ACOG: Could you go any slower in making changes?

My internet sources are all a-twitter today with the news that the American College of Obstetricians and Gynecologists have issued a new statement which says, in essence, that all the ultrasound that they have been doppling into the brains of unborn babies has not been done in any kind of scientific way and has not done anything to improve health but, rather, has unnecessarily driven up the cesarean rate to all time highs.

The science has been there for a long time. In 1999, I wrote an article for Midwifery Today Magazine called “Pelvises I Have Known and Loved”. Within the article is this information:

 

In a similar vein, I find it interesting that in 1999, doctors now advocate discontinuing the use of the electronic fetal monitor. This is something natural birth advocates have campaigned hard for and have not been able to accomplish in the past twenty years. The natural-types were concerned about possible harm to the baby from the Doppler ultrasound radiation as well as discomfort for the mother from the two tight belts around her belly. Now in l999, the doctors have joined the campaign to rid maternity wards of these expensive pieces of technology. Why, you ask. Because it has just dawned on the doctors that the very strip of paper recording fetal heart tones that they thought proved how careful and conscientious they were, and which they thought was their protection, has actually been their worst enemy in a court of law. A good lawyer can take any piece of “evidence” and find an expert to interpret it to his own ends. After a baby dies or is damaged, the hindsight people come in and go over these strips, and the doctors are left with huge legal settlements to make. What the literature indicates now is that when a nurse with a stethoscope listens to the “real” heartbeat through a fetoscope (not the bounced back and recorded beat shown on a monitor read-out) the cesarean rate goes down by 50 percent with no adverse effects on fetal mortality rates.

Of course, I am in favour of the abolition of electronic fetal monitoring but it would be far more uplifting if this was being done for some sort of health improvement and not just more ways to cover butt in court. > end of exerpt

Now, it has been ten more years.  Parents usually don’t realize that the electronic fetal monitor is doppler ultrasound.  That doppler ultrasound is 30 times more non-ionizing radiation going into the baby than imaging ultrasound.  Both types of ultrasound cause cellular changes in the baby.

Continuous electronic fetal monitoring ties a mother to the bed and prevents her from moving about freely.  It is one factor in the “cascade of interventions” that leads to a cesarean surgery.  Once the membranes release (waters break), hospital workers often press for continuous internal fetal monitoring.  This is an even more evil crime to inflict on an unborn baby.  An electrode is screwed into the crown of the baby’s head in order to get direct access to the heartbeat.  Breaking the skin to screw in the monitor makes a wide open path for bacteria and viruses to invade the baby.  Any baby outside of the womb would scream if you put one of these devices into his/her head.  Often the baby goes into distress as soon as the electrode is placed—another instance of “you create what you fear” that seems rampant in obstetrics.  The parents are not shown what will screw into their baby’s scalp and the “informed consent” usually is the nurse saying “The doctor wants me to put a little clip on your baby’s head”.  The coiled pin at the end of this device is what is actually screwed into the baby’s scalp by turning it several times:

internal scalp monitor electrode

So, now that ACOG has seen the light, can we expect that hospitals will throw out the electronic fetal monitors and get fetoscopes?  We shall see.  I’ll keep recommending homebirth to parents who want to avoid the danger of cesarean section, infection and non-ionizing radiation.

11 thoughts on “ACOG: Could you go any slower in making changes?

  1. Ugh. I just feel sick that we didn’t know better and allowed my son’s birthing team use the fetal heart monitor. He went into distress twice and suffered all sort of additional trauma (thank heavens we kept him from being circumcised!). He’s had a scar on his crown along with lifelong depression and OCD.

    There are good parenting moments and bad ones. This is a bad one. 🙁

  2. Gloria… Thank you SO much for posting this. I can’t help but wonder what else ACOG will be backpedaling about after years/decades of use or practice (and results/consequences) while others- like probably you and me- questioned the wisdom, efficacy and/or necessity of particular practices and/or technology in the context of birth? (I say this with the current discussion of “pit to distress” discussions going on among women and birth workers across the internet (which means perhaps globally.) Again… thank you so much.

  3. Hi Gloria,
    I found your site from Rixa’s blog. I was intrigued by a comment regarding nursing advocacy you left. It actually inspired me to write a post about this concept, which included your comment. I would love to have your take on this. (sorry to leave a comment, but I could not access you contact info)
    Here is the link: http://realityrounds.com/2009/07/10/are-nurses-cowards-or-what-does-it-mean-for-a-nurse-to-advocate-for-a-patient-post-1/
    Cheers.

  4. As an OB nurse, I totally agree that interventions are over the top.

    If it’s any reassurance to moms, though, I will defend a little by saying that on the unit I work, we don’t use internal monitoring very often. Usually we ONLY do it when the OB would otherwise already be considering a c-section based on external monitoring, so when it’s done, it very often really saves our girls from a section if the more precise monitoring given by internals reveals that the external monitoring was inaccurate or inadequate.

    If this kind of use is lumped together with places that use them routinely on healthy moms, then it’s going to taint the numbers.
    And yes, I know that continuous electronic monitoring of any kind hasn’t been found to be helpful for the overall numbers. 🙂 I’m just saying, within the world of already doing monitoring, since most places do it at this time…

    I also honestly don’t remember ANY of my fetuses exhibiting distress when/after/related to placing a scalp electrode (as opposed to, say, epidurals, which I do sometimes see some level distress after).

    Again, I understand the reticence at the thought of getting one during labor, but in almost all the cases I have done it, I would have agreed if I were the patient, based on the circumstances (keeping in mind that we do NOT do them routinely for healthy labors). “Screwing something into the baby’s head” sounds awful, but when weighing the risk vs. benefit, is lower risk than a section. It may help moms to know that it’s fairly small- smaller than an neonatal IV, smaller than the vitamin K injection. The curved, shallow “screw” shape allows it to curve just under the skin, not deep at all, not as long a shot or IV.

    All that said, leave normal, healthy moms alone!!!!! (I don’t see many normal, healthy moms in my work – it seems like maybe 10-20% of my patients don’t have some sort of complication or risk factors, but still).

    Positive change is maddeningly slow!!!

    ***It is SOOOOOO important to chose providers carefully, but most women just don’t know…*** Moms, do your homework! Educate yourselves.

  5. Dear Mitchsmom, I think the last line of your post sums up one of the big problems that keeps nurses justified in continuing practices that are useless at best and harmful at worst. It’s a ticket out of guilt for the nurse. The “moms” should have done their homework, they should have educated themselves, they should have declined the treatment, they should stick up for themselves.

    I would ask you “What if we were talking about personnel on an airline?” When you travel on a plane do you do reading and planning about what you will do if the oxygen masks fall down? No, of course not. You rely on the personnel to tell you what to do every step of the way so that you don’t get into trouble and you come off that plane in the best way possible.

    That is the unspoken agreement with the public that medical personnel have made. It is not stated anywhere but it’s implied “Come to our hospital. Don’t have a baby at home. We will do everything we can to make sure you go home with a baby born in the healthiest way possible.” The public is led to believe that with all the nursing claims that they advocate for patients. It’s a lie and it’s time that nurses either delivered on the implied promise or declared themselves to be too professionally handcuffed to do a proper job. Nurses didn’t always have screws to put into baby’s heads. They listened to heartbeats with stethoscopes and the cesarean rate was much lower and the infant mortality rate was the same.

    Would you be willing to have another nurse put an internal fetal monitor in the crown of your head? I’ve never met an adult yet who would allow me to do that. We can not justify doing these awful things to the smallest, most vulnerable humans just because they can’t talk and fight for themselves.

    Childbearing is done by women, not “girls”. Those women have a right to expect that the professionals will act in their very best interests at all times. Women don’t want to have to do 4 intensive years of study in order to have a safe birth at a hospital. They are busy with their own careers/lives and have a fundamental right to the truth from childbirth professionals.

  6. EVERYONE needs to do their job. EVERYONE has a part and a responsibility, and yes, that includes the patient. I can’t feed her decent foods, I can’t keep the street drugs from her, I can’t force her to take her hypertension, diabetes, or other medications, and I can’t force her to stop going to the crappy provider that she might be seeing.

    What I can do, and what we do at my work, as far as I know, is the MD’s and nurses on my unit follow the guidelines of our respective professional organizations, so I couldn’t agree that we don’t advocate for our patients. (There may be one MD who doesn’t always follow guidelines, so far I have not personally come into conflict in a situation with him, but if he wanted me to do something against my professional guidelines, YOU BET I would refuse & go up the chain of command.)

    Yes, sometimes the change is maddeningly slow, but what would have us do it the meantime? Quit? Then there would be no providers.

    We are not generally going to stray from the guidelines of our organizations, because of lawsuits. Reality. That is the biggest problem that needs to be fixed to stop the cascade. That and the insurance system that encourages providers to see so many patients that they don’t have the opportunity to form a trusting bond.

    You’ll probably see this as yet another cop-out, but most of the time these decisions truly are in the hands of the MD (who again, in turn, largely acts by her organization per the legal ramifications).

    To wit, I can’t say “no, I’m not going to put her on monitoring”. I would be fired.
    I of course agree that patients shouldn’t have to get an in-depth education in order to get a safe birth and compatible provider. But I do think that they should put more thought and time into these decisions than they should for, say, buying a grill or watching Judge Judy. At least as much as for buying a car! Please.

    I constantly educate my patients, aim for truly informed consent, and advocate for things that they want. And the minute that MD walks in the room, they become MUTE. They aren’t even the same person I was just talking to 5 minutes ago. The MD is a god who magically imparts the zombie-like “ok” response of almost all patients. So yes, I feel that I fulfill my part, AND yes, the patient does share responsibility on her part as well. They are NOT mutually exclusive. Birth is not all or none, all this way or all that way.

    Does that mean that everything I do is in vain?

    When I decided to go into working with pregnant women, I purposely and deliberately chose to work in the hospital setting to be “closer to the enemy”, to help change views, and to support women the best I can within the given constraints.
    While I support women’s decision to birth in whatever setting they want (except unassisted, which I don’t agree with), I feel most home birth women are already on the same page with me or close to it, and I don’t think I would find that as fulfilling and challenging. I would be preaching to the choir.

    Some are healthy, imformed women that need the kind of support and “normal birth” advocacy that we’re talking about, and I LOVE doing that.

    Sometimes my support is subtle, and it’s usually totally unknown to my patients. I love that, too.

    Like when the MD calls for an update, telling the MD that yes, a pt is fine and yes, she is going to be able to do this, rather than making a face and saying “she’s circling the drain” and “when are you going to cut her?” if she hasn’t made progress “fast” enough.

    It is often letting her labor down or push way down before I call that MD who may be more likely to turn on the last minute interventions (vacuum, episiotomy or whatever- although we don’t do many of either of those, still) if present and feeling that it’s taking “too long”.

    It’s suggesting to the MD to “let” her walk while “ruling out” early labor before admitting her inpatient (to the routine orders of continuous monitoring).

    It’s not reminding the MD that she forgot to break the patient’s water (too early on). It’s a million things like that, that I can do within my scope, constraints, and professional guidelines.

    Most often my patients are not very educated, from a rural, low socioeconomic background with some degree of high risk & need a vigilant, intelligent eye watching and caring that their complication doesn’t impart harm, death or disability to them or their babies. Someone who knows when intervention IS truly needed and when it’s not. Someone who can balance the truth and STAT actions with calm reassurance and caring in a critical situation. Someone who will take the time to explain the why’s of smoking being bad for the baby, what the fetal fibronectin test is and how it can alert us to further risk of another preterm baby for her, why protein shows up in her urine with preeclampsia, why her baby is at higher risk for hypoglycemia since she’s diabetic, on and on.

    I LOVE the whole spectrum – advocating for the most normal, low intervention births that I can all the way to the most high risk critical situations.

    And yes, I already wrote that I would consent to an FSE in the vast majority of scenarios in which we place them at my work. If we put them on adults, yes, I would get it on my own head in the proper situation. As I implied, I would rather get that than an IV or IM injection (all the more so if my skin was fluid-and-vernix-softened and easy to slide just under as an about-to-be-born baby’s is). I would venture to guess that the adults on my unit who know what they are and have observed many, and other adults that understand fully what is is, would agree, given an indication for it and not for a healthy routine patient.

    Thanks for making me think about my job, my decisions, and the care I give to my patients.
    After reflecting, I feel that all in all, it has been the right choice. I love my work and I feel that the vast majority of my patients are very happy with my care. Would I want someone like me caring for my sister, daughter or friend? You bet. Have I made mistakes? Of course. Does it always go the way I would have liked? No. But most of the time, yes. And have I been able to help for more positive outcomes for my patients? Absolutely.

    I am lucky that my husband’s income can support us, and I don’t work because I have to financially. I could quit, I could chose something else. But I don’t.

    We both probably have more beliefs in common than not, we have just chosen different ways to work toward fulfilling those goals and beliefs.

    P.S. I used the term “girls” is used as a term of endearment and with a motherly, friendly, protective instinct in mind. I don’t use it in conversations with patients in any case. My colleagues and I use it for patients, each other, and our female MD’s (i.e. “Which one of the girls is on call tonight?”). If that’s one of the worst things I’m doing, I’ll take it.

  7. As I said earlier on FB, I honestly can not understand the reasoning that went through a persons brain when they came up with the idea of the internal monitor. On what planet is it acceptable to even dream about screwing an electronic device into an unborn babies head?! And when that person brought the idea to the “board of directors” (so to speak), why did they not immediately have him committed to a home for the freakishly insane?

    Just over 18 years ago, I had a doctor try to ram one of these things through my closed cervix (ok 1/2cm dialated….same difference)…. after I kicked him in the chest and told him to get the hell away from me, He just shrugged and said, “OK, book her for a C/S”…… but I don’t have harbour any harsh feelings about it. Much.

  8. I do know there are no easy answers and I do know that I am living in an idealistic bubble because I work with very motivated women. I think I would last about 10 minutes as a labour/delivery nurse.

    There does need to be a revolution amongst nurses though. I remember when I first started doing birth coaching in hospital 30 years ago. At that time, if you got your dr. to agree to something in the office, then, we could say to the nurses “Well, the dr. agreed to that.” and they would acquiesce. I remember the first time a nurse said to me “Well, I won’t do that. It’s against my ethics as a nurse and if you don’t like it, you can talk to my nurse manager—she’ll back me up!” That was a breakthrough moment for nurses. It made it difficult for me to manipulate them but I was proud of them for finally growing a spine and for backing each other up.

    Then, another memorable moment. The doctors (mostly male) would come in to the labour room, wash their hands and then stand and wait expectantly while the nurses opened a package of sterile gloves for them and spread the paper package and lining reverentially on the end of the bed. A good nurse would always remember what size each doctor wore. One night, the doctor said to the nurse who seemed to be oblivious to his needs “Nurse, I need a size 8”. She replied “They’re in the bottom drawer.” I’ll never forget the hurt, confused look on his face. Another revolutionary moment in nursing as far as I was concerned!

    That’s why I have a dream of a major revolution in nursing. Nurses really standing up (and, yes, risking their jobs), joining forces with each other and refusing to keep the b.s. going. All this nonsense about the dr “delivering” the baby–even the cleaning person can catch a baby that’s being born spontaneously. All the butt covering. All the put downs of women and their partners. All the persecution of midwives and their clients coming in from homebirths (the police are called any time I show my face in a hospital, nice).

    Just as those shifts around obeying the dr and opening gloves have happened in the past, I think there’s a huge possibility of nurses having work they can be proud of when they realize how much power they could have to really enhance the formation of new families.

  9. Girls? Patients? Methinks it’s more than monitoring you need to think about, Mitchsmom. Language is a direct reflection of what’s happening in our minds. If you think of yourself and your clients as children, no wonder you perceive the system as beyond your capacity to change.

    There simply is no justification of monitoring, no science backs it and as an advocate of normal physiological birth, I prefer science. There is likewise no genuine need for birth to even happen in a hospital unless illness is present and how easily that would remove the justifications for all that rubbish about monitoring if women just birthed under their own steam when their babies were ready.

    Women give birth, children don’t, as a rule.

    Thanks, Gloria. Great post.

  10. Pingback: It’s Distressing « Woman to Woman Childbirth Education

  11. I hope ACOG stops doing male circumcisions, since there are more people suing their circumcisers either for lack of real ‘informed consent’ or when they become 18 years of age. Sue them sue them, that is the only thing that seems to work, fear of lawsuits!

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