fetal heart rate electronically in non-upright positions.

Not all types of continuous EFM restrict mothers from movement, though. Mobile monitors are designed to free up mothers, but they are not perfect. Because they are a continuous monitor, they may carry the same increased risk of Cesarean. Like the continuous belts do, they, too, can shift on the mother’s abdomen when she moves, which may lead hospital staff to discourage movement and position changes.

It’s a common theme, and I was even guilty of it when I worked on the floor in L&D, for monitors to take the focus off the person and place it onto the machine.

If Hands-on Listening is Evidence-Based, Why Don’t More Hospitals Use It?

Liability.

One of the main reasons it is so common is that doctors, nurses, midwives, and hospitals think litigation based vs research based. And that’s unfortunate for outcomes.

Time.

With hands-on listening, someone actually has to be at the bedside of the laboring person each time they listen, and that takes time. It is more convenient for staff to look at the monitor on a screen at the nurse’s station.

It’s important to realize that less time spent with the mother comes at a price. Research shows that continuous support during childbirth is linked to a 25% decrease in the risk of Cesarean, an 8% increase in the likelihood of spontaneous vaginal birth, a 10% decrease in the use of any medications for pain relief, shorter labors by 41 minutes, and a 38% decrease in the baby’s risk of a low five minute Apgar score.

In the United States, the American College of Obstetricians and Gynecologists has endorsed hands-on listening as an “appropriate and safe alternative” to electronic fetal monitoring for laboring people without complications. They state that “Continuous EFM has not improved outcomes for women with low-risk pregnancies” and recommend that care providers should “monitor using a handheld Doppler devices.” Yet, they don’t follow their recommendation or the research.

American College of Nurse Midwives agrees and states that hands-on listening—not electronic fetal monitoring—should be the preferred method.

Summary

Pros for hands-on fetsl monitoring:

  • Linked to fewer Cesareans and vacuum-/forceps-assisted births
  • Leads to frequent contact between laboring people and care providers, which provides benefits from continuous labor support
  • More chances for care providers to observe the health of the mother
  • Supports movement and the ability to use many positions for labor and birth, leading to potential benefits from active labor and upright birthing positions
  • Can be used during water therapy in a tub or shower

The bottom line

Electronic fetal monitoring (EFM) was brought into labor rooms in the 1970s, despite the fact that there was no research evidence to show that it was safe or effective. Randomized trials have found that it has contributed to an increase in the Cesarean rate, without making any improvements in cerebral palsy, Apgar scores, cord blood gases, admission to the neonatal intensive care unit, low-oxygen brain damage, or perinatal death.

To make a fully informed choice, people need to understand the potential risks and benefits of the different approaches to fetal monitoring.

Questions from guests:

  • How serious are the changes in baby’s heart rate during contractions?Most of the time they don’t change. And more often than not, the change is not a big deal. (Especially if the change goes back to baseline rather quickly.) Depending on what part of labor you are in and where in the contraction the change occurs is what we really consider.
  • With intermittent Doppler monitoring, how can you tell if the baby is in distress without actually seeing it on a monitor? There isn’t any research describing that, but the data does show that outcomes are not better with continuous monitoring. They are actually worse. What is typically happening is an overreaction to heart tones that are categorized as Category II, and then, interventions happen that are not research based. Babies and mothers suffer. Sometimes babies have decelerations that make sense. Head compression with pushing etc. can cause decelerations. The best option is to look at the big picture of where we are and what baby is doing vs looking at a screen.  I’ts all in the timing. You should always listen right after a contraction or at the end of the contraction. You are listening for late decelerations. You should also periodically listen through a contraction. I would be concerned if I was hearing late decelerations in early labor and the baby was high.

Resources:

The Evidence for Doulas

Positions During Labor and Their Effects on Pain Relief

The Evidence on: Birthing Positions

 

Check out last week’s talk on VBAC!

If you are in Houston and surrounding areas, check out hhhomebirth.com!

 

About the Author

A certified nurse midwife and doctorate student has been in the Houston birth community for over a decade. Her experience includes elementary school nursing, hospital L & D, birth center, and home birth. Andie is confident in a woman's ability to grow and birth her baby. She feels a partnership in care is empowering and hopes to foster that relationship with families. She has a tender, lighthearted, and hands off approach to the evidence based care she offers. She has been joyfully dating her husband of 16 years since junior high and has five children. Her passions beyond bellies, birth, and breastfeeding are mission work and reading.