by Margaret Lent

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that
auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.

The medical profession depends on the latest medical technologies to provide top quality care and to extend that care to a greater pool of patients. This dependence is all well and good where the method, drag, or device is tested in clinical trials that establish its efficacy and safety. But what happens when new technology diffuses rapidly into mainstream medicine well before it has been adequately tested?

The story of electronic fetal heart monitoring (EFM) reveals the problems posed to physicians and patients by the hasty acceptance of relatively unproven devices and techniques. When EFM was introduced in the 1960s, enthusiastic advocates promised that by enabling the continuous, electronic monitoring of the fetal heart rate during labor and delivery, EFM would enable physicians to detect dangerous heart rate patterns and to intervene more promptly than with intermittent auscultation, the long-employed technique of periodically monitoring fetal heart rate with an obstetrical stethoscope. Thus, announced EFM proponents, the device would reduce rates of neonatal illness and death. Based on these promises, EFM became the predominant form of fetal heart monitoring by the mid- to late 1970s.(1) However, experts now conclude that these promises remain unfulfilled and that EFM is, at best, a “disappointing story.”(2) In the twenty-five years of its almost
ubiquitous use, no randomized controlled trial has demonstrated that electronic monitoring does a better  job of saving babies or improving infant health than intermittent auscultation.(3)

Moreover, studies indicate that the inaccuracy of the technique prompts unnecessary interventions and contributes to the nation’s excessively high rate of cesarean delivery, a major surgical procedure which places mother and infant at greater risk of injury and death than noncesarean delivery.(4) Despite the increased risks, the device remains employed in nearly all American delivery rooms. Continued high use of EFM is often attributed to physician concerns about medical malpractice liability and professional inertia. As one EFM critic has observed: “[Doctors] talk about [abandoning EFM] at conferences and at [medical] rounds and listen intently and all of that, but it’s not measurable in terms of changes in behavior. Everybody’s waiting for the next person to get brave.”(5)
 A quarter century of failure in clinical trials and striking new evidence documenting EFM’s imprecision indicate that now is the ideal time for the obstetrical profession to “get brave.” To ensure the safety of their patients and to preserve national confidence in the profession, obstetricians must abandon EFM and adopt safer, more effective monitoring methods such as intermittent auscultation. Close analysis of the legal and medical consequences of the use of EFM reveals that obstetricians have little to fear in discontinuing use of the technique. Not only is EFM an inferior diagnostic tool in the delivery room, but it fails to offer the courtroom protection obstetricians suppose. Moreover, a physician’s decision to return to safer, effective methods such as auscultation should not expose her to liability. In short, there are no excuses left to defend the continued use of EFM.

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Added September 2015

Study showing no value proven for doing so called “non stress tests” before baby is born.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
We found no good evidence to support the use of traditional cardiotocography
(CTG), or computerised CTG, in pregnancy for
improving fetal outcomes. The data are not of high quality and
lacked power to detect possible important differences in either
benefit or harm. We recognise that many aspects of maternity care
may have changed since the trials reviewed here were carried out,
so new studies are needed to assess the effects of traditional and
computerised antenatal CTG before they are used in clinical practice.
http://apps.who.int/rhl/reviews/CD007863.pdf