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.

Women typically spend spend a large portion of their labor hooked up to machines in bed while laboring in the hospital.

Women typically spend spend a large portion of their labor hooked up to machines in bed while laboring in the hospital.

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.

Comments

15 Comments

Post a comment
  1. March 8, 2011

    This is the stuff that gets me so worked up! Very articulate, tho. Thank you!

  2. Tracy #
    March 9, 2011

    Even without a hand held doppler available, one can use the EFM paddles to do IA. We do IA using the monitor at our hospital all the time. Just turn off the paper printer and use it intermittently the same way you do a doppler.

    It’s not the lack of technology, its motivation to provide 1-1 care and training to responsibly and correctly do IA (it’s a skill that definitely many nurses lack). We follow a set of Fetal Health Surveillance guidelines here which strongly discourages continuous EFM unless clearly indicated.

    Tracy, Registered Midwife BC Canada

    • March 9, 2011

      Tracy, unless the L and D unit has a wireless set (most in the US don’t, or they only have one, maybe two) the laboring woman still has to interrupt herself and go over to the EFM machine which can cause a significant shift in a laboring woman’s rhythm, eh? And I agree completely, the motivation simply is not there. It’s interesting how hospitals will go to great lengths now to appeal to women aesthetically — how many L and D units have undergone recent remodeling complete with the tubs that cannot hold enough water to cover a mama’s belly, and of course, are not for birthing. But when it comes right down to it, it’s just a remodel. The status quo has not changed, relatively little has become “mother-friendly” in practice. Increasing the nursing staff available to laboring women would require a cut into profits.

      • L&D RN #
        July 17, 2011

        well, going to the hospital in and of itself causes a significant shift in the laboring woman’s rhythm! As an L&D nurse, we do have a doppler in a drawer with a fetoscope (and I know how to use them, I practiced with OOH mws for years). If a mama wants intermittent efm I am obviously all for it, but also use the monitor transducer most of the time, as mama usually is around the bed (I like to put the bed all the way up in high position to provide an area for mama to stand and lean on). If she’s not, I’ll get the doppler out. If a doppler wasn’t available I would definitely think that using the monitor and getting the mom to move close to bed would be better than just giving up and strapping mom to the monitor. it’s still intermittent if they have to move within 5 ft of the monitor. honestly, I don’t think the fetoscope has been broken out for labor auscultation ever.

        It is sucky that hospital policy is for cEFM, and intermittent requires “permission” from their doc. I work hard to still get my mamas out of bed or however they are comfortable (the mesh panties actually work well to hold the transducer in, and they stay fine if they are standing or leaning, but not so much sitting) while still doing cEFM, but it’s hard.

        In my experience, those telemetry monitors really suck. I love the idea of them if we have to do cEFM, but in practice they just never work, no matter how hard I try.

        If you want/need a hosp birth and this is important to you (as it would be to me), make sure you discuss it with your doc first. It’s not the nurse that gets to call the shots in this case, we need to get permission from the doc to to intermittent EFM, and, yes, it’s not about safety so much as a legal record. If you have an induction or are being augmented with pit (ugh), then there’s not much you can do to get out of cEFM.

  3. March 26, 2011

    I work for a diagnostic imaging company (with my father) and, whenever someone asks about which hospital/OBGYN we’re using, I’m rewarded with sad and concerned looks as I carefully explain that, “Actually, we won’t be going to a hospital to have the baby and we’ve chosen to use a naturopathic midwife to help us with the birth.” I was actually told by a coworker that midwives don’t know what they’re doing and that I needed to see a “real doctor.” My father regularly tells me that I’m going to “regret” the choices that my husband and I are making for our child. He’s even gone so far as to tell me that my mother must not remember my birth accurately because “She definitely did not enjoy natural childbirth. I felt horrible for her because she was so worn out she could hardly enjoy you.”

    There seems to be a total lack of education in medical schools on the dangers of the making birth into a medical emergency. When I mentioned that I am nearly 4 times more likely to die in childbirth here than in Bosnia, some of our doctors (and my father) simply did not believe me. Even when shown the exact WHO 2010 statistics sheet which lists the numbers, they still have a difficult time believing that it could possible be correct. Accepting that women can (and should) give birth with minimal assistance goes against everything they are taught.

    Erin, you’re exactly right that the mentality of hospital birthing has to change. Until that happens, women will still be labeled irresponsible and will continue to be given unnecessary and dangerous interventions.

    • March 31, 2011

      Amanda, thank you! You are so right. “Real Doctors” are great for times of sickness and disease, or when moms and babies become high-risk. But for most women (who are low-risk), birth at home is safe, beautiful, magical, empowering, and NORMAL. I hope your courage to follow your instincts is an inspiration to the women around you!

  4. nikki #
    April 6, 2011

    I was a victim of the cascade of intervention with my first born and fetal monitoring was a part of it. The doctor used a blip on the graph where i had shifted the monitor as evidence of ‘fetal distress’ and forced me onto pitocin against my will by threatening to send me away to another hospital if I didn’t conform to her professional demands for my care. I believe that one nurses’ intervention may have saved me from further intervention (such as suction extracting the baby by the head or possibly c-section). When I was too tired to push after many hours of labor on a high pitocin drip, the nurse got on the bed with me holding my hands and her feet on my feet and helped me to counter push. She literally pushed the doctor aside and got on the bed. I’ve never known her name as she was even there after her shift ended and I didn’t see her again. I wish she had intervened much earlier in the cascade, but I’m thankful that she finally got in the doctor’s way. Today I use midwives for my care and I’m much happier and healthier as they don’t consider drugs and surgery as the first recourse and don’t treat pregnancy as illness to be relieved of.

    (On a separate tale- my brother once questioned a doctor about the care decisions being made in the hospital and as a result was reported to cps! years later they continue to have had escalating issues with cps that have cost thousands in lawyers and have impeded their ability to work as they attend court dates and have lost one of their jobs because of the time required to be at court. Hospital doctors will use force to make people conform, be it by verbal threat or by use of authorities against you. You may have rights, but they are more concerned about being right and about covering their asses against malpractice.)

    Thank you for your blog! I can’t say how much I’ve felt better to find homebirthing and the people practicing it and participating in it. I feel at ease, like I’m not crazy for doubting the system in place. Thank God for hospital medical practice for the worst cases, but it really needs put into perspective for so many reasons and not the primary approach to healthy pregnancy!
    ~n<3

  5. April 22, 2011

    Well — you may not need your own doppler, but you definitely should have a at least one, and preferably two, well-prepared support people with you!
    I agree with Tracy that it is quite possible to do IA using the fetal monitor US as a doppler. And I think that most L&D nurses are pretty well trained in finding FHT with that instrument. Personally, I don’t think it is much less of an interruption in your rhythm to have your care provider apply the doppler across the room than it is to move to within monitoring distance of the machine for an IA check.
    When I was first working with Labor and Delivery Nursing, I found it quite possible to attend more than one laboring couple at a time using IA in a hospital setting – as long as the couples were educated in supporting one another and actively cooperating in the process. But that was a generation ago.
    After a number of years at home with my children (6 boys), I found myself back in Labor and Delivery nursing. Between 1998 and 2006, the practices and policies I worked with seemed to become more and more oriented to what I can only call production-line birthing and I stopped working in a hospital L&D area.
    Personally, only one of my boys was born at home, but I did a lot of self-directed learning and after that only seemed to arrive at the hospital just in time to deliver the others (Attendant wouldn’t come to my house!). Today I have several friends who are interested and involved in home birthing options.
    Since I am convinced that education is the key to liberating families from what I see as the tyranny of paternalistic medicine (practiced by much of the medical establishment), I have authored an Internet site to combat the endemic ignorance in our society regarding pregnancy in general – and labor management specifically. VirtualPregnancyCourse.com encourages pregnant couples to learn about the options and work with their primary care provider as a cooperative birthing team – led by the pregnant couple themselves.
    I hope it will help today’s generation of pregnant couples use pregnancy, labor and delivery as a natural learning and bonding experience.

    • April 22, 2011

      Margaret, thank you for your comments! I look forward to checking out your site!

      There is so little transparency in hospital birth, it is imperative that women hear the insider perspective. I know countless L and D nurses — physicians even — who had their babies at home.

      In terms of IA in the hospital, I do think it is a significant interruption to ask a laboring woman to move over to the machine every 15-30 minutes to be monitored. What if she is laboring in the tub? Or starts pushing in the tub? Or is simply in labor-land over a birth ball? I hate to disrupt a laboring woman who has found her rhythm and is in the trenches of labor. Even unnecessary taking can be a disruption to her work. I’m coming from a homebirth setting however, so I suppose in the grand scheme of hospital interventions having to accommodate a fixed EFM device is a relatively minor disruption.

  6. Jac #
    July 16, 2011

    Actually, the most recent (and largest) study into EFM shows that it is associated with lower rates of early neonatal mortality.

    http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937811004807.pdf

    • July 19, 2011

      Thanks for sharing this! I’ll take a close look. Quickly glancing at this though, it does not compare EFM to other intermittent auscultation. It only compares babies who were monitored with EFM to babies who received no EFM. Who were the babies who received no monitoring? We would expect that babies were not monitored in any way to have worse outcomes. Relying on birth certificate data can be tricky like that.

  7. Chanda #
    January 7, 2012

    I am pregnant now and have had to make the difficult decision to give birth to my baby in a hospital because our insurance company flat out refuses to pay the birthing center that I chose and regardless of how ridiculous it sounds…it’s going to cost me more to give birth naturally at a birthing center than it will to have the baby in the hospital with all the interventions. I’m now going to be seeing a nurse midwife at an OB center and am having to have the baby in the hospital and am extremely concerned that my birth plan will not be respected by the staff at the hospital. This is my 3rd child and I’ve never had even the slightest complications either during pregnancy or labor and delivery. Both of my previous labors were subject to continuous monitoring and I had really hoped to NOT have to have this because I find the process extremely annoying, frustrating and uncomfortable. Being confined to bed is not my idea of how things should go during labor. I am hoping that with the switch to a nurse midwife I’ll be able to have some autonomy in how I choose to labor but as I’ve never used one before I’m really anxious that because of her affiliation with the hospital she’ll bow to the hospitals wishes for cEFM. Does anyone have any experience with nurse midwives and how their care decisions are influenced by the environment in which they work?

    • February 25, 2012

      Chanda, THANK YOU for posting this. I feel like everyone frames hospital birth versus home/birthing center birth as a choice–as in, “Oh, if you feel safer in a hospital, then by all means, choose a hospital birth”–when in reality, insurance-based health care calls the shots. None of the home birth midwives or birthing centers I’ve consulted work with insurance companies at all, so it looks like it’s a hospital birth for me.

      The hospital I’m currently slated to give birth at has a well-regarded midwifery practice, but at our first prenatal appointment, the midwife told us that a 20 minute period of EFM and a saline lock (an open vein without an IV attached) are “nonnegotiable” hospital policy. I’m wondering what will happen if, when I show up in labor, I simply refuse to submit to them.

      Out of curiosity, do you have a doula? I know there are a lot of doulas that work on sliding scale costs, or as volunteers. I’m hoping that whatever doula I work with will help me push back against hospital policies.

      Honestly, the whole idea of spending 2+ days in a hospital when I’m not sick is just ridiculous–extravagantly wasteful and utterly degrading.

      • Chanda #
        February 29, 2012

        Hi Julia!

        At least I’m not the only one that feels pressured into the hospital birth because of the health insurance thing. It’s obnoxious! After I posted my earlier note, I actually got to meet my midwife and I had the chance to ask her these questions. She told me that if I don’t want the IV port and I’m not having an epidural, I don’t have to have it (but the hospital makes me sign a waiver) and that if there is no medical necessity for EFM that we don’t have to submit to that either. Luckily for us though, even if we do need EFM they have telemetry monitors so I don’t have to be tied to the bed for monitoring purposes. Although I have to say…what use is the jet tub in the labor room if the mom can’t actually sit in it because she’s hooked up to so much stuff!? lol Here’s hoping that we have a smooth birth so I can get through it relatively relaxed and unmeddled with. I think a lot of the time it really depends on your doula and your midwife to be your advocates. You have to have one that really sticks to what your birth plan is unless it’s absolutely necessary to deviate from it for the safety of you or the baby. I think I lucked out, especially considering that there is only 1 hospital in the area that will work with midwives. We’ll see though! I’m not having an actual doula for this birth, however I have a good friend who is training to become a midwife and has offered to stand in as a sort of doula for me. I think between her and my midwife I’m going to be in good hands. :)

        Good luck to you! I hope both our births go smoothly and peacefully!

Trackbacks & Pingbacks

  1. Evidence-Based Fetal Monitoring « Evidence Based Birth

Leave a Reply