March 5th, 2011
Imagine a woman in labor at the hospital. How she is moving? Where is she in the room? What is she doing? Probably you see a woman lying down in the bed, wearing a hospital gown, hooked up to various monitors, straps and tubes.
In some high-risk labors these procedures may truly be necessary for the safety of moms and babies (or for women using epidural medications). Most healthy low-risk women do not need to be hooked up to anything in order to safely birth a baby. Imagine how different hospital birth would be if most women could move around as they pleased without any sensors or straps attached to them. Imagine women moving instinctively, following their own inner rhythm and positioning themselves in ways that made their bodies feel powerful, relaxed, and productive.
How might this freedom to be mobile affect their sense of privacy and autonomy? How might nurses and doctors entering the room approach a woman who was walking around and moving instinctively rather than laying confined on the bed? When women are mobile and moving with the rhythm of their labor they are less likely to accept the battery of routine procedures and vaginal checks than if they were lying in bed. Women would have more self-confidence and a stronger connection to their primal birthing instincts if they could move how and where they pleased without being attached to fetal monitors, which effectively serves as an constant (if subconscious) reminder that their bodies or babies could fail at any moment.
Electronic fetal monitoring (EFM) surely has its place. It can help us observe what the heart is doing, how well oxygenated the baby is, and whether the baby appears to be struggling or happily trucking along. EFM became routine in the 1980′s under the assumption that it was going to save babies lives and make birth safer. It was believed that continuous monitoring would pick up the small number of babies who show signs of hypoxia or distress and allow them to be ‘saved’ by cesarean section. Today we have decades of evidence showing that continuous EFM has no effect on neonatal mortality or morbidity — it does not help babies be born any healthier. It does however increase the risk of cesarean birth by about three times. As with many obstetrical interventions that become standard before adequately being studied to see if they do any good, EFM was studied after it became a routine part of hospital birth.
We now know that a baby’s heart rate in labor is not great indicator of how well the baby is going to do after s/he is born. Regrettably, the technology has been applied in such an extreme manner — virtually all women in the US are attached to a fetal monitor during most or all of their labor — without consideration of whether there could be too much of a good thing. Physicians know this, and many will freely discuss it. Both the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care recommend against routine EFM for low-risk women and cannot even recommend it for high-risk women in labor.
Why then are healthy, low-risk, un-medicated women still being confined to fetal monitors when we know they don’t make birth any safer?
1) Electronic fetal monitoring produces a permanent written record of the baby’s heart rate. It is believed that this record will help protect physicians against claims of malpractice or negligence should a patient decide to sue in the future. One labor and delivery nurse on My OB Said What?!? shared the truth:
“We always do continuous fetal monitoring, not because we think it helps, but just for legal reasons.”
2) Nurses are overworked and maternity floors are often under-staffed. It is easier for nurses to manage multiple patients when they are being monitored electronically. Nurses already perform the majority of care given to women in labor and they have heaps of charting to keep up with on top of patient care. A well-known physician and midwifery advocate confided to me that, as with many aspects of maternity care, EFM boils down to dollars and cents. Keeping women strapped in and hooked up affords hospitals a higher nurse-to-patient ratio.
There is another way to monitor babies that does not require being strapped to a monitor: periodic monitoring with a hand-held doppler (or fetoscope if you are hoping to avoid ultrasound). This kind of monitoring is called “intermittent auscultation.” It is what midwives do at homebirths. ACOG even acknowledges it is a safe and appropriate method of monitoring babies. Physicians and nurses do not typically use intermittent monitoring because it requires one-on-one nursing care — something hospital labor and delivery units do not provide. It also requires that maternity floors keep a hand-held doppler readily available. I have attended numerous births where women have been told that yes, they could be monitored with a doppler if only they knew where one was. (I wanted to include a photo here of a hand-held doppler being used in the hospital. After about forty-five minutes of searching I gave up.)
Some women ask their physicians or midwives prenatally about how long they are required to be hooked up to the monitor. They are commonly reassured that they will only have to be on the monitor periodically each hour, maybe twenty minutes. Twenty minutes each hour adds up to a lot of time for mothers to be hooked up and immobilized if there is no wireless EFM. And it is a slippery slope. When you add in pitocin and pain medication, or a “concern” about the baby’s well-being, periodic monitoring quickly turns into continuous monitoring (cEFM). When one intervention leads to numerous others we call it the cascade of intervention. EFM is a significant component of this cascade.
This is an area however where pregnant women CAN create change. You can demand the freedom to be mobile in labor. You can demand to labor without electrodes and sensors on your belly. The science is on your side. Midwives are on your side. ACOG even supports you (in theory). So yes — you CAN say no to the monitor, but you will need to bring your own doppler … and your own nurse.