Perpetuating Myths, Fables, and Fairy Tales: A Half Century of Electronic Fetal Monitoring

 

 Permissions and Reprints

Abstract

Electronic fetal monitoring (EFM) entered clinical medical practice at the same time bioethics became reality. Bioethics changed the medical ethics landscape by replacing the traditional Hippocratic benign paternalism with patient autonomy, informed consent, beneficence, and nonmaleficence. But EFM use represents the polar opposite of bioethics' revered principles—it has been documented for half a century to be completely ineffectual, used without informed consent, and harmful to mothers and newborns alike. Despite EFM's ethical misuse, there has been no outcry from the bioethical world. Why? This article answers that question, discussing EFM's history and the reasons it was issued an ethics pass. And it explores the reason that even today mothers are still treated with blatant medical paternalism, deprived of autonomy and informed consent, and subjected to real medical risks under the guise that EFM is an essential safety device when in fact it is used almost solely to protect physicians and hospitals from cerebral palsy lawsuits.

• References

• 1 The American College of Obstetricians and Gynecologists and American Academy of Pediatrics. Neonatal Encephalopathy and Neurologic Outcome. 2nd ed. 2014
  PubMedGoogle Scholar
• 2 Ayres-de-Campos D. Introduction: why is intrapartum fetal monitoring necessary—impact on outcomes and interventions. Best Pract Res Clin Obstet Gynaecol 2015; June 23 (Epub ahead of print); doi: 10.1016/j.bpobgyn.2015.05.005
  PubMedGoogle Scholar
• 3 Nageotte MP. Fetal heart rate monitoring. Semin Fetal Neonatal Med 2015; 20 (3) 144-148
  CrossrefPubMedGoogle Scholar
• 4 Berkowitz RL, D'Alton ME, Goldberg JD , et al. The case for an electronic fetal heart rate monitoring credentialing examination. Am J Obstet Gynecol 2014; 210 (3) 204-207
  CrossrefPubMedGoogle Scholar
• 5 Freeman RK, Garite TJ, Nageotte MP, Miller LA. Fetal Heat Rate Monitoring. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012
  Google Scholar
• 6 Sartwelle TP, Johnston JC. Neonatal encephalopathy 2015: opportunity lost and words unspoken. J Matern Fetal Neonatal Med 2015; June 22 (Epub ahead of print)
  PubMedGoogle Scholar
• 7 Parer JT. Personalities, politics and territorial tiffs: a half century of fetal heart rate monitoring. Am J Obstet Gynecol 2011; 204 (6) 548-550
  CrossrefPubMedGoogle Scholar
• 8 MacDonald D. Cerebral palsy and intrapartum fetal monitoring. N Engl J Med 1996; 334 (10) 659-660
  CrossrefPubMedGoogle Scholar
• 9 Sartwelle TP. Electronic fetal monitoring: a bridge too far. J Leg Med 2012; 33 (3) 313-379
  CrossrefPubMedGoogle Scholar
• 10 MacLennan AH, Thompson SC, Gecz J. Cerebral palsy: causes, pathways, and the role of genetic variants. Am J Obstet Gynecol 2015; May 21 (Epub ahead of print); doi: 10.1016/j.ajog.2015.05.034
  PubMedGoogle Scholar
• 11 Sartwelle TP, Johnston JC. Cerebral palsy litigation: change course or abandon ship. J Child Neurol 2015; 30 (7) 828-841
  CrossrefPubMedGoogle Scholar
• 12 Donn SM, Chiswick ML, Fanaroff JM. Medico-legal implications of hypoxic-ischemic birth injury. Semin Fetal Neonatal Med 2014; 19 (5) 317-321
  CrossrefPubMedGoogle Scholar
• 13 Badawi N, Keogh JM. Causal pathways in cerebral palsy. J Paediatr Child Health 2013; 49 (1) 5-8
  CrossrefPubMedGoogle Scholar
• 14 Costantine MM, Saade GR. The first cesarean: role of “fetal distress” diagnosis. Semin Perinatol 2012; 36 (5) 379-383
  CrossrefPubMedGoogle Scholar
• 15 MacLennan AHA. A “no-fault” cerebral palsy pension scheme would benefit all Australians. Aust N Z J Obstet Gynaecol 2011; 51 (6) 479-484
  CrossrefPubMedGoogle Scholar
• 16 Obladen M. Lame from birth: early concepts of cerebral palsy. J Child Neurol 2011; 26 (2) 248-256
  CrossrefPubMedGoogle Scholar
• 17 Grimes DA, Peipert JF. Electronic fetal monitoring as a public health screening program: the arithmetic of failure. Obstet Gynecol 2010; 116 (6) 1397-1400
  CrossrefPubMedGoogle Scholar
• 18 Khalil A, O'Brien P. Fetal heart rate monitoring—is it a waste of time?. J Obstet Gynecol India 2006; 56 (6) 481-485
  PubMedGoogle Scholar
• 19 MacLennan A, Hankins G, Speer N. Only an expert witness can prevent cerebral palsy. Obstet Gynecol 2006; 8 (1) 28-30
  PubMedGoogle Scholar
• 20 Greene MF. Obstetricians still await a deus ex machina. N Engl J Med 2006; 355 (21) 2247-2248
  CrossrefPubMedGoogle Scholar
• 21 MacLennan A, Nelson KB, Hankins G, Speer M. Who will deliver our grandchildren? Implications of cerebral palsy litigation. JAMA 2005; 294 (13) 1688-1690
  CrossrefPubMedGoogle Scholar
• 22 Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy—fact and fiction. Am J Obstet Gynecol 2003; 188 (3) 628-633
  CrossrefPubMedGoogle Scholar
• 23 Freeman R. Intrapartum fetal monitoring—a disappointing story. N Engl J Med 1990; 322 (9) 624-626
  CrossrefPubMedGoogle Scholar
• 24 Jenkins HML. Thirty years of electronic intrapartum fetal heart rate monitoring: discussion paper. J R Soc Med 1989; 82 (4) 210-214
  PubMedGoogle Scholar
• 25 Quilligan EJ, Paul RH. Fetal monitoring: is it worth it?. Obstet Gynecol 1975; 45 (1) 96-100
  PubMedGoogle Scholar
• 26 Johnston JC, Sartwelle TP. The expert witness in medical malpractice litigation: through the looking glass. J Child Neurol 2013; 28 (4) 484-501
  CrossrefPubMedGoogle Scholar
• 27 Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA 1996; 275 (2) 152-156
  CrossrefPubMedGoogle Scholar
• 28 Veatch RM. The Basics of Bioethics. 3rd ed. Boston, MA: Pearson Education, Inc.; 2012
  Google Scholar
• 29 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press; 2009
  Google Scholar
• 30 Clark SL, Nageotte MP, Garite TJ , et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013; 209 (2) 89-97
  CrossrefPubMedGoogle Scholar
• 31 Sartwelle TP. Defending a neurologic birth injury. Asphyxia neonatorum redux. J Leg Med 2009; 30 (2) 181-247
  CrossrefPubMedGoogle Scholar
• 32 Illingworth RS. Why blame the obstetrician? A review. BMJ 1979; 1 (6166) 797-801
  CrossrefPubMedGoogle Scholar
• 33 Sholapurkar SL. Interpretation of British experts' illustrations of fetal heart rate decelerations by Consultant Obstetricians, registrars and midwives: a prospective study—reasons for major disagreements with the experts and implications for clinical practice. Open J Obstet Gynecol 2013; 3: 454-465
  PubMedGoogle Scholar
• 34 Hruban L, Spilka J, Chudacek V , et al. Agreement on intrapartum cardiotocogram recordings between expert obstetricians. J Eval Clin Pract 2015; 21 (4) 694-702
  CrossrefPubMedGoogle Scholar
• 35 Spilka J, Chudáček V, Janků P , et al. Analysis of obstetricians' decision making on CTG recordings. J Biomed Inform 2014; 51: 72-79
  CrossrefPubMedGoogle Scholar
• 36 Osterman MJK, Kochanek KD, MacDorman MF, Strobino DM, Guyer B. Annual summary of vital statistics: 2012–2013. Pediatrics 2015; 135 (6) 1115-1125
  CrossrefPubMedGoogle Scholar
• 37 Parer JT. Standardization of fetal heart rate pattern management: is international consensus possible?. Hypertens Res Pregnancy 2014; 2 (2) 51-58
  CrossrefPubMedGoogle Scholar
• 38 Cahill AG, Roehl KA, Odibo AO, Macones GA. Association and prediction of neonatal acidemia. Am J Obstet Gynecol 2012; 207 (3) 206.e1-206.e8
  CrossrefPubMedGoogle Scholar
• 39 Maso G, Piccoli M, De Seta F , et al. Intrapartum fetal heart rate monitoring interpretation in labour: a critical appraisal. Minerva Ginecol 2015; 67 (1) 65-79
  PubMedGoogle Scholar
• 40 Kesselheim AS, Studdert DM. Characteristics of physicians who frequently act as expert witnesses in neurologic birth injury litigation. Obstet Gynecol 2006; 108 (2) 273-279
  CrossrefPubMedGoogle Scholar
• 41 Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120 (5) 1181-1193
  CrossrefPubMedGoogle Scholar
• 42 Ecker J. Elective cesarean delivery on maternal request. JAMA 2013; 309 (18) 1930-1936
  CrossrefPubMedGoogle Scholar
• 43 Villar J, Carroli G, Zavaleta N , et al; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007; 335 (7628) 1025-1032
  CrossrefPubMedGoogle Scholar
• 44 American College Obstetricians & Gynecologists and Society for Maternal Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (3) 179-193
  CrossrefPubMedGoogle Scholar
• 45 Silver RM, Fox KA, Barton JR , et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212 (5) 561-568
  CrossrefPubMedGoogle Scholar
• 46 Sevelsted A, Stokholm J, Bønnelykke K, Bisgaard H. Cesarean section and chronic immune disorders. Pediatrics 2015; 135 (1) e92-e98
  CrossrefPubMedGoogle Scholar
• 47 Friedrich MJ. Unraveling the influence of gut microbes on the mind. JAMA 2015; 313 (17) 1699-1701
  CrossrefPubMedGoogle Scholar
• 48 Borre YE, O'Keeffe GW, Clarke G, Stanton C, Dinan TG, Cryan JF. Microbiota and neurodevelopmental windows: implications for brain disorders. Trends Mol Med 2014; 20 (9) 509-518
  CrossrefPubMedGoogle Scholar
• 49 Neu J. The pre- and early postnatal microbiome: relevance to subsequent health and disease. NeoReviews 2013; 14 (12) e592-e599
  CrossrefPubMedGoogle Scholar
• 50 Devoe LD. Electronic fetal monitoring: does it really lead to better outcomes?. Am J Obstet Gynecol 2011; 204 (6) 455-456
  CrossrefPubMedGoogle Scholar
• 51 Jonsen AR. A Short History of Medical Ethics. New York, NY: Oxford University Press; 2000
  Google Scholar
• 52 Zuspan FP, Quilligan EJ, Iams JD, van Geijn HP. NICHD Consensus Development Task Force report: predictors of intrapartum fetal distress---the role of electronic fetal monitoring. J Pediatr 1979; 95 (6) 1026-1030
  CrossrefPubMedGoogle Scholar
• 53 Zuspan FP, Quilligan EJ, Iams JD, van Geijn HP ; Report of the National Institute of Child Health and Human Development Consensus Development Task Force. Predictors of intrapartum fetal distress: the role of electronic fetal monitoring. Am J Obstet Gynecol 1979; 135 (3) 287-291
  CrossrefPubMedGoogle Scholar
• 54 Gilfix MG. Electronic fetal monitoring: physician liability and informed consent. Am J Law Med 1984; 10 (1) 31-90
  PubMedGoogle Scholar
• 55 International Federation of Gynaecology and Obstetrics and Family Health International. Guidelines for the use of fetal monitoring. Int J Gynaecol Obstet 1987; 25: 159-167 . Available at: http://www.geburtshilfe.usz.ch/Documents/HealthProfessionals/Guidelines/fetal_monitoring.pdf . Accessed July 11, 2015
  CrossrefPubMedGoogle Scholar
• 56 Rhoden NK. Informed consent in obstetrics: some special problems. West New Engl Law Rev 1987; 9 (1) 67-88
  PubMedGoogle Scholar
• 57 Wood SH. Should women be given a choice about fetal assessment in labor?. MCN Am J Matern Child Nurs 2003; 28 (5) 292-298 , quiz 299–300
  CrossrefPubMedGoogle Scholar
• 58 Heelan L. Fetal monitoring: creating a culture of safety with informed choice. J Perinat Educ 2013; 22 (3) 156-165
  CrossrefPubMedGoogle Scholar
• 59 Abrams JR. The illusion of autonomy in women's medical decision-making. Fla State Univ Law Rev 2015; 42: 17-60
  PubMedGoogle Scholar
• 60 Grady C. Enduring and emerging challenges of informed consent. N Engl J Med 2015; 372 (9) 855-862
  CrossrefPubMedGoogle Scholar
• 61 Schenker Y, Meisel A. Informed consent in clinical care: practical considerations in the effort to achieve ethical goals. JAMA 2011; 305 (11) 1130-1131
  CrossrefPubMedGoogle Scholar