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July 18, 2019

Electronic Fetal Monitoring to Prevent Fetal Brain Injury: A Ubiquitous Yet Flawed Tool

Author Affiliations
  • 1Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
  • 2Obstetrics and Gynecology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
JAMA. 2019;322(7):611-612. doi:10.1001/jama.2019.8918

One of the central objectives of obstetrical care is the delivery of healthy infants. In modern obstetrics, no tools are relied on more heavily to achieve this objective than monitoring of fetal heart rate and obstetrical ultrasound.

Heart rate monitoring during labor is an attempt to identify fetal oxygen deprivation (and the related acidosis that results from anaerobic metabolism) in its early stages, potentially allowing medical staff to intervene before hypoxic brain injury occurs. Fetal cardiac rate monitoring has been practiced since at least the 1830s, when Kennedy recommended auscultation of the fetal heart using Laennec’s new stethoscope. Eventually it was recognized that certain fetal cardiac rhythms during labor, specifically tachycardia, bradycardia, and transient decreases in pulse rate (ie, “decelerations,” usually either coincident with or delayed in relation to uterine contractions), are associated with neonatal depression and central nervous system injury. The guidelines for intermittent auscultation (listening to the fetal heartbeat for 1 minute every 15-30 minutes during the first stage of labor and every 5 minutes during the second stage; ie, while pushing) were developed in the 1920s. These guidelines and the specialized stethoscope, or fetoscope, used for auscultation remained essentially unchanged until the advent of continuous electronic fetal monitoring (EFM) in the 1970s.

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    1 Comment for this article
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    Electronic Fetal Monitoring (EFM): an Unsuitable Diagnostic Tool Based on Wrong Assumptions
    Raimond Giard, MD, JD, PhD | Prof. Emeritus of Tort Law, Erasmus School of Law, Rotterdam, the Netherlands and clinical pathologist and clinical epidemiologist
    For electronic fetal monitoring (EFM) to be effective, the following prerequisites must apply:

    1. Until parturition, the child is healthy and the unwanted injuries come into existence only during the stage of labour.
    2. The underlying disease mechanism is asphyxic injury of the child’s brain.
    3. The disease process is gradually evolving and the child progressively shows signs of distress, diagnosable by means of EFM. This allows proper timing of an emergency intervention before irreversible brain injuries have taken place.
    4. Timely intervention based on proper interpretation of these stress signals averts or at least lessens the brain
    damages.

    These assumptions however are corrupted by the overwhelming evidence that the incidence of cerebral palsy is not reduced by electronic fetal monitoring, an assertion also powerfully made in Hirsch’ viewpoint. [1,2] Especially intrapartum asphyxia as the general underlying pathogenetic mechanism for this harm has been disproven. [3,4] However, the obstetrical community seems to hold on to this meanwhile overthrown theory and the EFM-practice.
    The cardinal driver of cerebral palsy litigation is this faulting of electronic fetal monitoring, which has continued unabated now for 5 decades. By adhering to the above-mentioned suppositions, the wrong disease mechanism, and a flawed diagnostic device, obstetricians are digging their own legal graves. Expert witnesses serve mostly as helpful grave-diggers.[5]

    What is desperately needed is the awareness that cerebral palsy is an umbrella term for a disease with a complex and diverse pathogenesis and that the possibilities for its prevention are limited [6]. As such, the unrestrained continuation of EFM poses an enormous ethical dilemma. [7]

    References
    1. Nelson KB, Sartwelle TP, Rouse DJ. Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence. BMJ 2016;355:i6405.
    2. Hirsch E. Electronic fetal monitoring to prevent fetal brain injury. A ubiquitous yet flawed tool. JAMA. 2019; epub ahead of publication.
    3. Freeman JM, Nelson KB. Intrapartum asphyxia and cerebral palsy. Pediatrics 1988;82(2):240–9.
    4. Gilles F, et al. Hypoxia– ischemia is not an antecedent of most preterm brain damage: the illusion of validity. Dev Med Child Neurol 2018;60:120–5.
    5. MacLennan A, Hankins G, Speer M. Only an expert witness can prevent cerebral palsy! Obstetrics & Gynecology 2006;8(1):8–10.
    6. Nelson KB, Blair E. Prenatal factors in singletons with cerebral palsy born at or near term. New Engl J Med 2015;373(10):946–953.
    7. Sartwelle TP, Johnston JC, Arda B, Zebenigus M. Cerebral palsy, cesarean sections, and electronic fetal monitoring: All the light we cannot see. Clin Ethics. 2019;epub ahead of publication.
    CONFLICT OF INTEREST: None Reported
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